Survivorship of autologous structural bone graft at a minimum of 2 years when used to address significant glenoid bone loss in primary and revision shoulder arthroplasty: a computed tomographic and clinical review.

BACKGROUND: Severe glenoid bone loss remains a challenge in patients requiring shoulder arthroplasty and often requires autogenous bone grafting. The purpose of this study was to assess the integrity of the bone graft at 2 years in a series of primary and revision shoulder replacements where glenoid bone loss was managed using a structural autograft (humeral head or iliac crest bone graft) in combination with a trabecular titanium (TT) implant. METHODS: Ethical approval was sought, and the study has a portfolio study status by the NIHR (17/YH/0318). We contacted patients who had primary and revision shoulder arthroplasty with Lima Axioma TT metal-back glenoid with autologous bone graft and were more than 2 years since their operation. All eligible patients underwent computed tomographic evaluation, clinical review, and scoring. Early failures of composite fixation and patients who had revision procedures were excluded (2 patients). RESULTS: Forty-one patients (43 shoulders) with a mean age of 65 years (range 33-85 years) were reviewed. There were 24 women and 17 men. The average follow-up period was 40 months (range 24-59 months). Primary arthroplasty was performed in 24 shoulders, whereas 19 shoulders had revision arthroplasty. Twenty-five shoulders had reverse shoulder replacement and 18 had anatomic shoulder replacement. Twenty-four shoulders had graft taken from the humeral head, and 19 had iliac crest bone graft, reflecting the number of revisions. We used Wrightington classification for porous metal implant and bone graft incorporation. Satisfactory bone graft incorporation (>50%) was seen in 40 shoulders, and only 3 patients had <50% graft incorporation. The scans at 2 years or later showed no significant deterioration in the bone graft from the early postoperative scans. Average forward elevation improved from 50° (preoperative) to 98° (range 35°-150°). The mean improvement in mean Oxford Shoulder Score was 16 (preoperative, 15; postoperative, 31) and the mean improvement in Constant score improvement was 36 (preoperative, 12; postoperative, 48). The mean postoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score was 64 (range 30-85). CONCLUSION: The use of TT in conjunction with autologous bone graft provides a reliable method of addressing glenoid bone defects in primary and revision shoulder arthroplasty. This graft-trabecular metal composite has been shown to integrate well and remain largely unchanged over a 2-year period. A stable baseplate is essential in difficult primary and revision arthroplasty situations. The stability of this construct in our series is reflected in the satisfactory outcomes.

Treatment principles, prognostic factors and controversies in radial neck fractures in children: A systematic review.

INTRODUCTION: Radial Neck fractures are rare injuries in children. There is controversy surrounding their prognosis and management. AIMS: This review aims to produce an up-to-date summary to clarify prognostic factors and management principles, in the light of recent, better-quality evidence. METHODS: A systematic review was undertaken in accordance to PRISMA guidelines, applying pre-defined selection criteria. 6 papers were found suitable after quality assessment. All were observational cohort studies, one prospective and the rest retrospective. A semi-qualitative review was undertaken as heterogeneity, especially in the fracture classification and outcome assessment tools used, prevented quantitative synthesis. RESULTS: Majority of these fractures occur at the metaphysis. Consistently good results are seen with simple immobilization in fractures angulated<30° with translation<50%, with nearly all achieving a good outcome. In more displaced fractures, results are poorer and only about 70% patients achieve a good outcome. Both higher fracture displacement and more invasive treatment are associated with worse outcomes, but also with each other. Associated injuries are common, with Proximal Ulna fractures being commonest (71%), but their effect on outcomes is unclear. Age more than 10 years is associated with worse displacement, more invasive treatment and worse results. There is much confounding among all these factors which remains to be convincingly addressed. An algorithmic approach is advisable for these fractures, with stepwise application of more invasive treatment only if less invasive methods fail. Percutaneous fixation with either K-wires or retrograde intramedullary elastic nails is acceptable. Fractures reduced closed in theatre fare better if fixed percutaneously to prevent re-displacement. Open treatment should be considered only if the fracture can't be reduced to within the displacement limits of angulation<30° and translation<50%. Incidence of serious complications is generally low (3-5%), but their effect on outcomes is unclear. CONCLUSIONS: The treatment of higher-grade radial neck fractures is still controversial, needing further research, possibly through multi-center prospective data collection in pediatric fracture registries using validated outcome measures.

Histological incorporation of acellular dermal matrix in the failed superior capsule reconstruction of the shoulder.

