Prediction of the Irreparability of Rotator Cuff Tears.

PURPOSE: To determine the influence of preoperative factors on reparability of rotator cuff tears (RCTs) and yield a predictive model for predicting irreparability preoperatively. METHODS: Among patients with full-thickness RCTs, the reparable group underwent arthroscopic rotator cuff repairs for reparable RCTs whereas the irreparable group underwent alternative surgical procedures for irreparable RCTs. We analyzed age, sex, chronic pseudoparalysis (CPP), mediolateral and anteroposterior tear sizes, acromiohumeral distance (AHD), tangent sign, fatty infiltration (FI) (group 1, Goutallier stage 0 or 1; and group 2, Goutallier stage 2, 3, or 4), and tendon involvement (TI) (type 1, supraspinatus; type 2, supraspinatus and subscapularis; type 3, supraspinatus and infraspinatus; and type 4, all 3 tendons). RESULTS: The irreparability rate was 12.5%. Between the reparable (663 patients) and irreparable (95 patients) groups, significant differences were found in age (58.8 ± 8.3 years vs 65.6 ± 8.0 years, P < .001); female sex (46.9% vs 63.2%, P = .014); CPP (6.5% vs 36.8%, P < .001); mediolateral tear size (23.7 ± 12.1 mm vs 47.4 ± 9.1 mm, P < .001); anteroposterior tear size (17.9 ± 11.5 mm vs 43.4 ± 16.2 mm, P < .001); AHD (9.0 ± 1.7 mm vs 5.8 ± 1.6 mm, P < .001); tangent sign (2.9% vs 61.1%, P < .001); group 2 FI of the subscapularis (6.9% vs 20.0%, P < .001), supraspinatus (12.1% vs 58.9%, P < .001), infraspinatus (26.8% vs 69.5%, P < .001), and teres minor (4.2% vs 10.5%, P = .008); and type 1, 2, 3, and 4 TI (88.1%, 6.2%, 5.4%, and 0.3%, respectively, vs 29.5%, 21.1%, 28.4%, and 21.1%, respectively; P < .001). Multiple logistic regression analysis showed CPP, mediolateral tear size, AHD, tangent sign, group 2 FI of the supraspinatus, and type 4 TI were significant independent predictors of irreparability, with odds ratios of 3.539 (P = .007), 1.087 (P < .001), 0.624 (P < .001), 6.141 (P < .001), 2.233 (P = .034), and 12.350 (P = .016), respectively. These factors yielded a predictive model for irreparability as follows: Logit P = 1.264 × CPP + 0.084 × Mediolateral tear size - 0.472 × AHD + 0.804 × Group 2 FI of supraspinatus + 1.815 × Tangent sign + 2.514 × Type 4 TI - 3.460. CONCLUSIONS: The irreparability of RCTs is strongly associated with CPP, mediolateral tear size, AHD, tangent sign, group 2 FI of the supraspinatus, and type 4 TI and can be preoperatively calculated using the predictive equation. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Risk Factors for Retear After Arthroscopic Repair of Full-Thickness Rotator Cuff Tears Using the Suture Bridge Technique: Classification System.

PURPOSE: To identify factors that predict retears after arthroscopic repair of full-thickness rotator cuff tears. METHODS: Factors included age, sex, diabetes, smoking, symptom duration (group I, <12 months; group II, ≥12 months), tear size according to the Kim classification (group I, A and B; group II, C; group III, D), tendon involvement (group I, supraspinatus; group II, supraspinatus and subscapularis; group III, supraspinatus and infraspinatus; group IV, all 3 tendons), and degree of fatty degeneration of the supraspinatus and infraspinatus (group I, Goutallier stages 1 and 2 for each tendon; group II, Goutallier stages 3 and 4 for each tendon). RESULTS: Two hundred eighty-two patients underwent arthroscopic repairs of full-thickness rotator cuff tears. The overall retear rate was 13.1%. Age, sex, diabetes, smoking, and degree of fatty degeneration of the supraspinatus and infraspinatus did not affect retear rates. However, symptom duration (P = .006), Kim classification (P < .001), and tendon involvement (P < .001) did affect retear rates. The retear rates were 8.5% (14 of 165 patients) and 19.7% (23 of 117) in symptom duration groups I and II, respectively; 8.0% (13 of 163), 15.2% (16 of 105), and 57.1% (8 of 14) in Kim classification groups I, II, and III, respectively; and 6.6% (11 of 167), 22.2% (18 of 81), 10.0% (2 of 20), and 42.9% (6 of 14) in tendon involvement groups I, II, III, and IV, respectively. In the multiple logistic regression analysis, the respective odds ratios of symptom duration group II, Kim classification group III, tendon involvement group II, and tendon involvement group IV were 2.853 (P = .011), 18.108 (P = .001), 4.184 (P = .001), and 5.727 (P = .021), respectively. CONCLUSIONS: To preoperatively predict retears after arthroscopic repair of full-thickness rotator cuff tears, the duration of symptoms before surgery, tear size, and tendon involvement can be used. In addition, regarding tear size, the Kim classification can be used more effectively than the modified DeOrio and Cofield classification. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Does the Use of Injectable Atelocollagen during Arthroscopic Rotator Cuff Repair Improve Clinical and Structural Outcomes?

