Dynamic Sling Research Articles

Cadaveric Biomechanical Study of Partial Glenoid Arthroplasty Versus the Latarjet Procedure for Anterior Glenoid Bone Loss

Background: For severe anterior glenoid bone loss due to recurrent shoulder instability, the Latarjet procedure offers a dynamic sling effect in addition to bone augmentation. Yet, it heavily alters the surrounding anatomy, while fixation and graft union issues are also common. Purpose/Hypothesis: The purpose of this study was to compare a novel printed 3-dimensional (3D) partial glenoid arthroplasty (PGA) implant with the classic Latarjet procedure. It was hypothesized that by replicating the original glenoid geometry and preserving soft tissue anatomy, PGA may better reproduce normal joint kinematics. In addition, the locking screw construct may offer stronger fixation. Study Design: Controlled laboratory study. Methods: A total of 14 matched cadaveric shoulders were tested. The PGA implant was 3D printed in titanium based on preoperative computed tomography. The intact, 25% anterior glenoid bone loss, and postoperative states were tested in the scapular and coronal planes. The following parameters were measured: articular surface area and stepoff, rotational range of motion and the humeral head apex position during rotation, and load and linear stiffness at 25% anterior translation and at 2-mm construct displacement. Results: The baseline dimensions of the glenoid articular surface were comparable between the groups. The articular surface area after PGA was significantly larger (P = .006) with less articular stepoff (P = .030). PGA better approximated the intact state’s external (P = .006) and total (P = .019) rotational range of motion in the scapular plane. The course of the humeral head apex after PGA better followed that of the intact state (P < .001). Resistance against anterior translation after PGA was not significantly different compared with after the Latarjet procedure. Greater linear stiffness (P = .031) and loading (P = .002) at 2-mm construct displacement were demonstrated in the PGA group. Conclusion: In addressing anterior glenoid bone loss, PGA better approximated intact glenohumeral joint kinematics compared with the Latarjet procedure with less articular stepoff in a cadaveric model. PGA was comparable in resisting anterior translation while being significantly stronger against loading at 2-mm construct displacement. Further clinical studies are warranted to validate this novel procedure. Clinical Relevance: A 3D-printed PGA implant may offer an alternative treatment option for severe glenoid bone loss due to shoulder instability, overcoming the previous drawbacks of the Latarjet procedure, including altered kinematics, fixation failure, and hardware issues.

A Novel Technique to Convert Static Sling into a Dynamic Sling in Reconstruction of Total Lower Lip Defects Using Palmaris Longus Tendon with Free Radial Forearm Flap and Case Series.

Lower lip reconstruction has been a major challenge for the reconstructive surgeons since time immemorial. Various types of reconstruction had been described for the reconstruction of lower lip ranging from local flaps to free tissue transfer to free functioning muscle transfer. For complete lower lip defects, the free radial forearm flap with palmaris longus tendon has been the standard of reconstruction for many years. Literatures suggests various techniques for utilizing palmaris longus tendon sling as a static as well as dynamic structure. The limitation with static reconstruction is the loss of sling support with time leading to eversion and drooping of the reconstructed lower lip and drooling of saliva. In this article we describe a simpler and novel technique which converts static reconstruction into a dynamic one with a series of 5 patients. Aim of this prospectivestudy wasto evaluate the post operative functional and aesthetic outcome of our technique of total lower lip reconstruction using free radial forearm flap with palmaris longus sling reconstruction. The medical records included were demographics, including age, gender, and reason for the acquired defect, lip reconstructed, reconstructive method, flap survival, and outcomes. At 6months follow up, all patients had satisfactory outcome and were able to take oral diets and none of the patients complained of drooling, an inability to eat in a public setting, or microstomia. This technique which is a simpler modification can be helpful in converting the traditional static sling reconstruction of lower lip into a dynamic one resulting in good aesthetic and functional outcomes.

