Post-traumatic Instability Research Articles

Dorsal Wrist Plication for Midcarpal Instability.

Midcarpal instability (MCI) is a cause of chronic wrist pain for which treatment remains controversial. This study's purpose was to determine the outcome of a treatment algorithm for MCI that included immobilization and surgical interventions. We prospectively enrolled 23 consecutive patients (12 males, average age 27 years) with 27 symptomatic wrists. All had generalized wrist pain with an average duration of 22 months. All had MCI and a catch-up clunk that reproduced the symptoms. Initial treatment was full immobilization for 6 weeks. When necessary, recurrence after immobilization was treated with an anatomically based surgical procedure to plicate the dorsal capsule and extrinsic ligaments to stabilize the midcarpal joint. Failure of surgical plication was followed by 4-corner intercarpal arthrodesis when necessary. Patients were observed for instability, grip strength, wrist motion, and Patient-Rated Wrist Evaluation. For 22 wrists there was partial relief of symptoms with full-time cast or orthosis immobilization; however, symptoms quickly returned with mobilization. The other wrists had previously been immobilized and patients refused further nonsurgical care. All patients underwent surgical plication of the dorsum of the wrists. Postoperative follow-up (35 months) showed statistically significant improvements in grip strength and Patient-Rated Wrist Evaluation scores. All patients had improved pain at final follow-up. Most improvement was in female patients aged under 25 years, with hypermobility and without major traumatic or work-related injuries. This contrasted with poorer outcomes in men aged over 25years who had moderate or severe trauma that was mostly work-related. Instability recurred in 2 patients who then had a 4-corner arthrodesis. Immobilization was not successful in controlling pain and recurrence of instability in patients with MCI. Surgical midcarpal capsular plication was less effective in men with posttraumatic instability. The capsular plication procedure was successful in young female patients with ligament laxity and a history of only minor or repetitive trauma and no history of major trauma. Therapeutic IV.

An anatomic reconstruction of the distal radioulnar joint for posttraumatic instability by Adams-Berger procedure

INTRODUCTION : The distal radio ulnar joint has an important and complex role in the motion of the wrist joint and the entire upper limb. The anatomical relations between the distal radius, ulna and the ulnar carpus are very fine and precise and even minor disturbances in their congruence may lead to significant changes in motions and pronounced pain syndrome. The post-traumatic instability of the distal radio ul­nar joint (DRUJ) affects all age groups. However, the contingent of professional athletes may be determined as the risk one. DRUJ instability resulting from a trauma can lead to significant discomfort expressed in ul­nar pain syndrome involving the ulnocarpal joint, weakness and limitation of the motion of the radiocar­pal joint. AIM : The aim of this paper is to present the Adams-Berger surgical procedure and the results after the ana­tomical reconstruction in cases of DRUJ instability. MATERIALS AND METHODS : During the period 2009 - 2015, at the Clinic of Orthopedics and Traumatol­ogy at St. Anna University Hospital for Active Treatment, Varna, 17 patients with DRUJ instability were op­erated on by the Adams procedure. RESULTS : DRUJ stability was observed three years after the surgery on average and 1st degree instability was seen in one of the patients. The average Modified Mayo Wrist Score was 70.01 points prior to the surgery and 93.6 points at the 36th month after the surgery. The subjective opinion of 14 of the patients was that the result was excellent, two of them determined it as very good and one of them - as good. In all of the patients an improvement in a number of parameters was observed, such as flexion, extension, radial and ulnar devi­ation, pronosupination and muscle strength reaching values comparable to those in the health hand. DISCUSSION : There are many surgical techniques aimed at restoring DRUJ stability. An alternative option is ligamentoplasty with half of the tendon of flexor capri ulnaris, which, however, does not give absolute sta­bility and has limited indications. In the presence of malposition after distal radius fracture, the stability can be improved after corrective osteotomy.

