Corrective osteotomy of the distal femur with fixator assistance: A novel technique of minimally invasive osteosynthesis.

PURPOSE: Varus or valgus deformity of the distal femur may progress into knee osteoarthritis. To delay or prevent this, various types of corrective osteotomy techniques have been used to shift the mechanical axis from the diseased compartment to the healthy one. We introduced a new, minimally invasive osteotomy of the distal femur with the assistance of temporary external fixation. METHODS: We retrospectively studied 25 legs that underwent open-wedge osteotomy of the distal femur, involving insertion of a Schanz pin at the medial femoral condyle and another pin at the distal diaphysis of the femur. At the meta-diaphyseal junction, osteotomy was performed. After achieving angular correction, two pins were locked for temporary external fixation and a locking plate was fixed at the lateral side of the femur submuscularly. Radiological and functional outcomes were evaluated, including mechanical lateral distal femoral angle (m-LDFA), mechanical axis deviation, tibiofemoral angle, osseous union, and knee joint motion. RESULTS: The minimum follow-up was 12 months (mean, 39 months; range, 12-88 months). Bone healing occurred in all legs, with an average of 16.6 weeks. The m-LDFA was corrected from 77.7° (18 valgus) and 104.6° (7 varus) to 88.1° after surgery, with an average correction of 12.9°. At the final follow-up, the mechanical axis deviation averaged 7.6 mm and the tibia-femoral angle averaged 5.6°. Most of legs (88%) achieved acceptable m-LDFA (87° ± 3°). CONCLUSIONS: A new, minimally invasive osteotomy of the distal femur offers excellent bone healing with few complications, attributable to preserved blood supply.

Comparison of intramedullary nail, plate, and external fixation in the treatment of distal tibia nonunions.

PURPOSE: The purpose of this study was to examine time to union of extra-articular distal tibia nonunions based on fracture type and fixation methods: intramedullary nail (IMN), plate osteosynthesis (PO), and external fixation (EF). METHODS: This retrospective chart review included all patients who presented at a Level I trauma center with AO/OTA 43A & distal third 42A-C fracture nonunions between 2008 and 2014. Fixation methods were recorded and patient course was followed until nonunion had healed clinically. RESULTS: Thirty-three distal tibia nonunions were included, and 29 reached eventual union (88%). Five AO/OTA fracture types were present. Mean times to union from nonunion diagnosis between original fracture types were compared (p = 0.203). Comminuted fracture types had longer times to union from nonunion diagnosis compared to simple fracture types (78 vs. 46 weeks, p = 0.051) and more revision fixations (1.5 vs. 0.5, p = 0.037). Mean time to union from nonunion diagnosis was shorter when no revision fixation was done compared to revisions (15 vs. 42 weeks, p = 0.102). Times to union from nonunion diagnosis without revision fixation were: IMN (12 weeks), PO (27 weeks), and EF (13 weeks) (p = 0.202). Times to union from definitive revision fixation were: IMN (17 weeks), PO (21 weeks), and EF (66 weeks) (p = 0.009), with EF taking significantly longer than both other methods. 21 patients (64%) underwent revision fixation. Revision fail rates were: IMN (0/6, 0%), PO (2/8, 25%), and EF (15/21, 71%). Time to union was longer in revisions that changed fixation method compared to revisions that used the same method (51 vs. 18 weeks, p = 0.030). Deep infections were also associated with longer union times (81 vs. 47 weeks, p = 0.040). CONCLUSIONS: In this nonunion population, comminuted fracture types needed more time and revisions to reach union. Time to union was only clinically shorter when revision fixation was not performed, but IMN and PO were both successful fixation options with significantly shorter times to union than EF. Mean time to union increased even more when revision of fixation method was performed vs. exchange revision, as did nonunions with deep infections.

Surgical considerations with the operative fixation of unstable paediatric pelvic ring injuries.

