Intraoperative evaluation of DRUJ instability through dorsal stress radiography in distal radius fractures.

INTRODUCTION: Certain type of injury of the triangular fibrocartilage complex associated with distal radius fracture can result in distal radioulnar joint instability (DRUJ). Untreated DRUJ instability may lead to poor result in the treatment of acute distal radius fractures. The aim of this study was to evaluate DRUJ instability in distal radius fractures through dorsal stress radiography comparing the affected and unaffected wrists intraoperatively. MATERIALS AND METHODS: 49 patients with a distal radius fracture who were operatively treated with a volar locking plate were included. Dorsal stress radiography was used to evaluate both affected and unaffected wrists peri-operatively to detect DRUJ instability. Under general anesthesia, a dorsal stress test was performed on the unaffected wrist. Additionally, after fixation of the affected wrist, a dorsal stress test was performed. The ulnar translation ratio (UTR) was measured through the dorsal stress radiograph. Arthroscopic examination was performed on all affected wrists according to Palmer's and Atzei classification. RESULTS: The UTR of the affected wrist and the TFCC injury Palmer-type IB tendency were positively correlated (odds ratio: 1.18, p-value: 0.002). Additionally, as the UTR difference between the affected and unaffected wrists enlarged, it revealed a significant DRUJ instability tendency due to Palmer-type IB TFCC injury (p-value: 0.000006, Wilcoxon rank-sum test). CONCLUSIONS: Dorsal stress radiography is a reliable, simple procedure to evaluate DRUJ instability intraoperatively. UTR value from dorsal stress radiography could be useful for evaluating DRUJ instability associated with distal radius fracture.

Improvement in scapular dyskinesis after rotator cuff repair and subacromial decompression.

PURPOSE: To investigate the incidence of scapular dyskinesis (SD) in patients with rotator cuff tears using pre- and postoperative 3D computed tomography, analyze the changes in scapular kinematics that occur after arthroscopic rotator cuff repair, and identify the contributing clinical factors. METHODS: Thirty-five patients (mean age, 62.5 ± 8.4 years) were included. Four scapular angles (upward rotation, internal rotation, protraction, and posterior tilt) were measured. The patients were categorized into three pre-existing SD types according to the difference in measured scapular angles between the affected and unaffected sides (type 1 SD, posterior tilt angle difference < - 5°; type 2 SD, internal rotation angle difference > 5°; and type 3 SD, upward rotation angle difference > 5°). The prevalence, factors influencing SD, and outcomes were compared between the improved and sustained SD groups. RESULTS: Twenty three of the 35 patients (65.7%) with rotator cuff tears had SD (type 1, 11; type 2, six; type 3, six). Of the 23 preoperative SD patients, 12 (52.1%) showed improved SD postoperatively. Most of the patients with improved SD (9/12) had type 1 SD (p = 0.021) and a significantly improved posterior tilt angle (p = 0.043). The improvement in SD was correlated with a higher range of motion of forward flexion and higher Constant scores (all p < 0.05). No healing failure occurred in the improved SD group (p = 0.037). CONCLUSION: The prevalence of SD was high in patients with degenerative rotator cuff tears. More than half of the SD cases, especially type 1 SD, improved postoperatively. SD recovery correlated with better function and successful rotator cuff healing. LEVEL OF EVIDENCE: IV.

Transient postoperative inferior subluxation of the shoulder after surgical stabilization of recurrent anterior dislocation in a patient with myasthenia gravis: a case report.

The authors present a case of transient postoperative inferior subluxation of the shoulder after arthroscopic surgical stabilization for recurrent anterior dislocation. The patient was a 61-year-old woman with myasthenia gravis (MG). The first anterior shoulder dislocation occurred because of a fall to the ground. Despite a successful closed reduction, two more dislocations occurred in 3 weeks. Magnetic resonance imaging revealed an anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion, an engaging Hill-Sachs lesion, and large tears of the supraspinatus and infraspinatus tendons. The patient underwent arthroscopic rotator cuff repair and ALPSA repair with a remplissage procedure. Intraoperatively, no tendency for instability was found; however, a widened glenohumeral joint space and inferior subluxation of the humeral head without functional compromise was observed on the day after surgery and disappeared spontaneously on radiographs 2 weeks later. To the authors' knowledge, this is the first report documenting the occurrence of transient postoperative inferior subluxation of the shoulder in a patient with MG.

Biomechanical Comparison of 1.2-mm Suture Tape, 2.0-mm Suture Tape, and 0.5-mm Suture Using Various Arthroscopic Knot Techniques.

