Novel susceptibility loci for steroid-associated osteonecrosis of the femoral head in systemic lupus erythematosus.

Osteonecrosis of the femoral head (ONFH) involves necrosis of bone and bone marrow of the femoral head caused by ischemia with unknown etiology. Previous genetic studies on ONFH failed to produce consistent results, presumably because ONFH has various causes with different genetic backgrounds and the underlying diseases confounded the associations. Steroid-associated ONFH (S-ONFH) accounts for one-half of all ONFH, and systemic lupus erythematosus (SLE) is a representative disease underlying S-ONFH. We performed a genome-wide association study (GWAS) to identify genetic risk factors for S-ONFH in patients with SLE. We conducted a two-staged GWAS on 636 SLE patients with S-ONFH and 95 588 non-SLE controls. Among the novel loci identified, we determined S-ONFH-specific loci by comparing allele frequencies between SLE patients without S-ONFH and non-SLE controls. We also used Korean datasets comprising 148 S-ONFH cases and 37 015 controls to assess overall significance. We evaluated the functional annotations of significant variants by in silico analyses. The Japanese GWAS identified 4 significant loci together with 12 known SLE susceptibility loci. The four significant variants showed comparable effect sizes on S-ONFH compared with SLE controls and non-SLE controls. Three of the four loci, MIR4293/MIR1265 [odds ratio (OR) = 1.99, P-value = 1.1 × 10-9)], TRIM49/NAALAD2 (OR = 1.65, P-value = 4.8 × 10-8) and MYO16 (OR = 3.91, P-value = 4.9 × 10-10), showed significant associations in the meta-analysis with Korean datasets. Bioinformatics analyses identified MIR4293, NAALAD2 and MYO16 as candidate causal genes. MIR4293 regulates a PPARG-related adipogenesis pathway relevant to S-ONFH. We identified three novel susceptibility loci for S-ONFH in SLE.

Anatomical evaluation of the superficial medial collateral ligament distal tibial attachment of the knee.

This study aimed to evaluate the superficial medial collateral ligament distal tibial attachment (sMCL-dTA) morphologically and morphometrically. Seventeen unpaired formalin-fixed cadaveric knees were used. The sMCL was divided into anterior and posterior sections in the paracoronal plane along the midline of the sMCL. The distance from the medial edge of the tibial plateau and the joint line to the proximal margin, center, and distal margin of the sMCL-dTA and the length of the sMCL-dTA were measured in the anterior section, respectively. The sMCL-dTA was histologically observed in the posterior section with hematoxylin and eosin and Masson's trichrome staining. The distance from the medial edge of the tibial plateauto the proximal margin, center, and distal margin of the sMCL-dTA were 38.1 ± 4.2, 49.7 ± 4.4, and 61.5 ± 5.1 mm, respectively. The perpendicular distance from the joint line to the proximal margin, center, and distal margin of the sMCL-dTA were 36.1 ± 4.0, 47.4 ± 4.2, and 59.1 ± 4.8 mm, respectively. The length of the sMCL-dTA was 23.6 ± 3.2 mm. Histologically, the sMCL-dTA was formed by two layers of collagen fibers: the unidirectional fibrous layer and the multidirectional fibrous layer. The respective thicknesses of the two layers both decreased distally. The anatomical location, the length, and the attachment morphology of sMCL-dTA have been clarified using human cadaveric knees. Anatomical data in the present study contribute to the quality of surgery associated with sMCL-dTA.

Hand lesion after arthroscopic rotator cuff repair: Association with complex regional pain syndrome.

