Age, Tear Size, Extent of Retraction, and Fatty Infiltration Associated With a High Chance of a Similar Rotator Cuff Tear in the Contralateral Shoulder Regardless of Symptoms in Patients Undergoing Cuff Repair in the Index Shoulder.

PURPOSE: To investigate the prevalence of a contralateral rotator cuff tear (RCT) in patients with a symptomatic RCT requiring repair and to determine whether findings from magnetic resonance imaging (MRI) of the affected shoulder can predict the presence of a contralateral tear. METHODS: Patients with atraumatic RCTs who had undergone arthroscopic repair between March 2019 and February 2021 were reviewed in this study. MRI of both shoulder joints was performed to evaluate the bilaterality of RCT. Demographic factors and MRI findings of index shoulders were assessed using logistic regression analysis to reveal any correlations with the presence of RCT in the contralateral shoulder. RESULTS: A total of 428 patients were enrolled in this study. When the affected shoulders had a posterosuperior rotator cuff (PSRC) or subscapularis tear including either an isolated or combined tear, 63.6% and 67.8% had the same tears on the contralateral side, respectively. A contralateral-side tear was found in 74.6% (185/248) of symptomatic cases and 44.8% (65/145) of asymptomatic cases, which represents a significant difference (P < .001). Logistic regression analysis revealed that age ≥67.5 years, tear size ≥17 mm, Goutallier grade ≥1.5, and Patte grade ≥1.5 were found to be indicative of potential contralateral PSRC tears. By contrast, the presence of a subscapularis tear in the affected shoulder was the only significant risk factor in predicting a potential subscapularis tear in the contralateral shoulder. CONCLUSIONS: Among patients with a symptomatic RCT requiring arthroscopic repair, 63.6% with a PSRC tear and 67.8% with a subscapularis tear in the affected shoulder were found to have a similar tear in the contralateral shoulder regardless of symptoms. Age, tear size, extent of retraction, fatty infiltration of PSRC tears, and the presence of subscapularis tears were identified as factors predictive of tears on the contralateral side. LEVEL OF EVIDENCE: Level IV, case series.

High failure rate after conservative treatment for recurrent shoulder dislocation without subjective apprehension on physical examination.

PURPOSE: The purpose of this study was to investigate the outcomes of conservative treatment for recurrent shoulder dislocation without subjective apprehension, despite the presence of a Bankart lesion or glenoid defect. METHODS: A retrospective analysis was performed for 92 patients with recurrent shoulder dislocation treated with conservative treatment due to negative apprehension between 2009 and 2018. The failure of the conservative treatment was defined as a dislocation or subluxation episode or subjective feeling of instability based on a positive apprehension. The Kaplan-Meier method was used to estimate failure rates over time, and a receiver operating characteristic (ROC) curve was constructed to determine a cut-off value for a glenoid defect. The clinical outcomes were compared between patients who completed conservative treatment without recurrence of instability (Group A) and those who failed and subsequently underwent surgical treatment (Group B) using shoulder functional scores and sports/recreation activity level. RESULTS: This retrospective study included 61 of 92 eligible patients with recurrent shoulder dislocation. Among the 61 patients, conservative treatment failed in 46 (75.4%) over the 2-year study period. The cut-off value for a glenoid defect was 14.4%. The association between glenoid defect size (≥ 14.4% or as a continuous variable) and survival was statistically significant (p = 0.039 and p < 0.001, respectively). The mean glenoid defect size in Group B increased from 14.6 ± 3.0% to 17.3 ± 3.1% (p < 0.001), and clinical outcomes for Group A were inferior to those for Group B at the 24-month follow-up. CONCLUSIONS: Conservative treatment for recurrent shoulder dislocation in patients without subjective apprehension showed a high failure rate during the study period, especially if the glenoid defect was ≥ 14.4% in size. Despite clinical improvement in patients who completed conservative treatment without recurrence, functional outcome scores and sport/recreation activity levels were better in the patients who underwent arthroscopic Bankart repair. Therefore, for recurrent anterior shoulder instability, even without subjective apprehension, surgical treatment is warranted over conservative treatment. LEVEL OF EVIDENCE: Level IV.

Subscapularis tendon tears hidden by the medial biceps sling can be missed on arthroscopic examination.

