Reverse Shoulder Arthroplasty for the Treatment of 3 and 4- Part Fractures of the Humeral Head in the Elderly.

BACKGROUND: Proximal humeral fractures in elderly patients present with severe comminution and osteoporotic bone quality. Reverse shoulder arthroplasty has lately been proven beneficial in treating patients with complex proximal humeral fractures. The above technique is recommended and has better results in elderly than in younger individuals. METHODS: We performed a literature search in the databases Pubmed, Medline, EMBASE and Cochrane Library for published articles between 1970 and 2016 using the terms: proximal humerus fractures and reverse shoulder arthroplasty. RESULTS: Significant benefits with the use of reverse prosthesis, especially in patients older than 70 years with a proximal humeral fracture, include reduced rehabilitation time as well as conservation of a fixed fulcrum for deltoid action in case of rotator cuff failure. Compared with hemiarthroplasty and internal fixation, reverse prosthesis may be particularly useful and give superior outcomes in older patients, due to comminuted fractures in osteopenic bones. However, significant disadvantages of this technique are potential complications and a demanding learning curve.Therefore, trained surgeons should follow specific indications when applying the particular treatment of proximal humeral fractures and be familiar with the surgical technique. CONCLUSION: Although long-term results and randomized studies for reverse prosthesis are lacking, short and mid- term outcomes have given promising results encouraging more shoulder surgeons to use this type of prosthesis in proximal humeral fractures.

Rotator cuff repair: a biomechanical ex vivo ovine study.

The purpose of this study was to assess load to failure of sutures, suturing techniques, and suture anchors used in rotator cuff surgery in order to explore their weaknesses. Ten types of sutures (absorbable and nonabsorbable), four types of suturing techniques, and eight types of suture anchors (bioabsorbable and metallic) were tested. Material Testing Machine and attached load cell were used to test the biomaterials in ex vivo ovine tissues. The results show that the mean load to failure and stiffness were higher in nonabsorbable sutures. Massive cuff tear and modified Mason-Allen suturing techniques had higher failure strength and stiffness when compared to simple and mattress techniques, but there was no substantial difference between them. Metallic suture anchors had higher failure strength when compared to bioabsorbable ones. Often either in metallic or in bioabsorbable anchors, the eyelet fails first. The failure sequence in ovine tissues is found to be in the following order: simple and mattress suturing techniques, nonabsorbable sutures, massive cuff tear and modified Mason-Allen suturing techniques, bioabsorbable anchors, and metallic anchors. Thus, it is concluded that metallic anchors mounted with modern nonabsorbable sutures will fail last. If we use simple and mattress techniques, the tendon-suture level will fail first, but it will improve substantially using more sophisticated suturing techniques (massive cuff tear or modified Mason-Allen).

Genu Recurvatum Deformity in a Child due to Salter Harris Type V Fracture of the Proximal Tibial Physis Treated with High Tibial Dome Osteotomy.

Salter-Harris type V fracture is a very rare injury in the immature skeleton. In most cases, it remains undiagnosed and untreated. We report a case of genu recurvatum deformity in a 15-year-old boy caused by a Salter-Harris type V fracture of the proximal tibial physis. The initial X-ray did not reveal fracture. One year after injury, genu recurvatum deformity was detected associated with significant restriction of knee flexion and limp length discrepancy (2 cm) as well as medial and posterior instability of the joint. Further imaging studies revealed anterior bone bridge of the proximal tibial physis. The deformity was treated with a high tibial dome osteotomy combined with a tibial tubercle osteotomy stabilized with malleolar screws and a cast. Two years after surgery, the patient gained functional knee mobility without clinical instability. Firstly, this case highlights the importance of early identification of this rare lesion (Salter-Harris type V fracture) and, secondly, provides an alternative method of treatment for genu recurvatum deformity.

A giant scapular aneurysmal bone cyst in a child.