BACKGROUND: It is known that complex regional pain syndrome (CRPS) occurs after arthroscopic rotator cuff repair (ARCR); however, few studies have investigated this complication. Therefore, the purpose of the present study was to evaluate CRPS after ARCR. METHODS: A total of 182 patients who underwent ARCR were enrolled in this study. The average age of patients was 62.8 ± 10.0 years, with an average follow-up period of 21.5 ± 38.1 months. CRPS criteria outlined by the Ministry of Health, Labor, and Welfare study team for CRPS in Japan (MHLWJ) and International Association for the Study of Pain (IASP 2005) were utilized for diagnosis. There are two rating systems for the "clinical purpose" and "research purpose" in both criteria, respectively. Clinical outcomes, including Japanese Orthopedic Association (JOA) and University of California, Los Angeles scores, were evaluated using univariate and multivariate analysis. RESULTS: CRPS exclusively occurred in the hand of the operated limb, developing within 3 months of surgery. Two or more of the following symptoms were noted in patients with the hand lesion associated with CRPS: edema (93.4%), restricted range of motion (83.4%), hyperalgesia (30.1%), paridrosis (20.4%), and atrophic change (12.2%). Under these conditions, the incidences of CRPS were 24.2% (44/182) when evaluated by the MHLWJ rating system for the "clinical purpose;" 11% (22/182) by the MHLWJ rating system for the "research purpose;" 6% (11/182) by the IASP 2005 for the "clinical purpose;" and 0.5% (1/182) by the IASP 2005 for the "research purpose." Results of multivariate analysis demonstrated that "Function" in the JOA score was a risk factor for the development of CRPS after ARCR, when evaluated by a system for the "clinical purpose" of the MHLWJ. CONCLUSION: Following ARCR, CRPS-induced hand lesions occur more frequently than is generally believed, thereby suggesting that its impact on surgical outcomes should be clarified in the future.

Cutoff value of Japanese Orthopaedic Association shoulder score in patients with rotator cuff repair: Based on the University of California at Los Angeles shoulder score.

BACKGROUND: The Japanese Orthopaedic Association shoulder score cutoff values were calculated in patients with rotator cuff repair using the University of California at Los Angeles shoulder score. METHODS: Overall, 175 patients with rotator cuff repair were subjects in this study. The University of California at Los Angeles and Japanese Orthopaedic Association shoulder scores were evaluated before surgery and at 3, 6, 9, and 12 months after surgery. The cutoff value of the Japanese Orthopaedic Association shoulder score was determined using the 4-stage criteria of the University of California at Los Angeles shoulder score and a University of California at Los Angeles shoulder score of 28 points, which is the boundary between an excellent/good group and a fair/poor group. RESULTS: Both the JOA shoulder and UCLA shoulder scores showed significant improvement at 6, 9, and 12 months from the preoperative scores (p < 0.0001). There was a strong correlation between the total values of the two scores (r = 0.85, p < 0.0001). The cutoff value of the Japanese Orthopaedic Association shoulder score based on the highest accuracy from receiver operating characteristic curve analysis was 83 points. CONCLUSION: A Japanese Orthopaedic Association shoulder score cutoff value of 83 was equivalent to a University of California at Los Angeles shoulder score cutoff value of 28 for distinguishing between excellent/good and fair/poor outcomes after rotator cuff repair.

Factors Affecting Clinical Outcome in Patients With Structural Failure After Arthroscopic Rotator Cuff Repair.

PURPOSE: (1) To compare clinical outcomes between patients with large or massive rotator cuff tears who have healed cuffs and patients with postoperative structural failure (retear after complete or partial repair) and (2) to identify factors associated with clinical outcomes in patients with postoperative structural failure. METHODS: We conducted a retrospective study of consecutive patients with large or massive cuff tears who underwent arthroscopic repair at our institution between 2005 and 2012. On the basis of intraoperative findings and magnetic resonance imaging at final follow-up, the patients were divided into 3 groups: healed group, retear group (after complete repair), and partial-repair group. The outcome measures comprised the Japanese Orthopaedic Association (JOA) and University of California, Los Angeles (UCLA) scores; muscle strength; and range of motion. The tear length, tear width, muscle atrophy, and fatty degeneration were evaluated by preoperative and postoperative magnetic resonance imaging. The extent of tendon reattachment to the superior, middle, and inferior facets and the lesser tuberosity was examined on magnetic resonance images at final follow-up. RESULTS: In total, 74 patients (healed, 41; retear, 19; and partial repair, 14) were included in this study. The mean age was 63.8 ± 8.5 years, with a mean follow-up period of 3.6 ± 1.4 years. The postoperative JOA and UCLA scores significantly improved in all 3 groups, but the differences were not significant. In the retear and partial-repair groups, postoperative tendon preservation at the middle facet significantly affected the JOA and UCLA scores (P = .003 and P = .014, respectively). CONCLUSIONS: The JOA and UCLA scores were significantly improved in patients with structural failure. Under these conditions, the only clinical factor that affected patient outcome was tendon healing at the middle facet. Thus tendon preservation at the middle facet was a predictor of good clinical outcomes in patients who underwent arthroscopic rotator cuff repair of large or massive tears and had postoperative structural failure. LEVEL OF EVIDENCE: Level III, case-control study.

