Graft Position Research Articles

Anterior cruciate ligament graft forces are sensitive to fixation angle and tunnel position within the native femoral footprint during passive flexion

BackgroundAnterior cruciate ligament (ACL) graft position within the anatomic femoral footprint of the native ACL and the flexion angle at which the graft is fixed (i.e., fixation angle) are important considerations in ACL reconstruction surgery. However, their combined effect on ACL graft force remains less well understood. HypothesisDuring passive flexion, grafts placed high within the femoral footprint carry lower forces than grafts placed low within the femoral footprint (i.e., high and low grafts, respectively). Forces carried by high grafts are independent of fixation angle. All reconstructions impart higher forces on the graft than those carried by the native ACL. Study DesignControlled laboratory study. MethodsFive fresh-frozen cadaveric knees were mounted to a robotic manipulator and flexed from full extension to 90° of flexion. The ACL was sectioned and ACL force was calculated via superposition. ACL reconstructions were then performed using a patellar tendon autograft. For each knee, four different reconstruction permutations were tested: high and low femoral graft positions fixed at 15° and at 30° of flexion. Graft forces were calculated from full extension to 90° of flexion for each combination of femoral graft position and fixation angle again via superposition. Native ACL and ACL graft forces were compared through early flexion (by averaging tissue force from 0 to 30° of flexion) and in 5° increments from full extension to 90° of flexion. ResultsWhen fixed at 30° of flexion, high grafts carried less force than low grafts through early flexion bearing a respective 64 ± 19 N and 88 ± 11 N (p = 0.02). Increasing fixation angle from 15° to 30° caused graft forces through early flexion to increase 40 ± 13 N in low grafts and 23 ± 6 N in high grafts (p < 0.001). Low grafts fixed at 30° of flexion differed most from the native ACL, carrying 67 ± 9 N more force through early flexion (p < 0.001). ConclusionACL grafts placed high within the femoral footprint and fixed at a lower flexion angle carried less force through passive flexion compared to grafts placed lower within the femoral footprint and fixed at a higher flexion angle. At the prescribed pretensions, all grafts carried higher forces than the native ACL through passive flexion. Clinical RelevanceBoth fixation angle and femoral graft location within the anatomic ACL footprint influence graft forces and, therefore, should be considered when performing ACL reconstruction.

The effects of connective tissue graft position on clinical and aesthetical outcomes of gingival recession treatment: a controlled randomized clinical trial

This randomized controlled clinical trial with 1-year follow-up compared the clinical and aesthetic results of coronally advanced flap (CAF) + connective tissue graft (CTG) positioned apical to the cemento-enamel junction (CEJ) (CAF + CTG-ACEJ) with CAF + CTG positioned on the CEJ (CAF + CTG-CEJ) for treating isolated gingival recession defects. Thirty-eight patients with recession type 1 (RT 1) with a depth ≥ 3, gingival recessions were enrolled. Nineteen patients were randomly assigned to the CAF + CTG-ACEJ group or CAF + CTG-CEJ group. Clinical and aesthetical evaluations were made at 6 and 12months. While the 6months results showed that both surgical techniques were similar for clinical outcomes, the results achieved at the 6th month were more stable in the CAF + CTG-ACEJ group at the 12th month with significantly better recession depth, mean, and complete root coverage values and aesthetical results. Isolated gingival recession defects can be clinically successfully treated by both CAF + CTG-ACEJ and CAF + CTG-CEJ techniques. Limited studies have compared the clinical and aesthetical effects of positioning CTG apical to the CEJ for the treatment of gingival recessions. This randomized clinical study showed that CAF + CTG-ACEJ technique can provide additional benefit for the treatment. The described technique is effective in obtaining better long-term CRC stability and aesthetics.

