Suture Contamination During Arthroscopic Rotator Cuff Repair Is Associated With Significantly Higher Retear Rates in Magnetic Resonance Imaging: A Matched-Pair Analysis.

PURPOSE: To evaluate the correlation between suture contamination and rotator cuff tendon retear after arthroscopic rotator cuff repair. METHODS: Patients undergoing primary arthroscopic rotator cuff repair from April 1, 2020, to September 30, 2022, were enrolled. Those younger than 18 years, with a history of shoulder surgeries or shoulder infection episodes, or who declined participation were excluded. A 5-cm section of the first-cut suture, originating from the anchor eyelet ends, in each rotator cuff repair surgery was subjected to bacteria culture and polymerase chain reaction analysis. Patients with positive culture findings were matched 1:1 to those with negative culture reports based on age, sex, tear size as well as involved tendons, preoperative fatty infiltration grade (Goutallier grade), and preoperative muscle atrophy grade (Warner score). Postoperative rotator cuff tendon retear assessments were conducted at the 6-month mark using the Sugaya classification via magnetic resonance imaging. The Wilcoxon signed-rank test was used for matched-pair comparisons between the groups. RESULTS: A total of 141 patients (60 men and 81 women) with a mean age of 61.0 ± 8 years were finally enrolled. Twenty-six patients (18 men and 8 women) had a positive culture, while 115 patients (42 men and 73 women) had a negative culture. After the propensity score matching process, 24 culture-negative patients (16 men and 8 women) were selected as the culture-negative group. Age, fatty infiltration grade, and muscle atrophy grade were not significantly different between matched groups. The retear grade in the culture-positive group was significantly higher than that in the culture-negative group (P = .020) under the matched-pair comparison. Cutibacterium acnes was the most prevalent bacterial species responsible for suture contamination. CONCLUSIONS: The matched-pair analysis revealed that the presence of bacterial contamination on sutures was associated with a higher risk of retear on magnetic resonance imaging following arthroscopic rotator cuff repair. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Factors associated with reparability of rotator cuff tears: a systematic review and meta-analysis.

BACKGROUND: To identify and quantify the factors associated with the reparability of rotator cuff tears (RCTs). METHODS: PubMed, Scopus, and Web of Science databases were searched for clinical studies published in English focusing on RCT reparability by using the keywords "rotator cuff tear" and "reparability". A meta-analysis was conducted if ≥3 studies examined the same factor and provided enough data to assess RCT reparability. Quality assessment was completed using the quality assessment of diagnostic accuracy studies tool. RESULTS: Eighteen studies (2700 patients) were enrolled and 26 factors were included in the meta-analysis. The dichotomous variables associated with irreparability were Patte stage 3 (odds ratio (OR): 8.0, 95% confidence interval [CI]: 4.3-14.9), massive tear vs. large tear (OR: 3.1, 95% CI: 1.3-7.2), Goutallier stage for each tendon, and tangent sign (OR: 11.1, 95% CI: 4.3-28.4). The continuous variables associated with irreparability were age (mean difference (MD): 3.25, 95% CI: 1.4-5.1), mediolateral tear size (MD: 12.3, 95% CI: 5.8-18.9), anteroposterior tear size (MD: 10.4, 95% CI: 5.2-15.6), acromiohumeral distance on X-ray (MD: -2.3, 95% CI: -3.0 to -1.6) and magnetic resonance imaging (MD: -1.8, 95% CI: -2.8 to -0.9), and inferior glenohumeral distance on magnetic resonance imaging (MD: 2.2, 95% CI: 1.4-3.0). CONCLUSION: This study revealed that older age, larger tear size, severe fatty infiltration, muscle atrophy, and advanced superior migration of the humeral head were strongly associated with irreparable RCTs. Conversely, clinical symptoms provided limited information for predicting reparability. Additionally, the tangent sign emerged as a powerful and simple tool for individual prediction, and several quantitative scoring systems also proved useful.

Biomechanical Comparisons of All-Suture Suspensory Button versus Interference Screw for Inlay Subpectoral Bicep tenodesis.

