Outcomes of surgical treatment of patellar instability in children with Down syndrome.

BACKGROUND: patellar instability is a relatively frequent musculoskeletal disorder in children with Down syndrome (DS). However, such a condition has seldom been studied in the literature, even less its surgical treatment. Different techniques have been offered for this condition; the evidence for surgical options is scarce and primarily based on case reports or case series with few patients and heterogeneous techniques. Given this background, we aimed to evaluate the outcomes of a uniform kind of surgical procedure for such a condition that combined lateral soft tissue release, medial patellofemoral ligament (MPFL) reconstruction (using a partial-thickness quadriceps tendon autograft), the Roux-Goldthwait procedure, and V-Y quadricepsplasty (if needed). MATERIALS AND METHODS: This retrospective study involved 11 skeletally immature patients (12 knees; 9 males and 2 females), 5.5 to 14.1 years of age, with DS who had patellofemoral instability (PFI) and were managed by this technique between October 2018 and March 2020. Preoperative radiography, CT scan, and MRI were performed to evaluate the physis status, lower limb alignment, patellar height, trochlear morphology, and any associated knee pathology. A functional knee assessment was done by using the Kujala score and the modified Lysholm score. RESULTS: The mean time of follow-up (± SD) was 47.7 ± 5.8 months (range: 39-56). Pre-operatively, the Kujala score (± SD) was 52.6 ± 14.3 (range: (31-74), and at final follow-up, it was 92.2 ± 4.4 (range: (88-98), showing a significant improvement (P < 0.001). The preoperative modified Lysholm score (± SD) was 54.3 ± 8.1 (range: 39-62), and at final follow-up it was 92.4 ± 5.3 (range: 82-96), showing a significant improvement (P < 0.001). All patients had a stable patella without a recurrence of instability and regained full ROM. There was no incidence of a patellar fracture or femoral physis injury. CONCLUSIONS: Our proposed technique of combined soft tissue procedures, including lateral soft tissue release, MPFL reconstruction (using a partial-thickness quadriceps tendon autograft), the Roux-Goldthwait procedure, and V-Y quadricepsplasty, was an effective method for treating patellar instability in children with DS while avoiding physeal injury and patellar fracture. Functional scores and radiological outcomes were improved. LEVEL OF EVIDENCE: IV; retrospective case series.

Dual-mobility bearings reduce instability but may not be the only answer in revision total hip arthroplasty for recurrent dislocation.

Aims: There is little information in the literature about the use of dual-mobility (DM) bearings in preventing re-dislocation in revision total hip arthroplasty (THA). The aim of this study was to compare the use of DM bearings, standard bearings, and constrained liners in revision THA for recurrent dislocation, and to identify risk factors for re-dislocation. Methods: We reviewed 86 consecutive revision THAs performed for dislocation between August 2012 and July 2019. A total of 38 revisions (44.2%) involved a DM bearing, while 39 (45.3%) and nine (10.5%) involved a standard bearing and a constrained liner, respectively. Rates of re-dislocation, re-revision for dislocation, and overall re-revision were compared. Radiographs were assessed for the positioning of the acetabular component, the restoration of the centre of rotation, leg length, and offset. Risk factors for re-dislocation were determined by Cox regression analysis. The modified Harris Hip Scores (mHHSs) were recorded. The mean age of the patients at the time of revision was 70 years (43 to 88); 54 were female (62.8%). The mean follow-up was 5.0 years (2.0 to 8.75). Results: DM bearings were used significantly more frequently in elderly patients (p = 0.003) and in hips with abductor deficiency (p < 0.001). The re-dislocation rate was 13.2% for DM bearings compared with 17.9% for standard bearings, and 22.2% for constrained liners (p = 0.432). Re-revision-free survival for DM bearings was 84% (95% confidence interval (CI) 0.77 to 0.91) compared with 74% (95% CI 0.67 to 0.81) for standard articulations, and 67% (95% CI 0.51 to 0.82) for constrained liners (p = 0.361). Younger age (hazard ratio (HR) 0.92 (95% CI 0.85 to 0.99); p = 0.031), lower comorbidity (HR 0.44 (95% CI 0.20 to 0.95); p = 0.037), smaller heads (HR 0.80 (95% CI 0.64 to 0.99); p = 0.046), and retention of the acetabular component (HR 8.26 (95% CI 1.37 to 49.96); p = 0.022) were significantly associated with re-dislocation. All DM bearings which re-dislocated were in patients with abductor muscle deficiency (HR 48.34 (95% CI 0.03 to 7,737.98); p = 0.303). The radiological analysis did not reveal a significant relationship between restoration of the geometry of the hip and re-dislocation. The mean mHHSs significantly improved from 43 points (0 to 88) to 67 points (20 to 91; p < 0.001) at the final follow-up, with no differences between the types of bearing. Conclusion: We found that the use of DM bearings reduced the rates of re-dislocation and re-revision in revision THA for recurrent dislocation, but did not guarantee stability. Abductor deficiency is an important predictor of persistent instability.

