Surgical treatment of Rockwood grade-V acromioclavicular joint dislocations: 50 patients followed for 15­22 years.

BACKGROUND AND PURPOSE: Long-term outcome after surgery for grade-V acromioclavicular joint dislocation has not been reported. We performed a retrospective analysis of functional and radiographic outcome 15-22 years after surgery. PATIENTS AND METHODS: We examined 50 patients who were treated at our hospital between April 1985 and December 1993. Various methods of stabilization were used: K-wires (n = 36), 4.5-mm screw (n = 12), or biodegradable screw (n = 2). Osteosynthesis material was removed after 6-8 weeks. Mean follow-up time was 18 (15-22) years. Outcomes were assessed with the Constant shoulder (CS) score, Disabilities of the Arm, Shoulder, and Hand (DASH) score, the simple shoulder test (SST), the Copeland shoulder impingement test, the cross-arm test, pain, stability of the AC joint, and complications. From radiographs, we evaluated AC and glenohumeral (GH) arthrosis, osteolysis of the lateral clavicle, and alignment of the clavicle with the acromion. RESULTS: Mean values were 90 (75-100) in CS score, 5.1 (0-41) in DASH score, and 11 (2-12) in SST. There was no statistically significant difference in CS score between the injured shoulder and the uninjured shoulder. The AC joint was clinically stable in 42 patients. In 38 patients, the clavicle alignment with the acromion was normal in radiographs. Lateral clavicle osteolysis (10 patients) appeared to be associated with permanent AC joint dislocation. INTERPRETATION: Surgery with a temporary fixation for acute grade-V AC joint dislocation leads to successful long-term functional results. Only minor disability occurred in some patients.

Operative and nonoperative treatment of clavicle fractures in adults.

BACKGROUND AND PURPOSE: Traditionally, clavicle fractures have been treated nonoperatively. However, many recent studies have concentrated on the results of operative treatment. We assessed and compared the outcomes of operative and nonoperative treatment for acute clavicle fractures in adults. METHODS: We performed a systematic search of the medical literature from 1966 until the end of March 2011. We included randomized controlled trials and controlled clinical trials comparing operative and nonoperative treatment and studies comparing different operative and nonoperative treatments. We required that there should be at least 30 adult patients and a follow-up of at least 6 months in each individual trial. We used the GRADE method to assess the quality of evidence. RESULTS: 6 randomized controlled trials (n = 631) and 7 controlled clinical trials (n = 559) were included. There was moderate-quality evidence (i.e. of grade B) (1) that surgery has considerable effectiveness on better function and less disability at short follow-up, (2) of similar risk of relatively mild complications after operative or nonoperative treatment, (3) that delayed union and nonunion were more common in patients who were treated nonoperatively than in those treated operatively, and (4) that the osteosynthesis method had no effect on the incidence of delayed union or nonunion. Only 1 controlled clinical trial was found on lateral clavicle fractures with very limited (grade D) evidence. INTERPRETATION: Patients treated operatively have slightly better function and less disability than those treated nonoperatively at short follow-up, but then the effectiveness diminishes and is weak at 6 months. The different operative techniques may not differ in effectiveness or in adverse effects, but the evidence is very limited or conflicting. Surgery could be considered for active patients who require recovery to the previous level of activity in the shortest possible time.

Early results of 827 trabecular metal revision shells in acetabular revision.

We evaluated the survival of 827 acetabular revisions with Trabecular Metal Revision Shell using data from a nationwide arthroplasty register. The mean age of the patients was 69.1 years. The 3-year overall survivorship was 92% (95% confidence interval, 88-95), which coincides with earlier reports. Revision rate for aseptic loosening was only 2%. The most common reason for revision was dislocation of the prosthesis with or without malposition of the socket (60%). Age was found to have significant effect on cup survivorship: each additional year in age decreased the risk of revision by 2.4% (95 % confidence interval, 0.1-4.7; P = .044). We found no differences in survival rates between aseptic and septic revisions. Furthermore, sex, diagnosis, and hospital volume did not affect the survival.