MATHEMATICAL MODELING OF GRAFT FIXATION VARIANTS TO THE ANTERIOR MARGIN OF THE GLENOID PERFORMING LATARJET PROCEDURE

Latarjet procedure is a common standard in the treatment of anterior and anterior-inferior shoulder instability with a significant glenoid defect. However, like any other surgical technique, it has a list of certain intra- and postoperative complications, including mistakes in the positioning of the bone block. A necessary guarantee of prevention and reduction of the frequency of possible complications associated with graft positioning is a well-performedpreoperative planning with an understanding of the biomechanical functioning of the shoulder joint with the translated bone block. Objective. According to the mathematical modelling we studied the changes that occur in the stress-strain state of the shoulder joint model depending on the options for graft fixation and may occur during the Latarjet procedure. Methods. To solve this problem, a finite element model of the shoulder was created. The simulationswere performed using the SolidWorks computer-aided design system. The following situations were simulated: variants of fixing screws relative to the plane of the articular surface of the glenoid (parallel to the plane, at an angle of 10° and 20°) and variants of graft fixation height at the anterior edge of the glenoid (at the lower edge of the glenoid, 10 mm and 20 mm upper edge). Calculations of the stress-strain state of the models were performed with the CosmosM software package. Results and conclusions. The presence of a bone graft fixed with metal screws at the area of the defect at the anterior edge of the glenoid, leads to an increase in stress levels in the bone elements of the model. Changes in the stress-strain state of the shoulder model also occur, depending on the angle of the screws that secure the graft. The highest stress level was determined when providing the fixing screws at an angle of 10°, the lowest — when providing the screws parallel to the articular surface of the glenoid. The stresses on the locking screws increased slightly with increasing angle of the screws. When studying the height of graft fixation, the most favorable option, in terms of stress distribution on the articular surface of the glenoid and fixing screws, is its location in the lower part of the anterior edge of the glenoid.

Arthroscopic Distal Clavicular Autograft for Congruent Glenoid Reconstruction

Arthroscopic distal clavicular autograft (DCA) is effective in shoulder instability with glenoid bone loss. The original technique uses an osteochondral autograft, fixed with screws or suture anchors. We developed a modified procedure called “congruent arc DCA” characterized by (1) use of drilling guides to optimize graft positioning and make the all-arthroscopic procedure safer and reproducible; (2) rotation of the DCA of 90° to reach a congruent arc with its undersurface; (3) fixation of the graft with cortical buttons to simplify its intra-articular passage, avoid hardware problems, and facilitate possible revision surgery; and (4) intraoperative use of a suture tensioner to achieve satisfactory compression of the graft and increase its consolidation.

Early outcomes of the arthroscopic Latarjet procedure in a series of 37 patients with shoulder instability

BackgroundAnterior shoulder dislocation remains a clinical challenge. This study aimed to assess the graft position and clinical outcomes of the arthroscopic Latarjet procedure and capsular repair for the treatment of recurrent anterior shoulder dislocation with significant glenoid bone loss in 37 patients.MethodsBetween 2017 and 2017, 37 patients underwent arthroscopic Latarjet plus capsular repair procedure for recurrent anterior shoulder dislocation combined with significant glenoid bone loss. In follow-up examinations, Walch-Duplay scores, subjective shoulder value (SSV) scores, Rowe scores, and active range of motion (AROM) were assessed. Three-dimensional computed tomography (CT) was used to evaluate coracoid graft position and bone resorption. A new method of evaluating the position of the coracoid bone block after Latarjet (H-Z method) was developed.ResultsThirty-seven patients were included in this study. Follow-up ranged from 6 to 36 months postoperatively (with an average of 13 months). No recurrent dislocation occurred at the final follow-up, and there was no significant effect on the AROM (all p > 0.05). Rowe (from 42.2 ± 5.6 to 91.1 ± 3.3), Walch-Duplay (from 31.5 ± 8.0 to 92.6 ± 3.7), and SSV (from 63.9 ± 6.1 to 79.3% ± 5.0%) scores were improved significantly after surgery (all p < 0.001). CT showed that the 29 patients had varying degrees of bone resorption, and 23 recovered to the preinjury level of motional function within 6–12 months after surgery.ConclusionsIn active patients with recurrent anterior shoulder dislocations and significant glenoid bone loss, the arthroscopic Latarjet procedure plus capsular repair could restore shoulder stability satisfactory.

