Mid- to long-term survivorship of the cemented, semiconstrained Discovery total elbow arthroplasty.

BACKGROUND: The incidence of total elbow arthroplasty (TEA) is increasing, and an improved understanding of elbow kinematics and biomaterials has driven advances in implant design. In modern practice, cemented, semiconstrained devices are most frequently used. The Discovery TEA has demonstrated promising early results, although there are a paucity of follow-up studies and no dedicated mid- to long-term series. We therefore present the longest, most complete such study to date. METHODS: A prospectively maintained local joint registry was interrogated to yield a consecutive series of Discovery TEAs performed at a single non-design center. The minimum follow-up period was set at 5 years. Revision procedures and TEAs performed for acute trauma were excluded. The primary outcome was survivorship of the implant. The secondary outcomes included clinical, radiographic, and patient-reported outcomes. RESULTS: We identified 67 TEAs in 58 patients for inclusion at a mean of 98.5 ± 20.4 months from surgery. Four cases (6%) were lost to follow-up, and implant survival was censored accordingly. The implant was revised in 14 cases (20.9%). The Kaplan-Meier method showed an implant survivorship rate of 76.8% at 119 months. A significant difference in survival was found between dominant and nondominant elbows (P = .012, Breslow test), with elbow dominance conferring a 4.5-fold increased risk of revision (relative risk, 4.5; 95% confidence interval, 1.1-18.5). Pooled clinical outcomes (70.9% follow-up at minimum of 60 months and median of 77.8 months) were also determined. CONCLUSIONS: We present the longest-term and most complete single-center follow-up study of the Discovery TEA to date. Further long-term survival studies are required to elucidate the performance of this implant compared with more established designs. We have also demonstrated differences in implant survivorship owing to hand dominance for the first time.

Clinical Outcomes of Arthroscopic Revision Rotator Cuff Repair.

Aims: Multiple studies have shown excellent clinical results in primary rotator cuff repairs; however, not much evidence is available in the literature on the outcomes of arthroscopic revision rotator cuff repairs. The purpose of this study was to report a cohort of patients who underwent revision arthroscopic rotator cuff repair and identify factors that may influence its outcomes. Methods: We examined a cohort of 62 patients which underwent revision arthroscopic rotator cuff repair in a single UK institution with a minimum of 24 months follow-up. Active shoulder movements including forward flexion, abduction and external rotation were evaluated, as well as Oxford Shoulder Score (OSS). Further subgroup analysis was performed looking of the effects of age, size of tear, obesity and diabetes mellitus had on clinical outcomes. Results: 59 patients were available for final review. 39 male and 23 were female. The mean age was 64 years. Overall, significant improvements were seen in terms of OSS (p < 0.05), active forward flexion (p < 0.05), active abduction (p < 0.05) and active external rotation (p < 0.05). Our study showed that a significant proportion of patients undergoing arthroscopic revision rotator cuff repair achieve good outcomes. Repairing small- and medium-size tears was successful, diabetics had no post-operative improvements, obese patients achieved significant improvement in range of movement and age was not a predictor of surgical success. Conclusion: Overall, arthroscopic revision surgery is a successful option; however, appropriate patient selection and counselling is paramount.

Primary open elbow arthrolysis in post-traumatic elbow stiffness - A comparison of outcomes in severity of elbow injury.

