Physeal Migration During Knee-guided Growth With Tension Band Plates: Influence of Implant Position.

OBJECTIVE: Physeal migration during guided growth with tension band plates (TBPs) has been poorly described. The positioning factors associated with this phenomenon and its clinical implications are unknown. Our aim is to determine the influence of implant position on the risk of physeal migration during knee-guided growth with TBP. METHODS: Retrospective study of 491 patients who underwent temporary hemi or epiphysiodesis with TBP around the knee between 2007 and 2019. We identified 29 patients who presented physeal migration during follow-up. Demographic and clinical data were collected, and the following measures were obtained from the immediate postoperative radiographs: epiphyseal screw base-physis distance/epiphyseal screw tip-physis distance, interscrew angle, epiphyseal screw-physis angle(ES-PHa)/metaphyseal screw-physis angle, plate-physis angle, epiphyseal screw-plate angle/metaphyseal screw-plate angle, and epiphyseal screw-physis length ratio. Using follow-up radiographs, the type of physeal migration of the epiphyseal screw (touch, occupy, or traverse) and the status of the physis after implant removal (unaltered, physeal bar, and skeletal maturity) were also recorded. A descriptive analysis of the cases and a case-control comparison of imaging studies were performed. RESULTS: The median patient age at intervention was 12.2 years (interquartile range: 11.3 to 14.1), and 76% were males. A statistically significant difference between cases and controls was obtained for epiphyseal screw base-physis distance (3.7 vs 6.3; P = 0.029), epiphyseal screw tip-physis distance (3.6 vs 7.85; P = 0.002), ES-PHa (-0.1 vs 7.45; P = 0.007), and plate-physis angle (85.45 vs 88.60; P = 0.012). In a categorical analysis, a significant difference was found for the ES-PHa categories ( P = 0.002) and for the ES-PHa/metaphyseal screw-physis angle categorical pair ( P = 0.018). In 16, 17, and 12 cases the physis was touched, occupied, or traversed, respectively, although we found no physeal alterations after plate removal. CONCLUSIONS: In our study, physeal migration of TBP is not an uncommon phenomenon, although no physeal abnormalities were detected. Convergent placement of the epiphyseal screw with the base or tip close to the physis should be avoided as this position is associated with a higher risk of physeal migration. LEVEL OF EVIDENCE: Level III-case-control study.

Functional results of Circumferential Capsular Release in adhesive shoulder capsulitis. Comparative study of patients over and under fifty years of age.

INTRODUCTION: The aim of our study is to evaluate the functional and mobility outcomes in patients who have undergone arthroscopic circumferential arthrolysis of the shoulder and to find out if there are differences in the results in relation to the patient's age. MATERIALS AND METHODS: This is a retrospective case series of patients with idiopathic adhesive capsulitis treated by arthroscopic 360º circumferential capsulotomy in lateral position and followed for a minimum of 2 years. Range of motion (ROM), functional outcomes using the Constant Score (CS), health-related quality of life outcomes with the EuroQol Five Dimensions tool (EQ-5D), pain using the Visual Analogue Scale (VAS). RESULTS: A total of 26 shoulders were included, 10 men (41.7%) and 14 women (58.3%), with 2 patients being bilateral. The mean age was 48.64 ± 7.5 years, and the mean follow-up was 50.2 months. Postoperative ROM improved significantly compared to preoperative ROM (p < 0.05). Shoulder forward flexion improved by 38.6° (95%CI 22.3-54.9, p < 0.01), abduction by 35.2° (95%CI 17.6-52.8, p < 0.01) and external rotation by 21.9° (95%CI 12.8-30.9, p < 0.01 p < 0.01). Median internal rotation improved from buttock to T12 (p < 0.01). The mean improvement in CS was 54.3 ± 24.4 points (p < 0.01). The EQ-5D and VAS scores at the end of follow-up were 0.73 ± 0.23 and 2.73 ± 2.55, respectively. There were no statistical differences between young patients and patients aged 50 years or older in ROM or functional results. CONCLUSIONS: Patient age did not affect outcomes significantly, with patients older than 50 years showing similar results to younger patients.

Do the humeral radiographic changes at 5-year follow-up affect the clinical outcomes of press-fit humeral stems in primary reverse shoulder arthroplasties?

