Augmented Reality Assisted Intraoperative Navigation Increases Precision of Glenoid Inclination in Reverse Shoulder Arthroplasty.

BACKGROUND: Reverse Total Shoulder Arthroplasty (RTSA) is the standard of care for patients with glenohumeral osteoarthritis and rotator cuff deficiency. Preoperative RTSA planning based on medical images and patient-specific instruments has been established over the last decade. This study aims to determine the effects of using augmented reality assisted intraoperative navigation (ARIN) for baseplate positioning in RTSA compared to preoperative planning. It is hypothesized that ARIN will decrease deviation between preoperative planning and postoperative baseplate positioning. Moreover, ARIN will decrease deviation between the (senior) more (> 50 RTSA/year) and less experienced (junior) surgeon (5-10 RTSA/year). METHODS: Preoperative CT scans of sixteen fresh-frozen cadaveric shoulders were obtained. Baseplate placements were planned using a validated software. The data was then converted and uploaded to the augmented reality system (NextAR; Medacta International, Castel San Pietro, Switzerland). Each of the eight RTSAs were implanted by a senior and a junior surgeon, with four RTSAs utilizing ARIN and four without. A postoperative CT scan was performed in all cases. The scanned scapulae were segmented, and the preoperative scan was laid over the postoperative scapula by nearest iterative point cloud analysis. The deviation from the planned entry point and trajectory was calculated regarding the inclination, retroversion, medialization (reaming depth)/lateralization, antero-posterior position and superior/inferior position of the baseplate. Data are reported as mean ± standard deviation (SD) or mean and 95% confidence interval (CI). P values <0.05 were considered statistically significant. RESULTS: The use of ARIN yielded a reduction in the absolute difference between planned and obtained inclination from 9° (SD: 4°) to 3° (SD°:2) (p=0.011). Mean difference in planned-obtained inclination between surgeons was 3° in free-hand surgeries (95%CI: -4,10, p=0.578), while this difference reduced to 1° (95%CI: -6, 7, p=0.996) using ARIN. Retroversion, medialization (reaming depth)/lateralization, antero-posterior position and superior/inferior position of the baseplate were not affected by using ARIN. Surgical duration was increased using ARIN for both the senior (10 mins) and junior (18 mins) surgeon. CONCLUSIONS: The implementation of augmented reality assisted intraoperative navigation (ARIN) leads to greater accuracy of glenoid component placement, specifically with respect to inclination. Further studies have to verify if this increased accuracy is clinical important. Furthermore, ARIN allows less experienced surgeons to achieve a similar level of accuracy in component placement comparable to more experienced surgeons. However, the potential advantages of ARIN in RTSA are counterbalanced by an increase in operative time.

Minimum 5-Year Clinical and Return-to-Sport Outcomes After Primary Arthroscopic Scapulothoracic Bursectomy and Partial Scapulectomy for Snapping Scapula Syndrome.

BACKGROUND: Snapping scapula syndrome (SSS) is a rare condition that is oftentimes debilitating. For patients whose symptoms are resistant to nonoperative treatment, arthroscopic surgery may offer relief. Because of the rarity of SSS, reports of clinical outcomes after arthroscopic SSS surgery are primarily limited to small case series and short-term follow-up studies. PURPOSE: To report minimum 5-year clinical and sport-specific outcomes after arthroscopic bursectomy and partial scapulectomy for SSS and to identify demographic and clinical factors at baseline associated with clinical outcomes at minimum 5-year follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who underwent arthroscopic bursectomy and partial scapulectomy for SSS between October 2005 and February 2016 with a minimum of 5 years of postoperative follow-up were enrolled in this single-center study. Clinical outcome scores, including the 12-Item Short Form Health Survey (SF-12), American Shoulder and Elbow Surgeons (ASES) Shoulder Score, shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) score for pain, were collected at a minimum 5-year follow-up. Additionally, it was determined which patients reached the minimal clinically important difference. Bivariate analysis was used to determine whether baseline demographic and clinical factors had any association with the outcome scores. RESULTS: Of 81 patients eligible for inclusion in the study, follow-up was obtained for 66 patients (age 33.6 ± 13.3 years; 31 female). At a mean follow-up of 8.9 ± 2.5 years (range, 5.0-15.4 years), all of the outcome scores significantly improved compared with baseline. These included the ASES (from 56.7 ± 14.5 at baseline to 87.2 ± 13.9 at follow-up; P < .001), QuickDASH (from 38.7 ± 17.6 to 13.1 ± 14.6; P < .001), SANE (from 52.4 ± 21.2 to 82.7 ± 19.9; P < .001), SF-12 Physical Component Summary (from 39.7 ± 8.3 to 50.3 ± 8.2; P < .001), SF-12 Mental Component Summary (from 48.2 ± 11.7 to 52.0 ± 9.0; P = 0.014) and VAS pain (from 5.2 ± 2.1 to 1.4 ± 2.0; P < .001). The minimal clinically important difference in the ASES score was reached by 77.6% of the patients. Median postoperative satisfaction was 8 out of 10. It was found that 90.5% of the patients returned to sport, with 73.8% of the patients able to return to their preinjury level. At the time of final follow-up, 8 (12.1%) patients had undergone revision surgery for recurrent SSS symptoms. Older age at surgery (P = .044), lower preoperative SF-12 Mental Component Summary score (P = .008), lower preoperative ASES score (P = .019), and increased preoperative VAS pain score (P = .016) were significantly associated with not achieving a Patient Acceptable Symptom State on the ASES score. CONCLUSION: Patients undergoing arthroscopic bursectomy and partial scapulectomy for SSS experienced clinically significant improvements in functional scores, pain, and quality of life, which were sustained at a minimum of 5 years and a mean follow-up of 8.9 years postoperatively. Higher patient age, inferior mental health status, increased shoulder pain, and lower ASES scores at baseline were significantly associated with worse postoperative outcomes.

