Allografts are not necessary for displaced proximal humeral fractures in patients less than 65 years old,a retrospective cohort study

IntroductionDisplaced proximal humeral fractures (PHF) are frequently treated with locking plates to achieve osteosynthesis. Bone grafts are used as augmentation techniques to improve stability in osteoporotic patients. However, there has been little research into whether bone grafts are necessary for patients younger than 65 years old. This study compared radiographic and clinical outcomes between PHFs augmented with bone grafts or not in a younger population.MethodsBetween January 2016 and June 2020, 91 patients treated with a locking plate alone (LP), and 101 patients treated with locking plates augmented with bone grafts (BG) were analyzed. Potential confounding factors for outcomes were adjusted by propensity score-matching analyses. For the retrospective cohort study, 62 patients from each group were evaluated for radiographic outcomes and clinical outcomes and compared.ResultsSixth-two patients in each group, both with a mean age of 52 years old, were with a mean follow-up time of 25 months in the LP group and 26 months in the BG group. There was no difference in demographic or surgical characteristics between the two groups after propensity score-matching. With regard to radiographic outcomes, the changes in neck-shaft angle (−5.1 ± 4.9 vs. −3.1 ± 5.3, p = 0.015) and humeral head height (−1.5 ± 2.5 vs. −0.4 ± 2.7, p = 0.002) were more obvious in the BG group. However, regarding functional outcomes, there were no significant differences between the two groups in DASH score, Constant–Murley score, or VAS score. Moreover, the complication rate was not significantly different between two groups.DiscussionAllografts only provide minor improvements of stability in radiography for patients less than 65 years old after locking plate fixation of PHFs, but don't improve shoulder function, relieve pain or reduce complications. We concluded that allografts are unnecessary for younger patients with displaced PHFs.     

Comparison Between the Simultaneous Reconstructions of the Anterior Talofibular Ligament and Calcaneofibular Ligament and the Single Reconstruction of the Anterior Talofibular Ligament for the Treatment of Chronic Lateral Ankle Instability

This study aimed to evaluate the procedures of reconstruction surgery for chronic lateral ankle instability. We compared single anterior talofibular ligament reconstruction to simultaneous reconstructions of the anterior talofibular and calcaneofibular ligaments. From 2015 to 2019, 14 consecutive patients diagnosed with chronic lateral ankle instability underwent arthroscopic anterior talofibular ligament reconstruction with or without calcaneofibular ligament reconstruction after conservative treatment. Seven patients underwent single anterior talofibular ligament reconstruction (group AT), and 7 patients underwent simultaneous reconstructions of the anterior talofibular ligament and calcaneofibular ligament (group AC). The Japanese Society for Surgery of the Foot scale scores and Karlsson scores significantly improved in all patients 1 year postoperatively. The radiographic measurement of the talar tilt angle and the talar anterior drawer distance at 1 year after surgery were also significantly improved compared to preoperative values. The postoperative talar tilt angle was significantly greater in group AT (median 6°, range 3°-7°) than that in group AC (median 3°, range 2°-5°; p = .038). The postoperative talar anterior drawer distance, Japanese Society for Surgery of the Foot scale score, and Karlsson score were not significantly different between the 2 groups.We found that although the clinical outcomes after the anterior talofibular ligament reconstruction with or without the calcaneofibular ligament reconstruction for chronic lateral ankle instability were good, instability of the talar tilt angle at 1 year postoperatively in patients who underwent single anterior talofibular ligament reconstruction was greater than that in patients who underwent simultaneous anterior talofibular and calcaneofibular ligament reconstructions.     

Prospective clinical comparisons of semitendinosus versus semitendinosus and gracilis tendon autografts for anatomic double-bundle anterior cruciate ligament reconstruction

Background

The data available from the previously reported clinical studies remains insufficient concerning the hamstring graft preparation in double-bundle anterior cruciate ligament (ACL) reconstruction.

Objective

To test the hypothesis that there are no significant differences between the semitendinosus tendon alone and the semitendinosus and gracilis tendon graft fashioning techniques concerning knee stability and clinical outcome after anatomic double-bundle ACL reconstruction.

