Aims. Hydroxyapatite (HA)-coated collars have been shown to reduce aseptic loosening of massive endoprostheses following primary surgery. Limited information exists about their effectiveness in revision surgery. The aim of this study was to radiologically assess osteointegration to HA-coated collars of cemented massive endoprostheses following revision surgery. Methods. Retrospective review of osseointegration frequency, pattern, and timing to a specific HA-coated collar on massive endoprostheses used in revision surgery at our tertiary referral centre between 2010 to 2017 was undertaken. Osseointegration was radiologically classified on cases with a minimum follow-up of six months. Results. In all, 39 patients underwent radiological review at mean 43.5 months; 22/39 (56.4%) showed no osseointegration to the collar. Revision endoprostheses for aseptic loosening were less likely to show osseointegration compared with other indications for revision. Oncological cases with previous or current infection were more likely to show osseointegration to ≥ 1 collar side than those without evidence of prior infection. Conclusion. This seven-year review identified osseointegration of HA-coated collars after revision surgery is less likely (43.6%, 17/39) than after primary surgery. Young patients who undergo revision surgery following initial oncological indication may benefit the most from this collar design. Use in revision oncological cases with a history of infection may be beneficial. HA-coated collars showed limited benefit for patients undergoing revision for failed arthroplasty with history of infection. Cite this article: Bone Jt Open 2021;2(6):371–379

Massive irreparable rotator cuff tears often lead to superior migration of the humeral head, which can markedly impair glenohumeral kinematics and function. Although treatments currently exist for treating such pathology, no clear choice exists for the middle-aged patient demographic. Therefore, a metallic subacromial implant was developed for the purpose of restoring normal glenohumeral kinematics and function. The objective of this study was to determine this implant's ability in restoring normal humeral head position. It was hypothesized that (1) the implant would restore near normal humeral head position and (2) the implant shape could be optimized to improve restoration of the normal humeral head position. A titanium implant was designed and 3D printed. It consisted of four design variables that varied in both implant thickness (5mm and 8mm) and curvature of the humeral articulating surface (high constraint and low constraint. To assess these different designs, these implants were sequentially assessed in a cadaver-based biomechanical testing protocol. Eight cadaver specimens (64 ± 13 years old) were loaded at 0, 30, and 60 degrees of glenohumeral abduction using a previously developed shoulder simulator. An 80N load was equally distributed across all three deltoid heads while a 10N load was applied to each rotator cuff muscle. Testing states included a fully intact rotator cuff state, a posterosuperior massive rotator cuff tear state (cuff deficient state), and the four implant designs. An optical tracking system (Northern Digital, Ontario, Canada) was used to record the translation of the humeral head relative to the glenoid in both superior-inferior and anterior-posterior directions. Superior-Inferior Translation. The creation of a posterosuperior massive rotator cuff tear resulted in significant superior translation of the humeral head relative to the intact cuff state (P=0.016). No significant differences were observed between each implant design and the intact cuff state as all implants decreased the superior migration of the humeral head that was observed in the cuff deficient state. On average, the 5mm low and high constraint implant models were most effective at restoring normal humeral head position to that of the intact cuff state (-1.3 ± 2.0mm, P=0.223; and −1.5 ± 2.3mm, P=0.928 respectively). Anterior-Posterior Translation. No significant differences were observed across all test states for anterior-posterior translation of the humeral head. The cuff deficient on average resulted in posterior translation of the humeral head, however, this was not statistically significant (P=0.128). Both low and high constraint implant designs were found to be most effective at restoring humeral head position to that of the intact cuff state, on average resulting in a small anterior offset (5mm high constraint: 2.0 ± 4.7mm, P=1.000; 8mm high constraint: 1.6 ± 4.9mm, P=1.000). The 5mm high constraint implant was most effective in restoring normal humeral head position in both the superior-inferior and anterior-posterior directions. The results from this study suggest the implant may be an effective treatment for restoring normal glenohumeral kinematics and function in patients with massive irreparable rotator cuff tears. Future studies are needed to address the mechanical efficiency related to arm abduction which is a significant issue related to patient outcomes

