A Knotless Single-Row Suture Bridge Technique to Repair a Partial Articular Suproaspinatus Tendon Avulsion-Type Rotator Cuff Tear: Surgical Technique.

With improving surgical and technological solutions for repairing rotator cuff tears, there has been increased interest in treatment of partial rotator cuff tears. The most prevalent type of partial tear is the PASTA (partial articular supraspinatus tendon avulsion) lesion. There is an ongoing debate on the best surgical technique to repair a PASTA lesion, which has led to the development of many different arthroscopic techniques. This Technical Note provides a cost-effective and reproducible technique of a transtendinous single-row bridge repair of PASTA lesions, using two 1.8 FiberTak Knotless Soft Anchors.

Lateralising reverse shoulder arthroplasty using bony increased offset (BIO-RSA) or increasing glenoid component diameter: comparison of clinical, radiographic and patient reported outcomes in a matched cohort.

BACKGROUND: This study aims to compare the range of motion (ROM) of reverse shoulder arthroplasty lateralised by bony increased offset (BIO-RSA) using a standard 38-mm (mm) component to regular reverse shoulder arthroplasty (RSA) lateralised by using a 42-mm glenoid component. The secondary aims are to compare patient-reported and radiographic outcomes between the two groups. MATERIALS AND METHODS: All patients with a BIO-RSA and size 38 glenosphere were retrospectively identified and matched to patients with a regular RSA and size 42 glenosphere. Matched patients were invited for a follow-up visit. ROM was assessed as well as radiographic outcomes (lateralisation, distalisation, inferior overhang, scapular notching, heterotopic bone formation, radiolucency, stress shielding, bone graft healing and viability and complications) and patient-reported outcomes (subjective shoulder value, Constant score, American Shoulder and Elbow Surgeons, activities of daily living which require internal rotation, activities of daily living which require external rotation and a visual analogue scale for pain). Outcomes were compared between the two groups. RESULTS: In total, 38 BIO-RSAs with a size 38 glenosphere were matched to 38 regular RSAs with a size 42 glenosphere. Of the 76 matched patients, 74 could be contacted and 70 (95%) were included. At the final follow-up, there were no differences between the two groups in ROM, patient-reported outcomes or radiographic outcomes (p > 0.485). CONCLUSIONS: Using a larger glenosphere is a feasible alternative to BIO-RSA for lateralising RSA, providing comparable ROM, patient-reported and radiographic results, while potentially decreasing costs, operative time and complication rates.

High Vertical and Horizontal Stability at Short-Term Follow-Up After an All-Endoscopic Double Cerclage Endobutton Technique for Acute Acromioclavicular Joint Separations.

PURPOSE: To evaluate the clinical and radiological outcomes in the treatment of acute acromioclavicular (AC) joint separations using an all-endoscopic double cerclage endobutton technique compared with an arthroscopic-assisted single-bundle endobutton technique and to analyze the complication, failure, and revision rates of both procedures. METHODS: All patients with acute Rockwood type IIIB and V AC joint separations who were operated on using an all-endoscopic double cerclage technique (2019-2022) or an arthroscopic-assisted single-bundle technique (2017-2019) were included. The follow-up period was at least 12 months. Clinical and radiographic assessment was performed at follow-up. Complications, failures, and revisions were also investigated. RESULTS: Twenty-eight patients (14 double cerclage group, 14 single-bundle group, all male) with an average age of 37 years (interquartile range [IQR], 15) were available for follow-up after 45 months (IQR, 38). The median time between trauma and surgery was 7 days (IQR, 8). Very good clinical results without significant differences were observed in both groups (Constant score, 94 [IQR, 12] vs 95 [IQR, 15], P = .427, AC joint instability score, 95 [IQR, 11] vs 87 [IQR, 22], P = .210). All patients returned to sport, with an average sports level of 95% compared with preoperative status. The single-bundle group showed significantly increased anteroposterior instability (6 vs 0, P = .006). A total of 5 complications occurred (2 vs 3), leading to 1 revision surgery in each group. CONCLUSIONS: Excellent clinical results and high vertical and horizontal stability can be achieved with the all-endoscopic double cerclage technique. Horizontal instability occurred significantly more frequently with the single-bundle technique. The prolonged operation time in the double cerclage group had no negative impact on postoperative outcomes, including complication and failure rates, and a learning curve to reduce this prolonged operative time should be considered. LEVEL OF EVIDENCE: Level III, retrospective comparative clinical series.

