To assess the current literature on suture anchor placement for the purpose of identifying factors that lead to suture anchor perforation and techniques that reduce the likelihood of complications. Three databases (PubMed, Ovid MEDLINE, EMBASE) were searched, and two reviewers independently screened the resulting literature. Methodological quality of all included papers was assessed using Methodological Index for Non-Randomized Studies criteria and the Cochrane Risk of Bias Assessment tool. Results are presented in a narrative summary fashion using descriptive statistics. Fourteen studies were included in this review. Four case series (491 patients, 56.6% female, mean age 33.9 years), nine controlled cadaveric/laboratory studies (111 cadaveric hips and 12 sawbones, 42.2% female, mean age 60.0 years), and one randomized controlled trial (37 hips, 55.6% female, mean age 34.2 years) were included. Anterior cortical perforation by suture anchors led to pain and impingement of pelvic neurovascular structures. The anterior acetabular positions (three to four o'clock) had the thinnest bone, smallest rim angles, and highest incidence of articular perforation. Drilling angles from 10° to 20° measured off the coronal plane were acceptable. The mid-anterior (MA) and distal anterolateral (DALA) portals were used successfully, with some studies reporting difficulty placing anchors at anterior locations via the DALA portal. Small-diameter (< 1 .8-mm) suture anchors had a lower in vivo incidence of articular perforation with similar stability and pull-out strength in biomechanical studies. Suture anchors at anterior acetabular rim positions (3–4 o'clock) should be inserted with caution. Large-diameter (>2.3-mm) suture anchors increase the likelihood of articular perforation without increasing labral stability. Inserting small-diameter (< 1 .8-mm) all-suture suture anchors (ASAs) from 10° to 20° using curved suture anchor drill guides, may increase safe insertion angles from all cutaneous portals. Direct arthroscopic visualization, use of fluoroscopy, distal-proximal insertion, and the use of nitinol wire can help prevent articular violation

Suture anchors have gained popularity in recent years, particularly owing to their ease of use for attaching soft tissues to bone and improved biomechanical properties. Three methods to reattach avulsed finger flexor tendons to the distal phalanx were biomechanically compared: a 1.8mm metal Mitek barbed suture anchor, twin 1.3mm PLA suture anchors (Microfix), or a pull-out suture over a button. The suture-anchor interface was tested by pulling the suture at 0, 45, 90° to the anchor's axis. The anchors were tested similarly in plastic foam bone substitute. Repairs of transected tendons in cadaveric fingers were loaded cyclically, then to failure. The results were subject to statistical analysis using Student t test (p< 0.001) and 1-way ANOVA (p<0.0001). The suture failed prematurely if pulled across the axis of the anchor. Conversely, fixation in bone substitute was stronger when pulling at an angle from the axis. Cyclic loads caused significantly more gap formation in-vitro with twin 1.3mm anchors than the other methods; this method was significantly weaker. The 1.8mm anchor gave similar performance to the pull-out suture and button, while the twin 1.3mm anchors were weaker and vulnerable to gap formation even with passive motion alone. A suture anchor embedded at between 45 and 90o to the direction of pull gave greater strength than if the pull was in-line. The absorbable 1.3 mm Microfix PLA anchors appeared to be a weak construct, even when twin 1.3 mm anchors were compared to a single metallic 1.8 mm Mitek anchor or the pull-out suture over button technique. All three methods are likely to be satisfactory for reattachment of finger flexor tendons if a low load or non-loading rehabilitation of the hand is planned; however the gap formation on cyclic loading with the Microfix is a concern even if patients are restricted to passive motion