Objective. The purpose of this study was to determine the outcomes of revision ankle replacements, using the Invision implant and impaction allograft for massive talar dome defects following primary ankle replacement failure. Outcomes were assessed in terms of bone graft incorporation; improvement in patient reported outcome measures (PROMs); and survivorship of the revision ankle arthroplasty. Methods. A retrospective review of prospectively collected data identified eleven patients who had massive bone cysts and underwent revision of a failed primary total ankle replacement to the Invision revision system, combined with impaction grafting using morselized femoral head allograft. These revisions occurred at a single high volume ankle arthroplasty centre. Computed tomography (CT) scans were used to assess bone graft incorporation and the Manchester-Oxford Foot Questionnaire (MOXFQ) and EQ-5D scores were used pre and post operatively to assess PROMs. Results. The mean follow up was 18 months (12–48months). In all eleven patients, improvement was reported in the post-operative MOXFQ and EQ-5D scores. CT scans showed bone graft incorporation in all cases. None of the patients have required further surgery and are continue to do well clinically at latest follow up. Conclusions. In the short term, this study confirms revision ankle replacements with the Invision prosthesis and impaction with morselized femoral head allograft is a suitable revision option for primary ankle replacement failure with massive talar bone loss. Long term follow up continues of these complex patients

The treatment of massive rotator cuff tears remains controversial. There is lack of studies comparing patient-reported outcomes (PROM) of arthroscopic massive rotator cuff repairs (RCR) against large, medium and small RCRs. Our study aims to report the PROM for arthroscopic massive RCR versus non-massive RCR. Patients undergoing an arthroscopic RCR under a single surgeon over a 5-year period were included. Demographic data were recorded. Pre-operative Quick-DASH and Oxford Shoulder Score (OSS) were prospectively collected pre-operatively and at final review (mean of 18 months post-operatively). The scores were compared to a matched cohort of patients who had large, medium or small RCRs. A post-hoc power analysis confirmed 98% power was achieved. 82 patients were included in the study. 42 (51%) patients underwent massive RCR. The mean age of patients undergoing massive RCR was 59.7 and 55% (n=23) were female. 21% of massive RCRs had biceps augmentation. Quick-DASH improved significantly from a mean of 46.1 pre-operatively to 15.6 at final follow-up for massive RCRs (p<0.001). OSS improved significantly from a mean of 26.9 pre-operatively to 41.4 at final follow up for massive RCRs (p<0.001). There was no significant difference in the final Quick-DASH and OSS scores for massive and non-massive RCRs (p=0.35 and p=0.45 respectively). No revision surgery was required within the minimum one year follow up timescale. Arthroscopic massive rotator cuff repairs have no functional difference to non-massive rotator cuff repairs in the short term follow up period and should be considered in appropriate patient groups

The purpose of this study is to enhance massive bone allografts osseointegration used to reconstruct large bone defects. These allografts show >50% complication rate requiring surgical revision in 20% cases. A new protocol for total bone decellularisation exploiting the vasculature can offer a reduction of postoperative complication by annihilating immune response and improving cellular colonization/ osseointegration. The nutrient artery of 18 porcine bones - humerus/femur/radius/ulna - was cannulated. The decellularization process involved immersion and sequential perfusion with specific solvents over a course of one week. Perfusion was realized by a peristaltic pump (mean flow rate: 6ml/min). The benefit of arterial perfusion was compared to a control group kept in immersion baths without perfusion. Bone samples were processed for histology (HE, Masson's trichrome and DAPI for cell detection), immunohistochemistry (IHC : Collagen IV/elastin for intraosseous vascular system evaluation, Swine Leukocyte Antigen – SLA for immunogenicity in addition to cellular clearance) and DNA quantification. Sterility and solvent residues in the graft were also evaluated with thioglycolate test and pH test respectively. Compared to native bones, no cells could be detected and residual DNA was <50ng/mg dry weight. Intramedullary spaces were completely cleaned. IHC showed the preservation of intracortical vasculature with channels bounded by Collagen IV and elastin within Haversian systems. IHC also showed a significant decrease in SLA signaling. All grafts were sterile at the last decellularization step and showed no solvent residue. The control group kept in immersion baths, paired with 6 perfused radii/ulnae, showed that the perfusion is mandatory to ensure complete decellularisation. Our results prove the effectiveness of a new concept of total bone decellularisation by perfusion. These promising results could lead to a new technique of Vascularized Composite Allograft transposable to pre-clinical and clinical models