The outcome of revision total hip arthroplasty for instability.

Aims: Instability is a common indication for revision total hip arthroplasty (THA). However, even after the initial revision, some patients continue to have recurrent dislocation. The aim of this study was to assess the risk for recurrent dislocation after revision THA for instability. Methods: Between 2009 and 2019, 163 patients underwent revision THA for instability at Stanford University Medical Center. Of these, 33 (20.2%) required re-revision due to recurrent dislocation. Cox proportional hazard models, with death and re-revision surgery for periprosthetic infection as competing events, were used to analyze the risk factors, including the size and alignment of the components. Paired t-tests or Wilcoxon signed-rank tests were used to assess the outcome using the Veterans RAND 12 (VR-12) physical and VR-12 mental scores, the Harris Hip Score (HHS) pain and function, and the Hip disability and Osteoarthritis Outcome score for Joint Replacement (HOOS, JR). Results: The median follow-up was 3.1 years (interquartile range 2.0 to 5.1). The one-year cumulative incidence of recurrent dislocation after revision was 8.7%, which increased to 18.8% at five years and 31.9% at ten years postoperatively. In multivariable analysis, a high American Society of Anesthesiologists (ASA) grade (hazard ratio (HR) 2.72 (95% confidence interval (CI) 1.13 to 6.60)), BMI between 25 and 30 kg/m2 (HR 4.31 (95% CI 1.52 to 12.27)), the use of specialized liners (HR 5.39 (95% CI 1.97 to 14.79) to 10.55 (95% CI 2.27 to 49.15)), lumbopelvic stiffness (HR 6.03 (95% CI 1.80 to 20.23)), and postoperative abductor weakness (HR 7.48 (95% CI 2.34 to 23.91)) were significant risk factors for recurrent dislocation. Increasing the size of the acetabular component by > 1 mm significantly decreased the risk of dislocation (HR 0.89 (95% CI 0.82 to 0.96)). The VR-12 physical and HHS (pain and function) scores improved significantly at mid term. Conclusion: Patients requiring revision THA for instability are at risk of recurrent dislocation. Higher ASA grades, being overweight, a previous lumbopelvic fusion, the use of specialized liners, and postoperative abductor weakness are significant risk factors.

Changes in Spinal Instability After Conventional Radiotherapy for Painful Vertebral Bone Metastases.

OBJECTIVE: Precise assessment of spinal instability is critical before and after radiotherapy (RT) for evaluating the effectiveness of RT. Therefore, we retrospectively evaluated the efficacy of RT in spinal instability over a period of 6 months after RT, utilizing the spinal instability neoplastic score (SINS) in patients with painful spinal metastasis. We retrospectively evaluated 108 patients who received RT for painful vertebral metastasis in our institution. Mechanical pain at metastatic vertebrae, radiological responses of irradiated vertebrae, and spinal instability were assessed. Follow-up assessments were done at the start of and at intervals of 1, 2, 3, 4, and 6 months after RT, with the pain disappearing in 67%, 85%, 93%, 97%, and 100% of the patients, respectively. The median SINS were 8, 6, 6, 5, 5, and 4 at the beginning and after 1, 2, 3, 4, and 6 months of RT, respectively. Multivariate analysis revealed that posterolateral involvement of spinal elements (PLISE) was the only risk factor for continuous potentially unstable/unstable spine at 1 month. In conclusion, there was improvement of pain, and recalcification results in regaining spinal stability over time after RT although vertebral body collapse and malalignment occur in some irradiated vertebrae. Clinicians should pay attention to PLISE in predicting continuous potentially unstable/unstable spine.

