Computed tomography-based structural rigidity analysis can assess tumor- and treatment-induced changes in rat bones with metastatic lesions.

BACKGROUND: Breast cancer (BrCa) is a predominant malignancy, with metastasis occurring in one in eight patients, nearly half of which target the bone, leading to serious complications such as pain, fractures, and compromised mobility. Structural rigidity, crucial for bone strength, becomes compromised with osteolytic lesions, highlighting the vulnerability and increased fracture risk in affected areas. Historically, two-dimensional radiographs have been employed to predict these fracture risks; however, their limitations in capturing the three-dimensional structural and material changes in bone have raised concerns. Recent advances in CT-based Structural Rigidity Analysis (CTRA), offer a promising, more accurate non-invasive 3D approach. This study aims to assess the efficacy of CTRA in monitoring osteolytic lesions' progression and response to therapy, suggesting its potential superiority over existing methodologies in guiding treatment strategies. METHODS: Twenty-seven female nude rats underwent femoral intra-medullary inoculation with MDA-MB-231 human breast cancer cells or saline control. They were divided into Control, Cancer Control, Ibandronate, and Paclitaxel groups. Osteolytic progression was monitored weekly using biplanar radiography, quantitative computed tomography (QCT), and dual-energy X-ray absorptiometry (DEXA). CTRA was employed to predict fracture risk, normalized using the contralateral femur. Statistical analyses, including Kruskal-Wallis and ANOVA, assessed differences in outcomes among groups and over time. RESULTS: Biplanar radiographs showed treatment benefits over time; however, only certain time-specific differences between the Control and other treatment groups were discernible. Notably, observer subjectivity in X-ray scoring became evident, with significant inter-operator variations. DEXA measurements for metaphyseal Bone Mineral Content (BMC) did not exhibit notable differences between groups. Although diaphyseal BMC highlighted some variance, it did not reveal significant differences between treatments at specific time points, suggesting a limited ability for DEXA to differentiate between treatment effects. In contrast, the CTRA consistently demonstrated variations across different treatments, effectively capturing bone rigidity changes over time, and the axial- (EA), bending- (EI), and torsional rigidity (GJ) outcomes from the CTRA method successfully distinguished differences among treatments at specific time points. CONCLUSION: Traditional approaches, such as biplanar radiographs and DEXA, have exhibited inherent limitations, notably observer bias and time-specific inefficacies. Our study accentuates the capability of CTRA in capturing real-time, progressive changes in bone structure, with the potential to predict fractures more accurately and provide a more objective analysis. Ultimately, this innovative approach may bridge the existing gap in clinical guidelines, ushering in enhanced Clinical Decision Support Tool (CDST) for both surgical and non-surgical treatments.

Redisplacement of reduced distal radius fractures in adults: does the type of casting play a role? The CAST study, a multicentre cluster randomized controlled trial.

Aims: It is not clear which type of casting provides the best initial treatment in adults with a distal radial fracture. Given that between 32% and 64% of adequately reduced fractures redisplace during immobilization in a cast, preventing redisplacement and a disabling malunion or secondary surgery is an aim of treatment. In this study, we investigated whether circumferential casting leads to fewer the redisplacement of fewer fractures and better one-year outcomes compared with plaster splinting. Methods: In a pragmatic, open-label, multicentre, two-period cluster-randomized superiority trial, we compared these two types of casting. Recruitment took place in ten hospitals. Eligible patients aged ≥ 18 years with a displaced distal radial fracture, which was acceptably aligned after closed reduction, were included. The primary outcome measure was the rate of redisplacement within five weeks of immobilization. Secondary outcomes were the rate of complaints relating to the cast, clinical outcomes at three months, patient-reported outcome measures (PROMs) (using the numerical rating scale (NRS), the abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Patient-Rated Wrist/Hand Evaluation (PRWHE) scores), and adverse events such as the development of compartment syndrome during one year of follow-up. We used multivariable mixed-effects logistic regression for the analysis of the primary outcome measure. Results: The study included 420 patients. There was no significant difference between the rate of redisplacement of the fracture between the groups: 47% (n = 88) for those treated with a plaster splint and 49% (n = 90) for those treated with a circumferential cast (odds ratio 1.05 (95% confidence interval (CI) 0.65 to 1.70); p = 0.854). Patients treated in a plaster splint reported significantly more pain than those treated with a circumferential cast, during the first week of treatment (estimated mean NRS 4.7 (95% CI 4.3 to 5.1) vs 4.1 (95% CI 3.7 to 4.4); p = 0.014). The rate of complaints relating to the cast, clinical outcomes and PROMs did not differ significantly between the groups (p > 0.05). Compartment syndrome did not occur. Conclusion: Circumferential casting did not result in a significantly different rate of redisplacement of the fracture compared with the use of a plaster splint. There were comparable outcomes in both groups.

