Hombro/Shoulder/Schulter/Épaule: cuando hay suficientes razones para descomprimir el espacio subacromial

A preoperative scoring system to select patients for arthroscopic subacromial decompression.

Singh HP, Mehta SS, Pandey R

J Shoulder Elbow Surg 2014 Sep; 23(9):1251-6.

Abstract

BACKGROUND

This study investigated the clinical and radiographic factors that influence outcome after arthroscopic subacromial decompression (ASAD) for shoulder impingement syndrome. The goal was to develop a new preoperative scoring system to identify patients who would have a prompt and sustained benefit from ASAD.

METHODS

We prospectively reviewed 112 consecutive patients with impingement syndrome who subsequently underwent ASAD. The Oxford Shoulder Score (OSS) was recorded preoperatively and 3 and 12 months postoperatively. A statistically significant improvement in OSS at 3 months after surgery was considered a good outcome.

RESULTS

The variables associated with good outcome were shoulder pain with overhead activities, persistent symptoms for more than 6 months, symptoms persistent despite a 3-month course of supervised physiotherapy, consistently positive Hawkins test result, radiologic changes of impingement on both acromion and humerus in the subacromial region, and improvement for more than 1 week after a steroid injection. These 6 criteria were combined into a single score for this study, termed the preoperative score (PrOS). Sixty-two patients who had been symptomatic for 1 year with a preoperative score of 5 to 6 showed significant improvement in OSS at 3 months after surgery (P < .001). Thirty-eight patients with a score 3 to 4 had no statistically significant improvement in OSS at 3 months but had a further slight improvement at 1 year. Twelve patients with a score of ≤2 had no significant improvement in OSS at 3 months or 1 year.

CONCLUSION

This scoring system can identify patients who would have a prompt benefit from ASAD. The impact of surgery in patients with a PrOS of ≤4 points is questionable.

ADDENDUM

http://www.ouh.nhs.uk/shoulderandelbow/information/documents/OxfordShoulderScore.pdf

Cadera/Hip/Hüfte/Hanche: El hundimiento del vástago femoral tiene un tope

Loosely implanted cementless stems may become rotationally stable after loading.
Kannan A1, Owen JR, Wayne JS, Jiranek WA.
Clin Orthop Relat Res. 2014 Jul;472(7):2231-6

Abstract

BACKGROUND:
Experimental studies have suggested that initial micromotion of cementless components may lead to failure of osteointegration. Roentgen stereophotogrammetric analyses have shown durable implant fixation can be achieved long-term even when initial instability exists, as evidenced by subsidence. However improved implant stability as a result of subsidence, before osteointegration, has not been shown biomechanically.

QUESTIONS/PURPOSES:
We asked whether insertionally loose cementless tapered femoral stems show (1) less rotational stability (more toggle); (2) more subsidence; and (3) reduced ability to resist torsion (lower initial construct stiffness), lower torque at failure, and greater rotation to failure in comparison to well-fixed cementless tapered femoral stems.

METHODS:
Ten matched pairs of cadaveric femurs were implanted with well-fixed and loose cementless tapered stems. The loose stem construct was obtained by appropriately broaching the femur but afterwards inserting a stem one size smaller than that broached. Femoral stem rotational stability of implanted femurs was tested by measuring the angular rotation (ie, toggle) required to produce a torque of 2 N-m at 0 N, 250 N, and 500 N vertical load in 25° adduction simulating single-legged stance. Subsidence was measured as vertical movement during the toggle tests. Then at 500 N initial vertical load, femoral stems were externally rotated to failure. The construct stiffness between 5 and 40 N-m was determined to assess ability to resist torsion. The torque and rotation to failure were recorded to compare failure characteristics. Groups were compared using mixed model ANOVA followed by Tukey-Kramer post hoc pairwise comparison for toggle and subsidence tests and by Student's paired t-tests for stiffness, torque at failure, and rotation to failure tests.

RESULTS:
Loose tapered cementless stems were less stable (ie, more toggle) than well-fixed at 0 N of load (p < 0.0001), but no difference was detectable in toggle between loose and well-fixed stems at 250 N (p = 0.7019) and 500 N (p = 0.9970). Loose tapered cementless stems showed significant subsidence at 250 N (p < 0.0001) and 500 N (p < 0.0001), which was not found in the well-fixed stems at 250 N (p = 0.8813) and 500 N (p = 0.1621). Torsional stiffness was lower for loose stems as compared with well-fixed stems (p = 0.0033). No difference in torque at failure (p = 0.7568) or rotation to failure (p = 0.2629) was detected between loose and well-fixed stems.

CONCLUSIONS:
In this study, we observed that insertionally loose cementless stems have the ability to subside and become rotationally stable with loading. They did not exhibit a lower torque or rotation to failure in comparison to well-fixed stems when under simulated single-legged stance.

