Aims

Extensive literature exists relating to the management of shoulder instability, with a more recent focus on glenoid and humeral bone loss. However, the optimal timing for surgery following a dislocation remains unclear. There is concern that recurrent dislocations may worsen subsequent surgical outcomes, with some advocating stabilization after the first dislocation. The aim of this study was to determine if the recurrence of instability following arthroscopic stabilization in patients without significant glenoid bone loss was influenced by the number of dislocations prior to surgery.

Bone defects are frequently observed in anterior shoulder instability. Over the last decade, knowledge of the association of bone loss with increased failure rates of soft-tissue repair has shifted the surgical management of chronic shoulder instability. On the glenoid side, there is no controversy about the critical glenoid bone loss being 20%. However, poor outcomes have been described even with a subcritical glenoid bone defect as low as 13.5%. On the humeral side, the Hill-Sachs lesion should be evaluated concomitantly with the glenoid defect as the two sides of the same bipolar lesion which interact in the instability process, as described by the glenoid track concept. We advocate adding remplissage to every Bankart repair in patients with a Hill-Sachs lesion, regardless of the glenoid bone loss. When critical or subcritical glenoid bone loss occurs in active patients (> 15%) or bipolar off-track lesions, we should consider anterior glenoid bone reconstructions. The techniques have evolved significantly over the last two decades, moving from open procedures to arthroscopic, and from screw fixation to metal-free fixation. The new arthroscopic techniques of glenoid bone reconstruction procedures allow precise positioning of the graft, identification, and treatment of concomitant injuries with low morbidity and faster recovery. Given the problems associated with bone resorption and metal hardware protrusion, the new metal-free techniques for Latarjet or free bone block procedures seem a good solution to avoid these complications, although no long-term data are yet available.

Cite this article: Bone Joint J 2024;106-B(10):1100–1110.

Aims

The aim of this study was to evaluate the outcome of complex radial head fractures at mid-term follow-up, and determine whether open reduction and internal fixation (ORIF) or radial head arthroplasty (RHA) should be recommended for surgical treatment.

The December 2023 Trauma Roundup³⁶⁰ looks at: Distal femoral arthroplasty: medical risks under the spotlight; Quads repair: tunnels or anchors?; Complex trade-offs in treating severe tibial fractures: limb salvage versus primary amputation; Middle-sized posterior malleolus fractures – to fix?; Bone transport through induced membrane: a randomized controlled trial; Displaced geriatric femoral neck fractures; Risk factors for reoperation to promote union in 1,111 distal femur fractures; New versus old – reliability of the OTA/AO classification for trochanteric hip fractures; Risk factors for fracture-related infection after ankle fracture surgery.

Aims. This study aimed to establish the optimal fixation methods for calcaneal tuberosity avulsion fractures with different fragment thicknesses in a porcine model. Methods. A total of 36 porcine calcanea were sawed to create simple avulsion fractures with three different fragment thicknesses (5, 10, and 15 mm). They were randomly fixed with either two suture anchors or one headless screw. Load-to-failure and cyclic loading tension tests were performed for the biomechanical analysis. Results. This biomechanical study predicts that headless screw fixation is a better option if fragment thickness is over 15 mm in terms of the comparable peak failure load to suture anchor fixation (headless screw: 432.55 N (SD 62.25); suture anchor: 446.58 N (SD 84.97)), and less fracture fragment displacement after cyclic loading (headless screw: 3.94 N (SD 1.76); suture anchor: 8.68 N (SD 1.84)). Given that the fragment thickness is less than 10 mm, suture anchor fixation is a safer option. Conclusion. Fracture fragment thickness helps in making the decision of either using headless screw or suture anchor fixation in treating calcaneal tuberosity avulsion fracture, based on the regression models of our study. Cite this article: Bone Joint Res 2023;12(8):504–511

Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered.

Cite this article: Bone Joint J 2023;105-B(2):112–123.

