Postoperative HbA1c Level as a Predictor of Rotator Cuff Integrity After Arthroscopic Rotator Cuff Repair in Patients With Type 2 Diabetes.

Background: In patients with type 2 diabetes mellitus (DM), preoperative glycosylated hemoglobin (HbA1c) is associated with outcomes after arthroscopic rotator cuff repair (ARCR); however, the relationship between outcomes and postoperative serum glycosylated hemoglobin (HbA1c) after ARCR has not been investigated. Purpose: To evaluate outcomes after ARCR in patients (1) with and without DM and (2) with DM according to their pre- and postoperative HbA1c levels. Study Design: Cohort study; Level of evidence, 3. Method: Included in this study were 148 patients without DM and 35 patients with type 2 DM who underwent ARCR between January 1, 2017, and December 31, 2019. Clinical and radiological outcomes were evaluated preoperatively and at the latest clinical follow-up. Postoperative magnetic resonance imaging was performed after 12 months. In patients with type 2 DM, HbA1c levels were evaluated preoperatively as well as 6 and 12 months postoperatively; patients with an HbA1c level of ≥7% were defined as having uncontrolled DM. Multivariate logistic regression analyses were performed to determine the factors for retears after ARCR. Results: The retear rates after ARCR were 22.9% (8/35) and 16.9% (25/148) in patients with and without DM, respectively. The retear rates were significantly higher in the 6-month postoperative uncontrolled DM group than in the controlled DM and non-DM groups (50% vs 8.7% and 16.8%; P < .05). The odds ratio for retears in the postoperative uncontrolled DM group was 5.555 (P =0.01) compared with the non-DM group. Among the patients with DM, in the uncontrolled DM group, 6-month postoperative hyperglycemia was superior in accuracy, sensitivity, and specificity for predicting retears after ARCR than preoperative hyperglycemia (77.1% vs 62.9%, 75% vs 37.5%, and 77.8% vs 70.4%, respectively). Conclusion: This study demonstrated the association between uncontrolled postoperative DM and an increased risk of retears compared with no DM or controlled DM. Furthermore, postoperative HbA1c values were correlated more closely with the risk of retears than preoperative HbA1c values.

Stem cell sheet interpositioned between the tendon and bone would be better for healing than stem cell sheet overlaid above the tendon-to-bone junction in rotator cuff repair of rats.

BACKGROUND: Although stem cells might enhance natural enthesis healing in surgical rotator cuff repair, not much attention has been given to the delivery and location of delivering stem cells. The purpose of this study to know where to locate those stem cells during repair. METHODS: Animal model of chronic rotator cuff tear was created in 24 rats. Adipose-derived stem cells were engineered as a sheet and transplanted 1) between a torn tendon and humerus (interposition group) or 2) over a repaired tendon-to-bone junction (overlay group) at the time of surgical repair. Tracking of stem cells with overexpression of green fluorescent protein (GFP) were carried out at the time of sacrifice in additional 4 shoulders in each group. Histological and Biomechanical evaluation was performed to compare the differences in tendon-to-bone healing. RESULTS: Histology showed increased fibrocartilage, a clear boundary at the mineralized fibrocartilage, abundant collagen type III, and higher total scores, especially in the interposition group. GFP-overexpression was observed at the transplanted site at 2 weeks after repair. Although two groups where stem cell sheets applied showed higher load to failure than the repair-only group, the load to failure was not different between the interposition and overlay group. CONCLUSION: In the chronic rotator cuff repair model, stem cell sheets enhanced regeneration of the tendon-to-bone junction. This regeneration was effective when the stem cell sheet was interpositioned at the tendon-to-bone interface. LEVEL OF EVIDENCE: Basic Science Study; In Vivo Animal Model; Histology and Biomechanics.

Poor Prognostic Factors in Patients With Rotator Cuff Retear.

BACKGROUND: The treatment for retears after arthroscopic rotator cuff repair (ARCR) has long been a challenge. PURPOSE: This study aimed to (1) summarize the characteristics of patients with a retear after primary ARCR and (2) determine the risk factors for poor clinical outcomes after a retear. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: We collected the data of patients with a retear after primary ARCR between January 2011 and December 2016. There were 45 patients with retears included (19 men [42.2%] and 26 women [57.8%]; mean ± SD age, 63.11 ± 8.87 years). Initially, the demographic and outcome data of patients with a retear were analyzed. Patients were classified into good and poor outcome groups according to their overall satisfaction at final follow-up. Univariable and multivariable logistic regression analyses were performed to determine the factors for poor clinical outcomes after a retear. RESULTS: A total of 31 patients were classified into the good outcome group, and 14 patients were classified into the poor outcome group. Both the good and the poor outcome groups showed that clinical scores significantly improved at the time of the retear diagnosis, but the final scores were maintained or worse compared with scores at the time of the retear diagnosis. Final range of motion (ROM), except external rotation in the good outcome group, was worse or had no significant change compared with ROM at the time of the retear diagnosis. On multivariable logistic regression analysis, current smoking (odds ratio [OR], 45.580 [95% CI, 3.014-689.274]; P = .006), female sex (OR, 32.774 [95% CI, 2.433-441.575]; P = .009), and retears of the same or larger size than the initial tear (OR, 10.261 [95% CI, 1.544-68.202]; P = .016) showed a higher OR for poor clinical outcomes after a retear. CONCLUSION: Smoking, female sex, and retears of the same or larger size than the initial tear were independent risk factors for poor clinical outcomes after a rotator cuff retear. Final clinical scores and ROM were similar or worse compared with the scores and ROM at the time of the retear diagnosis. Therefore, revision surgery should be actively considered in female patients or those who smoke with poor clinical outcomes and a larger retear size than the preoperative tear size at the time of the retear diagnosis.