Trauma: Tardar mucho operando se complica con infección

Surgical site infection after open reduction and internal fixation of tibial plateau fractures.
Lin S, Mauffrey C, Hammerberg EM, Stahel PF, Hak DJ.
Eur J Orthop Surg Traumatol. 2014 Jul;24(5):797-803

Abstract

OBJECTIVE:
The aim of this study was to identify risk factors for surgical site infections and to quantify the contribution of independent risk factors to the probability of developing infection after definitive fixation of tibial plateau fractures in adult patients.

METHODS:
A retrospective analysis was performed at a level I trauma center between January 2004 and December 2010. Data were collected from a review of the patient's electronic medical records. A total of 251 consecutive patients (256 cases) were divided into two groups, those with surgical site infections and those without surgical site infections. Preoperative and perioperative variables were compared between these groups, and risk factors were determined by univariate analyses and multivariate logistic regression. Variables analyzed included age, gender, smoking history, diabetes, presence of an open fracture, presence of compartment syndrome, Schatzker classification, polytrauma status, ICU stay, time from injury to surgery, use of temporary external fixation, surgical approach, surgical fixation, operative time, and use of a drain.

RESULTS:
The overall rate of surgical site infection after ORIF of tibial plateau fractures during the 7 years of this study was 7.8% (20 of 256). The most common causative pathogens was Staphylococcus aureus (n=15, 75%). Independent predictors of surgical site infection identified by multivariate analyses were open tibial plateau fracture (odds ratio=3.9; 95% CI=1.3-11.6; p=0.015) and operative time (odds ratio=2.7; 95% CI=1.6-4.4; p<0.001). The presence of compartment syndrome (odds ratio=3.4; 95% CI=0.7-15.9; p=0.119), use of temporary external fixation (odds ratio=0.5; 95% CI=0.2-1.7; p=0.298), and ICU stay (odds ratio=1.0; 95% CI=1.0-1.1; p=0.074) were not determined to be independent predictors of surgical site infection.

CONCLUSIONS:
Both open fracture and operative time are independent risks factors for postoperative infection.

Trauma: Más grande no es mejor

A biomechanical comparison between locked 3.5-mm plates and 4.5-mm plates for the treatment of simple bicondylar tibial plateau fractures: is bigger necessarily better?
Hasan S, Ayalon OB, Yoon RS, Sood A, Militano U, Cavanaugh M, Liporace FA.
J Orthop Traumatol. 2014 Jun;15(2)

Abstract

BACKGROUND:
Evolution of periarticular implant technology has led to stiffer, more stable fixation constructs. However, as plate options increase, comparisons between different sized constructs have not been performed. The purpose of this study is to biomechanically assess any significant differences between 3.5- and 4.5-mm locked tibial plateau plates in a simple bicondylar fracture model.

MATERIALS AND METHODS:
A total of 24 synthetic composite bone models (12 Schatzker V and 12 Schatzker VI) specimens were tested. In each group, six specimens were fixed with a 3.5-mm locked proximal tibia plate and six specimens were fixed with a 4.5-mm locking plate. Testing measures included axial ramp loading to 500 N, cyclic loading to 10,000 cycles and axial load to failure.

RESULTS:
In the Schatzker V comparison model, there were no significant differences in inferior displacement or plastic deformation after 10, 100, 1,000 and 10,000 cycles. In regards to axial load, the 4.5-mm plate exhibited a significantly higher load to failure (P = 0.05). In the Schatzker VI comparison model, there were significant differences in inferior displacement or elastic deformation after 10, 100, 1,000, and 10,000 cycles. In regards to axial load, the 4.5-mm plate again exhibited a higher load to failure, but this was not statistically significant (P = 0.21).

CONCLUSIONS:
In the advent of technological advancement, periarticular locking plate technology has offered an invaluable option in treating bicondylar tibial plateau fractures. Comparing the biomechanical properties of 3.5- and 4.5-mm locking plates yielded no significant differences in cyclic loading, even in regards to elastic and plastic deformation. Not surprisingly, the 4.5-mm plate was more robust in axial load to failure, but only in the Schatzker V model. In our testing construct, overall, without significant differences, the smaller, lower-profile 3.5-mm plate seems to be a biomechanically sound option in the reconstruction of bicondylar plateau fractures.

Trauma: Condromalacia después de los hundimientos de meseta tibial

Second-look arthroscopy after surgical treatment of Schatzker type II plateau fractures through the lateral submeniscal approach.
Lee HJ, Jung HJ, Chang EC, Lee JS, Jung HS.
Arch Orthop Trauma Surg. 2014 Apr;134(4):495-9

Abstract

MAIN PROBLEM:
To evaluate cartilage healing using second-look arthroscopic examination in tibia plateau fracture patients who have undergone open reduction and internal fixation with a submeniscal approach technique.

METHODS:
Between January 2007 and January 2010, we used second-look arthroscopy during 18-24-month follow-up of 20 patients with Schatzkar type II tibial plateau fractures who had undergone open reduction and internal fixation with a submeniscal approach technique. We classified patients according to step-off, knee range of motion, and Knee Society Score, and compared the results with those obtained by arthroscopy.