More histologic and ultrastructural degenerative signs in the subscapularis tendon and the joint capsule in male patients with shoulder impingement

PurposeThe purpose of the present study was to analyze biopsy samples from the subscapularis tendon and from the joint capsule from male patients with shoulder impingement syndrome (SAIS) and compare them with samples from male patients with post-traumatic recurrent shoulder instability. The hypothesis of the study was that patients with SAIS would have more histologic and ultrastructural degenerative changes in their subscapularis tendon and joint capsule than patients with post-traumatic recurrent shoulder instability.MethodsMale patients scheduled for surgery, with either subacromial decompression or Bankart reconstruction, were included. Four biopsies from each patient were obtained from the capsule and four from the subscapularis tendon during arthroscopic surgery. The histologic characteristics and the presence of glycosaminoglycans were assessed using the light microscope, and the ultrastructure was assessed using a transmission electron microscope.ResultsEight patients, median age 53 (45–74) years (p < 0.0001), were included in the impingement group, and 12 patients, median age 27 (22–48) years, were included in the instability group. The histologic assessment revealed significantly higher cellularity and total degeneration score in the capsule (p = 0.016 and p = 0.014 respectively) in patients with subacromial impingement compared with the instability patients. The corresponding finding was not made for the subscapularis tendon. The ultrastructural evaluation revealed that the instability patients had more fibrils with a large diameter (indicating less degeneration) in both the subscapularis tendon and the capsule compared with the impingement patients (p < 0.0001).ConclusionMale patients with subacromial impingement have more histologic and ultrastructural degenerative changes in their shoulder compared with patients with post-traumatic recurrent shoulder instability.Clinical relevanceIt appears that in patients with subacromial impingement, the whole shoulder joint is affected and not only the subacromial space. It is the opinion of the authors that intra-articular therapeutic injections could be tried more often in these patients.Level of evidenceIII.

Which Technique for Treatment of Chronic Thumb MCP Joint Instability? Comparison of 3 Techniques With a Mean Follow-up of 84 Months

Objective: Injuries to the thumb collateral ligament are common whose acute surgery gives good functional results. But they are often unrecognized and surgical procedures for chronic instability are still being discussed. The aim of this study was to compare retrospectively the clinical and radiological results of the 3 main treatments for chronic instability of the metacarpophalangeal (MCP) joint of the thumb to identify trends and optimize outcome. Materials and Methods: In this retrospective and monocentric study, we included all the patients operated between 2000 and 2012 from a chronic posttraumatic instability of the MCP joint of the thumb by 1 of 3 techniques: primary repair (37 cases), ligament reconstruction (14 cases), and arthrodesis (43 cases). Patients with hyperextension instability, degenerative instability, and a follow-up less than 2 years were excluded from this study. Subjective and objective results and rates of complications and recurrence were compared at end of the follow-up. Results: Sixty-seven patients were included, 55 followed up for a mean 84 months (range, 24-164 months). Whichever the procedure, all patients considered themselves improved or healed. Forty-eight patients (87.3%) were satisfied or very satisfied. The relief of pain was significantly better in the arthrodesis group. The mean Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) for primary repair group were 17.4 (0-89.5), for ligament reconstruction group 25.7 (0-58.3), and for the arthrodesis group 17.8 (0-50). Pinch strength, on average of the value on the unoperated side, was 89% for primary repair group, 84% for ligament reconstruction group, and 94% for the arthrodesis group. Six of 10 ligament reconstructions had MCP joint laxity at end of follow-up. There were significantly fewer patients who considered themselves cured in the ligament reconstruction group. There were 4 failures by end of follow-up: 1 associated with primary repair, 1 with arthrodesis, and 2 with ligament reconstruction. Discussion and Conclusion: Surgery in treating chronic instability of the MCP joint of the thumb gives generally good results. Primary repair should be considered as much as possible. In contrast to literature report, ligament reconstruction does not give better results than arthrodesis.

Arthroscopic treatment of shoulder instability in professional athletes.

Post-traumatic shoulder instability is a common disease, especially in sportsmen. If inadequately or late treated, it may be responsible for an articular biomechanics alteration, with serious problems. This is much more obvious for professionals athletes, because corporate and market needs force them to a premature return to sport. The purpose of this retrospective study is to evaluate if arthroscopic approach may be better than the open one and allowing a shoulder function rapid recovery, with fast return to sport. From January 2003 to January 2014, 46 professional athletes underwent surgical treatment for post traumatic shoulder instability. Two groups were made: 25 athletes treated arthroscopically and 21 treated with open approach. Patients were followed up from 36 to 92 months, according to Rowe Score for Instability and VAS scoring system. Patients in the open group returned later than the first one to sport. Moreover, pain in postoperative period and during rehabilitation, was lower in the arthroscopic group. There was only one recurrence in the open group. Arthroscopic surgical approach appears to be excellent in shoulder instability management, reducing recovery time, allowing a faster return to sport, with less pain, if compared with open surgery. III, a case control-study.

