Soft Tissue Instability Research Articles

Arthroscopic Anatomic Glenoid Reconstruction Using Distal Tibial Allograft for Recurrent Anterior Shoulder Instability: Clinical and Radiographic Outcomes

Background: The all-arthroscopic anatomic glenoid reconstruction technique using a distal tibial allograft avoids damage to the subscapularis muscle and allows repair of the capsulolabral tissue. Purpose: To analyze the clinicoradiologic outcomes of patients who underwent this procedure to treat anterior shoulder instability with glenoid bone loss with a minimum 2-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: Over 6 years, 73 patients (52 male and 21 female; mean age, 28.8 years) under the care of the same surgeon underwent arthroscopic stabilization with capsulolabral Bankart repair and bony allograft augmentation of the glenoid for recurrent shoulder instability with significant bone loss. Pre- and postoperative patient-reported functional assessment was performed using 2 questionnaires, the Western Ontario Shoulder Instability Index (WOSI) and the Disabilities of the Arm, Shoulder and Hand, and radiological assessment was performed using radiographs and computed tomography scans obtained preoperatively and approximately 1 year later (mean ± SD, 0.9 ± 1.1 years). Results: The mean follow-up was 4.7 ± 1.1 years. The mean pre- and postoperative WOSI scores were 71.1 ± 17.5 and 25.6 ± 21.9, respectively (P < .001). There were no recurrences of dislocation, although 1 patient had symptoms of subluxation; however, 5 patients had hardware complications that required screw removal. There were no cases of nerve injury. Postoperative computed tomography scans were available for 66 patients. Seven patients were lost to follow-up. The graft union rate was 100%. Overall, graft resorption was <50% in 86% of patients (57/66). Eighteen patients (27%) had no resorption (grade 0), 39 (59%) had <50% (grades 1 and 2), and 9 (14%) had ≥50% (grade 3); however, none had symptoms of instability. The mean alpha angle of the screw between the screw shaft axis and the native glenoid axis was 18.3°± 5.7°. Graft positioning was flush with the glenoid in 61 of 66 patients (92.4%), and vertical positioning was excellent in 64 of 66 patients (97.0%) (3- to 5-o’clock position). Conclusion: Arthroscopic stabilization using distal tibial allograft augmentation resulted in excellent clinicoradiologic outcomes at a 2-year follow-up. This procedure has the advantages of being an anatomic reconstruction that addresses bony and soft tissue instability. However, long-term follow-up studies are necessary for better assessment of outcomes.

The use of static external fixation for chronic instability of the elbow

Chronic elbow instability after trauma is a challenging problem. Clinical results of external elbow fixation in this setting are limited, with most studies focusing on hinged external fixation. A static fixator is an alternative for maintaining joint reduction. Advantages of a static frame include ease of application, decreased need for special instrumentation, and more secure maintenance of a concentrically reduced joint in the setting of bone or soft tissue instability. The primary limitation of static fixation is the potential for stiffness. This retrospective review represents the largest reported cohort evaluating the use of static elbow external fixation for the treatment of chronic elbow instability. Twenty-seven cases treated by a single surgeon between 2004 and 2015 were identified. Twenty patients were available for a clinical evaluation, including radiographs and a physical examination at a mean follow-up of 5.8 years (range, 1.4-12.4 years). Of note, 19 of 20 were clinically obese or overweight. At final evaluation, range of motion averaged from 20° ± 13° of extension to 134° ± 9° of flexion. All patients had stable elbows, except 1 patient who had valgus and varus laxity on stress examination. Radiographs of this patient showed an incongruous joint. Eight patients required an additional operation after external fixator removal, 3 for infection and 5 for stiffness. At almost 6 years of follow-up, static elbow external fixator resulted in a congruous joint with adequate functional and clinical outcomes in 95% of patients.

Causes and Frequencies of Reoperations After Endoprosthetic Reconstructions for Extremity Tumor Surgery: A Systematic Review.

