Faster strength recovery and better strength ratio with arthroscopic Latarjet compared to the open technique: An observational study.

INTRODUCTION: The arthroscopic bone block has shown reliability and reproducibility regarding functional scores and shoulder mobility compared to the open bone block technique. The recovery of muscle strength, especially the strength ratio external rotator/internal rotator (ER/IR), is crucial to recovering satisfactory function. This ratio should be as near to 1 as possible, meaning a good strength balance. Little is known about the difference in strength recovery between the open and arthroscopic techniques. HYPOTHESIS: Arthroscopic Latarjet reduces surgical stress and improves the strength recovery and strength ratio. OBJECTIVES: To compare arthroscopic and open Latarjet procedures for shoulder muscle strength and functional outcomes. MATERIAL AND METHODS: It was an observational longitudinal and prospective cohort follow-up. Two groups of patients were accessible for comparison: 35 in an arthroscopy group and 38 in an open group. The main outcome was the muscle strength of shoulder muscles measured with a dynamometer and expressed in Newton (N) at day 21 (D21), D45, D90, D180, and D365 in the operated and contralateral shoulders. The measurements were made for the pectoralis major, the three deltoid fascicles, and the subscapularis. The shoulder ER/IR strength ratio was calculated. Other variables were the range of motion (ROM), the Walch-Duplay (WD), the Western Ontario Shoulder Instability score (WOSI), and the Visual Analogic Scale for pain assessment. The strength, ROM, and functional scores were compared between open and arthroscopy with linear mixed models. RESULTS: The median strengths at 52 weeks were significantly higher than at 3 weeks (P<10-4): anterior deltoid (AD) 8N (Q1:7, Q3: 9) versus 4N (Q1:2, Q3: 5), lateral deltoid (LD) 9N (Q1:9, Q3: 11) versus 6N (Q1:4, Q3: 7), posterior deltoid (PD) 14N (Q1:12, Q3: 15) versus 9N (Q1:8, Q3: 10), subscapularis 10N (Q1:9, Q3: 12) versus 7N (Q1:5, Q3: 8), and pectoralis major (PM) 11N (Q1:9, Q3: 12) versus 7N (Q1:5, Q3: 10). The overall strengths were lower in the open group compared to the arthroscopy group: AD -2.1N (CI95%[-3.1--1.2], p=0.0005), LD -1.3N (CI95% [-2.4--0.15], p=0.03), PD -0.35N (CI95% [-1-0.9], p=0.52), subscapularis -2.1N (CI95% [-3.3--0.7], p=0.006), and PM -1.4N (CI95% [-2.2--0.02], p=0.03). The ER/IR ratio was stable throughout the follow-up for both the operated and contralateral shoulders (p>0.5). The overall mean ratio was 1.3 (median 1.2, Q1: 1, Q3:1.45) for the operated shoulder and 1.1 (median 1, Q1: 0.9, Q3:1.3) for the contralateral shoulder (p=0.0004). The average ER/IR ratio was 0.27 points higher in the open group (CI95% [0.1-0.46], p=0.003). The ROM was similar between the two groups, and there was no correlation between the ER/IR ratio and the ROM (p>0.5). The VAS < 3 weeks and WD > 12 weeks were significantly poorer in the open group: +0.61 (CI95% [0.03-1.16] p=0.02), and -7.3 points (CI95% [-13--0.01], p=0.05), on average, respectively. CONCLUSION: The patients in the arthroscopy group had a better ER/IR strength ratio (closer to 1) and better WOSI after 12 weeks. The strength and the ROM were not correlated with each other. LEVEL OF EVIDENCE: III.

Quality and stability of reduction of operated acromioclavicular dislocation using dual acromioclavicular and coracoclavicular stabilization.

INTRODUCTION: Dual stabilization is advocated in acute acromioclavicular dislocation (ACD), but has been little assessed. OBJECTIVE: This preliminary study performed clinical and radiological assessment of dual acromioclavicular (AC) and coracoclavicular (CC) stabilization in acute ACD. The study hypothesis was that dual stabilization allows satisfactory reduction that remains stable over time. MATERIALS AND METHODS: A button was used under endoscopy for CC stabilization. For AC stabilization, a short approach was used; the joint was cleansed then stabilized by an anchored tape between the acromion and the clavicle to promote ligament healing. Clinical assessment was based on a visual analog pain scale (VAS), joint range of motion and Quick-DASH and Constant scores. Radiological reduction was assessed on the ratio of CC distance between the operated and healthy sides on two views. MRI was used in follow-up to screen for ligament healing: thickening and continuity. RESULTS: Thirty-five patients with stage 3-5 acute dislocation were included. At a minimum 24 months' follow-up, mean clinical scores were very satisfactory, with recovery of motion and pain relief. Radiography showed 94% stable reduction in both vertical and horizontal planes. MRI confirmed CC and AC ligament healing. Postoperative complications mainly comprised 4 cases of reduction loss (11%). One clavicle fracture occurred, at 6 months. CONCLUSION: Dual AC-CC stabilization provided very good radiographic reduction in both horizontal and vertical planes. Functional results were very satisfactory, and complications were few, with some cases of reduction loss. These good results encourage us to continue with dual stabilization in acute ACD. LEVEL OF EVIDENCE: II; prospective cohort.

