All-epiphyseal versus trans-epiphyseal screw fixation for tillaux fractures: Does it matter?

BACKGROUND: Tillaux fractures occur primarily in adolescents due to the pattern of physeal closure and are classified as Salter-Harris type III physeal fractures. Operative management with screw fixation is recommended for more than 2 mm of displacement or more than 1 mm of translation. However, the efficacy and complications of trans-physeal vs all-physeal screw fixation have not been investigated extensively. AIM: To compare the clinical and functional outcomes of trans-physeal (oblique) and all-epiphyseal (parallel) screw fixation in management of Tillaux fractures among pediatric patients. METHODS: This was an ethics board approved retrospective review of pediatric patients who presented to our tertiary children's care facility with Tillaux fractures. We included patients who had surgical fixation of a Tillaux fracture over a 10 year period. Data analysis included demographics, mode of injury, management protocols, and functional outcomes. The patients were divided into group 1 (oblique fixation) and group 2 (parallel fixation). Baseline patient characteristics and functional outcomes were compared between groups. Statistical tests to evaluate differences included Fisher's Exact or Chi-squared and independent samples t or Mann Whitney tests for categorical and continuous variables, respectively. RESULTS: A total of 42 patients (28 females and 14 males) were included. There were no significant differences in body mass index, sex, age, or time to surgery between the groups [IK2]. Sports injuries accounted for 61.9% of the cases, particularly non-contact (57.1%) and skating (28.6%) injuries. Computed Tomography (CT) scan was ordered for 28 patients (66.7%), leading to diagnosis confirmation in 17 patients and change in management plan in 11 patients. [GRC3] Groups 1 and 2 consisted of 17 and 25 patients, respectively. For mid to long-term functional outcomes, there were 14 and 10 patients in groups 1 and 2, respectively. Statistical analysis revealed no significant differences in the functional outcomes, pain scores, or satisfaction between groups. No infections, non-unions, physeal arrest, or post-operative ankle deformities were reported. Two (4.8%) patients had difficulty returning to sports post-surgery due to pain. One was a dancer, and the other patient had pain while running, which led to hardware removal. Both patients had parallel fixation. Hardware removal for groups 1 and 2 were 4 (23.5%) and 5 (20.0%) patients, respectively. The reasons for removal was pain in 2 patients, and parental preference in the remaining. CONCLUSION: This is the largest reported series of pediatric patients with Tillaux fractures comparing functional outcomes of different methods of screw fixation orientation to the physis, which showed no difference regarding functional outcomes.

Patient satisfaction and clinical outcomes of reverse shoulder arthroplasty: a minimum of 10 years' follow-up.

BACKGROUND: Reverse shoulder arthroplasty (RSA) has been shown to reliably improve pain and functional outcomes for multiple pathologies. Despite its increasing use in the United States since its introduction in 2004, few studies have investigated long-term outcomes of this procedure. This information is vital in many ways, including durability of functional outcomes, complication profiles, and implant survivorship. METHODS: Our prospectively collected shoulder arthroplasty registry included 471 patients who had undergone RSA prior to December 31, 2010, by a single surgeon at a high-volume shoulder arthroplasty center. The study sample included 94 patients with a minimum of 10 years' follow-up, and we evaluated the indications for RSA, complications, pain, Single Assessment Numeric Evaluation (SANE), and patient satisfaction on these patients at baseline, 2-5 years, and 10 or more years of follow-up. Prosthesis survivorship was determined by Kaplan-Meier survival analysis performed with revision for any reason as the end point for all 471 patients in the study period regardless of follow-up interval. RESULTS: The 93 patients with at least 10 years of follow-up were 63% female (60) and 37% male (34), with an average age of 66±10 years at the time of RSA. There were 70 (75%) primary RSAs and 23 (25%) revision RSAs. Patient-reported outcome measures at 10 years or more included a current pain rating averaging 2±3 on a 0-10 scale and Single Assessment Numeric Evaluation (SANE) of 73±28. There was no deterioration in function or pain from midterm to long-term follow-up, as the SANE and pain score changed by less than the minimal clinically important difference or improved in 87% and 90% of patients, respectively. Overall, patients were satisfied with the RSA procedure, with 52 (56%) very satisfied, 24 (26%) satisfied, 13 (14%) dissatisfied, and 4 (4%) very dissatisfied. For the subset of 68 patients who were contacted for follow-up, 64 (94%) would have the procedure again and 4 (6%) would not. Kaplan-Meier prosthesis survival rate for all 471 RSA patients was 88% (95% confidence interval [CI] 84%-92%) at 5 years and 81% (95% CI 74%-86%) at 10 years. CONCLUSIONS: This study presents the largest American cohort of Grammont design RSA at a minimum 10-year follow-up. Although RSA provided clinically significant and durable improvements in pain and function, the complication and revision rates were higher than prior reports. Despite this, the vast majority of patients were satisfied and would have the procedure again.

Does the stabilization of the calcaneocuboid joint with Steinmann pin in Evans osteotomy affect its incidence of arthritis?