Excision of bone tumors and endoprosthetic reconstruction allow patients early weightbearing and a potential functional advantage compared with amputation. These reconstructions do not restore the limb to normal status, however, and patients are subject to complications that may result in revision or loss of the limb. Because better understanding of these complications based on current information might help the patient and surgeon in decision-making, we undertook a systematic review of studies published on this topic. (1) What are the primary modes and proportion of failure of tumor endoprostheses in patients undergoing reconstruction after excision of primary extremity bone sarcomas? We systematically searched MEDLINE, Embase, and the Cochrane Library for all studies published from April 15, 1998, to April 15, 2018. Three reviewers independently reviewed studies reporting endoprosthetic reconstruction survival and events requiring revision for primary extremity bone tumors treated with endoprosthetic reconstruction for inclusion and performed independent data extraction. We excluded all studies with fewer than five patients, any systematic review/meta-analyses, and any study not reporting on primary extremity bone tumors. All discrepancies were resolved by the study's senior author. Data extracted from included studies were any reoperation event for wound dehiscence, any operative fixation for a pathologic fracture, and any revision of the primary endoprosthesis for implant wear or breakage, deep infection not amenable to prosthesis retention, or for local recurrence. We assessed the overall quality of the evidence with the Methodological Index for Non-Randomized Studies (MINORS) approach with a higher MINORS score representative of a more methodologically rigorous study with a total possible score of 16 points for noncomparative and 24 points for comparative studies. Forty-nine studies met criteria for inclusion from an initial search return of 904 studies, of which no studies were randomized controlled trials. From a total patient population of 2721, there was a mean followup of 93 months (range, 1-516 months) with loss to followup or death occurring in 447 of 2118 (21%) patients with six studies not providing loss to followup data. The mean MINORS score was 14 for prospective studies and 11 for retrospective studies. Overall, there were 1283 reoperations among the 2721 (47%) patients. Reoperation for mechanical endoprosthetic events (soft tissue dehiscence or periarticular soft tissue instability, aseptic loosening, or implant wear/fracture) occurred in 907 of 2721 (33%) patients. Aseptic loosening occurred at a mean of 75 months (range, 1-376 months) in 212 of 315 patients (67%). Deep infection requiring removal of the initial prosthesis occurred in 247 of 2721 (9%) patients with deep infection occurring at a mean of 24 months (range, 1-372 months) in the 190 infections (77%) with time to infection data available. Local recurrence rates requiring revision or amputation occurred in 129 (5%) of all patients. There was an overall primary endoprosthesis survival rate without any surgical reintervention of 63% among reporting studies at a mean of 79 months followup. Failures of endoprosthetic reconstructions after extremity tumor surgery are common, most often resulting from implant wear or fracture, aseptic loosening, and infection. Importantly, the aggregated data are the first to attempt to quantify the time to specific complication types within this patient population. Deep infection not amenable to endoprosthesis retention appears to occur approximately 2 years postoperatively in most patients, with aseptic loosening occurring most commonly at 75 months. Although endoprosthetic reconstruction is one of the most common forms of reconstruction after bone tumor resection, the quality of published evidence regarding this procedure is of low quality with high loss to followup and data quality limiting interstudy analysis. The quality of the evidence is low with high loss to followup and inconsistent reporting of times to reintervention events. Although the most common modes of endoprosthetic failure in this population are well known, creation of quality prospective, collaborative databases would assist in clarifying and informing important elements of the followup process for these patients. Level IV, therapeutic study.

The Varus-Valgus Constrained Knee Implant: Survivorship and Outcomes.