INTRODUCTION: To investigate (1) the prevalence of "hidden lesions" and "non-hidden lesions" of subscapularis tendon tears requiring repair during arthroscopic examination that would be missed by a 30° arthroscope, but could be identified by a 70° arthroscope, from the standard posterior portal and (2) the correlation of preoperative internal rotation weakness and findings of magnetic resonance imaging (MRI) indicating hidden lesions. MATERIALS AND METHODS: We retrospectively examined 430 patients who underwent arthroscopic subscapularis repair between was initially nonvisible with a 30° arthroscope but became visible only with a 70° arthroscope from the standard posterior portal. The preoperative and intraoperative findings of the hidden lesion group (n = 82) were compared with those of the non-hidden lesion group (n = 348). 2016 and 2020. A hidden lesion was defined as a subscapularis tendon tear requiring repair that preoperative internal rotation weakness was assessed using the modified belly-press test. Preoperative MR images were reviewed using a systemic approach. RESULTS: The prevalence of hidden lesions was 19.1% (82/430). No significant difference was found in preoperative internal rotation weakness between the groups. Preoperative MRI showed a significantly lower detection rate in the hidden lesion group than in the non-hidden group (69.5% vs. 84.8%; P = 0.001). The hidden lesions were at a significantly earlier stage of subscapularis tendon tears than the non-hidden lesions, as revealed by the arthroscopic findings (Lafosse classification, degree of retraction; P = 0.003 for both) and MR findings (muscle atrophy, fatty infiltration; P = 0.001, P = 0.005, respectively). CONCLUSIONS: Among the subscapularis tears requiring repair, 19.1% could be identified by a 70° arthroscope, but not by a 30° arthroscope, through the posterior portal. The hidden lesions showed a significantly lower detection rate on preoperative MRI than the non-hidden lesions. Thus, for subscapularis tears suspected on preoperative physical examination, the 70° arthroscope would be helpful to avoid a misdiagnosis.

Comparison of arthroscopic primary and revision Bankart repair for capsulolabral restoration: a matched-pair analysis.

INTRODUCTION: There have been no previous studies comparing serial radiologic results between primary and revision Bankart repair despite the significance of capsulolabral height and slope restoration. The purpose of this study was (1) to compare serially the height and slope of the repaired labrum in the early postoperative period among primary and revision Bankart repair groups, and (2) to compare clinical outcomes between the two groups. MATERIALS AND METHODS: This study included each 24 patients who underwent arthroscopic primary Bankart repair (Group A) and revision Bankart repair (Group B) matched by age, sex, and glenoid defect ratio. Postoperative serial radiologic assessment of the repaired labral height and slope was proceeded using magnetic resonance imaging (MRI) or computed tomographic arthrography (CTA) at 3 weeks and 6 months. RESULTS: There were no significant differences in labral height and slope at 3 weeks and 6 months postoperatively in Group A. However, significant reductions in labral height and slope were evident between 3 weeks and 6 months postoperatively in Group B (P < 0.05). Group A yielded superior results to Group B with respect to labral height and slope at each time point (P < 0.05) in between-group analyses. The clinical outcomes were not significantly different between the two groups except for the patients' return to their premorbid sports activity level (P = 0.024). CONCLUSIONS: The height and slope of the repaired capsulolabral structures in the early postoperative period after arthroscopic revision Bankart repair group were significantly lower than those of the primary Bankart repair group. Also the reduction of labral height and slope was significant in the revision Bankart repair group over time. Nonetheless, clinical outcomes did not differ significantly except return to premorbid sports activity level at final follow-up.

Does an "Off-Track" Hill-Sachs Lesion That Is Misclassified as "Non-Engaging" Affect Outcomes From Bankart Repair Alone Compared With Bankart Repair Combined With Remplissage?

PURPOSE: To determine how intraoperative assessment (engagement test) may affect recurrent dislocation rate and to compare the clinical outcomes, recurrence rates, and presence of on-/off-track conditions between cases that received arthroscopic Bankart repair alone (nonengaged Hill-Sachs lesion) and Bankart repair with remplissage (engaged Hill-Sachs lesion). METHODS: We retrospectively reviewed 213 patients who underwent arthroscopic Bankart repair alone (186 patients with nonengaging lesions, group A) or with remplissage (27 patients with engaging lesion, group B) for recurrent anterior shoulder instability with <25% glenoid bone defect. The presence of an engaging Hill-Sachs lesion was determined during arthroscopic evaluation. On-track or off-track lesions were assessed retrospectively from preoperative 3-dimensional (3D) computed tomography (CT). RESULTS: Mean glenoid bone defect was 13.7% in group A and 20.7% in group B (P < .001). Off-track lesions were identified in 8.1% (15/186) and 100% (27/27) in group B. At the final follow-up (minimum 2 years; mean follow-up periods after surgery of 50.1 months in group A and 47.7 months in group B), there were no significant differences in shoulder functional scores and recurrence rates between groups, despite improvement after surgery. In the off-track lesion (group A-1: nonengaging but off-track lesion), recurrence instability occurred in 9 patients (60%, 9/15). Also, comparing group A-1 and group B, we noted significant differences in shoulder functional scores and recurrence rates (P < .001). CONCLUSION: Of 186 patients, 8.1% with nonengaging Hill-Sachs lesions during direct arthroscopic examination under anesthesia actually demonstrated off-track lesions on preoperative 3D CT scans retrospectively, with 60% experiencing recurrent instability. Intraoperative manual assessment for Hill-Sachs engagement was inferior to 3D CT scan in establishing the presence of off-track defects. LEVEL OF EVIDENCE: III, retrospective comparative study.