Classic Versus Congruent-Arc Latarjet Procedures

Glenohumeral instability remains a frequent pathology, specifically in athletes and active patients. As such, several treatment options have been described. In the setting of significant glenoid bone loss (i.e., >20%), off-track Hill–Sachs lesions, and failed previous soft-tissue–based repairs, glenoid bone–augmentation techniques must be considered. These techniques restore stability by a triple blocking effect of the bony graft, the capsulolabral complex repair, and the dynamic sling effect of the conjoined tendon. The classic Latarjet procedure consists in performing a coracoid osteotomy along with the conjoined tendon attachment followed by transfer and fixation to the anterior glenoid, positioning the lateral surface of the coracoid to be flush with the articular side. Then, a modification of this technique defined as “congruent-arc Latarjet” (CAL) was described. This approach involves rotating the coracoid process 90° along its longitudinal axis using the inferior surface to recreate the native glenoid arc. Biomechanical studies have discussed advantages and disadvantages of these techniques. The CAL allows a greater glenoid surface area, which may be relevant in patients with increased glenoid bone loss. However, the bone contact area is reduced, which increases the technical difficulty of screw positioning with an increased risk of graft fragmentation. The classic Latarjet technique has a greater initial fixation strength between the graft and the glenoid and a greater potential for bone consolidation due to the broader contact bone area. Excellent clinical and sports outcomes with low recurrence rates have been observed in both techniques. Imaging findings have exhibited high bone block healing and no difference in graft placement, but CAL demonstrated a greater incidence of fibrous or nonunion rates and errors in screw fixation. Finally, while similar early complications have been reported, long-term outcomes are still needed in CAL for comparing osteoarthritis progression. These results emphasize that either technique can be considered to manage glenohumeral instability when appropriately indicated.

Elastic Dynamic Sling on Subluxation of Hemiplegic Shoulder in Patients with Subacute Stroke: A Multicenter Randomized Controlled Trial.

Background: Shoulder subluxation occurs in 17–64% of hemiplegic patients after stroke and develops mostly during the first three weeks of hemiplegia. A range of shoulder orthoses has been used in rehabilitation to prevent subluxation. However, there is little evidence of their efficacy. AIM: This study aimed to investigate whether there is a difference in the subluxation distance, pain, and functional level of the hemiplegic upper extremity among patients with two different shoulder orthoses. Design: This is a prospective, randomized controlled trial with intention-to-treat analysis. SETTING: Multicenter, rehabilitation medicine department of two university hospitals in South Korea. Population: Forty-one patients with subacute stroke with shoulder subluxation with greater than 0.5 finger width within 4 weeks of stroke were recruited between January 2016 and October 2021. Methods: The experimental group used an elastic dynamic sling while sitting and standing to support the affected arm for eight weeks. The control group used a Bobath sling while sitting and standing. The primary outcome was to assess the distance of the shoulder subluxation on radiography. The secondary outcomes were upper-extremity function, muscle power, activities of daily living, pain and spasticity. Result: The horizontal distance showed significant improvement in the elastic dynamic sling group, but there were no significant differences in the vertical distance between the elastic dynamic and Bobath sling groups. Both groups showed improvements in upper-extremity movements and independence in daily living after 4 and 8 weeks of using shoulder orthoses, and the differences within the groups were significant (p < 0.05). However, there were no significant differences in upper-extremity movements and independence in daily living between the two groups. Conclusions: The subluxation distance showed better results in the elastic dynamic sling, which has both proximal and distal parts, than in the Bobath sling, which holds only the proximal part. Both shoulder orthoses showed improvements in the modified Barthel index, upper-extremity function, and manual muscle testing.

Functional outcome of open latarjet procedure for recurrent anterior shoulder instability: A prospective study

Introduction: Shoulder joint owing to its anatomy and biomechanics is the most unstable and frequently dislocated joint in our body. Anterior shoulder instability is often caused by glenoid and/or humeral bony defects in addition to soft tissue injuries. Most commonly seen in young and athletic population with high demand activities. Arthroscopic Bankart repair and open Latarjet procedure are the mainstay of treatment for recurrent anterior shoulder instability. Here we analyse the functional outcome of the shoulder joint repair following Open Latarjet procedure for recurrent anterior shoulder instability. Methods: Prospective study conducted for 2 years among 34 patients who met our criteria for open Latarjet procedure. In which coracoid process along with the conjoint tendon is transferred and fixed with non-absorbable to the margin of glenoid. This procedure provides stability by bony effect, Bankart effect and dynamic sling effect. Phased Rehabilitation was customised based on tissue quality, stability of repair. Outcome was assessed with ISIS score (Injury Severity Index Score), Rowe score, quick DASH (The Disabilities of Arm, Shoulder and Hand) score, ASES score (The American Shoulder and Elbow Surgeons Shoulder Score) and Visual analogue scale. Results: Follow up done at 2 weeks,1 month,3 month and 6 month showed progressive improvement in Range of motions, Apprehension relief, pain relief, return to normal activities and no any recurrence of instability and improved assessment scores.Conclusion: For recurrent anterior shoulder instability Open Latarjet procedure showed satisfactory result in terms of stability and range of motion mainly with significant bony defect of glenoid.

