Background: This study aimed to identify implant positioning parameters and patient factors contributing to acromial stress fractures (ASFs) and scapular spine stress fractures (SSFs) following reverse shoulder arthroplasty (RSA). Methods: In a multicenter retrospective study, the cases of patients who underwent RSA from June 2013 to May 2019 and had a minimum 3-month follow-up were reviewed. The study involved 24 surgeons, from 15 U.S. institutions, who were members of the American Shoulder and Elbow Surgeons (ASES). Study parameters were defined through the Delphi method, requiring 75% agreement among surgeons for consensus. Multivariable logistic regression identified factors linked to ASFs and SSFs. Radiographic data, including the lateralization shoulder angle (LSA), distalization shoulder angle (DSA), and lateral humeral offset (LHO), were collected in a 2:1 control-to-fracture ratio and analyzed to evaluate their association with ASFs/SSFs. Results: Among 6,320 patients, the overall stress fracture rate was 3.8% (180 ASFs [2.8%] and 59 SSFs [0.9%]). ASF risk factors included inflammatory arthritis (odds ratio [OR] = 2.29, p < 0.001), a massive rotator cuff tear (OR = 2.05, p = 0.010), osteoporosis (OR = 2.00, p < 0.001), prior shoulder surgery (OR = 1.82, p < 0.001), cuff tear arthropathy (OR = 1.76, p = 0.002), female sex (OR = 1.74, p = 0.003), older age (OR = 1.02, p = 0.018), and greater total glenoid lateral offset (OR = 1.06, p = 0.025). Revision surgery (versus primary surgery) was associated with a reduced ASF risk (OR = 0.38, p = 0.019). SSF risk factors included female sex (OR = 2.45, p = 0.009), rotator cuff disease (OR = 2.36, p = 0.003), osteoporosis (OR = 2.18, p = 0.009), and inflammatory arthritis (OR = 2.04, p = 0.024). Radiographic analysis of propensity score-matched patients showed that a greater increase in the LSA (ΔLSA) from preoperatively to postoperatively (OR = 1.42, p = 0.005) and a greater postoperative LSA (OR = 1.76, p = 0.009) increased stress fracture risk, while increased LHO (OR = 0.74, p = 0.031) reduced it. Distalization (ΔDSA and postoperative DSA) showed no significant association with stress fracture prevalence. Conclusions: Patient factors associated with poor bone density and rotator cuff deficiency appear to be the strongest predictors of ASFs and SSFs after RSA. Final implant positioning, to a lesser degree, may also affect ASF and SSF prevalence in at-risk patients, as increased humeral lateralization was found to be associated with lower fracture rates whereas excessive glenoid-sided and global lateralization were associated with higher fracture rates. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Limb lengthening using an external fixator requires a long period of external fixation and may be associated with several complications such as axial deformity, fracture of the regenerated bone, and joint stiffness. With the goal of reducing the time of external fixation as well as some of these complications, we performed femoral or tibial lengthening over an intramedullary nail, according to Paley’s technique, in 28 patients, followed up after a mean period of 8 years.Materials and methods: Twenty-eight patients treated for lower limb discrepancy by limb lengthening over an intramedullary nail were reviewed from 5 to 11 years after healing of regenerated bone. There were 20 femurs and 8 tibiae, with average age at surgery of 14.2 years and average length inequality of 6.1 cm for femurs and 5.3 cm for tibiae.Results: The mean lengthening was 5.8 cm for femurs and 4.8 cm for tibiae. The mean period of radiographic consolidation of the regenerated bone was 6 months for femoral lengthening and 4.5 months for tibial lengthening. At follow-up, we observed 8 excellent results, 15 good results, 4 fair results, and 1 poor result, based on Paley’s evaluation criteria. The main complications were one deep infection, one nonunion of the distracted segment, one breakage of the distal fiche of the external fixator, and one breakage of both distal locking screws of the intramedullary nail.Discussion: We believe that limb lengthening over an intramedullary nail still represents a good method to treat limb length discrepancy because it reduces the time of external fixation, prevents axial deformities and fractures of regenerated bone, and allows early rehabilitation. The new intramedullary lengthening nails, which theoretically are the ideal device for treating limb length inequality, are still very expensive and need longer follow-up for definitive evaluation.Level of evidence: 4.

The authors report the long-term outcome in a series of 26 patients surgically treated for a fracture-dislocation of the ankle by open reduction and internal fixation (ORIF), reviewed after an average followup of 5.2 years. The average age of the patients was 46.8 years; 17 were female and 9 male; the right side was involved in 22 patients and the left side in 4; 10 patients had a unimalleolar fracture, 11 a bimalleolar fracture, and 5 a trimalleolar fracture. The quality of reduction was excellent in 14 cases and good in 12. The functional results were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score, while radiographic results followed the Van Dijk classification. At followup, the AOFAS score ranged from 75 to 98 points with an average of 87.9, while the radiographic results were evaluated as grade 0 in 16 ankles and grade I in 10. Fracture-dislocations of the ankle occurred more frequently after high-energy traumas in younger patients on the right side, but they were also observed in older females after low-energy trauma. Excellent reduction was correlated with better radiographic results at long term followup. However, these injuries may lead to a poor functional outcome, despite an anatomical reduction and good radiographic results; in fact, in nine of our cases (34.6 percent), the AOFAS score was less than 90 points.

Background: Peripheral nerve blocks improve both pain control and functional outcomes following total knee arthroplasty (TKA). However, few studies have examined the effects of different peripheral nerve block protocols on postoperative range of motion. The present study assessed the impact of a single-shot femoral nerve block (SFNB) versus continuous femoral nerve block (CFNB) on postoperative range of motion and the need for subsequent manipulation following TKA. Methods: We retrospective reviewed patient charts to identify patients who had undergone primary elective unilateral TKA by 2 surgeons at a high-volume orthopaedic specialty hospital over a 3-year period. A total of 1,091 patients received either SFNB or CFNB and were included in the data analysis. Identical surgical techniques, postoperative oral analgesic regimens, and rehabilitation protocols were used for all patients. Patients with 0.05). No significant differences were observed between the groups in terms of postoperative range of motion, either at the time of discharge or at 6 weeks postoperatively. A history of knee surgery, decreased preoperative range of motion, and decreased range of motion at the time of discharge were significantly associated with the need for further MUA (p = 0.0002, p < 0.0001, and p < 0.0001, respectively). Conclusions: Despite similar final postoperative range of motion between patients in both groups, our results suggest that CFNB may be superior to SFNB for reducing the need for postoperative manipulation after primary TKA. Furthermore, a history of ipsilateral knee surgery, decreased preoperative range of motion, and decreased range of motion at the time of discharge were identified as independent risk factors for postoperative stiffness requiring MUA after primary TKA. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.