Treatment of Unfixable Inferior Pole Fractures of the Patella Using an All-Suture Internal Fixation Technique.

Inferior pole fractures of the patella are a type of patellar fracture that has various complexities. Most current techniques are associated with hardware-related complications, which is one of the main concerns when treating this complex fracture. We present a new technique that does not require metal implant removal, causes little to no irritation of the quadriceps muscle, and provides strong fixation that allows for early range of motion postoperatively.

Preoperative patient factors that predict achieving the minimal clinically important difference following arthroscopic treatment of snapping scapula syndrome.

BACKGROUND: The aim of this study was to define the minimal clinically important difference (MCID) values for patient-reported outcomes (PROs) after arthroscopic treatment of snapping scapula syndrome (SSS) using a distribution-based method, and to identify demographic, clinical, and intraoperative factors significantly associated with the achievement of MCID. It was hypothesized that subjective satisfaction scores after the procedure would be strongly associated with the achievement of MCID thresholds for the PROs and that pain, preoperative response to injection, and a scapulectomy in addition to bursal resection would be predictive of clinically relevant improvement. METHODS: Patients who underwent arthroscopic treatment of SSS between October 2005 and September 2020 with a minimum of 2-year short-term postoperative follow-up were enrolled in this retrospective single-center study. The MCID was calculated using a distribution-based approach for the following PROs: 12-Item Short Form Health Survey (SF-12), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) pain "today" and "at worst." The association between achievement of the MCID and postoperative subjective satisfaction was investigated, and factors associated with achievement of MCID were determined using bivariate analysis. RESULTS: Of a total of 190 patients assessed for eligibility, 77 patients (38.1 ± 14.3 years; 36 females) were included. Within the study population, statistically significant improvements in postoperative SF-12 physical component summary (PCS) (P < .001) and mental component summary (MCS) (P < 0.034), ASES (P < .001), QuickDASH (P < .001), SANE (P < .001), and VAS pain (P < .001) scores were observed at the minimum 2-year follow-up. The calculated MCID threshold values based on the study population were 5.0 for SF-12 PCS, 5.8 for SF-12 MCS, 11.3 for ASES, -10.5 for QuickDASH, 14.7 for SANE, 1.5 for VAS pain, and 1.7 for VAS pain at worst. Reaching the MCID was strongly associated with postoperative satisfaction (rated on a scale of 1-10). Across the PROs, younger age, favorable preoperative response to injection, partial scapuloplasty or scapulectomy, no prior surgery, and pain and function at baseline were significantly associated with attaining MCID. CONCLUSIONS: Patients who underwent arthroscopic treatment for SSS experienced clinically significant improvements in functional scores, pain, and quality of life. This study demonstrated predictive roles for certain patient-specific factors and diagnostic variables for achieving MCID in PROs, which may help surgeons preoperatively assess the probability of success and manage patient expectations.

Mid-term outcomes of microfracture for the treatment of focal, full-thickness cartilage defects isolated to the humeral head.

