We treated surgically 16 shoulders with an isolated traumatic rupture of the subscapularis tendon over a six-year period. Nine patients had a total and seven a partial tear of the subscapularis tendon. Repair was undertaken through a small deltopectoral groove approach. The mean Constant score improved in total tears from 38.7 to 89.3 points (p = 0.003) and in partial tears from 50.7 to 87.9 points (p = 0.008). The total tears were significantly more improved by surgery than the partial tears (p = 0.001). The delay between trauma and surgery was inversely proportional to the improvement in the Constant score suggesting that early diagnosis and surgical repair improves outcome.

Aims. The study aimed to assess the clinical outcomes of arthroscopic debridement and partial excision in patients with traumatic central tears of the triangular fibrocartilage complex (TFCC), and to identify prognostic factors associated with unfavourable clinical outcomes. Methods. A retrospective analysis was conducted on patients arthroscopically diagnosed with Palmer 1 A lesions who underwent arthroscopic debridement and partial excision from March 2009 to February 2021, with a minimum follow-up of 24 months. Patients were assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Mayo Wrist Score (MWS), and visual analogue scale (VAS) for pain. The poor outcome group was defined as patients whose preoperative and last follow-up clinical score difference was less than the minimal clinically important difference of the DASH score (10.83). Baseline characteristics, arthroscopic findings, and radiological factors (ulnar variance, MRI, or arthrography) were evaluated to predict poor clinical outcomes. Results. A total of 114 patients were enrolled in this study, with a mean follow-up period of 29.8 months (SD 14.4). The mean DASH score improved from 36.5 (SD 21.5) to 16.7 (SD 14.3), the mean MWS from 59.7 (SD 17.9) to 79.3 (SD 14.3), and the mean VAS pain score improved from 5.9 (SD 1.8) to 2.2 (SD 2.0) at the last follow-up (all p < 0.001). Among the 114 patients, 16 (14%) experienced poor clinical outcomes and ten (8.8%) required secondary ulnar shortening osteotomy. Positive ulnar variance was the only factor significantly associated with poor clinical outcomes (p < 0.001). Positive ulnar variance was present in 38 patients (33%); among them, eight patients (21%) required additional operations. Conclusion. Arthroscopic debridement alone appears to be an effective and safe initial treatment for patients with traumatic central TFCC tears. The presence of positive ulnar variance was associated with poor clinical outcomes, but close observation after arthroscopic debridement is more likely to be recommended than ulnar shortening osteotomy as a primary treatment. Cite this article: Bone Joint J 2024;106-B(4):380–386

Aims

Failure of healing is a well-known problem after repair of the rotator cuff. This study aimed to investigate if early repair of trauma-related full-thickness rotator cuff tears (FTRCTs) could prevent this failure.

The June 2024 Wrist & Hand Roundup. 360. looks at: One-year outcomes of the anatomical front and back reconstruction for scapholunate dissociation; Limited intercarpal fusion versus proximal row carpectomy in the treatment of SLAC or SNAC wrist: results after 3.5 years; Prognostic factors for clinical outcomes after arthroscopic treatment of traumatic central tears of the triangular fibrocartilage complex; The rate of nonunion in the MRI-detected occult scaphoid fracture: a multicentre cohort study; Does correction of carpal malalignment influence the union rate of scaphoid nonunion surgery?; Provision of a home-based video-assisted therapy programme in thumb carpometacarpal arthroplasty; Is replantation associated with better hand function after traumatic hand amputation than after revision amputation?; Diagnostic performance of artificial intelligence for detection of scaphoid and distal radius fractures: a systematic review

