To analyze the learning curves of 5 experienced, fellowship-trained shoulder surgeons and their respective 25 first arthroscopic Latarjet cases in regard to surgical time, graft placement, ...complication rates, and recurrent instability.
The first 25 arthroscopic Latarjet procedures of 5 surgeons were retrospectively analyzed in an international multicenter setting, and thus 125 patients were included in this study. The surgical time, intraoperative and postoperative events out of the ordinary, and graft positioning were examined.
The 125 patients consisted of 16 women (12.8%) and 109 men (87.2%). In 81.6% (n = 102), surgery was undertaken as a first-line procedure, whereas 18.4% (n = 23) were revisions. Surgical time decreased significantly from an average of 123.8 minutes (range 70 to 210) to 92.6 minutes (range 50 to 160) from the first 5 cases to the last 5 cases of each surgeon within a period of <2 years. Overall, 22 events in 21 patients requiring additional treatment were reported (17.6%). Five (4%) were unlikely to affect final outcome and did not require revision surgery. Twelve (9.6%) required revision surgery that was not trauma related yet was prone to affect outcomes. Five events were trauma-related (4%), 4 requiring revision surgery and 1 treated conservatively. Overall, 6 patients (4.8%) had recurrent shoulder instability, 3 as a result of a traumatic event. Conventional radiology showed the bone-block in ideal positioning in 93 cases (74.4%), flush with the glenoid in a true anteroposterior view. In 3 cases (2.4%), it was considered too high, 15 too low (12%), 5 too lateral (4%), and 15 too medial (12%). Some patients had combinations of the above.
This analysis shows that surgical time in arthroscopic Latarjet can be significantly reduced after only 20 cases. However, complication rates did not decrease over this time. The authors believe that the arthroscopic Latarjet is a challenging yet viable technique to treat anterior shoulder instability, achieving results equal to the open technique with advantages of the arthroscopic setting.
Level IV, retrospective cohort study.
The role of bipolar radial head prostheses (RHP) in elbow fracture-dislocation is controversial, with some reports of poorer stabilization than with monopolar designs. The aim of the present study ...was to compare mono- versus bi-polar RHPs in elbow fracture-dislocation. The study hypothesis was that mono- and bi-polar RHPs do not differ in clinical and radiological results, complications or revision rates.
A single-center retrospective study included 58 patients, with a mean age of 55 years (range, 21–84 years). All received RHP for elbow dislocation with association: terrible triad, Monteggia fracture-dislocation, transolecranal dislocation or divergent dislocation. Two groups were compared: Mono-RHP, with monopolar prosthesis (n=40), and Bi-RHP, with bipolar prosthesis (n=18). All patients underwent clinical and radiological examination at last follow-up.
Mean follow-up was 42.7 months (range, 12–131 months). There were no significant (p>0.05) inter-group differences in range of motion or Mayo Elbow Performance Score. Mono- versus bi-polar design did not correlate with onset of complications (p=0.89), surgical revision (p=0.71), persistent or recurrent instability (p=0.59), or ulnohumeral (p=0.62) or capitulum (p=0.159) osteoarthritis at last follow-up.
No differences were found between mono- and bi-polar RHPs in the treatment of elbow fracture-dislocation. Clinical and radiographic results were similar, as were complications and revision rates. The literature is inconclusive, reporting contradictory conclusions. We see no contraindications to bipolar RHPs in elbow dislocation with association, notably terrible triad injury.
III, Retrospective case-control study.
Purpose
The two-dimensional fluoroscopic method of percutaneous pedicle screw instrumentation has been clinically described as reliable method in the caudal thoracic and lumbosacral spine. Its ...accuracy has not been clearly reported in the cranial thoracic spine. The aim of this in vitro study was to investigate percutaneous pedicle screw placement accuracy according to pedicle dimensions and vertebral levels.
Methods
Six fresh-frozen human specimens were instrumented with 216 screws from T1 to S1. Pedicle isthmus widths, heights, transversal pedicles and screws were measured on computed tomography. Pedicle cortex violation ≥ 2 mm was defined as screw malposition.
