Extra-Articular Abscess Expansion as a Specific Complication of Septic Arthritis of the Shoulder Joint: Report of Three Cases with Extension of the Infection through the Biceps Groove Producing a Large Abscess.

BACKGROUND: Septic arthritis of shoulder is a rare clinical entity as the metaphysis is extracapsular and there is no communication between epiphyseal and metaphyseal vessels. Septic arthritis of the shoulder joint is a diagnostic and surgical emergency because joint destruction develops rapidly and can cause significant morbidity and mortality. Unusual complications of septic arthritis of the shoulder joint may include extra-articular abscess extension to the upper arm through the biceps groove and osteomyelitis of the greater tuberosity. CASE PRESENTATION: Septic arthritis of the shoulder, if left untreated, can lead to complications such as extra-articular abscess extension and osteomyelitis. Three patients with septic arthritis of the shoulder joint with no clear history of trauma were reported in this study. The initial presentation was pseudoparalysis with upper arm swelling. MRI diagnosed septic arthritis of shoulder joint together with an upper arm abscess. Arthroscopic debridement with through irrigation and open drainage of the extra-articular abscess extension to the upper arm improved both the shoulder pain and abscess completely. However, if shoulder pain or abnormalities in laboratory findings continue after initial treatment, uncontrolled septic arthritis or secondary osteomyelitis are possibilities that should be concerned. MRI is a useful tool for detecting those atypical complications. CONCLUSIONS: Rarely, septic arthritis of the shoulder joint can extend to the upper arm through the biceps tendon groove and cause an abscess. Also, acute osteomyelitis of the tuberosity should be considered in patients with long-standing refractory septic arthritis of the shoulder joint who have continued pain and uncontrolled laboratory findings after initial treatment.

Complications and Reinterventions of Reverse Total Shoulder Arthroplasty in a Korean Population: 14-Year Experience in Reverse Shoulder Arthroplasty.

Background: There are few reports on the revision or reintervention of reverse total shoulder arthroplasty (RTSA) in South Korea. The purpose of this study was to evaluate the true incidence of complications and reintervention of RTSA and clinical and radiological outcomes based on our 14-year experience in RTSA in a Korean population. Methods: Between March 2008 and June 2022, 412 consecutive cases of RTSA were performed in 388 patients with an average age of 74.4 years at our institute. Excluding 23 patients lost to follow-up, 365 patients (373 shoulders including 8 bilateral cases) who underwent primary RTSA with more than 6 months of follow-up were enrolled in this study. We evaluated those who had complications or reintervention including revision RTSA for failed RTSA. Patient charts were reviewed, and clinical outcomes including clinical scores, complications, and reintervention and radiologic outcomes were evaluated at the last follow-up. Results: Among the 373 shoulders that underwent primary RTSA, complications were found in 50 patients (13.94%, 10 men and 40 women with a mean age of 75.9 ± 6.7 years [range, 51-87 years]). The causes of complications were as follows: 13 acromion, coracoid, or scapular spine fractures, 10 loosening (glenoid: 5, humeral stem: 5), 5 infections, 4 periprosthetic fractures, 2 instability, 2 neurologic complications, and 14 miscellaneous complications. Twenty patients (5.63%, 4 men and 16 women with a mean age of 74.2 ± 8.2 years [range, 51-87 years]) underwent reintervention. The interval to the first reintervention was 27.8 ± 23.1 months (range, 0.1-78 months). The causes of reintervention (20 cases) were 8 loosening (glenoid: 4, humeral stem: 4), 5 infections, 5 fractures, and 2 instability. Among them, 15 component revisions (4.02%) were performed. At the last follow-up, American Shoulder and Elbow Surgeons, University of California at Los Angeles, and Simple Shoulder Test scores were improved from 25.4, 12.4, and 1.6 preoperatively to 40.4, 16.2, and 3.2, respectively. Forward flexion (48° to 87°), abduction (52° to 79°), external rotation (18° to 22°), and internal rotation (buttock to L2) were improved. Conclusions: After primary RTSA in a Korean population, the complication, reintervention, and revision rates were 13.94%, 5.63%, and 4.02%, respectively. Careful evaluation of the complications and adequate treatments should be performed.

Arthroscopic cuff repair: footprint remnant preserving versus debriding rotator cuff repair of transtendinous rotator cuff tears with remnant cuff.

