Long-term results of arthroscopic Bankart repairs for anterior instability of the shoulder in patients aged thirty years or older.

INTRODUCTION: Bankart repair is a popular treatment for anterior shoulder instability. However, long-term failure rates of arthroscopic Bankart repair remain higher than Latarjet procedures. The purpose of this study was to report long-term results of arthroscopic Bankart repair in patients greater than 30 years old and analyze risk factors of failure following arthroscopic Bankart repair that are independent of younger age. MATERIALS AND METHODS: Between January 1999 and December 2003, 41 patients aged 30 years or older treated with arthroscopic Bankart repair for anterior shoulder instability were evaluated. Outcome measures included pain (VAS), range of motion, post-operative Walch-Duplay, WOSII scores, complications, failure rate, and risk factors of failure. Failure was defined as recurrent dislocation or subluxation. RESULTS: At a mean 12-year follow-up (range; 10-15 years), the failure rate of arthroscopic Bankart repair in patients aged 30 years and older was 37%. The mean post-operative Walch-Duplay score was significantly higher in patients who had no recurrence compared to those who had had recurrence of instability (100 versus 90, p=0.02). An ISIS score≥3 (p=0.02), a glenoid bone lesion (p=0.06), and a Hill-Sachs lesion>15% defect (p=0.001) were risk factors for recurrent instability. When considering a modified ISIS score that accounted for bony defects on the glenoid and humeral side, patients with an ISIS score <3 + no glenoid lesion + Hill-Sachs ≤ 15% had a recurrence rate of 0%. CONCLUSION: The failure rate of arthroscopic Bankart repairs in patients over 30 was higher than previously reported. Specifically, patients with an ISIS >3 and bony glenoid defects and/or Hill-Sachs lesions > 15% may be at higher risk for recurrent instability following an isolated arthroscopic Bankart repair. Alternative stabilization techniques may need to be considered for this subset of patients.

Arthroscopic treatment in split depression-type tibial pilon fracture.

Treatment of tibial pilon fractures is complicated and often very invasive. Partial fractures with a depressed component raise the question of the choice of surgical technique. Minimally invasive surgical reduction under arthroscopic guidance appears to be a promising alternative in this type of fracture. We describe a technique for arthroscopically assisted treatment of a split depression tibial pilon fracture.

Screw Removal Can Resolve Unexplained Anterior Pain Without Recurrence of Shoulder Instability After Open Latarjet Procedures.

BACKGROUND: Anterior shoulder instability can be successfully treated using Latarjet procedures, although a small proportion of patients report unexplained pain. PURPOSE/HYPOTHESIS: The purpose was to report the prevalence and characteristics of patients with unexplained pain without recurrent instability after open Latarjet procedures and to determine whether screw removal can alleviate pain. The hypothesis was that unexplained pain without recurrent instability might be due to soft tissue impingements against the screw heads and that the removal of screws would alleviate or reduce pain. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We retrospectively reviewed the clinical and radiographic records of 461 consecutive shoulders treated by open Latarjet procedures for anterior instability between 2002 and 2014. Unexplained anterior pain was present in 21 shoulders (4.6%) and treated by screw removal at 29 ± 37 months (mean ± SD). Postoperative assessment at >12 months after screw removal included complications, visual analog scale for pain (pVAS), subjective shoulder value, Rowe score, Walch-Duplay score, and ranges of motion. The study cohort comprised the shoulders of 20 patients (9 women, 11 men) aged 25 ± 6 years (median, 25 years; range, 16-34 years) at screw removal and involved the dominant arm in 13 (62%) shoulders. RESULTS: Screw removal alleviated pain completely in 14 shoulders (67%; pVAS improvement, 6.4 ± 1.8; median, 6; range, 3-8) and reduced pain in the remaining 7 (33%; pVAS improvement, 2.4 ± 1.4; median, 2; range, 1-5). At 38 ± 23 months after screw removal, 2 recurrences of instability unrelated to screw removal occurred. The subjective shoulder value was 79% ± 22% (median, 90%; range, 0%-95%); Rowe score, 85 ± 20 (median, 95; range, 30-100); and Walch-Duplay score, 82 ± 19 (median, 85; range, 25-100). Mobility improved in active forward elevation (171°± 14°), external rotation with the elbow at the side (61°± 12°), and external rotation with the arm at 90° of abduction (67°± 13°) and especially in internal rotation, with only 2 shoulders (10%) limited to T12 spine segment. CONCLUSION: The present findings confirm that unexplained anterior pain after Latarjet procedures can be related to the screws used to fix bone blocks, which can safely be alleviated or reduced by screw removal.

Biomechanical Comparison of Anatomic and Extra-Anatomic Reconstruction Techniques Using Local Grafts for Chronic Instability of the Acromioclavicular Joint.