Aims. Olecranon fractures are usually caused by falling directly on to the olecranon or following a fall on to an outstretched arm. Displaced fractures of the olecranon with a stable ulnohumeral joint are commonly managed by open reduction and internal fixation. The current predominant method of management of simple displaced fractures with ulnohumeral stability (Mayo grade IIA) in the UK and internationally is a low-cost technique using tension band wiring. Suture or suture anchor techniques have been described with the aim of reducing the hardware related complications and reoperation. An all-suture technique has been developed to fix the fracture using strong synthetic sutures alone. The aim of this trial is to investigate the clinical and cost-effectiveness of tension suture repair versus traditional tension band wiring for the surgical fixation of Mayo grade IIA fractures of the olecranon. Methods. SOFFT is a multicentre, pragmatic, two-arm parallel-group, non-inferiority, randomized controlled trial. Participants will be assigned 1:1 to receive either tension suture fixation or tension band wiring. 280 adult participants will be recruited. The primary outcome will be the Disabilities of the Arm, Shoulder and Hand (DASH) score at four months post-randomization. Secondary outcome measures include DASH (at 12, 18, and 24 months), pain, Net Promotor Score (patient satisfaction), EuroQol five-dimension five-level score (EQ-5D-5L), radiological union, complications, elbow range of motion, and re-operations related to the injury or to remove metalwork. An economic evaluation will assess the cost-effectiveness of treatments. Discussion. There is currently no high-quality evidence comparing the clinical and cost effectiveness of the tension suture repair to the traditional tension band wiring currently offered for the internal fixation of displaced fractures of the olecranon. The Simple Olecranon Fracture Fixation Trial (SOFFT) is a randomized controlled trial with sufficient power and design rigour to provide this evidence for the subtype of Mayo grade IIA fractures. Cite this article: Bone Jt Open 2023;4(1):27–37

Aims

To evaluate the outcomes of terrible triad injuries (TTIs) in mid-term follow-up and determine whether surgical treatment of the radial head influences clinical and radiological outcomes.

Aims

Many biomechanical studies have shown that the weakest biomechanical point of a rotator cuff repair is the suture-tendon interface at the medial row. We developed a novel double rip-stop (DRS) technique to enhance the strength at the medial row for rotator cuff repair. The objective of this study was to evaluate the biomechanical properties of the DRS technique with the conventional suture-bridge (SB) technique and to evaluate the biomechanical performance of the DRS technique with medial row knots.

Suture anchor have been used in surgical procedure of tendon or ligament repair. Recently, there has been developed an all suture anchor (soft anchor) which can be used even when the insertion area is narrow. But, the stability of soft anchors due to narrow zone has not been elucidated. This purpose of this study was to investigate stability of soft anchors with respect to their fixation intervals. Polyurethane foams with two different bone densities (10 pcf; 0.16g / cm³, 20 pcf; 0.32g / cm³) were used. All suture anchors and conventional suture anchors were fixed at 10mm, 5mm, and 2.5mm intervals. The failure load was measured using a mechanical testing machine. The average load to failure of conventional suture anchor were 200.4N, 200.2N, 184.7N in the 10mm, 5mm and 2.5mm interval with 10pcf foam bones and 200.4 N, 200.2 N and 184.7 N with the 20 pcf foam bone respectively. Average load to failure load of soft anchor was 97.3N, 93.9N and 76.9N with 10pcf foam bones and 200.4 N, 200.2 N and 184.7 N with 20 pcf foam bone. Suture screw spacing and bone density are important factors in anchor pullout strength. In osteoporotic bone density, insertion of the suture screw interval of 5 mm might be necessary.

Introduction

Suture anchor have been used in surgical procedure of tendon or ligament repair. Recently, there has been developed an all suture anchor (soft anchor) which can be used even when the insertion area is narrow. But, the stability of soft anchors due to narrow zone has not been elucidated. This purpose of this study was to investigate stability of soft anchors with respect to their fixation intervals.

In this study we evaluated whether the Instability Severity Index Score (ISIS) and the Western Ontario Shoulder Instability Index (WOSI) could detect those patients at risk of failure following arthroscopic Bankart repair. Between April 2008 and June 2010, the ISIS and WOSI were recorded pre-operatively in 110 patients (87 male, 79%) with a mean age of 25.1 years (16 to 61) who underwent this procedure for recurrent anterior glenohumeral instability.

A telephone interview was performed two-years post-operatively to determine whether patients had experienced a recurrent dislocation and whether they had returned to pre-injury activity levels. In all, six (5%) patients had an ISIS > 6 points (0 to 9). Of 100 (91%) patients available two years post-operatively, six (6%) had a recurrent dislocation, and 28 (28%) did not return to pre-injury activity. No patient who dislocated had an ISIS > 6 (p = 1.0). There was no difference in the mean pre-operative WOSI in those who had a re-dislocation and those who did not (p = 0.99). The pre-operative WOSI was significantly lower (p = 0.02) in those who did not return to pre-injury activity, whereas the ISIS was not associated with return to pre-injury activity (p = 0.13).

