Early versus delayed repair of traumatic rotator cuff tears. Does timing matter on outcomes?

INTRODUCTION: The purpose of this study was to determine if delay (before or after 4 months) in repairing a symptomatic traumatic rotator cuff tear affected clinical outcome, re-rupture rates and use of interpositional dermal grafts. METHODS: This was a case matched (age + tear size) series of patients who underwent an early (≤ 4 months) or delayed (> 4 months) rotator cuff repair following a traumatic tear. If a direct repair could not be achieved a dermal interposition graft was used. Outcomes were collected at a median time of 30 months post-operatively using the Oxford, Constant and EQ5D scores. RESULTS: Twenty patients underwent rotator cuff repair within 4 months (1-4) of injury. Twenty age and cuff tear size-matched patients were identified who had undergone a delayed repair (4.1-24 months) after injury. We found no significant difference (p > 0.05) in patient reported outcomes scores between the early and delayed repair. [Oxford scores; Early 43(13-48), Delayed 45 (31-48); Constant scores; Early 73 (21-94), Delayed 73.5 (44-87); EQ5D; Early 0.75 (0.25-1), Delayed 0.77 (0.4-1)]. Time to full recovery was significantly longer (14 vs 33.8 months) for the delayed repair group (P > 0.05). When cuff tears were subdivided into < 3 cm tears or ≥ 3 cm tears, no significant difference outcome scores were founds. However, use of dermal interposition graft was 44% in delayed group for tears ≥ 3 cm. No grafts were used in early repair group. There was one symptomatic re-tear in our series which was in the early repair group. CONCLUSION: When compared to the delayed repair group, patients that underwent early repair of traumatic rotator cuff tears had shorter time of recovery, and less need for allograft augmentation for tears 3 cm or greater. However, at mid-term follow-up, this study found no difference in patient reported outcomes following early versus delayed repair of traumatic rotator cuff tears. LEVEL OF EVIDENCE: 3.

HTK versus multidose cardioplegias for myocardial protection in adult cardiac surgery: A meta-analysis.

BACKGROUND: Histidine-tryptophan-ketoglutarate (HTK) cardioplegia for myocardial protection obviates the need for maintenance cardioplegia doses, and thus allows for greater focus on procedure accuracy. The aim of this meta-analysis is to evaluate the safety and efficacy of HTK versus multidose cardioplegias during cardiac surgery in an adult population. METHODS: Electronic searches were performed using PubMed, Science Direct, and Google Scholar databases. The key search terms included HTK cardioplegia AND cardiac surgery AND adult. This was followed by a meta-analysis investigating cardiopulmonary bypass (CPB) duration, cross-clamp duration, spontaneous defibrillation, inotropic support, mortality, atrial fibrillation, creatine kinase muscle brain band (CK-MB) and troponin I (TnI). RESULTS: Seven randomized controlled trials (n = 804) were analyzed. Spontaneous defibrillation following aortic cross-clamp removal significantly favored HTK (odds ratio [OR], 2.809; 95% confidence interval [CI], 1.574 to 5.012; I2 = 0%; p < .01). There were no other notable significant differences between HTK and multidose cardioplegia in any of the parameters measured. In particular, the OR for mortality was 1.237 (95% CI, 0.385 to 3.978; I2 = 0%; p = .721) and the mean difference for CPB duration overall was 2.072 min (95% CI, -2.405 to 6.548; I2 = 74%; p = .364). CONCLUSION: HTK is safe and effective during adult cardiac surgery when compared with multidose cardioplegias for myocardial protection during surgical correction of acquired pathology in the adult population. HTK may, therefore, be suitable for complex cases or those of extensive duration, without the prospect of increased postoperative morbidity or mortality.

Initial experience with xenograft bioconduit for the treatment of complex prosthetic valve endocarditis.

