Traumatic rotator cuff injury: does delayed surgery worsen functional outcomes?

PURPOSE: The optimal timing of surgery after traumatic rotator cuff tears (RCT) is unclear, with its impact on functional outcomes under debate. This study aimed to review functional outcomes after RCT repair in patients who underwent early vs delayed surgery at our unit. METHODS: This was single-centre retrospective evaluation. Patients with an acute traumatic RCT that underwent repair between 2017 and 2019 and had local follow-up were included and placed into two groups: early surgery (within 6 months from injury) and delayed surgery (more than 6 months from injury). Patient demographics, RCT data and pre- and post-operative (after 12 months) Oxford Shoulder Score (OSS) were extracted from medical records. Data was analysed to compare OSS scores between groups, as well as the effect of cuff tear sizes on OSS scores. RESULTS: Forty-nine patients were included in the analysis (15 early, 34 delayed). There were no significant differences in age, sex or cuff tear sizes between groups. No difference was identified in the mean post-operative OSS between early vs delayed groups (40.9 ± 6.34 vs 40.5 ± 7.65, p = 0.86). The mean improvement in OSS after surgery was also similar between groups (22.5 ± 7.81 vs 20.97 ± 7.19, p = 0.498). Having a large or massive RCT did not worsen OSS compared to small or medium RCT (p = 0.44), even when stratified by early or delayed surgery. CONCLUSION: Delayed surgery for traumatic RCT greater than 6 months from injury did not negatively impact long-term functional outcomes at our unit. Patients should be reassured as applicable before surgery in the event of prolonged or unavoidable delays.

Patella Fracture Fixation Technique with Suture Anchors.

Introduction: Patella fracture can occur due to direct injury to the knee or indirect eccentric contraction of the quadriceps tendon. These injuries can present in different configurations which require acceptable reduction and good fixation. Patients are at risk of not only losing their knee extensor mechanism but also having a defective patellofemoral articulation. Hence, the main aim in treating such fractures is to restore the knee extensor mechanism. Surgical options for treating patella fracture include tension band wiring, wiring through cannulated screws, fixation with plate, and suture anchor (SA) fixation. Case Report: We demonstrate a new fixation technique for patella fracture with SAs in two of our patients. They presented with patella fracture following a fall and sustained closed injury with intact distal neurovascular status. The authors describe their technique using double-loaded SAs to obtain anatomical reduction and solid fixation. With three SAs, each inserted in a third portion of a distal fragment. Conclusion: There are several modalities and techniques available for fixation of patella fracture. However, authors recommend that their described novel technique can provide more strength and satisfactory outcome. Furthermore, this technique uses a smaller incision compared to conventional suture tunnel repair as in this technique only the fracture that needs to be exposed distally.

Effect of surgical approach on the early outcome of total hip replacement for femoral neck fractures.

We reviewed the short-term outcome of 171 patients treated with total hip replacement for femoral neck fractures using the lateral (94 patients) or posterior approach (77 patients). The Sernbo score and the Abbreviated Mental Test Score were used to assess patients' pre-injury functional and cognitive status respectively. Patients were uniformly treated with regard to the type of prosthesis, size of femoral head and rehabilitation. They were followed up to a mean of 25 months (range : 13-42 months). The dislocation rate in the lateral group was 2.1% versus 0% in the posterior group. There was no difference with regards to leg length discrepancy and the restoration of medial offset. Our results were attributed the standardised patients' selection and adequate soft tissue repair.

Dynesys dynamic stabilization: less good outcome than lumbar fusion at 4-year follow-up.

Dynamic semirigid stabilization of the lumbar spine was introduced in 1994 in an attempt to overcome the drawbacks of fusion. It is supposed to preserve motion at the treated levels, while avoiding hypermobility and thus spondylosis at the adjacent levels. Although the early reports showed promising results, the long term effects are still debated. We retrospectively compared outcomes of Dynesys dynamic stabilization with those of the traditional fusion technique. Thirty-two patients who had undergone Dynesys between 2004 and 2006 (group 1) were compared to 32 patients who had been treated with fusion between 2005 and 2006 (group 2). VAS for back and leg pain, and ODI improved significantly in both groups (p < 0.001). These scores were all better in the fusion group, and even significantly so as far as VAS for back pain was concerned (p = 0.014). Similarly, more patients were satisfied or very satisfied after fusion than after Dynesys: 87.5% versus 68.8% (p = 0.04). Interestingly, in the Dynesys group scatter plot graphs showed a positive correlation between older age and improvement in the two VAS scores and in ODI. Dynamic stabilization with Dynesys remains controversial. Older patients are relatively more satisfied about it, probably because of their low level of demands.