Method for Glenoid Bone Defect Plasty in Recurrent Shoulder Instability

Technique for glenoid bone defect plasty in posttraumatic shoulder instability using the porous titanium nickelide (Ti-Ni) graft is presented. This method is an alternative to Latarjet operation and autoplasty with the graft from the iliac crest. The shape and size of the graft was determined by MSCT data and the graft was sawed out from cylindrical billets with diameter of about 2.5 cm and wall thickness - 1 cm. Two screw holes were drilled and the graft was placed into the defect. That technique was applied in 6 patients with long lasting history of recurrent anterior instability and instability relapses after shoulder stabilization using other surgical techniques. Preoperative shoulder functional state by Rowe scale averaged 35.0 points versus 93.3 points after operation. One year follow up showed no cases of instability relapse. The advantages of this technique are the possibility of accurate glenoid anatomic shape reconstruction, absence of graft resorption and reduction of intervention duration.

Method for Glenoid Bone Defect Plasty in Recurrent Shoulder Instability

Technique for glenoid bone defect plasty in posttraumatic shoulder instability using the porous titanium nickelide (Ti-Ni) graft is presented. This method is an alternative to Latarjet operation and autoplasty with the graft from the iliac crest. The shape and size of the graft was determined by MSCT data and the graft was sawed out from cylindrical billets with diameter of about 2.5 cm and wall thickness - 1 cm. Two screw holes were drilled and the graft was placed into the defect. That technique was applied in 6 patients with long lasting history of recurrent anterior instability and instability relapses after shoulder stabilization using other surgical techniques. Preoperative shoulder functional state by Rowe scale averaged 35.0 points versus 93.3 points after operation. One year follow up showed no cases of instability relapse. The advantages of this technique are the possibility of accurate glenoid anatomic shape reconstruction, absence of graft resorption and reduction of intervention duration.

Risk Factors for Recurrence of Shoulder Instability after Bankart Lesion Arthroscopic Treatment

Analysis of treatment results for 408 patients (17-48 years old) with posttraumatic anterior shoulder instability was performed. In all cases arthroscopic Bankart repair with the use of suture anchors was performed from 1997 to 2013. Follow up period made up 5.7±1.2 years. Recurrent instability was observed in 45 (11%) patients. Comparison of patients with and without recurrent shoulder instability enabled to identify the following risk factors: high-level of sports activity (78.0% vs 27,8%, p

Lateral elbow ligamentoplasty by autologous tendon graft in posterolateral rotatory instability: Results in 18 cases at a mean 5 years’ follow-up

IntroductionPosterolateral rotatory instability is the most frequent form of elbow instability. This clinical entity, described by O’Driscoll et al. in 1991, concerns young subjects following elbow trauma. Diagnosis is founded on symptomatology and positive posterolateral rotatory instability test. Treatment is based on reconstruction of the ulnar bundle of the lateral collateral ligament. The present study assessed medium-term clinical and radiological results in lateral ligamentoplasty for posterolateral elbow instability. Materials and methodsA retrospective continuous single-center series included 19 cases: 11 male, 8 female, operated on between 1995 and 2010; mean age was 37.8 years (range, 20–63 years). Surgery consisted in lateral ulnar collateral ligament reconstruction by autologous palmaris longus tendon graft following Nestor et al. (1992). ResultsEighteen patients were assessed at a mean 61 months’ follow-up. Mean time off work was 3.2 months (range, 2–7 months); all patients returned to work. No revision surgery was required. Mean range of motion in flexion, extension, pronation and supination was respectively 135°, 8°, 84° and 76°. Instability test was systematically negative at follow-up. Mean Mayo Clinic and Quick-DASH scores were respectively 90 (range, 60–100) and 21 (range, 0–63). All patients were satisfied or very satisfied with their result. ConclusionLateral ulnar collateral ligament reconstruction by autologous palmaris longus tendon graft provided reliable and lasting results. We consider it to be the reference treatment for chronic instability, and sometimes in acute post-traumatic instability. Level of evidenceIV.

