Two-year follow-up after operative treatment of an osseous Bankart lesion with a flap-detached cartilage lesion of the glenoid: A case report.

Glenoid articular cartilage lesion is a rare complication following traumatic anterior dislocation of the shoulder. We report the case of a 14-year-old male rugby player with traumatic anterior shoulder instability, an extensively flapped lesion on the glenoid articular cartilage, and an osseous Bankart lesion. Arthroscopic findings revealed that the glenoid cartilage was flap-detached, extending from the anteroinferior to the center. Repair of the osseous Bankart lesion using suture anchors and resection of the unstable peripheral part of the cartilage was performed arthroscopically. The main region of the injured articular surface was left untouched. During postoperative follow-up, absorption of the glenoid articular surface near the suture anchor holes was identified. Arthroscopic examination three months post-surgery showed that the flap detached lesion of the residual cartilage was stable and appeared adapted on the glenoid surface. The resected area was covered by fibrous tissue. A follow-up computed tomography scan revealed that the osseous lesion was united. The patient returned to his previous sports capacity eight months following the operation. At the 2-year-follow-up, magnetic resonance imaging revealed that the glenoid surface was remodeled to a flattened round shape with no signs of osteoarthritis, exhibiting proper conformity of the joint surfaces to the humeral head. Arthroscopic Bankart repair using suture anchors may cause bone resorption at the glenoid surface, leading to remodeling of the glenoid surface from the damaged glenoid cartilage lesion in young patients.

Uncemented total hip arthroplasty using alumina ceramic bearings at a minimum of 14 years of follow-up.

INTRODUCTION: The effectiveness of modern ceramic bearings has been well established in reducing the osteolysis associated with wear of the bearing surfaces in total hip arthroplasty (THA). However, there are limited mid- to long-term follow-up data for complications associated with ceramic bearings. MATERIALS AND METHODS: This case series analyzed 124 consecutive primary uncemented THAs in 108 patients with a mean age of 61 years using alumina ceramic-on-alumina ceramic bearing couples. Seventy THAs (56%) were evaluated at a minimum 14 years of follow-up; the mean follow-up period was 16 ± 1 years (14-20 years). Kaplan-Meier survivorship was determined with revision surgery for any reason as the end point. Complications were recorded focusing on osteolysis, ceramic fracture, and abnormal sounds until the final follow-up. Clinical data were scored according to the Merle d'Aubigne and Postel hip score at 14 years after THA. RESULTS: The survivorship was 93.5% (95% CI 86.7-97.0%) at 14-years postoperatively. Five patients (4.0%) underwent revision surgery due to instability or infection before 1-year postoperatively. Two patients (1.6%) underwent revision surgery due to ceramic liner fracture at 9- and 12-years postoperatively, respectively. There was no radiographic evidence of osteolysis. A total of 27 complications occurred: dislocations (n = 7/124), squeaking sounds (n = 3/124), clicking sounds (n = 6/124), ceramic liner fractures (n = 2/124), periprosthetic fractures (n = 4/124), deep infections (n = 2/124), transient sciatic nerve palsy (n = 2/124), and femoral stem breakage (n = 1/124). The Merle d'Aubigne and Postel hip score was 16.8 ± 1.4 points. CONCLUSIONS: The survivorship analysis demonstrates the uncemented THA using alumina ceramic bearings may provide favorable clinical outcome and can offer minimal wear at a minimum 14-year follow-up. Revision surgery was mostly required due to instability and infection in the short-term, and implant breakage in the mid- to long-term.

Arthroscopic Bankart Repair and Open Bristow Procedure in the Treatment of Anterior Shoulder Instability With Osseous Glenoid Lesions in Collision Athletes.