INTRODUCTION: The treatment of complex prosthetic valve endocarditis (PVE) with aortic root abscess remains a surgical challenge. Several studies support the use of biological tissues to minimize the risk of recurrent infection. We present our initial surgical experience with the use of an aortic xenograft conduit for aortic valve and root replacement. METHODS: Between October 2013 and August 2015, 15 xenograft bioconduits were implanted for complex PVE with abscess (13.3% female). In 6 patients, concomitant procedures were performed: coronary bypass (n=1), mitral valve replacement (n=5) and tricuspid annuloplasty (n=1). The mean age at operation was 60.3±15.5 years. The mean Logistic European system for cardiac operating risk evaluation (EuroSCORE) was 46.6±23.6. The median follow-up time was 607±328 days (range: 172-1074 days). RESULTS: There were two in-hospital deaths (14.3% mortality), two strokes (14.3%) and seven patients required permanent pacemaker insertion for conduction abnormalities (46.7%). The mean length of hospital stay was 26 days. At pre-discharge echocardiography, the conduit mean gradient was 9.3±3.3mmHg and there was either none (n=6), trace (n=6) or mild aortic insufficiency (n=1). There was no incidence of mid-term death, prosthesis-related complications or recurrent endocarditis. CONCLUSIONS: Xenograft bioconduits may be safe and effective for aortic valve and root replacement for complex PVE with aortic root abscess. Although excess early mortality reflects the complexity of the patient population, there was good valve hemodynamics, with no incidence of recurrent endocarditis or prosthesis failure in the mid-term. Our data support the continued use and evaluation of this biological prosthesis in this high-risk patient cohort.

Early in-vivo hemodynamic comparison of supra-annular aortic bioprostheses: Trifecta versus Perimount Magna Ease.

BACKGROUND AND AIM OF THE STUDY: The study aim was to compare early postoperative hemodynamic gradients after supra-annular implantation of the Trifecta and Perimount Magna Ease aortic bioprostheses. METHODS: Between January 2010 and December 2011, a total of 235 patients (105 males, 130 females; mean age at surgery 73.8 +/- 10.2 years) underwent supra-annular aortic valve replacement (AVR), with or without concomitant procedures. The patients were divided into 2 groups receiving either the Perimount Magna Ease (n = 117) or Trifecta (n = 118). Concomitant procedures were performed in 133 patients (56.6%), and 25 procedures (10.6%) were redos. Patients with postoperative severe left ventricular dysfunction and moderate to severe mitral regurgitation were excluded. Gradients were calculated pre-discharge using transthoracic echocardiography. Effective orifice area calculations were not performed. Data were collected retrospectively from hospital databases and analyzed using SPSS 17. RESULTS: Both groups compared well for 14 variables. Group A had a higher number of redo operations and the patients were younger. Postoperative peak and mean gradients (in mmHg) for the Magna Ease group versus Trifecta group were: 19 mm valves, 33.5 +/- 16 versus 24.7 +/- 10 (p = 0.11) and 17.4 +/- 6.5 versus 12.7 +/- 4.4 (p = 0.05); 21 mm, 27.2 +/- 9.1 versus 21.8 +/- 7.2 (p = 0.001) and 13.8 +/- 4.7 versus 10.7 +/- 3.4 (p = 0.001); 23 mm, 25.6 +/- 7.8 versus 20.1 +/- 7.9 (p = 0.005) and 13 +/- 4 versus 10.1 +/- 4.3 (p = 0.002); 25 mm, 22.3 +/- 7.8 versus 15.6 +/- 5.1 (p = 0.01) and 12.8 +/- 4.1 versus 8 +/- 2.8 (p = 0.02). The overall mortality was 3.4%. The median hospital stay was nine days in both groups (p = 0.13). Mortality (p = 0.5), and incidences of perioperative stroke (p = 0.45), postoperative new-onset atrial fibrillation (p = 0.26) and permanent pacemaker implantation (p = 0.8) were similar in both groups. CONCLUSION: Early postoperative gradients were significantly lower in patients receiving Trifecta valves, although the long-term clinical outcome and durability of the valve will require further evaluation.

Midterm Clinical Outcomes of Reimplantation Versus Remodeling Valve-Sparing Aortic Root Replacement in Patients With Connective Tissue Disorders: A Meta-Analysis.