RESULTS:
Radiologically, 16 cases (80 %) were reduced within 2 mm of step-off. In 11 of these cases, according to the Outerbridge classification, we checked for chondromalacia from grade II to III. We observed 2 mm of step-off in four cases, and each had chondromalacia of at least grade III. The Knee Society Score was associated with chondromalacia grade (p < 0.05).

CONCLUSION:
Even in patients with normal joint range of motion and good clinical and radiological results, the actual condition of the articular cartilage varied significantly. Therefore, more long-term and regular follow-up is needed for proximal plateau fractures.

Trauma: Un balón para recuperar la forma

Reduction and Stabilization of Depressed Articular Tibial Plateau Fractures: Comparison of Inflatable and Conventional Bone Tamps: Study of a Cadaver Model.

Heiney JP, Kursa K, Schmidt AH, Stannard JP

J Bone Joint Surg Am 2014 Aug 6; 96(15):1273-1279

BACKGROUND

Restoration of articular congruity and mechanical integrity of subchondral bone are important surgical goals of the treatment of intra-articular fractures. The purpose of this study was to compare the reduction quality and biomechanical integrity between cadaveric intra-articular tibial plateau fractures reduced with an inflatable bone tamp and contralateral fractures reduced with a series of cylindrical conventional metal bone tamps.

METHODS

A standardized lateral tibial plateau split-depression fracture was created in each leg of fourteen pairs of cadaver legs. In each pair, the fracture on one side was reduced under fluoroscopy with use of an inflatable bone tamp and the fracture on the contralateral, control side was reduced with conventional bone tamps and a mallet. Any residual bone defects were filled with calcium phosphate bone-void filler. The constructs were stabilized with a lateral tibial plateau buttress plate. Each articular reduction was qualitatively graded by blinded observers using fluoroscopic images, three-dimensional computed tomography (CT) scans, and visual inspection of the articular surface. Quantitative volumetric analysis was performed to calculate under-reduction, over-reduction, and total malreduction volumes. Each reduced fracture was cyclically loaded and then statically loaded to failure under axial compression, and the strength and stiffness of the constructs were compared between sides.

RESULTS

The majority (eleven) of the fourteen fractures reduced with the inflatable bone tamp were rated as having a better reduction than the contralateral fracture reduced with the conventional bone tamps. The median over-reduction and malreduction in the inflatable-tamp group (7% and 21.6%, respectively) were significantly less than those in the conventional-tamp group (19.2% and 47.1%), although the median under-reduction (6.2% in the inflatable-tamp group and 9.6% in the conventional-tamp group) did not differ significantly between groups. The fractures reduced with the inflatable tamp displaced less during cyclic loading than those reduced with the conventional tamp. Median static stiffness and yield load were also significantly higher in the inflatable-tamp group (880 N/mm and 704 N) than in the conventional-tamp group (717 N/mm and 641 N).

CONCLUSIONS

As compared with contralateral control fractures treated with conventional bone tamps, fractures treated with an inflatable bone tamp had qualitatively and quantitatively better reduction, typically resulting in a smoother articular surface with less residual defect volume. Fractures reduced with an inflatable bone tamp exhibited less subsidence during cyclic loading and greater stiffness under static loading compared with those treated with conventional bone tamps.

CLINICAL RELEVANCE

Using an inflatable bone tamp in association with calcium phosphate bone-void filler to reduce and maintain reduction of an articular fracture may help in achieving the surgical goal of a more anatomic reduction with better resistance to subsidence.

Trauma: ¿Qué poner antes, el substituto óseo o los tornillos?

Bone substitute first or screws first? A biomechanical comparison of two operative techniques for tibial-head depression fractures.

Hoelscher-Doht S, Jordan MC, Bonhoff C, Frey S, Blunk T, Meffert RH

J Orthop Sci 2014 Aug 12.

Abstract

BACKGROUND

The aim of this study was to investigate a drillable and injectable bone substitute (calcium phosphate cement) and the operative technique enabled by the drillable option in a new biomechanical fracture model for tibial depression fractures in synthetic bones.

MATERIALS AND METHODS

Lateral depression fractures of the tibial plateau (AO 41-B2, Schatzker III) were created in a biomechanical fracture model in three different synthetic bones (Sawbone 3401, Synbone 1110/1116). Reproducible fractures were generated employing Synbone 1110, which exhibited a comparable strength to human osteoporotic bones and was used for the further experiments. After reduction of the fractures, the stabilization was performed with two different operative techniques. In group 1, first an osteosynthesis with four screws was performed and then the metaphyseal defect was filled up with calcium phosphate cement (Norian drillable). In group 2, initially the filling up with Norian drillable was done enabling a complete filling of the defect, followed by placing of the screws. Displacement under cyclic loading with 250 N for 3,000 cycles, stiffness, and maximum load in load-to-failure tests were determined.