Background: The biomechanical properties of the 1.2-mm suture tape have outperformed conventional sutures in previous studies. Purpose: To compare the loop and knot security of 2 tape-type and 1 cord-type sutures using different arthroscopic knot techniques. Study Design: Controlled laboratory study. Methods: The biomechanical characteristics of the 1.2-mm tape, 2.0-mm tape, and 0.5-mm No. 2 suture were compared using 4 different knot types: 2 sliding knots (Samsung Medical Center [SMC] and Tennessee) and 2 nonsliding knots (2-throw surgeon's and 2-throw square) with 2 and 3 additional reverse half-hitches on alternating posts (RHAPs) in a closed-loop system on a materials testing device. Each configuration was tested for loop security (maximal load applied between 0 and 3 mm of displacement), knot security (ultimate failure load), and failure mode with cyclical loading (30 N load for 20 cycles at 1 cycle per sec until failure). Loop and knot security among the configurations were compared using an analysis of variance. Results: With 2 RHAPs, the 2.0-mm tape showed significantly greater loop security than the 1.2-mm tape and suture (P = .001). With 3 RHAPs, the loop security of the suture was significantly superior compared with the 1.2-mm tape (P = .010). Regarding knot security, with 2 RHAPs, the 2.0-mm tape was significantly better than the 1.2-mm tape and suture (P < .001), while with 3 RHAPs, the suture was significantly superior to the 1.2-mm tape (P = .012). Using a square knot with 2 RHAPs, the 2.0-mm tape had significantly greater loop security (P = .001) and better knot security (P = .001) to the 1.2-mm tape and suture. Using the Tennessee knot with 2 RHAPs, the 1.2-mm tape had less loop security (P = .011) and knot security (P = .005) than the suture. Using the SMC knot with 3 RHAPs, the 2.0-mm tape and suture were significantly superior in loop security (P = .001) and knot security (P < .001) to the 1.2-mm tape. There was no significant difference in the failure mode between tapes and sutures with 2 and 3 RHAPs. Conclusion: With 2 RHAPs, the 2.0-mm tape demonstrated greater resistance to suture loop displacement and better knot security compared with the 1.2-mm tape and suture. However, with 3 RHAPs, the 1.2-mm tape manifested weaker loop and knot security compared with the suture.

Biceps Tenodesis Versus Superior Labral Anterior and Posterior (SLAP) Lesion Repair for the Treatment of SLAP Lesion in Overhead Athletes: A Systematic Review and Meta-analysis.

BACKGROUND: Superior labral anterior and posterior (SLAP) lesions are common injuries in overhead athletes. As a surgical treatment for SLAP lesions, SLAP repair has been traditionally performed. Recently, biceps tenodesis has been performed as an alternative treatment option; however, there is no review for outcome comparisons between these 2 procedures in overhead athletes. PURPOSE: The aim of this study was to compare the outcomes of SLAP repair versus biceps tenodesis, especially in overhead athletes with SLAP lesions. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: An electronic literature search was performed in Medline, Embase, Scopus, and the Cochrane Library. The studies were appraised using the Methodological Index for Non-randomized Studies (MINORS) tool. Studies that had a minimum follow-up of 2 years, included only patients with SLAP lesions without other major shoulder pathologies, and included only patients who engaged in overhead sports were included. The functional outcomes of the American Shoulder and Elbow Surgeons (ASES) score, rate of return to sport, rate of return to preinjury level of sport, and complication rate were subjected to meta-analysis. RESULTS: A total of 332 articles were identified, and 13 were included in the systematic review. Even though the postoperative ASES scores were slightly higher in the biceps tenodesis group than in the SLAP repair group, no statistically significant differences were found between the groups (biceps tenodesis, 95% CI = 91.71-96.75, I2 = 0.00; SLAP repair, 95% CI = 85.47-94.46, I2 = 16.3; P = .085) The rate of return to sport and the return to preinjury level of sport were slightly higher in the biceps tenodesis group than in the SLAP repair group; however, in meta-analysis these factors did not reach statistical significance (return to sport: biceps tenodesis, 95% CI = 0.66-0.91, I2 = 0.00; SLAP repair, 95% CI = 0.68-0.93, I2 = 70.23; P = .94) (return to preinjury level of sport: biceps tenodesis, 95% CI = 0.61-0.89, I2 = 17.78; SLAP repair, 95% CI = 0.53-0.82, I2 = 58.07; P = .37). The biceps tenodesis group showed a lower complication rate compared with the SLAP repair group without statistical significance (biceps tenodesis, 95% CI = 0.013-0.145, I2 = 0.00; SLAP repair, 95% CI = 0.049-0.143, I2 = 0.00; P = .25). CONCLUSION: The results of biceps tenodesis, compared with SLAP repair, were not inferior in the surgical treatment of overhead athletes with SLAP lesions with regard to the ASES score, rate of return to sport, rate of return to preinjury level of sport, and complication rate. Further high-level, randomized controlled studies are needed to confirm this result.

