Selective Dorsal Scapular Nerve and Long Thoracic Nerve Blocks for Rescue Analgesia in Scapulothoracic Arthrodesis Surgery: A Case Report.

Scapulothoracic arthrodesis (STA) surgery is performed to stabilize the scapula in patients with facioscapulohumeral dystrophy (FSHD). Postoperative pain could be a major problem even while using erector spinae plane block (ESPB). We performed a preoperative ESPB with an intraoperative ESPB catheter, but rescue analgesia was needed for pain in the periscapular area in the postoperative period. The patient's pain score was reduced by applying an ultrasound-guided dorsal scapular nerve (DSN) and long thoracic nerve (LTN) block. Selective DSN and LTN blocks can be effective in enhancing postoperative analgesia in STA surgery.

Functional outcomes of pediatric true and equivalent Monteggia fractures - Review of the literature.

BACKGROUND: This study aims to describe the functional outcome of true and equivalent Monteggia fracture-dislocations in the pediatric population. We also provided a review of the literature about the treatment options. METHODS: Five surgically and three conservatively treated patients were identified who were treated in 2009-2021. The study pop-ulation consisted of six female and two male patients. The mean age at the time of treatment was 7. The mean follow-up time was 55 months (range, 12-128). The Mayo Elbow Performance Score and the Oxford Elbow Score were used for outcome evaluation. Range of motion and grip strengths were also evaluated. RESULTS: There were two Bado type 1 and six Monteggia equivalent injuries. Closed reduction and casting were utilized for the two Bado type 1 injuries as the initial treatment. However, one had a radial head re-dislocation and had to be treated operatively. This patient had a radial head re-dislocation after the surgery and was followed up conservatively. Three Monteggia equivalent injuries were treated with closed reduction and casting, with no complications. One patient had a radial head anterior dislocation with plastic deformation of the ulna, and this patient was managed with CORA-based corrective ulnar osteotomy. For Monteggia injuries, the main treatment objective is to restore the ulnar length. Bilateral computed tomography imaging with 3D reconstruction can be utilized in preoperative planning of Monteggia fracture-dislocations to customize the treatment. Close observation is essential to detect radial head subluxation, which needs early intervention before irreversible changes occur. CONCLUSION: The true/equivalent Monteggia fractures' main treatment goal is to restore the ulnar length. Conservative treatment, with a close follow-up, is the first option if closed reduction can be achieved. If closed reduction is not possible, careful preop-erative planning and early rehabilitation are key to success for management of Monteggia fractures.

Comparison of anterior suprascapular nerve block versus interscalane nerve block in terms of diaphragm paralysis in arthroscopic shoulder surgery: a prospective randomized clinical study.

OBJECTIVE: This prospective, randomized study aimed to compare anterior suprascapular nerve block versus interscalene block in terms of diaphragm paralysis in arthroscopic shoulder surgery. METHODS: Fifty-two patients undergoing shoulder arthroscopy surgery were prospectively randomly assigned to interscalene block (n=25) or anterior suprascapular nerve block groups (n=27) (each group receiving 5 mL, 0.5% bupivacaine). The ipsilateral diaphrag matic excursion was assessed in all patients using ultrasound imaging before (baseline), 30 minutes, and 24 hours after block completion. Pain scores were recorded 1 hour preoperative, 30-60 minutes in the postoperative recovery unit, and at 6 and 24 hours postoperatively. RESULTS: No complete paralysis was observed in either treatment group. The incidence of a partial decrease in diaphragm movements was significantly lower in the anterior suprascapular nerve block than in the interscalene block group (1 vs. 21 patients) (P < .01). Twenty-six patients in the anterior suprascapular nerve block and 4 in the interscalene block group had less than a 25% decrease in hemidiaphrag matic movements, 30 minutes after the blockade. Pain scores were similar in the 2 groups. However, mean pain scores at 24 hours post operatively were significantly higher in the interscalene block than in the anterior suprascapular nerve block group (P < .05). Time to first pain post-block was significantly longer in the anterior suprascapular nerve block compared to the interscalene block group (677.04 ± 52.17 minutes vs. 479.2 ± 99.74 minutes, P < .05). CONCLUSION: Anterior suprascapular nerve block and interscalene block both appear to be clinically effective in providing postoperative analgesia for patients undergoing arthroscopic shoulder surgery under general anesthesia. However, the time to first pain is significantly longer with anterior suprascapular nerve block. Pain scores at 24 hours postoperatively were significantly lower in the anterior supra scapular nerve block compared to the interscalene block group. Diaphragmatic movements after anterior suprascapular nerve block were also better preserved at both 30 minutes after the block and 24 hours after surgery. LEVEL OF EVIDENCE: Level I, Therapeutic Study.

