Pre-operative transverse tendon thickness in small and mid-sized rotator cuff tears does not affect clinical outcomes after arthroscopic repair.

INTRODUCTION: Previous studies on rotator cuff tears have examined both clinical and radiographic parameters which may influence post-operative clinical outcomes. While rotator cuff tears are frequently classified by size or depth, there is currently no literature available examining the thickness of the remnant tendon, and its impact on post-operative outcomes. We hypothesize that decreased pre-operative transverse tendon thickness will result in poorer post-operative clinical outcomes. METHODS: We prospectively recruited patients who underwent arthroscopic repair of small to medium full-thickness rotator cuff tears. These patients were followed up for a minimum of 2 years post-operatively. Basic biodata, as well as Visual Analog Scale (VAS) for pain, Constant-Murley Score (CMS), UCLA Shoulder Score (USS), and Oxford Shoulder Score (OSS) at 3 different time points (pre-operatively, 1 year post-operatively, and 2 years post-operatively) were collected. Transverse tendon thickness was measured by independent blinded radiologists on pre-operative ultrasonographic images. Wilcoxon signed-rank test was used to compare outcome scores and multivariable robust linear model was fitted to assess the effect of transverse tendon thickness on post-operative scores. RESULTS: A total of 63 patients were enrolled in this study, predominantly female (65%) and had a median age of 72 years. Pre-operatively, the median transverse cuff thickness was 5.0 â€‹mm and median tear size was 1.4 â€‹cm. The median VAS at preoperative was 7, which reduced to 0 â€‹at 2 year post-operative, indicating statistically significant improvement in pain levels (p â€‹< â€‹0.001). Statistically significant improvement in shoulder function measured by CMS, UCLA score and OSS were also seen over time (p â€‹< â€‹0.001). Robust regression analysis revealed that transverse cuff thickness had no statistically significant effect on VAS (p â€‹= â€‹0.99), CMS (p â€‹= â€‹0.84), UCLA score (p â€‹= â€‹0.22), and OSS scores (p â€‹= â€‹0.73) at 2 years postoperatively. DISCUSSION: Pre-operative transverse tendon thickness of small- to mid-sized supraspinatus tears does not influence clinical outcomes after arthroscopic repair. Differences in transverse tendon thickness may have an association with tendon healing but do not translate to an association with post-operative outcomes in terms of pain, function, and patient-reported outcome measures. LEVEL OF EVIDENCE: IV.

Different types of rotator cuff tear morphology do not affect post-repair clinical outcomes in large to massive tears.

OBJECTIVES: The primary aim of this current study is to evaluate the effects of rotator cuff tear morphology on clinical outcomes in large to massive tears, using a modified version of the existing classification system, with specific focus on tear symmetry and use of margin convergence. METHODS: Patients who underwent arthroscopic repair of large to massive, full thickness rotator cuff tears were retrospectively analysed. The tear pattern was classified at the time of surgery as Type IA, Type IB, Type IIA, and Type IIB according to tear symmetry and direction of maximum tear diameter, with Type I being symmetrical and Type II being asymmetrical. Type IA (U-shaped) had greater mediolateral (ML) than anteroposterior (AP) diameter while Type IB (crescent shaped) had greater AP than ML diameter. Type IIA tears have an anterior extension towards the rotator interval while IIB tears have a posterior extension into the infraspinatus, similar to AP L-shaped tears established in the literature. Type I tears were typically repaired from medial to lateral while Type II tears were repaired diagonally. All types were repaired using double row technique, with the addition of margin convergence for Types IA and IIB, which had larger tears in the medial and lateral directions. Primary outcome measures were Oxford Shoulder Score, Constant Shoulder Score, University of California at Los Angeles Shoulder Score followed-up at 6, 12, and 24-months as well as retear rates at latest follow-up. RESULTS: In total, 109 patients were included in the study with a mean age of 65.5 â€‹± â€‹9.4. The prevalence of each tear morphologies from Type IA to IIB was 22.0 â€‹%, 34.9 â€‹%, 27.5 â€‹%, and 15.6 â€‹%, respectively. All four groups showed statistically significant improvement from pre-operative scores in all 3 outcome measures at 24 months (p â€‹< â€‹0.001 for all). No significant difference in primary outcome measures or retear rates was detected between all 4 groups. CONCLUSION: This study found that different types of cuff tear morphology, despite affecting surgical repair technique, does not influence clinical outcomes post-arthroscopic rotator cuff repair at mid-term follow-up. LEVEL OF EVIDENCE: Retrospective Cohort study, Level III.

Bone-on-Bone Contact on Radiograph is not a Prerequisite for Successful Outcome in Fixed-Bearing Medial Unicompartmental Knee Arthroplasty-A 10-Year Follow-Up Study.