Arthroscopic approach in initial training: Study of a novice cohort using inverse direct and indirect approaches and its implication in the development of training programs.

INTRODUCTION: Arthroscopic training includes successive stages of observation, reproduction and then repetition. Learning through simulation in 2D virtual reality makes it possible to repeat these different stages to enhance the learner's experience in complete safety and a shorter timeframe. Some procedures require inversion of the optical and instrumental approaches in the axial plane, disrupting the existing psychomotor and technical skills. The objective of this study was to compare the degree of difficulty and the distribution of results for the same exercise carried out alternately in classical holding and inverted holding of the instruments in a cohort of novice learners. MATERIALS AND METHODS: Twenty-two medical students, novices in arthroscopic surgery, participated in the study. Each performed an exercise consisting of grasping ten targets with arthroscopic forceps and placing them in a basket on the VirtaMed ArthroS™ simulator. The exercise was performed with the scope and grasping instrument pointed away from the operator, "catch the stars front" (CTSF), then directed towards the operator, "catch the stars back" (CTSB). The simulator recorded several parameters making up an overall composite score ("overall performance score", OPS) out of 120 points. Voluntary abandonment of the exercise was also collected. RESULTS: All students completed the CTSF exercise but 6 dropped out of the CTSB exercise (27%, p=0.01). In the CTSF exercise, the average OPS was higher with 45.9 points versus 22.8 points in the CTSB exercise (p<0.001). By detailing the components of the OPS score, the parameters of interest on the Fundamentals of Arthroscopic Training (FAST) module of the simulator included: the distance traveled by the scope and the grasping forceps was significantly greater in the CTSB group (p<0.001), the duration of the exercise was significantly greater in the CTSB group (p<0.001), the time spent with the instruments in the videoscopic field was significantly lower in the CTSB group (p=0.001) and finally the absence of a significant difference in the camera alignment compared to the horizontal plane between the two groups. CONCLUSION: The exercise with the instruments directed towards the operator is more difficult with a greater distribution for all the secondary criteria except for the camera alignment, which suggests that it could be more discriminating. The dropout rate is also higher. It would therefore be interesting to introduce CTSB type training in initial training programs in arthroscopy. LEVEL OF EVIDENCE: III, comparative prospective study.

Wide awake local anesthesia no tourniquet (WALANT) versus axillary brachial plexus block for carpal tunnel release in a French public university hospital: Care pathways and operating room costs.

INTRODUCTION: The wide awake local anesthesia no tourniquet (WALANT) is a local anesthetic technique that theoretically cuts costs and shortens surgical waiting times, but this has yet to be demonstrated in France. The main objective of this study was to assess and compare the comprehensive care pathways and costs of performing carpal tunnel release (CTR) procedures in the ambulatory surgery unit using WALANT and axillary brachial plexus block (ABPB). METHODS: A total of 72 CTRs in 66 patients were reviewed after a minimum follow-up of 6 months. The anesthesia was performed by an anesthesiologist after a preoperative consultation. The surgical waiting time, operating room occupancy time, total time taken off work (TOW) and the return to work rate were recorded. The estimated total direct cost per patient (TDCPP) was the sum of the specialist consultation fees, the French diagnosis-related group (DRG) rates and the minimum daily cost of TOW (€27.30/day). RESULTS: Only the total operating room occupancy time differed significantly: 27minutes for the WALANT versus 37minutes for the ABPB (p=0.004). There were no complications or reoperations in either group. The total cost for the cohort was estimated at €190,970. The mean estimated TDCPP was €2,870 for the entire cohort, €2,543 for the ABPB and €2,713 for the WALANT (p=0.791). Twenty-seven of the 45 patients returned to work after a mean TOW of 3.1 months. Fourteen CTRs were preceded by a mean preoperative TOW of 27 days, which resulted in a cost of €24,948 (13% of the total cost). There were no significant differences in TOW or revision rate between WALANT and ABPB. CONCLUSION: Although WALANT significantly reduced operating room occupancy times in our public hospital, the societal costs were the same regardless of the anesthesia technique. Reducing surgical waiting times in France could result in a theoretical saving of nearly €14 million annually. LEVEL OF EVIDENCE: IV.

Contribution of shear wave elastography in evaluation of the deltoid in reverse shoulder arthroplasty: reproducibility study and preliminary results.

