Arthroscopically Assisted Suprapatellar Tibial Nail Removal.

Intramedullary nailing remains the most popular and preferred method of fixation for tibial shaft fractures. The infrapatellar approach through the patellar tendon has long been considered the gold standard. However, the suprapatellar approach has gained popularity because of the advantages of being easier to perform when treating proximal shaft and metaphyseal fractures and there being less postoperative anterior knee pain. Despite increased use of this approach, the removal of the implant from the same suprapatellar approach is tricky, and in most cases, the removal is performed through a new transpatellar tendon approach. This article describes arthroscopically assisted suprapatellar tibial nail removal using the same approach and instrumentation of the nail insertion. The technique has the advantage of preserving the patellar tendon without causing secondary damage to it. Through arthroscopy, direct visualization of the patellofemoral joint aids in preventing possible cartilage injury. Moreover, any associated intra-articular lesions can be diagnosed and addressed.

Improved outcomes of older patients with acute and displaced proximal humerus fractures treated with window bone ingrowth fracture-specific stem reverse shoulder arthroplasty.

BACKGROUND: The optimal treatment of displaced proximal humerus fractures (PHFs) in the older people population remains controversial. Reverse shoulder arthroplasty (RSA) is a popular surgical treatment option that provides improved and reproducible results. However, the relevance of fracture-specific stem designs for RSA to improve tuberosity consolidation and shoulder function remains debatable. METHODS: This study included all patients 70 years or older with acute and displaced PHFs primarily treated with RSA at a single institution in Portugal, between January 2010 and December 2019 who participated in a minimum follow-up of 2 years. RESULTS: A total of 112 patients (15 men and 97 women) with a median clinical follow-up of 52 months were included. The mean age at the time of fracture was 78.6 years. All fractures were classified as Neer types 3 and 4 (n = 50 and n = 62, respectively). A window bone ingrowth fracture-specific stem was used for 86 patients, and a conventional humeral stem was used for 26 patients. Regarding the tuberosity fixation technique, 76 tuberosities were attached using technique A (according to Boileau's principles), 36 tuberosities were attached using technique B (not following Boileau's principles) and 11cases were classified as technique C (if fixation was not possible). The overall survival rate during the 2-year follow-up was 88.2%; however, this decreased to 79% at 5 years. Only three patients had complications (two infections and one dislocation) requiring revision surgery. In the multivariable analysis, the tuberosity fixation technique (P = 0.012) and tuberosity anatomical consolidation (P < 0.001) were associated with improved Constant scores (median Constant Score 62.67 (technique A), 55.32 (technique B), 49.70 (technique C). Fracture-specific humeral implants (P = 0.051), the tuberosity fixation technique (P = 0.041), tuberosity anatomical consolidation (P < 0.001), and dementia influenced the achievement of functional mobility (P = 0.014). Tuberosity anatomic consolidation was positively associated with bone ingrowth fracture-specific humeral implants (P < 0.01) and a strong tuberosity fixation technique (P < 0.01). CONCLUSION: RSA is used for complex and displaced fractures of the proximal humerus in older patients. Dementia was negatively correlated with functional outcomes. A window bone ingrowth fracture-specific stem combined with strong tuberosity fixation can yield better clinical and radiological results. LEVEL OF EVIDENCE: Level II; prospective comparative study; treatment study.

Risk factors for refracture after proximal femur fragility fracture.

Introduction: Proximal femur fragility fractures (PFFFs) are a growing worldwide concern. Recognizing the risk factors for subsequent fracture is essential for secondary prevention. This study aimed to analyze the risk factors for refracture and mortality rates in patients who suffered a PFFF. Methods: Patients aged 65 years or older with PFFF who underwent surgical treatment during the year of 2017 in the same institution were retrospectively analyzed and at least four years after the index fracture were evaluated. Results: From a total of 389 patients, 299 patients were included, with a median age of 83 years, and 81% female. Thirty-two (10.7%) suffered a refracture, with a mean time to refracture of 19.8 ± 14.80 months, being the female sex a risk factor for refracture (OR-4.69; CI [1.05-20.95]). The 1-year mortality rate was 15.4%. Seventy-three (24.4%) patients had previous fragility fractures. After the index fracture, 79% remained untreated for osteoporosis. No statistical association was found between antiosteoporotic treatment and refracture. Patients with refracture had higher prefracture functional level compared with patients without refracture (OR-1.33; CI [1.08-1.63]) and were discharged more often to rehabilitation units (31% versus 16%, P =.028). After 4 years of follow-up, patients with refracture had lower functional level compared with patients without. Chronic kidney disease was a risk factor (P = .029) for early refracture (<24 months). Conclusion: Female sex and higher prefracture functional level may increase the risk of refracture. Chronic kidney disease was associated with a shorter refracture time. Despite having a PFFF or other fragility fractures, the majority of patients remained untreated for osteoporosis.