How Many Proximal Screws Are Needed for a Stable Proximal Humerus Fracture Fixation?

PURPOSE: This biomechanical study investigates the optimal number of proximal screws for stable fixation of a 2-part proximal humerus fracture model with a locking plate. METHODS: Twenty-four proximal humerus fracture models were included in the study. An unstable 2-part fracture was created and fixed by a locking plate. Cyclic loading and load-to-failure tests were used for the following 4 groups based on the number of screws used: 4-screw, 6-screw, 7-screw, and 9-screw groups. Interfragmentary gaps were measured following cyclic loading and compared. Consequently, the load to failure, maximum displacement, stiffness, and mode of failure at failure point were compared. RESULTS: The interfragmentary gaps for the 4-screw, 6-screw, 7-screw, and 9-screw groups were significantly reduced by 0.24 ± 0.09 mm, 0.08 ± 0.06 mm, 0.05 ± 0.01 mm, and 0.03 ± 0.01 mm following 1000 cyclic loading, respectively. The loads to failure were significantly different between the groups with the 7-screw group showing the highest load to failure. The stiffness of the 7-screw group was superior compared with the 6-screw, 9-screw, and 4-screw groups. The maximum displacement before failure showed a significant difference between the comparative groups with the 4-screw group having the lowest value. The 7-screw group had the least structural failure rate (33.3%). CONCLUSION: At least 7 screws would be optimal for proximal fragment fixation of proximal humerus fractures with medial comminution to minimize secondary varus collapse or fixation failure. LEVEL OF EVIDENCE: Basic science study.

Peripheral nerve sheath tumor: differentiation of malignant from benign tumors with conventional and diffusion-weighted MRI.

OBJECTIVES: To evaluate potential of conventional MRI and diffusion-weighted imaging (DWI) for differentiating malignant from benign peripheral nerve sheath tumors (PNSTs). METHODS: Eighty-seven cases of malignant or benign PNSTs in the trunk or extremities that underwent conventional MRI with contrast enhancement, DWI, and pathologic confirmation between Sep. 2014 and Dec. 2017 were identified. Of these, 55 tumors of uncertain nature on MRI were included. Tumor size, signal, and morphology were reviewed on conventional MRI, and apparent diffusion coefficient (ADC) values of solid enhancing portions were measured from DWI. Patient demographics, MRI features, and ADC values were compared between benign and malignant tumors, and robust imaging findings for malignant peripheral nerve sheath tumors (MPNSTs) were identified using multivariable models. RESULTS: A total of 55 uncertain tumors consisted of 18 malignant and 37 benign PNSTs. On MRI, tumor size, margin, perilesional edema, and presence of split fat, fascicular, and target signs were significantly different between groups (p < 0.05), as were mean and minimum ADC values (p = 0.002, p < 0.0001). Most inter-reader agreement was moderate to excellent (κ value, 0.45-1.0). The mean ADC value and absence of a split fat sign were identified as being associated with MPNSTs (odds ratios = 13.19 and 25.67 for reader 1; 49.05 and 117.91 for reader 2, respectively). The C-indices obtained by combining these two findings were 0.90 and 0.95, respectively. CONCLUSIONS: Benign and malignant PNSTs showed different features on MRI and DWI. A combination of mean ADC value and absence of split fat was excellent for discriminating malignant from benign PNSTs. KEY POINTS: • It is important to distinguish between malignant peripheral nerve sheath tumors (MPNSTs) and benign peripheral nerve sheath tumors (BPNSTs) to ensure an appropriate treatment plan. • On conventional MRI and diffusion-weighted imaging (DWI), MPNSTs and BPNSTs showed significant differences in tumor size, margin, presence of perilesional edema, and absence of split fat, fascicular, and target signs. • Absence of a split fat sign and mean apparent diffusion coefficient (ADC) values were robust imaging findings distinguishing MPNSTs from BPNSTs, with a C-index of > 0.9.

Role of inferomedial supporting screws for secondary varus deformity in non-osteoporotic proximal humerus fracture: A biomechanical study.

