Evaluation of Conventional MR Imaging of the Shoulder in the Diagnosis of Lesions of the Biceps Pulley.

RATIONALE AND OBJECTIVES: To determine the diagnostic accuracy and reproducibility of conventional MR imaging (MRI) of the shoulder in evaluating biceps pulley lesions using arthroscopy as the standard of reference. METHODS: In a retrospective study, MR examinations of 68 patients with arthroscopically proven torn or intact biceps pulley were assessed for the presence of pulley lesions by three radiologists. The following criteria were evaluated: displacement of the long head of the biceps tendon (LHBT) relative to the subscapularis tendon (displacement sign), subluxation/dislocation of the LHBT, the integrity of the superior glenohumeral ligament (SGHL) and the coracohumeral ligament (CHL), lesions of the supraspinatus (SSP) and subscapularis (SSC) tendons adjacent to the rotator interval, presence of biceps tendinopathy and subacromial bursitis. RESULTS: There were 42 patients with pulley lesions in the study group. Conventional MR imaging showed an overall sensitivity of 95.2%, 88.1% and 92.9%, a specificity of 61.5%, 73.1%, and 80.8% and an accuracy of 82.4%, 82.4% and 88.2% in the diagnosis of pulley lesions. Interobserver agreement was substantial (multirater k = 0.75). Biceps tendinopathy (97.6%, 95.2%, 97.6%), defects of the SGHL (86.3%, 81.0%, 88.1%) and the displacement sign (88.1%, 81.0%, 85.7%) were the most sensitive diagnostic criteria. Subluxation/dislocation of the LHBT was insensitive (78.6%, 42.9%, 33.3%), but specific (69.2%, 100,0%, 96.2%). CONCLUSION: In the diagnosis of pulley lesions, conventional MR imaging is reproducible and shows high sensitivity and accuracy but moderate specificity.

Multicentric development and validation of a multi-scale and multi-task deep learning model for comprehensive lower extremity alignment analysis.

Osteoarthritis of the knee, a widespread cause of knee disability, is commonly treated in orthopedics due to its rising prevalence. Lower extremity misalignment, pivotal in knee injury etiology and management, necessitates comprehensive mechanical alignment evaluation via frequently-requested weight-bearing long leg radiographs (LLR). Despite LLR's routine use, current analysis techniques are error-prone and time-consuming. To address this, we conducted a multicentric study to develop and validate a deep learning (DL) model for fully automated leg alignment assessment on anterior-posterior LLR, targeting enhanced reliability and efficiency. The DL model, developed using 594 patients' LLR and a 60%/10%/30% data split for training, validation, and testing, executed alignment analyses via a multi-step process, employing a detection network and nine specialized networks. It was designed to assess all vital anatomical and mechanical parameters for standard clinical leg deformity analysis and preoperative planning. Accuracy, reliability, and assessment duration were compared with three specialized orthopedic surgeons across two distinct institutional datasets (136 and 143 radiographs). The algorithm exhibited equivalent performance to the surgeons in terms of alignment accuracy (DL: 0.21 ± 0.18°to 1.06 ± 1.3°vs. OS: 0.21 ± 0.16°to 1.72 ± 1.96°), interrater reliability (ICC DL: 0.90 ± 0.05 to 1.0 ± 0.0 vs. ICC OS: 0.90 ± 0.03 to 1.0 ± 0.0), and clinically acceptable accuracy (DL: 53.9%-100% vs OS 30.8%-100%). Further, automated analysis significantly reduced analysis time compared to manual annotation (DL: 22 ± 0.6 s vs. OS; 101.7 ± 7 s, p ≤ 0.01). By demonstrating that our algorithm not only matches the precision of expert surgeons but also significantly outpaces them in both speed and consistency of measurements, our research underscores a pivotal advancement in harnessing AI to enhance clinical efficiency and decision-making in orthopaedics.

Establishing the Minimal Clinically Important Difference and Patient Acceptable Symptomatic State following Patellofemoral Inlay Arthroplasty for Visual Analog Scale Pain, Western Ontario and McMaster Universities Arthritis Index, and Lysholm Scores.

BACKGROUND: The purposes of the study were to define the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) after patello-femoral inlay arthroplasty (PFA) and to identify factors predictive for the achievement of clinically important outcomes (CIOs). METHODS: A total of 99 patients who underwent PFA between 2009 and 2019 and had a minimum of 2-year postoperative follow-up were enrolled in this retrospective monocentric study. Included patients had a mean age of 44 years (range, 21 to 79). The MCID and PASS were calculated using an anchor-based approach for the visual analog scale (VAS) pain, Western Ontario and McMaster Universities Arthritis Index (WOMAC), and Lysholm patient-reported outcome measures. Factors associated with CIO achievement were determined using multivariable logistic regression analyses. RESULTS: The established MCID thresholds for clinical improvement were -2.46 for the VAS pain score, -8.5 for the WOMAC score, and + 25.4 for the Lysholm score. Postoperative scores corresponding to the PASS were <2.55 for the VAS pain score, <14.6 for the WOMAC score, and >52.5 points for the Lysholm score. Preoperative patellar instability and concomitant medial patello-femoral ligament reconstruction were independent positive predictors of reaching both MCID and PASS. Additionally, inferior baseline scores and age were predictive of achieving MCID, whereas superior baseline scores and body mass index were predictive of achieving PASS. CONCLUSION: This study determined the thresholds of MCID and PASS for the VAS pain, WOMAC, and Lysholm scores following PFA implantation at 2-year follow-up. The study demonstrated a predictive role of patient age, body mass index, preoperative patient-reported outcome measure scores, preoperative patellar instability, and concomitant medial patello-femoral ligament reconstruction in the achievement of CIOs. LEVEL OF EVIDENCE: Prognostic Level IV.