Comparative clinical and radiologic evaluation between patients undergoing standard reversed shoulder arthroplasty or bony increased offset.

BACKGROUND: Modifications of the medialized design of Grammont-type reverse shoulder arthroplasty (RSA) using a bony increased offset (BIO-RSA) has shown better clinical results and fewer complications. The aim of this study is to compare the clinical results, complications, and radiological outcomes between patients undergoing standard RSA and BIO-RSA. METHODS: A retrospective review was performed of 42 RSA procedures (22 standard RSA and 20 BIO-RSA). With a minimum of 1 year of follow-up, range of motion (ROM), Constant shoulder score (CSS), visual analog scale (VAS), and subjective shoulder score (SSS) were compared. Radiographs and computed tomography (CT) scan were examined for scapular notching, glenoid and humeral fixation, and graft healing. RESULTS: At a mean follow-up of 27.6 months (range, 12-48 months), a significant difference was found for active-internal rotation (P=0.038) and for passive-external rotation (P=0.013), with better results in BIO-RSA. No other differences were found in ROM, CSS (P=0.884), VAS score, and SSS. Graft healing and viability were verified in all patients with CT scan (n=34). The notching rate was 28% in the standard RSA group and 33% in the BIO-RSA group, but the standard RSA had more severe notching (grade 2) than BIO-RSA (P=0.039). No other significative differences were found in glenoid and humeral fixation. CONCLUSIONS: Bone-graft lateralization is associated with better internal and external rotation and with less severe scapular notching compared to the standard RSA. Integration of the bone graft occurs effectively, with no relevant changes observed on radiographic evaluation.

Is preoperative fat infiltration in lumbar spine muscles associated with worse clinical outcomes after lumbar interbody fusion?

PURPOSE: Lumbar musculature has a fundamental role in spine stability and spinal balance. Muscle atrophy and fat infiltration play an important role in pain pathophysiology. Accordingly, the preoperative condition of lumbar muscles may influence clinical outcomes after surgical treatment. In this context, the aim of this study was to evaluate the association between preoperative lumbar paravertebral muscle fat infiltration and clinical outcomes after lumbar interbody fusion. METHODS: A retrospective study of patients with lumbar pathology submitted to lumbar transforaminal (TLIF) or posterior interbody fusion (PLIF) was performed, with a minimum of two years of follow-up. Preoperative lumbar magnetic resonance imaging (MRI) images were classified for fat infiltration in lumbar multifidus muscle and correlated with clinical outcomes. RESULTS: Seventy-five patients were included: 24 submitted to PLIF and 51 to TLIF. Most patients underwent surgery for spondylolisthesis (67%). Higher degrees of fat infiltration were associated with more advanced age (54.8 vs. 49.1 years old, p = 0.04) and more leg pain after surgery (p = 0.04). No statistically significant differences in other clinical outcomes such as Oswestry Disability Index, visual analogue scale for back and leg pain, self-reported back pain relief, return to work and overall satisfaction were found between different groups of fat infiltration. The improvement in leg pain was associated with improvement in self-reported lumbar pain (p < 0.001). CONCLUSION: Age and preoperative degree of fat infiltration may be important to predict improvement in leg pain after lumbar interbody fusion. The absence of solid literature on this topic and universal assessment methodologies reinforce the need for further studies.

Shoulder Arthroplasty Options for Glenohumeral Osteoarthritis in Young and Active Patients (<60 Years Old): A Systematic Review.

