Recurrent Subluxation Research Articles

Derotational distal femoral osteotomy yields better outcomes in patellar subluxation with proximal femoral torsion compared with distal femoral torsion: A retrospective comparative study.

Controversy exists regarding the origin of femoral torsion, and specific treatment rules regarding the optimal position of femoral osteotomy in patients with recurrent patellar subluxation and excessive femoral torsion are scarce. To establish a novel classification system for such patients, and to compare clinical and radiological outcomes after distal derotational femoral osteotomy (DDFO) between femoral torsion at proximal (neck and shaft) and distal levels. Between January 2014 and June 2019, patients who underwent DDFO were retrospectively reviewed. The segmental torsion analysis was performed to establish a novel classification system, and classify included patients into two groups: 35 patients in proximal torsion group and 38 patients in distal torsion group. These patients were followed-up for at least 3years. Clinical evaluations included functional outcomes, physical examinations, quality of life, activity level, satisfaction, and complications. Radiological outcomes included patellofemoral osteoarthritis, congruence, and alignment. Type I was defined as the proximal torsion. Type II was defined as the distal torsion. Proximal torsion group had lower postoperative femoral torsion (12.6 ± 2.6° vs. 14.8 ± 3.6°; P = .004) and higher surgical correction angle (21.6 ± 5.0° vs. 19.1 ± 3.0°; P = .009). All clinical and radiological outcomes improved significantly in both groups, but proximal torsion group had significantly higher quality of life (EQ-5D-5L: 0.96 ± 0.06 vs. 0.91 ± 0.07; P = .003. 92.0 ± 6.0 vs. 88.7 ± 5.8; P = .021) and Tegner activity score (5.2 ± 1.5 vs. 4.5 ± 1.4; P = .040), and fewer patellofemoral osteoarthritis (8.6% vs. 26.3%; P = .048). Two patients in the distal torsion group had subjective patellar instability. The percentage of patients with anterior knee pain was higher in the distal torsion group. A novel classification system for patients with recurrent patellar subluxation and excessive femoral torsion based on segmental femoral torsion analysis was established. DDFO was more appropriate for patients with proximal torsion, yielding higher surgical correction angle, and better clinical and radiological outcomes. Cohort study; Level of evidence, 3.

Impact of the Shape of the Skull Base on Morphometric Parameters of the First and Second Cervical Vertebrae in 8–12-Year-Old Children: Assessment of the Condition Under Norm and Recurrent Subluxation in the C1–C2 System

The aim of the study is to determine the impact of the shape of the skull base on the morphometric parameters of the first (C1) and second (C2) cervical vertebrae in children aged 8–12 under normal conditions and under recurrent subluxation of C1–C2. Materials and methods. The authors analysed computed tomography (CT) scans of 212 children aged 8–12 without pathology of the cervical spine and 65 patients of the same age group with recurrent subluxations of the C1-C2 vertebrae. Computed tomography was performed on a computer tomography GE OPTIMA CT 660, 64-slice machine (Russia). CT morphometry was carried out using the Radiant program (Russia). The width and length of the skull base, parameters of the first (C1) and second (C2) cervical vertebrae, and interosseous parameters were determined, the basilar index was calculated; three groups of individuals with dolicho-, meso-, or brachybasilar shape of the skull base were formed based on the value of the basilar index. One-way analysis of variance was carried out. Results The impact of the shape of the skull base of moderate strength on the transverse dimensions of the upper articular surfaces of C1 on the right and left in children without pathology of the cervical spine was revealed. Among the examined individuals with recurrent subluxation in the C1–C2 system, there was a strong connection between the shape of the skull base and the longitudinal dimensions of the upper articular surfaces of the atlas. A moderately close relationship was revealed between the shape of the skull base and the height of the body of the second cervical vertebra and with the angle of inclination of the C2 tooth in the sagittal plane in those examined without pathology of the cervical spine. In children with recurrent subluxation, a strong relationship of the controlled factor was determined with the height of the C2 body and the angle of inclination of its tooth in the sagittal plane, and a mediumstrong relationship with the sagittal diameter of the tooth. The influence of the shape of the skull base of moderate strength on the size of the anterior atlantoaxial joint space was revealed both in children without pathology of the cervical spine and in children with recurrent subluxation. In case of right-sided subluxation, a mediumstrong relationship between the shape of the skull base and the lateral distance between the base of the tooth and the medial surface of the lateral mass of C1 on the side contralateral to the subluxation was revealed. Conclusion. The shape of the skull base affects a number of anatomical structures of the first two cervical vertebrae in children aged 8–12.

Short-Term Complications of Arthroscopic Bristow or Latarjet Procedure with Screw Versus Suture-Button Fixation: A Prospective Study of 308 Consecutive Cases by a Single Surgeon.

