Difficulty in performing activities of daily living associated with internal rotation after reverse total shoulder arthroplasty.

BACKGROUND: Reverse total shoulder arthroplasty (RSA) is a widely accepted treatment for irreparable massive rotator cuff tear (mRCT) and cuff tear arthropathy (CTA), but its impact on activities of daily living (ADLs) remains unclear. METHODS: We retrospectively analyzed 77 patients (age range, 54-87 years; follow-up range, 36.1-120.3 months) with irreparable mRCT and CTA treated by medialized RSA between 2008 and 2015. Ten activities considered essential for daily living were selected and scored from 0 to 3. RESULTS: The mean visual analog scale scores during motion and University of California at Los Angeles and Constant scores significantly improved at final follow-up (all P < .001). Active forward flexion, external rotation at the side, and internal rotation to the posterior (IRp) were 92.5%, 79.6%, and 48.4% of the contralateral side, respectively, at final follow-up. Active forward flexion and external rotation at the side recovered within 6 months after surgery, similar to the level at final follow-up, but IRp did not reach the preoperative status until final follow-up. ADLs with mean scores of less than 2.0 at final follow-up were "wash the opposite shoulder," "wash the opposite axilla," "use a back pocket," "manage the toilet," and "wash the back" (only 36.4% of patients were able to wash their back at final follow-up). CONCLUSIONS: RSA for irreparable mRCT and CTA showed satisfactory clinical outcomes. However, IRp was associated with a limited range compared with the other shoulder motions; therefore, all ADLs associated with internal rotation demonstrated lower recovery rates than expected.

Rapidly destructive arthropathy of shoulder joint.

BACKGROUND: Rapidly destructive arthropathy (RDA) of the shoulder is rare. Consequently, there are very few studies that have reported the characteristic findings of this disease. This study aimed to analyze the clinical, radiographic, and histologic features of patients with RDA of the shoulder. METHODS: In total, 9 cases (8 patients) were enrolled in this study. All patients were elderly women, with a mean age of 72.7 years (range, 57-78 years). The mean duration of symptoms was 4.1 months (range, 1.2-5.9 months). Reverse total shoulder arthroplasty and total shoulder arthroplasty were performed in 5 cases with massive rotator cuff tears and 4 without them, respectively. RESULTS: The mean duration of radiologically evident joint destruction after negative results on radiography was 3.1 months (range, 1.0-5.9 months). On plain radiography, humeral head flattening and collapse that appeared like cut grass were observed (100%). Relatively good preservation of the glenoid with a normal joint space was observed in 7 cases, whereas glenoid erosion was observed in 2 (22.2%). T1-weighted magnetic resonance imaging showed a subchondral fracture (100%) of low signal intensity with associated bone marrow edema. Histologically, chronic inflammation of the synovium and osteocytes in the lacunae, as well as callus formation, were observed along the subchondral fracture. CONCLUSION: Flattening and collapse of the humeral head within an average of 4 months of symptom onset are characteristic of RDA of the shoulder. Bone marrow edema, joint effusion, and subchondral fracture on magnetic resonance imaging and fracture fragments and callus formation on histopathologic analysis were observed. Glenoid erosion was observed in 2 cases with arthrosis progression.

Hematologic profile in reverse total shoulder arthroplasty: perioperative and postoperative blood loss.