Subscapularis re-tears associated with preoperative advanced fatty infiltration and greater subscapularis involvement, leading to inferior functional outcomes and decreased acromiohumeral distance.

PURPOSE: This study aimed to investigate the influence of repaired subscapularis integrity on midterm results for anterosuperior massive rotator cuff tears (MRCTs) treated with partial rotator cuff repair. METHODS: This study included 57 patients who underwent arthroscopic partial repair for an anterosuperior MRCT. They were assigned to the healed subscapularis group (Group H 37 patients) or subscapularis re-tear group (Group R 20 patients). Preoperative and postoperative functional scores and active ranges of motion (ROMs) were assessed. Preoperative and 6-month follow-up magnetic resonance arthrography (MRA)/computed tomography arthrography (CTA) images were compared between groups. RESULTS: At the final follow-up, mean functional shoulder scores including ROMs improved significantly in both groups compared to preoperative values (p < 0.001), except for forward flexion and internal rotation in Group R. All final functional values and ROMs (excluding external rotation) were better in Group H than in Group R (p < 0.001). Preoperative stage of fatty infiltration in the subscapularis muscle was significantly worse in Group R (p < 0.001). On follow-up MRA/CTA, the immediate residual defect after partial repair increased in 81% (30/37; mean, 17.8 mm) of patients in Group H and 100% (mean 24.6 mm) in Group R (p < 0.001). At final follow-up, mean acromiohumeral distance significantly decreased from 8.2 to 6.0 mm in Group H (p < 0.001) and from 8.3 to 4.9 mm in Group R (p < 0.001). There was a significant difference in final acromiohumeral distance between groups (p < 0.001). CONCLUSION: After a minimum 5-year follow-up after arthroscopic partial repair of anterosuperior MRCT, subscapularis re-tear was identified in 35% of patients (20/57) on early postoperative follow-up MRA/CTA. The subscapularis re-tear group exhibited more preoperative advanced fatty infiltration and greater extents of subscapularis involvement, which led to statistically inferior functional outcomes and decreased acromiohumeral distance at final follow-up. Nonetheless, in terms of a minimal clinically important difference, substantial clinical benefit, and patient-acceptable symptomatic state for clinical significance, there were no significant differences between the groups. LEVEL OF EVIDENCE: III.

Anterior rotator cable disruption does not affect outcomes in rotator cuff tear with subscapularis involvement.

PURPOSE: The purpose of this study was to compare clinical and radiological outcomes after arthroscopic repair of two different rotator cuff tear configurations: anterosuperior rotator cuff tear and rotator cuff tears with subscapularis involvement. It was hypothesized that, although both tear configurations would show significant improvement in clinical outcomes after arthroscopic repair, the rotator cuff tears with subscapularis involvement where the anterior rotator cable maintains its integrity would have better clinical outcomes and structural integrity. METHODS: This study included 226 patients who underwent arthroscopic repair of anterosuperior rotator cuff tears (n = 107, group A) and rotator cuff tears with subscapularis involvement (n = 119, group B). The visual analog scale (VAS) pain score, subjective shoulder value (SSV), American Shoulder and Elbow Surgeons (ASES) score, University of California at Los Angeles (UCLA) shoulder score, and active range of motion (ROM) were assessed. Modified belly press test was performed to assess the strength of the subscapularis muscle. Cuff integrity was evaluated using magnetic resonance arthrography or computed tomographic arthrography at 6 months after operation. RESULTS: At 3-year follow-up, the VAS score, SSVs, ASES scores, UCLA shoulder scores, active ROM, and modified belly press test showed significant improvement in both groups (p < 0.001). However, these improvements showed no statistical significance between the two groups. On follow-up radiologic evaluations, no significant difference in re-tear rates between group A (25 of 107, 23.4%) and group B (23 of 119, 19.3%) was observed. CONCLUSIONS: The presence of anterior cable involvement of the anterosuperior rotator cuff tear did not affect postoperative clinical outcomes and re-tear rate compared to rotator cuff tears with subscapularis involvement where the anterior cable integrity was maintained, although the anterosuperior rotator cuff tear was associated with more significant preoperative supraspinatus fatty infiltration. Therefore, the present study determined that it would not be necessary to differentiate treatment protocols between these patterns. LEVEL OF EVIDENCE: Level III.

