Minimally invasive plate osteosynthesis (MIPO) for distal humeral fractures: a cadaveric study and first clinical application.

BACKGROUND: The indication for minimally invasive plate osteosynthesis (MIPO) may include articular fractures depending on the fracture pattern. The goal of this study was to evaluate the feasibility of the MIPO technique for extra- and intra-articular distal humeral fractures. METHODS: The feasibility of the MIPO technique was assessed on 8 cadaveric elbows and 2 clinical cases. The four surgical approaches tested included a 20-mm ulnar incision, a 20-mm dorsoradial incision, and two incisions for olecranon osteotomy (A and B). Surgical incision A was 40 mm on the osteotomy level of the olecranon, and surgical incision B was an extension of the radial incision toward the osteotomy of the olecranon (80 mm). The four approaches were tested on 4 extra-articular (AO 13 A3) fractures and 4 intra-articular (AO 13 C3) fractures. RESULTS: Reduction and plate fixation of all distal humeral fractures (8 cadaveric) with and without osteotomy was feasible. However, when using approach B, the soft tissue tension is reduced due to the wider incision. Nevertheless, both approaches A and B showed the same adequate intra-articular fracture control and reduction. CONCLUSION: The MIPO technique for reduction and plate fixation in distal humeral fractures is feasible. LEVEL OF EVIDENCE: As a feasibility study, this study cannot be clearly classified into a level of evidence. It corresponds most closely to level IV.

A comparison of the outcomes of anterior curciate ligament reconstruction with large-size graft versus reconstruction with average-size graft combined with extraarticular tenodesis.

INTRODUCTION: Many patients who have had anterior cruciate ligament (ACL) reconstruction (R) complain of instability, inability to return to previous levels of sports activity, and possible ACL graft failure. Graft size was discovered to be an important factor in lowering ACL failure rates. Also, extraarticular tenodesis decreases recurrent instability, A comparative study was done to compare the effect of graft size and lateral external tenodesis on the recurrence of instability after ACL-R. PATIENTS AND METHODS: A Prospective Blinded Randomized Controlled study included 100 consecutive patients who underwent ACL-R with hamstring tendon grafts in our Hospital. The patients were allocated into two groups (Group A and B) with randomization; group A received ACL-R with a large-size ACL-graft diameter of 6 strands, and group B received ACL-R of 4 strands combined with lateral extraarticular tenodesis (LET) (Modified Lemaire). Each group had fifty patients. The follow-up time was two years. They were examined for graft failure, anterolateral rotatory instability with the pivot shift test, and clinical outcomes, which were evaluated with the International Knee Documentation Committee score (IKDC) both subjective and objective. RESULTS: In this study; group A, graft failure occurred in three (6.3%) patients, a positive pivot shift test grade I was detected in eight (17.8%) patients, grade II in three (6.7%) patients, and grade III in one (2.2%) patient. The subjective IKDC score was 87.9 (± 7.19) points. The objective IKDC score was normal or nearly normal in 43 (93.4%) patients. In group B, one (2.1%) patient had graft failure, five (10.9%) had a positive pivot shift test grade I, one (2.1%) had a grade II, and no patient had a grade III. The subjective IKDC score was 91.9 (± 8.9) points. The objective IKDC score was normal or nearly normal in 44 (95.6%) patients. As regard the subjective IKDC score, there was a non-significant difference between both groups (p value = 0.465). CONCLUSION: Both groups showed a low ACL-graft failure rate, low anterolateral rotatory instability, and a good clinical outcome. Although there was no significant difference in subjective IKDC score between both groups, the failure rate and anterolateral rotatory instability were significantly lower in the ACL-R (4 strands) with LET combination group than in the group with the large-diameter (6 strands) graft. LEVEL OF EVIDENCE: Level 1; Randomized Comparative Study.

Distal humerus fracture in patients over 70 years of age: results of open reduction and internal fixation.

