Giuseffi, Steven A.

Short uncemented humeral stems can preserve humeral bone stock and facilitate revision surgery but may be prone to malalignment or loosening, especially when used in reverse total shoulder replacement (TSR). We undertook a retrospective review of 44 patients with a mean age of 76 years (59 to 92) who underwent primary reverse TSR with a short uncemented humeral stem. There were 29 females. The indications for joint replacement included cuff tear associated arthropathy (33), avascular necrosis (six), post-traumatic arthritis (two), and inflammatory arthritis (three). At a mean follow-up of 27 months (24 to 40), pain was rated as mild or none in 43 shoulders (97.7%). The mean active elevation improved from 54° (sd 20°) to 142° (sd 25°) and the mean active external rotation from 14° (sd 13°) to 45° (sd 9°). The outcome, as assessed by the modified Neer score, was excellent in 27 (61.3%), satisfactory in 15 (34.1%), and unsatisfactory in two shoulders (4.5%). Stems were well-positioned, without evidence of significant valgus or varus malalignment in 42 TSRs (95.5%). There was no radiological evidence of loosening of the humeral stem in any patient; 13 TSRs (29.5%) had evidence of proximal humeral remodelling and scapular notching was noted in three (6.8%). Cite this article: Bone Joint J 2014;96-B:526–9.

Objectives: Peroneal nerve injuries are not uncommon with multiligament (ML) knee dislocations. However, there remains little information on outcome of these injuries. Therefore, the purpose of this study was to (1) report the clinical and functional outcomes after ML knee injury with concomitant peroneal nerve palsy, (2) compare recovery and outcome with partial versus complete peroneal nerve injury, (3) compare outcomes to a matched cohort of ML knee injuries without concomitant peroneal nerve palsy. Methods: Patients that underwent surgical reconstruction of a ML knee injury from 1993 to 2010 were reviewed and concomitant nerve injuries were identified, forming the peroneal nerve injury group (PI). Patient demographics, injury mechanism, modified Schenck classification, and peroneal nerve function, treatment, and recovery were documented. Patients were divided into two sub-groups: complete peroneal nerve palsy (CNP) and partial peroneal nerve palsy (PNP). A second group of patients with ML knee injury without peroneal nerve injury were identified, forming the no nerve injury group (NI). The PI and NI groups were matched based on Modified Schenck Classification, age, and gender. Peroneal nerve motor grade was assessed at last clinical follow-up and outcome scores were obtained using the International Knee Documentation Committee (IKDC) and Lysholm forms at a minimum of 2 years post-op. Data was analyzed using univariate and multivariate models to assess for predictive factors between the groups. Results: 27 patients (24 males, 3 females) met inclusion criteria for the PI group (9 CNP and 18 PNP). Treatment for CNP included an AFO for all patients, non-operative (1), neurolysis (2), tendon transfer (3), nerve transfer (1), and combined nerve/tendon transfer (1). One patient in the CNP group required additional surgery, undergoing below knee amputation. Treatment for PNP included non-op (12), neurolysis (4), nerve transfer (1), and combined nerve/tendon transfer (1). 2 patients with incomplete nerve palsy required additional surgery, undergoing an arthrodesis and a total knee arthroplasty. 3 CNP (37.5%) and 15 PNP (83.3%) regained 3/5 or greater tibialis anterior (TA) strength. PNP was associated with increased recovery of 3/5 extensor hallucis longus (EHL) strength (p=0.0093). Outcome scores were obtained for 17 of the remaining patients at a mean 6.6 (range 2-18) years. Univariate analysis revealed no difference between the CNP and PNP groups. Final motor grade of 3/5 did not predict improved outcomes. Not undergoing a tendon transfer procedure predicted better outcomes on the IKDC score (70.5 vs 45.0; p=0.027). All other peroneal nerve interventions were not associated with improved motor or functional outcome. 20 patients formed the NI group. The PI and NI groups were matched on gender (18 M, 2 F), age (mean 30.8 vs 29.5 years), and Modified Schenck Classification (2 KD-I, 10 KD-IIIL, 5 KD-IV, 3 KD-V vs 2, 7, 8, and 3 respectively). In univariate analysis, the PI group had inferior outcomes on both the IKDC (64.5 vs 77.3; p=0.036) and Lysholm (67.1 vs 83.0; p=0.023) scores. Conclusion: Patients with partial peroneal nerve palsy are more likely to regain antigravity EHL strength, but not antigravity TA strength. There is no significant difference in outcomes between partial and complete peroneal nerve palsy. In ML knee injuries, patients with peroneal nerve injury have significantly worse outcomes than similar patients without peroneal nerve injury.

AbstractPurposeNumerous surgical techniques have been described for the treatment of peroneal nerve palsy after knee dislocation with less than optimal outcomes. The purpose of this article is to present a review of the literature including modern surgical treatment options for peroneal nerve palsy after knee dislocation.MethodReview of the current body of literature relevant to the topic was undertaken and summarized accordingly. Mechanism of injury, pathology and prognosis as well as current and novel treatment options are presented.ResultsNeurolysis and nerve grafting results are dependant on nerve graft length, with documented recovery rates of only 44% for nerve grafts longer than 6 cm. Posterior tibial tendon transfer procedures have had reasonable success in allowing patients to return to ambulation without assistive devices; however, dorsiflexion strength on the affected side has been reported at only 30% that of the normal contralateral side, and return to activities more strenuous than walking has not been reported. Future concepts including partial nerve transfer of a motor branch of the tibial nerve to the peroneal nerve have been described, but no outcome data is currently available.ConclusionPeroneal nerve palsy after knee dislocation leads to significant functional impairment. Prior treatment strategies utilized for restoration of dorsiflexion and peroneal nerve function have yielded overall poor results. Newer surgical techniques are being developed and clinical trials are under way to evaluate their effectiveness.