Can a Two Simple Stitches Method Provide Secure Fixation Strength in Biceps Tenodesis?: Biomechanical Evaluation of Various Suture Techniques.

Background: The purpose of this study was to compare the initial fixation strength between four different suture methods for the long head of the biceps. Methods: Forty-eight fresh frozen porcine flexor hallucis longus tendons (mean width at suture site, 8.5 ± 0.9 mm) and phalanx bones were randomly assigned to one of the four arthroscopic biceps tenodesis techniques: simple stitch (SS), mattress suture (MS), lasso-loop (LL), and two simple stitches (2SS). A biceps tenodesis was performed according to the four techniques using all-suture type suture anchors (1.9-mm SUTUREFIX anchor with No. 1 ULTRABRAID sutures). Biomechanical evaluations were performed to test load to failure (N), stiffness (N/mm), stress (N/m2), and mode of failure. Results: As for the SS, MS, LL, and 2SS, the mean load to failure was 50.9 ± 14.61 N, 82.3 ± 24.8 N, 116.2 ± 26.7 N, and 130.8 ± 22.5 N (p < 0.001), respectively; mean stiffness was 6.1 ± 1.3 N/mm, 6.7 ± 2.6 N/mm, 7.8 ± 1.4 N/mm, and 8.1 ± 4.2 N/mm, respectively (p = 0.258); and mean stress was 0.7 ± 0.3 N/m2, 1.4 ± 0.8 N/m2, 2.9 ± 0.7 N/m2, and 2.7 ± 0.8 N/m2, respectively (p < 0.001). All the failures happened by the suture cutting through the tendon along its longitudinal fibers. Conclusions: Neither the SS nor the MS method was enough to securely fix the biceps tendon with a significantly lower mechanical strength; however, the 2SS method showed similar initial fixation strength as the LL technique.

Metastasis of renal cell carcinoma around suture anchor implants.

We present an unusual case of bone metastases from renal cell carcinoma around orthopedic implants in a 78-year-old female with osteolytic, expansile, highly vascularized, malignant infiltration around suture anchors in the proximal humerus. The patient had undergone arthroscopic rotator cuff repair using suture anchor implants 6 years previously. After diagnosis of bone metastasis, she was successfully treated with metastasectomy and internal fixation using a plate and screws, with cement augmentation. This report is the first to document metastases around a suture anchor in a bone and suggests the vulnerability of suture anchor implants to tumor metastasis.

Delayed Anticipatory Muscle Activation in Rotator Cuff Tendinopathy.

BACKGROUND: Previous research investigating rotator cuff (RC) tendinopathy has usually focused on pathoanatomy. The pathologic response to anticipatory postural adjustments (APAs) has not yet been investigated. PURPOSE/HYPOTHESIS: To explore changes in APAs as detected by pre-emptive activation of shoulder muscles during ball catching. It was hypothesized that anticipatory muscle activation (AMA) would be present in the unaffected shoulder but delayed or absent in the affected shoulder in patients with RC tendinopathy. STUDY DESIGN: Controlled laboratory study. METHODS: This study included 21 RC tendinopathy patients with a mean age of 49.5 years. Patients were required to grab a ball embedded with an electromyography sensor when it dropped on their hand, and surface electromyography signals were recorded from the infraspinatus, upper trapezius, anterior deltoid, and biceps. The trials utilized 2 balls, weighing 200 g and 500 g. Each ball was used in 2 trials, 1 involving a number count preceding the ball drop (predictable) and the other involving a sudden drop (unpredictable). The onsets of AMA between the affected and unaffected limbs were compared. RESULTS: Regardless of the experimental condition, significantly delayed AMA onsets were identified in all investigated muscles of the affected side compared with those of the unaffected side, except for the biceps muscle in the 500-g predictable trial. For the infraspinatus, the mean onset time in the 200-g predictable trial was -141.0 ± 60.2 ms on the affected side and -211.9 ± 67.1 ms on the unaffected side (P < .001); in the 200-g unpredictable trial this value was -139.5 ± 54.9 ms on the affected side and -199.5 ± 56.2 ms on the unaffected side (P < .001). CONCLUSION: Delayed AMA was observed in the affected shoulder compared with the unaffected shoulder in patients with RC tendinopathy, not only in the RC muscle but also in the periscapular and upper arm muscles. This may indicate that central hypoexcitability is partly responsible. CLINICAL RELEVANCE: The basis for RC tendinopathy treatment should not be limited to the tendon pathoanatomy. Delayed AMA around the shoulder joint could provide insight into potential mechanisms related to the central nervous system.