BACKGROUND: Due to the complexity of distal humerusfractures and often poor bone quality in elderly patients, these entities remain a challenge. However, because of a high rate of complications related to total elbow prostheses, reconstruction of distal humerus fractures should still be considered a therapeutic option, also in the elderly patient. The purpose of the present study was to investigate the clinical outcomes after open reduction and internal fixation and to evaluate whether the results justify reconstruction even in elderly patients. We hypothesized that despite advanced age, reasonable clinical results can be achieved, using a standardized surgical technique and aftertreatment protocol for the treatment of distal humerus fractures in elderly patients. METHODS: Between 2004 and 2012, 30 patients with a mean age of 78 years at the time of injury with a recent distal humerus fracture were evaluated. All patients underwent the identical aftertreatment protocol with no weight bearing for 6 weeks and weekly increasing range of motion. Follow-up rate was 90%. 22 patients were treated with double plate, 4 with single plate, and 1 with screw fixation only. Patients were evaluated based on clinical criteria. Primary outcome measures were Mayo Elbow Performance Score, VAS and joint range of motion, secondary was radiological evaluation. RESULTS: After a mean follow-up period of 3.8 years (min. 1 year, max. 9 years, SD ± 2), the average range of motion was flexion of 127° (min. 100°; max. 150°; SD ± 16.5) and average loss of extension of 20.9° (min. 5°; max. 40°; SD ± 11). Average pronation and supination was 68.3° (min. 0°; max. 90°; SD ± 25.3) and 75.3° (min. 0°; max. 90°; SD ± 19.7), respectively. Average Mayo Elbow Performance (MEPS) score was 88.7 (min. 60; max. 100; SD ± 12.1). 6 patients developed heterotopic ossification without significant effect on the clinical outcome. 7 patients had radiological evidence of at least partial non-union with one requiring revision, 2 discrete hardware dislocations were treated conservatively. There were no infections in the presented cohort. Our results regarding the surgical approach showed significantly higher patient satisfaction scores in the osteotomy group, compared to the group with Triceps-On Approach (PTOA). CONCLUSION: The present data support indication for open reduction internal fixation (ORIF) even in the elderly patient. Advanced age should not be seen as a contraindication for ORIF of fractures of the distal humerus. Although the rate of complications is higher than in younger patients, complications such as non-union are often asymptomatic, patient satisfaction scores are high, and the possible devastating complications of failed elbow replacement can be evaded. LEVEL OF EVIDENCE: IV.

Immobilization in External Rotation and Abduction Versus Arthroscopic Stabilization After First-Time Anterior Shoulder Dislocation: A Multicenter Randomized Controlled Trial.

BACKGROUND: Treatment of first-time shoulder dislocation (FSD) is a topic of debate. After high rates of recurrent instability after nonoperative management were reported in the literature, primary repair of FSD significantly increased. At the same time, new concepts were proposed that had promising results for immobilization in external rotation (ER) and abduction (ABD). PURPOSE: The aim of this study was to evaluate the recurrence rates (primary outcome) and clinical outcomes (secondary outcome parameters) of immobilization in ER+ABD versus arthroscopic primary stabilization after FSD. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: In a multicenter randomized controlled trial, patients with FSD were randomized to either treatment with immobilization in 60° of ER plus 30° of ABD (group 1) or surgical treatment with arthroscopic Bankart repair (group 2). Clinical evaluation was performed 1, 3, and 6 weeks as well as 6, 12, and 24 months postoperatively or after reduction, including range of motion, instability testing, subjective shoulder value, Constant-Murley score, Rowe score, and Western Ontario Shoulder Instability Index. Recurrent instability events were prospectively recorded. RESULTS: Between 2011 and 2017, a total of 112 patients were included in this study. Of these, 60 patients were allocated to group 1 and 52 to group 2. At the 24-month follow-up, 91 patients (81.3%) were available for clinical examination. The recurrence rate was 19.1% in group 1 and 2.3% in group 2 (P = .016). No significant differences were found between groups regarding clinical shoulder scores (P > .05). Due to noncompliance with the immobilization treatment protocol, 4 patients (6.7%) were excluded. CONCLUSION: Immobilization in ER+ABD versus primary arthroscopic shoulder stabilization for the treatment of FSD showed no differences in clinical shoulder scores. However, recurrent instability was significantly higher after nonoperative treatment.

