All-arthroscopic supraspinatus and infraspinatus muscle advancement leads to high healing rate and excellent outcomes in patients with massive, retracted rotator cuff tears, even in patients with pseudoparalysis.

PURPOSE: The purpose of this study was to evaluate the clinical and radiographic outcomes of an all-arthroscopic rotator cuff repair technique involving muscle advancement and double-layer lasso loop (DLLL) repair for massive, retracted posterosuperior cuff tears. METHODS: This is a retrospective case series of patients with massive, retracted posterosuperior cuff tears who underwent the all-arthroscopic muscle advancement technique from March 2017 to September 2021, with minimum follow-up of 12 months. Key steps included suprascapular nerve release, advancement of supraspinatus and infraspinatus muscles, and DLLL repair. Preoperative and postoperative visual analogue scale for pain, American Shoulder and Elbow Surgeons (ASES) score, Constant score, University of California Los Angeles (UCLA) shoulder score, active range of motion (ROM), and strength were compared. Preoperative and postoperative structural radiological characteristics were analysed. RESULTS: Forty-three shoulders in 38 patients were evaluated with mean follow-up of 18.8 months (range 12-55 months). Of the 43 shoulders, 4 repairs failed (9.3% retear rate). VAS, ASES, Constant, and UCLA scores significantly improved (p<0.001) in patients who demonstrated healing on postoperative MRI (n=39). ASES, Constant, and UCLA scores were significantly better in the healed group, with 100% exceeding MCIDs for ASES and UCLA scores, and 84.2% for Constant score. A lower proportion of patients in the retear group achieved MCIDs. Active ROM in all planes significantly improved for those who had healed repairs. (p<0.001). Relative strengths of abduction, supraspinatus, and infraspinatus were at least 90% of the contralateral side. Recovery rate of pseudoparalysis (7 patients) was 100%. CONCLUSION: All-arthroscopic muscle advancement, coupled with double-layer lasso loop repair, leads to a high healing rate with excellent clinical outcomes and recovery of strength to at least 90%, even in patients with pseudoparalysis.

Does forearm referencing using a retroversion guide achieve the targeted retroversion of the humeral component in reverse shoulder arthroplasty?

BACKGROUND: Component positioning affects clinical outcomes of reverse shoulder arthroplasty, which necessitates an implantation technique that is reproducible, consistent, and reliable. This study aims to assess the accuracy and precision of positioning the humeral component in planned retroversion using a forearm referencing guide. METHODS: Computed tomography scans of 54 patients (27 males and 27 females) who underwent primary reverse shoulder arthroplasty for osteoarthritis or cuff tear arthropathy were evaluated. A standardized surgical technique was used to place the humeral stem in 15° of retroversion. Version was assessed intraoperatively visualizing the retroversion guide from above and referencing the forearm axis. Metal subtraction techniques from postoperative computed tomography images allowed for the generation of 3D models of the humerus and for evaluation of the humeral component position. Anatomical humeral plane and implant planes were defined and the retroversion 3D angle between identified planes was recorded for each patient. Accuracy and precision were assessed. A subgroup analysis evaluated differences between male and female patients. RESULTS: The humeral retroversion angle ranged from 0.9° to 22.8°. The majority (81%) of the measurements were less than 15°. Mean retroversion angle (±SD) was 9.9° ± 5.8° (95% CI 8.4°-11.5°) with a mean percent error with respect to 15° of -34% ± 38 (95% CI -23 to -44). In the male subgroup (n = 27, range 3.8°-22.5°), the mean retroversion angle was 11.9° ± 5.4° (95% CI 9.8°-14.1°) with a mean percent error with respect to 15° of -21% ± 36 (95% CI -6 to -35). In the female subgroup (n = 27, range 0.9°-22.8°), mean retroversion angle was 8.0° ± 5.5° (95% CI 5.8°-10.1°) and the mean percent error with respect to 15° was -47% ± 36 (95% CI -32 to -61). The differences between the 2 gender groups were statistically significant (P = .006). CONCLUSION: Referencing the forearm using an extramedullary forearm referencing system to position the humeral stem in a desired retroversion is neither accurate nor precise. There is a nonnegligible tendency to achieve a lower retroversion than planned, and the error is more marked in females.

Healing of acute anterior cruciate ligament rupture on MRI and outcomes following non-surgical management with the Cross Bracing Protocol.