Glenohumeral chondrolysis is a devastating condition characterized by the rapid dissolution of glenohumeral cartilage and resultant joint destruction. Excessive intra-articular use of thermal heat, suture anchors that are prominent or loose, and the use of an intra-articular pain pump (IAPP) delivering local anesthetics have all been implicated as causative factors. Between November 2007 and February 2010, 29 patients presented with glenohumeral chondrolysis related to one or more of the causative factors noted above. Seventeen patients have been followed since their initial presentation, with the remainder presenting for evaluation only, at the suggestion of their attorneys. Of those 17 patients, 7 were male and mean age at the time of their index surgery was 28.6 years (range 15-55 years). Two patients developed chondrolysis as a result of prominent suture anchors and 15 as a result of an IAPP delivering bupivacaine. Two patients underwent placement of an IAPP following closed manipulation for adhesive capsulitis and 13 underwent IAPP placement following arthroscopic labrum repair or capsular plication using one to seven suture anchors. Onset of symptoms related to chondrolysis, such as increased pain, stiffness and crepitation, occurred at a mean 8 months (range 1-32 months) following the index procedure. Twelve of the 17 patients underwent one or more additional arthroscopic procedure, typically for debridement and chondroplasty, and in some cases, capsular release. A loose suture anchor was found in one joint at arthroscopy, which was removed. Eleven patients had radiographs documenting joint space obliteration at most recent follow-up or at the time of prosthetic shoulder arthroplasty. At most recent follow-up, 7 patients had undergone 3 total shoulder replacements and 4 humeral head resurfacing procedures. Four other patients were contemplating prosthetic shoulder arthroplasty. For those undergoing shoulder replacement, range of motion recovered modestly so that active forward elevation improved from 111° to 137° (p<0.05) and active abduction improved from 99° to 123° (p<0.05). Seven of the 12 patients presenting for evaluation only had also undergone prosthetic shoulder arthroplasty elsewhere by the time of their presentation, so that overall, 14 of 29 patients had undergone their first prosthetic shoulder replacement for chondrolysis within 25 months (range 9-54 months) of their index procedure. The onset of chondrolysis in two patients following the use of an IAPP after closed manipulation has not been reported previously. Post-arthroscopic glenohumeral chondrolysis (PAGCL) is a devastating condition that strikes young patients and frequently requires shoulder replacement surgery. The use of an intra-articular pain pump delivering local anesthetics is the principal causative factor for glenohumeral chondrolysis in most patients and should be abandoned

Quadriceps tendon ruptures are a rare but debilitating injury resulting in loss of knee extension necessitating surgical intervention. Currently, multiple different surgical techniques and rehabilitation programs are utilized by surgeons. Researchers have been unable to determine the best surgical technique with respect to function and complication rate; certain techniques are more cost-effective than others. Early vs. late motion rehabilitation programs are utilized; recent evidence suggests that less aggressive initial rehabilitation may lead to decreased extensor lag and fewer additional surgeries. The goal of our study is to determine the treatment practices of orthopaedic surgeons across Canada. Our study was completed anonymously via . SurveyMonkey.com. (Palo Alto, California). Based on current literature, a 26-question survey was distributed. E-mail invitations were be sent to all members of the Canadian Orthopaedic Association. Participation is voluntary. Currently, 104 surveys have been completed. 78% of respondents utilize transosseous drill holes, 13% utilize suture anchors and 9% utilize a combined surgical technique. The majority of surgeons begin range of motion (ROM) at 2 weeks (42%) or 6 weeks (24%); ROM is then commonly progressed in a step-wise fashion at 2-week intervals (58%). Approximately half of respondents have performed revision surgery for quadriceps re-rupture. Surgical management of quadriceps tendon ruptures is fairly consistent amongst Canadian orthopaedic surgeons. However, wide variation exists regarding rehabilitation, favoring early initiation and progression of ROM despite some evidence recommending a longer period of immobilization

Purpose. Tenodesis of the long head of biceps is an established technique for management of biceps pathology including tears, instability, and chronic tendinosis intractable to non-operative management. Very few studies have reported on clinical outcomes of all-arthroscopic, non-interference, biceps tenodesis techniques. The purpose of this study is to evaluate the functional and quality of life outcomes of patients treated with an all-arthroscopic biceps tenodesis with a suture anchor. Method. Case Series Level 4 Evidence. Fifty-eight (58) patients with a mean age of 58.5 years were treated with an arthroscopic biceps tenodesis in a single surgeons practice. A single suture anchor was used with a non-interference technique, either in isolation or in association with an arthroscopic rotator cuff repair. A retrospective analysis was performed on prospectively collected outcome measures on patients with a minimum one-year follow-up. Patients were evaluated with an ASES, Constant, and WORC scores pre-operatively and at 6 and 12 months post-operatively. In addition, patients were questioned post-operatively as to whether they experienced any biceps cramping, fatigue, or cosmetic deformity (popeye sign). Results. Following an all-arthroscopic biceps tenodesis, the ASES, Constant, and WORC scores improved significantly from 45, 54, 32 to 58, 75, 73 respectively (P<0.001). When analyzed separately, patients who underwent an arthroscopic biceps tenodesis in isolation (no cuff repair) and in association with an arthroscopic cuff repair demonstrated similar gains in functional and quality of life outcomes. (P<0.001). Few patients reported post-operative bicipital cramping, fatigue, or cosmetic deformity. Conclusion. The all-arthroscopic biceps tenodesis is a reliable procedure that results in significant improvement in functional outcome and quality of life measures

