Clinical and radiographic outcomes of the open Latarjet procedure in skeletally immature patients.

INTRODUCTION: Recurrent anterior glenohumeral instability has been studied in the young population and limited evidence is available for adolescent patients. Our study is a retrospective review of patients aged <17 years who underwent open Latarjet procedure. METHODS: Forty-five patients were available for review. Clinical outcomes were assessed by range of movements, stability, Walch-Duplay score (WDS), Rowe score (RS), Constant-Murley score (CMS), Subjective Shoulder Value (SSV), and return to sport. Radiographs were reviewed for osteoarthritis and complications. RESULTS: The median age of patients was 15.7 years (13-17), and 56% had hyperlaxity. The median follow-up time was 6.6 years (3-26). The median postoperative movements showed recovered elevation (175°), external rotation (60°), and internal rotation (T9 level). Seventy-five percent of patients returned to the same level of sport, and 98% were satisfied. Clinical outcomes showed WDS, RS, and CMS scores of 85, 95, and 84 points, respectively, and an SSV of 95%. Twenty percent of patients described mild postoperative pain, and 1 had persistent stiffness. Other complications included 24% subjective apprehension, 4% redislocation, 4% wound problems, and 2% infection. Nine percent of cases had postoperative arthritis. The overall reoperation rate was 11%: 1 open washout for infection and 4 arthroscopic screw removal due to persistent pain. We found that hyperlaxity, female sex, and large or deep Hill-Sachs lesions were frequently associated with persistent apprehension at the last follow-up. CONCLUSIONS: The open Latarjet procedure provides a low rate of recurrent instability with acceptable complication rates in the long term for skeletally immature patients. It is an effective, safe treatment option without any significant glenoid growth disturbance.

Grammont Award 2018: Scapular fractures in reverse shoulder arthroplasty (Grammont style): prevalence, functional, and radiographic results with minimum 5-year follow-up.

BACKGROUND: Scapular fractures after reverse shoulder arthroplasty (RSA) are an increasingly reported complication. Information is missing regarding midterm to long-term follow-up consequences. The aim of this study was to determine the rate of scapular fracture (acromial base and spine) after Grammont-style RSA and to report functional and radiographic results of patients with a minimum 5-year follow-up. MATERIALS AND METHODS: We retrospectively reviewed 1953 Grammont-style RSAs in 1745 patients in a multicenter study. Of these, 953 patients (1035 RSAs) had minimum 5-year follow-up for functional and radiographic assessment (anteroposterior and scapular Y views. RESULTS: Twenty-six patients (1.3%) had sustained a scapular fracture; of these, 19 (10 acromial base and 9 spine fractures) had minimum 5-year follow-up and were reviewed at a mean follow-up of 97 months. Three patients (15.8%) were diagnosed at the last follow-up after an undiagnosed fracture. There were 3 traumatic cases (15.8%) and 13 (68.4%) without antecedent trauma. These 16 patients underwent nonoperative treatment. The fracture was healed in 8 (4 acromion and 4 spine). The average active forward elevation was 109° (range, 50°-170°), and the Constant score was 47.0 points (range, 8-81 points). CONCLUSIONS: Scapular fractures after Grammont-style RSAs are rare (1.3%) but remain a concern. These fractures occur mainly in the early postoperative 6 months. Immobilization with an abduction splint frequently resulted in nonunion or malunion. Final functional outcomes are poor regardless of acromial or spine fracture compared with primary RSA without fracture.

Clinical and radiographic outcomes of open Latarjet procedure in patients aged 40 years or older.