Methods

A prospective study was performed on 120 patients who underwent anatomic double-bundle ACL reconstruction according to the graft fashioning technique. The authors developed the protocol to use hamstring tendon autografts. When the harvested doubled semitendinosus tendon is thicker than 6 mm, each half of the semitendinosus tendon is doubled and used for the anteromedial (AM) and posterolateral (PL) bundle grafts (Group I). On the other hand, when the harvested semitendinosus tendon is under 6 mm in thickness, the gracilis tendon is harvested additionally. The distal half of the semitendinosus and gracilis tendons are doubled and used for the AM bundle graft, and the remaining proximal half of the semitendinosus tendon is doubled and used for the PL bundle grafts (Group II). Sixty-one patients were included in Group I, and 59 patients in Group II. The two groups were compared concerning knee stability and clinical outcome 2 years after surgery.

Results

The postoperative side-to-side anterior laxity averaged 1.3 mm in both groups, showing no statistical difference. There were also no significant differences between the two groups concerning the peak isokinetic torque of the quadriceps and the hamstrings, the Lysholm knee score, and the International Knee Documentation Committee evaluation.

Conclusion

There were no significant differences between the two graft fashioning techniques after anatomic double-bundle ACL reconstruction concerning knee stability and postoperative outcome. The present study provided orthopedic surgeons with important information on double-bundle ACL reconstruction with hamstring tendons.

Level of evidence

Level II; prospective comparative study.     

Comparison of clavicular hook plate with and without coracoclavicular suture fixation for acute acromioclavicular joint dislocation

ObjectiveThe aim of this study was to compare the clinical and radiographic outcomes of clavicular hook plate fixation with and without coracoclavicular (CC) tape augmentation for the treatment of acute unstable AC dislocation.MethodsWe treated 47 patients (31 men and 16 women; mean age: 47 years (range, 21–81)) with unstable acute AC dislocations (Rockwood III–V) and divided them into two groups according to the treatment modality, with hook plate fixation (hook plate group) or hook plate plus CC tape augmentation (combined group). We assessed radiologic findings, such as subacromial osteolysis and AC osteoarthritis. We also evaluated the clinical outcomes using a visual analogue scale (VAS) for pain, as well as the University of California at Los Angeles (UCLA) Shoulder Rating Scale and the American Shoulder and Elbow Surgeons (ASES) Shoulder Score.ResultsWe found that the combined group had less subacromial osteolysis upon radiography, although the CC distance was similar in both groups (119 ± 29.7% of contralateral side CC distance in hook plate group versus 119 ± 34.8% in the combined group, p = 0.77). Compared with the hook plate group, the combined group had a lower VAS score (4.5 ± 2.3 in hook plate group versus 2.3 ± 1.4 in the combined group, p < 0.001), better UCLA scores (19.9 ± 4.9 in hook plate group versus 27.2 ± 4.0 in the combined group, p < 0.001) as well as better ASES scores (51.9 ± 17.8 in hook plate group versus 73.8 ± 13.1 in the combined group, p < 0.001) at 3 and 6 months after surgery.ConclusionHook plate fixation plus CC tape augmentation may prevent subacromial osteolysis and yield better short-term functional outcomes.Level of EvidenceLevel III, Therapeutic Study.     

Biomechanik aktueller Rekonstruktionstechniken bei Schultereckgelenksprengungen

Current techniques for acromioclavicular (AC) joint repair primarily focus on the reconstruction of the coracoclavicular (CC) ligaments. However, it is unclear whether this approach is sufficient to restore vertical as well as horizontal AC joint stability and kinematics. Therefore, this review summarizes the biomechanical characteristics of current procedures as they have been revealed by in vitro investigations. As a basic result, neither selective repairs of the CC ligaments nor selective repairs of the AC ligaments could be shown to restore both vertical and horizontal joint stability. Similar to the intact ligaments, CC repair primarily provides vertical joint stability, while AC repair is able to restore horizontal stability. Thereby, the lack of horizontal stability of the CC repairs could not be compensated using tendon grafts, double-bundle techniques, and flip-button fixation. In conclusion, a biomechanical effective treatment of AC joint separation should analyze the individual instability pattern in the first step. In the second step, an adequate surgical treatment considering CC and AC stabilization should be performed meeting the individual demands.     