Subacromial Balloon Spacer Does Not Reduce the Retear Rate for Massive Rotator Cuff Tears: A Comparative Study.

PURPOSE: To determine whether a subacromial spacer decreases the recurrent rotator cuff tear rate in arthroscopically managed massive rotator cuff tears (MRCTs) with 1 year of follow-up. METHODS: We selected all patients who met the following criteria: (1) an MRCT excluding Collin type A, (2) Goutallier stage equal or less than 2, and (3) complete arthroscopic repair of the MRCT. Patients were allocated into 2 groups: A (without subacromial spacer) or B (with subacromial spacer) for a prospective evaluation 1 year after surgery. The primary outcome was the retear rate, determined with magnetic resonance imaging (MRI) according to the classification of Sugaya. Secondary outcome measures were the functional outcomes using visual analog score, Shoulder Subjective Value, and Constant-Murley Score. Preoperative rotator cuff characteristics such as number of tendons involved and the tear retraction also were evaluated. Patient-related data such as sex, age, laterality, history of smoking, and diabetes mellitus were analyzed. RESULTS: In total, 31 patients were included in group A and 33 in group B. Preoperatively, only 2 differences were found between both groups: a significant (but not clinical) greater Constant score in group A (P = .034) and a slightly greater retraction of the supraspinatus in group B (P = .0025). The overall retear rate between the 2 groups was similar regarding the number of patients (P = .746) and the total number of tendons involved in the recurrent tear (P = .112). At 1-year follow-up, no differences were found in VAS (P = .397), SSV (P = .309), and Constant score (P = .105). CONCLUSIONS: In reparable massive rotator cuff tears (excluding Collin type A), the augmentation of repair with a subacromial spacer did not significantly reduce the number of patients with recurrent rotator cuff tears identified by MRI. It was also ineffective in reducing the number of re-ruptured tendons in these patients. No patient-reported or clinically significant findings were noted in Constant, SSV, and VAS scores at 1-year postoperative follow-up. Patients with MRI findings of a healed rotator cuff (Sugaya 1-3) had better clinical outcomes compared with those without. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Standard views do not suffice in assessing distal scaphoid articular cannulated screw penetration.

BACKGROUND: Articular screw penetration is one of the most common hardware-related problems after scaphoid fracture fixation, occurring in up to two-thirds of patients, in particular into the scaphotrapezotrapezoidal (STT) joint. The aim of this study was to investigate whether this clinically important issue could be detected using standard anteroposterior (AP) and lateral, as well as additional nonstandard fluoroscopic views using direct open visualization with magnifying loupes as reference standard. MATERIALS AND METHODS: Ten fresh cadaver wrists were used for this imaging study. A 2.2 mm cannulated compression screws with a length of 24 mm was placed in the scaphoid and incrementally left to protrude at the STT joint up to 2 mm. Eight fluoroscopic views of the wrist were then obtained by rotating the forearm using goniometric measurements, keeping the image beam parallel to the floor: (1) anteroposterior with the wrist in neutral rotation, (2) anteroposterior with the wrist in ulnar deviation, (3) supinated oblique 60° from neutral (60° supinated oblique), (4) supinated oblique 45° from neutral (45° supinated oblique), (5) a true lateral, (6) a true lateral with the wrist in radial deviation, (7) pronated oblique 45° from neutral (45° pronated oblique), and (8) a pronated oblique 60° from neutral (60° pronated oblique). RESULTS: Standard anteroposterior and lateral fluoroscopy views (radiographically calibrated) of a percutaneous cannulated screw fixation of a scaphoid fracture were insufficient to detect distal articular penetration, missing half the amount of screw penetrations in the current study. The 45° pronated oblique view was found as the most sensitive in detecting STT penetration (p < 0.0001). CONCLUSIONS: Standard anteroposterior and lateral fluoroscopy views of a percutaneous cannulated screw fixation of a scaphoid waist fracture are insufficient to detect STT screw penetration. According to the current study, standard views would have missed half the amount of screw penetrations, which seems to reflect the high incidence of this problem in current practice. The most sensitive view was the 45° pronated oblique view, which detected STT screw penetration in all cases. Level of Evidence Not applicable.

