The October 2012 Shoulder & Elbow Roundup³⁶⁰ looks at: fast-absorbing suture anchors for use in shoulder labral tears; double-row rotator cuff repair; degenerate massive rotator cuff tears addressed with partial repair; open and arthroscopic stabilisation of Bankart lesions; predicting the risk of revision humeral head replacement; arthroscopic treatment for frozen shoulder; and long-term follow-up of the Bristow-Latarjet procedure.

The outcome of one-stage bilateral open reduction through a medial approach for the treatment of developmental dysplasia of the hip in children under 18 months was studied in 23 children, 18 girls and five boys. Their mean age at operation was 10.1 months (6 to 17) and the mean follow-up was 5.4 years (3 to 8).

Acceptable clinical and radiological results were achieved in 44 (95.7%) and 43 (93.5%) of 46 hips, respectively. Excellent results were significantly evident in patients younger than 12 months, those who did not require acetabuloplasty, those whose ossific nucleus had appeared, and in those who did not develop avascular necrosis.

One-stage bilateral medial open reduction avoids the need for separate procedures on the hips and has the advantages of accelerated management and shorter immobilisation and rehabilitation than staged operations.

The February 2014 Children’s orthopaedics Roundup³⁶⁰ looks at: flexible plasters; dual 8-plate or ablation for knee epiphysiodesis; ultrasounds for pulled elbow; leg length without the radiation; Boyd amputation in limb deficiencies; gold standard club foot treatment; quadrupled semitendinosis graft effective in paediatric ACL reconstruction; and predicting complications following cerebral palsy hip reconstruction

Objectives

A variety of operative techniques have been described as under the term ‘Bristow-Latarjet’ procedure. This review aims to define the original procedure, and compare the variation in techniques described in the literature, assessing any effect on clinical outcomes.

We reviewed 15 patients, nine girls and six boys, with chronic anterior dislocation of the radial head which was treated by ulnar osteotomy, external fixation and open reconstruction of the elbow joint but without repair of the annular ligament. Their mean age was 9.5 years (5 to 15) and the mean interval between the injury and reconstruction was 22 months (2 months to 7 years).

All radial heads remained reduced at a mean follow-up of 20 months (6 months to 5 years). Normal ranges of movement for flexion, extension, pronation and supination were unchanged in 96.1% (49/51) and worse in 3.9% (2/51). Limited ranges of movement were improved in 77.8% (7/9), unchanged in 11% (1/9) and further decreased in 11% (1/9).There were two superficial pin-track infections and two cases of delayed union but with no serious complications. Reconstruction of the radiocapitellar joint is easier using external fixation since accurate correction of the ulna can be determined empirically and active functional exercises started immediately. Only patients with a radial head of normal shape were selected for treatment by this method.

The incidence of clinically significant avascular necrosis (AVN) following medial open reduction of the dislocated hip in children with developmental dysplasia of the hip (DDH) remains unknown. We performed a systematic review of the literature to identify all clinical studies reporting the results of medial open reduction surgery. A total of 14 papers reporting 734 hips met the inclusion criteria. The mean follow-up was 10.9 years (2 to 28). The rate of clinically significant AVN (types 2 to 4) was 20% (149/734). From these papers 221 hips in 174 children had sufficient information to permit more detailed analysis. The rate of AVN increased with the length of follow-up to 24% at skeletal maturity, with type 2 AVN predominating in hips after five years’ follow-up. The presence of AVN resulted in a higher incidence of an unsatisfactory outcome at skeletal maturity (55% vs 20% in hips with no AVN; p < 0.001). A higher rate of AVN was identified when surgery was performed in children aged < 12 months, and when hips were immobilised in ≥ 60°of abduction post-operatively. Multivariate analysis showed that younger age at operation, need for further surgery and post-operative hip abduction of ≥ 60° increased the risk of the development of clinically significant AVN.

Cite this article: Bone Joint J 2014;96-B:279–86.

We treated 15 hips (15 patients) with developmental dysplasia by a single-stage combination of open reduction through a medial approach and innominate osteotomy. The mean age of the patients at the time of operation was 20 months (13 to 30). The mean follow-up period was 9.6 years (4 to 14).

At the final follow-up, 14 hips were assessed clinically as excellent and one hip as good. Radiologically, ten hips were rated as class I, four as class II and one as class III according to the criteria of Severin. No avascular necrosis was seen. No patient required subsequent surgery. Our results indicate that satisfactory results can be obtained with the single-stage combination of open reduction by the medial approach and innominate osteotomy for developmental dysplasia of the hip in a selected group of children older than 12 months. To our knowledge, no similar combined technique has been previously reported.

