Comparison of revision rates and epidemiological data of a single total knee arthroplasty system of different designs (cruciate retaining, posterior stabilized, mobile bearing, and fixed bearing): a meta-analysis and systematic review of clinical trials and national arthroplasty registries

BACKGROUND

This study aimed to meta-analyze epidemiological data, revision rates, and incidences of different designs of a single Total Knee Arthroplasty System and compare these factors across different countries.

METHODS

A systematic review was conducted on clinical studies and arthroplasty registries of ATTUNE TKA from 1999 to 2020. The main endpoints analyzed were revision rates and epidemiological data.

RESULTS

The average age of patients was 67.8 years, with a gender distribution of 60% female and 40% male. The pooled average BMI was 29.4 kg/m2. Eight clinical studies showed a pooled revision rate per 100 observed CY of 0.5 (n = 1343 cases). Cumulative revision rates after 1, 3, and 5 years varied among registries, with the Swiss registry having the highest revision data (after 5 years: 6.3%) and the American registry having the lowest revision data (after 5 years: 1.7%). A comparison of the revision rates of mobile bearing and fixed bearing (41,200 cases) as well as cruciate retaining and posterior stabilized (n = 123,361 cases) showed no significant advantage in the first 5 years after implantation.

CONCLUSION

In conclusion, pooled data from 41,200 cases of TKA with a single Total Knee Arthroplasty System in two arthroplasty registries revealed that there was no significant difference in revision rates between the mobile bearing and fixed bearing design within the first 5 years after implantation. In addition, a comparison of the revision rates in n = 123,361 cases showed no significant advantage for cruciate retaining or posterior stabilized in the first 5 years after implantation.

Return to Sports and Clinical Results After All-Arthroscopic Biceps Tenodesis Using a 2.7-mm Knotless PEEK Suture Anchor

Background

The long head of the biceps tendon (LHBT) is a well-known source of pain in the shoulder, especially in active patients.

Purpose

To evaluate the outcomes and return-to-sports rate after all-arthroscopic suprapectoral tenodesis of the LHBT using a small knotless anchor.

Study Design

Case series; Level of evidence, 4.

Methods

In this retrospective study, 27 patients-who underwent all-arthroscopic tenodesis of the LHBT using a 2.7-mm knotless polyether ether ketone anchor-were evaluated. Sports activities, the return-to-sports rate, and other sports-related parameters (eg, pain during sports, level of sports) were examined. Sports-related data, the Constant score with isometric force (at 90° of abduction in the scapular plane), the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST) score, the visual analog scale (VAS) score for satisfaction, range of motion, and the presence of a Popeye deformity were assessed at a mean follow-up of 15.3 ± 8.7 months. The data were initially analyzed using descriptive statistics.

Results

The postoperative ASES, Constant, and SST scores were 81.61, 85.74 and 8.85, respectively. Of the 27 patients, 4 patients (14.8%) showed a Popeye deformity. Preoperatively, 25 patients (92.6%) participated regularly in some type of sports activity. All 25 patients (100.0%) were able to return to sports activities after surgery. 24 (96.0%) returned to the same level preoperatively, with 88.0% (22/25) within 6 months. Patient satisfaction with the outcome was high (VAS score: 2.15 ± 2.78). Neither bicipital groove pain nor cramping was reported. There were no signs of osteolytic bone around the anchor or a fracture of the humeral bone.

Conclusion

Our clinical results after using a 2.7-mm knotless anchor for LHBT tenodesis as well as the return-to-sports rate were satisfying. Using an anchor this size can lower the risk of cortical bone damage and therefore the risk of fractures of the humeral head while still enabling patients to perform at a high level.

The Value of Computed Tomography-Based Planning in Shoulder Arthroplasty Compared to Intra-/Interobserver Reliability of X-ray Planning

Background: Reversed total shoulder arthroplasty (RTSA) is an established surgery for many pathologies of the shoulder and the demand continues to rise with an aging population. Preoperative planning is mandatory to support the surgeon's understanding of the patient's individual anatomy and, therefore, is crucial for the patient's outcome. Methods: In this observational study, we identified 30 patients who underwent RTSA with two- and three-dimensional preoperative planning. Each patient underwent new two-dimensional planning from a medical student and an orthopedic resident as well as through a mid-volume and high-volume shoulder surgeon, which was repeated after a minimum of 4 weeks. The intra- and interobserver reliability was then analyzed and compared to the 3D planning and the implanted prosthesis. The evaluated parameters were the size of the pegged glenoid baseplate, glenosphere, and humeral short stem. Results: The inter-rater reliability showed higher deviations in all four raters compared to the 3D planning of the base plate, glenosphere, and shaft. The intra-rater reliability showed a better correlation in more experienced raters, especially in the planning of the shaft. Conclusions: Our study shows that 3D planning is more accurate than traditional planning on plain X-rays, despite experienced shoulder surgeons showing better results in 2D planning than inexperienced ones.

Short stem hip arthroplasty with the optimys prosthesis is a safe and effective option for obese patients: a mid-term follow-up multicenter study

INTRODUCTION

Short stems are a valuable option in young patients undergoing total hip arthroplasty (THA) because of their bone stock preserving properties facilitating revision hip arthroplasty. Although the effect of obesity on conventional THA is well studied, data about short stem THA in obese patients are lacking. Therefore, this study aimed to investigate the influence of obesity on complications, revisions, and outcome after short stem THA.

MATERIALS AND METHODS

This multicenter, observational cohort study included patients undergoing short stem THA with the optimys prosthesis. Follow-up examinations were performed at specific intervals up to 7 years postoperatively. Operation characteristics, general and specific complications, revisions, VAS rest pain, VAS load pain, VAS patient satisfaction, and Harris Hip Score (HHS) were recorded and statistically compared between obese (BMI ≥ 30 kg/m2) and non-obese (BMI < 30 kg/m2) patients.

RESULTS

Of the 224 patients included with a mean follow-up of 87.2 months (range 81.9-104.0), 69 were assigned to the OB group and 155 to the non-OB group. A minimally invasive approach was significantly less often selected in obese patients (p = 0.049), whereas operating time and length of hospital stay were not significantly different. The rate of general and specific complications did not significantly differ between both groups. Survival of the optimys prosthesis was 99.1% at 7-year follow-up and one patient per group had to undergo revision surgery. VAS rest pain, load pain, and satisfaction improved from preoperatively to postoperatively in both groups without a significant difference between both groups. While the HHS was improved from preoperatively to postoperatively, obese patients showed a significantly lower HHS at the 7-year follow-up (p = 0.01) but still exhibited an excellent scoring above the PASS threshold.

CONCLUSION

Short stem THA with the optimys prosthesis is a safe and effective option also in obese patients with an excellent clinical outcome and a low complication rate.

Subsidence after calcar-guided short stem total hip arthroplasty: five-year results of a prospective multicentre study

PURPOSE

Calcar-guided short-stem total hip arthroplasty (THA) has shown excellent clinical outcomes. However, the migration pattern of such prostheses and its effect on clinical outcomes are less known. Therefore, we assessed the five-year subsidence after calcar-guided short-stem THA and its implications on clinical outcomes, patient-related factors, and complications.

METHODS

In this prospective multicentre study, we enrolled 213 patients (224 hips) who underwent calcar-guided short-stem THA mostly for degenerative hip diseases. We examined patients radiographically and clinically after six to 12 weeks, one year, two years, and five years. We evaluated subsidence using Einzel-Bild-Roentgen-Analyse femoral component analysis, assessed clinical outcomes, and systematically recorded all complications.

RESULTS

Overall, 131 patients (133 hips) were available for final follow-up at a median of 60 months (range, 2 to 72 months). We found a mean subsidence of 0.63 ± 1.22 mm at three months, 1.03 ± 1.60 mm at one year, 1.21 ± 1.91 mm at two years, and 1.54 ± 1.97 mm at five years. Patient-related factors (sex, age, weight, and BMI) did not significantly impact subsidence at five years (P > 0.05). Additionally, the Harris hip score, pain, and satisfaction improved significantly at five years compared to pre-operative values (P < 0.0001). Lastly, five patients underwent revision.