Polyethylene Wear Associated With 26- and 32-mm Heads in Total Hip Arthroplasty: A Multicenter, Prospective Study.

BACKGROUND: Although there were many clinical studies of highly cross-linked polyethylene (XLPE) wear among different femoral head diameters, few referred to thickness of XLPE in case larger femoral heads were used because smaller sockets were frequently used for Asian population. METHODS: This prospective study included 240 hips that underwent primary total hip arthroplasty using XLPE combined with 26-mm (group S) or 32-mm (group L) cobalt-chromium head with maximum follow-up of 10 years. We measured 3-dimensional (3-D) linear penetration rate of XLPE among same implant design groups except head diameter and estimated the validity of thinner XLPE. RESULTS: Our study demonstrated comparable 3-D linear penetration rates, which were 0.06 ± 0.07 mm/y for group S and 0.03 ± 0.02 mm/y for group L at 10 years after surgery and penetration rates seemed to be almost constant with no significant difference after 3 years. Minimum liner thickness (5.3 mm for 48-mm socket in combination with 32-mm femoral head) and the second thinnest XLPE (6.3 mm in case of socket from 50 mm to 54 mm combined with 32-mm femoral head) was distributed in 25% and 72% with group L, respectively, and there were no significant differences in penetration rates between 5.3-mm- and 6.3-mm-thickness groups. CONCLUSION: Our study suggested that whether to select 26- or 32-mm diameters of femoral head does not affect XLPE wear in combination with this type of articulation.

Rapid collapse of the humeral head after arthroscopic rotator cuff repair.

UNLABELLED: This report presents a case of rapidly progressive collapse of the humeral head following arthroscopic rotator cuff repair. We performed humeral head replacement 8 months after the index surgery; histological examination of the collapsed area revealed necrosis, degeneration, fibrillation, and granulation in the cartilage and trabeculae. Osteonecrosis due to the use of metal anchors was considered the primary cause of the post-operative humeral head collapse. As the demand for arthroscopic cuff repair is expected to increase in the future, we recommend that surgeons become aware of the potential for complications, as seen in the present case. LEVEL OF EVIDENCE: IV.

Effects of adipose-derived cell supplementation on tendon-bone healing in a rat model of chronic rotator cuff tear with suprascapular nerve injury.

OBJECTIVE: To investigate the effect of adipose-derived cells (ADCs) on tendon-bone healing in a rat model of chronic rotator cuff tear (RCT) with suprascapular nerve (SN) injury. METHODS: Adult rats underwent right shoulder surgery whereby the supraspinatus was detached, and SN injury was induced. ADCs were cultured from the animals' abdominal fat. At 6 weeks post-surgery, the animals underwent surgical tendon repair; the ADC (+ve) group (n = 18) received an ADC injection, and the ADC (-ve) group (n = 18) received a saline injection. Shoulders were harvested at 10, 14, and 18 weeks and underwent histological, fluorescent, and biomechanical analyses. RESULTS: In the ADC (+ve) group, a firm enthesis, including dense mature fibrocartilage and well-aligned cells, were observed in the bone-tendon junction and fatty infiltration was less than in the ADC (-ve) group. Mean maximum stress and linear stiffness was greater in the ADC (+ve) compared with the ADC (-ve) group at 18 weeks. CONCLUSION: ADC supplementation showed a positive effect on tendon-bone healing in a rat model of chronic RCT with accompanying SN injury. Therefore, ADC injection may possibly accelerate recovery in massive RCT injuries.