BACKGROUND: All-suture buttons (ASB) and interference screw (IS) are commonly utilized in the inlay subpectoral biceps tendon tenodesis. However, the biomechanical characteristics of these two methods have not been compared directly. The aim of present study was to compare the biomechanical properties of ASB versus IS for inlay subpectoral biceps tendon tenodesis in a human cadaveric model. METHODS: Sixteen fresh-frozen human cadaveric shoulders were randomly divided into two experimental inlay biceps tenodesis groups: ASB or IS. After tenodesis, every specimen was preloaded at 5 N for 2 minutes, followed with a cyclic loading test from 5 to 70 N for 500 load cycles. Then the load-to-failure test was performed. Afterwards, the humerus was placed in a cylinder tube and secured with anchoring cement. Lastly, a two-point bending test was performed to determine the strength of the humerus. Destructive axial force was applied, and the failure strength and displacement were recorded. RESULTS: No difference in stiffness was observed between the two groups (ASB=27.4 ± 3.5 N/mm vs IS= 29.7 ± 3.0 N/mm; P=.270). Cyclic displacement was significantly greater in the ASB group (6.8 ± 2.6 mm) than the IS group (3.8 ± 1.1 mm; P=.021). In terms of failure load, there were no statistical differences among the two groups (P=.234). The ASB group was able to withstand significantly greater displacement (11.9 ± 1.6 mm) before failure than the IS group (7.8 ± 1.5mm; P=.001). During the humeral bending test, the ASB group exhibited significantly greater maximal load (2354.8 ± 285.1 N vs 2086.4 ± 296.1 N; P=.046) and larger displacement (17.8 ± 2.8mm vs 14.1± 2.8 mm; P=.027) before fracture. CONCLUSIONS: In inlay subpectoral bicep tenodesis, ASB fixation appears to offer comparable stiffness and failure load to that of IS fixation. Additionally, the ASB group exhibited greater resistance to load and displacement before humeral fracture. However, the ASB group did demonstrate increased cyclic displacement compared to IS group.

Definition of irreparable rotator cuff tear: a scoping review of prospective surgical therapeutic trials to evaluate current practice.

BACKGROUND: The definition of irreparable rotator cuff tear (IRCT) is controversial. This scoping review provides definitions used to describe IRCT in the literature. This scoping review (1) identified criteria used in the definition of IRCT and (2) investigated the current state of those criteria in prospective surgical therapeutic trials. METHODS: This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. PubMed, Scopus, and Web of Science were searched in March 2023. Studies were screened against predetermined inclusion and exclusion criteria. Criteria regarding clinical symptoms, preoperative images, and intraoperative findings were captured respectively. RESULTS: A total of 41 prospective studies were eligible for inclusion, and 35 studies (85.4%) defined IRCT. IRCT was defined on the basis of the following main criteria: preoperative image findings (28/35), intraoperative findings (24/35), and symptoms (16/35). With regard to preoperative images, IRCT was mainly defined on the basis of retraction of the tendon in the coronal plane (22/28), the severity of fatty degeneration (19/28), and ruptured tendon number or width of the defect in the sagittal plane (17/28). CONCLUSION: This scoping review highlights the lack of a standardized definition for IRCT in clinical practice, with common predictive criteria including a duration of over 6 months, retraction beyond 5 cm, Goutallier grade 3 fatty infiltration, and the rupture of two or more tendons. However, surgeons should apply more than one criterion when examining preoperative images and confirm reparability during surgery. A more objective manner of evaluating intraoperative reparability is necessary.

Extended skin cleaning on the shoulder with chlorhexidine reduces the cutaneous bacterial load but fails to decrease suture contamination in patients undergoing arthroscopy rotator cuff repair.

BACKGROUND: It remains unclear whether preoperative skin cleaning of the chin, neck, and chest with chlorhexidine soap can reduce suture contamination by Cutibacterium acnes in patients undergoing arthroscopic rotator cuff repair. METHODS: This study included patients who underwent primary arthroscopic rotator cuff repair. Exclusion criteria included age <18 years, previous shoulder surgery, history of shoulder infection, and allergy to chlorhexidine. Patients were randomized into 3 groups. Patients in the control group cleaned their skin with soap and water, as usual. Patients in the shoulder group cleaned their shoulders with chlorhexidine soap 3 days before surgery, whereas patients in the extended shoulder group additionally cleaned their chest, back, neck, and face with chlorhexidine soap. On the day of surgery, skin swab samples were obtained from the shoulder after surgical draping. After rotator cuff repair, sutures were cut from the anchor ends. Both traditional culture methods and polymerase chain reaction (PCR) were used. RESULTS: Ninety patients were enrolled (32 in the control group, 29 in the shoulder group, and 29 in the extended shoulder group) in the present study. The culture-positive rate from the posterior shoulder skin samples in the extended shoulder group (17.2%) was significantly lower than that in the control (40.6%) and shoulder (48.3%) groups (P = .036), whereas the culture-positive rates were not different among the 3 groups in other skin samples as well as the suture samples. The detection rates of C acnes in suture samples were 12.5%, 13.8%, and 17.2% in the control, shoulder, and extended shoulder groups, respectively (P = .603). CONCLUSION: Extensive skin cleaning of the shoulder region with chlorhexidine helps reduce the shoulder cutaneous bacterial load, but the detection of C acnes suture contamination in patients undergoing arthroscopic rotator cuff repair remained untouched regardless of the use of chlorhexidine soap in skin cleaning on the preoperative days.