Aneurysmal bone cysts (ABCs) are rare benign bone tumours. Scapula is a very rare location, and the relative literature is sparse. The purpose of this study is to present a case of a giant aggressive scapular aneurysmal bone cyst in a child. A 7-year-old boy presented to our hospital with pain and a palpated mass on the right scapula. Imaging studies (radiographs computed tomography scintigraphy) were indicative of aneurysmal bone cyst. We performed curettage and bone grafting after the diagnosis was set by pathological examination through a posterior shoulder approach. Five years later, the patient has only residual signs of the lesion on radiographic control without signs of recurrence.

Lower limb deformity following proximal tibia physeal injury: long-term follow-up.

BACKGROUND: Proximal tibial physeal injuries are quite rare, but their complications can be of great importance. The purpose of this study was to evaluate the effect of this injury on the axis and length of a child's limb. MATERIALS AND METHODS: This study focused on 12 patients with proximal physeal injury of the tibia (8 boys and 4 girls; mean age at the time of injury: 8.9 years). Injuries were classified according to the Salter-Harris scheme into 5 types (type II--7 patients, type III--3 patients, type IV--1 patient, type V--1 patient). In 5 cases, a coexisting fracture of the injured limb was observed (fibular fracture--3 cases, intercondylar fracture--1 case, tibial tubercle fracture--1 case). Ten patients were treated conservatively and 2 patients underwent an operation. Seven of the 12 patients were available for long-term follow-up, with a mean duration of 14.4 years (11.2-22.0 years). RESULTS: Angular deformity was observed in 6 of the 7 patients, with a mean valgus deformity of 2.7°, within an average of 5.8 months after the injury. After 3 years of follow-up, complete remodeling was observed in all of those 6 cases (4 of the patients were treated conservatively and 2 underwent surgery). One patient developed 6 mm of tibial shortening. No functional limitation or pain was recorded in any of the patients during the follow-up. CONCLUSIONS: Injury to the proximal tibial epiphysis, while rare, may result in angular or length disturbance, regardless of the initial treatment (conservative or surgical). Parents should always be informed of this possibility, and long follow-up is indicated. Nevertheless, this type of injury rarely results in functional limitations.

Outcome of distal clavicular fracture separations and dislocations in immature skeleton.

BACKGROUND: There are only a few studies with long-term follow-up of distal clavicular injuries in children and their treatment is not clearly defined. The purpose of our study is to suggest a new classification system according to the fracture pattern and the degree of the displacement, to evaluate the long-term follow-up and also to propose an algorithm for treatment. METHODS: We conducted a retrospective study from 1983 to 2008. Seventy-five children and adolescents, age ranging from 3 to 16 years (46 >8 years), were treated in our department. We classified all these injuries into five groups according to the fracture pattern and into subgroups according to the displacement of the bony particles: greenstick fractures as group I, transverse fractures as group II, oblique fractures as group III (IIa and IIIa: undisplaced, IIb and IIIb: displaced), comminuted fractures as group IV and true dislocation of the acromioclavicular joint as group V. Sixty-three patients were treated conservatively, while 12 sustained surgical treatment. RESULTS: Fifty-nine patients were re-examined after 2-18 years. All the patients included in groups I, IIa and IIIa had no loss in the motion of their shoulder. Seven of the 29 patients in groups IIb, IIIb, IV and V appeared to have minor loss of motion. A constant score was noted in 52 patients and the results were excellent. None of the patients complained of limitations in daily activities, while five patients, who were treated conservatively, complained of visible prominence at the fracture site. One of them had a clavicular duplication, while another patient treated surgically complicated with coracoclavicular synostosis. CONCLUSION: The aforementioned proposed classification of these injuries is based on the fracture pattern and is simple, leading to decision making concerning therapy of these injuries. The functional results after a distal clavicle fracture will be excellent, either after conservative or surgical treatment. Older patients (>8 years) from groups IIb, IIIb, IV and V, with greater displacement, could be treated surgically to have better cosmetic results.