BACKGROUND: Few studies have investigated the amount of blood loss during reverse total shoulder arthroplasty (RTSA). The purpose of this study was to investigate blood loss in patients who underwent RTSA for massive irreparable rotator cuff tear (MIRCT) using the hemoglobin (Hb) balance method and total Hemovac amount and to identify predictors of blood transfusion in these patients. METHODS: We retrospectively reviewed 121 patients who underwent RTSA for MIRCT. The mean age was 71.2 ± 6.9 years, and 75 were women. Age, sex, body mass index, use of anticoagulants, American Society of Anesthesiologists physical status score, comorbidities (eg, hypertension, diabetes mellitus, cerebrovascular accident), preoperative Hb level, preoperative hematocrit level, preoperative prothrombin time/international normalized ratio, use of cement, and operative time were evaluated as values predicting blood transfusion. RESULTS: The overall blood loss was 846.6 ± 527.6 mL, which included 346 ± 231.2 mL of intraoperative blood loss and 500.3 ± 196.4 mL of postoperative blood loss. Values predicting blood transfusion were a lower preoperative Hb level (P < .001), hematocrit level (P < .001), hypertension (P = .018), and cerebrovascular accident (P = .008). Receiver operating characteristic analysis identified the following cutoff values for predicting transfusion: preoperative Hb level of 13.5 g/dL (90.3% sensitivity) and hematocrit of 40% (90.3% sensitivity). CONCLUSIONS: RTSA for MIRCT is associated with blood loss during and after surgery. The amount of blood loss should be noted, and blood transfusion could be predicted by calculating the blood loss and predictive values. Lower preoperative Hb level, hematocrit, hypertension, and cerebrovascular accident are predictors of blood transfusion. Blood transfusion should be considered if a patient with preoperative Hb level <13.5 g/dL and hematocrit <40% has a history of hypertension or cerebrovascular accident.

Bearing Dislocation and Progression of Osteoarthritis After Mobile-bearing Unicompartmental Knee Arthroplasty Vary Between Asian and Western Patients: A Meta-analysis.

BACKGROUND: Implant survivorship is reported to be lower and complications, particularly bearing dislocation, are reported to be more frequent in Asian than in Western patients with medial knee osteoarthritis (OA) undergoing Oxford® Phase III unicompartmental knee arthroplasty (UKA). To date, however, these complications have not been compared between these groups of patients. QUESTIONS/PURPOSES: The purpose of this study was to perform a meta-analysis comparing the standardized incidence rates of (1) all-cause reoperation; (2) reoperation related to bearing dislocation; and (3) reoperation related to progression of lateral compartment arthritis in Asian and Western patients with medial knee OA who underwent Oxford Phase III UKA. METHODS: We searched MEDLINE® (January 1, 1976, to May 31, 2017), EMBASE® (January 1, 1985, to May 31, 2017), and the Cochrane Library (January 1, 1987, to May 31, 2017) for studies that reported complications of Oxford Phase III UKAs. Studies were included if they reported reoperation rates attributable to bearing dislocation and/or progression of lateral knee OA after surgery with this implant. Twenty-seven studies were included in this systematic review and 16 studies with followups > 5 years were included in the meta-analysis. These rates were converted to standardized incidence rate (that is, reoperations per 100 observed component years) based on mean followup and number of involved knees in each study. After applying prespecified inclusion and exclusion criteria, the studies were categorized into two groups, Asian and Western, based on hospital location. Twenty-five studies, containing 3152 Asian patients and 5455 Western patients, were evaluated. Study quality was assessed by the modified Coleman Methodology score (MCMS). Although all studies were Level IV, their mean MCMS score was 66.92 (SD, 8.7; 95% confidence interval [CI], 63.5-70.3), indicating fair quality. Because the heterogeneity of all subgroup meta-analyses was high, a random-effects model was used with estimations using the restricted maximum likelihood method. RESULTS: There was no difference in the proportion of Asian patients versus Western patients undergoing reoperation for any cause calculated as 100 component observed years (1.022 of 3152 Asian patients; 95% CI, 0.810-1.235 versus 1.300 of 5455 Western patients; 95% CI, 1.067-1.534; odds ratio, 0.7839; 95% CI, 0.5323-1.1545; p = 0.178). The mean reoperation rate attributable to bearing dislocation per 100 observed years was higher in Asian than in Western patients (0.525; 95% CI, 0.407-0.643 versus 0.141; 95% CI, 0.116-0.166; odds ratio, 3.7378; 95% CI, 1.694-8.248; p = 0.001) Conversely, the mean reoperation rate attributable to lateral knee OA per 100 observed years was lower in Asian than in Western patients (0.093; 95% CI, 0.070-0.115 versus 0.298; 95% CI, 0.217-0.379; odds ratio, 0.3114; 95% CI, 0.0986-0.9840; p < 0.001). CONCLUSIONS: Although total reoperation rates did not differ in the two populations, reoperation for bearing dislocation was more likely to occur in Asian than in Western patients, whereas reoperation for lateral knee OA progression was more likely to occur in Western than in Asian patients after Oxford Phase III UKA. Although possible explanations for these findings may be hypothesized, additional randomized, prospective comparative studies are needed. However, better survival outcomes after UKA may require consideration of ethnicity and lifestyle choices in addition to traditional surgical technique and perioperative care. LEVEL OF EVIDENCE: Level III, therapeutic study.