BACKGROUND: In transtendinous full thickness rotator cuff tears (FTRCT) with remnant cuff, conventionally, cuff remnant of the greater tuberosity (GT) is debrided for better tendon to bone healing. However, larger cuff defect caused overtension on the repaired tendon. The purpose of this study was to compare the clinical outcomes and tendon integrity between remnant preserving and remnant debriding cuff repairs in the transtendinous FTRCT with remnant cuff. METHODS: From March, 2012 to October, 2017, a total of 127 patients who had the transtendinous FTRCT with remnant cuff were enrolled in this study. Rotator cuff tears were repaired arthroscopically, with patients divided into two groups: group I (n = 63), where rotator cuff remnants were preserved during the repair, and group II (n = 64), where the remnants were debrided during the repair. Clinical outcomes were assessed at the last follow-up (minimum 2 years) using the UCLA score, ASES score, SST score, Constant Shoulder score, and range of motion (ROM). The analysis of structural integrity and tendon quality was performed using the Sugaya classification on postoperative MRI scans at 8 months after surgery. RESULTS: At the final follow-up, UCLA, ASES, SST, and CS scores significantly improved from preoperative values to postoperative (all p < 0.05): UCLA (I: 19.6 ± 6.0 to 31.7 ± 3.2, II: 18.0 ± 5.7 to 31.5 ± 3.2), ASES (I: 54.3 ± 10.7 to 86.5 ± 12.5, II: 18.0 ± 5.7 to 85.8 ± 12.4), SST (I: 5.6 ± 2.8 to 10.2 ± 2.0, II: 5.0 ± 2.9 to 10.1 ± 2.5), CS (I: 74.0 ± 17.2 to 87.8 ± 9.7, II: 62.0 ± 19.2 to 88.3 ± 6.2). However, there were no significant differences between the two groups (p > 0.05). Also, remnant preserving cuff repair yielded significantly better tendon quality on postoperative MRI (p < 0.05). The incidence of re-tear (Sugaya's Type IV and V) was not significantly different between the two groups (I:17% vs. II:19%; p = 0.053). CONCLUSIONS: Remnant preserving rotator cuff repairs, which facilitate tendon-to-tendon healing, are superior in terms of tendon quality and are the preferred option for transtendinous FTRCT. TRIAL REGISTRATION: Retrospectively registered.

Comparison between arthroscopic suture anchor fixation and open plate fixation in the greater tuberosity fracture of the proximal humerus.

INTRODUCTION: The purpose of this study is to compare the clinical and radiological outcomes of patients undergoing open reduction and internal fixation (OR/IF) using a plate or patients undergoing an arthroscopic suture anchor fixation for the greater tuberosity (GT) fracture of the proximal humerus. The purpose of this study is to compare the clinical and radiological outcomes of patients undergoing OR/IF or an arthroscopic suture anchor fixation for the GT fracture. MATERIALS AND METHODS: Between January, 2010 and December, 2020, 122 patients with GT fracture underwent operative fixation. Either OR/IF using proximal humeral locking plate (50 patients) or arthroscopic suture anchor (72 patients) fixation was performed. Fourteen patients were lost to follow-up and finally, 108 patients were enrolled in this study. We divided these patients into two groups: (1) OR/IF group (Group I: 44 patients) and arthroscopic anchor fixation group (Group II: 64 patients). The primary outcome was subjective shoulder function (shoulder functional scale). Secondary outcomes were range of motion, and complications including GT fixation failure, fracture migration, or neurologic complication. Also, age, sex, BMI, operation time, shoulder dislocation, fracture comminution, AP (anteroposterior), SI (superoinferior) size and displacement were evaluated and compared between two groups. RESULTS: Both groups showed satisfactory clinical and radiological outcomes at mid-term follow-up. Between 2 groups, there were no significant differences in age, sex, BMI, presence of shoulder dislocation or comminution. Group II showed higher clinical scores except VAS score (p < 0.05) and longer surgical times (95.3 vs. 61.5 min). Largest fracture displacement (Group I vs. II: SI displacement: 40 vs. 13 mm, and AP displacement: 49 vs. 11 mm) and higher complication rate (p = 0.049) was found in Group I. CONCLUSIONS: Both arthroscopic anchor fixation and open plate fixation methods showed satisfactory outcomes at mid-term follow-up. Among them, OR/IF is preferred for larger fracture displacement (> 5 mm) and shorter operation time However, arthroscopic anchor fixation group showed better clinical outcomes and less complications than the OR/IF group. LEVEL OF EVIDENCE: Level 4, Case series with subgroup analysis.

