Operative vs. conservative treatment of AC-Joint Dislocations Rockwood grade ≥ III -An economical and clinical evaluation.

INTRODUCTION: Acromioclavicular joint dislocations (ACD) are one of the most common shoulder injuries. There is no consensus in how to treat higher graded ACD ≥ Rockwood grade III. This study compares operative versus conservative treatment regarding costs and clinical outcome parameters. MATERIALS AND METHODS: This retrospective, consecutive case-control-study includes 14 patients. Seven operatively treated patients were matched, by Rockwood grade, with seven conservatively treated patients. The cost was extracted out of the clinical- and insurance-based cost sheets and furthermore these include the loss of earnings. Clinical examination, demographic data as well as different outcome-questionnaires were recorded. RESULTS: There were no significant differences between operative and conservative treated patients for outcome Questionnaires. Of note, there was a significantly higher incidence of tenderness over the AC-joint (p = 0.0038) postoperatively. As expected, economical evaluation showed various findings in favor of the conservative treatment. The costs for medical services (11012.39vs.1163.81USD; p = 0.0061), days of hospitalization (3.3vs.0days; p < 0.0001); total cost for medical treatment (30262.17 vs. 7833.82 USD; p = 0.0358) were significantly higher in the operative group. CONCLUSION: Even with a limited case number and a retrospective study design almost all clinical results were equal in both groups. Operative therapy of higher graded ACDs (Rockwood > III) compared to conservative is economically inefficient. Under consideration of clinical comparable results, indications for operative treatment should be set very carefully.

Why is female gender associated with poorer clinical outcomes after reverse total shoulder arthroplasty?

INTRODUCTION: There is a lack of gender-specific research after reverse total shoulder arthroplasty (RTSA). Although previous studies have documented worse outcomes in women, a more thorough understanding of why outcomes may differ is needed. We therefore asked: (1) Are there gender-specific differences in preoperative and postoperative clinical scores, complications, surgery-related parameters, and demographics? (2) Is female gender an independent risk factor for poorer clinical outcomes after RTSA? (3) If so, why is female gender associated with poorer outcomes after RTSA? MATERIALS AND METHODS: Between 2005 and 2019, 987 primary RTSAs were performed in our institution. After exclusion criteria were applied, data of 422 female and 271 male patients were analyzed. Clinical outcomes (absolute/relative Constant Score [a/rCS] and Subjective Shoulder Value [SSV]), complications (intra- and/or postoperative fracture, loosening), surgery-related parameters (indication, implant-related characteristics), and demographics (age, gender, body mass index, and number of previous surgeries) were evaluated. Preoperative and postoperative radiographs were analyzed (critical shoulder angle, deltoid-tuberosity index, reverse shoulder angle, lateralization shoulder angle, and distalization shoulder angle). RESULTS: Preoperative clinical scores (aCS, rCS, SSV, and pain level) and postoperative clinical outcomes (aCS and rCS) were significantly worse in women. However, the improvement between preoperative and postoperative outcomes was significantly higher in female patients for rCS (P = .037), internal rotation (P < .001), and regarding pain (P < .001). Female patients had a significantly higher number of intraoperative and postoperative fractures (24.9% vs. 11.4%, P < .001). The proportion of female patients with a deltoid-tuberosity index <1.4 was significantly higher than males (P = .01). Female gender was an independent negative predictor for postoperative rCS (P = .047, coefficient -0.084) and pain (P = .017, coefficient -0.574). In addition to female sex per se being a predictive factor of worse outcomes, females were significantly more likely to meet 2 of the 3 most significant predictive factors: (1) significantly worse preoperative clinical scores and (2) higher rate of intra- and/or postoperative fractures. CONCLUSIONS: Female sex is a very weak, but isolated, negative predictive factor that negatively affects the objective clinical outcome (rCS) after RTSA. However, differences did not reach the minimal clinically important difference, and it is not a predictor for the subjective outcome (SSV). The main reason for the worse outcome in female patients seems to be a combination of higher preoperative disability and higher incidence of fractures. To improve the outcome of women, all measures that contribute to the reduction of perioperative fracture risk should be used.

Inadvertent, intraoperative, non- to minimally displaced periprosthetic humeral shaft fractures in RTSA do not affect the clinical and radiographic short-term outcome.

