Palliative single-level selective dorsal rhizotomy for children with spastic cerebral palsy Gross Motor Function Classification System level IV and V: a case series and systematic review of the literature.

OBJECTIVE: Single-level selective dorsal rhizotomy (SDR), typically indicated for ambulatory patients, is a controversial topic for severe spastic cerebral palsy (CP) with Gross Motor Function Classification System (GMFCS) level IV or V. The objective of this case series and systematic literature review was to outline the indication and outcome of palliative SDR for nonambulatory patients with CP and GMFCS level IV and V, focusing on improvement of spasticity and of patient and caregiver reported quality of life assessment. METHODS: A retrospective case series of patients with CP and GMFCS level IV or V who underwent single-level SDR at the authors' institution is presented. Furthermore, two databases (PubMed and Embase) were searched and a systematic review with a search string based on the terms "selective dorsal rhizotomy," "cerebral palsy," and "outcome" was conducted. The primary outcome was the reduction of spasticity based on the modified Ashworth scale (MAS). Secondary outcomes were change on the Gross Motor Function Measure-66 (GMFM-66), evaluation of patient-reported outcome measures (PROMs), surgical morbidity, and mortality. RESULTS: Eleven consecutive children under the age of 25 years undergoing palliative single-level SDR were included. All patients showed a reduction in MAS score (mean 1.09 ± 0.66 points) and no surgical morbidity and mortality occurred. For the systematic review results from our case series, in addition to 4 reports, 274 total patients were included. Reduction of spasticity based on MAS score was noted in all studies (mean range 1.09-3.2 points). Furthermore, in 2 studies spasticity of the upper extremities showed a MAS score reduction as well (range 1.7-2.8 points). The GMFM-66 score improved in 72% of the patients, while bladder function improved in 78% of the patients. Based on the PROMs, 92% of the patients/caregivers were satisfied with the outcome and their quality of life after the procedure. Two wound infections (2.7%) and one CSF leak (1.3%) occurred, while no surgery-related deaths were described. CONCLUSIONS: This analysis showed an improvement in spasticity, daily care, and comfort for patients with CP and GMFCS levels IV and V. Larger cohorts analyzing the outcome of palliative single-level SDR, based on the MAS, GMFM-66, and PROMs, are still needed and should be the focus of future studies. Systematic review registration no.: CRD42024495762 (https://www.crd.york.ac.uk/prospero/).

Mid-Term Follow Up of the Nexel Total Elbow Arthroplasty.

INTRODUCTION: Aseptic loosening is one of the most common complications of total elbow arthroplasty (TEA). Modern implants, such as the Nexel, have been designed in an attempt to decrease loosening. The present study aims to report implant survivorship, radiographic assessment of loosening and lucency, and patient-reported outcome measures (PROMs) in patients treated with the Nexel TEA at mid-term follow-up. METHODS: Consecutive series of adult patients underwent TEA using the Nexel by a single surgeon via standardized technique. Patients with minimum 3 year follow-up with radiographic and PROM data were included. Survivorship was defined by the absence of revision. Loosening was assessed via Wrightington method by three independent fellowship-trained shoulder and elbow surgeons. Lucency was analyzed across individual radiographic zones on orthogonal radiographs. PROMs included the Quick Dash (QDASH), Patient Rated Elbow Evaluation (PREE), and EuroQoL (EQ5D). RESULTS: 38 consecutive patients (22 female, 16 male) with mean age of 67 underwent TEA via triceps-sparing isolated medial window approach. Mean follow-up was 5.5 years (range 3-9). Primary diagnoses were: 19 osteoarthritis (OA), 9 rheumatoid arthritis (RA), 9 post-traumatic arthritis (PA), 1 conversion of elbow arthrodesis. Overall survivorship was 97.4%, with one patient undergoing revision for infection. Loosening was found in 5.3% of elbows, averaged across three observers. Lucency was most pronounced at the level of the humeral condyles. PROMs demonstrated significant and clinically meaningful improvements in 76%, 92%, and 73% of patients for QDASH, PREE, and EQ5D, respectively. No significant correlations were found between patient age, gender, loosening, lucency, and PROMs. CONCLUSION: At mid-term follow-up, the Nexel TEA demonstrated excellent overall survivorship and low rate of implant loosening. The single failure requiring revision for infection was conversion of a prior elbow arthrodesis. PROMs overall exhibited marked and consistent improvement from preop to final postop follow-up. Although promising, these results should be interpreted with some caution as long term data regarding this prosthesis are still lacking.