The aim of this study was to determine cell viability in different stages of rotator cuff tendon tears using a cell viability molecular probe. Surgical biopsies taken from the edge of the Supraspinatus tendon tear from12 patients, 5 women and 7 men, mean age of 61 years were subjected to a cell viability assay using Molecular Probes Live/Dead cell viability assay. Specimens were then incubated with Calcein-AM and Ethidium Homodimer-1 and following snap freezing, sections were viewed under fluorescent microscopy. Cells which remained metabolically active fluoresced green, whereas dead cells were red. Populations of live and dead cells were counted for each specimen on ten high powered (x400 magnification) fields of view. The results show that the percentage of live cells is reduced in large chronic degenerate tears but greatest in acute traumatic tears. In addition, for those cases where tissue was assayed from the edge of the tear and 1 cm more proximally, there was a considerable increase in the percentage of viable cells in more proximal tissue. Use of this simple assay demonstrates high cell viability and consequently good quality tissue in traumatic tears, but lower quality tissue in larger more degenerate tears. This suggests that traumatic lesions have a high propensity to heal while larger more degenerate tears are less likely to heal but have better quality tissue more proximally

Purpose: The surgical correction of FAI deformity is a well accepted treatment in patients presenting with hip pain with associated labral-chondral damage. The anterior approach with assisted hip arthroscopy provides access to the anterior head-neck junction with potentially quicker recovery for patients. The purpose of this study is to present the safety and efficacy of this approach in performing impingement surgery. Method: Forty-eight Hueter procedures were performed in 45 patients (13 males and 32 females). Mean age was 42.09 years (range, 21–65 years), and mean BMI was 24.31(range, 21–33). The scope was performed first to deal with intra-articular damage. All patients were diagnosed with CAM type FAI with labral pathology based on MRI arthrogram with an alpha angle > 50.5 degrees. Results: At a mean follow-up of 21.8 months (range 12–30 months), Harris Hip scores improved from 64.66 (range, 42.0–93.0) to 79.97 (range, 47.0–96.0). There were 5 re-operations at a mean time of 15.2 months (range, 4–22). One had a repeat hip scope for intra-articular adhesions, and another for recurrent traumatic tear of the labrum. Three cases with residual hip dysplasia had corrective surgery with a peri-acetabular osteotomy at an average of 16.67 months (range, 15–18 months). Conclusion: Overall, we have found this to be a reliable, safe and reproducible approach to the treatment of FAI. This is a day care procedure as compared to the classic open procedure. Uncorrected hip dysplasia in the presence of a CAM deformity is a risk factor for early failure

We report four children aged two to nine years with traumatic tears of the transverse ligament of the atlas and atlanto-axial subluxation. This is extremely rare in this age group since trauma usually causes a skeletal rather than a ligamentous injury. The injuries resulted from falls or motor vehicle accidents, with considerable delay in diagnosis. Flexion radiographs showed atlas-dens intervals (ADI) of 6, 7, 8 and 13 mm; all four patients were treated by posterior fusion at C1-C2 after the failure of conservative treatment. In one child with quadriparesis and a fixed ADI of 13 mm, transoral anterior resection of the odontoid was performed before the fusion. Diagnosis of this traumatic lesion requires a high level of suspicion. Conservative treatment is likely to fail; surgical stabilisation is indicated

Ruptures of the patellar and/or quadriceps tendon are rare injuries requiring immediate repair to re-establish knee extensor continuity and to allow early motion. Ultrasound is extensively used as a diagnostic tool before surgery on acute traumatic tears of the patellar tendon and quadriceps tendons. Our aim was to re-evaluate the value/role of sonography in diagnosing quadriceps and patellar tendon rupture and in differentiating partial from complete tears. To correlate the intra operative findings with the ultrasound report. A retrospective review of 32 consecutive patients who had a surgical intervention for suspected acute quadriceps and patellar tendon rupture over the last 3 years. Intra-operative findings, clinical, x-ray, ultrasound and MRI reports were correlated. Seventeen patients had a suspected patellar tendon rupture on clinical examination and 15 patients had suspected quadriceps tendon rupture. Diagnosis was confirmed by clinical examination and x-rays alone in 9 patients, with additional ultrasound in 18 patients and with MRI scan in 5 patients. There were 6 false positives out of 18 [33.3%] in the ultrasound proven group and 1 false positive out of 9 [11.1%] in the clinical examination and x-ray only group. MRI was 100% accurate [n=5]. This is a small, but important study. Ultrasound offers a low degree of sensitivity and specificity in diagnosing acute quadriceps and patellar tendon ruptures. As a result, patients are being exposed to the risks of surgery unnecessarily. We recommend MRI scan as a first line of investigation in patients where the diagnosis is clinically ambiguous. Ultrasound assessment should not be relied upon in when making the decision to operate

