Immobilization in external rotation after primary shoulder dislocation reduces the risk of recurrence in young patients. A randomized controlled trial.

INTRODUCTION: Patients that sustain anterior shoulder dislocation frequently experience recurrence. Immobilisation in external rotation has been proposed as a treatment that could lower this risk. HYPOTHESIS: There is a difference in recurrence rates between immobilization in internal or external rotation following a first-time anterior shoulder dislocation. PATIENTS AND METHODS: Single-center randomized controlled trial. Fifty patients with a first episode of traumatic anterior dislocation were randomly assigned to immobilization in internal rotation (IR; 25 patients) or external rotation (ER; 25 patients) for three weeks. Clinical follow-up: 24 months. Additionally, some patients underwent a magnetic resonance imaging with intra-articular contrast (MR arthrography) within seven days after trauma, and then at three months. PRIMARY OUTCOME: recurrence of dislocation. Secondary outcome: healing rate of labral lesions on MR arthrography. RESULTS: Follow-up rate in the IR and ER group was 92% and 96% respectively. Recurrence rate did not show a statistically significant difference overall (IR 47.8% vs. ER 29.2%; p=0.188), but showed a significant difference favouring ER in the 20-40 years subgroup (IR 50% vs. ER 6.4%; p=0.044). Labral lesions' healing rate was 46.2% vs. 60% (IR vs ER; p=0.680). The recurrence rate among those with healed vs. non-healed labrum (regardless of immobilization) was 11.1% vs. 77.7% (p=0.001). DISCUSSION: This study suggests that immobilization in ER compared to IR reduces the risk of recurrence after a first-time anterior shoulder dislocation in patients aged between 20 and 40 years. LEVEL OF EVIDENCE: II, low-powered prospective randomized trial.

Traumatic Rupture of an Intermediate Tendon in a Patient with Patellar Duplication.

Patellar duplication is a rare asymptomatic condition. The diagnosis is often made following a traumatic event associated with an injury to the knee extensor mechanism. The treatment is often surgical and consists in removal of the smaller part of the patella with tendon reinsertion. The presence and rupture of an intermediate tendon between the two parts of the patella have not been reported in the modern literature. We present a traumatic rupture of an intermediate tendon in a patient with horizontal patellar duplication. The surgical management consisted of tenorrhaphy protected with a figure-of-eight tension band wire approximating the two parts of the patella. The patient recovered full knee range of motion and quadriceps strength at the last 8-month follow-up.

Quadriceps muscle reconstruction with free functioning latissimus dorsi muscle flap after oncological resection.

INTRODUCTION: The concept of limb salvage led to increased demand for more complex and sophisticated reconstructive options to achieve better functional and cosmetic outcome. Reconstruction of the total or partial loss of quadriceps muscle after soft tissue sarcomas excision with free functioning latissimus dorsi muscle transfer had become more popular in the last years. PATIENTS AND METHODS: Between November 1993 and October 2004, 11 patients with average age 45.5 years underwent excision of quadriceps muscle followed by simultaneous reconstruction with free functioning latissimus dorsi muscle. There were six men and five women. The tumors were high grade in 90.9% of patients and were >10 cm in 81.8% of patients. The tumor extension required the resection of the entire quadriceps in four cases, of three heads in six cases, of only two heads in one case. RESULTS: The average follow up was 69 months. The average time of recovery of the contractile activity of the muscle was 8.3 months after operation. The musculoskeletal tumor society rating score (MTSRS) scored excellent or good in 73% of patients. Three patients (27.3%) died of metastatic disease. Local recurrence occurred in one patient (9.1%). Limb salvage was achieved in all the patients (100%). CONCLUSION: This method of reconstruction is a reliable technique not only to fill the defect resulting from oncological resection but also to provide better function. Microsurgical reconstruction of soft tissue sarcoma helps to expand the indications of limb salvage by allowing better local control and achieving adequate function and coverage.