The transportal technique shows better clinical results than the transtibial techniques for single-bundle anterior cruciate ligament reconstruction.

PURPOSE: Although anatomical and independent drilling techniques, such as transportal (TP) technique, have become more popular in anterior cruciate ligament (ACL) reconstruction, the TP technique has not been shown to yield superior clinical or functional outcomes compared to the transtibial (TT) technique. The aim of the current meta-analysis was to compare clinical outcomes of the TP and TT techniques, as determined by patient-reported outcome scores and knee joint laxity tests. It was hypothesized that the TP and TT techniques of ACL reconstruction would yield similar patient-reported functional outcomes and similar results on knee joint laxity tests. METHODS: Studies were included if they reported at least one of the following clinical outcomes: IKDC score, IKDC examination, Lysholm knee score, and Tegner activity score. Knee stability was evaluated by single or multiple parameters of the following knee laxity examinations: the Lachman test, the pivot shift test, and side-to-side difference on the instrumented knee laxity test. RESULTS: Sixteen studies were finally included in this meta-analysis. The proportions of patients with normal grade on the IKDC examination [odds ratio (OR) 2.23; 95% confidence interval (CI) 1.41-3.53; P = 0.0006] and Lysholm score (mean difference 1.27; 95% CI 0.23-2.31; P = 0.02) after surgery were higher with the TP than with the TT technique, but there were no differences in IKDC and Tegner scores. The postoperative proportion of normal knee joint stability was significantly higher with the TP than the TT technique, on both Lachman (OR 2.29; 95% CI 1.35-3.92; P = 0.002) and pivot shift (OR 2.13; 95% CI 1.12-4.05; P = 0.02) tests. The pooled mean side-to-side difference was 0.73 mm lower with the TP than the TT technique (95% CI - 1.14 to - 0.32 mm; P = 0.0005). CONCLUSION: This meta-analysis showed that the clinical outcomes of ACL reconstruction were better with the TP than the TT technique, both on knee functional outcome scales and knee laxity tests. The findings thus suggest that the TP technique would be a better option for single-bundle ACL reconstruction compared to the TT technique. LEVEL OF EVIDENCE: III.

Combination chemotherapy with methotrexate and vinblastine for surgically unresectable, aggressive fibromatosis.

OBJECTIVE: To elucidate the clinical benefit and safety of low-dose chemotherapy using methotrexate and vinblastine in patients (mostly adults) with progressive and/or symptomatic fibromatosis. METHODS: Patients were enrolled if they were treated with methotrexate and vinblastine chemotherapy for recurrences after surgical excision or newly diagnosed aggressive fibromatosis that was not amenable to surgical resection at the Korea University Medical Center from May 2008 to February 2016. RESULTS: Twenty-two patients were treated with this regimen, and 21 were eligible for safety and efficacy analysis. Eleven (52%) of 21 patients showed a documented partial response (PR), and 11 showed stable disease (SD) by the end of treatment. All the patients who achieved PR reported a significant reduction in pain and improvement in the function of the affected lesions. Median progression-free survival was not reached at the time of analysis. The most common adverse event was abnormalities of the liver transaminases (overall 84.2%). The most common grade 3 or higher toxicity was neutropenia (36.8%), but no febrile neutropenic event was observed. The elevated levels of transaminases were normalized by reducing the dose of methotrexate or delaying treatment. CONCLUSIONS: Low-dose chemotherapy with methotrexate and vinblastine for 1 year was effective and well tolerated by adult patients with aggressive, recurrent fibromatosis.

