Background. Primary dislocation of the patella is a common acute knee disorder in children, adolescents and young adults. While primary dislocation of the patella has traditionally been treated non-operatively, primary operative repair of the medial patella-stabilizing soft tissues has been popularized more recently and thought to reduce the risk of dislocation. However, several studies have shown substantial rates of redislocation with longer follow-up time, irrespective of treatment. The purpose of this systematic review was to compare operative and non-operative treatment for primary dislocation of the patella, regarding redislocation rates and symptoms. Methods. Based on a systematic literature search of the medical literature from 1950 to 2010, three randomized and two quasi-randomized controlled clinical trials comparing surgical stabilization with non-operative treatment for patients with primary patellar dislocation were selected. The Risk of Bias Tool (Cochrane Handbook, 2008) was used to assess the quality of the studies included. Study results were pooled using the fixed-effects and random-effects models with mean differences and risk ratios for continuous and dichotomous variables, respectively. Heterogeneity across studies was assessed with Q test and I-square statistic. A sensitivity analysis was performed by assessing the change on effect size by eliminating each single trial. Results. In total, 341 patients from 5 trials were included. 158 patients were treated non-operatively and 183 patients were treated operatively. For primary outcome of patellar redislocation, while significant heterogeneity was found using the random-effects model, no significant difference was observed between the treatment groups (pooled RR=1.36, 95% CI 0.8–2.31, p=0.25). No significant difference was observed between the treatment groups (pooled RR=1.36, 95% CI0.8–2.31, p=0.25). No significant differences were found between both groups for symptoms ofinstability (RR of 1.24, 95% CI 0.96–1.59, p=0.10), Kujala knee score (−5.66, 95% CI −15.51 −4.19, p=0.26) or requirement for later surgery (RR=0.92, CI 0.61–1.39, p=0.69). Conclusions. This meta-analysis found no differences in patellar redislocation rate, patient reported instability symptoms, Kujala Knee score and rate of later surgery after initial treatment, between operative and non-operative treatment of primary patellar dislocation. Level of evidence. Level II

Of 545 consecutive patients with anterior shoulder dislocations, 108 (20%) were aged 60 years or more at the time of injury. We reviewed and radiographed 95 of these elderly patients after a mean follow-up of 7.1 years. Axillary nerve injuries were seen in 9.3% of the 108 patients, but all recovered completely in 3 to 12 months. There were single or multiple recurrences of dislocation in 21 patients (22.1%), but within this group age had no influence on the tendency to redislocate. Tears of the rotator-cuff were diagnosed by imaging studies or clinically in 58 patients (61%), including all who had redislocations. Sixteen patients required surgery. Eight with a single dislocation and a cuff tear had only repair of the torn cuff. Of the eight patients with multiple dislocations requiring operation, five also had a torn cuff and needed either a stabilising procedure and a cuff repair or repair of the cuff only. All patients who were operated on had a satisfactory result, with the exception of those with multiple redislocations and a cuff tear who had repair of the cuff only. Anterior shoulder dislocation in elderly subjects is more common than is generally believed; 20% suffer redislocation and 60% have a cuff tear. Operation may be needed to repair a torn cuff or to stabilise the shoulder. Patients with multiple redislocations will probably require both procedures

The aim of this study was to determine if the extent of the glenoid and humeral bone loss affects the rate of recurrent instability and the functional outcome following the Latarjet procedure. 161 patients underwent open Latarjet procedure during the period 2006–2015 (Mean age 30.0 years, 150t (93.2%) Male, 118 (73.3%) primary procedure). Functional outcome was measured using the Western Ontario Shoulder Instability Index (WOSI) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDash) score at a mean of 4.7 years post-operatively. All patients underwent computed tomographic (CT) imaging pre-operatively. Using three-dimensional reconstruction, the glenoid bone loss, Hill-Sachs lesion and ‘Glenoid Track’ status was recorded. Radiographically-confirmed redislocation was rare (1.2%), but 18.5% (n=23/124) reported ongoing subjective shoulder instability. Fifty-two shoulders (32.3%) were classified as “Off-Track”. The median Quick DASH and WOSI scores were 2.27 (IQR 9.09; range 0–70.45) and 272.0 (IQR 546.5; range 0–2003), respectively. There were no significant differences observed between overall Quick DASH scores or WOSI scores for either On-Track or Off-Track groups (p=0.7 and 0.73, respectively). Subjective instability was not influenced by the degree of glenoid bone loss (p=0.82), the overall size of the Hill-Sachs lesion (p=0.80), or the presence of an ‘Off-Track’ lesion (p=0.84). Functional outcome and recurrent instability following the Latarjet procedure do not appear to be influenced by the extent of glenohumeral bone loss prior to surgery