AIMS: The current difficulty of reverse shoulder arthroplasty (RSA) is soft tissue management, and adequate deltoid tension and at present there is no consensus and available tools (X-ray, MRI, EMG) remain difficult to apply in clinical follow-up. The objective of this study was (1) to determine reliability and feasibility of deltoid elasticity assessment using ultrasound elastographyand (2) to assess the change of deltoid stiffness after RSA by comparing shear wave speed (SWS) between healthy and RSA shoulders. MATERIAL AND METHODS: Twenty-six healthy (native shoulder, painless and complete range of motion) subjects and twelve patients with RSA were included. Two independent investigators performed 3 measurements on each segment. Measurements were bilateral. Anterior segment was also evaluated at 45° and 60° of passive abduction. Reliability and feasibility have been assessed (ISO5725-standard). RESULTS: Coefficient of measurements variation was less than 6.1% and 0.13 m/s. In the healthy group, SWS was not significantly different between anterior and middle segments; however, the SWS of the posterior segment was significantly lower than others (p<0.0001). In abduction position, compared to the rest position, SWS of the anterior segment decreased at 45° abduction (p=0.0003) and increased at 60° abduction (p<0.0001). Variability of measurement was higher in the RSA group. No significant difference was found between the SWS measurement of the operated and non-operated side. SWS measurements of the operated side of the anterior and middle segment were significantly higher compared to the healthy group. In abduction position, compared to rest position, no difference in SWS of the anterior segment was found at 45° abduction (p=0.71) and nor at 60° abduction (p=0.75). CONCLUSION: This study demonstrated feasibility and reliability of shoulder assessment with shear wave elastography. Reference values for asymptomatic patients can already be used in future studies on shoulder pathology and surgery.

Displaced three and four part proximal humeral fractures: prospective controlled randomized open-label two-arm study comparing intramedullary nailing and locking plate.

PURPOSE: The aim of this study was (1) to compare clinical and radiological outcomes of 3- and 4-part proximal humeral fractures using either IMN or LP (2) and to report complications related to each technique. METHODS: A prospective controlled randomized open-label two-arm study was performed. Ninety-nine consecutive adult patients with a 3- and 4-part displaced acute proximal humeral fractures were randomized to be treated with IMN (n = 49) or LP (n = 50). Constant, ASES and SST scores were recorded by the surgeon. Range of motion was evaluated. A visual analog scale (VAS) was used to assess shoulder pain. Complications and revision surgeries were reported. RESULTS: Eighty-five patients were analyzed, nine were lost, and five died during the follow-up period. The mean age was 73.7 years (± 13.3,, and the mean follow-up was 66 months (± 13.5). At last follow-up, VAS was lower in the IMN group (0.9 (± 1.1) vs. 1.9 (± 1.7), p = 0.001). The median Constant score was significantly higher in the IMN group (81.6 (± 10.9) points) vs. in the LP group (75.6 (± 19.5) points) (p = 0.043), and ASES score was also significantly higher in the IMN group (86.3 (± 9.5) vs. 75.2 (± 19.6), p = 0.001). There was no difference in the range of motion or SST scores between the two groups. Complications were seen higher in the LP group (9 (21%) vs. 22 (52%), p = 0.003). Revision surgery was higher in the LP group (37% vs. 21%). CONCLUSION: Satisfactory results were accomplished in both groups according to the reported clinical outcomes. Complication and revision rates were higher in LP group.

Arthroscopic Reduction and Fixation With a Knotless Double-Row Construct Provides Good Results for Displaced Greater Tuberosity Fractures.

PURPOSE: The purpose of the study is to describe the functional and structural outcomes of the arthroscopic 4-strand, knotless, double-row construct with suture tapes for the surgical treatment of displaced and/or comminuted greater tuberosity fractures of the humerus. METHODS: Patients were enrolled between December 2012 and January 2018. The main inclusion criteria were a comminuted and/or displaced tuberosity fracture with a displacement of at least 5 mm in any plane fixed under arthroscopy using a 4-strand, knotless, double-row construct. The technique involves reducing the displaced fragment with 2 medially placed, transtendinous anchors and compressing the greater tuberosity using the tapes from these medial anchors in 2 laterally placed anchors. The exclusion criteria were a fracture that was more than 10 days old at the time of surgery or a history of shoulder surgery and 3- or 4-part fractures. The postoperative rehabilitation protocol was similar for all patients. Constant scores, Quick Dash, return to work and sport, and complications were reported after a minimum follow-up period of 24 months. Bone healing was systematically evaluated on standardized radiographs, including lateral scapula view and anteroposterior views. RESULTS: Twenty-one patients were enrolled in this study. One patient did not complete the follow-up examination period and thus was excluded, leaving 20 patients in this study. At a median (SD) follow-up of 32 (9) months, the median (SD) Constant score was 94.7 (7.3) points, the median (SD) Quick Dash was 1.7 (4) points, and median (SD) visual analog scale score was 0.5 (1.4). All patients returned to previous work and sport level. No malunions or nonunions were seen. One conversion to open surgery was required for failure of the lateral row during surgery in a 62-year-old woman with osteopenic bone. Two patients experienced complex regional pain syndrome in the postoperative period that resolved after nonoperative treatment. CONCLUSIONS: In this series, the use of arthroscopy combined with the biomechanical properties of knotless double-row constructs contributed to postoperative satisfactory functional results and healing of greater tuberosity fracture. In addition, range of motion was early, and no hardware removal was required. However, care should be taken with osteopenic bone where anchorage can fail. LEVEL OF EVIDENCE: Level IV, case series.

