Autologous triceps tendon graft for LUCL reconstruction of the elbow: clinical outcome after 7.5 years.

PURPOSE: The objective of this study was to assess mid- to long-term functional outcomes in patients treated for symptomatic posterolateral instability of the elbow (PLRI) using an autologous ipsilateral triceps tendon as graft. METHODS: A total of 196 patients were treated with autologous triceps tendon graft for symptomatic PLRI at single orthopedic institution from 2006 to 2013. The surgical treatment contained arthroscopic instability testing, reconstruction of the lateral ulnar collateral ligament (LUCL) and harvesting autologous ipsilateral triceps tendon as graft. The follow-up outcomes included range of motion (ROM), pain measured on a visual analogue scale (VAS), Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES) and ultrasound to evaluate the integrity of the refixation of the common extensor. RESULTS: A total of 178 patients (female: 73; male: 105) were available for follow-up at a mean of 91 months (range 48-144). No patient reported pain at rest; VAS during activity was 1.8 (range 0-5). The ROM decreased slightly compared to preoperative measurements. Flexion decreased significantly from 135.4 to 131.1, though still within the functional arc of motion. All but 13 patients (8.5%) were clinically stable. However, only two patients received a revision of the LUCL reconstruction due to subjective instability. The mean MEPS in the final follow-up was 91.3 (range 73-100). The mean OES was 46.5 (range 39-48). Three patients reported a pain-free clicking of the elbow. No patient complained about donor site morbidity of the ipsilateral triceps tendon. Ultrasound evaluation showed integrity of the common extensors in all patients. CONCLUSIONS: LUCL reconstruction using the ipsilateral triceps tendon as graft shows good to excellent mid- to long-term results in the treatment of symptomatic posterolateral elbow joint instability with a low re-instability and complication rate.

Clinical and radiological outcomes of a stemless reverse shoulder implant: a two-year follow-up in 56 patients.

BACKGROUND: Since the introduction of stemless anatomic shoulder arthroplasty, many studies have been published on anatomic implants. For reverse stemless implants, however, there are only a few clinical follow-up studies available. The current clinical case series aims to present clinical and radiological outcomes of a new stemless reverse prosthesis system (Lima Shoulder Modular Replacement stemless). METHODS: We prospectively evaluated the outcome of 56 stemless total shoulder arthroplasties in 56 patients with a mean age of 61.2 years (46-76 years) at the time of implantation at a minimum follow-up of 24 months (range 24-41 months). All patients were physically and radiologically examined. Clinical outcomes were evaluated by using the Constant-Murley Score and the Subjective Shoulder Value. RESULTS: The mean Subjective Shoulder Value was 84.27% at the latest follow-up. Significant improvements from preoperative to latest follow-up were documented for Constant-Murley Score (34.9 pts to 74.43 pts, P < .001) and active range of motion (abduction 72° to 130°, flexion 36° to 138°, and external rotation 16°to 28°). There was one complete loosening of the humeral component without reoperation. Radiolucency lines were observed in anteroposterior or axial radiographs at the humeral component in 23% of the cases, most of them in anteroposterior view at the calcar region. Radiolucency line findings did not affect clinical outcomes. Major complications or revisions did not occur so far. CONCLUSION: At short-term follow-up, stemless reverse shoulder systems show comparable clinical and radiological outcomes compared to stemmed reverse implants in the literature.

Revision of a Stemless Anatomic Implant into a Stemless Reverse Implant.