BACKGROUND: Anatomic reconstruction techniques are increasingly used to address cases of acromioclavicular (AC) joint chronic instability. These usually involve an additional surgical site for autograft harvesting or an allograft. PURPOSE: To describe a triple-bundle (TB) anatomic reconstruction using on-site autografts, the semiconjoint tendon (SCT) and the coracoacromial ligament (CAL), and compare its primary stability to the native AC joint ligamentous complex and to a modified Weaver-Dunn (WD) reconstruction. STUDY DESIGN: Controlled laboratory study. METHODS: Intact AC joints of 12 paired cadaveric shoulders were tested for anterior, posterior, and superior translations under cyclic loading with a servo-hydraulic testing system. One shoulder from each pair was randomly assigned to the TB group, where 2 SCT strips were used to reconstruct the coracoclavicular ligaments while the distal end of the CAL was transferred to the distal extremity of the clavicle to reconstruct the AC ligaments; the other shoulder received a modified WD reconstruction. After reconstruction, the same translational testing was performed, with an additional load-to-failure test in the superior direction. RESULTS: In both the TB and the WD groups, no significant differences were found before and after reconstruction in terms of joint displacements after cyclic loading, in all 3 directions. Compared with the WD reconstruction, the TB repair resulted in significantly lower displacements in both the anterior (ie, 2.59 ± 1.08 mm, P = .011) and posterior (ie, 10.17 ± 6.24 mm, P = .014) directions, but not in the superior direction. No significant differences were observed between the 2 reconstructions during the load-to-failure testing, except for the displacement to failure, which was significantly smaller (ie, 5.34 ± 2.97 mm) in the WD group ( P = .037). CONCLUSION: Anterior, posterior, and superior displacements after an anatomic reconstruction of the AC joint complex using the SCT and CAL as graft material were similar to those of native AC joints and significantly smaller in the axial plane than those of AC joints after a WD repair. CLINICAL RELEVANCE: An anatomic reconstruction is achievable using the CAL and the SCT as on-site graft materials, providing satisfactory initial stability and thereby allowing earlier mobilization.

Arthroscopic Screw Removal After Arthroscopic Latarjet Procedure.

Arthroscopic Latarjet procedure is an efficient and reliable approach for the treatment of shoulder instability. Nevertheless, the screws fixing the bone block may sometimes be responsible for pain and uncomfortable snapping in the shoulder that is triggered during active external rotation. We propose an all-arthroscopic technique for screw removal in cases of complications involving the screws from a Latarjet procedure. The all-arthroscopic screw removal is reliable and efficient. This procedure is indicated in more cases than thought because of the bone block resorption. It permits a revision of the glenohumeral joint in case of persisting pain.

Acute felon and paronychia: Antibiotics not necessary after surgical treatment. Prospective study of 46 patients.

Paronychia and felon are the most common infections of the hand. Surgical treatment is required once an abscess develops, but systematic use of postoperative antibiotic therapy remains open for discussion. Antibiotics both favor the selection of resistant bacteria and increase the cost of treatment. To our knowledge, no study has demonstrated their benefit following excision, yet many practitioners prescribe them systematically and empirically. In our current practices, we do not use antibiotic coverage following excision of uncomplicated paronychia or felon (no signs of arthritis, osteitis, flexor tenosynovitis, lymphangitis), except in potentially at-risk patients (immunosuppressed, diabetic, cardiac valve prosthesis recipient). Since this approach seems to lead to good outcomes, our objective was to evaluate them clinically in this study. Our prospective study included 46 patients who were not considered at risk. There were 26 cases of paronychia, 3 cases of felon and 17 patients presenting both paronychia and felon. All cases were abscessed and uncomplicated. All patients underwent surgical excision, and none received postoperative antibiotics. Follow-up took place on the day after surgery, at days 7, 14, 21 and 45. The main criterion for evaluation was healing of the infection and the wound. We recorded 45 cases of healing with no complications and a single case of recurrence. Surgical excision of paronychia or felon without antibiotic coverage gives excellent results with only rare recurrence. The single failure can be attributed to inadequate excision. Antibiotic therapy has no role in managing uncomplicated felon or paronychia in patients who are otherwise not at risk. Successful treatment depends above all on the completeness of the surgical excision.

Terrorist attacks in Paris: Surgical trauma experience in a referral center.

BACKGROUND: On November 13th, 2015, terrorist bomb explosions and gunshots occurred in Paris, France, with 129 people immediately killed, and more than 300 being injured. This article describes the staff organization, surgical management, and patterns of injuries in casualties who were referred to the Teaching European Hospital Georges Pompidou. METHODS: This study is a retrospective analysis of the pre-hospital response and the in-hospital response in our referral trauma center. Data for patient flow, resource use, patterns of injuries and outcomes were obtained by the review of electronic hospital records. RESULTS: Forty-one patients were referred to our center, and 22 requiring surgery were hospitalized for>24h. From November 14th at 0:41 A.M. to November 15th at 1:10 A.M., 23 surgical interventions were performed on 22 casualties. Gunshot injuries and/or shrapnel wounds were found in 45%, fractures in 45%, head trauma in 4.5%, and abdominal injuries in 14%. Soft-tissue and musculoskeletal injuries predominated in 77% of cases, peripheral nerve injury was identified in 30%. The mortality rate was 0% at last follow up. CONCLUSION: Rapid staff and logistical response, immediate access to operating rooms, and multidisciplinary surgical care delivery led to excellent short-term outcomes, with no in-hospital death and only one patient being still hospitalized 45days after the initial event.