BACKGROUND: While microfracture has been shown to be an effective treatment for chondral lesions in the knee, evidence to support its use for chondral defects in the shoulder is limited to short-term outcomes studies. The purpose of this study is to determine if microfracture provides pain relief and improved shoulder function in patients with isolated focal chondral defects of the humeral head at a minimum 5-year follow-up. METHODS: Patients who underwent microfracture procedure for isolated focal chondral defects of the humeral head with a minimum follow-up of 5 years between 02/2006 and 08/2016 were included. At minimum 5-year follow-up, pre- and postoperative patient-reported outcome (PRO) measures were collected, including the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Short Form-12 (SF-12) Physical Component Summary (PCS), Visual Analog Scale (VAS) for pain, and patient satisfaction level (1 = unsatisfied, 10 = very satisfied). Demographic, injury, and surgical data were retrospectively reviewed. Surgical failure was defined as revision surgery for humeral chondral defects or conversion to arthroplasty. Kaplan-Meier analysis was performed to determine survivorship at 5 years. RESULTS: A total of 17 patients met inclusion/exclusion criteria. There were 15 men and 2 women with an average age of 51 years (range 36-69) and an average follow-up of 9.4 years (range 5.0-15.8). The median ASES score improved from 62 (range: 22-88) preoperatively to 90 (range: 50-100) postoperatively (P = .011). Median satisfaction was 8 out of 10 (range: 2-10). There was no correlation between patient age or defect size and PROs. Postoperatively, patients reported significant improvements in recreational and sporting activity as well as the ability to sleep on the affected shoulder (P ≤ .05). Three patients failed and required revision surgery. The Kaplan-Meier analysis determined an overall survivorship rate of 80% at 5 years. CONCLUSION: The presented study illustrates significant improvements for PROs, improved ability to perform recreational and sporting activities, and a survival rate of 80% at a mean of 9.4 years after microfracture for focal chondral humeral head defects.

Patient-reported outcomes of arthroscopic repair for partial or full-thickness upper third subscapularis tendon tears with open sub-pectoral biceps tenodesis: minimum 10-year outcomes.

BACKGROUND: Although short-term results are promising, there are limited data for long-term results of arthroscopic subscapularis (SSC) repair. The purpose of this study is to report minimum 10-year outcomes of primary arthroscopic repair of isolated partial or full-thickness tears of the upper third of the SSC tendon. METHODS: Patients who underwent arthroscopic repair of isolated upper third SSC tears, Lafosse type I (>50% of tendon thickness) or type II were included. Surgeries were performed by a single surgeon between November 2005 and August 2011. Patient-reported outcome measures were prospectively collected and retrospectively reviewed at minimum follow-up of 10 years. Patient-reported outcomes utilized included the American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score (SANE), Quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH), the Short Form 12 physical component summary, return to activity, and patient satisfaction. A subanalysis of patient age and outcomes was performed. Retears, revision surgeries, and surgical complications were recorded. RESULTS: In total, 29 patients with isolated upper third SSC repairs were identified. After application of exclusion criteria, 14 patients were included in the final analysis. Follow-up could be obtained from 11 patients. The mean age at surgery was 52.7 years (range: 36-72) and the mean follow-up was 12 years (range 10-15 years). The American Shoulder and Elbow Surgeons score improved from 52.9 ± 21.8 preoperatively to 92.2 ± 13.7 postoperatively (P < .001). Regarding the SANE and QuickDASH scores, only postoperative data were available. Mean postoperative SANE, QuickDASH, and Short Form 12 physical component summary scores were 90.27 ± 10.5, 14.6 ± 15.5, and 49.2 ± 6.6, respectively. Median patient satisfaction was 10 (range 6-10). Patients reported improvements in sleep, activities of daily living, and sports. There was no correlation between patient age and clinical outcome (P > .05). No patients underwent revision surgery for a SSC retear. CONCLUSION: Arthroscopic repair of upper third SSC tendon tears leads to improved clinical scores and high patient satisfaction at minimum 10-year follow-up. The procedure is durable, with no failures in the presented cohort.

Outcomes of total shoulder arthroplasty in patients with prior anterior shoulder instability: minimum 5-year follow-up.

BACKGROUND: Patients with a history of anterior shoulder instability (ASI) commonly progress to glenohumeral arthritis or even dislocation arthropathy and often require total shoulder arthroplasty (TSA). The purposes of this study were to (1) report patient-reported outcomes (PROs) after TSA in patients with a history of ASI, (2) compare TSA outcomes of patients whose ASI was managed operatively vs. nonoperatively, and (3) report PROs of TSA in patients who previously underwent arthroscopic vs. open ASI management. METHODS: Patients were included if they had a history of ASI and had undergone TSA ≥5 years earlier, performed by a single surgeon, between October 2005 and January 2017. The exclusion criteria included prior rotator cuff repair, hemiarthroplasty, or glenohumeral joint infection before the index TSA procedure. Patients were separated into 2 groups: those whose ASI was previously operatively managed and those whose ASI was treated nonoperatively. This was a retrospective review of prospective collected data. Data collected was demographic, surgical and subjective. The PROs used were the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) score, and 12-item Short Form physical component score. Failure was defined as revision TSA surgery, conversion to reverse TSA, or prosthetic joint infection. Kaplan-Meier survivorship analysis was performed. RESULTS: This study included 36 patients (27 men and 9 women) with a mean age of 56.4 years (range, 18.8-72.2 years). Patients in the operative ASI group were younger than those in the nonoperative ASI group (50.6 years vs. 64.0 years, P < .001). Operative ASI patients underwent 10 open and 11 arthroscopic anterior stabilization surgical procedures prior to TSA (mean, 2 procedures; range, 1-4 procedures). TSA failure occurred in 6 of 21 patients with operative ASI (28.6%), whereas no failures occurred in the nonoperative ASI group (P = .03). Follow-up was obtained in 28 of 30 eligible patients (93%) at an average of 7.45 years (range, 5.0-13.6 years). In the collective cohort, the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) score, and 12-item Short Form physical component score significantly improved, with no differences in the postoperative PROs between the 2 groups. We found no significant differences when comparing PROs between prior open and prior arthroscopic ASI procedures or when comparing the number of prior ASI procedures. Kaplan-Meier analysis demonstrated a 79% 5-year survivorship rate in patients with prior ASI surgery and a 100% survivorship rate in nonoperatively managed ASI patients (P = .030). CONCLUSION: At mid-term follow-up, patients with a history of ASI undergoing TSA can expect continued improvement in function compared with preoperative values. However, TSA survivorship is decreased in patients with a history of ASI surgery compared with those without prior surgery.