BACKGROUND: Since the establishment of biological augmentation to improve the treatment of rotator cuff tears, it is imperative to explore newer techniques to reduce the retear rate and improve long-term shoulder function after rotator cuff repair. This study was undertaken to determine the consequences of a gel-type atelocollagen injection during arthroscopic rotator cuff repair on clinical outcomes, and evaluate its effect on structural integrity. METHODS: Between January 2014 and June 2015, 121 patients with full thickness rotator cuff tears underwent arthroscopic rotator cuff repair. Of these, 61 patients were subjected to arthroscopic rotator cuff repair in combination with an atelocollagen injection (group I), and 60 patients underwent arthroscopic rotator cuff repair alone (group II). The visual analogue scale (VAS) for pain and the Korean Shoulder Society (KSS) scores were evaluated preoperatively and postoperatively. Magnetic resonance imaging (MRI) was performed at 6 months postoperatively, to assess the integrity of the repair. RESULTS: VAS scores were significantly lower in group I than in group II at 3, 7, and 14 days after surgery. KSS scores showed no significant difference between groups in the 24 months period of follow-up. No significant difference was obtained in the healing rate of the rotator cuff tear at 6 months postoperatively (p=0.529). CONCLUSIONS: Although a gel-type atelocollagen injection results in reduced pain in patients at 2 weeks after surgery, our study does not substantiate the administration of atelocollagen during rotator cuff repair to improve the clinical outcomes and healing of the rotator cuff.

Open reduction of a chronic proximal dislocation after total hip arthroplasty.

We report an unusual case of a chronic prosthetic dislocation that was caused by the buttonholing of a prosthetic femoral head by anterior soft tissue, which impeded reduction. A surprisingly good functional result was achieved by an open reduction and revision operation on a 56-year-old man, who had a chronic dislocation of a total hip prosthesis. Successful treatment with open reduction of a chronic proximal dislocation after total hip arthroplasty has not been reported previously in the literature.

The proximally-based sural artery flap for coverage of soft tissue defects around the knee and on the proximal third and middle third of the lower leg: 10 patients followed for 1-2.5 years.

BACKGROUND AND PURPOSE: There have been few reports regarding the proximally based sural artery flap, which is useful for reconstruction of soft tissue defects around the knee and on the proximal third and middle third of the lower leg. Here we report our experience with 10 patients. PATIENTS: The defects in our 10 cases were around the knee (4), on the proximal third of the lower leg (4), and on the middle third (2). 8 patients had fasciocutaneous flaps and 2 had adipofascial flaps. The flap size ranged from 4 to 10 cm in length, and from 5 to 8 cm in width. The pedicle length ranged from 12 to 20 cm. RESULTS: All 10 flaps survived. Congestion and tip necrosis occurred in 1 case with a fasciocutaneous flap, which healed without complications. A superficial infection occurred in 1 case with a fasciocutaneous flap, which healed with antibiotic treatment. Necrosis of grafted skin occurred in 2 cases of adipofascial flap; only one of them, however, required additional surgery. No morbidity of the donor site and no functional deficits were detected in any of the 10 cases. INTERPRETATION: The proximally based sural artery flap is useful for reconstruction of soft tissue defects around the knee joint and on the proximal third and middle third of the lower leg. It is a relatively easy and reliable procedure.