CONCLUSION

Calcar-guided short-stems revealed the highest subsidence rate within the first three months after THA and stabilisation after one year through the final follow-up examination. Moreover, patient-related factors had no influence on subsidence. Finally, clinical scores and patient satisfaction remained high at five years.

Stem Design in Total Hip Arthroplasty Influences Ipsilateral Knee Valgus: A Retrospective Comparative Analysis of 2953 Cases

BACKGROUND

Total hip arthroplasty (THA) affects the biomechanics of the hip and the patient gait. The stem design influences femoral lever ratios and tissue trauma. Biomechanical changes such as these have the potential to induce knee arthritis. A varus or valgus configuration of knee arthritis is formed by asymmetric loadings. The aim of this study was to evaluate the impact of stem design in THA on knee valgus by comparing a standard implant with an implant with a short stem.

METHODS

A total of 2953 patients who underwent primary total knee arthroplasty for end-stage osteoarthritis between 2015 and 2021 were included in this retrospective data analysis. Patients were divided into three groups, depending on hip status (straight stem, short stem, and native joint). Leg alignment was distinguished as varus or valgus, and the degree of axial deviation was measured. Descriptive and explorative statistical analyses were performed, with a p value < 0.05 set as significant.

RESULTS

Ipsilateral knee valgus occurred significantly more often in patients with straight stems (57.2%) than in those with short stems (29%) and native joints (25.8%) (p < 0.001). Additionally, mean valgus deviation was significantly increased in patients with straight stems (8.9°) compared to those with short stems (6.4°) or native hip joints (6.7°). Both findings were accentuated in women.

CONCLUSIONS

Previous ipsilateral straight-stem THA is associated with knee valgus deformity, especially in women. Short-stem THA seems to be better suited to restoring physiological biomechanics and preventing the development of valgus osteoarthritis of the ipsilateral knee.

Subsidence analysis of a cementless short stem THA using EBRA-FCA - A seven-year prospective multicentre study

Background

Metaphyseal fixation of short stem THA allows for minimally invasive surgery, less bone removal, improved bone load transfer and reduced stress shielding. Short stems facilitate the anatomic restoration i.a. of leg length, femoroacetabular offset, and center of rotation. However, metaphyseal fixation might cause impaired primary and/or secondary stability resulting in an inherent tendency for early axial migration and aseptic loosening eventually. The objective of this study was to investigate the long-term outcome and migration pattern of a calcar-guided short stem.

Methods

In a prospective multicenter study, 213 patients (224 THAs) were enrolled. Patients were followed for up to 84 months postoperatively. Clinical outcome was assessed using the Harris Hip Score and the VAS for pain and satisfaction. Standardized and calibrated radiographs were screened i.a. for stress shielding and loosening. Einzel-Bild-Roentgen-Analyse - femoral component analysis (EBRA-FCA) was used to detect longitudinal subsidence.

Results

At 7 year follow-up, n = 139/224 cases were available for analysis. All clinical parameters improved significantly (p < 0.001) and improvement persisted. There were no radiographic changes indicating stress shielding. EBRA-FCA revealed a mean subsidence of -1.44 mm followed by a stabilization. Weight >80 kg (p = 0.115), BMI <30 kg/m2 (p = 0.282), male gender (p = 0.246), and age <65 years (p = 0.304) seemed to be associated with a higher risk for migration. The cumulative revision rate was 2.23%. Revisions due to stem migration (0.89%) occurred early (mean time between index surgery and revision: 3.3 months).

Conclusions

If at all, there appears to be a pronounced initial subsidence, which stabilizes thereafter. Stem migration was rarely a compelling reason for failure or revision. Demographics do not seem to have a significant effect on migration pattern. The absence of radioluce lines, resorption or hypertrophy of the proximal femora support the hypothesis of a reduced stress shielding for metaphyseal anchoring short stems.

Pancreatitis, panniculitis and polyarthritis syndrome: A case report

BACKGROUND

Pancreatitis, panniculitis, and polyarthritis (PPP) syndrome is a rare form of pancreatic disease. It is characterized by bullous erythematous skin lesions and arthritis, and both are triggered by pancreatic malfunction. Few cases have been described in the literature thus far. Due to the inconsistency in its clinical presentation, its diagnosis can be a challenge. Early therapy initiation is essential to reduce mortality; however, there is currently no gold standard for treatment.

CASE SUMMARY

A 66-year-old polymorbid male patient presented with several superficial abscesses on both lower legs and painful swelling in the knee. Treatment for septic arthritis and septic skin infection over several weeks failed. His general condition deteriorated gradually and worsened with sudden onset of abdominal pain. A diagnosis of necrotizing pancreatitis was made. He subsequently underwent a laparotomy and drainage of the pancreas. Eventually, our patient improved, and his abdominal complaints, knee pain, and dermal lesions resolved.

CONCLUSION

PPP syndrome is rare and easily misdiagnosed, as abdominal symptoms may be delayed or absent. Clinicians should consider PPP syndrome if they encounter refractory panniculitis in combination with joint infection.

Learning Curve for Short-Stem Total HIP Arthroplasty through an Anterolateral Approach

Background and Objectives: Short-stem total hip arthroplasty has become increasingly popular in recent years. While many studies have shown excellent clinical and radiological results, very little is known about the learning curve for short-stem total hip arthroplasty through an anterolateral approach. Therefore, the aim of this study was to determine the learning curve for short-stem total hip arthroplasty among five residents in training. Materials and Methods: We performed retrospective data analysis of the first 30 cases of five randomly selected residents (n = 150 cases) with no experience before the index surgery. All patients were comparable, and several surgical parameters and radiological outcomes were analyzed. Results: The only surgical parameter with a significant improvement was the surgical time (p = 0.025). The changes in other surgical parameters and radiological outcomes showed no significant changes; only trends can be derived. As a result, the correlation between surgical time, blood loss, length of stay, and incision/suture time can also be seen. Only two of the five residents showed significant improvements in all examined surgical parameters. Conclusions: There are individual differences among the first 30 cases of the five residents. Some improved their surgical skills faster than others. It could be assumed that they assimilated their surgical skills after more surgeries. A further study with more than 30 cases of the five surgeons could provide more information on that assumption.

Facet joint violation after open and percutaneous posterior instrumentation: a comparative study

PURPOSE

Posterior instrumentation is the state-of-the-art surgical treatment for fractures of the thoracic and lumbar spine. Options for pedicle screw placement comprise open or minimally invasive techniques. Open instrumentation causes large approach related muscle detachment, which minimally invasive techniques aim to reduce. However, concerns of accurate pedicle screw placement are still a matter of debate. Beside neurological complications due to pedicle screw malplacement, also affection of the facet joints and thus motion dependent pain is known as a complication. The aim of this study was to assess accuracy of pedicle screw placement concerning facet joint violation (FJV) after open- and minimally invasive posterior instrumentation.

METHODS

A retrospective data analysis of postoperative computer tomographic scans of 219 patients (1124 pedicle screws) was conducted. A total of 116 patients underwent open screw insertion (634 screws) and 103 patients underwent minimally invasive, percutaneous screw insertion (490 screws).

RESULTS

In the lumbar spine (segments L3, L4, L5), there were significantly more and higher grade (open = 0.55 vs. percutaneous = 1.2; p = 0.001) FJV's after percutaneously compared to openly inserted screws. In the thoracic spine, no significant difference concerning rate and grade of FJV was found (p > 0.56).

CONCLUSION

FJV is more likely to occur in percutaneously placed pedicle screws. Additionally, higher grade FJV's occur after percutaneous instrumentation. However, in the thoracic spine we didn't find a significant difference between open and percutaneous technique. Our results suggest a precise consideration concerning surgical technique according to the fractured vertebrae in the light of the individual anatomic structures in the preop CT.

Periprosthetic knee joint infection caused by Brucella melitensis which was first -osteoarticular brucellosis or osteoarthrosis: A case report

BACKGROUND

Brucellosis is the most common zoonosis worldwide and is endemic in the Middle East, Africa, Asia, and Latin America. However, it is uncommon in Central Europe, and periprosthetic infections caused by Brucella are therefore rare. Due to the low prevalence and nonspecific clinical presentation of the disease, accurate diagnosis can be challenging; no gold standard currently exists for treating brucellosis.