Age-related localised deposition of amyloid in connective tissue has been found in degenerative articular and periarticular tissue. Biopsies of the supraspinatus tendon of 28 patients undergoing repair of the rotator cuff were analysed histologically for the presence of localised deposition of amyloid. There was a long history of impingement in 20 patients, and eight patients had suffered an acute traumatic tear with no preceding symptoms. Localised deposition of amyloid identified by Congo Red staining was detected in 16 samples (57%). Amyloid was present in 14 (70%) of the degenerative tears, but in only two (25%) of the acute tears. Immunohistochemical staining showed that the amyloid deposits were positive for P component, but negative for κ and λ light chains, prealbumin, and β2 microglobulin. Critical electrolyte staining revealed highly-sulphated glycosaminoglycans at sites of deposition of amyloid. The presence of localised deposition of amyloid in tears of the rotator cuff is likely to represent irreversible structural changes. These findings support the theory that impingement and tears are due to intrinsic degenerative changes within the tendons of the rotator cuff

Aims

The aim of this study was to evaluate the cost-effectiveness of arthroscopic partial meniscectomy versus physical therapy plus optional delayed arthroscopic partial meniscectomy in young patients aged under 45 years with traumatic meniscal tears.

Aims

The primary aim of this study was to assess if traumatic triangular fibrocartilage complex (TFCC) tears can be treated successfully with immobilization alone. Our secondary aims were to identify clinical factors that may predict a poor prognosis.

Aims

Wrist arthroscopy is a standard procedure in hand surgery for diagnosis and treatment of wrist injuries. Even though not generally recommended for similar procedures, general administration of perioperative antibiotic prophylaxis (PAP) is still widely used in wrist arthroscopy.

The February 2023 Wrist & Hand Roundup³⁶⁰ looks at: ‘Self-care’ protocol for minimally displaced distal radius fractures; Treatment strategies for acute Seymour fractures in children and adolescents: including crushed open fractures; Routinely collected outcomes of proximal row carpectomy; Moving minor hand surgeries in the office-based procedure room: a population-based trend analysis; A comparison between robotic-assisted scaphoid screw fixation and a freehand technique for acute scaphoid fracture: a randomized, controlled trial; Factors associated with conversion to surgical release after a steroid injection in patients with a trigger finger; Two modern total wrist arthroplasties: a randomized comparison; Triangular fibrocartilage complex suture repair reliable even in ulnar styloid nonunion.

Purpose of the study: Free patellar tendon plasty is the most common technique for repairing anterior knee laxity. Functional outcome can be compromised by invalidating knee pain. The purpose of this prospective randomized study was to compare the outcome of plasty procedures using hamstring tendon versus patellar tendon autografts. Material and methods: From May 1998 through May 2001, 100 patients presenting an isolated grade I anterior cruciate ligament (ACL) tear were included. Exclusion criteria were: history of fracture, advanced-stage laxity (grade II or greater), and contralateral ACL tear. Randomization was performed in the operative theater using the closed envelop method. Two groups of 50 patients were designated: group A: arthroscopic free bone-tendon-bone patellar autograft; group B: arthroscopic free four-strand hamstring autograft. Two metallic interference screws were used for fixation in both groups. The two groups were comparable for demographic features and clinical, radiological, and instrumental laxity variables recorded before surgery. The position of the tunnels was noted according to Aglietti and was the same in the two groups. The same rehabilitation protocol in a dedicated center was used for both groups. All patients (none lost to follow-up) were assess using the IKDC 1993 criteria with objective instrumental measurement of residual laxity. The level of significance was set at 5%. Results: There was no significant difference between the groups regarding: resumption of sports activity (level and delay), joint motion, ligament examination, the overall IKDC score, and radiological findings ate mean 40±13 months (range 13–69 months) follow-up. Pain at the harvesting site was observed in 34.78% of patients in group A at six months and in 39.5% of those in group B. Conversely, anterior pain was found in 8.5% of patients in group B at six months and 6.6% at one year (p< 0.05). This statistically significant difference disappeared at two years. Instrumental differential laxity was 0.57±1.3 mm in group A and 1.22±1.9 mm in group B (p=0.56, but with power < 80%). There were two cases of repeated traumatic tears in each group. Repeated meniscectomy was performed in one patient in group A and in three in group B (p=0.3074). Conclusion: The results at 40 months follow-up of this prospective randomized study with no patients lost to follow-up confirmed the minimal morbidity observed at the harvesting site for hamstring plasty. There was no significant difference between the transplants (patellar tendon, hamstring). Anterior pain with the patellar tendon plasty attenuated after two years. Residual laxity was greater when using the hamstring method

