The novel dynamic MPFL-reconstruction technique: cheaper and better?

PURPOSE: Reconstruction of the medial patellofemoral ligament (MPFL) is an established procedure to restore patellar stability. Aim of this study is to evaluate the results of a dynamic MPFL reconstruction technique in a large university hospital setting. METHODS: Two hundred and thirteen consecutive patients with 221 knees were surgically treated for recurrent lateral patellar dislocation. All patients obtained dynamic reconstruction of the MPFL with detachment of the gracilis tendon at the pes anserinus while maintaining the proximal origin at the gracilis muscle. Patellar fixation was performed by oblique transpatellar tunnel transfer. Follow-up data including Kujala and BANFF score, pain level as well as recurrent patella instability were collected at a minimum follow-up of 2 years. RESULTS: Follow-up could be obtained from 158 patients (71%). The mean follow-up time was 5.4 years. Mean pain level was 1.9 ± 2.0 on the VAS. Mean Kujala score was 78.4 ± 15.5. Mean BANFF score was 62.4 ± 22.3. MPFL-reconstructions that were performed by surgeons with a routine of more than ten procedures had a significantly shorter surgical time 52.3 ± 17.6 min. Male patients yielded higher satisfaction rates and better clinical scores compared to females. Complications occurred in 27.2% of procedures, 20.9% requiring revision surgery of which were 9.5% related to recurrent patellar instability. 78% of all patients indicated they would undergo the procedure again. CONCLUSION: Dynamic MPFL reconstruction presents a reproducible procedure with increased complication rates, inferior to the results of static reconstruction described in the literature. Despite, it appears to be an efficient procedure to restore patellar stability in a large university hospital setting, without the necessity for intraoperative fluoroscopy. TRIAL REGISTRATION: The study was registered in ClinicalTrials.gov with the registration number NCT04438109 on June 18th 2020.

Quadriceps and hamstring tendon autografts in ACL reconstruction yield comparably good results in a prospective, randomized controlled trial.

INTRODUCTION: Comparable data of functional outcomes of anterior cruciate ligament reconstruction using either hamstring- or quadriceps tendon grafts is controversial. This prospective, randomized controlled trial aims to provide data comparing both grafts regarding the functional outcome. MATERIALS AND METHODS: A two centre trial involving symptomatic patients 18 years of age or older with an anterior cruciate ligament tear was conducted. We randomly assigned 27 patients to quadruple hamstring tendon reconstruction and 24 to quadriceps tendon reconstruction. The patients were evaluated preoperatively, at 3, 6, 12 and 24 months post-surgery. The primary outcome parameter was the side-to-side knee laxity measured with an arthrometer. Secondary outcomes included results in the International Knee Documentation Committee (IKDC) and Lysholm Scores and isokinetic testing of strength in knee extension and flexion. RESULTS: Forty-four patients (86%) completed the 2-year follow-up. There was significantly improved knee stability at all time intervals with no difference between the two study groups. The manual side-to-side displacement improved by 4.7 ± 3.0 mm in patients with hamstring tendon reconstruction and 5.5 ± 2.9 mm in patients with quadriceps tendon reconstruction. In addition, muscle strength and outcome scores (IKDC and Lysholm Score) did not show any differences between the hamstring tendon group and the quadriceps tendon group. Patients in the hamstring tendon group returned to their pre-injury activity level after 95.2 ± 45.5 days while patients in the quadriceps tendon group needed 82.1 ± 45.6 days. CONCLUSION: Quadriceps and hamstring tendon autografts yield comparably good results in primary anterior cruciate ligament reconstruction.

Management, outcome, and novel classification system of periprosthetic fractures in patients with transcutaneous osseointegrated prosthetic systems (TOPS)-a retrospective cohort analysis.