CASE SUMMARY

Here, we present a 68-year-old Afghan woman living in Austria with a periprosthetic knee infection caused by Brucella melitensis. The interval from total knee arthroplasty to septic loosening was five years. A profound medical history and examinations suggested that the patient had been suffering from unrecognized chronic osteoarticular brucellosis prior to total knee arthroplasty. She was successfully treated by two-stage revision surgery and combined antibiotic therapy over three months.

CONCLUSION

Clinicians should consider brucellosis as a possible cause of chronic arthralgia and periprosthetic infection in patients originating from countries with a high brucellosis burden.

Age- and Gender-Related Differences in the Morphology of Cuff Tear Arthropathy: A Cross Sectional Analysis

Rotator cuff tear arthropathy (CTA) is the most common reason for reverse total shoulder arthroplasty (RSA). There is minimal understanding of the natural progression of osteoarthritis of the shoulder and of the morphologic differences between men and women and between younger and older patients. This trial comprised 309 patients (342 shoulders) who underwent RSA due to CTA in the period between January 2009 and September 2019. The patients were divided into gender and age groups. Preoperative X-rays, computed tomography and magnetic resonance imaging were conducted using various classifications to describe the morphology of the CTA. Of all 342 analyzed shoulders, 209 were right and 133 were left shoulders. A total of 257 female shoulders and 85 male shoulders were assessed. Both mean age and age distribution were significantly different (74.37 years in female and 70.11 years in male patients, p = 0.001; 70.2% female patients in the age group <75.5 years and 80.1% in the age group >75.5 years, p = 0.045). A larger extent of progression of the fatty infiltration was detected both in the female cohort (p = 0.006) and in the older age group (p = 0.001). Additionally, older patients had significantly higher levels of muscle retraction (Patte; p = 0.003), a lower acromiohumeral distance (p = 0.042) and more advanced CTA (Seebauer; p = 0.006).

Assessment of atlantoaxial rotation: how accurate is clinical measurement? a comparative study of cervical range of motion using MRI and standard orthopedic techniques

PURPOSE

Measurement of neck rotation is currently reliant on radiologic imaging. Given the radiation exposure for CT imaging and the additional inconvenience for the patients, an alternative assessment is needed. Goniometers are comfortably to use and easy to access, also for private consulting. The aim of this study was the assessment of whether a handheld goniometer can be used for accurately measuring the rotation of C1-C2.

METHODS

Clinical measurement of rotation was taken in flexed position of the neck. As comparison functional MRI was used. The measured rotation of C1-C2 was compared to identify the accuracy of the goniometer, in comparison to functional MRI scan.

RESULTS

Analysis of accuracy using a goniometer and dynamic MRI to assess C1-2 axial rotation showed significant differences for absolute values, but not regarding the percentage of rotation compared to total neck rotation.

CONCLUSION

The goniometer is exact to impartially determine the percentage contribution of C1-2 rotation to total neck rotation.

The Effect of Strength Training on Undetected Shoulder Pathology in Asymptomatic Athletes: An MRI Observational Study

BACKGROUND

Data on the effects of weight training on joint morphology are mostly restricted to muscle gain. However, in many circumstances, it is not stated if there are negative consequences for the joints and their surrounding components. This study was conducted to explore whether long-term excessive resistance training (RT) causes hidden pathological alterations in the shoulder.

METHODS

A total of eleven asymptomatic sportsmen (22 shoulders) underwent clinical and radiological examination of both shoulder joints. All participants had engaged in bodybuilding for at least four years, at least three times per week, and for at least four hours per week. All participants were examined clinically using the Constant Murley Score (CMS), Simple Shoulder Test (SST), UCLA Activity Test, and a specially designed questionnaire. All participants received a bilateral shoulder MRI. The MRI scans were checked for pathology using a checklist.

RESULTS

Maximum scores were observed for the SST and UCLA Activity Test. The CMS was 97.7 points on average (range, 87-100). RT had been conducted for a mean of 10.7 years (range, 4-20), for an average of 8.8 h a week (range, 4-12). MRI examinations revealed two supraspinatus tendinopathies (9.1%), one labral change (4.5%), three humeral tuberosity cysts (13.6%), fourteen acromioclavicular (AC) joint hypertrophies (63.6%), five AC joint osteophytes (22.7%), and ten signs of AC joint inflammation (45.5%).

CONCLUSIONS

The research results show that strength is associated with MRI-documented AC joint pathology. However, it appears that RT may not negatively affect other anatomical structures of the shoulder.

Femoral antetorsion after calcar-guided short-stem total hip arthroplasty: A cadaver study

Calcar-guided short stems in total hip arthroplasty (THA) permit surgeons to successfully reconstruct postoperative femoroacetabular offset, accurately restore leg length, and adequately re-establish a wide range of caput-collum-diaphyseal angles. However, their effect on femoral antetorsion is less known. Indeed, controlling antetorsion of the femoral stem can be challenging because of the differences in individual femoral geometry and curvature. Therefore, we investigated if calcar-guided short-stem THA alters femoral antetorsion and compared it with conventional-stem THA. Using 12 Thiel-fixed, full-body cadaver specimens from donors without known hip disorders, we compared an uncemented calcar-guided femoral short-stem prosthesis with an uncemented conventional straight-stem prosthesis. In a paired study setup, each specimen received a calcar-guided short stem on one side and a conventional stem on the other. On the acetabular side, all specimens received a press-fit, monobloc acetabular cup. Femoral antetorsion angles were measured using the Waidelich method, and pre- and post-operative angles of both sides were recorded. The mean preoperative femoral antetorsion angles were similar in both groups (24.8°  ± 7.5° vs. 23.8° ± 6.1°, p = 0.313). Mean postoperative femoral antetorsion angles were 23.0° ± 5.5° in short-stem and 13.5° ± 7.1° in conventional-stem hips. Short-stem hips had a small but nonsignificant difference in femoral antetorsion angles pre- and post-operatively (1.8° ± 3.2°, p = 0.109), while the difference for conventional-stem hips was much larger and highly significant (10.3° ± 5.8°, p < 0.001). Calcar-guided short-stem THA effectively restores femoral antetorsion. However, how this affects long-term clinical outcomes and complications warrants further exploration.

Single or Double Plating for Acromial Type III Fractures: Biomechanical Comparison of Load to Failure and Fragment Motion

Background: Acromial Levy III fractures after inverse shoulder arthroplasty occur in up to 7% of patients. To date, it is not clear how these fractures should be treated as clinical outcomes remain unsatisfactory. The aim of this study was to evaluate the biomechanical performance of three different plating methods of type III acromion fractures. Methods: Levy III fractures in synthetic scapulae were fixed with three different methods. Angular stable locking plates were placed on the spina scapula to bridge the fracture either dorsally, caudally, or on both aspects by double plating. In a biomechanical experiment, the pull of the deltoid muscle at 40° abduction of the arm was simulated by cyclic loading with increasing load levels until failure. Failure load, cycles to failure, and fragment motions were evaluated. Results: The results showed that double plating (350 ± 63 N) withstood the highest loads until failure, followed by dorsal (292 ± 20 N) and caudal (217 ± 49 N) plating. Similarly, double plating showed significantly smaller fragment movement than the other two groups. Conclusions: Double plating appeared to provide the largest biomechanical stability in type III acromion fracture under arm abduction. Caudal plating in contract resulted in insufficient fracture stability and early failure and can thus not be recommended from a biomechanical point of view.

The Patellar Instability Probability Calculator: A Multivariate-Based Model to Predict the Individual Risk of Recurrent Lateral Patellar Dislocation

BACKGROUND

Predicting the risk of recurrence is of great interest when counseling patients after primary lateral patellar dislocation (LPD).

PURPOSE

To investigate a multivariate model to predict the individual risk of recurrent LPD.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

The study population included patients with primary LPD, knee imaging, and a minimum 2-year follow-up after nonoperative treatment. Data including patient characteristics and anatomic patellar instability risk factors were collected retrospectively from 7 national study centers. Bivariate and multivariate regression analyses were carried out to identify risk factors for recurrent LPD and to generate an accuracy-optimized model for out-of-sample prediction.