The Salter innominate osteotomy has been used successfully for many years in the treatment of developmental dysplasia of the hip. One of its main drawbacks is the need for internal fixation with pins and their subsequent removal. We describe a modification of this osteotomy that does not require pin fixation and secondary removal. We retrospectively reviewed 114 hips in 94 patients who had been operated on by a single surgeon. An oblique rather than the original horizontal osteotomy was used without internal fixation. There were 80 female and 14 male patients. The mean age at operation was 25 months (18 to 84) and the mean follow-up was 30 months (12 to 88). Most patients required additional open reduction and capsuloplasty. The mean pre-operative acetabular index was 37.9° (24° to 54°), which decreased to 19.9° (7° to 29°) in the immediate post-operative period, and improved to 14.6° (5° to 25°) at the final follow-up (student’s t-test, p < 0.0001).

We believe that by changing the direction of the osteotomy line, it is possible to avoid pin fixation. The radiological outcomes are comparable to those of the original technique, but longer follow-up will be necessary.

We describe our experience in the reduction of dislocation of the hip secondary to developmental dysplasia using ultrasound-guided gradual reduction using flexion and abduction continuous traction (FACT-R). During a period of 13 years we treated 208 Suzuki type B or C complete dislocations of the hip in 202 children with a mean age of four months (0 to 11). The mean follow-up was 9.1 years (five to 16). The rate of reduction was 99.0%. There were no recurrent dislocations, and the rate of avascular necrosis of the femoral head was 1.0%. The rate of secondary surgery for residual acetabular dysplasia was 19.2%, and this was significantly higher in those children in whom the initial treatment was delayed or if other previous treatments had failed (p = 0.00045). The duration of FACT-R was significantly longer in severe dislocations (p = 0.001) or if previous treatments had failed (p = 0.018).

This new method of treatment is effective and safe in these difficult cases and offers outcomes comparable to or better than those of standard methods.

Cite this article: Bone Joint J 2015;97-B:405–11.

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.

Hip replacement is a very successful operation and the outcome is usually excellent. There are recognised complications that seem increasingly to give rise to litigation. This paper briefly examines some common scenarios where litigation may be pursued against hip surgeons. With appropriate record keeping, consenting and surgical care, the claim can be successfully defended if not avoided. We hope this short summary will help to highlight some common pitfalls. There is extensive literature available for detailed study.

We identified ten patients who underwent arthroscopic revision of anterior shoulder stabilisation between 1999 and 2005. Their results were compared with 15 patients, matched for age and gender, who had a primary arthroscopic stabilisation during the same period.

At a mean follow-up of 37 and 36 months, respectively, the scores for pain and shoulder function improved significantly between the pre-operative and follow-up visits in both groups (p = 0.002), with no significant difference between them (p = 0.4). The UCLA and Rowe shoulder scores improved significantly (p = 0.004 and p = 0.002, respectively), with no statistically significant differences between groups (p = 0.6). Kaplan-Meier analysis for time to recurrent instability showed no differences between the groups (p = 0.2).

These results suggest that arthroscopic revision anterior shoulder stabilisation is as reliable as primary arthroscopic stabilisation for patients who have had previous open surgery for recurrent anterior instability.

The tensile strength of the medial patellofemoral ligament (MPFL), and of surgical procedures which reconstitute it, are unknown. Ten fresh cadaver knees were prepared by isolating the patella, leaving only the MPFL as its attachment to the medial femoral condyle. The MPFL was either repaired by using a Kessler suture or reconstructed using either bone anchors or one of two tendon grafting techniques. The tensile strength and the displacement to peak force of the MPFL were then measured using an Instron materials-testing machine.

The MPFL was found to have a mean tensile strength of 208 N (SD 90) at 26 mm (SD 7) of displacement. The strengths of the other techniques were: sutures alone, 37 N (SD 27); bone anchors plus sutures, 142 N (SD 39); blind-tunnel tendon graft, 126 N (SD 21); and through-tunnel tendon graft, 195 N (SD 66). The last was not significantly weaker than the MPFL itself.

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.

We present our experience with a double-mobility acetabular component in 155 consecutive revision total hip replacements in 149 patients undertaken between 2005 and 2009, with particular emphasis on the incidence of further dislocation. The mean age of the patients was 77 years (42 to 89) with 59 males and 90 females. In all, five patients died and seven were lost to follow-up. Indications for revision were aseptic loosening in 113 hips, recurrent instability in 29, peri-prosthetic fracture in 11 and sepsis in two. The mean follow-up was 42 months (18 to 68). Three hips (2%) in three patients dislocated within six weeks of surgery; one of these dislocated again after one year. All three were managed successfully with closed reduction. Two of the three dislocations occurred in patients who had undergone revision for recurrent dislocation. All three were found at revision to have abductor deficiency. There were no dislocations in those revised for either aseptic loosening or sepsis.

These results demonstrate a good mid-term outcome for this component. In the 29 patients revised for instability, only two had a further dislocation, both of which were managed by closed reduction.