PURPOSE: This study aims to determine the effect of retaining a Steinmann pin in the calcaneocuboid joint on its rates of arthritis following Evans calcaneal osteotomy lengthening procedure. The study hypothesized that leaving the pin across the calcaneocuboid joint post-operatively would lead to higher rates of arthritis. METHODS: This is a retrospective review of patients under 18 years of age who underwent Evans osteotomy at our hospital from January 2015 to May 2020. The Patients were stratified into 2 groups: Group 1 (pin was left post-operatively across the joint and removed on follow-up) and Group 2 (pin was removed during surgery). Demographic data were recorded, including age, sex, and body mass index. Calcaneocuboid arthritis was determined by radiographic imaging at least one-year follow-up. Time to pin removal, size of the pin and graft, and subluxation were analyzed as possible risk factors for arthritis. Odds ratios (OR) and corresponding 95% confidence intervals (CI) were estimated. RESULTS: 39 patients were included in the study: 24 patients had the pin removed post-operatively, and 15 had the pin removed intra-operatively. There were no significant differences between the 2 groups regarding body mass index, age, sex, or laterality. Calcaneocuboid arthritis rates were significantly higher in the Group 1 than Group 2 (12(50%) vs. 2(13.3%), respectively; p = 0.02). On multivariate regression, both age (OR, 1.305 [95%CI: 1.009-1.696]; p = 0.044) and leaving the pin in the joint postoperatively (OR, 7.661 [95%CI: 1.208-48.570]; p = 0.031) were found as risk factors for arthritis at follow-up. The mean time to pin removal, the size of the pin, and the size of the graft were not found to be significant predictors of arthritis (p > 0.05). CONCLUSIONS: This study shows that leaving the Steinmann pin in the calcaneocuboid joint in children post-operatively is associated with an increased risk of developing early radiographic signs of calcaneocuboid joint arthritis.

Novel assessment of leukocyte-rich platelet-rich plasma on functional and patient-reported outcomes in knee osteoarthritis: a pilot study.

Background: Leukocyte-rich platelet-rich plasma (LR-PRP) has demonstrated to be beneficial for patients with knee osteoarthritis (KOA); however, reliable objective end points to accurately assess its therapeutic effects is lacking. Aim: To investigate the efficacy of LR-PRP as assessed by functional and patient-reported outcomes at early time points (6 weeks). Materials & methods: We conducted a prospective cohort study in 12 patients with diagnosed KOA (Kellgren Lawrence score of II-III), who underwent a single ultrasound-guided LR-PRP injection. Results: There was significant improvement in timed up and go, pain and quality of life scales and balance parameters. There were nonsignificant improvements in range of motion and gait parameters. Conclusion: LR-PRP demonstrates efficacy in meaningful end points for functional and patient-reported outcomes at early time points in patients with KOA.

Anatomic and reverse shoulder arthroplasty in patients 70 years of age and older: a comparison cohort at early to midterm follow-up.

BACKGROUND: Reverse shoulder arthroplasty (RSA) has gained popularity in elderly patients because of its limited reliance on rotator cuff function and high survivorship rates. However, although there are theoretical advantages of RSA over anatomic total shoulder arthroplasty (TSA) in elderly patients, there is little data to guide surgeons on implant selection in this population. METHODS: Patients were identified from our prospectively collected shoulder arthroplasty registry. We included patients between the age of 50 and 89 years who underwent primary TSA for osteoarthritis with intact rotator cuff or primary RSA for cuff tear arthropathy. The minimum and mean clinical follow-up was 2 and 3.1±1.3 years, respectively. Four patient groups were formed for analysis: (1) TSA age 50-69 years (n=274), (2) TSA age 70-89 years (n=208), (3) RSA age 50-69 years (n=81), and (4) RSA age 70-89 years (n=104). We evaluated age group differences in pain, Constant score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, patient satisfaction, complications, and revisions. RESULTS: All groups showed significant improvements from preoperative to final follow-up for all outcome measures (P < .001). Visual analog scale for pain average score decreased from 5.8 preoperatively to 1.1, with no significant differences between groups (TSA P = .180; RSA P = .103). Final ASES scores and improvement from preoperative ASES score between the age groups were not significantly different (TSA P = .520; RSA P = .065). There were no significant differences in outcomes between TSA in patients older than 70 years vs. patients younger than 70 years (all P > .05); however, older RSA patients reported better function during activities of daily living (P = .020) than their younger counterparts. Patients undergoing TSA had a lower revision rate of 3.9% compared with 8.1% in the RSA group (P = .043). CONCLUSIONS: TSA and RSA are reliable procedures for patients older than 70 years, and have comparable results to their respective patient cohorts younger than 70 years. Although some surgeons anecdotally advocate for RSA in patients older than 70 years with primary osteoarthritis and an intact rotator cuff, we found no difference in outcomes for TSA based on our age cutoff. Given satisfactory results following TSA in patients 70 years of age and older, we do not routinely perform RSA for primary osteoarthritis with an intact rotator cuff solely based on age. Further studies and longer follow-up are needed to determine the optimal implant selection for elderly patients with primary osteoarthritis.

Rectus femoris intrasubstance tear in a collegiate football kicker and its mechanism.

Rectus femoris muscle belly tears have not been reported in the literature to our knowledge. This is a case of an isolated rectus femoris intrasubstance tear in a healthy college football kicker possibly caused by the eccentric and concentric load cycles associated with kicking activities. Dynamic ultrasound was crucial in establishing a diagnosis and investigating the mechanism behind this rare injury.