Onlay patch augmentation in rotator cuff repair for moderate to large tears in elderly patients: clinical and radiologic outcomes.

BACKGROUND: This study evaluated the clinical and radiologic outcomes of onlay patch augmentation in rotator cuff repair for moderate-to-large tears in elderly patients. METHODS: We reviewed 24 patients who underwent onlay augmentation with dermal allograft after arthroscopic rotator cuff repair from January 2017 to March 2020. Inclusion criteria were patients aged >65 years with tears >2.5 cm, who were followed for >12 months after surgery, and patients who could raise their arms above 90° preoperatively. American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, pain visual analog scale (VAS), and VAS for satisfaction were used as clinical outcomes. For the evaluation of cuff integrity, magnetic resonance imaging scans were performed every 3 months after surgery. The results were compared before and after surgery in all patients and between the retear and intact groups. RESULTS: The average follow-up period was 16.38 months, and the mean age of patients was 71.05 years. All patients showed significant improvement in ASES score, Constant-Murley score, and pain VAS at the last evaluation. The average value of satisfaction VAS was 7.27/10. The retear rate was 25% (6/24) if Sugaya type 3 was categorized in the retear group, otherwise 16.7% (4/24), if Sugaya type 3 was categorized into the intact group. Irrespective of Sugaya type 3 being included in the retear group, there was no significant difference in outcome variables between the intact and retear groups during follow-up. CONCLUSIONS: In moderate-to-large rotator cuff tear in elderly patients, onlay patch augmentation improved clinical outcomes. Retear did not adversely affect clinical outcomes.

Complications and Frequency of Surgical Treatment with AO-Type Hook Plate in Shoulder Trauma: A Retrospective Study.

We investigated the complications and frequency of hook plate fixation in patients with shoulder trauma. We reviewed 216 cases of hook plate fixation use at our hospital between January 2010 and May 2020. Finally, we included 76 cases of acute distal clavicle fracture (DCF) and 84 cases of acute acromioclavicular joint dislocation (ACD). We investigated all complications after hook plate use, bony union in the DCF group, and reduction loss in the ACD group. We defined painful shoulder stiffness (PSS) as aggravating resting pain with stiff shoulder, and pain on shoulder elevation (PSE) as continued shoulder pain on elevation without PSS before plate removal. PSS was managed with intra-articular steroid injections or manipulation with or without arthroscopic capsular release (ACR). PSS occurred in 36 and 33 cases of DCF and ACD, respectively. PSE occurred in 17 of 76 fractures and 13 of 84 dislocations. However, no iatrogenic rotator cuff injury was verified by magnetic resonance imaging in patients with PSS or PSE. Subacromial erosion in patients with hook plate fixation should be considered a sequela and not a complication because it is unavoidable in surgery with an AO-type hook plate. The most common complication was PSS, followed by PSE.

Can manipulation under anesthesia alone provide clinical outcomes similar to arthroscopic circumferential capsular release in primary frozen shoulder (FS)?: the necessity of arthroscopic capsular release in primary FS.

BACKGROUND: We evaluated the need for arthroscopic capsular release (ACR) in refractory primary frozen shoulder (FS) by comparing clinical outcomes of patients treated with ACR and manipulation under anesthesia (MUA). METHODS: We assessed patients with refractory primary FS, 57 patients (group A) who were treated with MUA and 22 patients (group B) who were treated with ACR. In group A, manipulation including a backside arm-curl maneuver was performed under interscalene brachial block. In group B, manipulation was performed only to release the inferior capsule before arthroscopic circumferential capsular release, which was carried out for the unreleased capsule after manipulation. Pain, range of shoulder motion, and American Shoulder and Elbow Surgeons score were recorded at 1 week, 3 months, 6 months, and 1 year after surgery. We compared outcome variables between treatment groups and between diabetics and non-diabetics and also evaluated the numbers of patients receiving additional intra-articular steroid injection. RESULTS: Outcome variables at 3 months after surgery and improvements in outcome variables did not differ between groups. Group A showed significantly better results than group B in the evaluation of pain and range of motion at 1 week. Diabetics showed comparable outcomes to non-diabetics for most variables. Eleven patients required additional steroid injections between 8 to 16 weeks after surgery: 12.2% in group A, 18.2% in group B. Additional injections were given three times more often in diabetics compared to non-diabetics. CONCLUSIONS: MUA alone can yield similar clinical outcomes to ACR in refractory FS.

Strut Support with Tricortical Iliac Allografts in Unstable Proximal Humerus Fractures: Surgical Indication and New Definition of Poor Medial Column Support.