Surgical reattachment of torn rotator cuff tendons can lead to satisfactory clinical outcome but failures remain common. Ortho-R product is a freeze-dried formulation of chitosan (CS) that is solubilized in platelet-rich plasma (PRP) to form injectable implants. The purpose of the current pilot study was to determine Ortho-R implant acute residency, test safety of different implant doses, and assess efficacy over standard of care in a sheep model. The infraspinatus tendon (ISP) was detached and immediately repaired in 22 skeletally mature ewes. Repair was done with four suture anchors in a suture bridge configuration (n = 6 controls). Freeze-dried formulations containing 1% w/v chitosan (number average molar mass 35 kDa and degree of deacetylation 83%) with 1% w/v trehalose (as lyoprotectant) and 42.2 mM calcium chloride (as clot activator) were solubilized with autologous leukocyte-rich PRP and injected at the tendon-bone interface and on top of the repaired site (n = 6 with a 1 mL dose and n = 6 with a 2 mL dose). Acute implant residency was assessed histologically at 1 day (n = 2 with a 1 mL dose and n = 2 with a 2 mL dose). Outcome measures included MRI assessment at baseline, 6 weeks and 12 weeks, histopathology at 12 weeks and clinical pathology. MRI images and histological slides were scored by 2 blinded readers (veterinarian and human radiologist, and veterinarian pathologist) and averaged. The Generalized Linear Model task (SAS Enterprise Guide 7.1 and SAS 9.4) was used to compare the different groups with post-hoc analysis to test for pairwise differences. Ortho-R implants were detected near the enthesis, near the top of the anchors holes and at the surface of ISP tendon and muscle at 1 day. Numerous polymorphonuclear cells were recruited to the implant in the case of ISP tendon and muscle. On MRI, all repair sites were hyperintense compared to normal tendon at 6 weeks and only 1 out 18 repair sites was isointense at 12 weeks. The tendon repair site gap seen on MRI, which is the length of the hyperintense region between the greater tuberosity and tendon with normal signal intensity, was decreased by treatment with the 2 mL dose when compared to control at 12 weeks (p = 0.01). Histologically, none of the repair sites were structurally normal. A trend of improved structural organization of the tendon (p = 0.06) and improved structural appearance of the enthesis (p = 0.1) with 2 mL dose treatment compared to control was seen at 12 weeks. There was no treatment-specific effect on all standard safety outcome measures, which suggests high safety. Ortho-R implants (2 mL dose) modulated the rotator cuff healing processes in this large animal model. The promising MRI and histological findings may translate into improved mechanical performance, which will be assessed in a future study with a larger number of animals. This study provides preliminary evidence on the safety and efficacy of Ortho-R implants in a large animal model that could potentially be translated to a clinical setting

Objective. To define the common pathology of the hips with irreducible posterior dislocation combined with femoral head fracture and the outcome of surgical treatment using surgical hip dislocation technique. Design: retrospective observational clinical study. Setting: Level III referral trauma center. Patients/Participants: from January 2011till February 2014 five patients with irreducible posterior hip dislocation and femoral head fracture who underwent operation were included and they followed for at least 18 months. Intervention. Open reduction and internal fixation of fractured femoral head and labral repair by suture anchors using surgical hip dislocation through trochanteric flip osteotomy approach. Main Outcome Measures: Clinical and radiographical findings of the irreducible posterior hip dislocation, intraoperative findings, clinical outcomes using Merle d'Aubigné & Postel and Thompson & Epstein scores, and radiological outcome. Results. All patients presented clinically with a shortened lower limb in neutral or external rotation of the hip (not in Internal rotation). All were Pipkin type II fracture of femoral head with the intact part of the head buttonholed on the posterior wall of the acetabulum through a capsule-labral flap. Postoperative computed tomography revealed perfect reduction except one case with severe comminution with good reduction. Only one patient with delayed operative management developed avascular necrosis and underwent total hip arthroplasty. Conclusion. Irreducible femoral head fracture-dislocation is rare injury with different clinical presentation that shows neutral or externally rotated limb and optimal surgical management is not clear. Surgical hip dislocation gives full access to the femoral head for reconstruction and opportunity to direct repair of the labral tears