This meta-analysis aimed to compare the midterm clinical outcomes of reimplantation versus remodeling techniques for valve-sparing aortic root replacement (VSARR) in patients with connective tissue disorders (CTDs). Studies were screened and identified after the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines from the PubMed, Web of Science, and Embase databases. Forest plots were produced using Review Manager 5.3 (Cochrane, UK). Studies comparing early and midterm clinical outcomes of reimplantation versus remodeling VSARR in patients with CTD with a mean age ≥18 years were included. The sensitivity analysis excluded studies and subgroups of patients that received ring or suture annuloplasty in addition to remodeling surgery. The study selection identified 9 eligible studies. After analysis of the study period and location for patient crossover, 7 retrospective studies consisting of 597 patients (301 reimplantation and 296 remodeling) were pooled. The pooling revealed no significant difference in postoperative mortality (estimated mean follow-up of 10.5 years) (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.30 to 1.48, I2 = 30%, p = 0.32), reoperation (OR 0.35, CI 0.04 to 3.30, I2 = 81%, p = 0.36), or occurrence of postoperative aortic regurgitation of ≥2 (OR 0.56, CI 0.31 to 1.02, I2 = 47%, p = 0.06). The sensitivity analysis excluding annuloplasty demonstrated improved mortality (OR 0.19, CI 0.06 to 0.64, I2 = 0%, p = 0.007) and decreased aortic regurgitation of ≥2 (OR 0.23, CI 0.10 to 0.53, I2 = 47%, p = 0.0005) in reimplantation VSARR. The rates of reoperation remained insignificant in the sensitivity analysis (OR 0.43, CI 0.05 to 3.53, I2 = 71%, p = 0.43). In conclusion, this meta-analysis has demonstrated no significant difference in the midterm clinical outcomes of reimplantation versus remodeling techniques of VSARR. The sensitivity analysis excluding studies and patient subgroups that received remodeling and annuloplasty suggests remodeling alone to be inferior to reimplantation in patients with CTDs. Further research is required to assess remodeling and annuloplasty against reimplantation in patients of this demographic because the current body of knowledge does not allow sufficient analysis.

Management of type III acromioclavicular joint dislocation: A Delphi consensus survey by Shoulder & Elbow Society, India (SESI).

PURPOSE: The study aimed to report the results of the Delphi survey conducted by the Shoulder, Elbow Society India (SESI), to achieve consensus on ambiguous topics in managing type III acromioclavicular joint (ACJ) dislocations. METHODS: This study was based on responses from the Shoulder Elbow Society India (SESI) panel of peer-selected twenty senior surgeons practicing shoulder orthopedics. They participated in two rounds of the survey to obtain consensus on several topics pertaining to the management of type III ACJ dislocations. Consensus was achieved when at least 70 % of the panel members selected at least a 4-point on a 5-point Likert scale. RESULTS: Our Delphi survey reached a consensus on seven topics of ambiguity. An anteroposterior and axillary view of the shoulder without any traction or weight in hand is sufficient in the setting of a suspected type III ACJ dislocation. Magnetic resonance imaging (MRI) is not routinely indicated in type III ACJ dislocation. Either cross-arm adduction X-rays or clinical examination may be used to distinguish between ISAKOS (International Society of Arthroscopy, Knee surgery and Orthopaedics Sports medicine) IIIA and B classification of ACJ to identify stable and unstable injuries. Conservative treatment can be offered to patients who have stable injuries and who are not high-demand individuals in acute type III ACJ dislocations. In conservative management of type III ACJ dislocation, a two-week sling suffices. Jones strapping has no clear advantage over a shoulder sling. Coracoclavicular reconstruction with an autograft is an acceptable way to treat symptomatic, chronic grade III ACJ dislocation. CONCLUSION: The survey helped achieve consensus on several controversial issues related to type III ACJ dislocations. However, there remains ambiguity on the definition of chronicity of such dislocations, the necessity of bilateral Zanca views, and the duration of conservative trial before switching to a surgical line of management.

Transcatheter aortic valve implantation versus surgical aortic valve replacement in dialysis-dependent patients: a meta-analysis.