Differences in bone mineral density between the right and left hips in postmenopausal women.

Bone mineral density (BMD) using dual energy radiography absorptiometry are commonly used for the diagnosis of osteoporosis. It is usually measured at the spine and also at one hip joint. Controversy still exists regarding the use of bilateral hip scanning. We analyzed the difference of BMD at bilateral hips in 384 postmenopausal women, retrospectively. The concordance and discordance rates of the lowest T-score and BMD between both hips were evaluated. The BMDs of the femoral neck and trochanter were significantly different between both hips (P < 0.05). There were also discrepancies between the lowest T-scores of both hips (P < 0.05). The discordance rates were about 30%. Due to significant differences in BMD between both hips at the femoral neck and trochanter and high discordance rate, bilateral hip measurements using DEXA are recommended to avoid underestimating osteoporosis.

Clinical and Radiological Outcomes of Meniscal Repair Versus Partial Meniscectomy for Medial Meniscus Root Tears: A Systematic Review and Meta-analysis.

BACKGROUND: Given the superiority of meniscal repair over partial meniscectomy according to biomechanical data, the clinical outcomes of meniscal repair are likely to be better than those of partial meniscectomy for a medial meniscus root tear (MMRT). PURPOSE/HYPOTHESIS: This review was designed to compare the clinical and radiological results between meniscal repair and partial meniscectomy for MMRTs. It was hypothesized that meniscal repair would result in better clinical and radiological results compared with partial meniscectomy. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Studies were included in the review if they (1) included patients with MMRTs who underwent primary arthroscopic meniscal repair or partial meniscectomy and (2) analyzed validated patient-reported outcomes and/or radiological evaluations. Summary odds ratios (ORs) with 95% CIs were calculated to compare partial meniscectomy with meniscal repair for each outcome. RESULTS: A total of 13 studies were included. The mean duration of follow-up was 33.5 and 47.2 months in the meniscal repair group and partial meniscectomy group, respectively. The change in the Lysholm score from preoperatively to postoperatively was statistically significantly in favor of meniscal repair (OR, 2.20 [95% CI, 1.55-3.12]), while no difference was found with respect to the change in the Tegner score between the 2 surgical approaches (OR, 1.21 [95% CI, 0.65-2.24]). The prevalence of postoperative severe knee osteoarthritis (OR, 0.31 [95% CI, 0.17-0.54]) as well as that of reoperations (OR, 0.05 [95% CI, 0.01-0.19]) were significantly in favor of meniscal repair. CONCLUSION: Better outcomes were seen after meniscal repair compared with partial meniscectomy for MMRTs, with greater improvements in Lysholm scores, and lower rates of progression to knee osteoarthritis, and lower reoperation rate.

Patellar Redislocation Rates and Clinical Outcomes After Medial Patellofemoral Ligament Reconstruction: Suture Anchor Versus Double Transpatellar Tunnel Fixation.