Range of Motion Measurements of the Hip Joint Are Useful in Screening for Acetabular Dysplasia in Healthy Young Japanese Women.

The purpose of this study is to clarify whether a hip range of motion (ROM) measurement is useful in screening for early hip osteoarthritis with acetabular dysplasia (AD). Subjects were 58 healthy Japanese women volunteers (21.1 ± 0.7 (20 - 22)). We evaluated a total of 116 hip joints in these 58 cases. Sharp angle and centeredge angle were 44.1° ± 3.1° (37.0° - 51.5°) and 30.7°± 6.2° (19.5° - 47.0°), respectively. AD was present in 47.4%, but there were no severe cases. First, we compared the ROM of the hip joints with AD (AD group) and without AD (control group) according to the Mann-Whitney U test. Extension angles and external rotation angles in the AD group were significantly smaller than in the control group (18.9°± 6.1° VS. 22.1°± 4.2°, p= 0.01636, 26.3°± 8.9° VS. 34.1°± 8.8°, p= 0.001362, respectively). Next, we evaluated the following factors associated with AD by logistic regression analysis after adjustment for age: flexion, extension and internal and external rotation angles of the hip joint. As a result, internal rotation and external rotation were extracted as related factors. The area under the ROC curve was determined to have a moderate accuracy (0.72996). Cut off values of internal rotation and external rotation angles were 50 degrees and 35 degrees, respectively. Our findings suggest that ROM measurement of the internal and external rotation angles would be useful as a screening for AD in healthy young Japanese women without symptoms.

Increased matrix metalloprotease-3 gene expression in ruptured rotator cuff tendons is associated with postoperative tendon retear.

PURPOSE: The role of matrix metalloproteases (MMPs) in ruptured rotator cuff tendons remains unknown. This study aimed to investigate the gene expression of MMPs in ruptured rotator cuff tendons and to compare their expression levels between patients with and without postoperative tendon retear. METHODS: Twenty-four patients (a median age of 61 years: interquartile range, 55-66 years) with full-thickness rotator cuff tears were examined in this study. The marginal site of the ruptured tendon was harvested during surgery. The mRNA expression levels of collagen types I and III, MMP-1, MMP-3, MMP-7, MMP-9, MMP-13, tissue inhibitor of MMP (TIMP)-1, and TIMP-2 were analysed by real-time reverse transcription polymerase chain reaction. Postoperative retear was evaluated by magnetic resonance imaging at a minimum of 1 year following surgery. RESULTS: The mRNA expression levels of MMP-3 and TIMP-1 in ruptured rotator cuff tendons were significantly increased in patients with postoperative retear (n = 6), compared with patients without retear (n = 18) (P = 0.04). For collagens, MMP-1, MMP-7, MMP-9, MMP-13, and TIMP-2, there were no significant differences in the mRNA expression levels in ruptured tendons between patients with and without retear. CONCLUSIONS: These results suggest that, in addition to up-regulation of TIMP-1 gene expression, increased MMP-3 gene expression in ruptured rotator cuff tendons is associated with postoperative tendon retear. Thus, drug therapy specifically targeting MMP-3 after rotator cuff repair should be considered in the future.

Effect of suprascapular nerve injury on muscle and regenerated enthesis in a rat rotator cuff tear model.

