Morphological and Quantitative Parametric MRI Follow-up of Cartilage Changes Before and After Intra-articular Injection Therapy in Patients With Mild to Moderate Knee Osteoarthritis: A Randomized, Placebo-Controlled Trial.

BACKGROUND: Intra-articular injections are routinely used for conservative treatment of knee osteoarthritis (OA). The detailed comparative therapeutic effects of these injections on cartilage tissue are still unclear. OBJECTIVE: The aim of this study was to detect and compare knee cartilage changes after intra-articular injection of glucocorticoid, hyaluronic acid, or platelet-rich plasma (PRP) to placebo using quantitative (T2 and T2* mapping) and morphological magnetic resonance imaging parameters in patients with mild or moderate osteoarthritis. MATERIALS AND METHODS: In a double-blinded, placebo-controlled, single-center trial, knees with mild or moderate osteoarthritis (Kellgren-Lawrence grade 1-3) were randomly assigned to an intra-articular injection with 1 of these substances: glucocorticoid, hyaluronic acid, PRP, or placebo. Cartilage degeneration on baseline and follow-up magnetic resonance imaging scans (after 3 and 12 months) was assessed by 2 readers using quantitative T2 and T2* times (milliseconds) and morphological parameters (modified Outerbridge grading, subchondral bone marrow edema, subchondral cysts, osteophytes). RESULTS: One hundred twenty knees (30 knees per treatment group) were analyzed with a median patient age of 60 years (interquartile range, 54.0-68.0 years). Interreader reliability was good for T2 (ICC, 0.76; IQR, 0.68-0.83) and T2* (ICC, 0.83; IQR, 0.76-0.88) measurements. Morphological parameters showed no significant changes between all groups after 3 and 12 months. T2 mapping after 12 months showed the following significant ( P = 0.001-0.03) changes between groups in 6 of 14 compartments: values after PRP injection decreased compared with glucocorticoid in 4 compartments (complete medial femoral condyle and central part of lateral condyle) and compared with placebo in 2 compartments (anterior and central part of medial tibial plateau); values after glucocorticoid injection decreased compared with placebo in 1 compartment (central part of medial tibial plateau). No significant changes were seen for T2 and T2* times after 3 months and T2* times after 12 months. No correlation was found between T2/T2* times and Kellgren-Lawrence grade, age, body mass index, or pain (Spearman ρ, -0.23 to 0.18). CONCLUSIONS: Platelet-rich plasma injection has a positive long-term effect on cartilage quality in the medial femoral compartment compared to glucocorticoid, resulting in significantly improved T2 values after 12 months. For morphological cartilage parameters, injections with glucocorticoid, PRP, or hyaluronic acid showed no better effect in the short or long term compared with placebo.

Acne cream reduces the deep Cutibacterium acnes tissue load before elective open shoulder surgery: a randomized controlled pilot trial.

BACKGROUND: Cutibacterium acnes is the main pathogen in periprosthetic shoulder infections. In acne vulgaris therapy, benzoyl peroxide-miconazole nitrate cream effectively reduces the superficial C acnes burden of the skin. Its additional potential in the subcutaneous and capsular layers (eg, for prevention of future periprosthetic shoulder infections) is unknown. The aim of this study was to investigate the efficacy of a topical acne vulgaris cream (benzoyl peroxide-miconazole nitrate) to reduce subcutaneous and capsular C acnes in individuals with C acnes skin colonization undergoing open shoulder surgery. METHODS: A prospective randomized pilot trial was performed, allocating 60 adult patients (1:1) to either a 7-day preoperative application of a commercial acne cream (benzoyl peroxide-miconazole nitrate) on the preoperative skin (intervention group) or no cream (control group) from November 1, 2018, to May 31, 2020. The superficial skin of the shoulder was sampled at enrollment and before incision, and deep subcutaneous and capsular shoulder samples were taken during surgery. RESULTS: Sixty patients (mean age, 59 years; 55% female patients) undergoing primary open shoulder surgery (17 Latarjet procedures and 43 arthroplasties) were included in the study. At baseline, both randomized groups showed the presence of C acnes on the skin at a rate of 60% (18 of 30 patients in intervention group and 19 of 30 patients in control group, P = .79). In patients with C acnes skin colonization, the intervention resulted in a significant reduction in the overall number of intraoperative samples with positive findings compared with the control group (8 of 18 patients vs. 16 of 19 patients, P = .01), especially in capsular samples (0 of 18 patients vs. 4 of 19 patients, P = .04). CONCLUSION: The topical 7-day preoperative skin application of acne cream (benzoyl peroxide-miconazole nitrate) significantly reduced the intraoperative C acnes load in 56% of the patients in the intervention group compared with 16% of the control patients.