Corticosteroid-Refractory Myositis After Dual BRAF and MEK Inhibition in a Patient with BRAF V600E-Mutant Metastatic Intrahepatic Cholangiocarcinoma.

Intrahepatic cholangiocarcinoma is a rare malignancy, which is rich in actionable alterations. Genomic aberrations in the mitogen-activated protein kinase (MAPK) pathway are common, and BRAF exon 15 p.V600E mutations are present in 5-7% of biliary tract cancers (BTC). Dual inhibition of BRAF and MEK has been established for BRAF-mutated melanoma and lung cancer, and recent basket trials have shown efficacy of this combination in BRAF V600E-mutant BTCs. Here, we report on a patient with BRAF exon 15 p.V600E mutant metastatic intrahepatic cholangiocarcinoma who was started on BRAF and MEK inhibition with vemurafenib and combimetinib. Shortly thereafter, he developed debilitating myositis, which was refractory to corticosteroids, requiring therapeutic plasma exchange and intravenous immunoglobulin. We also review BRAF as a target in BTCs, relevant clinical trials, and adverse events associated with BRAF and MEK inhibition.

Intraosseous calcific tendinitis of the rotator cuff yields similar outcomes to those of intratendinous lesions despite worse preoperative scores.

PURPOSE: To evaluate the surgical outcomes of arthroscopic removal of intraosseous deposits in patients with intraosseous calcific tendinitis of the rotator cuff. METHODS: This study involved a retrospective review of 96 patients operated on from 2004 to 2019. Patients were divided into two groups according to the location of calcific deposits. Group I had pure tendinous involvement (n = 71), and Group II had tendinous and intraosseous involvement (n = 25). The mean follow-up time was 6.4 ± 3.9 years. There were 71 patients (46 women, 25 men) in Group I, and the mean age was 49.3 ± 8.2 years (range 30-65 years). In group II, there were 25 patients (18 women, 7 men); the mean age was 47.3 ± 11.2 years (range 28-70 years). RESULTS: The mean preoperative VAS pain score was 8.8 ± 1.4 in Group I compared to 9.5 ± 0.5 in group II (p = 0.017). The median preoperative Constant and Oxford scores were 42 (20-65) and 22 (8-34) in Group I and 25.5 (22-46) and 10 (8-16) in group II, respectively (p < 0.001). There was no difference in postoperative pain scores (Group I: 0.7 ± 1.6 and group II: 0.5 ± 0.6, p = 0.926), Constant scores [Group I: 100 (80-100) and group II: 100 (90-100), (n.s).] and Oxford scores [Group I: 48 (28-48) and group II: 46.5 (4-48), (n.s.)] between the two groups. The number of preoperative injections was higher in Group II (p = 0.05). There was no correlation between the size of the soft tissue calcific deposit and the preoperative pain, Constant, and Oxford scores (n.s.). CONCLUSION: Arthroscopic debridement of calcific tendinitis with intraosseous involvement is a safe and effective treatment method similar to that of pure tendinous involvement. LEVEL OF EVIDENCE: III.

Cemented radial head arthroplasty: Does radiographic loosening have an effect on clinical and functional outcomes? Average 10 years' results.

