Anterior deltoid muscle reflection using a deltopectoral approach is safe and does not influence outcome of reverse shoulder arthroplasty.

BACKGROUND: The deltopectoral approach is well accepted for shoulder arthroplasty procedures. The extended deltopectoral approach with detachment of the anterior deltoid from the clavicle allows increased joint exposure and can protect the anterior deltoid from traction injury. The efficacy of this extended approach has been demonstrated in anatomic total shoulder replacement surgery. However, this has not been shown in reverse shoulder arthroplasty (RSA). The primary aim of this study was to evaluate the safety of the extended deltopectoral approach in RSA. The secondary aim was to evaluate the performance of the deltoid reflection approach in terms of complications and surgical, functional, and radiologic outcomes up to 24 months after surgery. METHODS: A prospective, nonrandomized comparative study was performed between January 2012 and October 2020 including 77 patients in the deltoid reflection group and 73 patients in the comparative group. The decision for inclusion was based on patient and surgeon factors. Complications were recorded. Patients were followed up for ≥24 months to evaluate their shoulder function and undergo ultrasound evaluation. Functional outcome measures included the Oxford Shoulder Score, Disabilities of the Arm, Shoulder and Hand score, American Shoulder and Elbow Surgeons score, pain intensity (rated on visual analog scale [VAS] from 0 to 100), and range of motion (forward flexion, abduction, and external rotation). A regression analysis was performed to evaluate any factors of influence on the VAS score. RESULTS: There were no significant differences in the complication rate between the 2 groups (14.5% in deltoid reflection group and 13.8% in comparative group, P = .915). Ultrasound evaluation was available in 64 patients (83.1%), and no proximal detachment was observed. In addition, there were no significant differences in functional outcome measures both preoperatively and at 24 months after surgery between the groups assessed based on the mean VAS pain score, Oxford Shoulder Score, Disabilities of the Arm, Shoulder and Hand score, American Shoulder and Elbow Surgeons score, forward flexion, abduction, and external rotation. Adjustment for possible confounders in a regression model indicated that only prior surgery significantly influenced the VAS pain score after surgery (P = .031; 95% confidence interval, 0.574-11.67). Deltoid reflection (P = .068), age (P = .466), sex (P = .936), use of glenoid graft (P = .091), prosthesis manufacturer (P = .382), and preoperative VAS score (P = .362) were not of influence. DISCUSSION: The results of this study show that an extended deltopectoral approach for RSA is safe. Selected reflection of the anterior deltoid muscle improved exposure and prevented anterior deltoid muscle injury followed by reattachment. Patients had similar functional scores preoperatively and at 24 months postoperatively compared with a comparative group. Furthermore, ultrasound evaluation showed intact reattachments.

Ninety-day complication rate based on 532 Latarjet procedures in Dutch hospitals with different operation volumes.

BACKGROUND: In this study, we aimed to provide insight into the 90-day complication rates following the Latarjet procedure. Data from 2015 were collected from multiple hospitals in the Netherlands, with different volumes of Latarjet procedures. Our second aim was to examine which patient and surgical factors were associated with complications. METHODS: We conducted a retrospective chart review of 13 hospitals between 2015 and 2022. Data regarding complications within 90 days of Latarjet procedures were extracted. The effect of sex, age, body mass index (BMI), smoking, previous shoulder operations, fixation material, hospital volume, screw size, and operation time on the complication rate was assessed by multivariable logistic regression analysis. RESULTS: Of the 532 included patients, 58 (10.9%) had complications. The most common complications were material failure (n = 19, 3.6%) and nerve injury (n = 13, 2.4%). The risk of complications was lower for male patients than for female patients (odds ratio, 0.40; 95% confidence interval, 0.21-0.77; P = .006). Age, BMI, smoking, previous shoulder operations, type of fixation material, hospital volume, screw size, and operation time were not associated with complications. CONCLUSION: The 90-day complication rate after the Latarjet procedure was 10.9% and was higher in female patients than in male patients. Age, BMI, smoking, previous shoulder operations, type of fixation material, hospital volume, screw size, and operation time did not affect complication rates. We advise setting up a national registry to prevent under-reporting of complications.

Compensatory Movement Patterns Are Based on Abnormal Activity of the Biceps Brachii and Posterior Deltoid Muscles in Patients with Symptomatic Rotator Cuff Tears.