Scaphoid Length Loss Following Nonunion Is Associated with Dorsal Intercalated Segment Instability.

Background Dorsal intercalated segment instability (DISI) in scaphoid nonunions is frequently attributed to fracture location relative to ligamentous attachments onto the scaphoid apex. We hypothesize scaphoid length loss to have a stronger correlation with DISI deformity than fracture location in patients with scaphoid nonunion. Questions/Purposes To investigate the correlation between (1) scaphoid length loss, (2) fracture location relative to the scaphoid apex, and (3) type of nonunion (Herbert classification) and DISI deformity in skeletally mature patients with scaphoid nonunion. Patients and Methods Twenty-seven cases of computed tomography (CT)-confirmed scaphoid nonunion (>6 months) were retrospectively included. Our primary outcome was the degree of DISI as measured by the radiolunate (RL) angle on CT. Scaphoid length loss was expressed as height-to-length (H/L) ratio. Fracture location was classified as proximal or distal to the scaphoid apex. Nonunions were classified as fibrous unions (type D1) or pseudoarthrosis (type D2). The correlation between RL angle, H/L ratio, fracture location, and nonunion type was evaluated. Results H/L ratio was the only factor associated with the degree of DISI as measured by RL angle. As scaphoid length loss increased (increasing H/L ratio), the RL angle increased. There was no significant difference in RL angle between fractures located proximal (30 degrees) or distal (28 degrees) to the scaphoid apex, or type D1 (31 degrees) versus type D2 (28 degrees) nonunions. There was no correlation between patient age, sex, or wrist side affected and RL angle. Conclusions Scaphoid length loss, rather than fracture location, is correlated to the degree of DISI deformity in patients with scaphoid nonunion. This highlights the importance of restoring scaphoid height when planning scaphoid nonunion reconstruction. Level of Evidence Level III, diagnostic study.

Developing a machine learning algorithm to predict the probability of aseptic loosening of the glenoid component after anatomical total shoulder arthroplasty: protocol for a retrospective, multicentre study.

INTRODUCTION: Despite technological advancements in recent years, glenoid component loosening remains a common complication after anatomical total shoulder arthroplasty (ATSA) and is one of the main causes of revision surgery. Increasing emphasis is placed on the prevention of glenoid component failure. Previous studies have successfully predicted range of motion, patient-reported outcomes and short-term complications after ATSA using machine learning methods, but an accurate predictive model for (glenoid component) revision is currently lacking. This study aims to use a large international database to accurately predict aseptic loosening of the glenoid component after ATSA using machine learning algorithms. METHODS AND ANALYSIS: For this multicentre, retrospective study, individual patient data will be compiled from previously published studies reporting revision of ATSA. A systematic literature search will be performed in Medline (PubMed) identifying all studies reporting outcomes of ATSA. Authors will be contacted and invited to participate in the Machine Learning Consortium by sharing their anonymised databases. All databases reporting revisions after ATSA will be included, and individual patients with a follow-up less than 2 years or a fracture as the indication for ATSA will be excluded. First, features (predictive variables) will be identified using a random forest feature selection. The resulting features from the compiled database will be used to train various machine learning algorithms (stochastic gradient boosting, random forest, support vector machine, neural network and elastic-net penalised logistic regression). The developed and validated algorithms will be evaluated across discrimination (c-statistic), calibration, the Brier score and the decision curve analysis. The best-performing algorithm will be used to create an open-access online prediction tool. ETHICS AND DISSEMINATION: Data will be collected adhering to the WHO regulation on data sharing. An Institutional Review Board review is not applicable. The study results will be published in a peer-reviewed journal.