PURPOSE: Stiffness is a sequelae of elbow trauma. Arthrolysis may be considered to increase range of movement (ROM). Little is published on the outcomes/complications of elbow arthrolysis. We present our series of primary open arthrolysis in posttraumatic elbow stiffness. METHODS: A consecutive series of patients that underwent primary open arthrolysis for posttraumatic elbow stiffness in our unit (2011-2018) were analysed. All procedures were performed by an elbow surgeon. Postoperative rehabilitation followed protocol with early motion; continuous passive motion (CPM) was utilised if requested. Data collected included patient demographics, traumatic injury type, arthrolysis technique, preoperative, intraoperative and postoperative elbow ROM, complications and postoperative Oxford Elbow Score (OES). RESULTS: 41 patients were included. 59% were male. Mean age at time of arthrolysis was 43 years (range 12-79 years). Mean duration of follow-up was 53 months (range 8-100 months). Median duration from time of injury to arthrolysis was 11 months (range 2-553 months). Mean preoperative flexion-extension arc (FEA) was 70°, improving to 104° postoperatively (p < 0.001). Mean preoperative pronosupination arc (PSA) was 125°, improving to 165° postoperatively (p < 0.001). Mean postoperative OES was 37 (n = 28). Complication rate was 24% with 7 recurrence requiring surgery, 2 nerve injuries and 1 infection. CPM, 10 patients, saw mean FEA improvement of 56°. Mean PSA improvement was 36°. Complication rate for these patients was 40%. Severe traumatic injury was associated with increased preoperative stiffness (FEA 61° vs 84°, PSA 111° vs 149°) but larger improvements in ROM (postoperative FEA 98° [p < 0.001], PSA 165° [p < 0.001]). CONCLUSION: This series demonstrates improvement in elbow ROM following open arthrolysis with significantly higher gain in pronosupination for those withsevere injury. Moderate results were seen in a patient reported outcome measure. Patients considering arthrolysis should be counselled regarding expectations/complication rate.

Minimum five-year outcomes of reverse total shoulder arthroplasty using a trabecular metal glenoid base plate.

AIMS: Reverse total shoulder arthroplasty (RTSA) using trabecular metal (TM)-backed glenoid implants has been introduced with the aim to increase implant survival. Only short-term reports on the outcomes of TM-RTSA have been published to date. We aim to present the seven-year survival of TM-backed glenoid implants along with minimum five-year clinical and radiological outcomes. METHODS: All consecutive elective RTSAs performed at a single centre between November 2008 and October 2014 were reviewed. Patients who had primary TM-RTSA for rotator cuff arthropathy and osteoarthritis with deficient cuff were included. A total of 190 shoulders in 168 patients (41 male, 127 female) were identified for inclusion at a mean of 7.27 years (SD 1.4) from surgery. The primary outcome was survival of the implant with all-cause revision and aseptic glenoid loosening as endpoints. Secondary outcomes were clinical, radiological, and patient-related outcomes with a five-year minimum follow-up. RESULTS: The implant was revised in ten shoulders (5.2%) with a median time to revision of 21.2 months (interquartile range (IQR) 9.9 to 41.8). The Kaplan-Meier survivorship estimate at seven years was 95.9% (95% confidence interval (CI) 91.7 to 98; 35 RTSAs at risk) for aseptic mechanical failure of the glenoid and 94.8% (95% CI 77.5 to 96.3; 35 RTSAs at risk) for all-cause revision. Minimum five-year clinical and radiological outcomes were available for 103 and 98 RTSAs respectively with a median follow-up time of six years (IQR 5.2 to 7.0). Median postoperative Oxford Shoulder Score was 38 (IQR 31 to 45); median Constant and Murley score was 60 (IQR 47.5 to 70); median forward flexion 115° (IQR 100° to 125°); median abduction 95° (IQR 80° to 120°); and external rotation 25° (IQR 15° to 40°) Scapular notching was seen in 62 RTSAs (63.2%). CONCLUSION: We present the largest and longest-term series of TM-backed glenoid implants demonstrating 94.8% all-cause survivorship at seven years. Specifically pertaining to glenoid loosening, survival of the implant increased to 95.9%. In addition, we report satisfactory minimum five-year clinical and radiological outcomes. Cite this article: Bone Joint J 2021;103-B(8):1333-1338.

Use of articular wrist views to assess intra-articular screw penetration in surgical fixation of distal radius fractures.