BACKGROUND: Massive rotator cuff tears (RCTs) are complicated by muscle atrophy, fibrosis, and intramuscular fatty degeneration, which are associated with postoperative tendon-to-bone healing failure and poor clinical outcomes. We evaluated muscle and enthesis changes in large tears with or without suprascapular nerve (SN) injury in a rat model. METHODS: Sixty-two adult Sprague-Dawley rats were divided into SN injury (+) and SN injury (-) groups (n=31 each), comprising tendon (supraspinatus [SSP]/infraspinatus [ISP]) and nerve resection and tendon resection only cases, respectively. Muscle weight measurement, histological evaluation, and biomechanical testing were performed 4, 8, and 12 weeks postoperatively. Ultrastructural analysis with block face imaging was performed 8 weeks postoperatively. RESULTS: SSP/ISP muscles in the SN injury (+) group appeared atrophic, with increased fatty tissue and decreased muscle weight, compared to those in the control and SN injury (-) groups. Immunoreactivity was only positive in the SN injury (+) group. Myofibril arrangement irregularity and mitochondrial swelling severity, along with number of fatty cells, were higher in the SN injury (+) group than in the SN injury (-) group. The bone-tendon junction enthesis was firm in the SN injury (-) group; this was atrophic and thinner in the SN injury (+) group, with decreased cell density and immature fibrocartilage. Mechanically, the tendon-bone insertion was significantly weaker in the SN injury (+) group than in the control and SN injury (+) groups. CONCLUSIONS: In clinical settings, SN injury may cause severe fatty changes and inhibition of postoperative tendon healing in large RCTs. Level of evidence: Basic research, controlled laboratory study.

Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ): a patient-based evaluation tool for hip-joint disease. The Subcommittee on Hip Disease Evaluation of the Clinical Outcome Committee of the Japanese Orthopaedic Association.

BACKGROUND: The Japanese Orthopaedic Association Hip Score is widely used in Japan, but this tool is designed to reflect the viewpoint of health-care providers rather than that of patients. In gauging the effect of medical therapies in addition to clinical results, it is necessary to assess quality of life (QOL) from the viewpoint of patients. However, there is no tool evaluating QOL for Japanese patients with hip-joint disease. METHODS: With the aim of more accurately classifying QOL for Japanese patients with hip-joint disease, we prepared a questionnaire with 58 items for the survey derived from 464 opinions obtained from approximately 100 Japanese patients with hip-joint disease and previously devised evaluation criteria. In the survey, we collected information on 501 cases, and 402 were subjected to factor analysis. From this, we formulated three categories-movement, mental, and pain-each comprising 7 items, for a total of 21 items to be used as evaluation criteria for hip-joint function. RESULTS: The Cronbach's α coefficients for the three categories were 0.93, 0.93, and 0.95, respectively, indicating the high reliability of the evaluation criteria. The 21 items included some related to the Asian lifestyle, such as use of a Japanese-style toilet and rising from the floor, which are not included in other evaluation tools. CONCLUSIONS: This self-administered questionnaire may become a useful tool in the evaluation of not only Japanese patients, but also of members of other ethnic groups who engage in deep flexion of the hip joint during daily activities.

Posterior decentering of the humeral head in patients with arthroscopic rotator cuff repair.

BACKGROUND: In some patients with rotator cuff tear (RCT), the axial view of magnetic resonance imaging (MRI) shows subtle posterior decentering (PD) of the humeral head from the glenoid fossa. This is considered to result from a loss of centralization that is typically produced by rotator cuff function. There are few reports on PD in RCT despite the common occurrence of posterior subluxation in degenerative joint disease. In this study, we investigated the effect of PD in arthroscopic rotator cuff repair (ARCR). METHODS: We conducted a retrospective study of consecutive patients who underwent ARCR at our institute and were followed-up for at least 1 year. PD was identified as a 2-mm posterior shift of the humeral head relative to the glenoid fossa in the axial MRI view preoperatively. The tear size and fatty degeneration (FD, Goutallier classification) were also evaluated using preoperative MRI. Retears were evaluated through MRI at 1 year postoperatively. RESULTS: We included 135 shoulders in this study. Ten instances of PD (including seven retears) were observed preoperatively. Fifteen retears (three and 12 retears in the small/medium and large/massive tear groups, respectively) were observed postoperatively. PD was significantly correlated with tear size, FD, and retear occurrence (p<0.01 each). The odds ratio for PD in retears was 34.1, which was greater than that for tear size ≥3 cm and FD grade ≥3. CONCLUSIONS: We concluded that large tear size and FD contribute to the occurrence of PD. Furthermore, PD could be a predictor of retear after ARCR.