INTRODUCTION: The purposes of this study were to analyze and compare the functional outcomes and radiological changes around the press-fit humeral components in two contemporary medialized reverse total shoulder arthroplasty (RTSA) systems at a minimum of 5-year follow-up. MATERIALS AND METHODS: Between December 2003 and December 2015, 249 consecutive RTSAs were performed at our hospital. Of these, 68 primary uncemented RTSA met our inclusion criteria. The Constant-Murley score (CMS), the modified Constant score, a visual analog scale (VAS) and active shoulder range of motion (ROM) were measured pre- and postoperatively. Radiological assessment was performed by plain radiographs at a minimum of 5 years postoperatively. RESULTS: At a mean follow-up of 80.2 months, there was no significant difference (p = .59) between the postoperative functional scores and range of motion of the two groups (Delta Xtend and Lima SMR). Radiological data of stress-shielding were observed in 38 patients (55.9%) being slightly more frequent in the Lima SMR group (21 patients) than in the Delta Xtend group (17 patients) (p = .62). CONCLUSIONS: Our study shows that the good functional results are similar between the two uncemented RTSA systems used and that they do not depend on the presence of radiological changes (stress-shielding) in the humeral stem at a minimum 5-year follow-up.

The Spanish version of the Constant-Murley Shoulder Score: translation, cultural adaptation, and validity.

BACKGROUND: The Constant-Murley Score (CMS) is one of the most employed tools for assessing shoulder function. It was first devised in 1987 for the English population and is now widely used internationally. However, it had yet to be cross-culturally adapted and validated to Spanish, which is the world's second-most native language. Formal adaptation and validation of clinical scores is paramount for them to be used with rigorous scientific methodology. METHODS: Following international recommendations for the cross-cultural adaptation of self-report measures, the CMS was first adapted into Spanish in six stages: translation, synthesis, back-translation, a review by expert committee, pretesting, and final appraisal by expert committee. After conducting a pretest with 30 individuals, the Spanish version of the CMS was tested on 104 patients with various shoulder pathologies to assess content, construct, criterion validity, and reliability. RESULTS: No major conflicts were encountered in the process of cross-cultural adaptation, with 96.7% of pretested patients having a full understanding of every item in the test. The validation showed excellent content validity (content validity index = .90), construct validity (strong correlation between items within the same subsection of the test), and criterion validity (CMS - Simple Shoulder Test, Pearson r = .587, P = .01; CMS - American Shoulder and Elbow Surgeons, Pearson r = .690, P = .01). Reliability of the test was also excellent, with high internal consistency (Cronbach's α = .819), interrater reliability (intraclass correlation coefficient = .982), and intrarater reliability (intraclass correlation coefficient = .937), without showing ceiling or floor effects. CONCLUSION: Spanish version of the CMS has been proved to accurately reproduce the original score and to be easily comprehensible by native Spanish speakers with acceptable intrarater-interrater reliability and construct validity. INTRODUCCIóN: La escala de Constant-Murley (CMS) es una de las más empleadas para evaluar la función del hombro. Se ideó por primera vez para la población inglesa en 1987 y actualmente es ampliamente empleada a nivel internacional. Sin embargo, su validación y adaptación transcultural no se han realizado al español, la segunda lengua nativa más hablada en el mundo. Actualmente no puede resultar admisible el empleo de escalas en las que no tengamos la seguridad de que existe una equivalencia conceptual, cultural y lingüística entre la versión original y la empleada. MATERIAL Y MéTODO: La versión traducida al español de la CMS se realizó siguiendo las recomendaciones internacionales: traducción, síntesis de la traducción, retrotraducción, revisión por comité de expertos, pretest y validación. Tras la realización del pretest en 30 individuos, la versión española de la escala de CMS se probó en 104 pacientes con diferentes patologías de hombro para evaluar las propiedades psicométricas de la escala: contenido, constructo, validez de criterio y fiabilidad. RESULTADOS: No se encontraron problemas importantes durante el proceso de adaptación transultural con un entendimiento completo de todos los ítems del pretest por el 96.7% de los pacientes. La escala adaptada demostró una excelente validez de contenido (índice de validez de contenido = .90), de constructo (fuerte correlación entre ítems de la misma subsección del test), y de criterio (CMS-SST Pearson's r = .587, p = .01; CMS-ASES Pearson's r = .690, p = .01). La Fiabilidad del test resultó excelente, con una elevada consistencia interna (Cronbach's α = .819), fiabilidad interobservador (ICC = .982) e intraobservador (ICC = .937), sin efectos techo y suelo. CONCLUSIóN: La versión Española de la CMS garantiza la equivalencia con respecto al cuestionario original. Los presentes resultados, sugieren que esta versión es válida, fiable y reproducible para la evaluación de la patología de hombro en nuestro entorno.