INTRODUCTION: The operative treatment of unstable pelvic injuries in paediatrics is not frequently indicated. The detailed modes of pelvic ring failure, surgical techniques, fixation choices, and peri-operative difficulties are not well reported. METHODS: From September 2010 to March 2016, 62 paediatric patients were admitted to an academic level I trauma center with the diagnosis of pelvic ring injury. Of them, 29 (17 males and 12 females) had operative fixation of unstable pelvic injuries. Their average age was 11.7 ± 4.4 years. RESULTS: There were six Tile's B injuries and 23 type C injuries. The commonest modes of pelvic ring failure were pubic rami fractures anteriorly and ligamentous sacroiliac joint injuries posteriorly. The iliac apophysis was avulsed in nine patients. Supra-acetabular external fixators were frequently used for anterior fixation while iliosacral IS screws and lateral compression LC screws were commonly used posteriorly. Difficulties were encountered with open reduction and repair of avulsed iliac apophyses in two patients. The IS screws pierced the soft iliac wing in three patients. In two patients with open triradiate cartilage, the purchase of retrograde LC screws was weak due the small sized crescent fragment. CONCLUSION: The iliac apophysis needs to be repaired following reduction of the displaced hemipelvis. Anterior supra-acetabular external fixation is a good choice in paediatrics even with pubic symphysis diatasis as the pathology is commonly a pubic apophysis avulsion. IS screws might be inserted through plates to prevent piercing the soft iliac wing. Retrograde LC screws should be avoided in young children.

Management of Pediatric Forearm Torus Fractures: A Systematic Review and Meta-Analysis.

OBJECTIVES: Pediatric forearm torus fracture, a frequent reason for emergency department visits, can be immobilized by both rigid cast and nonrigid methods. However, controversy still exists regarding the optimal treatment of the disease. The aim of this study was to compare, in a systematic review, clinical efficacy of rigid cast with nonrigid methods for immobilization of the pediatric forearm torus fractures. METHODS: Literature search was performed of PubMed and Cochrane Library by 2 independent reviewers to identify randomized controlled trials comparing rigid cast with nonrigid methods for pediatric forearm torus fractures from inception to December 31, 2013, without limitation of publication language. Trial quality was assessed using the modified Jadad scale. RESULTS: Eight randomized controlled trials with a total of 781 participants met all inclusion criteria. The nonrigid methods for immobilization included soft cast, splint, bandage, and slab. Results showed that nonrigid immobilizations had better clinical efficacy than rigid cast regarding functional recovery, treatment cost, and complication rate (relative risk, 3.02; 95% confidence interval, 1.70-5.37; P = 0.0002). Compared with rigid cast, more patients would like to choose the nonrigid methods of immobilization for future use. However, discrepant results sill surrounds the pain levels of the patients. CONCLUSIONS: The current study suggests that the nonrigid immobilization methods have more advantages than rigid cast for immobilization of pediatric forearm torus fracture. The former strategies are also safe enough for clinical therapy.

[EXOTHERMIC REACTIONS OF PLASTER IMMOBILIZATION ­ ANALYSIS OF THREE KINDS OF PLASTER BANDAGES].

Exothermic reaction of plaster is a very important characteristic to understand, especially when it comes to complications which can occur during local temperature change during molding plaster of Paris. And these complications directly influence the speed and quality of treatment. In this paper we measured temperatures of plaster bandage tiles 10×10 cm, from three different manufacturers in Croatian hospitals: Safix plus (Hartmann, Germany), Cellona (Lohmann &Rauscher, Austria) and Gipsan ( Ivo Lola Ribar, Croatia). We made three different plaster tiles 10×10 cm, from 10, 15 and 30 layers of plaster bandages. We immersed plaster tiles in two different water temperatures, one group in water 22 °C, and another in 34 °C. Although all plaster bandages have similar chemical characteristics, we have measured some differences. All three kinds of plaster bandages used in Croatia have low exothermic reaction when plaster molding is done in standard conditions, average local temperature is low and there is no danger of local burns. We immersed a plaster tile with 15 layers in water on 34° C, and highest average temperature was measured at Gipsan (46.2 °C), then Cellona (41.3 °C) and Safix plus (38.9 °C). On the same water immersion temperature, on plaster tile with 30 layers average temperatures were Gipsan (48.4°C), Cellona (45.4 °C), and lowest in Safix plus (41.3 °C). Plaster tiles form all manufacturers, when used 15-30 layers thick, and water immersion temperature is 34°C, develop average temperature over 40°C, in duration from 8-12 minutes. Between three different plaster bandages analyzed, Gipsan (Ivo Lola Ribar, Croatia) developed highest temperature, and some plaster tiles were measured over 50 °C.