RESULTS

In total, 115 of 201 patients (57%) experienced recurrent LPD within 2 years after primary LPD. Age ≤16 years at primary LPD (odds ratio [OR], 5.0), history of contralateral instability (OR, 2.4), and trochlear dysplasia (Dejour type B-D: OR, 2.5; lateral trochlear inclination ≤12°: OR, 2.7) were significant risk factors for recurrent LPD (P < .05). The prediction accuracy including these 3 risk factors was 79%. Patella alta, an increased tibial tubercle to trochlear groove distance, and patellar tilt had neither an association with increased recurrence rates nor an influence on prediction accuracy of recurrent LPD.

CONCLUSION

Young age and trochlear dysplasia are major risk factors for early recurrent LPD. A multivariate model including age at primary LPD, lateral trochlear inclination, and history of contralateral LPD achieved the highest prediction accuracy. Based on these findings, the patellar instability probability calculator is proposed to estimate the individual risk of early recurrence when counseling patients after primary LPD.

Functional and Radiological Outcomes after Treatment with Custom-Made Glenoid Components in Revision Reverse Shoulder Arthroplasty

Glenoid implant position and fixation are challenging in severe glenoid defects in reverse total shoulder arthroplasty (rTSA). Custom-made glenoid implants are metal augmented implants that are specially produced for a certain defect. They provide the restoration of the joint line and proper fixation. This retrospective data analysis investigated the clinical and radiological outcomes after revision using custom-made glenoid implants. Between 2018 and 2020, nine patients (10 shoulders) with severe glenoid defects underwent revision rTSA using a custom-made glenoid implant (Materialise Glenius or Lima ProMade). The pre- and postoperative Constant Murley Score (CMS), UCLA Score and Subjective Shoulder Value (SSV) were assessed. Postoperative CT scans and X-rays in two planes were available. The minimum follow-up was 12 months, with a mean follow-up of 23.1 months. The mean preoperative CMS, UCLA Score and SSV were 10.9, 4.1 and 11.0, respectively. The mean postoperative CMS, UCLA Score and SSV showed significant increases of 51.7 (<0.001), 22.9 (<0.001) and 52.0 (<0.001), respectively. There were no signs of loosening implants or scapular notching, and no revision was necessary. This trial showed promising clinical and radiological short-term outcomes for custom-made glenoid components in revision rTSA.

Muscle volume imbalance may be associated with static posterior humeral head subluxation

BACKGROUND

The transverse force couple (TFC) of the rotator cuff (subscapularis vs. infraspinatus and teres minor muscle) is an important dynamic stabilizer of the shoulder joint in the anterior-posterior direction. In patients with posterior static subluxation of the humeral head (PSSH), decentration of the humeral head posteriorly occurs, which is associated with premature arthritis. We hypothesize that not only pathologic glenoid retroversion but also chronic muscle volume imbalance in the transverse force couple leads to PSSH.

METHODS

A retrospective analysis of the TFC muscle volumes of 9 patients with symptomatic, atraumatic PSSH, within 8 were treated with glenoid correction osteotomy, was conducted. The imaging data (CT) of 9 patients/10 shoulders of the full scapula and shoulder were analyzed, and the muscle volumes of the subscapularis (SSC), infraspinatus (ISP) and teres minor muscles (TMM) were measured by manually marking the muscle contours on transverse slices and calculating the volume from software. Furthermore, the glenoid retroversion and glenohumeral distance were measured.

RESULTS

The mean glenoid retroversion was - 16° (- 7° to - 31°). The observed mean glenohumeral distance was 4.0 mm (0 to 6.8 mm). Our study population showed a significant muscle volume imbalance between the subscapularis muscle and the infraspinatus and teres minor muscles (192 vs. 170 ml; p = 0.005). There was no significant correlation between the subscapularis muscle volume and the glenohumeral distance (r = 0.068), (p = 0.872).

CONCLUSION

The muscle volume of the SSC in patients with PSSH was significantly higher than the muscle volume of the posterior force couple (ISP and TMM). This novel finding, albeit in a small series of patients, may support the theory that transverse force couple imbalance is associated with PSSH.

LEVEL OF EVIDENCE

Level 4 - Case series with no comparison group.

Functional and radiological outcomes after treatment with custom-made acetabular components in patients with Paprosky type 3 acetabular defects: short-term results

Background

Severe acetabular defects require special treatment with either impaction bone grafting, metal augmented cups or cup-cage constructs. Even these options are often not adequate, especially in hips with Paprosky type 3 defects with loss of anterior and posterior columns. This study investigates the clinical and radiological outcomes of custom-made acetabular components (© Materialise NV, Leuven, Belgium) for Paprosky type 3 defects.

Methods

Sixteen patients were eligible for this trial, nine of whom agreed to be included. All of them completed one year of follow-up. The Harris hip score and the Oxford hip score were used to compare pre- and postoperative functional outcomes. Radiological follow-up comprised anteversion and inclination of the implanted cup and offset measurements in both hips (femoral, medial, ischial offset and center of rotation). Statistical analyses were performed with IBM SPSS Statistics.

Results

The mean follow-up time of the nine patients was 12.2 months (range: 10–18). The Oxford hip score and Harris hip score improved from 19.8 and 50.1 to 29.4 and 68.8, respectively (p = 0.009 and 0.01). There were complications in three cases (33.3%), which led to one re-revision (11.1%). Radiologic follow-up showed restoration of the height of the center of rotation and of the global offset. Significant difference was detected in the femoral offset.

Conclusions

The functional and radiological outcomes are promising. However, long-term outcomes still need to be examined.

Level of evidence

Therapeutic Level IV.

Clinical and radiological results after Internal Brace suture versus the all-inside reconstruction technique in anterior cruciate ligament tears 12 to 18 months after index surgery

BACKGROUND

 Anterior cruciate ligament (ACL) injury can lead to reduced function, meniscal lesions, and early joint degeneration. Preservation of a torn ACL using the Internal Brace technique might re-establish normal knee kinematics, avoid donor-site morbidity due to tendon harvesting, and potentially maintain proprioception of the knee.

METHODS

 Fifty subjects were recruited for this study between December 2015 and October 2016. Two groups of individuals who sustained a unilateral ACL rupture were included: those who underwent surgery with preservation of the injured ACL (Internal Brace technique; IB) and those who underwent ACL reconstruction using a hamstring tendon graft (all-inside technique; AI). Subjective self-administered scores were used: the German version of the IKDC Subjective Knee Form (International Knee Documentation Committee), the German version of the WOMAC (Western Ontario and McMaster Universities Arthritis Index), SF-36 (short form), the German version of the KOOS (Knee Osteoarthritis Outcome Score), and the German version of themodified Lysholm Score by Lysholm and Gillquist. Anterior tibial translation was assessed using the KT-1000 Arthrometer (KT-1000 Knee Ligament Arthrometer, MEDmetric Corp., San Diego, CA, USA). Magnetic resonance evaluation was performed in all cases.

RESULTS

 Twenty-three subjects (46 %) were men, and the mean age was 34.7 years. The objective IKDC scores were "normal" in 15 and 14 patients, "nearly normal" in 11 and 7 patients, and "abnormal" in 1 and 2 patients, in the IB and AI groups, respectively. KT-1000 assessment showed a sideto-side difference of more than 3 mm on maximum manual testing in 11 (44 %) and 6 subjects (28.6 %) in the IB and AI groups, respectively. In the postoperative MRI, 20 (74 %) and 22 subjects (96 %) in the IB and AI groups had an intact ACL. Anterior tibial translation was significantly higher in the IB group compared with the AI group in the manual maximum test.

CONCLUSIONS

 Preservation of the native ACL with the Internal Brace primary repair technique can achieve comparable results to ACL reconstruction using Hamstring autografts over a short term. Clinically relevant limitations such as a higher incidence of pathologic laxity, with patients more prone to pivot-shift phenomenon were observed during the study period.

Minimally invasive surgery for intra-articular calcaneus fractures: a 9-year, single-center, retrospective study of a standardized technique using a 2-point distractor

BACKGROUND

A fracture of the calcaneus can be a painful and disabling injury. Treatment modalities may be conservative or operative. Surgical treatment strategies include open reduction and internal fixation (ORIF) techniques, as well as a variety of minimally invasive methods. The aim of this study was to evaluate the treatment options and post-treatment complication rates for intra-articular calcaneal fractures at the Traumacenter Linz over a 9-year period.

