Effect of tuberosity repair on functional outcome of reverse shoulder arthroplasty in proximal humerus fractures.

PURPOSE: Unsatisfactory results of hemiarthroplasty in Neer's 3- and 4-part proximal humerus fractures in elderly, have led to the shift towards reverse shoulder arthroplasty (RSA). The objective of our study was to repair the tuberosities that are generally overlooked during RSA and observe its impact on the functional outcome and shoulder scores. METHODS: We include elderly patients with acutely displaced or dislocated 3- or 4-part proximal humerus fractures from July 2013 to November 2019 who were treated with RSA along with tuberosity repair by non-absorbable sutures and bone grafting harvested from the humeral head. Open injuries and cases with neuro-muscular involvement of the deltoid muscle were excluded. According to the tuberosity healing on radiographs of the shoulder at 9th postoperative month, the patients were divided into 2 groups, as the group with successful tuberosity repair and the other with failed tuberosity repair. Statistical analysis of the functional outcome and shoulder scores between the 2 groups were done by independent t-test for normally distributed parameters and Mann-Whitney test for the parameters, where data was not normally distributed. RESULTS: Of 41 patients, tuberosity healing was achieved in 28 (68.3%) and failed in 13 (31.7%) cases. Lysis of the tuberosity occurred in 5 patients, tuberosity displacement in 2, and nonunion in 2. Mean age was 70.4 years (range 65 - 79 years) and mean follow-up was 58.7 months (range 18 - 93 months). There were no major complications. Group with successful tuberosity repair showed improvement in mean active range of movements, like anterior elevation (165.1° ± 4.9° vs. 144.6° ± 9.4°, p < 0.000), lateral elevation (158.9° ± 7.2° vs. 138.4° ± 9.6°, p < 0.000), external rotation (30.5° ± 6.9° vs. 35.0° ± 6.3°, p = 0.367), internal rotation (33.7° ± 7.5° vs. 32.6° ± 6.9°, p = 0.671) and in mean shoulder scores including Constant score (70.7 ± 4.1 vs. 55.5 ± 5.7, p < 0.000), American shoulder and elbow surgeons score (90.3 ± 2.4 vs. 69.0 ± 5.7, p < 0.000), disability of arm shoulder and hand score (22.1 ± 2.3 vs. 37.6 ± 2.6, p < 0.000). CONCLUSION: Successful repair and tuberosity healing around the RSA prosthesis is associated with statistically significant improvement in postoperative range of motion, strength and shoulder scores. Standardized repair technique and interposition of cancellous bone grafts, harvested from the humeral head can improve the rate of tuberosity healing.

Exposed versus buried K-wire fixation in paediatric lateral condyle humerus fractures: preliminary communication of a prospective comparative study.

Buried Kirschner's wires (K-wires) following internal fixation of paediatric Lateral condyle fracture of humerus allow them to hold the bone until radiological consolidation but requires another surgical procedure for implant removal. Exposed wires need meticulous pin tract care, earlier implant removal and may carry a higher risk of infection. The objective of this study was to compare the outcomes of buried versus exposed K-wires for these fractures. This prospective comparative(nonrandomised) study was conducted from July 2016 to April 2020 at a tertiary care level I trauma centre on 80 children, <12 years of age, divided into group 1(n = 40), where K-wires were left exposed, and group 2 (n = 40), where K-wires were buried. Functional outcome and complications were compared between the two groups with at least 3 months follow-up. Infection rate was significantly lower in buried K-wire group with 7 patients (17.5%) compared to 15 (37.5%) in exposed group, P = 0.045. Four out of those 15 patients needed debridement suggesting that exposed K-wires carry a higher risk of bone infection and subsequent morbidities. There was no significant difference in union time, range of motion (mean flexion 135.3° in exposed vs. 132.5° in buried, P = 0.988), carrying angle (8.5° vs. 8.6°, P = 0.981), or lateral condyle hypertrophy; 12 (30%) vs. 9 (22.5%), P = 0.446. Skin pigmentation was more in the exposed group; 13 (32.5%) vs. 10 (25%), P = 0.459. We recommend that K-wires should be buried subcutaneously, particularly when meticulous pin tract care is doubtful.

A Newer Technique of Extended Cortical Fixation to Salvage Intratunnel Blowout during Revision Anterior Cruciate Ligament Reconstruction - A Case Report.

