Long-term outcomes of hemiarthroplasty using a smaller head combined with rotator cuff reconstruction in patients with cuff-tear arthropathy.

Background: Hemiarthroplasty (HHR) using a smaller head with rotator cuff reconstruction is a treatment option for cuff-tear arthropathy, offering advantages like facilitating rotator cuff-tear closure, increasing the lever arm of deltoid, and restoring function in irreparable cuff tears. This study aimed to evaluate the long-term outcomes of this procedure. Methods: A retrospective analysis was conducted for 91 shoulders undergoing HHR using a smaller head with rotator cuff reconstruction between May 2005 and September 2012. Surgery involved reducing the size of humeral head and performing rotator cuff reconstruction based on the site of the deficient rotator cuff. The study analyzed University of California, Los Angeles shoulder scores, Japanese Orthopaedics Association shoulder scores, range of motion, and postoperative radiographs. Results: Twenty-eight patients, divided into an elderly group (14 women, 2 men, mean age 74.5 ± 3.8 years) and a younger group (6 women, 6 men, mean age 63.5 ± 3.1 years) were followed up for a mean of 133.2 ± 14.1 months. No complications were reported. The clinical scores and range of motion significantly improved postoperatively and remained over 10 years. Radiographs revealed high incidence of glenoid wear (82.1%), bone resorption (43%) and cranial humeral head migration (54%), with no prosthesis loosening. Conclusion: We believe that HHR using a smaller head with rotator cuff reconstruction is a surgical technique that can maintain stable long-term outcomes in both elderly and younger individuals with cuff-tear arthropathy.

Differences in incidence rate and onset timing of undiagnosed finger symptom among shoulder surgeries related to complex regional pain syndrome.

The purpose of this study was to clarify the difference in onset timing and incidence of undiagnosed finger symptom (UDFS) between various shoulder surgical procedures. In this study, UDFS symptoms included the following four symptoms in the fingers;edema, limited range-of-motion, skin color changes, and abnormal sensations. UDFS cases were defined as those presenting with at least one UDFS. In result, the incidence rate of UDFS cases was 7.1% overall (58/816 shoulders), 7.4% (32/432) in arthroscopic rotator cuff repair (ARCR), 9.0% (11/122) in open rotator cuff repair (ORCR), 1.4% (2/145) in arthroscopic subacromial decompression (ASD), 13.2% (5/38) in open reduction and internal fixation (ORIF), 11.1% (3/27) in humeral head replacement, 4.8% (1/21) in anatomical total shoulder arthroplasty, and 12.9% (4/31) in reverse total shoulder arthroplasty cases. The Rate was significantly higher with ARCR compared to ASD (p<.01). About onset timing in weeks postoperatively, the ORIF group had a statistically earlier symptom onset than the Rotator cuff repair (ARCR + ORCR) group (2.4 weeks vs. 6.0 weeks, p<.01). When classifying the onset timing into before and after the removal of the abduction pillow, the ORIF group showed a statistically higher rate of onset before brace removal than the Rotator cuff repair groups (p<.01). Differences in UDFS among shoulder surgeries were demonstrated in this study. J. Med. Invest. 70 : 415-422, August, 2023.

Relationship between hematoma-like tissue on the footprint and structural outcome of arthroscopic rotator cuff repair with a transosseous technique.

Background: We have tried to create hematoma over the footprint site at the end of arthroscopic rotator cuff repair (ARCR) surgery, expecting to apply biochemical effects of the platelet-related factors. The purpose of this study was to investigate the presence of hematoma-like tissue (HLT) on postoperative magnetic resonance imaging, and to evaluate the relationship between the HLT and the structural outcomes of ARCR. Materials and methods: Twenty-five patients were reviewed with a mean age at surgery of 69.8 years (range, 52-85 years). Postoperative magnetic resonance imaging was performed at 1 week, 6-8 weeks, and >6 months postoperatively. Structural outcomes for the repaired cuff and thickness of HLT were evaluated on coronal T2-weighted images. Signal intensity of HLT was evaluated on coronal T2-weighted fat-suppressed images as the ratio compared to supraspinatus tendon intensity (HLT/SSP ratio). Results: Structural outcomes showed Sugaya type 1 in 12 shoulders, type 2 in 4, and type 3 in 9. HLT thickness was significantly thicker at 1 week and 6-8 weeks postoperatively in Sugaya type 1 patients than in type 3 patients (1 week; P = .014, 6-8 weeks; P < .001). HLT/SSP ratio gradually decreased (at 1 week; 1.9 ± 0.7, 6-8 weeks; 1.6 ± 0.6, >6 months; 1.2 ± 0.5), and differed significantly between >6 months and both 1 week and 6-8 weeks (P < .001 each).