BACKGROUND: Abnormal movement patterns due to compensatory mechanisms have been reported in patients with rotator cuff tears. The long head of the biceps tendon may especially be overactive and a source of pain and could induce abnormal muscle activation in these patients. It is still unknown why some patients with a rotator cuff tear develop complaints and others do not. QUESTIONS/PURPOSES: (1) Which shoulder muscles show a different activation pattern on electromyography (EMG) while performing the Functional Impairment Test-Hand and Neck/Shoulder/Arm (FIT-HaNSA) in patients with a symptomatic rotator cuff tear compared with age-matched controls with an intact rotator cuff? (2) Which shoulder muscles are coactivated on EMG while performing the FIT-HaNSA? METHODS: This comparative study included two groups of people aged 50 years and older: a group of patients with chronic symptomatic rotator cuff tears (confirmed by MRI or ultrasound with the exclusion of Patte stage 3 and massive rotator cuff tears) and a control group of volunteers without shoulder conditions. Starting January 2019, 12 patients with a chronic rotator cuff tear were consecutively recruited at the outpatient orthopaedic clinic. Eleven age-matched controls (randomly recruited by posters in the hospital) were included after assuring the absence of shoulder complaints and an intact rotator cuff on ultrasound imaging. The upper limb was examined using the FIT-HaNSA (score: 0 [worst] to 300 seconds [best]), shoulder-specific instruments, health-related quality of life, and EMG recordings of 10 shoulder girdle muscles while performing a tailored FIT-HaNSA. RESULTS: EMG (normalized root mean square amplitudes) revealed hyperactivity of the posterior deltoid and biceps brachii muscles during the upward phase in patients with rotator cuff tears compared with controls (posterior deltoid: 111% ± 6% versus 102% ± 10%, mean difference -9 [95% confidence interval -17 to -1]; p = 0.03; biceps brachii: 118% ± 7% versus 111% ± 6%, mean difference -7 [95% CI -13 to 0]; p = 0.04), and there was decreased activity during the downward phase in patients with rotator cuff tears compared with controls (posterior deltoid: 89% ± 6% versus 98% ± 10%, mean difference 9 [95% CI 1 to 17]; p = 0.03; biceps brachii: 82% ± 7% versus 89% ± 6%, mean difference 7 [95% CI 0 to 14]; p = 0.03). The posterior deltoid functioned less in conjunction with the other deltoid muscles, and lower coactivation was seen in the remaining intact rotator cuff muscles in the rotator cuff tear group than in the control group. CONCLUSION: Patients with a symptomatic rotator cuff tear show compensatory movement patterns based on abnormal activity of the biceps brachii and posterior deltoid muscles when compared with age-matched controls. The posterior deltoid functions less in conjunction with the other deltoid muscles, and lower coactivation was seen in the remaining intact rotator cuff muscles in the rotator cuff tear group than the control group. CLINICAL RELEVANCE: This study supports the potential benefit of addressing the long head biceps tendon in the treatment of patients with a symptomatic rotator cuff tear. Moreover, clinicians might use these findings for conservative treatment; the posterior deltoid can be specifically trained to help compensate for the deficient rotator cuff.

Arthroscopic isolated long head of biceps tenotomy in patients with degenerative rotator cuff tears: mid-term clinical results and prognostic factors.

INTRODUCTION: The long head of biceps tendon is frequently involved in degenerative rotator cuff tears. Therefore, this study explored the clinical results of an isolated biceps tenotomy and identified prognostic factors for improvement in pain and function. MATERIALS AND METHODS: Between 2008 and 2017, an arthroscopic isolated biceps tenotomy was performed on 64 patients with a degenerative rotator cuff tear (> 65 years). Primary outcome was patient-perceived improvement in pain and function. Potential prognostic factors for improvement in pain and function were identified. RESULTS: A perceived improvement in pain was reported in 78% of the patients at three months after surgery and in 75% at a mean follow-up of 4.2 years (1-7 years; n = 55). A perceived improvement in function was observed in 49% of patients at three months and in 76% of patients at follow-up. Patients with a preoperatively normal acromiohumeral distance (> 10 mm) reported an improvement in pain and function significantly more often. Retraction of the supraspinatus tendon Patte 3 was significantly associated with worse functional outcome. CONCLUSIONS: A biceps tenotomy can be a reliable treatment option for patients with symptomatic degenerative cuff tears who fail conservative treatment and have a normal acromiohumeral distance (> 10 mm).