BACKGROUND: The execution of fibular allograft augmentation in unstable proximal humerus fractures (PHFs) was technically demanding. In this study, the authors evaluated the clinical and radiographic outcomes after tricortical iliac allograft (TIA) augmentation in PHFs. METHODS: We retrospectively assessed 38 PHF patients treated with locking-plate fixation and TIA augmentation. Insertion of a TIA was indicated when an unstable PHF showed a large cavitary defect and poor medial column support after open reduction, regardless of the presence of medial cortical comminution in preoperative images. Radiographic imaging parameters (humeral head height, HHH; humeral neck-shaft angle, HNSA; head mediolateral offset, HMLO; and status of the union), Constant score, and range of motion were evaluated. Patients were grouped according to whether the medial column support after open reduction was poor or not (groups A and B, respectively); clinical outcomes were compared for all parameters. RESULTS: All fractures healed radiologically (average duration to complete union, 5.8 months). At final evaluation, the average Constant score was 73 points and the mean active forward flexion was 148°. Based on the Paavolainen assessment method, 33 patients had good results and 5 patients showed fair results. The mean loss of reduction was 1.32 mm in HHH and 5.02% in HMLO. None of the parameters evaluated showed a statistically significant difference between the two groups (poor and not poor medial column support). CONCLUSIONS: In unstable PHFs, TIA augmentation can provide good clinical and radiological results when there are poor medial column support and a large cavitary defect after open reduction.

Posterior Interosseous Nerve Palsy Caused by a Ganglion of the Arcade of Frohse.

A 51-year-old male who is right-handed visited the outpatient for right fingers-drop. The patient's fingers, including thumb, were not extended on metacarpophalangeal joint. The active motion of the right wrist was available. The electromyography and nerve conduction velocity study were consistent with the posterior interosseous neuropathy. Further evaluation was done with the magnetic resonance imaging for finding the space-occupying lesion or any possible soft tissue lesion around the radial nerve pathway. On magnetic resonance imaging, the ganglion cyst, which was about 1.8 cm in diameter, was observed on the proximal part of the superficial layer of the supinator muscle (Arcade of Frohse). The surgical excision was done on the base of ganglion cyst at the base of stalk of cyst which looked to be connected with proximal radioulnar joint capsule. The palsy had completely resolved when the patient was observed on the outpatient department a month after the operation.

Effect of Weight-Bearing in Conservative and Operative Management of Fractures of the Base of the Fifth Metatarsal Bone.

BACKGROUND: There is no established principle regarding weight-bearing in conservative and operative management of fifth metatarsal base fractures. METHODS: We reviewed 86 patients with acute fifth metatarsal base fractures. Conservatively treated late or early weight-bearing patients were assigned to Group A or C, respectively. Operatively treated late or early weight-bearing patients were assigned to Group B or D, respectively. Results were evaluated by clinical union, bone resorption, and the American Orthopaedic Foot and Ankle Society (AOFAS) and Visual Analogue Scale (VAS) scores. RESULTS: All 4 groups had bone union at a mean of 6.9 weeks (range, 5.1-15.0). There were no differences between the groups in the AOFAS and VAS scores. In the early weight-bearing groups, there were fewer cases of bone resorption, and the bone unions periods were earlier. CONCLUSIONS: Early weight-bearing may help this patient population. Moreover, conservative treatment could be an option in patients with underlying diseases.

Reverse Total Shoulder Arthroplasty without Bone-Grafting for Severe Glenoid Bone Loss in Patients with Osteoarthritis and Intact Rotator Cuff.

BACKGROUND: Treating shoulders with osteoarthritis, an intact rotator cuff, and substantial glenoid bone loss is challenging. One option is reaming the glenoid flat and inserting a reverse prosthesis. This study reports the subjective, objective, and radiographic results of reverse total shoulder arthroplasty (RTSA) in this population. METHODS: We retrospectively reviewed 42 consecutive patients (23 women; mean age, 71 years [range, 53 to 89 years]) with primary glenohumeral osteoarthritis, intact rotator cuffs, and Walch type-A2 (n = 19), B2 (n = 5), or C glenoids (n = 18) who had undergone a total of 42 RTSAs with glenoid reaming without bone-grafting between 2008 and 2013 (mean follow-up, 36 months [range, 24 to 66 months]). All patients were evaluated before and after surgery subjectively (using a visual analog scale for pain and 5 shoulder-specific outcome instruments), objectively (with goniometric examination of shoulder range of motion), and radiographically (to assess baseplate loosening and degree of scapular notching). RESULTS: One baseplate (2%) failed, requiring revision surgery. There were no other signs of baseplate loosening in any patient at the last follow-up. Preoperatively to postoperatively, pain improved significantly (p < 0.001), as did all patient-reported outcome measures and the following range-of-motion parameters (p ≤ 0.001): active abduction, active flexion, and active external rotation with the arm elevated 90°. Eight (19%) of the patients had notching. CONCLUSIONS: RTSA without bone-grafting and with medialization of the baseplate in patients with osteoarthritis and severe glenoid bone loss resulted in significant improvement in pain and function with reliable short-term implant survivorship and may be a good alternative to anatomical TSA. Longer follow-up is needed to determine the relative advantages and disadvantages. This was an "off-label" indication for this device. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Which Is Better for Arthroscopic Tenodesis of the Long Head of the Biceps: Soft Tissue or Bony Interference Fixation?