Correlation of suprascapular notch morphology with suprascapular nerve palsy: a 3D-computed tomography study.

Background: The morphology of the suprascapular (SS) notch is a very important factor in treatment of suprascapular nerve (SSN) palsy. Several studies have reported SS notch morphology in cadavers or using a three-dimensional computed tomography (3D-CT); however, none has reported the distribution of SS notch morphology according to the age group. In addition, the correlation between SS notch morphology and SSN palsy remains unclear. The purposes of this study were to investigate the morphological distribution of the SS notch by age group in a large population and to assess the relationship between SS notch morphology and SSN palsy. Methods: We studied the 3D-CT images of 1063 shoulders in 1009 patients (mean age, 60.8 years; age range, 14-96 years). There were 53 shoulders with SSN palsy and 1010 shoulders without SSN palsy. Morphology of the SS notch was classified by Rengachary's classification (types I-VI). Shoulders with types I-IV were classified into the nonossified superior transverse scapular ligament (STSL) group (group N) and those with types V and VI into the ossified STSL group (group O). Results: The Rengachary's classifications of the 1063 shoulders were as follows: type I: n = 113, 10.6%; type II: n = 313, 29.4%; type III: n = 383, 36.0%; type IV: n = 109, 10.3%; type V: n = 107, 10.0%; and type VI: n = 38, 3.6%. Mean age was significantly older in the ossified STSL group, and the age was <40 years for only two shoulders in this group. The Rengachary's classifications of the SSN palsy cases were as follows: type I: 7.5%, II: 24.5%, III: 34.0%, IV: 15.1%, V: 13.2%, and VI: 5.7%. There was no statistical difference in age and sex, Rengachary type, or ossification between SSN palsy and non-SSN palsy cases. Conclusions: Ossification of the STSL was significantly more common in older patients, which suggests age-related change. In addition, no relation was identified between narrow notch or ossification of the STSL with the onset of SSN palsy.

Electromyographic activities of glenohumeral joint muscles during shoulder forward flexion with isometric horizontal abduction loading.

BACKGROUND: Isometric horizontal abduction loading has been applied to improve imbalanced scapular muscle activities during shoulder exercises; however, the effect on glenohumeral joint muscle activity remains unclear. The purpose of this study was to investigate the changes in electromyographic activity of shoulder muscles during forward flexion with isometric horizontal abduction loading in healthy participants. METHODS: Thirteen healthy men were recruited for this study. Participants performed shoulder forward flexion with isometric horizontal abduction loading using an elastic band (Flex-band condition) and forward flexion without shoulder loading (Normal-flex condition). Muscle activities were evaluated while maintaining shoulder flexion at 60°, 90°, 120°, and 150° (static task) and during active shoulder flexion from 0° to maximum elevation (dynamic task). Surface electrodes were placed on the deltoid, pectoralis major, infraspinatus, and teres minor muscles to measure the activities of the shoulder muscles during each task. The muscle activities during the static task were compared using a 2-way analysis of variance with repeated measures of the 2 factors, loading condition and flexion position, and a paired t test was used for comparisons between the 2 conditions during the dynamic task (significance level set at P < .05). RESULTS: For the static task, the Flex-band condition significantly increased the deltoid middle and posterior activities by 2-15 times and the infraspinatus and teres minor activities by 2-3 times compared with the Normal-flex condition at all positions. In contrast, the Flex-band condition significantly decreased (by about half) the activities of the deltoid anterior (at 120° and 150°) and pectoralis major (at all positions) compared with the Normal-flex condition. For the dynamic task, the Flex-band condition significantly increased the deltoid middle, deltoid posterior, infraspinatus, and teres minor activities by 2-7 times and decreased the deltoid anterior activity by approximately two-thirds. CONCLUSIONS: Applying isometric horizontal abduction loading during shoulder forward flexion may be useful in improving the imbalanced muscle activities of the glenohumeral joint, such as excessive activity of the deltoid anterior and pectoralis major and dysfunction of the deltoid middle, deltoid posterior, and shoulder external rotator muscles. Shoulder forward flexion with horizontal abduction loading could be available for exercise in patients who have massive rotator cuff tears or who have undergone rotator cuff repair and shoulder arthroplasty.

Computed tomography revealed the correlation between radiolucency and alignment of all-polyethylene pegged glenoid component more than 10 years after total shoulder arthroplasty in the Japanese population.