No difference in long-term outcome between open and arthroscopic rotator cuff repair: a prospective, randomized study.

BACKGROUND: Arthroscopic rotator cuff repair techniques have almost replaced open repairs. Short- and mid-term studies have shown comparable outcomes, with no clear superiority of either procedure. The aim of this study was to compare the long-term clinical and imaging outcomes following arthroscopic or open rotator cuff repair. METHODS: Forty patients with magnetic resonance imaging (MRI)-documented, symptomatic supraspinatus or supraspinatus and infraspinatus tears were randomized to undergo arthroscopic or open rotator cuff repair. Clinical and radiographic follow-up was obtained at 6 weeks, 3 months, 1 year, 2 years, and >10 years postoperatively. Clinical assessment included measurement of active range of motion, visual analog scale score for pain, functional scoring according to the Constant-Murley score (CS), and assessment of the Subjective Shoulder Value. Imaging included conventional radiography and MRI for the assessment of cuff integrity and alteration of the deltoid muscle. RESULTS: We enrolled 20 patients with a mean age of 60 years (range, 50-71 years; standard deviation [SD], 6 years) in the arthroscopic surgery group and 20 patients with a mean age of 55 years (range, 39-67 years; SD, 8 years) in the open surgery group. More than 10 years' follow-up was available for 13 patients in the arthroscopic surgery group and 11 patients in the open surgery group, with mean follow-up periods of 13.8 years (range, 11.9-15.2 years; SD, 1.1 years) and 13.1 years (range, 11.7-15 years; SD, 1.1 years), respectively. No statistically significant differences in clinical outcomes were identified between the 2 groups: The median absolute CS was 79 points (range, 14-84 points) in the arthroscopic surgery group and 84 points (range, 56-90 points) in the open surgery group (P = .177). The median relative CS was 94% (range, 20%-99%) and 96% (range, 65%-111%), respectively (P = .429). The median Subjective Shoulder Value was 93% (range, 20%-100%) and 93% (range, 10%-100%), respectively (P = .976). MRI evaluation showed a retear rate of 30% equally distributed between the 2 groups. Neither fatty infiltration of the deltoid muscle, deltoid muscle volume, nor the deltoid origin were different between the 2 groups. CONCLUSION: In a small cohort of patients, we could not document any difference in clinical and radiographic outcomes at long-term follow-up between arthroscopic and open rotator cuff repair. The postulated harm to the deltoid muscle with the open technique could not be confirmed.

Optimization of the antibiotic management of diabetic foot infections: protocol for two randomized controlled trials.

BACKGROUND: Few studies have addressed the appropriate duration of antibiotic therapy for diabetic foot infections (DFI) with or without amputation. We will perform two randomized clinical trials (RCTs) to reduce the antibiotic use and associated adverse events in DFI. METHODS: We hypothesize that shorter durations of postdebridement systemic antibiotic therapy are noninferior (10% margin, 80% power, alpha 5%) to existing (long) durations and we will perform two unblinded RCTs with a total of 400 DFI episodes (randomization 1:1) from 2019 to 2022. The primary outcome for both RCTs is remission of infection after a minimal follow-up of 2 months. The secondary outcomes for both RCTs are the incidence of adverse events and the overall treatment costs. The first RCT will allocate the total therapeutic amputations in two arms of 50 patients each: 1 versus 3 weeks of antibiotic therapy for residual osteomyelitis (positive microbiological samples of the residual bone stump); or 1 versus 4 days for remaining soft tissue infection. The second RCT will randomize the conservative approach (only surgical debridement without in toto amputation) in two arms with 50 patients each: 10 versus 20 days of antibiotic therapy for soft tissue infections; and 3 versus 6 weeks for osteomyelitis. All participants will have professional wound debridement, adequate off-loading, angiology evaluation, and a concomitant surgical, re-educational, podiatric, internist and infectiology care. During the surgeries, we will collect tissues for BioBanking and future laboratory studies. DISCUSSION: Both parallel RCTs will respond to frequent questions regarding the duration of antibiotic use in the both major subsets of DFIs, to ensure the quality of care, and to avoid unnecessary excesses in terms of surgery and antibiotic use. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04081792. Registered on 4 September 2019.

