Long head of biceps tendon augmentation for massive rotator cuff tears improves clinical results regardless of the number of tendons involved.

PURPOSE: Management of massive rotator cuff tears (MRCTs) remains debated, and various arthroscopic and open techniques have been described for their management. Nevertheless, the optimal strategy remains unclear. The present study evaluated the clinical results in patients managed arthroscopically for MRCTs augmented with the long head biceps tendon (LHBT) at a minimum 1-year follow-up, considering different type of tears, demographic data and number of torn tendons. METHODS: Patients treated in a secondary referral centre from January 2021 to April 2022 were enroled prospectively. Inclusion criteria were pain, inability to fully elevate the affected shoulder, irreparable tears and active and motivated patients. All patients were managed within 2 months from diagnosis in a single centre by the same surgeons. Preoperative shoulder radiographs and magnetic resonance imaging (MRI) were collected, and clinical assessment was also performed using the Numerical analogue scale (NAS), Constant score (CS) American Shoulder and Elbow Surgeons Shoulder Score (ASES). Tissue retraction and tendon fatty infiltration were evaluated using Patte and Fuchs scale, respectively. Clinical assessment was performed using the same scales at 3-6 months and 1-year follow-up. RESULTS: A total of 55 patients (31 female and 24 male) with a mean age of 60 ± 7.1 years were enroled for a mean follow-up of 18.2 ± 4.3 months. The mean preoperative NAS was 7.8 ± 0.6, CS was 20.5 ± 7.6 and ASES was 22.6 ± 9.2, increasing, respectively, to 0.3 ± 0.6, 91.5 ± 6.9 and 94.2 ± 6.7. No adverse side effects (infection, rejection, allergy) were reported during the study period. All patients were evaluated after surgery at 3 and 6 months and 1 year with statistically significant improvement for each score at the first and last follow-up (p < 0.05). CONCLUSIONS: The use of LHBT augmentation in patients with MRCTs in appropriately selected patients is safe and effective and can lead to pain relief and acceptable clinical outcomes. Furthermore, its use carries low donor site morbidity and is cost effective. Comparative studies, including randomised controlled trials, with other proposed techniques are needed to confirm these findings. LEVEL OF EVIDENCE: Level IV.

The use of long head biceps tendon autograft for massive rotator cuff tears: a PRISMA compliant systematic review.

INTRODUCTION: Rotator cuff tears (RCT) are a common cause of shoulder pain and disability, with massive RCT accounting for 10-40% of all rotator cuff tears. SOURCES OF DATA: A systematic search of PubMed and Scopus electronic databases was performed up to August 2022, and a total of 17 scientific articles were included in the present PRISMA compliant systematic review. AREAS OF AGREEMENT: Understanding the geometric patterns in RCT is essential to achieve appropriate repositioning of the injured tendons in their anatomic location. The long head of the biceps tendon (LHBT) is usually exposed when defects of the anterolateral corner are present and can be easily used to augment rotator cuff repairs. AREAS OF CONTROVERSY: There are no definite guideline regarding the management of massive rotator cuff tears. GROWING POINTS: The use of LHBT graft is safe and effective, but technically demanding. All studies were level IV articles of medium to high quality. AREAS TIMELY FOR DEVELOPING RESEARCH: Prospective long term follow-up studies and randomized controlled trials are needed, adding imaging evaluation and appropriate clinical outcome measures at follow-up.

Single-row vs. double-row arthroscopic rotator cuff repair: clinical and 3 Tesla MR arthrography results.

