Is combined MPFL reconstruction and tubercule tibial osteotomy superior to isolated reconstruction? A systematic review and meta-analysis.

Purpose: There is no consensus for management of patellar instability, even in the case of malalignment. The purpose of the review is to evaluate outcomes in the literature of MPFL reconstruction with and without tibial tubercle osteotomy. Methods: Two databases PubMed and Scopus were searched for studies comparing MPFL reconstruction with and without concomitant tibial tuberosity osteotomy. PRISMA guidelines were followed. Data on functional outcomes via Kujala score, redislocation rates and return to sport rates were reported. Results: 9 studies included data from 806 knees: 463 submitted to isolated MPFL reconstruction, and 343 submitted to the combined surgery. Patients submitted to the combined procedure had all TT-TG values superior to 18, while the ones with isolated reconstruction had more heterogeneous values, varying between 13 and 20 mm. 77.78% of the studies reported on postoperative Kujala scores, with a mean value of 83.53 in patients who underwent MPFL reconstruction alone and 83.72 in those who underwent the combined procedure. The mean difference between the two groups was -0.83, with the improvement of the score statistically significant in 22.22% of the studies, regardless of the surgery. Concerning redislocation rate, odds ratio comparing both procedures was 0.84 (p = 0.67). Conclusion: The principal finding is that the MPFL reconstruction with or without TTO resulted in similar functional outcomes, assessed by the Kujala score, and low complications concerning recurrent patellar dislocation. More robust literature is needed in the setting of a high TT-TG distance. Level of evidence: IV.

The Surgical Vascular Anatomy of the Lower Lumbar Arteries and Its Implications in Minimally Invasive Spine Surgery: A Cadaveric Study.

BACKGROUND: Minimally invasive lateral lumbar interbody fusion is a technique that has become increasingly popular for the treatment of degenerative lumbar spine disease; however, the pertinent surgical vascular anatomy has not been examined in detail. The goal of this study is to examine the anatomy of the lower lumbar and median sacral arteries, which are important determinants of these surgical outcomes. METHODS: This is an observational, experimental study based on cadaveric models, including 20 embalmed adult human cadavers. The following measurements were made: length of the lumbar and median sacral arteries, vertical distance between the third and fourth lumbar arteries and the superior end plate of the corresponding vertebrae, anterior vertebral body height, and intervertebral disc height. RESULTS: Our sample showcased considerable variability regarding vascular anatomy around the lower lumbar spine. In 10% of specimens, the abdominal aorta bifurcated at the level of the L3-L4 intervertebral disc, and 20% showed variations in vena cava origin. Regarding the lumbar arteries, in 10% of the sample, the fourth lumbar artery was absent on the right side, and 10% presented a fifth lumbar artery. The median sacral artery was present in all cadavers; however, in 15% of specimens, it originated from a common trunk that also gave rise to the fourth pair of lumbar arteries. Anterior vertebral body height was smaller in L3 comparing with L5 (P = 0.003), and there was a significant cephalocaudal increase in the anterior intervertebral disc height in the analyzed levels (P < 0.001). Bilaterally, the distance between the fourth lumbar arteries and the superior end plate of the L4 vertebral body was shorter than this distance at the L3 vertebral body (P < 0.001 and P = 0.002 on the right and left, respectively). CONCLUSIONS AND CLINICAL RELEVANCE: These data may be useful in spine surgery planning and operative management. These anatomic variations should be identified beforehand to prevent difficulties during surgery and possible complications.

Proximal humerus fractures: epidemiology and trends in surgical management of hospital-admitted patients in Portugal.

Background: Proximal humerus fractures (PHFs) are frequent and associated with significant health care burden. National epidemiological data are limited. Our objective is to characterize the Portuguese population admitted with PHFs and analyze therapeutic management, the impact of associated lesions, and mortality rate. Methods: This was a retrospective, observational study of admissions from mainland public hospitals (2000-2015), with primary or secondary diagnosis of PHFs. Incomplete records, pathologic lesions, malunion/nonunion, and hardware removal were excluded. Age, gender, admission date, hospitalization period, associated injuries, treatment, and mortality were recorded. Results: A total of 19,290 patients were included. Through the analyzed period, an increase in the absolute number and incidence of PHFs was observed. The mean age at diagnosis was 62.6 ± 21.0 years old (57% elderly; 63.5% female). The mean length of stay was 10.0 ± 14.1 days, higher in patients submitted to arthroplasty (P < .001) and in those with associated fractures (25%; P < .001). A total of 14,482 patients were operated, most frequently with open reduction and internal fixation (28%). The inpatient mortality rate was 3.2%, significantly higher in patients with associated fractures (odds 2.77 for lower limb vs. upper limb). Conclusion: There is a trend toward an increase in surgical management of PHFs. The relative proportion of open reduction and internal fixation and arthroplasty (particularly reverse arthroplasty) increased, probably reflecting biomechanical implant properties, fracture pattern, and demand for better functionality. Associated fractures are an important comorbidity, associated with increased mortality and length of stay.