BACKGROUND: Anatomical total shoulder arthroplasty (TSA) provides successful long-term outcomes but complications can occur after 10 years that require revision. Computed tomography (CT) is a useful tool for assessing radiolucent lines around the glenoid component of TSA; however, the merits of long-term post-TSA follow up with CT are unclear. The purpose of this study was to evaluate the long-term outcomes after TSA of Japanese population and to identify factors related to radiolucency around the glenoid component using CT. METHODS: A retrospective review was conducted of TSA patients who had completed at least 10 years of clinical follow up. Radiographs and CT images of the affected shoulder obtained at the last follow up were evaluated for radiolucent lines around the stem and each peg, superior inclination and retroversion of the glenoid component, subluxation index, and critical shoulder angle (CSA). Shoulder ROM, Constant-Murley score and UCLA score were compared between the preoperative and last follow up period. RESULTS: Eighteen shoulders in 16 patients met the inclusion criteria. Mean patient age was 61 years, mean follow up period was 137 months, and mean Yian CT score was 19%. CT score was significantly highest in pegs located inferiorly (p < 0.05). Mean glenoid superior inclination was 12.6°, retroversion was -0.3°, subluxation index was 46%, and CSA was 33.7°. Glenoid superior inclination was significantly lower (p = 0.007) in shoulders with possible loosening than in cases with no loosening (5.0° vs 15.6°). Mean Constant score and UCLA score improved significantly after TSA, from 25.8 to 10.7 points preoperatively to 70.1 and 28.9 points postoperatively, respectively. Mean shoulder flexion, internal rotation, and external rotation also showed improvement postoperatively. CONCLUSION: TSA provides good long-term outcomes. Radiolucency was present most frequently around the inferior pegs of the glenoid component. Glenoid superior inclination may affect the formation of radiolucent lines around glenoid pegs. LEVEL OF EVIDENCE: Level IV; Case Series; Treatment study.

Glenoid wear after humeral head replacement with using a single implant in patients with cuff tear arthropathy more than five years.

BACKGROUND: The aim of this study was to investigate glenoid wear in patients with humeral head replacement with a smaller humeral head, who were observed for >5 years, and to examine the relationship between radiographic changes and clinical outcome. METHODS: In this study, 41 shoulders of 41 patients (13 men, 28 women) were followed up for >5 years. The mean patient age at the time of surgery was 70.5 years. The average follow-up period at short-term was 26.0 months, and intermediate-term was 66.5 months. We classified glenoid wear into four grades (i.e., Grade 0 to Grade 3). Age, sex, clinical scores, and range of motion were investigated in relation to the grade of glenoid wear. Radiographs of glenoid wear evaluated in the short-term were subsequently compared to radiographs obtained in the intermediate-term period. RESULTS: At the final follow-up, 16 (39%) patients had Grade 0 wear, 11 (27%) patients had Grade 1 wear, 10 (24%) patients had Grade 2 wear, and 4 (10%) patients had Grade 3 wear. The University of California-Los Angeles score, Japanese Orthopaedic Association score, and active forward flexion were significantly lower in the Grade 3 patients; however, Grade 3 patients did not have significant pain. No significant difference in age, sex, Constant score, active external rotation, and active internal rotation in relation to the grade of glenoid wear was observed. In total, 25 (61%) patients showed a progression of glenoid wear. Cases in which glenoid wear progressed after 4 years after surgery were rare. Two patients of Grade 3 underwent total shoulder arthroplasty revision at 16 months and 38 months, respectively. CONCLUSIONS: Glenoid wear occurred in 61% of patients at 5 years follow-up. Pain of Grade 3 patients was mild, therefore, if pain is not severe, revision surgery may not be necessary.

Risk factors for eccentric glenoid wear after humeral head replacement for cuff tear arthropathy.

Background: In our previous report, glenoid wear (GW) after humeral head replacement for cuff tear arthropathy was classified with modified Goya's classification (grade 0-3), and, among 3 subtypes of grade 3 (glenoid bone erosion), grade 3B (superior eccentric erosion) showed significantly more pain and limited active flexion postoperatively compared to grade 3C (concentric erosion). The purpose of this study was to detect individual risk factors for the progression to grade 3B GW. Methods: Seventy-nine shoulders in 70 patients who were followed up for a mean of 8.2 years (range, 5.0-13.2 years), including 29 men and 41 women, with a mean age at the surgery of 71.1 years (range, 54-87 years), were reviewed. Atrophy and fatty degeneration of torn cuff muscle, preoperative humeral head displacement (superior translation ratio [STR], anterior translation ratio, and other several parameters) on preoperative magnetic resonance imaging, and other individual factors were analyzed as possible risk factors. Results: GW at the final follow-up was grade 0: 5 shoulders, grade 1: 17, grade 2: 20, and grade 3: 37 (3A: 4, 3B: 22, and 3C: 11). Preoperative higher STR was defined as a risk factor for grade 3 GW (odds ratio, 35.5; 95% confidence interval, 1.8-693.0; P = .018). Comparison among the three subtypes of grade 3 showed that patients with grade 3B GW had larger STR than 3C (41.4 ± 14.2% vs. 23.5 ± 13.3 % P = .006). Conclusion: Patients with preoperative high STR are considered to have a risk for grade 3B GW, which possibly relates to poor clinical outcome and future revision.