Does glenoid version and its correction affect outcomes in anatomic shoulder arthroplasty? A systematic review.

BACKGROUND: Correction of glenoid retroversion is commonly performed in anatomic total shoulder arthroplasty (TSA) to increase component contact area and decrease eccentric loading of the glenoid component. Despite demonstrated biomechanical advantages, limited information exists on the clinical benefit of correcting glenoid retroversion. The purpose of this systematic review is to critically evaluate the existing literature on the effect of preoperative and postoperative glenoid retroversion on clinical functional and radiologic outcomes in patients who underwent anatomic TSA. METHODS: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses using PubMed, Embase, and Cochrane Library evaluating the impact of glenoid retroversion on clinical and radiologic outcomes of TSA. English-language studies of level I through IV evidence were included. Blinded reviewers conducted multiple screens and methodological quality was appraised using the Modified Coleman Methodology Score. RESULTS: Sixteen studies, including 3 level III and 13 level IV studies (1211 shoulders), satisfied all inclusion criteria. To address glenoid retroversion, 9 studies used corrective reaming techniques, and 4 studies used posteriorly augmented glenoids. Two studies used noncorrective reaming techniques. Mean preoperative retroversion ranged from 12.7° to 24° across studies. Eleven studies analyzed the effect of glenoid retroversion on clinical outcomes, including patient-reported outcome scores (PROs), range of motion (ROM), or clinical failure or revision rates. Most studies (8 of 11) did not report any significant association of pre- or postoperative glenoid retroversion on any clinical outcome. Of the 3 studies that reported significant effects, 1 study reported a negative association between preoperative glenoid retroversion and PROs, 1 study reported inferior postoperative abduction in patients with postoperative glenoid retroversion greater than 15°, and 1 study found an increased clinical failure rate in patients with higher postoperative retroversion. Ten studies reported radiographic results (medial calcar resorption, Central Peg Lucency [CPL] grade, Lazarus lucency grade) at follow-up. Only 1 study reported a significant effect of pre- and postoperative retroversion greater than 15° on CPL grade. CONCLUSION: There is currently insufficient evidence that pre- or postoperative glenoid version influences postoperative outcomes independent of other morphologic factors such as joint line medialization. Given that noncorrective reaming demonstrated favorable postoperative outcomes, and postoperative glenoid version was not significantly and consistently found to impact outcomes, there is inconclusive evidence that correcting glenoid retroversion is routinely required.

Biomechanical Evaluation of the 2 Different Levels of Coracoid Graft Positions in the Latarjet Procedure for Anterior Shoulder Instability.