Combined glenoid and humeral bone loss has been identified as an important factor in predicting recurrence after arthroscopic shoulder stabilisation. The “glenoid track” concept is proposed to predict recurrent instability by comparing the relative size of the glenoid to the humeral bone defect. The aim of this study was to investigate whether assessment of the glenoid track on a pre-operative MR arthrogram could be used to predict subsequent instability in a typical UK population. A retrospective study was undertaken of 175 primary arthroscopic stabilisation procedures of which 82% (n=143) were men. The median age was 26 years (IQR 22 to 32, range 16 to 77). The median follow-up was 76 months (range 21 to 125). A pre-operative MR arthrogram was used to determine if the shoulder was on-track or off-track. The endpoint of recurrent dislocation was examined. The prevalence of “off-track” bone loss in this group was 14.2% (n=25). There were 6 (24%) dislocations in the off-track group compared with 5 (3.33%) dislocations in the on-track group (RR 7.2, 95% CI 2.45 to 20.5, p=0.001). At 5 years, the cumulative redislocation rate was 26.1% in the off-track group compared with 8.7% in on-track group. The rate of any recurrent instability was 60% (n=15) v 18% (n=27) (RR 3.33, 95% CI 2.02 to 5.20, p<0.0001). Glenoid track (on v off) was not predicted by gender (p=0.411). In a typical UK population assessment of the glenoid track on an MR arthrogram can be used to risk stratify patients with shoulder instability

Objective. Overviewing the literature, pain and redislocation after surgical treatment of patellofemoral instability (PFI) is described with up to 30 %, especially with techniques involving the extensor mechanism, the lateral retinaculum or the medial vastus. However, outcome data about revision surgery is missing. Therefore, it was the purpose of this prospective study to evaluate the clinical outcome after revision surgery with an isolated or a combined reco. of the medial patellofemoral ligament (MPFL) with a follow up of 12 months. The indication for additional procedures such as distal femoral osteotomies (DFO), trochleoplasty, reclosing of the lateral retinaculum (RLR) or lateralisation of the tuberosity (LT) were performed depending on the clinical and radiological pathomorphologies. Methods. In between 3/07–4/09, 42 pat. with a mean age of 24 years (13–46ys) were revised due to persistent PFI after mean 1.8 failed previous operations (lateral release, medial gather/VMO-distal., medial. of the tuberosity) in our department. An isolated reco. of the MPFL was performed in 15 cases, while a combination with a DFO due to massive femoral axis deformity (n=5), trochleoplasty due to a convex trochlear morphology (n=1) and/or LT (n=4) and/or RLR due to medial instability or lateral pain (n=22) was done in 27 cases. The clinical result was evaluated by the pre- and postop. IKDC/Kujala/Tegner-score and by a subjective questionnaire. Radiologically, the patellashift/-tilt/-height and level of the eventual degeneration were defined preop. and at the point of follow up with the help of straight lateral radiographs and by MRI. Significance level was set at p=.05, statistical calculation was done by the use of the t-test. Results. 87 % were very satisfied/satisfied with the treatment., None redislocation of the patella occurred during the follow up. We could evaluate a significant decrease of the pain during daily activities. The IKDC/Kujala/Tegner score have shown a significant increase overall. However, a significant difference concerning the scores could not be noticed in between the groups without and with additional procedures. Patellar shift, tilt, height decreased significantly to anatomical values. The level of preexisting degeneration showed no aggravation. Conclusion. Since it is known that PFI is a multifactorial problem, revision surgery should set about only after comprehensive examinations. Regarding our results, isolated or combined MPFL reco. seems to be a very effective treatment of recurrent patella dislocation and results in a significant increase of stability, functionality as well as in a reduction of pain. Additional pathomorphologies of the bony structures or a lateral release, which causes pain or an aggravation of instability, have to be addressed additionally to reach same results like with an isolated therapy. Level of Evidence. II