INTRODUCTION: Transcutaneous osseointegrated prosthetic systems (TOPS) are anchored prosthetic systems for major limb loss. Sometimes TOPS patients suffer from periprosthetic fractures. The aim of this study was to analyze the management and outcomes of periprosthetic fractures in patients with TOPS and to introduce a novel classification system for this entity. MATERIAL/METHODS: Since 2010, 140 patients were treated with TOPS after transfemoral amputation in two centers in Germany. Fifteen patients sustained periprosthetic fractures, with five intra- and ten postoperative fractures. The outcome was analyzed by Prosthesis Mobility Questionnaire (PMQ), K-level and prosthesis wear time per day. A subgroup analysis for the body mass index (BMI) was performed. RESULTS: All postoperative fractures were treated with implant-retaining osteosynthesis. Fourteen fractures healed without complications after a mean of 3 months. One postoperative fracture developed a clinically asymptomatic firm non-union. No Endo-Fixstem had to be removed. For the fracture and control group, a significant increase of the PMQ (p < 0.001) and K-level (p < 0.001) was observed after TOPS treatment compared to the preoperative baseline. Furthermore, the subgroup analysis showed a significant increase of the PMQ and K-level for both normal weight (p = 0.002) and overweight patients (p < 0.001). Of interest, overweight patients even showed a significantly higher increase in scores compared to normal weight patients, regardless of periprosthetic fracture. CONCLUSION: Periprosthetic fractures do not necessarily worsen outcomes of TOPS treatment. Proper classification and standardized appropriate treatment strategies according to fracture morphology are paramount for reliably good outcomes. We recommend to not remove or exchange the implant (Endo-Fixstem) even if it is assembly. Higher BMI did not have an impact onto rehabilitation success after TOPS to major limb loss of the lower extremity.

Salivary cortisol levels and anxiety in melanoma patients undergoing sentinel lymph node excision under local anesthesia versus general anesthesia: a prospective study.

BACKGROUND: Sentinel lymph node excision (SLNE) can be performed in tumescent local anesthesia (TLA) or general anesthesia (GA). Perioperative cortisol level changes and anxiety are common in surgical interventions and might be influenced by the type of anesthesia. In this study, we intended to determine whether the type of anesthesia impacts the patients' perioperative levels of salivary cortisol (primary outcome) and the feeling of anxiety evaluated by psychological questionnaires (secondary outcome). METHODS: All melanoma patients of age undergoing SLNE at the University Hospital Essen, Germany, could be included in the study. Exclusion criteria were patients' intake of glucocorticoids or psychotropic medication during the former 6 months, pregnancy, age under 18 years, and BMI ≥ 30 as salivary cortisol levels were reported to be significantly impacted by obesity and might confound results. RESULTS: In total, 111 melanoma patients undergoing SLNE were included in our prospective study between May 2011 and April 2017 and could choose between TLA or GA. Salivary cortisol levels were measured three times intraoperatively, twice on the third and second preoperative day and twice on the second postoperative day. To assess anxiety, patients completed questionnaires (Hospital Anxiety and Depression Scale (HADS), State-Trait Anxiety Inventory (STAI)) perioperatively. Patients of both groups exhibited comparable baseline levels of cortisol and perioperative anxiety levels. Independent of the type of anesthesia, all patients showed significantly increasing salivary cortisol level from baseline to 30 min before surgery (T3) (TLA: t = 5.07, p < 0.001; GA: t = 3.09, p = 0.006). Post hoc independent t tests showed that the TLA group exhibited significantly higher cortisol concentrations at the beginning of surgery (T4; t = 3.29, p = 0.002) as well as 20 min after incision (T5; t = 277, p = 0.008) compared to the GA group. CONCLUSIONS: The type of anesthesia chosen for SLNE surgery significantly affects intraoperative cortisol levels in melanoma patients. Further studies are mandatory to evaluate the relevance of endogenous perioperative cortisol levels on the postoperative clinical course. TRIAL REGISTRATION: German Clinical Trials Register DRKS00003076, registered 1 May 2011.

A Dermatologist's Ammunition in the War Against Smoking: A Photoaging App.