Arthroscopic gel-type autologous chondrocyte implantation presents histologic evidence of regenerating hyaline-like cartilage in the knee with articular cartilage defect.

PURPOSE: To investigate the clinical, radiological, and histological results of arthroscopic gel-type autologous chondrocyte implantation (GACI) in treating chondral defects of the knee. METHODS: This study prospectively examined five males and five females with a mean age of 40.3 ± 10.3 years who underwent arthroscopic GACI between March 2012 and February 2013. The gel comprised a mixture of 1 ml of fibrinogen plus 0.1-0.2 ml of thrombin. The mean size of chondral defect was 2.9 ± 1.2 cm2 (range 1.2-5.4 cm2). International knee documentation committee (IKDC) subjective score, knee injury and osteoarthritis outcome score (KOOS), knee society score, and visual analog scale (VAS) for pain were assessed preoperatively and during regular follow-up examinations performed for up to 5 years postoperatively. Serial magnetic resonance imaging was performed for up to 2 years after the surgery to observe healing, using the modified magnetic resonance observation of cartilage repair tissue (MOCART) score. In eight patients, second-look arthroscopy was performed at 1 year after the implantation to assess the status of treated cartilage, and a portion of regenerated cartilage was harvested for histologic evaluation. RESULTS: The mean VAS score (p = 0.045), IKDC subjective score (p = 0.041), KOOS pain (p = 0.025), KOOS activities of daily living (p = 0.048), and KOOS quality of life (p = 0.029) showed significant improvement at 5 years after the surgery. The modified MOCART evaluation showed that the scores were 59.5 ± 29.4 and 85.0 ± 8.0 at 12 weeks and 2 years after the operation, respectively. Histologic examination demonstrated a mean regenerated cartilage thickness of 3.5 ± 0.8 mm and a mean Oswestry score of 8.2 ± 1.8. Immunohistochemistry analysis showed that the expression of collagen type II was more evident and more evenly distributed than collagen type I in regenerated cartilage. There was a significant correlation between Oswestry score and change in VAS scale from postoperative 2-5 years. CONCLUSIONS: Arthroscopic GACI produces satisfactory clinical and radiologic outcomes, and histologic evaluation confirms sufficient regeneration of hyaline-like cartilage that correlates with improved symptoms. Therefore, it is an acceptable, minimally invasive, and technically simple option for the restoration of cartilage defects of the knee. LEVEL OF EVIDENCE: IV.

An intact subscapularis tendon and compensatory teres minor hypertrophy yield lower failure rates for non-operative treatment of irreparable, massive rotator cuff tears.

PURPOSE: To investigate whether subscapularis integrity and compensatory teres, minor hypertrophy is associated with maintaining relatively good function and tolerable pain levels during non-operative treatment. METHODS: This study included 108 patients with irreparable, massive rotator cuff tears involving at least two tendons and stage III or IV muscle hypotrophy and fatty infiltration on oblique sagittal magnetic resonance imaging, in which even a partial repair does not seem feasible. All supraspinatus and infraspinatus muscles were grade IV; if the subscapularis was involved, only stage III or IV was included. Patients were divided into two groups: group A consisted of 67 patients with both an intact subscapularis and teres minor hypertrophy; group B consisted of 41 patients lacking either one or both. The Visual Analogue Scale pain score, the American Shoulder and Elbow Surgeons score, the University of California at Los Angeles shoulder score, and active range of motion (ROM) were assessed. RESULTS: During the follow-up period, failure of non-operative treatment was found in 29 (43%) patients in group A and 28 (68%) in group B (p = 0.012). Conversion to surgery was noted in 26 (39%) patients in group A and 27 (66%) in group B (p = 0.006). Among the remaining nonsurgical patients, there were no significant differences in clinical outcomes between the groups except ROM in internal rotation at final follow-up. CONCLUSIONS: Although conservative treatment was not always successful in patients with irreparable, massive cuff tears, patients with both an intact subscapularis tendon, and teres minor hypertrophy experienced significantly lower incidences of failure and conversion to surgery, since force couple is maintained in the setting of minimal arthritis. LEVEL OF EVIDENCE: III.