Background: In the Latarjet procedure, the ideal placement of the coracoid graft in the medial-lateral position is flush with the anterior glenoid rim. However, the ideal position of the graft in the superior-inferior position (sagittal plane) for restoring glenohumeral joint stability is still controversial. Purpose: To compare coracoid graft clockface positions between the traditional 3 to 5 o'clock and a more inferior (for the right shoulder) 4 to 6 o'clock with regard to glenohumeral joint stability in the Latarjet procedure. Study Design: Controlled laboratory study. Methods: A total of 10 fresh-frozen cadaveric shoulders were tested in a dynamic, custom-built robotic shoulder model. Each shoulder was loaded with a 50-N compressive load while an 80-N force was applied in the anteroinferior axes at 90° of abduction and 60° of shoulder external rotation. Four conditions were tested: (1) intact, (2) 6-mm glenoid bone loss (GBL), (3) Latarjet procedure fixed at 3- to 5-o'clock position, and (4) Latarjet procedure fixed at 4- to 6-o'clock position. The stability ratio (SR) and degree of lateral humeral displacement (LHD) were recorded. A 1-factor random-intercepts linear mixed-effects model and Tukey method were used for statistical analysis. Results: Compared with the intact state (1.77 ± 0.11), the SR was significantly lower after creating a 6-mm GBL (1.14 ± 0.61, P = .009), with no significant difference in SR after Latarjet 3 to 5 o'clock (1.51 ± 0.70, P = .51) or 4 to 6 o'clock (1.55 ± 0.68, P = .52). Compared with the intact state (6.48 ± 2.24 mm), LHD decreased significantly after GBL (3.16 ± 1.56 mm, P < .001) and Latarjet 4 to 6 o'clock (5.48 ± 3.39 mm, P < .001). Displacement decreased significantly after Latarjet 3 to 5 o'clock (4.78 ± 2.50 mm, P = .04) compared with the intact state but not after Latarjet 4 to 6 o'clock (P = .71). Conclusion: The Latarjet procedure in both coracoid graft positions (3-5 and 4-6 o'clock) restored the SR to the values measured in the intact state. A more inferior graft position (fixed at 4-6 o'clock) may improve shoulder biomechanics, but additional work is needed to establish clinical relevance. Clinical Relevance: An inferior coracoid graft fixation, the 4- to 6-o'clock position, may benefit in restoring normal shoulder biomechanics after the Latarjet procedure.

Sternoclavicular Joint Reconstruction With Gracilis Tendon Autograft.

Clinical instability of the sternoclavicular (SC) joint is a challenging problem. Recurrent subluxation and pain can lead to significant functional limitations. Although many patients respond positively to conservative treatment, chronic dislocations often require operative intervention. The complex anatomy of the diarthrodial SC joint and the existence of concomitant SC joint degenerative changes compounded with close-by neurovascular structures present a surgical challenge. The purpose of this Technical Note is to describe a technique for the open management of symptomatic sternoclavicular joint instability using a figure-of-8 reconstruction with a gracilis autograft. The present authors believe this technique provides a technically safe and reproducible method for reconstructing the SC joint without compromising biomechanical strength.

Arthroscopic Labral Repair and Pancapsular Shift With Knotless All-Suture Anchors in the Setting of Multidirectional Instability of the Shoulder.

In the management of multidirectional type of shoulder instability (MDI), arthroscopic surgical stabilization is a preferred treatment option after failed conservative therapy regimens because of the ability to easily access all aspects of the capsule with one surgical procedure. As arthroscopic techniques have evolved, factors critical to postoperative success have been elucidated. Currently, optimal arthroscopic treatment of MDI involves circumferentially restoring labral integrity, a tailored, patient-specific surgical reduction of capsular volume, and adequately managing potential lesions of the biceps anchor. The purpose of this article and accompanying video is to present our technique for arthroscopic circumferential labral repair and pancapsular shift using knotless all-suture anchors in the setting of MDI with a concurrent type II SLAP lesion.

Biomechanical Analysis of Meniscotibial Ligament Tenodesis to Treat Meniscal Extrusion in the Setting of Posterior Medial Meniscus Root Repair.

BACKGROUND: Meniscal extrusion often persists after a medial meniscus root repair. If the meniscus is extruded, the function of the meniscus as a load-sharing device and secondary knee stabilizer is compromised. HYPOTHESIS: It was hypothesized that repairing the meniscotibial ligament (MTL) would decrease meniscal extrusion in the settings of both an isolated MTL tear and a repaired medial meniscus root while also improving medial compartment contact mechanics. STUDY DESIGN: Controlled laboratory study. METHODS: Ten fresh-frozen cadaveric knees (mean age, 50.5 years) were tested in 5 conditions: intact, MTL deficiency, MTL deficiency + posterior medial meniscus root deficiency, MTL deficiency + posterior medial meniscus root repair, and MTL tenodesis + posterior medial meniscus root repair. Specimens were mounted to a load frame that applied a 1000-N axial load. Joint contact pressures were measured using thin pressure sensors, and the peak and mean pressures were analyzed. Ultrasound was used to measure meniscal extrusion. RESULTS: The MTL tear in isolation resulted in significant meniscal extrusion compared with the intact state (P = 0.035) without a detectable difference in medial compartment pressures. The addition of a root tear to the MTL tear state resulted in significantly more extrusion (P = 0.001) and significant increases in medial compartment pressure (P = .030) compared to the MTL tear state. Root repair alone restored extrusion, mean contact pressure, and peak contact pressure back to the intact state (P > .05). CONCLUSION: This study showed that MTL disruption led to increased meniscal extrusion in a cadaveric model. Unlike the root tear state, MTL disruption did not change contact mechanics. Furthermore, root repair alone was sufficient in restoring intact biomechanics and extrusion. CLINICAL RELEVANCE: This study may help clinicians understand the origin of medial meniscus root tears and aid in the decision-making process for whether to add an MTL tenodesis in the setting of root repair.