The use of volar locking plates for fixation of distal radius fractures is increasing in modern orthopedic practice. They have the advantage of limited dissection, early mobilization, and improved function over previous fixation devices. Standard anteroposterior and lateral radiographs would normally be requested by the orthopedic team, but these may not give an accurate representation of the articular anatomy of the fracture fixation. This study evaluated the effectiveness of a series of radiographs, the articular wrist series, which accurately represent the wrist joint and clarify doubt regarding screw placement or articular congruity. With this method, 2 additional radiographs are taken and are oriented in such a manner as to produce an image parallel to the radiocarpal joint on both anteroposterior (11 degrees elevation) and lateral (23 degrees elevation) projections. Since the introduction of such a system, we have been able to interpret radiographs in this setting much more easily.

Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss.

PURPOSE: The purpose of this study was to analyze the results of the modified Latarjet procedure for shoulder instability associated with an inverted-pear glenoid (bone loss of at least 25% of the width of the inferior glenoid) or an engaging Hill-Sachs lesion. METHODS: From March 1996 to December 2002, 102 patients underwent an open Latarjet procedure for shoulder instability with an inverted-pear glenoid, with or without an associated engaging Hill-Sachs lesion, by the 2 senior authors (S.S.B. and J.F.D.), and 47 of them were available for follow-up physical examination. The remaining 55 patients were contacted by telephone or letter to see if they had had recurrent dislocation or subluxation. The mean age of the patients was 26.5 +/- 6.6 years (range, 16 to 41 years). There were 46 male patients and 1 female patient. Preoperatively, mean forward elevation was 177.2 degrees +/- 13.6 degrees (range, 90 degrees to 180 degrees) and mean external rotation with the arm at the side was 55.3 degrees +/- 16.1 degrees (range, 0 degrees to 80 degrees). All patients had a positive apprehension sign preoperatively. The median number of dislocations before surgery was 6, with 20 patients having had more than 15 dislocations preoperatively. RESULTS: The mean follow-up time for the 47 patients who were personally examined was 59.0 +/- 18.5 months (range, 32 to 108 months). Postoperatively, mean forward elevation was 179.6 degrees +/- 2.0 degrees (range, 170 degrees to 180 degrees; gain of 2.4 degrees) and external rotation with the arm at the side was 50.2 degrees +/- 12.6 degrees (range, 22 degrees to 78 degrees; loss of 5.1 degrees). As for postoperative functional scores, the mean Constant score was 94.4 and the mean Walch-Duplay score was 91.7. None of these 47 patients showed any further dislocation, and 1 of them still had a positive apprehension sign (2.2%) indicating subluxation. However, 4 patients out of the total 102 who underwent the modified Latarjet procedure had a recurrence. With 4 recurrent dislocations and 1 recurrent subluxation, there was a 4.9% recurrence rate. The 4 patients with recurrent dislocations were not among the 47 who returned for personal follow-up evaluation. CONCLUSIONS: The 2 senior authors (S.S.B. and J.F.D.) have previously reported an unacceptably high recurrence rate (67%) for arthroscopic Bankart repair in the presence of an inverted-pear glenoid with or without an engaging Hill-Sachs lesion. They have recommended an open modified Latarjet procedure in such patients. The present study confirms the validity of that recommendation, because the same 2 surgeons have had only a 4.9% recurrence rate in that same category of patient at a mean follow-up of 59 months. Furthermore, the results of this study show the efficacy of the modified Latarjet procedure in the extremely challenging category of patients who present with such dramatic bone loss that soft-tissue reconstruction, either open or arthroscopic, is not a reasonable option. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

A simple and safe technique for reconstruction of the acromioclavicular joint.

Surgical reconstruction of the dislocated acromioclavicular joint often requires exposure and instrumentation of the coracoid. This carries risks to the surrounding neurovascular structures. We present a safe and simple technique of primary fixation of the acromioclavicular joint, relying on mechanical principles and biological repair, without the need for metalwork. By avoiding the coracoid we hope this approach will appeal to the general orthopedic surgeon. We have found that this technique is suited to both acute and chronic acromioclavicular joint dislocation.