Editorial Commentary: Capsule Repair Is Necessary at the Conclusion of Arthroscopy to Optimize Return to Full Activity

Hip capsulotomy and capsule repair have minimal effect on joint kinematics during activities of daily living. With low demands placed on the hip, the hip capsule may provide little to no role on hip stability or microinstability. But the majority, if not all, patients undergoing hip arthroscopy are not content with only resuming basic activities of daily living. Seeking to optimize the hip joint to its maximum capacity should be the goal. Capsule repair is necessary in most to achieve that goal.

Editorial Commentary: Interportal Capsulotomy for Hip Arthroscopy in Patients With Borderline Hip Dysplasia May Result in Inferior Outcomes: Periportal Capsulotomy May Reduce Hip Capsular Damage

Management of the hip capsule remains an ongoing discussion in the field of hip arthroscopy. Interportal and T-capsulotomies remain the most common approaches to gain access to the hip during surgery, and biomechanical and clinical research supports repair of these types of capsulotomies. Less is known, however, about the quality of the tissue that heals at these repair sites during the postoperative period, particularly in the setting of patients with borderline hip dysplasia. The capsular tissue provides important joint stability to these patients, and disruption to the capsule can result in significant functional impairments. There is also an association between borderline hip dysplasia and joint hypermobility, which increases the risk of insufficient healing after capsular repair. Patients with borderline hip dysplasia show poor capsular healing after arthroscopy followed by interportal hip capsule repair, and incomplete healing results in inferior patient-reported outcomes. Periportal capsulotomy may limit capsular violation and improve outcomes.

Midterm Results of Arthroscopy-Assisted "Tent Form" Triangular Fibrocartilage Complex Repair With Dorsal Distal Radioulnar Joint Capsule Imbrication for Posttraumatic Chronic Distal Radioulnar Joint Instability

PURPOSE

To evaluate the outcomes of "tent form" triangular fibrocartilage complex (TFCC) repair combined with dorsal distal radioulnar joint (DRUJ) capsule imbrication for posttraumatic chronic DRUJ instability.

METHODS

All patients treated with arthroscopic "tent form" TFCC repair and DRUJ capsule imbrication from 2016 to 2019 were retrospectively reviewed. The inclusion criteria were symptomatic chronic DRUJ instability for >6 months and dorsal DRUJ subluxation on magnetic resonance imaging. The Disabilities of the Arm, Shoulder, and Hand score, Patient-Rated Wrist Evaluation, grip strength, Modified Mayo Wrist Score, range of motion, and distal radioulnar joint stability were assessed for a minimum of 2 years postoperatively.

RESULTS

Thirty-eight patients were included in the final analysis. The average follow-up duration was 35.6 months (range, 24-48 months). The 24-month postoperative grip strengths and 3-dimensional motions of wrist were not significantly different from that of the nonoperated wrist. Compared with their preoperative status, Disabilities of the Arm, Shoulder, and Hand score, Patient-Rated Wrist Evaluation, and Modified Mayo Wrist Score indicated the significant improvement with P values of .001, .001, and .002, respectively.

CONCLUSIONS

In chronic DRUJ instability with a loosening dorsal capsule, "tent form" TFCC transcapsular repair combined with DRUJ capsule imbrication restored the integrity of TFCC and dorsal DRUJ capsule and achieved a promising outcome. We recommend this procedure as an option of treatment for patients with posttraumatic chronic DRUJ instability.

LEVEL OF EVIDENCE

IV, case series.

Adverse Local Tissue Reactions are Common in Asymptomatic Individuals After Hip Resurfacing Arthroplasty: Interim Report from a Prospective Longitudinal Study

BACKGROUND

The evaluation of the natural history prevalence of adverse local tissue reactions (ALTRs) using MRI has focused only on metal-on-metal (MoM) bearing surfaces without comparison to nonMoM bearing surfaces.

QUESTIONS/PURPOSES

To determine (1) the longitudinal changes and differences in blood metal ion levels in patients with hip resurfacing arthroplasty (HRA), ceramic-on-ceramic (CoC) THA, and metal-on-polyethylene (MoP) THA compared with those undergoing ceramic-on-polyethylene (CoP) THA; (2) how the longitudinal change of synovial reaction classification in patients with HRA, CoC THA, and MoP THA compares with those undergoing CoP THA, and whether there is an association between the presence of an ALTR or metallosis on MRI with corresponding patient-reported outcomes, or the presence of capsular dehiscence; and (3) differences in blood metal ion levels between patients undergoing HRA with an ALTR or metallosis on MRI and those with HRA without these conditions.

METHODS

Between March 2014 and February 2019, 22,723 patients underwent primary HRA and THA at one center. Patients received an HRA based on their desired athletic level after surgery and the presence of normal acetabular and proximal femoral bone morphology without osteopenia or osteoporosis. Two percent (342 of 22,723) of patients were contacted to participate, and 71% (243 of 342 hips in 206 patients) were enrolled for analysis at baseline. The patients underwent arthroplasty for degenerative joint disease, and 25 patients withdrew over the course of the study. We included patients who were more than 1 year postarthroplasty. All participants had an MRI examination and blood serum ion testing and completed a Hip Disability and Osteoarthritis Outcome Score survey annually for four years (baseline, year 1, year 2, year 3). Morphologic and susceptibility-reduced MR images were evaluated by a single radiologist not involved in the care of patients for the presence and classification of synovitis (Gwet AC1: 0.65 to 0.97), synovial thickness, and volume (coefficient of repeatability: 1.8 cm3). Linear mixed-effects models were used to compare the mean synovial thickness, synovial volume, and Hip Disability and Osteoarthritis Outcome Score subscales between bearing surfaces at each timepoint and within each bearing surface over time. Marginal Cox proportional hazards models were used to compare the time to and the risk of developing ALTR only, metallosis only, and ALTR or metallosis between bearing surfaces. All models were adjusted for age, sex, BMI, and length of implantation based on known confounders for hip arthroplasty. Adjustment for multiple comparisons was performed using the Dunnett-Hsu method.

RESULTS

Patients with unilateral HRA had higher cobalt and chromium serum ion levels (baseline: 1.8 ± 0.8 ppb, year 1: 2.0 ± 1.5 ppb, year 2: 2.1 ± 1.2 ppb, year 3: 1.6 ± 0.7 ppb) than those with unilateral CoP bearings (baseline: 0.0 ± 0.1 ppb, year 1: 0.1 ± 0.3 ppb, year 2: 0.0 ± 0.2 ppb, year 3: 0.0 ± 0.0 ppb) at all timepoints (p < 0.001 for each time point). More patients who received an HRA developed ALTR or metallosis on MRI than did patients with CoP bearings (hazard ratio 4.8 [95% confidence interval 1.2 to 18.4]; p = 0.02). There was no association between the longitudinal change of synovial reaction to ALTR or metallosis on MRI with patient-reported outcomes. In addition, there was no association between the presence of dehiscence at baseline and the subsequent development of ALTR or metallosis, as seen on MRI. There were elevated cobalt (4.7 ± 3.5 ppb) and chromium (4.7 ± 2.6 ppb) serum levels in patients with unilateral HRA who had an ALTR or metallosis present on MRI at year 1 compared with patients without an ALTR or metallosis on MRI (cobalt: 1.8 ± 1.0 ppb, mean difference 4.7 ppb [95% CI 3.3 to 6.0]; p < 0.001; chromium: 2.3 ± 0.5 ppb, mean difference 3.6 ppb [95% CI 2.2 to 5.0]; p < 0.001) as well as for chromium at year 3 (3.9 ± 2.4 ppb versus 2.2 ± 1.1 ppb, mean difference 1.3 ppb [95% CI 0.3 to 2.4]; p = 0.01).

CONCLUSION

We found a higher proportion of ALTR or metallosis on MRI in patients with HRA compared with patients with CoP, even when patient self-assessed symptomatology of those with an ALTR or metallosis on MRI was not different than the absence of these features. MRI detected ALTRs in high-function patients, emphasizing that an annual clinical assessment dependent on survey or blood ion testing alone may not detect soft tissue complications. The results of this study are in line with prior consensus recommendations of using MRI as part of a routine follow-up protocol for this patient population.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Improved Outside-In Suture through the Joint Capsule to Repair the Palmer I-B Triangular Fibrocartilage Complex Superficial Injury

BACKGROUND

The treatment of type I-B triangular fibrocartilage complex superficial injury is always a challenge to orthopedists. The traditional outside-in suture method often causes a risk of nervous irritation. We designed a modified outside-in suture through the joint capsule to repair the Palmer I-B triangular fibrocartilage complex superficial injury.