Effects of Arthroscopic Atelocollagen Insertion in High-Grade Partial Articular Supraspinatus Tendon Avulsion Lesions: A Retrospective Cohort Study With Propensity Score Matching.

Background: This study sought to evaluate the effect of atelocollagen insertion into the bone-tendon interface of the repaired tendon after arthroscopic rotator cuff repair for high-grade partial articular supraspinatus tendon avulsion (PASTA) lesions. Purpose: To compare clinical and radiological outcomes of atelocollagen-inserted rotator cuff repair and atelocollagen-noninserted rotator cuff repair in the high-grade PASTA lesions. Study Design: Cohort study; Level of evidence, 3. Methods: The data from 301 consecutive patients who underwent arthroscopic rotator cuff repair of PASTA lesions between January 2017 and June 2020 were retrospectively reviewed. Patients with minimum 2-year follow-up data were included and divided into 2 groups: those treated with transtendon suture-bridge repair without additional augmentation (group 1) and those with atelocollagen-inserted transtendon suture-bridge repair (group 2). Patients in group 2 were matched 1:1 to patients in group 1 using propensity score matching (n = 68 per group); and pain visual analog scale, American Shoulder and Elbow Surgeons, University of California, Los Angeles, Korean Shoulder Scoring System, Simple Shoulder Test, and range of motion scores were compared between these groups. Also, repaired tendon integrity and thickness were compared immediately, 6 months, and 1 year after surgery on magnetic resonance imaging (MRI) using the vertical distance from the midpoint footprint of the greater tuberosity. Results: In most comparisons, there were no significant differences in outcome measures and range of motion between groups. However, less residual discomfort at the final follow-up was also documented in group 2 (P = .043). Also, the difference in forward flexion was 3.7° at 1 year and 5.4° at final follow-up, and the difference in abduction was 2.2° at final follow-up, which were all significantly greater in the experimental group. Group 2 showed significant greater tendon thickness of the repaired tendon immediately, 6 months, and 1 year after surgery on MRI (P≤ .001). Conclusion: Addition of atelocollagen did not improve outcome scores. However, there was slightly greater flexion and abduction at final follow-up. Also, there was less residual discomfort at final follow-up.

Metallosis-Induced Conversion Shoulder Arthroplasty: A Unique Experience and Literature Review.

BACKGROUND: Total shoulder arthroplasty (TSA) can fail for several reasons, such as component loosening, periprosthetic fracture, instability, infection, soft tissue failure, or joint overstuffing. Severe metallosis without loose glenoid components after TSA may result in the need for revision to reverse TSA. CASE PRESENTATION: Four years before the current presentation, an 86-year-old woman suffered from right shoulder pain and swelling. The initial diagnosis was osteoarthritis of the shoulder joint, for which she underwent TSA. Four years later, she complained of shoulder joint pain, swelling, and limited range of motion. On sonography, subscapularis and supraspinatus tendon tears were identified. Plain radiographs and computed tomography (CT) scans showed metallosis around the shoulder joint. Due to the rocking horse mechanism, wear of the upper portion of the glenoid component and bearing caused a foreign-body reaction and severe metallosis around the joint. Due to a massive rotator cuff tear combined with glenoid component wear, the patient eventually underwent reverse TSA (RTSA) and was satisfied with the final results. CONCLUSIONS: Severe metallosis due to glenoid component wear combined with a massive rotator cuff tear in TSA may cause the need for revision to RTSA.

Mid-term comparative study between the glenoid and humerus lateralization designs for reverse total shoulder arthroplasty: which lateralization design is better?

INTRODUCTION: The complications of the conventional medialized design for reverse total shoulder arthroplasty (RSA) are increased scapular notching, and decreased external rotation and deltoid wrapping. Currently, lateralization design RSA, which avoid scapular notching and improve impingement-free range of motion, is commonly used. Especially, humeral lateralization design was most commonly used and glenoid lateralization design was preferred for glenoid abnormities. We compared mid-term clinical and radiologic outcomes of glenoid and humeral lateralization RSA in an Asian population in this study. MATERIALS AND METHODS: We enrolled 124 shoulders of 122 consecutive patients (mean age 73.8 ± 6.8 years) who received glenoid or humeral lateralization RSA from May, 2012 to March, 2019. We divided these patients into two groups according to RSA using either glenoid or humeral lateralization design. These different designs were introduced consecutively in Korea. The clinical and radiological results of 60 glenoid lateralization RSA (Group I, 60 patients) and 64 humeral lateralization RSA (Group II, 62 patients) were retrospectively evaluated and also were compared between the two groups. All patients were followed for mean 3 years. RESULTS: The clinical and radiologic outcomes of the two groups did not differ significantly, including scapular notching (p = 0.134). However, humeral lateralization RSA showed a larger glenoid-tuberosity (GT) distance (p = 0.000) and less distalization shoulder angle (DSA) (p = 0.035). The complication rate did not differ significantly either. But, revision surgery was performed for 2 humeral loosening in the Group II. CONCLUSION: The clinical and radiologic outcomes of the two groups did not differ significantly, including scapular notching at mid-term follow-up. However, humeral lateralization design showed larger GT distance and less DSA. Humeral lateralization design RSA could preserve the normal shoulder contour due to a larger GT distance (more lateralization) and provide less deltoid tension due to less DSA (less distalization of COR).

