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Featured Publications

Three-year functional outcome of transosseous-equivalent double-row vs. single-row repair of small and large rotator cuff tears: a double-blinded randomized controlled trial

Background

The clinical trial aimed to prospectively compare the functional outcome of patients undergoing arthroscopic rotator cuff repair using Transosseous-Equivalent Double-Row (TEDR) or single-raw (SR) suture anchor techniques at three years postoperatively for both large (over 3cm) and small (under 3cm) tears.

Methods

Eighty patients with a symptomatic and MRI proven full-thickness RC tear, who had failed conservative management of at least 6 months duration and who had a complete passive range of motion of the affected shoulder were enrolled in the trial. Patients were randomized to TEDR repair (n=40) or SR repair (n=40). Subgroup analysis was conducted for tears < 3 cm (TEDR n = 17, SR n=19) and tears > 3 cm (TEDR n=23, SR n=21). Primary outcomes included the Oxford Shoulder Score (OSS), the University of California, Los Angeles score (UCLA), and the Constant-Murley Outcome Score (CMS). The secondary outcomes included a 0-100 mm Visual Analogue Scale (VAS) for pain, range of motion (ROM) and EQ-5D.

Results

There was a significant difference in the mean OSS postoperative score for tears >3cm (p=0.01) and mean improvement from baseline in the TEDR group (p=0.001). For tears >3cm, mean postoperative scores were also significantly higher in the TEDR group for UCLA (p=0.015) and CMS (p=0.001). Post Hoc testing showed that the differences between these groups was statistically significant (p<0.05). For tears <3cm, a significant postoperative difference in favor of SR repair was seen with mean CMS (p=0.011), and post hoc testing showed that the difference was statistically significant (p=0.015). No significant difference was seen with mean postoperative OSS or UCLA and post hoc testing did not show a statistically significant difference between groups.

Conclusion

TEDR repair showed improved functional outcomes for tears greater than 3cm when compared to SR repair. For tears less than 3cm, no clear benefit was seen with either technique. Level of evidence: Level I; Randomized Controlled Trial; Treatment Study

Long-term results of total elbow arthroplasty in patients with hemophilia

Methods

From 2002 to 2012, 13 primary TEAs (Coonrad-Morrey design) were implanted in 9 consecutive patients with an average age of 55 (range, 39-76) years. TypeAhemophilia was diagnosed in 7 patients and type B hemophilia in 2 patients. Clinical and radiographic results of all (11 TEAs) but 1 patient were retrospectively analyzed.

Results

After a mean of 9.1 (range, 5-14) years, the mean visual analog scale score for pain, total Mayo Elbow Performance Score, and subjective elbow value were significantly improved from 5 (standard deviation, ±3) to 2 (±2; P = .007) points, from 64 (±16) to 89 (±11; P = .008) points, and from 47% (±15%) to 81% (±11%; P < .001), respectively. Whereas the flexion arc remained unchanged (P = .279), mean active pronation improved significantly (P = .024). Postoperative complications were recorded in 8 TEAs (62%), whereas 5 TEAs (38%) underwent partial component exchange after a mean of 7.2 (range, 3-10) years: 2 for periprosthetic infection, 2 for polyethylene wear, and 1 for humeral component loosening. Of the living patients after partial component exchange (n = 3), the mean final total Mayo Elbow Performance Score, flexion and rotation arc, visual analog scale score for pain, and subjective elbow value were comparable with the results of the living patients without revision surgery (n = 8).

Conclusion

TEA for patients with advanced hemophilic arthropathy is associated with a substantial complication and revision rate. However, even after revision without implant removal, it provides good functional and subjective long-term results.

Pull-Over technique for All Arthroscopic Rotator cuff Repair with Extracellular Matrix Augmentation

Study

Despite the vast improvement in techniques for arthroscopic rotator cuff surgery, repairs of massive and large tears remain an issue as they are associated with significantly high failure rates, particularly in the elderly population. As a result, there has been a focus of attention to improve rotator cuff repair healing rates. One of the strategies is augmentation of the repair with a patch. Arthroscopic augmentation is, however, technically demanding with challenges in introduction and stabilization of the patch. The purpose of this Technical Note is to describe a technique for arthroscopic rotator cuff repair with augmentation, which offers additional advantages over previous techniques because it facilitates the passage of the patch as well as providing a more robust medial stabilization of the augment and therefore possibly a stronger construct.