A rare case of traumatic bilateral fibular head fractures.

Avulsion fibular head fractures are rare. There is only one reference of bilateral fibular fractures after epileptic seizure. We aim to present the mechanism and the treatment of this rare injury. We present the case of a 30-year-old woman who was hit by a car on the anteromedial side of both knees. Clinical and radiographic control showed bilateral fibular head fractures. Knee instability was not found at both knees and MRI did not show any concomitant ligament ruptures. Bone bruises of both medial condyles found in MRI explain the mechanism of this injury. The patient was treated conservatively with functional knee braces for 6 weeks allowing full range of motion, but otherwise mobilised as normal without any support. Six weeks after the trauma, there were no symptoms while the fractures sites had united completely after 6 months. One year postinjury the patient was free from symptoms.

Management of distal clavicle fractures.

Management of type II distal clavicle fractures has always been a challenge. Non-operative treatment has a high risk of complications and should be considered only for elderly and frail patients. For younger and active patients there is a wide variety of operative options, each with advantages and disadvantages. According to our unit's experience the first choice could be hook plate fixation, with very good and reproducible results. Another option could be Kirschner-wire fixation with or without tension band wiring; however, because of potential wire complications or difficulties in rehabilitation, the method should be reserved for reliable patients and used with a meticulous technique.

Long-term follow-up of combined fractures of the proximal radius and ulna during childhood.

Forty-five children with combined fractures of the proximal end of the radius and ulna were treated in our orthopedic department over a period of 16 years (1984-1999). The age of the patients ranged from 5 to 12 years (mean 8 years) with a peak of 7-8 years. The mechanism of injury was a fall on the outstretched hand with the elbow extended and with a valgus force being applied to the elbow. In 35 patients, closed reduction or immobilization in plaster, or both, were performed. In the other 10 patients, a surgical treatment was followed either for fractures of the radius (4) or for both the radius and ulna (6). The follow-up period ranged from 4 to 20 years (mean 12 years 3 months). The functional results were satisfactory in most cases despite the poor radiological appearance of some of them. In three patients we found a notable restriction, mainly in forearm pronation-supination and less in elbow flexion-extension, because of upper radioulnar joint synostosis. Poor results related with initial damages at the time of injury and the age of the patient (> 10 years) rather than with the way of treatment. Valgus deformity, restriction in flexion-extension, and pronation-supination were related with the extent of the initial injury but not related with the way of treatment. Overgrowth of the radial head, which had minor impact mainly on the pronation-supination, was found in the majority of cases that underwent surgical treatment. Minor residual abnormalities of the radius, ulna, or both were present without having marked functional influence.

The effect of proximal tibial fractures on the limb axis in children.

Between 1985 and 2002 we treated 38 children with 39 fractures of the proximal tibia. Fractures affecting the proximal tibial physis were excluded from this study. Mean age at the time of injury was 7.1 years (range: 2.5 to 14). Conservative treatment was followed in 34 cases and four patients underwent surgery. We examined 31 children with 32 fractures followed up for an average of 4.8 years (range: 16 months to 15 years). Twenty eight (90.3%) patients developed post-traumatic tibia valga. Deformities were observed at an average 5.3 months after injury. All the cases with fractures of the medial cortex developed valgus angulation. The mean valgus angular deformity was 5.5 degrees. There was also an average of 5.31 mm limb lengthening in 27 patients. Eleven patients with an angulation >5 degrees were reevaluated at an average of 7.4 years from the initial injury. Partial remodelling was observed in 6 patients (54.5%) and total remodelling in 3 (25%). We recommend that children with proximal metaphyseal tibial fractures should be initially treated conservatively and followed up during skeletal development, because valgus deformity tends to remodel with age.

Late-presenting developmental dysplasia of the hip treated with the modified Hoffmann-Daimler functional method.