Two cases of ascending TEVAR for primary repair of acute type A dissection. Pre-operative and post-operative CT scans are included to demonstrate the location of the intimal tear and final position of the stent grafts

Two cases of ascending TEVAR for primary repair of acute type A dissection. Pre-operative and post-operative CT scans are included to demonstrate the location of the intimal tear and final position of the stent grafts

Comparing the Use of Flexible and Rigid Reaming Systems Through an Anteromedial Portal for Femoral Tunnel Creation During Anterior Cruciate Ligament Reconstruction: A Systematic Review.

Background:Recent studies have suggested that femoral tunnel drilling during anterior cruciate ligament (ACL) reconstruction (ACLR) with the use of a flexible reaming system through a standard anteromedial portal (AM-FR) may result in a different tunnel geometry compared with a rigid reamer through an accessory anteromedial portal with hyperflexion (AM-RR).Purpose:To summarize radiologic, anatomic, and clinical outcomes from available studies that directly compared the use of AM-FR versus AM-RR for independent femoral tunnel creation during ACLR.Study Design:Systematic review; Level of evidence, 4.Methods:A literature search was performed using the MEDLINE (PubMed) and Web of Science databases to identify all studies that directly compared radiologic, anatomic, and clinical outcomes between the use of AM-FR and AM-RR. The literature search, data recording, and methodological quality assessment was performed by 2 independent reviewers. The outcomes analyzed included resultant ACL graft positioning and graft bending angle; femoral tunnel positioning, aperture morphology, length, and widening; posterior wall breakage; and distance from various posterolateral knee structures.Results:A total of 13 studies met the eligibility criteria for inclusion. There was no difference in femoral tunnel aperture location between techniques. There were conflicting findings among studies regarding which technique resulted in a more acute graft bending angle. One study reported greater femoral tunnel widening upon follow-up with the use of AM-FR. AM-FR produced longer and more anteverted femoral tunnels than did AM-RR. The difference in tunnel length was significant and more prominent in lesser degrees of knee flexion. With AM-FR, femoral tunnels were farther from the lateral collateral ligament and peroneal nerve, and 1 of 5 studies had fewer reports of posterior wall breakage. There has been no literature comparing the clinical or functional outcomes of these techniques.Conclusion:Although no clinical studies exist comparing AM-FR and AM-RR for femoral tunnel creation during ACLR, both systems allow for reproducible positioning of an anatomic femoral tunnel aperture. The use of AM-FR results in longer and more anteverted femoral tunnels than using AM-RR, with exit points on the lateral femur that are different but safe. Surgeons should be aware of the technical differences with each method; however, further study is needed to identify any clinically important difference that results.

Salvage Iliac Crest Bone Grafting for a Failed Latarjet Procedure: Analysis of Failed and Successful Procedures

Background: The Latarjet is a successful procedure but can be associated with significant complications, including failure. Iliac crest bone grafting (ICBG) is one of the salvage options for such failure. Purpose: To analyze factors associated with failure or success to restore shoulder stability with ICBG after Latarjet failure. Study Design: Case series; Level of evidence, 4. Methods: Twenty consecutive patients with recurrence of instability after a Latarjet procedure underwent revision using ICBG. Sixteen patients (80%) with a mean age of 35.0 years (range, 25-55) could be personally reexamined clinically and radiographically (including computed tomography scan) after a mean follow-up of 4.5 years (range, 2-8). Twelve patients had redislocation and 4 had recurrent subluxation after the Latarjet. Results: Salvage ICBG failed in 7 patients because of recurrent dislocations, with 5 necessitating reoperations: 2 arthrodeses, 1 reverse total shoulder arthroplasty, 1 repeat ICBG, and 1 Hill-Sachs allograft reconstruction and Bankart repair. Factors associated with ICBG failure were multidirectional instability (n = 2), subscapularis insufficiency (n = 1), uncontrolled seizures (n = 1), static inferior glenohumeral subluxation (n = 1), total graft resorption (n = 1), and voluntary dislocation attributed to schizoaffective disorder (n = 1). The initial Latarjet graft was malpositioned (too medial) in 3 of these patients. In patients without recurrent instability (n = 9), reasons for Latarjet failure were graft related: 6 graft avulsions, 2 graft resorptions, and 1 medial graft malpositioning. The mean absolute Constant score (62 to 87 points, P = .012) and relative Constant score (66% to 91%, P = .012), pain (10 to 15 points, P < .001), and Subjective Shoulder Value (31% to 85%, P = .011) in the group with a successful procedure were significantly improved over the preoperative state, and the total Western Ontario Shoulder Instability Index averaged 64% at final follow-up. Except in 1 case of major resorption, mild graft resorption or none was observed in successful procedures. Axial and sagittal graft positioning was good in all 9 patients. Conclusions: Salvage ICBG for failed Latarjet procedures failed in 7 of 16 patients. It was successful in patients with clearly graft-related factors of the initial Latarjet procedure. However, patients with unclear instability symptoms, subscapularis insufficiency, inferior subluxation, uncontrolled seizures, or psychological disorders were poor candidates for salvage ICBG, underlining the importance of careful patient selection for the initial Latarjet procedure and for salvage ICBG.