BACKGROUND: Superior capsule reconstruction addresses massive rotator cuff tears using allografts and aims to restore the natural superior constraint of the shoulder and therefore shoulder biomechanics and function. There is no evidence relating to the histological incorporation of these grafts. METHODS: 27 superior capsule reconstructions were performed between June 2016 and November 2017. Follow-up was with clinical assessment and Magnetic Resonance Imaging, to identify graft failure. Reverse total shoulder replacement was offered for ruptured grafts and the graft was sent for histological analysis along with the footprint of graft attachment where possible. RESULTS: Five patients (18.5%) had evidence of graft failure, three of whom (11.1%) underwent revision procedures. Of the five ruptures, four failed at the glenoid insertion, and one was an intra-substance tear. Histological analysis showed extensive fibroblastic infiltration. The intra-substance tear showed some vascularity at the medial and lateral ends, and one of the glenoid pull-outs demonstrated micro-calcification and osteoid formation. There was no evidence of in-growth into the bone. DISCUSSION: An inflammatory response to the grafts was seen, with neo-vascularisation, and micro-calcification observed. These findings are from ruptured grafts, so may not represent the characteristics of those which have not ruptured. Further evidence from explanted intact grafts could be gained to improve our understanding of its incorporation. LEVEL OF EVIDENCE: Level IV evidence.

Medium- to long-term results of a randomized controlled trial to assess the efficacy of arthoscopic-subacromial decompression versus mini-open repair for the treatment of medium-sized rotator cuff tears.

BACKGROUND: We report on the medium- to long-term results of a randomized controlled trial (RCT) aiming to determine whether rotator cuff repair confers any advantage over arthroscopic sub-acromial decompression (ASAD) alone in the management of medium-sized rotator cuff tears. METHODS: Ethical approval was sought to follow-up patients previously enrolled in a completed and previously published RCT comparing the outcome of ASAD with mini-open cuff repair for the treatment of rotator cuff tear. Forty-two patients were enrolled in the original study, with a mean of 64 years (range 54 years to 77 years). RESULTS: Fifteen of the original 17 patients randomized to ASAD alone and 18 of the original 25 patients randomized to cuff repair were available for follow-up. Each patient underwent American Shoulder and Elbow Surgeons (ASES), Disabilities of the Arm, Shoulder and Hand (DASH) and Constant scoring, and clinical and ultrasound examination. Mean duration of follow-up was 7 years (range 5 years to 11 years). There was no statistically significant difference in terms of ASES, DASH and Constant scores at follow-up between the two groups. Some 33% of patients in the cuff-repair group had a proven re-rupture on ultrasound. This patient subgroup had significantly worse Constant scores compared to patients where the repair remained intact. None of the patients from either group developed cuff-tear arthropathy requiring arthroplasty surgery. CONCLUSIONS: In this medium- to longer-term study, there is no demonstrable significant benefit of cuff repair over decompression alone for the treatment of medium-sized rotator cuff tears, in terms of ASES, DASH and Constant scores for pain, function and strength modules. The presence of cuff tear does not necessitate surgical repair. This conclusion should drive surgical strategies and shared decision-making between patients and surgeons.

Management of Posterior Malleolar Fractures: A Systematic Review.

Posterior malleolar fractures are relatively common and usually result from rotational ankle injuries. Although treatment of associated lateral and medial structures is well established, several controversies exist in the management of posterior malleolus fractures. We performed a systematic review of the current published data with regard to the diagnosis, management, and prognosis of posterior malleolus fractures. A total of 33 studies (8 biomechanical and 25 clinical) with >950 patients were reviewed. The outcome of ankle fractures with posterior malleolar involvement was poor; however, the evidence was not enough to prove that the size of the posterior malleolus affects the outcome. Significant heterogeneity was noted in the cutoff size of the posterior malleolar fragment in determining management. The outcome was related to other factors, such as fracture displacement, congruency of the articular surface, and residual tibiotalar subluxation. Indirect evidence showed that large fracture fragments were associated with fracture dislocations and ankle instability and, thus, might require surgical fixation. We have concluded that the evidence to prove that the size of the posterior malleolar affects the outcome of ankle fractures is not enough, and the decision to treat these fractures should be determined by other factors, as stated previously.

Arthroscopic Evaluation of Impingement and Osteochondral Lesions in Chronic Lateral Ankle Instability.

BACKGROUND: Anterolateral impingement associated with intra-articular synovitis, scarring, and fibrosis is a less recognized feature in patients with chronic lateral ankle instability. The aim of our study was to ascertain the incidence of intra-articular synovitis, osteochondral lesions (OCLs), impingement lesions (both intra- and extra-articular), and other associated pathologies in patients undergoing modified Broström-Gould ankle ligament reconstruction. METHODS: We performed a retrospective review of all patients who underwent arthroscopically assisted modified Broström-Gould ankle ligament reconstruction for symptomatic recurrent ankle instability. Patients who had previous ankle surgery or inflammatory arthropathy were excluded. Ankle arthroscopy was performed prior to reconstruction in all patients. Data were obtained from clinical and radiological records including magnetic resonance imaging scans. Arthroscopic findings were recorded in detail intraoperatively. A total of 100 patients (53 females and 47 males) with an average age of 37 years (range, 15-65 years) were reviewed over a 10-year period. RESULTS: Sixty-three patients (63%) had intra-articular synovitis mostly in the anterior and/or anterolateral compartment, which required arthroscopic debridement. Seventeen patients (17%) were found to have OCLs, and 12 (12%) patients had anterior bony impingement lesions. CONCLUSION: This study found a high incidence of anterior/anterolateral synovitis in patients with chronic lateral ankle instability. However, there was a relatively low incidence of anterior bony impingement lesions or OCLs in our series. LEVEL OF EVIDENCE: Level IV, retrospective case series.