METHODS

From December 2014 to December 2018, we retrospectively collected the medical records of 18 patients in our hospital who used the modified outside-in suture through the joint capsule to repair type I-B triangular fibrocartilage complex superficial injury. Among them, there were 12 males and 6 females, with an average age of 36.2 years. There were 6 cases on the left side and 12 cases on the right side. Record the healing time of all patients after surgery and the occurrence of related complications, and record the pain visual analogue scale (VAS), grip strength, wrist flexion and extension, radioulnar deviation and forearm rotation range of motion, modified Mayo wrist joint function score, and disability of arm-shoulder-hand (DASH) score before operation and at the last follow-up.

RESULTS

One patient was lost to follow-up, and a total of 17 patients received the final follow-up. Patients were followed up for 24 to 36 months, with an average of 29.6 ± 3.0 months. No wound infection, nerve damage, or irritation occurred after the operation. At the last follow-up, 15 cases of wrist pain disappeared completely, and 2 cases had mild discomfort during exercise. At the last follow-up, VAS decreased from 3.8 ± 0.7 points before operation to 0.8 ± 0.7 points (P < 0.05); grip strength increased from 15.1 ± 3.1 kg before operation to 23.2 ± 1.5 kg (P < 0.05); wrist flexion and extension, radioulnar deflection, and forearm rotational mobility increased from 116.3 ± 2.2°, 37.0 ± 3.5°, and 141.6 ± 2.2° before operation to 117.2 ± 2.5° (P < 0.05), 38.9 ± 3.0° (P < 0.05), and 142.4 ± 1.9° (P < 0.05), respectively; the modified Mayo wrist joint function score increased from 66.1 ± 3.6 points to 82.5 ± 3.9 points (P < 0.05), of which 10 cases were excellent, 5 cases were good, 2 cases were fair, and the excellent and good rate was 88.2%; DASH score improved from 37.0 ± 5.7 points preoperatively to 8.0 ± 2.5 points (P < 0.05).

CONCLUSION

The modified outside-in suture through the joint capsule to repair the superficial injury of Palmer I-B triangular fibrocartilage complex has a good clinical effect and is worthy of clinical widespread promotion.

Why Does Hip Arthroscopy Fail? Indications and PEARLS for Revision Success

The surgical treatment of femoroacetabular impingement has been shown to have successful early and mid-term clinical outcomes. Despite these favorable clinical outcomes that have been published in the literature, there is a subgroup of patients that present with continued or recurrent symptoms after surgical treatment. Not only has there been an increase in the number of hip arthroscopy procedures, but also there has been a corresponding increase in the number of revision hip arthroscopy and hip preservation surgeries. Previous studies have reported residual deformity to be the most common reason for revision hip arthroscopy. However, chondral, labral, and capsular considerations also are important when addressing patients not only in the primary but also, the revision setting. In this review, we outline the evaluation and treatment of the patient that presents with continued hip and groin pain after undergoing a hip.

Talectomy by Medial Surgical Approach for Congenital Vertical Talus in Arthrogryposis Multiplex Congenita

Arthrogryposis multiplex congenita involves stiff contracture of joints and weak atrophic muscles presenting at birth. The two most common forms are amyoplasia and distal arthrogryposis. Amyoplasia affects all 4 extremities: internally rotated shoulders, extended fixed elbows, flexed fixed wrists, extended fixed knees, clubfeet, and decreased muscle volume. Distal arthrogryposis is a group of syndromes with a genetic basis. The distal joints are contracted. Clubfeet and congenital vertical talus are the most common foot deformities. A 10-year-old boy presented with distal arthrogryposis with bilateral congenital tali. He reported having deformed and painful feet and difficulty wearing shoes. His rocker-bottom foot deformities caused him to walk with a heel to heel gait. He also had stiff extended knees. His previous foot surgeries included failed open reduction and pin fixation of the talonavicular joints with Achilles tendon lengthening and capsulotomies. The boy underwent bilateral talectomies and releases of contracted joint capsules and lengthening of multiple extrinsic tendons through separate incisions. The talectomy of each foot was performed via a novel medial surgical approach. At 2-year follow-up, he had normal-appearing plantar grade feet. He had a painless gait, could ambulate independently, and was considered to have an excellent result. This is the first detailed report of performing a talectomy via a medial approach for bilateral congenital tali in a patient with arthrogryposis multiplex congenita. [Orthopedics. 2020; 43(6):e623-e626.].

The efficacy of bidirectional barbed sutures for incision closure in total knee replacement: A protocol of randomized controlled trial

BACKGROUND

Barbed suture is a novel type of suture introduced in different surgical specialties. Nevertheless, its effect in total knee replacement is still unclear in terms of wound complications and cost effectiveness. The purpose of the present work is to evaluate the safety and efficacy of bidirectional barbed suture in reducing postoperative wound complications in the patients undergoing total knee replacement.

METHODS

This prospective, randomized, and controlled study was performed from January 2017 to December 2018. It was authorized via institutional review committee of Yuebei People's Hospital (GDYB1002189). Hundred participants were divided randomly into 2 groups, namely, control group (n = 50) and the study group (n = 50), respectively. All operations were performed using the Miller-Galante prosthesis (Zimmer; Warsaw, IN). For study groups, the joint capsule (Stratafix1-0) and subcutaneous (Stratafix2-0) and intracutaneous (Stratafix3-0) tissues were sutured by a bidirectional barbed suture. At the end, extra 4 to 5 stitches were made to avoid detachment and incision rupture. For control group: the joint capsule was sutured by a traditional absorbable suture (Ethicon VICRYL* Plus 1-0), and the subcutaneous tissue was sutured by an absorbable suture (Ethicon VICRYL* Plus 2-0). The skin was sutured by staples. Incision length, suture time, operation time, postoperative length of hospital stay, and incision complications (such as effusion, infection, hematoma, and skin necrosis) were recorded. All data analyses are implemented through utilizing SPSS for Windows Version 20.0.

RESULTS

The results will be shown in Table 1.

CONCLUSION

This study can reach a reliable evidence for utilizing bidirectional barbed suture in wound closure in total knee replacement.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry5823).

Anatomical superficial medial collateral ligament reconstruction with posteromedial capsule reefing successfully restores valgus knee laxity

The goal of this study was to present the results of an anatomical superficial medial collateral ligament (sMCL) reconstruction combined with reefing of the posteromedial capsule in a series of 10 patients with symptomatic valgus instability complaints in combined injuries of the knee. All patients under- went an sMCL reconstruction with reefing of the posteromedial capsule. If cruciate ligament insuf- ficiency was present, this was reconstructed as well. Pre- and postoperatively, multiple subjective knee outcome scores were obtained, and valgus stress radiographs objectively evaluated laxity. Median valgus laxity of the injured knee on valgus stress radiographs improved significantly. There was no statistically significant difference between post- operative valgus laxity of the injured knee and valgus laxity of the uninjured knee. All subjective knee outcome scores improved significantly compared with the preoperative situation. The described procedure restores valgus laxity to a level comparable to the uninjured knee.

Dorsal Intercarpal Ligament Preserving Arthrotomy and Capsulodesis for Scapholunate Dissociation

Carpal instability secondary to scapholunate (SL) ligament tears can lead to a significant disability of the wrist. Different surgical procedures have been proposed to treat SL instability. A variety of dorsal capsulodesis techniques tethering the scaphoid have been used in patients with SL dissociation. We report a novel technique of modified dorsal intercarpal ligament (DICL) capsulodesis for the treatment of SL dissociation. The surgical indication for this procedure is complete SL ligament tear with a reducible carpal malalignment and no secondary osteoarthritis. This procedure is indicated when the remnant of torn ligament in the dorsal SL interosseous space is available for repair. First, carpal malalignment is corrected and the scaphoid and the lunate are temporarily fixed with a transosseous screw or Kirschner wires. Using a dorsal approach, the DICL is then exposed, which originates from the triquetrum and attaches to the scaphoid, trapezium, and trapezoid. The distal and proximal borders of the ligament are identified and elevated without detaching the attachment sites. The DICL is transferred proximally to reinforce the dorsal SL interosseous ligament. The wrist joint is immobilized for 3 weeks postoperatively, and dart-throwing motion is permitted until temporary SL fixation is removed at 2 to 3 months after surgery. A wrist brace is recommended until 3 to 6 months after the first surgery depending on the patient's occupation and sports activity.

Chronic anterior knee pain

Palpation of the knee yielded a key diagnostic sign.