Balloon-Assisted Rib Graft Placement in Endoscopic Posterior Cricoid Split Procedure.

View Video S1 Laryngoscope, 132:212–214, 2022

The Influence of Ciprofloxacin-Dexamethasone Ear Drops on Perforation Closure Rates After Endoscopic Tympanoplasty.

Topical ciprofloxacin and dexamethasone have both been shown to disrupt healing of tympanic membrane perforations in animal models. There have been no clinical studies evaluating the effect of ciprofloxacin-dexamethasone (CD) ear drops on success of tympanoplasty. We compare perforation closure rates in pediatric endoscopic tympanoplasty with and without use of postoperative CD. Retrospective comparative cohort study. Tertiary referral centre. One hundred sixty-two totally endoscopic tympanoplasties with porcine-derived collagen graft in children, mean age 12.0 years (range 2.3-17.9 yrs). Prescription of CD versus no ear drops in the immediate postoperative period. Perforation closure rate 2 months after totally endoscopic tympanoplasty. Postoperative CD was given to 65 (40%) ears and no drops given to the remainder. Overall, successful closure of tympanic membrane perforation was achieved in 140 (86%) of ears. The closure rate was not significantly different in those ears given CD postoperatively than those not given CD (54/65 [83%] vs 86/97 [89%], Fisher's p = 0.35). Multiple logistical regression revealed no confounding effect of other variables on outcome including age, revision surgery, graft position, or type of postoperative packing material. Our results reveal no harm or benefit with prescription of drops containing ciprofloxacin and dexamethasone on success of perforation closure after tympanoplasty. Allocation to treatment in this retrospective study was nonrandomized and was predominantly based on a change in practice. No other variables are known to have influenced this finding but a randomized prospective study could be justified for more reliable evidence.

Secondary DMEK following failed primary DMEK.

To report the outcomes of secondary Descemet Membrane Endothelial Keratoplasty (DMEK) performed for failed primary DMEK. The medical records of all patients undergoing secondary DMEK due to failure of primary DMEK were reviewed. Reasons for failure were sought and best-corrected visual acuity (BCVA), endothelial cell density (ECD) and complications of secondary DMEK were evaluated. A total of 10 cases undergoing secondary DMEK following failed primary DMEK were identified. Presumed reasons for failure included donor ECD ≤ 2300 cells/mm2 (n = 4), difficulty during graft preparation (n = 2), graft detachment (n = 2), acute angle closure due to retroiridal air dislocation (n = 1), inverse graft positioning (n = 1) and phacoemulsification (n = 1). Eyes with low visual potential were not excluded from the study group. We should note that one patient (case no7) had both low ECD and graft detachment as reasons for failure and as a result he is counted twice. Median BCVA (decimal fraction) increased from 0.1 (range, 0.01; 0.3) to 0.5 (0.05; 1.0) at one month and remained stable thereafter. A BCVA of 0.5 or higher was achieved in 7 cases at the final follow-up. Mean ECD fell from 2628 ± 284 cells/mm2 to 1391 ± 252cells/mm2 at 6months (47% reduction) and 959 ± 225cells/mm2 at 24months (64% reduction) (P ≤ 0.028). Complications included the incomplete removal of the primary graft and mild iris bleeding, decompensation of a preexisting primary open-angle glaucoma and retroiridal air dislocation. Apart from low donor ECD, surgical challenges, i.e., difficulty with graft preparation, inverse graft positioning, and retroiridal air dislocation, were main reasons for failure of primary DMEK. Secondary DMEK showed a good safety profile and reasonable visual outcomes.