Collagen production at the edge of ruptured rotator cuff tendon is correlated with postoperative cuff integrity.

PURPOSE: The purpose was to evaluate the correlation between messenger RNA (mRNA) expression of collagen at the edge of the ruptured rotator cuff tendon and postoperative cuff integrity. METHODS: The edge of the ruptured tendon was sampled during open rotator cuff surgery in 12 patients with full-thickness rotator cuff tears (mean age, 58.2 years). The mean period from symptom onset was 9.3 months (range, 1 to 36 months), and the mean tear size was 4.1 cm. As controls, rotator cuff tendons with no gross rupture were taken from 5 fresh cadavers. Production of type I and type III collagen was examined by real-time reverse transcription polymerase chain reaction. By use of magnetic resonance imaging, postoperative cuff integrity was evaluated based on the classification of Sugaya et al. and then scored, ranging from 5 points for type I to 1 point for type V. RESULTS: Looking at the mRNA of type I and type III collagen in tendons, we found that the expression of mRNA for both collagen types in ruptured tendons was significantly greater than in control tendons (P = .0462 for type I collagen and P = .0306 for type III collagen). Correlating the mRNA of type I and type III collagen with repaired cuff integrity on postoperative magnetic resonance imaging, we found a close relation between expression of mRNA for both collagen types and postoperative rotator cuff integrity (r = 0.63 [P = .038] for type I collagen and r = 0.626 [P = .03] for type III collagen). Furthermore, expression of type I collagen mRNA showed a significant inverse correlation with the period from symptom onset (r = -0.845, P < .0005). CONCLUSIONS: This study showed that expression of mRNA for type I and type III collagen at the edge of the ruptured rotator cuff tendon was significantly correlated with postoperative cuff integrity and that mRNA expression for type I collagen was significantly associated with the period from symptom onset. These results may suggest that conservative treatment should not be prolonged if patients do not respond within a certain period. LEVEL OF EVIDENCE: Level III, prognostic case-control study.

Saphenous Nerve Entrapment Neuropathy After Closed Tibial Fracture: A Case Report.

CASE: A 43-year-old man who underwent intramedullary nailing for a closed tibial fracture developed saphenous nerve entrapment neuropathy. He developed severe medial leg pain, which was worse on walking or standing, 2 years postoperatively. Surgical neurolysis resulted in complete pain relief and functional recovery of the limb without recurrence of symptoms. CONCLUSION: Clinicians should consider several etiologies in the diagnostic evaluation of a patient with chronic pain after limb trauma. If a patient complains of lower extremity pain after intramedullary fixation of closed fractures of the tibial shaft, the possibility of saphenous nerve entrapment neuropathy should be considered.

Incidence of Re-Dislocation/Instability After Arthroscopic Bankart Repair: Analysis via Telephone Interviews.

INTRODUCTION: Current advances in arthroscopic surgery have led to good outcomes for arthroscopic Bankart repair (ABR) for recurrent anterior shoulder dislocation. However, recent studies have reported recurrence rates of 4%-19% after ABR. In our survey conducted from February 2002 to December 2010, the post-ABR re-dislocation rate was 8.8%. In 2011, we began performing the ABR with open Bristow (B) procedure or Remplissage (R) procedure in patients with large glenoid or humeral head bone defects and in patients who play collision sports. Therefore, the present study is the second series evaluating the incidence of re-dislocation and instability after recurrent anterior shoulder dislocation. METHOD: Surgery was performed for 84 cases of shoulder instability from January 2011 to August 2017. After excluding 7 open surgeries, 6 reoperations, and 2 patients with multidirectional instability, telephone interviews were conducted with 69 patients. The average follow-up duration was 46.9 months (range, 13-92 months). RESULT: ABR alone was performed 61 patients; the B procedure was added for 3 patients, and the R procedure was added for 5 patients. Telephone interviews were conducted with 61 patients. There were no cases of re-dislocation or reoperation. Four patients who underwent only ABR experienced postoperative instability, but not to the extent that their daily lives were affected. CONCLUSION: This study showed that the addition of R or B technique to ABR for recurrent anterior shoulder dislocation resulted in a 0% re-dislocation rate.