INTRODUCTION: The purpose of this study was to evaluate the effect of a medial support screw through a proximal humerus fracture. For this purpose, we verified whether the biomechanics are different according to the position of the screw while using the same number of screws. In addition, we tried to verify whether the insertion of additional inferomedial screws would make a difference in stability. MATERIALS AND METHODS: Twenty-four proximal humerus bones were included in the study. A two-part fracture was created and fixed using a locking plate. Cyclic loading and load-to-failure test were applied to three groups: group A (proximal 6 screws + calcar screws), group B (proximal 6 screws), and group C (proximal 4 screws + calcar screws). Interfragmentary gaps were measured following cyclic loading and compared. The failure was defined when the bone breakage or medial gap closing was observed during ultimate failure load applied. The load-to-failure, maximum displacement, stiffness, and yield load were recorded and compared. RESULTS: The interfragmentary gap was differently reduced by 0.29 ± 0.14 mm, 0.73 ± 0.25 mm, and 0.53 ± 0.09 mm following 1000 cyclic loading for groups A, B, and C, respectively. The load-to-failure was 945.22 ± 101.02 N, 941.40 ± 148.90 N, and 940.58 ± 91.78 N in groups A, B, and C, respectively. The stiffness of group A (214.76 ± 34.0 N/mm) was superior when compared to that of group C (171.12 ± 23.0 N/mm; p = 0.025). The maximum displacement prior to failure, yield load, showed no significant difference between comparative groups. CONCLUSION: Our study did not show any additional biomechanical effects with the use of inferomedial supporting screws in non-osteoporotic proximal humerus fracture, besides making the fracture-plate construct stiff. The role of the inferomedial supporting screw was also unclear. However, the groups that used increased screw fixation and inferomedial screw insertion seemed to be more resistant to cyclic loading.

Navigation-assisted anchor insertion in shoulder arthroscopy: a validity study.

BACKGROUND: This study aimed to compare conventional and navigation-assisted arthroscopic rotator cuff repair in terms of anchor screw insertion. METHODS: The surgical performance of five operators while using the conventional and proposed navigation-assisted systems in a phantom surgical model and cadaveric shoulders were compared. The participating operators were divided into two groups, the expert group (n = 3) and the novice group (n = 2). In the phantom model, the experimental tasks included anchor insertion in the rotator cuff footprint and sutures retrieval. A motion analysis camera system was used to track the surgeons' hand movements. The surgical performance metric included the total path length, number of movements, and surgical duration. In cadaveric experiments, the repeatability and reproducibility of the anchor insertion angle were compared among the three experts, and the feasibility of the navigation-assisted anchor insertion was validated. RESULTS: No significant differences in the total path length, number of movements, and time taken were found between the conventional and proposed systems in the phantom model. In cadaveric experiments, however, the clustering of the anchor insertion angle indicated that the proposed system enabled both novice and expert operators to reproducibly insert the anchor with an angle close to the predetermined target angle, resulting in an angle error of < 2° (P = 0.0002). CONCLUSION: The proposed navigation-assisted system improved the surgical performance from a novice level to an expert level. All the experts achieved high repeatability and reproducibility for anchor insertion. The navigation-assisted system may help surgeons, including those who are inexperienced, easily familiarize themselves to of suture anchors insertion in the right direction by providing better guidance for anchor orientation. LEVEL OF EVIDENCE: A retrospective study (level 2).

Engineered Cell Sheets for the Effective Delivery of Adipose-Derived Stem Cells for Tendon-to-Bone Healing.

BACKGROUND: Efforts are being made to treat rotator cuff tears (RCTs) that exhibit poor healing and high retear rates. Tendon-to-bone healing using mesenchymal stem cells is being explored, but research is needed to establish effective delivery options. PURPOSE: To evaluate the effects of an adipose-derived stem cell (ADSC) sheet on mesenchymal stem cell delivery for tendon-to-bone healing of a chronic RCT in rats and to demonstrate that ADSC sheets enhance tendon-to-bone healing. STUDY DESIGN: Controlled laboratory study. METHODS: Mesenchymal stem cells were obtained from rat adipose tissue, and a cell sheet was prepared using a temperature-responsive dish. To evaluate the efficacy of stem cells produced in a sheet for the lesion, the experiment was conducted with 3 groups: repair group, cell sheet transplantation after repair group, and cell sheet-only group. Histological, biomechanical, and micro-computed tomography (micro-CT) results were compared among the groups. RESULTS: Hematoxylin and eosin staining for histomorphological analysis revealed that the cell sheet transplantation after repair group (5.75 ± 0.95) showed statistically significant higher scores than the repair (2.75 ± 0.50) and cell sheet-only (3.25 ± 0.50) groups (P < .001). On safranin O staining, the cell sheet transplantation after repair group (0.51 ± 0.04 mm2) had a larger fibrocartilage area than the repair (0.31 ± 0.06 mm2) and cell sheet-only (0.32 ± 0.03 mm2) groups (P = .001). On micro-CT, bone volume/total volume values were significantly higher in the cell sheet transplantation after repair group (23.98% ± 1.75%) than in the other groups (P < .039); there was no significant difference in the other values. On the biomechanical test, the cell sheet transplantation after repair group (4 weeks after repair) showed significantly higher results than the other groups (P < .005). CONCLUSION: Our study shows that engineered stem cells are a clinically feasible stem cell delivery tool for rotator cuff repair. CLINICAL RELEVANCE: This laboratory study provides evidence that ADSCs are effective in repairing RCTs, which are common sports injuries.