BACKGROUND: Arthroscopic rotator cuff repair has become popular in the last few years because it avoids large skin incisions and deltoid detachment and dysfunction. Earlier arthroscopic single-row (SR) repair methods achieved only partial restoration of the original footprint of the tendons of the rotator cuff, while double-row (DR) repair methods presented many biomechanical advantages and higher rates of tendon-to-bone healing. However, DR repair failed to demonstrate better clinical results than SR repair in clinical trials. MR imaging at 3 Tesla, especially with intra-articular contrast medium (MRA), showed a better diagnostic performance than 1.5 Tesla in the musculoskeletal setting. The objective of this study was to retrospectively evaluate the clinical and 3 Tesla MRA results in two groups of patients operated on for a medium-sized full-thickness rotator cuff tear with two different techniques. METHODS: The first group consisted of 20 patients operated on with the SR technique; the second group consisted of 20 patients operated on with the DR technique. All patients were evaluated at a minimum of 3 years after surgery. The primary end point was the re-tear rate at 3 Tesla MRA. The secondary end points were the Constant-Murley Scale (CMS), the Simple Shoulder Test (SST) scores, surgical time and implant expense. RESULTS: The mean follow-up was 40 months in the SR group and 38.9 months in the DR group. The mean postoperative CMS was 70 in the SR group and 68 in the DR group. The mean SST score was 9.4 in the SR group and 10.1 in the DR group. The re-tear rate was 60% in the SR group and 25% in the DR group. Leakage of the contrast medium was observed in all patients. CONCLUSIONS: To the best of our knowledge, this is the first report on 3 Tesla MRA in the evaluation of two different techniques of rotator cuff repair. DR repair resulted in a statistically significant lower re-tear rate, with longer surgical time and higher implant expense, despite no difference in clinical outcomes. We think that leakage of the contrast medium is due to an incomplete tendon-to-bone sealing, which is not a re-tear. This phenomenon could have important medicolegal implications. Level of evidence III. Treatment study: Case-control study.

Infra-patellar fat pad cysts: a case report and review of the literature.

Infra-patellar fat pad cysts are an uncommon type of intra-articular ganglia. We report a case of a young woman with a painful little mass in the anterior aspect of the left knee. Ultrasound revealed a multiloculate cyst, that was initially drained with a spinal needle. Four months later, she had a recurrence of symptoms and a ultrasound guided aspiration was performed. Cytological examination revealed synovial cells, synovial fluid, macrophages and debris: diagnosis was ganglion cyst. We reviewed the literature about infra-patellar fat pad cysts. Clinical diagnosis of an intraarticular cyst is very difficult, but sometimes an infra-patellar fat pad cyst could be suspected because it could be visible and palpable. MRI is the best diagnostic option in all cases. There are several treatment option, operative or conservative. In our opinion ultrasound guided aspiration is the treatment of choice in symptomatic ganglia, because it allows to drain all lacunae, preventing recurrence.

New solution for massive, irreparable rotator cuff tears: the subacromial "biodegradable spacer".

Massive, irreparable rotator cuff tears are a source of pain and disability. Although most rotator cuff tears can be completely repaired, a significant number are considered massive and irreparable. Numerous operative techniques have been described for the treatment of these kinds of tears including arthroscopic debridement, biceps tenotomy, tendon transfer, grafting, and reverse arthroplasty. We describe a surgical technique using a biodegradable subacromial balloon spacer (InSpace; OrthoSpace, Kfar Saba, Israel) implanted between the humeral head and acromion that permits smooth, frictionless gliding, restoring the shoulder biomechanics. The technique is easy to perform and is less invasive than the conventional surgical techniques available, and it may potentially serve as a bridging option in patients with massive, irreparable tears who are normally candidates for reverse arthroplasty.

Sequelae of an undiagnosed unilateral congenital fixed anterior shoulder dislocation in a 40-year-old female.

Congenital shoulder dislocation is a rare condition. A review of the literature showed that 0.018-0.07% of newborns suffer from shoulder dislocations. There have been only few reports about this entity, clinic and radiologic features, treatment, and etiology of this condition remains unclear. We report a case of undiagnosed unilateral congenital fixed anterior shoulder dislocation in a 40-year-old female, which affected the day quality of life. Pediatrists and orthopaedic surgeons should know this rare condition and the importance of a proper diagnosis in the early childhood when an appropriate treatment could be performed.

A technique for treating patello-femoral instability in immature patients: the tibial tubercle periosteum transfer.

Patello-femoral problems are frequently encountered in knee clinic. The most important role of the patella is to increase the quadriceps efficiency, although this function could be altered in the patello-femoral instability. Active stability of the patello-femoral joint is provided by the surrounding muscles and ligaments, passive stability is provided by the bony and cartilage structures. Patellofemoral instability is defined, from Henry Dejour, as a disease without engagement the patella in the femoral trochlea during knee range of motion. Every time should be performed careful radiological preoperative investigations (radiographs and computed tomography) involving an expert musculoskeletal radiologist. Surgical procedures may be divided into those that address the soft tissues (muscles and ligaments), generally on the immature skeletal, and those that effect bony changes, generally on the mature skeletal; sometimes, it is necessary to combine soft-tissue and bony procedures. In this report, the authors describe a tibial tubercle periosteum transfer technique for patello-femoral instability in immature patients, which may potentially improve clinical results in very young symptomatic patients with patello-femoral instability.