Dynamic functional performance and kinematic analysis of the rotational patterns of single- versus double-bundle anterior cruciate ligament reconstruction

BackgroundThe evaluation of anterior cruciate ligament (ACL) reconstruction has typically focused on the restoration of rotatory stability. Some studies have compared single-bundle and double-bundle ACL reconstruction using subjective clinical tests and questionnaires, but these studies only provide limited data on rotational stability. The purpose of this study is to determine the rotational patterns that present during high-demand pivoting tasks and to evaluate any difference in kinematic rotational patterns between patients who have undergone single- or double-bundle ACL reconstruction.Materials and MethodsTwenty-four males were divided into four groups for this study: intact, ACL deficient, single-bundle reconstructed, and double-bundle reconstructed. Kinematic data were collected using a 10-camera optoelectronic motion analysis system while the participants performed high-demand landing and pivoting tasks. The evaluation period was defined as the time from when the tested foot made contact with the ground to takeoff, and the range of tibial rotation was measured.ResultsRotation was significantly reduced in the single-bundle ACL reconstructed knees (7.8° ± 3.4°) and double-bundle ACL reconstructed knees (7.5° ± 2.6°) in comparison with ACL-deficient knees (13.5° ± 3.7°; p < 0.05). There was no significant difference in terms of tibial rotation between the intact knees (6.5° ± 3.5°) and the single-bundle or double-bundle ACL reconstructed knees after >2 years of follow up (p > 0.05).ConclusionBy using a dynamic functional biomechanical assessment, we demonstrate that the single-bundle ACL reconstruction technique using a composite hamstring tendon graft and the double-bundle ACL reconstruction technique can adequately restore excessive tibial rotation during high-demand activities such as landing and pivoting.     

Minimalinvasive Schultereckgelenkstabilisierung mit freiem Sehnentransplantat

Revision surgery following unsuccessful acromioclavicular (AC) joint stabilization and chronic joint instability presents a great challenge in orthopedics. In those cases, sufficient healing of the coracoclavicular (CC) ligaments cannot be expected. Different kinds of procedures are described for the operative treatment of chronic AC joint instability that can be divided into anatomic and non-anatomic techniques. The basic idea is to provide stability and a biological basis for the ligamentization process of the CC ligaments. The anatomic, minimally invasive operation techniques using TightRope? or similar pulley systems in combination with a free tendon autograft have turned to a widely accepted and used treatment for chronic acromioclavicular (AC) joint separations.     

前交叉韧带单束重建和双束解剖重建短期临床疗效的病例对照研究

目的:比较关节镜下采用单束重建和双束重建前交叉韧带的临床效果。方法:自2009年1月至2010年5月,45例前交叉韧带撕裂患者分别行前交叉韧带解剖双束重建(双束重建组)和自体腘绳肌腱前交叉韧带单束重建(单束重建组)。双束组22例,男15例,女7例;年龄(27.04±3.68)岁;运动损伤3例,交通损伤19例。单束组18例,男13例,女5例;年龄(28.16±4.76)岁;运动损伤2例,交通损伤16例。按照IKDC、Lysholm膝关节评分标准及Lachman试验、轴移试验及KT-1000评估疗效。结果:双束重建组22例、单束重建组18例均获随访,时间12个月。单束重建组IKDC评分从术前(41.40±6.30)分提高至(95.70±3.10)分;Lysholm评分从(47.20±6.30)分提高至(94.20±2.40)分,双束重建组IKDC评分从术前(40.90±6.10)分提高至(96.10±3.40)分,Lysholm膝关节评分从术前(48.10±6.50)分提高至(95.10±2.49)分,两组差异无统计学意义。两组患者中均有1例Lachman试验I度阳性,1例轴移试验阳性。双束重建组KT-1000值(1.5±1.2)mm,单束重建组KT-1000值(1.9±1.5)mm,两组差异无统计学意义。结论:关节镜下采用单束重建和双束重建前交叉韧带临床疗效无明显差异。     

Acute high-grade acromioclavicular dislocations treated with triple button device (MINAR): Preliminary results