This study aimed to investigate the short-term complications (minimum 1-year follow-up) after either an arthroscopic Bristow or Latarjet procedure for anterior shoulder instability utilizing screw or suture-button fixation. Patients undergoing arthroscopic Bristow or Latarjet procedures between November 2016 and April 2021 were enrolled. Data were collected at baseline, 3 months, 6 months, and every year after surgery. Risks of postoperative complications and unplanned reoperations were assessed. A multivariable regression model was used to identify risk factors for complications and to determine the association of complications with patient-reported outcomes. A total of 412 patients (425 shoulders) undergoing arthroscopic Bristow or Latarjet procedures performed by a single surgeon between November 2016 and April 2021 were reviewed. Two hundred and ninety-nine patients (308 shoulders, 76.2% of 404 eligible) with a mean follow-up of 22.3 ± 4.2 months were included for analysis. Two hundred and sixty-nine shoulders (87.3%) underwent a Bristow procedure (165 with screw and 104 with suture-button fixation), while 39 (12.7%) underwent a Latarjet procedure (18 with screw and 21 with suture-button fixation). Eighty-two patients (83 shoulders) reported a total of 85 complications within 2 years after surgery, with an overall complication rate of 26.9%. The rates of recurrent dislocation or subluxation and infection were 1.9% and 0.6%, respectively, while a total of 4 (1.3%) of the shoulders had unplanned reoperations. The most common complications were graft-related (11.7%), followed by complications involving neurologic symptoms (10.7%). The overall, graft, and neurologic complication rates following Bristow or Latarjet procedures were 27.1% versus 25.6%, 12.3% versus 7.7%, and 10.0% versus 15.4%, respectively. Compared with the Bristow technique with screw fixation, Bristow with suture-button fixation yielded a lower risk of any complications (odds ratio [OR], 0.55; p = 0.04). Paying with rural insurance and poor sleep quality prior to surgery were associated with increased risk of any complications. Compared with arthroscopic Bristow procedures with screw fixation, Bristow procedures with suture-button fixation resulted in a lower overall complication risk. Both patient demographic and implant-specific factors were associated with the development of a complication. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic medial patellofemoral ligament reconstruction with polyethylene suture combined with medial retinaculum plication for the treatment of acute patellar dislocation in young and middle-aged patients with a follow-up of at least 2 years

PurposeThe purpose of this study was to propose a surgical technique for arthroscopic medial patellofemoral ligament (MPFL) reconstruction with polyethylene suture combined with medial retinaculum plication and to evaluate the efficacy of this surgical technique in the treatment of acute patellar dislocation.MethodsClinical data of patients with acute patellar dislocations treated with arthroscopic MPFL reconstruction with polyethylene tape (FiberTape) combined with medial support band compression were analyzed retrospectively from January 2018 to January 2021. The mean age of the patients was 25.15 ± 4.66 years; the mean follow-up time was 27.5 (24–36) months. Clinical evaluation consisted of apprehension test results, patellar extrapolation test results, Lysholm score, Kujala score, and IKDC score, the Patellar lateral shift distance and patellar tilt angle (PTA) measured by CT scan.ResultsAll patients had no recurrent patellar dislocation or subluxation after surgery, and the apprehension test was negative. In all patients, the Kujala score (36.0 ± 9.9 vs. 98.2 ± 3.1), the IKDC score (48.6 ± 7.0 vs. 90.6 ± 4.4) and the Lysholm score (32.8 ± 10.4 vs. 96.7 ± 3.1) had improved at the 24-month follow up (P < 0.05). In addition, PTA was significantly lower at the 12-month follow-up and 24-giving-month follow-up compared to the preoperative period (P < 0.05, Table 2). The patellar lateral shift distance decreased from 14.94 ± 6.11 mm preoperatively to 3.00 ± 1.40 mm (12-month follow up) and 3.26 ± 1.37 mm (24-month follow up), respectively.ConclusionArthroscopic MPFL reconstruction with polyethylene suture combined with medial retinaculum plication is a safe and reliable surgical technique for the treatment of acute patellar dislocation in young and middle-aged patients.Level of EvidenceLevel III, Therapeutic Study.

Comparison of Safety and Efficacy of Four-Point Scleral Intraocular Lens Fixation and the Yamane Technique.