METHODS

All patients with calcaneal fractures treated at the Traumacenter Linz between 2007 and 2015 were included in this study. The patients records were retrospectively reviewed, and the data, including demographic parameters, cause of injury, and the time between injury and operative treatment were analyzed. The number of secondary operative interventions due to soft-tissue complications, hardware removal, and the long-term arthrodesis rate were evaluated.

RESULTS

A minimally invasive 2-point-distractor method was used in 85.8% (n = 182) of all operatively managed calcaneal fractures (n = 212) in our department. The majority of the operations (88.7%) were performed within 2 days after the accident. The secondary operation rate resulting from wound complications was 2.7% in the 2-point distractor group and 16.7% in the ORIF group. A secondary arthrodesis was performed in 4.7% (n = 9) of the subtalar joints in the entire study population.

CONCLUSIONS

Our data supported the assumption that severe wound complications would be less likely to occur after minimally invasive treatment compared to ORIF treatment. The rate of secondary arthrodesis in the study cohort was comparable to that in the literature.

LEVEL OF EVIDENCE

IV.

Peri-acetabular bone remodelling after uncemented total hip arthroplasty with monoblock press-fit cups: an observational study

Background

Bone stock preservation in total hip replacement is essential to allow for later revisions in an increasingly younger and fitter index patient population. While contemporary modular press-fit acetabular cups lead to rigid fixation with equatorial stress and central osteolysis, more elastic fixation may cause different peri-acetabular bone remodelling. The purpose of this study was to investigate changes in peri-acetabular bone mineral density (BMD) in uncemented elastic fixation with monoblock press-fit cups.

Methods

This prospective observational study included 45 patients with monoblock cups. We evaluated peri-acetabular BMD using dual-energy X-ray absorptiometry and reported functional outcomes and complications.

Results

At a mean follow-up of 24.2 ± 2.2 months, we found that BMD stabilised in DeLee and Charnley zones I and III and recovered to baseline value in zone II. The mean Harris Hip Scores improved significantly from 56.9 ± 20.0 to 97.2 ± 4.0 (p <  0001). Other than one peri-operative dislocation, we saw no post-operative complications.

Conclusions

We found favourable adaptive bone changes with BMD stabilisation in the equatorial zones and recovery to pre-operative values in the central zone. Additionally, excellent clinical outcomes and few prosthesis-related complications strengthened the favourable results of monoblock acetabular cups.

Trial registration

Registration number DRKS00017076.

Return to Sports after Anterior Cruciate Ligament Injury: a Matched-Pair Analysis of Repair with Internal Brace and Reconstruction Using Hamstring or Quadriceps Tendons

PURPOSE

 The purpose of this study was to evaluate sports activity before anterior cruciate ligament (ACL) injury and after surgical treatment of ACL rupture comparing ACL repair with an Internal Brace to ACL reconstruction using either a hamstring (HT) or quadriceps tendon (QT) autograft.

METHODS

 Between 12/2015 and 10/2016, we recruited 69 patients with a mean age of 33.4 years for a matched-pair analysis. Twenty-four patients who underwent Internal Brace reconstruction were matched according to age (± 5 years), gender, Tegner activity scale (± 1), BMI (± 1) and concomitant injuries with 25 patients who had undergone HT reconstruction and 20 patients who had undergone QT reconstruction. The minimum follow-up was 12 months.

RESULTS

 Overall, the return-to-sports rate was 91.3 %. There were no significant differences (p ≥ 0.05) in the number of sports disciplines and the time before return to sports within or among the groups. Overall and within the groups, the level of sports participation did not change significantly (p ≥ 0.05) postoperatively. The patients' sense of well-being was excellent after either ACL repair with an Internal Brace or ACL reconstruction with autologous HT or QT.

CONCLUSION

 At short-term follow-up, ACL repair using an Internal Brace enables sports activity and provides a sense of well-being similar to that of classic ACL reconstruction using hamstring or quadriceps tendon autografts in a selected patient population.

LEVEL OF EVIDENCE

Level III Retrospective comparative study.

Femoral bone remodeling after short-stem total hip arthroplasty: a prospective densitometric study

PURPOSE

Due to improved prosthesis designs and surgical techniques, indications for total hip arthroplasty (THA) now include younger and more active patients. Preserving bone stock and soft tissue in these patients is paramount to allow for future revision. Designed for anatomical reconstruction, short femoral stems have the potential to reduce adaptive bone loss and stress shielding. To confirm this, we evaluated bone remodeling around a short femoral stem and the accuracy of hip joint reconstruction.

METHODS

This prospective observational study involved 46 patients with short-stem THA for clinical and radiographic analysis. We evaluated bone remodeling by Gruen zone using dual-energy X-ray absorptiometry in 45 patients and assessed the accuracy of hip joint reconstruction using caput-collum-diaphyseal angles. Additionally, we reported functional scores and pain.

RESULTS

Patients were followed for a mean of 24.1 (SD 2.2) months. Bone mineral density increased mainly in the lateral region (Gruen zones 2 and 3) and in the distal-medial region (Gruen zone 5), suggestive of lateral loading. Most caput-collum-diaphyseal angles remained stable after surgery, especially in patients with varus hips. Harris Hip Scores improved significantly, from 57.2 (SD 20.0) pre-operatively to 97.2 (SD 4.0) at 24 months post-operatively (P < 0.0001). Finally, we encountered one peri-operative dislocation but no post-operative complications.

CONCLUSION

Short femoral stems successfully limited stress shielding and minimized periprosthetic bone loss without compromising primary stability. We were able to accurately reconstruct anatomical relationships in most patients. Finally, excellent clinical outcomes and low complication rates confirmed the favourable results of short-stem THA.

TRIAL REGISTRATION

DRKS00017076.

Return to Sport After Short-Stem Total Hip Arthroplasty

OBJECTIVES

Information about sport activity after short-stem total hip arthroplasty (THA) is scarce in the literature. We therefore aimed to evaluate the rate of return to sport after short-stem THA.

METHODS

We evaluated the sport pattern, rate of return to sport, activity level, extent of sport activity, and subjective rating and sense of well-being in 137 patients (137 hips) after short-stem THA. The minimum follow-up time was 18 months. All results were analyzed according to gender (male and female) and age (≤60, >60-≤70, and >70 years).

RESULTS

Ninety-two percent of all patients practiced sport before surgery, and 91% of the patients returned to sport. Most patients returned to sport within the first 6 months after surgery. There was a decline in the number of sport disciplines from preoperatively to postoperatively, which was from 2.9 to 2.6 (P = 0.025). High-impact activities decreased postoperatively, but most low-impact activities did not change significantly. Eighty percent of all patients were involved in recreational sports.

CONCLUSION

In this study, we observed an excellent rate of return to sport after short-stem THA. Most patients returned to the same level of sport activity that they had before the onset of restricting symptoms, with the majority of patients having a great sense of well-being during and after sports, and almost no pain in the affected hip.

Correction to: Sleep improvement after hip arthroplasty: a study on short-stem prosthesis

Authors first and last names have been interchanged. The correct presentation is given above.

Joint-preserving treatment for type 3 sequelae following fracture of the proximal humerus with small head fragments

BACKGROUND

Although nonunions of the proximal humerus are rare, they cause significant disability to patients. Surgical reconstruction is challenging, especially with small and excavated head fragments. A promising surgical option is open reduction and stabilization using the Humerusblock device along with tension wires. The aim of this retrospective investigation was to evaluate the clinical and radiological results of this procedure.

MATERIALS AND METHODS

Fifteen patients with symptomatic surgical neck nonunions were treated with open reduction and internal fixation using the Humerusblock device without bone grafting. All patients showed a loss of bone stock, leading to excavated head fragments. The mean interval from injury to the described treatment was 6.2 months (range, 3.4-10.7). At a mean follow-up of 40.5 months, the Constant-Murley score was documented, pain and patient satisfaction were evaluated using a visual analogue scale, and x-rays were taken in two planes.