INTRODUCTION: Little information is available on the clinical and radiographic outcome of intraoperative, non- to minimally displaced humeral fractures that occur during implantation of a stemmed, reverse shoulder prosthesis but are only recognized on routine postoperative radiographs. The goal of this study is to report the clinical and radiographic outcome for this rarely reported fracture type. MATERIALS AND METHODS: 39 conservatively treated non- to minimally displaced intraoperative periprosthetic humeral fractures after stemmed RTSA were detected from our radiographic database between 1.1.2006 and 31.1.2018. Exclusion criteria were lack of patient consent, preoperative humeral fracture, and revision arthroplasties. Clinical (absolute and relative Constant score, the Subjective Shoulder Value) and radiographic (conventional radiographs) assessment was performed preoperatively, at 6 weeks (only radiographically) and at latest follow-up with a minimum follow-up of 2 years. RESULTS: 35 patient's with a mean age of 72 years (range 32-88, SD ± 11 years) and a mean follow-up of 53 months (range 24-124, SD ± 31) were included in the study. At latest follow-up, all clinical outcome parameters except external rotation improved significantly. A complication rate of 17% (n:6) was recorded. At 6 weeks after the index surgery, none of the radiographs showed a fracture displacement or a sintering of the stem. At latest follow-up, all fractures were healed and no stem loosening was observed in any of the shoulders. CONCLUSIONS: Non- to minimally displaced intraoperative periprosthetic humeral fractures in RTSA have an incidence of about 5% in this series of mainly uncemented press-fit stems. They generally heal without any further treatment and are not associated with stem loosening or compromise the clinical outcome after primary RTSA. Except slight restriction in the postoperative rehabilitation protocol, no further attention or action is needed.

Femoral head and neck autograft in arthroplasty for developmental dysplasia of the hip: a systematic review of long-term outcomes.

PURPOSE: Total hip arthroplasty (THA) with an acetabular component and an autogenous femoral head graft for acetabular reconstruction in developmental dysplasia of the hip was first described by Harris et al. in 1977. While a number of studies have addressed the aforementioned scenario over the last decades, most lack sufficient numbers and follow-up. As such, we analyzed long-term outcomes of THAs with femoral autograft for arthrosis secondary to hip dysplasia. METHODS: A systematic review was performed using a structured PubMed, Web of Science, Ovid MEDLINE, and Cochrane analysis, based on the PRISMA criteria. All original studies from 1977 to 2022 with a mean follow-up of 10 or more years were included. Methodological Index for Nonrandomized Studies (MINORS) were used for quality assessment. RESULTS: A total of 26 studies with 1316 patients (87% females) undergoing 1543 THAs with femoral autograft (2 times neck graft, 24 times head graft) were included. Mean age was 52 years (range, 28-73) and the mean follow-up was 13 years (range, 9-18). The revision rate was 8.3% (n = 129), and 73% of revisions were for loosening. Rate of infection (0.5%) and dislocations (1%) were low. Radiographic analysis revealed 167 loose acetabular components (11%) and 118 cases of graft resorption (7.6%). Mean Harris Hip Score increased from 42 to 85. Mean MINORS score was 11, and no study was level of evidence I or II. CONCLUSIONS: Femoral autograft with THA may be a viable long-term option for hip reconstruction in developmental dysplasia of the hip. However, moderate loosening rates and low level of evidence must be acknowledged before drawing the final conclusions. LEVEL OF EVIDENCE: Therapeutic Level III.

No clinical consequence of liner malseating in dual-mobility THAs at short term: a systematic review.

BACKGROUND: Liner malseating is well described in ceramic-on-ceramic total hip arthroplasties (THAs). However, limited information is known on this complication among dual-mobility articulations. As such, this systematic review analyzed liner malseating in dual-mobility THAs concerning prevalence, clinical implications, and associated risk factors. METHODS: A PRISMA criteria-based systematic review was performed, and PubMed, Web of Science, MEDLINE, and Cochrane used as data bases. All original studies from 1980 to 2022 were considered eligible for inclusion, and Methodological Index for Nonrandomized Studies (MINORS) used for quality assessment. RESULTS: In total, five retrospective cohort studies with 2330 patients (2673 dual-mobility THAs) were included. Mean age was 66.9 years, mean BMI was 29.8 kg/m2, and 35% of patients were female. Rates of malseating ranged from 0.15% to 5.8%, with a total of 53 malseated liners identified throughout all studies (1.98%). Based on THA manufacturer, malseating occurred in 48 Stryker (1.96%) and 5 Biomet Zimmer (2.14%) THAs. Mean clinical follow-up was 2.2 years (mean range, 1.3 to 6.4 years). Except one patient reporting of pain at 2 years, no revision or negative clinical implication was noted in any of the malseated liners, including normal ranged metal ions measured in four cases. A smaller acetabular component size was identified as a statistically significant risk factor for malseating in one study. Mean MINORS score was 9.8. CONCLUSIONS: Liner malseating is a rare finding in patients undergoing THAs with dual-mobility articulations. While prelim results demonstrate no negative clinical consequences to date, existing studies are limited, refer to short-term outcomes only, and do not prospectively follow-up affected patients. LEVEL OF EVIDENCE: IV.