INTRODUCTION: Patients without bone-on-bone osteoarthritis are excluded from mobile-bearing unicompartmental knee arthroplasty due to higher revision rates and poorer outcomes. However, we do not know if the same indication applies to fixed-bearing unicompartmental knee arthroplasty implants. Our study aims to compare functional outcomes and revision rates in patients with and without bone-on-bone arthritis undergoing fixed-bearing medial unicompartmental knee arthroplasty. MATERIALS AND METHODS: We reviewed 153 fixed-bearing medial unicompartmental knee arthroplasties in a single institution. Patients were divided into four groups based on joint space remaining measured on preoperative radiographs. Group 1 included knees with bone-on-bone contact; group 2 included knees with less than 2 mm joint space; group 3 included knees with 2 to 4 mm joint space; group 4 included knees with more than 4 mm joint space. Patients were followed up for 10 years postoperatively and assessed using the Oxford Knee Score, the Functional Score and Knee Score from the Knee Society Clinical Rating Score, and the Short Form 36 Health Survey. RESULTS: There was no difference in terms of demographic data and preoperative scores. Postoperative Knee Society Functional Score was found to be lower in group 1 as compared with the other groups. There was no difference between the four groups of patients in terms of Knee Society Knee Score, Oxford Knee Score, and Physical Component Summary and Mental Component Summary Scores from the Short Form 36 Health Survey. There was no difference in terms of survivorship free from all-cause revision at a minimum of 10 years' follow-up. CONCLUSION: Symptomatic patients with varying degrees of arthritis on preoperative radiographs had comparable clinical outcomes. We conclude that symptomatic patients with clinical and radiographic evidence of medial compartment osteoarthritis of any grade can benefit from a fixed-bearing medial unicompartmental knee arthroplasty.

Association of Predominantly Peripheral Lesions on Ultra-Widefield Imaging and the Risk of Diabetic Retinopathy Worsening Over Time.

Importance: Ultra-widefield (UWF) imaging improves the ability to identify peripheral diabetic retinopathy (DR) lesions compared with standard imaging. Whether detection of predominantly peripheral lesions (PPLs) better predicts rates of disease worsening over time is unknown. Objective: To determine whether PPLs identified on UWF imaging are associated with increased disease worsening beyond the risk associated with baseline Early Treatment Diabetic Retinopathy Study (ETDRS) Diabetic Retinopathy Severity Scale (DRSS) score. Design, Setting, and Participants: This cohort study was a prospective, multicenter, longitudinal observational study conducted at 37 US and Canadian sites with 388 participants enrolled between February and December 2015. At baseline and annually through 4 years, 200° UWF-color images were obtained and graded for DRSS at a reading center. Baseline UWF-color and UWF-fluorescein angiography (FA) images were evaluated for the presence of PPL. Data were analyzed from May 2020 to June 2022. Interventions: Treatment of DR or diabetic macular edema was at investigator discretion. Main Outcomes and Measures: Predominantly peripheral lesions were defined as DR lesions with a greater extent outside vs inside the 7 standard ETDRS fields. Primary outcome was disease worsening defined as worsening 2 steps or more on the DRSS or receipt of DR treatment. Analyses were adjusted for baseline DRSS score and correlation between 2 study eyes of the same participant. Results: Data for 544 study eyes with nonproliferative DR (NPDR) were analyzed (182 [50%] female participants; median age, 62 years; 68% White). The 4-year disease worsening rates were 45% for eyes with baseline mild NPDR, 40% for moderate NPDR, 26% for moderately severe NPDR, and 43% for severe NPDR. Disease worsening was not associated with color PPL at baseline (present vs absent: 38% vs 43%; HR, 0.78; 95% CI, 0.57-1.08; P = .13) but was associated with FA PPL at baseline (present vs absent: 50% vs 31%; HR, 1.72; 95% CI, 1.25-2.36; P < .001). Conclusions and Relevance: Although no association was identified with color PPL, presence of FA PPL was associated with greater risk of disease worsening over 4 years, independent of baseline DRSS score. These results suggest that use of UWF-FA to evaluate retinas peripheral to standard ETDRS fields may improve the ability to predict disease worsening in NPDR eyes. These findings support use of UWF-FA for future DR staging systems and clinical care to more accurately determine prognosis in NPDR eyes.

Association of Ultra-Widefield Fluorescein Angiography-Identified Retinal Nonperfusion and the Risk of Diabetic Retinopathy Worsening Over Time.