PURPOSE: The aim of this study was to evaluate the possible effect of radiographic loosening on clinical and functional outcomes, while presenting the mid-term radiographic and functional outcomes of cemented, monopolar RHA applied to patients with comminuted radial head fractures. METHODS: We performed a retrospective study by evaluating the records of patients who were diagnosed in a single center with radial head fractures between 2001 and 2013. Twenty-six patients with comminuted radial head fractures with a mean age of 48.9 and a mean follow-up time of 132.2 months were included. The radiographic evaluation was performed by assessing peri-prosthetic radiolucent lines around the stem to evaluate loosening, while the clinical evaluation was performed by utilizing elbow range of motion (ROM), Mayo elbow performance score (MEPS), Oxford elbow score (OES) and quick-DASH scores. RESULTS: 13 patients (Group 1) with peri-prosthetic stem lucency were defined as radiographic loosening (50%), while the remaining 13 patients (Group 2) were not detected to have stem lucency. One patient in group 1 also had concomitant pain and underwent removal of the prosthesis, while 12 patients (92.3%) remained pain-free. On the latest follow-up visit, there was no significant difference between the groups regarding ROM, MEPS, OES and quick-DASH scores. CONCLUSIONS: Within ten years following surgery, half of the patients with radial head prostheses were noted to show radiographic signs of loosening which did not have any major negative effect in terms of clinical-functional outcomes and quality of life, except requiring the removal of the implant in one patient. LEVEL OF EVIDENCE: Level III.

A novel lower bound for tip-apex distance.

PURPOSE: The cut-out of the cephalomedullary nail is among the most common post-surgery complications for intertrochanteric fractures. As a risk predictor, a tip-apex distance (TAD) below 25 mm, observed from orthogonal fluoroscopic views, is recommended in the literature. This study aims to demonstrate that TAD < 25 mm is a mathematically insufficient risk definition and to complement the TAD upper bound with an appropriate lower bound, with the introduction of a novel distance parameter, TADX, based on the orthogonal projection of the nail tip on the central femoral midline. METHOD: Through a mathematical simulation software, all the possible points that lie inside the AP and lateral views of the proximal femoral hemisphere are utilized to create a 3D grid that is sorted into geometrically safe and risk-bearing regions. Extending this methodology, TAD < 25 mm, 10 mm < TAD < 25 mm, and the ideal tip position volumes are simulated. Finally, intersection volumes are created by a combination of different candidate lower TADX bounds and TAD < 25 mm upper bound to determine satisfactory TADX limits. RESULTS: Simulation of TAD-bound zones exposed that TAD is only a mathematically suitable parameter for defining the upper boundary but not the lower boundary for the optimal region. However, using a TADX lower limit creates a 3D volume that is much closer to the optimal tip region volumetrically and can still be as quickly calculated from 2D AP and lateral views. CONCLUSIONS: According to the mathematical simulations, the use of a TADX lower bound of 9 mm for small, 7.5 mm for medium, and 7 mm for large femoral heads in conjunction with a TAD upper bound of 25 mm is suggested.

Patients without re-dislocation in the short term after arthroscopic knotless Bankart repair for anterior shoulder instability may show residual apprehension and recurrence in the long term after 5 years.

HYPOTHESIS: The aim of this study was to report the long-term results, residual instability, and recurrence rate of arthroscopic Bankart repair surgery without a re-dislocation event in the first 5 years. METHODS: We performed a retrospective analysis of Bankart repairs performed in a single center, by a single surgeon, with a minimum of 5 years' follow-up. Patients without a re-dislocation in the first 5 years of surgery were included. Patients who underwent open repair, those who underwent revision surgery, and those with critical glenoid bone loss were excluded. A total of 68 shoulders in 66 patients (51 male and 15 female patients) were included. Patients were analyzed in 2 domains: (1) failures defined as re-dislocation and (2) failures defined as apprehension and re-dislocation combined (residual instability). Clinical outcomes were assessed using shoulder range of motion, the American Shoulder and Elbow Surgeons score, and the Western Ontario Shoulder Instability Index (WOSI) score. Pain, residual apprehension, re-dislocations, and additional surgical procedures were recorded. RESULTS: The mean age of patients was 31.16 (range, 16-60 years), and the mean follow-up duration was 8.42 ± 2.1 years. The median number of dislocations was 3 (range, 1-20), and the median time from first dislocation to surgery was 16 months (interquartile range, 3-100.5 months). Five patients reported re-dislocations (7.4%) with a mean period of 6.54 ± 2.5 years (range, 5-10.8 years). Seven patients without re-dislocations and 2 patients with re-dislocations reported residual apprehension. Mean shoulder elevation and mean external rotation were 161.3° ± 12.4° and 39.2° ± 11°, respectively. The mean visual analog scale, American Shoulder and Elbow Surgeons, and WOSI scores were 0.5 ± 1.4, 91 ± 11.9, and 88 ± 12.1, respectively. Age was similar in patients with stable shoulders and those with shoulders with re-dislocation or residual instability. The WOSI score was lower in patients with re-dislocation and residual instability (P = .030 and P = .049, respectively). CONCLUSIONS: Arthroscopic Bankart repair is a successful surgical option for anterior shoulder instability. The 7.4% re-dislocation rate after 5 years indicates there may be a deterioration of capsulolabral repair in certain patients. The long-term failure pattern may be underestimated in short- to mid-term projections.