OBJECTIVES: This meta-analysis aims to compare the clinical outcomes of transcatheter aortic valve implantation (TAVI) versus aortic valve replacement (AVR) for aortic stenosis in dialysis-dependent patients. METHODS: Literature searches employed PubMed, Web of Science, Google Scholar and Embase to identify relevant studies. Bias-treated data were prioritized, isolated and pooled for analysis; raw data were utilized where bias-treated data were unavailable. Outcomes were analysed to assess for study data crossover. RESULTS: Literature search identified 10 retrospective studies; following data source analysis, five studies were included. Upon pooling of bias-treated data, TAVI was significantly favoured in early mortality [odds ratio (OR), 0.42; 95% confidence interval (95% CI), 0.19-0.92; I2  = 92%; P  = 0.03], 1-year mortality (OR, 0.88; 95% CI 0.80-0.97; I2  = 0%; P  = 0.01), rates of stroke/cerebrovascular events (OR, 0.71; 95% CI 0.55-0.93; I2  = 0%; P  = 0.01) and blood transfusions (OR, 0.36; 95% CI 0.21-0.62; I2  = 86%; P  = 0.0002). Pooling demonstrated fewer new pacemaker implantations in the AVR group (OR, 3.33; 95% CI 1.94-5.73; I2  = 74%; P  ≤ 0.0001) and no difference in the rate of vascular complications (OR, 2.27; 95% CI 0.60-8.59; I2  = 83%; P  = 0.23). Analysis including raw data revealed the length of hospital stay to favour TAVI with a mean difference of -9.20 days (95% CI -15.58 to -2.82; I2  = 97%; P  = 0.005). CONCLUSION: Bias-treated meta-analysis comparing surgical AVR and TAVI favoured TAVI in early mortality, 1-year mortality, rates of stroke/cerebrovascular events and blood transfusions. There was no difference in the rates of vascular complications; however, TAVI required more pacemaker implantations. Data pooling including raw data revealed that the length of hospital admission favours TAVI.

Right ventricular blood cyst causing outflow tract obstruction in an adult.

Blood cysts are benign intracardiac masses that are well described in infants. We present a rare adult presentation of a blood cyst tethered to the right ventricular wall and the tricuspid valve causing right ventricular outflow obstruction. Multimodality imaging approach was found to be of great importance in the diagnosis and treatment of this patient.

Reconstruction of irreparable rotator cuff tears with an acellular dermal matrix in elderly patients without joint arthritis.

Background: Reverse shoulder arthroplasty is the mainstay of treatment for symptomatic irreparable rotator cuff tears in elderly patients without arthritis. However, this treatment incurs significant costs and is a major surgical undertaking. This study explores an alternative that involves the reconstruction of irreparable rotator cuff tears using an acellular dermal matrix in elderly patients without established joint arthritis. Methods: We prospectively evaluated the reconstruction of massive irreparable rotator cuff tears in 21 patients aged 68 years and over without radiographic glenohumeral joint osteoarthritis in whom conservative management had failed. A human dermal acellular matrix graft was used as a bridging graft for reconstruction. Pain scores, Oxford Shoulder Scores and ranges of movement were all assessed preoperatively and postoperatively. The mean follow-up period was 5.8 years (range 2.6 to 8.9 years). Results: Statistically significant (p < 0.05) improvements were observed in Oxford Shoulder Scores (mean preoperative score, 21; mean postoperative score, 46), pain scores (mean preoperative score, 6; mean postoperative score, 0) and ranges of movement. Patients also reported a high satisfaction rate with the procedure. Discussion: Human tissue matrix allografts could serve as a suitable option for the treatment of elderly patients with massive irreparable rotator cuff tears without arthritis.

Morphological characteristics and management of greater tuberosity fractures associated with anterior glenohumeral joint dislocation: A single centre 10-year retrospective review.

Introduction: Greater tuberosity (GT) fractures associated with anterior gleno-humeral (GH) dislocations are unstable, with inadequate treatment leading to displacement, malunion, stiffness and functional disability. We explored its morphological characteristics to ultimately optimize their management. Methods: We retrospectively reviewed all shoulder radiographs with GT fractures associated with anterior GH dislocations in a university hospital between December 1, 2009 and December 31, 2019. Special considerations were given to fracture morphology, presence and site of comminution, degree of displacement and need for surgical intervention. Results: 133 patients were identified. Most of the fracture-dislocations were multi-fragmentary (86.5%) and located antero- or postero-superiorly (68.7%). Superiorly comminuted GT fractures were twice as likely to displace compared to other sites of comminution (43% vs. 21%, p = 0.03), and require surgery (p = 0.03). Undisplaced comminuted GT fragments, particularly superior patterns, could undergo secondary migration if conservatively treated (p = 0.01). GT fractures fixed with interfragmentary screw suffered more secondary migration but those treated with double-row suture anchors (DRSA) did not on follow-up x-rays at two months. Conclusion: GT fractures with anterior GH dislocations are frequently comminuted. Those with superiorly situated comminution should have a low threshold for surgical fixation, particularly with DRSA which can prevent secondary fragment migration.