Association of Insurance Type With Inpatient Surgery 30-Day Complications and Costs.

INTRODUCTION: Safety-net hospitals (SNHs) have higher postoperative complications and costs versus low-burden hospitals. Do low socioeconomic status/vulnerable patients receive care at lower-quality hospitals or are there factors beyond providers' control? We studied the association of private, Medicare, and vulnerable insurance type with complications/costs in a high-burden SNH. METHODS: Retrospective inpatient cohort study using National Surgical Quality Improvement Program (NSQIP) data (2013-2019) with cost data risk-adjusted by frailty, preoperative serious acute conditions (PASC), case status, and expanded operative stress score (OSS) to evaluate 30-day unplanned reoperations, any complication, Clavien-Dindo IV (CDIV) complications, and hospitalization variable costs. RESULTS: Cases (Private 1517; Medicare 1224; Vulnerable 3648) with patient mean age 52.3 y [standard deviation = 14.7] and 47.3% male. Adjusting for frailty and OSS, vulnerable patients had higher odds of PASC (aOR = 1.71, CI = 1.39-2.10, P < 0.001) versus private. Adjusting for frailty, PASC and OSS, Medicare (aOR = 1.27, CI = 1.06-1.53, P = 0.009), and vulnerable (aOR = 2.44, CI = 2.13-2.79, P < 0.001) patients were more likely to undergo urgent/emergent surgeries. Vulnerable patients had increased odds of reoperation and any complications versus private. Variable cost percentage change was similar between private and vulnerable after adjusting for case status. Urgent/emergent case status increased percentage change costs by 32.31%. We simulated "switching" numbers of private (3648) versus vulnerable (1517) cases resulting in an estimated variable cost of $49.275 million, a 25.2% decrease from the original $65.859 million. CONCLUSIONS: Increased presentation acuity (PASC and urgent/emergent surgeries) in vulnerable patients drive increased odds of complications and costs versus private, suggesting factors beyond providers' control. The greatest impact on outcomes may be from decreasing the incidence of urgent/emergent surgeries by improving access to care.

Sex-Related Differences in Acuity and Postoperative Complications, Mortality and Failure to Rescue.

INTRODUCTION: Yentl syndrome describing sex-related disparities has been extensively studied in medical conditions but not after surgery. This retrospective cohort study assessed the association of sex, frailty, presenting with preoperative acute serious conditions (PASC), and the expanded Operative Stress Score (OSS) with postoperative complications, mortality, and failure-to-rescue. METHODS: The National Surgical Quality Improvement Program from 2015 to 2019 evaluating 30-d complications, mortality, and failure-to-rescue. RESULTS: Of 4,860,308 cases (43% were male; mean [standard deviation] age of 56 [17] y), 6.0 and 0.8% were frail and very frail, respectively. Frailty score distribution was higher in men versus women (P < 0.001). Most cases were low-stress OSS2 (44.9%) or moderate-stress OSS3 (44.5%) surgeries. While unadjusted 30-d mortality rates were higher (P < 0.001) in males (1.1%) versus females (0.8%), males had lower odds of mortality (adjusted odds ratio (aOR) = 0.92, 95% confidence interval [CI] = 0.90-0.94, P < 0.001) after adjusting for frailty, OSS, case status, PASC, and Clavien-Dindo IV (CDIV) complications. Males have higher odds of PASC (aOR = 1.33, CI = 1.31-1.35, P < 0.001) and CDIV complications (aOR = 1.13, CI = 1.12-1.15, P < 0.001). Male-PASC (aOR = 0.76, CI = 0.72-0.80, P < 0.001) and male-CDIV (aOR = 0.87, CI = 0.83-0.91, P < 0.001) interaction terms demonstrated that the increased odds of mortality associated with PASC or CDIV complications/failure-to-rescue were lower in males versus females. CONCLUSIONS: Our study provides a comprehensive analysis of sex-related surgical outcomes across a wide range of procedures and health care systems. Females presenting with PASC or experiencing CDIV complications had higher odds of mortality/failure to rescue suggesting sex-related care differences. Yentl syndrome may be present in surgical patients; possibly related to differences in presenting symptoms, patient care preferences, or less aggressive care in female patients and deserves further study.