Innervation of the hip joint capsular complex: A systematic review of histological and immunohistochemical studies and their clinical implications for contemporary treatment strategies in total hip arthroplasty

The hip joint capsule contributes to the stability of the hip joint and lower extremity, yet this structure is incised and often removed during total hip arthroplasty (THA). Increasing incidence of osteoarthritis is accompanied by a dramatic rise in THAs over the last few decades. Consequently, to improve this treatment, THA with capsular repair has evolved. This partial restoration of physiological hip stability has resulted in a substantial reduction in post-operative dislocation rates compared to conventional THA without capsular repair. A further reason for the success of this procedure is thought to be the preservation of the innervation of the capsule. A systematic review of studies investigating the innervation of the hip joint capsular complex and pseudocapsule with histological techniques was performed, as this is not well established. The literature was sought from databases Amed, Embase and Medline via OVID, PubMed, ScienceDirect, Scopus and Web of Science; excluding articles without a histological component and those involving animals. A total of 21 articles on the topic were identified. The literature indicates two primary outcomes and potential clinical implications of the innervation of the capsule. Firstly, a role in the mechanics of the hip joint, as mechanoreceptors may be present in the capsule. However, the nomenclature used to describe the distribution of the innervation is inconsistent. Furthermore, the current literature is unable to reliably confirm the proprioceptive role of the capsule, as no immunohistochemical study to date has reported type I-III mechanoreceptors in the capsule. Secondly, the capsule may play a role in pain perception, as the density of innervation appears to be altered in painful individuals. Also, increasing age may indicate requirements for different strategies to surgically manage the hip capsule. However, this requires further study, as well as the role of innervation according to sex, specific pathology and other morphometric variables. Increased understanding may highlight the requirement for capsular repair following THA, how this technique may be developed and the contribution of the capsule to joint function and stability.

Reconstruction of the Acromioclavicular Ligament Complex Using Dermal Allograft: A Biomechanical Analysis

PURPOSE

To analyze the posterior translational and rotational stability of the acromioclavicular (AC) joint following reconstruction of the superior acromioclavicular ligament complex (ACLC) using dermal allograft.

METHODS

Six fresh-frozen cadaveric shoulders were used (mean age of 65.3 ± 6.9 years). The resistance force against posterior translation (10 mm) and torque against posterior rotation (20°) was measured. Specimens were first tested with both the intact ACLC and coracoclavicular ligaments. The ACLC and coracoclavicular ligaments were then transected so simulate a Type III/V AC joint dislocation. Each specimen then underwent 3 testing conditions, performed in the following order: (1) ACLC patch reconstruction alone, (2) ACLC patch with an anatomic coracoclavicular reconstruction (ACCR) using semitendinosus allograft, and (3) the transected ACLC with an ACCR only. Differences in posterior translational and rotational torque across testing conditions were analyzed with a one-way repeated analysis of variance analysis.

RESULTS

Mean resistance against posterior translation in the intact condition was 65.76 ± 23.8 N. No significant difference found between the intact condition compared with specimens with the ACLC-patch only (44.2 ± 11.3 N, P = .06). The ACCR technique, when tested alone, had significantly less posterior translational resistance compared with the intact condition (38.5 ± 8.94 N, P = .008). ACLC patch in combination with an ACCR was closest in restoring native posterior translation (57.1 ± 19.2 N, P = .75). For rotational resistance, only the addition of the ACLC patch with an ACCR (0.51 ± 0.07 N-m) demonstrated similar torque compared with the intact joint (0.89 ± 0.5 N-m, P = .06).

CONCLUSIONS

The ACLC-patch plus ACCR technique was able to closest restore the percent of normal posterior translational and rotational stability.

CLINICAL RELEVANCE

Recurrent posterior instability of the AC joint is a potential complication after coracoclavicular reconstruction surgery. In the in vitro setting, this study demonstrated increased AC joint stability with the addition of an ACLC reconstruction using dermal allograft.

Hip Joint Capsular Anatomy, Mechanics, and Surgical Management

➤Hip joint capsular ligaments (iliofemoral, ischiofemoral, and pubofemoral) play a predominant role in functional mobility and joint stability. ➤The zona orbicularis resists joint distraction (during neutral positions), and its aperture mechanism stabilizes the hip from adverse edge-loading (during extreme hip flexion-extension). ➤To preserve joint function and stability, it is important to minimize capsulotomy size and avoid disrupting the zona orbicularis, preserve the femoral head size and neck length, and only repair when or as necessary without altering capsular tensions. ➤It is not fully understood what the role of capsular tightness is in patients who have cam femoroacetabular impingement and if partial capsular release could be beneficial and/or therapeutic. ➤During arthroplasty surgery, a femoral head implant that is nearly equivalent to the native head size with an optimal neck-length offset can optimize capsular tension and decrease dislocation risk where an intact posterior hip capsule plays a critical role in maintaining hip stability.

Anterior capsule re-attachment in terrible triad elbow injury with coronoid tip fracture

BACKGROUND

During the surgical treatment of terrible triad elbow injury (TTEI), the usefulness of re-attaching the anterior joint capsule when the coronoid tip is fractured remains unclear. The primary objective of this study was to assess potential benefits during surgery for TTEI of re-attaching the joint capsule when the coronoid tip is fractured.

HYPOTHESIS

Re-attaching the anterior joint capsule in TTEI with a fractured coronoid tip improves clinical and radiological outcomes and decreases the complication and revision rates.

MATERIALS AND METHODS

This single-centre retrospective study included patients who underwent surgery at the acute phase of TTEI with a fractured coronoid tip. In all patients, a physical examination and elbow radiographs were performed at least 1year after surgery. A statistical analysis was done to compare the groups with vs. without re-attachment of the anterior capsule and coronoid tip.

RESULTS

The study included 30 patients, 16 females and 14 males, with a mean age of 51years (range: 21-84years). Among them, 11 did and 19 did not undergo re-attachment. The two groups were comparable regarding demographic features and follow-up duration. No significant differences were found at last follow-up for flexion-extension motion arc (p=0.75), pronation-supination motion arc (p=0.3051), or the Mayo Elbow Performance Score (p=0.19). Radiographic evidence of humero-radial osteoarthritis was significantly more common in the absence of re-attachment (p=0.04), whereas no differences were evidenced regarding humero-ulnar osteoarthritis (p=0.73), the occurrence of subluxation or dislocation (p=0.43), or loosening of the radial head implant (p=0.47). The complication and revision rates were similar in the two groups.

CONCLUSION

In our experience, re-attaching the anterior capsule during the surgical treatment of TTEI with a coronoid tip fracture did not improve the clinical or radiographic outcomes after a mean follow-up of 54months.

LEVEL OF EVIDENCE

IV, retrospective study.

Arthroscopic treatment of posterior instability of the shoulder with an associated reverse Hill-Sachs lesion using an iliac bone-block autograft

Posterior dislocation of the shoulder is often accompanied by an impression fracture in the anterior surface of the humeral head, called a reverse Hill-Sachs injury. This bone defect can engage on the posterior glenoid rim, which can lead to recurrent instability and progressive joint destruction. We describe a new arthroscopic procedure that fills the reverse Hill-Sachs lesion with an iliac bone-block autograft and repairs the posterior articular capsule arthroscopically, which can stabilize the posterior shoulder. It avoids the need to detach the subscapularis tendon and can reduce the risks associated with open procedures. LEVEL OF EVIDENCE: V, technical note.

An Extensile Approach to the Radial Aspect of the Carpus: "The Link Incision"

The structures on the radial side of the wrist and thumb base can be approached by a longitudinal incision on the radial side of the wrist. However, longer longitudinal scars can be cosmetically unacceptable and can result in a scar contracture. It is preferable to curve longer incisions along the Langer's skin lines to achieve better scar characteristics. Curving the incision also enables an extensile approach and provides easy access to the thumb base, radial carpus, and radial wrist joint. We describe our approach as a "Link" between the most common approaches that surgeons are familiar with; the dorsoulnar approach to the thumb metacarpophalangeal joint for ulnar collateral ligament repair and the flexor carpi radialis approach for distal radial fracture fixation. The zone between these two incisions is not as frequently approached. Our incision connects these two well established incisions and we have described a step by step approach to this unfamiliar area. This "Link zone" overlies the thumb trapeziometacarpal joint, scaphotrapeziotrapezoid joint, and the radial styloid. It contains superficial branches of the radial nerve, first extensor compartment tendons, and the deep branch of radial artery in the anatomic snuff box. The "Link incision" is an extensile approach in both the proximal and distal directions.

Interposition Arthroplasty of the Elbow Utilizing a Lateral Epicondyle Osteotomy

Management of severe elbow arthritis in young or active patients presents a challenging problem. Interposition arthroplasty is a useful salvage procedure for these patients but has a significant failure rate associated with postoperative instability. Previous studies have sought to preserve the integrity of the medial elbow ligament complex to decrease postoperative instability and the need for external fixation. Our lateral epicondylar osteotomy technique preserves the native lateral elbow ligament complex. Potential advantages include bone-to-bone healing of the osteotomy, decreased postoperative instability, and the decreased need for and associated costs and potential complications of supplemental external fixation.

