Modified cerclage and suture mesh fixation for comminuted patellar fracture – “Cobweb Technique”: A case report

Displaced comminuted patellar fractures necessitate surgical treatment to restore the function of the extensor mechanism of the knee. One of the main challenges in the fixation of comminuted fracture of the patella is achieving an anatomic articular reduction with a stable fixation to allow early mobilization and prevent knee stiffness. Various common surgical fixation methods necessitate the use of metallic implants. Due to its superficial location, hardware-related complications and re-operations are common after patellar fixation.We present a case of a comminuted patellar fracture fixed using a modified cerclage and suture mesh fixation technique using high-strength braided nonabsorbable sutures. This provided a rigid fixation that allowed early range of motion while avoiding the risk of having symptomatic hardware

Surgical management of periprosthetic scapular spine and acromion fractures

Periprosthetic fractures of the acromion and scapular spine have been reported increasingly as an early complication of reverse shoulder arthroplasty (RSA). The mechanics of RSA, which involves medializing the center of rotation and lengthening the moment arm for the deltoid muscle, increases the load on the acromion and subsequently the risk for postoperative fatigue fractures. The modification of the original Grammont design with a more lateralized construct seems to increase the incidence of this complication. Other authors have associated this with the superior or posterior screw of the glenoid baseplate inserted toward the scapular spine, impingement of the greater tuberosity on the acromion on abduction, or history of traumatic fall. Most of the fractures occur during the first postoperative year. Patients with acromial or scapular spine fracture typically have unremarkable postoperative course with good pain control and improved range of motion and then would suddenly experience severe pain over the shoulder with inability to actively elevate the arm. These fractures may often be missed in a plan radiograph; hence, CT scan is recommended if there is a high index of suspicion. SPECT-CT may also be done if CT scan is still inconclusive. Three types of acromial/scapular spine fractures are described, wherein Type 1 is a fracture of mid acromion, Type 2 is a fracture of the posterior part of the acromion, and Type 3 is a fracture of the scapular spine. Type 2 is further divided into type 2a (posterolateral acromion) and 2b (acromial base). Type 3 is also divided into type 3a (scapular spine fracture) and type 3b (sagittal transscapular fracture). Management is usually based on this classification. Type 1 and 2 fractures are typically treated conservatively with immobilization for at least 6 weeks. Operative treatment may be indicated for those with failed conservative management and with symptomatic delayed unions or nonunions. On the other hand, type 3 fractures favor primary operative treatment. Double-plate osteosynthesis in combination with structural bone graft is the recommended technique of fixation for these fractures. Despite these recommendations, there is still no concensus regarding the treatment of acromial and scapular spine fractures and further studies are still needed to define the best treatment for these fractures.</p

The clinical course and outcomes following arthroscopic frozen shoulder 360 degree release

Background: Frozen shoulder (FS) is a debilitating inflammatory condition affecting the shoulder capsule that causes significant pain and stiffness. Its etiology, pathophysiology, and treatment remain poorly understood. Although regarded as self-limiting, FS can have profound implications on the activities of daily living and usually takes 1-4 years to resolve on its own accord. In recalcitrant or severe cases where active range of motion (AROM) is extensively restricted, an arthroscopic 360° release may be performed. The aim of this study is to evaluate the clinical outcomes following the FS 360° arthroscopic release. Methods: An observational prospective cohort study was conducted assessing patient-reported outcome measures (PROMs) in patients who underwent the 360° arthroscopic release between July 2013 and January 2019. Various questionnaires were used to evaluate their shoulder preoperatively and at 2 weeks, 6 weeks, 3 months, 6 months, 12 months, and 24 months postoperatively. Relevant PROMs included the Oxford Shoulder Score; Western Ontario Shoulder Instability Index; Disabilities of the Arm, Shoulder, and Hand; Constant-Murley Score; American Shoulder and Elbow Surgeons score; and general measures of pain intensity (visual analog scale) and well-being (EQ-5D-3L). AROM movements included forward flexion, abduction, external rotation, internal rotation, as well as external and internal rotation at 90° of abduction. Results: Fifty consented patients underwent the arthroscopic FS 360° release. The mean age was 52.1 ± 7.7 years (range 35-72), and mean body mass index was 27.1 ± 4.7 kg/m2 (range 19.5-37.5). All PROMs, AROM movements, patient satisfaction, and EQ-5D-3L scores improved significantly between preoperative and 24-month time points (P .05). No complications or reoperations were reported. Conclusion: The arthroscopic 360° release is an effective and safe treatment modality for severe or recalcitrant FS. Statistically and clinically significant improvements in AROM and PROMs (Oxford Shoulder Score; Western Ontario Shoulder Instability Index; Disabilities of the Arm, Shoulder, and Hand; Constant-Murley Score; and American Shoulder and Elbow Surgeons score) occurred shortly after the surgery and progressively improved from 2 weeks to 24 months postoperatively, with the operative shoulder achieving similar range of motion as the nonpathological contralateral shoulder at 24 months.</p