Arthroscopic knotless repair: an effective technique for small-sized supraspinatus tendon tears.

PURPOSE: The purpose was to evaluate the clinical and radiological results of knotless repair with flat-braided suture in full small-sized supraspinatus tendon tears (< 1 cm). METHODS: A consecutive series of 54 patients with isolated small supraspinatus tendon tear (< 1 cm and Goutallier index < 2) was evaluated in the study. Patients underwent a knotless arthroscopic repair using flat-braided suture (2 mm wide). Minimal follow-up required was 5 years. Changes in Murley-Constant score, ASES score, strength, and pain relief were assessed. The Sugaya score was used to confirm the tendon repair on MRI. Data were analyzed in two subgroups: technique with additional U point for dog ear deformity (group 1) and technique without additional U point (group 2). The immobilization period was 3 weeks long. Passive mobilization was immediate. RESULTS: Fifty-four patients were included. Mean age was 57 ± 4 years. The average follow-up was 68 ± 10 months. Average preoperative score of Constant was 51.2 ± 8.5 and 83.1 ± 14.6 at the end of the follow-up (p < 0.001). Mean VAS went from 5.8 ± 1.8 to 1.9 ± 2.1 (p < 0.001). Average forward elevation of the shoulder went from 86.3° ± 9 preoperatively to 169.6° ± 15.9 at the end of the follow-up (p < 0.001). The strength score was significantly higher post-operatively (18.4 vs. 8.3, p < 0.001.). The ASES score was significantly improved 49.1 ± 13.1 vs. 88.6 ± 15.8, p < 0.001). The MRI assessment revealed 94% of Sugaya 1-2. No significant difference was observed between group 1 and 2 regarding all clinical outcomes. Two complex regional pain syndromes were described with a favorable evolution. Three patients presented a retear requiring an iterative arthroscopic repair. CONCLUSION: The use of a knotless arthroscopic construct with flat-braided suture for small supraspinatus repair achieved excellent structural and clinical results. This technique is fully adequate for the arthroscopic treatment of such tears, enabling early mobilization. LEVEL OF EVIDENCE: Level III.

Safety of shoulder arthroplasty in lung transplant recipients.

PURPOSE: Although shoulder arthroplasty is relatively safe in general population, it remains unclear in transplant recipient. Aim of this study was to determine outcomes and morbidity after shoulder arthroplasty in lung transplant recipients. METHODS: A retrospective analysis was performed at our university hospital center from 2001 to 2015. Main inclusion criterion was all lung transplant recipient who underwent shoulder arthroplasty. Clinical outcomes including Constant score, visual analogue scale (VAS), American Shoulder and Elbow Surgeons score (ASES) were determined in pre-operative period and a minimum follow-up of 36 months. Special attention was taken about complications. RESULTS: Among 700 lung transplant recipients, we identified 12 patients who underwent 14 shoulder arthroplasties. Arthroplasties were performed after proximal humeral avascular necrosis (n = 10), degenerative osteoarthritis (n = 1) and non-union of proximal humeral fracture (n = 1). 8 anatomical total shoulder arthroplasties and 6 reversed shoulder arthroplasties were performed. Mean follow-up was 61.4 months (± 22.1). Mean age was 47.1 (± 9.3) years. All patients had immunosuppression therapy at the time of surgery. Mean Constant score was improved at last follow-up [43(± 9.7) vs 94(± 4), p < 0.001]. VAS decreased from 6.4 (± 1.2) to 0.4 (± 0.8), p < 0.001. Mean ASES was improved from 33 (± 6) to 91 (± 5) at last follow-up (p < 0.001). Range of motion were improved between early post-operative evaluation and last follow-up: forward flexion: 85° (± 8°) vs 119°(± 13°); abduction: 83° (± 14°) vs 106°(± 23°); external rotation (RE1): 26° (± 7°) vs 36°(± 10°). At last follow-up, one revision was required for humeral prothesis loosening at 2 years post-surgery. One patient died due to acute pulmonary decompensation on chronic rejection 66 months after shoulder arthroplasty. CONCLUSION: Shoulder arthroplasty is a safe procedure in this vulnerable population of lung transplant recipients. Such results encourage us to continue arthroplasty surgery when required. LEVEL OF EVIDENCE: IV.

Outcomes of reverse shoulder arthroplasty using a short stem through a superolateral approach.