The effect of manual therapy to the thoracic spine on pain-free grip and sympathetic activity in patients with lateral epicondylalgia humeri. A randomized, sample sized planned, placebo-controlled, patient-blinded monocentric trial.

BACKGROUND: The treatment of first choice for lateral epicondylalgia humeri is conservative therapy. Recent findings indicate that spinal manual therapy is effective in the treatment of lateral epicondylalgia. We hypothesized that thoracic spinal mobilization in patients with epicondylalgia would have a positive short-term effect on pain and sympathetic activity. METHODS: Thirty patients (all analyzed) with clinically diagnosed (physical examination) lateral epicondylalgia were enrolled in this randomized, sample size planned, placebo-controlled, patient-blinded, monocentric trial. Pain-free grip, skin conductance and peripheral skin temperature were measured before and after the intervention. The treatment group (15 patients) received a one-time 2-min T5 costovertebral mobilization (2 Hz), and the placebo group (15 patients) received a 2-min one-time sham ultrasound therapy. RESULTS: Mobilization at the thoracic spine resulted in significantly increased strength of pain-free grip + 4.6 kg ± 6.10 (p = 0.008) and skin conductance + 0.76 µS ± 0.73 (p = 0.000004) as well as a decrease in peripheral skin temperature by - 0.80 °C ± 0.35 (p < 0.0000001) within the treatment group. CONCLUSION: A thoracic costovertebral T5 mobilization at a frequency of 2 Hz shows an immediate positive effect on pain-free grip and sympathetic activity in patients with lateral epicondylalgia. CLINICAL TRIAL REGISTRATION: German clinical trial register DRKS00013964, retrospectively registered on 2.2.2018.

Do the radiological changes seen at mid term follow up of stemless shoulder prosthesis affect outcome?

BACKGROUND: The Eclipse® (Eclipse® is a trademark of Arthrex, Naples, Florida) stemless shoulder prosthesis offers the surgeon the advantage of bone stock preservation and at the same time avoids the drawbacks of a resurfacing arthroplasty. Previous studies have shown radiographic changes on serial follow up of the Eclipse prosthesis. This study attempts to assess the significance of these radiographic changes and effect of cuff related pathology on the mid-term outcome of the Eclipse prosthesis. METHODS: Between July 2005 and October 2008, 29 shoulders underwent shoulder arthroplasty with the Eclipse prosthesis; 23 shoulders, (seven women and 16 men) were available for the final follow up. The range of motion, Constant Score; age adjusted Constant Score, Subjective Shoulder Value and radiographs were assessed at serial follow-ups. RESULTS: Significant improvements were seen in the Constant Score (78.9 ±20.1) compared to pre-operative score (32.9 ±5.2); also forward elevation, abduction and external rotation improved to 142.9 ± 36.6 °, 135.2 ± 40.5 ° and 49.8 ± 21.9 ° at 72 months (p < 0.001). Radiolucent lines and localised osteopenia, did not statistically impact on the clinical outcome. Partial tears of the supraspinatus and subscapularis had a negative impact on the Subjective Shoulder Value (p < 0.05) Partial or complete tears of the subscapularis led to worse Constant Score on follow up (p < 0.05). CONCLUSIONS: The presence of radiolucent lines or localised osteopenia does not influence the mid term clinical outcome. Pre -operative partial supraspinatus tears or tears of the subscapularis lead to an inferior outcome.

Latissimus dorsi transfer for massive posterosuperior rotator cuff tears: what affects the postoperative outcome?