BACKGROUND: The Latarjet procedure is often used to treat shoulder instability in younger patients. Little is reported on the outcomes of this procedure in older (≥40 years) populations. The purpose of this study was to evaluate the clinical and radiographic outcomes of patients aged 40 years or older with recurrent anterior shoulder instability who underwent open Latarjet stabilization. METHODS: A total of 168 patients aged 40 years or older were treated surgically for recurrent anterior shoulder instability with an open Latarjet procedure between 1988 and 2014. Bankart lesions or anteroinferior glenoid fractures were confirmed preoperatively with a computed tomography arthrogram. Outcomes were assessed with preoperative and postoperative physical examinations, clinical outcome scoring, and radiographic examinations. RESULTS: Ninety-nine patients with complete data were available with a mean follow-up period of 13 years (range, 3-23 years). At the time of final follow-up, 94% of patients did not have recurrence of instability. Of the patients, 90% were satisfied or very satisfied with their outcomes and 54% returned to their preinjury level of activity. The overall complication rate was 21% (the most common complications being subjective apprehension [9%] and recurrent instability [6%]), with 9% of patients requiring reoperation. A full-thickness rotator cuff requiring repair was identified in 22% of patients. CONCLUSIONS: The Latarjet procedure is an effective treatment option for older patients (aged ≥ 40 years) with recurrent anterior shoulder instability in the setting of an anteroinferior capsulolabral and/or bony injury.

Functional weight-bearing mobilization after Achilles tendon rupture enhances early healing response: a single-blinded randomized controlled trial.

PURPOSE: Functional weight-bearing mobilization may improve repair of Achilles tendon rupture (ATR), but the underlying mechanisms and outcome were unknown. We hypothesized that functional weight-bearing mobilization by means of increased metabolism could improve both early and long-term healing. METHODS: In this prospective randomized controlled trial, patients with acute ATR were randomized to either direct post-operative functional weight-bearing mobilization (n = 27) in an orthosis or to non-weight-bearing (n = 29) plaster cast immobilization. During the first two post-operative weeks, 15°-30° of plantar flexion was allowed and encouraged in the functional weight-bearing mobilization group. At 2 weeks, patients in the non-weight-bearing cast immobilization group received a stiff orthosis, while the functional weight-bearing mobilization group continued with increased range of motion. At 6 weeks, all patients discontinued immobilization. At 2 weeks, healing metabolites and markers of procollagen type I (PINP) and III (PIIINP) were examined using microdialysis. At 6 and 12 months, functional outcome using heel-rise test was assessed. RESULTS: Healing tendons of both groups exhibited increased levels of metabolites glutamate, lactate, pyruvate, and of PIIINP (all p < 0.05). Patients in functional weight-bearing mobilization group demonstrated significantly higher concentrations of glutamate compared to the non-weight-bearing cast immobilization group (p = 0.045).The upregulated glutamate levels were significantly correlated with the concentrations of PINP (r = 0.5, p = 0.002) as well as with improved functional outcome at 6 months (r = 0.4; p = 0.014). Heel-rise tests at 6 and 12 months did not display any differences between the two groups. CONCLUSIONS: Functional weight-bearing mobilization enhanced the early healing response of ATR. In addition, early ankle range of motion was improved without the risk of Achilles tendon elongation and without altering long-term functional outcome. The relationship between functional weight-bearing mobilization-induced upregulation of glutamate and enhanced healing suggests novel opportunities to optimize post-operative rehabilitation.

Isokinetic strength test and functional outcomes in proximal humeral fractures treated with a locking plate.

BACKGROUND: Despite the use of many shoulder outcome scales in subjects with rotator cuff pathology or instability symptoms, it can be problematic to select an instrumental evaluation in the shoulder trauma population. In this study we evaluated patients with proximal humeral fractures treated with internal fixation with a locking plate, analyzing the recovery of strength with an isokinetic test and its correlation with clinical and functional outcomes. METHODS: We enrolled 46 individuals (17 men, 29 women). The evaluation included a structured interview, measurement of ROM, isokinetic strength test and Constant-Murley and QuickDASH scores. The isokinetic test was performed in flexion/extension and external/internal rotation of the operated shoulder in comparison with the contralateral side and concentric contractions in all movements. The parameter tested was peak torque. RESULTS: In the operated shoulder values we noticed a statistically significant correlation between the QuickDASH and Constant-Murley score. QuickDASH showed a significant correlation with flexion isokinetic strength, partial correlation with extension isokinetic values and no correlation with external/internal rotation values. In addition, we found a correlation between the Constant-Murley score and all the isokinetic strength parameters. Comparing the operated shoulder and the contralateral, in Neer type 2 fractures there was no significant difference in all the isokinetic peak torque values; in Neer type 3 and type 4, there was a significant statistical difference in both flexion peak torque values and no significant difference in the other movements. CONCLUSIONS: The isokinetic test can give objective data on strength recovery and could help the surgeon's clinical evaluation to assess the functional recovery of the operated shoulder over time. We believe that the isokinetic test and Constant-Murley score could act as a reference in the evaluation of post-surgical outcome of proximal humeral fractures. Furthermore, the type of fracture could be a post-surgical limb recovery predictor and the shoulder flexion force could be the best functionality recovery indicator.