Importance: Presence of predominantly peripheral diabetic retinopathy (DR) lesions on ultra-widefield fluorescein angiography (UWF-FA) was associated with greater risk of DR worsening or treatment over 4 years. Whether baseline retinal nonperfusion assessment is additionally predictive of DR disease worsening is unclear. Objective: To assess whether the extent and location of retinal nonperfusion identified on UWF-FA are associated with worsening in Diabetic Retinopathy Severity Scale (DRSS) score or DR treatment over time. Design, Setting, and Participants: This cohort study was a prospective, multicenter, longitudinal observational study with data for 508 eyes with nonproliferative DR and gradable nonperfusion on UWF-FA at baseline. All images were graded at a centralized reading center; 200° ultra-widefield (UWF) color images were graded for DR at baseline and annually for 4 years. Baseline 200° UWF-FA images were graded for nonperfused area, nonperfusion index (NPI), and presence of predominantly peripheral lesions on UWF-FA (FA PPL). Interventions: Treatment of DR or diabetic macular edema was at investigator discretion. Main Outcomes and Measures: Association of baseline UWF-FA nonperfusion extent with disease worsening, defined as either 2 or more steps of DRSS worsening within Early Treatment Diabetic Retinopathy Study fields on UWF-color images or receipt of DR treatment. Results: After adjusting for baseline DRSS, the risk of disease worsening over 4 years was higher in eyes with greater overall NPI (hazard ratio [HR] for 0.1-unit increase, 1.11; 95% CI, 1.02-1.21; P = .02) and NPI within the posterior pole (HR for 0.1-unit increase, 1.35; 95% CI, 1.17-1.56; P < .001) and midperiphery (HR for 0.1-unit increase, 1.08; 95% CI, 1.00-1.16; P = .04). In a multivariable analysis adjusting for baseline DRSS score and baseline systemic risk factors, greater NPI (HR, 1.11; 95% CI, 1.02-1.22; P = .02) and presence of FA PPL (HR, 1.89; 95% CI, 1.35-2.65; P < .001) remained associated with disease worsening. Conclusions and Relevance: This 4-year longitudinal study has demonstrated that both greater baseline retinal nonperfusion and FA PPL on UWF-FA are associated with higher risk of disease worsening, even after adjusting for baseline DRSS score and known systemic risk. These associations between disease worsening and retinal nonperfusion and FA PPL support the increased use of UWF-FA to complement color fundus photography in future efforts for DR prognosis, clinical care, and research.

Predictors of Patient Satisfaction in Hallux Valgus Surgery.

This study aims to analyze a combination of preoperative biodata, radiological parameters, and validated functional scores to determine predictors for patient satisfaction in patients who have undergone Hallux abducto valgus (HAV) surgery at 2 years postoperatively. Data from 288 patients who had undergone HAV surgery and 373 cases were collected between 2007 and 2013. The study group measured the HAV angle (HVA), tibial sesamoid position (TSP), as well as inter-metatarsal angle (IMA) on both pre- and postoperative radiographs for all patients. Clinical outcomes such as the Visual Analogue Scale for pain, the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale (MTP-ITP) Scale, and Short Form 36 Health Survey's physical and mental component scores (PCS and MCS) were captured preoperatively and postoperatively. Univariate analysis was performed first to determine possible predictors of patient satisfaction and the results were then included in a binary logistic regression model. Independent predictors of patient satisfaction include higher preoperative AOFAS (p value = .028, 95% confidence interval [CI] 0.958, 0.998) and the 2 years postoperative AOFAS (p = .001, 95% CI 1.027, 1.114). We also found PCS and MCS scores at 2 years postoperatively to be independent predictors of patient satisfaction (p = .004, 95% CI 1.015, 1.086 and p = .045, 95% CI 1.001, 1.064 respectively). Predictors of patient satisfaction include subjective outcomes such as the AOFAS score and the Short Form 36 composite quality of life scales of PCS and MCS, rather than objective radiological outcomes such as HVA, IMA, and TSP.

Do Patients Aged 70 Years and Older Benefit From Hallux Valgus Surgery?

The prevalence of hallux valgus increases with age. However, few studies have compared the effectiveness of surgical correction among different age groups. The authors present a retrospective evaluation of the influence of age on clinical outcomes. Patients who underwent corrective surgery for hallux valgus at an academic hospital were stratified into 2 age groups: ≥70 years old (Group 1) and <70 years old (Group 2). Following propensity score matching there were 106 patients: 53 patients in each group. Clinical outcomes, quality of life, and satisfaction questionnaires were collected preoperatively and at 6 months and 24 months postoperatively. There were no differences between both patient groups in preoperative biodata and clinical parameters. However, elderly patients had significantly poorer Physical Component Summary scores postoperatively at both 6 months (p = .001) and 24 months (p < .001), and significantly poorer American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal- Interphalangeal Scale at 24 months (p = .026). There was no difference between the 2 groups in patient satisfaction rates at 24 months postoperatively (70% vs 85%, p > .05). Elderly patients display significant improvements in their clinical scores 24 months postoperatively with no significant difference between satisfaction rates with their younger counterparts. Elderly patients can stand to benefit from hallux valgus surgery.

Posterior condylar offset and posterior tibial slope targets to optimize knee flexion after unicompartmental knee arthroplasty.

