Is Ultrasound-guided or Landmark-guided Intra-articular Lidocaine Injection More Effective for Pain Control in Anterior Shoulder Dislocation Reduction? A Randomized Controlled Trial.

BACKGROUND: Effective pain control during reduction of shoulder dislocation is essential for patient comfort. However, there is a lack of comprehensive research comparing the efficacy of different pain management techniques, specifically landmark-guided and ultrasound-guided intra-articular analgesic injections. QUESTIONS/PURPOSES: Among patients undergoing closed reduction of a shoulder dislocation, were there differences between an intra-articular shoulder injection placed using anatomic landmarks and an ultrasound-guided intra-articular injection in terms of (1) pain before versus after the injection and pain before injection versus after the reduction, or (2) length of stay in the emergency department and complications of the procedure? METHODS: Between August 2021 and March 2023, 28 patients with anterior shoulder dislocation were treated at the emergency department of a tertiary referral care center. They were randomly assigned to either the landmark-guided or ultrasound-guided intra-articular lidocaine injection group. Differences in pain levels between preinjection and postinjection, preinjection and postreduction, length of hospital stay, and complications were assessed and compared between the two groups. Patients were followed for 2 weeks. RESULTS: There were no between-group differences in terms of age, gender, baseline pain score, and any other relevant factors. There were no differences between the groups in terms of pain reduction between preinjection and postinjection (landmark-guided: ΔVAS 2.8 ± 1.1, ultrasound-guided: ΔVAS 2.9 ± 1.0, mean difference -0.14 [95% confidence interval -0.97 to 0.68]; p = 0.72) or between preinjection and postreduction (landmark-guided: ΔVAS 6.6 ± 2.1, ultrasound-guided: ΔVAS 5.8 ± 1.8, mean difference 0.79 [95% CI -0.74 to 2.31]; p = 0.30). There were no differences in length of stay in the emergency department (landmark-guided: 162 ± 38 minutes, ultrasound-guided: 184 ± 73 minutes, mean difference 22 minutes [95% CI -67 to 24]; p = 0.33), and no complications were reported in either group during the 2-week follow-up period. CONCLUSION: The results of the landmark-guided technique were not different from those of ultrasound-guided injection in terms of lower pain levels, length of stay, and complications. These findings provide valuable guidance for orthopaedic surgeons, enabling them to make informed decisions based on their expertise and available resources. LEVEL OF EVIDENCE: Level I, therapeutic study.

Efficacy of Preemptive Analgesia on Tourniquet and Postoperative Pain Relief in Open Carpal Tunnel Release: A Prospective Randomized Control Trial.

PURPOSE: Preemptive analgesia has been used to reduce postsurgery pain and improve patient satisfaction. The effectiveness of multimodal preemptive analgesia in open carpal tunnel release under local anesthetic with a tourniquet is still debated. This study aimed to determine the effectiveness of preemptive analgesia on the postoperative tourniquet site and the surgical site. METHODS: A total of 44 patients were randomly assigned to one of 2 groups. An experimental group was given 300 mg of gabapentin, 200 mg of celecoxib, and 500 mg of acetaminophen 2 hours before surgery. Placebos were given to the control group. All surgeries were done under local anesthetic by a specialist hand surgeon. A tourniquet was inflated to the recommended pressure. The outcomes included the immediate postoperative tourniquet site pain scores, surgical site pain scores (at 1, 6, 12, 18, and 24 hours after surgery), and acetaminophen consumption in the first 48 hours. RESULTS: The immediate postoperative tourniquet site pain score in the experimental group was significantly lower than in the placebo group. Although the surgical site pain score in the experimental group was significantly lower than the placebo group at 1, 6, 12, and 18 hours after surgery, these differences were not clinically significant. In addition, there was no statistically significant difference in surgical site pain score at 24 hours after surgery. The amount of acetaminophen consumed during the first 48 hours after surgery was significantly lower in the experimental group than in the placebo group. CONCLUSIONS: Multimodal preemptive analgesia effectively reduced immediate postoperative pain at the tourniquet site in open carpal tunnel release. It also reduced postoperative acetaminophen consumption. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Benefits of early application of pelvic circumferential compression device to reduce bleeding in pelvic fractures.