The characteristics and influence of iatrogenic fracture comminution following antegrade interlocking nailing for simple femoral shaft fractures, a retrospective cohort study.

AIM: The incidence and characteristics of iatrogenic comminution (IC) are unknown, and the influence of IC on fracture union is unclear. This study was aimed to investigate the (1) incidence and characteristics of IC and (2) the outcomes of IC following antegrade interlocking nailing of simple femoral shaft fractures. METHODS: We retrospectively collected data on patients who experienced simple femoral shaft fractures and underwent antegrade interlocking nailing between February 2009 and December 2016. The incidence and characteristics of IC were examined. According to the presence of IC, patients were divided into two groups: an IC group and a non-IC (NIC) group. Demographic information and nonunion rates were compared between the two groups. Potential risk factors for IC (age, gender, body mass index (BMI), nail fit ratio, reduction technique, and greater trochanter nail entry) were analyzed using univariate and multivariate logistic regression. The aforementioned variables, along with IC occurrence, were also assessed as potential risk factors for nonunion at 12 and 24 months after operation using multivariate logistic regression. RESULTS: Of the 211 total patients, IC occurred in 20.9% (n = 44) of patients. Most ICs were found at the level of the isthmus, and involved the medial cortex. Compared with the NIC group, higher nonunion rates were observed in the IC group at 12 months (31.8% vs. 12.5%, p = 0.002) and 24 months (18% vs. 6.5%, p = 0.017) after surgery. Age older than 35 years old was related with the occurrence of IC in univariate analysis. Multivariate analysis found no risk factor associated with IC. Open reduction technique, IC occurrence and higher BMI were identified as the risk factors of nonunion at 12 months and 24 months after surgery in multivariate analysis. CONCLUSION: IC is a non-rare complication in antegrade interlocking nailing of simple femoral shaft fractures and was associated with higher nonunion rate. Age older than 35 years old showed a trend toward increasing risk of iatrogenic fracture comminution. In multivariate analysis, open reduction technique, IC occurrence and higher BMI significantly correlated with fracture nonunion. LEVEL OF EVIDENCE: Level IV.

The lateral femoral notch sign and coronal lateral collateral ligament sign in magnetic resonance imaging failed to predict dynamic anterior tibial laxity.

PURPOSE: To investigate the relationship between the lateral femoral notch sign as well as the coronal lateral collateral ligament (LCL) sign and anterior tibial translation using the GNRB arthrometer in patients with anterior cruciate ligament (ACL) injuries. METHODS: Forty-six patients with ACL injuries were retrospectively included from May 2020 to February 2022; four patients were excluded due to incomplete data. Magnetic resonance imaging (MRI) were reviewed for the lateral femoral notch sign and the coronal LCL sign. The GNRB arthrometer was used to evaluate the dynamic anterior tibial translation of the knee, and the side-to-side differences (SSDs) in tibial translation between the injured knee and healthy knee were calculated at different force levels. Two types of slopes for displacement-force curves were acquired. RESULTS: Six patients (14.3%) had the positive lateral femoral notch sign (notch depth > 2.0 mm), and 14 patients (33.3%) had the positive coronal LCL sign. The SSD of the anterior tibial translations under different loads as well as the slopes of displacement-force curves were the same in the positive and negative notch sign groups (p all > 0.05) and between the positive and negative coronal LCL sign groups (p all > 0.05). Meanwhile, the measured notch depth and notch length were also not significantly correlated with the anterior tibial translation SSD in the GNRB. CONCLUSION: The presence of the lateral femoral notch sign and the coronal LCL sign did not indicate greater dynamic tibial laxity as measured using the GNRB.

Owen, Sugaya, and Hayashida Classifications Give Poor Intra- and Inter-Rater Agreement on a Magnetic Resonance Imaging Evaluation of Subscapularis Tendon Retears.