The purpose of our study was to compare the safety and efficacy of two scleral fixation intraocular lens (IOL) methods of four-point scleral fixation (Akreos AO60) and the Yamane technique (AcrySof MA60AC). This prospective, randomized study was conducted at the Military Institute of Medicine-National Research Institute in Warsaw between 2021 and 2023. We compared both groups for cause of aphakia, ocular history, refractive status, and complication. Our study included 50 eyes from 47 patients. Four-point fixation was performed in 25 eyes (group1), and the Yamane technique was used in 25 eyes (group2). Surgical time was 24.1min ± 8.9 in group1 and 25.1min ± 9.9 in group2 (p > 0.05). The postoperative BCVA (best-corrected visual acuity) for group1 and group2 at 1year's observation was 0.10 ± 0.15 and 0.09 ± 0.17 logMAR, respectively (p > 0.05). Postoperative total refractive error (RE) was - 0.06 ± 0.71 diopters (D) for four-point scleral fixation and 0.83 ± 0.70D for Yamane technique (p < 0.05). Endothelial cell density (ECD) loss was 0.9% in group1 and 3.5% in group2 (p > 0.05). Bleeding into the anterior chamber and vitreous body was more frequent in the group of patients operated on with the use of the Yamane technique (10 cases, 20%, p = 0.01). IOL displacement was found in one case (2%) in group2. Both analyzed techniques are well tolerated and ensure good refractive results (extremely predictable in four-point scleral fixation) and have a similar safety profile. Four-point scleral fixation of IOL would appear to be safe, effective and beneficial for young, active patients, especially after trauma or recurrent subluxation. ClinicalTrials.gov identifier NCT06389643.

Biomechanical simulation of radial head subluxation in cadaveric pediatric elbows

BackgroundRadial head subluxation, known as pulled elbow or nursemaid’s elbow, is a common pediatric condition that occurs when a longitudinal traction force is applied to an extended elbow. The purpose of our study was to demonstrate and quantify the axial traction force required to produce a nursemaid’s elbow in a pediatric cadaver specimen and to review the current relevant literature. MethodsWe performed a literature search to identify relevant articles describing the nursemaid’s elbow injury, as well as relevant biomechanical studies of the radiocapitellar joint. For the biomechanical model, 2 fresh-frozen cadaveric elbows from a single 3-year-old male donor were dissected by a fellowship-trained orthopedic surgeon. An Instron 5,944 testing machine with a 2 kN load cell was used to perform uniaxial testing. The radius and humerus were mounted to the Instron machine and loaded in the axial direction with the elbow in full extension. Loading occurred at a rate of 10 mm/second for 4 seconds, during which the force and actuator displacement were continuously recorded. The local instantaneous load and extension displacement at the time of subluxation were recorded. ResultsThe load to failure required to produce the nursemaid’s elbow injury in our first specimen was 31 N, with a failure displacement of 4.6 mm. The second specimen demonstrated a load to failure of 26 N, with a failure displacement of 4.6 mm. After subluxation, we reduced the annular ligament from the first specimen. The elbow was then retested and demonstrated a load to failure of 20 N, with a failure displacement of 2.6 mm. ConclusionsAxial traction applied to a pediatric elbow results in subluxation of the annular ligament into the radiocapitellar joint, at relatively low loads. We demonstrated a mean load to failure in a pediatric cadaveric model of 28.5 N, and a lower load to failure was required to produce a recurrent subluxation in a previously injured specimen. Key Concepts(1)Radial head subluxation, known as pulled elbow or nursemaid’s elbow, is a common pediatric condition that occurs when a longitudinal traction force is applied to an extended elbow.(2)This study is the first to demonstrate and quantify the axial traction force required to produce a nursemaid’s elbow in a pediatric cadaver specimen.(3)Axial traction applied to a pediatric cadaver specimen results in subluxation of the annular ligament into the radiocapitellar joint.(4)The mean load to failure is 28.5 N, and a lower load to failure is required to produce a recurrent subluxation in a previously injured specimen.(5)Literature supports that the nursemaid’s elbow injury is a result of subluxation of the annular ligament into the radiocapitellar joint, though this may involve a spectrum of injury to the annular ligament itself.

Recurrent Traumatic Subluxation of Peroneal Tendons Surgically Treated with Semitendinosus Tendon Graft – Case Report

Recurrent Traumatic Subluxation of Peroneal Tendons Surgically Treated with Semitendinosus Tendon Graft – Case Report

Medial quadriceps tendon femoral ligament reconstruction and medial patellofemoral ligament reconstruction have no significant differences in clinical outcomes for treatment of lateral patellar instability: a matched-cohort study