Long-term clinical outcome of arthroscopic Bankart repair with suture anchors.

BACKGROUND: The most common surgical technique in traumatic anterior shoulder instability is the arthroscopic Bankart repair, which has excellent short-term results. The long-term results of the arthroscopic Bankart repair are less frequently studied, with a high recurrence rate of 23% to 35%. The aim of this study was to evaluate the medium-term to long-term results of arthroscopic Bankart repair using suture anchors and to identify specific risk factors for recurrent instability. METHODS: Included were 147 patients after traumatic anterior shoulder dislocation who underwent an arthroscopic Bankart repair. The primary outcome was recurrent instability, defined as dislocation or subluxation as perceived by the patients. The secondary outcome was subjective shoulder stability and function as well as quality of life, evaluated using the Western Ontario Shoulder Instability Index, the Simple Shoulder Test, and the 12-Item Short Form Health Survey. Prognostic factors for recurrent instability were analyzed. RESULTS: Recurrent instability occurred in 22% of patients with a mean follow-up of 6.3 years. Survival at 5 and 10 years without recurrent instability was 79% and 78%, respectively (95% confidence interval, 72%-85% and 71%-85%, respectively). The Western Ontario Shoulder Instability Index score, the Simple Shoulder Test score, and the 12-item Short Form Physical Component Summary improved significantly in the nonrecurrence group (P < .001, P = .004, and P = .002, respectively). Younger age and use of fewer than 3 anchors were associated with a higher risk of recurrent dislocation (P = .008 and P = .039, respectively). CONCLUSION: We found an overall recurrent instability rate of 22% (dislocation or subluxation). Good long-term results were observed after arthroscopic Bankart repair in patients older than 20 years with 3 or more suture anchors used.

Appropriate care for orthopedic patients: effect of implementation of the Clinical Practice Guideline for Diagnosis and Treatment of Subacromial Pain Syndrome in the Netherlands.

Background and purpose - The multidisciplinary Clinical Practice Guideline for diagnosis and treatment of subacromial pain syndrome (SAPS) was created in 2012 by the Dutch Orthopedic Association. In brief, it stated that SAPS should preferably be treated nonoperatively. We evaluated the effect of the implementation of the guideline on the number of shoulder surgeries for SAPS in the Netherlands (17 million inhabitants). Patients and methods - An observational study was conducted with the use of aggregated data from the national database of the Dutch Health Authority from 2012 to 2016. Information was collected on patients referred to and seen at orthopedic departments. Data from the following Diagnoses Related Groupings were analyzed: 1450 (tendinitis supraspinatus) and 1460 (rotator cuff tear). Results - In 2016 fewer patients were diagnosed with tendinitis supraspinatus than in 2012-a decrease from 49,491 to 44,662 (10%). Of the patients diagnosed with tendinitis, 14% were treated surgically in 2012; this number dropped to 9% by 2016. More patients with a rotator cuff tear were diagnosed in 2016 than in 2012, an increase from 17,793 to 23,389 (32%), fewer were treated surgically: 30% in 2012, compared with 25% in 2016. Interpretation - After introducing the multidisciplinary Clinical Practice Guideline "Diagnosis and treatment of subacromial pain syndrome," a decrease in shoulder surgeries for related diagnoses was observed in the Netherlands. The introduction and dissemination of this guideline seems to have contributed to the implementation of more appropriate health care and prevention of unnecessary surgeries.

Biceps Autograft Augmentation for Rotator Cuff Repair: A Systematic Review.

PURPOSE: To improve surgical outcomes in patients with massive cuff defects, different techniques and augmentations are proposed. The biceps tendon is easily available as an autograft. Our aim was to conduct a qualitative systematic review of various methods and surgical techniques that use a biceps autograft (BAG) for rotator cuff repair. Functional outcomes are also reported. We hypothesized that by using a BAG to treat massive rotator cuff tears, a more anatomic and biomechanical reconstruction could be achieved compared with other techniques. METHODS: A qualitative systematic review was conducted (MEDLINE and Embase databases) to inventory surgical techniques for use of a BAG for rotator cuff repair. The following search terms were used for MEDLINE: biceps AND (augment* OR autograft* OR transplantation* OR (cuff AND graft*) OR biceps-incorporat*). Studies were included if the following criteria were fulfilled: description of surgical technique, only human subjects, functional outcomes noted, all study designs except technical notes, and no restrictions on study date. The quality of the studies was assessed in a standardized manner using a tool based on the Cochrane handbook. RESULTS: We identified 981 studies; among these, 8 case series met the inclusion criteria. We identified 6 studies as high quality and 2 as medium quality. Different techniques for harvest and augmentation were used. Some studies left the proximal or distal portion intact, whereas others used it as a free graft. The clinical results of these studies showed significantly improved function, pain relief, and range of motion at follow-up, although this was not compared with a control group. The constructs were intact on magnetic resonance imaging in most patients (82%) within 2 years. CONCLUSIONS: It can be concluded that use of a BAG is an option for augmentation in massive rotator cuff tears, although no definitive recommendations can be given. This is based on Level IV medium- and high-quality studies. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Predictive findings on magnetic resonance imaging in patients with symptomatic acromioclavicular osteoarthritis.