ObjectiveDescribe the clinical and radiological results of triple button device in the treatment of high-grade AC dislocations (Rockwood, type V) and assess whether improves vertical and horizontal stability compared to the techniques previously described.Material and methodsThis retrospective study included 39 patients with type V acromioclavicular dislocations treated with Twin Tail TightRope™ system (triple button device). Of the 39 patients, 33 (26 men and 7 women) were able to participate in clinical and radiographic follow up. At the time of surgery, the mean age was 25 years ± 7 (range, 17–49). All patients underwent bilateral-weighted Zanca (CC distance) and Alexander view (AC distance) as well as the Constant Score (CS) and Acromioclavicular Joint Instability Scoring System (ACJI). Radiological and clinical outcome was assessed during routine follow-up examinations preoperatively, postoperatively, 1, 3, 6 months and every year after the surgery. The presence of calcification, degenerative changes, mobilization of implants and bone resorption were also assessed.ResultsAfter a mean follow up of 25 ± 4 months (range 14–38), the results of the Constant (CS) were 94.1 ± 5,5 (range 76–100) and test ACJI 87.3 ± 9,8 (range 65–100), showing no significant differences with the uninjured shoulder (CS 95.8 ± 2.5, range 83–100; ACJI 94.1 ± 3.7, range 80–100). At final review, we observed that preoperative coracoclavicular distance (Zanca View) improved from 21,75 ± 1.97 mm to 8,73 mm ± 0.75 and the acromioclavicular distance (Alexander View) from 12,65 mm ± 1.99 to 0,35 ± 0.3 mm. Compared with healthy shoulder, these differences were not significant. There was no loss of reduction with this system in the vertical plane. 4 patients (12.12%) revealed signs of posterior instability with worse clinical test results. The presence of degenerative joint changes (6,06%), calcifications (27,2%) or mobilization of the implant (18,18%) was not associated with worse clinical outcomes.ConclusionTwin Tail device using minimally invasive technique improves stability in the vertical and, specially in the horizontal plane relative to the previously described techniques without increasing number of complications.     

Prospective evaluation of patients with anterior cruciate ligament reconstruction using a patient-based health-related survey: comparison of single-bundle and anatomical double-bundle techniques

Purpose  

To compare the treatment outcomes of single-bundle and anatomical double-bundle anterior cruciate ligament (ACL) reconstructions, we used the patient-based health-related QOL questionnaire SF-36 to evaluate patients with ACL injury who underwent surgical reconstruction using the two techniques.     

Double-bundle reconstruction of the anterior talofibular ligament by partial peroneal brevis tendon

BackgroundAnatomic anterior talofibular ligament (ATFL) reconstruction with autologous single-bundle tendon has been widely used in the treatment of ATFL injury. However, there are few clinical reports of using the peroneus brevis tendon (PBT) for double-bundle ATFL reconstruction. The aim of this study was to investigate the clinical effect of double-bundle ATFL reconstruction with PBT.MethodsThis was a retrospective review of all patients diagnosed with ATFL injury presenting from August 2019 to December 2021. Fifty-three patients were selected after screening based on the inclusion and exclusion criteria. The following data were compared before and after surgery: Visual Analogue Scale (VAS) score, American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), the pain interference (PI) and physical function (PF) scores of the Patient-Reported Outcomes Measurement Information System (PROMIS), the diameter and width of PBT in ultrasound and muscle strength.ResultsAll functional scores (VAS, PI/PF, AO-FAS, KAFS) and muscle strength were significantly improved at the last follow-up (P < 0.05). The diameter and width of the PBT on ultrasound postoperation were smaller than those preoperatively.ConclusionDouble-bundle ATFL reconstruction with the partial PBT technique is a feasible, anatomic reconstruction technique for chronic lateral instability of the ankle, which meets the anatomical characteristics of the double bundle of the ligament, and the absence of partial PBT does not affect the peroneal muscle strength.Level of evidenceLevel IV, retrospective case series.     

Residual graft tension after graft fixation in anterior cruciate ligament reconstruction: Manual vs tensioning boot techniques

BackgroundGraft fixation at quantitative tension using a manual tensioner was advocated in ACL reconstruction, while the measured tension that is based on the surgeon's hand with the tensioner decreases after graft fixation. Therefore, our purpose is to elucidate how effectively the pre-determined graft tension maintained after final fixation of the graft to the tibia using a tensioning boot system fixed to the calf with a bandage, while monitoring the graft tension based on tibia.MethodsEight cadaveric legs (mean age: 83; 3 males and 5 females) underwent an anatomic double-bundle anterior cruciate ligament (ACL) reconstruction with hamstring tendon grafts. Two tension-adjustable force gauges were installed on the lateral femoral cortex beside the femoral tunnel. Then #5 strong suture wires through the loop end of grafts were tied to the force gauges using Endo-Buttons. After manual maximum load was repeatedly applied to each graft for 3 min, the grafts were fixed to the tibia with 10 N or 20 N at 20 degree of flexion with the following tensioning techniques using double spike plate system: (1) Manually tensioning technique (MT); (2) Tensioning boot technique with flexion-extension motion (TB-FE); and (3) Tensioning boot technique with repetitive pull (TB-RP). The residual tension at 20 was measured 3 min after grafts fixation, and also after 10 and 50 times of repeated flexion-extension motion. One-way repeated measures ANOVA was used for statistical analysis among the three techniques.ResultsThere were significant differences among three techniques fixing grafts with 10/20 N of initial tension in the residual tension 3 min after graft fixation and after 10 and 50 times of repeated flexion-extension motion. Among them, the residual tension in TB-RP was the greatest in most conditions.ConclusionTB-RP is the most secure procedure to maintain the graft tension closer to the intended initial tension in ACL reconstruction.     