Management of Irreparable Posterosuperior Rotator Cuff Tears-A Current Concepts Review and Proposed Treatment Algorithm by the AGA Shoulder Committee.

Posterosuperior rotator cuff tears range among the most common causes of shoulder complaints. While non-operative treatment is typically reserved for the elderly patient with low functional demands, surgical treatment is considered the gold standard for active patients. More precisely, an anatomic rotator cuff repair (RCR) is considered the most desirable treatment option and should be generally attempted during surgery. If an anatomic RCR is impossible, the adequate choice of treatment for irreparable rotator cuff tears remains a matter of debate among shoulder surgeons. Following a critical review of the contemporary literature, the authors suggest the following evidence- and experience-based treatment recommendation. In the non-functional, osteoarthritic shoulder, treatment strategies in the management of irreparable posterosuperior RCT include debridement-based procedures and reverse total shoulder arthroplasty as the treatment of choice. Joint-preserving procedures aimed at restoring glenohumeral biomechanics and function should be reserved for the non-osteoarthritic shoulder. Prior to these procedures, however, patients should be counseled about deteriorating results over time. Recent innovations such as the superior capsule reconstruction and the implantation of a subacromial spacer show promising short-term results, yet future studies with long-term follow-up are required to derive stronger recommendations.

"Functional outcomes and MRI-based tendon healing after (antero-) superior rotator cuff repair among patients under 50 years: retrospective analysis of traumatic versus non-traumatic rotator cuff tears".

BACKGROUND: Rotator cuff tears among patients under 50 years either result from an adequate trauma or are considered non-traumatic due to work-related or athletic overuse. The impact of these different mechanisms on postoperative functional outcomes and tendon healing has not yet been fully understood. Therefore, it was the purpose of this study to investigate the influence of etiology of (antero-)superior rotator cuff tears on postoperative outcomes and the healing rates after arthroscopic rotator cuff repair in a young patient population. METHODS: Patients under 50 years who underwent arthroscopic rotator cuff repair between 2006-2017 for an anterosuperior rotator cuff tear with a minimum follow up of 24 months were included in this study. Revision surgeries or reconstructive concomitant procedures other than long head of the biceps tenodesis were excluded. Patients were divided into two groups according to the etiology of their rotator cuff tear (traumatic vs. non-traumatic). Demographic and outcome scores including the American Shoulder and Elbow Surgeons (ASES) score, the Constant Score (CS), bilateral strength measurements and postoperative tendon integrity evaluated on magnetic resonance imaging (MRI) were assessed and compared between both groups. RESULTS: The mean follow up for this study was 55.6 months (24 - 158). Twenty-one patients (50.0%) had a traumatic RCT and 21 patients (50.0%) had a non-traumatic tear. Outcome scores did not differ significantly between groups. Strength measurements of the supraspinatus revealed significantly decreased force of the affected side as opposed to the contralateral side (p = 0.001), regardless of etiology. Retear rates were similar in both groups (37.5% and 33.3%, p = n.s.). Cuff integrity at follow-up was not predictive of superior scores or strength. CONCLUSION: Surgical treatment of traumatic and non-traumatic RCT yields good clinical results in patients under the age of 50. The etiology of the rotator cuff tear did not significantly affect postoperative outcomes or healing rates. About one third of the patients suffered from a retear postoperatively, however retears were not predictive of inferior outcomes at midterm follow-up. STUDY DESIGN: Level III. TRIAL REGISTRATION: Retrospectively registered.

The recovery curve of anatomic total shoulder arthroplasty for primary glenohumeral osteoarthritis: midterm results at a minimum of 5 years.