BACKGROUND: Reverse shoulder arthroplasties have progressed in recent decades to become the most popular type of arthroplasty. Short stems with metaphyseal fixation have been developed to preserve bone stock and facilitate possible revision. Accurate positioning of these implants can be challenging using the superolateral approach. OBJECTIVE: This study aimed to evaluate the clinical and radiologic results of reverse short-stem arthroplasties using a superolateral approach with a minimum of 2 years' follow-up. METHODS: Between January 2015 and December 2016, a total of 76 patients underwent reverse shoulder arthroplasty surgery (79 shoulders) using a short uncemented humeral stem for shoulder arthritis with irreparable rotator cuff tear. Arthroplasties for post-traumatic osteoarthritis were excluded. Functional outcomes were assessed using Constant Score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), visual analog scale (VAS), and range of motion. Radiographic analysis was used to evaluate component loosening, implant position, and implant filling ratio. RESULTS: The mean age was 70.8 years. At a mean of 38.8-month follow-up, there were significant improvements in Constant score (44.2 to 87.9, P < .001), ASES score (36.2 to 84.3, P < .001), and VAS score (6.8 to 0.4, P < .001). Forward flexion improved from 89°to 131°(P < .001), and external rotation improved from 25° to 36°(P < .001). No evidence of periprosthetic loosening was visible. Mean varus of the humeral stem was 1°(±6°). The mean glenoidal inclination was 98°(±7°), which corresponds to a lower tilt of 8°. The average filling ratio was between 50% and 60% in both the metaphysis and the diaphysis. CONCLUSION: The clinical results obtained in this study were satisfying, with a significantly low complication rate. Hence, short-stem reverse shoulder arthroplasty using a superolateral approach, while taking particular care to protect the deltoid, remains our method of choice.

Arthroscopic Rotator Cuff Repair With a Knotless Suture Bridge Technique: Functional and Radiological Outcomes After a Minimum Follow-Up of 5 Years.

PURPOSE: To evaluate clinical and radiological outcomes of knotless suture bridge repair after a minimum of 5 years of follow-up. METHODS: A prospective consecutive series of full-thickness supraspinatus atraumatic chronic tears was evaluated in the study. Tears were medium or large. Further inclusion criteria were minimum clinical follow-up of 5 years with magnetic resonance imaging (MRI) at 24 months and fatty infiltration <2. Patients with shoulder stiffness, arthritis, or rotator cuff tear involving the subscapularis tendon were excluded. An arthroscopic cuff repair was performed using a knotless double-row suture bridge technique with braided suture tapes. Clinical outcomes were evaluated using the Constant score, the American Shoulder and Elbow Surgeons score, strength score, and a visual analog scale. Tendon healing was analyzed according to Sugaya MRI classification at 24 months. A Sugaya score of 1 or 2 was considered as tendon healing. Statistical analysis was performed with the Student's t-test. P = .05 were considered statistically significant. RESULTS: Sixty-eight patients were included in this series. Mean follow-up was equal to 68.8 ± 7 months. At last follow-up, the mean visual analog scale, American Shoulder and Elbow Surgeons score, and Constant scores improved significantly from 5.5 ± 1.6, 48.2 ± 13.1, 37.8 ± 8.3, to 2.1 ± 2.1 (P = 5.43 E-14), 87.4 ± 15.8 (P = 7.15 E-27), and 82.8 ± 14.7 (P = 1.01 E-33), respectively. Anteflexion improved from 99.3° ± 13.4° preoperatively to 136.6° ± 15.9° at last follow-up (P = 3.08 E-21). Strength score was significantly higher postoperatively (18.4 ± 6.7 vs 8.3 ± 3.5). MRI showed 88% (n = 57) of Sugaya 1-2 repairs. Patients with unhealed rotator cuffs showed significantly lower functional results than the Sugaya 1-2 group. No correlation between degree of retraction and rate of healing was observed. Four symptomatic patients (6%) required revision for failed rotator cuff repair. CONCLUSIONS: Despite potential confounding factors, arthroscopic knotless suture bridge repair of rotator cuff tears with acromioplasty demonstrated excellent long-term results of tendon healing, pain relief, and improvement of shoulder function. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Arthroscopic knotless tape bridging with autologous platelet-rich fibrin gel augmentation: functional and structural results.

Background: Rotator cuff repairs remain a source of iterative ruptures and disappointing functional results. In this goal, autologous platelet-rich plasma (PRP) has been used to improve tendon healing. This prospective study assessed the contribution of fully autologous gel concentrates (platelet concentrates and thrombin) on healing after cuff repair.Methods: A consecutive series of 69 patients who underwent primary arthroscopic knotless tape bridging primary cuff repair of supraspinatus tear were evaluated. Two groups were created (A: n = 32, B: n = 37). Autologous PRP gel, obtained preoperatively by PRP mixed with autologous thrombin extracted from platelet-poor plasma, was injected at bone-tendon interface at end of repair in group A. Gel structure avoided evacuation of concentrates with irrigation liquid. Constant, QuickDash and Visual Analogue Scale (VAS) scores were assessed pre-operatively and then successively post-operatively. Healing was assessed by 24-month control MRI according to Sugaya's classification. Sugaya 3, 4, and 5 were considered as iterative ruptures.Results: Average age was 56 years (±7.8). Mean follow-up was similar: 28.6 months (±3.3) vs 32.4 months (±9.4). Mean preoperative Constant was similar: 53.4 (±3.4) vs 54.6 (±5.4). Group A patients received 3.5 ml (±1.5 ml) of autologous PRP gel. No specific complication of injection was found. We observed higher trend in favour of PRP without significativity: Constant 86.7 (±11.1) vs 81.6 (±14.4), p = 0.11; VAS: 0.6 (±0.3) vs 1.1 (±0.9), p = 0.13; Forward flexion: 139.5° (±14.4°) vs 137.7° (± 16.5°), p = 0.63; Strength score: 17.6 vs 14.8, p = 0.66; QuickDash: 6.2 (±5.3) vs 8.2 (±6.9), p = 0.32 . On MRI, 90% (n = 3) of repairs were healed in group A versus 86% (n = 5) in group B.Conclusion: In this preliminary study, the group treated with autologous PRP gel showed a trend towards better clinical and radiological results. These results were not significant at the last follow-up. Only significantly higher clinical results were found at 3 months.Study design: Therapeutic prospective comparative cohort study; Level of evidence III.

