The pathology of oxidative stress-induced autophagy in a chronic rotator cuff enthesis tear.

Partial-thickness rotator cuff tears (PTRCTs) are often found in daily orthopedic practice, with most of the tears occurring in middle-aged patients. An anaerobic process and imbalanced oxygenation have been observed in PTRCTs, resulting in oxidative stress. Studies have shown the roles of oxidative stress in autophagy and the potential of unregulated mechanisms causing disturbance in soft tissue healing. This article aims to review literature works and summarize the potential pathology of oxidative stress and unregulated autophagy in the rotator cuff enthesis correlated with chronicity. We collected and reviewed the literature using appropriate keywords, in addition to the manually retrieved literature. Autophagy is a normal mechanism of tissue repair or conversion to energy needed for the repair of rotator cuff tears. However, excessive mechanisms will degenerate the tendon, resulting in an abnormal state. Chronic overloading of the enthesis in PTRCTs and the hypovascular nature of the proximal tendon insertion will lead to hypoxia. The hypoxia state results in oxidative stress. An autophagy mechanism is induced in hypoxia via hypoxia-inducible factors (HIFs) 1/Bcl-2 adenovirus E1B 19-kDa interacting protein (BNIP) 3, releasing beclin-1, which results in autophagy induction. Reactive oxygen species (ROS) accumulation would induce autophagy as the regulator of cell oxidation. Oxidative stress will also remove the mammalian target of rapamycin (mTOR) from the induction complex, causing phosphorylation and initiating autophagy. Hypoxia and endoplasmic reticulum (ER) stress would initiate unfolded protein response (UPR) through protein kinase RNA-like ER kinase (PERK) and activate transcription factor 4, which induces autophagy. Oxidative stress occurring in the hypovascularized chronic rotator cuff tear due to hypoxia and ROS accumulation would result in unregulated autophagy directly or autophagy mediated by HIF-1, mTOR, and UPR. These mechanisms would disrupt enthesis healing.

Total elbow arthroplasty with tricep turn-down flap in an old unreduced elbow dislocation: A case report.

INTRODUCTION AND IMPORTANCE: The treatment preference for neglected elbow dislocation is by open reduction and lengthening the tricep muscle. If the dislocation is not reduced for more than 6 months, degenerative resorption would have occurred. We did total elbow arthroplasty (TEA) with a tricep turn-down flap for the management in this case. The use of a tricep flap for tricep shortening after unreduced elbow dislocation has been reported in previous publications but none used a turn-down flap. CASE PRESENTATION: An 82-year-old woman came to the orthopedic outpatient clinic with pain and discomfort on her right elbow. The arm affected by the injury was her dominant hand, restricting her from farming and leisure activities. Exploration findings confirmed the presence of a dislocated elbow with associated soft tissue complications. The cartilage was degeneratively destructed, and the tricep muscle was retracted. CLINICAL DISCUSSION: In our case, tricep shortening was managed with elongation using a turn-down flap. The lack of soft tissue layers and thin fibrous fascias results in tension-vulnerable TEA surgical wounds. This is caused by the insufficient coverage of the joint, which leads to wound complications. Previous studies of turn-down flap procedures showed good flap survival and functional outcomes. CONCLUSION: Tricep turn-down flap could be an option for tricep lengthening procedures in unreduced neglected elbow joint dislocation.

Ultrasound-Guided Suprascapular Nerve Block at Spinoglenoid Notch and Glenohumeral Joint Hydrodilation.

Hydrodilation of the glenohumeral joint is commonly employed as a nonsurgical intervention for the frozen shoulder. Accuracy and pain during the procedure can be regarded as difficulties in performing this procedure. Ultrasonography (USG) guided injection and suprascapular nerve block can improve the accuracy and can decrease pain during the hydrodilation procedure. We present the step-by-step method for performing USG-guided injections for suprascapular nerve block and hydrodilation.

The role of suprascapular nerve block in hydrodilatation for frozen shoulder.