Midterm Outcomes Following Repair of Capsulotomy Versus Nonrepair in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement With Labral Repair

PURPOSE

The purpose of this study was to compare the midterm outcomes and conversion to total hip arthroplasty (THA) rate in patients who had repair of the capsulotomy versus nonrepair following arthroscopic hip labral repair and correction of femoroacetabular impingement (FAI).

METHODS

All patients undergoing primary arthroscopic hip labral repair and correction of FAI between 2005 and 2012 were eligible for this study. Exclusion criteria were age < 18 years, lateral center-edge angle < 25°, previous hip procedures, femoral avascular necrosis, radiographic joint space ≤ 2 mm, or microfracture at arthroscopy. Patients who did not have the capsulotomy repaired were matched 1:2 with patients who had the capsulotomy repaired. Patients were matched by age, gender, and intraoperative procedures. The primary outcome score was the Hip Outcome Score Daily Living (HOS-ADL).

RESULTS

Forty-two patients (18 female patients, 24 male patients) without repair of the capsulotomy were matched with 84 patients with repaired capsulotomy. The average age for both groups was 38 ± 15 years. Patients in the nonrepair group were 6.8 (95% confidence interval, 1.2-52) times more likely to undergo THA compared with the repair group. There was no difference in revision rate between the 2 groups. The mean follow-up time was 7.3 ± 2.7 years and 6.4 ± 2.3 years for the nonrepair and repair group, respectively (P = .107). Patients in the repair group had significantly higher HOS-ADL (P = .01) and modified Harris hip score (mHHS; P = .007). The percentage of patients who reached minimum clinically important difference was significantly higher in the repair group for HOS-ADL (P = .002) and HOS-Sport (P = .036) compared with the nonrepair group. However, there was no difference in the percentage of patients who reached minimal important change for the mHHS (P = .060). Following hip arthroscopy, the average alpha angle was 41.6° ± 6° in the nonrepair group and 40.8° ± 3° in the repair group.

CONCLUSIONS

Patients who undergo arthroscopic FAI correction and hip labral repair with repair of the capsulotomy had higher HOS-ADL and mHHS scores at midterm follow-up compared with patients with nonrepair, and the percentage of patients who reached the minimum clinically important difference was significantly higher in the repair group for HOS-ADL and HOS-Sport compared with the nonrepair group. In addition, a lower rate of conversion to THA was seen in the repair group.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

[Arthroscopic Superior Capsule Reconstruction Using the DX Reinforcement Matrix in Patients with Irreparable Rotator Cuff Tears - Pilot Data]

PURPOSE OF THE STUDY Irreparable rotator cuff tear continues to be a point of discussion. Several surgical techniques have been proposed so far. None of them, however, can be considered the method of choice. This study presents the first clinical results of superior capsule reconstruction (SCR) using the DX Reinforcement Matrix. MATERIAL AND METHODS The evaluation included patients with the minimum follow-up of 6 months. The follow-up period in these patients was 1 year (6-18 months) on average. The active (AROM) and passive (PROM) ranges of motion were assessed-anterior flexion, abduction, external rotation and external rotation at 90° abduction. The patients were assessed using clinical scores before and after the surgery-pain assessment scale (VAS), UCLA (University of California at Los Angeles) Shoulder Rating Scale and ASES (American Shoulder and Elbow Surgeons) Shoulder Score. RESULTS In the period from October 2016 to October 2018, a total of 20 SCRs were performed. The mean age of patients was 61 years. Nine patients were clinically assessed, with the mean follow-up of 1 year. The mean UCLA Shoulder Score was 10 points preoperatively. Postoperatively, the values went up to 29 points on average. The reported ASES score was 23.8 points preoperatively. Postoperatively, the mean score was 73.2 points. The VAS subjective pain score ranged around 7 points before the surgery. After the surgery, the mean VAS score was 2 points. The mean active shoulder flexion was 74° preoperatively and 161° postoperatively. The mean active abduction was 74° preoperatively and 161° postoperatively. The mean active external rotation of the shoulder joint was 20° preoperatively and 56° postoperatively. The mean active external rotation at 90° abduction was 21° preoperatively and 82° postoperatively. The changes in all the followed-up mean parameters of UCLA, ASES, VAS, AROM and PROM reported by our group show a relatively high level of substantive significance. DISCUSSION Results of arthroscopic superior capsule reconstruction using the DX Reinforcement Matrix have not been published in literature so far. Compared to the results for fascia lata published in literature, our results are slightly worse. By contrast, our results are similar to those achieved by human dermal allograft. CONCLUSIONS Arthroscopic superior capsule reconstruction currently appears to be the method of choice in unreconstructed supraspinatus and infraspinatus tear. Our group of patients shows that early clinical outcomes of SCR using xenograft are very promising. A significant pain relief and a considerable improvement in the range of motion of the operated shoulder joint were observed. No complication specifically associated with the use of xenograft has been reported as yet. A longer follow-up period and assessment of a larger group of patients will be necessary to confirm the success of this surgical procedure. Key words: massive rotator cuff tears; irreparable rotator cuff tears; superior capsular reconstruction; xenograft; DX Reinforcement Matrix.

Reconstruction of Traumatic Central Slip Injuries: Technique Using a Slip of Flexor Digitorum Superficialis

Multiple reconstruction techniques have been described for correction of boutonniere deformities including direct repair, central slip reconstruction, lateral band reconstruction, transverse retinacular ligament reconstruction, staged reconstruction, and extensor tenotomy. Each technique has been reported to have variable results with complications including capsular contracture, loss of proximal interphalangeal flexion, and residual deformity. We describe a surgical technique for central slip reconstruction using a slip of the flexor digitorum superficialis tendon through a bone tunnel.

Capsular Sparing Total Hip Replacement Technique Applied with a Dual-mobility Cup to Reduce Dislocations

Regardless of the surgical approach used, dislocation remains a complication following total hip replacement. In recent years, newer technologies, such as the use of large femoral heads, have reduced the rate of postoperative dislocation. The combination of such technology, together with a soft tissue repair technique, may reduce the dislocation rate even further. A single surgeon performed 513 primary total hip replacements on 505 patients using a posterior approach utilizing a technique designed to spare the capsule. There were 257 males and 248 females. Age ranged from 39 to 92 years. Surgeries were performed from January 2012 to December 2015. Implants used were cementless dual-mobility cups and cementless femoral stems. In all cases, the posterior capsule was incised and retracted, but not excised. Following implant placement, the capsule was repaired using a fiber reinforced suture. The superior border of the capsular incision, just above the piriformis, was sutured to the superior capsule or gluteus minimus muscle. The intent of this repair was to completely incarcerate the femoral head. Patients were followed at two weeks, six weeks, three months, one year, three years, and five years. Follow up was one to five years post-implantation. The dislocation rate was zero. The combination of a large dual-mobility femoral head, combined with a soft tissue repair that spares the deep capsule, has the potential to significantly reduce dislocation rates when using the posterior approach to the hip.

Anatomic Total Shoulder Arthroplasty Versus Reverse Total Shoulder Arthroplasty for Post-Capsulorrhaphy Arthropathy

Post-capsulorrhaphy arthropathy is a long-term sequela that can develop after open anterior stabilization surgeries, which have historically been performed. The purpose of this study was to compare anatomic total shoulder arthroplasty (ATSA) with reverse total shoulder arthroplasty (RTSA) for the treatment of post-capsulorrhaphy arthropathy. There were 19 patients in the ATSA cohort and 20 in the RTSA cohort. All patients included had a minimum of 2 years of follow-up (ATSA mean, 59.5 months; RTSA mean, 43.8 months). Patients were followed clinically (American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, range of motion analysis, and patient satisfaction) as well as radiographically, allowing a comparison of the 2 cohorts. Mean outcome scores were similar in the ATSA and the RTSA cohorts, with no difference between the 2 groups. The ATSA group had greater postoperative forward elevation (153° vs 139°; P=.01) than the RTSA group, but no other differences were noted in motion. The ATSA group had less satisfied patients (84% vs 95%), a higher complication rate (21% vs 10%), and a higher revision rate (16% vs 0%) compared with the RTSA group. For post-capsulorrhaphy arthropathy, patients treated with ATSA and patients treated with RTSA had comparable improvements in outcome scores and range of motion. However, the complication rate was higher in the ATSA group. All complications in the ATSA cohort were related to subscapularis insufficiency and postoperative anterior instability problems, resulting in a higher revision rate in this cohort (16%) compared with the RTSA cohort (0%). [Orthopedics. 2018; 41(5):275-280.].