Salvage reverse total shoulder arthroplasty for failed operative treatment of proximal humeral fractures in patients younger than 60 years: long-term results.

HYPOTHESIS: Is salvage reverse total shoulder arthroplasty (RTSA) a justifiable treatment for failed operative treatment (open reduction-internal fixation [ORIF] or primary and secondary hemiarthroplasty) of proximal humeral fractures in patients younger than 60 years? METHODS: Thirty patients (mean age, 52 years; age range, 30-59 years) were reviewed after a mean follow-up period of 11 years (range, 8-18 years). Of the patients, 7 (23%) underwent RTSA for failed ORIF and 23 (77%) for failed hemiarthroplasty. Clinical and radiographic outcomes were assessed longitudinally. RESULTS: At final follow-up, the mean relative Constant score had improved from 25% (±12%) to 58% (±21%, P < .001). Significant improvements were seen in the mean Subjective Shoulder Value (20% to 56%), active elevation (45° to 106°), abduction (42° to 99°), pain scores, and strength (P < .001). Clinical outcomes did not significantly deteriorate over a period of 10 years. Patients with salvage RTSA for failed secondary hemiarthroplasty (n = 8) vs. those for failed ORIF (n = 6) showed significantly inferior active abduction (77° vs. 116°, P = .023). Patients with a healed greater tuberosity (n = 9) showed significantly better external rotation than patients with a resorbed/resected greater tuberosity (n = 13, 21° vs. 3°, P = .025). One or more complications occurred in 18 shoulders (60%), and 6 (20%) resulted in explantation of the RTSA. CONCLUSIONS: Salvage RTSA in patients younger than 60 years is associated with a high complication rate. It leads nonetheless to substantial and durable improvement beyond 10 years, provided the complications can be handled with implant retention. Inferior shoulder function is associated with greater tuberosity resorption or resection and inferior overhead elevation with the diagnosis of failed hemiarthroplasty.

Long-Term Outcomes of Pectoralis Major Transfer for the Treatment of Irreparable Subscapularis Tears: Results After a Mean Follow-up of 20 Years.

BACKGROUND: One recognized salvage option in the treatment of an irreparable subscapularis tear is the pectoralis major tendon transfer (PMT). We aimed to analyze the long-term clinical and imaging outcome of PMT for irreparable subscapularis deficiency. METHODS: Twenty-eight consecutive patients representing 30 shoulders underwent PMT at a mean age of 53.0 years (range, 35 to 67 years). At a mean of 19.7 years (range, 18 to 22 years) postoperatively, 24 shoulders (80%) were clinically examined and 21 were radiographically and sonographically assessed. The long-term results were compared with preoperative findings and previously published short-term results. RESULTS: The mean relative Constant score (percentage of age and sex-matched normal scores; CS%) and the Subjective Shoulder Value (SSV) both improved significantly from preoperatively (CS%, 47%, and SSV, 22%) to postoperatively (CS%, 77%, and SSV, 71%; p < 0.001 for both). All patients rated their results as good or excellent. Active anterior elevation was improved from preoperatively (120°) to postoperatively (131°), but the difference was not significant. Active internal and external rotation decreased significantly from the short-term (32-month) follow-up to the time of the latest follow-up (p = 0.005 and p = 0.002, respectively); however, internal rotation remained at 6 points compared with the 8 points recorded at short-term follow-up and external rotation decreased only from a mean of 51° to 39°. Loss of active range of motion was not observed subjectively and was not subjectively limiting, represented by the high ultimate SSV and overall satisfaction. Four shoulders (19%) showed evidence of glenohumeral arthropathy (Samilson and Prieto grade 3), but clinically were mildly symptomatic to asymptomatic at the time of the latest follow-up (CS% range, 67% to 88%; SSV range, 70% to 80%). Rupture of the PMT was sonographically identified in 2 patients (10%) and was associated with radiographic evidence of advanced cuff tear arthropathy (Hamada stages ≥4). Six (20%) of the initial 30 shoulders were revised, and 1 (4%) of the 24 shoulders that were clinically examined underwent reverse total shoulder arthroplasty. CONCLUSIONS: At long-term follow-up, PMT for isolated and combined subscapularis tears is associated with good to excellent clinical results. Although one-third of the shoulders developed mildly symptomatic or asymptomatic osteoarthritis, the need for salvage with use of reverse total shoulder arthroplasty was rare. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic repair of isolated subscapularis tears: clinical outcome and structural integrity with a minimum follow-up of 4.6 years.