Free tissue versus local tissue: A comparison of outcomes when managing open tibial diaphyseal fractures

IntroductionOpen lower extremity fractures pose a challenge for treating surgeons. All surgical strategies have the common aim to facilitate fracture healing. Fracture union, however, should be critically considered in the context of functional recovery and not in isolation. Both local and free tissue transfer have benefits and drawbacks.AimThis study aims to compare the functional outcomes of open tibial diaphyseal fractures managed with internal fixation, comparing outcomes of those receiving free tissue transfer as opposed to local flapsMethodsThis study follows the STrengthening the Reporting of Observational studies in Epidemiology (STROBE) criteria. Data were collected retrospectively from a prospectively maintained database at our institution. Inclusion criteria included a non-comminuted Gustilo type-IIIB open tibial diaphyseal fracture requiring intramedullary nailing. Forty three patients with local flaps and 180 patients with free flaps were includedResults and conclusion233 patient underwent reconstruction for open fracture using local flaps (n=43) or free flaps (n=180). In the context of Gustilo type-IIIB non-comminuted, mid-tibial diaphyseal fractures treated with intramedullary nailing, free fasciocutaneous flap reconstructions leads to significantly improved functional outcomes in patients of all ages when compared to local fasciocutaenous flaps. (77 ± 19 v 50 ± 22 % for local flaps; P < 0.001).     

Outcome of conjoined tendon and coracoacromial ligament transfer for the treatment of chronic type V acromioclavicular joint separation

BackgroundNumerous surgical methods are used to treat acromioclavicular (AC) joint dislocations, and an anatomical reconstruction using a free tendon graft has attracted considerable attention, particularly for chronic cases. The purpose of this study was to introduce the results of lateral half conjoined tendon (LHCT) and coracoacromial ligament (CAL) transfer for chronic type V injuries.Materials and methodsA retrospective evaluation was performed on the clinical and radiographic outcomes of the 12 patients who underwent LHCT and CAL transfer for chronic type V AC injuries and had been followed for 2 years postoperatively. All 12 patients were males with a mean age of 37.3 ± 7.7 years (range: 26–49 years) at surgery. The causes of the injury were traffic accidents (five), falls (three) and sports injuries (four). The mean time elapsed between trauma and surgery was 12.5 ± 5.4 weeks (range: 7–22 weeks).ResultsNo reduction loss was observed at the final follow-up. The postoperative coracoclavicular (CC) distance was 8.9 ± 1.6 mm, which represented a significant improvement versus the preoperative status (20.3 ± 3.0 mm; p < 0.001), and no significant difference was observed between the injured and uninjured contralateral sides (8.7 ± 0.8 mm), postoperatively (p = 0.619). The temporary use of a Steinman pin for AC fixation did not cause any complications. On the other hand, there were eight cases of mild radiographic arthrosis at the AC joint and two cases of heterotopic ossification of the CC space, although neither affected the functional outcomes. The mean modified UCLA score was 18.5 ± 2.1 (range: 12–20), which represented an excellent result in 11 of the 12 cases. The single case with a poorer postoperative score had a pre-existing brachial plexus injury.ConclusionsDespite the small study cohort, the results of LHCT and CAL transfer in chronic type V AC separation are promising. CAL transfer alone has been shown to be biomechanically insufficient for an AC reconstruction, particularly in chronic situations. The advantage of LHCT transfer is that it does not require a distant donor site or incur the costs of an allograft or implant.     