The management of patients with massive irreparable rotator cuff tears (RCT) has traditionally proved challenging. This prospective study was undertaken with the aim to assess the overall functional outcome following the use of human dermal allograft in the reconstruction of massive irreparable RCT. 15 patients were included in the study, having a median age of 63 years. All patients underwent open reconstruction of massive irreparable RCT. None of the selected patients had evidence of significant gleno-humeral arthritis. All patients were evaluated pre- and post- operatively by the treating surgeon, and followed up for 12 months. The same physiotherapy protocol was prescribed for all patients. Initial and follow-up assessments were done at regular intervals using the Oxford and quick-DASH scoring systems. A very high patient satisfaction rate, with substantial improvement in pain and function was noted. There was substantial improvement in Oxford shoulder score from a mean of 23.3 to 8.7 (p<0.01), and a similar improvement in mean quick-DASH score from 50.3 to 23.0 (p<0.01). Of the 15 patients, 11 had an improvement of >10 in Oxford score, with these reporting a score of <10 after 12 months. None of the patients had any significant complications because of the surgery, and none had a deterioration in Oxford score from their pre-operative status. We found that Human dermal allograft is a very effective tool in the repair of massive irreparable RCT, with excellent follow-up results after one year

Massive posterosuperior cuff tears (mRCT) retracted to the glenoid are surgically challenging and often associated with high retear rates. Primary repair is a less-favourable option and other salvage procedures such as SCR and tendon transfers are used. This study presents clinical and radiological outcomes of muscle advancement technique for repair of mRCT. Sixty-one patients (mean age 57±6, 77% males and 23% females) (66 shoulders) underwent all-arthroscopic rotator cuff repair that included supraspinatus and infraspinatus subperiosteal dissection off scapular bony fossae, lateral advancement of tendon laminae, and tension-free double-layer Lasso Loop repair to footprint. Pre-and post-operative range of motion (ROM), cuff strength, VAS, Constant, ASES, and UCLA scores were assessed. Radiologic assessment included modified Patte and Goutallier classifications. All patients had MRI at 6 months to evaluate healing and integrity of repair was assessed using Sugaya classification with Sugaya 4 and 5 considered retears. Advanced fatty degeneration (Goutallier 3-4) was present in 44% and 20% of supraspinatus and infraspinatus. Tendon retraction was to the level of or medial to glenoid in 22%, and just lateral in 66%. 50.8% mRCT extended to teres minor. Subscapularis was partially torn (Lafosse 1-3) in 46% and completely torn (Lafosse 4-5) in 20%. At mean follow-up (52.4 weeks), a significant increase in ROM, Relative Cuff Strength (from 57% to 90% compared to contralateral side), VAS (from 4 ±2.5 to 1±1.7), Constant (50±17.8 to 74 ±13.0), ASES (52 ±17.5 to 87 ±14.9), and UCLA (16± 4.9 to 30 ±4.9) scores were noted. There were six retears (10%), one failure due to P. acnes infection. 93% returned to pre-injury work and 89% of cases returned to pre-injury sport. Satisfaction rate was 96%. Muscle advancement technique for mRCT is a viable option with low retear rates, restoration of ROM, strength, and excellent functional outcomes