Surgical stabilization for first-time shoulder dislocators: a multicenter analysis

BACKGROUND

Anterior shoulder dislocations in young patients are associated with high rates of recurrent instability. Although some surgeons advocate for surgical stabilization after a single dislocation event in this population, there is sparse research evaluating surgical treatment for first-time dislocators.

METHODS

Patients undergoing surgical stabilization for anterior shoulder instability were prospectively enrolled at multiple institutions from 2015-2017 and stratified by number of dislocations before surgery. Demographic data, preoperative patient-reported outcomes, imaging findings, surgical findings, and procedures performed were compared between groups. Analysis of variance, χ², and multivariate logistic regression were used for statistical analysis.

RESULTS

The study included 172 patients (mean age, 25.3 years; 79.1% male patients) for analysis (58 patients with 1 dislocation, 69 with 2-5 dislocations, 45 with >5 dislocations). There were no intergroup differences in demographic characteristics, preoperative patient-reported outcomes, or physical examination findings. Preoperative imaging revealed increased glenoid bone loss in patients with multiple dislocation events (P = .043). Intraoperatively, recurrent dislocators were more likely to have bony Bankart lesions (odds ratio [OR], 3.26; P = .024) and biceps pathology (OR, 6.27; P = .013). First-time dislocators more frequently underwent arthroscopic Bankart repair and/or capsular plication (OR, 2.22; P = .016), while recurrent dislocators were more likely to undergo open Bristow-Latarjet procedures (OR, 2.80; P = .049) and surgical treatment for biceps pathology (OR, 5.03; P = .032).

CONCLUSIONS

First-time shoulder dislocators who undergo stabilization are more likely to undergo an arthroscopic procedure and less likely to have bone loss or biceps pathology compared with recurrent dislocators. Future studies are needed to ascertain long-term outcomes of surgical stabilization based on preoperative dislocation events.

Arthroscopic posterior bone block stabilization-early results of an effective procedure for the recurrent posterior instability

PURPOSE

In the current study the clinical outcome of an arthroscopic posterior bone block augmentation in combination with a posterior capsular repair was investigated.

METHODS

Twenty-four shoulders (18 patients) with unidirectional posterior shoulder instability were treated with an arthroscopic posterior bone block and capsular reconstruction. The mean follow up period was 26 months. The patients were examined pre- and postoperatively using the Constant-Murley score, the Rowe score, Walch-Duplay score and Western Ontario Shoulder index.

RESULTS

At the follow up examination 21 shoulders were classified to be stable, while one patient reported a single redislocation and two further patients reported recurrent posterior subluxation or posterior apprehension. Thus, the recurrence rate was defined to be 12.5%. The Rowe-Score significantly improved from 50 points preoperatively to 75 points postoperatively (p = 0.0003). The WOSI-score significantly improved from 37% preoperatively to 66% postoperatively (p = 0.0001). Revision surgery commonly was required for screw removal.

CONCLUSION

The early clinical results of this arthroscopic bone block augmentation and capsular repair are promising.

LEVEL OF EVIDENCE

IV.

Does Closure of the Capsule Impact Outcomes in Hip Arthroscopy? A Systematic Review of Comparative Studies

Introduction

Arthroscopic management of the hip capsule has become a topic of debate in recent literature. Few comparative studies exist to help establish clear treatment recommendations.

Methods

Utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review of the literature was conducted using PubMed, CINAHL, EMBASE, sportDiscus (EBSCO) and Cochrane Central Register of Controlled Trials databases by two independent investigators. Comparative studies evaluating outcomes after two or more distinct treatment approaches to capsule management were included.

Results

The review yielded 7 articles that met inclusion criteria. Outcomes included in the review include patient reported outcome measures (mHHS, HOS, NASH) in 5 articles, return to sport in 1 article, and formation of postoperative heterotopic ossification (HO) in 1 article. In two articles evaluating the outcomes of revision hip arthroscopy, plication was associated with > 10 point improvements in HOS-ADL and mHHS scores when compared to no plication. The literature is inconclusive regarding routine hip capsule closure in primary arthroscopy, with one study supporting the practice, and one study showing no difference; capsular closure may help accelerate return to sports and improve outcomes while decreasing revisions in cases of borderline dysplasia. Closure does not influence HO rates after surgery.

Conclusion

There is insufficient evidence in the present literature to suggest routine closure of inter-portal capsulotomies after primary hip arthroscopy impacts patient outcomes. Capsular closure or plication should be given strong consideration in revision cases. Complete closure or plication may influence outcomes in patients with borderline dysplasia, for athletes wishing to return to sport, and in cases of extensile capsulotomies, although the data are inconclusive. Prospective, high level studies are indicated to create evidence-based treatment recommendations for capsular management in hip arthroscopy.

A biomechanical cadaveric study comparing superior capsule reconstruction using fascia lata allograft with human dermal allograft for irreparable rotator cuff tear

BACKGROUND

Biomechanical and clinical success of the superior capsule reconstruction (SCR) using fascia lata (FL) grafts has been reported. In the United States, human dermal (HD) allograft has been used successfully for SCRs; however, the biomechanical characteristics have not been reported.

METHODS

Eight cadaveric shoulders were tested in 5 conditions: (1) intact; (2) irreparable supraspinatus tear; (3) SCR using FL allograft with anterior and posterior suturing; (4) SCR using HD allograft with anterior and posterior suturing; and (5) SCR using HD allograft with posterior suturing. Rotational range of motion, superior translation, glenohumeral joint force, and subacromial contact were measured at 0°, 30°, and 60° of glenohumeral abduction in the scapular plane. Graft dimensions before and after testing were also recorded. Biomechanical parameters were compared using a repeated-measures analysis of variance with Tukey post hoc test, and graft dimensions were compared using a Student t-test (P < .05).

RESULTS

Irreparable supraspinatus tear significantly increased superior translation, superior glenohumeral joint force, and subacromial contact pressure, which were completely restored with the SCR FL allografts. Both SCR HD allograft repairs partially restored superior translation and completely restored subacromial contact and superior glenohumeral joint force. The HD allografts significantly elongated by 15% during testing, whereas the FL allograft lengths were unchanged.

CONCLUSIONS

Single-layered HD SCR allografts partially restored superior glenohumeral stability, whereas FL allograft SCR completely restored the superior glenohumeral stability. This may be due to the greater flexibility of the HD allograft, and the SCR procedure used was developed on the basis of FL grafts.

Case study: failure of superior capsular reconstruction using dermal allograft

Superior capsular reconstruction (SCR) is a novel technique for treating irreparable rotator cuff tears in younger patients in whom a reverse total shoulder arthroplasty is not the optimal treatment choice. This case study describes a middle-aged male with a recurrent, massive, irreparable rotator cuff tear treated with SCR that subsequently failed at the glenoid attachment. The patient underwent successful arthroscopic revision of the SCR. The case illustrates the MRI and arthroscopic correlations of the failed dermal allograft reconstruction, which to our knowledge has not been previously shown in the radiology literature.

All-Arthroscopic Superior Shoulder Capsule Reconstruction With Partial Rotator Cuff Repair

Massive irreparable rotator cuff tears are difficult to treat. Although several treatment options exist, none provides superior long-term results. There is no consensus on optimal surgical technique. Superior capsular reconstruction is an operative treatment option aimed at restoring native biomechanics of the glenohumeral joint by providing a restraint to superior subluxation. Partial rotator cuff repair for massive tears has also been shown to improve shoulder kinematics and can be performed in conjunction with superior capsule reconstruction. The authors describe a technique for arthroscopic superior capsular reconstruction with a dermal allograft with concomitant partial rotator cuff repair. [Orthopedics. 2017; 40(4):e735-e738.].

Surgical technique description : Transosseous 'over the top' reconstruction of capsule and tendons in primary total hip arthroplasty using a posterior approach

Dislocation after total hip arthroplasty (THA) remains a devastating complication and a primary cause for revision arthroplasty. Historical data indicate that a posterior approach is associated with a higher dislocation rate. In this study, we present a highly reliable and anatomical reconstruction, based on the biomechanical findings of a previous cadaveric experiment. The posterior soft tissues were repaired in 2 layers. First a reattachment of the posterior orbicular ligament is performed at the anterior capsule. Subsequently a transosseous 'over the top' reinsertion of both capsule and tendons is performed close to there anatomical insertion. We prospectively collected data of 408 THAs from January 2004 until December 2013, through a posterior approach and with a capsule and tendon reconstruction based on a previous cadaveric study. There was a low early dislocation rate in primary THA (one of 408 THAs, 0,2%) and no complications related to the technique. This anatomical reconstruction of both capsule and tendons is associated with a low dislocation rate without complications at the level of the greater trochanter.