Purpose: The objective of the present study was to evaluate whether horizontal cleavage and complex meniscus tears, which supposed to be degenerative tears, are associated with an increase of specific matrix metalloproteinases and an increased incidence of cartilage damage, in comparison with patients having other patterns of meniscal injury. 1. ,. 2. . Materials and Methods: Data were collected prospectively from 32 knee arthroscopies, patients were assigned by intraoperative findings due to their meniscal tear to one of two groups: “degenerative meniscal lesions” (horizontal cleavage and complex tears; n=20) or “traumatic tears” (longitudinal and radial tears; n=12). Patient data (age, duration of symptoms, mechanism of injury, body mass index [BMI]), intra-articular and radiographic findings were recorded. Samples of knee joint fluid were analyzed for the matrix matrix metalloproteinases pro-MMP-1, MMP-3 and pro-MMP-13, which are postulated to be involved in articular cartilage degradation. 3. Cartilage changes were classified intraoperative by Outerbridge (grade 0–4). Praeoperative bone morphology of the knee joint was graduated by Kellgren-Lawrence (Stadium 0–4). The Knee Injury and Osteoarthritis Outcome Score (KOOS) was used to assess the patients opinion about their knee and associated symptoms and function preoperative and 1.5 years postoperative. Results: Degenerative meniscus lesions appeared predominantly at the end of fifty years of age (58.5±13.9 years), whereas other patterns of meniscal lesions happened around 30 years of age (28.7±8.1 years; P< .0001; Fig. 1 [Median]). Patients with a degenerative meniscus lesion had marginally overweight, whereas patients with a traumatic tear were in the normal range regarding the body mass index (BMI 23.7±5.3 vs. BMI 26.8±3.9; P=.044). A comparison of patients with horizontal cleavage and complex meniscal tears (“degenerative tears”) to patients with longitudinal or radial (“traumatic”) tears showed for the former increased severity of chondral lesions (Outerbridge: 2.9±1.4 vs 1.1±0.9; P=.001; Fig. 2 [Median]) and radiographic osteoarthritis (Kellgren-Lawrence: 1.9±1.5 vs 0.4±0.5; P=.004; Fig. 3 [Median]). The KOOS improved after arthroscopic treatment in the degenerativemeniscal-tear group as well as in the traumatic-tear group significantly (Total-KOOS Score preoperative: 36.5±30.7 and 38.1±24.8; Total-KOOS Score 1.5 years postoperative: 87.8±6.7 and 49.2±21.9; p=.043 and p=.012; “0” indicates extreme knee problems; “100” indicates no knee problems; Fig. 4 [Median]). Pro-MMP-13 correlated significantly with an increase of chondral lesions and radiographic osteoarthritis (r=.534; p=.003; r=.457; p=.02). MMP-3 concentrations in the synovial fluid of patients with a degenerative meniscus lesion were about 20% higher compared to patients with other patterns of meniscal lesions. No one of the investigated MMPs correlated significantly with a specific meniscal injury (Fig. 5 [Median]). Conclusions: Complex and horizontal cleavage meniscal tears are not as benign as was previously thought and are highly associated with an increased severity of cartilage degeneration and radiographic osteoarthritis. In spite of distinct cartilage changes arthroscopic treatment improved knee-related symptoms at least on medium-term also in patients with degenerative meniscal tears. In this study, increased concentrations of the investigated MMPs did not seem to be associated with specific patterns of meniscal lesions