Shoulder problems after percutaneous antegrade intramedullary nailing in humeral diaphyseal fractures using contemporary straight third-generation nail.

BACKGROUND: Antegrade intramedullary nailing in humeral shaft fracture has been abandoned by certain orthopedic surgeons because of rotator cuff injury caused by first- and second-generation intramedullary nails (IMNs). However, only a few studies have specifically addressed the results of antegrade nailing for the treatment of humeral shaft fractures with a straight third-generation IMN; thus, complications need to be re-evaluated. We hypothesized that fixation of displaced humeral shaft fractures with a straight third-generation antegrade IMN with the percutaneous technique avoid shoulder problems (stiffness and pain) incurred by first- and second-generation IMNs. METHODS: This was a retrospective, single-center, nonrandomized study of 110 patients with a displaced humeral shaft fracture between 2012 and 2019 treated surgically with a long third-generation straight IMN. Mean follow-up was 35.6 months (range, 15-44 months). RESULTS: There were 73 women and 37 men with a mean age of 64.7 ± 19 years. All fractures were closed (37.3% 12A1, 13.6% 12B2, and 13.6% 12B3 AO/OTA classification). Mean Constant score was 82 ± 19, Mayo Elbow Performance Score 96 ± 11 and the mean EQ-5D visual analog scale score was 69.7 ± 21.5. Mean forward elevation 150° ± 40°, abduction 148° ± 45°, and external rotation 38° ± 15°. Symptoms associated with rotator cuff disease were present in 6.4%. Evidence of radiographic fracture healing was detected in all but 1 case. One postoperative nerve injury and 1 adhesive capsulitis were present. Overall, 6.3% underwent second surgeries (4.5% were minor surgeries like hardware removal). CONCLUSION: Percutaneous antegrade intramedullary nailing of humeral shaft fractures with a straight third-generation nail considerably reduced complications related to shoulder problems and achieved good functional results.

Reverse shoulder arthroplasty for proximal humeral fracture in the elderly. Cemented or uncemented stem?

OBJECTIVE: The purposes of this study were to compare functional outcomes, radiographic stem changes and complication rate in patients with proximal humeral fractures operated with cemented or uncemented RSA. METHODS: Retrospective review of 68 primary RSAs in PHF, 45 cemented/23 uncemented. Functional outcomes were evaluated according to constant, ASES scales and the range of motion (ROM). Radiographic assessment was performed at a minimum of two years post-operatively. RESULTS: The mean follow-up cemented/uncemented was 37.8/26.5 months (p = .04) and the mean age 78/80 years old (p = .09). The functional outcome and range of movement were equivalent in the two groups except for the forward flexion that was significantly higher in the cemented group (p = .03). Stress shielding was seen in 30.4% of uncemented group and none in the cemented. Anatomic tuberosity healing was significantly higher with uncemented components compared with cemented components (64% vs 91%, p = .02). Cemented stems had radiolucent lines with a width of 2 mm or more in three or more Gruen zones in 9% vs 0% in the uncemented group and an evident change in the stem position was present in 4% vs 0% in the non-cemented group. CONCLUSION: At mid-term follow-up, no differences in functional outcomes were detected depending on the stem fixation technique. Cemented stems, however, have a complication rate (including stem loosening) significantly higher than press-fit stems.

Third-generation intramedullary nailing for displaced proximal humeral fractures in the elderly: quality of life, clinical results, and complications.