A Prospective,Randomized Comparison of the Long-Term Clinical and Radiographic Results of an Ultra-Short vs a Conventional Length Cementless Anatomic Femoral Stem

BackgroundThe purpose of this study is to compare the long-term clinical and radiographic results, survival rates, and complication rates of an ultra-short vs a conventional length cementless anatomic femoral stem.MethodsWe reviewed 759 patients (858 hips) (mean age, 56.3 ± 12.9 y) who had an ultra-short cementless anatomic stem and 759 patients (858 hips) (mean age, 54.8 ± 12.3 y) who had a conventional length cementless anatomic stem. The mean follow-up was 16.5 years (range 14-17) in the ultra-short stem group and 17.5 years (range 17-20) in the conventional stem group.ResultsAt the latest follow-up, there were no significant differences between the 2 groups in terms of the Harris Hip Scores (92 ± 6 vs 91 ± 7 points, P = .173), Western Ontario and McMaster Universities Osteoarthritis scores (12 ± 8 vs 13 ± 7 points, P = .972), University of California Los Angeles activity scores (7.6 vs 7.8 points, P = .841), patient satisfaction scores (7.7 ± 2.3 vs 7.5 ± 2.5 points, P = .981), and survival rates (97.6% vs 96.6%). However, incidence of thigh pain (P = .031) and stress shielding (P = .001) was significantly higher in the conventional length stem group than in the ultra-short anatomic stem group. Complication rates were similar (1.8% vs 2.7%) between the 2 groups.ConclusionAlthough an ultra-short cementless anatomic femoral stem confers equivalent clinical and radiographic outcomes, survival rates, and complication rates to conventional length cementless anatomic stem, the incidence of thigh pain and stress shielding was significantly lower in the ultra-short cementless anatomic stem.Level of EvidenceTherapeutic Level I.     

Single vs Multiple Arterial Reconstructions in Living Donor Liver Transplant

BackgroundIt is true that multiple arterial reconstructions are sometimes required in living donor liver transplant (LDLT). However, the best procedure is still controversial regarding arterial reconstruction in liver grafts with multiple arteries.MethodsA total of 93 patients, 55 right lobe grafts and 38 left lobe grafts, who underwent LDLT at our university from 2003 to 2017 were enrolled for this study. Regarding arterial reconstruction in grafts with multiple hepatic arteries, the dominant artery was reconstructed first. Subsequently, when both the pulsating arterial flow from the remaining artery stumps and the intra-graft arterial flow by Doppler ultrasonography were confirmed, the remaining arteries were not reconstructed. The patients were divided into the following 3 groups: (1) single artery/single reconstruction (n = 81), (2) selective arterial reconstruction of multiple arterial grafts (n = 7), and (3) multiple arterial reconstructions (n = 5).ResultsA total of 12.9% (12/93; right lobe: 2/55; left lobe 10/38) of grafts had multiple arteries. The incidence of multiple arteries was significantly higher in the left lobe grafts (P = .0029). The arterial diameters (SD) of multiple arterial grafts were narrower (2.43 [0.84] mm) than single arterial grafts (3.70 [1.30] mm) (P = .0135). Extra-anatomic arterial reconstruction were frequently required in multiple arterial reconstructions (group 1 and 2 vs 3) (P = .0007). The strategy of selective arterial reconstruction with the above criteria did not negatively affect the rates of biliary complications or the overall patient survival (P = .52).ConclusionsIt can be argued that selective arterial reconstructions demonstrated acceptable outcomes in LDLT, provided that the above criteria were satisfied.     

Short-term clinical and radiographic outcomes in patients treated with a modern intramedullary nailing system for 2-part proximal humerus fractures