Results of heterodigital flexor digitorum profundus hemi-tendon transfer for 23 flexor tendon injuries in zones 1 or 2.

We report outcomes of reconstruction of zone 1 or 2 flexor tendon injuries using a heterodigital hemi-tendon transfer of the flexor digitorum profundus in 23 fingers of 23 patients. At mean follow-up of 57 months, the mean total active motion of the three finger joints including the metacarpophalangeal joint was 128 degrees preoperatively and 229 degrees at final follow up. According to Strickland criteria, the function was excellent for 14 fingers, good for seven fingers and poor for two fingers. The subgroup analysis showed that the results were better in cases of primary surgery, children, and for the index and little fingers. Complications included stiffness of three fingers, and rupture in one finger that was converted to a two-stage tendon reconstruction. We conclude that this technique restores good function in most patients with zone 1 and 2 flexor tendon injuries, in which primary tendon repair has not been performed or was unsuccessful, and where pulley reconstruction is not required. LEVEL OF EVIDENCE: IV.

Arthroscopic treatment of displaced tibial eminence fractures using a suspensory fixation.

BACKGROUND: Avulsion fractures of the tibial intercondylar eminence are fairly common injuries requiring surgery for the optimal functional outcome. The purpose of this study was to assess the clinical and radiological outcomes of an arthroscopic treatment of displaced tibial intercondylar eminence fractures using a suspensory device. MATERIAL AND METHODS: Five patients with type 2 and 3 displaced tibial intercondylar eminence fractures who received an arthroscopically assisted fixation using a double button device were enrolled from 2011 to 2012. Clinical assessment included the patient demographics, cause of injury, the delay before surgery, time for surgery, time to return to work and sport, the International Knee Documentation Committee (IKDC) and Lysholm knee scores. Stability was measured with the KT-2000 arthrometer with a force of 134 N. A side to side difference on the KT-2000 examination superior to 3 mm was considered as a significant and abnormal increase in the anterior translation. Radiological examination consisted of anteroposterior and lateral radiographs, as well as computed tomography (CT) scan of the affected knee. Clinical and radiological followup was done at 1, 2, 3, 6, and 12 months postoperatively and at final followup. CT-scan was performed before surgery and at 3 months followup. RESULTS: The median age of patients was 31 years. Mean followup was 27 ± 5.1 months. The average delay before surgery was 3 days. At final followup, the mean IKDC and Lysholm knee scores were, 93.9 and 94.5 respectively. All patients had a complete functional recovery and were able to return to work and to resume their sport activities. No secondary surgeries were required to remove hardware. No complication was noted. Bony union was achieved in all patients. CONCLUSION: The arthroscopic treatment of displaced tibial intercondylar eminence fractures using a suspensory system provided a satisfactory clinical and radiological outcome at a followup of 2 years.

Length-dependent intracellular bundling of single-walled carbon nanotubes influences retention.

Single-walled carbon nanotubes (SWCNTs) are increasingly being investigated for biomedical imaging, sensing, and drug delivery. Cell types, cellular entry mechanisms, and SWCNT lengths dictate SWCNT uptake, subsequent intracellular trafficking, and retention. Specialized immune cells known as macrophages are capable of two size-dependent entry mechanisms: endocytosis of small particles (diameter < 200 nm) and phagocytosis of large particles (diameter > 500 nm). In comparison, fibroblasts uptake particles predominantly through endocytosis. We report dependence of cellular processing including uptake, subcellular distribution, and retention on the SWCNT length and immune cell-specific processes. We chose SWCNTs of three different average lengths: 50 nm (ultrashort, US), 150 nm (short) and 500 nm (long) to encompass two different entry mechanisms, and noncovalently dispersed them in water, cell culture media, and phosphate buffer (pH 5) with bovine serum albumin, which maintains the SWCNT optical properties and promotes their cellular uptake. Using confocal Raman imaging and spectroscopy, we quantified cellular uptake, tracked the intracellular dispersion state (i.e., individualized versus bundled), and monitored recovery as a function of SWCNT lengths in macrophages. Cellular uptake of SWCNTs increases with decreasing SWCNT length. Interestingly, short-SWCNTs become highly bundled in concentrated phase dense regions of macrophages after uptake and most of these SWCNTs are retained for at least 24 h. On the other hand, both US- and long-SWCNTs remain largely individualized after uptake into macrophages and are lost over a similar elapsed time. After uptake into fibroblasts, however, short-SWCNTs remain individualized and are exocytosed over 24 h. We hypothesize that aggregation of SWCNTs within macrophages but not fibroblasts may facilitate the retention of SWCNTs within the former cell type. Furthermore, the differential length-dependent cellular processing suggests potential applications of macrophages as live cell carriers of SWCNTs into tumors and regions of inflammation for therapy and imaging.