INTRODUCTION: Antegrade insertion of third-generation intramedullary nail (IMN) has been shown to provide excellent results in young patients for treatment of displaced two-part surgical neck fracture. In elderly patients, osteoporosis makes internal fixation problematic and frequently contributes to failed fixation and poor clinical results. The purpose of this study was to report the health-related quality of life (HRQoL), functional results, and postoperative complications obtained with straight third-generation antegrade nailing of proximal humerus fractures (PHFs) in elderly patients. METHODS: A retrospective review of 32 patients aged 80 y.o. or older presenting a two-part or three-part PHFs treated with a straight IMN with a minimum follow-up of 12 months. Results assessed included 1) radiographic measures 2) clinical data: Charlson Comorbidity Index (CCI), VAS, range of motion (ROM), Individual Relative Constant score (IRC), Simple Shoulder Test (SST) and 3) Health-related Quality of life (HRQoL) with the EQ-5D index/EQ-VAS. RESULTS: Mean age was 82.1 (range 80-90) and mean follow-up was 45.6 months (range 16-53 months) with 91% of female patients and a mean CCI 4.6. 81% were two-part surgical neck fractures and 19% were three-part greater tuberosity fractures. The mean neck-shaft angle (NSA) at final follow-up was 132º ± 17.9º. 15.6% underwent hardware removal because of subacromial impingement and one patient (3%) was revised to RSA because of severe secondary fracture displacement. Mean IRC was 67,7 ± 30, the mean SST and VAS-Pain were 8.1 ± 3.1 and 3.2 ± 3.2, respectively, and the mean EQ-5D/EQ-VAS were 0.40 ± 0.33/64.2 ± 8.9. At last review, mean active forward flexion, abduction, and external rotation were 115º ± 35º, 100º ± 35º, and 20º ± 15º, respectively. CONCLUSION: Appropriate selection of fracture and proper operative technique with a third-generation nail result in good functional results and good HRQol with a low complication rate in elderly population.

Complex fractures of the distal humerus in the elderly: primary total elbow arthroplasty or open reduction and internal fixation? Mid-term follow-up.

OBJECTIVE: To compare the mid-term outcomes in intra-articular distal humerus fracture (AO/OTA type C) treated with either open reduction-internal fixation (ORIF) or total elbow arthroplasty (TEA) in patients older than 75 years and with more than five years of follow-up. METHODS: Retrospective study including 24 patients (11 TEA vs. 13 ORIF) with a mean age of 82 years and being all females. Results assessed included (1) radiographic measures; (2) functional results: range of motion, Mayo Elbow Performance Score (MEPS), quick-DASH; and (3) complications. RESULTS: TEA group vs. ORIF group achieved a mean flexion of 117° ± 9.6° vs. 106° ± 14°, extension loss of 38° ± 17° vs. 30.8° ± 16°, pronation 75° ± 5° vs. 85° ± 7° and supination 75° ± 4° vs. 70° ± 5°. Mean MEPS score was 71.6 vs. 83.6 (p = .183) and mean quick-DASH was 44.8 vs. 42.6 (p = .789). All 13 patients in the ORIF group demonstrated radiographic signs of bone union and none underwent conversion to TEA. Sixty-three percent of the patients in the TEA group underwent re-operation at an average of 72 months (62.4-75.2 months), including three  for periprosthetic fracture and four  for implant loosening. Whereas in the ORIF group, 23% of the patients were re-operated upon excluding olecranon osteotomy hardware, two  for stiffness, and one  for an olecranon tension band wire failure. CONCLUSIONS: Although there were no differences in mid-term functional outcomes between either treatment, our results suggest that the recent trend towards the use of TEA instead of ORIF in the elderly should be re-examined due to the high rate of complications beyond five  years of follow-up with TEA.

Concurrent uper limb and hip fracture in the elderly: experience at our centre. / Fracturas concomitantes de miembro superior y cadera en pacientes mayores de 65 años: experiencia en nuestro centro.