Diagnosis of Neurogenic Thoracic Outlet Syndrome Based on the Clinical Status.

OBJECTIVES: At our institute, we devised a clinical algorithm for diagnosis of neurogenic thoracic outlet syndrome (TOS). Our approach assisted in the accurate diagnosis and in detection of patients likely to benefit from surgical treatment. The purposes of this study were to propose our diagnostic approach to neurogenic TOS, and to describe the outcomes of surgical and conservative treatment. METHODS: Patients (n = 91) who were suspected to have neurogenic TOS, and therefore, underwent a routine clinical protocol from January 2012 to January 2018 were reviewed. Through the clinical protocol, diagnosis of "true neurologic TOS", "symptomatic TOS", and "not likely TOS" was made. The visual analog scale (VAS) pain score and Disabilities of the Arm, Shoulder and Hand (DASH) score were used to assess the treatment outcomes. Satisfaction with surgery was assessed according to the Derkash classification as excellent, good, fair, or poor. RESULTS: Among 91 patients with presumed neurogenic TOS, 25 patients were "true neurologic TOS", 61 patients were "symptomatic TOS", and five patients were "not likely TOS". Nineteen patients underwent supraclavicular decompression of the brachial plexus whose mean age at the time of surgery was 36.4 years. The VAS average pain score improved from 3.6 to 0.8, and the DASH score improved from 38.4 to 17.1. According to the Derkash classification, ten patients (53%) rated their recovery as excellent, four (21%) as good, and five (26%) as fair. Sixty-seven patients underwent conservative treatment. At the last follow-up visit, their VAS and DASH score were 2.3 and 11.8, respectively. CONCLUSIONS: By using an algorithm, we diagnosed the patients suspected to have neurogenic TOS into three groups based on clinical status. We surgically treated 19 patients using supraclavicular approach, and achieved favorable outcomes.

Extent of neck dissection for patients with clinical N1 oral cancer.

BACKGROUND: No clear consensus has been reached on the indication of supraomohyoid neck dissection (SOHND) for clinically positive lymph-node metastasis. PATIENTS: Consecutive 100 patients with previously untreated oral cancer treated at Kobe University Hospital were included in this study. All patients were clinically staged as anyTN1M0 and underwent radical dissection of the primary site and level I-V neck dissection as the initial treatment. RESULTS: None of the 100 patients had pathological lymph-node metastasis (pLN) to level V. pLN to level IV was observed in two patients with tongue cancer in whom clinical lymph-node metastasis was preoperatively observed at level II. CONCLUSIONS: Level V may be excluded in the neck dissection for patients with N1 oral cancers. Level IV dissection should be considered in the patient with tongue cancer and clinical lymph-node metastasis at level II.

A Genetic Predictive Model Estimating the Risk of Developing Adolescent Idiopathic Scoliosis.

BACKGROUND: Previous GWASs have revealed several susceptible variants associated with adolescent idiopathic scoliosis (AIS). Risk prediction based on these variants can potentially improve disease prognosis. We aimed to evaluate the combined effects of genetic factors on the development of AIS and to further develop a genetic predictive model. METHODS: A total of 914 AIS patients and 1441 normal controls were included in the discovery stage, which was followed by the replication stage composed of 871 patients and 1239 controls. Genotyping assay was performed to analyze 10 previously reported susceptible variants, including rs678741 of LBX1, rs241215 of AJAP1, rs13398147 of PAX3, rs16934784 of BNC2, rs2050157 of GPR126, rs2180439 of PAX1, rs4940576 of BCL2, rs7593846 of MEIS1, rs7633294 of MAGI1 and rs9810566 of TNIK. Logistic regression analysis was performed to generate a risk predictive model. The predicted risk score was calculated for each participant in the replication stage. RESULTS: The association of the 10 variants with AIS was successfully validated. The established model could explain approximately 7.9% of the overall variance. In the replication stage, patients were found to have a remarkably higher risk score as compared to the controls (44.2 ± 14.4 vs. 33.9 ± 12.5, p <0.001). There was a remarkably higher proportion of the risk score i.e. >40 in the patients than in the controls (59% vs. 28.9%, p <0.001). CONCLUSION: Risk predictive model based on the previously reported genetic variants has a remarkable discriminative power. More clinical and genetic factors need to be studied, to further improve the proba-bility to predict the onset of AIS.