ObjectivesThe purpose of this study was to compare clinical outcomes of medial quadriceps tendon-femoral ligament reconstruction (MQTFLR) and medial patellofemoral ligament reconstruction (MPFLR) among patients with recurrent lateral patellar instability. MethodsA retrospective matched-cohort study was conducted involving patients who underwent MQTFLR or MPFLR with or without tibial tubercle osteotomy (TTO) from 2019 to 2021. Subjects were matched 1:1 on age, concomitant osteochondral allograft (OCA), concomitant TTO, and follow-up time. Measured outcomes included 90-day complications, Visual Analog Scale (VAS) knee pain, return to sport/work, Kujala score, Tegner score, and MPFL-Return to Sport after Injury (MPFL-RSI) score. Outcomes were compared between groups using Mann–Whitney U-test for continuous variables and Fisher's exact test for categorical variables. P-values <0.05 were considered significant. ResultsTen MQTFLR patients (mean age 28.7 years, 80% female, mean follow-up 19.7 months) and ten MPFLR patients (mean age 29.1 years, 90% female, mean follow-up 28.3 months) were included in the study. One MQTFLR patient (10%) and three MPFLR patients (30%) underwent reoperation for postoperative arthrofibrosis. Postoperative VAS resting pain was not significantly different between the groups (MQTFLR mean 1.1, MPFLR mean 0.6, p ​= ​0.31). There were no significant differences in rates of recurrent subluxations (MQTFLR 20%, MPFLR 0%, p ​= ​0.47), return to sport (MQTFLR 50%, MPFLR 75%, p ​= ​0.61), return to work (MQTFLR 100%, MPFLR 88%, p ​= ​1.00), or MPFL-RSI pass rate (MQTFLR 75% vs. MPFLR 38%, p ​= ​0.31). ConclusionThere were no significant differences in knee pain and function, return to work, and rates of recurrent patellar instability between patients who underwent MQTFLR versus MPFLR, though these results should be interpreted with caution given the small sample size and potential selection bias. Level of EvidenceIII.

Distal Tibial Allograft for the Treatment of Anterior Shoulder Instability With Glenoid Bone Loss: A Systematic Review and Meta-analysis.

The use of a distal tibial allograft (DTA) for reconstruction of a glenoid defect in anterior shoulder instability has grown significantly over the past decade. However, few large-scale clinical studies have investigated the clinical and radiographic outcomes of the DTA procedure. To conduct a systematic review and meta-analysis of clinical studies with data on outcomes and complications in patients who underwent the DTA procedure for recurrent anterior shoulder instability with glenoid bone loss. Systematic review and meta-analysis; Level of evidence, 4. A comprehensive search of major bibliographic databases was conducted for articles pertaining to the use of a DTA for the management of anterior shoulder instability with associated glenoid bone loss. Postoperative complications and outcomes were extracted and compiled in a meta-analysis. Of the 8 included studies with 329 total participants, the mean patient age was 28.1 ± 10.8 years, 192 (83.8%) patients were male, and the mean follow-up was 38.4 ± 20.5 months. The overall complication rate was 7.1%, with hardware complications (3.8%) being the most common. Partial graft resorption was observed in 36.5% of the participants. Recurrent subluxation was reported in 1.2% of the participants, and recurrent dislocation prompting a reoperation was noted in 0.3% of the participants. There were significant improvements in clinical outcomes, including American Shoulder and Elbow Surgeons score (40.9-point increase; P < .01), Single Assessment Numeric Evaluation (47.2-point increase; P < .01), Western Ontario Shoulder Instability Index (49.4-point decrease; P < .01), Disabilities of the Arm, Shoulder and Hand (20.0-point decrease; P = .03), and visual analog scale (2.1-point decrease; P = .05). Additionally, postoperative shoulder range of motion significantly increased from baseline values. The DTA procedure was associated with a low complication rate, good clinical outcomes, and improved range of motion among patients with anterior shoulder instability and associated glenoid defects.

MANAGEMENT OF RECURRENT INTRAOCULAR LENS SUBLUXATION AFTER IOL REPOSITION IN APHAKIC PEDIATRIC PATIENT WITH SECONDARY GLAUCOMA AND DEPRIVATIVE AMBLYOPIA

Introduction : Malposition of the intraocular lens (IOL) can be in the form of decentration, subluxation, dislocation, or luxation. Conservative management and surgery are used to treat IOL subluxation.&#x0D; Case Illustration : A 14-year-old boy came to clinic with chief complaint of diplopia since 1 month ago. There were histories of cataract surgery of both eyes in 2014 and 2015 at a secondary hospital, secondary IOL implantation and membranectomy of right eye in December 2017, and IOL reposition of right eye in February 2022. Ophthalmologist examination revealed BCVA of right eye is 0.5 with S+10.00 C-2.25 x180 and left eye is 1/300. The right eye's intraocular pressure was 23 mmHg and the left eye's was 16 mmHg. Anterior segment examination of the right eye showed aphakia with subluxation of the IOL to the inferotemporal (Figure 1) and PC IOL of the left eye. Patient diagnosed with aphakia ODS with IOL subluxation OD, secondary glaucoma OD, astigmatisma Hypermetropia composite OD, astigmatism Myopia Compositus OS, Hypermetropia OD, Myopia Gravior OS, Deprivative Amblyopia ODS, and Last Eye OD. Patient given monofocal spectacles, prednisolone asetat eye drop tapering dose, and timolol maleate eye drop, with observation of IOL position&#x0D; Discussion : Recurrent IOL subluxation without clear signs of zonular or capsular instability in this patient was managed with conservative management using spectacles and medication due to secondary glaucoma. Long-term observation needed to evaluate possibility of repositioning or explanting the IOL in the future.&#x0D; Conclusion : Management of IOL subluxation could temporarily undergo conservative treatment. A surgical approach is considered in cases of recurrent dislocation