The generally-accepted treatment for large, displaced fractures of the glenoid associated with traumatic anterior dislocation of the shoulder is operative repair. In this study, 14 consecutive patients with large (> 5 mm), displaced (> 2 mm) anteroinferior glenoid rim fractures were treated non-operatively if post-reduction radiographs showed a centred glenohumeral joint. After a mean follow-up of 5.6 years (2.8 to 8.4), the mean Constant score and subjective shoulder value were 98% (90% to 100%) and 97% (90% to 100%), respectively. There were no redislocations or subluxations, and the apprehension test was negative. All fragments healed with an average intra-articular step of 3.0 mm (0.5 to 11). No patient had symptoms of osteoarthritis, which was mild in two shoulders and moderate in one. Traumatic anterior dislocation of the shoulder, associated with a large displaced glenoid rim fracture can be successfully treated non-operatively, providing the glenohumeral joint is concentrically reduced on the anteroposterior radiograph

Background. The functional outcome and risk of recurrence following arthroscopic stabilisation for recurrent anterior shoulder instability is poorly defined in large prospective outcome studies. This is the first study to prospectively evaluate these outcomes in patients who have been treated using this technique. Methods. We performed a prospective study of a consecutive series of 302 patients (265 men and 37 women, mean age 26.4 years) who underwent 311 (9 bilateral) arthroscopic Bankart repairs for recurrent anterior instability. Patients were evaluated preoperatively and postoperatively at 6 months, and annually thereafter. The chief outcome measures were risk of recurrence and the two-year functional outcomes (assessed using the WOSI and DASH scores). Results. On survival analysis, the overall re-dislocation rate after surgery was 13.5% (42/311 shoulders). The median time to recurrence was 12 months (range 3 to 110 months) and 55% of these developed recurrent instability within 1 year of their surgery. The median follow-up in those patients who did not re-dislocate was 70 months. There was a significant improvement in the WOSI and DASH scores at 2 years postoperatively of 21.4 and 9.9 points respectively (both p<0.001). The risk of redislocation was significantly increased by the presence of glenoid bone loss associated with or without a Hill-Sachs lesion, and the type and engagement of a Hill-Sachs lesion on arthroscopic examination (all p<0.001). However, the risk in these sub-groups was lower than that reported in previous studies. A multivariate model was produced from these parameters to estimate the risk of recurrence at the time of primary surgery. Conclusions. The majority of patients have successful functional outcomes and relatively low risk of recurrence following arthroscopic stabilisation. The identification of preoperative factors which increase the risk of instability has enabled us to better counsel patients of their risk of failure following arthroscopic repair

Introduction. The action of the radial head in the stability of the elbow is currently admitted. Its conservation is not always possible in complex fractures. The association with a posterolateral dislocation of the elbow leads to a higher risk of instability of the elbow joint and also at a longer term to degenerative changes. Some authors recommend the use of metallic radial head implant, acting as a spacer. The results seems encouraging but should the resection arthroplasty associated with the repair of the medial collateral ligament be abandoned?. Material and methods. In an amount of 35 consecutive patients who were taken in charge for an elbow dislocation 26 were included in this retrospective study, 13 of them had the association of a dislocation and a fracture of the radial head. In all 13 cases the radial head was considered as inadequate with a conservative treatment and was resected. The patients were assessed clinically according to the American Shoulder and Elbow Surgeons score (ASES) and the Mayo elbow performance index with a mean follow-up of 13 years (ranging from 5 to 15). The degenerative changes were assessed on plan × rays and an additional axial view according to the 4 stages described by Morrey. Results. No redislocation occurred. According to the Broberg/Morrey index 92% of the patients were considered as having a good result. They returned to work with no hindering. Signs of osteoarthritis grade 1 or 2 were observed and were clinically well tolerated. There was no difference for this item between the patients who conserved their radial head and those who sustained a resection. All patients were satisfied although they were protecting their joint against overuse while working. Discussion. The studies about the use of prosthesis of the radial head offer similar functional results. Degenerative changes on the trochleo ulnar joint are identical in all type of treatment. In order to prevent stiffness in the elbow joint an early post operative rehabilitation is recommended, it justifies a surgical stabilization associated with the use of an adapted dynamic splint. Conclusion. In case of elbow dislocation with a fracture of the radial head when its preservation is impossible, the resection without any prosthetic replacement remains a reasonable option if associated with a repair of the medial collateral ligament. At long term the functional results are still good with mild signs of osteoarthritis eliminating ipso facto the problem of an implant survivorship

