Do multiple fractures affect risk of fixation failure after surgical treatment of midshaft clavicle fracture? A retrospective cohort study.

BACKGROUND: Surgical treatment of midshaft clavicle fractures is associated with quick recovery and low risk of non-union. However, fixation failure may occur in case of severe comminution fractures. Moreover, clinical outcomes may be affected when clavicle fractures occur in combination with other injuries, particularly those involving the lower extremities, as the use of crutches or walkers may hinder the process of rehabilitation by adding strain on the acromioclavicular (AC) joint, resulting in possible fixation failure. This study aims to identify risk factors for fixation failure of midshaft clavicle fractures and elucidate the role of combined fractures in treatment outcomes. METHODS: This study included patients diagnosed with midshaft clavicle fractures who underwent initial surgery between January 2012 and November 2021 at a designated regional trauma center hospital. Retrospective evaluation of fixation failure was carried out in 352 patients with midshaft clavicle fractures using standard clinical evaluation protocols and conventional radiographs. The prevalence of fixation failure and the effects of several demographic variables on the risk of fixation failure and non-union were examined. Multivariate logistic regression analysis was carried out to identify independent risk factors for fixation failure. RESULTS: Fixation failure occurred in 40 patients (11.4%). Multivariate analysis identified comminution [odds ratio (OR) 3.532, p value = 0.003, 95% confidence interval (CI) 1.55-8.05)] and fewer number of screws (OR 0.223, p value = 0.022, 95% CI 0.06-0.80) as risk factors for fixation failure. Surgical techniques using wire cerclage reduced the chances of fixation failure in comminuted fractures (OR 0.63, p value = 0.033, 95% CI 0.05-0.80). Combined fractures that required rehabilitation using walkers or crutches increased the risk of non-union (OR 19.043, p value = 0.032, 95% CI 1.28-282.46). CONCLUSIONS: Additional fixation of comminuted fractures using cerclage can reduce the risk of treatment failure, while multiple fractures or rehabilitation for ambulation increases the risk of the same. LEVEL OF EVIDENCE: III.

Effect of Retear After Arthroscopic Rotator Cuff Repair on Return to Work and Sports in Nonathletes: A Retrospective Cohort Study.

Background: The impact of retear after arthroscopic rotator cuff repair (ARCR) on clinical outcomes of patients remains controversial. Purpose/Hypothesis: The purpose of this study was to determine the effects of retear on strength recovery, return to previous levels of work, and return to sports participation. It was hypothesized that retears (1) would not have a significant effect on patient-reported outcome measures (PROMs) and (2) would significantly inhibit strength recovery and return to previous work and sports. Study Design: Cohort study; Level of evidence, 3. Methods: The authors collected data from patients who underwent ARCR between January 2015 and December 2019. All included patients had undergone magnetic resonance imaging (MRI) and strength measurements 1 year postoperatively. Minimum 2-year postoperative PROMs (Constant score, pain visual analog scale, American Shoulder and Elbow Surgeons score, and Single Assessment Numeric Evaluation) and status on work and sports participation were collected, and PROM scores, strength recovery (percentage compared with the contralateral shoulder), return to work, and return to sports were compared between patients with versus without retear on 1-year postoperative MRI. Additionally, factors related to return to work and sports were identified through multivariable regression analysis. Results: A total of 159 patients were included, of whom 19 (11.9%) had evidence of retear. Return-to-work and return-to-sports status was evaluated in 134 (84.3%) and 93 (58.5%) patients, respectively. There were no significant differences in PROM scores between patients with and without retears; however, patients with retears exhibited significantly worse supraspinatus strength recovery (73% vs 86%; P = .018) and external rotation strength recovery (78% vs 88%; P = .030) compared with patients with intact shoulders. There were no between-group differences in return to work or sports. Active workload was associated with unsuccessful return to work, whereas preoperative participation in shoulder sports was associated with successful return to work. Conclusion: Patients with postoperative retears had significantly worse postoperative strength recovery than patients with intact shoulders. Active workload and preoperative shoulder sports participation were factors associated with ability to return to work.

Development of in vitro osteoporosis model in minipig proximal humerus and femur: validation in histological and biomechanical study.