Pseudoaneurysm - A Late and Rare Occurrence Following Shoulder Arthroscopy.

Introduction: The incidence of vascular injuries from arthroscopic surgeries has been reported to be 0.005%. Pseudoaneurysms account for 11% of those injuries. Case Report: In this case report, we discuss a 76-year-old female who presented with a pulsatile swelling in the right shoulder after 10 years following arthroscopic rotator cuff repair. Imaging confirmed the diagnosis of a posterior circumflex artery pseudoaneurysm. The patient was successfully embolised using a transradial approach with thrombosis of the pseudoaneurysm. Conclusion: Vascular injuries following arthroscopic shoulder surgery are rare. However, a pseudoaneurysm should be considered in patients who present with swelling at the surgical site, regardless of the post-operative interval.

Efficacy of corticosteroid injection versus size of plantar interdigital neuroma.

BACKGROUND: The aim of this prospective study was to assess the effectiveness of a single ultrasound-guided steroid injection in the treatment of Morton's neuromas and whether the response to injection correlates with the size of the neuroma. METHODS: Forty-three patients with clinical features of Morton's neuroma underwent ultrasound scan assessment. Once the lesion was confirmed in the relevant web space, a single corticosteroid injection was given using 40 mg of methylprednisolone along with 1% lidocaine. All scans and injections were performed by a single musculoskeletal radiologist. Patients were divided into two groups on the basis of the size of the lesion measured on the scan. Group 1 included patients with neuromas of 5 mm or less and group 2 patients had neuromas larger than 5 mm. A visual analog scale (VAS) for pain (scale 0 to 10), the American Orthopaedic Foot and Ankle Society (AOFAS) score, and the Johnson satisfaction scale were used to assess patients before injection and then at 6 weeks, 6 months, and 12 months following the injection. Thirty-nine patients had confirmed neuromas. Group 1 (lesion ≤ 5 mm) included 17 patients (mean age, 30 years) (7 males, 10 females) and group 2 (lesion >5 mm) had 22 patients (mean age, 33 years) (8 males, 14 females). RESULTS: VAS scores, AOFAS scores, and Johnson scale improved significantly in both groups at 6 weeks (p < .0001). At 6 months postinjection, this improvement remained significant only in group 1 with all scores (p < . 001). At 12 months, there was no difference between both groups and outcome scores nearly approached preinjection scores. At the final review, two patients in group 1 and four patients in group 2 had severe recurrent symptoms and therefore underwent surgical excision of the neuroma after they rejected the offer for a repeat injection (p = 0.6). CONCLUSION: A single ultrasound-guided corticosteroid injection resulted in generally short-term pain relief for symptomatic Morton's neuromas. The effectiveness of the injection appears to be more significant and long-lasting for lesions smaller than 5 mm.

Palmar lunate dislocation with Tran scaphoid fracture dislocation and trapezium fracture-A case report of rare fracture presentation.

Peri lunate and lunate dislocations are rare injuries associated with high energy impacts on a hyperextended and outstretched wrist. One-fourth (of peri lunate dislocations are missed at the initial presentation. We report a case of volar lunate dislocation along with proximal pole scaphoid and trapezium fracture in a patient who presented with high energy trauma. After the initial reduction of the dislocated lunate, he underwent open reduction internal fixation and soft tissue repair using through volar and dorsal approach. This was followed by K-wire removal and aggressive physiotherapy activities. At the end of three months he regained full movements with no recurrence of dislocation. Overall Peri lunate/lunate dislocation are one of the most important differential diagnosis in high energy injuries which requires immediate attention to prevent the potential risk of avascular necrosis of lunate, scaphoid leading to secondary osteoarthritis. As the injury transitions occurs from a dorsal peri lunate to a palmer lunate pattern, the most likely mechanism involved is a sheer fracture of the proximal pole of the scaphoid by the dorsal lip of the distal radius.