Randomized comparative study of suspension femoral fixation device in graft position maintenance in anterior cruciate ligament reconstruction: EndoButton CL vs TightRope RT

BackgroundIn double-bundle anterior cruciate ligament reconstruction (ACLR), fixed-loop and adjustable-loop cortical suspensory devices are commonly used to fix the soft graft on the femoral side. However, few studies have compared in vivo elongation of the two devices. The purpose of this study was to determine whether EndoButton CL (EB) and TightRope RT (TR), the suspensory fixation devices used in ACLR, maintained their length in vivo from the time of surgery through the postoperative period in a randomized controlled trial. MethodsThis study prospectively incorporated 30 patients undergoing initial ACLR at a single center. Participants were divided into two groups using a stratified randomization method with age and sex as assignment adjustment factors. EB or TR was used for fixation of the soft graft on the femoral side. The primary endpoint was to compare the elongation distance of the suspensory device. MRIs were taken within seven days after ACLR and 3,6,12 months postoperatively and measured by a radiologist in a blinded fashion. Secondary endpoints included the side-to-side difference in anterior translation, one leg hop test (HOP index), Lachman test, lateral pivot shift test, and Lysholm score one year postoperatively. ResultsTwenty-eight patients (EB, n = 13; TR, n = 15) were followed for one year. There was no significant difference between EB and TR groups in elongation from the immediate postoperative period to 3, 6, 12 months after surgery. However, the non-inferiority of TR to EB (non-inferiority margin: 1.5 mm) was not proved by the difference in measured elongation between the two groups (TR – EB, lower 95% CI. AM: 1.80 mm; PL: 1.86 mm) at 6 months. There was no significant difference in anterior translation, HOP index, Lachman test, lateral pivot shift test, or Lysholm score. ConclusionEB and TR had similar graft retaining ability in vivo for 12 months, but the non-inferiority of TR against EB was not verified statistically.

Full Arthroscopic Eden-Hybinette Procedure Using 2 Cortical Suture Buttons for the Reconstruction of Anteroinferior Glenoid Defects.

Therapeutic management of recurrent anterior shoulder instability with an anterior glenoid defect and a Hill-Sachs lesion requires a bone graft to restore the width of the glenoid. The Latarjet procedure is the most popular technique but an iliac crest bone graft is preferred when the coracoid process is dysplastic or too short or after failure of Latarjet or Bristow-Latarjet. The purpose of this manuscript is to describe a full arthroscopic Eden-Hybinette-guided technique with 2 cortical suture buttons for bone graft fixation. This procedure allows reconstruction of severe glenoid bone defects and treatment of concomitant capsulolabral lesions and humeral bone loss, while preserving the subscapularis muscle. In addition, the use of 2 cortical buttons for bone graft fixation simplify graft transport and positioning, provides good control of the rotation, improving healing of the iliac crest bone graft to the anterior glenoid rim.

The zone 2 concept and distal stent graft positioning in TH 2-3 are associated with high rates of secondary aortic interventions in frozen elephant trunk surgery.