BACKGROUND: The minipig has been used for research in various fields of medicine, even in orthopedics. Though previous studies have already suggested other methods to create osteoporotic bone, those methods had some disadvantages for taking time and efforts. Therefore, we aimed to generate osteoporotic proximal humerus and proximal femur of minipig using EDTA solution and validate their properties through dual energy X-ray absorptiometry (DEXA), micro-CT study, histological and biomechanical ways. METHODS: Six minipigs were used. Out of a total of 12 proximal humerus (PH) and 12 proximal femurs (PF), 6 PH and 6 PF were used as the decalcified group and the opposite side as the non-decalcified group. In vitro decalcification with Ca-chelating agents (0.5 M EDTA solution, pH 7.4) was used. Area BMD (aBMD) was measured using DEXA, Volumetric BMD (vBMD), and microstructure were measured using micro-CT. Universal testing machine was used to measure ultimate load to failure (ULTF). Each group was compared using two types of suture anchors (all-suture anchor, ASA, and conventional screw type anchor, CA). RESULTS: There was a significant difference in aBMD and cortical thickness (aBMD: decalcified, 0.433 ± 0.073 g/cm2, undecalcified, 0.962 ± 0.123 g/cm2, p < 0.001; cortical thickness: decalcified, 0.33 ± 0.34 mm, undecalcified, 1.61 ± 0.45 mm, p < 0.001). In the case of ASA, the ULTF was significantly lower in the decalcified group (decalcified: 176.6 ± 74.2 N, non-decalcified: 307.7 ± 116.5 N, p = 0.003). In the case of CA, there was no significant difference (decalcified: 265.1 ± 96.0 N, undecalcified: 289.4 ± 114.5 N, p = 0.578). CONCLUSION: We demonstrated that decalcification with EDTA solution significantly decreased aBMD, vBMD, and cortical thickness. Decalcified minipig bone using EDTA resulted in similar biomechanical properties as osteoporotic human bone with respect to anchor pull-out.

Comparison of the Analgesic Efficacy between Arthroscopically Placed Continuous Suprascapular Nerve Block and Ultrasound-guided Continuous Superior Trunk Block: A Double-blinded Randomized Controlled Trial.

BACKGROUND: Single-shot suprascapular nerve block and superior trunk block have been reported to provide a noninferior analgesic effect after shoulder surgery with a lesser incidence of hemidiaphragmatic paresis compared with interscalene brachial plexus block. This study hypothesized that continuous suprascapular nerve block provides noninferior analgesia with minimal effects on diaphragmatic movement compared with continuous superior trunk block in patients undergoing arthroscopic shoulder surgery. METHODS: 100 patients were randomized undergoing arthroscopic shoulder surgery between December 2020 and October 2021 into continuous suprascapular nerve block and continuous superior trunk block groups. Before the surgery, patients received either a single-shot superior trunk block or subomohyoid suprascapular nerve block. Thereafter, a superior trunk catheter was inserted by anesthesiologists in patients in the continuous superior trunk block group, and a posterior suprascapular nerve catheter was inserted with arthroscopic assistance during the surgery by surgeon in the continuous suprascapular nerve block group. The primary outcome was the postoperative pain score at postoperative 24 h, and the incidence of hemidiaphragmatic paresis was also compared. RESULTS: Overall, 98 patients were included in the final analysis. The worst and resting pain scores at postoperative 24 h in the continuous suprascapular nerve block group were inferior compared with those in the continuous superior trunk block group in the test with a noninferiority margin of 1 (worst pain score: mean difference, 0.9; 95% CI, 0.1 to 1.7; resting pain score: mean difference, 0.5; 95% CI, 0.0 to 1.0). However, the continuous suprascapular nerve block group had a significantly lower incidence of hemidiaphragmatic paresis at postoperative 24 h than the continuous superior trunk block group. CONCLUSIONS: Continuous suprascapular nerve block provides statistically inferior analgesia compared to the continuous superior trunk block; however, the continuous suprascapular nerve block had a minimal effect on the phrenic nerve function.

Remplissage in Addition to Arthroscopic Bankart Repair for Shoulder Instability With On-Track Hill-Sachs Lesions Reduces Residual Apprehension Without External Rotation Limitation.

PURPOSE: To evaluate the role of remplissage as an adjunct to Bankart repair in patients with recurrent anterior shoulder dislocation combined with on-track Hill-Sachs lesion. METHODS: Arthroscopic Bankart repair with remplissage data (December 2018-2020) were collected (BR group). Inclusion criteria were (1) recurrent anterior shoulder dislocation, (2) on-track Hill-Sachs lesion, (3) minimal/subcritical glenoid bone loss (<17%), and (4) postoperative follow-up >1 year. Exclusion criteria were (1) revision surgery, (2) first dislocation with acute glenoid rim fracture, and (3) combined with other surgery. The control group was identified in Bankart repair-only cohort (B group). All patients were evaluated preoperatively, and at 3 weeks, 6 weeks, 3 months, 6 months, and then annually postoperatively. Visual analogue scale for pain, Self-Assessment Numerical Evaluation, American Shoulder and Elbow Surgeons Shoulder score, ROWE, and Western Ontario Shoulder Instability were evaluated at preoperative and final follow-up. Residual apprehension experience and external rotation deficit were evaluated. Patients, who were followed-up for more than 1 year, were asked how often they experienced any subjective apprehension in 4 grades (1: always, 2: frequently, 3: occasionally, 4: never). Patients who had a history of recurrent dislocation or revision surgery were investigated. RESULTS: In total, 53 patients (B, 28; BR, 25) were included. At final follow-up, both groups showed improvement in 5 clinical scores postsurgery (P < .001). The BR group showed greater ROWE scores than the B group (B: 75.2 ± 13.6, BR: 84.4 ± 10.8; P = .009). Residual apprehension patient ratio (B: 71.4% [20/28], BR: 32% [8/25]; P = .004) and the mean subjective apprehension grade (B: 3.1 ± 0.6, BR: 3.6 ± 0.6; P = .005) showed statistically significant difference, whereas no patients in either group experienced external rotation deficit (B: 14.8 ± 12.9°, BR: 18.0 ± 15.2°, P = .420). Only 1 patient in the B group had not responded to surgery, with dislocation recurrence (P = .340). CONCLUSIONS: Remplissage with arthroscopic Bankart repair in on-track Hill-Sachs lesion has a role in reducing residual apprehension without external rotation limitation. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