BACKGROUND: To study of efficacy of early pelvic circumferential compression device using in patients with suspected pelvic trauma, compared with conventional stepwise approach. METHODS: Traumatic injury and at least one of the following criteria are required for inclusion: loss of consciousness or a Glasgow coma score (GCS) of less than 13; systolic blood pressure less than 90 mmHg; falling from more than 6 m; injury to several important organs; and a positive pelvic compression test. Patients who satisfied the inclusion criteria for the experimental group were given an early application of a commercial pelvic sling beginning in July 2019. The control group consisted of cases who got the device after clinical or radiological confirmation of a pelvic fracture in the previous year. Gender, age, mechanism of injury, GCS, hospital stay, amount of packed red blood cell transfusion, hematocrit in emergency room, and hematocrit 24 h after application of pelvic binder were all assessed and compared. RESULTS: The study had a total of 30 participants, with 15 in each group. The number of packed red blood cell transfusions in the early pelvic binder group (0.80 ± 1.42) is considerably lower than in the control group (2.4 ± 2.32) (P = 0.008), although the hematocrit change is not statistically different between the groups (2.1 VS 0.7) (P = 0.191). The time it took to install a pelvic binder was considerably shorter in the early pelvic binder group (16.40 ± 5.45) than in the control group (40.40 ± 13.64) (P = 0.001). There were no problems associated to soft tissue and skin necrosis in either group of patients. CONCLUSIONS: The use of the PCCD for 24 h prior to clinical and radiographic confirmation has significantly reduced the rate of packed red blood cell transfusion in any pelvic fracture patient without device-related complications. TRIAL REGISTRATION: The study was entered into the Thai Clinical Trials Registry ( TCTR20210809007 ).

Double-row fixation of the transferred coracoid process: a rescue technique for intraoperative coracoid fracture during the Latarjet procedure.

BACKGROUND: The Latarjet procedure is the preferred method to treat recurrent anterior shoulder instability with glenoid deficiency. An iatrogenic fracture of the transferred coracoid process is one possible intraoperative complication. METHODS: We propose a rescue technique using double-row suture bridge fixation. Double-loaded 4.5-mm suture anchors were placed medially in the scapular neck. These sutures were then brought over the top of the coracoid fragment, placed around the bony fragment, and fixated to the glenoid face with knotless suture anchors. RESULTS: Radiologic evidence of bone graft healing was observed in the desired position. CONCLUSIONS: We present a salvage procedure that will assist surgeons if an intraoperative fracture of the coracoid bone graft occurs during fixation when performing the Latarjet procedure.

Subscapularis tenotomy versus lesser tuberosity osteotomy during total shoulder arthroplasty for primary osteoarthritis: a prospective, randomized controlled trial.

BACKGROUND: There is no current consensus on subscapularis mobilization during total shoulder arthroplasty. The purpose of this prospective, randomized controlled trial was to compare functional and radiographic outcomes of the more traditional subscapularis tenotomy (ST) versus lesser tuberosity osteotomy (LTO). METHODS: This study enrolled 60 shoulders in 59 patients with primary osteoarthritis. Thirty shoulders were preoperatively randomized to each group. Preoperative and 6-week, 3-month, 6-month, and 1-year postoperative data were collected. Ultrasound was performed at 3 months to evaluate subscapularis healing in tenotomy subjects, whereas radiographs were used to evaluate osteotomy healing. Intraoperative data included operative time, tenotomy or osteotomy repair time, and osteotomy thickness. RESULTS: No significant differences in range of motion or clinical outcomes occurred at baseline or 1 year postoperatively between the 2 groups. The mean total case duration for ST was significantly less than that for LTO (129.3 minutes vs 152.7 minutes), along with a significantly shorter subscapularis repair time for ST (34.3 minutes vs 39.3 minutes, P = .024). At final follow-up, 27 of 29 LTO shoulders (93.1%) showed bone-to-bone healing on radiographs, whereas 26 of 30 ST shoulders (86.7%) had no full-thickness tear of the subscapularis on ultrasound at 3 months. CONCLUSIONS: Both techniques produced successful objective and subjective clinical outcomes. LTO heals more reliably than ST. Mean total case and subscapularis repair times were significantly greater for LTO than for ST.

Arthroscopic extra-articular suprapectoral biceps tenodesis with knotless suture anchor.