Aims. To evaluate the place of the massive prostheses in the most complex periprosthetic infections cases (PJis). Method. Between 2011 and 2017, 516 hip and knee revisions for periprosthetic infections had been performed in our hospital by the same senior surgeon. We report a prospective series of 58 patients treated between 2011 and the end of 2017. 26 males and 32 females with on average 69,4 years old (38–86). Infection involved TKA in 39 cases (26 TKA revisions, 11 primary TKA), THA in 18 cases (10 revisions, 7 primary THA), a femoral pseudoarthrosis with posttraumatic gonarthrosis in one case and a septic humeral pseudoarthrosis in one case. We used one stage procedures in 38 cases (14 hips, 23 knees, 1 shoulder) and 20 two stages surgeries (16 knees and 4 hips). Additional technics used with massive prostheses, all for TKA PJis: 4 massive extensor systemallografts performed two times in a one stage procedure, two local flaps (medial gastronecmienmuscle). Two perioperative hyperbaric procedures used to limit the risks of wound complications. Results. The average follow-up is 38 months (12–62 months). The rate of sucess to treat the infection at this follow-up is 89,7 %. We report our feedback of the different massive components uses and the qualities/defaults we noted. The most frequent complication was skin events like wound swelling and delayed cicatrisations in 13 cases. 3 cases of one stages needed a complementary debridement in the three weeks after the surgery with always a good local and infectious evolution. This series report 5 failures of two stages TKA revisions. In 4 cases, the initial local soft tissues conditions were compromised. Conclusions. The use of massive prostheses to treat PJIs is a good option for the complex cases. It can be a good alternative of knee arthrodesis. These components must be used, preferentially for oldest patients, in cases of extreme bone loss or extensed osteitis to secure the bone debridement and the quality of the reconstruction. In our series, the one stage procedure is a validated option even by using complementary technics as bone allografts, extensor system allografts or flaps. The two stages procedure is a secondary option, particularly when softtissues status is compromised before or after the debridement, and mostly for the knees

The treatment of massive chronic tears is problematic. The re-tear rate following surgery for extensive cuff tears remains high, and there is little consensus regarding optimum treatment. To investigate the outcome of a cohort of patients who had open repair of an extensive cuff tear using the Leeds Kuff patch as an augment. A retrospective cohort study of consecutive patients with a massive cuff tear who had surgery in our regional elective orthopaedic centre over a two year period from January 2015 to Dec 2016. All patients followed identical rehabilitation protocols, supervised by physiotherapists with an interest in the shoulder. Outcomes assessment was undertaken at a minimum of 12 months by a registrar or physiotherapist who was not part of the treating team. Pre-op data collection included; range of motion, pain score, Oxford shoulder score (OSS), assessment of muscle atrophy on MRI. Data collection was completed in 15 patients. The mean age was 62 yrs (56 – 75). The mean pre-op OSS was 22, improving to a mean of 43. The range of motion and pain score improved. There were no intra-operative complications. One patient required a second surgery for evacuation of a haematoma at 10 days post op. One patient had an obvious re-tear at 4 months. Open rotator cuff repair with synthetic Kuff patch augmentation for chronic degenerative tears appears worthwhile when assessed at 12 months and they continuous to improve even at 18 months. This treatment method may be a useful option for patients > 70 years old

Introduction. Treatment strategies for irreparable Massive Rotator Cuff Tears (MRCTs) are debatable, especially for younger, active patients. Superior Capsular Reconstruction (SCR) acts as a static stabilizer, while Lower Trapezius Transfer (LTT) serves as a dynamic stabilizer. This study compares the biomechanical effectiveness of SCR and LTT, hypothesizing that their combination will enhance shoulder kinematics. Methods. Eight human shoulders from donors aged 55-75 (mean = 63.75 years), balanced for gender, averaging 219.5 lbs, were used. Rotator cuff and deltoid tendons were connected to force sensors through a pulley system, with the deltoid linked to a servohydraulic motor for dynamic force measurement. Results. From intact to MRCT, deltoid force was reduced by 28% (p = 0.023). LTT increased deltoid force by 27.25 (p = 0.166). SCR decreased deltoid force by 34% (p = 0.208). Combining LTT with SCR increased deltoid force by 32.57% compared to SCR (p = 0.023) and decreased it by 13.6% compared to LTT alone (p = 0.017). Combined LTT and SCR reduced deltoid force by 20.9% from the control (p = 0.001). Subacromial contact pressure rose by 15% in MRCT over intact, but LTT decreased it by 7.6%, achieving nearly 50% correction. SCR increased subacromial space volume, raising pressure by 6.5%. The humeral head translation (HHT) increases with MRCT, reaching 3.33 mm (SD = 0.95) at 0 degrees, compared to 2.24 mm (SD = 0.78) in the intact. LTT and the combined LTT + SCR significantly reduce HHT, with combined LTT + SCR achieving HHT of 2.24 mm (SD = 0.63) at 0 degrees, comparable to the control. Conclusion. Notable changes in deltoid force were observed. LTT outperformed the combined SCR and LTT in reducing deltoid force and subacromial peak pressure. Both SCR and LTT corrected HTT, with LTT being more effective. However, combining SCR and LTT optimally corrected HHT