Carpal tunnel release under wide awake local anesthesia with no tourniquet in hemodialysis patients with arteriovenous shunt.

INTRODUCTION: Long-term hemodialysis patients experience many hand diseases caused by dialysis-related amyloidosis (DRA), with carpal tunnel syndrome (CTS) being the most common. For the patients with arteriovenous (AV) shunt, surgical decompression remains challenging because of the contraindications of a tourniquet. A technique called wide-awake local anesthesia with no tourniquet (WALANT), in which epinephrine provides hemostasis instead of the tourniquet, can be a good option for hemodialysis patients. The purpose of this study was to assess the prevalence of CTS and related factors in hemodialysis patients, and to establish the efficacy and safety of WALANT on hemodialysis patients with AV shunt. MATERIALS AND METHODS: This prospective study included 275 hemodialysis patients between March 2013 and July 2019. 43 patients were diagnosed with CTS, involving surgical treatment on 70 wrists. We performed mini-open carpal tunnel release using WALANT on the AV shunt arm (defined as the WALANT group), while using lidocaine and a tourniquet on the arm without an AV shunt (defined as the tourniquet group). The operative time, surgical field bleeding (blood loss and hemostasis score), surgical pain (injection pain and tourniquet pain), outcomes, complications, and satisfaction were compared between the two groups. RESULTS: The incidence of CTS in hemodialysis patients was 15.6%. Longer dialysis durations were related to higher proportions of patients with CTS. There was no significant difference in blood loss (p=0.184) and hemostasis score (p=0.165) between the two groups. Clinical symptoms improved in all patients, and there were no severe complications. The WALANT group had a significantly longer preparation time of approximately 20minutes, but they had low injection pain and no tourniquet pain. There was also no significant difference in terms of satisfaction levels (p=0.212). DISCUSSION: CTS is a very common disease among hemodialysis patients. WALANT provided sufficient hemostasis without a tourniquet, despite the patients' high bleeding tendency. The technique also had the advantages of low injection pain, no tourniquet pain, and no major complications. In this respect, WALANT can be a good choice for hemodialysis patients with AV shunt. LEVEL OF EVIDENCE: II.

Can deep learning reduce the time and effort required for manual segmentation in 3D reconstruction of MRI in rotator cuff tears?

BACKGROUND/PURPOSE: The use of MRI as a diagnostic tool has gained popularity in the field of orthopedics. Although 3-dimensional (3D) MRI offers more intuitive visualization and can better facilitate treatment planning than 2-dimensional (2D) MRI, manual segmentation for 3D visualization is time-consuming and lacks reproducibility. Recent advancements in deep learning may provide a solution to this problem through the process of automatic segmentation. The purpose of this study was to develop automated semantic segmentation on 2D MRI images of rotator cuff tears by using a convolutional neural network to visualize 3D models of related anatomic structures. METHODS: MRI scans from 56 patients with rotator cuff tears (T2 Linear Coronal MRI; 3.0T, 512 mm × 512 mm, and 2.5-mm slice thickness) were collected. Segmentation masks for the cuff tendon, muscle, bone, and cartilage were obtained by four orthopedic shoulder surgeons, and these data were revised by a shoulder surgeon with more than 20 years' experience. We performed 2D and 3D segmentation using nnU-Net with secondary labels for reducing false positives. Final validation was performed in an external T2 MRI dataset (10 cases) acquired from other institutions. The Dice Similarity Coefficient (DSC) was used to validate segmentation quality. RESULTS: The use of 3D nnU-Net with secondary labels to reduce false positives achieved satisfactory results, even with a limited amount of data. The DSCs (mean ± SD) of the cuff tendon, muscle, bone, and cartilage in the internal test set were 80.7% ± 9.7%, 85.8% ± 8.6%, 97.8% ± 0.6%, and 80.8% ± 15.1%, respectively. In external validation, the DSC of the tendon segmentation was 82.74±5.2%. CONCLUSION: Automated segmentation using 3D U-Net produced acceptable accuracy and reproducibility. This method could provide rapid, intuitive visualization that can significantly facilitate the diagnosis and treatment planning in patients with rotator cuff tears.