A new etiology of nontraumatic C0-C1-C2-Complex instability - abnormality of musculus rectus capitis posterior minor: a case report.

PURPOSE: This study presents an abnormality of the musculus rectus capitis posterior minor (RCPmi) as a new etiological factor for nontraumatic sagittal plane instability in the C0-C1-C2-complex, with a focus on identifying the absence or atrophy of RCPmi on both sides. METHODS: A 36-year-old male patient presented with recurring neck pain (VAS 8/10) and tingling paresthesia in the entire left hand over a six-month period, without significant neurological deficits. Radiated arm pain was not reported. Imaging examinations revealed sagittal plane instability in the C0-C1-C2-complex, spinal canal stenosis (SCS), and myelopathy at the C1 level. Subsequently, a dorsal C0-1 reposition and fusion with laminectomy were performed. RESULTS: The congenital absence or atrophy of RCPmi, leading to the lack of cephalad-rearward traction on the C1-tuberculum-posterius, induced a developmental failure of the C1 posterior arch. Consequently, the oblate-shaped C1 posterior arch lost support from the underlying C2 posterior arch and the necessary cephalad-rearward traction throughout the patient's 36-year life. This gradual loss of support and traction caused the C1 posterior arch to shift gradually to the anterior side of the C2 posterior arch, resulting in a rotational subluxation centered on the C0/1 joints in the sagittal plane. Ultimately, this led to SCS and myelopathy. Traumatic factors were ruled out from birth to the present, and typical degenerative changes were not found in the upper cervical spine, neck muscles, and ligaments. CONCLUSION: In this case, we not only report the atrophy or absence of RCPmi as a new etiological factor for nontraumatic sagittal plane instability in the C0-C1-C2-complex but also discovered a new function of RCPmi. The cephalad-rearward traction exerted by RCPmi on the C1 posterior arch is essential for the development of a normal C1 anterior-posterior diameter.

Anterior knee laxity is greater in athletic females who attain menarche at a younger age.

PURPOSE: Females with above-average anterior knee laxity values are at increased risk of anterior cruciate ligament (ACL) injury. The purpose of this study was to examine the effects of menarche age (MA) and menarche offset on anterior knee laxity in young, physically active women. METHODS: Anterior knee laxity (KT-2000) and menstrual characteristics (per self-report) were recorded in 686 Slovenian sportswomen from team handball, volleyball and basketball club sports (average years sport participation: 7.3 ± 3.6 years). Females were stratified into four groups based on their self-reported age at menarche: 9-11, 12, 13 and 14+ years. Anterior knee laxity was compared across MA groups using a univariate analysis of variance (ANOVA) with Bonferroni correction, with and without controlling for factors that could potentially differ between groups and influence anterior knee laxity. Females were then stratified into four groups based on the number of years they were away from their age at onset of menarche. Groups were compared using a univariate ANOVA with Bonferroni correction, with and without controlling for factors that differed between groups and could influence anterior knee laxity. RESULTS: Anterior knee laxity was greater in females who attained menarche at 12 years of age (6.4 ± 1.5 mm) or younger (6.6 ± 1.6 mm) compared to 14 years of age or older (5.8 ± 1.2 mm) (p < 0.001; partial η2 = 0.032). Anterior knee laxity was 0.7-1.4 mm greater in females who were 5 or more years away from menarche compared to those who were within 2 years of menarche (5.8 ± 1.3 mm; p < 0.001). CONCLUSION: Anterior knee laxity is greater in females who attained menarche at a younger age and in females who are 5 or more years postmenarche. Age of menarche represents a critical pubertal event that is easy for women to recall and may provide important insights into factors that moderate anterior knee laxity, a risk factor for ACL injury in women. LEVEL OF EVIDENCE: Level IV.

Patellar Instability Current Concepts and Controversies.