Potential use of EGFR-targeted molecular therapies for tumor suppressor CYLD-negative and poor prognosis oral squamous cell carcinoma with chemoresistance.

BACKGROUND: Tumor suppressor CYLD dysfunction by loss of its expression, triggers malignant transformation, especially drug resistance and tumor invasion/metastasis. Although loss of CYLD expression is significantly associated with poor prognosis in a large variety of tumors, no clinically-effective treatment for CYLD-negative cancer patients is available. METHODS: We focused on oral squamous cell carcinoma (OSCC), and sought to develop novel therapeutic agents for CYLD-negative cancer patients with poor prognosis. CYLD-knockdown OSCC cells by using CYLD-specific siRNA, were used to elucidate and determine the efficacy of novel drug candidates by evaluating cell viability and epithelial-mesenchymal transition (EMT)-like change. Therapeutic effects of candidate drug on cell line-derived xenograft (CDX) model and usefulness of CYLD as a novel biomarker using patient-derived xenograft (PDX) model were further investigated. RESULTS: CYLD-knockdown OSCC cells were resistant for all currently-available cytotoxic chemotherapeutic agents for OSCC, such as, cisplatin, 5-FU, carboplatin, docetaxel, and paclitaxel. By using comprehensive proteome analysis approach, we identified epidermal growth factor receptor (EGFR), a receptor tyrosine kinase, played key roles in CYLD-knockdown OSCC cells. Indeed, cell survival rate in the cisplatin-resistant CYLD-knockdown OSCC cells was markedly inhibited by treatment with clinically available EGFR tyrosine kinase inhibitors (EGFR-TKIs), such as gefitinib. In addition, gefitinib was significantly effective for not only cell survival, but also EMT-like changes through inhibiting transforming growth factor-ß (TGF-ß) signaling in CYLD-knockdown OSCC cells. Thereby, overall survival of CYLD-knockdown CDX models was significantly prolonged by gefitinib treatment. Moreover, we found that CYLD expression was significantly associated with gefitinib response by using PDX models. CONCLUSIONS: Our results first revealed that EGFR-targeted molecular therapies, such as EGFR-TKIs, could have potential to be novel therapeutic agents for the CYLD-negative OSCC patients with poor prognosis.

Glenoid wear and its impact on clinical results after humeral head replacement using a single prosthesis in cuff tear arthropathy with more than 8 years of follow-up.

BACKGROUND: Glenoid wear (GW) is a long-term complication after humeral head replacement (HHR) and is one of the major reasons for revision surgery. This study aimed to evaluate GW at >8 years of follow-up after HHR in patients with cuff tear arthropathy (CTA) by use of a modified classification of GW, to examine the relationship between GW and clinical outcomes, and to identify risk factors for GW progression. METHODS: This retrospective case-series study included 34 shoulders that were monitored for >8 years after HHR in patients with CTA (13 men and 21 women; mean age at surgery, 70.9 years [range, 55-82 years]). Patients were monitored for a mean of 10.3 years (range, 8.1-13.2 years). GW was classified using plain radiographs as follows: grade 0, no remarkable postoperative changes; grade 1, postoperative glenohumeral joint space narrower than preoperative glenohumeral joint space; grade 2, contact between glenoid and humeral head prosthesis; and grade 3, glenoid erosion. Grade 3 cases were further classified into the following subtypes: grade 3A, partial erosion of anterior glenoid; grade 3B, partial erosion of superior glenoid; and grade 3C, concentric erosion of glenoid. Clinical outcomes including range of motion (active flexion and active external rotation) and postoperative pain (Constant score) were compared between grade 0-2 shoulders and grade 3 shoulders, as well as between the grade 3 subtypes. Age, sex, preoperative range of motion, preoperative pain, and number of ruptured tendons were analyzed as possible risk factors for progression to grade 3. RESULTS: The final GW grade was grade 0 in 3 shoulders, grade 1 in 10, grade 2 in 6, and grade 3 in 15 (grade 3A in 2, grade 3B in 6, and grade 3C in 7). The grade 3 group had lower pain scores (10.7 ± 6.2 vs. 14.2 ± 1.9, P = .044) and limited active flexion (108.2° ± 42.3° vs. 140.6° ± 26.7°, P = .041) compared with the grade 0-2 group. Subtype comparison showed that the grade 3B group had lower pain scores (7.0 ± 6.7 vs. 15.0 ± 0.0, P = .007) and limited active flexion (80.0° ± 26.2° vs. 140.8° ± 27.5°, P = .010) compared with the grade 3C group. Limited preoperative active external rotation was an individual risk factor for grade 3 GW (odds ratio, 0.93; 95% confidence interval, 0.88-0.99; P = .009). CONCLUSIONS: In the long term (>8 years) after HHR with tendon transfer in patients with CTA, patients with the development of grade 3C GW ultimately achieve pain relief even without revision surgery whereas grade 3B GW is associated with persistent pain and might require revision surgery.