RESULTS

The patients' mean age was 69.7 years (range, 52-83). The mean Constant-Murley score improved from 24 points before surgery to 62 points at follow-up, which was an average of 80.8% of the score obtained for the contralateral arm. Radiological examination confirmed bony healing in 14 patients. All but one patient felt satisfied with the results. Three patients required revision surgery because of a hematoma, and early metal removal was performed in one patient because of infection.

CONCLUSION

Nonunions of humeral surgical neck fractures can be successfully treated by fixation using the Humerusblock device along with tension wires without the need for additional bone grafting. Especially in patients with flat, concave head fragments, this procedure remains a promising reconstructive option to arthroplasty.

LEVEL OF EVIDENCE

Level IV; Therapeutic retrospective case series.

Quantitative in vivo assessment of bone allograft viability using 18F-fluoride PET/CT after glenoid augmentation in reverse shoulder arthroplasty: a pilot study

BACKGROUND

Success after glenoid bone augmentation in total shoulder arthroplasty depends on osseous integration and non-resorption. Standard imaging techniques, such as computed tomography (CT) and X-rays, cannot quantify bone viability. Therefore, we introduce a new technique to assess graft viability using ¹⁸F-sodium fluoride (¹⁸F-NaF) PET-CT for femoral allografts in reverse total shoulder arthroplasty (RSA).

MATERIALS AND METHODS

Patient charts were reviewed following glenoid augmentation using femoral allografts in reverse total shoulder arthroplasty. A total of seven patients were included in this study. ¹⁸F-NaF PET-CT was used to assess graft viability and graft fusion. Semiquantitative assessment of ¹⁸F-NaF uptake was performed by means of a standardized uptake value (SUV). Radiographs were used to assess fusion. The mean age of the patients at the time of follow-up was 83.4 years (range 79-92), and the mean follow-up was 44.4 months.

RESULTS

Viability and fusion were confirmed in all allografts using semiquantitative analysis of ¹⁸F-NaF PET-CT by means of standardized uptake value (SUVmax). Metabolic activity of medullary region of a vertebral spine was defined as a reference background. The mean value of maximum tracer activity in the allograft was not statistically different from native bone in the reference vertebrae (p = 0.14).

CONCLUSIONS

¹⁸F-NaF PET-CT is a practicable tool to quantitatively assess viability in large bone allografts after glenoid augmentation in RSA. The study shows viability and fusion in all allografts.

LEVEL OF EVIDENCE

Level IV, treatment study.

Minimal invasive plating of distal radius fractures. A safe procedure?

BACKGROUND

Minimal invasive plate osteosynthesis (MIPO) with preservation of the pronator quadratus (PQ) muscle represents a new technique for stabilization of distal radius fractures. However, the complex anatomy of the distal radius metaphysis requires implants with features that address all morphologic specifics of this area to avoid complications, which are still reported with this technique. It was the aim of our anatomic investigation to evaluate the feasibility of plate insertion via a minimal transverse approach as well as the risk of soft- tissues compromise with the use of an implant, which is only partially adapted to the characteristics of distal radius metaphysis.

METHODS

Twenty forearm specimens, conservated with Thiels method, have been used for this study. The majority (n = 19/20) of implants (2.4 mm small fragment juxta-articular locking compression/ LCP T-plate -5-hole; Depuy - Synthes^®, Solothurn, Switzerland) could be inserted easily and all were seated proximal to the so called "watershed line" (n = 20/20).

RESULTS

In a total of 8/20 specimens close contacts or potential compromise to neighboring soft- tissues was seen: perforation of the PQ muscle by the plate occurred in 2/20 specimens and was related to an extreme muscle morphology. In 7/20 specimens close contacts between the T-plate and other soft tissues were observed, which were exclusively located at the radial edge of the distal transverse bar. They affected the brachio-radialis tendon (elevation: 2/20, side-to-side contact: 3/20, overriding: 1/20) and the radial artery (elevation: 4/20, side-to-side contact: 2/20, overriding: 1/20). No significant differences of morphologic types of PQ muscle and the difficulty of plate insertion, adjustment on the bone, PQ muscle damage and contact to neighboring soft-tissues could be evaluated.

CONCLUSIONS

Insertion of volar radius plates through a MIPO approach can be easily accomplished without detachment and damage to the PQ muscle even with grossly adapted implants. However, perfectly pre-shaped plates which are adapted to all anatomic aspects of the distal radius metaphysis are required to achieve optimal contact with the metaphyseal bone and to avoid potential complications.

Diagnostic parameters in periprosthetic infections: the current state of the literature

Despite progress in recent years, a definitive diagnosis of PPI is not yet possible. Due to new diagnostic possibilities and the further development of already existing diagnostic tools, a more accurate diagnostic clarification of uncertain cases should be possible. The following article includes an overview of common existing diagnostic tools and instruments, which will likely gain importance in the future.

Reverse shoulder arthroplasty combined with latissimus dorsi transfer: A systemic review

Reverse shoulder arthroplasty (RSA) combined with latissimus dorsi transfer (LDT) is described for patients with cuff arthropathy and a combined loss of abduction and external rotation. The purpose of this systemic review was to present clinical and radiological outcomes following RSA combined with LDT. A comprehensive literature review was performed to identify studies reporting clinical and radiological results of RSA combined with LDT. Seven articles that describe the treatment of 116 patients were selected. Functional scores, range of motion, radiological outcome, complications, rehabilitation regime, surgical technique, patient demographics and indication were analyzed and discussed. All studies reported significant improvement in functional scores and abduction and external rotation. Complications occurred in 26% of patients. Although high-level studies are lacking, this systemic review shows that RSA combined with LDT is a reliable surgical method with which to treat patients with loss of active abduction and loss of external rotation. The available data are insufficient to draw conclusions regarding the long-term outcomes of this procedure.

LEVEL OF EVIDENCE

IV.

Posterior open wedge osteotomy of the scapula neck for the treatment of advanced shoulder osteoarthritis with posterior head migration in young patients

BACKGROUND

Treatment of young, active patients with symptomatic glenohumeral osteoarthritis, excessive glenoid retroversion, and static posterior humeral subluxation is challenging. Correction of glenoid retroversion may lead to centric loading and perhaps recenter the humeral head. We describe the functional and radiologic outcomes after corrective osteotomy of the glenoid in this population of patients.

MATERIALS AND METHODS

In this retrospective study, we included 10 shoulders (8 patients) that were observed for a mean of 33.4 months (range, 24-52 months) after corrective osteotomy of the glenoid. The mean age at surgery was 41.5 years (range, 24-51 years). On standardized axial images, glenoid retroversion and posterior static humeral subluxation were measured preoperatively and postoperatively and at the final follow-up. At final follow-up, anterior and posterior axial radiographs were performed to determine humeral head position in different arm positions. Clinical follow-up included Constant-Murley score, subjective shoulder value, and patient satisfaction.

RESULTS

The mean Constant-Murley score improved significantly from 45.1 points (range, 24-71) to 64.1 points (range, 44-92; P < .001). The average degree of anterior flexion improved significantly from 117° (range, 50°-160°) to 143° (range, 110°-180°; P = .006). The mean glenoid retroversion changed from 16° (range, 11°-31°) preoperatively to 5° (range, 13° anteversion-16° retroversion; P = .003) at the final follow-up. The mean posterior static subluxation of the humeral head changed from 5 mm (range, 0-10 mm) preoperatively to 6 mm (range, 0-14 mm; P = .259) at the final follow-up.

CONCLUSIONS

This study shows that posterior open wedge osteotomy of the glenoid neck provides excellent correction of glenoid retroversion.

Long-term outcome following upper extremity replantation after major traumatic amputation

Background

Amputations in general and amputations of upper extremities, in particular, have a major impact on patients’ lives. There are only a few long-term follow-up reports of patients after macro-replantation. We present our findings in contrast with the existing literature.

Methods

Sixteen patients with traumatic macro-amputation of an upper extremity were eligible for inclusion in this study. Altogether, the patients underwent replantation in 3 institutions between 1983 and 2011.