The sternoclavicular joint (SCJ) is a pivotal articulation in the linked system of the upper limb girdle, providing load-bearing in compression while resisting displacement in tension or distraction at the manubrium sterni. The SCJ and acromioclavicular joint (ACJ) both have a small surface area of contact protected by an intra-articular fibrocartilaginous disc and are supported by strong extrinsic and intrinsic capsular ligaments. The function of load-sharing in the upper limb by bulky periscapular and thoracobrachial muscles is extremely important to the longevity of both joints. Ligamentous and capsular laxity changes with age, exposing both joints to greater strain, which may explain the rising incidence of arthritis in both with age. The incidence of arthritis in the SCJ is less than that in the ACJ, suggesting that the extrinsic ligaments of the SCJ provide greater stability than the coracoclavicular ligaments of the ACJ.

Instability of the SCJ is rare and can be difficult to distinguish from medial clavicular physeal or metaphyseal fracture-separation: cross-sectional imaging is often required. The distinction is important because the treatment options and outcomes of treatment are dissimilar, whereas the treatment and outcomes of ACJ separation and fracture of the lateral clavicle can be similar. Proper recognition and treatment of traumatic instability is vital as these injuries may be life-threatening. Instability of the SCJ does not always require surgical intervention. An accurate diagnosis is required before surgery can be considered, and we recommend the use of the Stanmore instability triangle. Most poor outcomes result from a failure to recognise the underlying pathology.

There is a natural reluctance for orthopaedic surgeons to operate in this area owing to unfamiliarity with, and the close proximity of, the related vascular structures, but the interposed sternohyoid and sternothyroid muscles are rarely injured and provide a clear boundary to the medial retroclavicular space, as well as an anatomical barrier to unsafe intervention.

This review presents current concepts of instability of the SCJ, describes the relevant surgical anatomy, provides a framework for diagnosis and management, including physiotherapy, and discusses the technical challenges of operative intervention.

Cite this article: Bone Joint J 2013;95-B:721–31.

Increased femoral head size may reduce dislocation rates following total hip replacement. The National Joint Registry for England and Wales has highlighted a statistically significant increase in the use of femoral heads ≥ 36 mm in diameter from 5% in 2005 to 26% in 2009, together with an increase in the use of the posterior approach. The aim of this study was to determine whether rates of dislocation have fallen over the same period. National data for England for 247 546 procedures were analysed in order to determine trends in the rate of dislocation at three, six, 12 and 18 months after operation during this time. The 18-month revision rates were also examined.

Between 2005 and 2009 there were significant decreases in cumulative dislocations at three months (1.12% to 0.86%), six months (1.25% to 0.96%) and 12 months (1.42% to 1.11%) (all p < 0.001), and at 18 months (1.56% to 1.31%) for the period 2005 to 2008 (p < 0.001). The 18-month revision rates did not significantly change during the study period (1.26% to 1.39%, odds ratio 1.10 (95% confidence interval 0.98 to 1.24), p = 0.118). There was no evidence of changes in the coding of dislocations during this time.

These data have revealed a significant reduction in dislocations associated with the use of large femoral head sizes, with no change in the 18-month revision rate.

In late developmental dysplasia of the hip in childhood, the deformed dysplastic acetabulum is malaligned and has lost its shape due to pressure from the subluxed femoral head. The outer part of the acetabulum involves the upper part of the original acetabulum, thereby giving a bipartite appearance. A clear edge separates the outer from inner part which represents the lower part of the original acetabulum and has no direct contact with the femoral head.

Combined pelvic osteotomy (CPO) using a Lance acetabuloplasty with either a Salter or a Pemberton procedure restores the original shape and realigns the acetabulum. A total of 20 children (22 hips), with a mean age of 46 months (28 to 94) at primary operation underwent CPO with follow-up for between 12 and 132 months.

In each case concentric stable reduction with good acetabular cover was achieved and maintained throughout the period of follow-up.

We evaluated the outcome in a series of patients with recurrent patellar dislocation who had either medial transfer of the tibial tuberosity and lateral release or an isolated lateral release as the primary treatment. The decision to use one or other procedure was based on a pre-operative distance between the tibial tuberosity to the trochlear groove (TTTG) of less than 10 mm to include the tibial tuberosity transfer in addition to the lateral release.

Between April 2002 and December 2006, 49 patients (63 knees) underwent one of these procedures. A total of 35 patients (46 knees) was evaluated at a mean of 38 months (13 to 71) post-operatively. Medial transfer of the tibial tuberosity was performed in 33 knees and isolated lateral release in the remaining 13. Evaluation included the International Knee Documentation Committee (IKDC), the Kujala and the Short-form 36 scores. From the tibial tuberosity group 23 knees also underwent radiological examination at follow-up.

There were further episodes of patellar dislocation in six of the 46 knees available for review. Further dislocation was noted in five of 33 knees (15.2%) in the tibial tuberosity transfer group and in one of 13 knees (7.7%) in the lateral release group. The mean subjective IKDC score was 80.4 (sd 11.6), the mean Kujala score 88 (sd 8.2) and the mean objective IKDC score was 79% normal and 21% nearly normal. The mean post-operative TTTG distance in the tibial tuberosity transfer group was 8.9 mm (3.2 to 15.7) compared with the mean pre-operative value of 16.8 mm (12.2 to 24.4).

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.