BACKGROUND: A magnetic resonance imaging (MRI) scan of the shoulder can have added value in diagnosing symptomatic osteoarthritis of the acromioclavicular (AC) joint. Specific MRI signs have been recognized but not analyzed extensively before. This study aims to identify predictive MRI signs in patients with symptomatic AC osteoarthritis. METHODS: The MRI scans of 70 patients with symptomatic AC osteoarthritis were compared with those of 70 patients with subacromial pain syndrome and no clinical signs of symptomatic AC osteoarthritis. Seven variables were evaluated on the MRI scans of the AC joint: joint space narrowing, inferior osteophytes, joint effusion, osteolysis, bone marrow edema, impression on the supraspinatus, and inferior joint distension. Logistic regression analysis of these variables was performed. RESULTS: The presence of inferior osteophytes, bone marrow edema, impression on the supraspinatus, and inferior joint distension was individually associated with symptomatic AC osteoarthritis. Bone marrow edema was observed only in patients with symptomatic AC osteoarthritis. Multivariate analysis showed a significant association between inferior joint distension, as well as impression on the supraspinatus muscle, and symptomatic AC osteoarthritis. The area under the receiver operating characteristic curve in the multivariate logistic model was 0.839 (95% confidence interval, 0.771 to 0.907). Interobserver and intraobserver variability showed good to excellent κ values (range, 0.68 to 0.88). CONCLUSION: We identified predictive MRI signs in patients with symptomatic AC osteoarthritis. These findings, including bone marrow edema, inferior joint distension, and impression on the supraspinatus muscle, showed good discriminative ability. They are practical and easy to use and can assist the physician in diagnosing symptomatic AC osteoarthritis.

Mid-term results of ankle fractures with and without syndesmotic rupture.

BACKGROUNDS: This study investigated the effect of short term removal of syndesmotic screws on the ankle function after 6 years, as there still exists controversy on the duration of screw stabilization. METHODS: Patients with an ankle fracture who received surgery between 1998 and 2004 were reviewed. One group was composed of patients with an ankle fracture needing a syndesmotic repair with screws. The second was composed of operated patients that did not need syndesmotic repair. The primary scoring used was the Olerud-Molander Ankle Score (OMAS). RESULTS: A total of 59 patients were studied with comparable characteristics, with no significant difference on the OMAS after 6 years between the repair group (81.9) and the non-repair group (90.4). On additional clinical scoring groups remained the same. Joint degeneration was seen in both groups (86.7% vs. 55.5%). CONCLUSIONS: Patients with ankle fractures using syndesmotic repair and screw removal after 8 weeks and operated patients without syndesmotic injury have comparable results after 6 years.

All-Arthroscopic Muscle Slide and Advancement Technique to Repair Massive Retracted Posterosuperior Rotator Cuff Tears.

Symptomatic massive posterosuperior rotator cuff tears without glenohumeral joint arthritis and chronic medial retraction often are deemed "irreparable." These patients often are treated with alternative joint-sparing procedures including superior capsular reconstruction or tendon transfer procedures. Open and arthroscopic-assisted muscle advancement techniques allow maximal lateral tendon mobilisation during rotator cuff repair. In this report, we present an all-arthroscopic technique of complete supraspinatus and infraspinatus muscle scapular detachment and advancement in retracted massive posterosuperior rotator cuff tears. This allows for an anatomical tendon footprint reduction and tension-free repair.

Pedicled-lesser tuberosity osteotomy for glenohumeral joint exposure: a technical note and case report highlighting its use in allograft reconstruction of a large engaging reverse Hill-Sachs lesion after posterior shoulder dislocation.