Aim. Acute postoperative infection is reported to occur in 0.3–2% after arthroscopic rotator cuff repair. Few reports have addressed this dreaded complication although the costs are high both for the patient and for society. The aim of this prospective study was to describe incidence, treatment and outcome after acute postoperative infections following arthroscopic rotator cuff repair. Method. Patients undergoing arthroscopic rotator cuff repair in our department have been prospectively registered since 2009. 11 out of 1072 patients undergoing surgery developed an acute postoperative infection. The patients were examined with an MRI scan and/or functional scores (Constant Murley (CM) and WORC) at final follow-up. Results. All 11 patients that developed acute postoperative infections were male. Mean age was 54 (41–68) years. Except for male gender, no common underlying predisposing risk factor for infection could be identified. 1/11 patient had diabetes mellitus and 2/11 smoked. Average BMI was 27 (21–36). 1/11 was categorized as ASA 3 and the rest of the patients were ASA 1 and 2. All patients underwent arthroscopic debridement and biopsies were collected 26 (14–50) days after primary surgery. In 10 patients Propionibacterium acnes was cultured, and 6 of these patients also had positive cultures for coagulase negative staphylococci. In the remaining patient only coagulase negative staphylococcus was cultured. 5/11 patients were treated with one arthroscopic debridement, 5/11 had two arthroscopic debridements, whereas 1/11 required arthroscopic debridement four times before the infection was eradicated. Only 2/11 patients had to have their implants removed during the reoperation due to loosening of the suture anchors. All 11 patients were treated with parenteral antibiotics for 7–28 days, followed by oral treatment for 1–5 weeks, and all infections had resolved at final follow-up. Median CM score was 84 and median WORC score was 81% at follow-up median 22(11–28) months. 10 patients had a postoperative MRI scan after median 23 (3–49) months, 8 of them showing a healed cuff repair. Conclusions. Acute postoperative infections after arthroscopic rotator cuff repair can be eradicated with arthroscopic debridement(s) and removal of implants may not be necessary if patency is adequate. Despite the postoperative acute infection our patients presented good functional results and were satisfied at last follow-up

Introduction. Rotator cuff tears remain a problem, with massive tears having a failure rate of repair reported of up to 60%, despite advances in surgical techniques. Tissue engineering techniques offers the possibility of regenerating damaged tendon tissue to a pre-injury state. We explore these techniques by implanting two novel tendon augmentation grafts with use of platelet rich plasma (PRP) in sheep. Methods. A total of 24 sheep were operated on, with the infraspinatus being surgically cut from its attachment to the humeral head. Each tendon was repaired using suture anchors and an interpositional implant according to 4 groups: (1) Empty control, (2) Novel collagen fibre implant with PRP (3) A novel collagen sponge implant (4) and the collagen sponge with PRP. The sheep were killed at 12 weeks and the implant site harvested and its histology evaluated. Results. Our findings showed that these novel grafts were well integrated into the tissue, with minimal inflammatory response. However, as expected, the material had not yet completely broken down. Our initial findings suggest that the combination of PRP with the collagen sponge best enhanced the repair of the tendon. Conclusion. Tissue engineered collagen graft hold great potential for the repair of tendons

Purpose. Chronic massive rotator cuff tears are challenging to repair completely because of the development of tendon retraction with inelasticity, muscle atrophy and fatty infiltration. The objective of this study was to investigate the clinical outcome and MRI findings after arthroscopic superior capsule reconstruction (ASCR) for symptomatic irreparable rotator cuff tears. Methods. From 2011 to 2013, 12 shoulders in 12 consecutive patients (mean, 70.8 years) with irreparable massive rotator cuff tears underwent ASCR using fascia lata. We used suture anchors to attach the graft medially to the glenoid superior tubercle and laterally to the greater tuberosity as same technique by Mihata et al. We added side-to-side sutures between the graft and infraspinatus tendon and between the graft and residual anterior supraspinatus/subscapularis tendon to improve force coupling. Physical examination, clinical rating system, and magnetic resonance imaging (MRI) were performed before surgery; at 6 and 12 months after surgery; and 6 months thereafter. Average follow-up was 19.1 months (12 to 28 months) after surgery. We assessed patients preoperatively by using the scoring systems of the shoulder index of the American Shoulder and Elbow Surgeons (ASES), the Japanese Orthopaedic Association, and the University of California, Los Angeles. Results. Mean active elevation increased from 59° to 111° significantly and external rotation increased from 28 to 33. The average preoperative scores were 16.0 points by ASES, 48.0 points by JOA, and 10.8 points by UCLA. Average clinical outcome scores all improved significantly after ASCR at the final follow-up (ASES, 73.3 points; JOA, 73.7 points; UCLA, 22.7 points). There was surgical complication as infection. Although infection was controlled by arthroscopic irrigation, the transplanted tendon was absorbed, and preoperative conditions did not functionally improve. Five patients had graft tear during follow-up. Postoperative active range of motion in the healed patients was significantly greater than in the unhealed patients who had graft tears. Conclusions. ASCR restored superior glenohumeral stability and function of the shoulder joint with irreparable rotator cuff tears compared to preoperative function in the cases without postoperative complications. However ratio of graft tears were 50% and clinical results of these cases were not improved sufficiently