Patients Have a 15% Redislocation Rate After Arthroscopic Bankart Repair With a Knotless Technique

PurposeThe aim of this study was to evaluate the redislocation rate after arthroscopic Bankart repair (ABR) with a standardized knotless anchor technique in a consecutive series of patients with anterior glenohumeral instability. MethodsInclusion criteria were patients who underwent ABR by a single surgeon between January 2008 and December 2018 with a minimum follow up of 2 years. We collected data through phone interviews, Western Ontario Shoulder Instability Index (WOSI) and review of patient records. The primary outcome was redislocation and secondary outcomes were recurrent subluxations, reoperation, postoperative complications, patient satisfaction and functional outcomes. We also performed survival analysis and risk factor analysis. ResultsOut of 88 patients (91 shoulders) that underwent ABR during the inclusion period, 70 patients (73 shoulders) were included (follow-up rate 80%). The mean follow-up was 7.5 years (range 2 to 12 years). Redislocation occurred in 15% (95% CI 7.8%-25.4%) of patients at a mean of 41 months after surgery (range 6 to 115 months). The reoperation rate for recurrent redislocation was 4.1%. Overall, 90.4% reported being currently satisfied with their shoulder and the mean WOSI score at follow-up was 73.8% (range 8.3-99.9%). Patients with redislocation were younger at primary operation than patients with no redislocation (mean 21 years vs. 28 years; P=0.023) and adjusted Hazard Ratio (HR) for age was 0.86 (95% CI 0.74-0.99; P=0.033). It was more common to have less than 3 anchors in patients with redislocation (P=0.024), but adjusted HR was 4.42 (95% CI 0.93-21.02; P=0.061). ConclusionsThe redislocation rate after ABR with a standardized knotless anchor technique in a consecutive series of patients with anterior glenohumeral instability was found to be 15% after a minimum 2-year follow-up (mean 7.5)

Defining Critical Humeral Bone Loss: Inferior Craniocaudal Hill-Sachs Extension as Predictor of Recurrent Instability After Primary Arthroscopic Bankart Repair

Background: The glenoid track concept for shoulder instability primarily describes the medial-lateral relationship between a Hill-Sachs lesion and the glenoid. However, the Hill-Sachs position in the craniocaudal dimension has not been thoroughly studied. Hypothesis: Hill-Sachs lesions with greater inferior extension are associated with increased risk of recurrent instability after primary arthroscopic Bankart repair. Study Design: Case-control study; Level of evidence, 3. Methods: The authors performed a retrospective analysis of patients with on-track Hill-Sachs lesions who underwent primary arthroscopic Bankart repair (without remplissage) between 2007 and 2019 and had a minimum 2-year follow-up. Recurrent instability was defined as recurrent dislocation or subluxation after the index procedure. The craniocaudal position of the Hill-Sachs lesion was measured against the midhumeral axis on sagittal magnetic resonance imaging (MRI) using either a Hill-Sachs bisecting line through the humeral head center (sagittal midpoint angle [SMA], a measure of Hill-Sachs craniocaudal position) or a line tangent to the inferior Hill-Sachs edge (lower-edge angle [LEA], a measure of Hill-Sachs caudal extension). Univariate and multivariate regression were used to determine the predictive value of both SMA and LEA for recurrent instability. Results: In total, 176 patients were included with a mean age of 20.6 years, mean follow-up of 5.9 years, and contact sport participation of 69.3%. Of these patients, 42 (23.9%) experienced recurrent instability (30 dislocations, 12 subluxations) at a mean time of 1.7 years after surgery. Recurrent instability was found to be significantly associated with LEA >90° (ie, Hill-Sachs lesions extending below the humeral head equator), with an OR of 3.29 (P = .022). SMA predicted recurrent instability to a lesser degree (OR, 2.22; P = .052). Post hoc evaluation demonstrated that LEA >90° predicted recurrent dislocations (subset of recurrent instability) with an OR of 4.80 (P = .003). LEA and SMA were found to be collinear with Hill-Sachs interval and distance to dislocation, suggesting that greater LEA and SMA proportionally reflect lesion severity in both the craniocaudal and medial-lateral dimensions. Conclusion: Inferior extension of an otherwise on-track Hill-Sachs lesion is a highly predictive risk factor for recurrent instability after primary arthroscopic Bankart repair. Evaluation of Hill-Sachs extension below the humeral equator (inferior equatorial extension) on sagittal MRI is a clinically facile screening tool for higher-risk lesions with subcritical glenoid bone loss. This threshold for critical humeral bone loss may inform surgical stratification for procedures such as remplissage or other approaches for at-risk on-track lesions.

Recurrent Instability After Arthroscopic Bankart Repair in Patients With Hyperlaxity and Near-Track Lesions.