Long-term outcomes after arthroscopic transosseous-equivalent repair: clinical and magnetic resonance imaging results of rotator cuff tears at a minimum follow-up of 10 years.

PURPOSE: The objective of this study was to evaluate the long-term functional outcomes and structural integrity of medium to massive rotator cuff tears at 10-12 years of follow-up after arthroscopic transosseous-equivalent (TOE) repair. METHODS: This was a retrospective study of a consecutive series of patients who underwent primary arthroscopic TOE repair of medium- to massive-sized degenerative rotator cuff tears performed by a single surgeon between January 2007 and August 2009. Patients were examined at a minimum follow-up of 10 years, and magnetic resonance imaging (MRI) was performed to assess tendon integrity. The Constant score (CS), American Shoulder and Elbow Surgeons score, and pain level documented using a visual analog scale were compared between intact repairs and recurrent defects. Univariate analysis was performed to identify factors related to recurrent defects. RESULTS: A total of 102 patients met the inclusion criteria, and 79 shoulders in 76 patients (74.5% of eligible patients) with a mean age at surgery of 55 ± 8 years (range, 40-72 years) were available for clinical evaluation at a mean follow-up time of 10.9 years (range, 10-12 years). The mean anteroposterior tear size was 3.1 ± 1.1 cm, and there were 41 medium (52%), 26 large (33%), and 12 massive (15%) tears. MRI was performed in 72 shoulders in 69 patients (91% of available shoulders) and revealed that 13 shoulders had recurrent defects (Sugaya stages 4 and 5). During the follow-up period, 3 patients underwent revision surgery, and the overall recurrent defect rate was 21.3%. A clinically meaningful improvement was observed in all outcome measures at the final follow-up regardless of tendon integrity. Patients with intact repairs showed superior outcomes compared with those with recurrent defects; however, only the overall CS met the threshold for clinical relevance. A significant linear correlation was observed between the Sugaya classification and all outcome scores except the CS pain subscale; however, the strength of correlation was weak. The presence of diabetes (odds ratio [OR], 8.6; 95% confidence interval [CI], 2.25-33.2; P = .002), tear size (OR, 2.08; 95% CI, 1.16-3.46; P = .012), and tear retraction (OR, 4.07; 95% CI, 1.11-14.83; P = .033) were associated with recurrent defects in the univariate analysis. CONCLUSION: Arthroscopic TOE repair of rotator cuff tears provided improved clinical outcomes with a recurrent defect rate of 21.3% at 10-12 years after surgery. Future research focusing on tendon healing is needed as repair integrity on MRI correlates with clinical outcomes.

Combining Neratinib with CDK4/6, mTOR, and MEK Inhibitors in Models of HER2-positive Cancer.

PURPOSE: Neratinib is an irreversible, pan-HER tyrosine kinase inhibitor that is FDA approved for HER2-overexpressing/amplified (HER2+) breast cancer. In this preclinical study, we explored the efficacy of neratinib in combination with inhibitors of downstream signaling in HER2+ cancers in vitro and in vivo. EXPERIMENTAL DESIGN: Cell viability, colony formation assays, and Western blotting were used to determine the effect of neratinib in vitro. In vivo efficacy was assessed with patient-derived xenografts (PDX): two breast, two colorectal, and one esophageal cancer (with HER2 mutations). Four PDXs were derived from patients who received previous HER2-targeted therapy. Proteomics were assessed through reverse phase protein arrays and network-level adaptive responses were assessed through Target Score algorithm. RESULTS: In HER2+ breast cancer cells, neratinib was synergistic with multiple agents, including mTOR inhibitors everolimus and sapanisertib, MEK inhibitor trametinib, CDK4/6 inhibitor palbociclib, and PI3Kα inhibitor alpelisib. We tested efficacy of neratinib with everolimus, trametinib, or palbociclib in five HER2+ PDXs. Neratinib combined with everolimus or trametinib led to a 100% increase in median event-free survival (EFS; tumor doubling time) in 25% (1/4) and 60% (3/5) of models, respectively, while neratinib with palbociclib increased EFS in all five models. Network analysis of adaptive responses demonstrated upregulation of EGFR and HER2 signaling in response to CDK4/6, mTOR, and MEK inhibition, possibly providing an explanation for the observed synergies with neratinib. CONCLUSIONS: Taken together, our results provide strong preclinical evidence for combining neratinib with CDK4/6, mTOR, and MEK inhibitors for the treatment of HER2+ cancer.