This viewpoint reviews the perspectives for dermatology as a specialty to go beyond the substantial impact of smoking on skin disease and leverage the impact of skin changes on a person's self-concept and behavior in the design of effective interventions for smoking prevention and cessation.

Photoaging Mobile Apps in School-Based Melanoma Prevention: Pilot Study.

BACKGROUND: Around 90% of melanomas are caused by exposure to ultraviolet (UV) radiation and are therefore eminently preventable. Tanning behavior is mostly initiated in early adolescence, often with the belief that it increases attractiveness; the problems related to malignant melanoma and other skin cancers are too far in the future to fathom. Given the substantial amount of time children and adolescents spend in schools, as well as with their mobile phones, addressing melanoma prevention via both of these ways is crucial. However, no school-based intervention using mobile apps has been evaluated to date. We recently released a photoaging mobile app, in which a selfie is altered to predict future appearance dependent on UV protection behavior and skin type. OBJECTIVE: In this pilot study, we aimed to use mobile phone technology to improve school-based melanoma prevention and measure its preliminary success in different subgroups of students with regard to their UV protection behavior, Fitzpatrick skin type and age. METHODS: We implemented a free photoaging mobile phone app (Sunface) in 2 German secondary schools via a method called mirroring. We "mirrored" the students' altered 3-dimensional (3D) selfies reacting to touch on mobile phones or tablets via a projector in front of their whole grade. Using an anonymous questionnaire capturing sociodemographic data as well as risk factors for melanoma we then measured their perceptions of the intervention on a 5-point Likert scale among 205 students of both sexes aged 13-19 years (median 15 years). RESULTS: We measured more than 60% agreement in both items that measured motivation to reduce UV exposure and only 12.5% disagreement: 126 (63.0%) agreed or strongly agreed that their 3D selfie motivated them to avoid using a tanning bed, and 124 (61.7%) to increase use of sun protection. However, only 25 (12.5%) disagreed with both items. The perceived effect on motivation was increased in participants with Fitzpatrick skin types 1-2 in both tanning bed avoidance (n=74, 71.8% agreement in skin types 1-2 vs n=50, 53.8% agreement in skin types 3-6) and increased use of sun protection (n=70, 68.0% agreement in skin types 1-2 vs n=52, 55.3% agreement in skin types 3-6), and also positively correlated with higher age. CONCLUSIONS: We present a novel way of integrating photoaging in school-based melanoma prevention that affects the students' peer group, considers the predictors of UV exposure in accordance with the theory of planned behavior, and is particularly effective in changing behavioral predictors in fair-skinned adolescents (Fitzpatrick skin types 1-2). Further research is required to evaluate the intervention's prospective effects on adolescents of various cultural backgrounds.

Cost-Effectiveness of Arthroscopic Rotator Cuff Repair Versus Reverse Total Shoulder Arthroplasty for the Treatment of Massive Rotator Cuff Tears in Patients With Pseudoparalysis and Nonarthritic Shoulders.

PURPOSE: To determine the most cost-effective treatment strategy for patients with massive rotator cuff tears and pseudoparalysis of the shoulder without osteoarthritis of the glenohumeral joint (PP without OA). Specifically, we aimed to compare arthroscopic rotator cuff repair (ARCR) versus reverse total shoulder arthroplasty (RTSA) and investigate the effect of patient age on this decision. METHODS: A Markov decision model was used to compare 3 treatment strategies for addressing PP without OA: (1) ARCR with option to arthroscopically revise once, (2) ARCR with immediate conversion to RTSA on potential failure, and (3) primary RTSA. Hypothetical patients were cycled through the model according to transition probabilities, meanwhile accruing financial costs, utility for time in health states, and disutilities for surgical procedures. Utilities were derived from the Short Form-6D scale and expressed as quality-adjusted life-years. Model parameters were derived from the literature and from expert opinion, and thorough sensitivity analyses were conducted. TreeAge Pro 2015 software was used to construct and assess the Markov model. RESULTS: For the base-case scenario (60-year-old patient), ARCR with conversion to RTSA on potential failure was the most cost-effective strategy when we assumed equal utility for the ARCR and RTSA health states. Primary RTSA became cost-effective when the utility of RTSA exceeded that of ARCR by 0.04 quality-adjusted life-years per year. Age at decision did not substantially change this result. CONCLUSIONS: Primary ARCR with conversion to RTSA on potential failure was found to be the most cost-effective strategy for PP without OA. This result was independent of age. Primary ARCR with revision ARCR on potential failure was a less cost-effective strategy. LEVEL OF EVIDENCE: Level IV, economic and decision analysis.