Results

Twelve male and four female patients with an average age at injury of 40.6 years (range, 14–61 years) were included in this study. The mean follow-up period was 13.5 years (range, 4.4–32.6 years; SD, 5.7 years). The mean disabilities of the arm, shoulder and hand (DASH) outcome measure was 41 (range, 5.2–94.8; SD, 18.2), functional independence measurement (FIM) was 125 (range, 120–126; SD, 1.8). Chen I representing very good function was accounted in six, Chen II representing good function in eight, Chen III (fair) in one and Chen IV (bad function) in one patient.

Conclusions

We found that while the majority of the included patients exhibited good or very good function of the extremity, none of the replanted appendages regained normal levels of functionality. In addition, all participants were very satisfied with their outcomes. Positive long-term results with high rates of subjective satisfaction are possible after replantation of upper extremities.

Blood loss and transfusion rate in short stem hip arthroplasty. A comparative study

PURPOSE

Little scientific evidence on blood loss and transfusion rates after short-stem hip arthroplasty exists. The hypothesis of this study was that the blood loss and transfusion rate is lower in short stems compared to straight stems.

METHODS

We compared 124 patients who underwent total hip arthroplasty (THA) using a short-stem design (group 1) and 141 patients using a straight-stem design (group 2). All patients were operated on by the same surgeon, and both groups were similar in age, gender, affected side, body mass index, and ASA score.

RESULTS

The calculated blood loss was 1139 ml in group 1 and 1358 ml in group 2 (p < 0.001). The transfusion rate was 8% in group 1 and 15.6% in group 2 (p < 0.001). There was no significant difference between groups 1 and 2 regarding complications and operation time (p > 0.05).

CONCLUSION

Compared to patients after straight stem THA, both blood loss and blood transfusion rates were lower in patients after short stem THA.

Reverse shoulder arthroplasty after failed pectoralis major tendon transfer with a minimum follow-up of 5 years. A case series

BACKGROUND

Treatment strategies after failed pectoralis major tendon transfer (PMTT) are scarce in literature and no information is available for patients treated with reverse shoulder arthroplasty (RSA) for failed PMTT.

METHODS

We performed a retrospective outcome study of all patients who underwent revision with RSA after failed PMTT at our institution. From 1999 to 2009 we included 8 patients (8 shoulders). The minimum follow-up was 5 years with a mean follow-up time of 97 months (range, 64-134). Clinical and radiological evaluation comprised range of motion, Constant Murley score (CMS), Simple Shoulder Test (SST) as well as standard X-rays in 2 planes. Pain was measured using VAS pain scale. The patients were asked to rate their satisfaction at final follow-up.

RESULTS

All outcome measures improved significantly post-surgical compared to pre-surgical, including the CMS (17.8-62.8), SST (1.8-7.3) and VAS (7.1-1). Active abduction and anterior flexion improved significantly (p < .001) from 65.6° to 125° and from 62.5° to 136.3°, respectively. There were 2 complications. One patient sustained transient musculocutaneous nerve palsy that resolved completely after 5 months and one patient sustained postoperative hematoma and had to be revised 4 days after surgery. 4 (50%) patients rated their results as excellent and 4 (50%) rated them as good.

CONCLUSIONS

RSA is a good option for treating patients after failed pectoralis major tendon transfer. After a minimum follow-up of 5 years, functional outcome is good and patient satisfaction is high.

LEVEL OF EVIDENCE

Level IV, Case series, Treatment study.

Comparison between minimally invasive, percutaneous osteosynthesis and locking plate osteosynthesis in 3-and 4-part proximal humerus fractures

Background

The ideal method for the surgical treatment of proximal humeral fractures has not yet been found. We therefore conducted a retrospective matched-pair analysis and compared osteosynthesis with open reduction and internal fixation and that with an angular stable plate with minimally invasive, closed reduction, percutaneous fixation with the Humerusblock.

Methods

During a study period of 3 years, we matched 30 patients treated with angular stable plates (group 1) for age, gender, fracture type and handedness (dominant or nondominant) to 30 patients treated using the Humerusblock (group 2). At a minimal follow-up of 24 months, clinical evaluation included the Constant-Murley score, the UCLA score and the Simple Shoulder Test. Subjective pain was evaluated using the VAS pain scale. Patients were asked to rate their subjective satisfaction of final outcome as excellent, good, satisfied or dissatisfied.

Results

The mean CMS, UCLA score and SST differed significantly between groups 1 and 2 (60.9 vs 71.9, p < 0.01), (25.1 vs 29.5, p < 0.01) and (8.1 vs 9.4, p < 0.05), respectively. The VAS pain score was significantly lower in group 2 than in group 1 (1.2 vs 2.4; p < 0.01).

The mean abduction (109.7° vs 133.7°; p < 0.01) and anterior flexion (128.3° vs 145.7°; p < 0.01) were significantly worse in group 1. The mean operation time was significantly shorter in group 2 (117.3 vs 72.1, p < 0.01). Complications occurred in 30 % (group 1) and 23 % (group 2) of patients.

Conclusions

In this study, the functional outcome is superior in the Humerusblock group. However, the general outcome after surgical treatment of 3-and 4-part fractures is moderate, and the complication rate has to be considered, even though it can be lowered with the use of minimally invasive implants.

[Posttraumatic arthrosis of the glenohumeral joint. From partial resurfacing to reverse shoulder arthroplasty]

BACKGROUND

Arthroplasty of symptomatic sequelae after fractures of the proximal humerus is a demanding procedure for surgeons. Exact preoperative planning is crucial in order to achieve acceptable functional results.

OBJECTIVE

Discussion of preoperative considerations in planning the procedure and choosing the appropriate implant taking the osseous anatomy and surrounding soft tissue situation into consideration.

METHODS

Selective literature review and description of personal experience.

RESULTS

The geometry and consolidation status of bone fragments as well as the conditions of the surrounding soft tissue have to be taken into account and influence the choice of implant used. Insufficient planning will not only cause intraoperative technical problems but can also greatly influence the subjective patient assessment of the postoperative outcome. Unequal strain distribution can cause early loosening of components resulting in malfunctioning of the implant. In this respect, knowledge of the position and consolidation status of fractured tuberosities with respect to the humeral shaft is essential and allows an approximate estimation of the achievable outcome. This is taken into account by the classification of Boileau which can also help to decide on which type of implant to use. Because such cases are scarce, reported results in the literature are heterogeneous, which is discussed in this article.

CONCLUSION

Each case needs a thorough and individualized preoperative assessment along with exact planning and should therefore be reserved for experienced shoulder surgeons only.

Rupture of the spleen following thoracoscopic spine surgery in a patient with chronic pancreatitis

PURPOSE

To highlight the perioperative risk of intracapsular haematoma of the spleen or splenic ruptures during thoracoscopic spine surgery in patients with chronic pancreatitis.

METHODS

A 38-year-old patient with an L1 burst fracture (AO A3.3) underwent a standard thoracoscopic corpectomy and replacement of the vertebral body with an extendable vertebral body replacement 10 days after posterior instrumentation of T12-L2. In patients history chronic abusive alcoholism with related diseases such as pancreatitis, followed by hemipancreatectomy was found. Six hours after the surgery, the patient became hemodynamically unstable. An emergency CT scan revealed a splenic rupture. Emergent splenectomy was performed.

RESULTS

After surgical treatment of the L1 burst fracture, a rupture of the spleen was detected. An immediate splenectomy was performed. At the 18-month follow-up, an unchanged stable position of the cage was observed on CT.

CONCLUSIONS

Due to its proximity to the thoracolumbar junction, the spleen is vulnerable to injury during spine surgery. If the patient has undergone previous intra-abdominal operations or chronic inflammation of the pancreas is found, special care of the spleen during the operation is necessary.

Peripheral nerve blocks in shoulder arthroplasty: how do they influence complications and length of stay?

BACKGROUND

Regional anesthesia has proven to be a highly effective technique for pain control after total shoulder arthroplasty. However, concerns have been raised about the safety of upper-extremity nerve blocks, particularly with respect to the incidence of perioperative respiratory and neurologic complications, and little is known about their influence, if any, on length of stay after surgery.

QUESTIONS/PURPOSES

Using a large national cohort, we asked: (1) How frequently are upper-extremity peripheral nerve blocks added to general anesthesia in patients undergoing total shoulder arthroplasty? (2) Are there differences in the incidence of and adjusted risk for major perioperative complications and mortality between patients receiving general anesthesia with and without nerve blocks? And (3) does resource utilization (blood product transfusion, intensive care unit admission, length of stay) differ between groups?