Recurrent anterior shoulder instability after arthroscopic Bankart repair presents a challenging clinical problem, with the primary stabilization procedure often portending the best chance for clinical success. To determine if capsuloligamentous laxity affects failure (recurrent dislocation, subluxation, and/or perceived instability symptoms) after arthroscopic Bankart repair in patients with near-track lesions (ie, those with smaller distance to dislocation [DTD]). Case-control study; Level of evidence, 3. The authors retrospectively reviewed consecutive patients who underwent primary arthroscopic Bankart repair for recurrent anterior glenohumeral instability at a single institution between 2007 and 2019 and who had at least 2 years of follow-up data. Patients with glenoid bone loss >20%, off-track lesions, concomitant remplissage, or rotator cuff tear were excluded. Capsuloligamentous laxity, or hyperlaxity, was defined as external rotation >85° with the arm at the side and/or grade ≥2 in at least 2 planes with the shoulder at 90° of abduction. Near-track lesions were defined as those with a DTD <10 mm. Included were 173 patients (mean age, 20.5 years; mean DTD, 16.2 mm), of whom 16.8% sustained a recurrent dislocation and 6.4% had recurrent subluxations (defined as any subjective complaint of recurrent instability without frank dislocation), for an overall recurrent instability rate of 23.1%. The rate of revision stabilization was 15.6%. The mean time to follow-up was 7.4 years. Independent predictors of recurrent instability were younger age (P = .001), smaller DTD (P = .021), >1 preoperative instability episode (P < .001), and the presence of hyperlaxity during examination under anesthesia (P = .013). Among patients with near-track lesions, those with hyperlaxity had a recurrent instability rate almost double that of patients without hyperlaxity (odds ratio, 34.1; P = .04). The increased rate of failure and recurrent dislocation in the near-track hyperlaxity cohort remained elevated, even in patients with no bone loss. Capsuloligamentous shoulder laxity was a significant independent risk factor for failure after primary arthroscopic Bankart repair without remplissage and was more predictive of failure in patients with versus without near-track lesions.

Sternoclavicular Joint Reconstruction With Gracilis Tendon Autograft

Clinical instability of the sternoclavicular (SC) joint is a challenging problem. Recurrent subluxation and pain can lead to significant functional limitations. Although many patients respond positively to conservative treatment, chronic dislocations often require operative intervention. The complex anatomy of the diarthrodial SC joint and the existence of concomitant SC joint degenerative changes compounded with close-by neurovascular structures present a surgical challenge. The purpose of this Technical Note is to describe a technique for the open management of symptomatic sternoclavicular joint instability using a figure-of-8 reconstruction with a gracilis autograft. The present authors believe this technique provides a technically safe and reproducible method for reconstructing the SC joint without compromising biomechanical strength.

Poster 158: Remplissage Reduces Recurrent Instability in High-Risk Patients with “On-Track” Hill-Sachs Lesions

Objectives: The objective of this study was to compare recurrent instability rates and patient reported outcomes (PROs) between patients with “on-track” Hill-Sachs lesions who underwent ALR alone versus patients who had received ALR with remplissage (ALR+R). Our hypothesis was that performing a remplissage in addition to ALR would decrease the recurrence rate, especially among high-risk subjects such as contact athletes. Methods: We performed a retrospective analysis of patients age 12-40 years old with “on-track” shoulders who underwent ALR+R between Jan 2014 and Dec 2019 at a single institution, with minimum 2-year follow-up. Exclusion criteria included: prior ipsilateral shoulder surgery, &gt;20% glenoid bone loss (GBL), concomitant rotator cuff repair, and connective-tissue disorder. We then identified a cohort of patients meeting the same inclusion and exclusion criteria who had undergone ALR alone. Patient age, gender, follow-up time, first-time dislocation vs. multiple dislocations, and contact sport participation were recorded. GBL, Hills-Sachs Interval (HSI), glenoid track (GT), and DTD were measured from pre-operative MRIs. The patients were then contacted to determine if they had had recurrent instability and/or revision surgery. We also obtained current Western Ontario Shoulder Instability Index (WOSI) and Single Assessment Numeric Evaluation (SANE) scores. Subgroup analysis was performed on “high-risk” patients (DTD &lt;10mm and contact sport participation) from each cohort. Results: The ALR+R cohort had 17 subjects and the ALR cohort had 51 subjects. There were no differences in demographic variables or GBL between cohorts (P&gt;0.05). The ALR+R subjects had larger HSI (14.7mm ± 2.4 vs 5.7mm ± 5.0; P&lt;0.001) and smaller DTD (8.2mm ± 3.2 vs 16.2mm ± 5.7; P&lt;0.001). There were no difference in WOSI (304.2 ± 213 vs 302.4mm ± 344.2; P=0.98) or SANE (84.3 ± 16.6 vs 87.3 ± 8.9; P=0.94) scores between groups. Only 1 (5.9%) subject in the ALR+R cohort had a recurrent subluxation, and there were no dislocations or revision surgeries. The ALR cohort had 7 (13.7%) recurrent dislocations, 3 (5.8%) recurrent subluxations, and 6 (11.8%) revision surgeries. Multivariate analysis indicated that smaller DTD (OR 0.71; 95% CI (0.56 – 0.87); P=0.001) and contact sport participation (OR 8.67; 95% CI (1.19 – 63.35); P=0.033) were associated with increased risk of recurrent instability. After adjusting for contact sport participation and DTD value, the ALR+R cohort had a 98.8% lower risk of recurrent instability compared to the ALR cohort (OR 0.012; 95% CI (0.0001 – 0.22); P=0.003). Among “high risk” subjects, there was only 1 (11.1%) instability event in the ALR+R group and 4 (80%) in the ALR alone group (P=0.023) Conclusions: DTD calculations can be used as an independent predictor of recurrent shoulder dislocation following ALR for treatment of anterior shoulder instability. For patients with “on- track” shoulder lesions, but small DTD measurements (“near-track” lesions), remplissage is protective against recurrent instability events and need for revision surgery. This may be especially true for “high- risk” patients, such as those who participate in contact sports.