Recurrent patellar instability can significantly impact patients' quality of life and function. A large amount of research on patellar instability has been conducted in the past two decades, and a number of traditionally held principles of treatment have been challenged. This review addresses three current concepts and controversies in the treatment of patellar instability, specifically what factors lead to an increased tibial tubercle-trochlear groove distance and how to address them, when to add a tibial tubercle osteotomy to a medial patellofemoral ligament (MPFL) reconstruction, and which medial patellar stabilizers should be reconstructed. Based on current evidence, there are a few recommendations that can be made at this time. While trochleoplasty does have concerns with regard to reproducibility and complication risk, surgeons should consider this technique especially in cases with Dejour D trochlear dysplasia given high failure rates with other techniques. When evaluating whether to concomitantly perform a tibial tubercle osteotomy (TTO) with a MPFL, a TTO does appear to improve outcomes in the presence of maltracking or a positive J sign even with a tibial tuberosity-trochlear grove distance (TT-TG) of 18 to 20 mm, whereas patients without maltracking with a TT-TG of up to 25 mm may do well with an isolated MPFL reconstruction. Lastly, while MPFL reconstruction continues to have the most robust data supporting favorable outcomes, a number of biomechanical studies and short-term clinical studies have suggested promising results with medial quadriceps tendon femoral ligament and hybrid techniques.

Graft Resorption After Posterior Distal Tibial Allograft Augmentation for Posterior Shoulder Instability: A Case Report.

CASE: A 19-year-old man underwent arthroscopic posterior glenoid reconstruction with a distal tibia allograft (DTA) after failing 2 posterior, soft-tissue instability surgeries. Although he experienced near-complete resolution of symptoms and return to sport, graft resorption was noted 7 months postoperatively. The patient underwent revision surgery for screw removal. CONCLUSION: Graft resorption has not previously been reported in the setting of arthroscopic DTA use for posterior instability. It is believed that stress shielding contributed to resorption. In such situations, screw removal may be warranted. Consideration of alternative fixation techniques and additional investigation into the causes, clinical significance, and optimal management of posterior DTA resorption are warranted.

Teres minor denervation and pathologies resulting in shoulder joint instability and rotator cuff tears: A retrospective cross-sectional MRI study.

Teres minor denervation (TMD) has gained increasing attention in recent years, particularly with the advent of magnetic resonance imaging (MRI). The potential association between TMD and shoulder instability or rotator cuff tear remains a subject of interest in the orthopedic community. In this retrospective and cross-sectional study, authors aim to investigate the potential association between TMD and shoulder instability or rotator cuff tears. Authors retrospectively analyzed MRI findings from 105 patients with TMD, focusing on rotator cuff pathologies, posterior labrocapsular complex (PLCC) tears, and posteroinferior glenohumeral joint capsule alterations. Authors assessed the association between TMD and rotator cuff and PLCC tears. For the multivariate analysis, partial proportional odds models were constructed for subscapularis (SSC) and SSP tears. Rotator cuff tears were present in 82.9% of subjects, with subscapularis (SSC) tears being the most frequent (77.1%). A significant association was observed between TMD and rotator cuff pathology (P = .002). PLCC tears were found in 82.3% of patients, and humeral position relative to the osseous glenoid was noted in 60% of patients with TMD. A significant association was identified between TMD and shoulder instability or labral/capsular abnormalities (P < .001). More than half of the cases exhibited a long tethering appearance toward the axillary neurovascular bundle on T1-weighted sagittal images. Our findings suggest that TMD is significantly associated with rotator cuff tears and shoulder instability. This study highlights the importance of identifying and treating PLCC tears in patients with TMD to address shoulder instability. Further research is needed to elucidate the role of TMD in the pathogenesis of shoulder instability and rotator cuff pathology.

Functional reconstruction of chronic acromioclavicular joint separation using a double suture technique combined with semitendinosus autograft.