Introduction. Surgical fixation of greater tuberosity fractures in the shoulder is the choice of treatment even if the fragment is minimally displaced. This helps to reduce the incidence of impingement secondary to a malunited tuberosity fragment especially in younger patients. We evaluated the functional outcome of our patients treated with open reduction and internal fixation of these fractures using cancellous screws. Materials and Methods. 19 patients with a mean age of 57.1 years (range 27–84) with 19 isolated greater tuberosity fractures treated with cancellous screws were included. These patients were evaluated after an average follow up period of nearly four years (range 66–444 weeks) using the DASH score and the Constant and Murley score. They were also clinically assessed to check for signs of impingement. Results. The median age in our study was 59. The mean Constant and Murley score was 75 (range 35–98) and the mean DASH score was 15.7 (0.8–45.0) which is a good result. Most patients had trouble in performing overhead activities (as per the DASH scoresheet) inspite of surgery. Impingement signs were also positive in nearly half of our patients (9 patients). Conclusions. Greater tuberosity fracture fixation using cancellous screws is a simple procedure associated with good results. However comparision needs to be made with the outcomes following fixation using suture anchors which is also a popular technique

Lunate or perilunate dislocations are common carpal injuries. Current treatment of these injuries by repair or reconstruction of intra-carpal ligaments is largely based on Mayfield's description of sequential failure of these ligaments. We do treat significant number of these injuries. We have observed that dorsal wrist capsule is attached to dorsal aspect of proximal carpal row and its interosseous ligaments by vertically oriented identifiable fibres. This can be seen as carpal bones suspended from dorsal capsule, akin to cloths suspended from a washing line. We have also observed that in lunate or perilunate dislocations, dorsal capsule is peeled off from the dorsal aspect of lunate and distal radius, similar to a Bankart lesion in the shoulder. We believe that dorsal capsule plays a bigger role in the stabilising mechanism of carpal bone than the intercarpal ligaments. It has not been described before. We dissected three cadaveric wrists and found vertical fibres running from dorsal wrist capsule/ligaments to the dorsal components of the scapholunate and lunotriquetralinterosseous ligaments. We have modified the Mayo approach to dorsal wrist capsule and use suture anchors to attach dorsal capsule/ligaments to scaphoid, lunate and triquetrum rather than repairing intra-carpal ligament. We have used this technique in 26 patients so far. Follow up for more than 4 years have shown satisfactory results and no significant recurrence of instability. We present a novel, so far unreported, method of repairing the intracarpal injuries, using the dorsal capsule/ligaments, based on anatomic and intra-operative observations

The aim of this study was to evaluate prospectively the outcome following arthroscopic Bankart repair using two types of suture anchors, absorbable and non-absorbable. Patients with a diagnosis of recurrent traumatic anterior instability of the shoulder, seen between April 2000 and June 2003 in a single unit, were considered for inclusion in the study. Patients were assessed pre-operatively and post-operatively using a subjective patient related outcome measurement tool (Oxford instability score), a visual analogue scale for pain and instability (VAS Pain and VAS instability) and a quality of life questionnaire (SF-12). The incidence of recurrent instability and the level of sporting ability were recorded. Patients were randomised to undergo surgical repair with either non-absorbable or absorbable anchors. 130 patients were included in the study. 6 patients were lost to follow-up and 124 patients (95%) completed the study. Both types of anchors were highly effective. There were no differences in the rate of recurrence or any of the scores between the two. Four patients in the non-absorbable group and 3 in the absorbable group experienced further episodes of dislocation after a traumatic event. The rate of redislocation in the whole series was therefore, 5.6%. In addition, 4 patients, all of them in the absorbable group (4%) described ongoing symptoms of instability but no true dislocations. 85% of the patients have returned to their previous level of sporting activity. There are no differences in the outcome of Arthroscopic Bankart repair using either absorbable or non-absorbable anchors. Both are highly effective, showing a redislocation rate of 5.6%