Low Transcondylar Fractures of the Distal Humerus: A Multicenter Cohort Study.

OBJECTIVES: To determine the demographic characteristics and clinical and radiologic results of low transcondylar fractures and compare them with those of other types of distal humerus fractures using multicenter data and to suggest an optimal method for their treatment. DESIGN: Retrospective cohort study. SETTING: Tertiary-care university hospital. PATIENTS: Between 2009 and 2019, 581 patients who underwent surgery for distal humerus fractures (OTA/AO classification A1 to C3) were enrolled at 7 university-affiliated hospitals. INTERVENTION: Internal fixation of low transcondylar fractures. MAIN OUTCOME MEASURES: Demographic characteristics, including sex, age, mechanism of injury, fixation methods, and complications, were compared between low transcondylar (group A) and other distal humerus (group B) fractures. Clinical outcomes assessed included pain, stability, and range of motion. Radiographs obtained at the latest follow-up were assessed for union, delayed union, nonunion, and implant failure. RESULTS: Mean age was 62.1 ± 19.1 (range, 20-95) years, and it was higher in group A (n = 100) than in group B (n = 376). Patients in group A were predominantly women. Low-energy trauma, such as that from a simple fall, was the most common cause of fracture in group A. Both column fixation, including parallel and orthogonal double plating, was performed more commonly in group A than in group B (87.4% vs. 66.4%, P < 0.001). The nonunion rate was higher in group A, but the difference was not significant. The incidence of ulnar nerve-related symptoms was higher in group A after surgery (6.3% vs. 2.0%, P = 0.003). No significant difference in clinical outcomes was found between the groups. CONCLUSIONS: Low transcondylar fractures occurred more frequently than other distal humerus fractures in older female patients and accounted for 21% of distal humerus fractures. The incidence of ulnar nerve-related symptoms was higher in patients with low transcondylar fractures after surgery. Clinical outcomes were not inferior in patients with low transcondylar fractures. The nonunion rate in patients with low transcondylar fractures treated with double plating was 3.6%. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparisons between treatment of isolated posterosuperior paralabral cysts and simultaneous treatment of cysts combined with associated shoulder pathologies: arthroscopic treatment of posterosuperior paralabral cysts.

INTRODUCTION: The purpose of this study is to report the radiologic and clinical outcomes of arthroscopic intervention for isolated posterosuperior paralabral cysts and simultaneous treatment of cysts combined with associated shoulder pathologies. MATERIALS AND METHODS: From March 2008 through December 2016, 70 cases (48 males and 22 females) operated on for symptomatic posterosuperior paralabral cysts were included. Mean age was 45 (range 18-69). These patients were classified into two groups depending on if they had accompanying lesions: Group I (isolated group, 27 patients) and Group II (concomitant group, 43 patients). Arthroscopic cyst decompression with a labral repair or posterior capsulotomy for patients without labral tear were performed. All concomitant pathologies were also operated simultaneously. Follow-up MRI were performed at postoperative 6 months and clinical outcomes were evaluated during the follow-up. RESULTS: Arthroscopic all intra-articular cyst decompression and labral repair was performed on 67 patients. In three patients, posterior capsulotomy without labral repair was performed for cyst removal. For 43 patients with concomitant lesions, 31 rotator cuff repairs, three SLAP repairs along with biceps tenodesis, two distal clavicle resections due to A-C joint arthritis, one calcific deposit removal, four Bankart repairs, and two acromioplasties were performed. The follow-up MRI showed complete cyst resorption except for two patients. The mean VAS, ASES, UCLA, SST and CS scores significantly improved at the last follow-up. Although both groups showed significantly improved range of motion after the surgery, improvement of ROM in Group II lagged at early periods of the rehabilitation. CONCLUSIONS: Arthroscopic labral repair with all intra-articular cysts decompression or simple posterior capsulotomy were both effective treatment modalities. If paralabral cysts were associated with other shoulder lesions, simultaneous treatment of combined lesions could be performed for the improved clinical outcomes at final follow-up with expected lag in the early rehabilitation period. LEVEL OF EVIDENCE: Level III, Retrospective Comparative Trial, Treatment Study.