Ultrasound-Guided Intralesional Methylene Blue Injection for the Arthroscopic Decompression of Spinoglenoid Notch Cyst Causing Suprascapular Neuropathy.

Symptomatic spinoglenoid ganglion cyst is a rare cause of shoulder pain and disability. Surgical treatment, which may be considered after failed nonoperative treatment, includes open or arthroscopic cyst debridement. Arthroscopic treatment is less invasive and has the advantage of addressing intraarticular pathologies; however, exposure of the cyst may be deemed difficult. Furthermore, the suprascapular nerve is susceptible to iatrogenic injury owing to its close proximity to the posterior glenoid rim. The purpose of this article is to present our technique for arthroscopic spinoglenoid cyst decompression after preoperative ultrasound-guided methylene blue injection.

How the Covid-19 pandemic affected shoulder and elbow practice in Turkey?

BACKGROUND: The Covid-19 pandemic drastically affected the health care delivery worldwide. Elective surgical interventions were cancelled or postponed to avoid disease transmission and excessive consumption of critical hospital resources. The main objective for composing this survey was to document the preventive attitude and its variations against the Covid-19 pandemic in a specific group: shoulder and elbow surgeons. The secondary objective was to evaluate their perception of emergency and to envisage the "new normal" with the altered order of priority in the upcoming post-coronavirus era. METHODS: An anonymous survey composed of 25 questions was sent to all the members of the Turkish Society of Shoulder and Elbow Surgery in April 22-29, 2020, while governmental preventive measures were maximal. A secure web-based application (SurveyMonkey Inc., San Mateo, CA, USA) was used for the composition of the survey and the analysis of the responses. RESULTS: Eighty-eight responses were collected from 129 members of the Turkish Society of Shoulder and Elbow Surgery (68%), with a mean 13.9 years of practice in shoulder and elbow surgery. A more than 75% decrease in surgical and outpatient clinical activity was documented. Half of respondents used telemedicine, and the rate of obtaining informed consent remained low. The preventive attitude showed significant variation. DISCUSSION: The perception of emergency and the protective measures showed a wide discrepancy among our respondents. Almost 80% of our respondents indicated the necessity of task forces for composing protocols to maintain subspecialty practice under adequate protective measures, and the subspecialty societies as the most eligible institutions to compose these criteria.

A novel shoulder disability staging system for scapulothoracic arthrodesis in patients with facioscapulohumeral dystrophy.

BACKGROUND: Scapulothoracic arthrodesis (STA) is a well-established surgical technique to provide scapular stabilisation in patients with facioscapulohumeral dystrophy (FSHD). There is no staging or scoring systems available to guide surgical decision. The aim of this study was to develop a staging system to evaluate the shoulder disability in patients with FSHD to guide surgical decision-making and assess its reliability among surgeons. METHODS: Fifty-seven shoulders of 29 patients (15 male, 14 female) with an average age of 34.5 years (13-73) were included. Six stages of the disease were defined to create a system consisting of shoulder elevation, deltoid function and scapular winging. Patients were assessed by two independent orthopaedic surgeons who were blind to each other. Statistical analyses included mean and standard deviation for descriptive variables, Pearson's correlation and Cohen's Kappa for inter- and intraobserver agreement. RESULTS: Measurement of elevation showed excellent correlation in both inter- and intraobserver assessment. There was substantial agreement on deltoid function and moderate agreement on scapular winging. Decisions on stage showed excellent agreement on interobserver and substantial agreement on intraobserver assessment. Surgical decision using the stage showed excellent agreement on both inter- and intraobserver assessment. CONCLUSION: This novel staging system has an excellent inter observer agreement on FSHD patients' shoulder disability. This would provide surgeons a beneficial tool to define patient groups that would have negatively or positively affected from STA.