Purpose. An open superior capsular shift is a well-established technique for the management of patients with multidirectional shoulder laxity and the absence of a Bankart lesion. Few studies have reported on functional and quality of life outcomes using arthroscopic technique for shoulder stabilization using superior capsular shift in patients with no Bankart lesion. The purpose of this study was to assess the functional and quality of life outcome scores following shoulder stabilization with a selective arthroscopic superior capsular shift with suture anchors, for treatment of multidirectional laxity and the absence of a Bankart lesion. Method. Case Series Level 4 Evidence. Thirty-six (36) patients with a mean age of 30.8 years, with a diagnosis of recurrent anterior atraumatic shoulder instability, and no Bankart lesion, were identified in a single surgeons practice. These patients underwent an arthroscopic shoulder stabilization with an anterior inferior to superior capsular shift. The labrum was arthroscopically released from the anterior/inferior glenoid and was shifted superiorly in conjunction with a capsular plication. A retrospective analysis was performed on prospectively collected outcome scores of patients who had with a minimum of 1 year of follow-up. The ASES and WOSI scores were administered pre-operatively and at 6 and 12 month follow-up. The presence of a positive post-operative apprehension sign was also recorded on follow-up. Results. After an arthroscopic capsular shift, the ASES and WOSI scores improved significantly from 57, 28 to 78, 68 respectively (P<0.001). Few patients had a positive apprehension sign at 1 year follow-up. Conclusion. An arthroscopic capsular shift is a reliable procedure that resulted in satisfactory outcomes in patients with shoulder instability and the absence of a Bankart lesion

Introduction. The operative management for Distal Tibialis Anterior Tendinopathy (DTAT) without rupture has not previously been described. We present 15 cases. Method. of 39 patients diagnosed clinically and radiographically with DTAT, we reviewed the 13 patients who underwent surgery for failure of non-operative management. Assessment included pre and post-operative AOFAS midfoot scoring, clinical examination and post-operative VAS pain scoring. Results. Twelve women (13 feet) and one man (two feet) underwent surgery. Mean age at surgery was 59 years (42 to 76 years). The mean duration of symptoms prior to surgery was one year (5 to 25 months). The mean pre-operative AOFAS score was 50 (23 to 75). Pre-operative MRI showed tendinosis in six tendons and tendinosis with longitudinal split tears in nine tendons. Five of the 14 cases showed some associated degenerative changes of the midfoot. Six tendons were simply debrided and the insertion reinforced with a suture anchor. Nine tendons were augmented with an Extensor Hallucis Longus (EHL) transfer into the medial cuneiform. The mean improvement in AOFAS score was 35 (4 to 57), with mean post-operative pain VAS of 1 (0 to 6.7) at a mean follow-up of 24 months (three to 65). Two patients underwent concomitant procedures on the same foot. Four of the nine treated with EHL transfer have some symptomatic hallux interphalangeal joint extensor lag. In seven cases the patient was completely satisfied. Five were satisfied with minor reservations. Of the three that were dissatisfied, two underwent subsequent surgery improving their symptoms. The third, though pain-free, was troubled by her toe catching when walking barefoot. No patients regret having had the surgery. Conclusion. Debridement and repair of DTAT, with EHL augmentation for greater than 50% tendon involvement, provides a high level of patient satisfaction if non-operative management fails

Objective. Rotational malalignment of the femoral component still causes patellofemoral complications that result in failures in total knee arthroplasty (TKA). To achieve correct rotational alignment, a couple of anatomical landmarks have been proposed. Theoretically, transepicondylar axis has been demonstrated as a reliable rotational reference line, however, intraoperative identification of the transepicondylar axis is challenging in some cases. Therefore, surgeons usually estimate the transepicondylar axis from posterior condylar axis (PCA) using twist angle determined by the preoperative X-rays and CT. While PCA is the most apparent landmark, radiographs are not able to detect posterior condylar cartilage. In most osteoarthritic knees, the cartilage thickness of the posterior condyle is different between medial and lateral condyles. The purpose of this study is to evaluate the effect of the posterior condylar cartilage on rotational alignment of the femoral component in large number of arthritic patients. Furthermore, we investigated whether the effect of posterior condylar cartilage is different between osteoarthritis (OA) and rheumatoid arthritis (RA). Methods. Ninety-nine OA knees and 36 RA knees were included. Detailed information is summarized in Table 1. All cases underwent TKA using navigation system. The institutional review board approved the study protocol and informed consent was obtained from each participants. To evaluate the effect of posterior condylar cartilage, we measured two different condylar twist angle (CTA) using navigation system and intraoperative fluoroscopy-based multi-planner reconstruction (MPR) images obtained by a mobile C-arm. To uniform the SEA in two different measuring systems, we temporary inserted a suture anchors in medial and lateral prominence. The CTA that does not include the posterior condylar cartilage (MPR CTA) is evaluated on MPR images and the CTA that does include the posterior condylar cartilage (Navi. CTA) is calculated by navigation system. The difference between these two angles corresponds to the effect of posterior condylar cartilage on the rotation of the femoral component (Fig. 1). The paired or unpaired t test was used to compare the obtained data. The statistics were performed using GraphPad Prism 6. A P value of 0.05 or less is considered as a significant difference. Results. The average MPR CTA in OA patients is 6.7 ± 2.1°, while the average MPR CTA in RA patients is 7.1 ± 2.0° (Fig 2A). On the other hand, the average Navi. CTA is 4.9 ± 2.1°, while the average Navi. CTA is 6.0 ± 2.1° (Fig. 2B). The difference of these two angles that corresponds to the cartilage remnant is 1.8 ± 1.4° in OA group and 1.1 ± 1.0° in RA groups. When we compared these angles between OA and RA population, the MPR CT – Navi CT was smaller in OA population than that of RA population (p < 0.05) (Fig. 2C). Conclusion. These results has demonstrated that twist angle measured on the X-rays or CT that does not include the cartilage would be overestimated compared to the true twist angle that includes cartilage in osteoarthritic knee. The effect of posterior condylar cartilage has less impact on femoral rotation in RA population