Attrition of rotator cuff without progression to tears during 2-5 years of conservative treatment for impingement syndrome.

PURPOSE: The purpose of this study was to investigate the natural history of intact rotator cuff in impingement syndrome patients with concomitant spur protruding from the undersurface of acromion. METHODS: This retrospective study included 119 patients with an intact rotator cuff who underwent conservative treatment for a spur protruding from the undersurface of the acromion. The protruded spur was defined as a trapezoid- or tetragon-shaped bony protrusion with a downward peak extending more than 3 mm in length from the baseline drawn along the acromial undersurface on the coronal view of magnetic resonance imaging (MRI) or computed tomography arthrography (CTA). Functional outcomes were evaluated by the visual analogue scale for pain, subjective shoulder value, American Shoulder and Elbow Surgeons score, University of California Los Angeles shoulder score, and active range of motion (ROM). To evaluate cuff integrity, follow-up MRI, CTA, or ultrasound were performed at least 2 years after the initial presentation. RESULTS: No new rotator cuff tears were noted in any patient during the follow-up imaging studies. However, 18 patients (15%) underwent arthroscopic acromioplasty during the study period. During the arthroscopic examinations, moderate to severe attrition of the cuff was identified, although no tears were seen. At the final follow-up, pain level and shoulder function, including ROM, showed satisfactory outcomes. CONCLUSION: Spurs protruding from the acromial undersurface did not lead to rotator cuff tears during 2-5 years of conservative treatment. However, attrition of the rotator cuff was found during arthroscopic acromioplasty, suggesting that the protruding spurs caused extrinsic impingement of the cuff. LEVEL OF EVIDENCE: Therapeutic case series Level IV.

A case report of multiple cervical artery dissection after peripheral type facial palsy and use of steroids.

BACKGROUND: Cervical artery dissection is one of the most important causes of ischemic stroke in young age patients. However, multiple cervical artery dissection simultaneously involving the anterior and posterior circulation is uncommon. Here, we would like to report a case of a patient with bilateral vertebral artery (VA) and internal carotid artery dissection (ICA) after a use of systemic steroid due to peripheral facial palsy. CASE PRESENTATION: A 44-year-old man with hypertension visited emergency department due to recurrent vertigo. He was receiving methyl prednisolone for two weeks for the treatment of right peripheral type facial palsy which occurred after retro-orbital headache. Neurologic examination revealed severe ataxia at left side. Sensory for pain and temperature was declined in the right arm and leg. Diffusion-weighted image showed an acute ischemic lesion at the whole territory of posterior-inferior cerebellar artery. Severe stenosis was observed from bilateral VAs and ICAs on conventional magnetic resonance angiography. Intramural hematoma and intimal flap was observed from the high-resolution MRI. CONCLUSIONS: Peripheral type facial palsy is an unusual presentation of carotid dissection. Steroids aggravate arterial dissection by increasing blood pressure and blood vessel fragility by its negative effect on connective tissue strength. Use of steroid in patients with peripheral type facial palsy with severe headache may need caution.

Clinical outcomes of minimally invasive open reduction and internal fixation by screw and washer for displaced greater tuberosity fracture of the humerus.

BACKGROUND: The purpose of this study was to investigate clinical and radiologic outcomes of open reduction and internal fixation with a screw and washer for a displaced greater tuberosity fracture of the proximal humerus through a small incision. METHODS: We retrospectively reviewed 29 patients who underwent open reduction and internal fixation with a screw and washer for a greater tuberosity fracture of the proximal humerus. After surgery, the patients were immobilized in a brace for 4 weeks. To determine clinical outcomes, we evaluated a visual analog scale pain score; the Subjective Shoulder Value; the University of California, Los Angeles shoulder score; the American Shoulder and Elbow Surgeons score; and active range of motion. RESULTS: All patients achieved bone union within 3 months after surgery. At the 2-year follow-up, the mean visual analog scale pain score was 1.1 ± 1.1; Subjective Shoulder Value, 93.4 ± 5.3; University of California, Los Angeles shoulder score, 31.2 ± 2.7; and American Shoulder and Elbow Surgeons score, 92.6 ± 6.7. Mean active forward flexion, external rotation, and internal rotation were 144° ± 16°, 33° ± 11°, and 13.3 ± 1.7, respectively. Postoperatively, 9 patients (31%) had stiffness and pain refractory to conservative treatment and underwent arthroscopic release. CONCLUSION: Although minimal open reduction and screw and washer fixation resulted in bone union in all cases, the incidence of postoperative stiffness was relatively high in patients with displaced greater tuberosity fractures because of prolonged immobilization after surgery.