Aim. To evaluate the results and complications of bone transport in the treatment of massive tibial bone defects, using the Ilizarov method. Methods. 15 patients underwent bone transport using the Ilizarov technique to treat massive tibial bone defects. The average age of the patients was 8.7 years (3–24 years) and the mean bone defect was 10.8 cms. Following a latent period of 1 week, distraction of the transport doughnut was commenced at 1mm/24 hours in 4 quarterly turns. A docking procedure was performed in 7 cases which involved freshening of the bone ends and autogenous bone grafting from the iliac crest. Following docking the fixator was removed once the regenerate had consolidated. Results. The fixators were removed after a mean 12.3 months (range 8–21 months). 1 patient required adjustment of the frame under anaesthetic due to translation of the docking doughnut and poor alignment. All patients had at least one superficial pin site infection successfully treated with oral antibiotics. Deep infection at the docking site was seen in 1 patient needing debridement and split skin grafting. There were no neuro-vascular complications. 1 patient had a recurvatum deformity at the regenerate due to early frame removal. There were no early fractures. Re-fracture of the docking site occurred in one patient, 17 months after the removal of the original frame. This needed open reduction and internal fixation. Non union at the docking site was seen in 3 patients, needing open reduction, internal fixation with bone grafting (1 case) and excision of non-union and compression with a further frame (2 cases). Conclusion. Massive bone transport in the tibia is an orthopaedic challenge. This paper highlights the complications of this procedure. It confirms the viability of this method but emphasises careful counselling of both the patient and parents prior to the commencement of such difficult treatment

Summary Statement. In this study, massive rotator cuff tears were treated using an absorbable collagen-based patch or a non-absorbable synthetic patch. Results demonstrated the efficacy of the use of the synthetic prolene patch especially for elderly patients. Introduction. The treatment of massive rotator cuff tears presents a challenging problem in shoulder surgery. Traditional repair techniques are associated with high rupture rates due to excessive tension on the repair and the presence of degenerated tendon tissue. These factors have led to attempts to reconstruct the rotator cuff with grafts, using synthetic materials or biologic tissues. The purpose of this study was to compare the efficacy of the use of pericardium patch with the use of prolene patch in the repair of extensive rotator cuff tears. Materials & Methods. A retrospective series of 180 patients, 115 men and 65 women with a mean age of 66.8 years treated for a massive rotator cuff tear from 1997 to 2008 is reported. The inclusion criteria were: patients symptomatic with pain, deficit of elevation, not responsive to the physiotherapy, tear size (massive: 2 or more tendons), minimum follow-up of 2 years since surgery, active and motivated patients. Patients were divided into three groups according to the type of treatment received: group 1 was treated with Pericardium patch, group 2 with Prolene patch, group 3 with simple suture. All groups were homogeneous. Plain radiographs, ultrasound and MRI were performed preoperatively and at 3 years. Patients were clinically evaluated using the UCLA score before surgery and at 2 months and 3 years after surgery (mean follow-up 2, 6 years). Pain was assessed by use of VAS scale, strength by the use of dynamometer. The surgical procedure (mini-open technique) was similar in all groups. Statistical analysis was conducted by one-way ANOVA between groups of treatment with Dunnett's C post-hoc correction for multiple comparisons. P-values of 0.05 or less were considered as statistically significant. Results. After 2 months the mean VAS was 6.85±1.11, 6.45±1.01, 4.9±0.9 while the mean UCLA was 11.28±1.43, 13.35±14.21, 20.85±12.77, respectively for Control, Collagen and Prolene group. After 36 months the mean VAS was 3.7±1.01, 4.05±0.98, 3.23±1.07, while the mean UCLA was 14.73±1.96, 14.86±2.08, 24.6±3.3 respectively for Control, Collagen and Prolene group. In addition, after 36 months elevation on the scapular plane was 140.75°±10.48, 141.58°±11.87, 174.75°±8.1 and abduction strength was 8.57kg±0.63, 8.82kg±0.7, 13.61kg±0.84, respectively for Control, Collagen and Prolene group. Retear rate after 12 months was 40% (24/60) for Control group, 48.33% (29/60) for Collagen group, 15% (9/60) for Prolene group. Conclusion. The use of Prolene patch as an augmentation graft in the treatment of massive rotator cuff tears is safe and, in most patients, can give a significant pain relief and improvement of range of motion and strength with few complications

