Infraspinatus function impairment after arthroscopic Bankart repair with Hill Sachs remplissage. Isokinetic, functional, and radiographic analysis.

PURPOSE: Arthroscopic Bankart repair with Hill Sachs remplissage (BHSR) is an option for anterior shoulder instability with humeral defect. Our hypothesis was that infraspinatus capsulo-tenodesis is an effective solution, with good clinical results and no consequences on shoulder strength and ranges of motion. METHODS: We performed a retrospective case-control study involving 22 patients operated with arthroscopic BHSR. We compared isokinetic evaluation of both shoulders using a dynanometer in concentric, eccentric force and endurance. Ranges of motion were measured using a goniometer and compared to the contralateral unaffected side. Functional assessment included Constant, Rowe, Walch and Duplay and WOSI scores. Healing and fatty degeneration were analyzed with magnetic resonance imaging. RESULTS: At mean 37.2 months follow-up, 21 patients (95.4%) were satisfied or very satisfied with the intervention. Range of motion in external rotation of the affected side decreased by 10.8° in adduction and 6° at 90° of abduction (p<0.05). Deficit in external rotation strength of the affected side greater than 15% was found in all isokinetic tests (p<0.05). Walch and Duplay, Rowe, WOSI and adjusted Constant average scores were respectively 71.05±14.1 (40-90), 67.63±19.7 (15-100), 34.6%±19.9 (8.43-76.23) and 69.8±13.57 (36.7-101). Postoperative MRI showed good capsulo-tenodesis healing without infraspinatus muscle fatty degeneration. CONCLUSION: Arthroscopic BHSR provides satisfactory functional outcomes but significant infraspinatus functional impairments in both strength and ranges of motion in external rotation. LEVEL OF EVIDENCE: III; case-control study.

Resumption of complete weight bearing after osteosynthesis of bimalleolar fractures using locking plates.

INTRODUCTION: Bimalleolar fractures represent 9% of fractures and affect 187/100,000 people per year. The gold standard for osteosynthesis is a one-third tubular or lateral locking plate and compression screwing or use of tension band wiring, with complete weight bearing planned around the 6th week. The development of locking plates seems to allow earlier resumption of weight bearing. The objective of our study was to evaluate the clinical and radiological results after internal fixation of bimalleolar fractures using locking plates with complete weight bearing authorized from the outset. The hypothesis was that this does not predispose to cutaneous or mechanical complications. HARDWARE AND METHOD: A continuous multi-operator retrospective study was performed. The clinical and radiological data of 55 patients operated on for bimalleolar fractures were collected. All underwent osteosynthesis with medial and lateral locking plates with authorization for weight bearing from the outset. RESULTS: Complete weight bearing was resumed at 27.4 days 14.7 [7-60] postoperatively. No non-union or malunion was found. Two patients presented with delayed medial healing without the need for hardware removal. Two patients required removal of the lateral Plate 1 month postoperatively due to infection. Seven patients presented with discomfort related to hardware, justifying its removal at 1 year. The Kitaoka score at 1 year was 94.6 7.7 [71-100]. CONCLUSION: The use of medial and lateral locking plates in bimalleolar fractures associated with complete weight bearing authorized from the outset allows complete consolidation. There was no increase in cutaneous or mechanical complications. LEVEL OF EVIDENCE: IV, retrospective study.

Surgical treatment of tibial metastases: Retrospective, multicenter, observational study of 25 patients.