Partial Denervation and Anterior Release of the Hip Joint Capsule to Relieve Pain and Improve Function at Five Years Follow-up

Traditionally, patients with significant hip pain due to degenerative hip disease, who are not surgical candidates for a total hip arthroplasty (THA), or are wary of the procedure, have been managed with various modalities with variable effectiveness.

OBJECTIVES

We have recently developed an anterior release of the contracted hip capsule along with par- tial denervation ofthe hip joint performed on an out- patient basis to relieve pain and improve function.

STUDY DESIGN

A case series of 24 patients.

METHODS

From November 2007 to April 2009, 24 partial,denervation procedures through an anterior approach were performed by a single surgeon. A clinical survey was conducted five years following the intervention.

RESULTS

Eighteen ofthe 24 patients were alive at the time of follow-up. Four of the six patients who were deceased at the time of follow-up had not undergone aTHA while two had. Fifteen ofthe 18 patients who were still living received a THA while three did not. Ihe interval time to arthroplasty was 19 months.

Severe Contracture of the Proximal Interphalangeal Joint in Dupuytren’s Disease: Does Capsuloligamentous Release Improve Outcome?

This prospective study assessed whether patients with severe proximal interphalangeal joint contracture (≥60°) due to Dupuytren’s disease which persisted after fasciectomy alone benefited from an additional capsuloligamentous release. Forty-three patients with 43 severely contracted proximal interphalangeal joints underwent operative correction followed by a standardized postoperative rehabilitation programme. All were followed for 6 months. In 11 patients correction of the proximal interphalangeal joint to 20° could not be achieved by fasciectomy alone, and an additional capsuloligamentous release was performed which effectively corrected all their residual flexion contractures. There were no statistically significant differences between the capsulotomy and the non-capsulotomy group with respect to the residual proximal interphalangeal joint contracture at the end of surgery, or at their last follow-up examination.

Middle Term Results of Simple Open Hip Reduction of Irreducible DDH - What Is the Cut-off Age to Safely Perform It with Lower Complications?

PURPOSE OF THE STUDY When developmental dysplasia of the hip (DDH) is irreducible by conservative means, then surgical open hip reduction is the choice. When done before walking age simple open hip reduction (SOHR) is most often enough to stabilize the hip. We tested the hypothesis that simple open hip reduction gives enough stability even in severe Tönnis 4 grades of dislocation. We tried to find what is the cut-off age to safely perform SOHR with lower complications. MATERIAL AND METHODS From 193 open hip reductions (OHR) of irreducible DDH in 123 children for the period 1995-2010 year with X-ray follow up of at least 8 years and full documentation we investigated 75 SOHR. Mean age at follow-up was 13 years and 5 months for the whole group and 8 years and 3 months for the SOHR patients. Age at operation - 7 months to 7.5 years for all patients with OHR, with average OR age for SOHR - 18 months. The traditional surgical technique of open hip reduction was performed through lateral Murphy's approach but with sparing the attachment of the piriformis muscle with the underlying blood supply to the epiphysis during circumferential capsulotomy. We used McKay clinical criteria, radiological classifications of Tönnis, Severin, Herring-Mose and Kalamchi & MacEwen. RESULTS When analyzing the results, there came up a strong statistical correlation between bilaterality and Tönnis grade 4. The final CE angle of Wiberg was on average 28º. According to Severin classification: 74% were excellent and 10% good or 84 % successful results. But according to Herring-Mose sphericity scoring - 60% were good and 30% fair. Mose's fair is a potential cam-type femoro-acetabular impingement (FAI). Clinically according to McKay criteria - 10% excellent and 54% good, or 64% of the operated hips were clinically acceptable, which correlates more with the radiological results according to Mose than with Severin. Avascular necrosis (AVN) of the femoral head (FH) according to Kalamchi was: Type I - 6%, Type II - 12 %, Type III - 0%, Type IV - 8 %. Types II and IV represent 20 % of the operated hips. The presence of ossific nucleus in the femoral epiphysis on initial X-ray didn't have a statistical impact on AVN frequency. When analyzing the impact of severity of dislocation and trying to find the cut-off age for fewer complications, there came up a strong statistical significance between AVN IV type appearance in Tonnis grade 4 hips when age at operation was above 9 months. CONCLUSIONS The thorough capsuloplasty after FH reduction in the acetabular socket is enough for stability even in Tonnis 4. When OR age is below 9 months severe AVN is lower and Herring-Mose FH sphericity scoring is higher. Key words: DDH, simple open hip reduction, avascular necrosis of femoral head.

Current Techniques in Treating Femoroacetabular Impingement: Capsular Repair and Plication

Management of the hip capsule has evolved with increased awareness that capsular closure during hip arthroscopy restores the normal anatomy of the ilio-femoral ligament and therefore restores the biomechanical characteristics of the hip joint. Both anatomical and clinical studies have found that capsular closure or plication after hip arthroscopy restores normal motion and allows patients to return to activity more quickly. Capsular closure is technically challenging and increases operative time, but gross instability and microinstability can be avoided with meticulous closure/plication. In this article, we describe capsular closure of a T-capsulotomy and an extensile interportal capsulotomy.

Poorer Arthroscopic Outcomes of Mild Dysplasia With Cam Femoroacetabular Impingement Versus Mixed Femoroacetabular Impingement in Absence of Capsular Repair

PURPOSE

To compare outcomes of mild dysplasia with cam femoroacetabular impingement (FAI) vs mixed FAI with hip arthroscopy without capsular repair.

METHODS

A retrospective review of a 2009 to 2010 multicenter prospective outcome study was performed comparing a cohort with mild dysplasia and cam femoroacetabular impingement (cohort D) to a cohort with mixed FAI (cohort M). Outcome measures included Nonarthritic Hip Score (NAHS) and satisfaction with minimum 2-year follow-up.

RESULTS

Of 150 patients/159 hips enrolled in the initial prospective outcome study, 10 patients/10 hips had acetabular dysplasia and 8 patients met the inclusion criteria. Cohort D had 8 patients (5 female) of mean age 49.6 years with mean lateral center-edge angle (LCEA) of 19° (range, 16°-24°) demonstrating a mean change in NAHS of +20.00 at 3 months (P = .25), +14.33 at 12 months (P = .03), and -0.75 at 24 months (P = .74). Mean satisfaction was 2.88 out of 5. Cohort M had 69 patients (32 female) of mean age 38.6 years with a mean LCEA of 33° (range, 25°-38°) demonstrating a mean change in NAHS of +12.09 at 3 months (P < .0001), +20.39 at 12 months (P < .0001), and +21.99 at 24 months (P < .0001). Mean satisfaction was 3.58 out of 5. Cohort D demonstrated significantly less improvement in NAHS (P = .002) and a difference of -31.06 points compared to cohort M at minimum 2-year follow-up. Dysplasia was the only statistically significant predictor of poorer outcomes.

CONCLUSION

The common combination of mild dysplasia and cam FAI has poorer outcomes than mixed FAI following arthroscopic surgery without capsular repair.

[Analysis of anterolateral approach and lateral approach for the treatment of coronal shear fracture of the distal humeral]

OBJECTIVE

To treat the coronal shear fracture of the distal humeral during open reduction and internal fixation by anterolateral approach and lateral approach, and to analyze the advantage and disadvantage of each approach.

METHODS

From September 2006 to July 2014, 10 patients with coronal fracture of the distal humeral were analyzed, who were all treated with Open Reduction and Internal Fixation (ORIF), 5 with anterolateral approach (group A) and 5 with lateral approach (group B). For the anterior-lateral approach, the radial nerve and brachioradialis were retracted laterally and the brachialis was retracted medially, the capsule was incised and the fracture line was exposed, usually the capitellum and the lateral part of the trochlear could be exposed clearly but the exposure was limited. For the lateral approach, the brachioradialis was retracted anteriorly, the lateral collateral ligament (LCL) was protected or released from the starting point on the lateral condyle of the humeral, the elbow could be dislocated and the capitellum and part of the trochlear could be exposed. The fractures were classified with the system of Dubberley, the complications were analyzed and the ultimate results were evaluated according to the Mayo elbow performance index (MEPI).

RESULTS

For group A, 4 re-operations were performed, 2 for the irritation of the screws,1 for stiff elbow and 1 for failure of the internal fixation. One radial nerve injury happened but recovered later. The mean MEPI was 82 points. For group B, 1 failure of the internal fixation and instability of the elbow happened. The revision operation was performed for this patient. The mean MEPI was 91 points.