Background: Excellent results have been reported for anatomic total shoulder arthroplasty (TSA) for the treatment of primary glenohumeral osteoarthritis (GHOA). We aim to assess the recovery curve and longitudinal effects of time, age, sex, and glenoid morphology on patient-reported outcomes (PROs) after primary anatomic TSA for primary GHOA. Methods: Patients who underwent primary anatomic TSA over 5 years ago were included: Short-Form 12 Physical Component Summary, American Shoulder and Elbow Surgeons scores, Quick Disabilities of the Arm Shoulder and Hand Score, Single Assessment Numeric Evaluation, and patient satisfaction were assessed. Linear mixed-effects models were used to model progression in PROs longitudinally. Unadjusted models and models controlling for sex and age were constructed. Results: Eighty-one patients (91 shoulders) were included. Significant improvements from the preoperative period to 1 year postoperatively in the median American Shoulder and Elbow Surgeons (48 to 93; P < .001), Quick Disabilities of the Arm Shoulder and Hand Score (42 to 11; P < .001), Single Assessment Numeric Evaluation (50 to 91; P < .001), and Short-Form 12 Physical Component Summary (35 to 53; P = .004) scores were noted. No significant decrease was observed for any of the outcome scores. Median satisfaction at the final follow-up was 10 out of 10. At 1, 2, 3, 4, 5, 6, and 7 years postoperatively, 77%, 64%, 79%, 57%, 86%, 56%, and 78% of patients, respectively, reported sports participation equal to or slightly below preinjury level. There was no association between the glenoid morphology and functional outcomes. Conclusion: Patients undergoing anatomic TSA for primary GHOA showed excellent improvement in PROs and satisfaction in the first year, and these results were maintained postoperatively for a minimum of 5 years. Age- and sex-adjusted models or glenoid morphology did not substantially alter any trends in PROs postoperatively.

The Morphology of the Acromioclavicular Joint Does Not Influence the Postoperative Outcome Following Acute Stabilization-A Case Series of 81 Patients.

Purpose: To specifically evaluate the influence of the acromioclavicular (AC)-joint morphology on the outcome after arthroscopically assisted coracoclavicular (CC) stabilization surgery with suspensory fixation systems and to investigate whether an additional open AC-joint reduction and AC cerclage improves the clinical outcome for patients with certain morphologic AC-joint subtypes. Methods: Patients with an acute acromioclavicular joint injury, who underwent arthroscopically assisted CC stabilization with suspensory fixation systems with or without concomitant AC cerclage between January 2009 and June 2017 were identified and included in this retrospective cohort analysis. AC-joint morphology was assessed on preoperative radiographs and categorized as "flat" or "non-flat" ("oblique"/"curved") subtypes. After a minimum of 2 years of follow-up, postoperative Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES), and visual analog scale (VAS) scores for pain were collected. A subgroup analysis of clinical outcomes depending on the surgical technique and morphological subtype of the AC joint was performed. Results: Eighty-one patients (95% male, mean age 35 ± 12 years) could be included at a mean follow-up of 57 ± 14 months. Radiographic assessment of AC-joint morphology showed 24 (30%) cases of flat type, 38 (47%) cases of curved type, and 19 (23%) cases of oblique morphology. Postoperatively, no clinically significant difference could be detected after the treatment of AC joint injury via CC stabilization with or without concomitant AC cerclage (VASrest: P = .067; VASmax: P = .144, ASES: P = .548; SANE: P = .045). No clinically significant differences were found between the surgical techniques for the flat morphologic subtype (VASrest: P = .820; VASmax: P = .251; SANE: P = .104; ASES: P = .343) or the non-flat subtype (VASres: P = .021; VASmax: P = .488; SANE: P = .243, ASES: P = .843). Conclusions: In arthroscopically assisted AC stabilization surgery with suspensory fixation systems for acute AC-joint injury, the AC-joint morphology did not influence the postoperative outcome, independent of the surgical technique. No clinical benefit of performing an additional horizontal stabilization could be detected in our collective at mid-term follow-up. Level of Evidence: Level IV, therapeutic case series.

Low rate of substantial loss of reduction immediately after hardware removal following acromioclavicular joint stabilization using a suspensory fixation system.

PURPOSE: To evaluate immediate loss of reduction in patients undergoing hardware removal after arthroscopically assisted acromioclavicular (AC) joint stabilization using a high-tensile suture tape suspensory fixation system and to identify risk factors associated with immediate loss of reduction. MATERIALS AND METHODS: Twenty-two consecutive patients with a mean age of 36.4 ± 12.6 years (19-56), who underwent hardware removal 18.2 ± 15.0 months following arthroscopically assisted stabilization surgery using a suspensory fixation system for AC joint injury between 01/2012 and 01/2021 were enrolled in this retrospective monocentric study. The coracoclavicular distance (CCD) as well as the clavicular dislocation/acromial thickness (D/A) ratio were measured on anterior-posterior radiographs prior to hardware removal and immediately postoperatively by two independent raters. Loss of reduction, defined as 10% increase in the CCD, was deemed substantial if the CCD increased 6 mm compared to preoperatively. Constitutional and surgical characteristics were assessed in a subgroup analysis to detect risk factors associated with loss of reduction. RESULTS: Postoperatively, the CCD significantly increased from 12.6 ± 3.7 mm (4.8-19.0) to 14.5 ± 3.3 mm (8.7-20.6 mm) (p < 0.001) while the D/A ratio increased from 0.4 ± 0.3 (- 0.4-0.9) to 0.6 ± 0.3 (1.1-0.1) (p = 0.034) compared to preoperatively. In 10 cases (45%), loss of reduction was identified, while a substantial loss of reduction (> 6 mm) was only observed in one patient (4.5%). A shorter time interval between index stabilization surgery and hardware removal significantly corresponded to immediate loss of reduction (11.0 ± 5.6 vs. 30.0 ± 20.8 months; p = 0.007), as hardware removal within one year following index stabilization was significantly associated with immediate loss of reduction (p = 0.027; relative risk 3.4; odds ratio 11.67). CONCLUSIONS: Substantial loss of reduction after hardware removal of a high-tensile suture tape suspensory fixation system was rare, indicating that the postoperative result of AC stabilization is not categorically at risk when performing this procedure. Even though radiological assessment of the patients showed a statistically significant immediate superior clavicular displacement after this rarely required procedure, with an increased incidence in the first year following stabilization, this may not negatively influence the results of ACJ stabilization in a clinically relevant way. LEVEL OF EVIDENCE: IV.