PURPOSE: We present the functional and clinical results of a combined surgical technique that functionally restores chronic Acromioclavicular Joint Instability (AJI). The method combines a double-looped suture fixation augmented with a semitendinosus autograft. METHODS: Between 2017 and 2021, 15 patients were treated using the surgical technique. All patients suffered an Acromioclavicular Joint Separation that remained untreated for at least 6 (6-16) weeks after the initial injury. Four Ethibond sutures were passed below the coracoid process and through a 4.5 drill hole in the clavicle. The sutures provided adequate horizontal and vertical reduction and stabilization of the clavicle. A semitendinosus autograft was passed below the coracoid process and looped around the clavicle. The remaining graft limbs were used to reconstruct the acromioclavicular capsule. Patients were radiologically evaluated with bilateral anteroposterior (AP), Zanca, and Alexander views. The clinical evaluation was based on the Acromioclavicular Joint Instability Score and the Constant-Murley Score. RESULTS: The mean follow-up period was 31.2 months (17-61). The mean last ACJIS and CMS scores were 96 (90-100) and 97.67 (87-100), respectively. Reduction of the clavicle was radiologically confirmed in all cases throughout the follow-up period. AC arthritis was reported in 1 case without associated clinical symptoms. No significant complications were reported, and all patients returned to the pre-injury activity level. CONCLUSION: The presented functional reconstruction of the AC joint disruption in chronic cases is an effective and secure method with low complication rates and good clinical results. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The use of hinged elbow orthosis following surgical management of terrible triad injuries of the elbow.

PURPOSE: To determine outcomes following surgical management of terrible triad injuries in patients treated with and without a hinged elbow orthosis (HEO) in the post-operative setting. METHODS: This study was a retrospective review of 41 patients who underwent surgical treatment of terrible triad injuries including radial head fracture, coronoid fracture, and ulnohumeral dislocation between 2008 and 2023 with at least 10-week follow-up. RESULTS: Nineteen patients were treated post-operatively without HEO, and 22 patients were treated with HEO. There were no differences in range of motion (ROM) between patients treated with and without HEO in final flexion-extension arc (118.4° no HEO, 114.6° HEO, p = 0.59) or pronation-supination arc (147.8° no HEO, 141.4° HEO, p = 0.27). Five patients treated without HEO and one patient treated with HEO returned to the operating room for stiffness (26%, 5%, p = 0.08). QuickDASH scores were similar between groups (p = 0.69). CONCLUSIONS: This study found no difference in post-operative ROM, complications, or QuickDASH scores in patients treated post-operatively with or without HEO. Based on these results, we cannot determine whether the use of HEO adds additional stability to the elbow while initiating ROM exercises post-operatively.

Dynamic Anterior Stabilization with Hill-Sachs Remplissage Can be Employed in Skeletally Immature Patients-Operative Technique.

BACKGROUND: Numerous studies indicate that glenoid bony augmentation raises the risk of complications during and after surgery. On the other hand, repairing the labrum alone in cases with subcritical glenoid bone loss results in recurrent instability and persistent apprehension. As a result, recent advancements in shoulder instability surgery prioritize fully restoring the anterior shoulder restraint. OPERATIVE TECHNIQUE: A novel method for treating recurrent anterior shoulder instability with subcritical glenoid bone loss and off-track Hill-Sachs lesion in skeletally immature patients is suggested: the use of dynamic anterior stabilization technique incorporating the long head of the biceps tendon onto the anterior glenoid rim via trans-subscapular transfer, in conjunction with Hill-Sachs remplissage. A practical, step-by-step surgical technique for a complete reconstruction of the anterior capsule-labral-ligamentous complex is provided. This involves utilizing a soft-tissue dynamic anterior sling, achieved through the trans-subscapularis transfer of the long head of the biceps tendon at the glenoid level. The procedure concludes with a Hill-Sachs remplissage to further prevent off-track events and alleviate apprehension. CONCLUSION: Dynamic anterior stabilization is a suitable approach for addressing recurring anterior shoulder instability in skeletally immature patients who have subcritical glenoid bone loss and bipolar bone lesions.

Finite element analysis of a customized coronoid prosthesis for traumatic coronoid deficiency.