Summary. In the sample studied, reparability of large and massive tears was associated with pre-op ASES and active external rotation in neutral position. Surgical factors affecting reparability were tear size, tendon mobility and shape of the tear. Introduction. The limited literature has shown good results with partial repairs of large and massive tears of rotator cuff but the role of factors that affect reparability is less clear . 1-3. The purpose of this study was twofold, 1) to explore the predictive value of clinical and surgical factors on reparability of large and massive rotator cuff tears and 2) to examine the relationship between reparability and clinical and disability measures. Patients and Methods. This was a secondary data analysis of consecutive patients with large or massive rotator cuff tear who required surgical treatment (full or partial repair) and had returned for their two year follow-up. Disability measures included the American Shoulder and Elbow Surgeons (ASES), the relative Constant-Murley score (RCMS) and the shortened version of the Western Ontario Rotator Cuff Index (ShortWORC). The relationship between predictors and reparability was examined through logistic regression and chi-square statistics as appropriate. Within group change over time and between group differences in disability outcomes, range of motion and strength were examined by student's T-tests and non-parametric statistics. Results. One hundred and fourteen patients (40 women, mean age 64, SD=9) were included in the analysis. There were 79 large (34 fully reparable, 45 partially reparable) and 35 (10 fully reparable, 25 partially reparable) massive tears. Reparability was not associated with age, sex, or pre-operative active flexion or abduction (p>0.05) but the fully repairable tear group showed a better pre-operative ASES score (p=0.01) and a better active external rotation in neutral (p=0.05). Reparability was associated with tear shape (p<0.0001) and size (p=0.007), and tendon mobility (p<0.0001). Discussion/Conclusion. Among demographics, clinical examination and patient-oriented outcomes, the pre-op scores of the ASES and active external rotation in neutral position were predictive of reparability of a large or massive tear. Surgical variables associated with a partial repair were the tear size, tendon mobility and shape of the tear. Patients with partial repair had a statistically significant improvement in range of motion and strength and all disability scores over time. However, they had less flexion and abduction and reported a higher level of residual disability at 2 years post-operatively

Study Design: Review of patients with massive disc prolapse, with a minimum of 50% canal occlusion, treated non-operatively. Objectives: To demonstrate the behaviour of massive disc prolapse treated non-operatively. Subjects: Patients with massive disc prolapse whose symptoms had started to resolve or who had refused surgery. Outcome Measures: Spontaneous reduction of disc herniation on MRI scans. Results: There were 10 patients who have had massive lumbar disc prolapse treated non-operatively. All had MRI scans which showed a lumbar disc prolapse occluding greater than 50% of the canal diameter on the axial cuts. The average occlusion of the canal was 62%. Repeat MRI scans showed reduction of the disc prolapse in all cases, with an average of 83% (range 68–100) reduction in the canal occlusion. The scans were performed between 6 and 68 months apart. 9/10 patients had resolution of leg pain. One patient had persistent leg pain despite complete resolution of the disc prolapse. He went on to have an exploration of the right S1 nerve root. No disc prolapse was identified and the S1 root was free and healthy. This however resolved the majority of his leg pain. Conclusion: We have demonstrated that the natural history, in these cases of massive prolapse was to resolve both clinically and radiologically in the majority of cases