OBJECTIVE: Investigate MRI evidence of anterior cruciate ligament (ACL) healing, patient-reported outcomes and knee laxity in patients with acute ACL rupture managed non-surgically with the Cross Bracing Protocol (CBP). METHODS: Eighty consecutive patients within 4 weeks of ACL rupture were managed with CBP (knee immobilisation at 90° flexion in brace for 4 weeks, followed by progressive increases in range-of-motion until brace removal at 12 weeks, and physiotherapist-supervised goal-oriented rehabilitation). MRIs (3 months and 6 months) were graded using the ACL OsteoArthritis Score (ACLOAS) by three radiologists. Mann-Whitney U tests compared Lysholm Scale and ACL quality of life (ACLQOL) scores evaluated at median (IQR) of 12 months (7-16 months) post-injury, and χ2 tests compared knee laxity (3-month Lachman's test and 6-month Pivot-shift test), and return-to-sport at 12 months between groups (ACLOAS grades 0-1 (continuous±thickened ligament and/or high intraligamentous signal) versus ACLOAS grades 2-3 (continuous but thinned/elongated or complete discontinuity)). RESULTS: Participants were aged 26±10 years at injury, 39% were female, 49% had concomitant meniscal injury. At 3 months, 90% (n=72) had evidence of ACL healing (ACLOAS grade 1: 50%; grade 2: 40%; grade 3: 10%). Participants with ACLOAS grade 1 reported better Lysholm Scale (median (IQR): 98 (94-100) vs 94 (85-100)) and ACLQOL (89 (76-96) vs 70 (64-82)) scores, compared with ACLOAS grades 2-3. More participants with ACLOAS grade 1 had normal 3-month knee laxity (100% vs 40%) and returned to pre-injury sport (92% vs 64%), compared with participants with an ACLOAS grades 2-3. Eleven patients (14%) re-injured their ACL. CONCLUSION: After management of acute ACL rupture with the CBP, 90% of patients had evidence of healing on 3-month MRI (continuity of the ACL). More ACL healing on 3-month MRI was associated with better outcomes. Longer-term follow-up and clinical trials are needed to inform clinical practice.

Outcomes and survivorship of anatomic total shoulder arthroplasty: current concepts.

Total shoulder arthroplasty (TSA) has been the gold standard of care for end-stage glenohumeral arthritis. Outcomes are varied and have been affected by both patient and implant characteristics. Patient factors, such as age, preoperative diagnosis, and preoperative glenoid morphology, can affect the outcomes after TSA. Similarly, the different glenoid and humeral component designs significantly affect the survivorship of TSA. Significant evolution has occurred in the design of the glenoid component with the aim of decreasing the glenoid-sided causes of failure in TSA. On the other hand, focus on the humeral component has been increasing as well, with a trend towards using shorter humeral stems. This article aims to look at the outcomes of TSA as affected by the various patient characteristics and design options for the glenoid and the humeral components. This review also aims to compare survivorship data from global literature and the Australian joint replacement registry and to provide insights into the implant combination that may provide the best patient outcome.

Single-Stage Revision Reverse Shoulder Arthroplasty: Preoperative Planning, Surgical Technique, and Mixed Reality Execution.

Revision shoulder arthroplasty is increasing with the number of primary shoulder replacements rising globally. Complex primary and revisions of shoulder arthroplasties pose specific challenges for the surgeon, which must be addressed preoperatively and intraoperatively. This article aimed to present strategies for the management of revision of shoulder arthroplasties through a single-stage approach. Preoperatively, patient factors, such as age, comorbidities, and bone quality, should be considered. The use of planning software can aid in accurately evaluating implants in situ and predict bony anatomy that will remain after explantation during the revision surgery. The planning from such software can then be executed with the help of mixed reality technology to allow accurate implant placement. Single-stage revision is performed in two steps (debridement as first step, implantation and reconstruction as the second step), guided by the following principles: adequate debridement while preserving key soft tissue attachments (i.e., rotator cuff, pectoralis major, latissimus dorsi, deltoid), restoration of glenoid joint line using bone grafting, restoration of humeral length, reconstruction and/or reattachment of soft tissues, and strict compliance with the postoperative antibiotic regimen. Preliminary results of single-stage revision shoulder arthroplasty show improvement in patient outcomes (mean 1 year), successful treatment of infection for those diagnosed with periprosthetic joint infection, and improved cost-benefit parameters for the healthcare system.

A Liposarcoma Arising in a Pulmonary Hamartoma, Coexisting With Benign Metastasizing Leiomyoma.

Pulmonary hamartoma is a common benign tumor that rarely degenerates into malignancy. This report documents a unique case of pulmonary hamartoma with malignant transformation into well-differentiated liposarcoma, coexisting in proximity to pulmonary nodules representing benign metastasizing leiomyoma in a 60-year-old woman.

Coronary stent rupture with infected false aneurysm and atrial fistula formation.

Infectious complications after percutaneous transluminal coronary angioplasty are uncommon and can occur at any point of time leading to high morbidity and mortality. We report a case of delayed coronary artery stent infection and rupture, with epicardial infected false aneurysm formation, and right coronary artery to right atrium fistula formation, presenting after 1 month of pyrexia.

Use and Outcome of Local Anesthetic Painkilling Injections in Athletes: A Systematic Review.