In conclusion, neither the pre-operative ISIS nor WOSI predicted recurrent dislocation within two years of arthroscopic Bankart repair. Patients with a lower pre-operative WOSI were less likely to return to pre-injury activity.

Cite this article: Bone Joint J 2014; 96-B:1688–92.

Introduction. This study was performed prospectively and randomly to compare clinical outcomes of modified-Brostrom procedure using single and double suture anchor for chronic lateral ankle instability. Material & Methods. Forty patients were followed up for more than 2 years after modified-Brostrom procedure for chronic lateral ankle instability. Twenty modified-Brostrom procedures with single suture anchor and 20 procedures with double suture anchor randomly assigned were performed by one surgeon. The mean age was 30.6 years, and the mean follow-up period was 2.6 years. The clinical evaluation was performed according to the Karlsson scale and Sefton grading system. The measurement of talar tilt angle and anterior talar translation was performed through anterior and varus stress radiographs. Results. At the last follow-up, the Karlsson scale had improved significantly from preoperative average 45.4 points to 90.5 points in single suture anchor group, from 46.2 points to 91.3 points in double suture anchor group. There were 8 excellent, 10 good, and 2 fair results according to the Sefton grading system in single anchor group, and 9 excellent, 8 good, 3 fair results in double anchor group. Therefore, 18 cases (90%) in single anchor group and 17 cases (85%) in double anchor group achieved satisfactory results. Talar tilt angle had improved significantly from preoperative average 15.7° to 6.1° in single anchor group, from 16.8° to 4.2° in double anchor group. There was significant difference in postoperative talar tilt angle between single and double anchor group. Conclusion. Significant differences in clinical and functional outcomes were not found between single and double suture anchor technique. On stress radiographs for evaluation of mechanical stability, modified-Brostrom procedure using double anchor showed less talar tilt angle than single anchor technique

Restoring of anatomic footprint may improve the healing and mechanical strength of repaired tendons. A double row of suture anchors increases the tendon-bone contact area, reconstituting a more anatomic configuration of the rotator cuff footprint. We aimed to investigate if there were differences in clinical and imaging outcome between single row and double row suture anchor technique repairs of rotator cuff tears. We recruited 60 patients affected by a rotator cuff tear diagnosed on clinical grounds, magnetic resonance imaging evidence of cuff tear and inadequate response to nonoperative management, an unretracted and sufficiently mobile full-thickness rotator cuff lesion to allow a double row repair found at the time of surgery. In 30 patients, rotator cuff repair was performed with single row suture anchor technique (Group 1). In the other 30 patients, rotator cuff repair was performed with double row suture anchor technique (Group 2). 8 patients (4 in the single row anchor repair group and 4 in the double row anchor repair group) were lost at follow up. A modified UCLA shoulder rating scale was used to evaluate preoperative and postoperative shoulder pain, function and range of motion, strength and patient satisfaction. All patients received a post-operative MR arthrography at the final follow up appointment. At the 2 year follow-up, no statistically significant differences were seen with respect to the UCLA score and ROM values. Post-operative MR arthrography at 2 years of follow up in group 1 showed intact tendons in 14 patients, partial thickness defects in 10 patients and full thickness defects in 2 patients. In group 2, MR arthrography showed an intact rotator cuff in 18 patients, partial thickness defects in 7 patients, and full thickness defects in 1 patient. Biomechanical studies comparing single versus double row suture anchor technique for rotator cuff repair show that a double row of suture anchors increases the tendonbone contact area and restores the anatomic rotator cuff footprint, providing a better environment for tendon healing. Our study shows that there are no advantages in using a double row suture anchor technique to restore the anatomical footprint. The mechanical advantages evidenced in cadaveric studies do not translate into superior clinical performance when compared with the more traditionally, technically less demanding, and economically more advantageous technique of single row suture anchor repair