Early surgical repair of combined latissimus dorsi and teres major avulsion.

A combined avulsion of both the latissimus dorsi muscle and teres major muscle is a rare occurrence and data focused on the treatment of this type of injury is limited to case studies and series. This case report presents the outcomes of early surgical repair for avulsions of the latissimus dorsi and teres major tendons in a high-demanding athlete. The patient underwent surgical repair using a single incision technique and endosteal button fixation of the avulsed tendons. This procedure was performed within 4 weeks of the initial injury, followed by a progressive mobilisation regimen in the postoperative phase. After a period of 3 months, the patient successfully participated in his first international competition. This report describes the effectiveness of early surgical repair after latissimus dorsi and teres major tendon avulsion. The single incision technique and the use of endosteal buttons for tendon fixation yielded excellent results for a professional judoka.

Documentation of Procedural Sedation by Emergency Physicians.

INTRODUCTION: Patients presenting to the emergency department (ED) frequently require procedural sedation and analgesia (PSA) to facilitate procedures, such as joint reduction. Proper documentation of screening demonstrates awareness of the necessity of presedation assessment. It is unknown if introducing emergency physicians (EPs) at the ED improves presedation assessment and documentation. In this study the differences in documentation of ED sedation and success rates for reduction of hip dislocations in the presence versus absence of EPs are described. METHODS: In this retrospective descriptive study, we analyzed data of patients presenting with a dislocated hip post total hip arthroplasty (THA) shortly after the introduction of EPs. The primary outcome measure was the presence of documentation of presedation assessment. Secondary outcomes were documentation of medication, vital signs, and success rate of hip reductions. RESULTS: In the two-year study period, 133 sedations for hip reductions were performed. Sixty-eight sedations were completed by an EP. The documentation of fasting status, airway screening, analgesia use, and vital signs was documented significantly more often when an EP was present (respectively 64.9%, 80.3%, 37.4%, and 72.7%, all P < 0.001). There was no difference in success rate of hip reductions between the groups. CONCLUSION: PSA in the ED is associated with superior documentation of presedation assessment, medication, and vital signs when EPs are involved.

Reduced psychosocial functioning in subacromial pain syndrome is associated with persistence of complaints after 4 years.

BACKGROUND: Patients with subacromial pain syndrome (SAPS) frequently present with coexisting psychosocial problems; however, whether this also associates with long-term outcome is currently unknown. We assessed whether psychosocial functioning in patients with SAPS is associated with persistence of complaints after 4 years of routine care. METHODS: In a longitudinal study, 34 patients with SAPS were selected after clinical and radiologic evaluation and assessed at baseline and after 4 years. For the assessment of psychosocial functioning, the RAND-36 questionnaire domains of social functioning, role limitations due to emotional problems, mental health, vitality, and general health were evaluated. Complaint persistence at follow-up was assessed by (1) an anchor question (reduced, persistent, or increased symptoms), (2) change in pain (change in visual analog scale score), and (3) change in quality of life (change in Western Ontario Rotator Cuff index score). RESULTS: Lower baseline mental health (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.85-0.98; P = .013), vitality (OR, 0.90; 95% CI, 0.83-0.98; P = .011), and general health (OR, 0.93; 95% CI, 0.88-0.98; P = .009) were associated with persistent complaints as reported by the anchor question, change in visual analog scale score, and change in Western Ontario Rotator Cuff index score. CONCLUSIONS: Evaluating psychosocial functioning parallel to physical complaints is currently not standard procedure in the treatment of SAPS. In this study, we showed that factors related to psychosocial functioning are associated with long-term persistence of complaints in SAPS. Future studies may investigate whether a multimodal treatment with assessment of psychosocial functioning may facilitate pain relief and recovery in SAPS.