Spinal fusion in facioscapulohumeral dystrophy for hyperlordosis: A case report.

RATIONALE: Facioscapulohumeral muscular dystrophy (FSHD) is the third most common muscular dystrophy, which is associated with facial, shoulder girdle, and paraspinal muscle atrophy. Most of the patients develop hypokyphosis and hyperlordosis in the course of the disease, to preserve standing posture. Corrective fusion is contraindicated in these patients as the surgery results with loss of compensatory hyperlordosis and leads to loss of trunk balance while standing. Although spinal fusion in neuromuscular scoliosis is a known treatment option, there are no studies in the literature on the spinal fusion of this specific patient group. PATIENT CONCERNS: In this case report we have presented a 66-year-old woman, who was admitted with back and abdominal pain, inability to sit straight, abdominal discomfort, and numbness in the lower extremities after prolonged sitting. DIAGNOSES: The patient developed severe hyperlordosis causing intra-abdominal disorders, radicular symptoms, and sitting discomfort due to FSHD. INTERVENTIONS: The patient underwent T2-S1 fusion and successful fusion was achieved. OUTCOMES: Individualized Neuromuscular Quality of Life Questionnaire (INQoL) was used to assess preoperative and 3 years postoperative functional outcomes. All domains and total score improved at the end of the follow-up period and successful fusion was verified radiologically. LESSONS: This case suggests that spinal fusion may provide functional improvement in carefully selected patient groups. Patient stratification considering spinal disability is required for further studies in this specific indication.

A Clinical Comparison of Home-Based and Hospital-Based Exercise Programs Following Arthroscopic Capsulolabral Repair for Anterior Shoulder Instability.

CONTEXT: Ideal rehabilitation method following arthroscopic capsulolabral repair surgery for anterior shoulder instability has not been proven yet. Although rapid or slow protocols were compared previously, home- or hospital-based protocols were not questioned before. OBJECTIVE: The aim of this prospective unrandomized controlled clinical trial is to compare the clinical outcomes of home-based and hospital-based rehabilitation programs following arthroscopic Bankart repair. DESIGN: Nonrandomized controlled trial. SETTING: Orthopedics and physical therapy units of a single institution. PATIENTS: Fifty-four patients (49 males and 5 females) with an average age of 30.5 (9.1) years, who underwent arthroscopic capsulolabral repair and met the inclusion criteria, with at least 1-year follow-up were allocated into 2 groups: home-based (n = 33) and hospital-based (n = 21) groups. INTERVENTIONS: Both groups received identical rehabilitation programs. Patients in the home-based group were called for follow-up every 3 weeks. Patients in the hospital-based group admitted for therapy every other day for a total of 6 to 8 weeks. Both groups were followed identically after the eighth week and the rehabilitation program continued for 6 months. MAIN OUTCOME MEASURES: Clinical outcomes were assessed using Disabilities of Arm Shoulder Hand, Constant, and Rowe scores. Mann-Whitney U test was used to compare the results in both groups. Wilcoxon test was used for determining the progress in each group. RESULTS: Groups were age and gender matched (P = .61, P = .69). Average number of treatment sessions was 13.8 (7.3) for patients in the hospital-based group. Preoperative Disabilities of Arm Shoulder Hand (27.46 [11.81] vs 32.53 [16.42], P = .22), Constant (58.23 [14.23] vs 54.17 [10.46], P = .13), and Rowe (51.72 [15.36] vs 43.81 [19.16], P = .12) scores were similar between groups. Postoperative scores at sixth month were significantly improved in each group (P = .001, P = .001, and P = .001). No significant difference was observed between 2 groups regarding clinical scores in any time point. CONCLUSIONS: We have, therefore, concluded that a controlled home-based exercise program is as effective as hospital-based rehabilitation following arthroscopic capsulolabral repair for anterior shoulder instability.

Functional Outcomes and Complications Following Scapulothoracic Arthrodesis in Patients with Facioscapulohumeral Dystrophy.