Biomodulating healing after arthroscopic rotator cuff repair: the protocol of a randomised proof of concept trial (BIOHACK).

PURPOSE/INTRODUCTION: Over the last decades, there has been increasing interest in biological stimulation or bioaugmentation after rotator cuff repair. So far, there is no consensus on the appropriate composition of biologicals or which patients would benefit most, and moreover, these biologicals are often expensive. However, there are other, non-pharmacological strategies that are also believed to achieve biological stimulation. This randomised controlled trial evaluates the possible cumulative effect of pragmatic application of cryobiomodulation, photobiomodulation and electrobiomodulation-collectively called biomodulation-on the bone-to-tendon healing process after rotator cuff repair. METHODS: In this randomised, controlled proof of concept study, 146 patients undergoing arthroscopic repair of a full thickness posterosuperior or anterosuperior rotator cuff tear will be 1:1 randomly assigned to either a control group or to the additional biomodulation protocol group. The adjuvant biomodulation protocol consists of seven self-applicable therapies and will be administered during the first 6 weeks after surgery. Primary outcome will be healing of the rotator cuff as evaluated by the Sugaya classification on MRI at 1-year postoperatively. ETHICS AND DISSEMINATION: This study has been accepted by the National Ethical Review Board CPP Sud-Est IV in France and has been registered at Clinicaltrials.gov. The results of this study will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT04618484.

Developing a machine learning algorithm to predict probability of retear and functional outcomes in patients undergoing rotator cuff repair surgery: protocol for a retrospective, multicentre study.

INTRODUCTION: The effectiveness of rotator cuff tear repair surgery is influenced by multiple patient-related, pathology-centred and technical factors, which is thought to contribute to the reported retear rates between 17% and 94%. Adequate patient selection is thought to be essential in reaching satisfactory results. However, no clear consensus has been reached on which factors are most predictive of successful surgery. A clinical decision tool that encompassed all aspects is still to be made. Artificial intelligence (AI) and machine learning algorithms use complex self-learning models that can be used to make patient-specific decision-making tools. The aim of this study is to develop and train an algorithm that can be used as an online available clinical prediction tool, to predict the risk of retear in patients undergoing rotator cuff repair. METHODS AND ANALYSIS: This is a retrospective, multicentre, cohort study using pooled individual patient data from multiple studies of patients who have undergone rotator cuff repair and were evaluated by advanced imaging for healing at a minimum of 6 months after surgery. This study consists of two parts. Part one: collecting all potential factors that might influence retear risks from retrospective multicentre data, aiming to include more than 1000 patients worldwide. Part two: combining all influencing factors into a model that can clinically be used as a prediction tool using machine learning. ETHICS AND DISSEMINATION: For safe multicentre data exchange and analysis, our Machine Learning Consortium adheres to the WHO regulation 'Policy on Use and Sharing of Data Collected by WHO in Member States Outside the Context of Public Health Emergencies'. The study results will be disseminated through publication in a peer-reviewed journal. Institutional Review Board approval does not apply to the current study protocol.

The O'Brien test demonstrates a higher diagnostic value in identifying posteroinferior labral tears than superior labral anterior to posterior (SLAP) tears.