Exposure of the humeral articular surface through an anterior approach to the shoulder for grafting humeral bone defects requires partial or complete detachment of the subscapularis tendon and traditionally is achieved through a subscapularis tenotomy, peel tuberosity osteotomy, or lesser tuberosity osteotomy. This case report presents a technique of performing a pedicled-lesser tuberosity osteotomy to allow adequate access for allograft reconstruction of a large reverse Hill-Sachs lesion after a traumatic posterior dislocation, to restore humeral head sphericity and prevent recurrent glenohumeral joint instability. The inferior subscapularis insertion is left intact leaving a periosteal sleeve and preserving the blood supply to the lesser tuberosity and humeral head, with the aim of improving healing of the osteotomy and preventing graft-related complications, such as resorption. Successful union of the pedicled-lesser tuberosity osteotomy and allograft was seen on a 6-month follow-upcomputed tomography scan, with adequate restoration of subscapularis function.

Topical use of MMC in the upper aerodigestive tract: a review on the side effects.

Not much is known about the side effects of mitomycin C (MMC), an anti-fibrogenetic agent, in the upper aerodigestive tract. However, its use in ophthalmology is widely known and without quantitatively important side effects. A literature review was performed for side effects of MMC in the upper aerodigestive tract. Forty-six articles, describing the use of MMC to prevent scarring, were retracted from PubMed. Thirty-two are human studies. MMC is used in different concentrations (0.1-10 mg/ml) with different application times (2-5 min) and frequencies (up to 4 times). Five hundred and thirty-eight patients were included in those publications, of whom 19 developed side effects (3.53%). No side effects developed in studies, where post-application irrigation with saline was reported. The longest mean follow-up period is 75.5 months. Direct relations between the reported side effects and MMC seem absent in most studies. Serious complications seem to occur when MMC is used in high concentrations. Unfortunately, sometimes crucial information is lacking. One patient was described who supposedly developed laryngeal carcinoma after repeated treatment of hyperkeratosis and anterior commissure webbing. Animal studies show that excessive fibrin production can lead to acute airway obstruction. In conclusion, topical application of MMC on a wound with consecutive irrigation with saline can be performed safely to prevent scar formation in circular structures of the upper aerodigestive tract. Long-term yearly control of the application site seems advisable.

The results of using a tendon autograft as a new rotator cable for patients with a massive rotator cuff tear: a technical note and comparative outcome analysis.

BACKGROUND: Several surgical reconstructive options are available to treat massive rotator cuff tears (MRCTs). The rotator cable has an important function and we evaluated the clinical result after arthroscopic reconstruction of the rotator cable with an autograft tendon. METHODS: A prospective pilot study was performed with inclusion of four patients, average age of 64 years, with an irreparable MRCT. The patients underwent an arthroscopic reconstruction of the rotator cable with the use of the long head of biceps tendon autograft, except for one which was reconstructed with a hamstring tendon. Pre- and postsurgically, the Constant-Murley Score (CMS), Western Ontario Rotator Cuff Index (WORC), Simple Shoulder Test (SST), visual analog scale (VAS) scores, and an MRI was performed. Clinical results of the study group were compared with clinical results of comparable cohort of patients with a MRCT, treated non-operatively with physiotherapy. RESULTS: The CMS score increased after surgery in three of the four patients. The improvement of CMS score was comparable to the improvement of the CMS score encountered in a comparable cohort. The MRI at 12 months follow-up showed that the reconstructed rotator cable was disintegrated in all patients and the rotator cuff was detached and retracted. CONCLUSIONS: In our pilot study, arthroscopic reconstruction of the rotator cable using a tendon autograft failed over time and showed no clinical benefit in comparison to the non-operative treatment with physiotherapy. TRIAL REGISTRATION: The regional Medical Ethical Committee (Zwolle) gave approval at 14th of October 2016 and assigned no. 16.06100.

Using the Long Head of Biceps Tendon Autograft as an Anatomical Reconstruction of the Rotator Cable: An Arthroscopic Technique for Patients With Massive Rotator Cuff Tears.