BACKGROUND: Traumatic anterior shoulder instability in collision sports athletes often involves osseous glenoid lesions, which make surgical treatment challenging. High redislocation rates have been seen in collision sports athletes treated using arthroscopic Bankart repair. PURPOSE: To investigate the effectiveness of a combined arthroscopic Bankart repair and open Bristow procedure for the treatment of traumatic anterior shoulder instability in collision sports athletes, with a focus on osseous glenoid lesions. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We reviewed 149 shoulders in 141 competitive collision sports athletes (mean ± standard deviation age, 20.1 ± 4.1 years; 8 bilateral cases) who underwent a combined arthroscopic Bankart repair and open Bristow procedure with minimum 2 years of follow-up. Osseous Bankart lesions were arthroscopically reduced and fixed using a coracoid graft. RESULTS: Clinical outcomes as indicated by mean Rowe score improved significantly from 50.0 preoperatively to 98.9 postoperatively (P < .001) at a median follow-up of 3.4 years (range, 2.5-7 years). There were 2 recurrent dislocations (1.3%), both of which had nonunion of the transferred coracoid. Osseous Bankart lesions were observed in 85 shoulders, and osseous glenoid lesions ≥10% of the diameter of the nonoperative side were found in 58 shoulders, including 24 off-track cases. Clinical outcomes were not significantly different between patients with a glenoid defect ≥10% and <10%. Nonunion of the transferred coracoid was observed in 16 shoulders (10.7%), which had inferior Rowe scores; however, we could not define any risk factors for nonunion, including patient characteristics or bone morphology. Postoperative computed tomography performed in 29 patients >1 year after surgery showed successful repair of the osseous glenoid lesions, with a restored glenoid articular surface in all cases. Significant pre- to postoperative increases were seen in glenoid diameter (mean, 13.1% [95% CI, 9.9%-16.3%]; P < .001) and area (mean, 10.6% [95% CI, 8.5%-12.7%]; P < .001). CONCLUSION: A combined arthroscopic Bankart repair and open Bristow procedure improved bone morphology and was a reliable surgical method for treating collision sports athletes with traumatic anterior shoulder instability involving osseous glenoid lesions.

Clinical Characteristics and Surgical Outcomes for Collision Athletes with Traumatic Posterior Instability.

BACKGROUND: Diagnosis and treatment of traumatic posterior instability of the shoulder have not been described in detail. The author investigated surgical outcomes for traumatic posterior shoulder joint instability in collision athletes. METHODS: The author surgically treated patients with a diagnosis of traumatic shoulder joint instability and investigated those that had been followed up for >2 years after surgery. RESULTS: Seven shoulders in six collision athletes with a history of traumatic injury were examined. All cases were negative for the general laxity sign and positive for the posterior jerk test; five shoulders showed positive anterior apprehension. Posterior glenoid osseous defects were found in three shoulders, and one shoulder injury involved anterior and posterior osseous lesions. As surgical treatment, one posterior capsulolabral lesion, two posterior osseous lesions, and three combined anterior and posterior capsulolabral lesions were repaired arthroscopically. In a patient with a combined anterior and posterior osseous lesion, the Bristow procedure was perfromed after arthroscopic osseous repair. Patients returned to competition at an average of 6.8 months after surgery. One patient developed anterior subluxation at 7 months, and another exhibited posterior re-dislocation at 8 months after returning to competition. CONCLUSION: Traumatic posterior instability in collision athletes often involves glenoid osseous lesions and is frequently accompanied by anterior apprehension and lesions. Although collision athletes can return to play after arthroscopic repair, such activity is associated with a risk of re-dislocation.

Post-operative pain control following arthroscopic rotator cuff repair: peri-articular injection versus interscalene brachial plexus block.

PURPOSE: To compare post-operative pain relief with peri-articular injection (PI) versus interscalene brachial plexus block (IBPB) after arthroscopic rotator cuff repair (ARCR) surgery. METHODS: We retrospectively reviewed 121 consecutive patients undergoing ARCR surgery divided into two groups: the PI group and the IBPB group. We compared complications and self-reported pain score measured using a Numerical Rating Scale (NRS) during the initial 24 hours after surgery. RESULTS: The NRS scores recorded in the recovery room (0), 0.5, and four hours post-operatively were higher in the PI group (n = 38) than the IBPB group (n = 52) (2.1 vs. 0.8, p = 0.014; 1.4 vs. 0.5, p = 0.0069; and 1.3 vs. 0.5, p = 0.012, respectively). However, the NRS scores recorded at 16, 20, and 24 hours post-operatively were lower in the PI group than in the IBPB group (1.4 vs. 3.1, p < 0.0001; 1.4 vs. 3.2, p < 0.0001; and 1.7 vs. 3.2, p = 0.00046, respectively). The incidences of post-operative nausea and temporary numbness in the upper arm were significantly lower in the PI group than in the IBPB group (7.9% vs. 33%, p = 0.0052; and 13% vs. 85%, p < 0.0001, respectively). CONCLUSIONS: Although IBPB provided superior pain control during the initial few hours after ARCR surgery, PI was superior from 16 to 24 hours post-operatively. The rates of side effects, such as nausea and temporary arm numbness, were also lower in the PI group than in the IBPB group.

Shorter recovery can be achieved from using walking boot after operative treatment of an ankle fracture.

