Subscapularis Lengthening with Synthetic Augmentation for Reversal of Putti-Platt Procedure: A Case Report.

Introduction: The Putti-Platt procedure is a historical technique for anterior shoulder stabilization, largely abandoned because it severely restricts movement, and causes arthritis and chronic pain. Patients continue to present with these sequelae, which can be difficult to manage. Here, we present the first published subscapularis re-lengthening for the reversal of Putti-Platt. Case Report: Patient: A 47-year-old Caucasian manual worker presented 25 years post-Putti-Platt, with chronic pain and movement restriction. External rotation was 0°, abduction was 60°, and forward flexion was 80°. He was unable to swim and struggled to work. Multiple arthroscopic capsular releases had provided no benefit. Technique: The shoulder was opened through the deltopectoral approach, and a coronal Z-incision lengthening tenotomy was made in subscapularis. The tendon was lengthened by 2 cm and the repair was reinforced using a synthetic cuff augment. Results: External rotation improved to 40°, and abduction and forward flexion to 170°. Pain resolved almost completely; Oxford Shoulder Score at 2-year follow-up was 43 (22 pre-operative). The patient returned to normal activity and reported complete satisfaction. Conclusion: This is the first application of subscapularis lengthening to Putti-Platt reversal. Two-year outcomes were excellent, demonstrating potential for significant benefit. Although presentations like this one are rare, our results support the potential of subscapularis lengthening (with synthetic augmentation) in the management of stiffness resistant to conventional treatment after Putti-Platt procedure.

Two-year clinical and radiographic outcomes following uncemented reverse shoulder replacements for proximal humerus fractures.

BACKGROUND: Uncertainty remains regarding the role and long-term outcomes following uncemented reverse shoulder replacements (RSRs) in managing displaced proximal humeral fractures (PHFs). Although RSRs for trauma have traditionally undergone cemented fixation of the humeral component, there is increasing interest in uncemented RSRs. Our primary aim was to evaluate 2-year outcomes following uncemented RSR fixation for 3- and 4-part PHFs in the elderly. A secondary aim was to evaluate if timing of surgery affected outcomes. METHODS: This cohort series evaluated 2-year outcomes for 42 patients with Neer 3- and 4-part PHFs treated with uncemented RSRs between October 2016 and December 2019. Thirty-eight patients (90%) had clinical and radiologic follow-up at a minimum of 2 years. The primary outcomes compared postoperative range of movement, radiographic outcomes, and patient-reported outcome measures (PROMs). The PROMs collected included Oxford Shoulder Scores (OSSs), satisfaction scores, and the Friends and Family Test. The secondary outcome involved a subanalysis to see if outcomes were affected by treatment timing-within 2 weeks, 2-12 weeks, and >12 weeks. RESULTS: The mean age of patients was 74.1 years (range 58-89). There were 11 males and 31 females. No intraoperative fractures were sustained. There was 1 transient axillary neurapraxia, which fully resolved by 4 months. Three patients required postoperative transfusions. During the study follow-up period, no patients developed either deep infections requiring a washout or dislocation, and none underwent further surgery. At 2-year follow-up, radiologic follow-up demonstrated tuberosity union in 29 of 38 cases (76%). Eight of 38 patients (21%) demonstrated some glenoid notching (Sirveaux 1 or 2 only) on radiographic follow-up. There was no evidence of loosening. The mean OSS was 38 (range 15-48). Mean range of movement achieved at 2 years was as follows: forward flexion 122° (50°-180°), abduction 116° (46°-180°), and external rotation 25° (range 5°-60°). Eighteen patients (47%) described their result as excellent, 17 (45%) as good, and 3 (8%) as poor. When comparing the time from injury to treatment, there was no statistically significant difference in complications or radiographic outcomes between the groups. Patients had a reduced forward flexion when treated between 2 and 12 weeks compared with the other groups (P = .019). CONCLUSION: Uncemented RSR is a safe treatment option for the management of complex PHFs in the elderly. We report low complication rates, high patient satisfaction, and good outcomes at 2-year follow-up.

A Virtual Fracture Clinic Pathway for Managing Suspected Paediatric Scaphoid Fractures.