Aim: This study aims to describe the shoulder arthroplasty options for young and active patients (<60 years old) with glenohumeral osteoarthritis. Methods: A systematic review of the literature was conducted by searching on Pubmed database. Studies that reported outcomes of patients with glenohumeral arthritis, younger than 60 years, that underwent shoulder arthroplasty [(Hemiarthroplasty (HA), Hemiarthroplasty with biological resurfacing (HABR), Total shoulder arthroplasty (TSA), Reversed total shoulder arthroplasty (RSA)] were included. Data include patient characteristics, surgical technique, range of motion, pain relief, outcome scores, functional improvement, complications, need for and time to revision. Results: A total of 1591 shoulders met the inclusion criteria. Shoulder arthroplasty provided improvements in terms of ROM on the 3 plains, forward flexion (FF), abduction (Abd) and external rotation (ER), in different proportions for each type of implant. Patients submitted to RSA had lower preoperative FF (p = 0.011), and the highest improvement (Δ) in Abd, but the worst in terms of ER (vsTSA, p = 0.05). HA had better ER postoperative values (vsRSA p = 0.049). Pain scores improved in all groups but no difference between them (p = 0.642). TSA and RSA groups had the best CS Δ (p = 0.012). HA group had higher complication rates (21.7%), RSA (19.4%, p = 0.034) and TSA (19.4%, p = 0.629) groups the lowest, and HABR had the highest rate of revisions (34.5%). Conclusions: HA had the highest rate of complications and HABR unacceptable rates of revision. These implants have been replaced by modern TSAs, with RSA reserved for complex cases. Surgeons should be aware of the common pitfalls of each option.

Awake Cranial Traction and Isolated Anterior Cervical Discectomy and Fusion in the Treatment of Traumatic Subaxial Cervical Facet Joint Dislocations: Analysis of a Cohort of 70 Patients and Predictors of Surgical Failure.

BACKGROUND: Cervical facet dislocations are among the most common traumatic spinal injuries. The management of this type of lesions is still controversial. The objective of the present study was to analyze the results of subaxial cervical facet dislocations submitted to an isolated anterior cervical discectomy and fusion (ACDF) after attempted closed reduction with cranial traction and to identify risk factors for treatment failure. METHODS: All patients who were operated on in a tertiary trauma center during an 11-year period (2008-2018) for traumatic single-level cervical facet joint dislocation (AO C F4 injuries) were retrospectively reviewed. Age, use of cranial traction, dislocation characteristics, neurologic injury, surgical data, and follow-up records were reviewed. A minimum of 18 months follow-up was required. RESULTS: A total of 70 patients with a mean age of 56 years (18-90) (72% men) were identified. The C6-C7 level was the most frequently affected (36/70 cases). Spinal cord injury (SCI) was present in 34% of the cases. Bilateral dislocations and rigid spines were risk factors for SCI. Cranial traction was performed in 59 cases with success in 52 cases (88%). There were 3 failures after anterior fusion, which required revision surgery with a 360° fusion, all occurring at the C7-T1 level. CONCLUSIONS: Cranial traction of the cervical spine is an effective and fast way to achieve closed reduction of cervical facet dislocations. After successful reduction, ACDF, as a single procedure, offers an excellent surgical option. All cases of failure occurred at the C7-T1 level, suggesting that a 360° fusion may be needed at this level.

Knee Meniscus Posterior Root Repair with FiberTak.

Repair of medial meniscal root tear is nowadays a validated procedure in order to restore knee biomechanics and to prevent early development of arthritis. There are various techniques described, without any being considered superior. This article describes a technique with a knotless suture anchor design, using a high posteromedial portal to insert the anchor and a meniscal suture passer device from the anteromedial portal. The technique eliminates the need for transtibial drilling and knot tying, and it certifies a strong reproducible tension.

Risk factors for cage subsidence and clinical outcomes after transforaminal and posterior lumbar interbody fusion.