Augmented reality through head-mounted display for navigation of baseplate component placement in reverse total shoulder arthroplasty: a cadaveric study.

BACKGROUND: To achieve an optimal clinical outcome in reverse total shoulder arthroplasty (RSA), accurate placement of the components is essential. The recently introduced navigation technology of augmented reality (AR) through head-mounted displays (HMD) offers a promising new approach to visualize the anatomy and navigate component positioning in various orthopedic surgeries. We hypothesized that AR through HMD is feasible, reliable, and accurate for guidewire placement in RSA baseplate positioning. METHODS: Twelve human cadaver shoulders were scanned with computed tomography (CT) and RSA baseplate positioning was 3-D planned using dedicated software. The shoulders were prepared through a deltopectoral approach and an augmented reality hologram was superimposed using the HMD Microsoft HoloLense. The central guidewire was then navigated through the HMD to achieve the planned entry point and trajectory. Postoperatively, the shoulders were CT-scanned a second time and the deviation from the planning was calculated. RESULTS: The mean deviation of the entry point was 3.5 mm ± 1.7 mm (95% CI 2.4 mm; 4.6 mm). The mean deviation of the planned trajectory was 3.8° ± 1.7° (95% CI 2.6°; 4.9°). CONCLUSION: Augmented reality seems feasible and reliable for baseplate guidewire positioning in reverse total shoulder arthroplasty. The achieved values were accurate.

Corynebacterium periprosthetic joint infection: a systematic review of 52 cases at 2.5 years follow-up.

INTRODUCTION: While large progress has been achieved in identifying and treating the most common pathogens involved in periprosthetic joint infections (PJI), there remains limited knowledge on atypical pathogens such as Corynebacterium. For that reason, we analyzed infection and diagnostical characteristics, as well as treatment outcome in Corynebacterium PJI. METHODS: A systematic review was performed based on a structured PubMed and Cochrane Library analysis using the PRISMA algorithm. The search was performed by 2 independent reviewers, and articles from 1960 to 2022 considered eligible for inclusion. Out of 370 search results, 12 studies were included for study synthesis. RESULTS: In total, 52 cases of Corynebacterium PJI were identified (31 knees, 16 hips, 4 elbows, 1 shoulder). Mean age was 65 years, with 53% females, and a mean Charlson Comorbidity Index of 3.9. The most common species was Corynebacterium striatum in 37 cases (71%). Most patients were treated with two-stage exchange (40%), isolated irrigation and debridement (21%), and resection arthroplasty (19%). Mean duration of antibiotic treatment was 8.5 weeks. At a mean follow-up of 2.5 years, there were 18 reinfections (33%), and 39% were for Corynebacterium. Initial infection by Corynebacterium striatum species was predictive of reoperation (p = 0.035) and reinfection (p = 0.07). CONCLUSION: Corynebacterium PJI affects multimorbid and elderly patients, with one in three developing a reinfection at short term. Importantly, the relative majority of reinfections was for persistent Corynebacterium PJI.

Reversed total shoulder arthroplasty after acromioclavicular joint resection yields equivalent clinical results compared to a matched control group.

INTRODUCTION: Reverse total shoulder arthroplasty (RTSA) is a well-establish procedure with increasing incidence. Depending on the medical history, many patients undergo multiple soft-tissue procedures before RTSA. The role of acromioclavicular pathology as well as the consequences of a distal clavicle resection (DCR) before RTSA has not been evaluated yet. MATERIAL AND METHODS: A retrospective single-center review was performed on all patients undergoing primary RTSA with or without DCR with a minimum follow-up of 2 years. We compared patient-reported outcome measures (Constant score (CS), subjective shoulder values (SSV), and range of motion (ROM)) with a matched control group. The control group consisted of patients treated with a RTSA without DCR and matching was performed for age, sex, operating side, American Society of Anesthesiologists (ASA), body mass index (BMI), and indication. Surgical time and complication rate were recorded. RESULTS: Thirty-nine patients with a mean follow-up of 63 months (SD 33) were enrolled in the study group. Mean age was 67 years (SD 7) with 44% male patients for both groups. The mean relative CS improved from 43% (SD 17) to 73% (SD 20) in the study group, and from 43% (18) to 73% (22) in the control group. The SSV improved from 29% (SD 17) to 63% (SD 29) in the study group, and from 28% (SD 16) to 69% (SD 26) in the control group (both n.s.). The postoperative ROM did not significantly differ between the two groups. Five patients in the study group and six in the control group had reoperations. CONCLUSION: Patients who received a DCR before RTSA showed equivalent clinical outcomes compared to a match-control group with RTSA only. Surgical time was not different, and no complication related to the open DCR was observed in the study group. Therefore, we conclude that a prior DCR does not influence the postoperative outcome after RTSA. LEVEL OF EVIDENCE: Level III: Retrospective comparative study.