BACKGROUND/OBJECTIVE: Ankle fractures, even if treated surgically, usually take a long time to heal. For all patients with ankle fracture, immobilisation is a critical part of treatment. Short-leg walking boots (WBs) have been reported to be an effective alternative to plaster casts (PCs) that could shorten this postoperative recuperative period. The aim of this study was to compare the functional recovery of a conventional PC with that of a WB after surgery for ankle fractures. METHODS: Forty-seven patients (mean age, 53.9 ± 12 years) who had undergone surgical operation for an unstable ankle fracture from January 2008 to October 2014 were reviewed retrospectively. Either a PC or a WB was prescribed postoperatively, with 25 patients and 22 patients, respectively. The time that it took the patient to stand unipedal on the affected side after allowing full-weight bear and to walk without crutches were used for assessment of functional recovery. The prevalence of postoperative loss of reduction and nonunion was also reviewed. RESULTS: Both the time of being able to stand unipedal on the injured side and to walk without crutches were significantly shorter in patients using WBs (WB, 2.6 weeks; PC, 4.5 weeks, p = 0.01; WB, 1.4 weeks; PC, 3.1 weeks, p = 0.03). There were no patients with loss of reduction or nonunion. CONCLUSION: Patients who used WBs showed a significantly faster recovery. WBs have an adjustable heel lift that allows users to change the ankle position slightly plantarflexed that helps walking in a postoperative swollen ankle. WBs are easy to slip on, and it is easy to adjust the ankle position in conformity with swelling so that the least painful position could be maintained during walking. WBs have good fixity to allow immediate weight-bearing postoperatively, and there were no cases with loss of reduction postoperatively. The Rocker bottom design minimises the sagittal plane motion in the specific joint of the foot, which also facilitates the course of recuperation. An ankle fracture fixed appropriately endures loading when a WB is used. The WB treatment results in faster functional recovery, allowing the patients to return to normal activity at a faster rate.

Correlation of alpha angle between various radiographic projections and radial magnetic resonance imaging for cam deformity in femoral head-neck junction.

PURPOSE: Radial magnetic resonance imaging (MRI) along the axis of the femoral head neck is the gold standard for detection of cam deformity of the proximal femur. This study was performed to identify which plain radiographic projection was best correlated with radial MRI. METHODS: Five different plain radiographic projections and 18 slices of radial MRI were applied to 35 consecutive hips with groin pain and positive impingement sign. Alpha angles were measured to detect the asphericity of the femoral head-neck junction in all images. Radiographs were taken in anteroposterior pelvis, cross-table lateral, 90° Dunn, 45° Dunn and modified 45° Dunn views. Pearson's correlation coefficients were determined to assess the association between the alpha angle obtained from radial MRI and each radiographic technique. The sensitivity, specificity, positive and positive predictive values and accuracy of plain radiographic alpha angle measurements were assessed using a threshold alpha angle value of 50.5° for cam deformity. RESULTS: Pearson's correlation coefficients in the alpha angle values between MRI and plain radiographic projections were 0.45, 0.70, 0.62, 0.81 and 0.69 for the anteroposterior pelvis, cross-table lateral, 90° Dunn, 45° Dunn and modified 45° Dunn views, respectively. In terms of sensitivity and accuracy, the 45° Dunn view had the greatest values. CONCLUSIONS: Alpha angle of the 45° Dunn view was best correlated with that of radial MRI. The 45° Dunn view had better sensitivity and accuracy than other radiographic projections. The 45° Dunn view may be preferable for screening of cam deformity. LEVEL OF EVIDENCE: II.

MRI for the diagnosis of scapular dyskinesis: a report of two cases.

Scapular dyskinesis describes the altered position of the scapula and/or abnormal movements of the scapulothoracic joint. It is caused by bony anatomical variations, bursitis, tumors, and muscular pathological conditions including loss of innervation and fibrosis. Scapular dyskinesis is just as often subclinical as it is symptomatic, and as the periscapular anatomical changes may not result in patient symptoms, a precise diagnosis of the etiology and pathophysiology has been a challenge. Scapular bony prominence is a common etiology of scapular dyskinesis, but does not always result in morbidity. We report a case of a 39-year-old man in whom an extensive MRI with fluid-sensitive imaging sequences covering the whole of the scapula was beneficial in diagnosing the inflammation adjacent to the bony deformity, which confirmed the etiology of scapular dyskinesis. Furthermore, in a 41-year old man without any anatomical variances, a similar MRI showed inflammation at the subscapular fossa that suggested altered scapular kinematics. An arthroscopic debridement of the lesion improved the symptoms. MRI in conjunction with plain radiographs, CT and physical examination enabled a precise diagnosis of the etiology. Fluid-sensitive MR images are important in defining the presence of inflammation, and are beneficial in determining the pathological significance of findings through other diagnostic measures.

