Treatment for displaced proximal humerus fractures: comparison of interlocking plate fixation versus minimal invasive techniques.

BACKGROUND AND PURPOSE: The functional results and the complications following interlocking plate fixation of displaced proximal humerus fractures should be evaluated and compared with those following minimal invasive fixation techniques. PATIENTS AND METHODS: Fifty patients (30 women, 20 men, mean age 62.7 (18-91) years) were treated for a displaced proximal humerus fracture using an interlocking plate fixation (PHILOS®) between 2003 and 2004. The mean follow-up time was 12 (9-36) months. Functional and radiographic results (Constant-Murley and Neer scores) were analyzed and compared with an equivalent historical control group of 53 patients operated for the same fracture types using minimal invasive techniques (K-wires and/or cannulated screws) between 1995 and 1997. According to the OTA/AO classification, there were 15 type A, 18 type B, and 17 type C fractures in the plate fixation group, and 23, 25, and 5 of these types in the control group, respectively. RESULTS: The mean Neer score was 85.9, the mean Constant-Murley score 84, whereas 82.4 and 75.4 for the control group, respectively. Good and excellent results were seen in 78%, whereas in 70% in the control group. The results were dependent upon the fracture's type, sex, and patient's age. Complications were seen in 9 patients, whereas in 16 patients in the control group. INTERPRETATION: Using an interlocking plate, the indication of fixation of displaced proximal humerus fractures had been expanded to type C fractures. The implant failure rate can be reduced. The functional results achieved are better compared with those following minimal invasive techniques.

Rupture of the anterior tibial tendon: three clinical cases, anatomical study, and literature review.

BACKGROUND: We report three cases of anterior tibial tendon ruptures and the results of an anatomical study in regard to the tendon's insertion site and a literature review. METHODS: Three patients were referred to our hospital with anterior tibial tendon ruptures. In the anatomical study, 53 feet were dissected, looking in particular for variants of the bony insertion of the tendon. RESULTS: Two patients had surgical treatment (one primary repair and one semimembranosus tendon graft) and one conservative treatment. After a mean followup of 14 weeks all patients had satisfactory outcomes. In the anatomical study, we noted three different insertion sites: in 36 feet the tendon inserted into the medial side of the cuneiform and the base of the first metatarsal bone and in 13 feet only into the medial side of the cuneiform bone. In the remaining four feet the tendon inserted into the cuneiform and the first metatarsal bone, but an additional tendon was noted taking its origin from the anterior tibial tendon near its insertion into the medial cuneiform and attaching to the proximal part of the first metatarsal. CONCLUSIONS: According to literature, surgical repair is the treatment of choice for acute ruptures and for patients with high activity levels. For chronic ruptures and patients with low demands, conservative management may lead to an equally good outcome. Knowledge of the anatomy in this region may be helpful for diagnosis and for the interpretation of intraoperative findings and choosing the most appropriate surgical procedure.

Cyclic loading of rotator cuff reconstructions: single-row repair with modified suture configurations versus double-row repair.

BACKGROUND: Double-row repair is suggested to have superior biomechanical properties in rotator cuff reconstruction compared with single-row repair. However, double-row rotator cuff repair is frequently compared with simple suture repair and not with modified suture configurations. HYPOTHESIS: Single-row rotator cuff repairs with modified suture configurations have similar failure loads and gap formations as double-row reconstructions. STUDY DESIGN: Controlled laboratory study. METHODS: We created 1 x 2-cm defects in 48 porcine infraspinatus tendons. Reconstructions were then performed with 4 single-row repairs and 2 double-row repairs. The single-row repairs included transosseous simple sutures; double-loaded corkscrew anchors in either a double mattress or modified Mason-Allen suture repair; and the Magnum Knotless Fixation Implant with an inclined mattress. Double-row repairs were either with Bio-Corkscrew FT using modified Mason-Allen stitches or a combination of Bio-Corkscrew FT and PushLock anchors using the SutureBridge Technique. During cyclic load (10 N to 60-200 N), gap formation was measured, and finally, ultimate load to failure and type of failure were recorded. RESULTS: Double-row double-corkscrew anchor fixation had the highest ultimate tensile strength (398 +/- 98 N) compared to simple sutures (105 +/- 21 N; P < .0001), single-row corkscrews using a modified Mason-Allen stitch (256 +/- 73 N; P = .003) or double mattress repair (290 +/- 56 N; P = .043), the Magnum Implant (163 +/- 13 N; P < .0001), and double-row repair with PushLock and Bio-Corkscrew FT anchors (163 +/- 59 N; P < .0001). Single-row double mattress repair was superior to transosseous sutures (P < .0001), the Magnum Implant (P = .009), and double-row repair with PushLock and Bio-Corkscrew FT anchors (P = .009). Lowest gap formation was found for double-row double-corkscrew repair (3.1 +/- 0.1 mm) compared to simple sutures (8.7 +/- 0.2 mm; P < .0001), the Magnum Implant (6.2 +/- 2.2 mm; P = .002), double-row repair with PushLock and Bio-Corkscrew FT anchors (5.9 +/- 0.9 mm; P = .008), and corkscrews with modified Mason-Allen sutures (6.4 +/- 1.3 mm; P = .001). CONCLUSION: Double-row double-corkscrew anchor rotator cuff repair offered the highest failure load and smallest gap formation and provided the most secure fixation of all tested configurations. Double-loaded suture anchors using modified suture configurations achieved superior results in failure load and gap formation compared to simple suture repair and showed similar loads and gap formation with double-row repair using PushLock and Bio-Corkscrew FT anchors. CLINICAL RELEVANCE: Single-row repair with modified suture configurations may lead to results comparable to several double-row fixations. If double-row repair is used, modified stitches might further minimize gap formation and increase failure load.

Minimally invasive endoscopic reconstruction technique of acute AC-joint dislocations: a cadaver study.

The treatment of acute Rockwood type III AC-joint dislocations is controversial. Problems related to open surgery are soft tissue healing, residual instability and the necessity of hardware removal. After non-operative therapy the cosmetic result may be problematic and in some cases symptomatic instabilities occur. The goal of the present cadaver study was to develop a new, minimally invasive technique for acute AC-joint reconstructions and to analyse its potential risk for neurovascular injuries. The surgical technique was based on an arthroscopically assisted reconstruction of the coracoclavicular ligaments with a suture anchor (Arthrex, Naples, FL, USA) and a supplemental stabilization of the AC-joint capsule with a suture cerclage (Fibre Wire 2, Arthrex) performed on ten cadaveric shoulder specimens. After surgery all specimens were dissected to analyse the anatomy of the coracoclavicular ligament complex, the position of anchors and sutures and to measure the distance to the neurovascular structures at risk. The supraspinatus muscle was never injured by the Neviaser approach. The insertion of the suture anchors never failed, resulting in a secure and reproducible anchor position. The mean distance between the coracoid and suprascapular nerve was 1.8 cm (1.5-2.2), between the coracoid and the suprascapular artery 1.5 cm (1.3-1.9). These structures were never injured. The resulting force vector of the suture located between the anchor and the drill hole was close to the anatomic force vector of the coracoclavicular ligament complex. The suture cerclage was always correctly positioned. The presented technique is at minimal risk for the surrounding neurovascular structures and allows for a minimally invasive and anatomically correct reconstruction of the AC-joint. Further biomechanical analysis is needed to evaluate the strength of the reconstruction technique. The proposed technique might be a reasonable alternative to existing invasive techniques of open reconstruction of acute type III AC-joint dislocations in high-demand patients.