PURPOSE: To evaluate the relationship between posterior tibial slope (PTS), posterior condylar offset (PCO), femoral sagittal angle (FSA) on clinical outcomes, and propose optimal sagittal plane alignments for unicompartmental knee arthroplasty (UKA). METHODS: Prospectively collected data of 265 medial UKA was analysed. PTS, PCO, FSA were measured on preoperative and postoperative lateral radiographs. Clinical assessment was done at 6-month, 2-year and 10-year using Oxford Knee Score, Knee Society Knee and Function scores, Short Form-36, range of motion (ROM), fulfilment of satisfaction and expectations. Implant survivorship was noted at mean 15-year. Kendall rank correlation test evaluated correlations of sagittal parameters against clinical outcomes. Multivariable linear regression evaluated predictors of postoperative ROM. Effect plots and interaction plots were used to identify angles with the best outcomes. (p < 0.05) was the threshold for statistical significance. RESULTS: There were significant correlations between PTS, PCO and FSA. Younger age, lower BMI, implant type, greater preoperative flexion, steeper PTS and preservation of PCO were significant predictors of greater postoperative flexion. There were significant interaction effects between PTS and PCO. Effect plots demonstrate a PTS between 2° to 8° and restoration of PCO within 1.5 mm of native values are optimal for better postoperative flexion. Interaction plot reveals that it is preferable to reduce PCO by 1.0 mm when PTS is 2° and restore PCO at 0 mm when PTS is 8°. CONCLUSION: UKA surgeons and future studies should be mindful of the relationship between PTS, PCO and FSA, and avoid considering them in isolation. When deciding on the method of balancing component gaps in UKA, surgeons should rely on the PTS. Decrease the posterior condylar cut when PTS is steep, and increase the posterior condylar cut when PTS is shallow. The acceptable range for PTS is between 2° to 8° and PCO should be restored to 1.5 mm of native values. LEVEL OF EVIDENCE: II.

The Relationship of Transepicondylar Width with the Distal and Posterior Femoral Condyles and Its Clinical Implications: A Three-Dimensional Study.

BACKGROUND: Restoration of the anatomical joint line, while important for clinical outcomes, is difficult to achieve in revision total knee arthroplasty (rTKA) due to distal femoral bone loss. The objective of this study was to determine a reliable method of restoring the anatomical joint line and posterior condylar offset in the setting of rTKA based on three-dimensional (3D) reconstruction of computed tomography (CT) images of the distal femur. METHODS: CT scans of 50 lower limbs were analyzed. Key anatomical landmarks such as the medial epicondyle (ME), lateral epicondyle, and transepicondylar width (TEW) were determined on 3D models constructed from the CT images. Best-fit planes placed on the most distal and posterior loci of points on the femoral condyles were used to define the distal and posterior joint lines, respectively. Statistical analysis was performed to determine the relationships between the anatomical landmarks and the distal and posterior joint lines. RESULTS: There was a strong correlation between the distance from the ME to the distal joint line of the medial condyle (MEDC) and the distance from the ME to the posterior joint line of the medial condyle (MEPC) (p < 0.001; r = 0.865). The mean ratio of MEPC to MEDC was 1.06 (standard deviation [SD]: 0.07; range: 0.88-1.27) and that of MEPC to TEW was 0.33 (SD: 0.03; range: 0.25-0.38). CONCLUSIONS: Our findings suggest that the fixed ratios of MEPC to TEW (0.33) and that of MEPC to MEDC (1.06) provide a reliable means for the surgeon to determine the anatomical joint line when used in combination.

Comparing the Predictors of Functional Outcomes After Arthroscopic Rotator Cuff Repair Modified Frailty Index, Clinical Frailty Scale, and Charlson Comorbidity Index.

BACKGROUND: The incidence of rotator cuff tears increases with age, and operative management is usually required in patients with persistent symptoms. Although several studies have analyzed the effect of age and comorbidities on outcomes after rotator cuff repair, no study has specifically examined the consequence of frailty. PURPOSE: To determine the best frailty/comorbidity index for predicting functional outcomes after arthroscopic rotator cuff repair. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The authors conducted a retrospective cohort study of 340 consecutive patients who underwent unilateral arthroscopic rotator cuff repair at a tertiary hospital between April 2016 and April 2018. All patients had undergone arthroscopic double-row rotator cuff repair with subacromial decompression by a single fellowship-trained shoulder surgeon. Patient frailty was measured using the Modified Frailty Index (MFI), Clinical Frailty Scale (CFS), and Charlson Comorbidity Index (CCI), calculated through retrospective chart review based on case notes made just before surgery; patient age and sex were also noted preoperatively. Functional outcomes using the Oxford Shoulder Score (OSS), Constant Shoulder Score (CSS), University of California Los Angeles (UCLA) Shoulder Score, and visual analog scale for pain were measured preoperatively and at 3, 6, 12, and 24 months postoperatively. RESULTS: The MFI was a consistent significant predictor in all functional outcome scores up to 24 months postoperatively (P < .05), unlike the CFS and CCI. Sex was also a significant predictor of postoperative OSS, CSS, and UCLA Shoulder Score, with male sex being associated with better functional outcomes. Patients with higher MFI scores had slower functional improvement postoperatively, but they eventually attained functional outcome scores comparable with those of their counterparts with lower MFI scores at 24 months postoperatively. CONCLUSION: The MFI was found to be a better tool for predicting postoperative function than was the CFS or CCI in patients undergoing arthroscopic rotator cuff repair. The study findings suggest that a multidimensional assessment of frailty (including both functional status and comorbidities) is important in determining functional outcomes after arthroscopic rotator cuff repair.