Emergency pelvic stabilization in patients with pelvic posttraumatic instability.

Unstable pelvic ring disruptions have been associated with high rates of morbidity. Accurate reduction with fixation diminishes pain, permits early patient mobility, and allows the pelvic ring to improve functional outcome. This was a retrospective study, whereby 30 polytrauma hospitalized patients were included, with unstable pelvic lesions stabilized with an external fixator as a mean of temporary or definitive fixation. Data collected for these sample were: age, sex, cause of trauma, type of pelvic lesion, associated lesions (ISS score), pelvic stabilization methods, and functional outcome. There were 17 male subjects (57%) and 13 female subjects (43%), with a mean age of 42.5 years (range 18-62 years). According to Tile classification, the unstable pelvic ring lesions prevailed; 60 % of patients were type C while three patients with type C instability had associated acetabular fractures, and 40% had type B rotational instability. Stabilization was achieved using an external fixator in 16 patients; in 14 patients the anterior ring fixation was used with an external fixator combined with posterior stabilization using percutaneous sacroiliac screws. The pelvic stabilization using the external fixator was later replaced with plates and screws (ORIF) in four patients. Follow-up at one, three, six and 12 months postoperatively was based on the Majeed functional score and radiographic assessment. Eighteen patients (78%) had an excellent Majeed functional score, four patients had a good score, and only one patient had a fair functional outcome. Malunions were recorded in four patients with Tile C that were stabilized only by external fixation, and superficial pin track infection occurred in three patients. Within the studied group seven deaths have been recorded (23%) in patients with extremely severe associated injuries (ISS over 50), this being the decisive factor that determined the unfavourable evolution in six patients. The external fixation stabilizes the anterior pelvic ring lesions and it can be combined with the posterior stabilization using percutaneous sacro-iliac screws in case of associated lesions of the posterior ring. The external fixator is very useful especially in the acute phase, acquiring an acceptable reduction and an adequate stability in the partially unstable lesions (Tile B) and also reduces the pelvic volume and bleeding, being considered essential within the resuscitation protocols. The external fixator can be used as a permanent stabilization method when it guarantees a satisfying reduction.

Circumferential fusion with lateral masses screws in cervical post-traumatic instability.

According to the AO cervical classification [1], a B-type fracture involves the posterior ligamentous complex with pure bony (B1), disco-ligamentous (B2) or distraction-extension (B3) fractures. In these cases, a complete reduction of eventual displacements is mandatory, together with a combined anterior-posterior fusion to restore the anterior column and recreate the posterior tension band. If an anterior cervical decompression and fusion (ACDF) with a cage and eventual plating is the choice for a single-level pathology, different techniques can be used for the posterior instrumentation and fusion [2–5]. In this specific case, the author performed a C5–6 ACDF with a tantalum cage without plating, and a posterior instrumentation of the lateral masses of C5 and C6.

Ultrastructural aspects of articular cartilage and sub- chondral bone in patients affected by post-traumatic shoulder instability: preliminary observations

Post traumatic shoulder instability is a frequent condition in young active popula- tion. Notwithstanding a lot of data have been collected on capsular-legament lesions and gleno-humeral defects, no data are available on early ultrastructural ostheo-condral damages that are known to be highly associated with the onset of invalidating pathologies, like osteoarthritis (OA). Thus, the mechanisms of joint instability and the identification of which components in the articular complex are primarily affected in instability are of clinical significance, particularly in the light of deepening knowledge on the onset/development of OA. In the present study, biopsies of the articular cartilage and sub-chondral bone were taken from 10 patients (aged 26-40) underwent surgery in Policlinico of Modena. The withdrawals were immediately fixed and embedded for Transmission Electron Microscopy (TEM). The observations were per- formed in tangential, arcuate, and radial layers of the articular cartilage as well as in sub-chondral bone. TEM observations showed that chondrocytes in the superficial layers (i.e. tangential and arcuate) display normal and very well preserved ultrastruc- ture, probably due to synovial liquid supply; otherwise, chondrocytes in the radial layer (not only in calcified but also in the un-calcified one) show various degrees of degeneration, with cytoplasm partially coerced and variously-sized vacuoles, both signs of suffering; occasionally, in the radial layer, chondrocytes with morphological signs of apoptosis or autophagy were also observed. As far as sub-chondral bone is concerned, osteocytes next the deeper calcified cartilage (within 80-100 micra from the cement line) also show evidences of degeneration, while osteocytes more dis- tant from the osteo-chondral border display normal ultrastructure probably due to the vascular bone supply. In all patients of the study, the ultrastructural features of osteo-chondral complex are not depending on age. The present study represents the first ultrastructural investigation of the articular osteo-chondral complex in shoulder instability, evaluating the state of preservation/viability of both chondrocytes and osteocytes throughout the successive layers of the articular cartilage and sub-chondral bone. These preliminary observations are the basis to understand if the early surgical treatment in shoulder instability could avoid the onset of OA.

