Posterior Deltoid Function After Transfer of Branch to the Long Head Triceps Brachii of the Radial Nerve to the Anterior Branch of the Axillary Nerve

PURPOSE

The aim of this study was to evaluate the function of the posterior part of the deltoid after nerve transfer of the long head triceps branch of the radial nerve to the anterior branch of the axillary nerve in patients with an upper brachial plexus injury or isolated axillary nerve injury.

METHODS

We retrospectively reviewed 26 patients diagnosed with an upper brachial plexus injury or isolated axillary nerve injury who underwent nerve transfer of the long head triceps muscle branch of the radial nerve to the anterior branch of the axillary nerve in our institute between 2012 and 2017. Data on age, sex, the mechanism of injury, the pattern of injury, and operative treatment were collected from medical records. Preoperative and postoperative clinical examinations, including motor powers of shoulder abduction and extension according to Medical Research Council grading, were evaluated. At a minimum of 2 years after the operation, we evaluated the recovery of the posterior deltoid function using the swallow-tail test.

RESULTS

Twenty-two patients (84.6%) had recovery of posterior deltoid function confirmed by the swallow-tail test. There were 23 patients (88.5%) who achieved at least Medical Research Council grade 4 of shoulder abduction.

CONCLUSIONS

Nerve transfer from the branch to the long head triceps to the anterior branch of the axillary nerve is an effective technique for restoring deltoid function in an upper brachial plexus injury or isolated axillary nerve injury. This technique can provide shoulder abduction and shoulder extension, which are the functions of the posterior deltoid muscle.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

What is the failure rate of constrained liners in complex revision total hip arthroplasty?

BACKGROUND

Recurrent hip dislocation after multiple revision total hip arthroplasty is a severe complication. Therefore, constrained acetabular liners (CL) have been used during salvage procedures. We report our experience of constrained liners in a re-revision setting with focus on re-dislocation. We also evaluated acetabular and femoral bone loss as potential risk factor.

METHODS

Between January 2013 and December 2016, 65 patients were treated in a single institution for revision and re-revision hip arthroplasty using CL. The indication for using a CL was a high risk of re-redislocation after multiple recurrent hip dislocation including failed Dual Mobility Cups (DMC). Compromising soft tissue defects as well as severe bone defect were therefore regarded as high risks. Thirty-eight patients (77.6%) underwent a minimum of three surgical procedures before the index revision procedure. Sixteen patients (24.6%) were excluded as they were lost to follow-up, expired before minimum follow-up or refused study participation, leaving 49 patients in the analysis (75.4%). The mean follow-up was 62 months (44-74; SD = 7.7). We assessed the following potential risk factors for revision or dislocation: type of surgical setting (septic/aseptic), BMI, cup inclination angle, size of liner used and acetabular and femoral bone loss according to Paprosky classification. The primary endpoints were dislocation or repeat revision for any reason.

RESULTS

Of the 49 patients, we found an overall re-revision rate of 40.8% (20/49) and a dislocation rate of 30.6% (15/49). There were no significant differences among the surgical re-revision rate or dislocation rate as a factor of patient characteristics. In terms of bone loss, there was a trend towards higher revision rates for increasing acetabular and femoral bone loss, but without statistical significance.

CONCLUSIONS

We found the use of a constrained liner in a re-revision setting still bears a high risk of re-revision and re-dislocation. Therefore we restrained from using constrained liners in favour of Dual mobility cups. In this study there was no significant higher dislocation rate in the subgroup of periprosthetic infection. Furthermore the rigid design of a constrained liner bears the known risk of structural failure of acetabular reconstruction implants. Severe acetabular or femoral bone defects seem to have an impact on the revision rate, but not on the dislocation rate with regards to the restored offset and center of the hip. Results have to be taken into context such that the study population inherently has a predisposition for poorer outcomes. Indications should be strongly filtered for patients at high risk for recurrent hip joint dislocation including failed DMCs with only limited bone loss and moderate soft tissue defects. Our modification to the existing classification with a high inter and intraobserver reliability will make future studies more comparable regarding revisions and bone stock loss. Still further research using objective and reproducible parameters is needed to better analyze data especially in the background of complex revision hip arthroplasty.