Systematic Review of the Surgical Outcomes of Elbow Plicae.

BACKGROUND: Surgical resection is usually required for symptomatic elbow plicae that have failed nonoperative therapy. However, evidence of surgical outcomes has not been presented. PURPOSE: To review the surgical outcomes for the treatment of synovial plicae in the radiocapitellar joint. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: We searched the PubMed, Ovid/MEDLINE, Cochrane Library, Google Scholar, and Embase databases using keywords as well as Medical Subject Headings terms and Emtree ([(elbow OR humeroradial joint OR radiohumeral joint) AND (meniscus OR plica)] OR snapping elbow OR snapping triceps OR synovial fold syndrome OR synovial fringe) for English-language studies. We conducted a systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS: A total of 14 articles comprising four level 5 and ten level 4 studies were identified, including 279 patients (284 elbows). The triggering factors reported for 58 patients were heavy labor (29 patients; 50.0%), sporting activities (17 patients; 29.3%), and nonspecific trauma (12 patients; 20.7%). Overall, 92 patients (33.0%) were administered a steroid injection before surgery. Arthroscopic plica resection was performed in 266 patients (95.3%). Intraoperatively, plicae were mostly found in the posterior (44.0%) and posterolateral (28.6%) sites, and chondromalacia of the radial head was observed in 25 patients (9.2%). Of the reported surgical outcomes, 67.7% showed a resolution of symptoms. However, 9.3% of patients had residual symptoms, which were likely associated with pre-existing radial head chondromalacia. The complication rate was reported as 1.8%. CONCLUSION: Symptomatic elbow plicae were mostly treated arthroscopically, with most of the results being favorable. Pre-existing chondromalacia and the underestimation of concomitant intra-articular abnormalities may yield an inferior outcome.

Do Modern Designs of Metal-Backed Glenoid Components Show Improved Clinical Results in Total Shoulder Arthroplasty? A Systematic Review of the Literature.

BACKGROUND: Despite the increased popularity of reverse total shoulder arthroplasty, total shoulder arthroplasty is the standard treatment for advanced shoulder arthritis in young adult patients. Conventional metal-backed glenoid (MBG) designs result in more loosening and revision surgery compared with cemented polyethylene glenoid components. However, modern MBG designs have been recently devised to overcome such drawbacks. PURPOSE: To compare the radiolucency, loosening, and failure rates of modern MBG designs with those of conventional designs. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A search for relevant articles was carried out using the PubMed, Cochrane Library, and Embase databases using MeSH (Medical Subject Headings) terms and natural keywords. A total of 362 articles were screened. We descriptively analyzed numerical data between the groups and statistically analyzed categorical data, such as the presence of loosening, failure, and revision surgery. The main outcome was the rate of revision surgery or failure. Subgroup analysis according to follow-up duration was performed to reduce heterogeneity. RESULTS: A total of 25 articles (2036 shoulders) were included; 15 articles (1579 shoulders) involved a conventional MBG design, and 10 (457 shoulders) involved a modern design. The mean age of the patients was 64.2 and 66.5 years in the conventional and modern design groups, respectively, with a mean follow-up duration of 102.0 and 56.1 months, a mean gain of forward elevation of 35.1° and 61.7°, and a mean gain of external rotation of 24.2° and 39.2°. The rate of radiolucency was 48.0% and 16.7%, the rate of loosening was 11.2% and 4.9%, and the rate of revision was 15.9% and 2.4%, for the conventional and modern design groups, respectively. Subgroup analysis according to follow-up duration showed that the rates of loosening and revision were significantly lower in the modern design group (P < .001). CONCLUSION: Our findings suggest that modern MBG designs showed significantly lower loosening and failure rates than conventional designs. The overall results of the comparison, including loosening, failure, change in range of motion, and clinical scores, indicate that modern MBG designs are promising. More long-term follow-up studies on modern MBGs should be conducted.

Distribution of Osteochondral Lesions in Patients With Simple Elbow Dislocations Based on MRI Analysis.