Effects of Fisetin Treatment on Cellular Senescence of Various Tissues and Organs of Old Sheep.

Fisetin has been shown to be beneficial for brain injury and age-related brain disease via different mechanisms. The purpose of this study was to determine the presence of senescent cells and the effects of fisetin on cellular senescence in the brain and other vital organs in old sheep, a more translational model. Female sheep 6-7 years old (N = 6) were treated with 100 mg/kg fisetin or vehicle alone on two consecutive days a week for 8 weeks. All vital organs were harvested at the time of sacrifice. Histology, immunofluorescence staining, and RT-Q-PCR were performed on different regions of brain tissues and other organs. Our results indicated that fisetin treatment at the current regimen did not affect the general morphology of the brain. The presence of senescent cells in both the cerebral brain cortex and cerebellum and non-Cornu Ammonis (CA) area of the hippocampus was detected by senescent-associated ß-galactosidase (SA-ß-Gal) staining and GL13 (lipofuscin) staining. The senescent cells detected were mainly neurons in both gray and white matter of either the cerebral brain cortex, cerebellum, or non-CA area of the hippocampus. Very few senescent cells were detected in the neurons of the CA1-4 area of the hippocampus, as revealed by GL13 staining and GLB1 colocalization with NEUN. Fisetin treatment significantly decreased the number of SA-ß-Gal+ cells in brain cortex white matter and GL13+ cells in the non-CA area of the hippocampus, and showed a decreasing trend of SA-ß-Gal+ cells in the gray matter of both the cerebral brain cortex and cerebellum. Furthermore, fisetin treatment significantly decreased P16+ and GLB1+ cells in neuronal nuclear protein (NEUN)+ neurons, glial fibrillary acidic protein (GFAP)+ astrocytes, and ionized calcium binding adaptor molecule 1 (IBA1)+ microglia cells in both gray and white matter of cerebral brain cortex. Fisetin treatment significantly decreased GLB1+ cells in microglia cells, astrocytes, and NEUN+ neurons in the non-CA area of the hippocampus. Fisetin treatment significantly decreased plasma S100B. At the mRNA level, fisetin significantly downregulated GLB1 in the liver, showed a decreasing trend in GLB1 in the lung, heart, and spleen tissues, and significantly decreased P21 expression in the liver and lung. Fisetin treatment significantly decreased TREM2 in the lung tissues and showed a trend of downregulation in the liver, spleen, and heart. A significant decrease in NRLP3 in the liver was observed after fisetin treatment. Finally, fisetin treatment significantly downregulated SOD1 in the liver and spleen while upregulating CAT in the spleen. In conclusion, we found that senescent cells were widely present in the cerebral brain cortex and cerebellum and non-CA area of the hippocampus of old sheep. Fisetin treatment significantly decreased senescent neurons, astrocytes, and microglia in both gray and white matter of the cerebral brain cortex and non-CA area of the hippocampus. In addition, fisetin treatment decreased senescent gene expressions and inflammasomes in other organs, such as the lung and the liver. Fisetin treatment represents a promising therapeutic strategy for age-related diseases.

Minimum 10-Year Outcomes After Arthroscopic Repair of Partial-Thickness Supraspinatus Rotator Cuff Tears.

BACKGROUND: The prevalence of partial-thickness rotator cuff tears (PTRCTs) has been reported to be 13% to 40% within the adult population, accounting for 70% of all rotator cuff tears. Approximately 29% of PTRCTs will progress to full-thickness tears if left untreated. The long-term clinical course after arthroscopic repair of PTRCTs is not well known. PURPOSE: To investigate minimum 10-year patient-reported outcomes (PROs) after arthroscopic rotator cuff repair (RCR) of the supraspinatus tendon and to report reoperation and complication rates. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients were included who underwent arthroscopic RCR of a PTRCT performed by a single surgeon between October 2005 and October 2011. Arthroscopic RCR was performed with a transtendon repair of partial, articular-sided supraspinatus tendon avulsions, bursal-sided repair, or conversion into a full-thickness tear and repair. PRO data were collected preoperatively and at a minimum 10 years postoperatively. PRO measures included the American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, the shortened version of Disabilities of the Arm, Shoulder and Hand score (QuickDASH), the 12-Item Short Form Health Survey Physical Component Summary, and patient satisfaction. Subanalyses were performed to determine if tear location or age was associated with outcomes. Retears, revision surgery, and surgical complications were recorded. RESULTS: In total, 33 patients (21 men, 12 women) at a mean age of 50 years (range, 23-68) met criteria for inclusion. Follow-up was obtained in 28 (87.5%) of the 32 eligible patients ≥10 years out from surgery (mean, 12 years; range, 10-15 years). Of the 33 PTCRTs, 21 were articular sided and 12 were bursal sided. Of the 33 patients, 26 underwent concomitant biceps tenodesis. At follow-up, the mean PROs were significantly improved when compared with preoperative levels: American Shoulder and Elbow Surgeons score from 67.3 to 93.7 (P < .001), Single Assessment Numeric Evaluation from 70.9 to 91.2 (P = .004), QuickDASH from 22.3 to 6.6 (P < .004), and 12-Item Short Form Health Survey Physical Component Summary from 44.8 to 54.2 (P < .001). Median postoperative satisfaction was 10 (range, 5-10). No patient underwent revision surgery. CONCLUSION: Arthroscopic repair of PTRCTs results in excellent clinical outcomes and high patient satisfaction at minimum 10-year follow-up. Furthermore, the procedure is highly durable, with a clinical survivorship rate of 100% at 10 years.