PURPOSE: To investigate the intra- and inter-rater agreements for magnetic resonance imaging (MRI) evaluations of subscapularis tendon integrity at 6 months after arthroscopic rotator cuff repairs. METHODS: Patients who had isolated or combined subscapularis tears and had undergone arthroscopic rotator cuff repairs were retrospectively included. The exclusion criteria included revision of arthroscopic surgery, minor subscapularis tears without repair, and inadequate postoperative images. MRI scans 6 months after surgery were used for the purpose of accessing the integrity of the subscapularis tendons. Three orthopaedic surgeons blindly evaluated the images twice at 2-week intervals. Three currently available classifications were used: the Owen classification, the Sugaya classification, and the Hayashida classification. Dichotomization and trichotomization methods were used for the Sugaya classification and Hayashida classifications. The aforementioned classification scores were combined for the agreement evaluation. Intra- and inter-rater agreement was assessed by calculating the Fleiss' kappa coefficients. RESULTS: A total of 35 patients were included. Both the Owen and Hayashida classifications had poor inter-rater agreements (κ = 0.10 and 0.04, respectively) and poor-to-weak intra-rater agreements (κ = 0.27-0.44 and 0.16-0.45, respectively). The Sugaya classification had poor inter-rater agreement (κ = 0.10) and poor intra-rater agreements (κ = 0.16-0.32). Dichotomization and trichotomization of Sugaya and Hayashida classifications did not lead to superior agreements. The classification combination resulted in poor inter- and intra-rater agreements (κ = 0.01-0.12 and 0.08-0.39, respectively). CONCLUSIONS: The Owen classification, Sugaya classification, and Hayashida classification had poor intra- and inter-rater agreement in terms of evaluating subscapularis tendon re-tears on 6 months' postoperative MRI. The dichotomized and trichotomized classifications as well as the combined classifications from currently available classifications did not lead to superior agreements. LEVEL OF EVIDENCE: Level IV, diagnostic: case series.

Biomechanical comparison between various screw fixation angles for Latarjet procedure: a cadaveric biomechanical study.

BACKGROUND: The Latarjet procedure is a reliable treatment for the management of anterior glenohumeral instability with glenoid bone loss. However, the biomechanical properties of different fixation angles between screw and glenoid surface (α angle) have rarely been studied. The aim of the study was to investigate and compare the fixation stability, failure load, and failure mechanism between different α angles for Latarjet procedures, which were performed on cadaver specimens. METHODS: Twenty-four shoulder specimens (8 in each of 3 groups) were dissected free of all soft tissue, and a 25% glenoid defect was created. The coracoid process was osteomized and fixed with 2 screws at 3 different α angles: 0° (group A), 15° (group B), and 30° (group C). Specimens were mounted to a testing apparatus, and cyclic loading (100 cycles at 1 Hz) was applied with a staircase protocol (50, 100, 150, and 200 N). Gross graft displacement and interface displacement were measured. The ultimate failure loads and failure mechanisms were recorded. RESULTS: There was no significant difference in gross displacement under any cyclic load between 3 groups. However, a significant larger interface displacement was noted in group C than in group A in 150-N cyclic loading (P = .017). Under failure strength testing, all 24 specimens failed because of screw cutout from the glenoid, and the ultimate failure load was similar among the three groups. CONCLUSION: Compared with the 0° α angle, the displacement after cyclic loading did not significantly increase when the α angle was increased to 15° but significantly increased at 30° for Latarjet procedures, which were performed on cadaver specimens. The results suggest that surgeons should apply the screws as parallel as possible to the glenoid surface when performing the Latarjet procedure. Although mild deviation may not reduce fixation stability, α angles greater than 30° should be avoided.

Biomechanical comparisons of hook plate and screw fixations in split-type greater tuberosity fractures of the humerus.

BACKGROUND: Screws and plate are commonly utilized for the fixation of split-type humeral greater tuberosity (GT) fractures. However, the mechanical properties of these 2 types of fixation methods have not been compared directly. The aim of the present study was to evaluate the classic 2 screws fixation with hook locking plate from a mechanical perspective. METHODS: Sixteen synthetic humerii (Sawbones Pacific Research Laboratories, Vashon, WA, USA) were divided into 2 groups. An osteotomy was performed to simulate a split-type GT fracture. Group A (n = 8) was fixed with 2 standard parallel screws. Group B (n = 8) was fixed with a hook plate. Each specimen was tested with traction force at 45° shoulder abduction. Following the 20-N preload, a 500-cycle loading test was applied with a force ranging from 20 to 200 N (valley/peak), and the interfragmental displacement was measured periodically at intervals of 100 cycles. Finally, all the specimens were pulled with destructive force at a rate of 5 mm/min until catastrophic failure. RESULTS: The hook plate exhibited greater construct stiffness than the screw fixation (63.2 ± 6.1 N/mm vs. 40.9 ± 3.4 N/mm, P < .001). All of the specimens completed the entire cyclic loading test without catastrophic failure, and the fragment displacement after 500 cycles was 0.4 ± 0.2 mm for the hook plate and 2.1 ± 0.3 mm for screw fixation, which was statistically lower in the plate group (P < .001). In terms of failure load, the hook plate group exhibited a significantly greater value than the screw group (770.6 ± 94.6 vs. 427.5 ± 45.1 N/mm, P < .001). The failure modes of both fixation methods were distinct. CONCLUSION: In humeral GT fracture fixation, hook plate fixation appears to offer greater construct stiffness and failure load while maintaining fragment stability to resist a physiological traction force. The current study provides support from a mechanical perspective for the clinical application of the hook plate.