Congruent Concavity Restoration of the Reconstructed Glenoid After the Latarjet Procedure: Compensation for the Position of the Graft.

BACKGROUND: Few clinical studies have addressed concavity restoration by natural remodeling after a Latarjet procedure. This study investigated the fibrous tissue and osseous remodeling of the reconstructed glenoid and concavity restoration after a Latarjet procedure using postoperative computed tomographic arthrography (CTA). METHODS: This retrospective study included 31 patients who underwent immediate postoperative computed tomographic (CT) scanning followed by CTA at 6 months postoperatively. We investigated whether fibrous tissue was newly created over the graft, whether the created fibrous tissue restored the congruity of the articular surface and the osseous remodeling of the graft to the glenoid level (whether the osseous portion of the graft was remodeled flush to the glenoid level) and the concavity of the glenoid using the radius of a best-fit circle on the articular surface, and the relationship between the amount of created fibrous tissue and the position of the graft. RESULTS: In all patients, the fibrous tissue on the graft yielded a smooth articular surface, as revealed by the CTA. The mean radius of the entire glenoid, including the transferred graft, was significantly smaller (p = 0.010) at 33.2 ± 8.5 mm than that of the glenoid posterior to the osseous step-off at 37.6 ± 9.4 mm, which is presumed to be the glenoid before the surgical procedure. Despite the congruity of the articular surfaces due to fibrous tissue seen in the CTA, 14 (45%) of 31 patients showed a subchondral osseous step-off on either the medial side or the lateral side in the immediate postoperative CT scans. However, through osseous remodeling, 8 of the 10 grafts with a lateral step-off and 2 of the 4 grafts with a medial step-off converted to a flush position. The position of the step-off was correlated with the thickness of the fibrous tissue, with a tendency for thicker tissue in cases of a step-off on the medial side (p = 0.014). CONCLUSIONS: Fibrous tissue formation plus remodeling of the transferred graft resulted in the restoration of a congruent concavity after a Latarjet procedure by compensating for initially non-flush positioning of the graft. However, due to the small sample size in our study, clinical outcomes could not be correlated with radiographic findings, and our recommendation is to continue placing the graft as anatomically as possible. LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Heated Tobacco Products Have Detrimental Effects on Rotator Cuff Healing, Similar to Conventional Cigarettes.

BACKGROUND: Cigarette smoking impairs rotator cuff healing, but no study, to our knowledge, has focused on the association between heated tobacco products and rotator cuff tears. METHODS: This study retrospectively investigated 1,133 patients who underwent arthroscopic repair of symptomatic rotator cuff tears between March 2011 and April 2021. Patients were grouped on the basis of their smoking patterns as nonsmokers, cigarette smokers, and heated tobacco smokers. Propensity score matching was used to reduce selection bias, and 45 subjects were selected from each group via 1:1:1 matching. Functional scores and active range of motion were compared among the 3 groups preoperatively and at a 2-year follow-up. Postoperative magnetic resonance imaging was performed 6 months after the surgical procedure to assess structural integrity. RESULTS: Except for sex, similar baseline characteristics were achieved after propensity score matching. There were no differences in the clinical scores or range of motion between the matched groups either preoperatively or at the 2-year follow-up. However, the retear rate for the matched nonsmoker group was significantly lower (8.9%) than those for the matched cigarette smoker group (31.1%) and the heated tobacco smoker group (28.9%) (p = 0.022). Multivariable logistic regression analysis revealed that the retear rates were 3.403 times higher for the cigarette smoker group and 3.397 times higher for the heated tobacco smoker group than that for the nonsmoker group. CONCLUSIONS: Heated tobacco users, like conventional cigarette smokers, have worse clinical outcomes with respect to rotator cuff healing than nonsmokers. Regardless of the type of cigarette, abstinence from smoking is necessary for patients undergoing rotator cuff repair surgery. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Optimal immobilization position for conservative treatment of proximal humerus fractures by fracture type: a biomechanical cadaveric study.