INTRODUCTION: Posterior femur wall blowout and consequent loss of femoral graft fixation are commonly encountered distally at the aperture of the tunnel facing into the joint during anterior cruciate ligament (ACL) reconstruction. However, intratunnel blowout of femoral tunnel at its outer cortical opening during a revision ACL reconstruction is very rare. It compromises the mechanical strength of the cortical bone at the tunnel opening on lateral cortex, making it weaker for providing stability to endobutton. We report this very rare event of intratunnel blowout of femoral tunnel at its proximal opening on the lateral femoral cortex during a revision ACL reconstruction, where the patient was treated with a modification in the suspensory fixation technique using a suture disc. CASE REPORT: Two years following a primary ACL reconstruction, our patient presented with a lax knee. Radiography and magnetic resonance imaging images showed malpositioning of femoral endobutton, lax, and degenerated autograft. During revision, we encountered intratunnel blowout at outer opening on lateral femoral cortex. It was rescued with a modification in the suspensory fixation technique by tying the endobutton with a suture-disc, placed directly over the proximal opening of femoral tunnel on lateral cortex. CONCLUSION: Our case report highlights, this rare critical surgical event during revision ACL reconstruction managed successfully with a suture disc, which is cost-effective, readily available and using the same prepared graft within a lesser operative time. Functional outcome was excellent and usage of a suture disc.

Role of percutaneous transpedicular biopsy in diagnosis of spinal tuberculosis and its correlation with the clinico-radiological features.

INTRODUCTION: Tuberculosis (TB) has long been an important cause of destructive lesions of spine in India. However the scenario is fast changing with atypical presentations and increasing reports of non-tubercular conditions. This poses a great diagnostic dilemma. AIM: The present study is aimed at evaluating the diagnostic efficacy of percutaneous transpedicular needle biopsy and the correlation of the histology with clinico-radiological features. METHODS: Forty-one patients diagnosed of TB spine by magnetic resonance imaging (MRI) were revaluated of their clinical presentations, radiological and MRI features and underwent transpedicular needle biopsy under fluoroscopic guidance. Quality of the sample and radiological/MRI features between the tubercular and non-tubercular lesions were studied. RESULTS: A good sample obtained in 92.7% patients. Of these 28 patients had TB, 3 non-specific inflammatory lesion and 7 with other non-tubercular conditions (3 pyogenic, 3 metastasis, 1 multiple myeloma). Statistically there is no significant difference among the TB and non-TB groups in terms of vertebral involvement and MRI features. However risk of presentation with cord compression, cord changes and neurodeficit are higher with TB spine. CONCLUSION: It is very difficult to differentiate between tubercular and non-tubercular pathology of spine on the basis of most of the clinical and MRI features. It is more difficult in early cases without any neurodeficit. Thus histopathological confirmation is must for further management and percutaneous needle biopsy is the best option considering the simplicity and minimally invasive nature of the procedure.

Significance of Vertebral Endplate Failure in Symptomatic Lumbar Disc Herniation.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: Endplate lesions though have been implicated in the genesis of lumbar disc herniation (LDH), very little is known regarding their clinical course. Thus, the present study is aimed to investigate the incidence and types of endplate failure (EPF) in LDH and its correlation with the clinical symptoms and prognosis. METHODS: Clinical and magnetic resonance imaging (MRI) features of 66 patients with isolated single level LDH were studied. Three-dimensional fast spoiled gradient (3D FSPGR) MRI and computed tomography scans were used to identify the bony and cartilaginous EPF. Twenty-five patients were operated on and 41 patients were treated conservatively. Changes in the pain score, function and neurology were noted at 3, 6, 12, 24, and 36 weeks. RESULTS: Endplate lesions were observed in 64 patients (96.9%), including bony endplate failure (bony failure) in 47 patients (71.2%) and isolated cartilaginous endplate lesions in 17 patients (25.7%). Bony failure group had similar pain and functional scores but more severe neurological deficit at the initial evaluation. Clinical parameters improved in all groups, but the recovery was lesser in conservatively treated bony failure patients. CONCLUSION: Endplate lesions are commonly associated with symptomatic LDH. Presence of bony failure can increase neurological deficit and reduce the chance of recovery with conservative management. The 3D FSPGR sequence of MRI can be successfully used for detection of the endplate lesions in the herniated disc.

Patellar ligament rupture during total knee arthroplasty in an ochronotic patient.

Ochronotic arthropathy mainly involves the spine and large joints. Along with blackening of the joint, degeneration rapidly progresses mostly in the knee, resulting in symptoms by the 4th or 5th decade. As the role of medical treatment and joint conservation surgeries are limited in the early stages, joint replacement is the only effective option in one third of patients. We present a case of the unique complication of patellar ligament rupture during total knee replacement (TKR) of an ochronotic joint. A 51-year-old male presented with bilateral severe tricompartmental osteoarthritis with varus deformities and restriction of motion. Bilateral TKR was performed. At the 28-month follow-up, the patient was walking pain free with acceptable position of implants in radiographs. To our knowledge this is the first report of rupture of the patellar ligament during TKR of an ochronotic joint. We propose appropriate preoperative preparation and greater care in the handling of the tendon during TKR of an ochronotic joint in order to avoid complication.