Weight-bearing or non-weight-bearing after surgical treatment of ankle fractures: a multicenter randomized controlled trial.

PURPOSE: The goal of this study was to assess if unprotected weight-bearing as tolerated is superior to protected weight-bearing and unprotected non-weight-bearing in terms of functional outcome and complications after surgical fixation of Lauge-Hansen supination external rotation stage 2-4 ankle fractures. METHODS: A multicentered randomized controlled trial was conducted in patients ranging from 18 to 65 years of age without severe comorbidities. Patients were randomized to unprotected non-weight-bearing, protected weight-bearing, and unprotected weight-bearing as tolerated. The primary endpoint of the study was the Olerud Molander Ankle Score (OMAS) 12 weeks after randomization. The secondary endpoints were health-related quality of life using the SF-36v2, time to return to work, time to return to sports, and the number of complications. RESULTS: The trial was terminated early as advised by the Data and Safety Monitoring Board after interim analysis. A total of 115 patients were randomized. The O'Brien-Fleming threshold for statistical significance for this interim analysis was 0.008 at 12 weeks. The OMAS was higher in the unprotected weight-bearing group after 6 weeks c(61.2 ± 19.0) compared to the protected weight-bearing (51.8 ± 20.4) and unprotected non-weight-bearing groups (45.8 ± 22.4) (p = 0.011). All other follow-up time points did not show significant differences between the groups. Unprotected weight-bearing showed a significant earlier return to work (p = 0.028) and earlier return to sports (p = 0.005). There were no differences in the quality of life scores or number of complications. CONCLUSIONS: Unprotected weight-bearing and mobilization as tolerated as postoperative care regimen improved short-term functional outcomes and led to earlier return to work and sports, yet did not result in an increase of complications.

What Factors Are Associated With Implant Breakage and Revision After Intramedullary Nailing for Femoral Metastases?

BACKGROUND: Actual and impending pathologic fractures of the femur are commonly treated with intramedullary nails because they provide immediate stabilization with a minimally invasive procedure and enable direct weightbearing. However, complications and revision surgery are prevalent, and despite common use, there is limited evidence identifying those factors that are associated with complications. QUESTIONS/PURPOSES: Among patients treated with intramedullary nailing for femoral metastases, we asked the following questions: (1) What is the cumulative incidence of local complications? (2) What is the cumulative incidence of implant breakage and what factors are associated with implant breakage? (3) What is the cumulative incidence of revision surgery and what factors are associated with revision surgery? METHODS: Between January 2000 and December 2015, 245 patients in five centers were treated with intramedullary nails for actual and impending pathologic fractures of the femur caused by bone metastases. During that period, the general indications for intramedullary nailing of femoral metastases were impending fractures of the trochanter region and shaft and actual fractures of the trochanter region if sufficient bone stock remained; nails were used for lesions of the femoral shaft if they were large or if multiple lesions were present. Of those treated with intramedullary nails, 51% (117) were actual fractures and 49% (111) were impending fractures. A total of 60% (128) of this group were women; the mean age was 65 years (range, 29-93 years). After radiologic followup (at 4-8 weeks) with the orthopaedic surgeon, because of the palliative nature of these treatments, subsequent in-person followup was performed by the primary care provider on an as-needed basis (that is, as desired by the patient, without any scheduled visits with the orthopaedic surgeon) throughout each patient's remaining lifetime. However, there was close collaboration between the primary care providers and the orthopaedic team such that orthopaedic complications would be reported. A total of 67% (142 of 212) of the patients died before 1 year, and followup ranged from 0.1 to 175 months (mean, 14.4 months). Competing risk models were used to estimate the cumulative incidence of local complications (including persisting pain, tumor progression, and implant breakage), implant breakage separately, and revision surgery (defined as any reoperation involving the implant other than débridement with implant retention for infection). A cause-specific multivariate Cox regression model was used to estimate the association of factors (fracture type/preoperative radiotherapy and fracture type/use of cement) with implant breakage and revision, respectively. RESULTS: Local complications occurred in 12% (28 of 228) of the patients and 6-month cumulative incidence was 8% (95% confidence interval [CI], 4.7-11.9). Implant breakage occurred in 8% (18 of 228) of the patients and 6-month cumulative incidence was 4% (95% CI, 1.4-6.5). Independent factors associated with increased risk of implant breakage were an actual (as opposed to impending) fracture (cause-specific hazard ratio [HR_cs], 3.61; 95% CI, 1.23-10.53, p = 0.019) and previous radiotherapy (HR_cs, 2.97; 95% CI, 1.13-7.82, p = 0.027). Revisions occurred in 5% (12 of 228) of the patients and 6-month cumulative incidence was 2.2% (95% CI, 0.3-4.1). The presence of an actual fracture was independently associated with a higher risk of revision (HR_cs, 4.17; 95% CI, 0.08-0.82, p = 0.022), and use of cement was independently associated with a lower risk of revision (HR_cs, 0.25; 95% CI, 1.20-14.53, p = 0.025). CONCLUSIONS: The cumulative incidence of local complications, implant breakage, and revisions is low, mostly as a result of the short survival of patients. Based on these results, surgeons should consider use of cement in patients with intramedullary nails with actual fractures and closer followup of patients after actual fractures and preoperative radiotherapy. Future, prospective studies should further analyze the effects of adjuvant therapies and surgery-related factors on the risk of implant breakage and revisions. LEVEL OF EVIDENCE: Level III, therapeutic study.