High incidence of posterior glenoid dysplasia of the shoulder in young baseball players.

BACKGROUND: Rounding of the posterior glenoid rim is observed in young throwing athletes with internal shoulder impingement and is considered developmental dysplasia of the glenoid. The aim of our study was to determine the incidence rate of dysplastic changes of the glenoid within a group of 92 young baseball players. METHODS: The study group included 92 male baseball players, with a mean age of 14.63 years. Of these patients, 30 were diagnosed with Little Leaguer's shoulder and 62 with a painful baseball-throwing shoulder with no abnormal findings on x-ray. The posterior glenoid rim of the affected shoulder was compared with the contralateral nonpainful shoulder, with the 2 following outcomes measured on radiographs obtained using the modified Bernageau imaging method: the distance between the anterior and posterior glenoid rims and the presence or absence of dysplasia of the posterior glenoid rim. RESULTS: The mean distance between the anterior and posterior glenoid rims was significantly shorter in the painful shoulders (mean, 26 mm) than in the nonpainful shoulders (mean, 29 mm; P < .0001). Dysplasia of the posterior glenoid rim was identified in 89 painful shoulders (96.7%), with 9 cases (9.7%) identified on the unaffected contralateral side (P < .001). The presence of dysplasia was not correlated with the age at which baseball playing began. CONCLUSION: The incidence of dysplasia of the posterior glenoid rim is high (96.7%) among young baseball players with a painful shoulder. The identified dysplasia may be related to impaired development of the inferior peripheral secondary glenoid ossification center due to repetitive throwing.

Comparable Cumulative Incidence of Late Periprosthetic Femoral Fracture and Aseptic Stem Loosening in Uncemented Total Hip Arthroplasty-A Concise Follow-Up Report at a Minimum of 20 Years.

BACKGROUND: There is a lack of long-term studies into the third decade reporting on the incidence of periprosthetic femoral fracture (PPFF) and aseptic stem loosening (ASL) after cementless total hip arthroplasty (THA). The aim of the present retrospective, longitudinal cohort study was to compare the cumulative incidence of PPFF and ASL in a consecutive cohort of 326 patients with 354 primary uncemented THAs after 20-25 years and to identify risk factors being associated with PPFFs. METHODS: Postoperative femoral fractures were investigated for timing, mechanism of injury, Vancouver classification, and subsequent treatment. The cumulative incidence of PPFF and ASL was estimated using Kaplan-Meier survival analysis. Risk factors for PPFFs were analyzed using a Cox proportional hazards regression model. RESULTS: One hundred sixty-three patients (180 hips) were available for follow-up at a mean of 22 years. Twenty-one fractures occurred during the follow-up period. The cumulative incidence of PPFF was 1.6% at 10 years, 4.5% at 17 years, and 9.4% at 22 years after surgery. The cumulative incidence of PPFF and ASL after 22 years was comparable (9.4% [95% confidence interval, 5.9%-14.7%] and 6.9% [95% confidence interval, 4.5%-10.5%]). Gender, age at surgery, diagnosis, cup revision, and canal fill index of the stem in the proximal femur were no risk factors for the occurrence of a PPFF. CONCLUSION: The cumulative incidence of PPFF after primary uncemented THA further increased in the second decade and reached the incidence of ASL in the third decade, while no risk factors for the occurrence of a PPFF could be identified.

Clinical and Radiographic Outcomes at 25-30 Years of a Hip Stem Fully Coated With Hydroxylapatite.