Clinical Outcomes of Interposition Graft Versus Superior Capsular Reconstruction in Patients With Irreparable Rotator Cuff Tears: A Systematic Review and Meta-analysis.

BACKGROUND: Interposition grafting (IG), also called bridging grafting, and superior capsular reconstruction (SCR) are the most commonly used joint-preserving surgical methods for irreparable rotator cuff tears (RCTs). PURPOSE: To compare the effectiveness of IG versus SCR to treat patients with irreparable RCTs. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A literature search was performed in MEDLINE, Embase, and Scopus. Included in this review were clinical studies evaluating the effect of IG or SCR in patients with irreparable RCTs with a minimum follow-up of 1 year. Various clinical results from the studies were extracted and compared between IG and SCR, and among them, the results of the American Shoulder and Elbow Surgeons score, graft retear rate, and complication rate were included in the meta-analysis. RESULTS: Of 1638 identified articles, 17 (10 studies of IG involving 321 patients and 7 studies of SCR involving 357 patients) were selected. Both surgical methods showed significantly improved clinical outcomes in all but 1 study; however, the IG group had lower pain visual analog scale score, higher Constant score, and bigger active forward flexion and internal rotation compared with the SCR group (all P < .001). The meta-analysis showed no difference in the American Shoulder and Elbow Surgeons score between groups (P = .44), but showed a significantly lower complication rate in the IG group compared with the SCR group (1.12% vs 8.37%, respectively; P < .001). The graft retear rate was not significantly different between groups (IG = 10.64% vs SCR = 12.67%; P = .79). The meta-analysis of graft type indicated no difference between groups in retear rate (autograft: 95% CI, 0.045-0.601; I 2 = 93.28 [IG], 91.27 [SCR]; P = .22; allograft: 95% CI, 0.041-0.216; I 2 = 80.39 [IG], 69.12 [SCR]; P = .64) or complication rate (autograft: 95% CI, 0.009-0.150; I 2 = 0 [IG], 65.89 [SCR]; P = .25; allograft: 95% CI, 0.012-0.081; I 2 = 0 [IG], 30.62 [SCR]; P = .09). CONCLUSION: Both IG and SCR techniques resulted in improvement in patients with irreparable RCTs. Meta-analysis showed a lower complication rate in the IG group; however, the lack of randomized studies limited our conclusions.

Effect of a Porous Suture Containing Transforming Growth Factor Beta 1 on Healing After Rotator Cuff Repair in a Rat Model.

BACKGROUND: The healing failure rate after rotator cuff repair is considerably high. PURPOSE: To evaluate the effect of a porous suture containing transforming growth factor beta 1 (TGF-ß1) on the sustained release of TGF-ß1 and rotator cuff healing in a rat model. STUDY DESIGN: Controlled laboratory study. METHODS: A porous suture was developed, and its tensile strength was measured. TGF-ß1 was delivered using the porous suture, and a TGF-ß1 release test and human fibroblast proliferation assay were performed. For the animal experiment, 30 rats were randomly allocated into 3 groups (n = 10 each). A bilateral supraspinatus tendon tear was made in all the rats, and repair was performed. Group 1 received repair only; group 2, repair and a single injection of TGF-ß1; and group 3, repair using the porous suture containing TGF-ß1. Eight weeks after repair, biomechanical and histological analyses were performed. RESULTS: The porous suture was successfully developed with mechanical properties compatible with the conventional suture, and the sustained release of TGF-ß1 from the porous suture was confirmed. In addition, the cell proliferation assay confirmed the biological safety of the porous suture. In the animal experiment, group 3 biomechanically exhibited the largest cross-sectional area and the highest ultimate failure load and ultimate stress (all P < .05). Histological examination revealed that group 3 showed significantly better collagen fiber density and tendon-to-bone maturation than did groups 1 and 2 (all P < .05). CONCLUSION: The porous suture containing TGF-ß1 could sustainedly and safely release TGF-ß1, and its use during rotator cuff repair could improve rotator cuff healing, as assessed on the basis of the biomechanical and histological changes in the rat model in this study. Considering the effectiveness, safety, and convenience of the porous suture without extra effort in surgery, the findings of the present study will have a far-reaching effect on the treatment of rotator cuff tears. CLINICAL RELEVANCE: The porous suture containing TGF-ß1 might improve healing after rotator cuff repair.