High return to sports and return to work rates after anatomic lateral ankle ligament reconstruction with tendon autograft for isolated chronic lateral ankle instability.

PURPOSE: To evaluate clinical outcomes as well as return to sports (RTS) and return to work (RTW) rates following anatomic lateral ankle ligament reconstruction with a tendon autograft for chronic lateral ankle instability (CLAI) in a high-risk population, and to compare these outcome parameters between patients having received a gracilis tendon autograft (GT) and free split peroneus brevis tendon (PBT) autograft. METHODS: Twenty-eight consecutive patients, who were diagnosed with CLAI, presenting with ≥ 1 risk factor (ligamentous hyperlaxity, insufficient substance of native ligament and/or high-demand athlete), who underwent ankle ligament reconstruction with a tendon autograft between January 2011 and December 2018, were included in this retrospective study. At 63.7 ± 28.0 months (24-112), 23 patients with a mean age of 29.7 ± 10.9 years were available for follow-up. The Karlsson Score, the Foot and Ankle Outcome Score (FAOS), the Tegner Activity Scale and the visual analog scale (VAS) for pain were collected at a minimum follow-up of 24 months. RTS and RTW were evaluated by questionnaire. A subgroup analysis with regard to the graft used for ankle ligament reconstruction (GT versus PBT) was performed. RESULTS: Patients reported a Karlsson score of 82.1 ± 17.5 (37-100), a FAOS score of 87.8 ± 8.4 (73-99), a median Tegner activity scale of 5.0 (IQR 4-6) and a VAS for pain of 0.5 ± 0.9 (0-4) at rest and of 2.0 ± 2.1 (0-7) during activities at final follow-up. Postoperatively, 96% of patients had returned to sports after 8.3 ± 6.2 months. All patients (100%) had returned to work at 3.5 ± 5.7 (0-24) months, with 87% reporting an equal or improved working ability compared to that preoperatively. Postoperatively, exercise hours per week were significantly reduced compared to preoperatively in patients with a split PBT (n = 12; 13.0 ± 12.9 to 5.6 ± 6.4 h, p = 0.038) autograft as opposed to patients with a GT autograft (n = 11; 13.1 ± 8.7 to 12.4 ± 7.1 h, n.s.). No other group differences were observed. CONCLUSION: Good patient-reported outcomes as well as excellent RTS and RTW rates can be achieved in high-risk patients undergoing ankle ligament reconstruction with a tendon autograft for CLAI. These results may be helpful in preoperatively managing patients' expectations regarding sports- and work-related outcomes and provide tangible data on the expectable time frame of the individual return to sports and work trajectory. LEVEL OF EVIDENCE: IV.

Evaluation of MR-derived simulated CT-like images and simulated radiographs compared to conventional radiography in patients with shoulder pain: a proof-of-concept study.

BACKGROUND: To evaluate the diagnostic value of MR-derived CT-like images and simulated radiographs compared with conventional radiographs in patients with suspected shoulder pathology. METHODS: 3 T MRI of the shoulder including a 3D T1-weighted gradient echo sequence was performed in 25 patients (mean age 52.4 ± 18 years, 13 women) with suspected shoulder pathology. Subsequently a cone-beam forward projection algorithm was used to obtain intensity-inverted CT-like images and simulated radiographs. Two radiologists evaluated the simulated images separately and independently using the conventional radiographs as the standard of reference, including measurements of the image quality, acromiohumeral distance, critical shoulder angle, degenerative joint changes and the acromial type. Additionally, the CT-like MR images were evaluated for glenoid defects, subcortical cysts and calcifications. Agreement between the MR-derived simulated radiographs and conventional radiographs was calculated using Cohen's Kappa. RESULTS: Measurements on simulated radiographs and conventional radiographs overall showed a substantial to almost perfect inter- and intra-rater agreement (κ = 0.69-1.00 and κ = 0.65-0.85, respectively). Image quality of the simulated radiographs was rated good to excellent (1.6 ± 0.7 and 1.8 ± 0.6, respectively) by the radiologists. A substantial agreement was found regarding diagnostically relevant features, assessed on Y- and anteroposterior projections (κ = 0.84 and κ = 0.69 for the measurement of the CSA; κ = 0.95 and κ = 0.60 for the measurement of the AHD; κ = 0.77 and κ = 0.77 for grading of the Samilson-Prieto classification; κ = 0.83 and κ = 0.67 for the grading of the Bigliani classification, respectively). CONCLUSION: In this proof-of-concept study, clinically relevant features of the shoulder joint were assessed reliably using MR-derived CT-like images and simulated radiographs with an image quality equivalent to conventional radiographs. MR-derived CT-like images and simulated radiographs may provide useful diagnostic information while reducing the amount of radiation exposure.