Choice of treatments of the coronal shear fractures of the humerus. A national survey of Italian AO members.

INTRODUCTION: Coronal shear fractures of the distal humerus are uncommon injuries representing 6% of distal humeral fractures. There is no univocal consensus about the correct management of this type of fracture. A national survey was conducted to gain more insight into the current classification, diagnosis and treatment of coronal shear fractures in Italy. MATERIALS AND METHODS: A postal survey was sent to all AO Italian members including residency orthopaedic surgeons. The survey consisted of general questions about personal experience in the management of these fractures: types of classification systems used, surgical approaches, treatment options and rehabilitation programs. RESULTS: 114 orthopaedic surgeons answered a 13-items questionnaire. The most used classification system was AO/OTA (72,8%). Independent screws and if necessary plates were the most answered regarding surgical treatment (81,6%). The most encountered post-surgical complication was stiffening of the elbow (81,6%). CONCLUSION: An algorithm of treatment has been proposed. To better classify coronal shear fractures, the authors recommended the integration of two classification systems: AO and Dubberley classifications. In the case of posterior wall comminution, a Kocher extensile approach is recommended, otherwise, if a posterior wall is intact, Kocher or Kaplan approach can be used. The posterior transolecranic approach can be reserved to Dubberley type III or AO 13B3.3. The best treatment choice is represented by independent screws and plates placed according to fracture patterns while arthroplasty is indicated when a stable ORIF is not possible. Mobilization is postponed for about 2 weeks.

Over the top or endobutton for ACL reconstruction?

There are an estimated 80-100,000 ACL repairs in the US each year: most ACL tears occurs from noncontact injuries. The 3.9% of the knee ligament injuries undergoes surgery: in the 80% of these patients, this means ACL reconstruction. The purpose of this study is to compare two surgical techniques normally used for acl recustruction; the first one is the intra- extra articular technique with single bundle fixed with staples and the second one is the intra-articular technique with double bundle and endobutton post-fixation. We evaluate the clinical outcome of our patients at the time of 4 years follow up. From January 2006 to April 2009 40 patients underwent to ACL reconstruction, all operated by using hamstring tendons: 20 patients with an average age of 28,75 years (12 men and 8 women) underwent surgery using the intra-extra articular technique, whereas the remaining 20 patients with an average age of 34,5 years (11 men and 9 women) benefited the intra-articular technique with double bundle ligament and endobutton post-fixation. Our study shows no substancial difference between these'two technique, but clinical outcome measures (I.K.D.C., Lysholm and Tegner) estimated better results for the double bundle technique with Endobutton post-fixation. (www.actabiomedica.it).

Contraindications and complications of the Latarjet procedure.

The Latarjet procedure is a well-known, safe and reliable technique to treat primary or recurrent anterior dislocations or subluxations, with or without hyperlaxity, with or without glenoid bone loss. Both the open and the arthroscopic methods produce excellent clinical results, with a low rate of recurrent instability. There have been concerns of a higher surgical complication rate associated with this procedure, however, large reviews reported an overall complication rate in the open Latarjet procedure of 15%. Meticulous surgical technique and a good understanding of the local anatomy can help to avoid the complications but postoperative shoulder arthritis and frequent bone block osteolysis remain unsolved additional challenges, which require further research. There are 2 main factors to further improve the clinical outcome and patient satisfaction: careful patient selection with good surgical indication, and reducing complications with adequate surgical techniques. The aim of this study is to provide the current overview of the contraindications and complications of the Latarjet procedure.

Posterior shoulder fracture-dislocation: double approach treatment. Our experience.