BACKGROUND: Few studies to date have compared clinical outcomes in patients who have undergone medial patellofemoral ligament (MPFL) reconstruction using the suture anchor and double transpatellar tunnel fixation methods. This meta-analysis therefore compared the clinical results, including the patellar redislocation rate and improvement in functional scores, of suture anchor and double transpatellar tunnel fixation. HYPOTHESIS: The recurrence rate and improvement in functional outcomes after surgery would be similar using the suture anchor and double transpatellar tunnel fixation methods. STUDY DESIGN: Meta-analysis. METHODS: Studies evaluating MPFL reconstruction using either the suture anchor or double transpatellar tunnel technique for patellar site fixation were included if they reported the patellar redislocation rate after surgery and/or validated patient-reported outcomes such as the Kujala and Lysholm scores. RESULTS: Twenty-one studies were included in this meta-analysis. The mean patellar redislocation rates were similar using the suture anchor (3.2% [95% CI, 1.6%-6.2%]) and double transpatellar tunnel (3.4% [95% CI, 2.1%-5.4%]) techniques ( P = .879). The mean improvement in the Kujala score from before to after MPFL reconstruction was greater using the suture anchor (37.2 [95% CI, 31.1-43.4]) method than the double transpatellar tunnel method (28.7 [95% CI, 21.2-36.1]) ( P = .018). However, the mean improvement in the Lysholm score did not differ significantly using the 2 techniques. CONCLUSION: The patellar redislocation rate did not differ significantly in patients who underwent MPFL reconstruction using the suture anchor and double transpatellar tunnel fixation methods. The suture anchor fixation method, however, resulted in a greater degree of improvement in patient-reported outcomes.

Status of the contralateral rotator cuff in patients undergoing rotator cuff repair.

BACKGROUND: Although the prevalence of rotator cuff tear (RCT) in the general population has been analyzed, little information is available on the status of the opposite-side rotator cuff in patients who have undergone arthroscopic rotator cuff repair. PURPOSE/HYPOTHESIS: To identify the characteristics of the contralateral shoulder and to identify factors associated with RCT of the contralateral shoulder in patients who underwent surgery for symptomatic RCT. The hypothesis was that the prevalence of RCT in the contralateral shoulder would be higher in patients with increasingly larger cuff tears requiring surgical intervention. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The study cohort consisted of 140 patients with RCT who underwent arthroscopic rotator cuff repair. Opposite-shoulder rotator cuff tendons of all patients were evaluated by ultrasonography. Demographic information and factors related to contralateral RCT were investigated, and risk factors associated with contralateral RCT were assessed. RESULTS: Of the 140 patients who underwent arthroscopic rotator cuff repair, 54 (38.6%) had an RCT of the contralateral shoulder. Of 51 patients with partial-thickness and small-sized full-thickness tears of the operated shoulder, 35 (68.6%) had no tears; 14 (27.5%) had partial-thickness tears; and 2 (3.9%) had small-sized full-thickness tears of the contralateral shoulder. Of 75 patients with medium-sized full-thickness tears, 43 (57.3%) had no tears; 12 (16%) had partial-thickness tears; and 20 (26.7%) had full-thickness tears of the contralateral shoulder. Of 14 patients with large to massive full-thickness tears, 8 (57.1%) had no tears; 1 (7.1%) had a partial-thickness tear; and 5 (35.7%) had full-thickness tears of the contralateral shoulder. The prevalence of RCT of the contralateral shoulder differed significantly among groups classified by tear size (P=.007). The mean American Shoulder and Elbow Surgeons score was significantly lower in the RCT than in the nontear group (55.8±16.9 vs 61.6±13.3; P=.03). Of 29 subjects with symptomatic tears involving the nondominant arm, 17 (58.6%) had contralateral asymptomatic RCT, compared with 37 of 111 (33.3%) subjects with symptomatic tears involving the dominant arm (P=.007). CONCLUSION: The prevalence of RCT of the contralateral asymptomatic shoulder tends to be higher in patients with more symptomatic RCT on one side, in patients with medium-sized or larger RCT in the operated shoulder, and in patients with symptomatic RCT in the nondominant arm.

Rare sleeve fracture of the superior patella pole in an adult due to forceful passive physiotherapy following cast immobilization.