BACKGROUND: The management of irreparable posterosuperior rotator cuff tears (IPSRCTs) in young active individuals is still a challenge. The aim of this study was to evaluate the influence of sex, surgical technique, previous surgical procedures, tear genesis, and presence of a preoperative external rotation lag sign on the functional outcome after latissimus dorsi transfer (LDT) for IPSRCTs. METHODS: Retrospectively, all patients with IPSRCTs treated with LDT during a 10-year period were followed up. Preoperative evaluation included the visual analog scale (VAS) score, range of motion, and the Constant score (CS). Postoperatively, the VAS score, range of motion, CS, American Shoulder and Elbow Surgeons score, and Subjective Shoulder Value were recorded. Preoperative and postoperative radiologic evaluation was performed using the Hamada-Fukuda classification and the acromiohumeral interval. RESULTS: In total, 67 of 79 patients (85%), with a mean age of 63 years, were available for follow-up at 54 ± 28 months. The CS improved from 24 ± 6 points preoperatively to 68 ± 17 points at follow-up (P < .001). Active flexion increased from 83° ± 47° to 144° ± 35°; abduction, from 69° ± 33° to 134° ± 42°; and external rotation, from 24° ± 18° to 35° ± 21°. Postoperatively, the Subjective Shoulder Value was 69% ± 19% and the American Shoulder and Elbow Surgeons score was 76 ± 21. The VAS score decreased from 6.3 ± 1.1 to 1.8 ± 2 (P < .001). Abduction strength increased from 0.4 ± 0.4 kg to 3.6 ± 2.2 kg (P < .001). The acromiohumeral interval decreased from 7.9 ± 2.6 mm to 5.1 ± 2.2 mm, and arthropathy worsened from Hamada-Fukuda stage 1.4 to stage 2.1. The rate of conversion to a reverse prosthesis was 6%. CONCLUSION: LDT represents a reliable and reproducible treatment option with good clinical midterm results after surgical treatment. Sex, genesis, preoperative presence of an external rotation lag sign, and previous surgical procedures do not affect the overall clinical outcome.

Does Acromion Morphology Depend on the Extremity or on Gender in the Population?

OBJECTIVE: The aims were to study the acromion parameters in the population and to assess the extremity or sex variation in the acromion morphology. METHODS: The lateral acromion angle (LAA) and the acromion index (AI) were assessed in a computed tomographic scan database of 250 individuals in the age group of 20 to 49 years. For the analysis of LAA and AI, 286 and 234 shoulders were available, respectively. RESULTS: The LAA was 73.6 ± 6.6 degrees; 73.7 ± 6.9 and 72.5 ± 6.1 degrees for the right and left shoulder, respectively. The AI was 0.755 ± 0.12; 0.82 ± 0.12 and 0.69 ± 0.12 for the left and the right shoulder, respectively. The AI of the right shoulder was significantly different between the 2 sexes (P = 0.04). The difference in the AI and the LAA of the right and left shoulders was significant (P < 0.0001, P = 0.04). CONCLUSIONS: The morphology of the acromion differs between the right and the left shoulders as well as between sexes.

PORTAL HYPERTENSION TREATMENT WITH CANDESARTAN PLUS PROPRANOLOL FOR NINE MONTHS RESTORES NORMAL PORTAL CIRCULATION HEMODYNAMIC PATTERN.

Post HCV liver cirrhosis is one of the most prominent etiologies behind the abnormal portal circulation hemodynamics. It occurs as a result of distorted balance between portal venous flow (PVF) and intrahepatic resistances (IHR). PVF is partially controlled by using both specific and non-specific beta blockers (NSBBs) that have insignificant effects on IHR. Angiotensin recep- tor blockers (ARBs) inhibit the activated hepatic stellate cell (HSC) contraction and thought to reduce the dynamic portion of IHR. The study aimed to slow down the venous blood flow and to reduce the IHR of portal vein vasculature to control sequelae of the enhanced post cirrhosis portal venous turbulence. We evaluated the effects of Candesartan plus propranolol compared to each of them individually in management of portal hypertension (PH). Three groups of 25 patients each, presented with chronic HCV infection and grade II- III esophageal varices (OV), were randomly assigned to one of three treatment regimens: Propranolol or Candesartan or both. Subjects were screened every three month by Doppler Ultrasound for a total of nine months. Damping Index(DI),,pu1se Pulsatiity Index (P), Portal Venous Flow (PVF) Volume, Portal Venous Peak Velocity (PVPV), and Portal Vein Diameter (PVD) were evaluated once every.third month. Our study concluded that combined therapy (Propranolol + Candesartan) induced highly significant improvements that led to restoration of normal values of DI, PI, PVF volume & PVPV overtime compared to monotherapy regimens (P>O.001). Data strongly recommended using Propranolol plus Candesartan' in overtime management of portal hypertension.