Interposition GraftJacket allografts for irreparable rotator cuff tears.

AIMS: Long-term outcomes following the use of human dermal allografts in the treatment of symptomatic irreparable rotator cuff tears are not known. The aim of this study was to evaluate these outcomes, and to investigate whether this would be a good form of treatment in young patients in whom a reverse shoulder arthroplasty should ideally be avoided. METHODS: This prospective study included 47 shoulders in 45 patients who underwent an open reconstruction of the rotator cuff using an interposition GraftJacket allograft to bridge irreparable cuff tears, between January 2007 and November 2011. The Oxford Shoulder Score (OSS), pain score, and range of motion (ROM) were recorded preoperatively and at one year and a mean of 9.1 years (7.0 to 12.5) postoperatively. RESULTS: There was significant improvement in the mean OSS from 24.7 (SD 5.4) preoperatively to 42.0 (SD 6.3) at one year, and this improvement was maintained at 9.1 years (p < 0.001), with a score of 42.8 (SD 6.8). Similar significant improvements in the pain score were seen and maintained at the final follow-up from 6.1 (SD 1.6) to 2.1 (SD 2.3) (p < 0.001). There were also significant improvements in the ROM of the shoulder, and patient satisfaction was high. CONCLUSION: The use of an interposition human dermal allograft in patients with an irreparable rotator cuff tear leads to good outcomes that are maintained at a mean of nine years postoperatively. Cite this article: Bone Joint J 2022;104-B(1):91-96.

The management of displaced humeral shaft fractures - A survey of UK shoulder and elbow surgeons.

Introduction: Indications for surgical management of displaced humeral shaft fractures are not clearly established, leading to variations in practice. The aim of this study was to determine the scale of these variations in the UK practice to help design a future national trial. Methods: An online survey was sent to all surgeon members of British Elbow and Shoulder Society to help define humeral shaft fractures, fracture displacement as well as indications for operative and non-operative management. Patient and injury related factors considered important when managing humeral shaft fractures were investigated. Results: The survey achieved a response rate of 32% (104/327). There was a lack of consensus on definitions for humeral shaft fractures and fracture displacement. A functional brace was the most common form of non-operative treatment (63%). Majority immobilise humeral shaft fractures for 4-8 weeks or until callus are visible (62%) with a similar number considering operative treatment if adequate signs of healing are not present at around 12-16 weeks. Around half of our respondents exclusively use plates with variations in preference of approach and a minority (2%) exclusively use intra-medullary nails. Conclusion: The significant variation in management of displaced humeral shaft fractures in the UK suggests a clear need to evaluate clinical and cost effectiveness through a multi-centre randomised trial.

Trends in Practice Among Shoulder Specialists in the Management of Frozen Shoulder: A Consensus Survey.

Background: The management of frozen shoulder (FS) differs depending on experience level and variation between scientific guidelines and actual practice. Purpose: To determine the current trends and practices in the management of FS among shoulder specialists and compare them with senior shoulder specialists. Study Design: Consensus statement. Methods: A team of 15 senior shoulder specialists (faculty group) prepared a questionnaire comprising 26 questions regarding the definition, terminology, clinical signs, investigations, management, and prognosis of FS. The questionnaire was mailed to all the registered shoulder specialists of Shoulder and Elbow Society, India (SESI) (specialist group; n = 230), as well as to the faculty group (n = 15). The responses of the 2 groups were compared, and levels of consensus were determined: strong (>75%), broad (60%-74.9%), inconclusive (40%-59.9%), or disagreement (<40%). Result: Overall, 142 of the 230 participants in the specialist group and all 15 participants in the faculty group responded to the survey. Both groups strongly agreed that plain radiographs are required to rule out a secondary cause of FS, routine magnetic resonance imaging is not indicated to confirm FS, nonsteroidal anti-inflammatory drugs should be administered at bedtime, steroid injection (triamcinolone or methylprednisolone) is the next best option if analgesics fail to provide pain relief, passive physical therapy should be avoided in the freezing phase, <10% of patients would require any surgical intervention, and patients with diabetes and thyroid dysfunction tend to fare poorly. There was broad agreement that routine thyroid dysfunction screening is unnecessary for women, a single 40-mg steroid injection via intra-articular route is preferred, and arthroscopic capsular release (ACR) results in a better outcome than manipulation under anesthesia (MUA). Agreement was inconclusive regarding the use of combined random blood sugar (RBS) and glycosylated hemoglobin versus lone RBS to screen for diabetes in patients with FS, preference of ACR versus MUA to treat resistant FS, and the timing of surgical intervention. There was disagreement over the most appropriate term for FS, the preferred physical therapy modality for pain relief, the most important movement restriction for early diagnosis of FS, and complications seen after MUA. Conclusion: This survey summarized the trend in prevalent practices regarding FS among the shoulder specialists and senior shoulder surgeons of SESI.