Background:. Massive rotator cuff tear can cause functional disability due to instability and degenerative changes of the shoulder joint. In patients with massive irreparable rotator cuff tear, tendon transfer is often used as the salvage procedure. Latissimus dorsi and pectoris major transfer are technically demanding procedures and may incur complications. The biceps tendon transfer may provide a biologically superior tissue patch that improves the biomechanics of the shoulder joint in patients with irreparable rotator cuff tear. This study evaluated the functional outcomes of biceps tendon transfer for irreparable rotator cuff tear in 6 patients with two years and longer follow-up. Methods:. Between September 2006 and October 2011, 50 patients with 50 shoulders underwent surgical repair for MRI confirmed rotator cuff tear. Among them, six patients with massive irreparable rotator cuff tear were identified intraoperatively, and underwent proximal biceps tendon transfer to reconstruct the rotator cuff tear. The biceps tendon was tenodesed at the bicipital groove, and the proximal intra-articular portion of the biceps tendon was transected. The biceps graft was fanned out and the distal end fixed to the cancellous trough around the greater tuberosity with suture anchor. The anterior edge was sutured to the subscapularis and the posterior edge to the infraspinatus tendon or supraspinatus if present. Postoperative managements included sling protection and avoidance of strenuous exercises for 6 weeks, and then progressive rehabilitation until recovery. Results:. The evaluation parameters included VAS pain score, UCLA score, Constant score and AHES score, and X-rays of the shoulder. At follow-up of 25.3 ± 25.0 (range 22 to 63) months, the mean VAS pain score decreased from 9.3 ± 0.8 preoperatively to 1.7 ± 1.4 postoperatively (p < 0.001). All patients presented with significant improvements in pain and function of the shoulder for daily activities after surgery, however, only one patient achieved excellent results. There is no correlation of functional outcome with age, gender and body mass index. There was no infection or neurovascular complication. Discussion:. The biceps transfer provides soft tissue coverage of the humeral head, and restores the superior stability of the shoulder joint. The transferred biceps tendon also improves the mechanics and increases the compression force of the humeral head to the glenoid fossa. The results of the current study showed significant pain relief and improvement of shoulder function after biceps tendon transfer for irreparable rotator cuff tear. Conclusion:. Biceps tendon transfer is effective in the management of massive irreparable rotator cuff tear. The procedure is technically accessible with minimal surgical risks