Tenodesis of the long head of the biceps tendon is a frequently performed procedure during shoulder arthroscopy. Various open and arthroscopic techniques have been described with comparable outcomes and complication rates. We describe a simple, knotless, arthroscopic extra-articular biceps tenodesis technique using a 4.5-mm knotless anchor. This technique avoids the complications associated with open tenodesis surgery while still removing the diseased biceps tendon from the bicipital groove. The benefits from knotless suture anchor include no requirement of arthroscopic knot tying and no risk of the knot irritation under the coracoid and coracoacromial ligament.

Diagnostic accuracy of the shaft-condylar angle for an incomplete supracondylar fracture of elbow in children.

OBJECTIVE: The incomplete supracondylar fracture of distal humerus poses difficulty for diagnosis. A shaft-condylar angle and a lateral capitellohumeral angle, which can be measured from a routine lateral view of plain film of the injured elbow, may be a clue to assist in the diagnosis. Nevertheless, no literature explains about the accuracy of these angles for diagnosis. Our goal is to investigate the accuracy, sensitivity, specificity, positive predictive value and negative predictive value of the shaft-condylar angle and the lateral capitellohumeral angle for diagnosis of the incomplete supracondylar fracture. METHODS: The retrospective study in tertiary care hospital was performed from January, 2014, to January, 2018. The patients aged below 15 years with elbow injury were recruited. The patients with complete fracture were excluded. The rest of the patients were divided into four groups which consisted of incomplete fracture and non-fracture group. With the shaft-condylar angle at 40° and the lateral capitellohumeral angle at 50°, the diagnostic accuracy of both angles were calculated. RESULTS: A total number of patients were 53. For the SCA, the accuracy was 92%, the sensitivity was 76%, the specificity was 93%, the positive predictive value was 92% and the negative predictive value was 93%. For the LCHA, the accuracy was 70%, the sensitivity was 55%, the specificity was 72%, the positive predictive value was 67% and a negative predictive value was 72%. CONCLUSION: The shaft-condylar angle less than 40° in lateral elbow film might be a useful tool for diagnosis of the incomplete supracondylar fracture in pediatric patients with elbow injury.

Demographic Causes of Chronic Lateral Elbow Pain along Arthroscopic Criteria.

Objective: We conducted this study in order to find out the demographic causes of pathology for chronic lateral elbow pain along arthroscopic criteria. Material and Method: We conducted descriptive study of the medical records of the patients with chronic lateral elbow pain who refractory to conservative treatment. Diagnostic arthroscopy of the elbow was performed by a specialist in elbow surgery at HRH Princess Maha Chakri Sirindhorn Medical Center from March 2011 to October 2014. Results: There were 29 patients who met inclusion criteria in our study. With regard to intra-articular pathologies, we found a radiocapitellaplica in 41% of the patients. In 21% of the patients, we found isolated tennis elbow. The concomitant radiocapitellaplica and tennis elbow were also found in 21% of patients. Cartilage lesion was found in 10% of the patients and plica with posterolateral impingement was found in 7% of patients. Conclusion: Causes of the chronic lateral elbow pain are complex. The diagnosis should be made by precise clinical sign and proper investigations. In our series, the lateral epicondylitis was not the majority cause of chronic lateral elbow pain. The benefits of arthroscopy are not just the minimal invasive approach directly to the lesion, but also the intra-articular and dynamic investigation allow the surgeon to make sure that all pathology were treated.

Autologous Fibrin-Base Scaffold for Chondrocytes and Bone Marrow Mesenchymal Stem Cells Implantation: The Development and Comparison to Conventional Fibrin Glue.

Objective: The authors developed the autologous fibrin-base scaffold for chondrocytes and bone marrow mesenchymal stem cells (BM-MSCs) implantation and evaluated cells viability in autologous fibrin-base scaffold comparing to commercial fibrin glue. Material and Method: The chondrocytes and BM-MSCs were seeded into autologous fibrin-base scaffold and commercial fibrin glue. The cell viability and proliferation were evaluated at 1 and 7 days. The histology were evaluated with hematoxylineosin (H&E) staining and cartilaginous matrices formation with Alcian blue, Saffanin-0, Toluidine blue, and Collagen type II staining at 6 weeks. The fixation of the scaffolds was observed. Results: The chondrocytes and BM-MSCs could not survive in commercial fibrin glue. The chondrocytes and BM-MSCs in autologous fibrin-base scaffold could proliferate and synthesize the cartilaginous matrices on Alcian blue, Saffanin-0, Toluidine blue, and Collagen type II staining at 6 weeks. The fixation strength is excellent. Conclusion: The developed autologous fibrin-base scaffold can be used as the scaffold for chondrocytes and BM-MSCs implantation with potential to implant chondrocytes and BM-MSCs arthroscopically.