CONCLUSION

Lateral approach is better,it gives more exposure for the joint and the radial nerve is safe, but the trochlear is difficult to be exposed, and the LCL must be protected or repaired during the operation. Anterolateral approach can be used to expose the capitellum and the radial side of the trochlear, but the radial nerve is dangerous and more complications may happen.

The Sauve–Kapandji Procedure and the Darrach Procedure for Distal Radio–Ulnar Joint Dysfunction after Colles’ Fracture

This retrospective study evaluated the results of the Darrach procedure and the Sauve–Kapandji procedure for the treatment of distal radio–ulnar joint derangement following malunion of dorsally displaced, unstable, intraarticular fractures of the distal radius in patients under 50 years of age. Twelve of 18 possible patients in the Sauve–Kapandji group completed the disabilities of the arm, shoulder, and hand survey at a mean of 4 years postoperatively and nine of the 18 returned for a follow-up examination at a mean of 2 years. Twenty-one of 30 possible patients in the Darrach group completed the disabilities of the arm, shoulder, and hand survey at a mean of 6 years postoperatively and 13 of these 30 returned for follow-up examination at a mean of 4 years. The Darrach procedure and the Sauve–Kapandji procedure yielded comparable and unpredictable results with respect to both subjective and objective parameters.

Inter-Carpal Soft Tissue Entrapment. A Possible Explanation for Chronic Dorsal Wrist Pain

This retrospective study evaluates the surgical treatment of a group of patients with unknown chronic dorsal wrist pain. The cause of their symptoms was interpreted as a painful entrapment of fibrous tissue in the radio-carpal and inter-carpal joints during specific movements. Between 1997 and 2001, 30 patients were treated by surgical excision of this tissue and 26 patients were traced for follow-up. Twenty-three patients were symptom free, or experienced major benefit from surgery. Wrist function measurements using the VAS scale showed improvement in 24 patients. Microscopic examination of the removed specimen shows fibrous tissue with non-specific changes. Inter-carpal soft tissue entrapment can explain the typical clinical findings in some patients with unknown chronic dorsal wrist pain. After careful selection, surgical excision of all entrapped tissue in the radio-carpal and mid-carpal joint may give relief of pain and improvement of wrist function.

The Arthroscopic Superior Capsular Reconstruction

In a subset of patients with rotator cuff tears, the glenohumeral joint has minimal degenerative changes and the rotator cuff tendon is either irreparable or very poor quality and unlikely to heal. Reverse shoulder arthroplasty (RSA) is often considered for these patients despite the lack of glenohumeral arthritis. However, due to the permanent destruction of the glenohumeral articular surfaces, complication rates, and concerns about implant longevity with RSA, we believe the superior capsular reconstruction (SCR) is a viable alternative. In this article, we describe our technique for the SCR.

Articular capsule repair in initial artificial hip replacement via anterolateral approach to the hip joint

This study was carried out to explore articular capsule repair in first artificial hip replacement (AHR) via anterolateral approach and its influence on postoperative dislocation. A total of 292 patients who received AHR via anterolateral approach and had the articular capsule repaired in People’s Hospital of Zhengzhou (Henan, China) from February 2008 to February 2014 were selected and divided into total hip replacement (THR) group (group A1) and artificial femoral head replacement (AFHR) group (group A2). Five hundred and five cases in the control group treated using the same approach but receiving no articular capsule repair were divided into THR group (group B1) and AFHR group (group B2). Condition of postoperative dislocation was compared between the two groups. All cases were followed up for 6 months to 5 years (average: 3.75 years); it was noted that the difference in average age, gender, disease constitution and follow-up time in the two groups was not significant (P>0.05). Moreover, groups A1 and B1 were found with 1 case of early hip joint dislocation (0.73%) and 13 cases of hip joint dislocation (5.24%) respectively post-operatively, and the comparison between the two groups was statistically significant (P less than 0.05). One case of hip joint dislocation (0.65%) was found in group A2 and 5 cases (1.95%) in group B2 in early post operation and the difference between two groups had no statistical significance (P>0.05). Neither the repair group nor the control group developed late-onset dislocation after the operation. Thus, we can state that articular capsule repair is feasible during the first AHR via anterolateral approach, which decreases the occurrence of early hip joint dislocation after operation and proves that repairing articular capsule during AFHR via anterolateral approach is unnecessary.

Arthroscopic Bankart repair: Have we finally reached a gold standard?

Traditionally, surgical stabilization of the unstable shoulder has been performed through an open incision. Arthroscopic Bankart repair with suture anchors is now widely considered the treatment of choice for anterior shoulder instability in patients who have failed conservative management. Many different factors have now been elucidated for adequate treatment of glenohumeral instability. Because of technical advances in instability repair combined with an increased understanding of factors that lead to recurrent instability, the outcomes following arthroscopic Bankart repair have significantly improved and approach those of open techniques.

Multidirectional Instability of the Shoulder: A Systematic Review

PURPOSE

To analyze outcomes of surgical and conservative treatment options for multidirectional instability (MDI).

METHODS

A systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. A comprehensive search of the PubMed, MEDLINE, CINAHL, Cochrane, EMBASE, and Google Scholar databases using various combinations of the keywords "shoulder," "multidirectional instability," "dislocation," "inferior instability," "capsulorrhaphy," "capsular plication," "capsular shift," "glenoid," "humeral head," "surgery," and "glenohumeral," over the years 1966 to 2014 was performed.

RESULTS

Twenty-four articles describing patients with open capsular shift, arthroscopic treatment, and conservative or combined management in the setting of atraumatic MDI of the shoulder were included. A total of 861 shoulders in 790 patients was included. The median age was 24.3 years, ranging from 9 to 56 years. The dominant side was involved in 269 (58%) of 468 shoulders, whereas the nondominant side was involved in 199 (42%) shoulders. Patients were assessed at a median follow-up period of 4.2 years (ranging from 9 months to 16 years). Fifty-two of 253 (21%) patients undergoing physiotherapy required surgical intervention for MDI management, whereas the overall occurrence of redislocation was seen in 61 of 608 (10%) shoulders undergoing surgical procedures. The redislocation event occurred in 17 of 226 (7.5%) shoulders with open capsular shift management, in 21 of 268 (7.8%) shoulders with arthroscopic plication management, in 12 of 49 (24.5%) shoulders undergoing arthroscopic thermal shrinkage, and in 11 of 55 (22%) shoulders undergoing arthroscopic laser-assisted capsulorrhaphy.

CONCLUSIONS

Arthroscopic capsular plication and open capsular shift are the best surgical procedures for treatment of MDI after failure of rehabilitative management. Arthroscopic capsular plication shows results comparable to open capsular shift.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I to IV studies.

Midterm Outcome of Bone-Ligament-Bone Graft and Dorsal Capsulodesis for Chronic Scapholunate Instability

PURPOSE

To assess midterm outcomes of our bone-ligament-bone (BLB) grafts for chronic scapholunate (SL) instability and better define criteria for their use.

METHODS

We conducted a retrospective review of 26 patients treated with BLB grafts and dorsal capsulodesis between 1997 and 2009. Twenty-four patients were reviewed. Mean follow-up was 8.2 years. Two patients had dynamic lesions, 7 had SL dissociation, 14 had a dorsal intercalated segment instability lesion, and 1 had SL advanced collapse stage 1. Mean age at surgery was 46 years. All patients presented with pain and 14 had lack of strength. Results were reviewed clinically and radiologically. Images were assessed by 4 surgeons and 1 radiologist for radial styloid, radioscaphoid, radiolunate, midcarpal, and scaphotrapeziotrapezoid degenerative changes.

RESULTS

Five patients needed subsequent 4-corner arthrodesis. Of the remaining 19 patients at follow-up, both extension and flexion decreased to 73% of the contralateral side. Postoperative grip strength improved from 78% to 90% of the nonsurgical wrist. Quick Disabilities of the Arm, Shoulder, and Hand score was 10 of 100 and the Patient-Rated Wrist Evaluation score was 10 of 100. Radiologically, the SL gap was improved and maintained at follow-up. The SL angle (mean before surgery, 79°) was initially corrected to 69° but returned to preoperative values at follow-up. Eleven of the 19 cases had signs of midcarpal arthritis.

CONCLUSIONS

Bone-ligament-bone grafts with SL dorsal capsulodesis were able to restore and maintain an improved SL interval in all patients. The technique achieved good clinical results and high patient satisfaction, but it did not stop the progression of arthritis, particularly at the midcarpal level. This technique is an option for isolated unrepairable lesion of the dorsal SL ligament with an easily correctable lunate and especially when restoration of grip strength is important.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Tissue preserving total hip arthroplasty using superior capsulotomy

OBJECTIVE

The goals of a tissue-preserving minimally invasive approach to the hip are to allow early short-term recovery, achieve hip joint stability, minimize muscle strength loss from surgery, spare the peri-articular soft tissues, and allow unrestricted motion in the long term.