Range of Movement and Patient-Reported Outcomes in Shoulder Arthroplasty in the Elderly: A Comparison of Anatomical Versus Reverse Shoulder Replacements.

Introduction Shoulder arthroplasty is in increasing demand in the elderly given the rising prevalence of glenohumeral osteoarthritis (OA) across the population. There is a dearth of evidence in the current literature comparing anatomical total shoulder arthroplasty and reverse total shoulder arthroplasty (RTSA) in the elderly population. This study compares patient-reported outcome measures and range of movement (ROM) between anatomical and reverse total shoulder replacements in matched patient cohorts over the age of 70 years. Materials and methods This retrospective cohort study compares range of movement and patient-reported outcomes between anatomical total shoulder arthroplasty and reverse total shoulder arthroplasty in matched cohorts over the age of 70 years at a single institution between 2011 and 2015. Overall, 75 patients were recruited, including 44 patients with anatomical total shoulder arthroplasty and 31 patients with reverse total shoulder arthroplasty. Cohorts were matched according to age, preoperative Oxford Shoulder Score (OSS), and preoperative range of movement. The minimum clinical follow-up was one year. Results At one year, range of movement metrics in flexion, abduction, and external rotation all demonstrated greater improvements in the anatomical total shoulder arthroplasty cohort in comparison to the reverse total shoulder arthroplasty cohort (p<0.0001). No statistical difference in Oxford Shoulder Score was evident between cohorts. Conclusion Anatomical total shoulder arthroplasty demonstrates a significant improvement in range of movement in comparison to reverse total shoulder arthroplasty in matched elderly patient cohorts. However, there was no statistical difference in functional assessment scores between reverse shoulder replacement and anatomical shoulder replacement.

Assessing the required glenoid peg penetration in native scapula when bone graft is used during primary and revision shoulder arthroplasty.

Aims: Achieving purchase in native glenoid bone is essential for the stability of the glenoid baseplate when bone graft is used to address bone loss in both primary and revision shoulder arthroplasty procedures. The aim of this study is to assess the required depth of the baseplate peg in native bone when bone graft is used to result in satisfactory integration. Patients and methods: The CT scans of patients who underwent either primary or revision arthroplasty procedures with bone graft using the SMR Axioma Trabecular Titanium (TT) Metal Backed glenoid system were assessed. We measured the depth of the glenoid peg in native glenoid bone. Measurements were taken by two authors separately. Results: The scans of 53 patients (mean age 68 years) with a minimum follow-up of two years were reviewed. Implants included 12 anatomical and 41 reverse geometry prostheses. There were 17 primaries and 36 revisions: hemiarthroplasties (20) total (14) and reverse (2) implants. Bone grafts were from humeral head (15), iliac crest (34) and allograft (4). The mean depths were 8.8 mm (first assessor) and 9.10 mm (second assessor). The glenoid peg violated the glenoid vault in 32 patients and this did not adversely affect the outcome. There were three failures of implants all of which were aseptic failures and had peg penetration of less than 6 mm. Conclusions: The mean depth of glenoid peg in native bone was 9 mm (variation between 0.2 and 0.52 mm at 95% confidence interval). Aseptic loosening was seen with peg penetration less than 6 mm in native bone. Glenoid vault violation was not associated with loosening.

Evaluating Accuracy of Plain Magnetic Resonance Imaging or Arthrogram versus Wrist Arthroscopy in the Diagnosis of Scapholunate Interosseous Ligament Injury.