Due to an arthroscopic’s surgery progress, almost all type of rotator cuff lesions including massive tears can be repaired. Correct preoperative surgical planning needs combination of dates coming from clinical history, diagnostic imaging and the demand of patient. Purpose: the goal of this study is to report on the arthroscopic repair of massive rotator cuff tear: surgical techniques used, outcome. Type of study: retrospective study in 2 Orthopedic Center in Rome (Italy). Methods: Between 2000 and 2007, 457 patients underwent arthroscopic repair of rotator cuff tear: 93 of these were complete massive cuff tear. The pre-op and postoperative outcomes were analyzed using the Costant Score (CS), Simple Shoulder Test (SST), a single question reflecting satisfaction. The patients were divided in 2 group: massive antero-superior and massive postero-superior cuff tear. The average age of patients was: 55–74 yrs; the average time from onset of symptoms to surgery was 16,7 months. Results: the CS score improved from 0–3 pre-op to 7–10 post op; the SST score from 18–32 pre-op to 68–90. The patient satisfaction rate was > 90%. Conclusion: The arthroscopic repair of massive rotator cuff tear is an effective procedure for decresing pain and improving function of the shoulder. The patient satisfaction rate is very high. The right indication to surgery, the correct surgical procedure and the appropriate physical terapy are the keys of success

Background: The purpose of this study was to evaluate the mid and long-term results of the open repair of the rotator cuff tears in patients where pain of the shoulder was the primary and function the secondary consideration. Material – Method: the study includes 48 patients, out of a total 64, operated on during the period 1985–2001 for full-thickness massive tears of the rotator cuff. The average age was fifty-two years. In all but six the main symptom was persistent pain resulting from a chronic tear. This group had clinical evidence of a rotator cuff defect in the form of weakness and limited range of active motion. The six additional patients suffered from acute tears following trauma and were led to early surgical repair. Their characteristic sign was extensive limitation of active motion, whereas the passive movements were near normal. The operation performed was the anterior acromioplasty with cuff repair through an anterosuperior incision. Several techniques were employed to advance the retracted tendons to their insertions, in the large and massive chronic tears. No patient had transfer of the latissimus dorsi tendon to bridge the gap in the rotator cuff. Results: The clinical evaluation according to the rating system of UCLA showed 36 excellent, 9 good and 3 fair results. There was no poor result after an average follow-up 7,4 years. Conclusions: The present series indicates that reconstruction of a torn rotator cuff can be successful in the majority of patients. Careful preoperative evaluation and planning is of great value in arranging the surgical technique. In large and massive chronic tears the retracted infl exible muscles do not allow easy advancement of their tendons in order to be securely fixed to the greater tubercle. Therefore the surgeon should be familiar with special techniques to achieve a so-called watertight repair, which is necessary for a long-lasting good result

Three cases of patients affected with massive bone defects are reported, in which over 50% of the segments are involved. The treatment options considered were original and not yet described in literature. The patients were affected with: partial agenesia of the tibia, congenital hypoplasia and pseudoarthrosis of the femur, and massive post-traumatic bone defect. In all these cases the Ilizarov’s method was applied. In the first case, instead of carrying out an osteotomy and callotasis of the residual bone tissue, an osteotomy was performed close to the tibiofibular syndesmosis and a distraction at this level was executed. In the second case of pseudoarthrosis with antecurvatum of the proximal femur of 135°, varus of 100°, length discrepancy of 63%, a multiplanar gradual correction of the proximal deformity of the femur was carried out followed by a distal lengthening. The third case concerning the pluri-fragmented exposed diaphyseal fracture of the tibia and fibula, with massive bone loss, was treated by restoring all the small fragments, even those without periosteal connections, to increase the proximal and distal bone mass. Once the fusion of the fragments occurred, a proximal osteotomy and callotasis was performed to rejoin the fracture’s segments