Augmented cerclage wire improves the fixation strength of a two-screw construct for humerus split type greater tuberosity fracture: a biomechanical study.

BACKGROUND: Poor functional outcome can result from humeral greater tuberosity (GT) fracture if not treated appropriately. A two-screw construct is commonly used for the surgical treatment of such injury. However, loss of reduction is still a major concern after surgery. To improve the biomechanical strength of screw fixation in GT fractures, we made a simple modification of the two-screw construct by adding a cerclage wire to the two-screw construct. The purpose of this biomechanical study was to analyze the effect of this modification for the fixation of GT fractures. MATERIALS AND METHODS: Sixteen fresh-frozen human cadaveric shoulders were used in this study. The fracture models were arbitrarily assigned to one of two fixation methods. Group A (n = 8) was fixed with two threaded cancellous screws with washers. In group B (n = 8), all screws were set using methods identical to group A, with the addition of a cerclage wire. Horizontal traction was applied via a stainless steel cable fixed directly to the myotendinous junction of the supraspinatus muscle. Displacement of the fracture fixation under a pulling force of 100 N/200 N and loading force to construct failure were measured. RESULTS: The mean displacements under 100 N and 200 N traction force were both significantly decreased in group B than in group A. (100 N: 1.06 ± 0.12 mm vs. 2.26 ± 0.24 mm, p < 0.001; 200 N: 2.21 ± 0.25 mm vs. 4.94 ± 0.30 mm, p < 0.001) Moreover, the failure load was significantly higher in group B compared with group A. (415 ± 52 N vs.335 ± 47 N, p = 0.01), CONCLUSIONS: The current biomechanical cadaveric study demonstrated that the two-screw fixation construct augmented with a cerclage wire has higher mechanical performance than the conventional two-screw configuration for the fixation of humeral GT fractures. TRIAL REGISTRATION: Retrospectively registered.

Does posterior configuration have similar strength as parallel configuration for treating comminuted distal humerus fractures? A cadaveric biomechanical study.

BACKGROUND: The posterior plating technique could be used as a clinical alternative to parallel plating for treating comminuted distal humerus fractures (DHFs) successfully with good clinical results. However, the biomechanical characteristics for posterior fixation are still unclear. The purpose of this study is to evaluate the biomechanical properties of the posterior fixation and to make comparisons between the parallel and the posterior fixation systems. MATERIALS AND METHODS: We performed a cadaveric biomechanical testing with two posterior plating systems (a posterior two plating and a single posterior pre-contoured Y plating system) and one parallel two plating system to treat AO/OTA type-C2.3 DHFs. Among three groups, we compared construct stiffness, failure strength, and intercondylar width changes after 5000-cycle fatigue loading and failure loads and failure modes after destructive tests in both the axial compression and (sagittal) posterior bending directions. The correlations between construct failure loads and bone marrow density (BMD) were also compared. RESULTS: In axial direction, there were no significant differences in the stiffness and failure load between the posterior and the parallel constructs. However, in sagittal direction, the two-plate groups (posterior two plating and parallel plating group) had significant higher stiffness and failure loads than the one-plate group (single posterior Y plating). There was no fixation failure after 5000-cyclic loading in both directions for all groups. Positive correlation was noted between BMD and failure loads on parallel fixation. CONCLUSIONS: We found that when using two plates for treating comminuted DHFs, there were no significant differences in terms of most biomechanical measurements between posterior and parallel fixation. However, the single pre-contoured posterior Y plate construct was biomechanically weaker in the sagittal plane than the parallel and the posterior two-plate constructs, although there was no fixation failure after the fatigue test for all groups regardless of the fixation methods. LEVEL OF EVIDENCE: Biomechanical study.

The Chinese version of the American shoulder and elbow surgeons standardized shoulder assessment form questionnaire, patient self-report section: a cross-cultural adaptation and validation study.