Predicting Retear after Repair of Full-Thickness Rotator Cuff Tear: Two-Point Dixon MR Imaging Quantification of Fatty Muscle Degeneration-Initial Experience with 1-year Follow-up.

Purpose To determine the degree of preoperative fatty degeneration within muscles, postoperative longitudinal changes in fatty degeneration, and differences in fatty degeneration between patients with full-thickness supraspinatus tears who do and those who do not experience a retear after surgery. Materials and Methods This prospective study had institutional review board approval and was conducted in accordance with the Committee for Human Research. Informed consent was obtained. Fifty patients with full-thickness supraspinatus tears (18 men, 32 women; mean age, 67.0 years ± 8.0; age range, 41-91 years) were recruited. The degrees of preoperative and postoperative fatty degeneration were quantified by using a two-point Dixon magnetic resonance (MR) imaging sequence; two radiologists measured the mean signal intensity on in-phase [S(In)] and fat [S(Fat)] images. Estimates of fatty degeneration were calculated with "fat fraction" values by using the formula S(Fat)/S(In) within the supraspinatus, infraspinatus, and subscapularis muscles at baseline preoperative and at postoperative 1-year follow-up MR imaging. Preoperative fat fractions in the failed-repair group and the intact-repair group were compared by using the Mann-Whitney U test. Results The preoperative fat fractions in the supraspinatus muscle were significantly higher in the failed-repair group than in the intact-repair group (37.0% vs 19.5%, P < .001). Fatty degeneration of the supraspinatus muscle tended to progress at 1 year postoperatively in only the failed-repair group. Conclusion MR imaging quantification of preoperative fat fractions by using a two-point Dixon sequence within the rotator cuff muscles may be a viable method for predicting postoperative retear. (©) RSNA, 2016.

Combined Arthroscopic Bankart Repair and Coracoid Process Transfer to Anterior Glenoid for Shoulder Dislocation in Rugby Players: Evaluation Based on Ability to Perform Sport-Specific Movements Effectively.

PURPOSE: To evaluate the outcomes of a combination of an arthroscopic Bankart repair and an open Bristow procedure in relation to the subjective quality of performance in movements that are typical in rugby. METHODS: Forty shoulders in 38 players who underwent surgery for traumatic anterior instability of the shoulder were reviewed. In all cases, arthroscopic Bankart repair was followed by a Bristow procedure, with preservation of the repaired capsular ligaments, during the same operation. The mean age at the time of surgery was 21 years. Patients were asked to describe common rugby maneuvers (tackle, hand-off, jackal, and saving) preoperatively and postoperatively as "no problem," "insufficient," or "impossible." RESULTS: There were no recurrent dislocations at a mean follow-up of 30.5 months. The mean Rowe score improved significantly from 65.0 (range, 55 to 75) to 97.5 (range, 95 to 100) (P < .001) after surgery. Preoperatively, regarding the tackling motion, none of the patients reported having no problem, whereas the ability was described as insufficient for 23 shoulders and impossible for 17 shoulders. Postoperatively, no problem with tackling was reported for 36 shoulders, whereas insufficiency was reported for 4. The results for the hand-off, jackal, and saving maneuvers were similar (P < .001). No patient rated any of the motions as impossible postoperatively. CONCLUSIONS: This combined surgical procedure clearly is effective in preventing recurrent dislocation in rugby players; however, some players complained of insufficiency in the quality of their play when they were tackling or performing other rugby-specific movements. LEVEL OF EVIDENCE: Level IV, case series.

Quantitative and qualitative analyses of subacromial impingement by kinematic open MRI.

PURPOSE: Quantitative and qualitative kinematic analyses of subacromial impingement by 1.2T open MRI were performed to determine the location of impingement and the involvement of the acromioclavicular joint. METHODS: In 20 healthy shoulders, 10 sequential images in the scapular plane were taken in a 10-s pause at equal intervals from 30° to maximum abduction in neutral and internal rotation. The distances between the rotator cuff (RC) and the acromion and the acromioclavicular joint were measured. To comprehend the positional relationships, cadaveric specimens were also observed. RESULTS: Although asymptomatic, the RC came into contact with the acromion and the acromioclavicular joint in six and five cases, respectively. The superior RC acted as a depressor for the humeral head against the acromion as the shoulder elevated. The mean elevation angle and distance at the closest position between the RC and the acromion in neutral rotation were 93.5° and 1.6 mm, respectively, while those between the RC and the acromioclavicular joint were 86.7° and 2.0 mm. When comparing this distance and angle, there was no significant difference between the RC to the acromion and to the acromioclavicular joint. The minimum distance between the RC and the acromion was significantly shorter than that between the greater tuberosity and the acromion. The location of RC closest to the acromion and the acromioclavicular joint differed significantly. CONCLUSION: Although asymptomatic, contact was found between the RC and the acromion and the acromioclavicular joint. The important role of the RC to prevent impingement was observed, and hence, dysfunction of the RC could lead to impingement that could result in a RC lesion. The RC lesions may differ when they are caused by impingement from either the acromion or the acromioclavicular joint.