Background: The primary aim was to determine the diagnostic value of the O'Brien test in localizing labral tears of the shoulder. Methods: A consecutive series of patients electing for labral repair between January 2005 and March 2021 were included in this retrospective study. Inclusion criteria were as follows: (1) any patient with a labral tear who was elected for arthroscopic labral repair and (2) had documentation of the O'Brien test in the preoperative evaluation. Exclusion criteria were patients that had a negative arthrographically enhanced computed tomography or magnetic resonance imaging scan. During arthroscopy, the localization and extension of the labral tear was documented in a standardized 12-o'clock configuration. Anteroinferior, posteroinferior, superior labrum anterior to posterior (SLAP), and combined labral tears were documented. The sensitivity, specificity, positive and negative predictive values, accuracy, positive and negative likelihood ratios, receiver operating characteristic curve, and area under the curve were calculated to determine the diagnostic value. Results: The cohort consisted of 271 patients (77% male) and included 105 anteroinferior, 86 posteroinferior, 46 SLAP, and 32 combined parts of the labrum. The mean age at time of surgery was 30 (±10.2) years. The O'Brien test was positive in 142 (52%) patients and showed the highest sensitivity and specificity for the posteroinferior tears (83% and 62%) compared to the anteroinferior (16% and 25%), combined labral parts (69% and 50%), and SLAP (65% and 50%) tears. In addition, receiver operating characteristic-analysis demonstrated a significantly higher area under the curve for posteroinferior tears compared to the other tears (P < .001). Conclusion: The O'Brien test demonstrates more diagnostic value for posteroinferior tears than other labral tears. This includes the SLAP tear, for which the O'Brien test was originally designed. Clinical Relevance: These findings are helpful towards reinterpreting the O'Brien test as well as diagnosing, and more specifically localizing labral tears in clinics.

Predictive value of Gagey's hyperabduction test in identifying inferior glenohumeral ligament lesions.

INTRODUCTION: Clinical tests that can identify inferior glenohumeral ligament (IGHL) complex injuries are indispensable for the diagnosis of shoulder instability. Gagey's hyperabduction test had been developed to diagnose IGHL hyperlaxity, however, it is unclear whether the test is able to accurately diagnose an IGHL lesion. The aim of this study was to (1) determine the diagnostic performance of the Gagey test in identifying an IGHL lesion and (2) determine if a positive Gagey test is more predictive for an anterior or posterior IGHL lesion thanks to the heatmapping of the lesions. It was hypothesized that a Gagey test can accurately predict IGHL lesions, but would not be able to distinguish between anterior and inferior IGHL lesions. METHODS: A retrospective diagnostic accuracy study was conducted including all consecutive patients who underwent glenoid labral repair between January 2005 and September 2021 with a documented Gagey test prior to surgery. Using arthroscopic findings as a reference standard, the diagnostic performance characteristics of the Gagey test for each type of IGHL lesion (anterior, posterior and combined) were calculated and labral heatmapping was used to depict its localisation. RESULTS: A total of 167 patients were included, with a mean age of 29±10 years. The sensitivity, specificity and accuracy of the Gagey test on determining an IGHL lesion were 46%, 38% and 46%, respectively. The positive and negative predictive values were 88% and 7%, respectively. Heatmapping of the labral lesions demonstrated that a positive Gagey test was most predictive of anterior IGHL and axillary pouch tears and non-predictive of posterior IGHL lesions. DISCUSSION: The Gagey test demonstrated a low sensitivity and specificity to identify an IGHL lesion and therefore the hypothesis could not be confirmed. However, the Gagey test has a high positive predictive value to diagnose anterior IGHL lesions. Further prospective research with a more evenly distribution of lesions is needed to investigate the clinical value of the Gagey test to identify these lesions. Based on this data, the Gagey test seems especially important to support the results of other clinical tests such as the apprehension, relocation and surprise tests. LEVEL OF EVIDENCE: III, Retrospective Case-Control study.

Development and training of a machine learning algorithm to identify patients at risk for recurrence following an arthroscopic Bankart repair (CLEARER): protocol for a retrospective, multicentre, cohort study.