Septuagenarians aged 75 years and older do benefit from arthroscopic rotator cuff repair: a propensity matched-pair analysis.

BACKGROUND: Numerous studies show that patients who failed conservative management, benefit from open, mini open and arthroscopic rotator cuff repair (ARCR). However, there is a paucity of literature addressing ARCR and outcomes in patients older than the age of 75 years. The purpose of our study was to compare the outcomes of ARCR in patients older than 75 years and younger than 75 years of age. METHODS: Between January 2010 and December 2016, 397 patients underwent unilateral ARCR; of which, 23 patients were 75 years of age and older. Outcome measures recorded include the Constant Shoulder Score (CSS), University of California, Los Angeles Shoulder Score (UCLASS), Oxford Shoulder Score (OSS), and visual analog scale (VAS) for pain assessment. RESULTS: There were no statistically significant differences in VAS, CSS, and UCLASS between the two groups at all time points of follow-up (all P > .05). At 2 years after surgery, the OSS was 2 ± 5 points better in the <75 group (P = .012). However, the improvement in OSS was comparable between both groups. The improvement in VAS, CSS, and UCLASS at 2 years after surgery compared with baseline was also similar between the two groups (all P < .05). CONCLUSIONS: The improvement in VAS, CSS, and UCLASS was similar in both groups of patients. We conclude that septuagenarians with symptomatic cuff tears, who have failed conservative management, experience significant improvement in pain, and function after surgery and should not be excluded from the benefits of ARCR.

The UCLA Shoulder Score Is a Better Predictor of Treatment Success Than the Constant and Oxford Shoulder Scores After Arthroscopic Rotator Cuff Repair: A 2-Year Follow-Up Study.

PURPOSE: The aim of this study was to determine the correlation between functional outcome scores and treatment success after arthroscopic rotator cuff repair. METHODS: We conducted a retrospective cohort study of patients who underwent unilateral rotator cuff repair at a tertiary hospital between 2010 and 2015. University of California at Los Angeles Shoulder Score (UCLASS), Constant Shoulder Score (CSS), and Oxford Shoulder Score (OSS) were measured before and at 6, 12, and 24 months after surgery. Patients were divided into 2 groups at each follow-up: (1) those with successful treatment and (2) those with unsuccessful treatment. Treatment success was defined as simultaneous fulfilment of 3 criteria: clinically significant improvement in pain, expectations for surgery met, and patient satisfied with surgery. RESULTS: A total of 214 subjects met the inclusion criteria. UCLASS was a consistent significant predictor of treatment success at 6 months (odds ratio [OR] 1.192, P = .005, 95% confidence interval [CI] 1.054-1.348), 12 months (OR 1.274, P < .001, 95% CI 1.153-1.406), and 24 months (OR 1.266, P < .001, 95% CI 1.162-1.380). Lower preoperative CSS was significant in predicting treatment success at 6 months (OR 0.952, P = .001, 95% CI 0.926-0.979), while larger tear size was significant in predicting treatment success at 24 months (OR 1.773, P = .043, 95% CI 1.019-3.083). CONCLUSION: UCLASS is a better tool for predicting treatment success than CSS and OSS in patients undergoing arthroscopic rotator cuff repair, up to a minimum of 24 months' follow-up. A holistic assessment of shoulder function, taking into account both subjective and objective evaluation of function, as well as patient-reported satisfaction, is important in determining treatment success after arthroscopic rotator cuff repair. LEVEL OF EVIDENCE: III, retrospective comparative study.

Increased preoperative greater tuberosity angle does not affect patient-reported outcomes postarthroscopic rotator cuff repair.