The purpose of this study was to estimate the survivorship of the varus-valgus constrained (VVC) knee implants in primary, aseptic, and septic revision total knee arthroplasty (TKA); determine functional outcomes; main modes of failure; and variables associated with increased mechanical failures. In this study, 685 consecutive cases of primary (n = 247), aseptic (n = 315), and septic revision (n = 123) TKAs with VVC implants were performed between 1999 and 2008; 533 knees (78%) had a mean follow-up of 8.2 years (range, 2-15.1). Kaplan-Meier method was used to evaluate implant survival with mechanical failure as the end point. Clinical outcomes were measured with a modified Knee Society Score (mKSS) and modified Knee Function Score (mKFS) and modes of failure were determined. Cox proportional hazards models were performed to assess for factors associated with implant failure. Ten-year survival was 88.5% (95% confidence interval [CI]: 83.9-93.5%) for primary TKAs, 75.8% (95% CI: 70.4-81.7%) for aseptic, and 54.6% (95% CI: 43.7-68.2%) for septic revisions. Improvement in pre- to postoperative mKSS and mKFS were significant in all three groups (p < 0.05). The most common mode of failure overall was infection. Mechanical modes of failures included periprosthetic fracture (45%) for primary TKA and soft tissue instability (19%) for aseptic revisions. A longer period since the last surgery in affected knee was associated with lower mechanical failures (hazards ratio of 0.55 [95% CI: 0.31-0.95], p = 0.03). VVC implant showed reliable survivorship at 10 years although careful patient selection is warranted due to the risk of infection. The main mechanical modes of failure were instability and periprosthetic fracture.

Premorbid retroversion is significantly greater in type B2 glenoids

Posterior glenoid erosion is thought to be initiated by humeral head subluxation. However, it is unknown whether subluxation is entirely caused by soft-tissue instability and unbalanced muscle activity or whether osseous morphology is a contributing factor. We hypothesized that patients with posterior erosion may exhibit premorbid glenoid morphology that is inherently retroverted and inferiorly inclined compared with age-matched normal glenoids. This study examined 80 scapulae, evenly distributed between 2 groups: osteoarthritic with type B2 glenoids and age-matched normal glenoids. From 3-dimensional computed tomography reconstructions, version and inclination were measured from the anterior paleoglenoid region of the B2 glenoids, which is representative of the premorbid glenoid, and compared with measurements obtained from similar regions in the normal cohort. The anterior paleoglenoid region of B2 glenoids was significantly (P < .001) more retroverted (-14° ± 6°) compared with similar regions in nonarthritic normal glenoids (-5° ± 5°). There were no significant differences (P = .166) in the glenoid inclination angle between type B2 glenoids (0° ± 6°) and nonarthritic normal glenoids (2° ± 5°). Negative values represent retroverted and inferiorly inclined glenoids. Understanding premorbid glenoid morphologic variations may provide insight into the pathoanatomy of humeral head subluxation, osteoarthritis, and posterior glenoid erosion. The results of this study indicate that patients with type B2 osteoarthritic glenoids have significantly greater premorbid glenoid retroversion compared with nonarthritic normal glenoids, suggesting that this premorbid morphologic variation may be one contributing factor to posterior erosion.

Outcomes of Modified Harrington Reconstructions for Nonprimary Periacetabular Tumors: An Effective and Inexpensive Technique.

Metastatic disease to the acetabulum presents a difficult technical and philosophical challenge: complicated surgeries in patients with often short life expectancies force us to examine both the outcome and cost of these operations. Therefore, we studied the durability of a cement-screw rebar reconstruction technique and risk factors for failure, and we compare the results to other reconstruction options. This is a retrospective review of 52 acetabular reconstructions in 50 patients for nonprimary disease using a retrograde screw-rebar-cement all-polyethylene technique. Mean age was 57 years (range 25-81 years). Twenty-four lesions were classified as Harrington class II; 28 were Harrington class III. Mean follow-up was 17.7 months (range 1-92 months). Outcomes included patient survival, prosthesis survival, and complications. Forty-eight of 50 (96 %) patients ambulated after surgery. Five of 52 (9.6 %) of prostheses failed, three from loosening due to tumor progression, one from aseptic loosening, and one from soft tissue instability (dislocation). The three cases of tumor progression failure occurred in patients with massive preoperative ischial tumor burden. Mean surgical time was 198 min, and hospital stay was 5.2 days. The screw-cement-rebar all-polyethylene cup reconstruction technique is a comparatively successful and inexpensive reconstruction option for treating nonprimary oncologic disease in the acetabulum. All cases of loosening occurred beyond the median patient survival. Surgeons should be wary of massive ischial tumor burden in patients with projected longevity, as it may be associated with implant failure. Surgical time and hospital stay are consistent with historical data for alternative implants, and implant cost is lower.