Recurrent shoulder instability in those with bony defects is a difficult surgical problem to resolve. Burkhart and De Beer described an unacceptably high recurrence rate for arthroscopic Bankart repair in the presence of an inverted-pear glenoid with or without an engaging Hill-Sachs lesion, with suggestions that an open modified Latarjet procedure should be recommended in such patients. The Congruent-Arc Latarjet is a modification of the Latarjet open bony stabilisation for shoulder instability developed by Burkhart and De Beer. It involves rotation of the coracoid so the curved under-surface lies congruent with the glenoid. At the Royal Derby Hospital, UK, this procedure has been adopted by our four shoulder surgeons, two of whom undertook fellowship training with De Beer, we studied the outcomes of the patients who had undergone the modified Congruent-Arc Latarjet procedure in our department. Fifty-two consecutive patients were identified over a five-year period at the Royal Derby Hospital or Derbyshire Royal Infirmary between 2006 and 2010 inclusive. With the approval of the clinical audit department, the data was collected using theatre records and clinical coding information to identify the patient group. A review of the case notes and local PACS system was undertaken to establish pre and post-operative examination findings, radiology findings regarding Hill-Sachs defects and glenoid bone loss, re-dislocation rates and post-operative function with return to normal activity. The endpoints of this study were aimed at finding out whether patients did return to normal function, were able to continue doing activity that would have provoked dislocation prior to surgery, and how many of the cases re-dislocated. No surgeon consultant had a patient who re-dislocated after this procedure. The follow-up period was from 1 year to 6 years post-operatively. The complications of this procedure were found to be the dislodgement of bone anchors in 2 patients, who required further arthroscopy to remove the suture anchor from the gleno-humeral joint. One patient had prolonged functionally limiting loss of external rotation, which resolved after intensive physiotherapy at 7 months follow up. We will provide graphical representation of the pre and post operative functional scores. We have demonstrated that the Congruent-Arc Latarjet is a reproducible procedure in the hands of surgeons other than the original authors, particularly when comparing our current 0% re-dislocation rate with the published literature, which suggests that 3.9% of patients undergoing this procedure with greater than 25% bone loss of the glenoid or an engaging Hill-Sachs will re-dislocate post-operatively, and this is better than the 6% re-dislocation rate of the standard Bristow-Latarjet procedure

Purpose. The remplissage technique of insetting the infraspinatus tendon and posterior joint capsule into an engaging Hill-Sachs lesion has gained in popularity. However, a standardized technique for suture anchor and suture placement has not been defined for this novel procedure. The purpose of this biomechanical study was to compare three remplissage techniques by evaluating their effects on joint stiffness and motion. Method. Cadaveric forequarters (n=7) were mounted on a custom active biomechanical shoulder simulator. Three randomly ordered techniques were conducted: T1- anchors in the valley of the defect, T2- anchors in the rim of the humeral head; T3- anchors in the valley with medial suture placement. The testing conditions included: intact, Bankart, Bankart repair, and 15% & 30% HS lesions with repairs (T1, T2, T3). Outcome measures including internal-external range of motion and stability were recorded. Stability was quantified in terms of glenohumeral joint stiffness against an externally applied anterior force of 70N. Results. In abduction, no significant reduction in range of motion was observed between any of the remplissage techniques compared to the intact for 15% defects. For 30% defects, T1 and T2 produced significant reductions (T1:14.36.7o, p=0.02; T2:20.79.8o, p=0.02), but T3 had the greatest mean reduction (26.816.6o, p=0.08) in range of motion. In adduction, for the 15% defect, T1 did not cause a significant reduction in internal-external rotation range of motion; however, T2 reached and T3 approached a significant difference compared to intact (T2:10.75.8o, p=0.02 and T3:20.914.7o, p=0.06, respectively). For the 30% defect, T1 and T3 repairs significantly reduced range of motion (11.0–28.2o, p <= 0.05), while the reduction in motion following T2 repair was not significant (18.815.9o, p=0.3). All three techniques were found to greatly increase joint stiffness when an external anterior force was applied in abduction and 60o of external rotation; however, no comparisons to the unrepaired defect or the intact state were significant. Additionally, T3 produced the greatest increases in stiffness followed by T1 and T2 (9.20 >= 7.06 >= 6.05 N/mm), but these differences were not significant. Conclusion. All remplissage techniques were observed to decrease shoulder motion. Specifically, T3 was found to consistently produce the greatest mean reductions in rotation while T1 produced the smallest decreases. The remplissage procedure also produced increases in joint stiffness in all cases, with T3 producing the greatest increases; however, excessive variation may have prevented these findings from being statistically significant. The choice of remplissage technique does have an impact on joint stiffness and motion. Further biomechanical and clinical studies are required to determine the optimum technique that maximizes stability and motion

Drug therapy forms an integral part of the management of many orthopaedic conditions. However, many medicines can produce serious adverse reactions if prescribed inappropriately, either alone or in combination with other drugs. Often these hazards are not appreciated. In response to this, the European Union recently issued legislation regarding safety measures which member states must adopt to minimise the risk of errors of medication.

In March 2014 the Medicines and Healthcare products Regulatory Agency and NHS England released a Patient Safety Alert initiative focussed on errors of medication. There have been similar initiatives in the United States under the auspices of The National Coordinating Council for Medication Error and The Joint Commission on the Accreditation of Healthcare Organizations. These initiatives have highlighted the importance of informing and educating clinicians.

Here, we discuss common drug interactions and contra-indications in orthopaedic practice. This is germane to safe and effective clinical care.

Cite this article: Bone Joint J 2015;97-B:434–41.