Range of motion and strength after surgery for brachial plexus birth palsy.

BACKGROUND: There is little information about the range of motion (ROM) and strength of the affected upper limbs of patients with permanent brachial plexus birth palsy. PATIENTS AND METHODS: 107 patients who had brachial plexus surgery in Finland between 1971 and 1998 were investigated in this population-based, cross-sectional, 12-year follow-up study. During the follow-up, 59 patients underwent secondary procedures. ROM and isometric strength of the shoulders, elbows, wrists, and thumbs were measured. Ratios for ROM and strength between the affected and unaffected sides were calculated. RESULTS: 61 patients (57%) had no active shoulder external rotation (median 0° (-75-90)). Median active abduction was 90° (1-170). Shoulder external rotation strength of the affected side was diminished (median ratio 28% (0-83)). Active elbow extension deficiency was recorded in 82 patients (median 25° (5-80)). Elbow flexion strength of the affected side was uniformly impaired (median ratio 43% (0-79)). Median active extension of the wrist was 55° (-70-90). The median ratio of grip strength for the affected side vs. the unaffected side was 68% (0-121). Patients with total injury had poorer ROM and strength than those with C5-6 injury. Incongruity of the radiohumeral joint and avulsion were associated with poor strength values. INTERPRETATION: ROM and strength of affected upper limbs of patients with surgically treated brachial plexus birth palsy were reduced. Patients with avulsion injuries and/or consequent joint deformities fared worst.

Permanent brachial plexus birth palsy does not impair the development and function of the spine and lower limbs.

Permanent brachial plexus birth palsy (BPBP) impairs the function of the affected upper limb. Avulsion type root injuries may damage the cervical spinal cord. Whether abnormal function of an upper limb affected by BPBP has any observable effects on the development of the locomotion system and overall motor function has not been clarified in depth. A total of 111 patients who had undergone brachial plexus surgery for BPBP in infancy were examined after a mean follow-up time of 13 (5-32) years. Patients' physical activities were recorded by a questionnaire. No significant inequalities in leg length were found and the incidence of structural scoliosis (1.7%) did not differ from that of the reference population. Nearly half of the patients (43%) had asynchronous motion of the upper limbs during gait, which was associated with impaired upper limb function. Data obtained from the completed questionnaires indicated that only few patients were unable to participate in normal activities such as: bicycling, cross-country skiing or swimming. Not surprisingly, 71% of the patients reported problems related to the affected upper limb, such as muscle weakness and/or joint stiffness during the aforementioned activities.

No correlation between patient outcome and abnormal lumbar MRI findings 21 years after posterior or posterolateral fusion for isthmic spondylolisthesis in children and adolescents.

Between 1977 and 1987, posterior (n=29) or posterolateral (n=73) fusion was performed for mild to moderate (slip <50%) isthmic spondylolisthesis on 102 patients (46 females, 56 males). The patients' average age at the time of operation was 15.9 (range, 8.1-19.8) years. Clinical (physical examination and Oswestry disability index (ODI)) and radiological (MRI and plain radiographs) examinations were performed on these patients after an average follow-up time of 21.0 (range, 26.2-15.1) years. In the radiographs, the mean slip preoperatively was 27% (range, 5-50%) and at the last follow-up visit 26% (range, 5-78%). Inside the fusion, there were a total of 148 intervertebral discs, 121 (82%) of them had decreased signal intensity in T2-weighted MR images and 113 (76%) were narrowed. Above the fusion level, 27 (27%) discs were speckled and 27 (27%) were black; 21 (21%) intervertebral disc spaces were narrowed. Two levels above the fusion level the numbers were 8 (8%), 16 (16%) and 16 (16%), respectively. Six (6%) patients had a prolapse. Degenerative facet joint hypertrophy above fusion was seen at 80 (79%) of the levels studied. When compared to healthy subjects higher frequency of disc and facet joint degeneration was found. In MR images, none of the patients had lumbar spinal stenosis inside or above the fusion. Narrowing of one or both of the neural foramina at the level of the L5-S1 interververtebral disc was noted in 32 (31%) patients. Seventeen (17%) of the patients had, usually mild, muscular atrophy of the psoas and 33 (32%) of the paraspinal muscles. There was no difference in frequency of abnormal MRI findings between patients (n=93) with ODI 20 or less compared with patients (n=9) with ODI more than 20. In situ fusion due to isthmic spondylolsthesis at adolescence is associated with moderate degenerative changes in the lumbar spine during a 20-year follow-up. Changes were most commonly found at the level of the spondylolisthesis and above fusion level. Neural foramina stenosis seems to be associated with spondylolisthesis and its severity to severity of the slip. Muscle atrophy tended to be mild. However, there was no correlation between patient outcome (ODI) and abnormal lumbar MRI findings.