Arthroscopic Iliac Bone Block Augmentation for Glenoid Reconstruction: Transglenoid Fixation Technique Using an All-Suture Anchor

Arthroscopic Bankart repair of anterior instability has shown relatively good results, but its effectiveness is unclear in cases wherein there is a bone defect in the glenoid bone. The surgical management of recurrent anterior shoulder instability with severe glenoid bone loss has been challenging until now. Therefore the Latarjet procedure was introduced as an alternative that provided good results in cases of full instability with a bone defect. In cases of recurrent anterior shoulder instability, bone defects are often present within the glenoid. To restore glenohumeral stability, a bone augmentation procedure is required, and the Latarjet procedure to use bony transfer from the coracoid is the most popular technique. However, resorption of the bone graft with metal screw protrusion is a serious concern, whereas the relative contribution of the dynamic sling effect of the Latarjet procedure remains controversial. The Latarjet procedure also destroys the normal kinematics, resulting in side effects such as scapular dyskinesia. Here we introduce an arthroscopic anterior bone block procedure for reconstructing anterior glenoid bone defects using an autologous iliac crest graft. This technique enables precise bone block placement and fixation using one all-suture anchor instead of screw fixation.

Modified Latarjet Procedure Without Capsulolabral Repair for Failed Previous Operative Stabilizations

The optimal management of recurrent anterior shoulder instability with significant glenoid bone loss continues to be a challenge. The high recurrence rates seen in arthroscopic Bankart repair in the presence of significant glenoid bone loss have led many surgeons to choose bony reconstructions to manage these injuries. The Latarjet procedure acts through the combination of 3 different mechanisms: the coracoid bone graft restores and extends the glenoid articular arc, the conjoint tendon acts as a dynamic sling on the inferior subscapularis and anteroinferior capsule when the arm is abducted and externally rotated, and the effect of repairing the capsule to the stump of the coracoacromial ligament. However, in patients with multiple recurrences and previous surgeries, the anteroinferior labrum and capsule are often very deficient or practically destroyed. This Technical Note provides a detailed description of the modified Latarjet procedure without capsulolabral repair for patients with failed previous operative stabilizations.

Arthroscopic Iliac Crest Bone Block for Reconstruction of the Glenoid: A Fixation Technique Using an Adjustable-Length Loop Cortical Suspensory Fixation Device

Recurrent anterior shoulder instability with significant bone loss represents a surgical challenge. Anterior bone block procedures including variations of the Latarjet coracoid transfer have been used in this setting. Bone graft resorption with prominence of the metalwork is a serious concern, whereas the relative contribution of the dynamic sling effect of a Latarjet procedure is still controversial. We describe an arthroscopic technique for anatomic reconstruction of anterior glenoid bone defects using autologous iliac crest graft. This technique allows accurate placement of the bone block; fixation with 2 knotless TightRope devices (Arthrex, Naples, FL), avoiding the use of screws; and a final labral repair.

Surgical Management of the Patient with Facial Paralysis

Program Description: Patients with facial nerve paralysis suffer significant cosmetic and functional morbidity. Most of these patients eventually require the attention of the facial plastic reconstructive surgeon. Management of the eye involves both loading the upper eyelid and tightening the lower eyelid. Mid-face reconstruction can be addressed by either dynamic sling using a temporalis muscle or adynamic with acellular suspension. The advantages and risks associated with the procedures and the operative results of these techniques will be discussed by the panel. Each panelist will present their preferred method of rehabilitation with case scenarios to explore subtleties of each surgical approach. Educational Objectives: (1) Upon completion of this session, the attendee will be able to determine the management of the upper and lower eyelid complex. (2) Attendees will be able to discuss the differences in dynamic and adynamic reconstruction of the lower face. (3) Attendees will be able to manage the nasal airway in patients with facial nerve paralysis.