Objectives. For a long time lateral release (LR) was performed as a standard procedure both, for patellofemoral pain syndrome (PFPS) and patellofemoral instability (PFI). However, recent biomechanical studies have shown that LR is not useful for decreasing the lateral force onto the patella, but is increasing not only medial but also lateral PFI. Furthermore, pain on palpation over the lateral patellofemoral joint space can result in patients treated with extensive LR. We postulate that in case of persistent PFI or PFPS after failed LR the reconstruction of the lateral retinaculum as an addition of the reconstruction of the medial patellofemoral ligament (MPFL) is necessary in terms of decreasing medial PFI as well as lateral pain. Materials and Methods. In between 03/07 and 04/09 we have seen a total of 25 patients (20 f, 5 m) with persistent PFI and palpatory pain over the lateral retinaculum due to unsuccessful treatment of PFI with a LR. These patients have undergone revision surgery with an anatomical reconstruction of the released lateral retinaculum in combination with a reconstruction of the medial patellofemoral ligament (MPFL) in an aperture-technique using the gracilis tendon. The average age at time of operation was 26.2 ± 9.8 years. Preoperatively, as well as 6 weeks, 3 months, 6 months, and 12 months postoperatively, clinical examinations were performed and subjective as well as objective scores (Kujala-, Tegner-, IKDC-score) were evaluated. Regarding radiological parameters measurement of patellar tilt and shift was carried out on axial radiographs before and after the operation. Results. During the first twelve months after the operation only one redislocation could be recorded. Pain on palpation over the reconstructed lateral retinaculum was remaining in four patients (16%). Although several patients complained about persistent patellofemoral pain on exertion or after enduring flexion of the knee, all of them reported about an improvement of their pain situation. This fact is reflected in a highly significant improved but still moderate IKDC- (from 46.5 ± 14.9 to 68.9 ± 22.7, p<0.001) and Kujala-score (from 47.7 ± 15.3 to 74.8 ± 24.8, p<0.001) at the one year follow up. As far as sports activity is concerned, a statistically significant improvement of the Tegner-score up to 4.7 ± 2.4 (preoperative 2.3 ± 1.5, p<0.001) could be achieved. The radiological analysis showed a highly significant decrease of both, patellar tilt (from 15.4 ± 6.5 to 10.3 ± 6.2, p<0.001) and patellar shift (from 4.3 ± 3.3 to 2.5 ± 1.3, p=0.002). Conclusions. After one or more unsuccessful previous efforts of stabilizing the patella by LR, the technique performed in this essay leads to a considerable improvement of subjective scores and objective clinical and radiological parameters as well as sports activity

Aims

There is a lack of long-term data for minimally invasive acromioclavicular (AC) joint repair. Furthermore, it is not clear if good early clinical results can be maintained over time. The purpose of this study was to report long-term results of minimally invasive AC joint reconstruction (MINAR) and compare it to corresponding short-term data.

Aims

This study assessed the association of classes of body mass index in kg/m² (classified as normal weight 18.5 kg/m² to 24.9 kg/m², overweight 25.0 kg/m² to 29.9 kg/m², and obese ≥ 30.0 kg/m²) with short-term complications and functional outcomes three to six years post-operatively for closed ankle fractures.

