Aerosol generating procedures in trauma and orthopaedics in the era of the Covid-19 pandemic; What do we know?

PURPOSE: COVID-19 pandemic has created havoc all over the globe and spared no one regardless of status, gender, location and ethnicity. There were questions raised if trauma and orthopaedic (T&O) procedures actually generated aerosols? The need for a review of literature highlighting the nature and impact of aerosol generation within T&O surgery was noted. METHODS: A comprehensive online search was performed for all published articles in the English language, evaluating AGPs in T&O surgery and the relevant personal protection equipment used. RESULTS: The search strategy populated 43 studies. Six studies were identified as duplicates. The shortlisted 37 studies were screened and nine studies were included in the review. An additional four studies were included from the bibliography review. CONCLUSION: Most orthopaedic procedures are high-risk aerosol generating procedures (AGPs). Conventional surgical masks do not offer protection against high-risk AGPs. In the current era of COVID-19 pandemic, there is a significant risk to the transmission of infection to the theatre staff. For protection against airborne transmission, appropriate masks should be used. These need proper fitting and sizing to ensure full protection when used.

Posterior shoulder fracture-dislocation: A systematic review of the literature and current aspects of management.

PURPOSE: Posterior fracture-dislocation of shoulder is an infrequent traumatic event; however, most orthopaedic surgeons may face the challenge of treating it. The aim of this study is to review and summarise systematically the current principles of the management of this complex injury, and create a treatment algorithm. METHODS: Both PubMed and Scopus Databases were systematically searched for the terms "posterior shoulder fracture-dislocation" or "posterior glenohumeral fracture-dislocation" or "posterior glenoid fracture-dislocation" for articles written in English and published in the last decade. RESULTS: A total of 900 articles were identified, of which 13 were retained for analysis. A total of 153 patients (161 shoulders) were identified. These patients were treated either with open reduction and internal fixation, modified McLaughlin procedure, allograft/autograft humeral head reconstruction or shoulder arthroplasty. The mean age was 40.15 years. The mean postoperative Constant score in cases treated by open reduction and internal fixation was 86.45, whereas by bone graft was 84.18. Further, the mean postoperative Constant score was between 79.6 and 67.1 in those that were managed by modified McLaughlin and arthroplasty procedure, respectively. CONCLUSION: The management of posterior shoulder fracture-dislocation may be challenging, and the best surgical option depends on many variables such as the chronicity of the injury, the presence of a fracture at the level of the surgical neck or tuberosities and the extend of the Hill-Sachs lesion if any. A treatment algorithm is proposed, based on the current literature in an effort to create a consensus for these injuries. For the acute shoulder fracture-dislocations, an open reduction should be performed. For the chronic fracture/dislocations in the elderly low-demand patients, conservative treatment should be performed. For the rest of the patients, depending on the severity of the Hill-Sachs lesion different surgical options are available such as the McLaughlin technique, the use of an allograft, osteotomy or arthroplasty.

Propionibacterium acnes: an underestimated etiology in the pathogenesis of osteoarthritis?

BACKGROUND: Propionibacterium acnes is a common pathogen in infections after shoulder surgery. Recent reports found positive P acnes cultures in a high percentage of patients who had revision shoulder arthroplasty for "aseptic loosening" without any overt signs of infection. Isolation of P acnes is difficult, and by use of conventional microbiological protocols of 48-hour incubation, a considerable proportion of patients with possible P acnes infection may remain unidentified. We recently noted P acnes in shoulder joint cultures in patients undergoing primary shoulder replacement for glenohumeral arthropathy without any signs of infection. METHODS: We collected aspirates and biopsy specimens from 55 consecutive patients with arthritic shoulders undergoing primary joint replacement and examined them for the presence of P acnes. Special measures were taken to ensure that the specimens were carefully taken from within the joint to reduce the risk of contamination to minimal. RESULTS: In 23 of 55 consecutive patients (41.8%) undergoing primary shoulder joint replacement, P acnes was found in the joint fluid and tissues taken before the insertion of the implants. All these patients were treated early postoperatively with pathogen-directed specific dual oral antibiotic treatment for 4 weeks. In none have any signs of infection developed. DISCUSSION AND CONCLUSION: This finding of a high incidence of P acnes in joints before arthroplasty may suggest a role of P acnes in the pathogenesis of glenohumeral arthropathy. In addition, it raises the question of whether development of painful joint replacement later on and presumed aseptic loosening do, in fact, comprise an unrecognized low-grade infection that has been present since before the index operation.

Spontaneous Avascular Necrosis of the Humeral Head Following COVID-19 Vaccination.