An Intra-articular Steroid Injection at 6 Weeks Postoperatively for Shoulder Stiffness After Arthroscopic Rotator Cuff Repair Does Not Affect Repair Integrity.

BACKGROUND: Shoulder stiffness is a common complication after arthroscopic rotator cuff repair. However, there is no consensus on the treatment of stiffness after repair. Although one treatment option is an intra-articular steroid injection, it may negatively affect repair integrity, and there is a paucity of literature regarding the timing of intra-articular injections for stiffness after repair and its effect on repair integrity. PURPOSE: To compare repair integrity and clinical outcomes after an intra-articular steroid injection administered at 6 weeks and 12 weeks postoperatively for shoulder stiffness after arthroscopic rotator cuff repair. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who developed stiffness after arthroscopic rotator cuff repair were given a series of 3 intra-articular steroid injections every 4 weeks from 6 (6-week group) and 12 weeks (12-week group) postoperatively. The control group had rotator cuff tears but neither stiffness nor injections. Shoulder range of motion (ROM), the Korean Shoulder Scoring System (KSS) score, and the University of California, Los Angeles (UCLA) shoulder score were assessed preoperatively with a minimum of 2-year follow-up. Repair integrity was assessed using magnetic resonance imaging at 6 months postoperatively. RESULTS: Seventy-four of 209 patients (35.4%) who underwent arthroscopic rotator cuff repair developed stiffness. There were no significant differences in retear rates among the 6-week (5.7%, 2/35 patients), 12-week (10.3%, 4/39 patients), and control groups (14.1%, 19/135 patients) ( P = .374). Both the 6- and 12-week groups showed significant improvement in ROM (both P < .001), KSS scores (both P < .001), and UCLA scores (both P < .001) at the final follow-up. The 6-week group showed significantly better ROM ( P < .001), KSS scores ( P < .001), and UCLA scores ( P < .001) than the 12-week group at 3 months postoperatively. However, both the 6- and 12-week groups showed significantly lower KSS (81.3 ± 12.0 [ P = .004] and 83.4 ± 8.6 [ P = .035], respectively) and UCLA (29.3 ± 4.6 [ P = .006] and 30.0 ± 3.3 [ P = .042], respectively) scores than the control group (90.4 ± 13.6 and 32.3 ± 4.7, respectively) at the last follow-up. CONCLUSION: An intra-articular steroid injection administered at 6 weeks postoperatively for shoulder stiffness after arthroscopic rotator cuff repair may be effective for reducing patients' pain and improving shoulder ROM at 3 months postoperatively without compromising repair integrity.

A Rotator Cuff Tear Concomitant With Shoulder Stiffness Is Associated With a Lower Retear Rate After 1-Stage Arthroscopic Surgery.