BACKGROUND: Traumatic coronoid deficiency with persistent elbow instability is a challenging condition. Autologous bone graft reconstruction is often associated with a range of additional clinical problems and the outcome is often unpredictable. The purpose of this study was to design a prosthetic device that can reconstruct coronoid deficiency of any height and to evaluate its mechanical properties using finite element analysis. MATERIALS AND METHODS: A customized coronoid prosthesis was designed based on image registration, automatic measurement, and computer-aided design. After pilot study and sample size calculation, image data collected from 6 patients who underwent bilateral complete upper extremity CT scans were reconstructed. The test was divided into 3 groups: coronoid intact, prosthesis and autograft. Regan-Morrey type II and autologous olecranon osteotomy models were established. The prosthesis and autogenous olecranon were assembled to the coronoid base. Stress was applied axially along the proximal humeral diaphysis and implant micromotion and contact mechanics of the humeroulnar joint were measured at 30°, 45°, 60° and 90° of joint flexion respectively. RESULTS: At all flexion angles, the maximum stress on the coronoid articular surface was significantly reduced in the prosthesis and autograft groups, with the reduction being more significant in the latter (P < .001). With increasing flexion, the maximum stress at the coronoid articular surface increased significantly after autograft reconstruction (7.2 to 68 MPa, P < .001), whereas the humeroulnar joint obtained a similar contact mechanics pattern to that of the control group after prosthetic reconstruction. As the flexion angle increased, the relative micromotion of both the prosthesis and autograft increased significantly (0.5-1.6 vs. 0.2-1.2, Pmeasure time < 0.001, Pgroups < 0.001). Contact pressure and center-of-force paths of the humeroulnar joint experience abrupt stress changes at approximately 60° of flexion. CONCLUSION: The contact stress pattern in the humeroulnar joint is similar in prosthesis and intact coronoid groups. Autograft reconstruction increases contact stresses at the articular surface and alters the joint center-of-force path. The "stress surge phenomenon" in the humeroulnar joint surface before and after 60° of flexion may be one of the mechanisms of traumatic elbow degeneration.

Anconeus-sparing minimally invasive approach for lateral ulnar collateral ligament reconstruction using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow.

BACKGROUND: Surgical treatment helps to restore stability of the elbow in patients with posterolateral rotatory instability (PLRI). The anconeus muscle is one of the most important active stabilizers against PLRI. A minimally invasive anconeus-sparing approach for lateral ulnar collateral ligament (LUCL) reconstruction using a triceps tendon autograft has been previously described. The purpose of this study was to evaluate the outcome of this intervention and identify risk factors that influenced the clinical and patient-reported outcomes. METHODS: Sixty-one patients with chronic PLRI and no previous elbow surgery who underwent surgical reconstruction of the LUCL using a triceps tendon autograft in a minimally invasive anconeus-sparing approach during 2012 and 2018 were evaluated. Outcome measures included a clinical examination and the Oxford Elbow Score (OES) and the Mayo Elbow Performance Score (MEPS) questionnaires. Subjective patient outcomes were evaluated with the visual analog scale (VAS) for pain and the Subjective Elbow Value (SEV). Integrity of the common extensor tendons and centering of the radial head were assessed preoperatively on standardized magnetic resonance images (MRIs). RESULTS: Fifty-two patients were available at final follow-up. The mean age of patients was 51 ± 12 years with a mean follow-up of 53 ± 14 months (range 20-76). Clinical examination after surgery (n = 41) showed no clinical signs of instability in 98% of the patients (P < .001) and a nonsignificant improvement in range of motion. OES, MEPS, and VAS scores averaged 40 ± 10 of 48 points, 92 ± 12 of 100 points, and 1 ± 2 points, respectively, all corresponding with good or excellent outcomes. The SEV was 88%, indicating very high satisfaction with the surgery. Only 1 patient had revision surgery due to pain, and there were no reported postoperative complications in this cohort. A radial head subluxation in the MRI correlated significantly with worse postoperative outcomes. CONCLUSIONS: The anconeus-sparing minimally invasive technique for posterolateral stabilization of the elbow using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow with substantial improvements in elbow function and pain relief with a very low rate of persistent clinical instability.

Editorial Commentary: Shoulder Bankart and Latarjet Procedures Show Different Complications at Different Time Periods.

In patients with shoulder instability, arthroscopic Bankart procedure results in a high recurrence rate if there is associated bone loss, even small-to-moderate bone loss. The Latarjet procedure mitigates against recurrence in such cases but has greater short-term (30-day) complications than an arthroscopic Bankart and a greater rate of revision or reoperation. In truth, short-term complications are low with both procedures. That said, complications after arthroscopic Bankart are less likely to manifest in the short term, and possible future failure is generally not discovered until after a patient is released and returns to sports and/or greater levels of activity. The ultimate pros and cons of each procedure require long-term follow-up. That said, in the short term after Latarjet, surgeons should be mindful to monitor for early infection, hematoma, and hardware malposition or failure. In the long term after Latarjet, surgeons could monitor for graft resorption, nonunion of the graft, hardware prominence, and postsurgical arthritis.