Trans-tendon Suture Bridge Rotator Cuff Repair With Biceps Tendon Augmentation for Retorn High-Grade Partial Articular Supraspinatus Tendon Avulsion (PASTA) Lesions.

Revision repair of retorn partial articular supraspinatus tendon avulsion (PASTA) lesion is difficult for poor tendon quality without tear completion and repair. Trans-tendon suture bridge repair with biceps tendon augmentation can preserve the intact bursal side cuff attachment and has shown satisfactory clinical outcomes. Moreover, trans-tendon suture bridge rotator cuff repair technique, along with biceps tendon augmentation, reinforces high-grade PASTA lesions by moving the tenotomized biceps tendon into the torn articular side cuff defect with added advantage of blood supply through the tenotomized biceps tendon graft. Retear after trans-tendon repair of high-grade PASTA lesions was rare, and its poor tendon quality cause the revision repair to be too difficult. Without tear completion and rotator cuff repair, this arthroscopic trans-tendon suture bridge rotator cuff repair with biceps tendon augmentation is a reliable procedure that could be expected to produce improved short-term functional and radiologic outcomes, along with improved tendon quality of repaired tendon.

Clinical evaluation of usefulness and effectiveness of sitting type continuous passive motion machines in patients with total knee arthroplasty: a study protocol for a single-blinded randomized controlled trial.

BACKGROUND: Total knee arthroplasty (TKA) is an important management strategy for patients with knee osteoarthritis (OA) refractory to conservative management. Postoperative range of motion (ROM) exercise is important to recover patients' activities of daily living. Continuous passive motion (CPM) is a machine that provides passive ROM exercises of the knee joint in a pre-defined arc of motion. The short- and long-term effects of CPM exercise are controversial. We hypothesized that the inconsistent results of the CPM exercise are due to poor fitting of CPM machines and measurement errors. This study aims to present a protocol for investigating a new type of CPM machine that could be applied in a sitting position in comparison with the conventional type of CPM machine for patients with unilateral TKAs. METHODS: This study presents the protocol of a prospective, multicenter, single-blinded, three-armed randomized controlled trial (RCT). One hundred and twenty-six patients receiving unilateral TKAs will be recruited at the physical medicine and rehabilitation clinics of two urban tertiary medical hospitals. The patients were randomly divided into three groups with a 1:1:1 allocation. The intervention group will receive two weeks of post-operative rehabilitation using a new type of CPM machine. The control group will receive 2 weeks of post-operative rehabilitation using conventional CPM machines. The third group will receive post-operative rehabilitation with both types of CPM machines. The primary outcome will be the change in the passive ROM of the affected knee joint from baseline to 2 weeks after baseline assessment. The secondary outcomes will be pain and functional measurements, and will include patient-reported outcomes and performance tests surveyed at multiple time points up to 3 months after TKA. DISCUSSION: This is the first RCT to investigate the effect of a new type of CPM machine. The results of this RCT will determine whether the position of the patients during CPM exercise is important in post-operative rehabilitation protocols after TKAs and will provide evidence for the development of proper rehabilitation guidelines after TKAs. TRIAL REGISTRATION: Clinical Research Information Service of Republic of Korea, KCT0005520, Registered on 21 October 2020, https://cris.nih.go.kr/cris/search/detailSearch.do/21750.

Use of an intramedullary fibular strut allograft and dual locking plate in periprosthetic fractures above total knee arthroplasty: new application of a well-known treatment method in trauma.