Results
The narrowest pedicles were at T3–T5. A large variability between transversal pedicle axes and percutaneous pedicle screw was present, depending on the spinal level. Screw malposition rates were 36.1% in the cranial thoracic spine (T1–T6), 16.7% in the caudal thoracic spine (T7–T12), and 6.9% in the lumbosacral spine (L1–S1). The risk for screw malposition was significantly higher at cranial thoracic levels compared to caudal thoracic (
p
= 0.006) and lumbosacral (
p
< 0.0001) levels. Cortex violation ≥ 2 mm was constantly present if the pedicle width was < 4.8 mm.
Conclusion
Percutaneous pedicle screw placement appears safe in the caudal thoracic and lumbosacral spine. The two-dimensional fluoroscopic method has a limited reliability above T7 because of smaller pedicle dimensions, difficulties in visualizing radiographic pedicle landmarks and kyphosis.
Purpose The aim of this study was to identify specific complications of locking plate fixation of proximal humerus fractures. Patients and Methods Seventy-threee adult patients with a displaced 3- ...(24%) or 4-part (76%) fracture of the proximal humerus were treated over a period of 2 years under the supervision of a trauma surgeon. Fourty-four patients came back for a clinical and radiographic examinations at least 18 months after the trauma; the others were evaluated at 6 weeks and 3 and 6 months. Results Out of the 73 patients (64.4% females, mean age of 65), 11 patients needed a second surgery and 18 were lost for follow-up after 6 months. Mean final constant score was 62.3 points. The incidence of secondary displacement was 8.2%. Nonunion rate was 5.5%, affecting the constant score ( P = .018). 16.4% of the patients developed a partial necrosis of the humeral head at the latest follow-up, which influenced on the constant score ( P = .029). Quality of the reduction of the greater tuberosity influenced final results ( P = .037). Screw cutout rate was 13.7%, with an influence to the constant score ( P = .001). A too high plate positioning influenced the constant score ( P = .002). Conclusion Locked screw-plates provide more secure fixation of fractures, especially in weak bone. Complications rate remains high. Two complications are to be distinguished: 1) technical complications in plate positioning, length of the screws or secondary screw cutout strongly influence the final clinical result; and 2) specific complications related to this technology such as pseudarthrosis or plate fracture.
Introduction
The medial head of the triceps brachii flap is already described as a local muscular or as a free flap. It allows coverage of defects of the posterior cubital region. The aim of this ...study was to describe the vascular anatomy of the musculocutaneous medial triceps brachii pedicled flap.
Methods
Eleven fresh–frozen upper limbs (6 come from women and 5 from men) were proximally injected with Indian ink agar solution. The medial head of the triceps brachii muscle was dissected and the superior ulnar collateral artery (SUCA) was isolated with its collaterals. The collateral arteries were dissected to determine whether there were septocutaneous or musculocutaneous arteries for vascularization of the skin in front of the medial head. Lengths of those collaterals arteries were measured.
Results
The average number of collaterals arteries from the SUCA supplying the medial head of the triceps brachii is 4.5 (from 3 to 6 arteries). Among these collaterals’ arteries, there are one average 1.5 (0.6–4.5) septocutaneous arteries and 3 (1–4.8) musculocutaneous arteries.
Discussion and conclusion
A musculocutaneous flap with the medial head of the triceps brachii muscle can be described with the muscle. The SUCA gives perforator arteries musculocutaneous and septocutaneous for the vascularization of the triceps brachii medial head. The use of local pedicled flap with similar tissue maximizes healing with a minimal morbidity of the donor site. This study demonstrated the feasibility of the medial head triceps brachii musculocutaneous flap to cover defect of the posterior aspect of the elbow.