Morphology of the coracoid process as a predictor of articular-side tear at the upper border of the subscapularis.

BACKGROUND: Articular-side tear at the upper border of the subscapularis (SSC-AST) is often detected during shoulder arthroscopic surgery, although its exact pathology remains unknown. The purpose of this study was to investigate the correlation between various characteristics of the coracoid process, including classification of the morphology of the coracoid process tip, and the presence of SSC-AST. METHODS: This retrospective, case-controlled study included patients who underwent arthroscopic subacromial decompression with or without rotator cuff repair between January 2018 and September 2021. A total of 130 shoulders in 124 patients, including 77 male and 53 female shoulders (mean age at surgery, 64 years [range, 39-88 years]), were included in this study. Three-dimensional (3D) computed tomography examination was performed preoperatively, and the following indices were measured: coracoid proximal length, coracoid distal length, coracoid angle, coracoglenoid angle, offset of the coracoid process and glenoid (anterior, lateral, and superior offset), and coracoid base angle. The morphology of the tip of the coracoid process was classified into 3 types according to 3D reconstructed views: flat type, round type, and beak type. The presence of SSC-AST was intraoperatively evaluated arthroscopically via a posterior glenohumeral portal. Morphologic risk factors for SSC-AST were evaluated between SSC-AST cases (group T) and non-SSC-AST cases (group N) by multivariable logistic analysis. In addition, the correlation between the incidence of SSC-AST and classification of the tip of the coracoid process was analyzed. RESULTS: SSC-AST was present in 53 shoulders (40.8%). Group T patients were significantly older than group N patients (68.4 ± 10.0 years vs. 61.5 ± 11.8 years, P < .001). No sex difference was detected between the 2 groups (28 male and 25 female shoulders in group T vs. 49 male and 28 female shoulders in group N, P = .28). Multivariate analysis of morphologic parameters between the 2 groups detected a smaller superior offset as a risk factor for SSC-AST (odds ratio, 0.91; 95% confidence interval, 0.84-0.98; P = .01). No significant differences were found in the other parameters. Regarding classification of the tip of the coracoid process, round- and beak-type coracoid tips had a significantly higher rate of SSC-AST than flat-type tips (flat type, 21.8%; round type, 64.7%; and beak type, 46.3%) (P < .001). CONCLUSIONS: Evaluation of the correlation between the morphology of the coracoid process on 3D computed tomography and the presence of SSC-AST visualized during arthroscopy indicated a significant association between SSC-AST and the morphology of the coracoid process.

The influence of testing positions and resistance locations on muscle activities during shoulder internal rotation strength measurements in young healthy adults.

BACKGROUND: Although some tests of shoulder internal rotator strength including subscapularis are commonly used in clinical practice, the differences in shoulder muscle activities other than subscapularis muscle among those tests are not well understood. The purpose of this study was to examine the activities of the superficial shoulder muscles in addition to internal rotation strength during two belly-press and three lift-off test positions. METHODS: Thirteen healthy young adult men (age 29.5 ± 5.4 years) were recruited for the present study. They performed isometric shoulder internal rotation against manual resistance during the belly-press test positions with two different resistance locations and the lift-off test with three different arm positions. The surface electromyographic activities of the superficial shoulder muscles, including the deltoid (anterior, middle, posterior), pectoralis major, long head of triceps and latissimus dorsi muscle, were collected and compared between the two belly-press tests, and among the three lift-off test positions (P < 0.05). RESULTS: The belly-press test position with resistance to elbow showed significantly greater activities of the anterior and middle deltoid muscle than the original belly-press test; but showed significantly smaller activities of pectoralis major, triceps and latissimus dorsi muscle than the original belly-press test. Among the three lift-off tests, all muscle activities, except for the pectoralis major, were greater in the lift-off at L4/5 than in the lift-off at buttock and thigh. Lift-off at thigh showed significantly smaller activity of pectoralis major than the lift-off at L4/5 and buttock. CONCLUSIONS: The findings of the present study suggest that clinician should give attention to compensatory motions by excessive shoulder extensor and adductor muscle activities for the original belly press test, by excessive deltoid muscle activities for the modified belly-press, and by excessive shoulder extensor muscle activities for the lift off test in the inferior arm positions.