Computed tomography-based prediction of the straight antegrade humeral nail's entry point and exposure of "critical types": truth or fiction?

BACKGROUND: Straight antegrade intramedullary nailing of proximal humerus fractures has shown promising clinical results. However, up to 36% of all humeri seem to be "critical types" in terms of the potential violation of the supraspinatus (SSP) tendon footprint by the nail's insertion zone. The aims of this study were to evaluate if a computed tomography (CT) scan could reliably predict the nail's entry point on the humeral head and if it would be possible to preoperatively estimate the individual risk of iatrogenic violation of the SSP tendon footprint by evaluating the uninjured contralateral humerus. METHODS: Twenty matched pairs of human cadaveric shoulders underwent CT scans, and the entry point for an antegrade nail as well as measurements regarding critical distances between the entry point and the rotator cuff were determined. Next, gross anatomic measurements of the same data were performed and compared. Furthermore, specimens were reviewed for critical types. RESULTS: Overall, 42.5% of all specimens were found to be critical types. The CT measurements exhibited excellent intra-rater and inter-rater reliability (intraclass correlation coefficients >0.90). Similarly, excellent agreement between the CT scan and gross anatomic measurements in contralateral shoulders (intraclass correlation coefficients >0.88) was found. CONCLUSION: Assessing the uninjured contralateral side, CT can reliably predict the entry point in antegrade humeral nailing and preoperatively identify critical types of humeral heads at risk of iatrogenic implantation damage to the SSP tendon footprint. This study may help surgeons in the decision-making processon which surgical technique should be used without putting the patient at risk for iatrogenic, implant-related damage to the rotator cuff.

Biomechanical evaluation of straight antegrade nailing in proximal humeral fractures: the rationale of the "proximal anchoring point".

PURPOSE: Varus failure is one of the most common failure modes following surgical treatment of proximal humeral fractures. Straight antegrade nails (SAN) theoretically provide increased stability by anchoring to the densest zone of the proximal humerus (subchondral zone) with the end of the nail. The aim of this study was to biomechanically investigate the characteristics of this "proximal anchoring point" (PAP). We hypothesized that the PAP would improve stability compared to the same construct without the PAP. METHODS: Straight antegrade humeral nailing was performed in 20 matched pairs of human cadaveric humeri for a simulated unstable two-part fracture. RESULTS: Biomechanical testing, with stepwise increasing cyclic axial loading (50-N increments each 100 cycles) at an angle of 20° abduction revealed significantly higher median loads to failure for SAN constructs with the PAP (median, 450 N; range, 200-1.000 N) compared to those without the PAP (median, 325 N; range, 100-500 N; p = 0.009). SAN constructs with press-fit proximal extensions (endcaps) showed similar median loads to failure (median, 400 N; range, 200-650 N), when compared to the undersized, commercially available SAN endcaps (median, 450 N; range, 200-600 N; p = 0.240). CONCLUSIONS: The PAP provided significantly increased stability in SAN constructs compared to the same setup without this additional proximal anchoring point. Varus-displacing forces to the humeral head were superiorly reduced in this setting. This study provides biomechanical evidence for the "proximal anchoring point's" rationale. Straight antegrade humeral nailing may be beneficial for patients undergoing surgical treatment for unstable proximal humeral fractures to decrease secondary varus displacement and thus potentially reduce revision rates.