One-Year Outcomes of the Anatomical Front and Back Reconstruction for Scapholunate Dissociation.

PURPOSE: Anatomical front and back (ANAFAB) reconstruction addresses the critical volar and dorsal ligaments associated with scapholunate dissociation. We hypothesized that patients with symptomatic, chronic, late-stage scapholunate dissociation would demonstrate improvements in all radiographic parameters and patient-reported outcomes (PROMs) after ANAFAB reconstruction. METHODS: From 2018 to 2021, 21 ANAFAB reconstructions performed by a single surgeon were followed prospectively, with 20 patients having a minimum follow-up of 12 months. In total, 17 men and four women were included, with an average age of 49 years. Three patients had modified Garcia-Elias stage 3 disease, eight stage 4, seven stage 5, and three stage 7. ANAFAB reconstruction of intrinsic and extrinsic ligament stabilizers was performed using a hybrid synthetic tape/tendon graft in a transosseous reconstruction. Pre- and postoperative radiographic parameters, grip, pinch strength, the Patient-Rated Wrist Evaluation, PROMIS Upper Extremity Function, and PROMIS Pain Interference outcome measures were compared. RESULTS: Mean follow-up was 17.9 months (range: 12-38). Radiographic parameters were improved at follow-up, including the following: scapholunate angle (mean 75.3° preoperatively to 69.2°), scapholunate gap (5.9-4.2 mm), dorsal scaphoid translation (1.2-0.2 mm), and radiolunate angle (13.5° to 1.8°). Mean Patient-Rated Wrist Evaluation scores for pain and function decreased from 40.6 before surgery to 10.4. We were unable to detect a significant difference in grip or pinch strength or radioscaphoid angle with the numbers tested. There were two minor complications, and two complications required re-operations, one patient who was converted to a proximal row carpectomy for failure of fixation, and one who required tenolysis/arthrolysis for arthrofibrosis. CONCLUSIONS: At 17.9-month average follow-up, radiographic and patient-reported outcome parameters improved after reconstruction of the critical dorsal and volar ligament stabilizers of the proximal carpal row with the ANAFAB technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

One-year effectiveness of high-load compared with low-load strengthening exercise on self-reported function in patients with hypermobile shoulders: a secondary analysis from a randomised controlled trial.

OBJECTIVES: To investigate the long-term effectiveness of high-load versus low-load strengthening exercise on self-reported function in patients with hypermobility spectrum disorder (HSD) and shoulder symptoms. METHODS: A secondary analysis of a superiority, parallel-group, randomised trial (balanced block randomisation 1:1, electronic concealment) including adult patients (n=100) from primary care with HSD and shoulder pain and/or instability ≥3 months. Patients received 16 weeks of shoulder exercises (three sessions/week): HEAVY (n=50, full-range, high-load, supervised twice/week) or LIGHT (n=50, neutral/mid-range, low-load, supervised three times in total). The 1-year between-group difference in change in self-reported function was measured using the Western Ontario Shoulder Instability Index (WOSI, scale 0-2100, 0=best). Secondary outcomes were self-reported measures including changes in shoulder-related symptoms, function, emotions and lifestyle, quality of life, patient-perceived effect, treatment utility and adverse events. A blinded analyst conducted the analyses using linear mixed model repeated measurements analysis. RESULTS: One-year data were available in 86 out of 100 participants (79% women, mean age 37.8 years) (LIGHT 84%, HEAVY 88%). The mean WOSI score between-group difference favoured HEAVY (-92.9, 95% CI -257.4 to 71.5, p=0.268) but was not statistically significant. The secondary outcomes were mostly inconclusive, but patients in HEAVY had larger improvement in the WOSI emotions subdomain (-36.3; 95% CI -65.4 to -7.3, p=0.014). Patient-perceived effect favoured HEAVY anchored in WOSI-emotions (55% vs 31%, p=0.027) and WOSI-lifestyle (50% vs 29%, p=0.042). CONCLUSION: High-load shoulder strengthening exercise was not superior to low-load strengthening exercise in improving self-reported function at 1 year. High-load strengthening exercise may be more effective in improving patient emotions about shoulder pain and function, but more robust data are needed to support these findings. TRIAL REGISTRATION NUMBER: NCT03869307.