Glenoid bone resorption after Bankart repair: finite element analysis of postoperative stress distribution of the glenoid.

BACKGROUND: There are various modifications of the Bankart repair, and postoperative changes to the glenoid morphology after the repair are reported. Among the various procedures performed, a decrease in the lateral glenoid diameter might be related to the surgery that involves removal of the articular cartilage and repair of the labrum-anterior inferior glenohumeral ligament complex on the glenoid surface. This is in contrast to cases without significant bony Bankart lesions that are not on the edge of the glenoid. Thus, this study aimed to compare glenoid rim stress after Bankart repair using 2 methods of finite element analysis: a method of removing the anteroinferior cartilage and repairing the glenohumeral ligament complex on the glenoid and a method of preserving the cartilage and repairing the glenohumeral ligament complex on the glenoid edge. METHODS: Five preoperative computed tomography scans of patients with traumatic anterior instability who underwent arthroscopic Bankart repair were used. Two models simulating different surgical procedures were created as follows: in model G, a 5-mm-thick cartilage on the glenoid rim was removed between 2 and 7 o'clock, and the glenohumeral ligament complex was repaired on the medial edge of the glenoid bone where the cartilage was removed. In model E, the cartilage on the glenoid rim was not removed, and the glenohumeral ligament complex was repaired on the glenoid edge. The load stresses on the anteroinferior area of the glenoid after Bankart repair with models G and E were measured using finite element analysis. RESULTS: The stress on the glenoid at 3-4 o'clock was 3.16 MPa in model G and 6.42 MPa in model E (P = .043). The stress at 4-5 o'clock was 1.68 MPa in model G and 4.53 MPa in model E (P = .043). The stress at 5-6 o'clock was 2.26 MPa in model G and 3.93 MPa in model E (P = .043). CONCLUSION: Significantly lower load stresses were observed at the anteroinferior rim of the glenoid in model G than in model E.

Dexamethasone added to levobupivacaine prolongs the duration of interscalene brachial plexus block and decreases rebound pain after arthroscopic rotator cuff repair.

BACKGROUND: It has been reported that the addition of dexamethasone to interscalene brachial plexus block (ISBPB) prolongs the duration of the block effect. However, there have been no studies focusing on the effects of dexamethasone on rebound pain after the block effect has worn off. The aim of this study was to investigate the effect on postoperative pain when dexamethasone was added to ISBPB for arthroscopic rotator cuff repair (ARCR). METHODS: In this multicenter, single-blinded, and randomized controlled study, 54 patients (33 males, 21 females) who received ARCR were randomly assigned to group L (ISBPB with 20 cc of 0.25% levobupivacaine; 21 patients) or group LD (ISBPB with 20 cc of 0.25% levobupivacaine + 3.3 mg dexamethasone; 33 patients). The primary outcome was the visual analog scale (VAS) for pain after the block effect had worn off. Secondary outcomes were the duration of analgesia, the time to the first request for additional analgesic, the number of additional doses of analgesic, and complications. RESULTS: The VAS scores on postoperative days 0 and 1 were significantly lower in group LD than group L (P = .005, .035). This indicated that the rebound pain was relieved in group LD. After postoperative day 1, there was no significant difference in VAS score (P = .43 and .19 for days 2 and 3, respectively). The duration of analgesia was significantly longer in group LD than group L (P < .001). The time to the first request for additional analgesic was significantly longer in group LD than group L (P < .001). The number of additional doses of analgesic was significantly lower in group LD (P < .001). CONCLUSION: In ARCR, the addition of dexamethasone to levobupivacaine not only prolongs the duration of ISBPB but also relieves rebound pain after the block effect wears off.

Humeral bone resorption after reverse shoulder arthroplasty using uncemented stem.