PURPOSE: To compare the outcome between arthroscopic soft tissue tenodesis (STT) at the rotator interval and bony interference fixation tenodesis (BIFT) at the distal bicipital groove for the long head of the biceps (LHB). METHODS: Twenty-five shoulders that underwent arthroscopic STT of the LHB were compared with 28 shoulders that underwent arthroscopic BIFT using a 5.5-mm Bio-Tenodesis screw (Arthrex, Naples, FL). American Shoulder and Elbow Surgeons scores, Constant score, and elbow flexion strength index (EFSI) were checked preoperatively, postoperative 1 year and 2 years. Ultrasound imaging evaluation took place at 1 year and 2 years postoperatively as well. RESULTS: The overall functional outcomes improved after surgery in both groups. The BIFT group showed a significant increase in EFSI (preop: 0.54, postoperative 2 years: 0.94) compared with that of the STT group (preop: 0.52, postoperative 2 years: 0.74) at postoperative 2 years (P = .006). However, no significant difference was seen in the increase of American Shoulder and Elbow Surgeons scores and Constant scores between the two groups. At postoperative 2 years, ultrasound showed seven empty grooves in the STT group, but only two empty grooves in the BIFT group (P = .046). CONCLUSIONS: Arthroscopic BIFT for the LHB showed better improvement in EFSI than arthroscopic STT. In addition, the STT group showed a higher failure rate than the BIFT group. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Treatment of superior labrum anterior posterior lesions: a literature review.

OBJECTIVE: Treatment of superior labrum anterior posterior (SLAP) lesions continues to be controversial, but with the development of suture anchors, it has become acceptable to repair these lesions arthroscopically. The aim of this study was to review recent trends in the evaluation and treatment of SLAP lesions, with particular emphasis on comparing the results of biceps tenodesis and SLAP repair. METHODS: All English language publications from the PubMed, Cochrane, and SCOPUS databases between 1928 and 2012 on biceps tendon, SLAP lesions, and biceps surgery were reviewed. Literature was reviewed in table form because of the lack of Level 1 studies. RESULTS: Surgical repair can have complications and may not return overhead athletes to their previous level of activity. Biceps tenodesis has become the preferred primary procedure in non-athletic individuals because of the high failure rate of SLAP repair. In patients with continuing symptoms after SLAP lesion repair, biceps tenodesis offers a more predictable operation than a second repair attempt. CONCLUSION: Biceps tenodesis may present a viable treatment option for SLAP repair or for failed SLAP repair in some patients.

The effect of notchplasty on tunnel widening in anterior cruciate ligament reconstruction.

PURPOSE: To investigate changes in femoral tunnel diameter, dimension, and volume after anterior cruciate ligament reconstruction with notchplasty. METHODS: Porcine knee specimens were divided into 2 groups of 10 specimens each. Group A did not receive notchplasty. A 2-mm notchplasty was conducted in group B. Seven-millimeter-diameter femoral tunnels were drilled and a doubled flexor digitorum profundus tendon was inserted and fixed with an EndoButton (Smith & Nephew, Andover, MA) in each knee specimen. Samples were mounted on a materials testing machine. Each group was preloaded at 10 N and subjected to 20 loading cycles (between 0 and 40 N), followed by 1,000 loading cycles in the elastic region (between 10 and 150 N). High-resolution computed tomography with 1.0-mm slices was conducted with all samples before and after testing. A 3-dimensional model was constructed to evaluate the degree of the tunnel change. RESULTS: In group B the mean longest diameter and dimension of the femoral tunnel significantly increased after the test (P = .005 and P = .001, respectively). The volumetric loss of bony structure after the test in group B was significantly greater than that in group A (P = .039). Meanwhile, no significant difference was found before and after the test in terms of tunnel diameter, dimension, and volumetric loss around the tunnel in group A. CONCLUSIONS: The intra-articular orifice of the femoral tunnel was enlarged after the uniaxial cyclic loading test after notchplasty. An enlarged tunnel orifice may lead to a discrepancy between the tunnel and the graft at the tunnel aperture. CLINICAL RELEVANCE: The data may have an implication that suspensory fixation with a notchplasty has a negative effect on the full graft accommodation at the tunnel aperture. Aperture widening may affect graft positioning, leading to subtle changes in graft biomechanics and laxity.