Optimizing pectoralis major tendon repair: a modified knotless suture anchor technique using high-strength suture and tape.

Background: Rupture of the pectoralis major (PM) tendon is infrequent but has shown an increased incidence in athletes, particularly weightlifters during bench presses. Various techniques for repair exist, yet no established gold standard has been defined. Methods: We present a modified surgical technique utilizing knotless suture anchors for PM tendon repair. The technique involves bringing the tendon end superiorly and inferiorly to the decorticated bone surface, ensuring broader tendon-to-bone contact. Knotless anchors with a unique suture locking mechanism facilitate tension adjustment. Additionally, the repair's strength is reinforced by employing both surgical tape and high-strength suture. Results: The utilization of both surgical tape and high-strength suture in conjunction with knotless suture anchors provides a secure and stable construct. This approach minimizes the risk of failure, reduces the potential for neurovascular injury associated with bicortical drilling, preserves imaging quality due to the absence of metal artifacts, and helps avoid the risk of fracture associated with traditional methods. However, surgeons should be aware of a potential disadvantage of increased surgical costs compared to traditional techniques. Conclusion: Our modified technique offers multiple advantages, including increased tendon-to-bone contact, enhanced stability, reduced neurovascular risks, and avoidance of potential fractures. This makes it a valuable option for successful PM tendon repairs. Surgeons should consider its benefits and weigh them against the associated costs for optimal patient care.

Transcending Patient Morphometry: Acromiohumeral Interval to Glenoid Ratio as a Universal Diagnostic Tool for Massive Rotator Cuff Tears.

Background: Morphological differences among various ethnicities can significantly impact the reliability of acromiohumeral interval (AHI) measurements in diagnosing massive rotator cuff tears. This variation raises questions about the generalizability of AHI studies conducted in Western populations to the Asian population. Consequently, the primary objective of this study was to develop a novel parameter that can enhance the diagnosis of massive rotator cuff tears, irrespective of morphometric disparities between individuals of different ethnic backgrounds. Methods: A 10-year retrospective analysis of shoulder arthroscopic surgery patients was conducted, categorizing them into 3 groups based on intraoperative findings: those without rotator cuff tears, those with non-massive tears, and those with massive tears. AHI-glenoid ratio (AHIGR) was measured by individuals with varying academic backgrounds, and its diagnostic performance was compared to AHI. Sensitivity, specificity, accuracy, and intra- and inter-rater reliability were evaluated. Results: AHIGR exhibited significantly improved sensitivity, specificity, and accuracy as a diagnostic tool for massive rotator cuff tears, compared to AHI. A proposed cut-off point of AHIGR ≤ 0.2 yielded comparable results to AHI < 7 mm. Intra- and inter-rater reliability was excellent among different observers. Conclusions: AHIGR emerges as a promising diagnostic tool for massive rotator cuff tears, offering improved sensitivity and specificity compared to AHI. Its reproducibility among diverse observers underscores its potential clinical utility. While further research with larger and more diverse patient cohorts is necessary, AHIGR offers significant potential as a reference for enhancing the assessment of massive rotator cuff tears.

New anti-diabetic agents for the treatment of non-alcoholic fatty liver disease: a systematic review and network meta-analysis of randomized controlled trials.