RESULTS

A comparison of the two operative techniques of stabilization showed a distinctly lower displacement and higher stiffness for group 2 when the defect was filled up first. For the maximum load, no significant differences could be demonstrated.

CONCLUSIONS

A complete filling of the defect by first applying the calcium phosphate cement significantly reduces the secondary loss of reduction of the depression fracture fragment under cyclic loading with a clinically relevant partial weight bearing. The beneficial effects of drillable calcium phosphate cement may also be transferable to defects other than tibial-head depression fractures.

Cadera/Hip/Hüfte/Hanche: Qué le espera el paciente joven tras una prótesis total de cadera

Mid-to long-term results of revision total hip replacement in patients aged 50 years or younger 
Lee, P. T. H., Lakstein, D. L., Lozano, B., Safir, O., Backstein, J., Gross, A. E.
Bone Joint J 2014;96-B:1047–51.

Revision total hip replacement (THR) for young patients is challenging because of technical complexity and the potential need for subsequent further revisions.

We have assessed the survivorship, functional outcome and complications of this procedure in patients aged < 50 years through a large longitudinal series with consistent treatment algorithms.
Of 132 consecutive patients (181 hips) who underwent revision THR, 102 patients (151 hips) with a mean age of 43 years (22 to 50) were reviewed at a mean follow-up of 11 years (2 to 26) post-operatively. We attempted to restore bone stock with allograft where indicated.

Using further revision for any reason as an end point, the survival of the acetabular component was 71% (sd 4) and 54% (sd 7) at ten- and 20 years. The survival of the femoral component was 80% (sd 4) and 62% (sd 6) at ten- and 20 years. Complications included 11 dislocations (6.1%), ten periprosthetic fractures (5.5%), two deep infections (1.1%), four sciatic nerve palsies (2.2%; three resolved without intervention, one improved after exploration and freeing from adhesions) and one vascular injury (0.6%). The mean modified Harris Hip Score was 41 (10 to 82) pre-operatively, 77 (39 to 93) one year post-operatively and 77 (38 to 93) at the latest review.

This overall perspective on the mid- to long-term results is valuable when advising young patients on the prospects of revision surgery at the time of primary replacement.

Rodilla/Knee/Knie/Genou: Monocitos para establecer una sinovitis por desgaste del polietileno

Synovial fluid differential cell count in wear debris synovitis after total knee replacement
Ran Schwarzkopf , Evan M. Carlson , Meagan E. Tibbo , Lee Josephs , Richard D. Scott
The Knee: Available online 28 July 2014

Background
Determining the cause of synovitis following total knee arthroplasty (TKA) can be challenging. The differential diagnoses include infection, hemarthrosis, instability, crystalline disease, wear debris or idiopathic causes. Wear particle synovitis can mimic periprosthetic infection with symptoms of pain and effusion. Radiographs and physical exam are often inconclusive in differentiating the two. Synovial fluid analysis is routinely used in evaluating periprosthetic infections. We examined the association between synovial white blood cell count and differentials, and polyethylene wear and osteolysis, to see if fluid analysis can aid in establishing the diagnosis of wear particle synovitis.

Methods
A cell count and differential was obtained from synovial fluid samples from 54 TKAs undergoing revision for aseptic failure. Explanted polyethylene inserts were analyzed for linear and volumetric wear, oxidation (ketone peak height), and damage features. Analysis was performed to assess the relationship between cell counts and polyethylene wear indicators as well as severity of intra-operative and radiographic osteolysis.

Results
Total and percent mononuclear (monocyte and lymphocyte) cell counts were found to be elevated in the presence of documented wear debris synovitis and an association was suggested between their levels and maximum ketone levels.

Conclusion
The present study implies that the differential cell count of knee fluid can help distinguish wear debris from infection as a source of synovitis following TKA and identifies the value of the mononuclear cell count as a possible tool to assess abnormal wear rates of the polyethylene insert. Further research into identifying the exact role of monocytes in the wear debris synovitis and osteolytic pathways is warranted.

Level of evidence
Level II, diagnostic study.

Rodilla/Knee/Knie/Genou: ¿Qué haces si se te cae al suelo la plastia reconstruyendo un LCA?

When the tendon autograft drops accidently on the floor: A study about bacterial contamination and antiseptic efficacy

O. Barbier, J. Danis, G. Versier, D. Ollat

The Knee

Available online 11 August 2014

Abstract

Background

Inadvertent contamination of the autograft could occur during ACL reconstruction if the autograft drops on the floor during surgery. A study was undertaken to determine the incidence of contamination when a graft dropped on the operating room floor and the efficacy of antimicrobial solutions to decontaminate it.

Methods

Samples from 25 patients undergoing ACL reconstruction with a hamstring tendon were sectioned and dropped onto the floor. Cultures were taken after immersion in an antiseptic solutions (a chlorhexidine gluconate solution (group 1), a povidone-iodine solution (group 2), a sodium-hypochlorite solution (group 3). A fourth piece (group 0) was cultured without being exposed to any solution. Cultures of a floor swab were taken at the same time.