BACKGROUND: The clinical relationship between osteochondral lesions and long-term outcomes and patterns in the elbow joint has not yet been established. A sole evaluation from plain standard radiography may underestimate the severity of bony lesions in patients with simple dislocations. It has been suggested that the mechanism of a posterior elbow dislocation could be inferred from the pattern of bony contusions and osteochondral lesions visible on magnetic resonance imaging (MRI) in patients with simple elbow dislocations. PURPOSE/HYPOTHESIS: The purpose of this study was to describe the incidence and distribution of osteochondral lesions based on MRI findings in patients with simple elbow dislocations. We hypothesized that (1) osteochondral lesions are consistently found in patients with simple elbow dislocations and (2) the distribution and severity of osteochondral lesions may explain the mechanism of the simple elbow dislocation. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of 43 patients with simple elbow dislocations was performed in tertiary-level hospitals from January 2010 to August 2019. Two orthopaedic surgeons separately assessed the initial plain radiographs and MRI scans. Osteochondral lesions were evaluated and categorized based on whether they were located (1) on the lateral side (posterolateral capitellum and radial head; type 1) or (2) on the medial side (posterior trochlea and anteromedial facet of the coronoid; type 2). The severity of the osteochondral lesions was assessed according to the Anderson classification. RESULTS: Of the 43 patients, 21 (48.8%) presented with osteochondral lesions on MRI. The type 1 pattern of osteochondral lesions was the most frequently observed on MRI in patients with simple elbow dislocations (69.8% of cases), and these were confirmed by simple radiography. Posterolateral capitellum osteochondral lesions were found in 13 patients. Among them, 10 (76.9%) were advanced-stage lesions (stages III and IV according to the Anderson classification). CONCLUSION: Osteochondral lesions were found on MRI after simple elbow dislocations at a rate of 48.8%. Osteochondral lesions in the posterolateral capitellum were associated with an advanced stage. Clinically, these findings may help surgeons in the diagnosis of osteochondral lesions and in determining how to manage patients with the progression of arthritic changes.

Minimal Clinically Important Difference, Substantial Clinical Benefit, and Patient Acceptable Symptomatic State After Arthroscopic Rotator Cuff Repair.

BACKGROUND: Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) are emerging criteria for patient-based treatment assessments. However, few studies have investigated these measures after rotator cuff repair. PURPOSE: (1) To determine MCID, SCB, and PASS values for pain visual analog scale (pVAS), Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) score, and University of California, Los Angeles (UCLA) score after arthroscopic rotator cuff repair. (2) To determine factors for achieving the MCID, SCB, and PASS. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: We analyzed prospectively collected data from a rotator cuff surgery registry between March 2018 and February 2019. Eighty-two patients were included, and anchor questions for deriving MCID, SCB, and PASS values were applied at 1-year follow-up after the surgery. The MCID and SCB for the pVAS, ASES, SANE, and UCLA scores were then derived via 2 methods: a sensitivity- and specificity-based approach, which was used alone to derive PASS values, and a between-patients approach. Additionally, univariable and multivariable logistic regression analyses were performed to determine factors for achieving the MCID, SCB, and PASS. RESULTS: All 4 scores showed acceptable areas under the curve. MCID, SCB, and PASS values for the pVAS were 1.5, 2.5, and 1.7; for ASES scores, 21.0, 26.0, and 78.0; for SANE, 13.0, 20.0, and 71.0; and for UCLA scores, 6.0, 8.0, and 23.0, respectively. Poor preoperative scores demonstrated significantly higher odds ratios (ORs) for achieving the MCID and SCB and lower ORs for achieving the PASS. Retear, large to massive tear, and older age showed lower ORs for achieving the MCID or SCB. For PASS items, male sex and biceps tenodesis had higher ORs, and older age had lower ORs. MCID, SCB, and PASS values per the sensitivity- and specificity-based approach were applied in factor analyses. CONCLUSION: Reliable MCID, SCB, and PASS values were obtained from patient evaluations 1 year after arthroscopic rotator cuff surgery. Poor preoperative score (MCID and SCB), male sex, and biceps tenodesis showed higher ORs, whereas poor preoperative score (PASS), retear, large to massive tear, and older age demonstrated lower ORs.

Risk Factors for Severe Proximal Humerus Fracture and Correlation Between Deltoid Tuberosity Index and Bone Mineral Density.

INTRODUCTION: The aims of this study were to investigate (1) whether demographic factors would be risk factors for severe proximal humerus fracture (PHF), (2) relationship of radiological parameters with bone mineral density (BMD), deltoid tuberosity index (DTI), or severe PHF, and (3) correlation between DTI and BMD. METHODS: We conducted a cross-sectional study based on radiographs and medical records taken during admission or the visit to the orthopedic clinic. We reviewed consecutive 100 adult patients who were diagnosed with PHF in our hospital from March 2014 to December 2016. Three- and 4-part fractures were regarded as severe PHFs. Univariable and multivariable logistic regression analyses were performed to evaluate risk factors for severe PHF. Also, we investigated the correlation between BMD and DTI using the additional BMD data of the patients who underwent shoulder surgeries. RESULTS: This study included 62 nonsevere PHFs and 38 severe PHFs. There were 30 male and 70 female patients with a mean age of 66.4 ± 16.4 years. Mean T score of BMD was -2.5 ± 0.9 at the time of injury. Logistic regression analyses showed that age (odds ratio: 1.044, range: 1.011-1.079, P = .009) and sex (odds ratio of females: 3.763, range: 1.236-11.459, P = .020) were related to severe PHF. The group satisfying the radiological parameter criteria had significantly higher rates of severe PHF. The correlation coefficient (r) between DTI and T score was 0.555 (P < .001). DISCUSSION AND CONCLUSION: Older age and female were the independent risk factors for severe PHF. Conversely, BMD and other medical comorbidities were not risk factors for severe PHF. Deltoid tuberosity index showed significantly high intraclass correlation coefficient and a strong correlation with the T score of BMD. Therefore, DTI may be useful for screening osteoporosis in PHF patients. LEVEL OF EVIDENCE: Level IV, Cross-sectional study.