BACKGROUND: Facioscapulohumeral dystrophy (FSHD) is an autosomal-dominant myopathy characterized by facial and shoulder girdle muscle weakness with scapular winging. Scapulothoracic arthrodesis is a successful treatment approach for patients with <90° of shoulder elevation. The purpose of the present study was to assess functional outcomes and complications following scapulothoracic arthrodesis in patients with FSHD. METHODS: We retrospectively reviewed the records of 40 patients (64 shoulders) in whom scapulothoracic arthrodesis was performed. To achieve fusion, multiple multifilament cables were used together with autologous bone and allograft bone. Preoperative and postoperative shoulder elevation and abduction; Disabilities of the Arm, Shoulder and Hand (Quick version, qDASH) scores; and pulmonary function were compared. Recorded complications were classified as pulmonary or scapular. RESULTS: The mean age of the patients at the time of the operation was 25.4 years (range, 15 to 60 years), and the mean duration of follow-up was 71.2 months (range, 12 to 185 months). When the preoperative values were compared with those at the latest follow-up, significant improvement was noted in terms of elevation (from a mean [and standard deviation] of 60.6° ± 17.2° to 123.7° ± 26.7°; p < 0.001), abduction (from 52.7° ± 15.8° to 98.8° ± 20.3°; p < 0.001), and qDASH scores (from 34.7 ± 11.4 to 13.3 ± 13.1; p < 0.001). The overall complication rate was 26.6%. There were 7 pulmonary complications (4 pneumothoraxes, 2 pleural effusions, and 1 major atelectasis), and 5 chest tube placements were required. Ten complications (including 3 rib fractures, 1 brachial plexus palsy, 2 cases of implant irritation, 2 nonunions, 1 delayed union, and 1 scapular fracture) were related to the scapular fixation, and 7 revision procedures were required. Scapulothoracic fusion was achieved in all patients but 1, who had a scapular fracture. Pulmonary function tests were performed for 19 patients, and no difference was observed between preoperative and postoperative results. CONCLUSIONS: Scapulothoracic arthrodesis with use of multifilament cables is a successful surgical technique with high fusion rates and low morbidity. Pulmonary complications are common but resolve with careful attention. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Do we need to stabilize and treat the os acromiale when performing reverse shoulder arthroplasty?

INTRODUCTION: The purpose of this study is to investigate the incidence of os acromiale in patients who had reverse shoulder arthroplasty (RSA) for rotator cuff tear arthropathy and the effect of presence of os acromiale on the functional results. HYPOTHESIS: We hypothesize than in the presence of os acromiale, the contraction strength of the deltoid would decrease due to the dynamic downward depression of the bony fragment leading to less favorable clinical results. MATERIAL AND METHOD: A total 46 patients with a mean age of 70.8 who had RSA and a minimum follow-up of 24 months were included in this study. Preoperative radiographs, computerized tomography scans and magnetic resonance images were examined to determine the presence of os acromiale. RESULTS: A total of 10 patients out of 46 (22%) with os acromiale, all of which were of mesoacromion type, were followed up for 59.7 months. While both groups had significant improvements in Constant, Q-DASH and VAS scores compared to their preoperative status, a significant difference between the groups could not be found. The radiological evaluation showed that the average acromiohumeral distance significantly increased postoperatively in both groups. The acromiohumeral distance was significantly shorter in patients with os acromiale. DISCUSSION: While the presence of os acromiale does not have an adverse effect on the clinical results of the RSA, the loose fragment can migrate distally in the postoperative period due to the tension in the deltoid. LEVEL OF EVIDENCE: III, case-control study.

Targeting ERBB2 (HER2) Amplification Identified by Next-Generation Sequencing in Patients With Advanced or Metastatic Solid Tumors Beyond Conventional Indications.