Comparing clinical outcomes between extended curettage and wide resection in Enneking stage 3 giant cell tumor of bone

PURPOSE

Our objectives were (1) to compare the recurrence, metastases, and complication rates of patients with Enneking stage 3 GCTB who underwent extended curettage vs wide resection and (2) examine the factors which might influence surgical options for each patient.

METHODS

We retrospectively reviewed the records of patients with Enneking stage 3 GCTB from January 2006-December 2015. Extended curettage was performed in patients in whom there was a moderate expansile lesion, minimal/no articular cartilage damage, and less than 50% of cortical deformation compared to its circumference from a CT scan/MRI. The percentages of cortical deformation were collected. Surgical complications, recurrence, and metastatic rates were analyzed.

RESULTS

There were 28 extended curettage and 41 wide resections. The mean percentages of cortical deformation compared to circumference were 52.6% (range, 23.9-81.9%) and 91.6% (range, 52.1-100%)(P < 0.01) for the curettage and wide resection groups, respectively. There were three recurrences, 2/28 (7.1%) from the curettage group and 1/41 (2.4%) from the resection group (P = 0.56). There were no cases of pulmonary metastasis. There were two complications in the curettage group and five complications in the resection group.

CONCLUSION

Both extended curettage and wide resection are useful methods to treat Enneking stage 3 GCTB. Extended curettage with proper technique is a viable option showing no difference in local recurrence rate and potentially fewer complications. Preference to do extended curettage in patients in whom when the articular cartilage has minimal or no destruction, a moderate expansile lesion and the cortical deformation is less than 50% of the circumference.

Twenty-year results of a neck-preserving short-stem prosthesis in primary total hip arthroplasty

PURPOSE

The use of short-stemmed femoral components with preservation of the femoral neck has been advocated for younger and more active patients undergoing joint replacement. This study reports the long-term outcomes of the Collum Femoris-Preserving (CFP) prosthesis on a previous report.

METHODS

Between January 1999 and December 2000, a total of 149 patients underwent total hip arthroplasty procedure using the CFP stem in a single institution. At latest follow-up, 79 patients were available and were included in this study. The mean age of the cohort was 73.4 (range, 44-92 years) with a mean follow-up of 20.7 years (range 20-21). The average age was 52.1 years at index procedure (range, 21-71 years).

RESULTS

The Kaplan-Meier survivorship free from revision for any cause at 5, 10 and 20 years was 93.2% (87.8-96.3%), 93.2% (87.8-96.3%) and 83.0% (75.7-88.3%), respectively. At 20 years follow-up, the revision for any cause occurred in 26.6% (21 of 79) of patients. The most common causes for revision surgery were aseptic loosening, dislocation, and polyethylene wear with 6.3% (5 out of 79), respectively. Periprosthetic fracture occurred in four patients (5.1%) followed by periprosthetic joint infection in two patients (2.5%). Revision surgery of the femoral stem was required in four patients (5.1%). There was a statistically significant improvement of the Harris Hip Scores from 53 to 83.7 (range 56-91).

CONCLUSION

The long-term outcomes of the CFP stem are excellent, demonstrating a low rate of aseptic loosening with an excellent survivorship within 2 decades.

Does Local Zoledronate Applied to Pasteurized Bone Autografts Improve the Likelihood of Union of Graft-Host Junctions after Limb-sparing Surgery?

BACKGROUND

Pasteurized bone autograft is a recycling biological reconstruction method for limb-sparing surgery when an allograft or other reconstruction technique is unavailable. Since the application of a local bisphosphonate to morselized allografts can reduce graft resorption and enhance bone formation without systemic complications, adding the local bisphosphonate to pasteurized bone autografts should reduce the graft resorption and improve the graft incorporation to host bone. However, no study that we know of has described the outcomes of local bisphosphonate application to massive allografts or pasteurized bone autografts. Thus, this study compared the outcomes of pasteurized bone autografts with and without local zoledronate.