PURPOSE: Augmenting fracture fixation with intramedullary fibular graft has seen several applications such as in comminuted proximal humerus fractures, and femoral neck and shaft nonunion. The purpose of this study was to report the first case series demonstrating the novel application of an intramedullary fibular allograft strut and dual locking plates on complicated periprosthetic fracture of distal femur. METHODS: The patient demographics, weight-bearing status, and radiographic and clinical outcomes of six patients, who were treated for periprosthetic distal femur fractures using an intramedullary fibular allograft strut and dual locking plate, between January 2018 and April 2020 were analyzed. RESULTS: Postoperative range of knee motion showed median 10' (range 10-20) of flexion contracture and 90' (range 80-110) of further flexion. Postoperative joint function was assessed according to the Kolmert functional criteria, with "excellent to good" in angular deformity and "Good to fair" result in range of motion and pain. RUSH score was assessed, and median score was 24 (range 18-26). All patients were able to ambulate without assistance 6 months after surgery. CONCLUSION: In summary, the application of fibular strut graft and dual locking plate might be an option in complicated distal femur fracture above total knee arthroplasty. Albeit with an available number, such application showed promise as an intramedullary and cortical support for both reduction and maintenance of correction alignment, length, and prevention of further angular deformity. LEVEL OF EVIDENCE IV: Surgical technique and Cases-series.

Biceps-incorporating rotator cuff repair with footprint medialization in large-to-massive rotator cuff tears.

PURPOSE: In large-to-massive rotator cuff tears (MRCTs), incorporating the long head of the biceps tendon (LHBT) with arthroscopic partial rotator cuff and margin convergence can improve clinical outcomes and preserve the acromio-humeral interval (AHI) during mid-term follow-up. The purpose of this study was to evaluate mid-term clinical and radiological outcomes of arthroscopic biceps-incorporating rotator cuff repair with partial release of the LHBT and footprint medialization through the Neviaser portal in MRCTs. METHODS: This study enrolled 107 patients (38 males and 69 females, mean age: 64.9 ± 8.6 years) with MRCTs. A novel arthroscopic biceps-incorporating repair was performed by footprint medialization, with a partially released biceps tendon covering central defects. Clinical outcomes such as pain VAS, KSS, ASES, UCLA, SST and CS scores and ROM were evaluated at a mean follow-up time of 35 months (range 12-132 months). Serial radiographs with a mean postoperative MRI follow-up duration of 33 months were used to evaluate AHI, tendon integrity, fatty infiltration (FI) and muscle hypotrophy. RESULTS: Postoperative pain VAS, KSS, ASES, UCLA, SST, and CS scores and ROM (except external rotation) were improved significantly. AHI also improved significantly from 8.6 to 9.3 mm. According to Sugaya's classification, type I, II, III, IV, or V healing status was found in 30 (28.0%), 29 (27.1%), 26 (24.3%), 14 (13.1%), and 8 (7.5%) patients, respectively. The retear rate was 22 (20.6%). CONCLUSIONS: Novel biceps-incorporating cuff repair with footprint medialization yielded satisfactory outcomes in MRCT patients at the 3-year follow-up. A partially released, repaired biceps tendon provided superior stability with preserved AHI similar to that of anterior cable reconstruction. LEVEL OF EVIDENCE: IV.

Transtendon Suture Bridge Repair of Both-Sided Partial-Thickness Rotator Cuff Tears: Midterm Outcomes.

BACKGROUND: Among symptomatic partial-thickness rotator cuff tears (PTRCT) indicated for surgery, both-sided (concurrent articular and bursal side) PTRCT are rarely reported and discussed in the literature. Without clinical data on and definite guidelines for treating these rare partial tears, appropriate management cannot be expected. PURPOSE: To calculate the prevalence of both-sided PTRCT and to evaluate clinical outcomes after arthroscopic transtendon suture bridge repair of both-sided PTRCT at a minimum 3-year follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Among symptomatic PTRCT that required arthroscopic surgery (765 patients) between March 2008 and December 2014, 178 both-sided partial tears were confirmed arthroscopically, and arthroscopic transtendon suture bridge repair was performed in 100 patients enrolled in our study after exclusion criteria were applied. The presence of concurrent articular and bursal side partial tears was confirmed via arthroscopy, with Ellman grade >2 on either the bursal or the articular side of these both-sided partial tears. Without tear completion, transtendon suture bridge repair was performed in all cases. Clinical outcomes including clinical scores and range of motion were evaluated at a mean of 5.3 ± 1.4 years (range, 3-8 years). Follow-up magnetic resonance imaging (MRI) was performed at 6 to 12 months (mean ± SD, 11 ± 5.20 months) after surgery to evaluate the tendon integrity (Sugaya classification) of the repaired rotator cuff. RESULTS: The mean age was 57.5 ± 7.8 years, and 65% of patients were women. Mean preoperative American Shoulder and Elbow Surgeons, University of California Los Angeles, Simple Shoulder Test, and Constant-Murley outcome scores of 52 ± 14, 19 ± 4, 6 ± 2, and 69 ± 10 significantly improved postoperatively to 94 ± 5, 33 ± 2, 11 ± 1, and 93 ± 5, respectively (P < .001). Mean forward flexion, abduction, external rotation, and internal rotation improved significantly from 148°± 31°, 134°± 39°, 22°± 13°, and L2 preoperatively to 154°± 17°, 151°± 60°, 29°± 14°, and T10 postoperatively, respectively (P < .001). The retear rate on follow-up MRI scans was 2%. As per Sugaya classification on postoperative MRI scans, type 1 healing was found in 29%; type 2, in 60%; type 3, in 9%; and type 4, in 2%. CONCLUSION: Among all symptomatic PTRCT that required surgery, both-sided PTRCT were more common than expected. Arthroscopic transtendon suture bridge repair of these both-sided PTRCT showed satisfactory clinical outcomes at a minimum 3-year follow-up.