Novel Strategies for the Diagnosis of Posttraumatic Infections in Orthopaedic Trauma Patients.

Orthopaedic infections that occur after trauma are common. Clinical examination, laboratory markers, imaging modalities, and culture and molecular technologies are used to aid the diagnosis of infection. Culture methods comprise the backbone of diagnostic systems used in hospital laboratory settings; however, several studies have questioned the ability of these techniques to adequately identify infections, particularly in cases where orthopaedic implants were used or when the presence of biofilm bacteria is suspected. Advances in imaging and molecular diagnostics can provide orthopaedic surgeons with an improved means of diagnosing and treating infections.

Biomechanical evaluation of supplemental percutaneous lumbo-sacro-iliac screws for spinopelvic fixation following total sacrectomy.

STUDY DESIGN: This is a cadaveric biomechanical study evaluating the biomechanical properties of a novel spinopelvic fixation technique with percutaneous lumbo-sacro-iliac (LSI) screws in an unstable total sacrectomy model. OBJECTIVE: To compare standard posterior dual rod spinopelvic fixation alone with dual rod fixation supplemented with LSI screw fixation. SUMMARY OF BACKGROUND DATA: Primary or metastatic tumors of the sacrum requiring a total sacrectomy can result in spinopelvic instability if inadequate fixation is achieved. Many fixation techniques have been proposed to address this instability. However, to date, an optimal fixation technique has not been established. MATERIALS AND METHODS: Ten fresh-frozen cadaveric spinopelvic specimens were randomized according to bone mineral density (BMD) to either posterior rod fixation (control group) or posterior rod fixation with supplemental LSI screws (LSI group). After fixation, a total sacrectomy of each specimen was performed. Specimens where then potted and axially loaded in a caudal direction. Stiffness, yield load, energy absorbed at yield load, ultimate load, and energy absorbed at ultimate load were computed. A Student t test was used for statistical analysis with significance set at P<0.05. RESULTS: The average age and BMD were not significantly different between the control and LSI groups (age: P=0.255; BMD: P=0.810). After normalizing for BMD, there were no significant differences detected for any of the biomechanical parameters measured between the 2 fixation techniques: stiffness (P=0.857), yield load (P=0.219), energy at yield load (P=0.293), ultimate load (P=0.407), and energy at ultimate load (P=0.773). However, both fixation techniques were able to withstand physiological loads. CONCLUSIONS: Our study did not demonstrate any biomechanical advantage for supplemental LSI screw fixation in our axial loading model. However, given the theoretical advantage of this percutaneous technique, further studies are warranted that take into account forward bending and sagittal stability.

[Infections associated with orthopaedic devices]. / Infections liées aux prothèses articulaires.

Surgical site infections are a major complication of instrumented orthopaedic surgery, affecting 0.5 to 2% of patients following arthroplasty, and up to 30% of patients after fixation of open fractures. Acute infections may result from exogenous inoculation during or in the weeks following surgery (early infections), or from hematogenous seeding from a remote origin at any time after implantation (late infections). These infections are generally due to virulent organisms, such as Staphylococcus aureus, and must be treated rapidly. Delayed infections, arising between 3 and 24 months after surgery, are caused by low-virulence organisms such as coagulase-negative staphylococci. Diagnosis of delayed infections may be difficult because clinical presentation is often subtle and limited to chronic pain, and relies on imaging studies and culture of synovial fluid aspirates. Strong collaboration between surgeon, microbiologist and infectious disease specialist is essential for management of implant-associated infections, which almost always necessitates surgical intervention and prolonged antimicrobial therapy. The choice of the type of surgical intervention (debridement, or removal with or without exchange of the implant) depends on the duration of infection signs, on the pathogen species and antibiotic susceptibility, and on the patient general and local condition. Antibiotics are chosen according to pathogen susceptibility and to pharmacokinetic parameters such as bioavailability and penetration into the bone tissue. Patients treated in accordance with current guidelines are cured of their infection in 60 to 80% of cases.

