Arthroscopic rotator cuff repair in patients over 65 years of age: successful functional outcomes and a high tendon integrity rate can be obtained after surgery.

Background: Although interest in studies evaluating the outcomes of rotator cuff repair is steadily increasing, the results and tendon integrity after arthroscopic rotator cuff repair in elderly patients have only been minimally investigated. The aim of this study was to evaluate clinical outcomes and repair integrity in patients over 65 years of age who underwent arthroscopic repair of full-thickness rotator cuff tears. Methods: A retrospective study was conducted with the following inclusion criteria: (1) elective shoulder arthroscopy for rotator cuff repair for full-thickness posterosuperior tears; (2) age over 65 years at surgery; and (3) participation in 24 months of follow-up. Preoperatively, the range of motion (ROM) and the Constant-Murley Score (CMS) and at follow-up, the ROM, the 12-Item Short Form Survey, the American Shoulder and Elbow Surgeons, and the CMS were evaluated; an ultrasonographic assessment of tendon integrity was performed according to the adapted Sugaya classification. Results: The final sample consisted of 110 patients with an average age of 69.2 ± 3.5 years. The mean duration of nonoperative management before surgery was 2.6 ± 0.8 months. The mean period of preoperative physical therapy was 0.6 ± 0.9 months. ROM and CMS showed statistically significant improvement (all P < .001) after a mean follow-up time of 54.5 ± 22.3 months. The ultrasonographic assessment showed tendon integrity (types I and II) in 75% of cases; 21% were type III repair, and rotator cuff retear (types IV and V) was recorded in 4% of cases. All scores directly correlated with the integrity of the tendon. In the multivariate analysis, higher postoperative CMS was associated with male sex (P < .001, ß = -6.085) and lower age (P = .004, ß = -0.533). Higher postoperative American Shoulder and Elbow Surgeons were associated with lower age (P = .020, ß = -0.414). Higher postoperative 12-Item Short Form Survey physical component score and mental component score were associated with lower age (P = .013, ß = -0.550 and P < .001, ß = -0.520, respectively) and shorter preoperative physical therapy period (P = .013, ß = -2.075 and P = .006, ß = -1.093, respectively). Conclusion: A significant ROM and CMS recovery and a rotator cuff integrity rate of 75% can be expected in patients over 65 years of age who undergo arthroscopic repair for full-thickness rotator cuff tears. Better functional, physical, and mental health outcomes correlate with rotator cuff integrity and are predicted by male sex and a shorter period of preoperative physical therapy.

Revision surgery for periprosthetic elbow infection: eradication rate, complications, and functional outcomes-a systematic review.

INTRODUCTION: The aim of this systematic review was to investigate the outcomes of revision surgery after periprosthetic elbow infection (PEI). MATERIAL AND METHODS: Eighteen studies with 332 PEI that underwent revision surgery were included. Demographics, laboratory and microbiological data, types of implants, surgical techniques with complications and reoperations, eradication rates, and clinical and functional outcomes were reported. RESULTS: Staphylococcus aureus was the most common microorganism (40%). Pre-operatively, the mean white blood cell count was 8400 ± 4000 per microliter; the mean C-reactive protein level was 41.6 ± 66.9 mg/dl, and the mean erythrocyte sedimentation rate was 45 ± 66.9 mm/h. The Coonrad-Morrey total elbow prosthesis represented 41.2% of the infected implant, and it also represented the most common system used for the PEI revision surgery. Two-stage revision and debridement and implant retention (DAIR) were the most common procedures performed for PEI, and, on the whole, they represented 35.7 and 32.7%, respectively. The eradication rate was 76% with 2-stage, 71% with resection arthroplasty (RA), 66.7% with 1-stage, 57.7% with DAIR, and 40% with arthrodesis (EA). DAIR showed a significantly lower eradication rate than 2-stage (P = 0.003). The mean postoperative Mayo Elbow Performance Score was significantly higher in patients who underwent DAIR, and 2-stage compared with RA (P < 0.001 for all). Postoperative flexion-extension ROM was significantly higher in patients who underwent DAIR compared with 1-stage, 2-stage, and RA (P < 0.001 for all). Moreover, 1-stage and 2-stage showed a significantly greater postoperative flexion-extension ROM compared with RA (P < 0.001 for all). Reoperations occurred in 40% of patients after EA, 33.3% after 1-stage, 26.9% after DAIR and RA, and 24.1% after 2-stage. Conversion to amputation occurred in 2.2% of patients after RA and 1% after DAIR. CONCLUSIONS: Two-stage revision and DAIR are the most common procedures used to manage PEI; however, the former procedure showed a significantly higher eradication rate. Resection arthroplasty showed a high eradication rate, but postoperative lower clinical and functional outcomes limit the indications for this technique. One-stage procedure showed a limited role in the current practice of PEI treatment. LEVEL OF EVIDENCE: Level IV.

Double-Incision Technique for the Treatment of Distal Biceps Tendon Rupture.