PURPOSE: Human epidermal growth factor receptor 2 (HER2) is an effective therapeutic target in breast and gastric and gastroesophageal junction cancers. However, less is known about the prevalence of ERBB2 (HER2) amplification and the efficacy of HER2-targeted treatment in other tumors. PATIENTS AND METHODS: We assessed HER2 amplification status among 5,002 patients with advanced disease (excluding breast cancer) who underwent next-generation sequencing. We evaluated the clinical benefit of HER2-targeted therapy by measuring the time-dependent overall survival (OS) from the genomic testing results, progression-free survival (PFS), and PFS during HER2-targeted therapy (PFS2) compared with PFS during prior therapy (PFS1). RESULTS: Overall, 122 patients (2.4%) had HER2 amplification, including patients with endometrial (5.3%), bladder (5.2%), biliary or gallbladder (4.9%), salivary (4.7%), and colorectal cancer (3.6%). Forty patients (38%) with nongastric, nongastroesophageal junction, or nonesophageal cancers received at least one line of HER2-targeted therapy. Patients receiving HER2-targeted therapy had a median OS of 18.6 months, compared with 10.9 months for patients who did not receive HER2-targeted therapy (P = .070). On multivariable analysis, HER2-targeted therapy was significantly associated with increased OS (hazard ratio, 0.5; 95% CI, 0.27 to 0.93; P = .029), regardless of sex, age, or number of prior lines of treatment. The PFS2-to-PFS1 ratio was 1.3 or greater in 21 (57%) of 37 patients who received HER2-targeted therapy not in the first line of systemic treatment, and the median PFS2 and PFS1 times were 24 and 13 weeks, respectively (P < .001). CONCLUSION: HER2 amplifications using next-generation sequencing can be identified in a variety of tumor types. HER2-targeted therapy may confer clinical benefit in tumor types other than those for which HER2 inhibitors are approved.

Identification of Actionable Genomic Alterations Using Circulating Cell-Free DNA.

PURPOSE: Cell-free DNA (cfDNA) next-generation sequencing is a noninvasive approach for genomic testing. We report the frequency of identifying alterations and their clinical actionability in patients with advanced/metastatic cancer. PATIENTS AND METHODS: Prospectively consented patients had cfDNA testing performed. Alterations were assessed for therapeutic implications. RESULTS: We enrolled 575 patients with 37 tumor types. Of these patients, 438 (76.2%) had at least one alteration detected, and 205 (35.7%) had one or more alterations of high potential for clinical action. In diseases with 10 or more patients enrolled, 50% or more had at least one alteration deemed of high potential for clinical action. Trials were identified in 80% of patients (286 of 357) with any alteration and in 92% of patients (188 of 205) with one or more alterations of high potential for clinical action of whom 57.6% (118 of 205) had 6 or more months of follow-up available. Of these patients, 10% (12 of 118) had received genomically matched therapy through enrollment in clinical trials (n = 8), off-label drug use (n = 3), or standard of care (n = 1). Although 88.6% of all patients had a performance status of 0 or 1 upon enrollment, the primary reason for not acting on alterations was poor performance status at next treatment change (28.1%; 27 of 96). CONCLUSION: cfDNA testing represents a readily accessible method for genomic testing and allows for detection of genomic alterations in most patients with advanced disease. Utility may be higher in patients interested in investigational therapeutics with adequate performance status. Additional study is needed to determine whether utility is enhanced by testing earlier in the treatment course.

Arthroscopic versus open release of internal rotation contracture in the obstetrical brachial plexus paralysis (OBPP) sequela.

BACKGROUND: Latissimus dorsi (LD) and teres major (TM) tendon transfers are effective surgical procedures to improve shoulder abduction and external rotation for children with obstetrical brachial plexus palsy (OBPP). Open pectoralis major (PM) tendon Z-plasty and arthroscopic subscapularis (SS) release are 2 options for the release of internal rotation contractures to enhance muscle transfers. This study compared the functional results of LD and TM tendon transfers with open PM tendon Z-plasty or arthroscopic SS release. METHODS: The study included 24 patients who underwent LD and TM tendon transfers for OBPP (9 arthroscopic SS release, 15 open PM tendon Z-plasty) with a mean follow-up of 41.33 months (range, 36-60 months) and 47.2 months (range, 36-60 months), respectively. Functional evaluation was made according to range of motion and Mallet scoring system. RESULTS: Shoulder abduction-external rotation degrees and scores in all sections of the Mallet scoring system significantly increased in both groups (P < .001). Postoperatively, the arthroscopic SS release group had significantly better abduction degrees (P = .003), total Mallet scores (P < .001), and superior abduction (P = .043), active external rotation (P = .043), hand-to-head (P = .043), and hand-to-mouth (P < .001) scores for the Mallet scoring system. DISCUSSION: Transfer of LD together with TM tendons combined with one of the internal rotation contracture release procedures yielded good clinical and functional results in patients younger than age 7, regardless of the type of release method. However, arthroscopic SS release, although requiring an experienced surgeon, revealed better clinical and functional outcomes and is considered to be a less invasive and superior method.