Long-term clinical, functional and radiological outcome 21 years after posterior or posterolateral fusion in childhood and adolescence isthmic spondylolisthesis.

Long-term radiological studies have shown that a high rate of fusion can be achieved with posterolateral spondylodesis. Radiological findings, however, do not always correlate with patient satisfaction and outcome. No studies have been conducted on the long-term results of functional outcome, including spinal mobility and trunk strength measurements, after operative treatment of spondylolysis and spondylolisthesis, as compared with the reference population. Of 129 consecutive patients with isthmic spondylolisthesis operated on with spondylodesis between 1977 and 1987, 107 (83%) participated in the study. Posterior spondylodesis was performed in 29 (27%) patients and posterolateral spondylodesis in 78 (73%) patients. The average follow-up time was 20.9 years (range 15.1-26.2 years). Radiographs obtained preoperatively and at the 2-year and final follow-ups were assessed for quality of the fusion and degenerative changes. Outcome was assessed at the last follow-up by physical examination, spinal mobility and non-dynamometric trunk strength measurements, and calculation of Oswestry disability index (ODI) scores. The fusion rate was 66% after posterior fusion and 83% after posterolateral fusion. Degenerative changes in the lumbar intervertebral discs above the fusion level were noted in 13 (12%) patients. At the final follow-up 14% of patients reported back pain often or very often. The mean ODI score was 7.6 (0-68). Moderate disability was found in 6% of patients and severe disability in 1%; one patient was crippled. No correlation was found between disc degeneration or solidity of the fusion and the ODI score. Non-dynamometric trunk strength measurements corresponded with the reference values. Lumbar flexion, but not extension, was diminished when compared with that of the reference population. The overall long-term clinical outcome is good in patients with spondylolysis and spondylolisthesis operated on with posterior or posterolateral fusion. The clinical and radiological outcomes do not, however, appear to correlate with each other. Lumbar flexion is diminished, but the patients perform, on average, as well as the general population in non-dynamometric trunk strength measurements.

MRI of rotator cuff muscle atrophy in relation to glenohumeral joint incongruence in brachial plexus birth injury.

PURPOSE: To evaluate rotator cuff muscles and the glenohumeral (GH) joint in brachial plexus birth injury (BPBI) using MRI and to determine whether any correlation exists between muscular abnormality and the development of glenoid dysplasia and GH joint incongruity. MATERIALS AND METHODS: Thirty-nine consecutive BPBI patients with internal rotation contracture or absent active external rotation of the shoulder joint were examined clinically and imaged with MRI. In the physical examination, passive external rotation was measured to evaluate internal rotation contracture. Both shoulders were imaged and the glenoscapular angle, percentage of humeral head anterior to the middle of the glenoid fossa (PHHA) and the greatest thickness of the subscapular, infraspinous and supraspinous muscles were measured. The muscle ratio between the affected side and the normal side was calculated to exclude age variation in the assessment of muscle atrophy. RESULTS: All muscles of the rotator cuff were atrophic, with the subscapular and infraspinous muscles being most severely affected. A correlation was found between the percentage of humeral head anterior to the middle of the glenoid fossa (PHHA) and the extent of subscapular muscle atrophy (r(s)=0.45, P=0.01), as well as between its ratio (r(s)=0.5, P P=0.01). Severity of rotator cuff muscle atrophy correlated with increased glenoid retroversion and the degree of internal rotation contracture. CONCLUSIONS: Glenoid retroversion and subluxation of the humeral head are common in patients with BPBI. All rotator cuff muscles are atrophic, especially the subscapular muscle. Muscle atrophy due to neurogenic damage apparently results in an imbalance of the shoulder muscles and progressive retroversion and subluxation of the GH joint, which in turn lead to internal rotation contracture and deformation of the joint.

