Early repair of trauma-related full-thickness rotator cuff tears does not eliminate the problem of healing failure.

AIMS: Failure of healing is a well-known problem after repair of the rotator cuff. This study aimed to investigate if early repair of trauma-related full-thickness rotator cuff tears (FTRCTs) could prevent this failure. PATIENTS AND METHODS: In this prospective trial, 62 consecutive patients (14 women (23%), 48 men (77%); median age 61 years (interquartile range (IQR) 54 to 65)) with trauma-related FTRCT underwent arthroscopic single-row repair within six weeks of trauma. Tendon integrity was assessed one year after surgery using the Sugaya score on MR images. Patients were followed up with Western Ontario Rotator Cuff (WORC) index, EuroQol visual analogue scale (EQ VAS), and the Constant-Murley score (CS) two years after repair. RESULTS: A total of 57 patients (92%) had MR images available at one year; 59 patients (95%) had CS (one year), WORC (two years), and EQ VAS scores (two years). Intact repair was found on MRI in 36 patients (63%); 13 patients (23%) displayed healing failure of at least one repaired tendon and eight patients (14%) displayed total healing failure. Median WORC index and relative CS improved from 30.8 points (IQR 20.1 to 38.6) at baseline to 85.0 points (IQR 60.6 to 95.7) at two years and 26.5 points (IQR 21.2 to 37.4) to 83.2 points (IQR 71.9 to 97.5) at one year, respectively. The relative CS at one year was significantly better among those with intact repairs compared with those with healing failure (91.6 vs 78.1 points; p = 0.031). CONCLUSION: Although early repair of trauma-related FTRCT improved patient relevant outcomes over two years for the entire cohort, only two out of three repaired rotator cuffs displayed intact structural integrity on MRI after one year. Consequently, early repair did not seem to prevent healing failure after trauma-related FTRCT. Cite this article: Bone Joint J 2019;101-B:603-609.

Occult fracture of the lesser tuberosity in a 9-year-old female swimmer.

The adolescent avulsion of the lesser tuberosity of the humerus has historically been considered as very rare. The youngest patient reported in the literature is 11 years old. We report a case of a 9-year-old girl who suffered a subscapularis tendon tear with an occult avulsion of the lesser tuberosity. Late repair restored function. Despite that late repair in this present case resulted in excellent outcome, we strongly recommend the additional axillary lateral view of the plain radiographs, as well as proper physical examination to facilitate early diagnosis.

Trauma research in the United Arab Emirates: reality and vision.

INTRODUCTION: Trauma is a major health problem in the United Arab Emirates, and it is the second leading cause of death. Research can help us find solutions for this problem. We evaluated the published literature on trauma from United Arab Emirates to define research areas which need improvement. METHODS: A MEDLINE search for articles on trauma and injury from the United Arab Emirates covering the period 1960-2005 was performed. The content of articles was studied, classified and summarised. RESULTS: 32 articles were found, of which 18 were published in the last six years. 18 articles were on prevention and epidemiology, ten on clinical management and four on education. The first author was affiliated to the university in 19 articles. There were no articles on pre-hospital care, experimental work, trauma systems, trauma registry or post-hospital rehabilitation. CONCLUSION: There is a need for a strategic plan to support research in areas like pre-hospital care, implementation of trauma systems, trauma registries and post-hospital rehabilitations to reduce the socioeconomic impact of trauma in the United Arab Emirates.

Acute plain anterioposterior radiograph of the pelvis is not useful in detecting fractures of iliac wing and os sacrum: a prospective study of 73 patients using CT as gold standard.

Conflicting opinions exist to what extent interpreters of an acute anterioposterior (AP) radiograph of the pelvis underdiagnose pelvic injury. We have prospectively evaluated the usefulness of a plain AP radiograph of the pelvis in detecting injuries, using CT as the gold standard. Seventy-three haemodynamically stable blunt trauma patients, who had an AP radiograph of the pelvis and an abdominopelvic CT as part of their initial imaging evaluation, were included. There were 14 women and 59 men, with a mean age of 30 (3-61) years. Two senior radiologists, with special interest in CT examinations evaluating trauma, reviewed the radiographs and a month later the CT scans, blinded and independently. Usefulness index of the plain AP radiograph of the pelvis in detecting specific injuries was calculated using CT as the gold standard. A radiograph is regarded as useful if the usefulness index is 0.35 or more. The usefulness index for a plain AP radiograph of the pelvis for detecting a fracture of iliac wing and os sacrum was 0.25 and 0.01, respectively. An acute AP radiograph of the pelvis is not useful in detecting a fracture of iliac wing or os sacrum.

Usefulness of different imaging modalities in the assessment of scapular fractures caused by blunt trauma.