Salvage reverse total shoulder arthroplasty for failed operative treatment of proximal humeral fractures in patients younger than 60 years: long-term results

Methods

From 2002 to 2012, 13 primary TEAs (Coonrad-Morrey design) were implanted in 9 consecutive patients with an average age of 55 (range, 39-76) years. TypeAhemophilia was diagnosed in 7 patients and type B hemophilia in 2 patients. Clinical and radiographic results of all (11 TEAs) but 1 patient were retrospectively analyzed.

Results

After a mean of 9.1 (range, 5-14) years, the mean visual analog scale score for pain, total Mayo Elbow Performance Score, and subjective elbow value were significantly improved from 5 (standard deviation, ±3) to 2 (±2; P = .007) points, from 64 (±16) to 89 (±11; P = .008) points, and from 47% (±15%) to 81% (±11%; P < .001), respectively. Whereas the flexion arc remained unchanged (P = .279), mean active pronation improved significantly (P = .024). Postoperative complications were recorded in 8 TEAs (62%), whereas 5 TEAs (38%) underwent partial component exchange after a mean of 7.2 (range, 3-10) years: 2 for periprosthetic infection, 2 for polyethylene wear, and 1 for humeral component loosening. Of the living patients after partial component exchange (n = 3), the mean final total Mayo Elbow Performance Score, flexion and rotation arc, visual analog scale score for pain, and subjective elbow value were comparable with the results of the living patients without revision surgery (n = 8).

Conclusion

TEA for patients with advanced hemophilic arthropathy is associated with a substantial complication and revision rate. However, even after revision without implant removal, it provides good functional and subjective long-term results.

Staged Revision With Antibiotic Spacers for Shoulder Prosthetic Joint Infections Yields High Infection Control

Questions/Purpose

(1) What is the likelihood of infection control after two-stage revision using an antibiotic cement spacer for patients with PJI of the shoulder?
(2) What are the improvements in Constant and Murley scores at 2 years after these staged revisions?

Between 2000 and 2013, we treated 48 patients with PJI of the shoulder using two-stage revision including an antibiotic-containing cement spacer during the first stage. Of those, 38 (79%) were available for review at a minimum of 24 months (mean, 52 6 34 months). During the first stage, removal of the prosthesis, d´ebridement, and implantation of a gentamicin and vancomycin-filled cement spacer were performed by four different surgeons followed by antibiotic therapy (2 weeks intravenous plus 10 weeks oral). For the second stage, we generally tried a reverse total shoulder arthroplasty (RTSA; n = 26). In case of severe glenoid destruction, hemiarthroplasty (HA; n = 8) was used as a salvage option. In 14 patients the cement spacer was left in place because the patients refused further surgery or were not operable owing to medical reasons.

Results

Successful infection control was achieved in 36 of 38 patients (95%). Patients who underwent treatment with a cement spacer had increased Constant and Murley scores at latest followup compared with their pretreatment scores. For patients who underwent staged treatment followed by second-stage RTSA (n = 23), the Constant and Murley scores increased. The Constant and Murley scores did not improve in patients who underwent HA  or who retained the spacer 

Conclusion

Revision arthroplasty using an antibiotic loaded cement spacer provided successful infection control in patients with periprosthetic shoulder infections in this small, retrospective series. Functional improvement was obtained after reimplantation of a reverse total shoulder prosthesis but was not seen after HA and cement spacer; however, baseline differences among patient groups very likely contributed to these differences, and they should not be attributed to implant selection alone.

The X-Pulley Technique for Subpectoral Long Head The Bicepts Tenodesis using All-Suture Anchors

Questions/Purpose

Subpectoral long head of the biceps tenodesis is gaining popularity as a technique for treating patients with various pathologies of the tendon or its anchor to the superior labrum. It has the added advantage of addressing bicipital groove pathologies. Various techniques for performing it have been described, but none is without problems. We present a modification of the previously described techniques that involves 2 all-suture anchors and offers the added advantage of a reduced risk of fracture without sacrificing the biomechanical strength of the construct. We also believe that it may potentiate healing by providing an adequate surface contact area between the tendon and bone with a minimal risk of damage to the tendon and neurovascular structures.