Occiput/C1–C2 fixations using intra-laminar screw of axis – A long-term follow-up

Background. The surgical management of the craniocervical junction is challenging. Rigid posterior fixation of occiput/C1–C2 can be performed using a variety of surgical techniques including C2 pedicle/pars interarticularis, transarticular and intralaminar screw fixations. Methods. Forty-one patients were treated with occipital plate/C1 lateral mass and C2 intra-laminar screw fixations for basilar invagination and congenital atlantoaxial subluxation, post-traumatic instability, tuberculous and rheumatoid arthritis-associated atlantoaxial dislocation. Out of forty-one, thirty-six patients had bilateral crossing intra-laminar screws and five had ipsilateral laminar screw fixation bilaterally. Results. Follow-up was done in thirty-nine patients from 6 months to 8 years (mean: 21 months) and solid osseous fusion could be achieved in all (100%). One patient was lost to follow-up and another patient died of a cause unrelated to surgical technique. Pre-operative and post-operative Neurosurgical Cervical Spine Scale showed improvement in all patients having features of myelopathy. There were no neurological or vascular complications. However, nine patients had posterior laminar breach, eight had anterior laminar penetrations and three had wound infections. One patient had transient bulbar palsy and one patient had hardware failure in the form of avulsion of the midline occipital plate. Conclusions. Intra-laminar screw fixation is a safe alternative to transarticular and transpedicular/pars interarticularis fixation of C2 with advantage of having no risk of injury to vertebral artery and comparable biomechanical and pull-out strength.

Midterm functional outcome after dorsal capsular imbrication for posttraumatic instability of the distal radioulnar joint.

The dorsal capsular imbrication of the distal radioulnar joint (DRUJ) which was performed because of posttraumatic dorsal instability showed promising functional results after the first postoperative years. Therefore, we hypothesized that patients after capsular imbrication are characterized by good subjective and functional outcome measurements after a midterm period. Eleven patients (range 21-50years of age; median 35years of age) were examined after capsular imbrication of the DRUJ because of posttraumatic instability with a mean follow-up time of 72months (range 46-114months; median 66months). Examination parameters included the determination of range of motion (ROM), grip strength, pain and functional outcome scores (modified Mayo wrist score (MMWS); Disabilities of the Arm, Shoulder and Hand questionnaire (DASH score)). A mean DASH score of 6.7 (range 0-22.5) and mean MMWS of 91.8 (range 75-100) were measured. Grip strength reached 96.7% of the contralateral hand. Range of motion reached at least 93.1% of the contralateral hand. Eight of 11 patients regarded functional outcome and pain reduction as excellent. Six of 11 patients did not recognize a diagnosed instability of DRUJ as such. Ulnar-sided wrist pain was the apparent symptom in these cases. Capsular imbrication of the DRUJ is a reliable and sufficient treatment option in case of posttraumatic dorsal instability. Since DRUJ instability is seldom recognized by the patients as such, a standardised diagnostic algorithm is mandatory to guarantee reliability and efficacy for identifying DRUJ instability.

