Introduction

Trochleoplasty is an effective surgical procedure for patients with severe trochlear dysplasia and recurrent patella instability. Previous work has suggested patients demonstrate early improvements in knee function and quality of life. However, concerns regarding longer term outcomes due to the development of stiffness and patellofemoral osteoarthritis remain a concern for these patients. Our aim was to assess mid-term patient-reported outcome and quality of life measures for trochleoplasty performed at a single centre for severe trochlear dysplasia.

Aims

The Oswestry-Bristol Classification (OBC) is an MRI-specific assessment tool to grade trochlear dysplasia. The aim of this study is to validate clinically the OBC by demonstrating its use in selecting treatments that are safe and effective.

Aims

Trochlear dysplasia is a significant risk factor for patellofemoral instability. The Dejour classification is currently considered the standard for classifying trochlear dysplasia, but numerous studies have reported poor reliability on both plain radiography and MRI. The severity of trochlear dysplasia is important to establish in order to guide surgical management. We have developed an MRI-specific classification system to assess the severity of trochlear dysplasia, the Oswestry-Bristol Classification (OBC). This is a four-part classification system comprising normal, mild, moderate, and severe to represent a normal, shallow, flat, and convex trochlear, respectively. The purpose of this study was to assess the inter- and intraobserver reliability of the OBC and compare it with that of the Dejour classification.

Introduction & Background

Clinical outcome after reverse total shoulder arthroplasty (RTSA) can be influenced by technical and implant-related factors, so the purpose of this study was to investigate whether individualizing humeral retroversion and subscapularis repair affect the clinical outcomes after RTSA.

Both conservative and operative forms of treatment have been recommended for patients with a ‘floating shoulder’. We compared the results of conservative and operative treatment in 25 patients with this injury and investigated the use of the glenopolar angle (GPA) as an indicator of the functional outcome. A total of 13 patients (ten male and three female; mean age 32.5 years (24.7 to 40.4)) were treated conservatively and 12 patients (ten male and two female; mean age 33.67 years (24.6 to 42.7)) were treated operatively by fixation of the clavicular fracture alone. Outcome was assessed using the Herscovici score, which was also related to changes in the GPA at one year post-operatively.

The mean Herscovici score was significantly better three months and two years after the injury in the operative group (p < 0.001 and p = 0.003, respectively). There was a negative correlation between the change in GPA and the Herscovici score at two years follow-up in both the conservative and operative groups, but neither were statistically significant (r = -0.295 and r = -0.19, respectively). There was a significant difference between the pre- and post-operative GPA in the operative group (p = 0.017).

When compared with conservative treatment, fixation of the clavicle alone gives better results in the treatment of patients with a floating shoulder. The GPA changes significantly with fixation of clavicle alone but there is no significant correlation between the pre-injury GPA and the final clinical outcome in these patients.

Cite this article: Bone Joint J 2013;95-B:815–19.

The results of PLLA screws for ACL reconstruction have demonstrated no significant clinical differences when compared to metallic screws up to two years. However, studies examining PLLA-HA screws are lacking, as are medium term outcomes of bioresorbable screws. This study aims to compare the clinical outcome of ACL reconstruction with a PLLA-HA to a titanium screw, and to assess the extent of resorption of the PLLA-HA screw at two and five years after ACL reconstruction.

Forty patients were randomised to receive either a PLLA-HA or titanium RCI interference screw for ACL reconstruction. Both examiners and patients were blinded to screw type. Patients were prospectively reviewed at 24 and 60 months after surgery with full IKDC assessment, Instrumented Ligament Testing, Lysholm knee score. MRI scans were performed at two and five years following surgery.

Five years after surgery, one patient with a titanium screw had an ACL graft rupture and had undergone revision surgery. Of the remaining 39 patients, 38 (97%) were reviewed at five years. There was no significant difference between the two groups in the volume of the tibial (p=0.89) or femoral (p=0.22) tunnels at five years. Significant screw resorbtion at five years was seen in 77% on the tibial side and 88% on the femoral side in the PLLA group. Good ossification was evident on five year MRI in 94% of the tibial screws and 56% of the femoral screws. In the PLLA-HA group peri tunnel bone marrow oedema was present in 35% of patients on the tibial side and 53% of patients on the femoral side at five years. There was no peri-tunnel bone marrow oedema evident in the titanium group. Peri-graft ganglion cyst was evident on MRI scan on the tibial side in 24% of patients from the PLLA-HA group and 18% of the titanium group (p=0.67). There was no significant difference between the PLLA-HA group and the titanium group on any of the other clinical parameters including IKDC subjective knee score (mean 93), symptoms, range of motion, instrumented ligament laxity (mean 1.8 mm) or overall IKDC grade (90% normal or nearly normal).

ACL reconstruction with PLLA-HA bioabsorbable screws affords comparable clinical and subjective results to titanium screws at five years after surgery. Significant progression of PLLA HA screw resorption occurs between two and five years, with over 75% of screws demonstrating some resorption by five years. However, complete resorption was only evident in a small number of patients. ACL reconstruction with a PLLA HA screw has excellent clinical outcomes and progressive screw resorption and ossification is evident at five years.