Incidence, radiographic predictors, and clinical outcome of acromial stress reaction and acromial fractures in reverse total shoulder arthroplasty.

BACKGROUND: Acromial and scapular spine fractures (ASFs) are known complications following implantation of reverse total shoulder arthroplasty (RTSA). The entity of acromial stress reaction (ASR) without fracture has recently been described. The purpose of this study was to analyze the incidence, radiographic predictors, treatment options, healing rates, and clinical outcomes of ASF and ASR compared with a control group. METHODS: A total of 854 primary RTSAs were implanted between 2005 and 2018 in a single shoulder unit of a tertiary referral hospital and retrospectively reviewed for the incidence of ASF and ASR. ASR was defined as pain at the acromion or scapular spine after fracture exclusion on computed tomography scans. The ASF group was matched to a control group. Preoperative and postoperative radiographs were analyzed for radiographic predictors of ASF or ASR. The impact of ASF and ASR, operative vs. nonoperative treatment, and fracture union on clinical outcomes (Constant-Murley score [CS], Subjective Shoulder Value [SSV], and range of motion) with a minimum follow-up period of 2 years was analyzed. RESULTS: A total of 46 ASFs (5.4%) in 44 patients and 44 ASRs (5.2%) in 43 patients were detected at a mean of 16 ± 24 months and 20 ± 23 months postoperatively, respectively. Predictive radiographic factors were an increased critical shoulder angle and lateralization shoulder angle. The overall union rate was 55% (22 of 40) but was significantly higher following operative treatment (9 of 11, 82%) compared with nonoperative treatment (13 of 29, 45%). Patients with ASF or ASR demonstrated inferior clinical outcomes (CS, 44 ± 21 and 48 ± 18; SSV, 52% ± 25% and 57% ± 27%) compared with the control group (CS, 66 ± 14; SSV, 82% ± 22%) independent of bony union or treatment at a mean of 59 ± 33 months (ASF) and 61 ± 38 months (ASR). CONCLUSION: ASF and ASR are frequent complications following RTSA implantation with similar poor clinical outcome measures. The healing rate was shown to be much higher with a surgical approach. Nevertheless, fracture consolidation does not result in better clinical outcomes compared with nonunion.

Reverse shoulder arthroplasty after failed tendon transfer for irreparable posterosuperior rotator cuff tears.

BACKGROUND: Tendon transfers (TTs) can be successful for the management of selected posterosuperior functionally irreparable rotator cuff tears. However, when these procedures fail to provide adequate pain relief or functional improvement, reverse shoulder arthroplasty (RSA) is commonly considered the next treatment option. The effect of prior TT on RSA remains largely unknown. The purposes of this investigation were to evaluate the outcomes of RSA after previous TT performed for posterosuperior functionally irreparable rotator cuff tears and to determine the effect of various TT types on RSA. METHODS: A retrospective review of 2 institutional databases identified 33 patients who underwent RSA implantation between 2006 and 2019 with a previous failed tendon transfer (FTT) of the shoulder and at least 2 years of clinical follow-up. FTTs included 21 latissimus dorsi transfers, 6 latissimus dorsi and teres major (LD-TM) transfers, and 6 lower trapezius transfers. RSAs were performed at an average of 5.5 years (range, 0.3-28 years) after FTT, with a mean follow-up period of 4.1 ± 2.0 years. Outcomes evaluated included the visual analog scale pain score, range of motion, absolute Constant-Murley score (CS) and relative CS, American Shoulder and Elbow Surgeons score, Subjective Shoulder Value, complications, and implant survivorship free of reoperation or revision. RESULTS: RSA significantly improved pain and function, with improvements in the visual analog scale pain score (6.2 preoperatively vs. 2.2 at most recent follow-up, P < .001), active elevation (85° vs. 111°, P < .001), American Shoulder and Elbow Surgeons score (51 vs. 74, P = .001), absolute CS (34 vs. 48, P = .003), and relative CS (42% vs. 59%, P = .002), exceeding the minimal clinically important difference threshold. There were 7 complications (21%) across the entire cohort, with dislocation (n = 3, 9.1%) as the most common complication. Comparison across TT groups showed that LD-TM transfer had the highest complication rate (3 shoulders, 50%), followed by lower trapezius transfer (1 shoulder, 16.7%); latissimus dorsi transfer had the lowest rate (3 shoulders, 14.3%; P = .037). Survivorship free of revision or reoperation was estimated to be 90.1% at 1 year, 84.9% at 2 years, and 71.2% at 5 years, with no difference among TT groups (P = .654). CONCLUSIONS: RSA can serve as a viable salvage option for FTT procedures. At mid-term follow-up, RSA led to significant improvements in pain, range of motion, and patient-reported outcomes. Patients with prior LD-TM transfers may have a higher complication rate, but no other differences were found between TT groups.