The goal of this study was to investigate the association between the localization of the distal anastomosis (zone 2/3), the stent graft length (100-160 mm), the position of the distal end of the hybrid prosthesis and the need for secondary aortic intervention (SAI) in acute and chronic thoracic aortic disease after the frozen elephant trunk procedure. From 2009 through 2020, a total of 232 patients (137 men; mean age, 61.7 ± 13.8 years) were treated with the frozen elephant trunk procedure. The main indications were acute aortic dissection type A (n = 106, 46%), chronic aortic dissection type A (n = 52, 22%) and degenerative thoracic aortic aneurysm (n = 74, 32%). The rate of SAI was significantly higher when we performed a distal anastomosis in zone 2 rather than in zone 3, whereas the rate of SAI was less frequent if the distal positioning of the hybrid prosthesis was below TH 4-5. Combining the zone 2 concept and the short stent graft length (100 mm) was associated with a significantly higher rate of SAIs. Patients with a distal anastomosis in zone 2 were significantly less likely to have a recurrent laryngeal nerve injury (P < 0.001). However, no association between a specific arch zone of a distal anastomosis and the occurrence of spinal cord injury was observed. Rates of SAIs are highest in patients who were treated with a distal anastomosis in zone 2 and a short stent graft (100 mm) with the distal end of the hybrid prosthesis at vertebral level TH 2-3.

Radiographic study of effect of lateral placement of bone graft on shoulder joint degeneration after modified arthroscopic Latarjet surgery with elastic fixation

To investigate the mid-term effect of lateral placement of bone graft on shoulder joint degeneration after modified arthroscopic Latarjet surgery with elastic fixation for recurrent anterior shoulder dislocation with an anterior glenoid bone defect. According to the inclusion and exclusion criteria, 18 patients with recurrent anterior shoulder dislocation and anterior glenoid bone defect who received the modified arthroscopic Latarjet surgery with elastic fixation between January 2015 and November 2016 were enrolled in this study. There were 12 males and 6 females with an average age of 26.2 years (range, 19-37 years). The number of shoulder dislocation ranged from 4 to 30 times (mean, 8.8 times). The disease duration was 8-49 months (mean, 23.8 months). The mean anterior glenoid bone defect was 25.2% of the glenoid surface (range, 20%-29%). The mean preoperative Instability Severity Index Score (ISIS) was 7.6 (range, 7-10). According to Samilson-Prieto classification, the shoulder joint degeneration was rated as grade 0 in 13 cases, grade Ⅰ in 3 cases, and grade Ⅱ in 2 cases. Before and after operation, the visual analogue scale (VAS) score, American Society of Shoulder and Elbow Surgery (ASES) score, Walch-Duplay score, Rowe score, and shoulder mobility were used to evaluate the effectiveness. Imaging examination was performed to observe the shoulder joint degeneration, the position of the bone graft, and the postoperative shaping of the scapular glenoid. All patients were followed up 55-62 months, with an average of 59.6 months. There was no neurovascular injuries, infections, fixation-related and bone graft-related complications. No re-dislocation and revision occurred. All patients returned to normal life, 17 of whom returned to sport. The VAS score was significantly decreased and ASES, Walch-Duplay, and Rowe scores were significantly improved at last follow-up ( P<0.05). No significant difference was found in range of motion of forward flexion, abduction, lateral rotation at 90° abduction, internal rotation at 90° abduction, or lateral rotation at 0° between pre- and post-operation ( P>0.05). Three-dimensional CT showed that the centers of all bone grafts were between 3∶30 and 4∶30 (right shoulder) or between 7∶40 and 8∶20 (left shoulder) and no bone grafts were positioned superiorly or inferiorly in the glenoid En-face view. All bone grafts were positioned lateral to the scapular glenoid with an average distance of 3.5 mm (range, 2.3-4.6 mm) in cross-sectional imaging by CT. Compared with the preoperative Samilson-Prieto classification results, all cases showed no progression of shoulder joint degeneration at 36, 48 months and last follow-up. All bone grafts remodeled to a steady state within 24 months after operation. The bone graft and glenoid finally remodeled analogous to the shape of the intact glenoid in the En-face view and became flush with the glenoid rim, remodeling to a curved shape congruent to the humeral head in cross-sectional imaging by CT. The shape of the remodeled glenoid at last follow-up was not significantly different from that at 24 months after operation. The lateral placement of the bone graft during modified arthroscopic Latarjet surgery with elastic fixation do not accelerate the imaging changes of shoulder joint degeneration.