Sleeve fractures are generally restricted to children or adolescents, and usually occur at the lower patella pole. Here we report on a superior pole sleeve fracture in an adult that occurred following forceful passive physiotherapy after cast immobilization. To our knowledge, this is the first report of a superior pole sleeve fracture in an otherwise healthy adult. The case highlighted that a diagnosis of a superior patella pole sleeve fracture in an adult can easily be missed because it is a rare injury, and hence is unlikely to be suspected by physicians.

Localized nodular synovitis of the infrapatellar fat pad.

We report a case of localized nodular synovitis of the infrapatellar fat pad impinging on the patellofemoral joint causing limitation of extension. Arthroscopy involved use of a superolateral portal because location of lesion hindered access via a conventional anterior portal. The infrapatellar mass impinged in the patellofemoral joint upon knee extension and retracted upon flexion. Superior-superior triangulation allowed for complete excision of the mass.

Location of the femoral tunnel aperture in single-bundle anterior cruciate ligament reconstruction: comparison of the transtibial, anteromedial portal, and outside-in techniques.

BACKGROUND: Previous 3-dimensional computed tomography (3D CT) studies of knees after anterior cruciate ligament (ACL) reconstruction have compared femoral tunnel positions obtained using the transtibial and anteromedial drilling techniques. This study used postoperative in vivo 3D CT analysis to compare the locations of the femoral tunnel aperture among 3 drilling techniques used in ACL reconstruction: transtibial, anteromedial portal, and outside-in. HYPOTHESIS: The use of the transtibial drilling technique might result in a less anatomically accurate femoral tunnel placement than the anteromedial portal and outside-in techniques. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Immediate postoperative in vivo 3D CT was used to assess the location of the femoral tunnel aperture in 153 patients who underwent single-bundle ACL reconstruction using the transtibial (n = 42), anteromedial portal (n = 73), or outside-in (n = 38) techniques. Femoral tunnel positions were measured by an anatomic coordinate axis method in the low-to-high and deep-to-shallow directions of the distal femur at 90° of knee flexion. RESULTS: The low-to-high femoral tunnel positions were significantly higher in the transtibial group than in the anteromedial portal (P < .001) and outside-in (P < .001) groups. There were no differences among the 3 groups in the deep-to-shallow femoral tunnel positions (P = .773). CONCLUSION: The transtibial technique of anatomic reconstruction resulted in more highly positioned femoral tunnels in the low-to-high direction than did the anteromedial portal and outside-in techniques. However, no significant differences in the femoral tunnel location were observed in the deep-to-shallow direction.

Snapping knee caused by a popliteomeniscal fascicle tear of the lateral meniscus in a professional Taekwondo athlete.

A 19-year-old male professional Taekwondo athlete presented with a 2-year history of pain-free snapping of his right knee. He reported that his right knee joint gave way during games and training and that he could induce pain-free snapping between the proximal-to-fibular head and the lateral knee joint line. None of these physical findings suggested a meniscal pathology or ligamentous instability. Routine radiographs were normal. Magnetic resonance imaging of his right knee joint showed that the shape of the lateral meniscus was normal, and no lateral meniscus tears existed. On arthroscopic examination, popliteal hiatus view showed a posterosuperior popliteomeniscal fascicle tear between the posterior horn of the lateral meniscus and the posterior joint capsule just posteromedial to the popliteus tendon. With medial traction by probing, this popliteomeniscal tear made visible the significant subluxation of the posterior horn of the lateral meniscus to the center or anterior half of the tibial plateau. Based on the diagnosis of a posterosuperior popliteomeniscal tear of the right knee, Fast-Fix (Smith & Nephew, Andover, Massachusetts) was used for the direct repair of the peripheral portion of the lateral meniscus and joint capsule, targeting the popliteomeniscal junction. At 24 months postoperatively, the patient was performing athletic exercises relevant to his profession and was taking part in Taekwondo games, with no pain or recurrence of snapping. To the authors' knowledge, this is the first report of snapping of the lateral aspect of the knee due to a popliteomeniscal fascicle tear.