A Combination Treatment of Raloxifene and Vitamin D Enhances Bone-to-Tendon Healing of the Rotator Cuff in a Rat Model.

BACKGROUND: Tearing and degeneration of the rotator cuff at the tendon-to-bone junction are common in adults aged ≥50 years. Few studies have reported on the relationship between estrogen and the rotator cuff enthesis. In addition to preventing bone loss, selective estrogen receptor modulators have been shown to improve tendon and muscle quality. PURPOSE: To evaluate the effects of raloxifene (RLX) and vitamin D on rotator cuff tendon-to-bone healing in a rat model. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 29 female rats (58 shoulders) were assigned to 4 groups: (1) control group, (2) ovariectomy (OVX)-only group, (3) no RLX group (OVX and rotator cuff repair [RCR]), and (4) RLX group (OVX, RCR, and RLX). Rats that did not undergo rotator cuff tear (RCT) surgery were divided into the control and OVX-only groups according to OVX surgery. Rats that underwent RCT surgery and RCR were divided into the no RLX and RLX groups according to RLX and vitamin D administration. An estrogen-deficient state was induced by OVX at 12 weeks of age. Bone mineral density (BMD) and trabecular bone characteristics were measured by micro-computed tomography, and healing of the tendon-to-bone junction was evaluated by biomechanical testing, histomorphometry, and micro-magnetic resonance imaging (MRI). RESULTS: The mean final body weight (BW; 461.6 ± 47.3 g) of the OVX-only group was significantly higher and BMD (0.25 ± 0.07 g/cm3) was significantly lower (P < .001) than the mean final BW (338.5 ± 35.1 g) and BMD (0.48 ± 0.05 g/cm3) of the control group. In contrast, the RLX group showed that the BW (369.6 ± 35.8 g) and BMD (0.41 ± 0.08 g/cm3) were not significantly different from the control group. The RLX group had a significantly higher histomorphometric total score (8.50 ± 1.05) than the no RLX group (4.83 ± 2.48). On biomechanical testing, the RLX group (29.7 ± 9.1 N) showed a significantly higher load to failure than the no RLX group (19.4 ± 8.8 N). On micro-MRI, the RLX group had a more homogeneous low signal and tendon continuity than the no RLX group. CONCLUSION: The combination treatment of RLX and vitamin D prevented a decrease in local BMD (greater tuberosity of the proximal humerus) and enhanced tendon-to-bone healing of the rotator cuff in a rat model. CLINICAL RELEVANCE: This study induced an estrogen-deficient state similar to the human postmenopausal state and used drugs that are actually being prescribed in a clinical situation.

An MRI-based decision tree to distinguish lipomas and lipoma variants from well-differentiated liposarcoma of the extremity and superficial trunk: Classification and regression tree (CART) analysis.

PURPOSE: To build and validate a decision tree model using classification and regression tree (CART) analysis to distinguish lipoma and lipoma variants from well-differentiated liposarcoma of the extremities and superficial trunk. METHODS: This retrospective study included patients who underwent surgical resection and preoperative contrast-enhanced MR imaging for lipoma, lipoma variants, and well-differentiated liposarcoma in two tertiary referral centers. Six MRI findings (tumor size, anatomical location, tumor depth, shape, enhancement pattern, and presence of intermingled muscle fibers) and two demographic factors (patient age and sex) were assessed to build a classification tree using CART analysis with minimal error cross-validation pruning based on a complexity parameter. RESULTS: The model building cohort consisted of 231 patients (186 lipoma and lipoma variants and 45 well-differentiated liposarcoma) from one center, while the validation cohort consisted of 157 patients (136 lipoma and lipoma variants and 21 well-differentiated liposarcoma) from another center. In the CART analysis, the contrast enhancement pattern (no enhancement or thin septal enhancement versus thick septal, nodular, confluent hazy, or solid enhancement) was the first partitioning predictor, followed by a maximal tumor size of 12.75 cm. The tree model allowed distinction of lipoma and lipoma variants from well-differentiated liposarcoma in both the model building cohort (C-statistics, 0.955; sensitivity 80 %, specificity 94.62 %, accuracy 91.77 %) and the external validation cohort (C-statistics, 0.917; sensitivity 66.67 %, specificity 95.59 %, accuracy 91.72 %). CONCLUSION: The distinction of lipoma and lipoma variants from well-differentiated liposarcoma can be achieved with the simple classification tree model.

Comparison Between Autografts and Allografts in Superior Capsular Reconstruction: A Systematic Review of Outcomes.