INTRODUCTION: The mismanagement of an occult scaphoid fracture is a significant concern in patients presenting with anatomical snuffbox tenderness and no radiographic signs of injury. AIM: This study investigated whether a virtual fracture clinic (VFC) could improve care efficiency and expedite management decisions surrounding suspected pediatric scaphoid fractures. METHOD: Data was reviewed for patients referred via the VFC for suspected scaphoid fractures at a local trauma unit over 19 months. Patients received an "appointment" in VFC. Based on their notes and imaging, patients were referred to an outpatient clinic for repeat radiographs within two weeks (if initial radiographs demonstrated no fracture). Patients with unremarkable second x-rays were contacted and informed to mobilize and return if the pain persisted at four weeks. RESULTS: The pathway received 175 referrals; 114 male, 61 female, mean age 14 years, range 9-17) with 42 scaphoid fractures diagnosed, 35 (83.3%) on first x-ray, and 7 (16.7%) occult fractures. The pathway managed all patients as intended; 71 patients were seen face-to-face in the clinic due to age or pathology picked up on the first x-ray, and 104 required repeat radiographs. Following the second radiograph, 78 patients were discharged directly. Twenty-six patients required further review in a face-to-face clinic after their second radiograph. CONCLUSION: VFC appears to be a safe and efficient method of managing patients with suspected scaphoid fractures on short-term follow-up analysis. This cohort presents no 'missed' injuries and therefore appears safe compared to conventional treatment pathways.

Outcomes for non-operatively managed fracture neck of femur patients: A single-institution study.

BACKGROUND: The majority of neck of femur (NOF) fractures are treated operatively in the United Kingdom. The literature reports the advantages of operative management for these patients. However, whilst a subset is treated non-operatively, there is currently no clear guidance for the selection and subsequent management of these patients. This study aims to explore the incidence, demographics, inpatient stay, use of imaging and outcomes of patients who have non-operatively managed NOF fractures. METHODS: A 6-year retrospective review (2013-2019) of all non-operatively managed NOF fractures at a tertiary teaching hospital and major trauma centre was conducted. Electronic patient records, radiographs and National Hip Fracture Database (NHFD) data were used to obtain information. We noted demographic details, fracture classification, rationale for non-operative management, mortality, clinical frailty score (CFS), use of imaging and analgesia requirements. Patients who were repatriated or transferred to other sites for specialist surgery were excluded. RESULTS: 3.2% (99/3132) of NOF fractures were managed non-operatively. The two commonest reasons for non-operative management were either 'comfortable mobilisation' (n = 44) or 'patient frailty/medically unwell' (n = 50). 74% (37/50) of the patients in whom operative risk was thought to outweigh benefit died within the 30 days of admission and 1-year mortality for this group was 92% (46/50). Of the "comfortable mobilisation" subgroup only 18% (8/44) of this patient subgroup subsequently required surgical intervention for failed non-operative management. The 30-day mortality for this cohort was 6.8% with a 1-year mortality rate of 25% (11/44). CONCLUSION: For a select group of patients whose fractures are stable enough to allow them to mobilise comfortably, non-operative management resulted in a 25% 1-year mortality rate and average length of stay of 10.1 days. This is comparable to statistics for overall NOF fracture management in the literature according to the NHFD January 2021 report. 82% of this group of patients were successfully managed without an operation indicating that there is a place for the consideration of non-operative management in a small select subgroup of hip fracture patients with minimally displaced, stable fractures. Further analysis is necessary to assess the functional outcomes of this subgroup, as well as the potential cost implications.

Limited sequence MRI to improve standards of care for suspected cauda equina syndrome.

AIMS: Early cases of cauda equina syndrome (CES) often present with nonspecific symptoms and signs, and it is recommended that patients undergo emergency MRI regardless of the time since presentation. This creates substantial pressure on resources, with many scans performed to rule out cauda equina rather than confirm it. We propose that compression of the cauda equina should be apparent with a limited sequence (LS) scan that takes significantly less time to perform. METHODS: In all, 188 patients with suspected CES underwent a LS lumbosacral MRI between the beginning of September 2017 and the end of July 2018. These images were read by a consultant musculoskeletal radiologist. All images took place on a 3T or 1.5T MRI scanner at Stoke Mandeville Hospital, Aylesbury, UK, and Royal Berkshire Hospital, Reading, UK. RESULTS: The 188 patients, all under the age of 55 years, underwent 196 LS lumbosacral MRI scans for suspected CES. Of these patients, 14 had cauda equina compression and underwent emergency decompression. No cases of CES were missed. Patients spent a mean 9.9 minutes (8 to 10) in the MRI scanner. CONCLUSION: Our results suggest that a LS lumbosacral MRI could be used to diagnose CES safely in patients under the age of 55 years, but that further research is needed to assess safety and efficacy of this technique before changes to existing protocols can be recommended. In addition, work is needed to assess if LS MRIs can be used throughout the spine and if alternative pathology is being considered. Cite this article: Bone Joint J 2020;102-B(4):501-505.