[Arthroscopic superior capsule reconstruction using a 6 mm thick acellular dermal allograft for irreparable posterosuperior rotator cuff tears]. / Arthroskopische superiore Kapselrekonstruktion mit einem 6 mm dicken azellulären dermalen Allograft bei irreparablen posterosuperioren Rotatorenmanschettenrupturen.

OBJECTIVE: Implantation of an acellular dermal allograft between glenoid and humerus to restore a stable glenohumeral center of rotation in cases of irreparable posterosuperior rotator cuff tears. INDICATIONS: Irreparable posterosuperior rotator cuff tears with low-grade cuff tear arthropathy (Hamada grade 1 and 2) and isolated pseudoparesis for flexion. CONTRAINDICATIONS: Absolute: Infection, nerve lesions (brachial plexus, axillary nerve), concomitant irreparable subscapularis tendon tear, anterosuperior subluxation of the humeral head ("anterosuperior escape"). Relative: Cuff tear arthropathy ≥ Hamada grade 3, fatty infiltration of the infraspinatus muscle ≥ Goutallier grade 2, deficiency of the deltoid muscle, inability to adhere to the rehabilitation program, poor compliance. SURGICAL TECHNIQUE: Arthroscopic fixation of a 6 mm thick acellular dermal allograft with three suture anchors at the superior glenoid rim and a double-row construct at the greater tuberosity. Dorsal and ventral interval closure with side-to-side sutures. POSTOPERATIVE MANAGEMENT: Abduction brace for 6 weeks with passive mobilization. Active motion exercises are commenced at 6 weeks with progression to strengthening exercises after 12 weeks. RESULTS: Between April 2019 and September 2020, 15 patients (5 women and 10 men) underwent arthroscopic superior capsule reconstruction using a 6 mm thick acellular dermal allograft for treatment of irreparable posterosuperior rotator cuff tears. After a mean follow-up of 15.4 ± 5.5 months, there was a significant improvement in active flexion (102°â€¯± 37°preop vs. 143°â€¯± 24°postop; P = 0.001; 95% CI 19.6-63.7), ASES score (45.5 ± 16.1preop vs. 68.2 ± 17.4postop; P < 0.001; 95% CI; 12.9-33.7) and DASH score (57.2 ± 18.6preop vs. 22.0 ± 17.4postop; P < 0.001; 95% CI; -46.0 to 24.7), along with significant pain reduction (4.5 ± 2.0preop vs. 2.5 ± 2.1postop; P = 0.001; 95% CI; -3.2 to 1.1). There were no complications requiring revision surgery.

The lack of retropatellar resurfacing at index surgery is significantly associated with failure in patients following patellofemoral inlay arthroplasty: a multi-center study of more than 260 patients.

PURPOSE: To evaluate the clinical outcomes of patients with a minimum 2-year follow-up following contemporary patellofemoral inlay arthroplasty (PFIA) and to identify potential risk factors for failure in a multi-center study. METHODS: All patients who underwent implantation of PFIA between 09/2009 and 11/2016 at 11 specialized orthopedic referral centers were enrolled in the study and were evaluated retrospectively at a minimum 2-year follow-up. Clinical outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Tegner Scale, the visual analogue scale (VAS) for pain, and subjective patient satisfaction. Pre- and perioperative risk factors were compared among failures and non-failures to determine potential risk factors. RESULTS: A total of 263 patients (85% follow-up rate) could be enrolled. The mean age at the time of index surgery was 49 ± 12 years with a mean postoperative follow-up of 45 ± 18 months. The overall failure rate was 11% (28 patients), of which 18% (5 patients) were patients with patella resurfacing at index surgery and 82% (23 patients) were patients without initial patella resurfacing. At final follow-up, 93% of the patients who did not fail were satisfied with the procedure with a mean transformed WOMAC Score of 84.5 ± 14.5 points, a mean KOOS Score of 73.3 ± 17.1 points, a mean Tegner Score of 3.4 ± 1.4 points and a mean VAS pain of 2.4 ± 2.0 points. An increased BMI was significantly correlated with a worse postoperative outcome. Concomitant procedures addressing patellofemoral instability or malalignment, the lack of patellofemoral resurfacing at the index surgery and a high BMI were significantly correlated with failure in our patient cohort. CONCLUSION: Patellofemoral inlay arthroplasty shows high patient satisfaction with good functional outcomes at short-term follow-up and thus can be considered a viable treatment option in young patients suffering from isolated patellofemoral arthritis. Patellar resurfacing at index surgery is recommended to decrease the risk of failure. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Reliable Clinical and Sonographic Outcomes of Subpectoral Biceps Tenodesis Using an All-Suture Anchor Onlay Technique.