BACKGROUND: The treatment of irreparable rotator cuff tears (IRCTs) is a significant challenge, and various treatment options have emerged. Superior capsular reconstruction (SCR) is a promising procedure for patients with IRCTs. PURPOSE: To investigate the clinical outcomes of SCR and compare allografts with autografts. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A search for relevant articles was carried out using the PubMed, Cochrane Library, Embase, Scopus, and Google Scholar databases. We used medical subject heading (MeSH) terms and natural keywords (superior AND (capsule OR capsular) AND reconstruction). Also, we filtered for high-quality articles using the Methodological Index for Non-Randomized Studies (MINORS). We summarized the characteristic data and commonly used outcome measures of each included study and performed a descriptive analysis using an evidence-based tendency concept as proposed by Huisstede et al (2013). RESULTS: A total of 10 articles (374 shoulders) with a mean follow-up of 27.2 months were selected and analyzed. There were 4 articles on SCR with an autograft, 4 on SCR with an allograft, and 2 on SCR with both an autograft and allograft. For autografts and allografts, respectively, the mean gain in forward elevation (FE) was 48.7° and 33.3°, the visual analog scale for pain score improved by 3.5 and 3.3, the American Shoulder and Elbow Surgeons (ASES) score increased by 47.3 and 31.9, and the acromiohumeral distance increased by 1.2 and 1.8 mm. In addition, the number of graft tears was 16 (10.0%) and 17 (12.9%), the number of other complications was 12 (7.5%) and 6 (3.9%), and the number of reoperations was 5 (3.1%) and 14 (8.2%) for autografts and allografts, respectively. CONCLUSION: Both autografts and allografts improved clinical outcomes. Although the graft tear rate appeared similar between the autograft and allograft groups, the autograft group had no cases of conversion to reverse total shoulder arthroplasty. In addition, we found 3 evidence-based tendencies: (1) a tendency for both autografts and allografts to have significantly improved FE and clinical scores, (2) a tendency that autografts improved internal rotation and allografts improved abduction, and (3) a weak tendency that autografts improved abduction and allografts improved internal and external rotation. Although it was not possible to compare the groups statistically, the differences in ASES scores might be clinically important and will need to be explored in future comparative studies.

Loosening and revision rates after total shoulder arthroplasty: a systematic review of cemented all-polyethylene glenoid and three modern designs of metal-backed glenoid.

BACKGROUND: Several modern designs of metal-backed glenoids (MBG) have been devised to overcome flaws such as loosening and a high failure rate. This review aimed to compare rates of complications and revision surgeries between cemented polyethylene glenoid (PEG) and three examples of modern MBG designs. METHODS: Literature search was carried out using PubMed, Cochrane Library, EMBASE, and Google Scholar using MeSH terms and natural keywords. A total of 1186 articles were screened. We descriptively analyzed numerical data between the groups and statistically analyzed the categorical data, such as the presence of radiolucent line, loosening, and revision surgery (failure). Articles were divided into three groups based on follow-up duration: < 36-month, 36-72-month, and > 72-month subgroups. RESULTS: This study included 35 articles (3769 shoulders); 25 on cemented PEG and ten on the modern MBG. Mean age was 66.4 (21-93) and 66.5 years (31-88). The mean duration of follow-up was 73.1 (12-211) and 56.1 months (24-100). Overall, the rate of the radiolucent line was 354/1302 (27%) and 47/282 (17%), the loosening rate was 465/3185 (15%) and 22/449 (5%), and the failure rate was 189/3316 (6%) and 11/457 (2%), for PEG and MBG, respectively. The results of < 36-month and 36-72-month subgroups showed lower rates of radiolucency and loosening in the cemented PEG group, but there was no significant difference in failure rate (P = 0.754 and 0.829, respectively). In the > 72-month subgroup, MBG was better in terms of loosening (P < 0.001) and failure rates (P = 0.006). CONCLUSIONS: The modern MBG component, especially TM glenoid, seems to be a promising alternative to cemented PEGs, based on subgroup revision rates according to the follow-up duration and overall results of ROM and clinical scores. All polyethylene glenoids tend to increase loosening and failure over time. Three modern MBG designs seem to have no difference in failure, at least in the < 36-month and 36-72-month subgroups compared to the cemented PEG. More long-term follow-up studies on modern MBG should be ultimately conducted. LEVEL OF EVIDENCE: Level IV, systematic review.

Uniplane medial opening wedge high tibial osteotomy relative to a biplane osteotomy can reduce the incidence of lateral-hinge fracture.