BACKGROUND: The greater tuberosity angle (GTA) is a newly described radiological parameter identified in a 2018 study by Cunningham et al that sought to investigate the effect of GT morphology on cuff tears. Increased GTA has been conceptualized to affect rotator cuff pathology through both extrinsic and intrinsic mechanisms. GTA > 70° was highly predictive of a degenerative rotator cuff tear. This study seeks to examine if increased GTA predicts for worse functional outcomes 2 years postoperatively after arthroscopic rotator cuff repair. METHODS: Between May 2010 and December 2016, 169 patients who underwent arthroscopic rotator cuff repair with subacromial decompression were included in this study. GTA was measured on preoperative radiographs. These patients were evaluated preoperatively and at 3 months, 6 months, 1 year, and 2 years postoperatively. Outcomes were assessed with the Visual Analog Scale Pain score, Constant Shoulder Score, and the Oxford Shoulder Score. Power analysis was performed based on the minimal clinically important difference of the Constant Shoulder Score. Statistical analysis was performed by dividing patients into two groups based on GTA: 1) ≤ 70 (control GTA); and 2) >70 (increased GTA) and comparisons were made between the 2 groups. RESULTS: The patients' demographics were comparable between both groups. All 169 patients had statistically significant improvements in all functional scores at 2 years postoperatively. There were no statistically significant differences between the two groups of patients in Visual Analog Scale and functional scores at 3 months, 6 months, 1 year, and 2 year postoperatively. The changes in functional scores from their preoperative baseline were also tabulated, and there were no statistically significant differences between the 2 groups. Finally, there was no significant correlation between GTA with CSS or Oxford Shoulder Score at 2 years follow-up. CONCLUSION: This study represents the largest single series available investigating the influence of GTA on midterm functional outcomes after arthroscopic rotator cuff repair. Although GTA remains a reliable radiographic predictor of rotator cuff tears, the authors conclude that increased GTA does not negatively influence midterm functional outcomes. As there is also no statistical significance between increased GTA vs. control in relative functional gain 2 years postoperatively, corrective tuberoplasty may not be mandatory during arthroscopic repair of cuff tears. Standard arthroscopic double-row rotator cuff repair with subacromial decompression can still be offered as a suitable treatment option.

The effect of tibial and femoral component coronal alignment on clinical outcomes and survivorship in unicompartmental knee arthroplasty.

AIMS: This study aimed to identify the tibial component and femoral component coronal angles (TCCAs and FCCAs), which concomitantly are associated with the best outcomes and survivorship in a cohort of fixed-bearing, cemented, medial unicompartmental knee arthroplasties (UKAs). We also investigated the potential two-way interactions between the TCCA and FCCA. METHODS: Prospectively collected registry data involving 264 UKAs from a single institution were analyzed. The TCCAs and FCCAs were measured on postoperative radiographs and absolute angles were analyzed. Clinical assessment at six months, two years, and ten years was undertaken using the Knee Society Knee score (KSKS) and Knee Society Function score (KSFS), the Oxford Knee Score (OKS), the 36-Item Short-Form Health Survey questionnaire (SF-36), and range of motion (ROM). Fulfilment of expectations and satisfaction was also recorded. Implant survivorship was reviewed at a mean follow-up of 14 years (12 to 16). Multivariate regression models included covariates, TCCA, FCCA, and two-way interactions between them. Partial residual graphs were generated to identify angles associated with the best outcomes. Kaplan-Meier analysis was used to compare implant survivorship between groups. RESULTS: Significant two-way interaction effects between TCCA and FCCA were identified. Adjusted for each other and their interaction, a TCCA of between 2° and 4° and a FCCA of between 0° and 2° were found to be associated with the greatest improvements in knee scores and the probability of fulfilling expectations and satisfaction at ten years. Patients in the optimal group whose TCCA and FCCA were between 2° and 4°, and 0° and 2°, respectively, had a significant survival benefit at 15 years compared with the non-optimal group (optimal: survival = 100% vs non-optimal: survival = 92%, 95% confidence interval (CI) 88% to 96%). CONCLUSION: Significant two-way interactions between the TCCA and FCCA demonstrate the importance of evaluating the alignment of the components concomitantly in future studies. By doing so, we found that patients who concomitantly had both a TCCA of between 2° and 4° and a FCCA of between 0° and 2° had the best patient-reported outcome measures at ten years and better survivorship at 15 years. Cite this article: Bone Joint J 2021;103-B(2):338-346.

Arthroscopic rotator cuff repair results in similar postoperative functional outcomes in patients with only rotator cuff tears and those with concomitant cervical radiculopathy.