Results

The floor swab cultures were positive in 96% of cases. The rate of contamination was 40% in group 0, 8% in group 1, 4% in group 2, and 16% in group 3. There was a significant difference between groups 1–2 and 0 (p < 0,05) but not between group 3 and 0.

Conclusion

Immersing a graft dropped onto the floor during surgery into in a chlorhexidine gluconate solution or povidone-iodine solution significantly reduces contamination of the graft. Soaking of the hamstring autograft in one of theses solutions is recommended in case of inadvertent contamination.

Clinical relevance: laboratory investigation (level 2)

 

General: El nuevo paradigma de la preartrosis

Osteoarthritis: From Palliation to Prevention: AOA Critical Issues.

Chu CR, Millis MB, Olson SA.

J Bone Joint Surg Am. 2014 Aug 6;96(15):e130. [Epub ahead of print]

Abstract

Osteoarthritis is a leading cause of disability. The traditional focus on late-stage osteoarthritis has not yielded effective disease-modifying treatments. Consequently, current clinical care focuses on palliation until joint replacement is indicated. A symposium format was used to examine emerging strategies that support the transformation of the clinical approach to osteoarthritis from palliation to prevention. Central to this discussion are concepts for diagnosis and treatment of pre-osteoarthritis, meaning joint conditions that increase the risk of accelerated development of osteoarthritis. The presentation of translational and clinical research on three common orthopaedic conditions-anterior cruciate ligament tear, intra-articular fracture, and hip dysplasia-were used to illustrate these ideas. New information regarding the use of novel quantitative magnetic resonance imaging (MRI) in the form of ultrashort echo time enhanced T2* (UTE-T2*) mapping to evaluate the potential for articular cartilage to heal subsurface damage in a mechanically sound environment was presented. These data indicate that improved diagnostics can both identify cartilage at risk and evaluate the effectiveness of early treatment strategies. With use of a new mouse model for intra-articular fracture, it was shown that inflammation correlated to fracture severity and that super-healer mice avoided early posttraumatic osteoarthritis in part through an enhanced ability to dampen inflammation. These findings suggest that there is a role for acute and sustained anti-inflammatory treatment in the prevention of osteoarthritis. For long-term treatment, contemporary gene-therapy approaches may offer an effective means for sustained intra-articular delivery of anti-inflammatory and other bioactive agents to restore joint homeostasis. To illustrate the potential of early treatment to prevent or delay the onset of disabling osteoarthritis, the positive clinical effects on articular cartilage and in long-term clinical follow-up after operative correction of structural abnormalities about the hip highlight the role for targeting mechanical factors in delaying the onset of osteoarthritis. Given that orthopaedic surgeons treat the full spectrum of joint problems, ranging from joint trauma to pre-osteoarthritic conditions and end-stage osteoarthritis, an awareness of the paradigm shift toward the prevention of osteoarthritis is critical to the promotion of improved clinical care and participation in clinical research involving new treatment strategies.

General: Los residentes son como angelitos

Impact of Resident Involvement on Orthopaedic Surgery Outcomes: An Analysis of 30,628 Patients from the American College of Surgeons National Surgical Quality Improvement Program Database.

Edelstein AI, Lovecchio FC, Saha S, Hsu WK, Kim JY.

J Bone Joint Surg Am. 2014 Aug 6;96(15):e131. [Epub ahead of print]

Abstract

BACKGROUND:

Operative procedural training is a key component of orthopaedic surgery residency. The influence of intraoperative resident participation on the outcomes of surgery has not been studied extensively using large, population-based databases.

METHODS:

We identified 30,628 patients who underwent orthopaedic procedures from the 2011 American College of Surgeons National Surgical Quality Improvement Program. Outcomes as measured by perioperative complications, readmission rates, and mortality within thirty days were compared for cases with and without intraoperative resident involvement.

RESULTS:

Logistic regression with propensity score analysis revealed that intraoperative resident participation was associated with decreased rates of overall complications (odds ratio, 0.717 [95% confidence interval, 0.657 to 0.782]), medical complications (odds ratio, 0.723 [95% confidence interval, 0.661 to 0.790]), and mortality (odds ratio, 0.638 [95% confidence interval, 0.427 to 0.951]). Resident presence in the operating room was not predictive of wound complications (odds ratio, 0.831 [95% confidence interval, 0.656 to 1.053]), readmission (odds ratio, 0.962 [95% confidence interval, 0.830 to 1.116]), or reoperation (odds ratio, 0.938 [95% confidence interval, 0.758 to 1.161]). A second analysis by propensity score stratification into quintiles grouped by similar probability of intraoperative resident presence showed resident involvement to correlate with decreased rates of overall and medical complications in three quintiles, but increased rates of overall and medical complications in one quintile. All other outcomes were equivalent across quintiles.