Delivering Single-Walled Carbon Nanotubes to the Nucleus Using Engineered Nuclear Protein Domains.

Single-walled carbon nanotubes (SWCNTs) have great potential for cell-based therapies due to their unique intrinsic optical and physical characteristics. Consequently, broad classes of dispersants have been identified that individually suspend SWCNTs in water and cell media in addition to reducing nanotube toxicity to cells. Unambiguous control and verification of the localization and distribution of SWCNTs within cells, particularly to the nucleus, is needed to advance subcellular technologies utilizing nanotubes. Here we report delivery of SWCNTs to the nucleus by noncovalently attaching the tail domain of the nuclear protein lamin B1 (LB1), which we engineer from the full-length LMNB1 cDNA. More than half of this low molecular weight globular protein is intrinsically disordered but has an immunoglobulin-fold composed of a central hydrophobic core, which is highly suitable for associating with SWCNTs, stably suspending SWCNTs in water and cell media. In addition, LB1 has an exposed nuclear localization sequence to promote active nuclear import of SWCNTs. These SWCNTs-LB1 dispersions in water and cell media display near-infrared (NIR) absorption spectra with sharp van Hove peaks and an NIR fluorescence spectra, suggesting that LB1 individually disperses nanotubes. The dispersing capability of SWCNTs by LB1 is similar to that by albumin proteins. The SWCNTs-LB1 dispersions with concentrations ≥150 µg/mL (≥30 µg/mL) in water (cell media) remain stable for ≥75 days (≥3 days) at 4 °C (37 °C). Further, molecular dynamics modeling of association of LB1 with SWCNTs reveal that the exposure of the nuclear localization sequence is independent of LB1 binding conformation. Measurements from confocal Raman spectroscopy and microscopy, NIR fluorescence imaging of SWCNTs, and fluorescence lifetime imaging microscopy show that millions of these SWCNTs-LB1 complexes enter HeLa cells, localize to the nucleus of cells, and interact with DNA. We postulate that the modification of native cellular proteins as noncovalent dispersing agents to provide specific transport will open new possibilities to utilize both SWCNT and protein properties for multifunctional subcellular targeting applications. Specifically, nuclear targeting could allow delivery of anticancer therapies, genetic treatments, or DNA to the nucleus.

Feasibility of individual patient data meta-analyses in orthopaedic surgery.

BACKGROUND: The number of individual patient data meta-analyses published is very low especially in surgical domains. Our aim was to assess the feasibility of individual patient data (IPD) meta-analyses in orthopaedic surgery by determining whether trialists agree to send IPD for eligible trials. METHODS: We performed a literature search to identify relevant research questions in orthopaedic surgery. For each question, we developed a protocol synopsis for an IPD meta-analysis and identified all related randomized controlled trials (RCTs) with results published since 2000. Corresponding authors of these RCTs were sent personalized emails that presented a project for an IPD meta-analysis corresponding to one of the research questions, with a link to the protocol synopsis, and asking for IPD from their RCT. We guaranteed patient confidentiality and secure data storage, and offered co-authorship and coverage of costs related to extraction. RESULTS: We identified 38 research questions and 273 RCTs related to these questions. We could contact 217 of the 273 corresponding authors (79 %; 56 had unavailable or non-functional email addresses) and received 68/273 responses (25 %): 21 authors refused to share IPD, 10 stated that our request was under consideration and 37 agreed to send IPD. Four corresponding authors required authorship and three others asked for financial support to send the IPD. Overall, we could obtain IPD for 5,110 of 33,602 eligible patients (15 %). Among the 38 research questions, only one IPD meta-analysis could be potentially initiated because we could receive IPD for more than 50 % of participants. CONCLUSION: The present study illustrates the difficulties in initiating IPD meta-analyses in orthopaedic surgery. Significant efforts must be made to improve data sharing.

Outcome of arthroscopic treatment for displaced lateral clavicle fractures using a double button device.