Introduction Scapholunate interosseous ligament injury (SLIL) is the most common cause of wrist instability and a cause of morbidity in a proportion of patients with wrist injuries. Aim To evaluate the accuracy of plain magnetic resonance imaging (MRI) and MR arthrogram (MRA) in the diagnosis of SLIL injury against the existing gold standard-wrist arthroscopy. Materials and Methods We retrospectively reviewed 108 cases by comparing MRI/MRA reports and their wrist arthroscopy operation notes. Results Overall MRI sensitivity to SLIL injuries was 38.5% (91.0% specificity). When broken down into plain MRI and MRA the results were: plain MRI sensitivity = 19.2% (91.4% specificity) and MRA sensitivity = 57.7% (90.5% specificity). Conclusion Neither MRI nor MRA scanning is sensitive enough compared with the gold standard. Positive predictive value remains too low (62.5 and 88.2%, respectively) to consider bypassing diagnostic arthroscopy and treating surgically. The negative predictive value (60.4 and 63.6%, respectively) is inadequate to confirm exclusion of injury from MRI results alone.

Effect of Implant Size, Version and Rotator Cuff Tendon Preservation on the Outcome of Reverse Shoulder Arthroplasty.

INTRODUCTION: Functional outcomes following reverse geometry shoulder arthroplasty can vary. This study assessed the effects of glenosphere size, humeral stem version, posterior rotator cuff status and subscapularis repair on patient-reported outcome and range of motion.  Methods: A consecutive series of 132 patients from two orthopaedic centres that use the same onlay system for reverse shoulder arthroplasty were reviewed over a six-year period. Outcome measures consisted of the Oxford Shoulder score (OSS) and range of motion (ROM) at one year following surgery. These were assessed against glenosphere sizes (small (36-38 mm) and large (40-42 mm)), humeral stem retroversion (less or more than 20 degrees), rotator cuff status (posterior rotator cuff present or absent) and subscapularis tendon (repaired or not) at the end of procedure. RESULTS: Larger glenospheres and less humeral stem retroversion yielded better ROM and OSS but this was not statistically significant. Subscapularis repair had no effect on outcomes. Preservation of posterior rotator cuff tendons improved functional outcomes. The number of tendons present at the end of procedure had a positive effect on outcome (best with two tendons and better with one compared to a completely bald humeral head). CONCLUSION: Preservation of posterior rotator cuff tendons during reverse shoulder arthroplasty improves clinical outcomes unlike subscapularis repair which was found to be unnecessary. Implant size and version in reverse geometry arthroplasty have no significant effects on clinical outcome.

Migration of a broken trochanteric wire to the popliteal fossa.

Wires used in fracture fixation or elective procedures can migrate within the body, and some lethal complications have been reported in the literature. We report a case of knee discomfort caused by a broken cerclage wire that has migrated from the hip region to the popliteal fossa after trochanteric osteotomy used in revision hip surgery. The authors point to the potential risks of broken orthopedic hardware.

Fashioning Osteochondral Allograft for Humeral Head Defects in Reverse Hill-Sachs Lesions - A Proposed Surgical Technique.

Introduction: Posterior glenohumeral joint dislocations with associated bony lesions are challenging to treat; namely, reverse Hill-Sachs's lesions increase humeral head excursion predisposing to recurrent dislocations. To add to the complexity of management, posterior shoulder dislocations are often missed on plain radiographs, leading to chronicity in presentation. Case Report: We describe here our technique in our case series of three patients. Case I, 32 years, gentleman, presented 3 days after injury. He had a locked posterior dislocation of shoulder which he sustained while he fell asleep and hit a glass table. Shoulder was not reducible in emergency department. Reverse Hill- Sachs's lesion involved 40% of humeral head. Case II, a 54- years- old gentleman, a keen gym trainer . Following sudden withdrawal of diazepam, he woke up lying on the floor and started experiencing shoulder pain. He presented a week following the injury. The dislocated shoulder could not be reduced in emergency department. Bony defect involved 50% of humeral head. Case III, 45 years gentleman who fell off from bike, presented on the same day to the emergency department. The dislocated shoulder was reduced. Defect size was 40% of humeral head.A thorough physical and radiological examination was performed to evaluate the lesion. Delto-pectoral approach was utilized for surgical exposure. Once fully assessed, the lesion is outlined and an oscillating saw is used to create uniform edges - - a regular "orange slice"- shaped defect. The prepared defect size is measured. Calcium phosphate cement is used to fill the defect and form a mould that represents the dimensions of allograft required to recreate the native sphericity of the humeral head. This mould then acts as a reference when fashioning the osteochondral femoral allograft to make sure this fits the defect anatomically. Once the graft is prepared, it is placed into the defect in the correct orientation and fixed in situ using headless screws. We utilized the same technique in all our patients. Conclusion: Reconstruction with osteochondral allograft is a promising technique to help shoulder surgeons achieve good outcomes for these patients. We propose a novel technique for fashioning allograft to anatomically fill the defects from bone loss, aiming to restores the native sphericity of the humeral head.