Arthroscopic Anatomical Acromioclavicular Joint Reconstruction using a Button Device and a Semitendinosus Graft.

OBJECTIVE: To report a new technique for anatomical acromioclavicular (AC) joint reconstruction. METHODS: In order to minimize such complications, the authors describe a new anatomical and biological AC joint repair. This technique aims to provide greater stability by using two anatomically placed clavicular tunnels and a combined construct with a double endobutton cortical fixation for primary stabilization, and to be biologically advantageous by using an autologous semitendinosus (ST) tendon graft. Additionally, the coracoclavicular ligament reconstruction is complemented with an AC joint cerclage and capsular reinforcement, which will protect the biological construction in its initial stage of healing. RESULTS: This technique provides adequate primary and secondary biomechanical stability by passing both a semitendinosus autogenous graft and a double endobutton device, through anatomically placed and small diameter clavicle holes, without the need for coracoid drilling. Our technique showed encouraging results regarding pain resolution, range of motion, and function. At final follow-up we experienced excellent results with average pain score of 1.6, and average ROM of 159° of forward flexion, 160° of abduction, 68° of external rotation, and internal rotation level at T11. Postoperative function also showed great improvements with average ASES of 85 points, an average Constant Score of 87 and a Subjective Shoulder Value of 89 points. This technique also achieved perfectly acceptable radiographic results, with an average coracoclavicular distance increase of 0.8 mm. Regarding complications, our sample showed one case of AC join subluxation, two cases of internal saphenous nerve injury, and two partial graft tears at the suture-button interface, with none of these requiring surgical revision. CONCLUSION: This technique is advantageous in treatment of acromioclavicular joint dislocation and can be performed in both the subacute and chronic setting.

Pseudo-patella baja after total knee arthroplasty: Radiological evaluation and clinical repercussion.

BACKGROUND: Anterior knee pain is an important complication after total knee arthroplasty (TKA). One possible contributor is the elevation of the joint line, known as pseudo-patella baja (PPB). Limited research has been conducted regarding this condition impacting TKA management. This study aims to evaluate the incidence, identify possible related factors and assess PPB clinical repercussions. METHODS: A total of 813 consecutive TKAs were retrospectively reviewed. Patients were submitted to the same surgical procedure and information regarding TKA characteristics was collected. Lateral postoperative knee radiographs were analyzed using the modified Insall-Salvati Ratio and the Blackburne-Peel Index. A clinical evaluation was conducted on 112 knees where the Oxford Knee and Kujala Scores were applied. Range of motion was evaluated, and knee pain was assessed using the numeric pain rating scale, in addition to analgesic consumption. RESULTS: A cohort of 612 knees was analyzed, of which 64 knees developed PPB (10.5% incidence). Statistically significant differences were found for advance components sizes (femoral P = 0.026 and tibial P < 0.001), polyethylene thickness (P < 0.001) and patients' height (P = 0.022) with smaller implant sizes, greater insert thicknesses and lower height showing an association with PPB. The PPB group had a significantly lower median Kujala score (P = 0.011), higher frequency of flexion contracture and of anterior knee pain (P = 0.039). CONCLUSION: PPB has a clinical relevance that should not be overlooked. Its prevention through the recreation of the natural position of the joint line and correct choice of implant sizes and polyethylene thickness is of major importance and should always be considered.

A Technique for a More Accurate Acromioclavicular Joint Reduction in Arthroscopic Coracoclavicular Stabilization of Acromioclavicular Joint Dislocation.

Loss of reduction is the most common complication following acromioclavicular dislocations treatment, with literature showing greater postoperative coracoclavicular distances associated with worse clinical results. We present a surgical gesture that aims to help surgeons achieve and secure an anatomic acromioclavicular reduction during coracoclavicular fixation. This technique has the possibility to improve radiological and functional results of acromioclavicular dislocation treatment.

Muscular Cysticercosis: An Incidental Finding in the Developed World.

CASE: We present a case of muscular cysticercosis incidentally diagnosed in a patient admitted for a femoral neck fracture and submitted to total hip arthroplasty. CONCLUSION: Human cysticercosis is a parasitic infection representing a major health concern in developing countries. The clinical features are variable and depend on the anatomic location, cyst burden, cysticerci stage, and host inflammatory response. Diagnosis is commonly incidental, and prompt pattern recognition is key to diagnosis, adequate referral, and treatment. This is one of the first reports of hip arthroplasty in a patient with a history of parasitic infection (without the need for directed pathogen treatment).

Distal Biceps Reconstruction With an Alternative Technique for Tendon Tensioning and Fixation: A Case Report.

CASE: A 41-year-old right-handed male patient presented to our institution with a chronic distal biceps rupture after failed primary surgery 6 months previously. We performed a reconstruction with semitendinosus autograft fixed proximally with a Pulvertaft weave and distally with a cortical button plus interference screw. The patient showed complete pain resolution and excellent functional results. CONCLUSION: This is the first case described with the use of a cortical button plus interference screw distally for distal biceps reconstruction after chronic distal biceps rupture. The option of doing the Pulvertaft proximally first also allowed us to fine-tune the final graft tension.