INTRODUCTION: Stemless anatomic implants are the growing standard for solving osteoarthritis of the shoulder. If there are secondary rotator cuff insufficiency and the need to revise the implant into a reverse total shoulder, there is usually the option to revise it into a stemmed implant with losing the benefits of stemless implants. There are only a few stemless reverse implants available on the market. Usually, they are recommended as primary implants, but not for revision surgery. Case Report. A 61-year-old male with an indwelling anatomic stemless TESS (Total Evolutive Shoulder System, Zimmer Biomet, Warsaw, USA) implant presented in our clinic with growing pain and loss of range of motion. The TESS was implanted in 2007 as a hemishoulder arthroplasty. The X-ray was showing a stable implanted corolla with clearly growing protrusion of the glenoid. Because of the clinical presentation and the ultrasound investigation that showed only remnants of the supraspinatus and infraspinatus left, we decided that it is necessary to revise the stable implant in a reverse total shoulder arthroplasty. As the TESS was not designed to be convertible, it was clear that it has to be explanted. Due to the young age of the patient, we proposed an "off-label" change to a stemless reverse implant, e.g., the LIMA SMR stemless reverse prosthesis. A revision was possible without much bone loss, so the stemless reverse implant could be used. The clinical and radiological 2-year follow-up showed a good result. CONCLUSION: Stemless implants are well known for anatomic implants, rarely for reverse implants, and seldom used for revision into reverse stemless. This case report shows that it is possible to revise a stemless anatomic implant with a stemless reverse, as long as the rules for implantation are applicable.

Arthroscopically Assisted Stabilization of Chronic Acromioclavicular Joint Instability.

This video article demonstrates biological and synthetic acromioclavicular (AC) and coracoclavicular stabilization with use of a hamstring tendon graft and a low-profile TightRope implant (Arthrex). The low-profile TightRope reduces soft-tissue irritation due to knot stacks1. The tendon graft is wrapped around the clavicle and the coracoid to avoid weakening of the osseous structures as a result of clavicular and coracoidal tunnel placement2. Description: For this procedure, the patient is placed in the beach chair position. After establishing standard posterior, anteroinferior, and anterolateral (transtendinous) portals, the arthroscopic preparation of the coracoid base is performed. Next, transcoracoidal-transclavicular drilling is performed, and a nitinol suture passing wire is utilized to aid the placement of the TightRope later in the procedure. The graft passage around the clavicle and the coracoid is then set up by placing 2 additional nitinol suture passing wires. Following this, coracoclavicular stabilization is performed with use of the low-profile TightRope device, after which the graft is shuttled around the clavicle and the coracoid with the help of the passing wires. After the acromial drilling, the graft is shuttled laterally transacromially and subcutaneously back to the clavicle, completing the AC cerclage. Finally, the graft ends are sewn together under tension. The deltotrapezial fascia is closed above the graft, incorporating the tendon ends into the suture. Finally, the skin can be closed. Alternatives: In case of chronic AC joint injuries, many surgical stabilization techniques have been described. On the one hand there are rigid stabilization techniques like the hook-plate or temporary Kirschner wire fixation. On the other hand, there are dynamic stabilization techniques like the modified Weaver-Dunn procedure or solitary synthetic coracoclavicular reconstruction with use of pulley-like devices, with or without additional AC stabilization3. As for nonsurgical alternatives, physiotherapy with periscapular stabilization and muscle strengthening may be an option4. Rationale: For the treatment of chronic AC joint instability, many techniques5-9 have been described that utilized horizontal and vertical stabilization with a tendon graft combined with a synthetic pulley-like device. Usually, multiple transclavicular and transcoracoidal drill holes are utilized for the graft passage, which could weaken the bone and may result in postoperative fractures of the coracoid and clavicle10. Considering this, we present a modified technique that focuses on the optimization of the graft passage. In contrast to other aforementioned techniques, this procedure requires only 1 transcoracoidal-transclavicular tunnel for the TightRope and another transacromial tunnel for the passage of the AC cerclage. By forming a loop of the graft around the coracoid and the clavicle, the graft passage is managed without any additional coracoidal or clavicular drilling. Expected Outcomes: A dedicated study investigating the specific clinical and radiographic results of our technique will be part of future research. Because the biomechanical principle of reconstruction of our technique is very similar to the technique described by Kraus et al., we refer to their clinical and radiographic results regarding the expected outcome. As shown in the chart in the video, Kraus et al. demonstrated good clinical and radiographic results with their biologic and synthetic AC-stabilization technique at a median follow-up of 24 months. The outcomes measured in that study were the Constant score, Subjective Shoulder Value, AC Joint Instability Score, and Taft score. Patients were divided into 2 groups. Group 1 included patients with failed prior conservative treatment, and group 2 included those with failed prior surgical treatment. Overall, the authors report complete dynamic posterior translation in 1 patient and partial dynamic posterior translation in 5 patients. Although there was no notable enlargement of the TightRope drill hole, the authors of that study found a significant enlargement of the clavicular graft tunnels. However, the enlargement had no clinical relevance10. Important Tips: Utilize a low-profile TightRope device to minimize the risk of suture irritation from knot stacks.The tendon graft should be ≥24 cm in length. If the graft is too short, perform an end-to-end anastomosis of 2 grafts.Utilize an image intensifier to ensure correct drill hole placement and avoid damage to neurovascular structures.The graft passage around the clavicle and the coracoid can be dilated by hand with the use of differently sized drill bits.Incorporate the graft into fascial closure at the end of the procedure.