Which lateralization designed prosthesis of reverse total shoulder arthroplasty (glenoid-based lateralization vs humerus-based lateralization) would be better? Network Meta-analysis.

PURPOSE: To demonstrate the differences between outcomes and complications after reverse total shoulder arthroplasty (rTSA), according to the types of lateralized prosthesis designs: glenoid-based lateralization (LG) and humerus-based lateralization (LH). METHODS: PubMed, Embase, and the Cochrane Library databases were systematically searched for studies published before 1 April 2021, using the PRISMA guidelines. A network meta-analysis was applied for indirect comparison, incorporating studies including medialized or conventional Grammont prosthesis and each lateralized prosthesis (LG vs control and LH vs control). Out of 1,989 screened studies, 11 studies were included to compare functional scores, range of motion (ROM), radiologic outcomes, and revision rates. In addition, six articles from the included studies, which had repaired subscapularis after rTSA were analyzed to exclude the potential influence of subscapularis repair on the outcomes. The data were pooled using a random-effects model. The pooled estimates of the mean differences (MDs) and 95% confidence intervals (CIs) were calculated for continuous data, while dichotomous data were analyzed using the pooled relative risk (RR) and their 95% CIs. RESULTS: The ROM, complications, and functional scores were similar between the two groups. In subgroup analysis of 6 studies involving concomitant subscapularis repair, the LH group showed higher American Shoulder and Elbow Surgeons (ASES) scores and Constant scores than the control group. Regarding the ROM, LH group showed better forward elevation than the LG group (LH vs LG: MD 10.07, 95% CI -9.05-29.19). CONCLUSION: Overall, the outcomes and occurrence of complications were not significantly different between the two lateralized prosthesis groups. However, when the subscapularis was repaired, LH prosthesis seems to be more suitable to obtain a better ASES score and ROM. LEVEL OF EVIDENCE: Level III, network meta-analysis.

Ulnar nerve decompression with osteocapsular arthroplasty for primary elbow osteoarthritis.

PURPOSE: The aim of this study was to suggest treatment guidline for primary elbow OA with ulnar nerve neuropathy or high-grade stiffness by evaluating the effect of ulnar nerve decompression on the outcome of osteocapsular arthroplasty. METHODS: A total of 30 patients who underwent primary osteocapsular arthroplasty for elbow OA were retrospectively reviewed. The surgical outcomes were evaluated for pain score (visual analog scale; VAS), range of motion (ROM), and Mayo Elbow Performance Score (MEPS). The ulnar nerve decompression was performed for (1) ulnar nerve neuropathy, and (2) high-grade stiffness of flexion, defined as the flexion angle, is <90°. Patients were categorized into the two groups: ulnar nerve decompression group (UD group, n = 11) and the non-decompression group (Non-UD group, n = 19). The surgical outcome was compared between the groups. RESULTS: Primary elbow OA with cubital tunnel syndrome or high-grade stiffness showed comparable improvement in MEPS, VAS, and ROM arc at final follow-up in the UD group compared with the non-UD group (UD group vs. non-UD group: MEPS 85.91 vs 86.84, p-value = 0.824, VAS 1.46 vs 1.16, p-value = 0.588, ROM arc 108 vs 109, p-value = 0.949). Improvement in ROM arc at 2 years follow-up was significantly higher in UD group (UD group vs. non-UD group: ROM arc difference, 42 vs 14, p = 0.002). CONCLUSION: Osteocapsular arthroplasty with ulnar nerve decompression for primary elbow OA with ulnar nerve neuropathy or high-grade stiffness provided improved motion arc and compatible clinical results. LEVEL OF EVIDENCE: Level III, Retrospective comparative study.

Initiation Timing of Continuous Interscalene Brachial Plexus Blocks in Patients Undergoing Shoulder Arthroplasty: A Retrospective Before-and-After Study.

