Long-term outcome of arthroscopic remplissage in addition to the classic Bankart repair for the management of recurrent anterior shoulder instability with engaging Hill-Sachs lesions.

PURPOSE: The evaluation of the long-term outcome of the arthroscopic remplissage performed in addition to the classic Bankart repair for the primary management of recurrent anterior shoulder instability with engaging Hill-Sachs lesion without inverted pear appearance of the glenoid during arthroscopy. METHODS: During a 6-year period, from 2007 to 2012, 65 patients whose average age was 30.1 ± 7.6 years were operated on in our department and satisfied the inclusion criteria of this study. They all had a positive apprehension sign preoperatively. Among them, 51 patients (82%) were available for long-term evaluation. The mean follow-up period was 8.1 ± 1.8 years (range 5.6-10.6). RESULTS: Three patients (5.6%) had suffered a new dislocation. The remaining patients (94.4%) were satisfied with the surgical result and returned to their previous daily activities, whereas 71% continued to participate in sports without restrictions. The ASES score increased from 72.5 (range 18-100) preoperatively to 100 (range 85-100) postoperatively (p < 0.01). The modified Rowe score increased from 40 (range 15-70) to 100 (range 70-100) (p < 0.001), and the Oxford Instability score from 29 (range 9-47) to 48 (range 36-48) (p < 0.001). No significant restriction in the shoulder range of motion was documented. CONCLUSIONS: The combination of the arthroscopic remplissage with the classic Bankart repair was proven to be a safe and effective procedure for the treatment of "engaging" Hill-Sachs lesions without inverted pear appearance of the glenoid. This combination has long-term outcomes in terms of the recurrence rate and does not significantly influence the range of motion of the shoulder. LEVEL OF EVIDENCE: Therapeutic Study-Case series with no comparison group, Level IV.

Midterm outcomes of arthroscopic remplissage for the management of recurrent anterior shoulder instability.

PURPOSE: The purpose of the study was to present midterm results concerning the management of recurrent anterior shoulder instability with the remplissage technique in addition to the classic Bankart repair, in patients with engaging Hill-Sachs lesions. METHODS: During a time period of 4 years (January 2007-December 2010), 48 patients with an average age of 28.9 ± 7.8 years were operated on in our department. They all had a positive apprehension sign pre-operatively and satisfied the inclusion criteria of this study. Seventy-nine per cent of these patients were involved in sport activities of different levels. The mean follow-up period was 37.2 ± 9.9 months. RESULTS: Three patients (6.3 %) had suffered a new dislocation: one of them after a low-energy trauma and the two other after a high-energy trauma. The rest of the patients (93.7 %) were satisfied with the surgical result and returned to their previous everyday activities while 70.8 % continued to participate in sporting activities without restrictions. The ASES score increased from 67.7 ± 21.5 points pre-operatively to 90.8 ± 21.7 points post-operatively (p < 0.01), the modified Rowe score from 38 ± 17.3 to 93.8 ± 14.5 (p < 0.001) and the Oxford Instability score from 27.6 ± 11.1 to 45.1 ± 8.3 (p < 0.001). No significant restriction in shoulder range of motion was documented. CONCLUSIONS: The outcome of the enhancement of the classic Bankart repair with tenodesis of the infraspinatus and posterior capsular plication is very good as far as the management of recurrent anterior shoulder instability is concerned, without significantly influencing the range of motion of the shoulder. LEVEL OF EVIDENCE: Therapeutic study-case series with no comparison group, Level IV.

Prospective randomised controlled trial of an intramedullary nail versus a sliding hip screw for intertrochanteric fractures of the femur.

PURPOSE: The purpose of this prospective randomised trial was to assess whether an intramedullary nail is superior to a sliding hip screw in the treatment of multifragmentary intertrochanteric fractures METHODS: Eighty patients with a 31-A2.2 or A2.3 Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) intertrochanteric fracture were randomly allocated to fixation with either the Gamma nail or the AMBI sliding hip screw device. RESULTS: All patients were followed up at one, three, six and 12 months postoperatively, except for nine who died. There was no statistical difference in Parker mobility score between groups. The Gamma nail group had significantly higher Barthel Index and EuroQol-5D (EQ-5D) scores than the AMBI group at 12 months. At the same time, the EQ-5D score had returned to its pre-operative values in the Gamma nail group but not in the AMBI group. There were no differences in mortality, radiation time and hospital stay. Duration of the operation, incision length and hip pain occurrence were significantly less in the Gamma nail group. CONCLUSIONS: Few failures occur when unstable 31-A2.2 and A2.3 AO/OTA fractures are fixed with a sliding hip screw. Nevertheless, an intramedullary nail seems superior in reconstituting patients to their pre-operative state.

All-Arthroscopic Treatment of Glenoid Rim Fractures.

We describe an arthroscopic technique for the management of glenoid rim fractures. It is performed with the patient placed in lateral decubitus position. The fracture is assessed through the anterosuperior portal, and the fragment is mobilized. A special glenoid guide is used from the posterior portal to reduce the fragment and to create 2 tunnels through the glenoid and through the glenoid rim fragment. Two pairs of round buttons are connected with high-strength sutures and are tightened posteriorly. This allows strong fixation of the fractured fragment and avoids all the anterior structures since all the instruments are inserted posteriorly.

Management of sternal fractures: 239 cases.

A review of the management of 239 patients with sternal fractures in a busy trauma center between October 1989 and May 2000 was undertaken to determine the incidence, significance, morbidity, and mortality of this injury. There were 140 men and 99 women with a mean age of 50.3 years (range, 15 to 93 years). Sternal fractures accounted for 8% of admissions for thoracic trauma. The causes were motor vehicle collisions in 215 patients (90%) and falls or direct blows in 24 (10%). Only 64 of 204 car accident patients (31%), 28 men and 36 women, were restrained by seat belts. Complications developed in 13 patients (5.4%). Mortality rate was 0.8%. Mean length of stay in the ward was 6.4 days (range, 1 to 32 days). Four patients (1.7%) underwent surgery. The results show that isolated sternal fractures have low associated morbidity and mortality. Admission is justified for the management of pain and treatment of cardiac complications and concomitant injuries.

Evolving concepts of stability and intramedullary fixation of intertrochanteric fractures--a review.

Intramedullary nailing is gradually emerging as the treatment of choice for pertrochanteric femoral fractures. Nevertheless, prospective randomised trials have failed to demonstrate the assumed superiority of cephalomedullary nails over the traditional treatment with the sliding hip screw. On the contrary, the gamma nail has been implicated in predisposing to secondary femoral fractures, although this seems to be rectified by newer techniques and nail designs. Sliding hip screw fixation remains the gold standard but can lead certain unstable pertrochanteric fracture subgroups to failure. Amongst these are transverse or reverse obliquity but also multifragmentary fractures, that suffer intra- or postoperative shattering of the lateral trochanteric wall. Nails seem to prevent failure by opposing the uncontrollable medialisation, and eventual failure, that occurs under these circumstances. The importance of the size of the proximal fracture fragment has not yet been elucidated. Nail fixation is, thus, mandatory in a small percentage of grossly unstable fractures, whose characteristics are still undergoing definition.