INTRODUCTION: The incidence of hip fracture in the elderly is on the rise, occasionally accompanied by concurrent upper limb fractures. Our investigation aims to determine whether these patients experience poorer functional outcomes, prolonged hospitalization, or higher mortality rates when compared to those with isolated hip fracture. MATERIAL AND METHODS: We retrospectively reviewed 1088 elderly patients admitted to our centre with hip fracture between January 2017 and March 2020. We recorded the presence of concomitant fractures and their treatment. We analyzed the duration of hospital stay, in-hospital mortality and function. RESULTS: We identified 63 patients with concomitant upper limb fracture (5.6%). Among them, 93.7% were women, and the average age was 86.4 years. 80.9% of the upper limb fractures were distal radius or proximal humerus. Patients with concomitant fracture had increased length of stay (mean, 19.6 vs 12.8, p=0.002), decreased proportion of patients returning to their own home at discharge (23.6% vs 26.3%, p=0.042) and increased in-hospital mortality rate (9.5% vs 5.9%, p=0.003). CONCLUSIONS: Patients with concomitant upper limb fracture require a longer length of stay and exhibit an elevated in-hospital mortality rate. Furthermore, this condition is associated with a reduced short-term functional recovery, thereby decreasing the chances of the patient returning home upon hospital discharge.

Poor Results After Arthroscopic Treatment of Irreparable Rotator Cuff Tears Using a Subacromial Balloon Spacer.

INTRODUCTION: Arthroscopic balloon spacer arthroplasty (BSA) is a relatively recent procedure for patients with irreparable rotator cuff tears, conceived to prevent degenerative joint changes and relieve subacromial pain. METHODS: This is a retrospective case series of 16 consecutive patients treated with BSA and followed up for a minimum 12 months. Besides BSA, partial tendon repair was done whenever possible. Radiographical parameters such as acromiohumeral distance and Hamada stage were measured preoperatively and postoperatively. Range of motion, functional results (Constant score; Simple Shoulder Test; American Shoulder and Elbow Surgeons score; and Disabilities of the Arm, Shoulder, and Hand score), health-related quality of life results with the EuroQol Five Dimensions tool, complications, and patient satisfaction were also analyzed. RESULTS: The mean age was 64 ± 10.3 years, and the male/female ratio was 6/10. Partial repair was achieved in five patients (31.2%) and did not influence functional or health-related quality of life results ( P = 0.11). The mean acromiohumeral distance and Hamada stage worsened from preoperative measures (3.7 ± 2.0 mm and 2.3 ± 1.1) to final follow-up measures (3.1 ± 2.4 mm and 3.1 ± 1.3). Shoulder abduction increased by 7.8° ± 26.8° and forward flexion decreased by 25.5° ± 32.4° after surgery. The functional results at the final follow-up were Constant 49.5 ± 18.0; American Shoulder and Elbow Surgeons 60.2 ± 27.2; Simple Shoulder Test 8.5 ± 4.6; and Disabilities of the Arm, Shoulder, and Hand 32.7 ± 12.1. The mean index value for the EuroQol Five Dimensions was 0.79, and perceived quality of life was 85.6 ± 15.4 of 100 points. 62.5% of the patients (10) were satisfied with surgery. The complication rate was 13% (2), accounting for one deep infection and one balloon migration. CONCLUSION: Theoretical benefits of BSA for delaying superior humeral head translation and arthropathic changes could not be demonstrated in our series. Its functional results and satisfaction rates are low, but self-reported quality of life after surgery does not seem impaired. Complications do not occur frequently but require reintervention and endanger joint viability. LEVEL OF EVIDENCE: Level IV (case series).

Acute Carpal Tunnel Syndrome After Radial Artery Cannulation: A Case Report.

CASE: A 20-year-old postpartum woman developed paresthesias and intolerable pain over the volar aspect of the first through fourth fingers, after radial artery cannulation (RAC) during cesarean section. Ultrasonography did not show any hematoma in the forearm. Urgent carpal tunnel release and median nerve decompression were performed, resulting in complete disappearance of symptoms. CONCLUSION: Acute median nerve compression is a rare injury in its own, but it is even rarer as a complication of RAC. Urgent decompression should be performed as soon as possible to avoid future neurological deficits.

Suspected Brown Recluse Spider Envenomation: Missed Diagnosis and Delayed Treatment of Loxoscelism: A Case Report.

CASE: We report the case of a previously healthy 51-year-old man who presented to our hospital after worsening clinical appearance of his left ring finger, despite antibiotics and previous surgical drainage for suspected abscess at an outside institution 3 weeks ago. He was admitted to our hospital for surgical debridement and decompression. After suspicion of cutaneous loxoscelism based on the clinical record and corticosteroid administration, the patient presented a favorable evolution. CONCLUSION: Cutaneous loxoscelism caused by a spider bite is present in Europe, mainly in the Mediterranean area, and should be considered in cases of skin infections which do not respond to antibiotics.