Minimum 5-Year Clinical Outcomes of Arthroscopically Repaired Massive Rotator Cuff Tears: Effect of Age on Clinical Outcomes.

BACKGROUND: Massive rotator cuff tears (MRCTs) can be challenging to treat, and the efficacy of repair of MRCTs in older patients has been debated. PURPOSE: To report minimum 5-year outcomes after primary arthroscopic rotator cuff repair of MRCT and determine whether age affects outcomes. STUDY DESIGN: Case series; Level of evidence 4. METHODS: The study included consecutive patients with MRCTs who were treated with arthroscopic rotator cuff repair by a single surgeon between February 2006 and October 2016. MRCTs were defined as ≥2 affected tendons with tendon retraction to the glenoid rim and/or a minimum exposed greater tuberosity of ≥67. Patient-reported outcome (PRO) data collected preoperatively and at a minimum of 5 years included the American Shoulder and Elbow Surgeons (ASES) score; Single Assessment Numeric Evaluation (SANE) score; the shortened version of the Disabilities of the Arm, Shoulder and Hand score (QuickDASH); the 12-Item Short Form Health Survey (SF-12) Physical Component Summary (PCS); and patient satisfaction. Surgical failure was defined as subsequent revision rotator cuff surgery or conversion to reverse total shoulder arthroplasty. Regression analysis was performed to determine whether age had an effect on clinical outcomes. RESULTS: A total of 53 shoulders in 51 patients (mean age, 59.7 years; range, 39.6-73.8 years; 34 male, 19 female) met inclusion criteria with a mean follow-up of 8.1 years (range, 5.0-12.1 years). Three shoulders (5.7%) failed at 2.4, 6.0, and 7.1 years. Minimum 5-year follow-up was obtained in 45 of the remaining 50 shoulders (90%). Mean PROs improved as follows: ASES from 58.8 to 96.9 (P < .001), SANE from 60.5 to 88.5 (P < .001), QuickDASH from 34.2 to 6.8 (P < .001), and SF-12 PCS from 41.1 to 52.2 (P < .001). Patient satisfaction was a median of 10 (on a scale of 1-10). Age was not associated with any PRO measures postoperatively (P > .05). CONCLUSION: This study demonstrated significantly improved clinical scores, decreased pain, and increased return to activity for patients with MRCT at midterm follow-up (mean, 8.1 years; range, 5.0-12.1 years). In this patient cohort, no association was found between age and clinical outcomes.

Capitellum Osteochondral Allograft Transplantation for Osteochondritis Dissecans of the Elbow.

Reconstruction of unstable osteochondritis dissecans lesions of the capitellum using fresh osteochondral allograft transplantation from the capitellum has the advantages of restoring hyaline cartilage, matching the native radius of curvature, and avoiding the donor-site morbidity encountered with osteochondral autograft transfer. This technical note describes the indications and contraindications, pertinent anatomy, and surgical technique of open osteochondral allograft transplantation using fresh distal humerus allograft for the treatment of unstable osteochondritis dissecans lesions of the capitellum.

Assessment of Complication Risk in the Treatment of Proximal Humerus Fractures: A Retrospective Analysis of 4019 Patients.

(1) Background: The treatment of proximal humeral fractures (PHFs) is debated controversially. Current clinical knowledge is mainly based on small single-center cohorts. The goal of this study was to evaluate the predictability of risk factors for complications after the treatment of a PHF in a large clinical cohort in a multicentric setting. (2) Methods: Clinical data of 4019 patients with PHFs were retrospectively collected from 9 participating hospitals. Risk factors for local complications of the affected shoulder were assessed using bi- and multivariate analyses. (3) Results: Fracture complexity with n = 3 or more fragments, cigarette smoking, age over 65 years, and female sex were identified as predictable individual risk factors for local complications after surgical therapy as well as the combination of female sex and smoking and the combination of age 65 years or older and ASA class 2 or higher. (4) Conclusion: Humeral head preserving reconstructive surgical therapy should critically be evaluated for patients with the risk factors abovementioned.