Role of high tibial osteotomy in chronic injuries of posterior cruciate ligament and posterolateral corner.

High tibial osteotomy (HTO) is a surgical procedure used to change the mechanical weight-bearing axis and alter the loads carried through the knee. Conventional indications for HTO are medial compartment osteoarthritis and varus malalignment of the knee causing pain and dysfunction. Traditionally, knee instability associated with varus thrust has been considered a contraindication. However, today the indications include patients with chronic ligament deficiencies and malalignment, because an HTO procedure can change not only the coronal but also the sagittal plane of the knee. The sagittal plane has generally been ignored in HTO literature, but its modification has a significant impact on biomechanics and joint stability. Indeed, decreased posterior tibial slope causes posterior tibia translation and helps the anterior cruciate ligament (ACL)-deficient knee. Vice versa, increased tibial slope causes anterior tibia translation and helps the posterior cruciate ligament (PCL)-deficient knee. A review of literature shows that soft tissue procedures alone are often unsatisfactory for chronic posterior instability if alignment is not corrected. Since limb alignment is the most important factor to consider in lower limb reconstructive surgery, diagnosis and treatment of limb malalignment should not be ignored in management of chronic ligamentous instabilities. This paper reviews the effects of chronic posterior instability and tibial slope alteration on knee and soft tissues, in addition to planning and surgical technique for chronic posterior and posterolateral instability with HTO.

Intercondylar eminence avulsion fracture in children: long-term follow-up of 14 cases at the end of skeletal growth.

The purpose of this study was to report the long-term clinical outcome in a group of 14 patients treated for an avulsion fracture of the tibial spine. On the basis of the Meyers and McKeever classification, there were four type I avulsions, three type II and seven type III. Seven patients were treated nonoperatively and seven patients were operated according to one of the two different protocols: open reduction and internal fixation and arthroscopic reduction and internal fixation. At follow-up, four patients had clinical signs of joint instability, but no subjective instability. One patient with a type III lesion treated nonsurgically showed severe instability. All other patients returned to the same sport activity level that they had had before the fracture. We obtained good results in 13 out of 14 cases. Good results can be obtained when type I fractures are treated nonoperatively. Type II and type III lesions showed better results after arthroscopic reduction and internal fixation. Nonabsorbable suture fixation for osteosynthesis is recommended. The prognosis is strictly related to the type of fracture, anatomic reduction and articular congruity.

Bilateral spontaneous concurrent rupture of the patellar tendon in a healthy man: case report and review of the literature.

Knee extensor mechanism disruption is a serious injury usually requiring emergent treatment. Rupture of the patellar tendon is rare in the normal population; bilateral spontaneous concurrent rupture in a healthy population is an exceptional event. We describe the case of a 39-year-old man with bilateral spontaneous concurrent rupture of the patellar tendon without any underlying systemic disease or drug use.

Chevron osteotomy with lateral release and adductor tenotomy for hallux valgus.

BACKGROUND: Distal chevron osteotomy is a procedure widely performed for the surgical treatment of painful hallux valgus. The risks and benefits of a lateral capsular release and adductor tenotomy combined with chevron osteotomy are still debated. The aim of our study was to report the clinical and radiographic outcomes of this combined procedure in mild and moderate incongruent bunion deformities, with a hallux valgus angle (HVA) up to 40 degrees and an intermetatarsal angle (IMA) up to 20 degrees. MATERIALS AND METHODS: Forty-two patients (52 feet) who consecutively underwent chevron osteotomy combined with lateral release and adductor tenotomy were reviewed 24-36 months after surgery. The mean age of the patients was 53.5 (range, 43 to 64) years. All the deformities were mild to moderate, with a mean preoperative value of 28 degrees in the HVA (range, 16 degrees to 40 degrees) and of 13 degrees in the IMA (range, 9 degrees to 20 degrees). RESULTS: At followup, the AOFAS hallux score improved from an average of 46 to an average of 88. The HVA and IMA had an average postoperative decrease respectively of 12 degrees and 6 degrees; lateral sesamoid displacement decreased by a mean of 15%. In no case did we observe infection or nonunion of the osteotomy. In one case, painless avascular necrosis of the first metatarsal head developed. CONCLUSION: Our short-term results show that distal chevron osteotomy combined with lateral release and adductor tenotomy is a feasible surgical option to address mild to moderate hallux valgus deformity, even with an IM angle between 15 and 20 degrees. Clinical and radiographic outcomes are generally good and patient satisfaction is generally high.