BACKGROUND: The use of local anesthetic painkilling injections to improve player availability is common practice in elite-level sport. OBJECTIVE: To document the published use of local anesthetic injections in sport, according to number of injections, sites of injections, and complications reported. DATA SOURCES: A systematic search of MEDLINE, Embase, CINAHL, AMED, Cochrane Database of Systematic reviews, SportDiscus, EBSCO Host, and Google Scholar. RESULTS: One thousand nine hundred seventy local anesthetic injections reported on 540 athletes in 10 studies (from rugby league, American football, Australian football, and soccer) were reviewed. The most common areas of injection were as follows: the acromioclavicular (AC) joint; hand (including fingers); sternoclavicular joint (including sternum); rib injuries; and iliac crest contusions. DISCUSSION: This review found some evidence of long-term safety for a limited number of injection sites (eg, AC joint) and some evidence of immediate complications and harmful long-term consequences for other sites. The quality of evidence is not high, with little long-term data and a lack of independent verification of the effects of the injections. Ideally, long-term follow-up should be conducted to determine whether these injections are safe, with follow-up undertaken independently of the treating physician and team. CONCLUSIONS: Based on limited publications, there is some evidence of long-term safety; however, there is a lack of clear proof of either absolute safety or long-term harm for many of these procedures. Physicians and players in professional sport should proceed with caution in using local anesthetic injections.

Australian Footballers Returning from Anterior Cruciate Ligament Reconstruction Later than 12 Months have Worse Outcomes.

BACKGROUND: There is evidence that early return to competition post-anterior cruciate ligament (ACL) injury increases risk of re-injury. AIMS: To compare subsequent ACL and other injury risks following ACL reconstruction for Australian Football League (AFL) players returning to competition at different times post-injury. METHODS: AFL players returning from ACL reconstruction in the 1992-2014 seasons were divided into three groups based on return to competition time (< 10, 10-12 and > 12 months). Non-reconstructed injuries and artificial ligament reconstructions were excluded. Subsequent ACL injury rates were calculated based on time since injury and number of return matches played. Risk of other knee and hamstring muscle injuries was also calculated. RESULTS: There were 233 ACL reconstructions that returned to play in the AFL during the time period under study and met our inclusion criteria. The per-game risk of subsequent ACL injury decreased with a log decay from 1.2 to 0.15% during the first 20 games back (R 2 = 0.43). Players returning at > 12 months had higher overall percentage of future career games missed through subsequent ACL injuries (4.8% vs. 2.4%), and through all hamstring and knee injuries combined (12.6% vs. 8.4%) than players who returned at ≤ 12 months (both P < 0.001). Players returning at > 12 months had higher risk of knee cartilage (3.7%) and patella tendon (0.6%) injury than those returning at 10-12 months (1.5%, 0.1%, respectively). CONCLUSION: Players returning from ACL reconstruction at greater than 12 months had significantly higher rates of future games missed through both subsequent ACL injuries and through all hamstring and knee injuries combined. It may be true that both early and late return to play lead to suboptimal outcomes compared to average return-to-play times.

Fifteen-week window for recurrent muscle strains in football: a prospective cohort of 3600 muscle strains over 23 years in professional Australian rules football.

OBJECTIVES: To determine the rates of muscle strain injury recurrence over time after return to play in Australian football and to quantify risk factors. METHODS: We analysed Australian Football League player data from 1992 to 2014 for rates of the four major muscle strain injury types (hamstring, quadriceps, calf and groin) diagnosed by team health professionals. Covariates for analysis were: recent history (≤8 weeks) of each of the four muscle strains; non-recent history (>8 weeks) of each; history of hip, knee anterior cruciate ligament, knee cartilage, ankle sprain, concussion or lumbar injury; age; indigenous race; match level and whether a substitute rule was in place. RESULTS: 3647 (1932 hamstring, 418 quadriceps, 458 calf and 839 groin) muscle strain injuries occurred in 272 759 player matches. For all muscle strains combined, the risk of injury recurrence gradually reduced, with recurrence risks of 9% (hamstring), 5% (quadriceps), 2% (calf) and 6% (groin) in the first match back and remaining elevated for 15 weeks after return to play. The strongest risk factor for each muscle injury type was a recent history of the same injury (hamstring: adjusted OR 13.1, 95% CI 11.5 to 14.9; calf OR 13.3, 95% CI 9.6 to 18.4; quadriceps: OR 25.2, 95% CI 18.8 to 33.8; groin OR 20.6, 95% CI 17.0 to 25.0), followed by non-recent history of the same injury (hamstring: adjusted OR 3.5, 95% CI 3.2 to 3.9; calf OR 4.4, 95% CI 3.6 to 5.4; quadriceps OR 5.2, 95% CI 4.2 to 6.4; groin OR 3.5, 95% CI 3.0 to 4.0). Age was an independent risk factor for calf muscle strains (adjusted OR 1.6, 95% CI 1.3 to 2.0). Recent hamstring injury increased the risk of subsequent quadriceps (adjusted OR 1.8, 95% CI 1.2 to 2.7) and calf strains (OR 1.8, 95% CI 1.2 to 2.6). During the 'substitute rule' era (2011-2014), hamstring (adjusted OR 0.76, 95% CI 0.67 to 0.86), groin (OR 0.78, 95% CI 0.65 to 0.93) and quadriceps (OR 0.70, 95% CI 0.53 to 0.92) strains were less likely than outside of that era but calf (OR 1.6, 95% CI 1.3 to 1.9) strains were more likely than before the substitute rule era. CONCLUSION: Recent injury is the greatest risk factor for the four major muscle strains, with increased risk persisting for 15 weeks after return to play.