The double-incision technique with bone-tunnel fixation provides anatomical reattachment of a distal biceps tendon rupture to the radial tuberosity1. This technique has been described by Boyd and Anderson2 and was later modified by Morrey et al.3. The aim of the procedure is to achieve good return of elbow strength and motion with a low rate of neurological complications. Description: A longitudinal antecubital incision of 3 to 4 cm allows dissection to identify and isolate the lateral antebrachial cutaneous nerve (LABCN). Supination of the forearm protects the posterior interosseus nerve, which often cannot be visualized. The distal portion of the distal biceps should be carefully identified and exposed. A high-resistance nonresorbable suture is sewn with use of a Krackow technique to whipstitch the distal 4 cm of the tendon. Alternatively, 2 sutures (4 strands) can be utilized. A curved forceps is placed in the interosseous space to identify the location for the second 4-cm incision, on the dorsal proximal forearm over the tip of the forceps with the forearm pronated. The radial tuberosity is exposed by bluntly separating the common extensor tendons, followed by transection of the supinator fibers. Two drill holes are made 5 mm apart from one another for suture passage. The tendon is passed across a loop of wire, from the anterior to the posterior incision. With the elbow at 90° of flexion and full pronation, the tendon is docked into the trough and the sutures are tied. Alternatives: Alternatively, the surgical repair of the distal biceps tendon rupture can be performed through a single anterior approach4. The exposure starts with a curved longitudinal antecubital incision, exploiting the interval between the brachioradialis and pronator teres with radial (lateral) retraction of the brachioradialis and medial retraction of the pronator teres. A single anterior incision allows repair through the use of various types of fixation devices, such as suture anchors, cortical buttons, and interference screws, but seems to carry an increased risk of neurological complications, especially in terms of paresthesias in the distribution of the LABCN. Nonoperative treatment might be acceptable for elderly patients with poor functional demands. Rationale: The double-incision technique with bone-tunnel fixation provides good fixation strength with an expected low rate of neurological complications1. This approach offers a useful treatment option for young and active patients with physically demanding lifestyles. Expected Outcomes: The double-incision technique is an effective and safe procedure to restore elbow functionality in patients with distal biceps tendon rupture. A meta-analysis1,4-16 revealed no significant differences in postoperative functional scores following procedures performed via the single-incision compared with double-incision approach. Although the differences were smaller than the minimal clinically important difference17, the single-incision technique yielded significantly greater flexion (mean ± standard deviation, 136° ± 13°) and pronation range of motion (79° ± 10°) compared with the double-incision technique (133° ± 13° and 75° ± 14°, respectively) at 2 years postoperatively. No differences in extension and supination were observed. Rates of heterotopic ossification ranged from 0.5% to 11% for the single-incision approach and from 1% to 21.4% for the double-incision approach, with significant differences favoring the single-incision technique, although in the majority of cases the heterotopic ossification was an incidental finding. Neurological complications were found in 24.5% and 13.4% cases for the single- and double-incision techniques, respectively, with a significant difference favoring the double-incision technique. When damage to specific nerves was evaluated, the double-incision technique was associated with significantly less risk of LABCN damage. Important Tips: One or 2 high-resistance nonresorbable sutures are sewn with use of a Krackow technique to whipstitch the distal 4 cm of the biceps tendon.A curved forceps is placed in the interosseous space to identify the location for the second incision, on the dorsal proximal forearm over the tip of the forceps.Pronation of the forearm protects the posterior interosseus nerve, which often cannot be visualized during volar dissection and bone fixation.Positioning the tendon more posteriorly on the radial tuberosity allows for optimal biomechanical function. Acronyms and Abbreviations: ROM = range of motionCR = conventional radiologyMRI = magnetic resonance imagingUS = ultrasoundLABC = lateral antebrachial cutaneousPIN = posterior interosseous nerveHO = heterotopic ossificationCI = confidence intervalSI = single incisionDI = double incision.

Single- versus double-incision technique for the treatment of distal biceps tendon rupture.

AIMS: The aim of this systematic review and meta-analysis is to evaluate differences in functional outcomes and complications between single- (SI) and double-incision (DI) techniques for the treatment of distal biceps tendon rupture. METHODS: A comprehensive search on PubMed, MEDLINE, Scopus, and Cochrane Central databases was conducted to identify studies reporting comparative results of the SI versus the DI approach. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used for search strategy. Of 606 titles, 13 studies met the inclusion criteria; methodological quality was assessed with the Newcastle-Ottawa scale. Random- and fixed-effects models were used to find differences in outcomes between the two surgical approaches. The range of motion (ROM) and the Disabilities of the Arm, Shoulder and Hand (DASH) scores, as well as neurological and non-neurological complications, were assessed. RESULTS: A total of 2,622 patients were identified. No significant differences in DASH score were detected between the techniques. The SI approach showed significantly greater ROM in flexion (standardized mean difference (SMD) -0.508; 95% confidence interval (CI) -0.904 to -0.112) and pronation (SMD -0.325, 95% CI -0.637 to -0.012). The DI technique was associated with significantly less risk of lateral antebrachial cutaneous nerve damage (odds ratio (OR) 4.239, 95% CI 2.171 to 8.278), but no differences were found for other nerves evaluated. The SI group showed significantly fewer events of heterotopic ossification (OR 0.430, 95% CI 0.226 to 0.816) and a lower reoperation rate (OR 0.503, 95% CI 0.317 to 0.798). CONCLUSION: No significant differences in functional scores can be expected between the SI and DI approaches after distal biceps tendon repair. The SI approach showed greater flexion and pronation ROM and a lower risk of heterotopic ossification and reoperation. The DI approach was favourable in terms of lower risk of neurological complications. Cite this article: Bone Joint J 2020;102-B(12):1608-1617.