A Comparison of 2 Surgical Treatments for Thoracolumbar Burst Fractures: Temporary Osteosynthesis and Arthrodesis.

BACKGROUND: We compared the clinical and radiological outcomes and complications of patients treated for thoracolumbar burst fractures via temporary percutaneous osteosynthesis or open definitive arthrodesis. METHODS: A retrospective case-control study was performed including patients treated between 2017 and 2019 for a burst fracture of the thoracolumbar junction, either with percutaneous osteosynthesis (case group) or open arthrodesis (control group). Clinical, functional, and radiographic results were analyzed and compared between treatment groups. RESULTS: We included 112 patients (56 osteosynthesis/56 arthrodesis, P = 1) in our study. The mean follow-up and mean age were 20 ± 3 months (20 ± 2/20 ± 3, P = 1), and 41 ± 10 years (40 ± 11/42 ± 10, P = 0.3), respectively. Fracture level was L1/L2 in 75% and T11/T12 in 25% of patients. The osteosynthesis group showed significantly shorter operative times (104 ± 20 minutes/176 ± 18 minutes, P < 0.01) and inpatient stays (11.6 ± 1.5 days/15.6 ± 3.8 days, P < 0.01). Both groups showed similar correction over kyphosis angle at final follow-up (5.8° ± 2.8°/6° ± 0.2°, P = 0.57), but the osteosynthesis group showed increased segment mobility after hardware removal (3.8° ± 1.2°/0.9° ± 0.3°, P < 0.01). There were no significant differences in complications, although the osteosynthesis group showed a significantly lower need for blood transfusion (21%/43%, P = 0.02). CONCLUSIONS: Both methods of treatment yielded good clinical and radiological results with similar complication rates. Temporary osteosynthesis seems to be more beneficial than open arthrodesis because it requires shorter operative time and hospitalization, causes less bleeding, and facilitates spinal movement.

Impact of the Subtle Lisfranc Injury on Foot Structure and Function.

BACKGROUND: The subtle Lisfranc injury is the disruption of the osteoligamentary complex between the first cuneiform and the second metatarsal, resulting in minor widening of this space that is often difficult to detect with plain radiographs. In this study, we assessed the results after treatment of the different stages of subtle Lisfranc injuries, focusing on their impact on foot arch anatomy and functionality at short- to midterm follow-up. METHODS: A retrospective study including patients treated in our center for a subtle Lisfranc injury between 2012 and 2019 was conducted. Demographic, epidemiologic, radiographic, and clinical data were obtained and assessed, focusing on foot arch structure and foot function, which was evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) midfoot score and the Foot Function Index (FFI). RESULTS: A total of 42 patients with a mean age of 49 ± 17.5 years were included, with an average of 4.3 years' follow-up (range, 1-8). Stage I injuries according to Nunley classification represented 19% and were treated conservatively. Stage II (66.7%) and stage III (14.3%) injuries were treated operatively, via osteosynthesis with screws (74%), K-wires (19%), or plates (7%). Flattening of foot arch after treatment was observed in 42.9% of patients, with significant increases in Costa-Bertani (12 ± 7 degrees), Hibbs (7 ± 6 degrees), and Meary (3 ± 1 degrees) angles. Other complications included complex regional pain syndrome (28.6%) and painful hardware (23.8%). Secondary joint arthrodesis was needed in 16.6% of patients. Chronic pain was present in 71.4% of patients with a mean visual analog scale (VAS) pain score at final follow-up of 4 of 10 points. Results in AOFAS midfoot score and FFI were 87.4 ± 8.3 and 15 ± 6.4, respectively. CONCLUSION: The subtle Lisfranc injury shows dissociation between the initial relatively mild radiographic changes and important future complications. Chronic pain and foot arch flattening were not uncommon. Overall foot function in the short- or midterm was found to be modestly diminished in this somewhat heterogenous cohort. LEVEL OF EVIDENCE: Level IV, therapeutic case series.