INDICATIONS

Hip arthroplasty in patients with no pre-existing hardware, with a sufficient space between the acetabular rim and greater trochanter; management of subcapital femoral fractures in older patients.

CONTRAINDICATIONS

Protrusio acetabuli. Joint stiffness. This is the main concern when undertaking the superior capsulotomy. Stiffness may result from bone causes, including ankylosis, large osteophytes, bone bridges etc., extra-articular retraction of surrounding soft tissues with capsular contracture of both ligaments and muscles, or a combination of bony and soft tissues causes, resulting in limited adduction. Indeed, maximal adduction is necessary to increase the distance between the apex of the greater trochanter and the superior acetabular edge. In the approach described in the present article, the real limitation is the impossibility to introduce a straight stem through the trochanteric fossa without weakening the trochantericarea. If adduction is restricted, excessive lateralization of the femoral stem would result in postoperative pain and discomfort, especially as we advocate immediate full weight bearing. Even though patients fare better when the trochanteric area is intact, many types of stem such as the GTS (Biomet), or stem Microplasty (Biomet) or even stem Parva (Adler Ortho) may pressurize the internal bone of the trochanteric structures. Therefore, these stems may be implanted in maximal hip adduction. This is the case in coxa profunda or coxa vara, which require more invasive and destabilizing surgical approaches.

SURGICAL TECHNIQUE

Lateral position, 5-8 cm incision from the tip of the greater trochanter, identification and transaction of piriformis tendon. Anterior mobilization of the gluteus minimus and exposure of the trochanteric fossa. Removal of the superior portion (bone block) of the head and neck, and preparation of the femoral canal. Preparation of the acetabulum. Complete muscle relaxion is helpful to proceed to satisfactory trial reduction.

POSTOPERATIVE MANAGEMENT

Patients may progress to motion and weight bearing without restriction.

RESULTS

From April 2009 to December 2010, the first author operated on 463 patients, 275 for osteoarthrosis of the hip, and 188 for subcapital fractures of the femoral neck. Thereof, 375 (75 %) patients could walk with full weight within 6 h from the operation, and climb stairs 24 h later with low loss of blood, and rapid recovery.

Anterior hip capsuloligamentous reconstruction for recurrent instability after hip arthroscopy

A variety of complications, including iatrogenic anterior hip instability, have been reported after hip arthroscopy. We present a case of a patient sustaining a postoperative anterior hip dislocation after cam resection for treatment of femoroacetabular impingement. Our patient developed persistent instability and required anterior capsuloligamentous reconstruction with iliotibial autograft. We present a comprehensive review of the literature on postoperative hip instability after hip arthroscopy, including the role of capsulotomy closure, and use of postoperative orthotics and weight-bearing restrictions.

[Dorsal intercarpal ligament capsulodesis for chronic static scapholunate dissociation]

OBJECTIVE

To investigate the radiographic and clinical outcomes of dorsal intercarpal ligament capsulodesis (DILC) procedure for chronic static scapholunate dissociation.

METHODS

Between January 2008 and January 2011, 12 patients with chronic static scapholunate dissociation were treated with DILC. Of 12 cases, 10 were male and 2 were female with an average age of 42 years (range, 20-66 years). All injuries were caused by falling. The interval from injury to surgery was 3-19 months (mean, 8 months). Physical examination at admission showed wrist tenderness and limited range of motion (ROM). Radiological examination showed that scapholunate gap was greater than 3 mm on posteroanterior view, and scapholunate angle more than 60° on the lateral view. Before operation, the grip strength was (25.4 ± 8.2) kg; the wrist ROM was (56.7 ± 11.5)° in flexion and (52.0 ± 15.2)° in extension; visual analogue scale (VAS) score was 6.3 ± 1.4; and disabilities of arm, shoulder & hand (DASH) score was 39.5 ± 7.4. According to Garcia-Elias staging criteria, all cases were rated as stage 4, indicating that the scapholunate interosseous ligament was completely injured and reduction could easily be obtained. Eight patients had wrist instability.

RESULTS

Primary healing of incision was achieved, no complication was found. All patients were followed up 13-34 months (mean, 15.9 months). During surgery, all deformities were corrected completely, but 7 patients (58%) recurred at 1 month after Kirschner wire removal. Compared with preoperative ones, the scapholunate gap, scapholunate angle, radiolunate angle, lunocapitate angle, and wrist height ratio at 1 month after Kirschner wire removal and last follow-up showed no significant difference (P > 0.05); the wrist flexion and extension ROM were significantly decreaed to (46.8 ± 7.2)° and (42.0 ± 9.0)° at last follow-up (P < 0.05); the grip strength was significantly increased to (32.7 ± 9.6) kg at last follow-up (P < 0.05); VAS score and DASH score were improved to 1.7 ± 1.0 and 8.1 ± 8.7 (P < 0.05).

CONCLUSION

Carpal collapse will recur in short time after DILC. DILC is not the best way to treat chronic static scapholunate dissociation.

[Arthroscopic posterior shoulder stabilization with an iliac bone graft and capsular repair]

OBJECTIVE

Arthroscopic posterior shoulder stabilization with an iliac bone graft and capsulolabral repair, which should combine the pre-existing open procedure with the advantages of improved arthroscopic visualization.

INDICATIONS

Posterior instability with concomitant pathologies (e.g. capsular insufficiency, posterior Bankart lesion, posterior glenoid dysplasia) and recurrent posterior instability after failed soft tissue reconstruction.

CONTRAINDICATIONS

Instability osteoarthritis, locked posterior shoulder dislocation, large reverse Hill-Sachs lesion, extended posterior defect of the glenoid.

SURGICAL TECHNIQUE

After arthroscopic evaluation of the shoulder joint and treatment of concomitant pathologies, a tricortical bone graft is harvested from the iliac crest. The posterior capsule is arthroscopically detached from the labrum and the posterior deltoid and rotator cuff are split in line of the muscle fibers. Then the bone graft is positioned and fixed to the posterior scapular neck as an extension of the articular glenoid surface. Thereafter, capsular reconstruction is performed after insertion of suture anchors in the posterior glenoid rim.

POSTOPERATIVE MANAGEMENT

During the first 6 weeks 60° of abduction and flexion are permitted without any rotation and full range of motion is developed gradually. Internal rotation is allowed after 8 weeks and return to sports after 12 weeks.

RESULTS

For posterior shoulder instability 13 of these operations were performed in our hospital since 2011. Until now, no recurrent instability was observed. After remodelling of the graft, one patient complained about posterior soft tissue irritation so the screws were removed.

Surgical treatment of posterolateral rotatory instability of the elbow

PURPOSE

The purpose of this systematic review was to critically examine the outcomes of lateral ulnar collateral ligament reconstruction for posterolateral rotatory instability (PLRI) of the elbow.

METHODS

A systematic review of the literature was performed. Two reviewers assessed and confirmed the methodologic and patient data from the included studies. Frequency-weighted means were calculated for outcomes that were present in multiple studies.

RESULTS

Eight studies fulfilled our criteria, and they included 130 patients. The mean age was 38.1 years, and the mean follow-up period was 44.5 months. Traumatic dislocation was the most common cause of PLRI. Of the studies that reported the Mayo Elbow Performance Score, 91% of patients had good or excellent results, with a frequency-weighted mean of 91. Improvement in elbow range of motion was noted (133° to 138° of flexion [P < .0001] and 6.6° to 3.9° of extension [P = .005]). A complication rate of 11% was noted, with recurrent instability noted to occur in 8% of patients.

CONCLUSIONS

PLRI of the elbow remains to be fully understood. Treatment strategies vary and should be performed based on surgeon experience and evidence available. Most patients will have good or excellent results after surgery; however, up to 11% of patients may have complications.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II through IV studies.

[Glomus tumor of volar elbow capsule. Case report]

Glomus tumors are rare tumors, benign but painful and responsible for a major functional impairment. Although their preferential localization is digital, 35% of glomus tumors are extradigital. Ignorance of this disease characterized by atypical clinical signs and the absence of specific imaging are responsible for a significant diagnostic delay, 7 to 10 years in extradigital forms. Treatment by surgical excision simply ensures immediate disappearance of pain without recurrence in 90% of cases. It is therefore necessary to emphasize the existence of this sometimes debilitating condition benefiting from effective therapeutic solution. We report the case of a glomus tumor of the anterior capsule of the left elbow in a 24-year-old woman with a diagnostic delayed by 12 years.