Mid-term outcomes of bony increased offset-reverse total shoulder arthroplasty in the Asian population.

BACKGROUND: To evaluate clinical and radiological outcomes of bony increased offset-reverse total shoulder arthroplasty (BIO-RSA) in the Asian population at mid-term follow-up. METHODS: From June 2012 to August 2017 at a single center, 43 patients underwent BIO-RSA, and 38 patients with minimum 2 years follow-up were enrolled. We evaluated the clinical and radiological outcomes, and complications at the last follow-up. In addition, we divided these patients into notching and no-notching groups and compared the demographics, preoperative, and postoperative characteristics of patients. RESULTS: Visual analogue scale, American Shoulder and Elbow Surgeons, University of California-Los Angeles Shoulder Scale, and Simple Shoulder Test scores improved significantly from preoperative (5.00, 3.93, 1.72, 3.94) to postoperative (1.72, 78.91, 28.34, 7.66) (p<0.05) outcomes. All range of motion except internal rotation improved significantly at the final follow-up (p<0.05), and the bone graft was well-incorporated with the native glenoid in all patients (100%). However, scapular notching was observed in 20 of 38 patients (53%). In the comparison between notching and no-notching groups (18 vs. 20 patients), there were no significant differences in demographics, radiological parameters, and clinical outcomes except acromion-greater tuberosity (AT) distance (p=0.003). Intraoperative complications included three metaphyseal fractures and one inferior screw malposition. Postoperative complications included ectopic ossification, scapular neck stress fracture, humeral stem relaxation, and late infection in one case each. CONCLUSIONS: BIO-RSA showed improved clinical outcomes at mid-term follow-up in Asian population. However, we observed higher scapular notching compared to the previous studies. In addition, adequate glenoid lateralization with appropriate humeral lengthening (AT distance) might reduce scapular notching.

Incidence and risk factors of acromial fracture following reverse total shoulder arthroplasty.

BACKGROUND: The occurrence and related predictors of acromial fracture following reverse total shoulder arthroplasty (RTSA) have not been fully elucidated. The aim of this study was to determine the incidence and risk factors of acromial fractures after RTSA. METHODS: We conducted a multicenter, retrospective case-control study of 787 cases (29 in acromial fracture group and 758 in control group) that underwent RTSA performed by 6 surgeons. The mean duration of follow-up after RTSA was 31.6 ± 21.8 months (range, 12-136 months). Demographic variables (age, sex, arm dominance, body mass index, working status, bone mineral density [BMD]), clinical variables (preoperative diagnosis, previous operation, implant design, preoperative clinical scores, screw size in glenoid fixation, postoperative rehabilitation), and radiographic variables (acromial thickness, critical shoulder angle, deltoid length, humeral offset to lateral acromion) were investigated. To determine risk correlation, univariate analysis and multivariate logistic regression analysis with calculated odds ratios (ORs) were performed. RESULTS: Postoperative acromial fractures occurred in 29 of the 787 shoulders with RTSA (3.7%). Acromial fractures were detected at a mean of 10.0 months (range, 1-66 months) postoperatively. Univariate analysis revealed that the occurrence of an acromial fracture was significantly associated with a previous operation (38% [11 of 29] vs. 21% [156 of 758], P = .025) and BMD (-2.33 vs. -1.74, P = .013). Multivariate logistic regression analysis found that the occurrence of a postoperative acromial fracture was significantly associated with a previous operation (P = .034; OR, 2.91; 95% confidence interval, 1.08-7.84) and deltoid length (P = .004; OR, 1.04; 95% confidence interval, 1.01-1.07). CONCLUSION: Acromial fracture following RTSA is not an uncommon complication, with an overall incidence of 3.7%. A previous operation, increased deltoid length, and low BMD were risk factors of acromial fracture following RTSA.