The Impact of Heterotopic Ossification on Self-Reported Outcomes After Total Hip Arthroplasty Using the Direct Anterior Approach.

BACKGROUND: Heterotopic ossification (HO) is a known finding after total hip arthroplasty (THA) that potentially affects clinical outcomes. The incidence of HO is related to various factors, including soft-tissue trauma, postoperative medication, surgical approach, and the surgeon's experience. Because use of the direct anterior approach (DAA) is gaining popularity, we aimed (1) to determine the incidence of HO after DAA-THA and (2) to evaluate the impact of HO on patient-reported outcomes (PROs). METHODS: We retrospectively reviewed 401 THAs (67 ± 10 years old, 210 men). The incidence and grade of HO were evaluated using the Brooker classification with anteroposterior and lateral radiographs. PROs were collected with use of the Oxford Hip Score (OHS) and the Core Outcome Measures Index (COMI)-Hip and were correlated with HO grades using generalized multiple regression models. RESULTS: The incidence of HO was 29.9% on the anteroposterior radiographic views (Brooker grade 1, 14.5%; grade 2, 11.1%; grade 3, 2.7%; and grade 4, 0.57%); the lateral radiographic views detected 9% additional HO when compared with the anteroposterior radiographs alone (Brooker grade 1, 8%, and grade 2, 1%). HO was more frequent in men. The American Society of Anesthesiologists (ASA) grade, age in women, and higher body mass index (BMI) in men were associated with higher HO grades. A transverse "bikini" incision was associated with a lower rate (4%) of Brooker grades 3 and 4 HO when compared with a longitudinal incision (12%). A Brooker grade of 0 to 3 HO did not impact outcomes. Only Brooker grade-4 HO was associated with significantly worse PROs; however, pain was not affected. CONCLUSIONS: Low-grade HO after DAA-THA is not uncommon, and its rate is underestimated when anteroposterior radiographic views are evaluated without lateral views. The risk factors for developing HO in our cohort were an ASA grade of >3, male sex (especially with a high BMI), older age in women, and use of longitudinal incisions. With use of the bikini incision, patients had lower rates of severe HO, but mostly senior surgeons with more experience performed their surgery. Age, ASA grade, experience level of the surgeon, and Brooker grade-4 HO all had a significant influence on PROs. Clinically important HO (Brooker grade 4) remains rare after DAA-THR. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Biological Augmentation With Subacromial Bursa in Arthroscopic Rotator Cuff Repair.

Rotator cuff tears can be associated with significant shoulder dysfunction and pain. Despite improved surgical techniques and new materials for rotator cuff reconstruction, there is no significant reduction in the re-rupture rate. Innovative approaches for enhanced tendon healing are required. The potential of biologically optimized tendon integration has probably been insufficiently explored so far. The existing practice of debridement might eliminate repair tissue and a major source of cells and blood vessels necessary for tendon healing. Biological augmentation may be an option to improve the healing process. The subacromial bursa is a highly proliferative tissue with mesenchymal stem cells capable of differentiating into various cell lines and is easily accessible during rotator cuff repair. We describe the technique of bursal augmentation in arthroscopic double-row SutureBridge repair of a posterosuperior rotator cuff tear with the aim of improving tendon-to-bone healing.