The Use of Glenoid Structural Allografts for Glenoid Bone Defects in Reverse Shoulder Arthroplasty

Background: The use of reverse shoulder arthroplasty as a primary and revision implant is increasing. Advances in implant design and preoperative surgical planning allow the management of complex glenoid defects. As the demand for treating severe bone loss increases, custom allograft composites are needed to match the premorbid anatomy. Baseplate composite structural allografts are used in patients with eccentric and centric defects to restore the glenoid joint line. Preserving bone stock is important in younger patients where a revision surgery is expected. The aim of this article is to present the assessment, planning, and indications of femoral head allografting for bony defects of the glenoid. Methods: The preoperative surgical planning and the surgical technique to execute the plan with a baseplate composite graft are detailed. The preliminary clinical and radiological results of 29 shoulders which have undergone this graft planning and surgical technique are discussed. Clinical outcomes included visual analogue score of pain (VAS), American Shoulder and Elbow Surgeons score (ASES), Constant–Murley score (CS), satisfaction before and after operation, and active range of motion. Radiological outcomes included graft healing and presence of osteolysis or loosening. Results: The use of composite grafts in this series has shown excellent clinical outcomes, with an overall graft complication rate in complex bone loss cases of 8%. Conclusion: Femoral head structural allografting is a valid and viable surgical option for glenoid bone defects in reverse shoulder arthroplasty

Single-stage vs. two-stage reconstruction of glenoid defects in revision shoulder arthroplasty

Glenoid pathologies are a common indication for shoulder arthroplasty revisions. In most revision cases, it is associated with rotator cuff defects or insufficiencies. Hence, only the reverse shoulder arthroplasty (RSA) can be considered as a revision implant. It is necessary to restore the three-dimensional (3D) glenoid anatomy and the glenoid joint line as physiologically as possible to achieve a stable fixation of the glenoid component, to avoid inferior glenoid notching, and to achieve an optimal biomechanical function of the residual rotator cuff and the deltoid muscles. The glenoid joint line "Zero Line" in the coronal plane is particularly important here. In addition, superior inclination or medialization must be avoided at all costs. In order to optimally address the individual glenoid pathologies in a differentiated manner, it is crucial to classify the defects. A basic distinction must be made between centric-contained and eccentric-uncontained defects. Combinations often occur. It is also essential to consider the defect's severity, depth, and 3D orientation. Therefore, CT analysis of the glenoid and associated planning is absolutely necessary preoperatively. However, metal artifacts of in situ prostheses may complicate preoperative 3D CT imaging and computer-assisted planning, which necessitate the use of special software to aid in these cases. The data obtained should serve as the basis for computer-assisted, software-guided planning to determine the position of the optimal anchorage of the central component of the glenoid baseplate and at least two additional locking peripheral screws that are absolutely necessary for primary stability. The type and shape of the revision implant, as well as the size and shape of the bone graft for the defect reconstruction, can also be planned in the same manner. For younger patients (<75 years) with good bone quality, we recommend defect reconstruction with autologous bone. In revision cases wherein the humeral head is not available, the use of structural iliac crest graft or allograft is recommended. The type of graft configuration and fixation, as well as the decision between a one- and two-stage procedure, depends on the type and severity of the defect. With technically correct preoperative planning, guiding intraoperative surgical reconstruction with the graft and proper component selection and implantation, sufficient integration of the bone graft, and durable fixation of the glenoid component can be expected with satisfactory clinical results.</p

Frozen Shoulder 360° Release

Arthroscopic capsular release has emerged as a safe and reliable method for treating severe frozen shoulder in patients with significant loss of range of motion. This article describes a reproducible technique for arthroscopic 360° release of the shoulder performed in the lateral decubitus position

Single-Stage Revision Reverse Shoulder Arthroplasty: Preoperative Planning, Surgical Technique, and Mixed Reality Execution

Revision shoulder arthroplasty is increasing with the number of primary shoulder replacements rising globally. Complex primary and revisions of shoulder arthroplasties pose specific challenges for the surgeon, which must be addressed preoperatively and intraoperatively. This article aimed to present strategies for the management of revision of shoulder arthroplasties through a single-stage approach. Preoperatively, patient factors, such as age, comorbidities, and bone quality, should be considered. The use of planning software can aid in accurately evaluating implants in situ and predict bony anatomy that will remain after explantation during the revision surgery. The planning from such software can then be executed with the help of mixed reality technology to allow accurate implant placement. Single-stage revision is performed in two steps (debridement as first step, implantation and reconstruction as the second step), guided by the following principles: adequate debridement while preserving key soft tissue attachments (i.e., rotator cuff, pectoralis major, latissimus dorsi, deltoid), restoration of glenoid joint line using bone grafting, restoration of humeral length, reconstruction and/or reattachment of soft tissues, and strict compliance with the postoperative antibiotic regimen. Preliminary results of single-stage revision shoulder arthroplasty show improvement in patient outcomes (mean 1 year), successful treatment of infection for those diagnosed with periprosthetic joint infection, and improved cost&ndash;benefit parameters for the healthcare system