Delayed surgical retrieval of retained guidewire following percutaneous coronary intervention.

An uncommon complication of percutaneous coronary intervention (PCI) is entrapment and/or fracture of the catheter guidewire. This report describes "delayed" surgical removal of retained guidewire from the ascending aorta following a PCI. The potential complications and the management options are further discussed.

Interposition grafting for irreparable rotator cuff tears: Systematic review and specialist practice report.

The treatment of symptomatic irreparable rotator cuff tears poses significant challenges to both patients and shoulder surgeons. Although reverse shoulder arthroplasty provides reliably good outcomes in the elderly, it is not a good option in younger patients. Various surgical techniques have been proposed for the treatment of irreparable rotator cuff tears; however, no gold standard currently exists. Interposition grafting is used when the rotator cuff cannot be fully repaired onto its footprint, and the remaining defect is bridged with either an allograft, autograft, xenograft or a synthetic graft. This review aims to present the literature on the use of various interposition grafts and techniques to treat large or massive irreparable rotator cuff tears and provide a specialist practice report.

Cardiac surgery and Brugada syndrome: operative considerations.

Brugada syndrome is an uncommon arrhythmic disease due to abnormality in myocardial transmembrane sodium channels and is associated with sudden death due to ventricular arrhythmias. We report our strategy and highlight precautions to reduce the risk of perioperative arrhythmias in a patient with Brugada pattern who underwent successful coronary artery bypass grafting.

The Management of Distal Clavicle Fractures - A Survey of UK Shoulder and Elbow Surgeons.

Background Distal clavicle fractures (DCF) are a management challenge frequently encountered by shoulder surgeons. Despite an array of surgical fixation strategies, the indications and role of surgery are unclear, with there being no gold standard or consensus regarding their management. The aim of this study was to identify current United Kingdom (UK) clinical practices relating to DCFs and to inform a future randomised control trial (RCT). Methods An online survey was sent to the consultant surgeon members of the British Elbow and Shoulder Society (BESS). Questions covered respondent indications for surgical fixation, important factors considered for management of DCFs, fixation strategies, the volume of patients treated, and willingness to participate in the conduct of a randomized trial. Results The response rate was 84/327 (26%). 64-67% of respondents reported surgically managing DCFs classified as Neer type 2A, 2B and 5. The most important factors considered by surgeons when deciding between operative and nonoperative intervention were degree of displacement (90%), clinical assessment of impending open fracture (87%), and age of the patient (74%). For conservatively managed DCFs, the preferred length of complete immobilization was 2-4 weeks (46%), followed by 4-8 weeks (17%). 30% reported not immobilizing their patients at all. For operative intervention, the locking plate was the preferred fixation method by most respondents (68%), although there was no clear consensus regarding other fixation methods. Most surgeons (52%) reported treating a low volume of patients with DCFs (0-10) per year. 58% of respondents were willing to randomize patients to non-operative treatment in a multi-centre RCT, with a further 22% undecided. Finally, 68% (n=79) of respondents would consider being co-investigators in such a trial. Conclusion There is considerable heterogeneity in the management of patients with DCFs in the UK. The indications for surgery and the optimal surgical fixation method remain uncertain. There is a clear need for pragmatic multi-centre clinical research in this area.