Mortality and pulmonary complications in patients undergoing upper extremity surgery at the peak of the SARS-CoV-2 pandemic in the UK: A national cohort study

This study reports the 30-day mortality, SARS-CoV-2 complication rate and SARS-CoV-2-related hospital processes at the peak of the first wave of the pandemic in the UK. 

Methods

 This national, multicentre, cohort study at 74 centres in the UK included all patients undergoing any surgery below the elbow at the peak of the UK pandemic. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The secondary outcomes were SARS-CoV-2 complication rates and overall complication rates. A clinician survey relating to SARS-CoV-2 safety processes was carried out for each participating centre. 

Results

 This analysis includes 1093 patients who underwent upper limb surgery from the 1 to 14 April 2020 inclusively. The overall 30-day mortality was 0.09% (1 pre-existing SARS-CoV-2 pneumonia) and the mortality of day case surgery was zero. Most centres (96%) screened patients for symptoms prior to admission, only 22% routinely tested for SARS-CoV-2 prior to admission. The SARS-CoV-2 complication rate was 0.18% (2 pneumonias) and the overall complication rate was 6.6% (72 patients). Both SARS-CoV-2-related complications occurred in patients who had been hospitalised for a prolonged period before their surgery and a total of 19 patients (1.7%) were SARS-CoV-2 positive. 

Conclusion

The SARS-CoV-2-related complication rate for upper limb surgery even at the peak of the UK pandemic was low at 0.18% and the mortality was zero for patients admitted on the day of surgery. Urgent surgery should not be delayed pending the results of SARS-CoV-2 testing. Routine SARS-CoV-2 testing for day case upper limb surgery not requiring general anaesthesia may be excessive and have unintended negative impacts.

Bony increased-offset reverse shoulder arthroplasty: The available evidence

Reverse shoulder arthroplasty (RSA) has revolutionized the management of many shoulder pathologies. Lateralization has become favourable to combat complications (e.g. notching, compromised external rotation), using a metallic, or autogenous bone-graft baseplates – bony increased-offset reverse shoulder arthroplasty (BIO-RSA). 

Methods

We systematically reviewed the literature to determine: Does BIO-RSA improve range of motion and outcome scores? Are notching rates decreased? Does the graft heal? Methods All available prospective studies, trials and case series reporting on BIO-RSA were included. Outcomes were grouped into outcome scores, range of motion and radiographic outcomes. Data were pooled and statistical analysis performed. 

Results

Results Eight studies reported on 385 RSA – 235 BIO-RSA and 150 standard-RSA (STD-RSA). Follow-up was 20–36 months; average age 74 years. Outcome scores: Constant-Murley and SSV scores showed statistically significant post-operative benefit of BIO-RSA (mean-difference 4.0 (95% confidence interval (CI): 0.79,7.1) and 6.8 (95% CI: 3.8, 9.9)). No Minimal Clinically Importance Difference was surpassed. Range of motion: No difference was found in any direction. Notching: Notching was less likely with BIO-RSA (odds ratio 0.19 (95% CI: 0.10, 0.38)). Healing and loosening: 92% grafts fully healed/incorporated. Loosening rate was 2.4%. 

Conclusion

Literature on BIO-RSA is limited with only one randomised controlled trial (RCT). Weak evidence exists for improved outcome scores. Range of motion is equivocal. Notching rates are significantly lower in BIO-RSA. The graft usually heals.

Normal Wrist Development in Children and Adolescents: A Geometrical Observational Analysis Based on Plain Radiographs

To investigate the geometric development of the wrist in relation to the changes in its ossification pattern. This study will help the treating surgeon to identify early deviations from normal in children with musculoskeletal disorders and provide a template for anatomic reduction after trauma scenarios.