Precision of the Wilson corrective osteotomy of the first metacarpal base using specific planning and instruments for treatment of basal thumb arthritis.

INTRODUCTION: Arthritis of the basal thumb is a relatively common condition also affecting younger patients. Wilson et al. described a 20°-30° closing wedge osteotomy of the first metacarpal bone to unload the trapeziometacarpal joint. It was the purpose of this study to analyze the clinical and radiographic outcome of patients who underwent proximal extension osteotomy of the first metacarpal bone using patient-specific planning and instruments (PSI). METHODS: All patients who underwent proximal metacarpal osteotomy for basal thumb arthritis at our tertiary referral center were retrospectively included. The patients underwent preoperative planning using computed tomography and 3D segmentation to build patient-specific guides and instruments for the operative treatment. Stable fixation of the osteotomy was achieved by internal plating. The inclusion criterion was a minimum follow-up of 1 year with clinical examination, including the Michigan Hand Outcomes Questionnaire (MHQ), and computed tomography to validate the correction. Complications and reinterventions were recorded. RESULTS: A total of eight Wilson osteotomies in six patients could be included at a mean follow-up duration of 33±16 months (range, 12 to 55 months). The patients were 49±8 years (range, 36 to 58 years) at the surgery and 88% were female. The postoperative MHQ for general hand function was 77±8 (range, 45 to 100) and the MHQ for satisfaction was 77±28 (range, 17 to 100). The working status was unchanged in 7/8 hands (6/7 patients). Radiographic analysis revealed successful correction in all cases with unchanged Eaton-Littler stage in 7/8 hands. No complications were recorded. CONCLUSION: The combined extending and ulnar adducting osteotomy using patient-specific guides and instrumentation provides an accurate treatment for early-stage thumb arthritis. LEVEL OF EVIDENCE: Type IV-retrospective, therapeutic study.

Reverse total shoulder arthroplasty in patients with type B2, B3, and type C glenoids: comparable clinical outcome to patients without compromised glenoid bone stock-a matched pair analysis.

BACKGROUND: Primarily posterior bone deficient (dysplastic) (Walch type C) or secondarily eroded (Walch type B2 or B3) glenoids represent a surgical challenge for shoulder arthroplasty. Due to the posteriorly static decentered head, reverse total shoulder arthroplasty (RTSA) is often considered as the treatment of choice. The purpose of this study is to report the clinical and radiographic outcomes, complications and reoperations of RTSA for posteriorly deficient glenoids. MATERIALS AND METHODS: All patients who underwent RTSA for osteoarthritis secondary to underlying glenoid deficiency (Walch type B2, B3 and C) between 2005 and 2018 (study group), were identified from our institutional shoulder arthroplasty database and gender- and age-matched to a cohort of patients with normal glenoid bone stock (control group). Longitudinal pre- and postoperative clinical [Constant-Murley (CS) score, Subjective Shoulder Value (SSV)] and radiographic outcomes were assessed. RESULTS: We included 188 patients (94 in each group). The median follow-up was 43 ± 26 (24-144) months in the study group and 59 ± 32 (24-124) months in the control group. The glenoid deficiency was addressed by using glenoid bone reconstruction. The surgical site complication and revision rate of RTSA in patients with bony deficient glenoids were 17% and 7%. Although glenoid loosening was slightly higher in the study group (5 vs. 2), overall no significant differences were found between the study and control groups in satisfaction scores, preoperative and postoperative absolute and relative Constant scores, complication and revision rates, respectively. CONCLUSION: Reverse total shoulder arthroplasty (RTSA) seems to be a valuable treatment option for patients with primary (dysplasia) or secondary (wear) posterior glenoid deficiency. Although severe glenoid bone loss seems to be a risk factor for glenoid component failure, the overall complication and revision rates as well as clinical and radiographic outcome are comparable to RTSA in patients without compromised glenoid bone stock. LEVEL OF EVIDENCE: Level III: case-control study.