BACKGROUND: After isolated subscapularis repair, improvement in shoulder function has been reported at short-term review. The purpose of this study was to determine whether arthroscopic subscapularis repair provides durable improvement in objective and subjective shoulder function with a low structural retear rate. METHODS: All patients treated with arthroscopic repair of an isolated subscapularis tear between August 2003 and December 2012 with a minimum follow-up period of 4.6 years were identified from our database. A number of patients in our study cohort underwent a prior complete midterm assessment, which allowed a subgroup analysis to detect changes in structural integrity and corresponding function. Clinical and radiographic outcomes, including outcomes on conventional radiography and magnetic resonance imaging or ultrasound, were assessed. RESULTS: The study enrolled 36 shoulders with a mean patient age of 57.7 years (range, 31-75 years; standard deviation, 10.6 years). The mean follow-up period was 8.6 years (range, 4.6-13.9 years; standard deviation, 2.44 years). Internal rotation to the thoracic vertebrae was achieved in 94% of cases and was significantly improved (P < .001) compared with the preoperative situation. The mean relative Constant score improved from 68% preoperatively to 93% at final follow-up (P < .001). Magnetic resonance imaging evaluation showed a rerupture rate of 2.7% (1 of 36 shoulders). Twenty patients underwent previous complete midterm assessment (mean, 2.9 years; range, 1-4.5 years), with comparisons between midterm and long-term follow-up showing comparable results without statistically significant deterioration. CONCLUSIONS: Functional and subjective improvements in shoulder function are maintained at a mean follow-up of more than 8 years after isolated subscapularis repair and are associated with a low structural failure rate of the repair.

Compliance with wearing an abduction brace after arthroscopic rotator cuff repair: A prospective, sensor-controlled study.

BACKGROUND: Immobilization, using a shoulder abduction brace, may be important after rotator cuff repair to achieve successful tendon-to-bone healing. Compliance with wear time is a concern. OBJECTIVES: Therefore, the abduction brace wearing time was assessed with temperature-sensitive sensors to objectively measure the abduction brace wearing compliance rate. STUDY DESIGN: Level of evidence I, prospective observational study. METHODS: A temperature sensor was implanted into 54 standard shoulder abduction braces, worn by 50 patients (27 women; mean age, 56 years). At 6 weeks post-surgery, patients reported the number of hours they had worn the brace. The patient-reported and sensor data were compared, and the compliance rate (relative to the recommended wearing time) was determined, with compliance being the primary end-point and the discrepancy between the measured and patient-reported wear time being the secondary end-point. RESULTS: Compliance was ⩾80% in 24 (48%) patients. Sensor-based compliance was lower than self-reported compliance (75% versus 96%, p ⩽ 0.001). Compliance was not predicted by age, sex, smoking, educational, employment, living status, or handedness. CONCLUSIONS: Roughly 50% of patients did not wear the brace at least 80% of the recommended time. Self-reported compliance is significantly lower than sensor-based compliance. Compliance was not predicted by measured demographic variables. CLINICAL RELEVANCE: This is the first study in which the abduction brace adherence of patients after rotator cuff repair was assessed by the use of a temperature-sensitive sensor. The postoperative use of these braces is questionable as the patient's abduction brace adherence is low. The self-reported wearing compliance is unreliable.

Longitudinal observational study of reverse total shoulder arthroplasty for irreparable rotator cuff dysfunction: results after 15 years.

HYPOTHESIS: This study investigated the hypothesis that functional outcome remains significantly improved over the preoperative state beyond 15 years of reverse total shoulder arthroplasty (RTSA) for irreparable rotator cuff dysfunction. METHODS: Operations were performed on 22 shoulders at a mean age of 68 (range, 54-77) years. The patients could personally be reviewed clinically and radiographically in intervals of 2 to 5 years and with a final follow-up examination at no less than 15 years (mean, 16.1; range, 15-19 years). The RTSA was a primary procedure in 7 procedures, and 15 patients had undergone at least 1 previous nonarthroplasty procedure. RESULTS: The mean absolute Constant score (CS) had improved from 23 ± 11 to 58 ± 19 points (P < .001) and the relative CS (rCS) from 30% ± 13% to 73% ± 23% (P < .001) at final follow-up. Significant improvements were seen in mean pain scores (4 to 12 points; P < .001), active anterior elevation (53° to 101°; P = .001), abduction (55° to 86°; P = .005), and Subjective Shoulder Value (27% to 78%; P = .001). The mean rCS and Subjective Shoulder Value did not significantly deteriorate over 15 years, but mean active abduction was significantly reduced over time (P = .018). One or more complications were recorded in 13 patients (59%), with 6 failed RTSAs (27%).The mean rCS of patients with complications (explantations excluded) was not significantly inferior compared with that of patients without complications (62% vs. 81%; P = .090). CONCLUSIONS: This early series of RTSA shows a substantial complication and failure rate. If, however, complications can be treated without removal of the implants, outcome is not compromised. Overall shoulder function and subjective outcome remained significantly improved and highly satisfactory during the entire study period.

