The effect of continuous interscalene brachial plexus block for arthroscopic rotator cuff repair.

Background: Arthroscopic rotator cuff repair (ARCR) is a minimally invasive surgical technique. However, it is challenging to control postoperative pain. This study aimed to investigate the difference between a single-shot interscalene block and a combined continuous block for ARCR. Methods: Ninety-four patients who underwent ARCR were included in this study. In the preceding period, 43 patients received a single-shot interscalene block and continuous postoperative intravenous opioid infusion (Single group). In the posterior period, 51 patients received a single-shot interscalene block preoperatively and a continuous block postoperatively (Continuous group). Their mean age at surgery was 64.9 years (range, 43-83 years). The mean follow-up period was 25.4 months (range, 24-54 months). The numerical rating scale (NRS) of pain was evaluated immediately after the surgery, at rest, and at night for 1-4 days after the surgery. One day postoperatively, the amount of food taken was assessed from 0 % (no food intake) to 100 % (all food taken). The University of California at Los Angeles (UCLA) shoulder score, range of motion (ROM), and isometric shoulder strength were evaluated. Results: NRS at rest in the Continuous group on the day of surgery was 3.7 ± 2.5. This was significantly lower than in the Single group (5.2 ± 1.8) (P = 0.002). NRS at rest in the Continuous group on the second day after surgery was 3.0 ± 2.1, significantly lower than in the Single group (3.9 ± 1.8) (P = 0.04). The amount of food taken in the morning in the Continuous group was 61 % ± 37 %, which was significantly greater than in the Single group (35 % ± 41 %) (P = 0.004). The ROM of extension at 6 months postoperatively in the Continuous group was 47 ± 7°, which was significantly greater than in the Single group (43 ± 6°) (P = 0.02). The postoperative strength of the external rotator at 6 months in the Continuous group was 95 ± 33 N, significantly greater than in the Single group (78 ± 28 N) (P = 0.01). There was no significant difference in UCLA score at any time. Conclusion: The continuous interscalene block with ultrasound guidance in ARCR effectively relieved pain. The recovery of ROM for extension and the strength of the external rotator was better in the Continuous group.

Muscle belly ratio is the most suitable estimate of the activity of the torn supraspinatus muscle.

Background: A torn rotator cuff muscle deteriorates over time leading with an increase in muscle atrophy and fatty infiltration. There are several clinical assessments for evaluating the atrophy of the torn supraspinatus muscle. However, it is unclear which approach can more accurately estimate the activity of the torn supraspinatus muscle. The purpose of this study was to determine which magnetic resonance imaging-based muscle atrophy imaging assessment currently implemented in the clinical setting accurately estimates the activity of the torn supraspinatus muscle. Methods: Forty patients who were diagnosed with a rotator cuff tear and were candidates for repairs were selected for this study. Cross-sectional area, occupation ratio, and tangent sign were analyzed on T1-weighted oblique sagittal plane magnetic resonance images in which the scapular spine leads to the Y-section. Muscle belly ratio of the supraspinatus muscle was analyzed by calculating the ratio of the width of the muscle belly to the distance from the greater tubercle to the proximal end of the muscle on T1-weighted coronal plane magnetic resonance imaging images. Fatty infiltration was evaluated using the Goutallier classification system. Tear size was obtained intraoperatively by measuring the width and length of the tear and classified based on the Cofield's classification. To assess activity of the torn supraspinatus muscle, participants were first instructed to sit on a chair with the affected arm resting on a table and the shoulder abducted to 60° in the scapular plane with neutral rotation. Elasticity of the supraspinatus muscle belly was then obtained at rest and during isometric contraction using with real-time tissue elastography. Muscle activity, a surrogate for contractility, was defined as the difference between the elasticities measured at rest and during isometric contraction. A stepwise multiple regression analysis was used to investigate independent factors, such as sex, tear width, cross-sectional area, occupation ratio, tangent sign, and muscle belly ratio, related to muscle activity. Results: Stepwise multiple regression analysis (R2 = 0.522, P < .001) revealed that supraspinatus muscle activity was significantly correlated with muscle belly ratio (ß = 0.306, P = .044) and Goutallier stage (ß = -0.490, P = .002). Conclusion: Estimations of muscle belly ratio are most suitable for assessing the activity of a torn supraspinatus muscle compared to other clinical measurements.

Combining Cylindrical Bone Graft and Headless Screw Fixation for Nonunion of the Medial Trochlea of the Elbow: A Case Report.