We report a case of a 40-year-old man who presented with left shoulder pain and marked functional impairment two days after receiving the second dose of the Pfizer COVID-19 vaccine. Advanced imaging demonstrated focal avascular necrosis (AVN) of his humeral head. Initial management included simple analgesics, activity modification, and an ultrasound-guided intra-articular hydrodilatation injection. The patient subsequently had an improved range of motion but persistent severe shoulder pain. He has now been offered surgical intervention. Despite having risk factors for developing AVN previously, the patient did not demonstrate any recent risk factors for developing the disease. COVID-19 vaccination is known to cause severe joint pain and stiffness rarely. However, avascular necrosis is not a known or documented side effect. His symptoms arose directly after the administration of the vaccine, with no other demonstrable cause. Therefore, we are reporting COVID-19 vaccination as a potential new risk factor for AVN of the humeral head.

Pattern and time phase of shoulder function and power recovery after arthroscopic rotator cuff repair.

BACKGROUND: It has been our observation that early during rehabilitation after rotator cuff repair, patients may take a step back before improving. The purpose of this study is to investigate the pattern and time phase of changes in Constant score and strength recovery after arthroscopic rotator cuff repair. MATERIALS AND METHODS: Forty-five patients undergoing arthroscopic rotator cuff repair were prospectively enrolled in this study. Patients underwent scoring preoperatively with the Constant score. All were followed up at 3 months and 6 months after surgery. The Constant score and strength at 3 months were compared with those at the 6-month mark. RESULTS: The mean Constant score improved from 46.4 points (SD, 17.3) preoperatively to 51.8 points (SD, 13.5) 3 months postoperatively (P = .0777). At 6 months postoperatively, the mean Constant score was 69.0 points (SD, 11.1), a significant increase from both the preoperative (P < .0001) and 3-month (P < .0001) results. The mean preoperative strength result of 4.5 kg (SD, 3.2) decreased significantly to 3.3 kg (SD, 1.8) at 3 months postoperatively (P = .0154) before improving to 5.8 kg (SD, 2.6) at 6 months postoperatively. The improvement in strength at 6 months was significant compared with both the preoperative (P = .0070) and 3-month (P < .0001) results. CONCLUSIONS: Although there is highly significant improvement in overall function (Constant score) and strength 6 months postoperatively, patients appear to take a step back before improving, in fact with a drop in strength at 3 months. This may cause concern in patients and may require assurance that time and effort with physiotherapy will improve function and symptoms.

Clinical outcomes and structural integrity rate of arthroscopic augmented rotator cuff repairs using extracellular porcine matrix patch.

Background: Structural failure rate in rotator cuff repairs is still high. The purpose of the study is to assess the structural integrity of a series of augmented rotator cuff repairs with porcine matrix patch and report the functional outcomes. Methods: Between 2014 and 2017, 44 consecutive patients underwent arthroscopic double-row repair of medium to massive rotator cuff tears with extracellular porcine dermal matrix augmentation. At one-year follow-up, magnetic resonance imaging scan was performed to assess the integrity of the repair. Oxford Shoulder Score (OSS), Constant Score (CS) and Visual Analogue Scale pain score, together with range of motion were used to assess patients. Results: Patients mean age was 68 (53-82); mean follow-up was 17.2 (12-24) months. On magnetic resonance imaging scans, seven rotator cuff repair failures (15.9%) were observed: tear size was an independent predictor of re-rupture at one-year follow-up. Clinical scores showed a statistically significant improvement at three months and until final follow-up (p< 0.001). No complications occurred. Conclusion: Observed structural failure rate of 15.9% is lower than those reported in the literature for standard rotator cuff repair of medium to massive tears in similar cohorts to ours. Extracellular matrix augmentation for rotator cuff repair was shown to be a safe and reliable support to the repairs and patients recovered good shoulder function.Level of Evidence: Level IV.

Lunotriquetral Ligament Repair Using Augmented Internal Brace.

Lunotriquetral (LT) ligament tear, usually in combination with an adjacent carpal ligament injury, can result in complete LT dissociation and VISI (Volarflexed Intercalated Segment Instability). Operative techniques for the management of instability are highly variable with many described in literature, although there is little evidence to demonstrate the superiority of one definitive therapeutic technique of repair and reconstruction. In this paper, we discuss our proposed technique for performing LT ligament repair using an augmented internal brace, which addresses triquetral extension and lunate flexion. The internal brace construct also provides biomechanical superiority as it includes the augmentation of the ligament and capsule repair. We use figures and references from our case example to demonstrate this technique.

Arthroscopic Allograft Bone Block Procedure with Remplissage for Bipolar Lesions.

Anterior shoulder instability with bone loss is a challenging condition. The two most performed procedures, Bankart repair & Latarjet, are not without issues. We describe a technique where arthroscopic free bone grafting was performed in conjunction with remplissage. We feel that this combined arthroscopic procedure offers advantages that include reduced risk of conventional Latarjet complications, including neurological deficits and metal hardware complications while preserving subscapularis and coracoid. Furthermore, these advantages may not come at the cost of compromised outcomes, particularly recurrence rate, as the remplissage may compensate for the possible lack of "sling effect" with free bone graft reconstruction.