Floor and ceiling effects in the Oxford Shoulder Score : an analysis from the National Joint Registry.

AIMS: The main objective of this study was to examine whether the Oxford Shoulder Score (OSS) demonstrated floor or ceiling effects when used to measure outcomes following shoulder arthroplasty in a large national cohort. Secondary objectives were to assess its pain and function subscales, and to identify independent predictors for patients achieving a postoperative ceiling score following shoulder arthroplasty. METHODS: Secondary database analysis of the National Joint Registry (NJR), which included 48,270 patients undergoing shoulder arthroplasty, was conducted. The primary outcome measure was the OSS. Secondary outcome measures were the OSS-Function Component Subscale and OSS-Pain Component Subscale. Floor and ceiling effects were considered to be present if > 15% of patients scored either the lowest or highest possible score. Logistic regression analysis was used to identify independent predictors for scoring the highest possible OSS score postoperatively. RESULTS: Preoperatively, 1% of patients achieved the lowest possible OSS score (0) and 0.4% of patients achieved the highest possible score (48). Postoperatively, < 1% of patients achieved the lowest score at all timepoints, but the percentage achieving the highest score at six months was 8.3%, at three years 16.9%, and at five years 17%. Male patients, those aged between 60 and 89 years, and those undergoing an anatomical total shoulder arthroplasty (ATSA) were more likely to contribute to the ceiling effect seen in the OSS questionnaire. Pain and function subscales exhibited greater ceiling effects at three years and five years when compared with the overall OSS questionnaire. Logistic regression analysis showed that sex, procedure type, and preoperative OSS score were independent predictors for scoring the highest possible OSS at years. CONCLUSION: Based on NJR patient-reported outcome measures data, the OSS does not exhibit a ceiling effect at six months, but does at three years and five years, in part due to outcome scores of ATSA. Preoperative OSS, age, male sex, and ATSA are independent predictors of achieving a ceiling score. Cite this article: Bone Joint J 2021;103-B(11):1717-1724.

Aortic root replacement using a biovalsalva prosthesis in comparison to a "handsewn" composite bioprosthesis.

BACKGROUND: The Biovalsalva aortic root prosthesis incorporates an Elan porcine stentless biological aortic valve suspended within a triple-layered vascular conduit with preformed aortic sinuses of Valsalva. This study compared implantation of the Biovalsalva prosthesis with a "handsewn" composite bioprosthetic graft (CE Perimount bovine bioprosthesis anastomosed to a gelatin-impregnated gelweave Dacron graft). METHODS: Between December 2004 and January 2009, 39 patients underwent elective or urgent aortic root replacement (modified Bentall procedure with coronary button reimplantation) using a Biovalsalva (n = 21) or a handsewn bioprosthesis (n = 18) for aortic root dilatation. RESULTS: There was no significant difference in the preoperative variables between the two study groups including age (70.7 +/- 1.7 vs. 67.6 +/- 2.9 years, p > 0.05). There was no in-hospital mortality. Three patients in each group underwent concomitant aortic hemi-arch replacement. Patients who underwent Biovalsalva implantation had a reduced need for transfusion of blood (1.25 +/- 0.32 vs. 3.17 +/- 0.71 units, p < 0.05) and fresh frozen plasma (2.78 +/- 0.39 vs. 1.85 +/- 0.31, p < 0.05), and reduced mediastinal blood loss (416 +/- 52 vs. 583 +/- 74 mL, p < 0.05) compared to those with a handsewn bioprosthesis. Cardiopulmonary bypass time (141 +/- 6 vs. 170 +/- 17 minutes, p = NS) and aortic cross-clamp time (113 +/- 6 vs. 115 +/- 7 minutes, p = NS) were similar. Postoperative echocardiography demonstrated excellent hemodynamic function of the Biovalsalva prosthesis (mean size 25.1 +/- 0.4 mm valved conduit) with a peak pressure gradient of 26.2 +/- 1.9 mmHg and no or trivial valvular regurgitation. CONCLUSIONS: The Biovalsalva prosthesis should be considered for patients requiring a biological aortic root replacement. It offers an "off-the-shelf" preassembled composite biological valve conduit with excellent hemostatic and hemodynamic properties.