Acromioclavicular Joint Pseudo-dislocations with Lateral end Clavicle Fracture: A Rare Injury and Proposed Technique of Fixation.

Introduction: Lateral end clavicle fractures are rare injuries in pediatric and adolescent population. Most of these injuries can be managed conservatively. However, in patients with acromioclavicular joint (ACJ) "pseudo-dislocations" associated with significant clinical deformity, some patients will benefit from operative intervention. Case Report: Our reported case is a young adolescent with a Type IV Dameron and Rockwood distal clavicle fracture and ACJ pseudo-dislocation, who underwent surgical fixation for this injury. We propose a novel technique of fixation with a suture anchor and endo button with temporary K wire stabilization. These are rare injuries and there are no standardized techniques for reconstruction and fixation. Stabilization with a suture anchor can provide a minimally invasive method of fixation for such injuries without the traditional plating and can lead to excellent final outcomes. Conclusion: ACJ pseudo-dislocations are rare injuries. There is limited evidence in guiding the management of such injuries. Our proposed technique of fixation with suture anchor, endo button and temporary stabilisation with K-wire can provide promising results.

Shoulder hydrodilatation for primary, post-traumatic and post-operative adhesive capsulitis.

BACKGROUND: Adhesive capsulitis (frozen shoulder) is characterised by pain and loss of range of motion of the glenohumeral joint. It can be present as primary (idiopathic) or secondary to surgery, trauma or other conditions that restrict the use of the shoulder joint. Various treatment options have been adopted including physiotherapy, manipulation under anaesthetic, hydrodilatation and arthroscopic or open capsular release but the optimal form of management remains uncertain. OBJECTIVES: The purpose of the study was to assess the clinical outcome of glenohumeral hydrodilatation in three cohorts of patients with different aetiologies with adhesive capsulitis. STUDY DESIGN & METHODS: We carried out a retrospective study of patient who underwent hydrodilatation for adhesive capsulitis between 2013 and 2015. The procedure was performed by a specialist musculoskeletal radiologist under radiological guidance. The injection consisted of steroids, local anaesthetics and NaCl solution with a target volume around 35 mL. Our outcome measures were range of motion, and pre- and post-operative pain. Patients were divided into three groups based on the presumed cause of their stiffness: idiopathic, post-traumatic and post-surgical. RESULTS: Two hundred fifty patients were included, with a mean age of 59 years (range: 20-79). Of these, 180 had idiopathic primary adhesive capsulitis (27 were diabetic), 23 were post-traumatic, and 20 following surgical procedures. Thirty-four required further intervention following initial hydrodilatation with 8 undergoing repeat hydrodilatation, and 26 requiring arthroscopic capsular release. The diabetic group accounted for 16 capsular releases and 4 repeat procedures, while the idiopathic group accounted for 9 and 4, respectively. One patient required capsular release in the surgical group. An improvement was recorded in ROM in all groups with mean abduction improving from 59° to 110°, flexion from 50° to 120° and external rotation from 20° to 50°. With regards to pain, the majority showed an improvement from severe or moderate pain to no or mild pain. CONCLUSIONS: Results show that hydrodilatation resulted in an improvement in all outcome measures, with only a small number of patients, especially those with diabetes, needing further procedures or showing no improvement in range of motion and pain. There was no difference between the post-traumatic and post-surgical groups.

Arthroscopic Superior Capsular Reconstruction for Management of Massive Irreparable Rotator Cuff Tears: A Simple Alternative Technique.