PURPOSE: To evaluate the clinical outcomes and structural integrity of primary subpectoral biceps tenodesis using an all-suture anchor onlay technique for long head of the biceps (LHB) tendon pathology. METHODS: We conducted a retrospective case series with prospectively collected data of patients who underwent primary, isolated subpectoral biceps tenodesis with a single all-suture anchor onlay fixation between March 2017 and March 2019. Outcomes were recorded at a minimum follow-up of 12 months based on assessments of the American Shoulder and Elbow Surgeons (ASES) score, LHB score, and elbow flexion strength and supination strength measurements. The integrity of the tenodesis construct was evaluated using ultrasound. RESULTS: Thirty-four patients were available for clinical and ultrasound examination at a mean follow-up of 18 ± 5 months. The mean ASES score significantly improved from 51.0 ± 14.2 points preoperatively to 89.8 ± 10.5 points postoperatively (P < .001). The minimal clinically important difference for the ASES score was 8.7 points, which was exceeded by 31 patients (91.2%). The mean postoperative LHB score was 92.2 ± 8.3 points. Regarding subcategories, an average of 47.2 ± 6.3 points was reached for "pain/cramps"; 26.4 ± 6.1 points, "cosmesis"; and 18.6 ± 2.6 points, "elbow flexion strength." Both elbow flexion strength and supination strength were similar compared with the nonoperated side (P = .169 and P = .210, respectively). In 32 patients, ultrasound examination showed an intact tenodesis construct, whereas 2 patients (5.9%) sustained failure of the all-suture anchor fixation requiring revision. CONCLUSIONS: Primary subpectoral biceps tenodesis using an all-suture anchor onlay technique for pathology of the LHB tendon provides reliable clinical results and a relatively low failure rate (5.9%). LEVEL OF EVIDENCE: Level IV, case series.

Center of pressure (COP) measurement in patients with confirmed successful outcomes following shoulder surgery show significant sensorimotor deficits.

PURPOSE: To determine the sensorimotor and clinical function of patients with confirmed successful outcome after either undergoing acromioclavicular joint (ACJ) stabilization, Bankart repair (BR), or rotator cuff repair (RC), and to compare these measures to the contralateral, healthy side without history of previous injuries or surgeries of the upper extremity. It was hypothesized that patients of each interventional group would have inferior sensorimotor function of the shoulder joint compared to the contralateral, healthy side, while presenting with successful clinical and functional outcomes. METHODS: Three intervention groups including ten patients who had confirmed successful clinical and functional outcomes after either undergoing ACJ stabilization, BR, or RC were evaluated postoperatively at an average follow-up of 31.7 ± 11.6 months. Additionally, a healthy control group (CG) of ten patients was included. Clinical outcomes were assessed using the Constant-Murley (CM) and American Shoulder and Elbow Surgeons (ASES) Score. Pain was evaluated using the visual analogue scale (VAS). Sensorimotor function was assessed by determining the center of pressure (COP) of the shoulder joint in a one-handed support task in supine position on a validated pressure plate. RESULTS: Each interventional group demonstrated excellent clinical outcome scores including the CM Score (ACJ 83.3 ± 11.8; BR 89.0 ± 10.3; RC 81.4 ± 8.8), ASES Score (ACJ 95.5 ± 7.0; BR 92.5 ± 9.6; RC 96.5 ± 5.2), and VAS (ACJ 0.5 ± 0.9; BR 0.5 ± 0.8; RC 0.5 ± 0.8). Overall, the CG showed no significant side-to-side difference in COP, whereas the ACJ-group and the BR-group demonstrated significantly increased COP compared to the healthy side (ACJ 103 cm vs. 98 cm, p = 0.049; BR: 116 cm vs. 102 cm, p = 0.006). The RC-group revealed no significant side-to-side difference (120 cm vs. 108 cm, n.s.). CONCLUSION: Centre of pressure measurement detected sensorimotor functional deficits following surgical treatment of the shoulder joint in patients with confirmed successful clinical and functional outcomes. This may indicate that specific postoperative training and rehabilitation protocols should be established for patients who underwent surgery of the upper extremity. These results underline that sensorimotor training should be an important component of postoperative rehabilitation and physiotherapeutic activities to improve postoperative function and joint control. LEVEL OF EVIDENCE: IV.

Patients return to sports and to work after successful treatment of septic arthritis following anterior cruciate ligament reconstruction.