Objectives: This network meta-analysis aims to compare the efficacy and safety of new anti-diabetic medications for the treatment of non-alcoholic fatty liver disease (NAFLD). Materials and methods: PubMed and Scopus were searched from inception to 27th March 2022 to identify all randomized controlled trials (RCTs) in NAFLD patients. Outcomes included reductions in intrahepatic steatosis (IHS) and liver enzyme levels. The efficacy and safety of DPP-4 inhibitors, GLP-1 agonists, SGLT-2 inhibitors, and other therapies were indirectly compared using a NMA approach. Unstandardized mean difference (USMD) with 95% confidence intervals (CI) were calculated. Results: 2,252 patients from 31 RCTs were included. "Add-on" GLP-1 agonists with standard of care (SoC) treatment showed significantly reduced IHS compared to SoC alone [USMD (95%CI) -3.93% (-6.54%, -1.33%)]. Surface under the cumulative ranking curve (SUCRA) identified GLP-1 receptor agonists with the highest probability to reduce IHS (SUCRA 88.5%), followed by DPP-4 inhibitors (SUCRA 69.6%) and pioglitazone (SUCRA 62.2%). "Add-on" GLP-1 receptor agonists were also the most effective treatment for reducing liver enzyme levels; AST [USMD of -5.04 (-8.46, -1.62)], ALT [USMD of -9.84 (-16.84, -2.85)] and GGT [USMD of -15.53 (-22.09, -8.97)] compared to SoC alone. However, GLP-1 agonists were most likely to be associated with an adverse event compared to other interventions. Conclusion: GLP-1 agonists may represent the most promising anti-diabetic treatment to reduce hepatic steatosis and liver enzyme activity in T2DM and NAFLD patients. Nevertheless, longer-term studies are required to determine whether this delays progression of liver cirrhosis in patients with NAFLD and T2DM. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42021259336.1.

Comparative cardiovascular benefits of individual SGLT2 inhibitors in type 2 diabetes and heart failure: a systematic review and network meta-analysis of randomized controlled trials.

Background: In patients with type 2 diabetes (T2D) and a history of heart failure (HF), sodium-glucose cotransporter-2 inhibitors (SGLT2is) have demonstrated cardiovascular (CV) benefits. However, the comparative efficacy of individual SGLT2is remains uncertain. This network meta-analysis (NMA) compared the efficacy and safety of five SGLT2is (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, and sotagliflozin) on CV outcomes in these patients. Materials and methods: PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched up to September 23, 2022, to identify all randomized controlled trials (RCTs) comparing SGLT2is to placebo in T2D patients with HF. The main outcomes included composite CV death/heart failure hospitalization (HFH), HFH, CV death, all-cause mortality, and adverse events. Pairwise and NMA approaches were applied. Results: Our analysis included 11 RCTs with a total of 20,438 patients with T2D and HF. All SGLT2is significantly reduced HFH compared to standard of care (SoC) alone. "Add-on" SGLT2is, except ertugliflozin, significantly reduced composite CV death/HFH relative to SoC alone. Moreover, canagliflozin had lower composite CV death/HFH compared to dapagliflozin. Based on the surface under the cumulative ranking curve (SUCRA), the top-ranked SGLT2is for reducing HFH were canagliflozin (95.5%), sotagliflozin (66.0%), and empagliflozin (57.2%). Head-to-head comparisons found no significant differences between individual SGLT2is in reducing CV death. "Add-on" SGLT2is reduced all-cause mortality compared with SoC alone, although only dapagliflozin was statistically significant. No SGLT2is were significantly associated with serious adverse events. A sensitivity analysis focusing on HF-specific trials found that dapagliflozin, empagliflozin, and sotagliflozin significantly reduced composite CV death/HFH, consistent with the main analysis. However, no significant differences were identified from their head-to-head comparisons in the NMA. The SUCRA indicated that sotagliflozin had the highest probability of reducing composite CV death/HFH (97.6%), followed by empagliflozin (58.4%) and dapagliflozin (44.0%). Conclusion: SGLT2is significantly reduce the composite CV death/HFH outcome. Among them, canagliflozin may be considered the preferred treatment for patients with diabetes and a history of heart failure, but it may also be associated with an increased risk of any adverse events compared to other SGLT2is. However, a sensitivity analysis focusing on HF-specific trials identified sotagliflozin as the most likely agent to reduce CV death/HFH, followed by empagliflozin and dapagliflozin. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022353754.

Efficacy and Safety of Antibiotic Impregnated Microporous Nanohydroxyapatite Beads for Chronic Osteomyelitis Treatment: A Multicenter, Open-Label, Prospective Cohort Study.