BACKGROUND: Humeral stem loosening has gained attention as it has been identified as a cause of revision surgery in reverse shoulder arthroplasty (RSA). In RSA, humeral stem revision is very difficult if there is humeral bone loss because of stress shielding. Some studies of humeral bone resorption after anatomic shoulder arthroplasty have been published, but there are few detailed reports of humeral bone resorption after RSA. This study aimed to investigate the prevalence of humeral bone resorption after RSA procedures and to evaluate the risk factors for bone resorption. METHODS: This study included 48 shoulders that underwent RSA with an uncemented humeral stem from July 2014 to May 2017 and were followed up for more than 1 year. The prevalence of humeral bone resorption and risk factors were investigated. Logistic, multiple logistic, and multivariate logistic regression analyses were performed to evaluate the data. RESULTS: Grade 0 bone resorption, the most advanced grade, occurred in 8 shoulders (16.7%); grade 1, in 0 (0%); grade 2, in 17 (35.4%); grade 3, in 14 (29.2%); and grade 4, in 9 (18.8%). A high occurrence of bone absorption was observed in zones 1, 2, and 7. Grade 4 bone resorption did not occur in zones 3, 5, and 6. Female sex and an onlay-type stem were significant independent risk factors for grade 4 bone resorption. CONCLUSIONS: Bone resorption was frequently observed in the greater tuberosity, lateral diaphysis, and calcar region. Significant risk factors included female sex and an onlay-type stem.

Loss of Tumor Suppressor CYLD Expression Triggers Cisplatin Resistance in Oral Squamous Cell Carcinoma.

Cisplatin is one of the most effective chemotherapeutic agents commonly used for several malignancies including oral squamous cell carcinoma (OSCC). Although cisplatin resistance is a major obstacle to effective treatment and is associated with poor prognosis of OSCC patients, the molecular mechanisms by which it develops are largely unknown. Cylindromatosis (CYLD), a deubiquitinating enzyme, acts as a tumor suppressor in several malignancies. Our previous studies have shown that loss of CYLD expression in OSCC tissues is significantly associated with poor prognosis of OSCC patients. Here, we focused on CYLD expression in OSCC cells and determined whether loss of CYLD expression is involved in cisplatin resistance in OSCC and elucidated its molecular mechanism. In this study, to assess the effect of CYLD down-regulation on cisplatin resistance in human OSCC cell lines (SAS), we knocked-down the CYLD expression by using CYLD-specific siRNA. In cisplatin treatment, cell survival rates in CYLD knockdown SAS cells were significantly increased, indicating that CYLD down-regulation caused cisplatin resistance to SAS cells. Our results suggested that cisplatin resistance caused by CYLD down-regulation was associated with the mechanism through which both the reduction of intracellular cisplatin accumulation and the suppression of cisplatin-induced apoptosis via the NF-κB hyperactivation. Moreover, the combination of cisplatin and bortezomib treatment exhibited significant anti-tumor effects on cisplatin resistance caused by CYLD down-regulation in SAS cells. These findings suggest the possibility that loss of CYLD expression may cause cisplatin resistance in OSCC patients through NF-κB hyperactivation and may be associated with poor prognosis in OSCC patients.

Humeral head histopathological changes in cuff tear arthropathy.

PURPOSE: The aim of this study was to investigate the histopathological changes in the humeral head in cuff tear arthropathy (CTA) compared with those in glenohumeral osteoarthritis (OA) and humeral neck fracture, which served as non-cuff tear controls. METHODS: Twenty-three humeral heads extracted at the time of shoulder prosthesis arthroplasty between June 2014 and July 2015 were evaluated in the present study. The diagnoses included four-part humeral neck fracture ( n = 4; average age, 85.0 years), glenohumeral OA ( n = 4; average age, 71.0 years), and CTA ( n = 15; average age, 73.0 years). The humeral heads were evaluated pathologically by hematoxylin and eosin and Safranin-O staining, and the thickness of the articular cartilage was measured. RESULTS: Fibrillation, thinning, and tearing of the cartilage were observed in the superior area of the humeral heads in CTA and glenohumeral OA. In CTA cases, clusters of chondrocytes in the cartilage were observed. Moreover, the thickness of the cartilage layer in the middle of the humeral head was 1.54 ± 0.07, 0.32 ± 0.46, and 2.19 ± 0.50 mm in humeral neck fracture, glenohumeral OA, and CTA, respectively. The cartilage layer in CTA was thicker than that in glenohumeral OA (CTA vs. OA: p < 0.05). CONCLUSION: OA changes in the superior area of the humeral heads and thickening of the cartilage layer from the middle to the inferior of the humeral heads were confirmed histopathologically, suggesting that simultaneous mechanical and nutritional factors might be contributing to CTA pathogenesis. The current study provided the better understanding of cartilage damage and thickening in CTA. This will help guide treatment options in the setting of CTA.

Doxycycline attenuates cisplatin-induced acute kidney injury through pleiotropic effects.