Anterior Shoulder Instability With Bristow Procedure Versus Conjoined Tendon Transfer Alone in a Simple Soft-Tissue Model

We compared the Bristow procedure with a conjoined tendon transfer to investigate the role of the sling alone in restoring anterior translation in a simple soft-tissue instability model without bony defects. Ten matched cadaveric shoulder pairs were randomly assigned to receive a Bristow procedure or a conjoined tendon transfer alone. Specimens were tested in a simple soft-tissue model with low load simulating anterior translation of the glenohumeral joint. The conditions (intact, cut, and repaired) and treatments (Bristow and conjoined tendon transfer alone) were compared for anteroposterior translation. Anterior translation increased from 3.4 +/- 0.6 mm (mean +/- SEM) to 12.0 +/- 1.3 mm after the cut and decreased to 5.2 +/- 0.7 mm with the Bristow procedure. Anterior translation increased from 2.8 +/- 0.4 mm to 12.2 +/- 1.9 mm after the cut and decreased to 4.9 +/- 0.5 mm after conjoined tendon transfer alone. Although the repair increased the stability of the glenohumeral joint as reflected in significantly decreased anterior translation, anterior translation in the repaired joint was significantly greater than that in the intact condition for both procedures (P < .05). There were no significant differences in anterior translation between the 2 treatments at any test stage. There was no difference between the Bristow procedure and conjoined tendon transfer alone in restoring anteroposterior translation in a simple soft-tissue shoulder instability model with low load and no bony defect. Further investigation of the described conjoined tendon procedure should be done to evaluate the procedure with significant bony defects.

Reconstruct coronoid process of ulna with ilium-fascia lata complex tissue

Objective To analyze and explore the operative effect of coraccid process basilar part fractures combined injury of ligamental structure. Methods Use ilium-fascia lata complex tissue to reconstruct coronoid process of ulna and medial collateral ligament, recoverd anterior and wall horn anatomic structure of elbow joint. Total 9 cases of ulna coracoid process fractures concomitancy with elbow posterior dislocation . Among these one with olec-ranon fracture,five patients with head of radius fracture. Anterior trance joint approach was used,removal bone chips, restore defect with ilium-fascia lata complex tissue after cuting and trimming. Once reduction was achieved,fixed with screw. Repaird the collateral ligament and anterior joint capsule use the fascia lata, If there were combined fracture of the radius head or olecranon fracture,fixed through lateral approach,All injured extremities were treated with a posterior plaster splint with functional position for 3 weeks followed by elbow rehabilitation training. Results According to Moneys evaluation method,2 patients were classified as excellent ,5 as good,l as fair and 1 as poor. The excellent and good rate was 77. 8%. Two patients with gently ossifying myositis but no patients with wound infection,internal fixation loosening or break,elbow joint destabilizing orcorpus libemm. Conclusions Coracoid process basilar part fractures was simultaneous with the instability of osteal frame and soft tissue. To attain the favourable anatomical foundation for elbow joint functional recovery, it should rebuild the height and shape of coronoid process first and think highly of repair or rebuild medial collateral ligament and joint capsule. It reconstructed the coronoid process osteal frame and soft tissue instability at the same time to use ilium-fascia lata complex tissue. The operative procedure is simplify with reliability effect and fine functional rehabilitation. Key words: Elbow Joint; Ulna fractures; Bone remodeling; Fascia lata; Ilium