In conservative treatment for proximal humerus fractures (PHFs), the immobilization position of the affected arm should not be determined uniformly. The aim of this study is to investigate the optimal immobilization position for conservative treatment of different types of PHFs. We hypothesized that the optimal position minimizing the deforming force in PHFs depends on the fracture components involved. PHF models involving either the surgical neck (SN) or greater tuberosity (GT) were created using 12 fresh-frozen cadaveric shoulders. In the SN model, the deforming forces on the pectoralis major muscle were measured in full adduction by increasing external rotation. In the GT model, the deforming force of the supraspinatus muscle was measured in neutral rotation by decreasing abduction, and the deforming force of the infraspinatus muscle was measured in full adduction by increasing internal rotation, respectively. In the SN model, the deforming force of the pectoralis major muscle increased significantly with external rotation from full internal rotation to neutral rotation (P = 0.006), indicating that the arm should be placed in full internal rotation. In the GT model, the deforming force of the supraspinatus muscle increased significantly with adduction from 45° of abduction to full adduction (P = 0.006); the deforming force of the infraspinatus muscle increased significantly with internal rotation from neutral rotation to full internal rotation (P = 0.006). These findings should be considered when placing the arm in abduction and neutral rotation so as to minimize the deforming force by either the supra or infraspinatus muscle. In conservative treatment for PHFs, the affected arm should be placed in a position that minimizes the deforming force on the fracture components involved.

The Treatment of Periprosthetic Fracture Revision of the Humerus with "Bamboo Support" Structural Allograft Technique-Atrophic Non-Union of a Post-Operative Periprosthetic Fracture after Reverse Total Shoulder Arthroplasty: A Case Report.

Periprosthetic fractures are a serious complication of joint replacement surgery. With the growing prevalence of reverse total shoulder arthroplasty (RTSA), the incidence of relatively uncommon periprosthetic humeral fractures has increased. Here, we present the unique case of a 74-year-old woman who developed atrophic non-union after plate osteosynthesis for a periprosthetic fracture associated with RTSA. Fixation failure was evident 3 months after the surgical intervention; the patient underwent a 3-month course of arm sling immobilization. However, bone resorption continued, and varus angulation of the fracture developed. In this case, surgical strategy involved the use of long proximal humerus internal locked system plate (DePuy Synthes, Paoli, PA, USA), augmented with autologous iliac bone graft and allogenic humerus structural bone graft with the "bamboo support technique", fixed with Cable System (DePuy Synthes, Paoli, PA, USA). No reports have addressed the management of failed periprosthetic fractures using allogeneic humeral strut bone grafts. This report aims to fill the gap by presenting a novel surgical technique for the management of periprosthetic fractures associated with RTSA in case of treatment failure.

Comparing the Biomechanical Stability of Cerclage Cable with Plate Insert Versus Locking Screw in Periprosthetic Humeral Fracture.

BACKGROUND: In the setting of periprosthetic humeral fractures, the humeral stem of the implant represents a substantial challenge to the optimal method of proximal fixation. This study aimed to compare the initial biomechanical stability provided by cerclage cables with a locking plate insert versus bicortical locking screws (i.e., the gold standard for fixation) in fresh cadaveric humeri. METHODS: After calculating the sample size, we utilized 10 sets of cadaveric specimens and created a 5-mm osteotomy gap 120 mm distal to the tip of the greater tuberosity, simulating a Wright and Cofield type-B periprosthetic humeral fracture on each specimen. Using 3 locking screws for distal fragment fixation, identical in all specimens, the specimens were assigned to Group A (3 cerclage cables with a plate insert) or Group B (3 locking bicortical screws) for proximal fragment fixation. Biomechanical tests included stiffness in varus and valgus bending, torsion, and axial compression, and a single load to failure. RESULTS: No significant differences were observed in the biomechanical metrics between the 2 groups. CONCLUSIONS: Our study revealed that fixation with use of cerclage cables with a plate insert demonstrated biomechanical stability comparable with that of bicortical locking screw fixation when addressing the proximal fragment in Wright and Cofield type-B periprosthetic humeral fractures. CLINICAL RELEVANCE: For proximal fragment fixation of periprosthetic humeral fractures, cerclage cables with a plate insert can be utilized as an effective fixation method that offers initial fixation strength that is comparable to the use of 3 locking bicortical screws.

Efficacy of combined osteotomy and ulnar nerve transposition for cubitus valgus with ulnar nerve palsy in adults.