A continuous interscalene brachial plexus block (CIBPB) is usually administered before surgery in awake patients. However, the use of CIBPB before surgery could hinder the identification of nerve injuries after total shoulder arthroplasty (TSA). This study aimed to compare the analgesic effects of preoperatively and postoperatively initiated CIBPBs in patients undergoing TSA. The medical records of patients who underwent TSA between January 2016 and August 2020 were retrospectively reviewed. The following analgesic phases were used: intravenous (IV) patient-controlled analgesia (PCA) phase (IV PCA group, n = 40), preoperative block phase (PreBlock group, n = 44), and postoperative block phase (PostBlock group, n = 33). The postoperative initiation of CIBPB after a neurologic exam provided better analgesia than IV PCA and had no differences with the preoperative initiation of CIBPB, except for the worst pain at the postanesthetic care unit. Opioid consumption was significantly greater in the IV PCA group, but there were no differences between the PreBlock and PostBlock groups on operation day after the transfer to the general ward. The initiation of CIBPB after a patient's emergence from general anesthesia had comparable analgesic efficacy with preoperative CIBPB but offered the chance of a postoperative neurologic exam.

The Patient Acceptable Symptom State as a Predictor of the Sports Activity Available State After Arthroscopic Rotator Cuff Repair.

Background: The patient acceptable symptom state (PASS) has emerged as a metric for evaluating patient satisfaction after treatment. There is little research on the relationship between sports activity and PASS values after arthroscopic rotator cuff repair (ARCR). Purpose: To (1) introduce the sports activity available state (SAAS) as an indicator of whether sports activities are possible based on patient symptoms after ARCR, (2) investigate the correlation between the SAAS and PASS, (3) predict the SAAS using derived PASS values, and (4) identify factors for achieving the PASS and SAAS. Study Design: Case-control study; Level of evidence, 3. Methods: Included were 201 patients who underwent ARCR between January 2015 and December 2016. At a mean follow-up of 38.7 ± 7.0 months, anchor questions were used to classify patients as SAAS+ (sports group) or SAAS- (nonsports group) and derive the PASS values for the pain visual analog scale (pVAS), American Shoulder and Elbow Surgeons (ASES), and Single Assessment Numeric Evaluation (SANE). The authors analyzed the correlation and difference between PASS and SAAS acquisition, and univariate and multivariate logistic regression analyses were performed to determine factors for PASS and SAAS achievement. Results: The final PASS values for the pVAS, ASES, and SANE were 0.5, 93.5, and 82.5, respectively. A significant correlation existed between PASS and SAAS acquisition (phi correlation coefficient, 0.647; P < .001). Sensitivity and specificity were >0.7 for all outcome scores when predicting SAAS using PASS values. A higher preoperative ASES score was significantly associated with achieving both the SAAS (OR, 1.032 [95% CI, 1.005-1.059]; P = .018) and PASS (OR, 2.556 [95% CI, 1.753-3.726]; P < .001). Diabetes (OR, 0.348 [95% CI, 0.130-0.931], P = .036) and a large to massive tear (OR, 0.378 [95% CI, 0.162-0.884]; P = .025) were significantly negatively associated with achieving the SAAS. Conclusion: The authors found the SAAS to be significantly correlated with the PASS. Also, SAAS was able to be predicted using the PASS value. Patients with higher preoperative ASES scores had higher odds of achieving both the PASS and SAAS, and patients with diabetes and those with large to massive tears had lower odds of achieving the SAAS.

Inter-rater agreement among shoulder surgeons on treatment options for proximal humeral fractures among shoulder surgeons.

BACKGROUND: The treatment approach for proximal humeral fractures is determined by various factors, including patient age, sex, dominant arm, fracture pattern, presence of osteoporosis, preexisting arthritis, rotator cuff status, and medical comorbidities. However, there is a lack of consensus in the literature regarding the optimal treatment for displaced proximal humeral fractures. This study aimed to assess and quantify the decision-making process for either conservative or surgical treatment and the choice of surgical method among shoulder surgeons when treating proximal humeral fractures. METHODS: Forty sets of true anteroposterior view, scapular Y projection view, and three-dimensional computed tomography of proximal humeral fractures were provided to 12 shoulder surgeons along with clinical information. Surveys regarding Neer classification, decisions between conservative and surgical treatments, and chosen methods were conducted twice with an interval of 2 months. The factors affecting the treatment plans were also assessed. RESULTS: The inter-rater agreement was fair for Neer classification (kappa=0.395), moderate for the decision between conservative and surgical treatments (kappa=0.528), and substantial for the chosen method of surgical treatment (kappa=0.740). The percentage of agreement was 71.1% for Neer classification, 84.6% for the decision between conservative and surgical treatment, and 96.4% for the chosen method of surgical treatment. The fracture pattern was the most crucial factor in deciding between conservative and surgical treatments, followed by age and physical activity. CONCLUSIONS: The decision between conservative and surgical treatment for proximal humeral fractures showed good agreement, while the chosen method between osteosynthesis and arthroplasty showed substantial agreement among shoulder surgeons.

Patient-specific instrumentation improves the reproducibility of preoperative planning for the positioning of baseplate components with reverse total shoulder arthroplasty: a comparative clinical study in 39 patients.