BACKGROUND: Little is known about the survival of total hip arthroplasty implants with bioactive coatings beyond the first 20 years. The authors aimed to report survival of a tapered hip stem fully coated with hydroxylapatite (HA) at follow-up of 25-30 years. METHODS: Of the original series of 320 patients (347 hips), 12 patients (12 hips) had stem and cup revisions, 54 patients (55 hips) had cup revisions, 17 patients (17 hips) had liner exchange. A total of 207 patients (225 hips) died with stems in place and 21 patients (24 hips) could not be reached. This left a cohort of 80 patients (86 hips) with their original stem for assessment. Survival was analyzed using the Kaplan-Meier (KM) method and cumulative incidence function (CIF). RESULTS: Considering stem revision as endpoint, the revision risk calculated using the KM method was 6.3%, whereas using the CIF it was 3.7%. Considering any reoperation as endpoint, the revision risk calculated using the KM method was 41.2%, whereas using the CIF it was 25.9%. The Harris Hip Score for 77 patients (18 hips) was 81.6 ± 15.2. Standard x-rays were available for 52 hips (49 patients), and 10 (19.2%) showed radiolucencies <2 mm thick. CONCLUSION: This study is the first to report outcomes of an HA-coated stem beyond 25 years. The survival of stem compares favorably with long-term survival of the Charnley cemented stem, and with shorter-term registry studies. The stem achieved its intended purpose of total osteointegration in the long-term, although the proximolateral region remains susceptible to radiolucencies.

11-Year Mean Follow-Up of Acetabular Impaction Grafting With a Mixture of Bone Graft and Hydroxyapatite Porous Synthetic Bone Substitute.

BACKGROUND: We report an 11-year mean follow-up of the effectiveness of bone impaction grafting with bone and hydroxyapatite (HA) for large, uncontained acetabular defects in primary and revision hip surgeries. METHODS: Over 5 years, 47 total hip arthroplasties with uncontained acetabular deficiencies were performed by augmentation using an impaction graft with 50:50 mixture of freeze-dried bone allograft and HA. Ten were primary total hip arthroplasties and 37 revision procedures. X-rays were taken postoperatively, 6 weeks, 3 months, and then annually to assess incorporation of the graft, radiolucent lines, resorption, or migration of components. Functional outcomes were assessed by annual pain and function parts of the Harris Hip Score. RESULTS: At a mean follow-up of 10 years, the survivorship was 100%. All patients were accounted for; 6 had died. The Harris Hip Score for pain improved from 9 and 17 (primaries and revisions, respectively) to 39 and 41. For function, there was an improvement from 20 and 19 to 32 (both groups). There were lucent lines in 8 cases, 3 cups had minor/stable migration, and one cup had significant migration (>15 mm). Graft incorporation had occurred in 20 hips. CONCLUSION: This is the longest survivorship of bone impaction grafting with morcellised bone and HA substitute. Although 11-year survivorship, function and pain are excellent, radiological findings of lysis in 8 and migration in 4 cases may be of concern for the immediate future and will need close monitoring. Even in these cases, revision may be easier because of restoration of bone stock.

Does Calipered Kinematically Aligned TKA Restore Native Left to Right Symmetry of the Lower Limb and Improve Function?

BACKGROUND: Kinematically aligned total knee arthroplasty (KA TKA) strives to restore the native left to right symmetry of the lower limb; however, the reproducibility of achieving this target is unknown. The present study determined the proportion of patients with left to right symmetry and the improvement in patient-reported function after calipered KA TKA. METHODS: A review of 562 postoperative scanograms identified 102 patients (53 women) with a KA TKA in one limb, no other skeletal abnormalities in either limb, and symmetrical rotation between limbs on the scanogram. All patients were treated with primary TKA that used caliper measurement of the thicknesses of the femoral bone and tibial bone resections to kinematically align the components. The hip-knee-ankle (HKA) angle, distal lateral femoral angle (DLFA), and proximal medial tibial angle (PMTA) were measured. Patient-reported Oxford Knee Score (OKS) measured preoperative and postoperative functions. RESULTS: The proportion of patients with a difference in the HKA angle, DLFA, and PMTA between limbs within ±3°, >3° varus, and <-3° valgus was 95%, 2%, and 3%, respectively, for the HKA angle; 97%, 1%, and 2%, respectively, for the DLFA; and 97%, 2%, and 1%, respectively, for the PMTA. The mean OKS improved from 20 preoperatively to 44 points (range 18-48 points) at 15 months postoperatively. CONCLUSION: Calipered KA TKA restored native left to right symmetry of the HKA angle, DLFA, and PMTA in nearly all patients with negligible risk of varus alignment of the tibial component with respect to the native tibial joint line. The mean postoperative OKS indicated clinically important improvement in patient-reported function.