Methods

Methods: A retrospective multicenter analysis was carried out of radiographs of 896 children (896 posteroanterior and 896 lateral views) with normal wrists from January 1996 till April 2016. We stratified patients into different yearly age groups; these included 16 age groups from 1 to 16 years, and 2 sex groups: males and females. We evaluated, depending on the wrist ossification pattern, the ulnar variance, radial and carpal heights, carpal height ratio, radial inclination, volar tilt, together with radiocarpal, scapholunate, and capitate-lunate angles and scapholunate distance

Results

Results: Our analysis showed that the ulna minus variance predominates in children. Radial height, radial inclination, and radiocarpal angle increase steadily during growth and reach their respective expected values at the beginning of the pubertal growth spurt. The scapholunate and capitolunate angles showed a downward trend with growth till reaching the adult values at puberty. Carpal height increased constantly, whereas the carpal height ratio was similar to that in adults. Volar tilt was not developed until the age of 12 years, when it started to increase gradually to reach the adult values by puberty. Both sexes have similar measurements.

 

Conclusion

Conclusions: Most radiologic parameters showed reproducible anatomic changes till the 12-year-old time-point. After that, there are minimal changes till adulthood.

Clinical relevance: The study findings offer a template of pediatric normal values guiding hand and pediatric surgeons in treatment of children with wrist pathology

Degenerative rotator cuff tear, repair or not repair? A review of current evidence

We review the literature and highlight the important factors to consider when counselling patients with non-traumatic rotator cuff tears on which route to take. Factors include the clinical outcomes of surgical and non-surgical routes, tendon healing rates with surgery (radiological outcome) and natural history of the tears if treated non-operatively.

Methods

A PRISMA-compliant search was carried out, including the online databases PubMed and Embase from 1960 to the end of June 2018.

Results

A total of 49 of the 743 (579 PubMed and 164 Embase™) results yielded by the preliminary search were included in the review. There is no doubt that the non-surgical route with an appropriate physiotherapy programme has a role in the management of degenerative rotator cuff tears. This is especially the case in patients with significant risk factors for surgery, those who do not wish to go through a surgical treatment and those with small, partial and irreparable tears. However, rotator cuff repair has a good clinical outcome with significant improvements in pain, range of motion, strength, quality of life and sleep patterns.

Conclusion

There is no doubt that the non-surgical route with an appropriate physiotherapy programme has a role in the management of degenerative rotator cuff tears. This is especially the case in patients with significant risk factors for surgery, those who do not wish to go through a surgical treatment and those with small, partial and irreparable tears. However, rotator cuff repair has a good clinical outcome with significant improvements in pain, range of motion, strength, quality of life and sleep patterns.

Salvage reverse total shoulder arthroplasty for failed operative treatment of proximal humeral fractures in patients younger than 60 years: long-term results

Is salvage reverse total shoulder arthroplasty (RTSA) a justifiable treatment for failed operative treatment (open reduction-internal fixation [ORIF] or primary and secondary hemiarthroplasty) of proximal humeral fractures in patients younger than 60 years?

Methods

Thirty patients (mean age, 52 years; age range, 30-59 years) were reviewed after a mean follow-up period of 11 years (range, 8-18 years). Of the patients, 7 (23%) underwent RTSA for failed ORIF and 23 (77%) for failed hemiarthroplasty. Clinical and radiographic outcomes were assessed longitudinally.

Results

At final follow-up, the mean relative Constant score had improved from 25% (±12%) to 58% (±21%, P < .001). Significant improvements were seen in the mean Subjective Shoulder Value (20% to 56%), active elevation (45° to 106°), abduction (42° to 99°), pain scores, and strength (P < .001). Clinical outcomes did not significantly deteriorate over a period of 10 years. Patients with salvage RTSA for failed secondary hemiarthroplasty (n = 8) vs. those for failed ORIF (n = 6) showed significantly inferior active abduction (77° vs. 116°, P = .023). Patients with a healed greater tuberosity (n = 9) showed significantly better external rotation than patients with a resorbed/resected greater tuberosity (n = 13, 21° vs. 3°, P = .025). One or more complications occurred in 18 shoulders (60%), and 6 (20%) resulted in explantation of the RTSA. 

Conclusion

Salvage RTSA in patients younger than 60 years is associated with a high complication rate. It leads nonetheless to substantial and durable improvement beyond 10 years, provided the complications can be handled with implant retention. Inferior shoulder function is associated with greater tuberosity resorption or resection and inferior overhead elevation with the diagnosis of failed hemiarthroplasty.