BACKGROUND: The application of patient-specific instrumentation (PSI) for reverse total shoulder replacement has been rapidly increasing, which could reduce errors in implant positioning. Although PSI theoretically holds promise, evidence of the accuracy and reliability of PSI in shoulder replacement surgery is limited. METHODS: Thirty-nine shoulders that underwent reverse total shoulder arthroplasty were included in this study and categorized into two groups: the conventional (n = 20) and PSI (n = 19) groups. Screw (length and angle) and baseplate (version, inclination, translation, and rotation) positioning were calculated based on postoperative computed tomography images using a three-dimensional measurement tool. The difference between the values of the preoperative target and postoperative measurement was calculated to evaluate the reproducibility of preoperative planning. Screw involvement in the suprascapular and spinoglenoid notches was assessed. Thus, the correlation between the position of the baseplate and the screws was assessed. RESULTS: The mean differences between the planned length and angle (anteroposterior and superoinferior angles) and postoperative measurement in the PSI group were significantly smaller than those in the conventional group. Similarly, the mean difference in baseplate rotation between the planned and postoperative measurements in the PSI group was significantly lower than that in the conventional group (4.5° vs 10.6°; P < .001). The spinoglenoid notch was involved in 10 cases in the conventional group and 2 cases in the PSI group, and this difference was significant (P = .014). Overall, the mean difference between the preoperative and postoperative version, inferior inclination, and rotation values for the baseplate position was significantly correlated with the values for screw position (length and angle). CONCLUSIONS: PSI improves the reproducibility of preoperative planning for baseplate and screw positioning and reduces the risk of neurovascular injury in reverse total shoulder arthroplasty.

Extracellular Vesicles Delivered by Injectable Collagen Promote Bone-Tendon Interface Healing and Prevent Fatty Degeneration of Rotator Cuff Muscle.

PURPOSE: This study aimed (1) to confirm the maintenance of the extracellular vesicles (EVs) delivered via injectable collagen at the application site, and (2) to evaluate the effect of EVs derived from the human umbilical cord-derived mesenchymal stem cells and loaded in an injectable collagen gel after rotator cuff repair (RCR). METHODS: Rabbits (n = 20) were assigned to normal (N), repair-only (R), and those administered with injectable collagen after repair (RC), and EV-laden injectable collagen after repair (RCE) groups. The EVs isolated by ultra-centrifugation from the human umbilical cord-derived mesenchymal stem cells spent medium were mixed with collagen and administered accordingly. After 12 weeks, the rabbits were sacrificed to evaluate the healing of the bone-to-tendon junction and the fatty degeneration of muscle. Histomorphometric scoring for bone-tendon interface, fatty infiltration (%), and biomechanical tests were performed. Separately, groups of 3 rabbits were assigned to 3 different time points to evaluate maintenance of green fluorescence-labeled EVs with injectable collagen via tracking on the bursal side of the rotator cuff (3 groups: 3 days, 2, and 4 weeks). RESULTS: The EVs delivered by injectable collagen remained until 4 weeks at the bursal side of the cuff tissue. The RCE group showed a significantly greater histomorphometric total score (P < .001, and P = .013, respectively) and significantly lower fatty degeneration than the RC and R groups (P = .001, and P = .013, respectively). The biomechanical tests revealed significant growing trends in load-to-failure and stiffness (P = .002, and P = .013, respectively), in the R, RC, RCE, and N groups. CONCLUSIONS: EVs mounted in injectable collagen remained at the repair site for at least 4 weeks after application. Furthermore, they effectively promote bone-to-tendon healing via collagen maturation in bone-tendon interface and preventing fatty degeneration of rotator muscle after RCR as compared with collagen-only or repair-only groups. CLINICAL RELEVANCE: The combination of collagen with EVs significantly promotes rotator cuff healing demonstrating potential clinical application during partial rotator cuff tear or after RCR.

Is reverse total shoulder arthroplasty (rTSA) more advantageous than anatomic TSA (aTSA) for osteoarthritis with intact cuff tendon? A systematic review and meta-analysis.

