Bilateral locked anterior shoulder dislocation in a bench-pressing athlete: case report.

Chronic bilateral anterior shoulder dislocation is a rare entity. Treatment options range from conservative to surgical reduction. We present a case of a young bench-pressing athlete with bilateral locked anterior shoulder dislocation without fracture. Upon presentation, the patient had no pain with functional range of motion so he refused surgery. Conservative treatment could be an acceptable alternative to surgical intervention if pain and functional status are satisfactory.

Concomitant ipsilateral femoral neck and pelvic ring fractures in the setting of a low energy fall in an elderly patient: A case report.

INTRODUCTION: Simultaneous ipsilateral fractures of the femoral neck and pelvic ring secondary to low energy falls are an extremely rare occurrence. Consequently, there is no standardized protocol for the management of such injury. Only few other cases were reported in the literature. CASE PRESENTATION: A 94-year-old woman presented with a left sub-capital femoral neck fracture, associated with comminuted and displaced fractures of the left superior and inferior pubic rami, after sustaining a fall from height. A decision was made to treat the femoral neck fracture with a left uncemented hemiarthroplasty, while the pubic rami fractures were managed conservatively. DISCUSSION: Coexisting femoral neck and pubic rami fractures due to low energy trauma is newly emerging in literature. Consequently, an elderly patient falling from standing height might require a CT or an MRI to reach an accurate diagnosis of the resultant injuries. While hip fractures are almost always treated surgically, pelvic ring fractures are only managed invasively when the conservative approach fails. This creates a dilemma when both fractures occur simultaneously, as appropriate measures must be taken to treat the patient with lowest risk of complications. CONCLUSION: Low-energy fractures of the hip and pelvic ring should no longer be regarded as mutually exclusive. Any patient presenting with one of them should be investigated for the other. A consensus should be reached regarding the most appropriate technique to manage such injuries.

Shoulder Arthroscopic Rotator Cuff Repair With Biceps Tenodesis and Acromioplasty Using a Single Working Portal.

Rotator cuff repair, acromioplasty, and biceps tenodesis operations have become some of the most common shoulder surgical procedures, evolving from open techniques to minimally invasive arthroscopic techniques. The use of many arthroscopic portals has been associated with surgical risks to many surrounding anatomic structures. We present an arthroscopic technique using a single anterolateral working portal for rotator cuff repair, acromioplasty, distal clavicle excision, and long head of the biceps tenodesis; this technique decreases the risk of injury to the surrounding neurovascular and musculotendinous structures, enables a faster recovery, and is minimally invasive.

Bilateral Reverse Total Shoulder Arthroplasty with Soft Tissue Release for Bilateral Posterior Fracture Dislocation after Status Epilepticus.

Proximal humerus fracture is a common orthopedic presentation, with bimodal age distribution. On the other hand, bilateral proximal humerus fracture dislocation is a rarely reported pathology, especially when it is not the result of direct trauma. We present a case of a 71-year-old female patient found to have simultaneous bilateral 4-part proximal humerus fractures following status epilepticus treated surgically with bilateral reverse shoulder arthroplasty with constraint and soft tissue release. In a patient with recurrent status epilepticus episodes, the combination of constrained reverse shoulder arthroplasty and the extensive soft tissue release should decrease the rate of failure and dislocation dramatically. We conclude, after reviewing the literature, that there is no straightforward algorithm for treating such patients and that a clear classification should take into account both bone quality and patient comorbidities which has yet to be developed.

Management of a Complex Supracondylar Periprosthetic Femur Fracture with Intramedullary Strut Allograft and Bilateral Locking Plates.

Supracondylar periprosthetic femoral fractures occurring above total knee replacements have been considered a rare entity. However, they continue to increase in frequency with the increasing number of arthroplasties and the improvement in morbidity and mortality in the concerned patient population. The management of periprosthetic distal femoral fractures is a challenging orthopedic problem. In this brief communication, a case of 49-year-old woman with rheumatoid arthritis who sustained a low distal comminuted periprosthetic femoral fracture is presented. Her fracture was eventually managed with an intramedullary fibular strut allograft and bilateral locking plate placement reaching satisfactory healing and restoration of alignment. The primary aim of this report is to provide insight into this novel technique as a successful alternative to other standard surgical options.

Intertrochanteric fractures treated by diaphyseal support arthroplasty with hook plate vs cerclage wires only: A retrospective cohort study.