Posterior Acromial Morphology Is Significantly Associated with Posterior Shoulder Instability

Background: The purpose of this paper was to determine whether acromial morphology influences anteroposterior shoulder stability. We hypothesized that a more horizontal and higher position of the acromion in the sagittal plane would be associated with posterior instability.

Methods

Methods: In this retrospective study, patients with unidirectional posterior instability were age and sex-matched to a cohort of patients with unidirectional anterior instability. Both cohorts were compared with a control group of patients with no instability and no degenerative glenohumeral (rotator cuff and/or joint surface) or acromial changes. Measurements on radiographs included posterior acromial tilt, anterior and posterior acromial coverage (AAC and PAC), posterior acromial height (PAH), and the critical shoulder angle (CSA).

Results

Results: The number of patients enrolled in each instability group was 41, based on a priori power analysis. The control group consisted of 53 shoulders. Of the measured anatomic factors, PAH showed the most significant association with posterior instability (odds ratio [OR] = 1.8; p < 0.001) in the logistic regression model. PAH was significantly greater in the posterior instability group compared with the anterior instability group (30.9 versus 19.5 mm; p < 0.001). With a cutoff value of PAH of 23 mm, the OR for posterior instability was 39. Shoulders with posterior instability were also significantly different from normal shoulders with regard to PAH (p < 0.001), AAC (p < 0.001), and PAC (p < 0.001) whereas, in the shoulders with anterior instability, all of these values except the AAC (p = 0.011) did not differ from those of normal shoulders.

Conclusion

Conclusions: Specific acromial morphology is significantly associated with the direction of glenohumeral instability. In shoulders with posterior instability, the acromion is situated higher and is oriented more horizontally in the sagittal plane than in normal shoulders and those with anterior instability; this acromial position may provide less osseous restraint against posterior humeral head translation. A steep “Swiss chalet roof-type” acromion virtually excluded recurrent posterior instability in an albeit relatively small cohort of patients. Additional investigation is needed to determine the relevance of these findings for future treatment.

Surgical Reconstruction of Unrepairable Pectoralis Major Rupture Using Tendo- Achilles Allograft Background

 We describe a technique for allograft reconstruction of the pectoralis major, with our preliminary outcomes, where it is found or anticipated that a direct repair is not possible. 

Our technique involves surgical Reconstruction Of Unrepairable Pectoralis Major Rupture Using Tendo-Achilles Allograft 

Methods

 Rupture of the pectoralis major remains an infrequent injury but recently has been reported more commonly. A number of surgical repair techniques have been described for direct repair. However, on occasion, the pectoralis major muscle is so retracted that a tension-free direct repair is not possible. Methods The main indication for surgery is pain and functional loss that adversely affects a manual worker to perform their job or competitive sporting activity. We describe a technique for allograft reconstruction of the pectoralis major where a direct repair is not possible. 

Results

We performed a total of 142 pectoralis major repairs over a ten year period, of which 19 re-quired allograft reconstruction. Of these 19 patients, 11 were available for response. All 11 patients were male with a mean age of 38.3 years (21 to 48 years). The mean time between injury and surgery was 12.2 months (4 to 30 months). Ten patients (91%) were unable to perform their previous level of work pre-operatively, with all patients returning to pre-injury occupation levels post-operatively. The main complaint prior to surgery was pain on pushing and moving the affected arm across the body, which improved in nine patients (82%), with no improvement reported in two patients. Strength improved significantly post-operatively, with only three patients reporting no im-provement (paired t-test p=0.01). Six patients reported an improvement in cosmesis (50%). 

Conclusion

Conclusions This technique involves the use of cadaveric tendo-achilles allograft to reconstruct the pectoralis major tendon attachment to the humerus when a direct repair is not possible.

The Incidence of Traumatic Posterior and Combined Labral Tears in Patients Undergoing Arthroscopic Shoulder Stabilisation

The incidence of traumatic posterior and combined labral tears in patients undergoing arthroscopic shoulder stabilisation; our aim is to assess the incidence and nature of capsulolabral pathology in a large cohort of patients with surgically treated traumatic shoulder instability, both in sporting and non-sporting populations.