PURPOSE: To determine specific return to sports (RTS) and return to work (RTW) rates of patients with septic arthritis following anterior cruciate ligament reconstruction (ACLR), and to assess for factors associated with a diminished postoperative return to physical activity after successful eradication of the infection. METHODS: In this study, patients who were treated for postoperative septic arthritis of the knee following anterior cruciate ligament reconstruction between 2006 and 2018 were evaluated at a minimum follow-up (FU) of 2 years. Patients' outcomes were retrospectively analyzed using standardized patient-reported outcome scores including the Lysholm score and the subjective IKDC score, as well as return to sports and return to work questionnaires to assess for the types, number, and frequency of sports performed pre- and postoperatively and to evaluate for potential occupational changes due to septic arthritis following ACLR. To assess for the signifiance of the graft at follow-up, outcomes were compared between patients with a functioning graft at FU and those without, as well as between patients with initial graft retention and those with graft removal and consecutive revision ACLR. RESULTS: Out of 44 patients eligible for inclusion, 38 (86%) patients at a mean age of 36.2 ± 10.3 years were enrolled in this study. At a mean follow-up of 60.3 ± 39.9 months, the Lysholm score and the subjective IKDC score reached 80.0 ± 15.1 and 78.2 ± 16.6 points, respectively. The presence of a graft at FU yielded statistically superior results only on the IKDC score (p = 0.014). There were no statistically significant differences on the Lysholm score (n.s.) or on the IKDC score (n.s.) between patients with initial graft retention and those with initial removal who had undergone revision ACLR. All of the included 38 patients were able to return to sports at a median time of 8 (6-16) months after their last surgical intervention. Among patients who performed pivoting sports prior to their injury, 23 (62.2%) returned to at least one pivoting sport postoperatively. Overall, ten patients (26.3%) returned to all their previous sports at their previous frequency. The presence of a graft at FU resulted in a significantly higher RTS rate (p = 0.010). Comparing patients with initial graft retention and those with graft removal and consecutive revision ACLR, there was no statistically significant difference concerning the RTS rate (n.s.). Thirty-one patients (83.8%) were able to return to their previous work. CONCLUSION: Successful eradication of septic arthritis following anterior cruciate ligament reconstruction allows for a postoperative return to sports and a return to work particularly among patients with ACL-sufficient knees. However, the patients' expectations should be managed carefully, as overall return rates at the pre-injury frequency are relatively low. LEVEL OF EVIDENCE: IV.

Research productivity during orthopedic surgery residency correlates with pre-planned and protected research time: a survey of German-speaking countries.

PURPOSE: The purpose of this study was to identify modifiable factors associated with research activity among residents working in orthopedic surgery and traumatology. METHODS: Residents at 796 university-affiliated hospitals in Austria, Germany, and Switzerland were invited to participate. The online survey consisted of questions that ascertained 13 modifiable and 17 non-modifiable factors associated with the residents' current research activities. Responses of 129 residents were analyzed. Univariate linear regression was used to determine the association of individual factors with the current research activity (hours per week). The impact of significant non-modifiable factors (with unadjusted p values < 0.05) was controlled for using multivariate linear regression. RESULTS: The univariate analysis demonstrated six non-modifiable factors that were significantly associated with the current research activity: a University hospital setting (p < 0.001), an A-level hospital setting (p = 0.024), Swiss residents (p = 0.0012), the completion of a dedicated research year (p = 0.007), female gender (p = 0.016), and the department's size (p = 0.048). Multivariate regression demonstrated that the number of protected research days per year (p < 0.029) and the percentage of protected days, that were known 1 week before (p < 0.001) or the day before (p < 0.001), were significantly associated with a higher research activity. CONCLUSIONS: As hypothesized, more frequent and predictable protected research days were associated with higher research activity among residents in orthopedic surgery and traumatology. LEVEL OF EVIDENCE: III.

Reliable improvements in participation in low-impact sports following implantation of a patellofemoral inlay arthroplasty at mid-term follow-up.

PURPOSE: The aim of this study was, to investigate the rate of return to sports (RTS) and physical activity after implantation of PFIA and to identify factors predictive of improved postoperative sporting ability. METHODS: Sixty-two patients with a mean age of 46 ± 11 years, who underwent implantation of PFIA at the senior authors' institution, were enrolled. They were prospectively evaluated preoperatively and at a minimum of 2 years postoperatively with a mean follow-up of 60 ± 25 months. Clinical outcomes, return to sports and activity, type of sport or activity, subjective satisfaction, and frequency were evaluated by questionnaire. RESULTS: The transformed overall Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score improved from 67 ± 16 to 77 ± 19 (p = 0.003), Tegner activity scale results improved from 3 ± 2 points to 4 ± 1 points (p < 0.001), and scores on the visual analog scale (VAS) pain scale decreased from 6 ± 2 points to 3 ± 2 points (p < 0.001). The sports frequency increased from 1 ± 2 sessions to 2 ± 1 sessions per week (p = 0.001). Ninety-four percent of the patients who did not fail could return to the same or higher level of sports, with 74% of the patients reporting an improved ability to perform sports. No preoperative factors could be detected to significantly influence RTS after surgery. CONCLUSIONS: PFIA is a valid treatment option for the active patient with end-stage isolated patellofemoral OA. Reliable improvements in knee function, pain, and participation in low-impact sports were found. LEVEL OF EVIDENCE: IV.

[Patellofemoral inlay implants-an innovation in patellofemoral joint arthroplasty?] / Patellofemorale Inlay-Implantate ­ ein Fortschritt in der patellofemoralen Endoprothetik?