PURPOSE: The aim of this study was to compare postoperative functional outcomes after arthroscopic rotator cuff repair in patients with only rotator cuff tears versus those with concomitant cervical radiculopathy. METHODS: A retrospective study of patients who underwent unilateral rotator cuff repair at a tertiary hospital between 2012 and 2016 was conducted. Patients included in the study were divided into two groups: (1) those with rotator cuff tears only (RC only) and (2) those with concomitant cervical radiculopathy (RC + radiculopathy). Cervical radiculopathy was treated non-surgically in these patients. Oxford Shoulder Score (OSS), Constant Shoulder Score (CSS), University of California at Los Angeles Shoulder Score (UCLASS) and Visual Analog Scale (VAS) pain score were measured for each patient preoperatively and at 3, 6, 12, and 24 months postoperatively. RESULTS: As compared to the RC-only group (n = 324), the RC + radiculopathy group (n = 33) had significantly poorer OSS (p = 0.001), CSS (p = 0.017) and UCLASS (p = 0.009) functional scores preoperatively. On follow-up, there were no significant differences in functional outcomes between the groups at 3, 6, 12 and 24 months postoperatively for OSS, CSS, UCLASS and VAS pain scores, with the exception of CSS which was higher in the RC-only group at 6 months (p = 0.007). The absolute change and number of patients that attained minimum clinically important difference (MCID) for OSS, CSS and UCLASS at 12- and 24-month follow-ups were also comparable between the groups. CONCLUSION: Patients with rotator cuff tears and concomitant cervical radiculopathy achieve similar postoperative functional outcomes to those with only rotator cuff tears, after arthroscopic rotator cuff repair. LEVEL OF EVIDENCE: III.

No difference in functional outcomes, quality of life and survivorship between metal-backed and all-polyethylene tibial components in unicompartmental knee arthroplasty: a 10-year follow-up study.

PURPOSE: The purpose of this study was to compare functional outcomes, quality of life and survivorship at a minimum of 10 years postoperatively, between MB and AP tibial components in fixed-bearing UKAs. METHODS: A retrospective cohort study of 146 Query ID="Q3" Text="Author names: Please confirm if the author names are presented accurately and in the correct sequence (Lo Ngai Nung, Yeo Seng Jin). Also, kindly confirm the details in the metadata are correct." UKAs performed between 2004 and 2007 by a single fellowship-trained arthroplasty surgeon was carried out. 27 UKAs received MB tibial components and 119 UKAs received AP tibial components. The cohort was followed up prospectively for 10 years. Functional outcomes were compared using the Knee Society Functional Score (KSFS), Knee Society Knee Score (KSKS) and Oxford Knee Score (OKS). Quality of life measures were obtained from the Physical Component Summary (PCS) and Mental Component Summary (MCS), derived from the Short Form 36 Health Survey (SF-36). Propensity score matching was performed in a 1:3 ratio of MB versus AP tibial components to account for possible confounding variables. Thereafter, outcomes between the two groups were compared. The proportion of patients who had attained the minimum clinically important difference (MCID) for the abovementioned scores was recorded as well. RESULTS: After propensity score matching, there were 28 UKAs with MB tibial components and 76 UKAs with AP tibial components. There was no significant difference between the two groups in functional outcomes (KSFS, KSKS and OKS), quality of life (PCS and MCS) and survivorship (92.3% vs 91.1%, respectively) at a minimum of 10 years postoperatively. However, a significantly higher proportion of patients in the group with AP tibial components attained the MCID for PCS at 10 years postoperatively, compared to those with MB tibial components (p = 0.031). CONCLUSION: In conclusion, there were no significant differences in functional outcomes measures, quality of life and survivorship between MP and AP tibial components at a minimum of 10 years postoperatively. LEVEL OF EVIDENCE: III.

Coronal Alignment of Fixed-Bearing Unicompartmental Knee Arthroplasty Femoral Component May Affect Long-Term Clinical Outcomes.

BACKGROUND: This study aims to investigate the clinical effects of femoral component coronal alignment in a cohort of fixed-bearing unicompartmental knee arthroplasty with clinical and radiological follow-up of 10 years. METHODS: Prospectively collected registry data of 264 consecutive, cemented, primary fixed-bearing medial unicompartmental knee arthroplasties performed at a single institution from 2004 to 2007 were reviewed. Femoral component coronal angle (FCCA), tibial component coronal angle, and hip-knee-ankle angle were measured on postoperative radiographs. Patients were grouped into acceptable (AG ≤ 3°) and outlier (OG > 3°) groups according to absolute FCCA. Clinical assessment at 6-month, 2-year, and 10-year follow-up was performed using Knee Society Knee and Function Scores, Oxford Knee Score (OKS), and Short Form-36. Fulfillment of expectations, satisfaction, and implant survivorship was recorded. RESULTS: There was no significant difference in demographics, tibial component coronal angle, hip-knee-ankle angle, and sagittal parameters in both groups. The OG had poorer OKS at 10 years and a larger deterioration from 2 to 10 years compared to AG (P = .02). Increase in FCCA was associated with deterioration in 2-year OKS (adjusted ß = 0.23, P = .01), 10-year OKS (adjusted ß = 0.26, P = .03), and 2-year Short Form-36 physical component score (adjusted ß = -0.44, P = .01). Expectation fulfillment at 2 years was lower in the OG vs the AG (88% vs 100%, P = .03). Both groups had similar 10-year survivorship (99% vs 98%, P = .65). CONCLUSIONS: FCCA may affect long-term clinical outcomes, but not short-term clinical outcomes nor 10-year survivorship. Given similar limb alignment, coronal and sagittal component positioning, a larger FCCA was associated with poorer outcomes at 10-year follow-up.