[Tendinopathies of the shoulder and elbow]. / Tendinopathien an Schulter und Ellenbogen.

BACKGROUND: Tendinopathies of the shoulder and elbow joint are a common problem. According to the current state of knowledge tendinopathies can be separated into acute and chronic tendinitis as well as degenerative tendinosis. ORIGIN: The causes of tendinopathy can be intrinsic, extrinsic or a combination of both. A false straining or overuse with repetitive microtrauma is often the cause. Particularly affected are tendons of the rotator cuff, the long biceps tendons and lower arm extensors. TREATMENT: Priority is given to conservative appproaches for these disease processes. Following appropriate diagnostics the pain can be reduced and function can be improved by specific training. When conservative treatment is unsuccessful and in the presence of certain indications, a surgical approach should be considered. In these cases a structural damage of the tendon often already exists, which could have resulted from the tendinopathy. The structural damage must be considered as a separate entity and differentiated from the tendinopathy.

Outcomes After Open Revision Repair of Massive Rotator Cuff Tears With Biologic Patch Augmentation.

PURPOSE: To assess minimum 2-year clinical outcomes after open revision biologic patch augmentation in patients with massive rotator cuff retears who had deficient rotator cuff tendons with healthy rotator cuff muscles. METHODS: Patients with massive posterosuperior rotator cuff retears who underwent open revision rotator cuff repair with patch augmentation were identified from a surgical registry. Outcomes data collected included American Shoulder and Elbow Surgeons; Quick Disabilities of the Arm, Shoulder and Hand; Single Assessment Numeric Evaluation; and Short Form-12 Physical Component Summary scores along with postoperative patient satisfaction, and activity modification. RESULTS: There were 10 men and 2 women (13 shoulders, 1 bilateral) with a mean age of 57 years (range, 26 to 68 years). All patients had at least one prior arthroscopic rotator cuff repair. After patch augmentation, there were no complications, no adverse reactions to the patch, and no patients required further surgery. One patient (7.7%) with 4 prior cuff repairs had a documented posterosuperior retear on magnetic resonance imaging 2 months after repair. Minimum 2-year outcome scores were available for 12 of 13 (92.3%) shoulders after a mean follow-up period of 2.5 years (range, 2.0 to 4.0 years). The ASES score improved by 21.5 points. Although the pain component of the ASES score and the total ASES score did not improve significantly, the function component of the ASES score improved significantly when compared with their preoperative baselines (P < .05). Median patient satisfaction at final follow-up was 9/10 (range, 2 to 10). CONCLUSIONS: Biologic patch augmentation with human acellular dermal allograft was a safe and effective treatment method for patients with massive rotator cuff retears with deficient posterosuperior rotator cuff tendons in the presence of healthy rotator cuff muscles. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Clinical Results After Conservative Management for Grade III Acromioclavicular Joint Injuries: Does Eventual Surgery Affect Overall Outcomes?