BACKGROUND: Few studies have reported on the radiological characteristics and repair integrity of coexistent rotator cuff tears (RCTs) and shoulder stiffness after simultaneous arthroscopic rotator cuff repair and capsular release. PURPOSE: To evaluate the radiological characteristics and repair integrity of 1-stage arthroscopic surgery of RCTs concomitant with shoulder stiffness. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Among patients who underwent arthroscopic repair of full-thickness RCTs, the stiff group underwent simultaneous capsular release for shoulder stiffness, and the nonstiff group had no stiffness. Symptom duration, prevalence of diabetes, tear size, tendon involvement (type 1, supraspinatus; type 2, supraspinatus and subscapularis; and type 3, supraspinatus and infraspinatus; type 4, supraspinatus, subscapularis, and infraspinatus), and fatty infiltration (Goutallier stages 0-4) were evaluated. A retear was appraised using magnetic resonance imaging, and clinical outcomes were assessed using range of motion, the Korean Shoulder Scoring System (KSS), and the University of California, Los Angeles (UCLA) shoulder score. RESULTS: The stiff group showed a significantly lower retear rate (1/39, 2.6%) than the nonstiff group (47/320, 14.7%) ( P = .043). There were significant differences in symptom duration (7.4 ± 6.6 vs 15.0 ± 23.7 months, respectively; P < .001), mediolateral tear size (18.9 ± 8.9 vs 24.1 ± 12.0 mm, respectively; P = .002), tendon involvement (94.9%, 5.1%, 0.0%, and 0.0% vs 85.3%, 6.9%, 7.8%, and 0.0%, respectively; P = .048), and fatty infiltration of the subscapularis (66.7%, 33.3%, 0.0%, 0.0%, and 0.0% vs 31.9%, 61.3%, 5.6%, 1.3%, and 0.0%, respectively; P < .001) and teres minor (74.4%, 20.5%, 5.1%, 0.0%, and 0.0% vs 47.2%, 48.8%, 3.8%, 0.0%, and 0.3%, respectively; P = .007) between the stiff and nonstiff groups. Preoperatively, the stiff group showed significantly worse forward flexion (95.9° ± 23.6° vs 147.7° ± 4.2°, respectively; P < .001), external rotation (17.4° ± 10.1° vs 51.6° ± 12.1°, respectively; P < .001), and internal rotation (L5 vs L2, respectively; P < .001) and lower KSS (52.1 ± 13.8 vs 66.3 ± 13.5, respectively; P < .001) and UCLA scores (18.7 ± 4.8 vs 22.5 ± 4.5, respectively; P < .001) than the nonstiff group. However, these differences became insignificant from 3 months postoperatively for forward flexion ( P > .05) and KSS ( P > .05) and UCLA scores ( P > .05), from 1 year postoperatively for external rotation ( P > .05), and at the last follow-up for internal rotation ( P > .05). A multiple logistic regression analysis revealed that only mediolateral tear size (odds ratio, 1.043; P = .014) and type 2 tendon involvement (odds ratio, 4.493; P = .003) were independent predictors of a retear. CONCLUSION: RCTs concomitant with shoulder stiffness showed a smaller mediolateral tear size, anterosuperior tendon involvement, and less severe fatty infiltration preoperatively and better repair integrity postoperatively than RCTs without stiffness. Furthermore, the clinical outcomes and range of motion at final follow-up were similar between the 2 groups.

Preoperative Korean Shoulder Scoring System Correlates with Preoperative Factors of Rotator Cuff Tears.

BACKGROUND: The Korean Shoulder Scoring System (KSS) is a reliable and valid procedure for discriminative assessment of the clinical status of patients with rotator cuff tears. This study evaluates the correlation between the preoperative KSS and factors in patients with rotator cuff tears. METHODS: From November 2009 to June 2016, 970 patients who underwent arthroscopic rotator cuff repair were retrospectively evaluated. A total of 490 patients met the study criteria. Preoperative factors included age, sex, symptom duration, mediolateral (ML) and anteroposterior (AP) tear size, acromiohumeral distance (AHD), tangent sign, tendon involvement (type I, supraspinatus; type II, supraspinatus and subscapularis; type III, supraspinatus and infraspinatus; type IV, all 3 tendons), fatty infiltration of rotator cuff muscles (group I, Goutallier stages 0 and 1; group II, Goutallier stages 2, 3, and 4), and KSS. RESULTS: Old age, ML tear size, and AP tear size negatively correlated with the preoperative KSS (p<0.001). AHD showed a positive correlation with the preoperative KSS (p<0.001). A significantly inferior preoperative KSS was found in females and type III tendon involvement (p<0.001). For supraspinatus and infraspinatus, the preoperative KSS of group II fatty infiltration showed a significantly lower score than group I fatty infiltration (p<0.05). CONCLUSIONS: A relatively lower preoperative KSS was associated with old age, large tear size, narrow AHD, female, type III tendon involvement, and group II fatty infiltration of the supraspinatus and infraspinatus. Our study indicates that preoperative KSS can be a good measurement for the preoperative status of patients with rotator cuff tears.

The Korean Mistletoe (Viscum album coloratum) Extract Has an Antiobesity Effect and Protects against Hepatic Steatosis in Mice with High-Fat Diet-Induced Obesity.