Anatomic observation of the running space of the suprascapular nerve at the suprascapular notch in the same direction as the nerve.

PURPOSE: The configuration of suprascapular notch was previously analysed from the anteroposterior viewing. However, the approach direction of the suprascapular nerve (SSN) to the inlet of the suprascapular notch is consistently craniocaudal and mediolateral. We propose a new method to observe the suprascapular notch according to the running course of the SSN. We reviewed the anatomic characteristics of the suprascapular notch in relation to the nerve. METHODS: In 30 formalin-fixed cadaveric shoulders, the morphology of the suprascapular notch and the attachments of the superior transverse scapular ligament (STSL) were examined from both the anteroposterior and the nerve approach direction. The dimensions of the opening of the SSN passage were measured. RESULTS: By observing from the nerve approach direction, the inlet of the suprascapular notch was recognized to be a space-bordered by the medial wall of the coracoid process, the deep fascia of subscapularis, and the STSL. The STSL formed a sheet-like structure, which ran parallel to the nerve and also to the deep fascia of subscapularis. The attachment of the ligament to the coracoid process was located at the posteromedial corner rather than the medial side. CONCLUSION: Based on the present study, the space between the STSL and deep fascia of the subscapularis formed the space for the nerve to run through. As a clinical implication, this new method to assess the suprascapular notch in the nerve approach direction might develop the imaging techniques for evaluation of SSN entrapment.

Penetrating injury to the cauda equina: a case report and review of the literature.

STUDY DESIGN: Case report. OBJECTIVE: To report a rare case of a penetrating injury to the cauda equina, secondary to a stab wound. SUMMARY OF BACKGROUND DATA: Penetrating injuries affecting the cauda equina by stab wounds, not by gunshot wounds, are of extremely rare occurrence compared with penetrating spinal cord injuries and have been previously reported only in 2 studies since 1969. METHODS AND RESULTS: A 43-year-old man was presented with a stab wound to the right lumbar region, with immediate paralysis of the left lower extremity accompanied by loss of perineal sensation. Magnetic resonance imaging suggested rupture of the cauda equina nerves at the L3 to L4 level. The patient was taken immediately for surgery for irrigation and debridement. We identified several cut ends of the cauda equina nerves and attempted to repair them, but had to determine that accurate matching of the severed ends would be problematic. At 2 years follow-up, there were no significant improvements in the neurological status. The patient was ambulatory with an ankle-foot orthosis, and had already returned back to work. CONCLUSIONS: We could not repair the cauda equina rootlets. However, similar to other central nervous system penetrating injuries, the priorities of treatment included an emphasis on infection control and sealing of the duro-cutaneous fistula, and we could easily manage both by the emergency surgery. Although there were no improvements in the neurological function, there were no complications and the patient returned to a reasonably good function.

The reverse shoulder prosthesis: A review of imaging features and complications.

BACKGROUND: The reverse shoulder prosthesis is a prosthesis that has been in clinical use in Europe since 1985 and was approved for use in the United States in 2004. This unique prosthesis has a baseplate attached to the glenoid, which holds a spherical component, while the humeral component includes a polyethylene insert that is flat. This design is the "reverse" configuration of that seen with a conventional arthroplasty, in which the spherical component is part of the humeral component. The indications for the reverse prosthesis are: (1) painful arthritis associated with irreparable rotator cuff tears (cuff tear arthropathy), (2) failed hemiarthroplasty with irreparable rotator cuff tears, (3) pseudoparalysis due to massive, irreparable rotator cuff tears, (4) some reconstructions after tumor resection, and (5) some fractures of the shoulder not repairable or reconstructable with other techniques. This prosthesis can produce a significant reduction in pain and some improvement in function for most of the indications mentioned. However, the unique configuration and the challenge of its insertion can result in a high incidence of a wide variety of unusual complications. Some of these complications, such as dislocation of the components, are similar to conventional shoulder replacement. Other complications, such as notching of the scapula and acromial stress fractures, are unique to this prosthesis. CONCLUSION: The configuration of the reverse prosthesis, its normal radiographic appearance and potential complications associated with its use are reviewed.