Primary reverse total shoulder arthroplasty in patients older than 80 years: clinical and radiologic outcome measures.

BACKGROUND: The use of reverse total shoulder arthroplasty (RTSA) has spread worldwide as a result of an expansion of indications and an aging society. However, the value of RTSA for very old patients is rarely analyzed. This study was conducted to investigate the outcome of primary RTSA in patients older than 80 years. METHODS: We identified 171 shoulders (159 patients) treated with RTSA at an age of more than 80 years between January 2005 and March 2018. The primary outcome parameters were Subjective Shoulder Value (SSV) and the Constant-Murley score, mortality, complications, and reoperation rates. Secondary outcomes were adverse radiographic outcomes. A minimum follow-up of 1 year was accepted in 14 patients (8%) because of these patients' older age. RESULTS: We included 171 cases (159 patients; 120 female) with a mean age of 84 ± 3 years (range 80.1-94). The main indication for RTSA was cuff tear arthropathy (43%), isolated rotator cuff tear (22%), and fracture (21%). A total of 136 patients (79%) were eligible for physical examination with a mean follow-up of 41 ± 25 months (12-121). Relative Constant-Murley scores improved significantly from 39% ± 19% to 77% ± 16% and SSV from 31% ± 18% to 74% ± 22%. The range of motion and force improved significantly as well. The surgical site complication rate was 30%, with a reoperation rate of 8% (13 patients) mainly due to fracture and glenoid loosening. The overall mortality was 16% with a mean time to death of 53 ± 31 months (95% confidence interval 15, 120), thereby no higher than the age-adjusted, expected mortality rate without this procedure. CONCLUSION: Despite a quite high postoperative complication rate, RTSA is a valid therapeutic option in patients older than 80 years, with an unexpectedly low medical complication rate and good to excellent improvement of shoulder function and pain.

Limited improvement and high rate of complication in patients undergoing reverse total shoulder arthroplasty for previous native shoulder infection.

BACKGROUND: The outcomes of reverse total shoulder arthroplasty (RTSA) surgery for the sequelae of former septic native joint shoulder arthritis are unknown but might be inferior to patients without prior bacterial arthritis. METHODS: We performed a single-center case-control study embedded in our prospective RTSA cohort. We matched all patients with prior infections in a 1:1 ratio with patients who underwent RTSA for other indications. The matching variables were indication for surgery, age, sex, dominant/nondominant shoulder, and body mass index. We evaluated outcomes by Constant score and active function. RESULTS: Among 1249 patients in the RTSA cohort, 14 were operated for sequelae of previous native shoulder joint infections. Although both groups significantly improved from preoperative to postoperative values, the outcome of postinfectious patients was clearly inferior in comparison with the control group (absolute [38 ± 17 vs. 75 ± 8, P < .01], relative Constant score [47 ± 19 vs. 88 ± 9, P < .01], Constant pain score [11.0 ± 3.1 vs. 14.3 ± 1.3, P < .01], subjective shoulder value [43 ± 26 vs. 85 ± 10, P < .01], abduction [70 ± 43 vs. 148 ± 29°, P = .001], and elevation [82 ± 49° to 131 ± 16°, P = .02]). Moreover, in the postinfectious group, overall surgical complications occurred in 36%, with the need for revision in 21%. There was, however, no recurrence of infection in any of the patients' shoulders. CONCLUSION: RTSA for end-stage postinfectious joint disease is associated with a high number of complications and reoperations. Clinical outcomes are inferior to those without past infection.

What are the outcomes of core decompression without augmentation in patients with nontraumatic osteonecrosis of the femoral head?