Original surgical technique for the treatment of patellofemoral instability after failure of conservative treatment

IntroductionAcute patellar dislocation is a common but serious injury that can significantly impact a patient's functional prognosis. The objective of this retrospective study is to evaluate the clinical outcomes of arthroscopic medial patellofemoral ligament (MPFL) reconstruction and plication of the medial patellar retinaculum using suture anchors in adolescent patients with first-time acute patellar dislocation (APD) and MPFL insertion injury. HypothesisTightening repair of the medial retinaculum complex can result in favorable clinical and functional outcomes in this patient population. Materials and methodsA total of 84 adolescent patients with first-time APD and with an average age of 15.5 years (10-22) were included in the study. Of these patients, 61 (7 male and 54 female) underwent arthroscopic suture anchor plication for medial patellar retinaculum, while the other 23 were successfully treated non-operatively. Radiographic outcomes, including the congruence angle (CA), lateral patellofemoral angle (LPA), and patellar tilt angle (PTA), were evaluated preoperatively and at the last follow-up visit in the surgical group. Functional outcomes were assessed using the Lille Patello-Femoral Score, Lysholm Score, and Kujala Score at the same time points. In addition, the surgical and non-operative treatment success groups were compared in terms of both radiographic and functional outcomes. ResultsMean follow-up was 40.9 months (24–60). Fifty-nine knees showed excellent or good results postoperatively, 2 patients had a recurrent patellar subluxation. The Lille Patello-Femoral Score was 96.9±4.7 at the last follow-up. The subjective Lysholm Score and Kujala Score improved significantly, from 58.6 to 91.9 and from 60.4 to 88.9, respectively. The radiographic CA, LPA and PTA improved significantly, from 19.8±2.1° to –6.7±1.7°, from –7.4±2.2° to 5.7±1.8° and from 23.8±2.9° to 12.3±2.3°, respectively. There was no statistically significant difference in functional and radiographic assessments between the success with non-operative treatment group and the surgery group. ConclusionThe results of this study suggest that arthroscopic MPFL insertion reconstruction and plication using suture anchors, which is less invasive and improves patella stability, can lead to favorable clinical and functional outcomes in adolescent patients with first-time acute patellar dislocation and insertion injury. This treatment approach should be considered as a viable option for this patient population. Level of evidenceIV; monocentric retrospective descriptive study.

Arthroscopic Posterior Bankart Repair Using the Wilmington Portal to Facilitate Suture Anchor Implantation

Posterior shoulder instability (PSI) accounts for 2% to 10% of all shoulder instability, with recurrent posterior subluxation being the most common type. One of the most important risk factors is the presence of an anterior humeral notch (so-called reverse Hill-Sachs lesion), and the most common lesion in PSI is a posterior labral lesion. When conservative treatment fails, surgery is recommended to provide long-term stability, manage pain, and enable a return to previous activity levels. Most posterior labral tears are treated by an arthroscopic posterior Bankart procedure. Visualization of the posterior aspect of the glenohumeral joint is technically challenging in this procedure. The instrumental portal is also a matter of concern because there is no rotator interval posteriorly for cannula placement. The purpose of this article is to propose a technique using a secondary posterolateral Wilmington instrumental portal to perform easy and reproducible placement of the posterior suture anchor at a 45° angle to the glenoid rim. We recommend implementing this technique in patients with painful PSI or with a type B2 lesion according to the Moroder classification.

A Novel Technique Using the Dorsal Capsule of the Distal Radioulnar Joint for Extensor Carpi Ulnaris Tendon Subsheath Reconstruction.