INTRODUCTION: Shoulder instability is a common injury, with a reported incidence of 23.9 per 100 000 person-years. There is still an ongoing debate on the most effective treatment strategy. Non-operative treatment has recurrence rates of up to 60%, whereas operative treatments such as the Bankart repair and bone block procedures show lower recurrence rates (16% and 2%, respectively) but higher complication rates (<2% and up to 30%, respectively). Methods to determine risk of recurrence have been developed; however, patient-specific decision-making tools are still lacking. Artificial intelligence and machine learning algorithms use self-learning complex models that can be used to make patient-specific decision-making tools. The aim of the current study is to develop and train a machine learning algorithm to create a prediction model to be used in clinical practice-as an online prediction tool-to estimate recurrence rates following a Bankart repair. METHODS AND ANALYSIS: This is a multicentre retrospective cohort study. Patients with traumatic anterior shoulder dislocations that were treated with an arthroscopic Bankart repair without remplissage will be included. This study includes two parts. Part 1, collecting all potential factors influencing the recurrence rate following an arthroscopic Bankart repair in patients using multicentre data, aiming to include data from >1000 patients worldwide. Part 2, the multicentre data will be re-evaluated (and where applicable complemented) using machine learning algorithms to predict outcomes. Recurrence will be the primary outcome measure. ETHICS AND DISSEMINATION: For safe multicentre data exchange and analysis, our Machine Learning Consortium adhered to the WHO regulation 'Policy on Use and Sharing of Data Collected by WHO in Member States Outside the Context of Public Health Emergencies'. The study results will be disseminated through publication in a peer-reviewed journal. No Institutional Review Board is required for this study.

Arthroscopic Bone Block Procedure for Posterior Shoulder Instability: Updated Surgical Technique.

Posterior shoulder instability is generally caused by traumatic posterior dislocations or repetitive microtrauma during sports or other activities and has an annual incidence rate of 4.64 per 100,000 person-years. Several surgical techniques to treat posterior shoulder instability have been described, including soft-tissue repair and both open and arthroscopic bone block procedures. However, even though patient-reported outcomes are commonly high, surgical procedures are associated with high complication and revision rates of up to 14% and 67%, respectively. In particular, accurate placement of the bone graft, screw orientation, and the treatment of concomitant lesions are considered challenging. Therefore, improvement of surgical techniques is desirable. This Technical Note describes an updated approach to the arthroscopic posterior bone block augmentation described by Lafosse et al. (2012), with tips and tricks on the harvest and positioning of the graft.

Voluntary Increase of Minute Ventilation for Prevention of Acute Mountain Sickness.

This study evaluated the feasibility and efficacy of voluntary sustained hyperventilation during rapid ascent to high altitude for the prevention of acute mountain sickness (AMS). Study subjects (n=32) were volunteer participants in a 2-day expedition to Mount Leoneras (4954 m), starting at 2800m (base camp at 4120 m). Subjects were randomized to either: 1) an intervention group using the voluntary hyperventilation (VH) technique targeting an end-tidal CO2 (ETCO2)<20 mmHg; or 2) a group using acetazolamide (AZ). During the expedition, respiratory rate (28±20 vs. 18±5 breaths/min, mean±SD, P<0.01) and SpO2 (95%±4% vs. 89%±5%, mean±SD, P<0.01) were higher, and ETCO2 (17±4 vs. 26±4 mmHg, mean±SD, P<0.01) was lower in the VH group compared to the AZ group - as repeatedly measured at equal fixed intervals during the ascent - showing the feasibility of the VH technique. Regarding efficacy, the incidence of 6 (40%) subjects registering an LLS score≥3 in the VH group was non-inferior to the 3 (18%) subjects in the acetazolamide group (P=0.16, power 28%). Voluntary increase in minute ventilation is a feasible technique, but - despite the underpowered non-inferiority in this small-scale proof-of-concept trial - it is not likely to be as effective as acetazolamide to prevent AMS.

Acute scaphoid fractures: making decisions for treating a troublesome bone.

Seven aspects of the management of acute scaphoid fractures are open to debate: Diagnosis of true fractures among suspected fractures, assessment of fracture displacement, cast immobilization strategies, the role of surgical fixation, proximal pole fractures, assessment of union, and the underlying objective of treatment. We reviewed current evidence, and our varied interpretations of it, to highlight areas of uncertainty where more evidence might be helpful.

Serogroup C meningococcal osteomyelitis: a case report and review of the literature.

A rare case of a 7-year-old boy with acute hematogenous osteomyelitis caused by Neisseria meningitidis serogroup C is presented. The diagnosis of osteomyelitis was made by bone scintigraphy and a blood culture confirmed meningococci as the cause of the disease. Meningococcal osteomyelitis is exceptionally rare and to our knowledge, serogroup C meningococci have not been previously reported as a cause.