PURPOSE: To compare the clinical outcomes in patients with grade III acromioclavicular (AC) joint injuries in whom nonoperative therapy was successfully completed and those who had nonoperative therapy failure and who proceeded to undergo surgical reconstruction. METHODS: Forty-nine patients were initially treated nonoperatively for grade III AC joint injuries with physical therapy. Patients completed questionnaires at initial presentation and after a follow-up period of 2 years. Outcome measures included the Short Form 12 Physical Component Score; American Shoulder and Elbow Surgeons score; Quick Disabilities of the Arm, Shoulder and Hand score; and Single Assessment Numeric Evaluation score. Failure of nonoperative treatment occurred when a patient underwent AC reconstruction before final follow-up. RESULTS: Forty-one patients with a mean age of 39 years (range, 18 to 79 years) were included. In this cohort, 29 of 41 patients (71%) successfully completed nonoperative therapy whereas 12 of 41 (30%) had nonoperative therapy failure at a median of 42 days (range, 6 days to 17.0 months). Of the 41 patients, 39 (95.3%) were contacted to determine treatment success. Of the 12 patients who had nonoperative therapy failure, 11 (92%) had sought treatment more than 30 days after the injury. Subjective follow-up data were available for 10 of 12 patients (83.3%) who had nonoperative therapy failure and for 23 of 29 patients (79.3%) who were successfully treated nonoperatively. The mean length of follow-up was 3.3 years (range, 1.8 to 5.9 years). Although there were no statistically significant differences in outcome scores between groups, those who sought treatment more than 30 days after their injury showed decreased postoperative Single Assessment Numeric Evaluation scores (P = .002) and Short Form 12 Physical Component Scores (P = .037). CONCLUSIONS: According to our results, (1) a trial of nonoperative treatment is warranted because successful outcomes can be expected even in patients who eventually opt for surgery and (2) patients who presented more than 30 days after their injury were less likely to complete nonoperative treatment successfully. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Biomechanical comparison of fixation techniques for medial collateral ligament anatomical augmented repair.

PURPOSE: Although the majority of medial collateral ligament (MCL) ruptures can be treated conservatively with good results, some injuries require operative treatment. Besides MCL reconstruction, anatomical augmented repair may be considered. This study was to assess biomechanical properties of different fixation techniques regarding elongation and ultimate load to failure. METHODS: MCL anatomical augmented repair was simulated by fixation of porcine superficial digital flexor tendon grafts at porcine tibiae. Ten different fixation techniques were assessed. Fixation of the tendon graft was performed using 4.0-mm cancellous screws and either (1) 13.5-mm spiked polyether ketone (PEEK) washers; (2) 14-mm spiked washers; (3) 14-mm suture washers; (4) 14-mm customized washers; (5-8) combination of washers and No. 2 polyester sutures (FiberWire©); or using (9) single or (10) double 5.5-mm titanium suture anchors with No. 2 polyethylene sutures (Ultrabraid®). Biomechanical analysis included pretensioning of the constructs at 20 N for 30 s following cyclic loading of 250 cycles between 20 and 100 N at 1 Hz for measurement of elongation. Additionally, ultimate failure load and failure mode analysis were performed. RESULTS: Spiked PEEK washers secured with polyester sutures (5) yielded best biomechanical properties at time zero for both, elongation during cyclic loading (2.9 ± 0.7 mm) and ultimate failure load (469.8 ± 64.3 N). CONCLUSIONS: These results suggest that spiked PEEK washers secured with polyester sutures are the most appropriate fixation technique for MCL anatomical augmented repair, thus providing best requirements to allow early knee mobilization and prevent secondary knee laxity.

Clinical outcomes after autograft reconstruction for sternoclavicular joint instability.

BACKGROUND: Instability of the sternoclavicular (SC) joint is a rare condition. However, in some cases, SC joint instability may lead to persistent pain and impairment of shoulder function that requires surgical management. This study evaluated clinical outcomes after SC joint reconstruction with hamstring tendon autograft in patients with SC joint instability. METHODS: From December 2010 to January 2014, 21 reconstructions of the SC joint with hamstring tendon autograft were performed. Outcomes data were prospectively collected and retrospectively reviewed. Data analyzed included American Shoulder and Elbow Surgeons score, Quick Disability of the Arm, Shoulder and Hand, physical component of the Short Form 12, and Single Assessment Numeric Evaluation scores. Pain with activities of daily living, work, and sleep were separately analyzed along with painless use of arm for activities. Patients were also questioned regarding postoperative satisfaction. RESULTS: Nine women and 10 men (2 bilaterals), with a mean age of 30 years (range, 15-56 years), were monitored for a mean of 2 years (range, 12-36 months) postoperatively. Mean American Shoulder and Elbow Surgeons, Quick Disability of the Arm, Shoulder and Hand, and Single Assessment Numeric Evaluation scores significantly improved (P < .001). Pain scores also improved over preoperative baselines, including pain with activities of daily living, work, and sleep (P < .001). Median satisfaction at final follow-up was 8.5 (range, 7-10). There were no intraoperative or postoperative complications and no cases of recurrent instability. CONCLUSION: Free hamstring tendon autograft reconstruction for SC joint instability resulted in significantly improved clinical outcomes with high patient satisfaction and no intraoperative or postoperative complications.