CONCLUSIONS:

Orthopaedic resident involvement during surgical procedures is associated with lower risk of perioperative complications and mortality in the National Surgical Quality Improvement Program database. The results support resident participation in the operative care of orthopaedic patients.

LEVEL OF EVIDENCE:

Therapeutic Level III. 

Trauma: Ojo a las lesiones concomitantes en las fracturas de meseta tibial

Arthroscopy-Assisted Surgery for Tibial Plateau Fractures.
Chen XZ, Liu CG, Chen Y, Wang LQ, Zhu QZ, Lin P.
Arthroscopy. 2014 Aug 12

Abstract

PURPOSE:
This study aimed to summarize the recent clinical outcomes of patients undergoing arthroscopy-assisted reduction and internal fixation (ARIF) for tibial plateau fractures.

METHODS:
A systematic electronic search of the PubMed and Cochrane databases was performed in January 2014. All English-language clinical studies on tibial plateau fractures treated with ARIF that were published after January 1, 2000 were eligible for inclusion. Basic information related to the surgery was collected.

RESULTS:
The search criteria initially identified 141 articles, and 19 studies were included in this systematic review. There were 2 retrospective comparative studies, 16 case series studies, and one clinical series based on a technique note. There were a total of 609 patients in this systematic review, with a mean follow-up time of 52.5 months. The most common fracture types were Schatzker types II and III. Concomitant injuries were common: 42.2% of the patients had meniscal injuries, and 21.3% had anterior cruciate ligament (ACL) injuries. In addition, the status of 90.5% of the patients was classified as good or excellent according to the clinical Rasmussen scoring system, and 90.9% of the patients were satisfied with the treatment. Only 6 severe complications were reported, including one case of compartment syndrome.

CONCLUSIONS:
ARIF is a reliable, effective, and safe method for the treatment of tibial plateau fractures, especially when they present with concomitant injuries.

LEVEL OF EVIDENCE:
Level IV, systematic review of Level III and Level IV studies.

Hombro/Shoulder/Schülter/Épaule: Los espolones acromiales están presentes en el manguito roto doloroso

Three-Dimensional Analysis of Acromial Morphologic Characteristics in Patients With and Without Rotator Cuff Tears Using a Reconstructed Computed Tomography Model.
Fujisawa Y, Mihata T, Murase T, Sugamoto K, Neo M1.
Am J Sports Med. 2014 Aug 12

Abstract

BACKGROUND:
The relationship between rotator cuff tears and acromial shape has yet to be clarified. As a result, the most suitable location for acromioplasty for the treatment of rotator cuff tears is not known.

PURPOSE:
To determine whether any particular change in acromial shape is significantly associated with the presence of rotator cuff tears.

STUDY DESIGN:
Cross-sectional study; Level of evidence, 3.

METHODS:
From 2007 to 2010, we examined 25 consecutive patients with unilateral full-thickness rotator cuff tears who underwent arthroscopic repair and 17 consecutive patients with adhesive capsulitis but intact rotator cuffs who underwent arthroscopic capsular release. Before surgery, a reconstructed 3-dimensional computed tomography model was used to evaluate the acromial structure. Changes in the shape of the affected scapula were qualitatively evaluated relative to the unaffected, contralateral scapula by use of proximity mapping. Differences in acromial structure between affected and unaffected shoulders were assessed at the anterior, lateral, and medial edges and the inferior surface. The association between rotator cuff tear size and change in acromial structure was also evaluated.

RESULTS:
Rates of bony projection at the anterior (>2 mm) and lateral (>3 mm) edges of the acromion in patients with rotator cuff tears were significantly greater compared with rates in patients without rotator cuff tears (P < .01). Tear size was not correlated with changes in acromial structure (P = .37-.73).

CONCLUSION:
Bone spurs at the anterior and lateral edges of the acromion are associated with the presence of full-thickness rotator cuff tears in symptomatic patients.

Cadera/Hip/Hüfte/Hanche: Ahí detrás, hay que pensar en el ligamento redondo

Ligamentum Teres Injuries of the Hip: A Systematic Review Examining Surgical Indications, Treatment Options, and Outcomes.

de Sa D, Phillips M, Philippon MJ, Letkemann S, Simunovic N, Ayeni OR

Arthroscopy. 2014 Aug 12

Abstract

PURPOSE:

Hip arthroscopy is becoming a common technique for the diagnosis and treatment of ligamentum teres pathologic conditions. This systematic review aims to determine the indications/contraindications, treatments, and surgical outcomes for management of ligamentum teres injuries.

METHODS:

We searched EMBASE, MEDLINE, and PubMed databases from 1946 to November 28, 2013 for all relevant English articles pertaining to surgical treatment of the ligamentum teres. A hand search of the reference sections of included articles was performed, and all relevant articles were systematically screened in duplicate, with agreement and descriptive statistics presented.