Comparative Analysis of the Reconstruction of Individual Hip Anatomy Using 3 Different Cementless Stem Designs in Patients With Primary Hip Osteoarthritis.

BACKGROUND: We questioned whether there was a radiographic difference in hip geometry reconstruction and implant fixation between 3 different cementless stem design concepts in patients with primary end-stage hip osteoarthritis. METHODS: We retrospectively evaluated the preoperative and postoperative radiographs by 2 independent and blinded reviewers in a series of 264 consecutive patients who had received either a straight double-tapered stem with 3 offset options (group A), a straight double-tapered stem with 2 shape options and modular necks (group B), and a bone-preserving curved tapered stem with 4 offset options (group C). The following parameters were assessed: acetabular, femoral and hip offset (HO), center of rotation height, leg length difference (LLD), and the endosteal fit of stem in the proximal femur (canal fill index). Group comparisons were performed using a one-way analysis of variance and subsequent pairwise comparisons (t-test). RESULTS: Postoperatively, HO could be equally restored with all 3 stem designs (P = .079). The postoperative LLD was smaller in group C compared to group A (0.8 mm [standard deviation, 3.2] vs 2.6 mm [standard deviation, 4.5], P = .002). Best combined reconstruction of HO and LLD could be achieved with the short curved stem by junior and senior surgeons (HO: -2.0 and -2.1 mm; LLD: 1.9 and 0.7 mm, respectively). The proximal and mid-height canal fill indexes were higher in groups B and C compared to group A, indicating a better metaphyseal and diaphyseal fit in the proximal femur (both P < .001). CONCLUSION: All 3 cementless stem designs allowed for good hip geometry reconstruction. Multiple shape and offset options allowed for a better metaphyseal stem fit and offered minor clinical advantages for leg length reconstruction. Modular necks did not provide reconstructive advantages in patients with primary hip osteoarthritis.

Total Hip Arthroplasty for Periacetabular Metastatic Disease. An Original Technique of Reconstruction According to the Harrington Classification.

BACKGROUND: Periacetabular metastatic disease requires complex acetabular reconstruction. The complication rate for these frail patients is high. Various cement-rebar reinforced techniques allowing cemented total hip arthroplasty (THA) have been described. The optimal procedure has not yet been identified. METHODS: A continuous series of 131 THAs performed in 126 patients with periacetabular metastatic disease was prospectively included in this study. After bone metastasis curettage and cementation, an original technique of acetabular reconstruction was performed using a dual mobility cup cemented into an acetabular reinforcement device (ie, Kerboull cross-plate or Burch-Schneider antiprotrusio cage) according to the Harrington classification. Functional outcome for independent ambulation in the community, pain relief, and occurrence of dislocation or mechanical failure of the acetabular reconstruction were assessed. RESULTS: At a mean follow-up of 33 ± 17 months, the improvement in the preoperative to postoperative functional outcome and pain relief was significant (P < .001). The dislocation rate was 2%. Two of the 3 cases of dislocation occurred in acetabular reconstructions associated with a proximal femoral arthroplasty. No mechanical failure or aseptic loosening of the acetabular reconstruction was observed. CONCLUSION: This study emphasized that our original technique combining bone metastasis curettage and cementation, acetabular reinforcement device and cemented dual mobility cup was effective to restore a painless functional independence and ensure a durable acetabular reconstruction able to face to adjuvant radiation therapy and mechanical solicitations for long survivors. In addition, dual mobility cup limited the risk of dislocation in patients undergoing THA for periacetabular metastatic disease.

Surgical versus conservative management of Type III acromioclavicular dislocation: a systematic review.