PURPOSE: To analyze the usefulness of chest and scapular trauma radiographs, axial computed tomography (CT), and two- and three-dimensional (2D and 3D) reconstruction CT in detecting fractures of the six anatomical regions of the scapula. MATERIAL AND METHODS: Forty-four patients, with a median age (range) of 34 (16-60) years, with scapular fractures caused by blunt trauma were prospectively collected between January 2003 and December 2005. Their chest and scapula radiographs, and axial, 2D, and 3D CTs were reviewed blindly and independently by two observers. Each modality was compared with a gold standard to determine its diagnostic usefulness. Our gold standard was consensus reached by all authors together examining all modalities at the same time. We also compared 3D CTs reconstructed from chest and scapula axial views. RESULTS: Axial and 3D reconstruction tomographic studies were the only useful modalities in assessing fractures in all six anatomical scapular regions. Three-dimensional CTs reconstructed from chest and scapula axial views were equally sensitive and specific. CONCLUSION: CT scanning with 3D reconstructions is the most useful imaging modality to detect and define the extent of scapular injury, and this can be done as part of a chest trauma computed tomography protocol.

Extramedullary fixation of 569 unstable intertrochanteric fractures: a randomized multicenter trial of the Medoff sliding plate versus three other screw-plate systems.

We compared the efficacy of the Medoff sliding plate (MSP) with 3 other screw-plate systems for fixation of unstable intertrochanteric fractures in a randomized multicenter trial of 569 elderly patients. The MSP has biaxial dynamic capacity along both the neck and the shaft of the femur unlike the other systems, which lack dynamic capacity along the shaft. 268 fractures were operated on with the MSP, and 301 with the dynamic hip screw (DHS), with or without a trochanteric stabilizing plate (DHS/TSP) or with the dynamic condylar screw (DCS). The MSP had recently been shown to the surgeons. The patients in the groups were similar as regards age, domestic situation, preinjury walking ability and type of fracture. We followed the patients clinically and radiographically for at least 1 year. There was no significant difference in walking ability at follow-up or rate of return to home. Fixation failure occurred in 18/268 fractures operated on with the MSP, in 8/238 with the DHS, in 3/49 with the DHS/TSP and in 1/14 with the DCS. The difference in the rate of fixation failure was not statistically significant when the MSP group was compared to the 3 other groups. In 14 of the 18 fixation failures in the MSP group, the biaxial dynamic capacity of the MSP had not been used due to technical errors by surgeons, unfamiliar with the new method. No selection bias was found regarding fracture types in the 2 subgroups of patients with correct or inadequate biaxial dynamization. Extramedullary fixation of unstable intertrochanteric fractures with these implants showed a low failure rate. When using the MSP, biaxial dynamization must be correctly performed.

Extracapsular hip fractures: fixation with a twin hook or a lag screw?

The twin hook, which has 2 oppositely directed apical hooks, is an alternative to the lag screw for use with a 'dynamic plate' in the fixation of trochanteric hip fractures. In this prospective study lasting 1 year, 102 consecutive patients with trochanteric hip fractures were treated by 19 surgeons with either a twin hook or a lag screw combined with a conventional sliding hip screw plate or a Medoff sliding plate. Seven intraoperative errors were made with the twin hook but postoperative migration did not differ significantly between the 2 groups. Postoperative fixation failures were equally distributed between the 2 groups. The twin hook provides adequate fixation, which is comparable to that produced by a lag screw.

Extramedullary fixation of 107 subtrochanteric fractures: a randomized multicenter trial of the Medoff sliding plate versus 3 other screw-plate systems.

We compared the efficacy of a load-sharing device, the Medoff sliding plate (MSP), with that of 3 other load-bearing screw-plate devices for the fixation of subtrochanteric fractures in a randomized multicenter trial of 107 elderly patients. 55 fractures were operated on with the MSP, and 52 with the dynamic hip screw (DHS) with or without a trochanteric stabilizing plate (TSP) or with the dynamic condylar screw (DCS). The patient material in the groups was similar regarding age, domestic situation, preinjury walking ability and fracture types. We followed the patients clinically and radiographically for a minimum of 1 year. There was no significant difference in walking ability or return rate to the home at follow-up. Fixation failure occurred in 1/55 fractures operated on with the MSP, in 3/32 with the DHS, in 3/12 with the DCS and in 2/8 with the DHS/TSR The difference in the rate of fixation failure was statistically significant, when the MSP group was compared to the 3 load-bearing devices in the other group (1 vs 8). On the basis of this experience, we think that the load-sharing principle of the MSP, which seems to facilitate fracture impaction and stability, appears to be a good alternative in extramedullary fixation of subtrochanteric fractures.

Different ways to treat subtrochanteric fractures with the Medoff sliding plate.