RESULTS:

We identified 1,016 studies, 9 of which (4 case series and 5 case reports) met our eligibility criteria. These studies had a total of 87 patients (89 hips) who had undergone either arthroscopic debridement (81 patients, 83 hips) or reconstruction with autografting, allografting, or synthetic grafting (6 patients) of a torn ligamentum teres. Major qualifications for surgery included persistent hip pain despite conservative treatment and mechanical symptoms or instability symptoms (e.g., clicking or locking). Advanced arthritis (i.e., radiographic joint space < 2 mm) was the only reported contraindication. Patients were followed postoperatively for 1.5 to 60 months and were assessed using subjective methods (i.e., modified Harris Hip Score [mHHS] and Non-Arthritic Hip Score [NAHS]). Overall, both debridement and reconstruction improved the condition of patients, with a 40% increase in reported postoperative functional scores as well as a reported 89% of patients who were able to return to regular activity/sport.

CONCLUSIONS:

Ligamentum teres debridement is indicated for short-term relief of hip pain caused by partial-thickness tears (type 2) failing conservative management, whereas reconstruction with autografts, allografts, or synthetic grafts may be indicated for type 1 (full-thickness) ligamentum teres tears that are deemed "reparable," cause instability, have failed previous debridement, or a combination of these conditions.

LEVEL OF EVIDENCE:

Level IV, systematic review of Level IV and Level V studies.

Rodilla/Knee/Knie/Genou: La meniscectomía medial parcial no daña tanto tras cinco años

Does Decreased Meniscal Thickness Affect Surgical Outcomes After Medial Meniscectomy?

Kim SJ, Lee SK, Kim SH, Jeong JH, Kim HS, Lee SW, Lee JH, Jung M.

Am J Sports Med. 2014 Aug 12

Abstract

BACKGROUND:

There have been no clinical studies regarding the effect of decreased meniscal thickness on outcomes after meniscectomy.

PURPOSE:

To examine the postoperative outcomes of partial meniscectomy with or without horizontal resection compared with the outcomes of subtotal meniscectomy and to evaluate the influence of decreased thickness of the medial meniscus on outcomes after partial meniscectomy.

STUDY DESIGN:

Cohort study; Level of evidence, 3.

METHODS:

A total of 312 patients who underwent medial meniscectomy were retrospectively reviewed. Patients were divided into 3 groups: group A (n = 84) included patients with partial meniscectomy with vertical resection, group B (n = 140) consisted of those with partial meniscectomy with horizontal resection, and group C (n = 88) included those with subtotal meniscectomy. Clinical function was evaluated by use of the Lysholm knee scoring scale, International Knee Documentation Committee (IKDC) subjective knee evaluation form, and Tapper and Hoover grading system. Radiologic evaluation was performed with the IKDC radiographic assessment scale as well as with measurements of the medial compartment height at the tibiofemoral joint. Preoperative values and postoperative values measured 5 years after operation were assessed.

RESULTS:

Functional outcomes in group C were inferior to those in groups A and B according to the Lysholm knee score (mean ± SD for group A = 96.1 ± 4.7, group B = 94.9 ± 5.2, group C = 84.8 ± 11.4; P < .001), IKDC subjective score (group A = 92.1 ± 6.5, group B = 91.3 ± 8.8, group C = 81 ± 11.4; P < .001), and Tapper and Hoover grading system (P = .003). There was no significant difference in scores between groups A and B. With regard to radiologic evaluation, the IKDC radiographic grade for group C was worse than the grades for groups A and B (P < .001); there was no significant difference between groups A and B. However, the postoperative joint space on the affected side was higher for group A (4.7 ± 0.6 mm) than for groups B (4.3 ± 0.5 mm; P < .001) and C (3.7 ± 0.8 mm; P < .001). The joint space was higher in group B than in group C (P < .001).

CONCLUSION:

Despite joint space narrowing, decreases in meniscal thickness after partial meniscectomy for horizontal tear had no additional adverse effect on 5-year functional and radiographic outcomes compared with conventional partial meniscectomy preserving whole meniscal thickness. In treating horizontal tears of the meniscus, partial meniscectomy with complete resection of the unstable leaf was an effective method in a 5-year follow-up study.:

Rodilla/Knee/Knie: Hay que mejorar los resultados de la plastia de LCA

Nonsurgical or Surgical Treatment of ACL Injuries: Knee Function, Sports Participation, and Knee Reinjury: The Delaware-Oslo ACL Cohort Study.

J Bone Joint Surg Am. 2014 Aug 6;96(15):1233-1241. [Epub ahead of print]

Grindem H, Eitzen I, Engebretsen L, Snyder-Mackler L, Risberg MA.

Abstract

BACKGROUND:

While there are many opinions about the expected knee function, sports participation, and risk of knee reinjury following nonsurgical treatment of injuries of the anterior cruciate ligament (ACL), there is a lack of knowledge about the clinical course following nonsurgical treatment compared with that after surgical treatment.