PURPOSE: The purpose of this study was to assess the clinical and radiological outcomes of an arthroscopically assisted fixation of type IIB fractures using a double button device. METHODS: Twenty-one patients with a type IIB displaced fracture of the clavicle who received an arthroscopically assisted fixation using a double button device were enrolled from 2009 to 2011. Clinical assessment included the patient's demographics, cause of injury, delay before surgery, time for surgery, time before resuming work and sports, the Shoulder and Hand (QuickDASH) score, the Constant-Murley score and the visual pain analogue scale (VAS). Radiological examination consisted of anteroposterior and axillary radiographs. RESULTS: The median age of patients was 33 years (range 18-67). Mean follow-up was 35 ± 8.9 months (range 24-51 months). The average delay before surgery was 3 days (range 1-7). At final follow-up, the mean QuickDASH score, Constant score and VAS were respectively 3.2 ± 6 (range 0-25), 94.8 ± 9.9 (range 62-100) and 0.5 ± 1.2 (range 0-4). Seventeen (81 %) patients were able to resume work, including heavy manual labour, and to resume their sport activities as well. Postoperative complications included one transient adhesive capsulitis, a symptomatic acromioclavicular joint osteoarthritis and an implant failure with nonunion. Bony union was achieved in all other patients. CONCLUSION: This study has demonstrated that the arthroscopic treatment using a double button device was effective at providing a satisfactory functional outcome, minimizing the risk of complications and presenting low implant failure and low nonunion rates in patients with Neer type IIB fractures of the distal clavicle. Such results lead us to consider this minimally invasive technique as a first-choice treatment. LEVEL OF EVIDENCE: IV.

Arthroscopic double row cuff repair with suture-bridging and autologous conditioned plasma injection: Functional and structural results.

PURPOSE: The double row cuff repair with suture bridging is commonly used for arthroscopic rotator cuff repair (RCR). Despite its biomechanical qualities, the rate of iterative tears with this technique is important. The aim of our study was to evaluate the effect of autologous conditioned plasma (ACP) on functional results and on the rate of iterative tears after RCR by suture bridging. MATERIALS AND METHODS: A consecutive series of 65 patients who underwent arthroscopic double-row suture bridge (Speed-Bridge, Arthrex) primary cuff repair of symptomatic full-thickness supraspinatus tear (retraction <3 in the Patte classification) were evaluated. Mean patient age was 60 (+/-8). The supraspinatus was repaired by knot-less bridging (SwiveLock, Arthrex) with suture tape material. 2 homogenous groups were created (A: 33 patients, B: 32 patients). In group A, all patients received, besides the cuff repair, an intra-tendinous ACP injection. Constant scores and Simple Shoulder Tests (SST) were measured pre-operatively and after a minimum follow-up period of 12 months post-operatively. Structural integrity of the repairs was evaluated by MRI according to the Sugaya classification. Sugaya >4 were considered as iterative tears. RESULTS: Mean follow-up was 19 months (+/-42) in the 2 groups. The mean quantity of ACP injected was 6ml. (+/-1.5) and no specific complication of the injection was found. Mean preoperative Constant-Murley scores were 41,2 (±7,7) and 38 (±11)in group B. Mean normalized Constant-Murley score increased from 41 points (±7) pre-operatively to 70 points (±8) post-operatively in group A and from 38 points (±11) to 73 points (±11) in group B. There were no significative differences between the two groups (P > 0.05). In group A, 31 repairs were Sugaya 1-3 (94%), vs. 30 in group B (93%), and 1 was type 4 in group A (5%) vs. 2 in group B (8%). CONCLUSION: In both groups, RCR with suture bridging gave successful functional outcomes, with a low rate of iterative tear. In this preliminary study, the adjuvant effect of ACP injections could not be showed on both functional and structural results. Longer follow-up is needed to evaluate potential differences.

In-vivo glenohumeral translation and ligament elongation during abduction and abduction with internal and external rotation.

STUDY DESIGN: Basic Science. To investigate humeral head translations and glenohumeral ligament elongation with a dual fluoroscopic imaging system. BACKGROUND: The glenohumeral ligaments are partially responsible for restraining the humeral head during the extremes of shoulder motion. However, in-vivo glenohumeral ligaments elongation patterns have yet to be determined. Therefore, the objectives of this study were to 1) quantify the in-vivo humeral head translations and glenohumeral ligament elongations during functional shoulder positions, 2) compare the inferred glenohumeral ligament functions with previous literature and 3) create a baseline data of healthy adult shoulder glenohumeral ligament lengths as controls for future studies. METHODS: Five healthy adult shoulders were studied with a validated dual fluoroscopic imaging system (DFIS) and MR imaging technique. Humeral head translations and the superior, middle and inferior glenohumeral ligaments (SGHL, MGHL, IGHL) elongations were determined. RESULTS: The humeral head center on average translated in a range of 6.0mm in the anterior-posterior direction and 2.5mm in the superior-inferior direction. The MGHL showed greater elongation over a broader range of shoulder motion than the SGHL. The anterior-band (AB)-IGHL showed maximum elongation at 90° abduction with maximum external rotation. The posterior-band (PB)-IGHL showed maximum elongation at 90° abduction with maximum internal rotation. DISCUSSION: The results demonstrated that the humeral head translated statistically more in the anterior-posterior direction than the superior-inferior direction (p = 0.01), which supports the concept that glenohumeral kinematics are not ball-in-socket mechanics. The AB-IGHL elongation pattern makes it an important static structure to restrain anterior subluxation of the humeral head during the externally rotated cocking phase of throwing motion. These data suggest that in healthy adult shoulders the ligamentous structures of the glenohumeral joint are not fully elongated in many shoulder positions, but function as restraints at the extremes of glenohumeral motion. Clinically, these results may be helpful in restoring ligament anatomy during the treatment of anterior instability of the shoulder.