Short-Term Bone Fusion With Arthroscopic Double-Button Latarjet Versus Open-Screw Latarjet

Background: Recently, arthroscopic double-button Latarjet (AL) has provided an alternative to conventional open Latarjet (OL) in the treatment of anterior shoulder instability with glenoid bone loss. Therefore, theoretically, the faster fusion is obtained, the sooner return to sports under safe conditions can occur. The emerging flexible fixation of the bone block has clearly offered a new approach to achieve bone fusion. However, the period required to achieve this goal remains controversial. Purpose/Hypothesis: The purpose was to compare computed tomography (CT) scan results of AL and OL in the early postoperative period. It was hypothesized that the bone block fusion with AL would require a longer time than that with OL. Study Design: Cohort study; Level of evidence, 3. Methods: In a retrospective 1-year study, the authors compared 17 primary double-button AL to 22 primary 2-screw OL procedures indicated for anterior shoulder instability in patients with an Index Severity Instability Score >3 points. These patients were reviewed with a CT scan at 1 day, 3 months, and 6 months postoperatively. The characteristics for the 2 groups were comparable. CT scans aimed to analyze graft position, bone contact area with the scapula, and fusion at 3 and 6 months. Clinical assessment was based on the Walch-Duplay and Rowe scores. Results: The mean preoperative Index Severity Instability Score was 5.3 ± 1.9 points, with a mean anterior glenoid bone loss of 9.1% ± 4.6%. At 3 months, the rates of fusion were 41% and 100% for the AL and OL groups, respectively (P < .001). This rate increased to 70% in the AL group at 6 months (P = .006). In the axial and sagittal planes, there was no difference in graft position between the AL group and the OL group. The bone block was longer and there was a more extensive bone contact area in the OL group (AL, 131 mm2 vs OL, 223 mm2; P < .001). At 6 months of follow-up, no significant difference in clinical scores was noted between the groups: Walch-Duplay score, 93.0 ± 10.9 points versus 91.8 ± 12.5 points (P = .867); and Rowe score, 99.0 ± 2.2 points versus 95.0 ± 8.4 points (P = .307) for the AL and OL groups, respectively. Conclusion: AL required more time to achieve bone block fusion than OL. This finding should be taken into account when considering this procedure for patients in a hurry to return to sports involving the shoulder.

Autologous free iliac crest bone grafting of glenoid through the rotator interval using double-barrelled cannula.

The primary aim of this study is to prove that reconstructing the anterior glenoid defect with iliac crest graft arthroscopically using double-barrelled cannula through the rotator interval is safe and prevents both recurrence of instability and the neurovascular injury because subscapularis muscle is not split and procedure is far away from important structures. Thirteen patients with anterior shoulder instability and engaging Hill-Sachs lesion were reviewed after arthroscopic reconstruction of the anterior glenoid with iliac crest autogenous graft. Patient satisfaction and Western Ontario İnstability Score (WOSI) were evaluated on clinical examination. Computed tomography was used to analyse graft position on sagittal and axial planes. The mean follow-up was 28.7months (SD 7.1), and age at surgery was 31years (21 to 64years). Post-operatively there was only one dislocation due to trauma. There was statistically significant improvement of WOSI scores (p: 0.001). There was not any neurological injury. Graft position on the axial plane was described as flush in 5 cases (41%), lateral in 2 (16%), too lateral in one (8%) and medial in 4 of the cases (33%). Graft position could be accepted as high in only three patients (23%). Arthroscopic reconstruction of glenoid defect using autogenous iliac bone graft, through rotator interval, without splitting subscapularis is safe and effective without any neurological injury, producing substantial graft position and good functional outcomes in patients.

From Wide Open Spaces to Tiny Robot Holes: Single-Center Comparison of Implant Techniques for Left Ventricular Assist Device (LVAD) Implantation