Compressive Stockings After Hindfoot and Ankle Surgery.

BACKGROUND: Swelling and pain are common after foot and ankle procedures. We hypothesized that compressive stockings (CS) treatment after hindfoot surgery would positively influence patient outcomes. METHODS: We undertook this randomized controlled trial in 87 consecutive patients to analyze the clinical effect of CS after hindfoot and ankle surgery and evaluate CS-wearing compliance using sensors that were implanted into CS. Ankle swelling, pain status, quality of life (SF-36 score), and the American Orthopaedic Foot & Ankle Score (AOFAS) were set as the primary end points. The CS wearing time in hours and percentage were investigated as the secondary end points. All participants with CS (group I) were informed about the implanted sensor after the CS were taken off. A subgroup analysis of group I was performed to detect differences between patients with high vs low compliance. RESULTS: At 12 weeks, the results of ankle swelling (mean 234 mm in group I and 232 mm in group II), pain in the visual analog scale (1.7 group I vs 1.9 in group II), the SF-36 score (38 points in group I vs 30 points in group II), and the AOFAS score (a mean of 76 points in both groups) showed no statistical differences between the 2 groups. The mean wearing time was 136 (range, 0-470) hours, which corresponds to a compliance rate of 65%. Sixteen participants had high compliance (>80%, >170 hours), and 21 patients had low or noncompliance. The clinical results of patients with high wearing compliance were not significantly better compared to the results of patients with low compliance. CONCLUSION: CS therapy after ankle and hindfoot surgery was associated with a low wearing compliance and did not influence ankle swelling, function, pain, and the quality of life compared to the control group. Furthermore, the clinical results of patients with high compliance were not better compared to the results of patients with low or noncompliance wearing behavior. LEVEL OF EVIDENCE: Level II, prospective randomized study of lower quality.

Arthroscopic Correction of the Critical Shoulder Angle Through Lateral Acromioplasty: A Safe Adjunct to Rotator Cuff Repair.

PURPOSE: To investigate whether arthroscopic lateral acromioplasty reliably decreases the critical shoulder angle (CSA) and whether it is associated with damage to the deltoid or other complications. METHODS: Patients undergoing arthroscopic rotator cuff repair (RCR) with lateral but without anterior acromioplasty for degenerative, full-thickness rotator cuff tears and a CSA of 34° or greater were retrospectively reviewed. Patients with traumatic or irreparable rotator cuff tears, osteoarthritis, or previous surgery were excluded. Clinical and radiographic outcomes were assessed at a minimum of 12 months' follow-up. RESULTS: We reviewed 49 consecutive patients (mean age, 56 years; age range, 39-76 years) at a mean of 30 months (range, 12-47 months). There were 7 RCR failures (14%). The mean CSA was reduced from 37.5° preoperatively (95% confidence interval [CI], 36.7°-38.3°) to 33.9° postoperatively (95% CI, 33.3°-34.6°; P < .001). There were no cases of dehiscence, increases in fatty infiltration, or significant atrophy of the deltoid. Scarring at the deltoid origin was noted in 18 patients (37%). The mean absolute and relative Constant scores increased from 59 points (95% CI, 54-64 points) to 74 points (95% CI, 70-78 points) and from 66% (95% CI, 61%-71%) to 83% (95% CI, 79%-87%) respectively, and the Subjective Shoulder Value increased from 45% (95% CI, 39%-50%) to 80% (95% CI, 74%-86%) (P < .001 for all 3 improvements). The postoperative CSA was significantly larger in failed than in healed repairs (P = .026). Patients with a healed RCR and a CSA corrected to 33° or less (n = 22) had 25% more abduction strength than patients with a healed cuff and a CSA corrected to 35° or greater (n = 14, P = .04). CONCLUSIONS: Arthroscopic lateral acromioplasty performed in addition to arthroscopic RCR can reduce the CSA without significantly compromising the deltoid origin, deltoid muscle, or function. It is not associated with any additional complications of arthroscopic RCR. Insufficiently corrected, abnormally large CSAs are associated either with a higher retear rate or with inferior strength of abduction if the tears heal. LEVEL OF EVIDENCE: Level IV, case series, treatment study.