Background Ulnar-sided wrist pain is a common problem encountered by hand surgeons. Symptomatic recurrent subluxation of the extensor carpi ulnaris (ECU) tendon has become increasingly recognized as one of the pathological conditions leading to ulnar-sided wrist pain. Surgical reconstruction of the subsheath is usually needed. ECU tendon subsheath reconstruction with the periosteal flap was first described by Schlesinger in 1907. Since then, various other techniques have been widely used. We describe a technique of ECU subsheath reconstruction using the dorsal capsule of the distal radioulnar joint (DRUJ). Description of Technique Two hand surgeons performed the surgeries with the same steps taken each time. A detailed description of our surgical technique, with the dorsal capsule of the DRUJ used to reconstruct the ECU tendon subsheath, is illustrated. Patient and Methods Patients who presented with symptomatic ECU instability despite conservative treatment or who have failed primary subsheath repair were offered this surgical option. Patients were followed up postoperatively for an average duration of 6.7 months in our outpatient clinics for assessment of wrist function. The surgical outcomes were reviewed and graded with the Modified Mayo Wrist Score (MMWS). Results All but one of the seven patients had an overall improvement in their range of movement of the wrist, grip strength, and pain scores. Four patients had excellent outcomes on the MMWS, one of whom had an asymptomatic recurrence seen on dynamic ultrasound. Two patients required subsequent surgeries: one had an excellent outcome and the other had a poor outcome on the MMWS. Conclusion We present our first seven cases of ECU subsheath reconstruction with the dorsal capsule of the DRUJ. Our results in the short term have been satisfactory. The technique does not disrupt the integrity of the extensor retinaculum, which is essential for optimal extensor tendon function, and can also be considered as an option to salvage failed procedures.

3D Printed Models of Trochlear Dysplasia and Trochleoplasty Simulation for Trainee Education

Trochlear dysplasia is a major contributor to patellofemoral instability and subsequent failure of isolated soft tissue reconstruction procedures in the treatment of recurrent patellar dislocation and/or subluxation. Trochleoplasty procedures aim to address abnormal osseous trochlear morphologic factors that contribute to patellar maltracking. However, teaching these techniques is limited by the lack of reliable training models for trochlear dysplasia and trochleoplasty simulation. Although a cadaveric knee model of trochlear dysplasia for trochleoplasty simulation has been recently described, cadaveric knees are less amenable for use in trochleoplasty planning and surgeon training because of the absence of reliable, natural dysplastic anatomic relationships, such as suprapatellar spurs due to the rarity of dysplastic cadavers and the high cost of cadaveric specimens. Furthermore, readily available sawbone models represent “normal” osseous trochlear morphology and are difficult to modify and bend due to their material composition. Given this, we have developed a cost-effective, reliable, and anatomically accurate three-dimensional (3D) knee model of trochlear dysplasia for trochleoplasty simulation and trainee education.

Surgical versus conservative management of patellar re-dislocation: clinical and radiological results at a mid-term follow-up of 5 years

Background: Patellar dislocation accounts for 2–3% of all knee lesions and is the second most common cause of traumatic hemarthrosis of the knee. Proper treatment is essential to minimize long term sequelae, such as recurrent dislocation, painful subluxation, and osteoarthritis. Aim: The purposes of this perspective randomized study were: 1) to evaluate the mid-term clinical and radiological results of the Elmslie–Trillat procedure for the treatment of traumatic patellar re-dislocation; and 2) to compare the results, especially radiological osteoarthritis development, with those of non-operative management for traumatic patellar re-dislocation. Methods: From June 2013 to February 2015, 65 patients were admitted to our Emergency Department for a first patellar dislocation episode. All patients were treated non-operatively. When a second episode occurred within two years, patients were randomly assigned in two groups: Group A, patients treated surgically with Elmslie-Trillat procedure, and Group B, patients were further treated non-operatively. The Knee Society Score (KSS), Lysholm scale and Kujala questionnaire were administered immediately after the re-dislocation and at the final follow-up. Tangential patella radiographs were evaluated for patellofemoral osteoarthritis and graded according to Sperner’s classification. Results: The mean follow-up was 6.4±1.7 years (range 5-8) in Group A and 6.3±2.1 years (range 5-9) in Group B. In Group A, the KSS and Lysholm scale showed significant differences between pre- and post-operatively values (p&lt;0.05). The mean Kujala score was significantly lower in Group B when compared with the mean value of Group A (p&lt;0.05). At the final follow-up of more than 5 five years, the mean grade of patellofemoral osteoarthritis according to Sperner’s classification changed in Group A and Group B, with respectively 25% and 29% of patients having a grade greater than or equal to 3. Conclusion: This study confirms that Elmslie-Trillat is a safe and effective procedure in the treatment of patellar instability, relieving pain and inability, and reducing recurrence risk. However, it cannot avoid the degenerative changes occurring in the natural evolution of patellar dislocation.