Biomechanical studies on transverse olecranon and patellar fractures: a systematic review with the development of a new scoring method.

INTRODUCTION: Several methods of transverse patellar and olecranon fixation have been described. This article compares biomechanical studies of various fixation methods using a newly developed scoring method. SOURCE OF DATA: The databases PubMed, Web of Science, Science Direct, Google Scholar and Google were searched for relevant studies. AREAS OF AGREEMENT: Fixation hardware failure remains a problem. Various materials and fixation techniques have been tested to provide an improved fixation of transverse olecranon and patellar fractures. AREAS OF CONTROVERSY: The difference in biomechanical testing setup between the studies makes it hard to compare different fixation techniques. GROWING POINTS: The newly developed grading method was proved to be unbiased and reliable; however, extra specifications need to be added at some criteria when adopting the scoring method. AREAS TIMELY FOR DEVELOPING RESEARCH: Non-metallic constructs may provide an improvement to the currently used metallic tension band wiring technique; however, clinical research is required.

Ventilatory function in children with severe motor disorders using night-time postural equipment.

AIM: Night-time postural equipment (NTPE) can prevent hip subluxation in children with severe motor disorders (SMDs). However, it is unclear how it affects ventilatory function. The aims of the study were to determine how NTPE use affects ventilatory function and to compare night-to-night variability of ventilatory function in children with SMDs and typically developing healthy children. METHOD: Fifteen NTPE users (six males, nine females), aged 1 to 19 years (mean age 8y 7mo) alternated sleep condition between NTPE and sleeping unsupported for 14 nights. In all but two participants, gross motor function was classified as Gross Motor Function Classification System (GMFCS) level V; in the other two it was level IV. Oxyhaemoglobin saturation (SpO2 ) was monitored each night and transcutaneous CO2 (PtcCO2 ) for one night in each sleep condition. In 17 healthy children of similar age, home SpO2 only was monitored for seven nights. RESULTS: In 13 of 15 NTPE users and 12 of the 17 typically developing children, SpO2 monitoring was satisfactorily completed. Of the children with SMDs, two had mean SpO2 levels below the treatment threshold for supplemental oxygen, which was uniquely associated with use of NTPE in only one participant, and three had nocturnal hypoventilation, which was uniquely associated with NTPE use in only one case. Night-to-night SpO2 variability was higher in children with SMDs than in typically developing children. INTERPRETATION: NTPE may impair or enhance ventilatory function in a minority of children. Owing to night-to-night variability in SpO2 , at least three nights of monitoring are recommended to determine optimal positioning for effective ventilation before and after NTPE introduction.

Modern spinal instrumentation. Part 2: multimodality imaging approach for assessment of complications.

Radiologists frequently encounter studies demonstrating spinal instrumentation, either as part of the patient's postoperative evaluation, or as incidental to a study performed for another purpose. It is important for the reporting radiologist to identify potential complications of commonly used spinal implants. Part 1 of this review examined both the surgical approaches used and the normal appearances of these spinal implants and bone grafting techniques. This second part of the review will focus on the multimodal imaging strategy adopted in the assessment of the instrumented spine and the demonstration of imaging findings of common postoperative complications.

Cervical spine injuries and collar complications in severely injured paediatric trauma patients.