Does an early post traumatic knee brace reduce the incidence of knee rotational instability?

PURPOSE: Several anterolateral stabilization procedures have been developed recently to address rotational instability of the knee. Currently, these procedures tend to be systematically used by some practitioners. However, antero-lateral structures of the knee (including the anterolateral ligament, ALL) have a self-healing potential which can reduce the need to perform an antero-lateral procedure. In this study, it was hypothesized that early post-traumatic immobilization of the knee with a knee brace would allow partial healing of antero-lateral structures and also allow control of the pivot shift, thus avoiding antero-lateral extra-articular stabilization. The objective of this study was to compare the severity of pivot shift between two groups of patients who all experienced anterior cruciate ligament (ACL) tear and respectively underwent post-traumatic immobilization of the knee versus no immobilization. METHODS: This was a comparative, multicentric (three centers' study) retrospective, consecutive study including 168 patients who underwent ACL reconstruction between May and September 2022. The application or not of post-traumatic immobilization and its duration, the severity of pivot shift observed in the operating room under general anesthesia, the presence of anterolateral lesions as revealed by MRI and the patients' pre-injury sport activity were recorded. RESULTS: A grade 3 pivot shift was found in 44 patients (27%). It was more frequently observed in the group without a brace compared to the group with a knee brace (18 patients out of 36: 50% versus 26 patients out of 132: 19.7%; p = 0.0012). Wearing a brace, whether hinged (OR = 0.221, [0.070-0.652]; p = 0.006) or not (OR = 0.232, [0.076-0.667]; p = 0.0064), was protective from the risk of developing a significant pivot shift. CONCLUSION: This study demonstrated that the presence of pivot-shift was lower in the patients that had an early post-injury knee brace before their ACL reconstruction. Based on this result, systematic brace placement could be advocated for in patients after knee trauma. LEVEL OF EVIDENCE: III, prognostic retrospective case-control study.

Risk Factors for Stiffness After Surgical Treatment of Pediatric Humeral Lateral Condyle Fractures: Results of a Multicenter Study.

INTRODUCTION: Pediatric humeral lateral condyle fractures are the second most common elbow fractures. Their treatment presents challenges due to physeal and intra-articular involvement. Postoperative stiffness is a common concern that can limit limb functionality. This study aims to identify risk factors for postoperative stiffness in a large cohort of these fractures across multiple institutions. METHODS: A large, multicenter retrospective review of medical records from 6 level I trauma centers was conducted. Data from children aged 1 to 12 years with lateral condyle fractures treated between 2005 and 2019 were collected. Elbow stiffness was defined in the present study as having a limited elbow ROM that led to requiring a physical or occupational therapy referral or needing surgical treatment to address stiffness. Relevant patient demographics, fracture characteristics, treatment approaches, and complications were analyzed. RESULTS: Six hundred sixty-five fractures were analyzed. The average patient age was 8.8 years with 21% experiencing stiffness. The stiffness group had older patients, a higher incidence of elbow dislocations, a higher rate of open reduction, and more severe fracture patterns. Multivariate regression analysis identified open reduction, increased age, and concurrent elbow dislocation as significant risk factors for stiffness. Patients with stiffness commonly utilized only physical or occupational therapy (96%), while a small percentage (4%) required surgical interventions. CONCLUSIONS: This study highlights the risk factors for postoperative stiffness in pediatric humeral lateral condyle fractures, namely increased age, concomitant elbow dislocation, and treatment with open reduction. Families of older patients or severe fracture patterns requiring open reduction and those with concurrent elbow instability should be counseled about their increased risk of stiffness. The authors recommend initially attempting a closed reduction in high-risk patients to help mitigate the risk of postoperative stiffness. Early initiation of range of motion exercises may also be beneficial for at-risk patients. LEVEL OF EVIDENCE: Level III: Therapeutic studies-Investigating the results of treatment.