Chondrocyte survival in osteochondral transplant cylinders depends on the harvesting technique.

PURPOSE: In autologous osteochondral transplantation, the edges of the harvested plug are particularly susceptible to mechanical or thermal damage to the chondrocytes. We hypothesised that the applied harvesting device has an impact on chondrocyte vitality. METHODS: Both knees of five blackhead sheep (ten knees) underwent open osteochondral plug harvesting with three different circular harvesting devices (osteoarticular transfer system harvester [OATS; diameter 8 mm; Arthrex, Munich, Germany], diamond cutter [DC; diameter 8.35 mm; Karl Storz, Tuttlingen, Germany] and hollow reamer with cutting crown [HRCC; diameter 7 mm; Dannoritzer, Tuttlingen, Germany]) from distinctly assigned anatomical sites of the knee joint. The rotary cutters (DC and HRCC) were either used with (+) or without cooling (-). Surgical cuts of the cartilage with a scalpel blade were chosen as control method. After cryotomy cutting, chondrocyte vitality was assessed using fluorescence microscopy and a Live/Dead assay. RESULTS: There were distinct patterns of chondrocyte vitality, with reproducible accumulations of dead chondrocytes along the harvesting edge. No statistical difference in chondrocyte survivorship was seen between the OATS technique and the control method, or between the HRCC+ technique and the control method (P > 0.05). The DC+, HRCC- and DC- techniques yielded significantly lower chondrocyte survival rates compared with the control method (P < 0.05). CONCLUSIONS: Chondrocyte survival in osteochondral cylinders depends on the applied harvesting technique. The use of rotary cutters without cooling yielded worst results, while the traditional OATS punch and rotary cutters with cooling achieved comparable rates of chondrocyte vitality.

Predictors for satisfaction after anatomic total shoulder arthroplasty for idiopathic glenohumeral osteoarthritis.

INTRODUCTION: The use of total shoulder arthroplasty (TSA) to treat primary glenohumeral osteoarthritis (GHOA) is increasing. Factors influencing patient satisfaction after surgery have not been well documented. The aim of this study was to determine demographic, radiologic, and surgical, factors predictive for satisfaction after TSA for GHOA. MATERIALS AND METHODS: Between 2005 and 2012, 95 shoulders undergoing TSA for GHOA by a single surgeon were eligible for inclusion in the study. Age, gender, previous surgeries, American Society of Anesthesiologists (ASA) score, and Walch glenoid morphology were analyzed as satisfaction predictors. Patients with Walch glenoid type C were excluded. RESULTS: Data on 80/92(87 %) shoulders were available at a mean of 3 years (range 2-9). Three complications (3 %) and 2 failures (2 %) occurred. The outcome scores collected significantly improved from preoperative values (p < 0.05). Median patient satisfaction was 10/10. Gender, age, previous surgery, ASA score, and Walch morphology were not associated with patient satisfaction. CONCLUSIONS: TSA provided excellent results for patients with idiopathic GHOA with low complication and failure rates. Outcomes after TSA for type B glenoid morphology with posterior subluxation were similar to outcomes after TSA for centered type A morphology. Overall patient satisfaction was high and was not influenced by the demographic, anatomic, and surgical variables investigated. LEVEL OF EVIDENCE: III, Therapeutic study, Retrospective Cohort Study.

Massive rotator cuff tears: pathomechanics, current treatment options, and clinical outcomes.