BACKGROUND: The treatment of unstable fractures of the intertrochanteric region of the hip in the elderly is controversial. Conventionally, internal fixation with intramedullary nail or a dynamic hip screw is the treatment of choice in intertrochanteric fractures. Nowadays, some authors encouraged the use hip arthroplasty for management of these fractures with good outcome. The aim of this study is to compare total hip arthroplasty with hook plate against total hip arthroplasty with cerclage cables in the management of unstable intertrochanteric fractures. MATERIALS AND METHODS: Out of 100 admitted patients to a central university hospital in Beirut between 2013 and 2019 with a diagnosis of unstable intertrochanteric fracture of the hip, only 64 (36 hook plate vs 28 cerclage) patients were selected. This is a retrospective study, patients were excluded if lost to follow up, or if follow up less than one year is available. The data were retrieved from inpatient and outpatient hospital files. Functional outcomes were assessed according to ambulatory capacity. The main clinical measures were early postoperative full weight bearing, postoperative complications, functional outcome and radiologic assessment done by a radiologist in addition to measuring the dysfunction via the Harris Hip Score. RESULTS: The time to full weight bearing, the rate of postoperative complications, radiologic outcome and the functional outcomes were more satisfactory in the hook - plate group than in the cerclage - cable group. CONCLUSION: According to the results, total hip arthroplasty with hook plate is considered the preferred modality of treatment in mobile elderly patients above sixty-five years of age with an unstable intertrochanteric femoral fracture, despite being a bulky foreign material that can lead to trochanteric bursitis.

Efficacy and safety of systemic tranexamic acid administration in total knee arthroplasty: A case series.

INTRODUCTION: Total knee arthroplasty (TKA) are associated with significant postoperative blood loss. Tranexamic acid (TXA) is a potent agent with antifibrinolytic activity, that can be administered via the intravenous (IV) and/or topical (intra-articular, IA) route, which can possibly interrupt the cascade of events due to hemostatic irregularities close to the source of bleeding. However, the literature contains scarce scientific evidence related to IV only TXA usage in TKA. The current study aims to compare the outcome between patients who were administered IV TXA and a control group in terms of blood loss, transfusion rate, and incidence of deep vein thrombosis (DVT) and thromboembolism (TE). METHODS: 110 patients, who underwent TKA were placed into two groups: 1) 34 patients who received IV TXA; and 2) 76 patients in the control group. In the TXA group, patients received an IV TXA dose of 1 g, 30 min before incision. Two drains were placed. RESULTS: Usage of IV TXA showed better results when compared to the control group in terms of mean blood transfusion (0.5 less transfusion during hospital stay), hemoglobin drop (10%). No cases of DVT or TE were noted among the two study groups. CONCLUSION: Use of IV TXA provided significantly better results compared to no TXA use with respect to all variables related to postoperative blood loss in TKA. Moreover, TXA use is safe in terms of incidence of symptomatic DVT and TE.

Intra-Articular Entrapment of the Medial Epicondyle following a Traumatic Fracture Dislocation of the Elbow in an Adult.

Medial epicondyle entrapment after an acute fracture dislocation of the elbow is a common finding in the pediatric population, but a rare finding in adults. We present a case of an adult patient diagnosed with a traumatic fracture dislocation of the elbow joint with intra-articular entrapment of the medial epicondyle. After initial evaluation, closed reduction was done. Stability testing after reduction showed an unstable joint; thus, open reduction and internal fixation was decided.

Physical examination for partial tears of the biceps tendon.

BACKGROUND: The accuracy of the physical examination for tears of the long head of the biceps remains controversial. PURPOSE: The goals were 1) to characterize the occurrence of partial tears of the long head of the biceps tendon in a group of consecutive patients, and 2) to analyze the diagnostic value of various clinical tests for pathologic lesions of the proximal biceps tendon. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Of 847 consecutive patients who underwent arthroscopic procedures for a variety of shoulder conditions, 40 were found at the time of arthroscopy to have partial biceps tendon tears. The average age of these 24 men and 16 women was 59 years (range, 18-83). Preoperative physical examinations had included 9 commonly used tests for shoulder examination. Statistical analysis included sensitivity, specificity, negative predictive value, positive predictive value, and likelihood ratios for these tests. RESULTS: The prevalence rate of partial tears was 5% (40/847) of all arthroscopic procedures. The most commonly associated conditions included rotator cuff tears (85% [34/40]) and anterior instability (7.5% [3/40]). Tenderness on palpation of the long head of the biceps tendon had a sensitivity of 53%, a specificity of 54%, and a likelihood ratio of 1.13. The sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratios for Speed's test were 50%, 67%, 8%, 96%, and 1.51, respectively. CONCLUSION: In patients with rotator cuff abnormality, the diagnosis of partial biceps tears cannot be made reliably with existing physical examination tests. Diagnostic arthroscopy is recommended, if clinically indicated, for potential partial tears of the long head of the biceps tendon. The treating physician should be prepared to treat unsuspected tears of the long head of the biceps tendon at the time of surgery.

Compartmental reconstruction for de Quervain stenosing tenosynovitis.