Chronic osteomyelitis is still a serious health problem that causes disabling conditions and has an impact on the quality of life. The objective of this study was to determine the clinical efficacy and safety of localized antibiotics delivery via impregnated microporous nanohydroxyapatite (nHA-ATB) beads for chronic osteomyelitis treatment. A total of 62 patients were enrolled in this study. After radical surgical debridement, the bone defect was filled with three types of antibiotics (vancomycin or gentamicin or fosfomycin) impregnated HA beads. The follow-up period was 48 weeks. It was found that the success rate was approximately 98% with a re-infection in only one patient. Quality of life of all patients after treatment improved significantly over time. Systemic exposure to vancomycin and gentamicin after beads implantation was limited and high local antibiotics concentrations were found in wound drainage fluid at 24, 48 and 72 h. Blood biochemistry measurements did not show any nephrotoxic or hepatotoxic effects. 20 adverse events were reported, but 90% of the events were resolved without having to remove the beads and the patients recovered. Satisfactory outcomes were observed in terms of success rate, quality of life and adverse effect. nHA-ATB beads impregnated by vancomycin or gentamicin or fosfomycin could potentially be employed as an alternative product of choice for localized antibiotics delivery in chronic osteomyelitis treatment.

Validation of the telemedicine-based goniometry for measuring elbow range of motion.

OBJECTIVE: To examine the validity of a Telemedicine-Based for measuring elbow range of motion. MATERIAL AND METHOD: Cross-sectional descriptive studies in elbow flexion-extension and forearm pronation-supination were measured on 30 subjects. RESULTS: The intraclass correlation (ICC) and the percentage of degree of difference within fifteen and ten degrees between measurements obtained by telemedicine-based technique (VDO-clip) and clinical goniometry were found high percentage of correlation inflexion and extension. Pronation and supination, although not as good as flexion and extension, still showed some degree of correlation. CONCLUSION: Remote range of motion assessment using telemedicine-based is technically feasible.

Number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation is associated with complication rate.

INTRODUCTION: Surgical treatment of distal humerus fractures can lead to numerous complications. Data suggest that the number of screws in the distal (articular) segment may be associated with complication rate. The purpose of this study is to evaluate the association between a number of screws in the distal segment and complication rate for surgical treatment of distal humerus fractures. We hypothesize that the number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation (ORIF) will be inversely proportional to the complication rate. METHODS: We performed a single-center retrospective cohort study of 27 patients who underwent ORIF of distal humerus fractures C-type with at least six months of radiographic and clinical follow-up. Clinical outcomes including a range of motion, pain, revision surgery for stiffness and/or heterotopic ossification (HO), nonunion, and persistent ulnar nerve symptoms requiring revision neurolysis were recorded. RESULTS: In C-type fractures, the use of three or fewer articular screws was significantly associated with nonunion or loss of fixation (RR 17, p = 0.006). Nineteen of 36 (53%) patients experienced at least one complication. The surgical approach, plate configuration, age, and ulnar nerve treatment (none, in situ release, transposition) were not associated with the need for revision surgery. Men had a higher risk of requiring surgical contracture release due to improving post-operative stiffness (RR 12, p = 0.02). CONCLUSION: In this retrospective study, the use of three or fewer screws to fix articular fragments in AO type C fractures was a significant risk for nonunion or loss of fixation. Plate configuration and surgical approach did not correlate with outcomes. Men had higher rates of complications and required more frequent revision surgery compared to women.

Reliability of the radiographic views in supine position for evaluation of displaced midshaft clavicle fracture length.

PURPOSE: To analyze the agreement of the displaced midshaft clavicle fracture length measurement between each of the supine radiographic position (chest anteroposterior (AP), both clavicle AP, and 20° cephalic tilt clavicle AP view) and computed tomography (CT) scan of the clavicle. Furthermore, the inter- and intraobserver reliability of each radiographic position was analyzed. METHODS: Prospective cross-sectional study was performed with patients diagnosed with displaced midshaft clavicle fracture treated conservatively. Three views of radiographs and CT scan of clavicle were obtained in supine position after informed consent. The measurement of fractured clavicle length was done by three observers at the time and after 4 weeks interval. RESULTS: Thirty-three patients (25 males and 8 females), with a mean age of 45, were recruited. The agreement between each of the radiographic measurement and CT scan was good. The interobserver reliability was moderate to good for radiographic measurement. The highest intraclass correlation coefficient (ICC) of 0.80-0.81 was shown between the 20° cephalic tilt and the CT scan, followed by the both clavicle AP (0.75-0.77) and the chest AP (0.69-0.75), respectively. There was an excellent intraobserver reliability for all of the radiographic measurement with the ICC 0.92-0.99. CONCLUSION: The supine radiographs could be a useful option to measure the displaced midshaft clavicle fracture length. The recommended view was the 20° cephalic tilt clavicle AP view in supine position to best evaluate the fractured clavicle length.