METHODS:

This prospective cohort study included 143 patients with an ACL injury. Isokinetic knee extension and flexion strength and patient-reported knee function as recorded on the International Knee Documentation Committee (IKDC) 2000 form were collected at baseline, six weeks, and two years. Sports participation was reported monthly for two years with use of an online activity survey. Knee reinjuries were reported at the follow-up evaluations and in a monthly online survey. Repeated analysis of variance (ANOVA), generalized estimating equation (GEE) models, and Cox regression analysis were used to analyze group differences in functional outcomes, sports participation, and knee reinjuries, respectively.

RESULTS:

The surgically treated patients (n = 100) were significantly younger, more likely to participate in level-I sports, and less likely to participate in level-II sports prior to injury than the nonsurgically treated patients (n = 43). There were no significant group-by-time effects on functional outcome. The crude analysis showed that surgically treated patients were more likely to sustain a knee reinjury and to participate in level-I sports in the second year of the follow-up period. After propensity score adjustment, these differences were nonsignificant; however, the nonsurgically treated patients were significantly more likely to participate in level-II sports during the first year of the follow-up period and in level-III sports over the two years. After two years, 30% of all patients had an extensor strength deficit, 31% had a flexor strength deficit, 20% had patient-reported knee function below the normal range, and 20% had experienced knee reinjury.

CONCLUSIONS:

There were few differences between the clinical courses following nonsurgical and surgical treatment of ACL injury in this prospective cohort study. Regardless of treatment course, a considerable number of patients did not fully recover following the ACL injury, and future work should focus on improving the outcomes for these patients.

LEVEL OF EVIDENCE:

Therapeutic Level II

Hombro/Shoulder/Schulter: prótesis de hombro invertida para mayores con fracturas complejas de humero proximal

Treatment of proximal humeral fractures with reverse shoulder arthroplasty in elderly patients.

Iacobellis C, Berizzi A, Biz C, Camporese 

Musculoskelet Surg 2014 Jun 11

BACKGROUND

Proximal humeral fractures in four or even only three parts, with metaphyseal hinge distances of <8 mm, represent a serious and widely debated problem. Reduction is complex and plating is often instable, especially in elderly patients. Failures, sometimes involving necrosis of the head, are frequent. Hemiarthroplasty has long been used for 3- or 4-part complex fractures, even in young patients, although often with sub-optimal results, due to reabsorption of tuberosities. This complication has partly been overcome with reverse shoulder prostheses which, although more invasive than partial ones, may lead to less disappointing results, even in cases of reabsorption of tuberosities. We have data on a homogeneous series of patients treated with reverse shoulder arthroplasty for proximal fractures, with a maximum follow-up of 10 years. The aim of this study was mainly to identify which cases can be selected for effective treatment and which technical aspects are best to adopt.

MATERIALS AND METHODS

There were 33 patients in this study, mean age 76.6 years (range 54-85). Fractures were classified according to Neer. Surgery was undertaken on average 4.4 days after trauma. The deltopectoral approach was used. Sutures were hooked over the major and lesser tubercles for later reduction and fixation after the prosthesis had been applied. This passage was sometimes not possible in cases of serious degeneration of the rotator cuff. One day after surgery, a shoulder brace providing an abducted angle of 15° was applied for 30 days. Patients were re-assessed with DASH and Constant scores (CS), and the ratio between healthy and operated shoulders was calculated. Physical examination was followed by X-rays, mainly to evaluate and classify any infraglenoid scapular notching according to Nerot.

RESULTS

Mean follow-up was 42.3 months (range 10-121). According to the CS, mean pain was 12.6/15 (range 3-15/15), activities of daily living 16.3/20 (range 8-20/20), ROM 21.8 (range 8-32/40) and power 5.4/25 (range 2-12/25). Total mean CS was 56.4 (range 23-80/100). The mean DASH score was 49.7 (range 32-90). The ratio of the CS parameters between opposite and operated shoulders was on average 72.8 % (range 28-90 %). Long-term complications were eight cases of scapular notching (24.2 %) of which four of grade 2 (12.1 %) and four of grade 1 (12.1 %).

CONCLUSIONS

Total reverse prostheses are more invasive because they also compromise the glenoid surface of the scapula, but they do offer good stability, even in cases of damage to the rotator cuff. Reverse prostheses have great advantages as regards to ROM, allowing functional recovery, which is good in cases with re-insertion of tuberosities, and acceptable in cases when tuberosities are not re-inserted or resorbed. In our cases, the first 3 reverse prostheses lasted 10, 8.3 and 7.3 years, and we believe that they will become increasingly long-lived, so that applying them in cases of complex fractures becomes more feasible. We prefer the deltopectoral approach because it can reduce and stabilize possible intra-operative diaphyseal fractures. Possible scapular notching must be foreseen when inserting the glenosphere. We had eight cases (24.2 %), of which four were Nerot grade 1 and four were grade 2. Applying the Kirschner wire in an infero-anterior position allows the glenosphere to be lowered with a tilt of 10°. Reverse prostheses are suitable for 3- or 4-part complex proximal humeral fractures in patients over 65. Prolonged physiokinesitherapy is essential.