BACKGROUND: The general consensus is that nonoperative treatment of developmental dysplasia of the hip should not be attempted for patients in whom previous treatment of the disease has failed, those in whom the disease was neglected, or those in whom the disease presented late. In such cases, it is believed that the optimum period for hip remodeling has passed and that operative methods are preferable. The purpose of the present study was to report the efficacy of a modified form of the Hoffmann-Daimler method for the treatment of late-presenting developmental dysplasia of the hip. MATERIALS: We retrospectively reviewed the records of sixty-nine patients (ninety-five hips) with neglected developmental dysplasia of the hip who had been managed nonoperatively with a modification of the Hoffmann-Daimler method from 1971 to 2000. With this method, the patient wears a flexion harness (Phase A), during which time the femoral head is gradually reduced, followed by an abduction splint (Phase B), during which time the reduced hip remodels. We have modified the original method by introducing new treatment strategies. The study group included nine boys and sixty girls. The average age of the patients was sixteen months (range, six to forty-four months) at the start of treatment and 11.5 years (range, six to twenty-nine years) at the time of the latest follow-up. Radiographs were assessed to determine the acetabular index, the Severin classification, and the presence of evidence of osteonecrosis of the proximal femoral epiphysis. Hips that were rated as Severin class I or class II were classified as satisfactory, whereas those that were rated as Severin class III or class IV were classified as unsatisfactory. RESULTS: On the basis of the most recent follow-up radiographs, eighty-eight (93%) of the dislocated hips were classified as satisfactory (sixty-seven were rated as Severin class I and twenty-one were rated as Severin class II) and seven were classified as unsatisfactory (six were rated as Severin class III and one was rated as Severin class IV). No hip was rated as Severin class V or VI. The average acetabular index was 40 degrees +/- 7.4 degrees prior to the onset of treatment and 24 degrees +/- 5.7 degrees at the end of treatment. No redislocations or other complications were noted. Osteonecrosis was noted in six of the ninety-five hips. CONCLUSIONS: Late-presenting or neglected developmental dysplasia of the hip can be successfully treated with use of a modified Hoffmann-Daimler method. The high rate of successful reduction, the low prevalence of osteonecrosis and residual dysplasia, and the limited complications may make this modified method a safe alternative to surgical treatment. LEVEL OF EVIDENCE: Therapeutic Level IV.

Chronic osteomyelitis of the pelvis in children and adolescents.

Osteomyelitis of the pelvis is rare in children as well as in adults. This explains why the diagnosis is often missed, so that the infection becomes chronic. The authors report five chronic paediatric cases, seen between 1993 and 2003. The diagnosis was initially missed in two patients. In two others, the osteomyelitis was recognised but insufficiently treated, so that it also became chronic. The fifth patient developed exogenous osteomyelitis 6 months after an open pelvic fracture. The bone scan was useful for the differential diagnosis, but laboratory and radiographic findings were not. Treatment was the same for all patients, including wide surgical debridement, antibiotic therapy and prolonged immobilisation. Four patients were free of symptoms at the last clinical evaluation, after an average follow-up period of 7 years. Only one patient had a recurrence 3 months postoperatively and was re-operated. This study demonstrates that surgical treatment of chronic pelvic osteomyelitis in children and adolescents yields encouraging results.

Post-traumatic cystic lesion following fracture of the radius.

Post-traumatic cystic lesions are an uncommon complication of fractures in children. They are benign, asymptomatic, non-expansive and tend to resolve spontaneously. Their cause seems to be the invasion of bone-marrow fat by subperiosteal hematoma, which may be visible on radiographs during fracture consolidation of the newly formed subperiosteal bone. The case we present is of cyst formation following a fracture of the distal radius and we evaluate the role of yellow bone marrow in the pathogenesis of the cyst. Its typical features clear differentiation from other lesions, preventing unnecessary and, possibly, invasive examinations.