Increased co-contraction of arm adductors is associated with a favorable course in subacromial pain syndrome.

BACKGROUND: Enhancement of arm adductor activity during abduction (ie, adductor co-contraction), may be effective in the treatment of subacromial pain syndrome (SAPS). We assessed whether an increase of adductor co-contraction is associated with a favorable course of SAPS. METHODS: At baseline and after nearly 4 years of follow-up, electromyography of the latissimus dorsi (LD), teres major (TM), pectoralis major, and deltoid muscle was obtained during isometric abduction and adduction tasks in 26 patients with SAPS. Changes in co-contraction were assessed with change in the activation ratio (ΔAR). The AR ranges between -1 and 1, where lower values indicate more co-contraction. Clinical course was determined from an anchor question (reduced, persistent, or increased complaints), the visual analog scale for pain (VAS), and the Western Ontario Rotator Cuff score (WORC). RESULTS: In patients indicating persistent complaints (31%), the VAS and WORC remained stable. In patients who indicated reduced complaints (69%), the VAS reduced (z score, -3.4; P = .001) and WORC increased (z score, 3.6; P < .001). Unchanged ARs associated with complaints persistence, whereas decreased AR of the LD (ΔARLD, -0.21; 95% confidence interval [CI], -0.36 to -0.06) and TM (ΔARTM, -0.17; 95% CI, -0.34 to -0.00) coincided with reduced complaints. There was a significant between-group difference in ΔARLD (-0.35; 95% CI, -0.60 to 0.10) and ΔARTM (-0.36; 95% CI, -0.66 to -0.05). CONCLUSIONS: Increased co-contraction of the LD and TM is associated with a favorable course of SAPS. This may be explained by widening of the subacromial space accomplished by adductor co-contraction.

Three-dimensional shoulder kinematics normalize after rotator cuff repair.

BACKGROUND: Patients with a rotator cuff (RC) tear often exhibit scapular dyskinesia with increased scapular lateral rotation and decreased glenohumeral elevation with arm abduction. We hypothesized that in patients with an RC tear, scapular lateral rotation, and thus glenohumeral elevation, will be restored to normal after RC repair. METHODS: Shoulder kinematics were quantitatively analyzed in 26 patients with an electromagnetic tracking device (Flock of Birds) before and 1 year after RC repair in this observational case series. We focused on humeral range of motion and scapular kinematics during abduction. The asymptomatic contralateral shoulder was used as the control. Changes in scapular kinematics were associated with the gain in range of motion. Shoulder kinematics were analyzed using a linear mixed model. RESULTS: Mean arm abduction and forward flexion improved after surgery by 20° (95% confidence interval [CI], 2.7°-36.5°; P = .025) and 13° (95% CI, 1.2°-36.5°; P = .044), respectively. Kinematic analyses showed decreases in mean scapular protraction (ie, internal rotation) and lateral rotation (ie, upward rotation) during abduction by 3° (95% CI, 0.0°-5.2°; P = .046) and 4° (95% CI, 1.6°-8.4°; P = .042), respectively. Glenohumeral elevation increased by 5° (95% CI, 0.6°-9.7°; P = .028) at 80°. Humeral range of motion increased when scapular lateral rotation decreased and posterior tilt increased. CONCLUSIONS: Scapular kinematics normalize after RC repair toward a symmetrical scapular motion pattern as observed in the asymptomatic contralateral shoulder. The observed changes in scapular kinematics are associated with an increased overall range of motion and suggest restored function of shoulder muscles.