Latissimus dorsi transfer: L'Episcopo versus Herzberg technique.

The purpose of this study was to compare the clinical results of two different techniques of latissimus dorsi transfer used in 28 patients, either a modified single incision mini-invasive Herzberg transfer (HT) or a combined latissimus dorsi and teres major transfer according to L'Episcopo (LE). Twenty-eight patients fulfilled the inclusion criteria. Minimum follow-up was 24 months. Sixteen patients were treated with the Herzberg transfer (HT group) and 12 patients had the L'Episcopo technique (LE group). The Constant score rose from 272 initially to 73.5 four years post-operatively in the LE group and from 32.2 to 76 three years and 3 months post-operatively in the HE group (statistically similar). The pre-operative acromiohumeral distance remained unchanged statistically. Radiological signs of osteoarthritis increased. Constant-Murley score, acromiohumeral distance and progression of rotator cuff tear arthropathy were not significantly different between the two groups.

Latissimus dorsi tendon transfer for irreparable rotator cuff tears: a modified technique to improve tendon transfer integrity: surgical technique.

BACKGROUND: Latissimus dorsi tendon transfer is a well-established method for the treatment of massive irreparable posterosuperior defects of the rotator cuff. Subsequent rupture of the transferred tendon may contribute to the rate of failure of the index procedure. We hypothesized that modification of our technique of tendon harvesting would lead to greater fixation stability and a reduced failure rate. METHODS: Forty-two patients (mean age, fifty-eight years) with a massive irreparable posterosuperior tear of the rotator cuff were managed with a latissimus dorsi tendon transfer. Sharp separation of the latissimus tendon from the humerus was performed in twenty-two patients (Group A), whereas the tendon harvest was carried out with a modified technique that involved removal of some bone along with the tendon at the humeral insertion in a subsequent group of twenty patients (Group B). The mean duration of follow-up was forty-seven months. Outcome measures included the Constant and American Shoulder and Elbow Surgeons (ASES) scores and a patient subjective satisfaction scale. Standard radiographs were made to determine the stage of osteoarthritis and proximal migration of the humeral head, and magnetic resonance imaging was performed to assess the integrity of the transferred muscle. RESULTS: In Group A, the mean Constant score improved from 43.4 preoperatively to 64.8 points at the time of follow-up and the mean ASES score improved from 49.3 to 69.6 points (p < 0.05). In Group B, the mean Constant score increased from 40.2 to 74.2 points and the mean ASES score, from 47.2 to 77.1 points (p < 0.05). The Constant pain score improved from 5.6 to 11.9 points in Group A and from 5.2 to 13.8 points in Group B. The results in Group B were significantly superior to those in Group A (p < 0.05). Magnetic resonance imaging revealed complete rupture at the tendon insertion with tendon retraction in four patients in Group A and none in Group B. The final outcome was rated as poor in 27% of the patients in Group A and in 10% in Group B. CONCLUSIONS: Latissimus dorsi tendon transfer achieves satisfactory clinical results in most patients who have a massive irreparable posterosuperior tear of the rotator cuff. Harvesting the tendon along with a small piece of bone enables direct bone-to-bone transosseous fixation, resulting in better tendon integrity and clinical results.

Latissimus dorsi tendon transfer for irreparable rotator cuff tears: a modified technique to improve tendon transfer integrity.