We describe a new surgical technique for the treatment of de Quervain tenosynovitis, which consists of lengthening the first dorsal compartment without disruption of continuity and without using a suture. Our results in 12 wrists operated on in 10 patients indicated complete relief of symptoms. The advantages of the technique include: simplicity, restoration of normal anatomy, and prevention of complications (scarring, adhesions, and subluxation of tendons).

Dynamic scapholunate dissociation in a child.

We describe a case of dynamic scapholunate dissociation in a skeletally immature ten-year-old girl. The patient presented for pain in the anatomical snuffbox and swelling over the dorsum of the wrist and hand. Standard static and dynamic radiographs of the wrist did not reveal any pathology. Magnetic resonance imaging was inconclusive. The scapholunate dissociation was diagnosed by wrist arthroscopy, reduced, and stabilised using standard techniques. Full and pain-free motion of the wrist was restored.

Arthroscopic treatment of non-homogeneous calcifying tendinitis of the rotator cuff.

The purpose of this study is to investigate the clinical outcome of arthroscopic treatment for patients with non-homogeneous infiltrated calcifying tendinitis of the rotator cuff (type III), and to assess the optimal method for this arthroscopic treatment. We retrospectively reviewed the charts of 81 patients who underwent arthroscopic treatment for non-homogeneous infiltrated calcifying tendinitis of the rotator cuff (type III). Patients were divided into two groups: Group A (n = 31) consisted of patients who underwent excision of calcification, and Group B comprised patients who underwent acromioplasty alone (n = 50). The clinical outcome of treatment was assessed using Constant-Murley score. Twenty-three of the 81 patients were males and 58 were females. The mean duration of symptoms from onset to the first clinic visit was 3.88 years (SD ± 3.06 years). The right side was involved in 47 patients, the left side in 34 patients, and none had bilateral involvement. Patients from Group B had higher 16 improvement of their Constant-Murley score (from 48.96 to 88.06) when 17 compared to group A (from 45.39 to 67.23). Treatment of type III calcifying tendinitis is different than type I and II. Subacromial decompression may be considered in all patients suffering from type III non-homogeneous infiltrated calcifying tendinitis of the shoulder.

Arthrofibrosis involving the middle facet of the talocalcaneal joint in children and adolescents.

BACKGROUND: Pain over the anterolateral aspect of the ankle in a patient with a history of repeated ankle sprains and with restricted subtalar movement may be associated with a tarsal coalition. Nineteen patients presented with such a history, but conventional imaging did not reveal a cartilaginous or osseous coalition. Since symptoms persisted despite nonoperative treatment, the middle facet was explored surgically. The purpose of this study was to discuss the operative findings and to report the results of treatment. METHODS: Nineteen patients (twenty-three feet) with pain over the anterolateral aspect of the ankle or a history of repeated ankle sprains had restricted subtalar joint motion and inconclusive findings on diagnostic imaging, except for bone-scanning. Their ages ranged from 9.1 to 18.5 years. The middle facet of the subtalar joint was explored surgically through a 3 to 4-cm-long incision centered over the sustentaculum tali. The results at a mean of 5.8 years were classified as good, fair, or poor on the basis of pain, talocalcaneal joint motion, and shoe wear. RESULTS: Routine radiographs, computed tomography, and magnetic resonance imaging revealed no major abnormality, whereas technetium-99m bone scintigraphy consistently showed slightly increased isotope uptake in the middle facet. Surgical removal of a hypervascular and thickened capsule and synovium in the area of the middle facet of the subtalar joint decreased pain and improved subtalar motion. The final result was good in seventeen patients (twenty feet) and fair in two patients (three feet). There were no poor results. CONCLUSIONS: A diagnosis of inflammatory arthrofibrosis should be considered when a patient with a painful rigid flatfoot has normal findings on radiographs and hematological studies but increased isotope uptake in the middle facet of the talocalcaneal joint on bone scintigraphy. Excision of the hypervascular capsule and synovium from this area can result in resolution of the symptoms. LEVEL OF EVIDENCE: Therapeutic Level IV.

Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome.

BACKGROUND: Several tests for making the diagnosis of rotator cuff disease have been described, but their utility for diagnosing bursitis alone, partial-thickness rotator cuff tears, and full-thickness rotator cuff tears has not been studied. The hypothesis of this study was that the degree of severity of rotator cuff disease affects the diagnostic values of the commonly used clinical tests. METHODS: Eight physical examination tests (the Neer impingement sign, Hawkins-Kennedy impingement sign, painful arc sign, supraspinatus muscle strength test, Speed test, cross-body adduction test, drop-arm sign, and infraspinatus muscle strength test) were evaluated to determine their diagnostic values, including likelihood ratios and post-test probabilities, for three degrees of severity in rotator cuff disease: bursitis, partial-thickness rotator cuff tears, and full-thickness rotator cuff tears. A forward stepwise logistic regression analysis was used to determine the best combination of clinical tests for predicting the various grades of impingement syndrome. RESULTS: The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of the eight tests varied considerably. The combination of the Hawkins-Kennedy impingement sign, the painful arc sign, and the infraspinatus muscle test yielded the best post-test probability (95%) for any degree of impingement syndrome. The combination of the painful arc sign, drop-arm sign, and infraspinatus muscle test produced the best post-test probability (91%) for full-thickness rotator cuff tears. CONCLUSIONS: The severity of the impingement syndrome affects the diagnostic values of the commonly used clinical tests. The variable accuracy of these tests should be taken into consideration when evaluating patients with symptoms of rotator cuff disease.