Hybrid Fixation in Pediatric Forearm Fractures, does it Predispose to Non-union? A Case Report and Literature Review.

INTRODUCTION: Pediatric fracture non-union is rare, with limited published evidence available. Whilst there have been certain predisposing factors identified throughout case reports/series, we present a case, hypothesizing a previously undocumented risk factor for non-union. CASE REPORT: A 9-year-old boy sustained closed, diaphyseal both bone forearm fractures. He underwent a hybrid fixation (plate fixation of the ulnar and elastic stable intramedullary nail of the radius). Whilst the ulnar fracture healed well, the radial fracture went on to non-union before a second procedure was performed, metalwork removed, and a compression plate utilized. At 2-month post-radial compression plate, there was a union at this site. CONCLUSIONS: There are numerous risk factors for non-union in pediatric fractures which have previously been highlighted throughout literature. We present a case hypothesizing a new risk factor, of hybrid fixation, for pediatric non-union.

Trajectory of physical activity after hip fracture: An analysis of community-dwelling individuals from the English Longitudinal Study of Ageing.

INTRODUCTION: To analyse physical activity participation in a community-dwelling people in England with hip fracture the interval prior to fracture, in the fracture recovery period, and a minimum of two years post-fracture. MATERIALS AND METHODS: 215 individuals were identified from the English Longitudinal Study of Ageing cohort (2002-2014) who sustained a hip fracture following a fall and for whom data were available on physical activity participation relating to the period pre-fracture, within-fracture recovery phase and post-fracture (minimum of two years). Physical activity was assessed using the validated ELSA physical activity questionnaire. Prevalence of 'low' physical activity participation was calculated and multi-level modelling analyses were performed to explore physical activity trajectories over the follow-up phase, and whether age, depression, gender and frailty were associated with physical activity participation. RESULTS: Prevalence of low physical activity participation within two years prior to hip fracture was 16.7% (95% Confidence Intervals (CI): 11.6% to 21.8%). This increased at the final follow-up phase to 21.3% (95% CI: 15.1% to 27.6%). This was not a statistically significant change (P = 0.100). Age (P = 0.005) and frailty (P < 0.001) were statistically significant explanatory variables (P = 0.005) where older age and greater frailty equated to lower physical activity participation. Neither gender (P = 0.288) nor depression (P = 0.121) were significant explanatory variables. CONCLUSION: Physical activity levels do not significantly change between pre-fracture to a minimum of two years post-hip fracture for community-dwelling individuals. This contrasts with previous reports of reduced mobility post-hip fracture, suggesting that 'physical activity' and 'mobility' should be considered as separate outcomes in this population.

A novel technique for accurate Poller (blocking) screw placement.

Achieving good results with intramedullary nailing of oblique long bone fractures at the metaphyseal-diaphyseal junction can be difficult. There is a strong tendency for axial displacement and an association with characteristic malalignment of the short fragment. Poller or blocking screws have been shown to be effective in aiding fracture reduction. While several papers describe methods for screw placement, these are confusing to understand, difficult to follow in clinical practice and not always applicable. Here we describe a new, simple, reproducible and easy to use method for ensuring accurate Poller screw placement, in order to maximise the benefits of their use and achieve good overall results.

Cementless hip arthroplasty in Paget's disease at long-term follow-up (average of 12.3 years).

We present a long-term follow-up report of 33 cementless total hip arthroplasties in 27 patients who have an established diagnosis of Paget's disease. The medium term results of this series were reported in 2007 (Lusty et al. Journal of Arthroplasty. 2007;22:692). Fourteen cases were available for follow-up at an average of 12.3 years (range 10-17). Harris Hip scores improved from 56/100 preoperatively (16-98/100) to 83/100 post operatively (72-90/100). All surviving components were radiographically ingrown. Based on these findings, cementless total hip arthroplasty has a good long-term outcome in Paget's disease.

Type A Aortic Dissection in Pregnancy: Two Operations Yielding Five Healthy Patients.

Type A aortic dissection in pregnancy is a rare, life-threatening condition with a higher incidence in patients with connective tissue diseases. Mortality is high, reflecting the challenges of protecting both maternal and fetal well-being. We discuss two pregnancies complicated by aortic dissection, including one twin pregnancy, and describe the successful aortic repair immediately following Caesarean section. A total of three healthy neonates were delivered. The challenging management and implications of this precarious condition are explored in the context of these cases.