BACKGROUND: Latissimus dorsi tendon transfer is a well-established method for the treatment of massive irreparable posterosuperior defects of the rotator cuff. Subsequent rupture of the transferred tendon may contribute to the rate of failure of the index procedure. We hypothesized that modification of our technique of tendon harvesting would lead to greater fixation stability and a reduced failure rate. METHODS: Forty-two patients (mean age, fifty-eight years) with a massive irreparable posterosuperior tear of the rotator cuff were managed with a latissimus dorsi tendon transfer. Sharp separation of the latissimus tendon from the humerus was performed in twenty-two patients (Group A), whereas the tendon harvest was carried out with a modified technique that involved removal of some bone along with the tendon at the humeral insertion in a subsequent group of twenty patients (Group B). The mean duration of follow-up was forty-seven months. Outcome measures included the Constant and American Shoulder and Elbow Surgeons (ASES) scores and a patient subjective satisfaction scale. Standard radiographs were made to determine the stage of osteoarthritis and proximal migration of the humeral head, and magnetic resonance imaging was performed to assess the integrity of the transferred muscle. RESULTS: In Group A, the mean Constant score improved from 43.4 preoperatively to 64.8 points at the time of follow-up and the mean ASES score improved from 49.3 to 69.6 points (p < 0.05). In Group B, the mean Constant score increased from 40.2 to 74.2 points and the mean ASES score, from 47.2 to 77.1 points (p < 0.05). The Constant pain score improved from 5.6 to 11.9 points in Group A and from 5.2 to 13.8 points in Group B. The results in Group B were significantly superior to those in Group A (p < 0.05). Magnetic resonance imaging revealed complete rupture at the tendon insertion with tendon retraction in four patients in Group A and none in Group B. The final outcome was rated as poor in 27% of the patients in Group A and in 10% in Group B. CONCLUSIONS: Latissimus dorsi tendon transfer achieves satisfactory clinical results in most patients who have a massive irreparable posterosuperior tear of the rotator cuff. Harvesting the tendon along with a small piece of bone enables direct bone-to-bone transosseous fixation, resulting in better tendon integrity and clinical results.

Direct pectoralis major muscle transfer for dynamic stabilization of scapular winging.

Twelve consecutive patients with long thoracic nerve palsy, who underwent transfer of the pectoralis major muscle for dynamic stabilization of the scapula, were reviewed. Direct transfer of the tendon to the lateral margin of the inferior scapular angle was performed with a bony chip from the tendon's insertion. All patients were followed up clinically by evaluation of the Constant score and radiographically with magnetic resonance imaging for an average of 92.5 months (range, 60-136 months). The mean Constant score improved from 41 to 85.4 points. Mean active flexion increased from 89 degrees to 171 degrees, mean abduction from 86 degrees to 161 degrees, and mean external rotation from 48 degrees to 63 degrees. The final outcome was rated as excellent in 10 patients and good in 2. The magnetic resonance imaging findings showed no structural alterations, such as fatty degeneration or muscle atrophy of the transferred muscle, but showed traumatic incomplete rupture of the transferred tendon in 1 patient.

Arthroscopic screw fixation of large anterior glenoid fractures.

Ten patients after traumatic shoulder dislocation with resulting instability due to an acute anterior glenoid fracture involving at least 21 percent of the glenoid length were treated by arthroscopic screw fixation of the fragment. The average fragment size measured 26.2% of the glenoid length. Pre- and postoperative radiographic evaluations were performed with three-dimensional CT scans. A cannulated titanium screw system was used for fragment fixation. All ten patients were followed up radiographically and, by evaluation of the Rowe score, clinically after a minimum of 2 years. At follow-up the Rowe score averaged 94 points. According to the rating scale, seven patients had an excellent result, two patients a good result, and one, fair result. In all patients CT scan confirmed that the fracture had healed in an anatomical position. One patient had one episode of traumatic redislocation with a positive apprehension test at follow up. In one case, removal of the screw was necessary due to mechanical impingement. We recommend this arthroscopic technique allowing for closed reduction and internal screw fixation of large anterior glenoid fractures, ensuring anatomical fracture healing and gleno-humeral joint stability.