The aim is to evaluate the effectiveness of pericardium patch as a tendon augmentation graft in the repair of massive rotator cuff tear. This is prospective study analysis of a consecutive series of 60 patients who underwent open repair of a massive rotator cuff tear with patch between 1999 and 2007. The inclusion criteria were: symptomatic with pain, deficit of elevation, not responsive to the physiotherapy, tear size (massive: 2 or more tendons), minimum follow-up of 2 years since surgery, active and motivated patients. All were assessed preoperatively with plain radiographs (anteroposterior and axillary views), ultrasound and NMR of the shoulder. The study group consistent of 60 patients (39 men and 21 women) with the mean age of was 66 years (range, 46–81). The mean duration of symptoms before repair was 18 months (range 3–48). Patients were assessed with UCLA score, visual analog scale (Vas scale) and ultrasound preoperatively, at 1 year, and at 3 years. The change in UCLA scores, Vas scale were analyzed with the paired Student's test, assuming a normal distribution of the total score. Satisfactory results were achieved in 49 patients: mean preoperative UCLA score improved from 9.3 to 16.9 at final follow-up. For pain, the mean preoperative value of Vas scale was 9,1, postoperative mean value was 4.9. Range of motion and abduction power improved not significantly after surgery, although patients satisfaction levels were high. Imaging studies identified intact patch in 15 patients and patch detachment in 45. No adverse side effects (infection, rejection, allergy) were reported during the study period. The results of our study suggest that patients (appropriately selected) with a massive full-thickness rotator cuff tear can be expected to have a pain relief after repair, but not a significantly improved of functional outcome

To evaluate the value of the use of massive prostheses in periprosthetic infections both in one stage and two stages procedures. Between 2008 and 2014, 236 revisions for PJI had been performed in our hospital by the same surgeon. For the most complex cases, we decided to introduce megaprostheses in our practice in 2011. We report a prospective series of 33 infected patients treated between 2011 and the end of 2014, 14 male and 19 female with on average 67.9 years old (38–85) Infection involved TKA in 22 cases (17 TKA revisions, 4 primary TKA), THA in 9 cases (6 revisions, 3 primary THA), a femoral pseudo-arthrosis with posttraumatic gonarthrosis in one case and a septic humeral pseudoarthrosis in one case. We used a total femoral component for two patients: the first one for a hip PJI with extended diaphyseal bone loss and multiples sinus tracks, and the second one for a massive infected knee prosthesis used in a knee reconstruction for liposarcoma. We used one stage procedures in 20 cases (8 hips, 12 knees, 1 shoulder) and two stages in 13 cases (12 knees and 1 hip). Additional technics included 3 massive extensor system allografts, two local flaps. Perioperative hyperbaric treatment was used for 2 patients. The average follow up is 19.8 months (6–48 months). The most frequent complications were wound swelling and delayed healing in 8 cases;). In 3 cases of one stage surgery a complementary debridement was necessary in the three weeks after the surgery with always a good local and infectious evolution. VAC therapy was used in four cases with good results. We report one early postoperative dead. In summary, the use of massive prostheses in PJI is a good option for complex cases. It can be a good alternative to knee arthrodesis. These components must be used preferentially for older patients, in cases of extreme bone loss or extensive osteomyelitis to secure the bone debridement and the quality of the reconstruction. In our series, the one stage procedure is a validated option even by using complementary technics as bone allografts, extensor system allografts or flaps. We believe the two stages surgery is a secondary option, particularly when soft tissues status is compromised before or after the debridement, and mostly for the knees. The longevity of the implantation must be evaluate by a long term follow up

The aim of this study is to assess the clinical outcome following latissiumus dorsi transfer for massive irreparable tears of the rotator cuff. Between 1996 and 2002 seven patients with massive irreparable rotator cuff tears were treated by transfer of the latissimus dorsi by a single surgeon. Their mean age at time of surgery was 65 years. Five patients were female, five were primary procedures and two were revisions. Patients were assessed with MRI pre-operatively; the decision to plan a transfer was made clinically. At time of operation all were found to massive irreparable tears of the cuff including Supraspinatus and Infraspinatus, Subscapularis was intact in all cases. Five of the transfers were implanted to a bone trough, one was sutured to a tendon stump, and one was augmented with a Teflon patch. Mean time to follow up was 21 months. All patients were assessed by the lead author or by his Specialist Registrar. Six patients had a good result, one had a poor result this was a revision procedure resulting in deltoid origin detachment. Functional outcome significantly improved post-transfer. Constant score 62.1% vs 36.1% (p< 0.0005, Paired t-test), Pain was also significantly reduced post-transfer, both when active 7.1 vs. 2.2 p (< 0.005) and when at rest 3.7 vs. 1.2 (p< 0.005). Conclusion: These results are compatible with those published for Latissimus Dorsi Transfer. Latissimus Dorsi Transfer can be effective in restoring shoulder function and reducing pain following massive irreparable tears of the rotator cuff