Cisplatin (CDDP) is a widely-used chemotherapeutic drug for solid tumors, but its nephrotoxicity is a major dose-limiting factor. Doxycycline (Dox) is a tetracycline antibiotic that has been commonly used in a variety of infections. Dox has been shown to possess several other properties, including antitumor, anti-inflammatory, antioxidative, and matrix metalloproteinase (MMP)-inhibiting actions. We, therefore, investigated whether Dox exerts renoprotective effects in CDDP-induced acute kidney injury (AKI). Twelve-week-old male C57BL/6J mice were divided into the following groups: 1) control, 2) Dox (2 mg/ml in drinking water), 3) CDDP (25 mg/kg body weight, intraperitoneally), and 4) CDDP+Dox. After seven days of pretreatment with Dox, CDDP was administered and the animals were killed at day 1 or day 3. We evaluated renal function along with renal histological damage, inflammation, oxidative stress, and apoptosis. MMP and serine protease activities in the kidney tissues were assessed using zymography. Administration of CDDP exhibited renal dysfunction and caused histological damage predominantly in the proximal tubules. Dox did not affect either expression of CDDP transporters or the accumulation of CDDP in renal tissues; however, it significantly ameliorated renal dysfunction and histological changes together with reduced detrimental responses, such as oxidative stress and inflammation in the kidneys. Furthermore, Dox inhibited the activity of MMP-2 and MMP-9, as well as serine proteases in the kidney tissues. Finally, Dox markedly mitigated apoptosis in renal tubules. Thus, Dox ameliorated CDDP-induced AKI through its pleiotropic effects. Our results suggest that Dox may become a novel strategy for the prevention of CDDP-induced AKI in humans.

Recurrent Cubital Tunnel Syndrome Caused by Ganglion: A Report of Nine Cases.

BACKGROUND: Cubital tunnel syndrome (CuTS) is generally treated successfully by surgery and recurrent cases are rare. This study retrospectively investigated the clinical characteristics of recurrent CuTS caused by ganglion. METHODS: We evaluated nine patients who were surgically treated for recurrent CuTS caused by ganglion. Age distribution at recurrence ranged from 43 to 79 years. The initial surgery for CuTS had been performed using various methods. The asymptomatic period from initial surgery to recurrence ranged from 22 to 252 months. Clinical, diagnostic imaging, and operative findings during the second surgery were analyzed. All patients were treated by anterior subcutaneous ulnar nerve transposition with ganglion resection and later examined directly within a mean of 71 months after the second surgery. RESULTS: The interval from recurrence to consultation was shorter than two months for eight cases. Chief complaints included numbness with or without pain in the ring and little fingers in all patients and resting pain in the medial elbow in five patients. Elbow osteoarthritis was present in all cases. Although four of 10 ganglia were palpable, ultrasonography and magnetic resonance imaging could identify all ganglia preoperatively. The ulnar nerve typically had become entrapped by the ganglion posteriorly and by fascia, scar tissue, and/or muscle anteriorly. Chief complaints and ulnar nerve function were improved in all patients following revision surgery. CONCLUSIONS: The acute onset of numbness with or without intolerable pain in the ring and little fingers after a long-term remission period following initial surgery for CuTS in patients with elbow osteoarthritis appears to be the characteristic clinical profile of recurrent CuTS caused by ganglion. As ganglia are often not palpable, ultrasonography and magnetic resonance imaging are recommended for accurate diagnosis.

A new scale measuring translation of the humeral head as a prognostic factor for the treatment of large and massive rotator cuff tears.

BACKGROUND: Failure rates after rotator cuff repair remain high in patients with massive tears. Although superior translation of the humeral head has been used to assess the severity of rotator cuff tears, the relevance of anterior migration of the humeral head to clinical outcomes has not been established. The purpose of this study was to investigate the potential role of the T-scale, a measure of the anterolateral translation of the humeral head, as a prognostic factor for rotator cuff repair. METHODS: One hundred twenty consecutive patients with full-thickness rotator cuff tears underwent primary rotator cuff repair. The T-scale and acromiohumeral interval (AHI) were measured preoperatively on axial computed tomography scans and radiographs, respectively. The correlations of the T-scale and AHI with previously published scores and active forward elevation (FE) were investigated. The outcome of rotator cuff repairs was compared between patients with positive and patients with negative preoperative T-scale values. RESULTS: The preoperative T-scale but not AHI correlated significantly with postoperative FE and clinical scores in patients with large to massive tears but not in those with small to medium tears. Postoperative FE and clinical scores were significantly higher in patients with positive T-scale values than in those with negative T-scale values. The relative risk of retear was 2.0 to 7.9 times greater in patients with negative T-scale values. CONCLUSION: Patients with large to massive tears and negative T-scale values had poorer clinical outcomes and higher retear rates. A negative T-scale value represents a useful prognostic factor for considering reverse shoulder arthroplasty in patients at greater risk of retear after rotator cuff repair.