QUESTIONS/PURPOSES

(1) What is the survival of pasteurized bone autografts and what complications lead to graft removal? (2) Does treatment of pasteurized bone autografts with zoledronate alter the survival of pasteurized bone autografts compared with grafts without treatment? (3) Does the local application of zoledronate reduce the proportion of patients with fractures because of metaphyseal graft resorption? (4) Does local application of zoledronate improve union at the graft-host bone junction compared with untreated grafts?

METHODS

Between July 2011 and December 2019, we performed 538 musculoskeletal bone tumor resections. Of these, 101 patients underwent reconstruction with pasteurized bone autografts. Other reconstructions included tumor prostheses (150 patients), allografts (70 patients), reconstruction using a bone cement-plate construct (62 patients), and resection only (155 patients). We generally used pasteurized bone autograft when tumors showed an osteoblastic pattern, had less than one-third cortical destruction, and less than half of metaphyseal bone destruction. Six percent (6 of 101) were lost to follow-up, 6% (6 of 101) had incomplete clinical data, and 16% (16 of 101) had a follow-up period less than 2 years without an event, leaving 73 patients for evaluation. The median (interquartile range) age of the patients was 18 years (15 to 26). Ninety-seven percent (71 of 73) had a diagnosis of bone sarcoma. The median follow-up time was 46 months (33 to 75). From 2011 to 2014, 21 pasteurized bone autografts were prepared without local zoledronate, and from 2014 to 2019, 52 pasteurized bone autografts were prepared with local zoledronate because we thought it might improve union and reduce resorption of the graft. From our tumor registry database, we obtained age, sex, use of chemotherapy, graft length and location, pasteurized bone graft type, fixation methods, the use of local zoledronate, osteotomy gap, complications, proportion of grafts that united by 2 years, and local recurrences. Curves for graft survival were determined using the Kaplan-Meier method with the endpoint of autograft removal and metaphyseal fracture from graft resorption. The probabilities of graft removal were estimated by cumulative incidences using the competing risk analysis, where death was considered as the competing event. Intergroup differences in survival and multivariable analyses were performed using the log-rank test and a Cox regression analysis. A logistic regression model was used to evaluate the association between graft-host osseous union by 2 years and other baseline factors. Union was defined when a callus was seen to bridge the osteotomy line for at least three cortices in both the AP and mediolateral planes.

RESULTS

The 5-year survival rate of all 73 pasteurized grafts was 85% (95% confidence interval 74% to 92%). With the numbers available, we found no difference in the 5-year survival rates between grafts with and without local zoledronate (90% [95% CI 78% to 96%] versus 74% [95% CI 48% to 89%]; p = 0.30). Eleven percent (8 of 73) of patients had metaphyseal fractures because of graft resorption, primarily associated with osteoarticular grafts (5-year fracture-free survival 56% [95% CI 20 to 80]) rather than pasteurized graft-prosthesis composites (94% [95% CI 78% to 98%]) and intercalary grafts (91% [95% CI 50 to 99]; p = 0.001); there was no association with the use of local zoledronate (13%; 7 of 52) compared with those without local zoledronate (5%; 1 of 21) (odds ratio 3.1 [95% CI 0.4 to 27]; p = 0.43). Of the 84 graft-host bone junctions, 85% (71) of the grafts unified within 2 years, 7% (6) unified after 2 years, and 8% (7) of grafts showed nonunion. Union within 2 years was associated with fixation using plate compared with those with stem and with both stem and plate (odds ratio 6.6 [95% CI 1.4 to 31]; p = 0.02) and grafts treated with local zoledronate compared with those without treatment (OR 5.9 [95% CI 1.3 to 28]; p = 0.02).

CONCLUSION

The application of local zoledronate to pasteurized bone autografts for limb-sparing surgery improved the likelihood of graft union compared with untreated grafts, especially when the osteotomy junctions were fixed using plate osteosynthesis, but it did not appear to alter the proportion of patients who experience metaphyseal fracture of the grafts because of graft resorption. Although this is a small study, it suggests that the treatment of pasteurized bone autografts and perhaps bone allografts should be studied further to determine whether bisphosphonates or other adjuncts can improve the union time and return to function in patients undergoing bone tumor resections using these reconstruction types.

LEVEL OF EVIDENCE

Level III, therapeutic study.