BACKGROUND: Tardy ulnar nerve palsy is a common late complication of traumatic cubitus valgus deformity. Whether both problems can be corrected together, safely and effectively, in a single surgical procedure remains unknown. QUESTIONS/PURPOSES: We therefore reviewed a patient cohort having this combined surgery and compared preoperatively and at a minimum of 24 months postoperatively (1) active elbow ROM; (2) radiographic correction of the cubitus valgus deformity of the preoperative and postoperative humerus-elbow-wrist angles and the medial prominence index; (3) ulnar nerve function through grip strength and static two-point discrimination; and (4) overall upper limb disability by the DASH score. METHODS: Between 2004 and 2009, 13 patients who had traumatic cubitus valgus deformities and tardy ulnar nerve palsy (Dellon's Grade III) were treated with simultaneous supracondylar dome osteotomy and anterior transposition of the ulnar nerve and were reviewed retrospectively. The minimum followup was 24 months (mean, 33 months; range, 24-52 months). RESULTS: The mean preoperative ROM was 16° to 124° and mean postoperative ROM was 10° to 126°. All osteotomies healed uneventfully. The mean postoperative humerus-elbow-wrist angle was 11° and the average correction was 24°. None of the patients had recurrence of the deformity or residual prominence of the medial condyle at the last followup. The mean grip strength and static two-point discrimination improved from 20 kg of force and 6.9 mm to 27 kg of force and 4.0 mm (p=0.002 and p=0.004, respectively). Subjective ulnar nerve symptoms improved in all but one patient. The mean DASH score improved from 29 points to 16 points (p=0.001). CONCLUSION: A combined supracondylar dome osteotomy and anterior transposition of the ulnar nerve is effective in correcting posttraumatic cubitus valgus deformity and its associated ulnar nerve palsy. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Effect of cigarette smoking on the maintenance of reduction after treatment of acute acromioclavicular joint dislocation with hook plate fixation.

BACKGROUND: The purpose of this study was to determine the association between smoking and clinical outcomes of hook plate fixation for acute acromioclavicular (AC) joint injuries. METHODS: This study retrospectively investigated 82 patients who underwent hook plate fixation for acute AC joint dislocation between March 2014 to June 2022. The patients were grouped by smoking status, with 49 in group N (nonsmokers) and 33 in group S (smokers). Functional scores and active range of motion were compared among the groups at the 1-year follow-up. Coracoclavicular distance (CCD) was measured, and difference with the uninjured side was compared at initial injury and 6 months after implant removal. RESULTS: No significant differences were observed between the two groups in demographic factors such as age and sex, as well as parameters related to initial injury status, which included time from injury to surgery, the preoperative CCD difference value, and the Rockwood classification. However, the postoperative CCD difference was significantly higher in group S (3.1±2.6 mm) compared to group N (1.7±2.4 mm). Multivariate regression analysis indicated that smoking and the preoperative CCD difference independently contributed to an increase in the postoperative CCD difference. Despite the radiographic differences, the postoperative clinical outcome scores and active range of motion measurements were comparable between the groups. CONCLUSIONS: Smoking had a detrimental impact on ligament healing after hook plate fixation for acute AC joint dislocations. This finding emphasizes the importance of smoking cessation to optimize reduction maintenance after AC joint injury. Level of evidence: III.

Disagreement Between the Accepted Best-Fit Circle Method to Calculate Bone Loss Between Injured and Uninjured Shoulders.

BACKGROUND: No study has evaluated whether best-fit circles based on glenoids with defects accurately represent normal inferior glenoids before injury. PURPOSE: To investigate whether the best-fit circles on the affected side with a glenoid defect can accurately represent native glenoids before injury. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: This retrospective study included 58 patients with unilateral recurrent anterior shoulder instability. First, we compared the diameter of best-fit circles based on affected and unaffected glenoids. Glenoid defect sizes based on each best-fit circle were then calculated and compared. Second, we created serial virtual glenoid defects (10%, 15%, 20%, 25%) on unaffected glenoids and compared diameters of best-fit circles on the glenoids before and after virtual defects. We also analyzed and compared the size of virtual and calculated glenoid defects. Bland-Altman plots and intraclass coefficients (ICCs) were used to compare and analyze agreement of measurements. After categorization of glenoid defects based on clinical cutoff values, Cohen κ and percentage agreement were calculated. RESULTS: The diameter of 55.2% (32/58) of best-fit circles from affected glenoids over- or underestimated the diameter on the unaffected side by >5%. In 28 of the 32 patients, the diameter of the affected side circle was overestimated. Consequently, 41.4% (24/58) of glenoid defects were over- or underestimated by >5%. In 19 of the 24 patients, the glenoid defect from the affected side was >5% larger. ICCs between sides for best-fit circle diameters and defect sizes were 0.632 and 0.800, respectively. Agreement of glenoid defect size between sides was 58.6% (34/58) overall, but when the defect was ≥10%, agreement decreased to 32.3% (10/31). Among 232 glenoids with virtual defects created from 58 normal glenoids, the diameter of 31.0% (72/232) of best-fit circles and the size of 11.6% (27/232) of defects were over- or underestimated by >5%. CONCLUSION: When assessing glenoid defects in anterior shoulder instability, best-fit circles based on affected glenoids do not always represent the native glenoid and may thus lead to inaccurate circle sizes and defect estimates.