We retrospectively analysed the clinical results of 30 patients with injuries of the sternoclavicular joint at a minimum of 12 months’ follow-up. A closed reduction was attempted in 14 cases. It was successful in only five of ten dislocations, and failed in all four epiphyseal disruptions. A total of 25 patients underwent surgical reduction, in 18 cases in conjunction with a stabilisation procedure.

At a mean follow-up of 60 months, four patients were lost to follow-up. The functional results in the remainder were satisfactory, and 18 patients were able to resume their usual sports activity at the same level. There was no statistically significant difference between epiphyseal disruption and sternoclavicular dislocation (p > 0.05), but the functional scores (Simple Shoulder Test, Disability of Arm, Shoulder, Hand, and Constant scores) were better when an associated stabilisation procedure had been performed rather than reduction alone (p = 0.05, p = 0.04 and p = 0.07, respectively).

We recommend meticulous pre-operative clinical assessment with CT scans. In sternoclavicular dislocation managed within the first 48 hours and with no sign of mediastinal complication, a closed reduction can be attempted, although this was unsuccessful in half of our cases. A control CT scan is mandatory. In all other cases, and particularly if epiphyseal disruption is suspected, we recommend open reduction with a stabilisation procedure by costaclavicular cerclage or tenodesis. The use of a Kirschner wire should be avoided.

Early total hip replacement (THR) for acetabular fractures offers accelerated rehabilitation, but a high risk of heterotopic ossification (HO) has been reported. The purpose of this study was to evaluate the incidence of HO, its associated risk factors and functional impact. A total of 40 patients with acetabular fractures treated with a THR weres retrospectively reviewed. The incidence and severity of HO were evaluated using the modified Brooker classification, and the functional outcome assessed. The overall incidence of HO was 38% (n = 15), with nine severe grade III cases. Patients who underwent surgery early after injury had a fourfold increased chance of developing HO. The mean blood loss and operating time were more than twice that of those whose surgery was delayed (p = 0.002 and p < 0.001, respectively). In those undergoing early THR, the incidence of grade III HO was eight times higher than in those in whom THR was delayed (p = 0.01). Only three of the seven patients with severe HO showed good or excellent Harris hip scores compared with eight of nine with class 0, I or II HO (p = 0.049). Associated musculoskeletal injuries, high-energy trauma and head injuries were associated with the development of grade III HO.

The incidence of HO was significantly higher in patients with a displaced acetabular fracture undergoing THR early compared with those undergoing THR later and this had an adverse effect on the functional outcome.

Cite this article: Bone Joint J 2013;95-B:95–100.

Four men who presented with chronic dislocation of the radial head and nonunion or malunion of the ulna were reviewed after open reduction of the radial head and internal fixation of the ulna in attempted overcorrection. Their mean age was 37 years (28 to 46) and the mean interval between injury and reconstruction was nine months (4 to 18).

The mean follow-up was 24 months (15 to 36). One patient who had undergone secondary excision of the radial head was also followed up for comparison.

The three patients who had followed the treatment protocol had nearly normal flexion, extension and supination and only very occasional pain. All had considerable loss of pronation which did not affect patient satisfaction.

Preservation of the radial head in chronic adult Monteggia fractures appears to be a promising mode of treatment.

Our aim was to evaluate the efficacy of a two-level reconstruction technique using subchondral miniscrews for the stabilisation of comminuted posterior-wall marginal acetabular fragments before applying lag screws and a buttress plate to the main overlying posterior fragment. Between 1995 and 2003, 29 consecutive patients with acute comminuted displaced posterior-wall fractures of the acetabulum were treated operatively using this technique.

The quality of reduction measured from three standard plain radiographs was graded as anatomical in all 29 hips. The clinical outcome at a mean follow-up of 35 months (24 to 90) was considered to be excellent in five patients (17%), very good in 16 (55%), good in six (21%) and poor in two (7%). The use of the two-level reconstruction technique appears to provide stable fixation and is associated with favourable results in terms of the incidence of post-traumatic osteoarthritis and the clinical outcome. However, poor results may occur in patients over the age of 55 years.