Weight bearing or non-weight bearing after surgically fixed ankle fractures, the WOW! Study: study protocol for a randomized controlled trial.

BACKGROUND: The optimal post-operative care regimen after surgically fixed Lauge Hansen supination exorotation injuries remains to be established. This study compares whether unprotected weight bearing as tolerated is superior to protected weight bearing and unprotected non-weight bearing in terms of functional outcome and safety. METHODS/DESIGN: The WOW! Study is a prospective multicenter clinical trial. Patients between 18 and 65 years of age with a Lauge Hansen supination exorotation type 2, 3 or 4 ankle fractures requiring surgical treatment are eligible for inclusion. An expert panel validates the classification and inclusion eligibility. After surgery, patients are randomized to either the 1) unprotected non-weight-bearing, 2) protected weight-bearing, or 3) unprotected weight-bearing group. The primary outcome measure is ankle-specific disability measured by the Olerud-Molander ankle score. Secondary outcomes are 1) quality of life (e.g., return to work and resumption of sport), 2) complications, 3) range of motion, 4) calf wasting, and 5) maximum pressure load after 3 months and 1 year. DISCUSSION: This trial is designed to compare the effectiveness and safety of unprotected weight bearing with two commonly used post-operative treatment regimens after internal fixation of specified, intrinsically stable but displaced ankle fractures. An expert panel has been established to evaluate every potential subject, which ensures that every patient is strictly screened according to the inclusion and exclusion criteria and that there is a clear indication for surgical fixation. TRIAL REGISTRATION: The WOW! Study is registered in the Dutch Trial Register ( NTR3727 ). Date of registration: 28-11-2012.

The minimal detectable change of the Constant score in impingement, full-thickness tears, and massive rotator cuff tears.

HYPOTHESIS: The purpose of this study was to determine the minimal detectable change (MDC) for the Constant score in patients with impingement, a supraspinatus tear, or a massive rotator cuff (RC) tear as observed changes smaller than the MDC might be the result of measurement error. METHODS: The Constant score was recorded in a total of 180 patients, including 34 patients with impingement, 105 with supraspinatus tears, and 41 with massive RC tears. We assessed the MDC in the 3 subgroups and total group using the samples standard deviation (SD), internal consistency (Cronbach α), and standard error of the measurement. Floor and ceiling effects were also reported. RESULTS: The absolute mean Constant score was 72 (SD, 11.2) in the impingement group, 44 (SD, 14.7) in the supraspinatus tear group, and 46 (SD, 18.9) in the massive RC tear group. There were no floor and ceiling effects for the absolute Constant score. In the total group, the internal consistency was 0.8 and the standard error of the measurement was 8. The MDC was 23 points on the Constant score in the total group and 17, 18, and 23 points on the Constant score for impingement, RC tears, and massive RC tears, respectively. CONCLUSION: This study demonstrates that the MDCs of the Constant score are different in patients with impingement, supraspinatus tears, and massive RC tears. Studies reporting the Constant score should be interpreted by use of the population-specific MDC and minimal clinical important change.

Clinical outcome and structural integrity of all-arthroscopic repair of degenerative subscapularis tendon tears.