BACKGROUND: Cage subsidence is a very common complication after lumbar interbody fusion. It may compromise vertebral interbody fusion through progressive spinal deformity and consequently cause compression of neural elements. Clinical relevance remains, however, unclear, with few studies on this subject and even less information regarding its correlation with clinical findings. The aim of this study was to identify risk factors for cage subsidence and clinical evaluation after transforaminal (TLIF) and posterior (PLIF) lumbar interbody fusion. METHODS: A retrospective study in patients submitted to TLIF and PLIF between 2008 and 2017 was conducted. RESULTS: A total of 165 patients were included (123 TLIF and 42 PLIF). Univariate analysis showed an increased risk of cage subsidence in spondylolisthesis comparing with degenerative disk disease (p = 0.007). A higher preoperative lumbar lordosis angle (p = 0.014) and cage placement in L2-L3 (p = 0.012) were associated with higher risk of subsidence. The posterior cage positioning on vertebral endplate was associated with a higher risk of subsidence (p = 0.028) and significant subsidence (p = 0.005), defined as cage migration > 50% of cage height. PLIF presented a higher risk when comparing with TLIF (p = 0.024). Hounsfield unit (HU) values < 135 (OR6; 95% CI [1.95-34]) and posterior positioning (OR7; 95% CI [1.7-27.3]) were independent risk factors for cage subsidence and significant subsidence, respectively, in multivariate analysis. There was a tendency for significant subsidence in degrees ≥ 2 of Meyerding spondylolisthesis (OR4; 95% CI [0.85-21.5]). Significant cage subsidence was not associated with worse clinical results. Other analyzed factors, such as age (p = 0.008), low bone mineral density (BMD) (p = 0.029) and type of surgery (TLIF) (p = 0.004), were associated with worse results. CONCLUSION: The present study shows that lower BMD and posterior cage positioning are relevant risk factors for lumbar cage subsidence. Low BMD is also a predictor of poor clinical results, so it must be properly evaluated and considered, through HU values measurement in CT scan, a feasible and reliable tool in perioperative planning.

Risk Factors for Acute Surgical Site Infection after Spinal Instrumentation Procedures: A Case-Control Study.

BACKGROUND: Surgical site infection (SSI) prevalence in spinal instrumentation varies, depending on patient and surgery factors. This study aims to identify patient- and procedure-related factors associated with SSI after spinal instrumentation in 3 patient-specific groups: those undergoing surgery for degenerative, trauma-related, and pediatric deformity conditions. METHODS: A case-control (1:2 ratio) analysis of SSI after spinal instrumentation, from 2009 to 2017, in a University Hospital and Spinal Trauma Centre was performed. RESULTS: From a total of 2582 surgeries, 33 cases (1.3%) were identified with SSI according to study inclusion criteria: 14 (out of 1326) in the degenerative group, 11 (out of 207) in the trauma group, and 8 (out of 850) in the pediatric deformity group. Cases were matched with controls (n = 66) of the same group. Univariate analysis identified procedure and anesthesia duration in the degenerative group (P = .032 and .038, respectively), age (P = .014) and need for intraoperative and postoperative blood transfusions (both P = .039) in the trauma group and American Society of Anesthesiologists score (P = .022) and neuromuscular scoliosis (P = .002) in the pediatric deformity group as associated with SSI. After multivariate analysis, procedure duration was independently associated with SSI in degenerative surgery (odds ratio [OR], 2.23; 95% confidence interval [CI], 1.03-4.82) and procedure duration (OR, 3.79; 95% CI, 1.27-11.32) and number of levels instrumented (OR, 11.77; 95% CI, 1.55-89.40) in the trauma group. CONCLUSIONS: This study identified procedure duration as a risk factor for SSI after spinal instrumentation in degenerative and trauma spine surgery and the number of levels instrumented in trauma spine surgery. Awareness of these factors will help develop strategies to improve patient and health system overall outcomes.

Alternative method of outside-in meniscal repair for anterior horn tears.

Treatment of symptomatic meniscal tears continues to evolve as we improve our understanding of the biomechanical role of the meniscus and its long-term importance to the health of the knee joint. Suture repair of meniscal tears is challenging and continues to rise as we aim to preserve meniscal tissue. Outside-in meniscal suture techniques may involve using expensive equipment that is not readily available for immediate use in most operating rooms. Aware of the different techniques available, the authors describe a fast and reproducible technique that does not require the use of specific material or equipment.