BACKGROUND: About 4% of glenohumeral dislocations are posterior and only 1% is associated with fracture of the humeral head. Most frequent causes are high energy traumas, seizures and electrocution. The fracture and the posterior dislocation, associated with the trauma and capsular lesion can cause an important vascular damage of the humeral head. METHODS: We describe 5 cases of posterior fracture-dislocation of the shoulder that required open reduction and internal fixation treated using double approach: posterior approach for reduction humeral head and eventually bone and capsular posterior repair and anterior approach for osteosynthesis. A Clinical examination was performed at one year and follow-up was at two years. CONCLUSIONS: This combined approach is less invasive, easier for dislocation reduction of the humeral head, with minimal biological damage that may occur during the reduction maneuvers. Our thought is that the posterior approach reduce vascular and bone damages during humeral head reduction and permit to suture and retention posterior capsula that is often damaged by the trauma.

Arthroscopic Rotator Cuff Tear Transosseous Repair System: The Sharc-FT Using the Taylor Stitcher.

Transosseous rotator cuff tear repair was first described in 1944. Over the years, it has represented the gold standard for such lesions. Through open and mini-open approaches, as well as the arthroscopic approach, the transosseous repair system represents one of the most reliable surgical techniques from a biological and mechanical perspective. Nevertheless, further improvements are required. This article describes an arthroscopic rotator cuff tear transosseous repair system, developed in collaboration with NCS Lab (Carpi, Italy): the Sharc-FT using the Taylor Stitcher. Our first experience in the clinical application of the arthroscopic technique using the transosseous suture system has shown encouraging clinical outcomes, confirming its efficacy. The patient satisfaction rate was high, and no patient expressed concern about the implant. The complication rate was very low. By improving the suture technique in the treatment of rotator cuff tears, a remarkable increase in the success rate in the treatment of this pathology could be reached; nevertheless, complications such as retears of the rotator cuff still occur.

Arthroscopic absorbable suture fixation for tibial spine fractures.

The purpose of this technical note and accompanying video is to describe a modified arthroscopic suture fixation technique to treat tibial spine avulsion fractures. Twenty-one patients underwent arthroscopic treatment for tibial spine avulsion with our technique; they were clinically and biomechanically evaluated at 2 years' follow-up and showed optimal clinical and radiographic outcomes. Repair with this arthroscopic technique provides a significant advantage in the treatment of type III and IV fractures of the tibial eminence by obtaining arthroscopic fixation within the substance of the anterior cruciate ligament: suture methods based on the avulsed bone fragment are technically impossible, but sutures through the base of the ligament itself provide secure fixation, reducing the risks of comminution of the fracture fragment and eliminating the time for hardware removal. This arthroscopic technique restores the length and the integrity of the anterior cruciate ligament and provides a simplified, reproducible method of treating patients, including young patients, with low hardware costs in comparison to sutures using anchors or other hardware.

Salter-Harris type II proximal humerus injuries: state-of-the-art treatment.

Proximal epiphyseal injuries of the humerus represent a very low percentage of traumatic growth pathologies, 5 % of all fractures during childhood. In the literature, there have been only a limited number of clinical studies investigating these injuries, basically from an epidemiological point of view, focusing on the incidence of the different types of fractures. We report our experience of 6 young patients with Salter-Harris type II proximal humerus epiphyseal injuries adopting a minimally invasive surgical technique consisting of closed reduction and percutaneous fixation with Kirschner wires. At 2 years of follow-up, the results consisting in constant; disabilities of the arm, shoulder, and hand; simple shoulder test; and Visual Analogue Scale scores obtained have been excellent and all the patients come back to a normal life with sports practice and normal daily activities. The range of motion was completely restored without any deficit in abduction-adduction, flection-extension, or intra-extra rotation. No differences in anthropometric parameters were found with no case of malangulation, vascular, or neurological complications. Our data support with evidence how the close reduction internal fixation with K-wires treatment can give to the surgeons and the patients a better security about the correct fracture healing. Furthermore, with this article, we will provide a detailed review of the literature in order to define the state-of-the-art treatment to better face such a challenging skeletal injury.