Arthroscopic Latarjet: Suture-Button Fixation Is a Safe and Reliable Alternative to Screw Fixation.

PURPOSE: To evaluate mid-term clinical outcomes, complications, bone-block healing, and positioning using suture-button fixation for an arthroscopic Latarjet procedure. METHODS: Patients with traumatic recurrent anterior instability and glenoid bone loss underwent guided arthroscopic Latarjet with suture-button fixation. We included patients with anterior shoulder instability, glenoid bone loss >20%, and radiographic and clinical follow-up minimum of 24 months. Patients with glenoid bone loss <20% or those that refused computed tomography imaging were excluded. Bone-block fixation was accomplished with 2 cortical buttons connected with a looped suture (4 strands). The looped suture was tied posteriorly with a sliding-locking knot. After transfer of the bone block on the anterior neck of the scapula, compression (100 N) was obtained with the help of a tensioning device. Clinical assessment was performed at 2 weeks, 3 months, 6 months, and then yearly with computed tomography completed at 2 weeks and 6 months to confirm bony union. RESULTS: A consecutive series of 136 patients underwent arthroscopic Latarjet with 121 patients (89%; mean age 27 years) available at final follow-up (mean follow-up, 26 months; range, 24-47 months). No neurologic complications or hardware failures were observed; no patients had secondary surgery for implant removal. The transferred coracoid process healed to the scapular neck in 95% of the cases (115/121). The bone block did not heal in 4 patients; it was fractured in 1 and lysed in another. Smoking was a risk factor associated with nonunion (P < .001). The coracoid graft was positioned flush to the glenoid face in 95% (115/121) and below the equator in 92.5% (112/121). At final follow-up, 93% had returned to sports, whereas 4 patients (3%) had a recurrence of shoulder instability. The subjective shoulder value for sports was 94 ± 3.7%. Mean Rowe and Walch-Duplay scores were 90 (range, 40-100) and 91 (range, 55-100), respectively. CONCLUSIONS: Suture-button fixation is an alternative to screw fixation for the Latarjet procedure, obtaining predictable healing with excellent graft positioning, and avoiding hardware-related complications. There was no need for hardware removal after suture-button fixation. The systematic identification of the axillary and musculocutaneous nerves reduced risk of neurologic injury. A low instability recurrence rate and excellent return to pre-injury activity level was found. Suture-button fixation is simple, safe, and may be used for both open and arthroscopic Latarjet procedure. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Displaced humeral surgical neck fractures: classification and results of third-generation percutaneous intramedullary nailing.

BACKGROUND: The high rates of complications and reoperations observed with the early designs of first-generation (unlocked) and second-generation (bent design) humeral intramedullary nail (IMNs) have discouraged their use by most surgeons. The purpose of this study was to report the results of a third-generation (straight, locking, low-profile, tuberosity-based fixation) IMN, inserted through a percutaneous approach, for the treatment of displaced 2-part surgical neck fractures. METHODS: We performed a retrospective review of 41 patients who underwent placement of a third-generation IMN to treat a displaced 2-part surgical neck fracture (AO/OTA type 11A3). The mean age at surgery was 57 years (range, 17-84 years). After percutaneous insertion through the humeral head, the IMN was used as a reduction tool. Static locking fixation was achieved after axial fracture compression ("back-slap" hammering technique). Patients were reviewed and underwent radiography with a minimum of 1 year of follow-up; the mean follow-up period was 26 months (range, 12-53 months). RESULTS: Preoperatively, 3 types of surgical neck fractures were observed: with valgus head deformity (Type A = 8 cases), shaft translation without head deformity (Type B = 19 cases), or with varus head deformity (Type C = 14 cases). At final follow-up, all fractures went on to union, and the mean humeral neck-shaft angle was 132° ± 5°. We observed 2 malunions and 1 case of partial humeral head avascular necrosis. No cases underwent screw migration or intra-articular penetration. At last review, mean active forward elevation was 146° (range, 90°-180°) and mean external rotation was 50° (range, 20°-80°). The mean Constant-Murley score and Subjective Shoulder Value were 71 (range, 43-95) and 80% (range, 50%-100%), respectively. CONCLUSIONS: Antegrade insertion of a third-generation IMN through a percutaneous approach provides a high rate of fracture healing, excellent clinical outcome scores, and a low rate of complications. No morbidity related to the passage of the nail through the supraspinatus muscle and the cartilage was observed. The proposed A, B, and C classification allows choosing the optimal entry point for intramedullary nailing.

Non-operative treatment of four-part fractures of the proximal end of the humerus: results of a prospective and retrospective multicentric study.