STUDY DESIGN: A retrospective registry review. OBJECTIVES: To determine the incidence of cervical spine (CS) injuries and collar complications in severely injured paediatric trauma patients. SETTING: Regional Trauma Centre, Children's Hospital. METHODS: A retrospective review of 365 paediatric severe trauma patients (0-17 years), defined as an Injury Severity Score (ISS)≥12, admitted to the paediatric intensive care unit (PICU). RESULTS: Clinically significant CS injuries occurred in 5% (n=18/365) of trauma patients, in 9% (n=13/149) of traumatic brain injury (TBI) patients and in 11% (n=6/56) of in-hospital trauma deaths. CS injuries were suspected before imaging in 33% (n=6/18) of patients based on either motor/sensory impairment or shock. CS injuries were deemed unstable in 61% (n=11/18) of patients. Patients with CS injuries had higher ISS, and longer PICU and hospital stays (P<0.05). CS collar complications occurred in 10% of patients, mainly identified by day 6 and consisting of either erythema or ulcers. Patients with CS collar complications were older and more likely to have TBI, lower Glasgow Coma Scale (GCS) scores, longer PICU and hospital stays, and increased days to CS clearance (P<0.05). Three CS X-rays, together with flexion/extension views, were used most frequently for CS clearance. CONCLUSION: CS injuries were prevalent in severely injured paediatric trauma patients, particularly in those with TBI and in nonsurvivors. CS collar complications were associated with a lower GCS and longer CS clearance times. Attention to CS collar management protocols and earlier CS clearance with computed tomography/magnetic resonance imaging in obtunded patients might reduce CS collar complications.

Increased complication rate following conversion total hip arthroplasty after cephalomedullary fixation for intertrochanteric hip fractures: a multi-center study.

Cephalomedullary devices (CMN) have become an increasingly popular for treatment of intertrochanteric hip fractures compared to sliding hip screw and side plate (SHS) devices. Failed fixation is often treated with conversion total hip arthroplasty (THA). We performed a multi-institutional study in which 60 patients with SHS devices and 31 patients with CMN devices were converted to THA. Harris Hip Score improved from 41.6 preoperatively to 83.6 at final follow-up in the SHS group and from 41.6 to 78.6 in the CMN group, with no significant difference between the groups (P=0.23). However, the complication rate in converted CMN patients was significantly higher at 41.9% compared with 11.7% (P=0.001) in converted SHS patients. Prior fixation with CMN may be associated with significantly higher complication rates during conversion.

Myxoid tumor associated to migration of a suspensory fixation device of a reconstructed anterior cruciate ligament: a case report.

A 16-year-old male who had undergone 6 months before an anterior cruciate ligament (ACL) reconstruction with an autologous hamstring graft fixed with a suspensory fixation device (XoButton device; ConMed Linvatec, Largo, FL), complained of a slightly painful mass in the distal posterolateral aspect of the thigh. The knee was otherwise stable. A 79 × 60 × 17 mm multilobulated tumor surrounding the implant device was observed in magnetic resonance images. The revision arthroscopy showed an intact ACL graft. The tumor was excised through a longitudinal posterolateral approach. It had a myxoid appearance. The undamaged implant was also removed. Two months after surgery, the patient was already asymptomatic. Although most fixation device problems occur in the perioperative period due to an inadequate technique which may lead to graft instability, this case reminds clinicians of the possibility of later developing clinically relevant complications with suspensory fixation devices.

Postoperative second metatarsal fractures associated with suture-button implant in hallux valgus surgery.