Midterm Functional and Structural Outcomes of Large/Massive Cuff Tears Treated by Arthroscopic Partial Repair.

BACKGROUND: Previous studies have shown good clinical outcomes in patients with irreparable large or massive rotator cuff tears treated using arthroscopic partial repair (APR); however, few studies have evaluated both functional and structural outcomes in these patients. PURPOSE: To evaluate both functional and structural outcomes in patients with large or massive rotator cuff tears treated using APR. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between March 2009 and November 2016, a total of 30 patients underwent APR because of the irreparability of their large or massive rotator cuff tears during surgery. Of these patients, 24 completed the minimum 24-month follow-up (mean, 61.8 ± 27.1 months; range, 24-112 months) and were included in this study. Functional outcome measures included the Japanese Orthopaedic Association (JOA) and University of California Los Angeles (UCLA) scores and the visual analog scale for pain. Structural outcome measures comprised preoperative fatty degeneration, mediolateral tear size, residual tendon attachment area, and glenohumeral (GH) arthritic changes evaluated on magnetic resonance imaging scans or plain radiographs before and after surgery. Functional and structural outcomes were evaluated preoperatively, at 3 months postoperatively, and at the final follow-up. RESULTS: The JOA scores for all patients significantly improved from 67.9 ± 11.3 preoperatively to 85.4 ± 15.6 postoperatively (P < .0001). Similarly, the UCLA scores significantly improved from 15.8 ± 4.20 preoperatively to 29 ± 6.69 at final follow-up postoperatively (P < .0001). The mediolateral tear size were significantly decreased at 3 months postoperatively (P < .001) and at the final follow-up (P < .001). Compared with preoperative scores, the novel score evaluating the residual tendon attachment area improved from 3.08 ± 0.46 to 3.54 ± 0.41 (P < .001) after surgery overall, although it significantly deteriorated from 3 months postoperatively to the final follow-up. GH osteoarthritis progressed in 6 patients (25%). Patients who developed osteoarthritis had lower JOA and UCLA scores than did those who did not (JOA, P = .010; UCLA, P = .037). CONCLUSION: In irreparable large or massive rotator cuff tears treated using APR, functional outcome improved after surgery. Although the residual tendon attachment area improved, functional outcome after APR corresponded to the GH alterations at the midterm follow-up. Longer-term follow-up is needed to further elucidate the effect of APR on clinical outcomes in these patients.

Functional and Structural Outcomes After Retears of Arthroscopically Repaired Large and Massive Rotator Cuff Tears.

BACKGROUND: Most studies have shown acceptable clinical results in patients with large or massive tears treated by arthroscopic rotator cuff repair (ARCR); however, the effects of retears after surgery in these patients remain unknown. PURPOSE: To evaluate functional and structural outcomes after retears of large and massive rotator cuff tears treated by ARCR. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 196 consecutive patients with large to massive rotator cuff tears underwent physical examination and magnetic resonance imaging before and after ARCR at 6, 12, and 24 months. Of these, 9 patients were lost at 6 months after surgery. Therefore, 187 patients were followed up for 24 months after surgery; 148 patients showed no postsurgical ruptures. Consequently, the remaining 39 patients with postsurgical ruptures were included in this study (mean age at surgery, 64.2 ± 8.7 years). Functional outcome measures comprised the University of California, Los Angeles (UCLA) and Japanese Orthopaedic Association (JOA) scores. Structural outcome measures consisted of the global fatty degeneration index (GFDI), mediolateral tear size, and residual tendon attachment area as evaluated by our own scoring system. RESULTS: The mean UCLA and JOA scores significantly improved from 16.3 ± 3.9 and 63.2 ± 10.7 preoperatively to 27.9 ± 5.5 (P < .0001) and 84.5 ± 9.4 (P < .0001) at final follow-up, respectively. The mean mediolateral tear size (P = .03, .02, and .02, respectively) and residual tendon attachment area (P = .04, .03, and .04, respectively) significantly improved from preoperatively to 6, 12, and 24 months postoperatively. The correlation analysis between the functional and structural variables confirmed significant associations between the residual tendon attachment area, the JOA and UCLA scores at 24 months postoperatively, and the preoperative GFDI (r = -0.81 to 0.78). CONCLUSION: The residual tendon attachment area after a retear was significantly larger at 24 months after surgery than before surgery. In addition, significant associations were confirmed between preoperative fatty degeneration, the residual tendon attachment area, and functional outcomes after a retear. These results may explain why functional outcomes significantly improved even after retears in this series.