Reverse Total Shoulder Arthroplasty for Massive, Irreparable Rotator Cuff Tears Before the Age of 60 Years: Long-Term Results.

BACKGROUND: There has been serious concern regarding the longevity and durability of outcomes of reverse total shoulder arthroplasty (RTSA) in younger patients. It was the purpose of this study to analyze long-term outcomes and complications of RTSA for irreparable rotator cuff tears in patients younger than 60 years. METHODS: Twenty patients (23 shoulders) with a mean age of 57 years (range, 47 to 59 years) were evaluated at a mean of 11.7 years (range, 8 to 19 years) after RTSA. Fifteen shoulders (65%) had undergone previous non-arthroplasty surgery. Longitudinal clinical and radiographic outcomes were assessed. RESULTS: At the time of final follow-up, the mean absolute and relative preoperative Constant score (CS) (and standard deviation) had improved from 24 ± 9 to 59 ± 19 points (p < 0.001) and from 29% ± 11% to 69% ± 21% (p < 0.001), respectively. The mean Subjective Shoulder Value (SSV) had increased from 20% ± 13% to 71% ± 27% (p < 0.001). There were also significant improvements in the mean active anterior elevation (from 64° to 117°), active abduction (from 58° to 111°), pain scores, and strength (all p ≤ 0.001). Clinical outcomes did not significantly deteriorate beyond 10 years and the functional results of patients with previous surgical procedures were not significantly inferior to the results of those with primary RTSA. The grade of, and number of patients with, radiographically apparent notching increased over time; the mean relative CS was lower in patients in whom the notching was grade 2 or higher (57%) than it was in those with no or grade-1 notching (81%; p = 0.006). Nine (39%) had ≥1 complication, with 2 failed RTSAs (9%). CONCLUSIONS: RTSA in patients younger than 60 years leads to substantial subjective and functional improvement without clinical deterioration beyond 10 years. It is associated with a substantial complication rate, and complications compromise ultimate subjective and objective outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Long-term results of total knee arthroplasty in haemophilic patients: an 18-year follow-up.

PURPOSE: Total knee arthroplasty (TKA) for patients with end-stage haemophilic arthropathy is considered to be a successful procedure with satisfying mid- to long-term results. It was the purpose of this study to provide clinical and radiological long-term results of TKAs implanted in a consecutive cohort of haemophilic patients. METHODS: Primary TKA was performed in 43 consecutive knees in 30 haemophilic patients. After a mean of 18 (SD ± 4) years, 15 patients (21 knees) with a mean age of 58 (SD ± 8) years were available for follow-up. The outcome was assessed using the Knee Society score, WOMAC, SF-36, Kaplan-Meier survivorship analysis as well as radiographic evaluation of radiolucency. RESULTS: In 13 (30%) of the 43 consecutive knees, revision surgery was necessary due to infection or aseptic loosening, among which eight (19%) due to aseptic loosening and five (12%) due to haematogenous infection. The calculated 20-year survival rates with revision for any reason or infection as the end points were 59 and 82%, respectively. All patients with the primary TKA in situ observed progressive radiolucent lines around the implants at the final follow-up. The Knee Society clinical and functional score significantly improved from pre- (36 points; SD ± 16 and 62 points; SD ± 19) to post-operatively (73 points; SD ± 15 and 78 points; SD ± 18; p < 0.001). Eighty-six per cent rated their result as either good or excellent. Whereas flexion did not improve, flexion contracture could be reduced significantly from 18° (SD ± 12) to 6° (SD ± 5; p < 0.001) post-operatively. CONCLUSION: Total knee arthroplasty in haemophilic patients is associated with high revision, loosening and infection rates after 18 years. However, if revision can be avoided, joint replacement in haemophilic patients helps to relieve pain, achieve higher subjective satisfaction and to restore knee function. Level of evidence IV.