Rotator cuff tendons are typically reattached to the proximal humerus using either transosseous sutures or suture anchors. Their primary mode of failure is at the tendon bone interface 1. Surgical adhesives are used to bond cartilage, tendons and bone, and to close wounds. In an attempt to increase the tendon-bone interface we investigated the addition of a novel adhesive secreted from a species of Australian frog (Notaden bennetti) 2 to different methods of rotator cuff repair. Forty two fresh frozen sheep infraspinatus tendons were repaired using 3 different techniques: transosseous sutures; two Mitek RC Quickanchors with 1 suture per anchor and two Opus Magnum anchors with 1 suture per anchor all using a mattress stitch configuration. In each group 7 shoulders were repaired with the addition of a small amount of frog glue to the infraspinatus footprint while 7 were used as control with no adhesive. Mechanical testing was performed using a mechanical tensile testing machine. The strongest construct in the control groups was the Mitek suture anchors (mean 86±5 N) followed by the Opus suture anchor (69±6N) and transosseous repair (50±6N). This proved significant (p< 0.05) between both metallic anchors and the transosseous repair.{BR}The addition of frog glue resulted in a significant increase in load to failure and total energy required until failure in all repair techniques (p< 0.01). There was a 2 fold increase in load to failure of both the Opus Magnum (143±8N) and Mitek RC Fastin (165N±20 N) anchors while the transosseous repair (86± 8 N) had a 1.7 fold increase in its load to failure. This data suggests that:. suture anchor fixation is a stronger construct requiring a larger amount of total force to fail than transosseous repair using a one suture repair technique, that. the addition of an adhesive to the tendon-bone interface significantly enhances both ultimate load and total energy required to failure in all repair types. The unique properties of this frog glue (strong, flexible, sets in water and biocompatibility) may ultimately lead to the production of a useful adjunct for rotator cuff repair in humans

Recurrence represents the leading complication of arthroscopic anterior shoulder stabilization. Even with modern suture anchor techniques, a recurrence rate of between 5 to 20% persists; emphasizing that arthroscopic Bankart repair cannot apply to all patients and selection must be done. Numerous prognostic factors have already been reported, but strict observance would eliminate almost all patients from arthroscopic Bankart repair. We hypothesised that clinical and radiological risk factors could be present and identifiable in the normal outpatient visit, and they could be integrated into a severity score. A case-control study was undertaken, comparing patients identified as failures after arthroscopic Bankart repair (i.e, recurrent instability) with those who had a successful result (i.e., no recurrence). Recurrence was defined as any new episode of dislocation or any subjective complains of subluxation. During a four-year period one hundred and thirty-one consecutive patients with recurrent anterior shoulder instability, with or without shoulder hyperlaxity, were operated by the senior shoulder surgeon with an arthroscopic suture anchor technique and followed for a minimum of two years. Patients were excluded if concomitant pathology, including multidirectional instability, were present. Bony lesions were not excluded. A complete pre and postoperative questionnaire, physical exam, and anteroposterior x-ray were recorded. Mean follow-up was 31.2 months (range, twenty-four to fifty-two months). Nineteen patients had a recurrent anterior instability (14.5%). Preoperative evaluation demonstrated that age below twenty years old, involvement in athletic competition, participation in contact or forced-overhead sports, presence of shoulder hyperlaxity, Hill-Sachs lesion visible on AP external X-ray, and loss of inferior glenoid sclerotic contour on AP x-ray were all factors related to increased recurrence. These factors were integrated in an Instability Severity Index Score and tested retrospectively on the same population. Patients with a score of six or less had a recurrence risk of 10% and those over six had a recurrence risk of 70% (p< 0.001). This study proved that a simple scoring system based on factors of a preoperative questionnaire, physical exam, and anteroposterior x-ray can help the surgeon to select patients who would benefit from arthroscopic stabilization with suture anchors and those for whom an open surgery, like the Latarjet procedure, is a better option

We compared time-dependent changes in the biomechanical properties of single-and double-row repair of a simulated acute tear of the rotator cuff in rabbits to determine the effect of the fixation techniques on the healing process.

A tear of the supraspinatus tendon was created in 80 rabbits which were separated into two equal groups. A single-row repair with two suture anchors was conducted in group 1 and a double-row repair with four suture anchors in group 2. A total of ten intact contralateral shoulder joints was used as a control group. Biomechanical testing was performed immediately post-operatively and at four and eight weeks, and histological analysis at four and eight weeks.

The mean load to failure in group 2 animals was greater than in group 1, but both groups remained lower than the control group at all intervals. Histological analysis showed similar healing properties at four and eight weeks in both groups, but a significantly larger number of healed tendon-bone interfaces were identified in group 2 than in group 1 at eight weeks (p < 0.012).

The ultimate load to failure increased with the number of suture anchors used immediately post-operatively, and at four and eight weeks. The increased load to failure at eight weeks seemed to be related to the increase in the surface area of healed tendon-to-bone in the double-row repair group.