Introduction: The management of Type III acromioclavicular (AC) dislocations is still controversial. We wished to compare the rate of recurrence and outcome scores of operative versus non-operative treatment of patients with Type III AC dislocations. Source of data: A systematic review of the literature was performed by applying the PRISMA guidelines according to the PRISMA checklist and algorithm. A search in Medline, PubMed, Cochrane and CINAHL was performed using combinations of the following keywords: 'dislocation', 'Rockwood', 'type three', 'treatment', 'acromioclavicular' and 'joint'. Areas of agreement: Fourteen studies were included, evaluating 646 shoulders. The rate of recurrence in the surgical group was 14%. No statistical significant differences were found between conservative and surgical approaches in terms of postoperative osteoarthritis and persistence of pain, although persistence of pain seemed to occur less frequently in patients undergoing a surgical treatment. Areas of controversy: Persistence of pain seemed to occur less frequently in patients undergoing surgery. Growing points: Persistence of pain seems to occur less frequently in patients treated surgically for a Type III AC dislocation. Areas timely for developing research: There is insufficient evidence to establish the effects of surgical versus conservative treatment on functional outcome of patients with AC dislocation. High-quality randomized controlled clinical trials are needed to establish whether there is a difference in functional outcome.

Reliability and Construct Validity of the 6-Minute Racerunner Test in Children and Youth with Cerebral Palsy, GMFCS Levels III and IV.

AIM: To determine the test-retest reliability and construct validity of a novel 6-Minute Racerunner Test (6MRT) in children and youth with cerebral palsy (CP) classified as Gross Motor Function Classification System (GMFCS) levels III and IV. The racerunner is a step-propelled tricycle. METHODS: The participants were 38 children and youth with CP (mean age 11 y 2 m, SD 3 y 7 m; GMFCS III, n = 19; IV, n = 19). Racerunner capability was determined as the distance covered during the 6MRT on three occasions. The intraclass correlation coefficient (ICC), standard error of measurement (SEM), and smallest detectable differences (SDD) were calculated to assess test-retest reliability. RESULTS: The ICC for tests 2 and 3 were 0.89 (SDD 37%; 147 m) for children in level III and 0.91 for children in level IV (SDD 52%; 118 m). When the average of two separate test occasions was used, the SDDs were reduced to 26% (104 m; level III) and 37% (118 m; level IV). For tests 1 to 3, the mean distance covered increased from 345 m (SD 148 m) to 413 m (SD 137 m) for children in level III, and from 193 m (SD 100 m) to 239 m (SD 148 m) for children in level IV. CONCLUSIONS: Results suggest high test-retest reliability. However, large SDDs indicate that a single 6MRT measurement is only useful for individual evaluation when large improvements are expected, or when taking the average of two tests. The 6MRT discriminated the distance covered between children and youth in levels III and IV, supporting construct validity.

A prospective 24 months follow-up of a three component press-fit prosthesis for hallux rigidus.

BACKGROUND: The aim of this study was to evaluate the results following total first metatarsophalangeal (FMTP) joint replacement arthroplasty using a modular three component press fit prosthesis at two year follow up. METHODS: All patient data was collected in a prospective way in four study centres. Both preoperative and postoperative evaluation consisted of an assessment using the AOFAS-HMI score, visual analogue scale for pain, evaluation of the range of motion and patient satisfaction scores. Postoperative X-rays were reviewed for loosening and radiolucency up to two years. RESULTS: Fifty-five feet were available for analysis at 24 months. Two implants were removed during the study. Six more feet had additional surgery due to stiffness or malalignment. Postoperative AOFAS-HMI scores improved significantly by 32.4 points at two year follow-up (p<0.001). The visual analogue scale for pain improved significantly from 6.8 (std 1,6) preoperatively to 1.6 (std 1,9) postoperatively (p<0.0001). Mean dorsiflexion improved from 12.6 (std 10,1) degrees preoperatively to 31.2 (std 16,8) degrees postoperatively. Eighty-seven percent of patients were moderately to well satisfied with the end result. Eighteen prostheses showed radiolucency at 24 months. CONCLUSION: Implantation of a Metis® modular three component press fit prosthesis for the metatarsophalangeal joint in hallux rigidus shows significant improvement in AOFAS-HMI scores and a decrease in pain. Concerns remain with regard to early reoperation rate (14.5%) and long term survival of the implant. Future studies will have to address these aspects.

Risk of insufficient internal rotation after bilateral reverse shoulder arthroplasty: clinical and patient-reported outcome in 57 patients.