Cervical spine in patients with diastrophic dysplasia--radiographic findings in 122 patients.

BACKGROUND: In previous studies, typical radiological findings in the cervical spine of patients with diastrophic dysplasia (DD) have been kyphosis, displacement of the vertebrae, spina bifida occulta (SBO), anterior hypoplasia of vertebrae C3-5, and hyperplasia and dysmorphism of the odontoid process. OBJECTIVES: To make a radiological analysis of the cervical spine in patients with DD. MATERIALS AND METHODS: The study comprised 122 patients (50 males, 72 females), with an average age of 19 years (range newborn-63 years). Follow-up was available on 62 patients (51%), for an average duration of 11 years. Cervical spine alignment was measured according to Cobb's method. The height (H) and depth (D) of the vertebral body and sagittal diameter (S) of the spinal canal were measured. H/D and S/D ratios were then calculated from the measurements. The shape of the vertebrae was assessed. Displacement and movement of cervical vertebrae in neutral and bending radiographs were measured. RESULTS. The average lordosis in the last radiograph was 17(degrees) (range 4 degrees -55(degrees)). Five (4%) patients had a cervical kyphosis with an average of 92(degrees) (range 10-165(degrees)) on their last radiograph. The H/D ratio increased slowly during growth and showed significant correlation with age. There was no growth spurt at puberty. The S/D ratio was fairly stable until 7-8 years of age, when it started to decline slowly. The percentage of vertebrae with a flat vertebral body and narrow spinal canal value tended to increase with age. Vertebral hypoplasia and displacement between vertebrae were most common in the mid-cervical region and resolved spontaneously with age. Degenerative changes seemed to increase with age and were already visible during the second decade of life. SBO was noted in 79% of patients. CONCLUSIONS: The most common alignment in the cervical spine is lordosis in adulthood. The vertebral bodies are flattened and the spinal canal is narrowed. Vertebral body hypoplasia and displacement usually resolve spontaneously during growth. Degenerative changes in the cervical spine are common, but vertebral anomalies are rare. Prevalence of SBO is high.

Does genotype predict development of the spinal deformity in patients with diastrophic dysplasia?

This study analyzed whether genotype can be used to predict development of spinal deformity in patients with diastrophic dysplasia (DD). Severity and natural history of scoliosis vary among patients, but the magnitude of the curves is similar among siblings. Plain radiographs were taken of 69 patients aged 16 years or older. The degree of scoliosis was measured according to Cobb's method. Blood samples were collected from patients clinically diagnosed as having DD and the genotype was determined. Fifty-six patients were found to be homozygous for the Finnish founder DTD mutation, DTDST(Fin). Of these 56, 51 (91%) had scoliosis, with an average curve of 43 degrees (range 12 degrees-188 degrees ). The DTDST(Fin)/R279 W genotype was found in nine patients, and of these, eight (89%) had scoliosis, with an average curve of 34 degrees (range 11 degrees-70 degrees ). The DTDST(Fin)/nondetermined genotype was found in four patients. Three (75%) of them had scoliosis, with an average curve of 126 degrees (range 77 degrees-188 degrees ). Statistical analysis found no difference in the prevalence or magnitude of curves between subgroups. The development and severity of the scoliosis cannot, therefore, be predicted from the genotype. It seems possible that scoliosis development is affected by several genes as well as by external factors.