Background In a retrospective multicenter study, we evaluated the efficiency and outcomes of the different therapeutic options for infection after reversed shoulder arthroplasty. Methods Thirty-two ...patients were reoperated on for infection after reversed shoulder arthroplasty between 1996 and 2011. The mean age was 71 (55-83) years. The involved implants were primary prostheses in 23 cases and revision prostheses in 9 cases. The average preoperative Constant score was 34 (11-69). Six of these patients needed 2 successive procedures. A total of 38 procedures were performed: débridement (13), 1-stage (5) or 2-stage revision (14), or implant removal (6). At last follow-up (mean, 36 months; range, 12-137 months), every patient had clinical, biologic, and radiographic evaluation. Results Infections were largely caused by coagulase-negative staphylococci (56%) and Propionibacterium acnes (59%). The complication rate was 26%. At last follow-up, 26 patients were free of infection (81%). The final Constant score was 46 (12-75). After débridement with implant retention, the mean Constant score was 51 (29-75), but the healing rate was only 54%. Implant revision (1 or 2 stage) led to better functional results than implant removal (46 vs. 25; P = .001), with similar healing rates (73% and 67%, respectively). Patients with low initial impairment (Constant score > 30) were not significantly improved by surgical treatment. Conclusion Débridement is the less aggressive option but exposes patients to healing failure. It should be proposed as a first treatment attempt. Revision of the implant is technically challenging but preserves shoulder function, with no higher rate of residual infection compared with implant removal.
Purpose
Despite their functional importance, the infraspinatus (ISP) and teres minor (TM) muscles have been little investigated. This study aimed to describe the macroscopic morphology, innervation, ...and inter-relations of the ISP and TM muscles.
Methods
Forty fresh cadaver dissections and histologic analysis were performed. Three groups of specimens were distinguished according to the rotator cuff tendon status: (1) intact rotator cuff; (2) supraspinatus tendon tears with intact ISP tendon; and (3) both supraspinatus and ISP tendons torn. Muscle fiber organization and muscle and tendon length were recorded. ISP and TM innervation and fiber structure were studied.
Results
ISP muscles were composed of three groups of fiber organized in two planes: two superficial groups, with mean pennation angles of, respectively, 27° ± 4° and 23° ± 3° with respect to the axis of the central tendon of the underlying group. TMs were thick fusiform muscles showing a parallel organization; 26 specimens (67 %) had aponeuroses isolating the TM, with a mean length of 5.2 ± 2.7 cm. Rotator cuff lesions were associated with relatively greater ISP tendon than muscle length. Innervation of the ISP muscle comprised 2–4 main branches from the suprascapular nerve and that of the TM 1 branch from the axillary nerve.
Conclusion
ISP muscle body morphology derives from three groups of fibers in two planes. The TM has a parallel organization. Several nerve branches innervate the ISP muscle, whereas only one supplies the TM. The limits between the two muscles bodies consist of an aponeurotic fascia in two-thirds of cases.
Background. The indications for reverse shoulder arthroplasty (RSA) have been widely expanded, but only a few studies report the long-term survival of these implants. Our objective was to report the ...long-term survivorship of a large series of RSAs implanted for different etiologies. Methods. A retrospective multicenter study including all the RSAs was performed in six shoulder-specialized centers with at least 2 years of follow up. We reviewed 1611 RSAs, operated between 1993 and 2010, including 497 cuff-tear arthropathies (CTA), 239 revision RSAs, 188 massive cuff tears (MCT), 185 fracture sequelae (FS), 183 failed previous cuff repairs (FCR), and 142 primary osteoarthritis (POA). The mean follow-up was 5.6 ± 3.9 years (range 2−20). Results. Overall, 266 RSAs (16.5%) had at least one complication leading to 64 reoperations (4.0%) and 110 revision surgeries (6.8%). The most frequent complications were infection (3.8%), instability (2.8%), and humerus-related complications (2.8%). At 10 years, the survival without revision surgery was 91.0% in primary RSAs and 80.9% in revision RSAs for failed arthroplasty (p < 0.001). In the primary RSA group, MCT and FCR led to 10-year survivals for over 95% but fracture sequelae and tumors had the lowest 10-year survivals (83.9% and 53.1%). Younger patients had a lower 10-year survival. In revision RSAs, male patients had a significantly lower survival than females (72.3% vs. 84.5% at 10 years, p = 0.020). Discussion. Primary RSA for cuff-deficient shoulders or POA leads to a high 10-year survival, but revision RSA or primary RSA for FS and tumors are at high-risk for revision. Surgeons should be aware of high rates of complications and lower survival rates of RSA in younger patients, in males, and in RSAs for revision surgery.
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