BACKGROUND: The patient self-report section of the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASESp) is one of the most validated and reliable assessment tools. This study aimed to establish a validated Chinese version of ASESp (ASESp-CH). METHODS: A clinical prospective study was performed (ClinicalTrials.gov Identifier: NCT04755049; registered on 2021/02/11). Following the guidelines of forward-backward translation and cross-cultural adaptation, a Chinese version of ASESp was established. Patients older than 18 years with shoulder disorders were included. Patients who could not complete test-retest questionnaires within the interval of 7-30 days and patients who received interventions were excluded. Intraclass correlation (ICC) was calculated for test- retest reliability, whereas internal consistency was determined by Cronbach value. Construct validity was evaluated by comparing the corresponding domains between the ASESp-CH and a validated Chinese version of 36-Item Short Form Health Survey (SF-36). RESULTS: A total of 86 patients were included with a mean test-retest interval of 12 ± 5.4 days. Test-retest reliability was excellent with an ICC of 0.94. Good internal consistency was found, with a Cronbach alpha of 0.86. Construct validity of the ASESp-CH questionnaire was good. The major domains of the ASESp-CH were significantly correlated with the respective domains in the SF-36 (p <  0.01), except for the domain of stability of ASESp-CH. CONCLUSIONS: The Chinese version of ASESp questionnaire is a highly validated and reliable tool for shoulder disorder assessment.

A biomechanical comparison of two screw fixation methods in a Letenneur type I Hoffa fracture.

BACKGROUND: The treatment of Hoffa fractures is challenging, for which the ideal fixation and approach are still controversial. Osteosynthesis with plate or screws fixation in different trajectories have been described in previous literature. The purpose of this study was to compare the biomechanical strength and stability of two types of screw trajectories used to stabilize displaced coronal fractures of the lateral femoral condyle. METHODS: Sixteen synthetic femurs (Sawbones Pacific Research Laboratories, Vashon, WA) were divided into two groups. A vertical osteotomy was performed to mimic a Letenneur type I Hoffa fracture. Group A (n = 8) was fixed with screw in anteroposterior direction (A-P) screws. Group B (n = 8) was fixed with crossed screws. Both groups were tested with a nondestructive axial compression aligned with the femur axis. After that, 10,000 cyclic loading tests were applied to the specimen with a force ranging between 200 to 600 N, and the interfragmental displacement was recorded, respectively, after 10, 100, 1000 and 10,000 cycles. Finally, a destructive axial compression test was applied until catastrophic failure. RESULTS: There were no statistical between-group differences in regard to the average axial stiffness, interfragmental displacement, and ultimate failure load. The average axial stiffness of the A-P screw was comparable to that of the crossed screw (361 ± 113 N/mm vs. 379 ± 65 N/mm, p = 0.753). All specimens completed the entire cyclic loading test without catastrophic failure, and the interfragmental displacement after loading for 10,000 cycles was 1.36 ± 0.40 mm for the A-P screw and 1.29 ± 0.61 mm for the crossed screw, there were no statistical differences between the groups (p = 0.823). The average ultimate failure loads for the A-P and crossed screws were 1214 ± 127 N and 1109 ± 156 N, respectively (p = 0.172). CONCLUSIONS: Based on our in vitro study, the crossed screws can provide comparable mechanical performance as traditional A-P screws in Hoffa fracture fixation. Considering the screws trajectories are commonly determined by the choice of surgical approach, the current study provides support from a biomechanical perspective for the application of crossed screws in direct lateral approach.

Using Interconnected Knotless Anchor for Suprapectoral Biceps Tenodesis Could Offer Improved Biomechanical Properties in a Cadaveric Model.

PURPOSE: To compare the biomechanical characteristics of the interconnected knotless anchor (IKA) fixation with the double knotless anchor (DKA) and interference screw (IS) fixation in the suprapectoral biceps tenodesis. METHODS: In total, 24 fresh-frozen human cadaveric shoulders (mean age, 67.3 ± 6 years) were used for the study. All the specimens were randomly divided into 3 experimental biceps tenodesis groups (n = 8): IKA, DKA, and IS. After tenodesis, each specimen was preloaded at 5 N for 2 minutes, followed by a cyclic loading test from 5 to 70 N for 500 load cycles. Finally, a destructive axial load to failure test (1 mm/s) was performed. All the values, including ultimate failure load, stiffness, cyclic displacement, and mode of failure were evaluated. RESULTS: The IKA provided the highest construct stiffness (38.9 ± 7.7 N/mm) and ultimate failure load (288.3 ± 47.6 N), the results for which were statistically better than the corresponding results in the IS and DKA groups. In terms of cyclic displacement, there were no statistical differences among the 3 fixation constructs. The most common failure mode was biceps tendon tearing in IS group (7/8) and IKA group (8/8). In the contrast, suture slippage accounted for the most common failure mode in DKA. CONCLUSIONS: In suprapectoral bicep tenodesis, IKA fixation appears to offer improved construct stiffness and ultimate failure load while maintaining comparable suture slippage as compared with IS fixation or DKA fixation in the current biomechanical study. CLINICAL RELEVANCE: The IKA fixation compares favorably with other techniques and could be an alternative clinical option for suprapectoral biceps tenodesis.