Isolated arthrosis of the patellofemoral joint is a rare and complex disease. After conservative therapy has been exhausted, the orthopedist has various soft-tissue and bone reconstructive procedures as well as cartilage regenerative procedures at his hands. In cases of failed or unsatisfactory therapy, patellofemoral arthroplasty continues to be controversially discussed as an alternative therapy. A closer look at these studies reveals promising results with the correct indication and patient selection. The different prosthesis designs provide good postoperative results while considering general and specific risks. The current generation of patellofemoral inlay prostheses shows high patient satisfaction with significant improvements in knee function and pain relief in mid-term outcomes. However, a relatively high revision rate must be considered.

Definition of the terms "acute" and "traumatic" in rotator cuff injuries: a systematic review and call for standardization in nomenclature.

BACKGROUND: Although of high relevance for clinical decision making, there exists no consensus throughout the literature of the terms "acute" and "traumatic" used in the classification of rotator cuff tears. With differing definitions, the comparability of outcome studies may be limited. The aim was to provide a detailed systematic review of the definitions used in the literature and present a suggestion for a standardization in nomenclature based on the findings. METHODS: Four different internet databases were searched in February 2020 using the terms ("acute" OR "traumatic" OR "trauma" OR "athlete" OR "young") AND ("rotator cuff tears" OR "rotator cuff tear" OR "rotator cuff" OR "rotator cuff rupture" OR "supraspinatus" OR "infraspinatus" OR "subscapularis" OR "teres minor"). Prospective, retrospective, cohort and case-control studies as well as case series were included. Systematic reviews, cadaveric or laboratory studies and studies on non-traumatic or non-acute rotator cuff tears were excluded. RESULTS: The literature search conducted 10,349 articles of which 10,151 were excluded based on the title, 119 based on the abstract and 33 based on the manuscript. A total of 46 studies were finally included for review and subsequently analyzed. Overall, there exists no consensus neither on the term "acute" nor on "traumatic" in the context of rotator cuff tears in the literature. The time span for acute injuries ranged between 2 weeks and 6 months. For traumatic injuries, only 20% of the selected studies described a specific and adequate injury mechanism in combination with adequate imaging. CONCLUSION: The term "acute" should be reserved for RCT showing muscle edema, wavelike appearance of the central part of the torn tendon and joint effusion, which typically requires adequate imaging within 2 weeks from trauma. Repair of acute tears should occur within 8 weeks from trauma to benefit from possibly superior biological healing capacities. The term "traumatic" should be used for a sudden onset of symptoms in a previously asymptomatic patient, triggered by an adequate trauma, e.g., a fall on the retroverted arm with an axial cranioventral force or a traumatic shoulder dislocation.

Preoperative patellofemoral anatomy affects failure rate after isolated patellofemoral inlay arthroplasty.

PURPOSE: To analyze whether preoperative patellofemoral anatomy is associated with clinical improvement and failure rate after isolated patellofemoral arthroplasty (PFA) using a modern inlay-type trochlear implant. METHODS: Prospectively collected 24 months data of patients treated with isolated inlay PFA (HemiCAP® Wave, Arthrosurface, Franklin, MA, USA) between 2009 and 2016, and available digitalized preoperative imaging (plain radiographs in three planes and MRI) were retrospectively analyzed. All patients were evaluated using the WOMAC score, Lysholm score, and VAS pain. Patients revised to TKA or not achieving the minimal clinically important difference (MCID) for the total WOMAC score or VAS pain were considered failures. Preoperative imaging was analyzed regarding the following aspects: Tibiofemoral OA, patellofemoral OA, trochlear dysplasia (Dejour classification), patellar height (Insall-Salvati index [ISI]; Patellotrochlear index [PTI]), and position of the tibial tuberosity (TT-TG and TT-PCL distance). RESULTS: A total of 41 patients (61% female) with a mean age of 48 ± 13 years could be included. Fifteen patients (37%) were considered failures, with 5 patients (12%) revised to TKA and 10 patients (24%) not achieving MCID for WOMAC total or VAS pain. Failures had a significantly higher ISI, and a significantly lower PTI. Furthermore, the proportion of patients with a pathologic ISI (> 1.2), a pathologic PTI (< 0.28), and without trochlear dysplasia were significantly higher in failures. Significantly greater improvements in clinical outcome scores were observed in patients with a higher preoperative grade of patellofemoral OA, ISI ≤ 1.2, PTI ≥ 0.28, TT-PCL distance ≤ 21 mm, and a dysplastic trochlea. CONCLUSION: Preoperative patellofemoral anatomy is significantly associated with clinical improvement and failure rate after isolated inlay PFA. Less improvement and a higher failure rate must be expected in patients with patella alta (ISI > 1.2 and PTI < 0.28), absence of trochlear dysplasia, and a lateralized position of the tibial tuberosity (TT-PCL distance > 21 mm). Concomitant procedures such as tibial tuberosity transfer may, therefore, be considered in such patients. LEVEL OF EVIDENCE: Level III, retrospective analysis of prospectively collected data.