Methods

 Posterior and combined shoulder instabilities are believed to be rare, accounting for only 2% to 5% of cases. More recently an increased incidence of posterior and combined shoulder instabilities in young, active populations has been reported. This was a retrospective study which evaluated 442 patients who underwent an examination under anaesthesia, arthroscopic assessment of the glenoid capsulolabral structures and subsequent repairs over a three-year period. Patients were categorised according to the location of their labral pathology (anterior, posterior, or combined anterior and posterior) and whether their injury was sustained during sporting or non-sporting activity. Proportions of labral tears between sporting and non-sporting populations were compared using the Chi square test and values were regarded as statistically significant when p<0.05. 

Results

Results The total cohort had a mean age of 25.9 years and 89.6% of patients were male; 74.9% of patients were categorised as sporting (n=331). Isolated anterior labral tears occurred in 52.9% (n=234) with posterior and combined labral tears accounting for 16.3% (n=72) and 30.8% respectively (n=136). In the non-sporting population 68.5% (n=76) of patients had isolated anterior labral tears with 12.6% (n=14) posterior and 18.9% (n=21) combined. A significant difference was noted when compared to the sporting group, where isolated anterior labral tears accounted for 47.7% (n=158), posterior 17.5% (n=58) and combined 34.7% (n=115) (p=0.013). 

Conclusion

Conclusions Posterior and combined labral tears are more prevalent than previously reported. Careful assessment for posterior instability both clinically and arthroscopically is mandatory in all instability cases, particularly in the sporting population.

Distal Triceps Rupture Repair: The Triceps Pulley-Pullover Technique

Distal triceps rupture is an uncommon but debilitating injury, and surgical fixation is almost invariably warranted. A number of techniques have been described in the literature in which combinations of transosseous tunnels and bone anchors have been used. We describe a modification to existing techniques—the triceps pulley-pullover technique with all-suture anchors. This technique minimizes bone loss, while maximizing the bone-tendon contact area and creating a double-row repair to optimize strength and healing.

The Surgical Technique

The surgical technique is explained in this Technical Note and is also detailed in Video 1, “Distal Triceps Rupture Repair: The Triceps Pulley-Pullover Technique.” 

The key steps

• The patient is placed in the lateral decubitus position with the arm over the bar.
• Use a posterior approach to olecranon curving radially around the olecranon tip.
• Identify and prepare the ruptured triceps tendon.
• Prepare the triceps footprint.
• All-suture anchors (Iconix): Two 2-strand all-suture anchors are positioned in the triceps footprint to create a proximal suture anchor row; drill first, then tap in each anchor.
• Both ends of each strand are passed deep to superficial through the ruptured tendon.
• Pulley technique: Create a loop by tying a strand from each anchor over the assistant’s finger.
• Pull on the other ends of the strands to snug the loop and knot down, bringing the ruptured triceps end down to the footprint—the “pulley technique.”
• Tie off the free ends of the anchor strands to the 2 created knots.
• Use the remaining strands from each anchor to form a locking stitch along each edge of the triceps tendon.
• Prepare a push-lock anchor site just distal to the triceps footprint.
• Four suture limbs that form the first row are passed into the standard lateral row rotator cuff anchor, which is inserted more distally.
• Cut all sutures short; check range of movement.
• Closure is performed in layers.

Long-term results of total elbow arthroplasty in patients with hemophilia

 It was hypothesized that the long-term survivorship and clinical outcome are reasonable, justifying total elbow arthroplasty (TEA) in patients with end-stage hemophilic arthropathy.

Methods

From 2002 to 2012, 13 primary TEAs (Coonrad-Morrey design) were implanted in 9 consecutive patients with an average age of 55 (range, 39-76) years. Type A hemophilia was diagnosed in 7 patients and type B hemophilia in 2 patients. Clinical and radiographic results of all (11 TEAs) but 1 patient were retrospectively analyzed.