Rotator cuff tear size has an important effect on clinical outcomes after repair. Management options for massive rotator cuff tears are numerous, and selection of the most appropriate treatment method for individual patients can be a challenge. An understanding of the pathomechanics, treatment, and clinical outcomes in patients with massive rotator cuff tears can serve as a guide for clinical decision-making. The purpose of this article was to review treatment options and clinical outcomes for the management of massive rotator cuff tears.

Association between scapula bony morphology and snapping scapula syndrome.

HYPOTHESIS AND BACKGROUND: Scapular incongruity has been described as a contributing factor to the development of snapping scapula syndrome (SSS). The purpose of this retrospective case-control study was to determine the association between scapula bony morphology on magnetic resonance imaging (MRI) and the diagnosis of SSS. METHODS: Bony morphologies of the scapula were evaluated on MRI scans of 26 patients with SSS and 19 patients with non-SSS pathologies. The medial scapula corpus angle (MSCA) was measured on axial MRI sequences. Scapulae were categorized as straight, S shaped, or concave. Two independent observers performed the measurements. Interobserver and intraobserver agreements of MSCA measurements were determined with intraclass correlation coefficients. RESULTS: Axial scapula bony morphology identified 28 scapulae of the straight type, 14 S-shaped scapulae, and 5 concave scapulae. All 5 concave scapulae had confirmed SSS. Measurement of the MSCA showed excellent interobserver agreement of 0.80 (95% confidence interval [CI], 0.67 to 0.89) and intraobserver agreement of 0.70 (95% CI, 0.52 to 0.82). There were significant differences in the mean MSCAs between shoulders with SSS (14.4° ± 19.3°) and non-SSS shoulders (-3.3° ± 15.3°, P = .001). The odds ratio was 8.4 (95% CI, 2.2 to 31.8) for positive MSCA and SSS. The scapulothoracic distance was significantly decreased in the SSS group (14.9 ± 5.8 mm) compared with the non-SSS patients (24.0 ± 6.7 mm, P < .001). DISCUSSION AND CONCLUSION: Anterior angulation of the medial scapula in the axial plane was associated with SSS. Patients with a concave-shaped scapula and a positive MSCA have a 12-fold increased risk of SSS. The MSCA may prove helpful in determining the location and amount of scapular resection needed for patients with SSS.

A novel implant-free tibial pull-press-fixation for ACL reconstruction.

INTRODUCTION: Extracortical fixation techniques in anterior cruciate ligament reconstruction bear the risk of tunnel enlargement, while close-to-aperture fixations often show lower failure loads. The purpose for this study was to investigate the biomechanical benefits of a novel implant-free combination of an extra-cortical and close-to-aperture fixation. MATERIALS AND METHODS: Quadrupled human cadaveric semitendinosus tendons were fixed to 30 porcine tibiae with either a cannulated interference screw (I), an implant-free post-fixation (S), or a novel pull-press fixation (P). Specimens were cyclically loaded 20 times between 20 and 60 N followed by 500 cycles with 60-200 N, followed by a load-to-failure test with 1 mm/s. RESULTS: The mean elongation of the tendons in the P-group during the 500 cycles between 60 and 200 N was significantly lower (5.69 ± 2.16 mm) compared to 9.20 ± 3.21 mm in S-group and 9.37 ± 3.1 mm in the I-group (p < 0.05). The mean maximum load-to-failure was significantly higher in the P-group (728.2 ± 76.4 N) compared to 476.4 ± 68.8 N in the S-group and 625.9 ± 82.5 N in the I-group (p < 0.05). Stiffness of the constructs in the P-group was significantly higher (121.7 ± 44.9 N/mm) compared to 46.2 ± 17.7 N/mm in the S- and 72.8 ± 29.8 N/mm in the I-group (p < 0.03). CONCLUSIONS: This study indicates superior biomechanical properties of a novel implant-free tibial pull-press fixation to conventional implant-free and close-to-aperture interference screw fixations in terms of cyclic elongation and maximum load-to-failure. LEVEL OF EVIDENCE: Not applicable, basic science study.