ObjectivesThe optimal surgical treatment of displaced proximal humerus fractures (PHFs) remains controversial. There are advocates for both open reduction and internal fixation with plate and screws (ORIF) and intramedullary nailing (IMN). The purpose this study was to evaluate the early-term clinical and radiographic outcomes of IMN for isolated, displaced 2-part surgical neck PHFs using a modern, straight nail system and to determine the effect of preoperative patient and fracture characteristics on outcome.MethodsThis was a case series of 23 patients with displaced 2-part surgical neck PHFs who were treated with ORIF using a straight IMN with minimum follow-up of 1 year (mean 2.5 years [range, 1.1–4.6]). Patients were identified retrospectively and contacted for measurement of active range of motion (AROM) and patient reported outcome measures (PROMs) including the American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder Score (OSS), and Single Assessment Numeric Evaluation (SANE), EuroQol-5D (EQ-5D), and Visual Analog Scale Pain score (VAS Pain). Plain radiographs were evaluated to assess the quality of the reduction and failure of fixation. Complications and reoperations were identified.ResultsReduction was anatomic in 12 (52%) patients, acceptable in 9 (39%), and 2 (9%) were malreduced. There were no differences in reduction quality based on sex (p = 0.37), age at surgery (p = 0.68), calcar comminution (p = 0.68), number of screws in the head (p = 0.99), or medial hinge disruption (p = 0.06). At final follow-up, the mean ASES score was 92 ± 10, OSS was 45 ± 4, SANE was 93 ± 7, EQ-5D of 0.85 ± 0.17, and VAS Pain was 0 ± 1. The mean active forward flexion was 143° ± 16°, active external rotation was 68° ± 20°, and internal rotation was T11 ± 4 vertebrae. Two (9%) patients underwent reoperation and 2 (9%) patients experienced clinical failure not requiring reoperation.ConclusionsStraight IMN is a reliable treatment for displaced 2–part surgical neck PHFs with excellent radiographic and clinical outcomes in early follow-up. The implant facilitated anatomic or acceptable alignment of the fracture in the vast majority of patients.     

The results of tension band rotator cuff suture fixation of locked plating of displaced proximal humerus fractures

IntroductionThe purpose of this study was to assess 1-year outcomes of patients with displaced proximal humerus fractures who underwent treatment with locked plate fixation with rotator cuff suture augmentation.MethodsA total of 86 patients who had sustained 2, 3 and 4-part displaced proximal humerus fractures underwent locked plate fixation with multiple sutures placed in the cuff tendons. Clinical outcome variables included active forward elevation (AFE), active external rotation (AER), and Constant and American Shoulder and Elbow Surgeons (ASES) scores. Post-operative variables included the following complications: varus re-collapse, loss of fixation, osteonecrosis of the humeral head (AVN), screw cut out, hardware failure and infection.ResultsForty-one patients were available with minimum of 1-year follow-up. Mean AFE was 142 ± 17.0° and AER was 41 ± 13.0°. The overall complication rate was 14.6%, with osteonecrosis being the most common (12.2%). Of the 21 patients (51.2%) that initially had varus displacement, all but one maintained anatomic reduction and fixation. Mean ASES score was 78.2 ± 20.0 and average Constant score was 72.7 ± 17.6. Bivariate analyses demonstrated that pre-operative medial comminution (p = 0.297) or varus collapse (p = 0.95) were not associated with an increased likelihood of sustaining a complication.ConclusionsFollow-up of patients in this series demonstrated a low overall complication rate and excellent functional outcomes. We believe suture augmentation of the rotator cuff can counteract varus forces on proximal humerus fractures fixed with locked plates, and should be performed routinely in displaced 2, 3 and 4 part fractures.     

Greater Knee Soft Tissue Thickness Predisposes Patients to Subsequent Periprosthetic Joint Infection After Total Knee Arthroplasty

BackgroundAlthough obesity is a risk factor for periprosthetic joint infection (PJI) after total knee arthroplasty (TKA), the role of soft tissue thickness (STT) at the surgical site has not been well studied. This study examined if increased STT in the medial and anterior aspects of the knee are independent risk factors for PJI.MethodsA retrospective study was conducted on 206 patients who underwent 2-stage exchange arthroplasty for PJI from 2000 to 2015. They were matched 1:3 to a control group of primary, noninfected TKA patients with minimum 2 years infection-free survival by age, gender, age-adjusted Charlson Comorbidity Index, date of surgery, and body mass index (BMI). Two blinded orthopedic surgeons measured the medial STT from the medial aspect of the knee at the level of the joint line on an anteroposterior radiograph, and anterior STT 8 cm above the joint line on a lateral radiograph from the skin to the quadriceps tendon.ResultsIncreased STT was significantly associated with a higher risk for PJI. The mean anterior STT was 29.74 ± 13.76 mm in the PJI group and 24.88 ± 9.76 mm in the control group. The mean medial STT was 42.42 ± 14.66 mm for PJI and 37.27 ± 12.51 mm for control. Both STT measurements were significantly higher in PJI cases with BMI <30 kg/m² vs control patients with BMI <30 kg/m².ConclusionAnterior and medial knee STT was an independent risk factor for PJI after primary TKA and represents a simple radiographic method to assess postoperative infection risk. Excess adipose tissue around the surgical site can predispose patients to PJI after TKA regardless of BMI.