PURPOSE: The purpose of this study was to evaluate the clinical outcome of all-arthroscopic repair of degenerative subscapularis tendon tears and post-operative structural integrity using magnetic resonance imaging with a short-term follow-up. METHODS: Twenty-one patients were treated all-arthroscopically for a full-thickness degenerative subscapularis tendon tear. Median patient age was 55 years (range, 41-69). Median follow-up was 25 months (range, 15-44). Patients were evaluated prior to surgery and at follow-up: active range of motion, VAS pain, Simple Shoulder Test (SST), and the Disabilities of the Arm, Shoulder, and Hand score (DASH). At final follow-up, the Constant-Murley score was evaluated. RESULTS: Mean active range of motion showed significant post-operative improvement (p < 0.001). VAS pain improved from 8.3 (SD ± 1.3) pre-operatively to 2.7 (SD ± 1.8) post-operatively (<0.001); SST increased from 20 % (SD ± 26) pre-operatively to 83 % (SD ± 27) post-operatively (<0.001); DASH scores improved 67 (SD ± 19) to 18 (SD ± 21) post-operatively (<0.001). Post-operative Constant-Murley score was 79 (SD ± 12). Two patients had failure of the repair on post-operative MRI. Twelve cases (57 %) showed post-operative progression of fatty muscle infiltration. CONCLUSION: All-arthroscopic repair is an effective treatment modality for degenerative subscapularis tendon tears with an anterosuperior tear pattern with good clinical results and high patient satisfaction. Although there was a high tendon-to-bone healing rate, fatty muscle infiltration was progressive in more than half of the patients. LEVEL OF EVIDENCE: Therapeutic case series, Level IV.

Clinical outcome in all-arthroscopic versus mini-open rotator cuff repair in small to medium-sized tears: a randomized controlled trial in 100 patients with 1-year follow-up.

PURPOSE: The purpose of this study was to compare clinical outcomes in the first postoperative year of patients with full-thickness small to medium-sized tears undergoing all-arthroscopic (AA) versus mini-open (MO) rotator cuff repair. METHODS: One hundred patients were randomized to either AA or MO rotator cuff repair at the time of surgery on an intention-to-treat basis. Patients were evaluated before and 6, 12, 26, and 52 weeks after surgery using the Disabilities of the Arm, Shoulder, and Hand (DASH) score as a primary outcome score and the Constant-Murley score, visual analog scale (VAS)-pain/impairment score, and measurement of active forward flexion/external rotation as secondary outcome measures. Ultrasound evaluation was used to assess structural integrity of the repair 1 year postoperatively. RESULTS: Forty-seven patients were analyzed in the AA group and 48 in the MO group. Five patients were lost to follow-up. Mean age was 57.2 (SD 8.0) years in the AA group and 57.8 (SD 7.9) years in the MO group. Primary and secondary outcome measures significantly improved in both groups postoperatively. Overall mean primary and secondary postoperative outcome scores did not statistically significantly differ between the treatment groups (DASH between-group mean difference: -3.4; 95% confidence interval [CI], -10.2 to 3.4; P = .317). However, at the 6-week follow-up, DASH score, VAS-pain and -impairment, and active forward flexion were significantly more improved in the AA group than in the MO group. A retear was seen in 8 patients (17%) in the AA group and 6 patients (13%) in the MO group. Five patients in the AA group (11%) and 6 patients (13%) in the MO group developed adhesive capsulitis. CONCLUSIONS: Functional outcome, pain, range of motion, and complications do not significantly differ between patients treated with all-arthroscopic repair and those treated with mini-open repair in the first year after surgery. Patients do attain the benefits of treatment somewhat sooner (6 weeks) with the arthroscopic procedure. LEVEL OF EVIDENCE: Level II, randomized controlled trial without postoperative blinding.

Preoperative agreement on the geometric classification and 2-dimensional measurement of rotator cuff tears based on magnetic resonance arthrography.