PURPOSE: The aim of this study was to evaluate the short- and medium-term results of non-operative treatment of four-part fractures of the proximal end of the humerus. The initial hypothesis was that non-operative treatment of fractures with little or no displacement is equivalent or superior to surgical treatment, and that non-operative treatment is probably insufficient for displaced fractures. METHODS: This was a multicentric, prospective and retrospective study, based on 384 four-part proximal humerus fractures, 58 of which involved non-operative treatments - 37 in the prospective study (Pro-CT4) and 21 in the retrospective study (Retro-CT4). The average patient age was 64 +/- 14 years (39-90); 66 % were female and 34 % male. In 88 % of these cases, non-operative treatment was chosen for the fracture, as there was little or no displacement. In 10 % of cases, non-operative treatment was chosen "by default", due to the patient's medical conditions, as surgery was contraindicated, and in 2 % of cases due to the patient refusing surgery. All patients were reviewed clinically and radiologically, with SSV evaluation, absolute and weighted Constant scores and the Quick DASH score all assessed. The main evaluation criterion was the weighted Constant score which was considered a failure when below 70 %. RESULTS: In the Pro-CT4 study, the average follow-up period was 11 +/- four months (5-18) with functional scores as follows: average SSV: 72 +/- 26 % (8-100); average Constant score: 65 +/- 21 points (21-95); average weighted Constant score: 86 +/- 26 % (32-130); average Quick DASH: 23 +/- 21 (0-64). 27 % of patients had a weighted Constant score below 70 %. In the Retro-CT4 study, the average follow-up period was 38 +/- 13 months (18-62) with functional scores as follows: average SSV: 73 +/- 17 % (30-100); average Constant score: 68 +/- 18 points (33-95); average weighted Constant score: 88 +/- 27 % (47-133); average Quick DASH: 18 +/- 16 (0-48); 24 % of patients had a weighted Constant score below 70 %. CONCLUSION: This study confirms our initial hypothesis. When non-operative treatment of four-part proximal humerus fractures is carried out by choice, the results are excellent. However, when this treatment is carried out "by default" - especially because surgery is contraindicated - the results are disappointing. LEVEL OF EVIDENCE IV: prospective and retrospective studies.

Antibiotic addition to cement - is it beneficial.

Antibiotic loaded acrylic cement (ALAC) is widely employed in primary as well as revision hip arthroplasties. There are prerequisites in relation to antibiotic choice and mixing techniques. The 2007 French Consensus Conference delivered recommendations for ALAC in primary arthroplasty. Decisions need to be more patient-specific in revision surgery. Appropriate use of ALAC (and associated antibiotics) and awareness of alternative possibilities such as collagen or bone graft impregnated with antibiotics may guide future practice.

Early reduction versus skin traction in the orthopaedic treatment of femoral shaft fractures in children under 6 years old.

BACKGROUND: Femoral shaft fractures occur very frequently in children, and their prognosis usually is good. Nonoperative treatment is the gold standard for children under 6 years because of the excellent bony union and the remodelling qualities. PURPOSE: The aim of this study was to compare two orthopaedic therapeutic methods: skin traction versus immediate reduction. MATERIALS AND METHODS: The study involved 35 children, divided into two groups: in group 1, treatment consisted of skin traction for 21 days followed by hip spica casting; in group 2, an immediate reduction with early hip spica casting was performed. The ranges of motion, the delay before weight bearing, the hospitalisation duration and the required amount of painkillers were recorded. We compared initial shortening, axial, sagittal and rotational alignment, and femoral length discrepancy. We calculated the injured femoral diaphysal overgrowth and correlated it to the fracture type and location and to the initial shortening. Economical variables were also studied. RESULTS: The mean overgrowth was 8.9 mm in group 1 and 8.5 mm in group 2. Three years after the trauma, length discrepancy was 4 mm in group 1 and 1 mm in group 2. Hip spica casting leads to significant reductions in weight-bearing delay, hospitalisation duration and pain. The cost of treatment with skin traction was four times higher (24,472 euros) than that of immediate reduction (6,384 euros). DISCUSSION: Our results are in accordance with the literature. The femoral overgrowth was proportional to the initial shortening. Masculine gender, an oblique fracture and injury of the lower third of the femur were associated with the greatest femoral overgrowth. During the first year of follow-up, the femoral length discrepancy hardly varied after immediate reduction (4 mm), whereas the overgrowth reached 6 mm after skin traction. Overall, immediate hip spica casting leads to significant reductions in weight-bearing delay, hospitalisation duration, complications and costs, while having similar clinical results as traction.