BACKGROUND: Bilateral reverse shoulder arthroplasty (RSA) is controversial because of potential rotational deficits impairing daily living activities. We assessed achievement of insufficient internal rotation (IR) and associated factors in bilateral RSA patients. METHODS: Fifty-seven staged bilateral RSA patients with a minimum of 1 year of follow-up after the second intervention were identified from our local monocentric register. Shoulder range of motion (including IR using the Apley scratch test), strength, and Constant and Shoulder Pain and Disability Index scores were assessed preoperatively and 6, 12, and 24 months postoperatively. RESULTS: Before surgery, both shoulders were similar regarding imaging parameters, but first operated shoulders tended to have poorer function. One year after the first RSA, 21% of patients had insufficient IR (not reaching the lumbosacral junction) compared with 33% after the second intervention (P = .180). At 2 years, 5% of patients had insufficient IR on both sides. Patients with insufficient IR on the second side at baseline (relative risk [RR], 1.8 [1.0-3.2]) and patients with insufficient IR 1 year after the first RSA (RR, 3.0 [1.6-5.6]) were more likely to have insufficient IR 1 year after the second RSA. Constant and Shoulder Pain and Disability Index scores and abduction of the second side were significantly worse 1 year after the second RSA (P ≤ .047); at 2 years, there were no differences in functional outcome between shoulders. CONCLUSION: A minority of bilateral RSA patients did not achieve sufficient IR on at least 1 side. Staged surgery is justified, particularly when the outcome of the initial operation is satisfactory.

Wound complications after distal humerus fracture fixation: incidence, risk factors, and outcome.

BACKGROUND: This study set out to accurately determine the incidence of wound complications after distal humerus fracture fixation, to assess risk factors, and to determine their implications on outcome. METHODS: Eighty-nine distal humerus fractures (mean patient age, 58 years) were treated with internal fixation at an average of 4 days after injury. Mean follow-up time was 15 months (range, 6-72 months). Twenty-nine (33%) fractures were open. Medical records and radiographs were reviewed to determine wound complications. Logistic regression analysis was carried out to determine associated risk factors. RESULTS: Fourteen patients (15.7%) developed a major wound complication requiring on average 2.5 (range, 1-6) additional surgical procedures. Six patients required plastic surgical soft tissue coverage. All 14 fractures complicated by wound problems united. The final mean range of motion in the major wound complication group was 100° (range, 65°-130°), compared with 100° (range, 10°-140°) in those with no or minor wound problems. Grade III open fractures and the use of a plate to stabilize the olecranon osteotomy were identified as significant risk factors for development of major wound complications. CONCLUSIONS: The incidence of major wound complications after fixation of distal humerus fractures is substantial. The presence of a grade III open fracture and the use of an olecranon osteotomy stabilized with a plate are significant risk factors for major wound complications. Fracture healing rates and functional elbow range of motion do not appear to be affected by major wound complications when they are handled with proper soft tissue coverage techniques.

Elbow arthroscopy: early complications and associated risk factors.

BACKGROUND: Elbow arthroscopy is increasingly used to treat complex pathology. The purpose of this study was to investigate early complication rates after elbow arthroscopy and identify risk factors for adverse events. METHODS: Consecutive elbow arthroscopies performed during a 13-year period were reviewed, identifying early perioperative complications. Major complications included deep infection, permanent nerve injury, or complications requiring additional anesthesia. Minor complications included superficial wound complications and transient nerve palsies. Complications were compared with a surgical complexity scale based on the procedure performed, the number of arthroscopic portals, and tourniquet time. RESULTS: Of 417 procedures, there were 37 minor (8.9%) and 20 major (4.8%) complications. The rates of superficial and deep infections were 6.7% and 2.2%, respectively. Major complications included 9 deep infections, 6 cases of heterotopic ossification requiring further surgery, and 4 manipulations under anesthesia. There were 7 transient sensory nerve complications, and no motor deficits. No differences in complication rates were seen between low-, moderate-, and high-complexity (10.2%, 16.3% and 14.4%, respectively) cases. Intraoperative steroid injections were strongly associated with postoperative superficial (14.1% vs 2.0%) and deep infection (4.9% vs 0.4%) in elbows receiving vs those not receiving steroid (P < .0001). CONCLUSIONS: Complications of elbow arthroscopy are seen in approximately 14% of cases. Most complications are minor, not affecting clinical outcome. Major complications occur in 5% of cases, often requiring repeat surgery. Intraoperative postsurgical steroid injections are associated with increased risk of perioperative infections. Case complexity does not appear to affect the rate of complications with modern surgical techniques.