Clinical outcome in patients with hand lesions associated with complex regional pain syndrome after arthroscopic rotator cuff repair.

BACKGROUND: Complex regional pain syndrome (CRPS)-related hand lesions are one of the complications following arthroscopic rotator cuff repair (ARCR). This study aimed to investigate the clinical outcomes of patients with CRPS-related hand lesions following ARCR. METHODS: Altogether, 103 patients with ARCR were included in this study (mean age, 63.6±8.2 years; 66 males and 37 females; follow-up period, preoperative to 12 months postoperative). Clinical assessment included the Japanese Orthopaedic Association (JOA) score, University of California, Los Angeles (UCLA) score, Constant score, 36-item short form health survey (SF-36) score, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score from preoperative to 12 months postoperatively. The patients were either assigned to the CRPS group or non-CRPS group depending on CRPS diagnosis until the final follow-up, and clinical outcomes were then compared between the groups. RESULTS: Of 103 patients, 20 (19.4%) had CRPS-related hand lesions that developed entirely within 2 months postoperatively. Both groups showed significant improvement in JOA, UCLA, and Constant scores preoperatively to 12 months postoperatively (P<0.001). Comparisons between the two groups were not significantly different, except for SF-36 "general health perception" (P<0.05) at 12 months postoperatively. At final follow-up, three patients had residual CRPS-related hand lesions with limited range of motion and finger edema. CONCLUSIONS: CRPS-related hand lesions developed in 19.4% of patients following ARCR. Shoulder or upper-limb function improved in most cases at 12 months, with satisfactory SF-36 patient-based evaluation results. Patients with residual CRPS-related hand lesions at the last follow-up require long-term follow-up.

Neurotropin protects rotator cuff tendon cells from lidocaine-induced cell death.

BACKGROUND: Local anesthetics often are used in rotator cuff tears as therapeutic tools, although some cases have reported that they have detrimental effects. Neurotropin (NTP) is used widely in Japan as a treatment for various chronic pain conditions and is shown to have protective effects on cartilage and nerve cells. In this study, we investigated the protective effect of NTP against lidocaine-induced cytotoxicity. METHODS: Tenocytes from rotator cuff tendons were incubated with lidocaine, NTP, lidocaine with NTP, and a control medium. Cell viability was evaluated using the WST-8 assay. Cell apoptosis was detected via annexin V staining using flow cytometry. The expression of BCL-2 and cytochrome c, which are involved in the intrinsic mitochondrial pathway of apoptosis, was evaluated via Western blotting and immunohistochemical staining. RESULTS: In the cell viability assay, lidocaine decreased cell viability in a dose-dependent manner, and NTP did not affect cell viability. Moreover, NTP significantly inhibited the cytotoxic effect of lidocaine. The flow cytometry analysis showed that lidocaine significantly induced apoptosis in tenocytes, and NTP considerably inhibited this lidocaine-induced apoptosis. Western blotting experiments showed that lidocaine decreased the protein expression of BCL-2, and that NTP conserved the expression of BCL-2, even when used with lidocaine. Immunohistochemical staining for cytochrome c showed that 0.1% lidocaine increased cytochrome c-positive cells, and NTP suppressed lidocaine-induced cytochrome c expression. CONCLUSIONS: NTP suppresses lidocaine-induced apoptosis of tenocytes by inhibiting the mitochondrial apoptotic pathway. Intra-articular/ bursal injection of NTP with lidocaine could protect tenocytes in rotator cuff tendons against lidocaine-induced apoptosis.