METHODS

We searched a nationwide discharge database for patients undergoing total shoulder arthroplasty under general anesthesia with or without addition of a nerve block. Groups were compared with regard to demographics, comorbidities, major perioperative complications, and length of stay. Multivariable logistic regressions were performed to measure complications and resource use. A negative binomial regression was fitted to measure length of stay.

RESULTS

We identified 17,157 patients who underwent total shoulder arthroplasty between 2007 and 2011. Of those, approximately 21% received an upper-extremity peripheral nerve block in addition to general anesthesia. Patients receiving combined regional-general anesthesia had similar mean age (68.6 years [95% CI: 68.2-68.9 years] versus 69.1 years [95% CI: 68.9-69.3 years], p < 0.0043), a slightly lower mean Deyo (comorbidity) index (0.87 versus 0.93, p = 0.0052), and similar prevalence of individual comorbidities, compared to those patients receiving general anesthesia only. Addition of regional anesthesia was not associated with different odds ratios for complications, transfusion, and intensive care unit admission. Incident rates for length of stay were also similar between groups (incident rate ratio = 0.99; 95% CI: 0.97-1.02; p = 0.467) CONCLUSIONS: Addition of regional to general anesthesia was not associated with an increased complication profile or increased use of resources. In combination with improved pain control as known from previous research, regional anesthesia may represent a viable management option for shoulder arthroplasty. However, further research is necessary to better clarify the risk of neurologic complications.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Purtscher's retinopathy after intramedullary nailing of a femoral shaft fracture in a 20-year old healthy female - report of a rare case and review of the literature

Background

Purtscher’s retinopathy is a sight threatening, occlusive microvasculopathy associated with trauma, it is rarely reported after long bone fractures.

Case presentation

A 20-year-old female sustained a femoral shaft fracture (AO 32-A2.3) in a ski accident colliding with a snowgun and was treated with intramedullary nailing one hour after the accident. 14 hours after surgery the patient complained of loss of vision in both eyes and was therefore referred to a neurologist, furthermore an MRI scan of the brain was performed. Neither showed any pathological findings. The patient was finally transferred to an ophthalmology department. After slit lamp examination and funduscopy Purtscher’s retinopathy was diagnosed. Treatment was started right after diagnosis and 5 days after the onset of symptoms. The patient was administered intravenous haemo-rheologic therapy for five days as well as low molecular heparine in therapeutic dose and Vasonit® 400 mg bid orally.

At follow-up 4 weeks and 6 months later visual acuity had improved after 4 weeks before that exam. At final follow-up the symptoms had almost resolved completely and uncorrected visual acuity (UCVA) and best corrected visual acuity had improved from originally 0.25 decimal in both eyes to 0.8 decimal UCVA and BCVA in both eyes.

Conclusions

Patients suffering from perioperative loss of vision have to be referred for ophthalmological and neurological assessment as soon as possible. History of trauma and visual loss can point to the diagnosis of Purtscher’s retinopathy.

Reverse shoulder arthroplasty combined with latissimus dorsi transfer using the bone-chip technique

PURPOSE

Reverse shoulder arthroplasty (RSA) can restore active elevation in rotator-cuff-deficient shoulders. However, RSA cannot restore active external rotation. The combination of latissimus dorsi transfer with RSA has been reported to restore both active elevation and external rotation. We hypothesised that in the combined procedure, harvesting the latissimus dorsi with a small piece of bone, leads to good tendon integrity, low rupture rates and good clinical outcome.

METHODS

Between 2004 and 2010, 13 patients (13 shoulders) were treated with RSA in combination with latissimus dorsi transfer in a modified manner. The mean follow-up was 65.4 months, and the mean age at index surgery was 71.1 years. All patients had external rotation lag sign and positive hornblower's sign, as well as radiological signs of cuff-tear arthropathy (Hamada 3, 4 or 5) and fatty infiltration grade 3 according to Goutallier et al. on magnetic resonance imaging (MRI). The outcome measures included the Constant Murley Score, University of California-Los Angeles (UCLA) shoulder score, Simple Shoulder Test (SST), visual analogue scale (VAS) and the Activities of Daily Living Requiring External Rotation (ADLER) score. Tendon integrity was evaluated with dynamic ultrasound. All patients were asked at final follow-up to rate their satisfaction as excellent, good, satisfied or dissatisfied.

RESULTS

The overall mean Constant-Murley Shoulder Outcome Score (CMS) improved from 20.4 to 64.3 points (p < 0.001). Mean VAS pain score decreased from 6.8 to 1.1 (p < 0.001)., mean UCLA score improved from 7.9 to 26.4 (p < 0.001), mean SST score improved from 2.3 to 7.9 (p < 0.001) and mean postoperative ADLER score was 26 points. The average degree of abduction improved from 45° to 129° (p < 0.001), the average degree of anterior flexion improved from 55° to 138° (p < 0.001) and the average degree of external rotation improved from -16° to 21° (p < 0.001). Eight patients rated their results as very satisfied, three as satisfied and two as dissatisfied.

CONCLUSION

This modified technique, which avoids cutting the pectoralis major tendon and involves harvesting the tendon together with a small piece of bone, leads to good or even better functional results compared with the results reported in the literature, and also has high patient satisfaction and low failure rates.

Delta III reverse shoulder arthroplasty in the treatment of complex 3- and 4-part fractures of the proximal humerus: 6 to 42 months of follow up

Background

There is a growing tendency for complex proximal humerus fractures (PHF) in osteoporotic patients to be treated with reverse shoulder arthroplasty (RSA). It has been proposed that RSA has more benefits than other treatment options. The aim of our study was to investigate preoperative characteristics as well as clinical and radiological outcomes in patients with complex 3- or 4-part PHF who had undergone primary RSA.

Methods

Patients with a minimum follow-up of 6 months who had undergone a primary RSA after 3- or 4-part PHF in the period between 2008 and 2011 were eligible for the study. Clinical records, X-rays and CT-scans were investigated and a clinical examination was performed. Disabilities of the Arm, Shoulder and Hand (DASH) score and Constant-Murley score (CMS) were calculated. Sixteen patients were examined as part of the study. The mean follow-up was 20 months (range 6-42 months). According to Codman-Hertel classification we encountered 15 Hertel “12” and 1 Hertel “8” type fractures.

Results

Thirty-two patients (27 female – 84.4%) with a mean age of 72 years underwent operations to treat complex 3- and 4-part fractures of the proximal humerus. Sixteen patients were reexamined. In 14 cases the dominant upper extremity was on the right, in 2 cases it was on the left, in 6 cases the right side was affected and in 10 cases the left side was affected. The mean CMS was 54.8 (range 18-95) and the mean DASH was 37.5 (range 2.9-81). A trend was established between the CMS and dominance of the affected shoulder. The CMS was better if the affected shoulder was on the non-dominant side (p-value 0.051). No statistical difference was noted between age and clinical outcome.

Conclusions

Our mid-term follow-up shows satisfying results in terms of the treatment of severe displaced fractures in elderly patients with RSA. RSA can provide immediate relief and good shoulder function in elderly patients. Nevertheless, the question of longevity of these implants remains to be observed.

Initially unrecognised lunate dislocation as a cause of carpal tunnel syndrome

A patient was admitted reporting tingling pain and numbness in the right hand. Neurological examination--including nerve conduction studies--diagnosed carpal tunnel syndrome. Operative carpal tunnel release was performed without complications. Four months postoperatively the otherwise healthy patient presented again due to persistent complaints, although preoperative symptoms had improved. On this occasion, the patient reported loss of strength accompanied by rigidity in the wrist. Clinical examination showed some swelling adjacent to the operation wound. A postoperative ganglion cyst was suspected and a conservative treatment option--splinting the wrist--was chosen. Four weeks later the patient presented again with further swelling and increasing rigidity of the wrist. Surgical intervention was planned. Preoperative plain radiographs of the wrist revealed chronic palmar dislocation of the lunate to be the cause of the symptoms in our patient. Radiological signs of scapholunate advanced collapse arthritis (SLAC wrist) were also observed.