Uncommon indications for reverse total shoulder arthroplasty.

Total shoulder arthroplasty and shoulder hemiarthroplasty have been the traditional method for treating a variety of shoulder conditions, including arthritis, cuff tear arthropathy, and some fracture types. However, these procedures did not provide consistently good results for patients with torn rotator cuffs. The development of the reverse prosthesis by Grammont in the late 20th century revolutionized the treatment of the rotator-cuff-deficient shoulder with arthritis. The main indication for the reverse prosthesis remains the patient with cuff tear arthropathy who has pain and loss of motion. Because the reverse total shoulder arthroplasty produced such good results in these patients, the indications for the reverse prosthesis have expanded to include other shoulder conditions that have previously been difficult to treat successfully and predictably. This review discusses and critically reviews these newer indications for the reverse total shoulder arthroplasty.

A novel repair method for the treatment of acute Achilles tendon rupture with minimally invasive approach using button implant: a biomechanical study.

BACKGROUND: Minimally invasive Q3 repair has been proposed for acute Achilles tendon rupture with low rate of complications. However there are still controversies about optimal technique. In this study we aimed to describe Endobutton-assisted modified Bunnell configuration as a new Achilles tendon repair technique and evaluate its biomechanical properties comparing with native tendon and Krackow technique. METHODS: 27 ovine Achilles tendons were obtained and randomly placed into 3 groups with 9 specimens ineach. The Achilles tendons were repaired with Endobutton-assisted modified Bunnell technique in group 1, Krackow suture technique in group 2 and group 3 was defined as the control group including native tendons. Unidirectional tensile loading to failure was performed at 25mm/min. Biomechanicalproperties such as peak force to failure (N), stress at peak (MPa), elongation at failure, and Young'smodulus (GPa) was measured for each group. All groups were compared with each other using one-wayANOVA followed by the Tukey HSD multiple comparison test (a=0.05). RESULTS: The average peak force (N) to failure of group 1 and group 2 and control group was 415.6±57.6, 268.1±65.2 and 704.5±85.8, respectively. There was no statistically significant difference between native tendon and group 1 for the amount elongation at failure (p>0.05). CONCLUSIONS: Regarding the results, we concluded that Endobutton-assisted modified Bunnell technique provides stronger fixation than conventional techniques. It may allow early range of motion and can be easily applied in minimally invasive and percutaneous methods particularly for cases with poor quality tendon at the distal part of rupture. LEVEL OF EVIDENCE: Level II, Biomechanical research study.

Surgical results of intradural extramedullary tumors.

BACKGROUND: To report the treatment results of 12 patients who underwent a total excision of intradural extramedullary tumors. METHODS: Twelve cases of histopathologically confirmed intradural extramedullary tumors were treated surgically between February 2002 and March 2005. There were 8 males and 4 females with an average age of 42.6 years. The mean postoperative follow-up period was 24.2 months. The histopathological findings, locations of the tumors, and clinical results were analyzed. The neurological findings obtained during the preoperative stage and the postoperative follow-up were evaluated according to the Frankel classification. RESULTS: The histopathological results are as follows: 4 cases of a meningioma, 4 cases of a schwannoma, 2 cases of an epidermoid cyst, 1 case of an arachnoid cyst, and 1 case of an ependymoma. The locations of the tumors were as follows: 7 cases in the thoracic region, 4 cases in the lumbar region, and 1 case in the cervical region. At the final follow-up, a 2-grade and 1-grade improvement was observed in 1 and 7 cases, respectively. There were no changes in the Frankel grade in 4 cases. The preoperative neurological deficit improved within 8 postoperative weeks in most cases and within 1 postoperative year in all cases. Postoperatively, there were 2 cases of cerebrospinal fluid leakage and 2 cases of paresthesia. CONCLUSIONS: Intradural extramedullary tumors detected by MRI are mostly benign and good clinical results can be obtained when treated surgically. Therefore, more active surgical approaches by orthopedic surgeons are recommended to decrease morbidity.