PURPOSE: Core decompression (CD) of the femoral head is performed to preserve the hip in avascular necrosis (AVN). The outcome following this procedure differs based on the medical centre and the technique. Also, the time to total hip replacement (THR) and the percentage of patients subsequently undergoing a THR are controversial. METHODS: A systematic review was performed following PRISMA guidelines. The search included CENTRAL, MEDLINE, EMBASE, Scopus, AMED and Web of Science Core Collection databases. Studies reporting the outcome of CD for AVN were assessed. Studies using additional implants, vascularized grafts or any type of augmentation were excluded. Quality assessment was performed using the Joanna Briggs Institute Critical Appraisal Checklist (JBI CAC) tool. TRIAL REGISTRATION: International prospective register of systematic reviews (PROSPERO) - CRD42018100596 . RESULTS: A total of 49 studies describing 2540 hips were included. The mean weighted follow-up time was 75.1 months and the mean age at surgery was 39 years. Twenty-four of 37 studies reported improvement in all outcome scores, whilst 9/37 studies report only partial improvement post-operatively. Four studies (4/37) described poor clinical outcomes following intervention. Data was pooled from 20 studies, including 1134 hips with a weighted mean follow-up of 56 months. The percentage of hips undergoing THR averaged 38%. The time to THR had a weighted mean of 26 months after CD. CONCLUSION: Pooled results from 1134 hips and of these nearly 80% with early stage of osteonecrosis, showed that approximately 38% of patients underwent a total hip replacement at an average of 26 months following core decompression without augmentation.

Augmented reality for base plate component placement in reverse total shoulder arthroplasty: a feasibility study.

BACKGROUND: Accurate glenoid positioning in reverse total shoulder arthroplasty (RSA) is important to achieve satisfying functional outcome and prosthesis longevity. Optimal component placement can be challenging, especially in severe glenoid deformities. The use of patient-specific instruments (PSI) and 3D computer-assisted optical tracking navigation (NAV) are already established methods to improve surgical precision. Augmented reality technology (AR) promises similar results at low cost and ease of use. With AR, the planned component placement can be superimposed to the surgical situs and shown directly in the operating field using a head mounted display. We introduce a new navigation technique using AR via head mounted display for surgical navigation in this feasibility study, aiming to improve and enhance the surgical planning. METHODS: 3D surface models of ten human scapulae were printed from computed tomography (CT) data of cadaver scapulae. Guidewire positioning of the central back of the glenoid baseplate was planned with a dedicated computer software. A hologram of the planned guidewire with dynamic navigation was then projected onto the 3D-created models of the cadaver shoulders. The registration of the plan to the anatomy was realized by digitizing the glenoid surface and the base of the coracoid with optical tracking using a fiducial marker. After navigated placement of the central guidewires, another CT imaging was recorded, and the 3D model was superimposed with the preoperative planning to analyze the deviation from the planned and executed central guides trajectory and entry point. RESULTS: The mean deviation of the ten placed guidewires from the planned trajectory was 2.7° ± 1.3° (95% CI 1.9°; 3.6°). The mean deviation to the planned entry point of the ten placed guidewires measured 2.3 mm ± 1.1 mm (95% CI 1.5 mm; 3.1 mm). CONCLUSION: AR may be a promising new technology for highly precise surgical execution of 3D preoperative planning in RSA.

Suprascapular nerve decompression in addition to rotator cuff repair: a prospective, randomized observational trial.

BACKGROUND: Tear and retraction of the supraspinatus (SS) and infraspinatus (IS) musculotendinous units and/or their repair may be associated with traction damage to the suprascapular nerve, potentially responsible for pain or weakness of the rotator cuff (RC). Arthroscopic release of the transverse scapular ligament at the suprascapular notch has been advocated to prevent or treat suprascapular nerve impairment associated with RC retraction and/or repair. The effect of this procedure on preoperative normal nerve function is, however, not well studied.We hypothesize that (1) decompression of the suprascapular nerve without preoperative pathologic neurophysiological findings will not improve clinical or imaging outcome and (2) suprascapular decompression will not measurably change suprascapular nerve function. METHODS: Nineteen consecutive patients with a magnetic resonance arthrography documented RC tear involving SS and IS but normal preoperative electromyography (EMG)/nerve conduction studies of the SS and IS were enrolled in a prospective, controlled trial involving RC repair with or without suprascapular nerve decompression at the suprascapular notch. Nine patients were randomized to undergo, and 10 not to undergo, a decompression of the suprascapular nerve. Patients were assessed clinically (Constant score, mobility, pain, strength, subjective shoulder value), with magnetic resonance imaging and neurophysiology preoperatively and at 3- and 12-month follow-up. RESULTS: There was no clinically relevant difference between the release and the non-release group in any clinical parameter at any time point. At magnetic resonance imaging, there was a slightly greater increase of fatty infiltration of the IS in the release group without any other differences between the 2 groups. Electromyographically, there were no pathologic findings in the non-release group at any time point. Conversely, 3 of the 9 patients of the release group showed pathologic EMG findings at 3 months, of whom 2 had recovered fully and 1 only partially at 12 months. CONCLUSION: In the presence of normal EMG findings, suprascapular nerve release added to arthroscopic RC repair is not associated with any clinical benefit, but with electromyographically documented, postoperative impairment of nerve function in 1 of 3 cases. Suprascapular nerve release does not therefore seem to be justified as an adjunct to RC repair if preoperative EMG findings document normal suprascapular nerve function. Based on these findings, the ongoing prospective randomized trial was terminated.

p38 MAPK Inhibition Improves Heart Function in Pressure-Loaded Right Ventricular Hypertrophy.