The use of acellular dermal allograft in arthroscopic superior capsular reconstruction is a promising treatment option for massive irreparable rotator cuff tears. However, indications are limited to a subset of patients, so it is not routinely performed. Therefore, the surgery is technically demanding, although it has evolved in recent years. The authors present a simple alternative technique that addresses common pitfalls. [Orthopedics. 2021;44(3):e458-e462.].

Clinical Outcome of Transtendon Repair of Partial Articular Supraspinatus Tendon Avulsion Tear.

Partial articular supraspinatus tendon avulsion (PASTA) tears are common. However, there is no consensus on the optimal surgical technique for the management of grade 3 tears (>50%). The authors report a retrospective consecutive case series of 64 patients with grade 3 PASTA lesions. The patients were treated by 2 surgeons from 2 centers with the same transtendon repair technique and implant system. The preoperative Oxford Shoulder Score (OSS) was compared with the postoperative OSS at final follow-up (mean, 28 months). Significant improvement in mean OSS occurred from 19.2 (SD, 7.5) preoperatively to 39.8 (SD, 7.8) postoperatively (P=.0001), and patient satisfaction rates were high (88%). The authors believe that transtendon repair of PASTA lesions of 50% or more is beneficial. High-quality randomized controlled trials are required to compare the benefit of repair vs debridement alone. [Orthopedics. 2020;43(6):e533-e537.].

Arthroscopic Superior Capsular Reconstruction of the Shoulder Using Dermal Allograft.

Irreparable massive cuff tears in young patients pose a difficult problem for shoulder surgeons. Arthroscopic superior capsular reconstruction has shown promise in recent years in the treatment of this challenging patient population. The majority of the literature is limited to surgical techniques. The authors present the 2-year clinical outcomes of 25 patients undergoing arthroscopic superior capsular reconstruction with dermal allograft from a single center. The Oxford Shoulder Score and range of motion were assessed preoperatively and then at 3 to 6 months, 1 year, and 2 years following surgery. Patient satisfaction was recorded at final follow-up. Magnetic resonance imaging was performed at 3 months postoperatively to assess graft integrity. All patients were available at 1-year follow-up, and 23 were available at 2 years. The mean Oxford Shoulder Score improved by a minimum of 10 points at all time points compared with preoperatively. The mean forward flexion and abduction improved by 20° and external rotation by 7°. Revision to reverse shoulder arthroplasty was seen in 3 patients (12%). Graft failure was seen in 4 patients (16%). Overall, 20 patients had successful outcomes at 1 year (80%) and 18 patients had successful outcomes at 2 years (72%). Superior capsular reconstruction offers a safe and effective short-term bridging option for young patients with irreparable supraspinatus tears in the absence of glenohumeral arthritis. However, long-term outcome studies are required to evaluate the true clinical effectiveness and failure rates. [Orthopedics. 2020;43(4):215-220.].

The Role of Clinical Examination in Predicting Relevant MRI Findings in Acute Knee Injuries: A Retrospective Study.

The objective of this study was to delineate the usefulness of clinical examination and magnetic resonance imaging (MRI) in acute knee injuries. We aim to establish whether the time period post acute knee injury is related to the diagnostic accuracy of clinical examination and to investigate the strength of specific clinical examination findings in predicting a clinically relevant MRI abnormality. Seventy patients were referred to fracture clinic with an acute knee injury who subsequently went on to be investigated with MRI over 12 months. These patients were retrospectively analyzed looking at the time period they were reviewed, the components that were assessed at physical examination, and the results of their eventual MRI scan looking for any correlation. A greater proportion of patients who were examined at 2 weeks had relevant positive findings on MRI scan, p = 0.03. Range of movement and lateral joint line tenderness were not associated with a positive MRI scan at any period after injury. The presence of a moderate to large effusion was not associated with an MRI abnormality if the examination was within 2 weeks of injury but was if present 2 weeks after injury, p = 0.0001. Range of movement should not form part of the decision making on whether an injury should be investigated with MRI. Joint effusion in isolation within 2 weeks after injury should not be an indication for MRI but a repeat clinical examination in 2 weeks, where if still present, should be investigated with MRI.