Results

After a mean of 9.1 (range, 5-14) years, the mean visual analog scale score for pain, total Mayo Elbow Performance Score, and subjective elbow value were significantly improved from 5 (standard deviation, ±3) to 2 (±2; P = .007) points, from 64 (±16) to 89 (±11; P = .008) points, and from 47% (±15%) to 81% (±11%; P < .001), respectively. Whereas the flexion arc remained unchanged (P = .279), mean active pronation improved significantly (P = .024). Postoperative complications were recorded in 8 TEAs (62%), whereas 5 TEAs (38%) underwent partial component exchange after a mean of 7.2 (range, 3-10) years: 2 for periprosthetic infection, 2 for polyethylene wear, and 1 for humeral component loosening. Of the living patients after partial component exchange (n = 3), the mean final total Mayo Elbow Performance Score, flexion and rotation arc, visual analog scale score for pain, and subjective elbow value were comparable with the results of the living patients without revision surgery (n = 8).

Conclusion

TEA for patients with advanced hemophilic arthropathy is associated with a substantial complication and revision rate. However, even after revision without implant removal, it provides good functional and subjective long-term results.

Are commercially-available precontoured anatomical clavicle plating systems offering the purported superior optimum fitting to the clavicle? A cadaveric analysis and review of literature

Purpose: The indication for operative treatment of displaced midshaft clavicle fractures remains controversial. However, if plate fixation is considered, implant prominence and skin irritation are the most common causes for re-operation. Low profile implants as well as closely contouring plates to the individual anatomy may reduce these complications. The aim of this study was to compare the fitting accuracy and implant prominence of 3.5mm pelvic reconstruction plates (PRP) with pre-contoured anatomical clavicle plates (PACP) for midshaft clavicle fractures.

Methods

Methods: Three-dimensional data of the largest, median and smallest male and female clavicle of an existing database of 89 cadaveric clavicles were included for analysis. A three-dimensional model of a commercially available PACP was used for digitally positioning of the plate on the segmented clavicles. Three-dimensional printouts of each clavicle were produced and the 3.5mm reconstruction plates were manually bent and positioned by the senior author. Computed tomography scans and three-dimensional reconstructions were then obtained to digitally compare the fitting accuracy and implant prominence.

Results

Results: Pelvic reconstruction plates offered superior fitting accuracy and lower implant prominence compared to PACP. The largest difference in implant prominence was observed in large sized female clavicles and measured 3.6mm.

Conclusion

Conclusion: Both, the less costly PRP plates and commercially available PACP for midshaft fractures of the clavicle demonstrated a clinically acceptable fitting accuracy. The manually bent pelvic-reconstruction plates demonstrated reduced implant prominence with superior fitting. Hypothetically this might contribute to a reduced rate of reoperation.

Useful Functional Outcome Can Be Achieved After Motor Nerve Transfers in Management of the Paralytic Hand. An Observational Study

Methods

Nerve transfers have demonstrated encouraging outcomes in peripheral nerve reconstructions compared with the conventional direct repair or grafting. We aimed to identify whether the patient’s demographics, delay to surgery, degree of loss of grip and pinch strengths, mechanism of injury, and compliance to hand therapy have an impact on the functional outcome of motor nerve transfers in patients with paralytic hand.

Fifty-five patients with a mean age of 31.05 (18–48) years with complete isolated high injuries of radial, ulnar, and median nerves, who underwent motor nerve transfers, were reviewed. The outcome was assessed using the Medical Research Council (MRC) scale and measurement of grip and pinch strengths of the hand at minimum 1-year follow-up (mean of 14.4 (12–18) months). Patient’s age and gender, delay to surgery, body mass index (BMI), degree of loss of grip and pinch strengths, educational level, occupation, mechanism of injury, and compliance to hand therapy were analyzed to determine their impact on the extent of recovery of hand function.

Results

Forty of fifty five (72.73%) patients regained useful functional recovery (M3–M4) with satisfactory grip hand functions. Worse motor recovery was observed in older ages, delayed surgical intervention, higher BMI, and greater postoperative loss of grip and pinch strengths in comparison to the healthy opposite hand. Better outcomes are significantly associated with higher educational level and postoperative compliance to hand therapy. Contrarily, there was no significant association between gender, occupation, mechanism of injury, and achievement of useful functional recovery.

 

Conclusion

Successful nerve transfers are expected with experienced skilled surgeons. However, outstanding outcomes are not the standard, with about one fourth failing to achieve M3 grade. The educational level, hand dominance, compliance to hand therapy, loss of grip and pinch strengths, age, injury-surgery interval, and BMI are possible predictors of patients’ outcome.