A prospective study to assess the outcomes of revision anterior cruciate ligament reconstruction.

PURPOSE: Continuously increasing numbers of primary anterior cruciate ligament (ACL) reconstructions invites a parallel increase in graft failures and need for revision ACL reconstruction surgery. High failure rates has previously stigmatised the revision surgery. We performed this study using multiple outcome measures together with clinical examination to offer a full assessment of the outcomes of this procedure. METHODS: Twenty patients, with mean age of 29.4 years (17-50 years), were included in this study prior to their revision ACL reconstruction surgery. All patients were followed prospectively collecting the Knee injury and Osteoarthritis Outcome (KOOS), International Knee Documentation Committee (IKDC) and Tegner-Lysholm scores pre- and post-operatively together with clinical assessment of the antero-posterior knee laxity. RESULTS: After a mean follow up interval of 30 months (16-60 months) significant post-operative improvement of IKDC, Tegner-Lysholm scores and knee antero-posterior laxity together with the Symptoms, Activities of Daily Living (ADL) and Quality of Life (QOL) components of the KOOS score was noticed (P < 0.05). However, there was no similar improvement in pain and sports components of the KOOS score (P > 0.05). There was no difference in the outcomes of different graft types. CONCLUSION: Good outcomes of revision ACL reconstruction surgery are achievable. The use of different graft types did not affect the outcome of the procedure. Most of the patients opted to less aggressive sports participation after the revision procedure.

Pseudoacetabulum a subtle radiological feature of a chronic dislocated total hip replacement.

We report the presence of an unusual radiological feature of formation of pseudoacetabulum in a chronically dislocated and asymptomatic total hip arthroplasty. An elderly demented patient with a history of recurrent dislocations presented to us after an unwitnessed fall and leg length discrepancy. Radiographs showed a dislocated hip arthroplasty with a well-defined, concentric, radio-opaque shadow around the dislocated femoral head suggestive of a pseudoacetabulum. Previous radiographs revealed formation of heterotopic ossification in the soft tissues surrounding the hip. The dislocated joint was reduced under a general anaesthetic with difficulty. This case highlights the presence of heterotopic ossification and formation of pseudoacetabulum as subtle radiological features of chronic instability and dislocation.

Primary total knee arthroplasty infected with Serratia marcescens.

We report an unusual case of a Serratia marcescens infection of total knee arthroplasty 4 weeks after the procedure following aspiration carried out on the ward (contrary to local protocol). This was successfully treated with thorough wound debridement, irrigation, change of the polyethylene liner and systemic antibiotics using intravenous meropenem for 3 weeks followed by oral ciprofloxacin for another 3 weeks. Our patient made an uneventful recovery and there was no reported recurrence of infection at 8 months of follow-up. We are unsure as to whether the infection was introduced at the time of the joint aspiration or was a complication of the initial procedure despite all the standard aseptic measures taken at the time of surgery.

Surgical outcome for foot drop in lumbar degenerative disease.

Controversy exists regarding the timing and outcome of surgery for lumbar degenerative disease (LDD) associated with foot drop. In this work, we report the results of a retrospective observational study from our center. We had a sample size of 26 patients with a minimum follow-up of 6 months. Of the 26 patients, 88% improved, with complete recovery observed in 61%. Thus, our data support the view that there is good recovery from operative management of foot drop secondary to LDD. Adjusting for preoperative strength, preoperative duration of weakness was a significant predictor of extent of recovery (odds ratio = 0.93; 95% confidence interval 0.88 to 0.98; p = 0.019). The model explained 50% of the variance in outcome in this study.

Bioabsorbable interference screw fixation of distal biceps ruptures through a single anterior incision: a single-surgeon case series and review of the literature.

INTRODUCTION: We present a single-surgeon series of 14 acute ruptured distal biceps tendons repaired using a biotenodesis screw through a single anterior incision. PATIENTS: The demographics of this population reveal a typical injury pattern and reflect the preponderance of distal biceps ruptures in the middle aged, active male. Goniometric post-operative assessment of flexion, pronation and supination range demonstrates excellent clinical function in these patients. METHOD: Subjective analysis is afforded by DASH and MEPS scoring at the 6-month follow-up. RESULTS: The results are discussed in relation to previous studies utilising disparate repair methods. This is the first prospective clinical series to be reported using this combination of fixation and approach. Clinical and patient assessed functions are excellent and complications are minimal. CONCLUSION: This is a safe and successful technique for the management of distal biceps tendon ruptures.