The treatment of massive rotator cuff tears (MRCT) is challenging. Insufficient tissue quality, size, and retraction of the cuff often lead to failures of repair. Different techniques like direct repair, partial repair, and graft applications have been developed, but results are not yet predictable. In this arthroscopic technique the objective is not to reconstruct the rotator cuff as a tissue layer but to restore the biomechanical function of the rotator cable with an autograft of the long head of the biceps tendon. After glenohumeral inspection, the long head of the biceps tendon is harvested and the retracted cuff is released and, if possible, closed partially side-to-side. The biceps graft is positioned from the posterior aspect of the greater tubercle to the superior part of the lesser tubercle and fixed with 2 biotenodesis anchors. Finally, the cuff remnants are securely sutured to the biceps graft with standard cuff repair sutures. This arthroscopic technique has several advantages because the biceps autograft is easily harvested, autologous, and rich in collagen. Previous studies show use of the biceps tendon differently for reconstruction of the rotator cuff, with promising results. Future studies are needed to evaluate clinical outcomes.

Outcome of the Cementless Zweymüller BICON-PLUS Cup and SL-PLUS Stem in the Very Elderly Individuals.

INTRODUCTION: There is current debate about which type of total hip prosthesis implants are best for the elderly patient. Implanting uncemented total hip arthroplasty (THA) in elderly people remains contested. The aim of present study was to evaluate the outcome of the uncemented Zweymüller BICON-PLUS THA in those with a minimum of 80 years of age. MATERIALS AND METHODS: A retrospective data collection was performed in a regional teaching hospital in the Netherlands. The primary outcome of interest was the operation-free period. Secondary outcomes included the revision rates of the femoral and acetabular components and postoperative complications of the procedure. After a follow-up of at least 7 years, the surviving patients were reviewed on functionality using validated scores (Hip Disability and Osteoarthritis Outcome Score, Timed Up and Go, and Harris Hip Score) and radiographic analysis. RESULTS: Between January 1999 and September 2004, 124 patients (128 THAs), aged 80 years and older, received an uncemented THA with a BICON-PLUS cup and SL-PLUS stem. The overall operation-free period was 6.5 years. One case of loosening of the cup was found among participants, with a survival rate of 99.2% of the BICON-PLUS cup in the analyzed group. In all, 28.8% of this group could be followed for a postoperative period of at least 7 years. The remainder of the patients died prior to the end of the 7-year period. Of these, 16.0% were eligible for clinical review. This group showed good function without evident signs of prosthetic loosening. CONCLUSION: The uncemented Zweymüller THA system, with threaded BICON-PLUS cup and SL-PLUS stem, showed good results, compared to outcome of other THA systems in elderly individuals. Therefore, it is a reliable option in older patients requiring THA.

A traumatic superficial temporal artery aneurysm after a bicycle accident.

A male cyclist presented with a swelling on the forehead. Six weeks before, he fell of his bike and smashed his head on the ground while wearing a helmet. A smooth lump of 1 cm had evolved on the temporal side of his forehead in a few weeks. Duplex ultrasonography demonstrated a dilated vessel with a minor defect in the luminal wall. Surgical exploration revealed an aneurysm of the superficial temporal artery (STA). The aneurysm was surgically removed and the patient recovered uneventfully. Owing to its superficial course, the STA is vulnerable to blunt head trauma. Traumatic aneurysms of the STA should be a differential diagnostic consideration in patients with a history of trauma and a swelling on their head.

Are there any advantages in using a distal aiming device for tibial nailing? Comparing the Centro Nailing System with the Unreamed Tibia Nail.

INTRODUCTION: The distal locking of an intramedullary tibial nail can be challenging and time consuming when performed freehand. This study was conducted to evaluate if a distal aiming device would reduce surgical time. MATERIALS AND METHODS: A case-controlled study was performed between 2007 and 2009 with 30 patients receiving a reamed tibial nail (Centronail) with the use of a distal aiming device and 30 patients who were treated with an Unreamed Tibia Nail (UTN), with freehand distal locking, in the same period. The primary outcome in this study was operative time. Secondary outcomes were the need for fluoroscopy, time to consolidation and complications. RESULTS: Operation time was longer in the Centronail group compared with the UTN group (126 min vs. 96 min, p=0.000). Use of fluoroscopy for distal locking was needed in half of the cases (n=16) using a distal aiming device. No differences were found regarding time to consolidation, time to removal of the nail and complications. CONCLUSION: The use of an aiming device for distal locking of a tibia nail lengthens operation time rather than reducing it. Fluoroscopy was still needed in about half of the cases. No difference was seen in clinical outcomes. The use of a distal aiming device to lock a tibial nail appears to have no benefit.