Reverse total shoulder arthroplasty for failed open reduction and internal fixation of fractures of the proximal humerus.

BACKGROUND: Open reduction and internal fixation (ORIF) of complex fractures of the proximal humerus may yield unsatisfactory results. This study analyzed the results obtained after revision of failed ORIF of proximal humeral fractures using reverse total shoulder arthroplasty (RTSA). METHODS: Fifty-four shoulders of 53 patients with a subjectively unacceptable outcome after ORIF of a complex fracture of the proximal humerus were revised with RTSA. At a minimum follow-up of 2 years (mean follow-up, 46 months; range, 24-108 months), 44 shoulders were clinically and radiographically reviewed for the purpose of this study. Six patients had been lost to follow-up, and 4 patients (7%) were excluded from functional analysis because of revision surgeries. RESULTS: The mean absolute Constant score improved from 26 (range, 4-54) to 55 (range, 19-80) points; the mean relative Constant score improved from 32% (range, 4%-85%) to 67% (range, 27%-94%) of an age- and gender-matched, normal shoulder. The mean subjective shoulder value improved from 29% (range, 0%-90%) preoperatively to 67% (range, 5%-95%) at final follow-up. Nineteen patients rated their outcome excellent, 16 good, and 7 fair; 2 patients were dissatisfied. CONCLUSION: RTSA is a valuable salvage procedure after failed ORIF of a proximal humeral fracture with relatively low revision rates. Shoulder function, patient satisfaction, and pain levels can be reliably improved.

Long-Term Restoration of Anterior Shoulder Stability: A Retrospective Analysis of Arthroscopic Bankart Repair Versus Open Latarjet Procedure.

BACKGROUND: Various operative techniques are used for treating recurrent anterior shoulder instability, and good mid-term results have been reported. The purpose of this study was to compare shoulder stability after treatment with the 2 commonly performed procedures, the arthroscopic Bankart soft-tissue repair and the open coracoid transfer according to Latarjet. METHODS: A comparative, retrospective case-cohort analysis of 360 patients (364 shoulders) who had primary repair for recurrent anterior shoulder instability between 1998 and 2007 was performed. The minimum duration of follow-up was 6 years. Reoperations, overt recurrent instability (defined as recurrent dislocation or subluxation), apprehension, the subjective shoulder value (SSV), sports participation, and overall satisfaction were recorded. RESULTS: An open Latarjet procedure was performed in 93 shoulders, and an arthroscopic Bankart repair was done in 271 shoulders. Instability or apprehension persisted or recurred after 11% (10) of the 93 Latarjet procedures and after 41.7% (113) of the 271 arthroscopic Bankart procedures. Overt instability recurred after 3% of the Latarjet procedures and after 28.4% (77) of the Bankart procedures. In the Latarjet group, 3.2% of the patients were not satisfied with their result compared with 13.2% in the Bankart group (p = 0.007). Kaplan-Meier analysis of survivorship, with apprehension (p < 0.001), redislocation (p = 0.01), and operative revision (p < 0.001) as the end points, documented the substantial superiority of the Latarjet procedure and the decreasing effectiveness of the arthroscopic Bankart repair over time. Twenty percent of the first recurrences after arthroscopic Bankart occurred no earlier than 91 months postoperatively, as opposed to the rare recurrences after osseous reconstruction, which occurred in the early postoperative period, with only rare late failures. CONCLUSIONS: In this retrospective cohort study, the arthroscopic Bankart procedure was inferior to the open Latarjet procedure for repair of recurrent anterior shoulder dislocation. The difference between the 2 procedures with respect to the quality of outcomes significantly increased with follow-up time. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reverse total shoulder arthroplasty for acute head-splitting, 3- and 4-part fractures of the proximal humerus in the elderly.