Suture anchor fixation of comminuted inferior pole patella fracture-novel technique: suture bridge anchor fixation technique.

PURPOSE: Comminuted inferior pole fractures of the patella are notorious fractures where it is difficult to obtain rigid internal fixation by conventional tension band wiring. The purpose of this study is to evaluate the clinical and radiological outcomes of the suture bridge anchor fixation for these comminuted inferior pole fractures of the patella. METHODS: From March 2012 to December 2018, suture bridge anchor fixation for the inferior pole comminuted fracture of the patella was performed in 22 patients. There were 21 patients of inferior pole comminuted fracture and 1 patient of lower periosteal sleeve avulsion fracture. Clinical outcomes including SF-36 score, Knee injury and osteoarthritis outcome score (KOOS) and post-operative range of motion were evaluated. In all patients, suture bridge anchor fixation was performed and, tension band wiring with K wire was added for large fragment fixation in two patients. We evaluated bony union, the patellar height using Insall-Salvati ratio and its complications. RESULTS: Mean age was 46 ± 20 (15-82) years. Mean follow-up period was 25 ± 18 (11-74) months. In all patients, bony union was achieved at postoperative 4 months. At final follow-up, mean SF-36 score was 72 ± 15 (30-91) points and KOOS score was 66.7 ± 16 (43-97). The average range of motion was 134 ± 5 (125-140) degrees. As a complication, one patient developed a wound infection and subsequent osteomyelitis of inferior pole fracture fragment. Compared to the normal knee, the Insall-Salvati ratio of the injured knee averages 0.73 and this smaller ratio less than 0.8 meant patella baja. CONCLUSIONS: In the comminuted inferior pole fractures of the patella, suture bridge anchor fixation showed good bony union and satisfactory clinical outcomes at the short-term follow-up and could be a satisfactory alternative treatment option. Even though suture bridge anchor fixation in these fractures caused decreased Insall-Salvati ratio (patella height), any patellofemoral pain and limited range of motion was not developed. LEVEL OF EVIDENCE: Level IV.

Isolated calcific tendinitis at the posterosuperior labrum: a rare case study.

Calcific tendinitis of the shoulder joint, also known as chemical furuncle of the shoulder, causes intense shoulder pain and usually occurs within 1-2 cm from the insertion of the rotator cuff. We experienced a rare case of calcific tendinitis in the posterosuperior labrum of the shoulder joint in a 39-year-old male patient who presented with severe pain and weakness in the right shoulder. Radiographs and magnetic resonance imaging (MRI) findings showed calcific tendinitis in the posterosuperior labrum of the shoulder joint. A 1-week attempt at conservative treatment failed, so the calcified deposit in the posterosuperior labrum was arthroscopically removed. The patient's symptoms were completely relieved, and satisfactory clinical outcomes were achieved. Postoperative follow-up X-ray and MRI showed no recurrence of calcific tendinitis.

Identification of Differentially Expressed Genes Associated with Extracellular Matrix Degradation and Inflammatory Regulation in Calcific Tendinopathy Using RNA Sequencing.

Calcific tendinopathy (CT), developed due to calcium hydroxyapatite deposition in the rotator cuff tendon, mostly affects women in their 40 s and 50 s and causes severe shoulder pain. However, the molecular basis of its pathogenesis and appropriate treatment methods are largely unknown. In this study, we identified 202 differentially expressed genes (DEGs) between calcific and adjacent normal tendon tissues of rotator cuff using RNA sequencing-based transcriptome analysis. The DEGs were highly enriched in extracellular matrix (ECM) degradation and inflammation-related processes. Further, matrix metalloproteinase 9 (MMP9) and matrix metalloproteinase 13 (MMP13), two of the enzymes associated with ECM degradation, were found to be highly upregulated 25.85- and 19.40-fold, respectively, in the calcific tendon tissues compared to the adjacent normal tendon tissues. Histopathological analyses indicated collagen degradation and macrophage infiltration at the sites of calcific deposit in the rotator cuff tendon. Our study acts as a foundation that may help in better understanding of the pathogenesis associated with CT, and thus in better management of the disease.