Core Strength Training Using a Combination of Home Exercises and a Dynamic Sling System for the Management of Low Back Pain in Pre-professional Ballet Dancers: A Case Series

Estimates of low back pain prevalence in USA ballet dancers range from 8% to 23%. Lumbar stabilization and extensor muscle training has been shown to act as a hypoalgesic for low back pain. Timing and coordination of multifidi and transverse abdominis muscles are recognized as important factors for spinal stabilization. The purpose of this study was to explore the effects of training methods using home exercises and a dynamic sling system on core strength, disability, and low back pain in pre-professional ballet dancers. Five participants were randomly assigned to start a traditional unsupervised lumbar stabilization home exercise program (HEP) or supervised dynamic sling training to strengthen the core and lower extremities. Measurements were taken at baseline and at weeks 3 and 6 for disability using the patient specific functional scale (PSFS), pain using the Numerical Pain Rating System (NPRS), core strength and endurance using timed plank, side-plank, and bridge positions, and sciatic nerve irritability using the straight leg raise (SLR). Data were analyzed using descriptive statistics. From initial to final measurements, all participants demonstrated an improvement in strength and SLR range, and those with initial pain and disability reported relief of symptoms. These results suggest that dynamic sling training and a HEP may help to increase strength, decrease pain, and improve function in dancers without aggravating sciatic nerve irritation.

Does the Dynamic Sling Effect of the Latarjet Procedure Improve Shoulder Joint Stability? A Biomechanical Evaluation

The Latarjet procedure, a transfer of the coracoid and the conjoint tendon, is commonly used to treat anterior glenoid bone loss due to instability. The transferred conjoint tendon is thought to provide a stabilizing sling effect; however, the significance of this mechanism is unknown. The purpose of this in-vitro study was to evaluate the effects of coracoid transfer, with and without conjoint tendon loading, on shoulder stability and range of motion (ROM).

Does the dynamic sling effect of the Latarjet procedure improve shoulder stability? A biomechanical evaluation

Glenohumeral instability with glenoid bone loss is commonly treated with the Latarjet procedure. The procedure involves transfer of the coracoid and conjoint tendon, which is thought to provide a stabilizing sling effect; however, its significance is unknown. This study evaluated the effects of the Latarjet procedure, with and without conjoint tendon loading, on shoulder stability and range of motion (ROM). A custom simulator was used to evaluate anterior shoulder stability and ROM in 8 cadaveric shoulders. Testing conditions included intact, 30% glenoid defect, and Latarjet with and without conjoint loading. Unloaded and 10-N loaded states were tested in adduction and 90° abduction. Outcome variables included dislocation, stiffness (neutral and 60° external rotation), and internal-external rotational ROM. All 30% defects dislocated in abduction external rotation. The loaded Latarjet prevented dislocation in all specimens, whereas the unloaded Latarjet stabilized 6 of 8 specimens. In abduction external rotation, there were no significant differences in stiffness between loaded and unloaded transfers (P = .176). In adduction, there were no significant differences between the intact and the loaded Latarjet (P ≥ .228); however, in neutral rotation, the unloaded Latarjet (P = .015) and the 30% defects (P = .011) were significantly less stiff. Rotational ROM in abduction was significantly reduced with the loaded Latarjet (P = .014) compared with unloaded Latarjet, and no differences were found in adduction. These findings indicate that glenohumeral stability is improved, but not fully restored to intact, with conjoint tendon loading. The results support the existence of the sling effect and its importance in augmenting stability provided by the transferred coracoid.

Can We Really Say That No Patients Benefit from Ligament Reconstruction Tendon Interposition?