Rotator Cuff Repair With Patch Augmentation: What Do We Know?

Background: Repair of massive rotator cuff tears remains a challenging process with mixed success. There is a growing interest in the use of patches to augment the repair construct and the potential to enhance the strength, healing, and associated clinical outcomes. Such patches may be synthetic, xenograft, or autograft/allograft, and a variety of techniques have been tried to biologically enhance their integration and performance. The materials used are rapidly advancing, as is our understanding of their effects on rotator cuff tissue. This article aims to evaluate what we currently know about patch augmentation through a comprehensive review of the available literature. Methods: We explore the results of existing clinical trials for each graft type, new manufacturing methods, novel techniques for biological enhancement, and the histological and biomechanical impact of patch augmentation. Results: There are promising results in short-term studies, which suggest that patch augmentation has great potential to improve the success rate. In particular, this appears to be true for human dermal allograft, while porcine dermal grafts and some synthetic grafts have also had promising results. Conclusion: However, there remains a need for high-quality, prospective clinical trials directly comparing each type of graft and the effect that they have on the clinical and radiological outcomes of rotator cuff repair.

Bony increased-offset reverse shoulder arthroplasty: A meta-analysis of the available evidence.

BACKGROUND: Reverse shoulder arthroplasty (RSA) has revolutionized the management of many shoulder pathologies. Lateralization has become favourable to combat complications (e.g. notching, compromised external rotation), using a metallic, or autogenous bone-graft baseplates - bony increased-offset reverse shoulder arthroplasty (BIO-RSA). We systematically reviewed the literature to determine: Does BIO-RSA improve range of motion and outcome scores?Are notching rates decreased?Does the graft heal? METHODS: All available prospective studies, trials and case series reporting on BIO-RSA were included. Outcomes were grouped into outcome scores, range of motion and radiographic outcomes. Data were pooled and statistical analysis performed. RESULTS: Eight studies reported on 385 RSA - 235 BIO-RSA and 150 standard-RSA (STD-RSA). Follow-up was 20-36 months; average age 74 years. Outcome scores: Constant-Murley and SSV scores showed statistically significant post-operative benefit of BIO-RSA (mean-difference 4.0 (95% confidence interval (CI): 0.79,7.1) and 6.8 (95% CI: 3.8, 9.9)). No Minimal Clinically Importance Difference was surpassed. Range of motion: No difference was found in any direction. Notching: Notching was less likely with BIO-RSA (odds ratio 0.19 (95% CI: 0.10, 0.38)). Healing and loosening: 92% grafts fully healed/incorporated. Loosening rate was 2.4%. CONCLUSIONS: Literature on BIO-RSA is limited with only one randomised controlled trial (RCT). Weak evidence exists for improved outcome scores. Range of motion is equivocal. Notching rates are significantly lower in BIO-RSA. The graft usually heals.

Clinical and Radiological Outcomes of Rotator Cuff Repairs Using All-Suture Anchors as Medial Row Anchors.

BACKGROUND: The aim of our study is to report the clinical and radiological outcomes of a series of prospectively enrolled patients who have had double-row transosseous equivalent rotator cuff repairs, where all-suture anchors were used as medial-row anchors, with a minimum follow-up of 1 year. METHODS: Twenty-two consecutive patients underwent arthroscopic transosseous equivalent double-row rotator cuff repair using all-suture anchors as medial-row anchors. Oxford Shoulder Score, Constant Score and Visual Analogue Scale pain score, together with shoulder range of motion, were used preoperatively and at 3 months, 6 months and final follow-up. Radiological evaluation was performed with magnetic resonance imaging at one-year post surgery to assess the structural integrity of the repair and the rate of cyst formation in greater tuberosity. RESULTS: The patient mean age was 61 years (range 46-75). Minimum follow-up was 1 year, and the mean final follow-up was 15 months (range 12-24). Healing failure in our patients was less than 5% (1/22 patients). There were significant improvements in shoulder function outcome scores at final follow-up. The Constant and Oxford scores were 78 and 44 at final follow-up respectively. There were similar magnitudes of improvement in range of motion (combined abduction and rotation), pain score and supraspinatus strength at final follow up. The improvements in outcome scores were already statistically significant at 3 months (P<.001). Using Kim's classification for cyst formation on T2-weighted MRI images, we observed no fluid or minimal fluid collection in 85% of the patients (17/22 patients). There were no correlations between the grade of bone changes and the clinical outcomes. CONCLUSION: It is safe to use all-suture anchors as medial-row anchors when performing double-row anchor transosseous equivalent rotator cuff repairs. The purported advantages of all-suture anchors may outweigh their perceived disadvantages in rotator cuff repair surgery.