CASE: A 19-year-old handballer presented with elbow pain and nonunion of the medial trochlea of the elbow. He had undergone earlier surgery for an elbow injury at 6 years of age. Revision surgery for nonunion was performed using an extra-articular method combining cylindrical bone graft and headless screw fixation. Partial union was observed, and he resumed sports after 3 months, with his limb largely pain-free and functional. At the 21-month follow-up, bone healing was complete. CONCLUSIONS: Combining cylindrical bone graft and headless screw fixation using the extra-articular technique is an option for managing nonunion of the medial trochlea of the elbow.

Factors correlated with the optimal tension for arthroscopic rotator cuff repair using Grasper Tensioning Attachment.

BACKGROUND: Little is known about the optimal tension in arthroscopic rotator cuff repair (ARCR). This study aimed to identify preoperative, intraoperative, and postoperative factors that correlate with the tension in ARCR and to determine the optimal intraoperative tension using Grasper Tensioning Attachment, a tension meter attached to the common arthroscopic surgical grasper. METHODS: This study included 63 patients with a mean age at surgery of 65.3 years (range, 45-83 years) who underwent ARCR. The mean follow-up period was 24.1 months (range, 24-28 months). We investigated the patients' demographic data, Japanese Orthopaedic Association score, DeOrio and Cofield classification, and Goutallier stage of the supraspinatus and infraspinatus muscles. We also evaluated cuff integrity based on the Sugaya classification via magnetic resonance imaging. The free edge of the torn retracted tendon was grasped, and the passive tension to the footprint was then measured with Grasper Tensioning Attachment with the arm at the side. The anteroposterior (AP) and mediolateral (ML) diameters were also measured. RESULTS: The preoperative Goutallier stage of the supraspinatus muscle was stage 0 in 7 cases, stage 1 in 34, stage 2 in 20, and stage 3 in 2. The mean intraoperative rotator repair tension was 10.0 ± 2.5 N (range, 7.5-17 N). The mean AP diameter of the rotator cuff tear was 22 ± 10 mm (range, 8-50 mm), and the mean ML diameter was 24 ± 10 mm (range, 10-50 mm). Age, DeOrio and Cofield classification, Goutallier stage, AP diameter, and ML diameter correlated with rotator repair tension. The rotator repair tension in Sugaya classification type III or IV cases (n = 12, 11.4 ± 2.4 N) was significantly larger than that in type I or II cases (n = 51, 9.7 ± 2.4 N; P = .03). Tension ≥ 10 N as a cutoff value from receiver operating characteristic curve analysis was a risk factor for poor cuff integrity (95% confidence interval, 0.53-0.88). CONCLUSIONS: Rotator repair tension ≥ 10 N was a risk factor for poor cuff integrity. Thus, care should be taken when performing intraoperative procedures and administering postoperative regimens.

A Systolic Blood Pressure of 100 mm Hg Is Optimal for Optimal Visualization in Arthroscopic Rotator Cuff Repair in the Beach-Chair Position.

PURPOSE: To investigate the relationship between visualization and blood pressure during arthroscopic rotator cuff repair (ARCR) in the beach-chair position and to clarify the optimal blood pressure to maintain good visualization during surgery. METHODS: One senior surgeon evaluated intraoperative visualization at the start of arthroscopy, at acromioplasty, at the refresh of the footprint on the greater tuberosity, at marrow vent creation in the footprint on the greater tuberosity, and at rotator cuff fixation. The evaluation grades were: 5, clear; 4, mild bleeding; 3, bleeding but operable; 2, poor visualization due to bleeding; and 1, inability to continue surgery due to massive bleeding. During ARCR, an arterial line was inserted, and blood pressure was measured continuously. The relationship between visualization and blood pressure was analyzed. Receiver operating characteristic analysis was performed with evaluation grades 5 and 4 as the good visualization group and the other evaluation grades as the poor visualization group. RESULTS: Visualization assessment and systolic/diastolic blood pressure were associated at the start of arthroscopy (P = .0257/.0057), at acromioplasty (P = .0023/.0399), and at the refresh of the footprint (P = .0201/.0272). The average blood pressure of evaluation grade 5 cases was 91/50 mm Hg. The cut-off values, based on the area under the curve on receiver operating characteristic analysis, were as follows: 104/60 mm Hg (0.91-0.95) at acromioplasty; 116/70 (0.94-0.96) at the refresh of the footprint; 116/70 mm Hg (0.94-0.96) at the refresh of the footprint; and 106/58 mm Hg (0.73-0.70) at marrow vent creation. CONCLUSIONS: Good visualization during ARCR in the beach-chair position was significantly associated with blood pressure. An optimal blood pressure resulting in good visualization that would not cause excessive hypotension during ARCR surgery in the beach-chair position might be a systolic blood pressure of 100 mm Hg. LEVEL OF EVIDENCE: III, prospective, nonrandomized, observational study.