POSTTRAUMATIC SHOULDER INSTABILITY IN CHILDREN: CLINICAL PRESENTATION, DIAGNOSIS AND TREATMENT

The article presents an analysis of the treatment of 15 patients with posttraumatic shoulder instability aged 11-17 years, as a result of primary traumatic dislocation and chronic instability. We identified the following causes of chronic shoulder instability: Bankart injury, SLAP-injury; Hill-Sachs defect; fracture of the glenoid, type 3 humeral head-glenoid relation, and retroversion of the humeral head, as well as defects in the treatment of primary shoulder dislocation. Surgical treatment is performed in 7 patients with chronic instability (7 joints). Unsatisfactory result was detected in 1 patient (1 joints), which is caused by a type 3 humeral head-glenoid relation.

Surgical interventions for post-traumatic anterior shoulder instability in adults

Reason for withdrawal from publication The protocol was withdrawn in June 2018 at the request of authors due to lack of progress.

The capsular attachment of the ulnar coronoid process

Background: Ulnar coronoid fractures are relatively rare injuries usually occurring in association with elbow dislocations and contributing to elbow instability. Recent evidence supports a role for coronoid tip fractures in elbow instability. The purpose of this study was to determine where the capsule inserts onto the ulnar coronoid process. Methods: Twenty MRI arthrograms from patients with no evidence of osteoarthrosis or posttraumatic changes were evaluated. The distance from the tip of the coronoid process to the proximal edge of the anterior elbow joint was recorded as was the coronoid height. Results: The average distance from the tip of the coronoid process to the proximal edge of the anterior elbow joint capsular insertion was 1.7±1.1 mm. The average coronoid height measured 17.6±1.9 mm. Conclusions: Elbow instability after posterior elbow dislocations is a difficult and well-described entity. There is recent evidence regarding the role of small coronoid fractures in posttraumatic instability. These data support the assertion that most coronoid tip fractures involve disruption of the anterior capsule, which potentially explains why instability can be associated with these fractures.

CT-Guided Iliosacral Screw Placement

Computed tomography (CT)-guided iliosacral screw placement for posttraumatic instability of that joint is a safe procedure that may be performed in a radiology department. CT guidance allows more accurate screw placement than traditional fluoroscopic imaging in the operating room. This article describes the technique for placing cannulated surgical screws percutaneously across the iliosacral joint in patients with unstable pelvic fractures using CT for guidance. We also discuss the pitfalls of the procedure and the complications.

Acute traumatic instability of the coccyx: results in 28 consecutive coccygectomies

Coccygeal instability includes hypermobility, subluxation and fracture-dislocation. Surgical resection is still controversial, with intractable post-traumatic coccygodynia being an indication to surgery. From 2001 to 2010, we enrolled 31 patients with post-traumatic coccygodynia (19 females, 12 males; mean age 31 years, range 21-47). Conservative treatment failed in 28 patients, who underwent surgical resection of the coccyx. Twenty-one were total, while seven were partial coccygectomies. At follow-up (mean 33 months; range 24-70), clinical outcomes evaluation included measurement of complications rate, pain relief and satisfaction degree. Nineteen patients experienced complete pain relief, while two had incomplete, and four had no relief. Partial coccygectomies were associated with poor results. Twenty-one patients were satisfied, whilst four were not. Coccygectomy is the treatment of choice for post-traumatic instability. Patients' selection allowed excellent or good results. This study favors a more aggressive approach including total resection of the coccyx.

Occipito-cervical fusion in post-traumatic instability of the upper cervical spine and cranio-cervical junction

Surgical management of upper cervical spine (UCS) unstable injuries may be challenging as the number of cases requiring this surgery collected in every single center is small. This retrospective study was conducted to analyze the radiographic and clinical results in 12 patients undergoing a posterior occipito-cervical fusion by a polyaxial screws-rod-plate system. There were eight male and four female patients with a mean age of 73.7 years (range 32-89 years). Six patients presented neurologic deficits at admission. Six patients had sustained major trauma. The remaining six patients had suffered a minor trauma. Two patients died postoperatively in Intensive Care Unit. All surviving patients achieved solid fusion at 6 months. No surviving patient had neurological deterioration postoperatively. There were no instrumentation failures or revision required. Two patients suffered from superficial occipital wound infection. Although the indication to occipito-cervical fusion decreased since the new C1-C2 posterior fixation techniques were described, it remains a valid and reliable option in UCS post-traumatic instability to be applied even in emergency especially in the elderly.