The Double Krackow Suture Technique Does Not Offer a Significant Benefit Compared to the Krackow Suture Technique in Subpectoral Biceps Tenodesis Using a Double-Loaded Suture Anchor.

PURPOSE: To compare the biomechanical properties of the double simple suture (DSS) technique, Krackow suture (KS) technique, and double Krackow suture (DKS) technique in subpectoral biceps tenodesis using a double-loaded suture anchor in a porcine tendon model. METHODS: A total of 30 artificial composite (polymer and glass fiber) humeri and porcine flexor profundus tendons with diameter of 4.5 mm were used. The sample size was determined based on the results of the pilot study. Metallic suture anchors with double-loaded No. 2 braided sutures were inserted at the subpectoral tenodesis site, 5 cm from the superomedial corner of the greater tuberosity. Three suture techniques were used to fix the tendons: a DSS used as the control, a KS, and a DKS, which is an alternative tendon graft fixation technique. A preload of 5 N was applied for 2 minutes, followed by cyclic loading for 500 cycles ranging from 5 to 70 N; next, a load-to-failure test at 1 mm/s was performed. RESULTS: The KS (283.5 ± 57 N) and DKS (270.4 ± 50 N) groups had significantly greater ultimate failure loads as compared with the DSS group (84.1 ± 6.4 N) (P < .001). Meanwhile, the peak displacement at failure loads in the KS group (9.3 ± 2.2 mm) and DKS group (7.8 ± 1.7 mm) were significantly smaller than that of the DSS group (11.3 ± 2.9 mm) (P = .015). Stiffness in the DSS group (36.4 ± 3.0 N/mm), KS group (39.6 ± 2.5 N/mm), and DKS group (36.9 ± 4.6 N/mm) was not significantly different (P = .125). All DSS constructs and 6 KS constructs failed with tendons being cut through by the sutures, whereas the other 4 KS constructs and all DKS constructs failed resulting from suture breakage. CONCLUSIONS: In this subpectoral biceps tenodesis model, both the KS technique and the DKS technique had similar time 0 biomechanical properties that were better than those of the double simple suture technique. CLINICAL RELEVANCE: A sturdy suture-tendon structure could prevent clinical failure of a subpectoral biceps tenodesis using a suture anchor.

Intravenous Administration of Tranexamic Acid Significantly Improved Clarity of the Visual Field in Arthroscopic Shoulder Surgery. A Prospective, Double-Blind, and Randomized Controlled Trial.

PURPOSE: To determine whether intravenous administration of tranexamic acid (TXA) before shoulder arthroscopic rotator cuff repair surgery can improve arthroscopy visual clarity. METHODS: This was a prospective, double-blind, randomized, and placebo-controlled study. From May 2016 to April 2018, patients requiring arthroscopic rotator cuff repair were enrolled and randomly assigned to either the TXA group. receiving 1000 mg of TXA intravenously 10 minutes before surgery. or the placebo group. receiving the same volume of plain saline. Patients with pre-existing liver/renal disease, coagulopathy, or concurrent use of anticoagulation medications were excluded. Visual clarity was rated using a Numeric Rating Scale from grade 1 (poor) to grade 3 (clear) every 15 minutes throughout the surgery. Secondary outcomes included estimated perioperative blood loss, operative time, degree of shoulder swelling, postoperative subjective pain score, inpatient duration, and associated comorbidities were recorded. Both parametric and nonparametric methods were used for the statistical analysis. RESULTS: In total, 72 patients were enrolled, 37 in the TXA group and 35 in the placebo group. The demographic data were similar between the 2 groups. Visual clarity was found to be significantly better in the TXA group, with a greater percentage of grade 3 vision clarity (53.7 ± 18.9 % vs 40.5 ± 22.1%, P = .036). The average visual score in the TXA group (2.5 ± 0.2) also was better than that of the control group (2.3 ± 0.3) (P = .048). The postoperative subjective pain score was significantly lower in the TXA group (3.0 ± 1.5) than in the control group (4.3 ± 2.0) (P = .009). In addition, postoperative analgesic usage was significant lower in the TXA groups (9.6 ± 9.7 morphine milligram equivalent) than in the control group (14.7 ± 13.4 morphine milligram equivalent) (P = .037). Other parameters, such as operative time, estimated perioperative blood loss, degree of shoulder swelling, and duration of inpatient stay were similar between the 2 groups. None of the patients developed complications after surgery. CONCLUSIONS: Intravenous administration of TXA is an alternative way to improve visual clarity in arthroscopic shoulder surgery. It also reduces subjective pain and analgesic consumption in the early postoperative period without significant side effects. LEVEL OF EVIDENCE: Therapeutic studies level II.

Patients older than 55 years prefer biceps tenodesis over tenotomy to the same degree as young patients.