<h3>Purpose</h3> Current studies are just beginning to reveal possible benefits of thoracotomy for LVAD implant but most have not included both durable device types or additional techniques such as robotic assistance. This review serves to evaluate our initial single-center experience with LVAD implant via thoracotomy (with both hemisternotomy and robotic assistance). <h3>Methods</h3> Primary sternotomy, reop sternotomy, thoracotomy with hemisternotomy, and robotic assisted thoracotomy implants of HeartWare and HeartMate 3 LVADs 2018-2020 were evaluated. Narcotic use, cost, outflow graft position, operative data, and mortality were compiled and t-test performed between primary sternotomy and other groups on selected data. <h3>Results</h3> All patients were alive or transplanted at 6 months post-implant. Compared to primary sternotomy, reop sternotomy and robot assisted thoracotomy had longer bypass times and robot assisted thoracotomy had less red blood cell and FFP use. Outflow graft position with robotic assist was consistently away from the sternum (Fig 1). <h3>Conclusion</h3> There were no significant differences between mortality and narcotic use between primary sternotomy, reop sternotomy, and thoracotomy LVAD implants. Despite the cost of robotic disposable equipment, overall cost was not significantly different. Lower blood product usage and more preferable outflow graft position with robotic assist may result in fewer antibodies and easier reentry for transplant. A multi-center data review should be undertaken to capitalize on gains as we continue to advance non-sternotomy approach.

Open Classic Latarjet Procedure Performed Using Freehand Technique-Surgical Technique and Outcome.

Latarjet procedure is commonly performed for recurrent anterior shoulder instability with glenoid side bone loss. Classic Latarjet procedure can be performed using specially designed drill guides, jigs, or by freehand technique. Here we have described a technical note on classic Latarjet procedure performed with freehand technique utilizing simple rulers and caliper. The functional and radiological outcomes of our patients have also been analysed. 149 open classic Latarjet procedures were performed using our technique between March 2015 and July 2018. The mean age of the patients was 32.95years (Range 22-59years). The functional outcome of the patients was measured using Western Ontario Shoulder Instability (WOSI) and Oxford Shoulder Instability Score (OSIS) at 2years of follow-up. Screw and graft positioning were studied in 24 consecutive patients with a postoperative computed tomography (CT) scan. There was no incidence of recurrent subluxation or dislocation post-surgery. Mean OSIS score increased from 15.63 ± 3.20 preoperatively to 42.44 ± 3.88 postoperatively (p value < 0.05). WOSI score decreased significantly from 62.54% ± 8.24 to 10.26 ± 6.33 postoperatively at 2-year follow-up (p value < 0.05). Postoperative CT scan also showed satisfactory screw placement in all patients. Open Latarjet procedure performed using freehand technique provides good functional and radiological outcomes in patients with recurrent anterior shoulder instability with glenoid side bone loss. The online version contains supplementary material available at 10.1007/s43465-021-00385-7.

Decreased motion with normal strength after Latarjet procedure has minimal impact on return to activity.

The Latarjet procedure can affect the range of motion (ROM) and strength of the shoulder, which determine the time to return to the preinjury level of activity. This study prospectively assessed whether the Latarjet procedure leads to a decrease in range of motion and muscle strength, affecting the time to return to the previous level of activity. Fifty-one consecutive patients who underwent the Latarjet procedure for recurrent dislocation of the shoulder were included prospectively. The ROM, strength, Walch-Duplay score, and Rowe score were measured every 3months for 1 year and then every 6months for 2 years. Radiological assessments were performed to confirm the graft location, union, and the humeral head position in abduction and external rotation (ER). Out of 51 patients, 49 completed all follow-ups. The median age was 27years (17-45years), and the dominant side was involved in 36 patients. The median number of dislocations was 11 (5-50). Twelve patients were sleep dislocators. There was a significant loss (p < 0.0001) of abduction, forward flexion (FF), ER, and internal rotation (IR) in the affected shoulder compared to the contralateral shoulder. Recovery plateaued at 12months. There was near complete recovery of muscle strength after the Latarjet procedure, and the difference between the affected and contralateral shoulders was not significant (n.s.). The modified Rowe score was excellent in 44 (90%) patients, and the Walch-Duplay score was excellent in 43 patients (88%) at 24months. Suboptimal results were associated with non-compliance with rehabilitation in two (4%) patients and neglected unreduced dislocation in one (2%) patient. The coracoid graft position was below the equator in 44 patients (90%). Forty-six patients (94%) could return to the previous level of activity. The Latarjet procedure results in a restricted ROM of the shoulder, but there is no loss of muscle strength. III.