BACKGROUND: The purpose of this study was to perform a retrospective review of a nonosteotomy technique for the reduction of the intermetatarsal (IM) angle in hallux valgus (HV) surgery using a modified nonabsorbable suture-button implant previously described for ankle syndesmotic injuries and to report on the outcomes and complications associated with this technique. METHODS: A retrospective review was performed of consecutive patients with a minimum follow-up of 1 year. Twenty-five patients, a total of 25 feet, were identified with a mean follow-up of 22.5 months. The mean age was 60 years. The pre- and postoperative HV and IM angles were compared. Each postoperative radiograph was assessed for loss of correction, implant failure, and second metatarsal (MT) stress fracture. The postoperative hallux American Orthopaedic Foot & Ankle Society (AOFAS) scores were obtained at the patient's final follow-up visit. Statistics were performed using the paired Student t test with the P value set at .05 to determine statistical differences. RESULTS: The preoperative mean IM and HV angles were 15.1 and 30.5 degrees, respectively. The postoperative mean IM and HV angles were 8.2 and 10.2 degrees, respectively. The reductions in the IM and HV angles were statistically significant (P < .05). The average postoperative AOFAS hallux score was 85. Two patients developed hallux varus (8%). Eight patients (32%) developed second metatarsal stress fractures. One patient (4%) with a second metatarsal stress fracture had a failure of the implant that required implant removal. The remaining stress fractures healed uneventfully. CONCLUSION: Suture-button fixation in hallux valgus achieved a satisfactory reduction in the first-second intermetatarsal angle compared with first metatarsal osteotomies but was associated with a high rate of second metatarsal stress fractures. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Smart toe® implant versus buried Kirschner wire for proximal interphalangeal joint arthrodesis: a comparative study.

The surgical correction of hammer digits offers a variety of surgical treatments ranging from arthroplasty to arthrodesis, with many options for fixation. In the present study, we compared 2 buried implants for arthrodesis of lesser digit deformities: a Smart Toe® implant and a buried Kirschner wire. Both implants were placed in a prepared interphalangeal joint, did not violate other digital or metatarsal joints, and were not exposed percutaneously. A retrospective comparative study was performed of 117 digits with either a Smart Toe® implant or a buried Kirschner wire, performed from January 1, 2007 to December 31, 2010. Of the 117 digits, 31 were excluded because of a lack of 90-day radiographic follow-up. The average follow-up was 94 to 1130 days. The average patient age was 61.47 (range 43 to 84) years. Of the 86 included digits, 48 were left digits and 38 were right. Of the digits corrected, 54 were second digits, 24 were third digits and 8 were fourth digits. Fifty-eight Smart Toe® implants were found (15 with 19-mm straight; 2 with 19-mm angulated; 34 with 16-mm straight; and 7 with 16-mm angulated). Twenty-eight buried Kirschner wires were evaluated. No statistically significant difference was found between the Smart Toe® implants and the buried Kirschner wires, including the rate of malunion, nonunion, fracture of internal fixation, and the need for revision surgery. Of the 86 implants, 87.9% of the Smart Toe® implants and 85.7% of the buried Kirschner wires were in good position (0° to 10° of transverse angulation on radiographs). Osseous union was achieved in 68.9% of Smart Toe® implants and 82.1% of buried Kirschner wires. Fracture of internal fixation occurred in 12 of the Smart Toe® implants (20.7%) and 2 of the buried Kirschner wires (7.1%). Most of the fractured internal fixation and malunions or nonunions were asymptomatic, leading to revision surgery in only 8.6% of the Smart Toe® implants and 10.7% of the buried Kirschner wires. Both the Smart Toe® implant and the buried Kirschner wire offer a viable choice for internal fixation of an arthrodesis of the digit compared with other studies using other techniques.

Does the Arthrex TightRope® provide maintenance of the distal tibiofibular syndesmosis? A 2-year follow-up of 64 TightRopes® in 37 patients.