Dyslipidemia With Perioperative Statin Usage Is Not Associated With Poorer 24-Month Functional Outcomes After Arthroscopic Rotator Cuff Surgery.

BACKGROUND: Current literature suggests a higher rate of rotator cuff disease development in patients with dyslipidemia (DL). Moderate to high levels of DL are associated with higher rates of retear and revision surgery after arthroscopic rotator cuff repair. Statins protect against development of rotator cuff disease and mitigate the need for rotator cuff repair. PURPOSE: We aimed to investigate the influence of DL and statin use on postoperative functional outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Between 2010 and 2016, 266 patients underwent arthroscopic double-row rotator cuff repair for atraumatic full-thickness tears. Evaluation was conducted preoperatively and at 3, 6, 12, and 24 months postoperatively. Three functional outcome measures were used (Constant Shoulder Score [CSS], Oxford Shoulder Score [OXF], and University of California, Los Angeles, Shoulder Rating Scale [UCLASS]), as well as a visual analog scale (VAS) for pain. DL and non-DL were classified through screening of health and assessment of lipid levels within 6 months of surgery (triglycerides, total cholesterol, low-density lipoprotein, and high-density lipoprotein). Patients with DL were divided into statin users and nonusers. Types and dosages of statins were recorded, and intensity and equivalency charts were employed for standardization. Mann-Whitney U test and Pearson chi-square test were used for analysis. Generalized estimating equations and linear mixed models were used to examine the influence of DL and statin dosage, respectively on percentage change of postoperative outcome scores. RESULTS: Increased age was associated with a higher incidence of DL (P < .001), and 86% of the DL group was taking statins. The DL group also exhibited poorer scores preoperatively (CSS, P = .001; OXF, P = .032). No significant difference in scores was elicited between the DL and non-DL groups at 24 months. However, patients with DL experienced greater percentage improvement of CSS and OXF from preoperative baseline than did patients without DL (P = .008 and P = .034, respectively) at 24 months. There was no significant difference in 24-month functional outcomes between statin users and nonusers. No statistically significant change of CSS; OXF; UCLASS; or VAS was noted with increasing statin doses at 24 months. CONCLUSION: Patients with DL with perioperative statin usage did not have poorer 24-month functional outcomes after arthroscopic rotator cuff surgery compared with those in patients without DL.

Application of Automated Quantification of Fluid Volumes to Anti-VEGF Therapy of Neovascular Age-Related Macular Degeneration.

PURPOSE: Anti-vascular endothelial growth factor (VEGF) treatment of neovascular age-related macular degeneration (AMD) is a highly effective advance in the retinal armentarium. OCT offering 3-dimensional imaging of the retina is widely used to guide treatment. Although poor outcomes reported from clinical practice are multifactorial, availability of reliable, reproducible, and quantitative evaluation tools to accurately measure the fluid response, that is, a "VEGF meter," may be a better means of monitoring and treating than the current purely qualitative evaluation used in clinical practice. DESIGN: Post hoc analysis of a phase III, randomized, multicenter study. PARTICIPANTS: Study eyes of 1095 treatment-naive subjects receiving pro re nata (PRN) or monthly ranibizumab therapy according to protocol-specified criteria in the HARBOR study. METHODS: A deep learning method for localization and quantification of fluid in all retinal compartments was applied for automated segmentation of fluid with every voxel classified by a convolutional neural network (CNN). Three-dimensional volumes (nanoliters) for intraretinal fluid (IRF), subretinal fluid (SRF), and pigment epithelial detachment (PED) were determined in 24 362 volume scans obtained from 1095 patients treated over 24 months in a phase III clinical trial with randomization to 2 drug dosages (0.5 mg and 2.0 mg ranibizumab) and 2 regimens (monthly and PRN). A multivariable mixed-effects regression model was used to test for differences in fluid between the arms and for fluid/function correlation. MAIN OUTCOME MEASURES: Fluid volume in nanoliters, structure-function as Pearson's correlation coefficient, and as a coefficient of determination (R2). RESULTS: Fluid volumes were quantified in all visits of all patients. Automated segmentation demonstrated characteristic response patterns for each fluid compartment individually: Intraretinal fluid showed the greatest and most rapid resolution, followed by SRF and PED the least. The loading dose treatment achieved resolution of all fluid types close to the lowest levels attainable. Dosage and regimen parameters correlated directly with resulting fluid volumes. Fluid/function correlation showed a volume-dependent negative impact of IRF on vision and weak positive prognostic effect of SRF. CONCLUSIONS: Automated quantification of the fluid response may improve therapeutic management of neovascular AMD, avoid discrepancies between clinicians/investigators, and establish structure/function correlations.