Preventing varus collapse in proximal humerus fracture fixation: 90-90 dual plating versus endosteal fibular allograft strut.

INTRODUCTION: Screw cut out and varus collapse are the most common complication of locked plate fixation of proximal humerus fractures. The purpose of this study was to compare dual plating and endosteal fibular allograft struts as augmentation strategies to prevent varus collapse. MATERIALS AND METHODS: A trapezoidal osteotomy was created at the metaphysis to create a 2-part proximal humerus model in 18 paired shoulder specimens. Each specimen was assigned to group A, B, or C and was fixed with either a lateral locking plate, a lateral locking plate and anterior one-third tubular plate in an orthogonal 90/90 configuration, or a lateral locking plate with intramedullary fibular strut, respectively. The specimens were stressed in axial compression to failure. Displacement, elastic limit, ultimate load, and stiffness were recorded and calculated. RESULTS: There was no difference in mean cyclic displacement between the three groups (0.71 mm vs 0.89 mm vs 0.61 mm for Group A, B, C, respectively). Lateral plating demonstrated the greatest absolute and relative displacement at the elastic limit (5.3 mm ± 1.5 and 4.4 mm ± 1.3) without significance. The elastic limit or yield point was greatest for fibular allograft, Group C (1223 N ± 501 vs 1048 N ± 367 for Group B and 951 N ± 249 for Group A) without significance. CONCLUSIONS: Dual plating of proximal humerus fractures in a 90-90 configuration demonstrates similar biomechanical properties as endosteal fibular strut allograft. Both strategies demonstrate superior stiffness to isolated lateral locked plating.

Implant-dependent behavior of tunnel widening and clavicular button migration after arthroscopic-assisted treatment of acromioclavicular joint instabilities.

INTRODUCTION: Despite ongoing discussions for the previous few decades, there is still no consensus regarding the optimal surgical technique for acromioclavicular joint instabilities. The purpose of this study was to determine the impact of various implant materials following arthroscopically assisted stabilization of acromioclavicular joint instabilities on tunnel widening and implant migration. We hypothesized an implant-dependent behavior for tunnel widening and implant migration with differences when comparing acute and chronic acromioclavicular joint instabilities. METHODS: This study compared 105 patients with acromioclavicular joint instabilities that were managed operatively with coracoclavicular double button constructs. Two of the groups containing acute cases were treated with either a double button construct with a wire (TR) or a tape (D) as a central pillar. The two groups with chronic cases were either treated with a wire (T+) or tape D+ as a central pillar and additional hamstring tendon augmentation (+). One central transclavicular-transcoracoidal drill channel was made in the acute cases, while additional medial and lateral drill channels to augment the central pillar with the hamstring tendon were made. The central drill channel in all cases and the medial/lateral drill channels in chronic cases were subsequently radiologically analyzed immediately postoperatively and at follow-up. Following this, additional radiological analysis of the implant migration of the clavicular button took place. RESULTS: All groups showed significant tunnel widening of the central drill channel at follow-up (p ≤ 0.001). The TR+ technique demonstrated significant widening in both the medial (p ≤ 0.001) and lateral (p ≤ 0.001) drill channels. The D and D+ group displayed significant higher rates of clavicular button migration to a cortical and intraosseous level (p ≤ 0.002). CONCLUSION: Tunnel widening and implant migration following arthroscopically assisted management of acromioclavicular joint instabilities are dependent on the chosen implant. The stable tape showed a significantly increased degree of tunnel widening with respect to the central drill channel in comparison with the wire. In contrast, a higher degree of load capacity of the tape ultimately favors a protected intraosseous graft healing for chronic cases, which leads to less tunnel widening of the medial and lateral drill channel. Finally, the D/D+ implant groups showed higher rates of implant migration due to lower contact surface area of the implant at the upper clavicular cortex.

Treatment options for massive irreparable rotator cuff tears: a review of arthroscopic surgical options.

While functional reconstruction of massive irreparable rotator cuff tears remains a challenge, current techniques aimed at recentering and preventing superior migration of the humeral head allow for clinical and biomechanical improvements in shoulder pain and function. Recentering of the glenohumeral joint reduces the moment arm and helps the deltoid to recruit more fibers, which compensates for insufficient rotator cuff function and reduces joint pressure. In the past, the concept of a superior capsular reconstruction with a patch secured by suture anchors has been used. However, several innovative arthroscopic treatment options have also been developed. The purpose of this article is to present an overview of new strategies and surgical techniques and if existing present initial clinical results. Techniques that will be covered include rerouting the long head of the biceps tendon, utilization of the biceps tendon as an autograft to reconstruct the superior capsule, utilization of a semitendinosus tendon allograft to reconstruct the superior capsule, superior capsular reconstruction with dermal allografts, and subacromial spacers.