Although p38 mitogen-activated protein kinase (MAPK) is known to have a role in ischemic heart disease and many other diseases, its contribution to the pathobiology of right ventricular (RV) hypertrophy and failure is unclear. Therefore, we sought to investigate the role of p38 MAPK in the pathophysiology of pressure overload-induced RV hypertrophy and failure. The effects of the p38 MAPK inhibitor PH797804 were investigated in mice with RV hypertrophy/failure caused by exposure to hypoxia or pulmonary artery banding. In addition, the effects of p38 MAPK inhibition or depletion (by small interfering RNA) were studied in isolated mouse RV fibroblasts. Echocardiography, invasive hemodynamic measurements, immunohistochemistry, collagen assays, immunofluorescence staining, and Western blotting were performed. Expression of phosphorylated p38 MAPK was markedly increased in mouse and human hypertrophied/failed RVs. In mice, PH797804 improved RV function and inhibited cardiac fibrosis compared with placebo. In isolated RV fibroblasts, p38 MAPK inhibition reduced transforming growth factor (TGF)-ß-induced collagen production as well as stress fiber formation. Moreover, p38 MAPK inhibition/depletion suppressed TGF-ß-induced SMAD2/3 phosphorylation and myocardin-related transcription factor A (MRTF-A) nuclear translocation, and prevented TGF-ß-induced cardiac fibroblast transdifferentiation. Moreover, p38 MAPK inhibition in mice exposed to pulmonary artery banding led to diminished nuclear levels of MRTF-A and phosphorylated SMAD3 in RV fibroblasts. Together, our data indicate that p38 MAPK inhibition significantly improves RV function and inhibits RV fibrosis. Inhibition of p38 MAPK in RV cardiac fibroblasts, resulting in coordinated attenuation of MRTF-A cytoplasmic-nuclear translocation and SMAD3 deactivation, indicates that p38 MAPK signaling contributes to distinct disease-causing mechanisms.

Double plating is a suitable option for periprosthetic distal femur fracture compared to single plate fixation and distal femoral arthroplasty.

Aims: The purpose of this study was to compare reoperation and revision rates of double plating (DP), single plating using a lateral locking plate (SP), or distal femoral arthroplasty (DFA) for the treatment of periprosthetic distal femur fractures (PDFFs). Methods: All patients with PDFF primarily treated with DP, SP, or DFA between 2008 and 2022 at a university teaching hospital were included in this retrospective cohort study. The primary outcome was revision surgery for failure following DP, SP, or DFA. Secondary outcome measures included any reoperation, length of hospital stay, and mortality. All basic demographic and relevant implant and injury details were collected. Radiological analysis included fracture classification and evaluation of metaphyseal and medial comminution. Results: A total of 111 PDFFs (111 patients, median age 82 years (interquartile range (IQR) 75 to 88), 86% female) with 32 (29%) Su classification 1, 37 (34%) Su 2, and 40 (37%) Su 3 fractures were included. The median follow-up was 2.5 years (IQR 1.2 to 5.0). DP, SP, and DFA were used in 15, 66, and 30 patients, respectively. Compared to SP, patients treated with DP were more likely to have metaphyseal comminution (47% vs 14%; p = 0.009), to be low fractures (47% vs 11%; p = 0.009), and to be anatomically reduced (100% vs 71%; p = 0.030). Patients selected for DFA displayed comparable amounts of medial/metaphyseal comminution as those who underwent DP. At a minimum follow-up of two years, revision surgery for failure was performed in 11 (9.9%) cases at a median of five months (IQR 2 to 9): 0 DP patients (0%), 9 SP (14%), and 2 DFA (6.7%) (p = 0.249). Conclusion: Using a strategy of DP fixation in fractures, where the fracture was low but there was enough distal bone to accommodate locking screws, and where there is metaphyseal comminution, resulted in equivalent survival free from revision or reoperation compared to DFA and SP fixation.