PURPOSE: We aimed to compare the outcomes and complications of anatomical shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) for primary glenohumeral osteoarthritis with intact cuff tissue. MATERIALS AND METHODS: The MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies published before March 2, 2021 using the PRISMA guidelines. Studies were included if they directly compared aTSA and rTSA for treating primary glenohumeral arthritis. A meta-analysis was performed using six studies that compared radiologic outcomes, functional scores, and range of motion (ROM). All the data were pooled using a random-effects model. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated as dichotomous data, while continuous data were analyzed using mean differences with 95% CIs. RESULTS: Two independent researchers reviewed 1,061 studies. Six studies met the inclusion criteria. The range of motion, especially external rotation, was better for aTSA than for rTSA (MD = - 10.28, 95% CI: - 16.69 to - 3.88, P = 0.002). Functional scores showed no difference between aTSA and rTSA. Glenoid loosening (OR = 0.17, 95% CI: 0.06-0.50, P = 0.001) was more common with aTSA, and scapula notching (OR = 10.63, 95% CI: 1.73-65.27, P = 0.01) with rTSA. In the mid-term follow-up, the overall revision rate showed no difference between aTSA and rTSA, with a pooled OR of 0.33 (95% CI: 0.07-1.57, P = 0.16). CONCLUSION: A better ROM was achieved after aTSA than after rTSA. There was no difference in the revision rate at mid-term follow-up between aTSA and rTSA. Glenoid loosening was more common with aTSA, and scapula notching with rTSA. LEVEL OF EVIDENCE: Level IV, Meta-analysis.

Retear bigger than preoperative tear size would lead to treatment failure after rotator cuff repair.

BACKGROUND: This study aimed to (1) define treatment failure using the referred patient acceptable symptomatic state (PASS) values for pain visual analog scale (PVAS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Single Assessment Numeric Evaluation (SANE) clinical scores and (2) identify the factors that lead to patient dissatisfaction after arthroscopic rotator cuff repair (ARCR). METHODS: We analyzed the arthroscopic rotator cuff surgery registry data from January 2015 to December 2016. Patients were followed for ≥2 years and categorized as dissatisfied or satisfied based on our own definition of treatment failure at 2 years postoperatively. For defining treatment failure, the referred PASS values for the PVAS, ASES, and SANE scores were used. Patients who failed to attain the PASS value for the PVAS, ASES, or SANE score were categorized into the dissatisfied group. Pre- and postoperative imaging and basic demographic data were compared between groups. Univariable and multivariable logistic regression analyses were performed to identify the factors affecting patient satisfaction at 2 years after rotator cuff repair. RESULTS: Of 117 patients, 30 (25.6%) were defined as the dissatisfied group (mean follow-up period, 37.5 months). Seventeen patients (14.5%) had confirmed retear on follow-up magnetic resonance imaging. In the univariate analysis, sex significantly differed between the groups (female, satisfied vs. dissatisfied groups: 39 [44.8%] vs. 22 [73.3%]; P = .010). Retear alone did not affect patient satisfaction in the univariate analysis (P = .11). Progressed retear size featured a significantly higher risk of patient dissatisfaction (P = .024; odds ratio 6.430, 95% confidence interval 1.270-32.541) in the multivariable analysis using symptom duration, sex, preoperative ASES score, preoperative tear size, retear, and progressed retear size as variables. Moreover, female sex had an increased odds for dissatisfaction (odds ratio 4.646, 95% confidence interval 1.590-13.578; P = .005). CONCLUSION: Two years after ARCR, most patients (74.4%) reported satisfaction with their outcomes. However, satisfaction levels can be altered by female sex or progressed retear size compared with the preoperative state.

Arthroscopic Superior Capsular Reconstruction for Older Patients With Irreparable Rotator Cuff Tears: A Comparative Study With Younger Patients.

BACKGROUND: Arthroscopic superior capsular reconstruction (ASCR) is a method for treating irreparable chronic rotator cuff tears. However, the extent to which ASCR can be performed with regard to the patient's age has yet to be determined. PURPOSE: To compare the surgical outcomes of ASCR for the treatment of irreparable rotator cuff tears (IRCTs) in patients aged <65 years versus patients aged ≥65 years. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Of 105 patients with IRCTs who underwent ASCR between March 2013 and June 2020, 73 patients were enrolled in this study based on the selection criteria. Polypropylene mesh augmentation to the graft was used in 18 of 36 patients in the younger adults group (age, <65 years) and 20 of 37 patients in the older adults group (age, ≥65 years). The clinical and radiological outcomes were evaluated preoperatively and at the final clinical follow-up. The graft integrity status was evaluated using serial magnetic resonance imaging and set as the primary endpoint. Furthermore, subgroup analysis was performed based on age group and graft type. RESULTS: The mean age of the patients was 59.2 ± 3.8 years in the younger adults group and 70.5 ± 4.1 years in the older adults group. Both groups showed improvement based on the clinical and radiological outcomes at the final follow-up. The mean American Shoulder and Elbow Surgeons scores improved from 52.3 ± 15.4 to 77.3 ± 13.5 in the younger adults group (P < .001) and from 45.7 ± 16.1 to 76.6 ± 11.4 in the older adults group (P < .001). The mean visual analog scale for pain scores improved from 5.5 ± 1.2 to 2.1 ± 0.9 in the younger adults group (P < .001) and from 5.5 ± 1.4 to 2.1 ± 1.2 in the older adults group (P < .001). The graft healing rate was significantly higher in the younger adults group (81%) than in the older adults group (65%) (P = .049). Subgroup analysis showed that after mesh augmentation, the healing rate in the younger adults group (84%) was similar to that in the older adults group (85%) (P = .299). CONCLUSION: ASCR resulted in a favorable surgical outcome for both younger and older adult patients with IRCT. The younger patients had lower graft failure rates and superior surgical outcomes. In older patients, ASCR using polypropylene mesh augmentation may reduce graft failure and result in surgical outcomes similar to those in younger patients.