PURPOSE: To determine the intraobserver and interobserver agreement on the geometric classification and 2-dimensional measurements of rotator cuff tears based on magnetic resonance arthrography. METHODS: We retrospectively reviewed preoperative magnetic resonance arthrograms of 73 consecutive patients who were surgically treated for their full-thickness rotator cuff tears. The images were blinded and evaluated by 2 orthopaedic shoulder surgeons and 2 musculoskeletal radiologists using the geometric classification of rotator cuff tears (type 1, crescent-shaped tear; type 2, longitudinal U- or L-shaped tear; type 3a, massive tear measuring between 20 and 30 mm; and type 3b, massive contracted tear measuring >30 mm) and measuring the sagittal/coronal dimensions of the tear. Review was performed twice with an interval of at least 8 weeks. Agreement was calculated using the linear weighted κ coefficient and the intraclass correlation coefficient (ICC). RESULTS: The intraobserver agreement was excellent for both the geometric classification and the sagittal/coronal dimension measurement (κ, 0.81 to 0.92; ICC, 0.84 to 0.98). The ICC for the interobserver agreement was excellent for all sagittal and coronal dimension measurements (ICC, 0.95 to 0.97). The interobserver agreement for the geometric classification was good for the orthopaedic surgeons (κ, 0.75 for round 1 and 0.73 for round 2). The interobserver agreement for the radiologists was excellent in observation round 1 (κ, 0.82) and good in observation round 2 (κ, 0.71). The interobserver agreement between orthopaedic surgeons and radiologists was found to be moderate to good (κ, 0.52 to 0.66). The Fleiss κ was 0.66 for round 1 and 0.62 for round 2. CONCLUSIONS: The geometric classification and the 2-dimensional measurement of rotator cuff tears using magnetic resonance arthrography have good to excellent intraobserver agreement and moderate to good interobserver agreement among experienced observers. LEVEL OF EVIDENCE: Level III, diagnostic study of nonconsecutive patients without consistently applied gold standard.

Arthroscopic side-to-side repair of massive and contracted rotator cuff tears using a single uninterrupted suture: the shoestring bridge technique.

PURPOSE: This study was performed to evaluate the clinical effectiveness of a new side-to-side repair technique for massive rotator cuff tears using a single uninterrupted suture in the configuration of a shoestring in a medial-to-lateral progression. METHODS: Thirty-one consecutive patients with a mean age of 59 years (SD, 4.7 years) had primary arthroscopic repair of their massive, U-shaped, contracted supraspinatus and infraspinatus tear by the shoestring bridge technique. Preoperatively and postoperatively, we measured active forward flexion and determined the visual analog scale score for pain, Simple Shoulder Test score, and Disabilities of the Arm, Shoulder and Hand (DASH) score. Repair integrity was evaluated by ultrasonography. RESULTS: At a mean follow-up of 26.5 months, all scores had significantly improved: active forward flexion, mean of 70° (SD, 29°) preoperatively to 139° (SD, 39°) postoperatively (P < .001); visual analog scale score for pain, 8.0 ± 1.4 points to 2.5 ± 1.8 points (P < .001); Simple Shoulder Test score, 15% ± 19% to 72% ± 23% (P < .001); and Disabilities of the Arm, Shoulder and Hand score, 62 ± 17 points to 21 ± 14 points (P < .001). Ultrasound evaluation showed that 25 of 31 patients (81%) had heeled tendons. Of 31 patients, 6 (19%) had a complete retear. Only 3 of these 6 patients were not satisfied with the result. CONCLUSIONS: Arthroscopic side-to-side repair by the shoestring bridge technique is effective in the treatment of massive, U-shaped, contracted supraspinatus and infraspinatus tears. It provides the shoulder surgeon a treatment modality with significant improvement in pain and function, high patient satisfaction, and a low retear rate. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

[Diagnosis and treatment of rotator cuff tears]. / Rupturen in de rotatorcuff: diagnose en behandeling.

A rotator cuff tear is a highly prevalent disorder, occurring in 25% of people over 60 years of age. In two thirds of patients the tear is small and asymptomatic. Acute, symptomatic cuff tears may occur in active sportsmen and women aged 30-50. There is often a considerable delay in diagnosis in this group, due to a lack of recognition by either the patient or the doctor. Recently identified risk factors for the development of cuff tear are nicotine abuse, hypercholesterolaemia, contralateral cuff tear and genetic predisposition. Conservative treatment can be very successful and consists of physical therapy and effective analgesics. Repeated steroid injections are harmful to the tendinous tissue and should be avoided. The aim of surgery is anatomical reinsertion of the ruptured tendon using an open or arthroscopic procedure. The arthroscopic procedure enables the surgeon to perform a more extensive evaluation and treatment of the joint. The arthroscopic procedure is technically more demanding than the open procedure, but seems to have a shorter rehabilitation period.