Bankart Repair Versus Latarjet Procedure for Recurrent Anterior Shoulder Instability: A Systematic Review and Meta-analysis of 3275 Shoulders.

BACKGROUND: Little consensus is available regarding the standard treatment for recurrent anterior instability of the shoulder. Typically, treatment selection has been based on training and tradition rather than the available evidence. PURPOSE: This study aimed to compare the clinical outcomes between arthroscopic Bankart procedure and the Latarjet procedure in the treatment of recurrent anterior shoulder instability with emphasis on follow-up time. STUDY DESIGN: Systematic review and meta-analysis. METHODS: We searched PubMed, Cochrane Central Register of Controlled Trials, Scopus, Ovid, and Web of Science up to January 2018 and included studies that compared arthroscopic Bankart versus Latarjet for treatment of anterior shoulder instability. Continuous data, such as operative time and patient-reported outcomes, were pooled as mean differences (MDs), whereas dichotomous data, such as recurrence, revision, redislocation, arthropathy, infection, and hematoma, were pooled as risk ratios (RRs), with 95% CIs. RESULTS: Pooling data from 7 cohort studies (3275 patients) showed that arthroscopic Bankart was associated with a higher risk of redislocation (RR, 2.74; 95% CI, 1.48-5.06; P = .03), a higher risk of recurrence (RR, 2.87; 95% CI, 1.91-4.30; P < .0001), and a lower risk of infection (RR, 0.16; 95% CI, 0.06-0.43; P = .0002) compared with Latarjet, while the effect size did not favor arthroscopic Bankart or Latarjet in terms of Rowe score (MD, 0.22; 95% CI, -5.64 to 6.08; P = .94), revision (RR, 0.34; 95% CI, 0.08-1.39; P = .13), and hematoma (RR, 0.20; 95% CI, 0.03-1.19; P = .07). The effect estimate showed a pronounced advantage for Latarjet from 6 to 10 years postoperatively in terms of recurrence and redislocation (RR, 3.00; 95% CI, 1.98-4.56 and RR, 2.85; 95% CI, 1.51-5.38, respectively). CONCLUSION: Our results showed that Latarjet had less risk of recurrence and redislocation with longer follow-up time. Both procedures were comparable in terms of Rowe score, the need for revision, and postoperative hematoma formation, whereas Bankart repair was associated with a lower risk of infection.

Posterior Shoulder Instability: The Augmented McLaughlin Procedure.

Posterior shoulder dislocation, whilst uncommon, is frequently missed and often associated with a significant defect on the antero-medial aspect of the humeral head (the reverse Hill-Sachs lesion). Several techniques for stabilisation have been described, depending on the size of the lesion. We describe an additional technique for stabilising the shoulder following posterior dislocation by augmenting the reverse Hill-Sachs lesion with layers of extracellular matrix, thus further filling the defect.

Hamburger Technique: Augmented Rotator Cuff Repair With Biological Superior Capsular Reconstruction.

Despite profound advancements in arthroscopic rotator cuff repair (RCR) techniques, radiologic failure rates may be in excess of 60% with repairs of large and massive tears in the elderly population. One of the strategies to improve these healing rates has been "patch" augmentation of the cuff repair. At the same time, superior capsular reconstruction (SCR) has gained significant popularity as an option for irreparable rotator cuff (RC) tears. Some have also advocated performing SCR in addition to arthroscopic RCR to reinforce the repair and improve healing rates. Techniques involving the use of fascia lata, ECM patches, and long head of the biceps (LHB) for SCR to reinforce the cuff repair have all been elegantly described. In this article, we propose a technique that enables a combination of the aforementioned procedures and involves performing RCR with patch augmentation, as well as SCR using LHB. In doing so, the repaired RC is bordered by the patch over its bursal surface and the LHB on the articular surface (functioning as the superior capsule), thus giving us the name "Hamburger technique" (a 3-layered construct).

Superior Capsule Reconstruction: What Do We Know?

The management of irreparable rotator cuff tears remains challenging. Since its introduction by Mihata in 2012, superior capsule reconstruction (SCR) has grown in popularity at an astonishingly rapid rate. The aim of this article is to provide a comprehensive review of the available literature, in order to highlight what has so far been published on SCR, covering all aspects including biomechanical, clinical and radiological studies as well as descriptions of the various techniques for performing the procedure. The short-term clinical results of SCR are promising, but there is need for further long-term studies, as well as randomised controlled trials comparing SCR to other treatment modalities for irreparable rotator cuff tears. Further imaging studies looking at graft healing rates are also required as the healing rates published so far are variable. Additionally, the mechanism of action by which SCR delivers good short-term functional outcomes needs further clarification, as does the importance of the choice of graft type and thickness.