Revision surgery for failed thermal capsulorrhaphy.

BACKGROUND: With the failure of thermal capsulorrhaphy for shoulder instability, there have been concerns with capsular thinning and capsular necrosis affecting revision surgery. PURPOSE: To report the findings at revision surgery for failed thermal capsulorrhaphy and to evaluate the technical effects on subsequent revision capsular plication. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Fourteen patients underwent arthroscopic evaluation and open reconstruction for a failed thermal capsulorrhaphy. The cause of the failure, the quality of the capsule, and the ability to suture the capsule were recorded. The patients were evaluated at follow-up for failure, which was defined as recurrent subluxations or dislocations. RESULTS: The origin of the instability was traumatic (n = 6) or atraumatic (n = 8). At revision surgery in the traumatic group, 4 patients sustained failure of the Bankart repair with capsular laxity, and the others experienced capsular laxity alone. In the atraumatic group, all patients experienced capsular laxity as the cause of failure. Of the 14 patients, the capsule quality was judged to be thin in 5 patients and ablated in 1 patient. A glenoid-based capsular shift could be accomplished in all 14 patients. At follow-up (mean, 35.4 months; range, 22 to 48 months), 1 patient underwent revision surgery and 1 patient had a subluxation, resulting in a failure rate of 14%. CONCLUSIONS: Recurrent capsular laxity after failed thermal capsular shrinkage is common and frequently associated with capsular thinning. In most instances, the capsule quality does not appear to technically affect the revision procedure.

Uncommon Variant of Type II Monteggia Fracture with Concomitant Distal Humeral Fracture.

Monteggia fracture-dislocation, a common injury sustained by pediatric population, is a rare entity in adults. It was first observed by Giovanni Battista Monteggia and later classified by Bado into 4 groups. The term "Monteggia equivalent or variant" was introduced to describe certain injuries with similar radiographic pattern and biomechanism of injury. Since then various types and their variants have been described in the literature. We present a complex fracture pattern in a 55-year-old male not previously described in the literature along with its treatment modality and favorable outcome.

Extra-articular Synovial Chondromatosis Eroding and Penetrating the Acromion.

Synovial chondromatosis of the shoulder is an uncommon disorder. It usually affects the glenohumeral joint and is characterized by metaplasia of the synovium leading to the formation of osteochondral loose bodies. Few cases of extra-articular subacromial synovial chondromatosis involving the rotator cuff tendon have been reported in the literature. The treatment of previously reported cases consisted of open bursectomy and removal of loose bodies. We report a case of subacromial synovial chondromatosis without rotator cuff involvement but with severe erosion and fracture of the acromion. Treatment consisted of shoulder arthroscopy to remove all loose bodies, total bursectomy, and debridement of the acromion. Potential benefits of arthroscopy were also evaluated.

Residual deformities following successful initial bone union in congenital pseudoarthrosis of the tibia.

The pathology of congenital pseudoarthrosis of tibia is an enigma and the treatment is challenging. Despite achieving union of the pseudoarthrosis, these patients may have compromised function secondary to residual deformities. The purpose of this study is to analyze the prevalence of these deformities, the morbidity caused by them, and the methods to overcome the problems. Sixteen patients who had a successful union were retrospectively reviewed. Clinically, the following parameters were assessed: pain, joint stiffness, and limb length discrepancy (LLD). Anteroposterior and lateral lower extremity radiographs were performed to analyze (1) union of the tibia and fibula, (2) deformity of the tibia, (3) degree of ankle valgus, (4) degree of calcaneus of the os calcis, (5) LLD, and (4) refracture. The average follow-up was 16 years from the first and 8 years from the last surgical procedure. Residual deformities included valgus of tibia (average 11.4 degrees) and procurvatum (average 19.4 degrees) deformities of the tibia or valgus deformity of the ankle (average 21.3 degrees) and calcaneus of the os calcis (average 46 degrees). There were 9 refractures in 8 patients. Nine patients had an LLD (average 3.5 cm). The study demonstrates that careful follow-up of these patients is necessary and residual problems are to be treated as they occur.