BACKGROUND: Anatomic reduction and stable internal fixation of complex proximal humeral fractures in the elderly is challenging. Secondary displacement, screw perforation, and humeral head necrosis are common complications. The outcome of hemiarthroplasty is unpredictable and strongly dependent on the uncertain healing of the greater tuberosity. This multicenter study retrospectively analyzes the midterm results of primary reverse total shoulder arthroplasty for the treatment of acute, complex fractures of the humerus in an elderly population. METHODS: Fifty-two shoulders in 51 patients with a mean age of 77 years treated with reverse total shoulder arthroplasty for an acute, complex fracture of the proximal humerus were clinically and radiographically analyzed after a mean follow-up period of 35 months (range, 12-90 months). RESULTS: There were no intraoperative complications. Revision surgery was performed in 4 shoulders. At final follow-up, the absolute and relative Constant scores averaged 62 points (range, 21-83 points) and 86% (range, 30%-100%), respectively, with a mean Subjective Shoulder Value of 83% (range, 30%-100%). Of the patients, 92% rated the treatment outcome as excellent or good. Patients with a resected or secondarily displaced greater tuberosity had an inferior clinical outcome to those with a healed greater tuberosity. CONCLUSION: The midterm clinical results are predictably good, with low complication rates and a rapid postoperative recovery of painfree everyday function. If secondary displacement of the greater tuberosity occurs, revision surgery may warrant consideration in view of potential improvement of ultimate outcome.

Secondary latissimus dorsi transfer after failed reverse total shoulder arthroplasty.

BACKGROUND: Combined single-stage reverse total shoulder arthroplasty (RTSA) plus latissimus dorsi transfer (LDT) has been reported to be a reliable treatment for pseudoparalysis of elevation and external rotation caused by irreparable rotator cuff tears. Secondary LDT in patients with pseudoparalysis of external rotation after previous RTSA has not yet been studied. METHODS: Ten patients were treated with LDT at a mean of 27 months (range, 4-134 months) after RTSA. Standard LDT was performed in 4 patients and a LDT plus teres major transfer according to L'Episcopo in 6 patients. All patients had preoperative and postoperative clinical evaluation, including the assessment of the Constant score and the subjective shoulder value. RESULTS: RTSA increased the preoperative mean relative Constant score from 26% (range, 11%-67%) to 51% (range, 20%-100%; P = .05). At a mean of 49 months (range, 23-67 months) after additional LDT, the relative Constant score further increased to 58% (range, 34%-100%; P = .141), remaining significantly superior to the score before RTSA (P = .021). The mean subjective shoulder value was 15% (range, 0%-30%) before and 44% (range, 20%-70%) after RTSA (P = .273) and was 56% (range, 20%-90%) after LDT (P = .686), a significant overall improvement of the state of the shoulder compared with before RTSA (P = .042). Mean active flexion increased from 36° (range, 0°-130°) to 86° (range, 10°-140°) after RTSA (P = .024) and to 109° (range,70°-140°) after LDT (P = 0.017 compared with pre-LDT; P = .011 compared with pre-RTSA). Mean active external rotation decreased from 0° (range, -80° to 50)° to -18° (range, -50°to 10)° after RTSA (P = .079) and was improved to 2° (-40° to 40)° after LDT (P = .24 compared with pre-LDT; P=.865 compared with pre RTSA). CONCLUSION: Secondary LDT significantly improves active mobility in patients with residual dysfunction after RTSA.

Long-term outcome of segmental reconstruction of the humeral head for the treatment of locked posterior dislocation of the shoulder.

BACKGROUND: Locked posterior glenohumeral dislocations with impaction fractures involving less than 30% to 35% of the humeral head are most frequently treated with lesser tuberosity transfer into the defect, whereas those involving more than 35% to 40% are treated with humeral head arthroplasty. As an alternative, reconstruction of the defect with segmental femoral or humeral head allograft has been proposed, but the long-term outcome of this joint-preserving procedure is unknown. METHODS: Twenty-two shoulders in 21 patients with a locked posterior shoulder dislocation and an impaction of at least 30% (mean, 43%) of the humeral head were treated with segmental reconstruction of the humeral head defect. They were reviewed clinically and radiographically at a minimum follow-up of 5 years. RESULTS: Of the 22 shoulders, 19 could be followed up at 128 months (range, 60-294 months) postoperatively. Only 2 of the 19 patients needed a prosthesis more than 180 months after the index operation. Of the other 17, 4 had radiographically advanced osteoarthritis (OA), 4 had mild OA, and 9 had no or minimal OA. Eighteen shoulders were rated as subjectively excellent, none were rated as good, and one was rated as fair. The final Constant-Murley score averaged 77 points (range, 52-98 points), the Subjective Shoulder Value averaged 88% (range, 75%-100%), and only 2 patients had mild to moderate pain. Mean active anterior elevation was 145°, and mean external rotation with the arm at the side was 42°. CONCLUSION: Segmental reconstruction of humeral head defects for large anteromedial impaction fractures caused by locked posterior dislocations durably restores stability and freedom from pain with an excellent subjective long-term outcome.