The acromion in supraspinatus outlet and Rockwood caudal tilt views from three-dimensional computed tomography scan of the shoulder.

BACKGROUND: A hooked acromion on an outlet view and a keeled acromion on Rockwood tilt radiographs are associated with rotator cuff tears. The identification of the acromial morphology may be helpful for acromioplasty planning with regarding the acromial types. METHODS: Descriptive Laboratory Study. Three-dimensional computed tomography scans models of 108 shoulders in 91 patients with; (1) Normal shoulders, (2) Shoulders with osteoarthritis, and (3) Irreparable rotator cuff tears; were created and adjusted manually to provide the proper supraspinatus outlet and Rockwood views. The acromial morphology/spurs were analyzed, classified and tested for reliability. RESULTS: The intra-observer reliability of supraspinatus outlet view had a weak-to-strong agreement [0.828 (95%CI: 0.716-0.945, p-value<0.001), and 0.475 (95%CI: 0.288-0.672, p-value<0.001 from 2 evaluators]. The inter-rater of the supraspinatus outlet view has a minimal-to-moderate agreement [0.782 (95%CI: 0.662-0.907, p-value<0.001), and 0.344 (95%CI: 0.157-0.539, p-value<0.001) in the first and second readings]. The intra-observer reliability of the Rockwood view has a moderate-to-almost-perfect agreement [0.752 (95%CI: 0.652-0.860, p-value<0.001), and 0.903 (95%CI: 0.833-0.974, p-value<0.001) from 2 evaluators]. The inter-observer reliability of the Rockwood view has a moderate-to-strong agreement [0.854 (95%CI: 0.777-0.936, p-value<0.001), and 0.737 (95%CI: 0.634-0.847, p-value<0.001) in the first and second readings]. CONCLUSION: The classification of acromion morphology under Three-dimensional computed tomography in the supraspinatus outlet view has poor reliability. The Rockwood caudal tilt view model results in moderate-to-almost-perfect reliability that can be developed to the plain radiographic classification to determine the need for acromioplasty in rotator cuff surgery.

Morphological classification of acromial spur: correlation between Rockwood tilt view and arthroscopic finding.

Purpose and hypothesis: Acromion spur is the extrinsic factor for impingement syndrome and rotator cuff tear. The Rockwood tilt view can be used to evaluate prominence of the anterior acromion, however no study has shown the correlation of findings between the Rockwood tilt view and the arthroscopic finding. METHODS: We developed the arthroscopic classification of acromion spur as type 1 flat spur, type 2 bump spur, type 3 heel spur, type 4 keel spur, and type 5 irregular spur. Patients with rotator cuff syndrome who underwent arthroscopic surgery were recruited. Two observers were asked to classify the type of spur from arthroscopic findings and Rockwood tilt views separately in random pattern. The prevalence of supraspinatus tendon tear was also recorded as no tear, partial-thickness tear, and full-thickness tear. RESULTS: The keel spur (33.9%) was the most common finding followed by the heel spur (27.8%). The correlation was high especially for the heel, the keel, and the irregular spur (75.47%, 74.03%, and 72.73%, respectively.) These three types of spurs have a high prevalence of full thickness of supraspinatus tendon tear. CONCLUSION: The Rockwood tilt view can be used to evaluate the morphology of an acromion spur, especially the at-risk spur that correlates highly with the full-thickness supraspinatus tendon tear. The arthroscopic classification will also be a useful tool to improve communication between the surgeon and the guide for appropriate treatment in a rotator cuff tear patient when encountering the heel, keel, and irregular spur.

Posterior Horn of Medial Meniscal Peripheral Capsular Lesion: The Arthroscopic Repair Technique Working in the Posterior Compartment.

A posterior horn of medial meniscal peripheral capsular is usually associated with the anterior cruciate ligament injury. The conventional repair technique with the camera in the anterolateral portal cannot precisely restore the slope capsular synovium to the original attachment point. We present the arthroscopic technique for improving the accuracy and quality of the repair by working in the posterior compartment. When the posterolateral portal is used as the viewing portal, the accuracy of repair is improved because we can assess the full extent of the lesion and lift the sagging peripheral tissue to the more central part.