PURPOSE: With surgical modifications reflecting plate design differences of the specific rigid locking plate adding a metal wedge, uniplane high tibial osteotomy (HTO) has fewer lateral-hinge fractures and fewer plate irritations than biplane HTO. METHODS: Uniplane HTO with a rigid locking plate adding a metal wedge was compared with biplane HTO with a rigid locking plate including a proximal D-hole. For comparison, the HTO patients' medical records and radiological results in a single institution were retrospectively reviewed. The Oxford knee score 2 years post-operation, CT scan at post-operative day 2 and serial standing long-bone scanography were reviewed to evaluate clinical outcome and radiological results, including the incidence of lateral-hinge fracture, plate irritation and correction loss to varus alignment. RESULTS: A total of 103 knees, including 59 uniplane HTO and 44 biplane HTO, were enrolled. The Oxford scores were 38.1 ± 7.8 in the uniplane group and 35.9 ± 8.3 in the biplane group (ns). On CT scans, more lateral-hinge fractures developed in the biplane group, and seven knees (12%) of the uniplane group and 12 knees (27%) of the biplane group had Takeuchi type I stable hinge fracture (p < 0.05); unstable fracture was not noted in either group. Plate irritation occurred in nine knees (19%) of the uniplane group and in 14 knees (32%) of the biplane group, and the difference was statistically significant (p < 0.05). CONCLUSION: In clinical situations including the use of surgical modifications reflecting plate design differences, fewer lateral-hinge fractures developed after uniplane medial opening-wedge HTO compared with biplane HTO. Uniplane HTO potentially represents a better option than biplane HTO for the prevention of lateral-hinge fracture. LEVEL OF EVIDENCE: IV.

Risk Factors for Diagnostic Failure of Ultrasound-Guided Core Needle Biopsy of Soft-Tissue Tumors Based on World Health Organization Classification Category and Biologic Potential.

OBJECTIVE. The purpose of this study is to evaluate the diagnostic outcome of ultrasound (US)-guided core needle biopsy (CNB) of soft-tissue tumors and to assess the factors associated with significant diagnostic failure. MATERIALS AND METHODS. We performed a retrospective analysis of biopsy specimens obtained from patients with soft-tissue tumors of the extremities and superficial trunk who underwent both US-guided CNB and surgical resection. In accordance with the World Health Organization classification, biopsy results and findings from final histologic analysis of the surgically resected specimen (hereafter known as final histologic findings) were categorized in terms of biologic potential as benign, intermediate (locally aggressive), intermediate (rarely metastasizing), or malignant. Biopsy results were considered to show a significant diagnostic failure if they resulted in incorrect classification of biologic potential compared with final histologic findings, if results were indeterminate, or if nondiagnostic specimens were obtained. World Health Organization classification categories and the biologic potential of the tumors according to final histologic findings were assessed to identify any relationship with diagnostic failure of CNB, as were other tumor- and patient-related factors. RESULTS. Significant diagnostic failure was seen for 40 of 303 biopsies (13.20%). Multivariate analysis showed a significant association between diagnostic failure and adipocytic tumors (odds ratio [OR], 9.686; p = 0.037) or vascular tumors (OR, 40.115; p = 0.005); intermediate (rarely metastasizing) biologic potential (OR, 12.279; p = 0.001), or malignant biologic potential (OR, 5.668; p < 0.001); and discordance between radiologic and final histologic findings or indeterminacy of biologic potential (OR, 2.500; p = 0.034). CONCLUSION. The World Health Organization classification categories (adipocytic or vascular), biologic potential (intermediate [rarely metastasizing] or malignant), and discordance between radiologic and final histologic findings or indeterminacy of biologic potential were found to be independent risk factors for significant diagnostic failure of CNB of soft-tissue tumors.

Range-of-motion improvement and complication rate in open and arthroscopic osteocapsular arthroplasty for primary osteoarthritis of the elbow: a systematic review.

PURPOSE: To analyze ROM changes by using a Bayesian method, to compare complication and re-operation rates between open osteocapsular arthroplasty (OPEN) and arthroscopic osteocapsular arthroplasty (ARTHRO) for primary osteoarthritis of the elbow, and find evidence-based tendencies. METHODS: The PubMed, Cochrane Library, and Embase databases were searched. We performed descriptive analysis to compare ARTHRO and OPEN, a Bayesian analysis of ROM changes, and methodological assessment to determine the tendencies of OPEN and ARTHRO. RESULTS: Eighteen articles (625 patients, 634 elbows) were analyzed. There were 11 articles on OPEN and 8 articles on ARTHRO (1 article was a comparative study between OPEN and ARTHRO). According to the Bayesian method, flexion and total arc of flexion-extension increased more with OPEN than with ARTHRO. Further, ARTHRO showed a narrower width in the ROM graph than OPEN. The number of complications was 17 (5.1%) and five (2.0%), and the number of re-operations was 32 (9.5%) and 14 (5.6%) for OPEN and ARTHRO, respectively. By analyzing six high-quality articles, we found three tendencies: OPEN and ARTHRO were both effective for improving pain score, flexion-extension arc, and functional outcome; OPEN did not improve the pronation-supination arc; and there was a weak tendency that OPEN was more effective than ARTHRO for improving the flexion arc. CONCLUSION: Both OPEN and ARTHRO improved ROM and clinical scores. The Bayesian method indicated that although OPEN increased the flexion and flexion-extension arc more than ARTHRO, ARTHRO resulted in a relatively consistent surgical outcome. Additionally, OPEN caused relatively higher complication and re-operation rates than ARTHRO.