Syndesmotic diastasis can occur as an isolated injury or with concomitant fractures. A review of 37 patients with 64 TightRopes® for syndesmotic repair was performed, with a mean follow-up of 23.6 ± 4.3 months, from 2007 to 2011. The patients' mean age was 40.67 (range 14 to 87) years. The mean initial measurements were as follows: tibiofibular clear space (TFCS) = 4.1 ± 1.1 mm, tibiofibular overlap (TFO) = 7.2 ± 2.7 mm, and medial clear space (MCS) = 2.9 ± 0.5 mm. The mean final measurements were as follows: TFCS = 4.2 ± 1.3 mm, TFO = 7.4 2.8 mm, and MCS = 3.0 0.5 mm. The calculated measurable difference from the initial to final TFCS, TFO, and MCS was significantly less than the maximum threshold for allowable widening of the syndesmosis: TFCS, p < .001; TFO, p < .002; and MCS, p < .001. Complications occurred in 10 patients; 7 (19%) experienced knot irritation and 3 (8%) developed an infection. The mean interval to weightbearing was 33.2 ± 12.7 days. The mean postoperative American Orthopaedic Foot and Ankle Society score was 97 (range 90 to 100). Of 64 suture endobuttons, 4 (6.25%) required removal. The fracture types were as follows: 3 (8%) isolated syndesmotic injuries, 9 (24%) trimalleolar fractures, 10 (27%) bimalleolar fractures, 7 (18%) Weber B fractures, 3 (8%) Weber C fractures, 1 (3%) Salter Harris type 3 fracture, and 4 (11%) Maisonneuve fractures. TightRope® fixation was advantageous because it rarely required removal, allowed for physiologic motion of the syndesmosis, and resulted in an early return to weightbearing. In addition, we have concluded that the TightRope® provides long-term stability of the ankle mortise, which was confirmed by the radiographic criteria and excellent American Orthopaedic Foot and Ankle Society scores.

Glenoid or not glenoid component in primary osteoarthritis.

The optimal choice for the treatment of end-stage primary glenohumeral osteoarthritis remains controversial, with alternatives including total shoulder replacement (TSR) and humeral head replacement (HHR). The objective of this review is to analyze the effect of TSR compared with HHR on rates of pain relief, range of motion, patient satisfaction and revision surgery in patients with primary glenohumeral osteoarthritis. Compared with HHR, TSR provided significantly greater pain relief, gain in forward elevation, and gain in external rotation and patient satisfaction. Furthermore, TSR required significantly less revision surgery glenoid component loosening than patients undergoing HHR (progression of osteoarthritis changes with subchondral sclerosis, joint space narrowing and glenoid subsidence). A convex-back pegged glenoid component with a modern instrumented cement pressurization technique achieves risk of loosening. For 10 years, a high interest regarding new designs of un-cemented metal back glenoid components has developed with promising results, because they allow glenoid bone graft in case of glenoid erosion or dysplasia and a one-stage glenoid bone reconstruction in case of revision surgery.

How to deal with glenoid type B2 or C? How to prevent mistakes in implantation of glenoid component?

BACKGROUND: Although TSA has been shown to significantly yield better outcomes than hemiarthroplasty, glenoid prosthesis loosening remains the most common complication. Inadequate primary fixation enables the glenoid component to move. In primary glenohumeral osteoarthritis (GHOA), glenoid involvement and proper morphology vary considerably. Postero-inferior glenoid hypoplasia could be associated with some degree of osteoarthritis. According to Walch, 24 % of glenoids in GHOA are type B2 or C (excessive posterior retroversion), which increases the challenge for the glenoid component fixation. MATERIALS AND METHODS: A total of 30 cases of TSR with glenoid type B2 (20 cases) and type C (10 cases) were reviewed. Mean follow-up was 11.2 months. A metal-backed (MB) glenoid component was implanted, with a posterior bone graft reconstruction. Pre- and post-operative clinical evaluation was done using the Constant-Murley score and the SST from Matsen. RESULTS: There is no glenoid loosening, no joint narrowing and no radiolucent line. There was no bone graft osteolysis. With 4 patients revised (4 conversions from TSR to RSR for 3 instabilities and 1 secondary rotator cuff tear), on the overall 30 patients cohort, Constant score pain increased from 1.6 to 13.4, forward flexion from 92° to 146° and Constant score from 27 (36 %) to 70 (95 %). The statistical difference between pre- and post-operative values is greatly significant. CONCLUSION: Although MB prostheses have been noted to have a higher rate of loosening than full-cemented PE, this is not our experience, even in case of glenoid type B2 or C, where the technical challenge is demanding and most of the time a posterior bone graft is necessary.