INTRODUCTION: Long bone metastasis to the tibia is somewhat rare and has only been studied in a few publications with a limited number of cases. This led us to carry out a large multicenter, observational, retrospective study to 1) evaluate the clinical and radiological outcomes of surgical treatment at this location and 2) highlight the specific risks associated with this condition. HYPOTHESIS: We hypothesized that the clinical outcomes and survivorship were comparable to those reported in the literature. MATERIAL AND METHODS: The case series included 15 men and 10 women with a mean age of 66±11.7 years. The most common primary cancers were kidney (10 patients) and lung (4 patients). Thirteen patients had a concurrent visceral metastasis and sixteen had metastasis in another bone. The tibial metastasis was the initial sign of cancer in seven patients. The surgical procedure was done to prevent an impending fracture in 19 patients and to treat a pathological fracture in 6 patients (initial sign of cancer in 4 patients). Osteolysis occurred in the proximal epiphysis/metaphysis in 12 patients, diaphysis in 9 patients and distal epiphysis/metaphysis in 4 patients. We performed fixation with a lateral cortex plate and cementoplasty in 14 patients, locked intramedullary nailing in 8 patients, cementoplasty only in 2 patients and knee arthroplasty in 1 patient. RESULTS: Three surgical site infections, one pulmonary embolism and one cardiac rhythm disturbance occurred. Four patients died before the 3rd month postoperative. At their best clinical status, 2 patients had not resumed walking, 10 could walk short distances with two canes or a walker, 3 had altered gait but could walk without aids and 6 could walk normally. The mean survival was 14±11.7 months (95% CI: 8.1-19.8) for all patients, 4±4 months (95% CI: 3-14) for those with a lung primary and 32±14 months (95% CI: 20-47) for those with a kidney primary. The survival was 15 months (95% CI: 4-29) after preventative treatment and 5 months (95% CI: 4-26) after fracture treatment. CONCLUSION: Our clinical outcomes are comparable overall to the three main published articles on this topic. The risk of infection and benefits of preventative fixation were apparent in our cohort. LEVEL OF EVIDENCE: IV, retrospective study.

Sectioning of the Anterior Intermeniscal Ligament Changes Knee Loading Mechanics.

PURPOSE: The purpose of this cadaver research project was to describe the biomechanical consequences of anterior intermeniscal ligament (AIML) resection on menisci function under load conditions in full extension and 60° of flexion. METHODS: Ten unpaired fresh frozen cadaveric knees were dissected leaving the knee joint intact with its capsular and ligamentous attachments. The femur and tibia were sectioned 15 cm from the joint line and mounted onto the loading platform. A linear motion x-y table allows the tibial part of the joint to freely translate in the anterior-posterior direction. K-scan sensors were used to define contact area, contact pressure, and position of pressure center of application (PCOA). Two series of analysis were planned: before and after AIML resection, mechanical testing was performed with specimens in full extension (1,400 N load) and in 60° of flexion (700 N load) to approximate heel strike and foot impulsion during the gait. RESULTS: Sectioning of the AIML produced mechanical variations below the 2 menisci when specimens were at full extension and loaded to 1,400 N: increasing the mean contact pressure (delta 0.4 ± 0.2 MPa, +15% variation P = .008) and maximum contact pressure (delta 1.50 ± 0.8 MPa, 15% variation P < .0001) and decreasing of tibiofemoral contact area (delta 71 ± 51 mm2, -15% variation P < .0001) and PCOA (delta 2.1 ± 0.8 mm). At 60° flexion, significant differences regarding lateral meniscus mechanical parameters were observed before and after AIML resection: mean contact pressure increasing (delta 0.06 ± 0.1 MPa, +21% variation P = .001), maximal contact-pressure increasing (delta 0.17 ± 0.9 MPa, +28% variation P = .001), mean contact area decreasing (delta 1.84 ± 8 mm2, 4% variation P = .3), and PCOA displacement to the joint center (mean displacement 0.6 ± 0.5 mm). CONCLUSIONS: The section of the intermeniscal ligament leads to substantial changes in knee biomechanics, increasing femorotibial contact pressures, decreasing contact areas, and finally moving force center of application, which becomes more central inside the joint. CLINICAL RELEVANCE: AIML resection performed ex vivo in this study, might potentially be deleterious in vivo. Clinical studies focusing on preserving or even repairing the AIML are needed to evaluate those ex vivo elements.