Do Nonsteroidal Anti-Inflammatory or COX-2 Inhibitor Drugs Increase the Nonunion or Delayed Union Rates After Fracture Surgery?: A Propensity-Score-Matched Study.

BACKGROUND: The effects of nonsteroidal anti-inflammatory drugs (NSAIDs)/cyclooxygenase (COX)-2 inhibitors on postoperative fracture-healing are controversial. Thus, we investigated the association between NSAID/COX-2 inhibitor administration and postoperative nonunion or delayed union of fractures. We aimed to determine the effects of NSAID/COX-2 inhibitor administration on postoperative fracture-healing with use of a common data model. METHODS: Patients who underwent operative treatment of a fracture between 1998 and 2018 were included. To determine the effects of NSAID/COX-2 inhibitor administration on fracture-healing, postoperative NSAID/COX-2 inhibitor users were compared and 1:1 matched to nonusers, with 3,264 patients matched. The effect of each agent on bone-healing was determined on the basis of the primary outcome (nonunion/delayed union), defined as having a diagnosis code for nonunion or delayed union ≥6 months after surgery. The secondary outcome was reoperation for nonunion/delayed union. To examine the effect of NSAIDs/COX-2 inhibitors on bone union according to medication duration, a Kaplan-Meier survival analysis was performed. RESULTS: Of the 8,693 patients who were included in the analysis, 208 had nonunion (178 patients; 2.05%) or delayed union (30 patients; 0.35%). Sixty-four (30.8%) of those 208 patients had a reoperation for nonunion or delayed union. NSAID users showed a significantly lower hazard of nonunion compared with the matched cohort of nonusers (hazard ratio, 0.69 [95% confidence interval, 0.48 to 0.98]; p = 0.040) but did not show a significant difference in the other matched comparison for any other outcomes. Kaplan-Meier survival analysis revealed significantly lower and higher nonunion/delayed union rates when the medication durations were ≤3 and >3 weeks, respectively (p = 0.001). For COX-2 inhibitors, the survival curve according to the medication duration showed no significant difference among the groups (p = 0.9). CONCLUSIONS: Our study demonstrated no short-term impact of NSAIDs/COX-2 inhibitors on long-bone fracture-healing. However, continued use of these medications for a period of >3 weeks may be associated with higher rates of nonunion or delayed union. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Failure Rate After Superior Capsular Reconstruction With Achilles Tendon-Bone Allograft for Irreparable Rotator Cuff Tears.

BACKGROUND: Superior capsular reconstruction (SCR) is an alternative to reverse shoulder arthroplasty for irreparable rotator cuff tears (IRCTs). The reconstructed capsule acts as a static restraint to prevent superior migration of the humeral head. Traditional SCR uses a fascia lata autograft, which has shown failure at the greater tuberosity. An Achilles tendon-bone allograft has been proposed to improve the failure rate. PURPOSE: To evaluate the surgical outcomes of SCR using an Achilles tendon-bone allograft for the treatment of IRCTs. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We retrospectively evaluated 6 patients with massive IRCTs who underwent SCR using an Achilles tendon-bone allograft between January 2017 and January 2018. Clinical outcomes were assessed using range of motion, the American Shoulder and Elbow Surgeons score, and the visual analog scale for pain. The acromiohumeral distance and the status of graft integrity were evaluated using serial magnetic resonance imaging. Second-look arthroscopy surgery was performed to evaluate graft integrity at the mean of 7.5 months postoperative. RESULTS: The mean ± SD clinical follow-up period was 14.5 months (range, 12-17 months). The American Shoulder and Elbow Surgeons and visual analog scale scores improved from 42.8 ± 11.9 and 4.0 ± 1.2 to 62.1 ± 14.7 and 2.8 ± 1.4, respectively. Forward flexion and external rotation improved from 98° ± 36° and 58° ± 4° to 123° ± 20° and 39° ± 8°, respectively. The acromiohumeral distance improved from 3.9 ± 0.8 mm to 6.4 ± 2.2 mm at final follow-up. However, second-look arthroscopy at a mean of 7.6 months postoperatively confirmed a graft failure rate of 83.3%. CONCLUSION: SCR using an Achilles tendon-bone allograft for the treatment of IRCTs had a high graft failure rate among patients in this case series.