Clinical Examination of the Hip Joint in Athletes

In recent years, a quantum leap has been made in the diagnosis and treatment of nonarthritic hip injuries. This evolution can be attributed in part to better imaging, improved understanding of the anatomy and biomechanics of the hip, and progress in surgical technology and techniques. Among other advances, labral tears and early cartilage damage have been identified as common sources of pain. Furthermore, important etiologies for hip injury have been explained, including femoroacetabular impingement (FAI).1 These advances have led to a rapid increase in the correct diagnosis of nonarthritic hip pain. Concurrent with the advances in diagnosis, a revolution in surgical treatment of hip injuries is emerging. Many joint-preserving surgeries including labral debridement or repair and decompression of impinging bone lesions can now be performed arthroscopically. These arthroscopic hip surgeries have provided new options with high clinical success rates for patients with nonarthritic hip pain.2 The nonarthritic hip poses a diagnostic dilemma because pain is difficult to localize for both the patient and the clinician. As many as 60% of patients requiring hip arthroscopy are initially misdiagnosed, and in one study these patients remained misdiagnosed for an average of 7 months.3 With the new body of knowledge involving nonarthritic hip injuries, clinicians have a tremendous opportunity to help such patients arrive at a diagnosis and be successfully treated. A thorough history and physical are extremely important in determining hip pathology, which is exceptionally relevant given current innovations in therapy for hip pathology. Although the hip is frequently overlooked as the original source of pain or pathology, one study demonstrated that clinical assessment can be 98% reliable in detecting the presence of a hip-joint problem.4 Examination of the hip region can be complex, however, because of coexistent pathology, secondary dysfunction, or coincidental findings. For example, hip-joint disease might coexist with lumbarspine disease. Disorders of the paravertebral muscles can cause soft-tissue instability and irregular tension on the hip,5 and contractures of the iliopsoas and hamstrings can cause back pain.6 In addition, hip pathology might coexist with athletic pubalgia, especially in male athletes. Symptoms of athletic pubalgia require a systematic and reproducible physical examination of the hip with appropriate

War injuries of the crural arteries.

Twenty-eight patients with military crural vascular injuries are presented. In the group undergoing immediate repair (21 patients), the time interval between trauma and surgery was 20 min to 30 h (mean 8 h 30 min). In those receiving delayed repair (seven patients), the interval between trauma and surgery was 3-47 (mean 14) days. Hyperbaric oxygenation therapy was used in conjunction with surgery and antibiotic therapy in 13 of the 28 patients. Explosive injuries were found in 14 patients and high-velocity missile injuries in nine; associated fractures were present in 20. Twenty of the 28 patients with crural vascular injuries had combined arterial and venous injuries, while eight had isolated arterial injuries. Twenty-five patients with distal ischaemia required arterial repair; five late amputations resulted. Military crural vascular injuries should be treated with soft tissue debridement, removal of foreign material, and microvascular arterial and concomitant vein reconstruction. This should be followed by external skeletal stabilization for bony and/or soft tissue instability, with fasciotomy for any associated compartment syndrome. The wound should be left open, with delayed closure or split skin grafting. It was felt that hyperbaric oxygen therapy reduced the amputation rate following combat-related crural vessel injuries.

The Results of Revision Total Knee Arthroplasty

Purpose: To analyze the clinical and radiographic results after revision total knee arthroplasty (TKA). Materials and Methods: 122 revision total knee arthroplasties (mean follow up: 5 years 8 months) were performed. The causes of the revision TKA were; polyethylene wear in 77 knees, deep infection in 21, aseptic loosening in 17, and others in 7. Clinical findings & radiologic measurements were assessed using the Hospital for Special Surgery knee rating score (HSS score) & Bauer’s methods, and by the roentgenographic method of the American Knee Society. Results: After revision TKA, the average range of motion improved from to , and the average HSS knee score from 69 points to 90 points. A posterior stabilized prosthesis was used in 84cases (77%), medullary stem in 49cases (40%), femoral augmentation in 36 cases (29.5%) and structural allograft in 38 cases (31.1%). After revision TKA; the average femoro-tibial angle was corrected from in valgus to in valgus. Complications after revision TKA were; 1 dislocation of the patella, 1 wound disruption and 1 deep infection. Conclusion: The causes of revision TKA included polyethylene wear, deep infection and aseptic loosening. After revision TKA, satisfactory results were obtained using a posterior stabilized prosthesis, medullary stem and augmentation, and a structural allograft for large bone defect and soft tissue instability, respectively.