Purpose: At a time when total knee arthroplasty (TKA) with an ultra-congruent tibial plateau or a mobile plateau are advocated by many, the question is whether TKA with a fixed plateau preserving the posterior cruciate ligament (PCL) should be abandoned. We analysed the results of 500 Wallaby I TKA with preservation of the PCL and presenting asymmetrical and divergent femoral condyles with a fixed, also assymetrical tibial plateau, at mean follow-up of seven years (1–10). Material and methods: This prospective multicentric study was performed by junior and senior surgeons. Mean patient age was 70.11 years and 91.4% of the patients had primary or secondary degenerative disease. Prior surgery had been performed in 130 knees, mainly for osteotomy (n=40, mostly tibial) and revision of uni-compartmental or total prostheses (n=18). The mean preoperative IKS knee score was 26.11 points, the function score was 29.54. Preoperative alignment was correct for 11.26% of the knees, 27.16% presented > 4° valgus and 61.56% > 3° varus. Nearly all tibial and patellar pieces were cemented. 5.8% of the femoral pieces were not cemented. A prosthesis was implanted on the patella in all knees except four. There were two early infections, one popliteal sciatic paralysis and twelve wound healing problems. General mobilisation under general anaesthesia was performed in 53 knees (10.6%). Results: Twenty-two patients were not retained for analysis, fifteen lost to follow-up and seven deceased at one year. Among the 478 knees followed for one to ten years, there were six late infections (1.25%), one aseptic bipolar loosening (0.2%), 25 patellar fractures (5.23%) including three which required revision (two cerclage, one prosthesis removal), three periprosthetic femur fractures without effect on the clinical or radiographic outcome, one traumatic tear of the medial collateral ligament, and two secondary tears of the PCL without clinical consequences. There were no revisions for instability, generally considered the most frequent reason for TKA revision. The mean postoperative IKS score was 90.6 points and the function score was 59.7 points basically due to patient age and comorbidity. The eight-year survival (Kaplan-Meier method) was 98.2% (95%CI: 99.4–96.9) irrespective of the reason for revision and 99.2% (95%CI 100–98.4%) if the revision was performed for a mechanical problem. Radiographically, more than 70% of the knees were aligned (between 3° valgus and 2° varus) and more than 90% were between 5° valgus and 5° varus. Although it was difficult to measure radiographically polyethylene wear, there was only one case of > 2 mm wear with osteolysis found in 50 knees selected randomly among the knees with more than seven years follow-up. Conclusion: This study, like others reported by authors preserving the PCL, show that preservation of the PCL limits the risk of instability, allowing excellent clinical and radiographic outcome without important polyethylene wear, opening perspectives for good long-term results

Purpose. Rectus femoris avulsion (RFA) injuries in paediatric patients are currently managed conservatively. However, the proximal attachment of the rectus femoris muscle lies in a critical zone in the hip joint with attachments to the anterior hip capsule and anterior inferior iliac spine. Violent avulsions therefore could cause damage to the adjacent acetabular labrum and articular cartilage initiating a process leading to early degenerative changes in the hip. To date, the association between rectus avulsions and labral tears has not been studied. Method. The complete medical records of patients who were presented to McMaster University Medical Center with rectus femoris avulsions between 1983 and 2008 who were between the ages of 2 and 18 were identified. Patients were included if they had documented plain radiographs and magnetic resonance arthrography images of their hip. MRIs were reviewed by an independent musculoskeletal radiologist blinded from the history of the patients. Results. 16 patients were identified in the database with rectus femoris avulsions diagnosed on plain radiograph and 7 were included in the study with documented MRIs. The average age of patients was 13 (Range 7–16). All injuries occurred during sports activity with 43% occurred during running, 29% with kicking during soccer and during skating acceleration while playing hockey. One patient had a concurrent sartorius avulsion. All patients with rectus femoris avulsions had labral tears identified on MRI in the zone adjacent to rectus insertion. All patients were treated conservatively. Clinical records suggested 72% of patients were still limping and 86% were experiencing residual pain at last follow-up. Conclusion. Patients with rectus femoris avulsions may be at risk for concurrent traumatic labral tears. These patients should be assessed for labral pathology including a clinical examination and MRI arthrography. Level of Evidence: Level IV