BACKGROUND: 55 years of age used to be the cutoff point when deciding between biceps tenotomy and tenodesis for treating biceps tendon pathologies. METHODS: Patients aged ≥18 years who had tendonitis in the long head of the biceps and were admitted for arthroscopic surgery were included. A questionnaire with a series of questions assessing patients' current symptoms, their concerns about their outcomes, and personal demographic information was introduced to the participants on the day before the surgery. The patients' preference toward tenotomy and tenodesis was assessed, and χ2 tests and logistic regressions were used to test the association with the categorical and ordinal variables, respectively. RESULTS: A total of 135 patients enrolled in the study, with 83 males and 52 females, the mean age of which was 56 years (range, 18-75 years). Of all patients, 86 (63.7%) preferred biceps tenodesis as opposed to tenotomy; meanwhile, there was no difference in preference toward tenodesis in each age- and gender-subgroup (range, 55.1% to 71.4%). The different subgroups had specific factors that were predictive of choosing either a tenotomy or tenodesis. In most subgroups, concerns about postoperative arm appearance and the so-called "Popeye" deformity due to tenotomy were factors predictive of choosing biceps tenodesis, whereas concern about longer rehabilitation due to tenodesis was the factor predictive of choosing biceps tenotomy. CONCLUSIONS: Biceps tenodesis is a more preferable choice for patients with biceps tendinopathies in all age and gender subgroups. Patients' concerns on postoperative arm appearance, "Popeye" deformity due to tenotomy, and longer rehabilitation due to tenodesis are the most important predictive factors.

The incidence of occult and missed surgical neck fractures in patients with isolated greater tuberosity fracture of the proximal humerus.

BACKGROUND: Occult and missed surgical neck fractures can be found in patients diagnosed with isolated greater tuberosity (GT) fracture during the follow up period. The purpose of this study was to retrospectively assess the incidence rate of occult and missed surgical neck fractures in those initially diagnosed with isolated GT fracture. METHODS: Records of patients diagnosed as having an isolated GT fracture were retrieved from a database in a medical center. Two senior orthopedic surgeons blindly reviewed all images of these patients three times to classify GT fracture types (split, avulsion and depression types), and recorded any surgical neck fractures found. Then a meeting was help to confirm the fracture types and presence of surgical neck fracture. RESULTS: Occult surgical neck fractures were found in 5 out of 68 (7.4%) patients, whereas missed surgical neck fractures were found in 3 out of 68 (4.4%) patients. In total, 32 patients had split type GT fracture, 32 had avulsion type and 4 had depression type. For those with occult surgical neck fractures, 7 had the split type GT fracture, while the remaining one had the avulsion type. Although the proportion of occult surgical neck fracture was higher in the split-type GT fracture (21.9%) than in the avulsion-type GT fracture (3.1%), the difference was not statistically significant (p = 0.056). CONCLUSION: Occult humeral surgical neck fractures occurred in 7.4% of isolated greater tuberosity fractures after re-evaluation, while missed humeral surgical neck fractures occurred in 4.4%.

The radiographic morphology of the greater tuberosity is associated with muscle degeneration in patients with symptomatic rotator cuff tears.

BACKGROUND: Atrophy and fatty infiltration of the rotator cuff muscles portend poor findings in terms of postoperative function and the probability of retears. We assumed that sclerosis and spurs of the greater tuberosity (GT) on radiographs are associated with this rotator cuff muscle degeneration. METHODS: We retrospectively reviewed the preoperative radiographs and magnetic resonance (MR) images of 91 shoulders (average age of patients, 59.7 years; age range, 36-79 years) arthroscopically repaired between 2012 and 2016. The radiographic morphology of the GT was defined as normal, sclerotic, or spurring. Atrophy and fatty infiltration of the rotator cuff muscles were evaluated using the occupation ratio and Goutallier classification, respectively, via the MR images. Diagnoses of rotator cuff tears were made during arthroscopic shoulder surgery. RESULTS: Significant associations between the radiographic GT morphology and the severity of both supraspinatus muscle atrophy (P = .002) and infraspinatus muscle atrophy (P = .047) were found. The mean occupation ratios of both the sclerotic GT group and the spurring GT group were significantly reduced compared with the mean occupation ratio of the normal GT group. Patients with GT spurs were found to be prone to severe supraspinatus fatty degeneration (P = .020). CONCLUSIONS: For patients with rotator cuff tears, the presence of GT spurs or sclerosis on radiographs predicted the occurrence of supraspinatus and infraspinatus muscle atrophy, as well as supraspinatus fatty infiltration, based on MR images. The clinical relevance is that MR imaging is suggested for patients with radiographic GT sclerosis or spurs to detect advanced rotator cuff lesions.