This study investigates the inhibitory effects of Korean mistletoe extract (KME) on adipogenic factors in 3T3-L1 cells and obesity and nonalcoholic fatty liver disease (NAFLD) in mice fed a high-fat diet. Male C57Bl/6 mice fed a high-fat diet were treated with KME (3 g/kg/day) for 15 weeks for the antiobesity and NAFLD experiments. Body weight and daily food intake were measured regularly during the experimental period. The epididymal pad was measured and liver histology was observed. The effects of KME on thermogenesis and endurance capacity were measured. The effects of KME on adipogenic factors were examined in 3T3-L1 cells. Body and epididymal fat pad weights were reduced in KME-treated mice, and histological examination showed an amelioration of fatty liver in KME-treated mice, without an effect on food consumption. KME potently induces mitochondrial activity by activating thermogenesis and improving endurance capacity. KME also inhibited adipogenic factors in vitro. These results demonstrate the inhibitory effects of KME on obesity and NAFLD in mice fed a high-fat diet. The effects appear to be mediated through an enhanced mitochondrial activity. Therefore, KME may be an effective therapeutic candidate for treating obesity and fatty liver caused by a high-fat diet.

Korean mistletoe (Viscum album coloratum) extract improves endurance capacity in mice by stimulating mitochondrial activity.

The beneficial effects of exercise on overall health make it desirable to identify the orally active agents that enhance the effects of exercise in an effort to cure metabolic diseases. Natural compounds such as resveratrol (RSV) are known to increase endurance by potentiating mitochondrial function. Korean mistletoe (Viscum album coloratum) extract (KME) has characteristics similar to those of RSV. In the present study, we determined whether KME could increase mitochondrial activity and exert an anti-fatigue effect. We found that KME treatment significantly increased the mitochondrial oxygen consumption rate (OCR) in L6 cells and increased the expression of peroxisome proliferator-activated receptor γ coactivator (PGC)-1α and silent mating type information regulation 2 homolog 1 (SIRT1), two major regulators of mitochondria function, in C2C12 cells. In the treadmill test, KME-treated mice could run 2.5-times longer than chow-fed control mice. Additionally, plasma lactate levels of exhausted mice were significantly lower in the KME-treated group. In addition, the swimming time to exhaustion of mice treated with KME was prolonged by as much as 212% in the forced-swim test. Liver and kidney histology was similar between the KME-treated and phosphate-buffered saline-treated animals, indicating that KME was nontoxic. Taken together, our data show that KME induces mitochondrial activity, possibly by activating PGC-1α and SIRT1, and improves the endurance of mice, strongly suggesting that KME has great potential as a novel mitochondria-activating agent.

MR-based parameters as a supplement to radiographs in managing developmental hip dysplasia.

BACKGROUND: Some dysplastic hips with favorable radiographic parameters fail to develop normally, suggesting that we should consider cartilaginous or soft tissue structures for further information regarding the condition of the hip. The purpose of this study was to provide a clear definition of concentric reduction in developmental dysplasia of the hip (DDH) based on magnetic resonance imaging (MRI), and to determine how radiographic and MR-based parameters could be used together to treat dysplastic hips. METHODS: We studied range of motion (ROM)-MRI of 25 patients with unilateral hip dysplasia (mean age at the time of MR imaging, 44.1 months). Each ROM-MRI consisted of a set of bilateral hip scans in the following positions: neutral; abduction; abduction- internal rotation; abduction-internal rotation-flexion; and adduction. Before MR scanning, the 25 patients received the following primary treatments: closed reduction (n = 15; at a mean age of 14.5 months); and open reduction (n = 10; at a mean age of 10.0 months). The following new parameters appear to be useful in treating DDH: 1) the labral angle, the angle the labrum makes with the acetabulum; 2) the uncorrected labral deformity (ULD), the "residual deformity" (deflection of the labrum) when the affected labrum is freed from pressure in abduction; and 3) the zone of compressive force (ZCF), the region of the acetabulum through which the body weight acts on the femoral head. RESULTS: A concentrically-reduced hip is one in which the labrum points downward in the neutral position, at the same angle as that of the normal side; and in which the ZCF is zone 3, the inner acetabular zone as defined herein. The ULD and the ZCF may be determined precisely as we have done, or the physician may simply observe the changes in the orientation of the labrum and compare the changes qualitatively to the unaffected side, and likewise for the medial joint space. CONCLUSIONS: Detailed analysis of the labrum as permitted by ROM-MRI, together with acetabular index and other parameters measured from radiographs, provides important information for physicians treating childhood hip dysplasia.