Thirty-two consecutive subtrochanteric fractures in 32 patients were stabilized using the Medoff sliding plate and were followed up prospectively for 1 year. Two patients died during the first postoperative year. Twenty-nine of the remaining 30 (97%) fractures united by 1-year followup. Two types of plate dynamization schema were used: uniaxial (17 patients) and biaxial (15 patients). With uniaxial dynamization, plate sliding averaged 12 mm along the femoral shaft without medialization of the femoral shaft. With biaxial dynamization along the femoral shaft and the neck, plate sliding averaged 11 mm and screw in barrel sliding averaged 9 mm; medialization of the femoral shaft ranged from 0% to 35% of the femoral shaft diameter. Three fractures treated with uniaxial dynamization had migration of the lag screw within the femoral head; all three fractures united without additional screw migration after secondary or staged biaxial plate dynamization.

A new radiographic method for evaluating the degree of sliding in devices used in hip-fracture surgery.

PURPOSE: To find a practical method for estimating the degree of sliding that occurs in screw-plate devices used in hip-fracture surgery. Greater understanding of the sliding mechanisms in different fracture types should improve surgical technique and reduce the failure rate. METHODS AND RESULTS: In dynamic screw-plate devices, the lag screw slides inside the barrel of the plate. A recent innovation allows the barrel-plate to slide inside a side-plate, thus making possible a combined fracture compression along the neck and the shaft of femur. The lengths of the different parts and the angle of a device in vivo, measured on a radiograph, depend on the position of the femur relative to the photographic film and the roentgen source. We obtained these measurements with a ruler and a protractor from sequential a.p. radiographs of the hip and implemented them in a special computerized program that used the principles of the scaled orthographic and the central projection models. These calculations provided the correct amount of sliding by the lag screw and by the barrel-plate within the side-plate. CONCLUSION: The method presented here can establish the real degree of sliding in screw-plate devices from standard a.p. radiographs independently of the position of the hip.

Biaxial dynamization in unstable intertrochanteric fractures. Good experience with a simplified Medoff sliding plate in 94 patients.

In a prospective study, 94 consecutive patients with unstable intertrochanteric fractures were treated by 16 surgeons, using a modified 4-hole Medoff sliding plate and followed clinically and radiographically for 1 year. Weight bearing after surgery was allowed as tolerated. This new device is smaller and uses a simpler technique of insertion than the original 6-hole Medoff sliding plate. The modification of the plate makes biaxial sliding along both the shaft and the neck of the femur obligatory. All fractures united and no postoperative lag screw penetration occurred. The use of a shorter side-plate with 4 cortical bone screws was sufficient for fixation and no plate loosening or breakage was observed. On the basis of this experience, biaxial dynamization seems to facilitate fracture impaction and stability, and the simplified 4-hole Medoff sliding plate appears to be a suitable method for the treatment of unstable intertrochanteric fractures.

Two-way compression along the shaft and the neck of the femur with the Medoff sliding plate: one-year follow-up of 108 intertrochanteric fractures.

The Medoff sliding plate (MSP) is a new device used to treat intertrochanteric and subtrochanteric fractures. There are three options for sliding; either along the shaft or the neck of the femur, or a combination of both. In a prospective series of 108 consecutive displaced intertrochanteric fractures we used combined dynamic compression. The patients were followed clinically and radiologically for one year. All fractures healed during the follow-up period. The only postoperative technical failure was one lag-screw penetration. Combined compression of the MSP gives increased dynamic capacity which reduces the risk of complications. The low rate of technical failure in our series compares favourably with that of the sliding hip screw or the Gamma nail but randomised trials comparing the MSP with other hip screw systems are necessary to find the true role of the MSP with its various sliding modes.

One-way compression along the femoral shaft with the Medoff sliding plate. The first European experience of 104 intertrochanteric fractures with a 1-year follow-up.

This is an assessment of a new device for treatment of intertrochanteric and subtrochanteric fractures. The Medoff sliding plate (MSP) allows compression in 3 different modes: along the femoral shaft, along the femoral neck or a combination of both. In this prospective series of 104 consecutive intertrochanteric fractures, dynamic compression was allowed only along the femoral shaft. Simple undislocated intertrochanteric 2-part fractures were excluded. The patients were followed clinically and radiographically for 1 year. 21 patients died within 1 year after the operation. 7 technical failures including 2 non-unions occurred. All were lag screw penetrations, 4 of which were considered to be due to unforced errors by the surgeons. The technical failure rate in this preliminary evaluation of the MSP is similar to that of the dynamic hip screw. Randomized trials comparing the MSP with other hip screw systems should follow to ascertain possible advantages of the MSP, with its various sliding modes in different types of fractures of the proximal femur.