Sir:FigureWe read with great interest the article entitled “Comparison of Trapeziectomy and Trapeziectomy with Ligament Reconstruction and Tendon Interposition: A Systematic Literature Review.”1 The article is clear and well designed, incorporating all of the major articles on this controversial topic in hand surgery. Although the authors conclude that “neither procedure produced greater benefit in terms of outcomes investigated,” this is still based on evidence without adequate power or sufficient follow-up. Indeed, patients were followed for an average of only 3 years in their comprehensive review. The insufficient power in assessing outcomes such as pain relief; Disabilities of the Arm, Shoulder and Hand questionnaire score; and grip strength are noted as limitations to the study in their discussion. Indeed, they have attempted to address and improve on the power in this study compared with previous reviews, but the data are still prone to a type II statistical error. These design flaws in the published literature make the surgeon reconsider whether it is the best option to perform trapeziectomy alone on such patients with basal thumb osteoarthritis. Although this is personal experience and more of a hypothesis that still needs to be addressed, we feel using a technique similar to an Eaton-Littler beak ligament reconstruction confers more stability to the thumb and addresses collapse in the long term. Importantly, it also allows the patient by means of the tenodesis effect to dynamically abduct and flex the thumb when the hand is placed into a prehensile position. One prospective study of 56 patients by De Smet et al. compared trapeziectomy with or without ligament reconstruction and tendon interposition; of significance, they noted that trapezial height was preserved much better in the ligament reconstruction and tendon interposition group, and the remaining trapezial height did correlate with key pinch force.2 Pelligrini3 identified that the degeneration of the anterior oblique ligament results in increased joint laxity and dorsal translation of the metacarpal on the trapezium when the thumb is in the position of lateral pinch. Ligament reconstruction and tendon interposition address anterior oblique reconstruction for carpometacarpal joint stability, whereas the tendon interposition addresses axial shortening.4 The volar beak ligament stabilizes the trapeziometacarpal joint; therefore, its reconstruction is important in reestablishing thumb stability.4 The senior author (R.J.) in our department harvests 50 percent of the flexor carpi radialis tendon, passing it through the base of the first metacarpal as a dynamic sling to stabilize the patient's thumb (Figs. 1 and 2).Fig. 1: The senior author's technique for ligament reconstruction and tendon interposition is shown. Fifty percent of the flexor carpi radialis tendon passes through the first metacarpal base, around the abductor pollicis brevis tendon, and back around the flexor carpi radialis tendon. Finally, the flexor carpi radialis tendon is anchored at the base of the first metacarpal.Fig. 2: A tendon interposition is finally constructed with the remaining flexor carpi radialis tendon.There is justification for performing trapeziectomy alone on elderly patients with fewer functional demands. However, there is a strong argument for ligament reconstruction and tendon interposition in the younger patient who remains active and at work. Longer term prospective studies with good follow-up comparing trapeziectomy with or without ligament reconstruction and tendon interposition are needed for more robust evidence. A large multicenter study is needed to compare trapeziectomy with or without ligament reconstruction and tendon interposition to determine which is superior, not just overall but in different patient groups. This question could not be answered in this review. We therefore believe it is more prudent to perform trapeziectomy with ligament reconstruction and tendon interposition to avoid the possibility of poor outcomes in the long term. Dariush Nikkhah, M.R.C.S. Jeremy Rodrigues, M.R.C.S. Plastic Surgery, Bradford Royal Infirmary Daniel B. Saleh, M.R.C.S. Plastic Surgery, Pinderfields General Royal Infirmary, Wakefield, United Kingdom Russell Jeffers, F.R.C.S. Bradford Royal Infirmary, Yorkshire, United Kingdom DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.

IIlizarov external fixator for bilateral severe flexion deformity of the knee in haemophilia: case report

Deformity correction by Illizarov method in haemophilic patients is a rare phenomenon. To correct the bilateral knee deformity by Illizarov in one sitting. Patient had fixed flexion deformity (100 degrees ) of both knees; posterior skin webs, posterior subluxation, wasting of quadriceps and <1% level of factor IX. Patient was managed with optimisation of factor IX level in perioperative period by factor IX supplementations. Deformities were corrected by Illizarov's fixator on both lower limbs at 3 months and fixator was removed at 4 months. At 3 months, patient developed bilateral equinus deformity which was corrected by a dynamic foot sling and gentle tendoachillis stretching exercises. Patient had superficial pin tract infection at three sites. There were no episodes of bleeding from pin tracts or in knee joint during distraction period. Patient had bilateral knees flexion up to 120 degrees with 5 degrees extensor lag on the right side. Patient is going to college and walks with intermittent use of a hinge knee brace at 3 years follow-up. Illizarov method is a safe, less invasive, effective, economical and truly biological method for correction of severe flexion deformities of knee in haemophilic patients.

Peroneus Longus Tendon Sling in Revision Surgery for Congenital Vertical Talus: A New Surgical Technique

When faced with revision surgery for recurrent congenital vertical talus deformity, the tibialis anterior tendon may be deficient or absent as a result of the initial procedure. This tendon cannot then be used as a dynamic sling to dorsiflex the talar neck. We present two cases in which the peroneus longus tendon was transferred dorsally into the talar neck as an alternative to an absent tibialis anterior tendon. Excellent corrections were achieved and maintained. The use of this tendon has not been described previously in surgery for this condition.

Fosiaol Paralizi Deformiteleri İçin Temporalis Kası Dinamik Askısı Uygulaması

SUMMARY Temporalis Muscle Dynamic Sling for the Correction of Facial Paralysis Deformities. Dynamic sling method by Temporalis muscle transposition for the corrects on of labial and palpebral deformities of facial paralysis has been presented. Ozet Fasial paralizi labial ve palpebral deformiteleri icin Temporalis kasi trans¬feri ile dinamik aski yontemi uygulamasi sunulmustur.