INTRODUCTION: Frozen shoulder is a debilitating problem that requires comprehensive diagnosis and management. Patients usually recover, but the possibility of not reobtaining a full range of motion exists. Thus, early shoulder exercises are necessary to achieve their full range of motion. This study aims to understand the effects of suprascapular nerve block (SSNB) augmentation at the spinoglenoid notch in hydrodilatation to treat frozen shoulder to facilitate early shoulder exercises. METHODS: The current study retrospectively observed 31 patients, including 40-60-year-old patients diagnosed and treated with primary frozen shoulder. The participants were divided into groups A (hydrodilatation) and B (hydrodilatation and the augmentation of an SSNB). Shoulder function and pain scores were assessed before, during, and after the intervention (at months 1 and 6). RESULTS: The result of this study shows that suprascapular nerve block plays a role in decreasing pain in intraintervention (0.69 vs. 5.73; p < 0.05), month 1 of follow-up (3.44 vs. 6.40; p < 0.05), but not significant on month 6 of group A and B after intervention (5.88 vs. 7.20; p > 0.05). Better delta functional scores were noted in the therapy group during month 1 of the follow-up (delta American shoulder and elbow surgeons [ASES]: 19.29 vs. 34.40, p < 0.05; delta disabilities of the arm, shoulder, and hand [DASH]: 17.88 vs. 38.15, p < 0.05). The difference in functional score on month 6 between both groups was not significantly different (delta ASES: 31.97 vs. 30.31, p > 0.05; delta DASH: 36.63 vs. 38.92, p > 0.05). DISCUSSION: One rationale for using an SSNB augmentation at spinoglenoid notch in hydrodilatation for treating frozen shoulder was to obtain pain relief immediately to facilitate early manual exercise. SSNB has positive effects on short-term evaluation of shoulder pain and function after glenohumeral hydrodilatation, but not in the long term.

Soft tissue reconstruction on the very late presenting neglected acromioclavicular dislocation Rockwood type IV. A case report.

INTRODUCTION AND IMPORTANCE: Acromioclavicular (AC) joint dislocation Rockwood type IV is a rare condition characterized by the posterior displacement of the distal clavicle and soft tissue damage. The rate of soft tissue healing markedly decreases as time from injury increases. In this case report, we had a very late presenting neglected AC joint dislocation Rockwood type IV successfully treated by AC and coracoclavicular (CC) reconstruction. CASE PRESENTATION: A 24-year-old female presented with pain around her right shoulder since a motorcycle accident four years prior to current presentation. She was diagnosed with a posterior AC joint dislocation and suggested undergoing surgery, but she refused and chose to seek an alternative treatment. The patient felt pain chronically and could not elevate her shoulder, and she decided to come to our hospital. We performed a physical and radiograph examination that showed an AC joint dislocation Rockwood type IV. The management, suggested to the patient, was AC and CC soft tissue reconstruction. CLINICAL DISCUSSION: The advantages of using this procedure were to restore effective anatomy and avoid bone-to-bone contact between the clavicle and acromion. The disadvantages were increased cost and needed to be evaluated for long-term results. We considered the idea of maintaining AC joint reduction by biologic soft tissue healing of the graft and augmentation fixation to replace the CC ligaments. We could not rely on biological soft tissues healing themselves due to the chronicity. CONCLUSION: AC and CC reconstruction can be an option of treatment in neglected AC joint dislocation Rockwood type IV with excellent clinical and radiographic results.

High-Grade Bursal Side Rotator-Cuff Repair: A Surgical Outcome Review.

PURPOSE: We aimed to evaluate surgical outcomes of high-grade bursal rotator cuff-tear repairs. METHODS: This systematic review was performed in May 2020 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed. Inclusion criteria were English-language studies reporting the results of pain improvement, functional outcome scores, and radiographic examinations after repair of bursal side partial rotator-cuff tears at any time point in patients of any age and with all levels of evidence. Exclusion criteria were articles not in English, in vitro or animal studies, epidemiological studies, and such article types as technical notes or narrative reviews. RESULTS: Of 58 articles, five were included in this study, of which three and two had level III and IV evidence, respectively, four were comparative studies, and one was a case series. Visual analogue scales were used in four of the five studies, all showing improvement in pain assessment from 5.87 preoperatively to 1.02 postoperatively. All five studies showed significant improvement on each functional outcome score at the final follow-up. The retear rate for all studies was 10.97% (27 of 246). CONCLUSION: High-grade bursal side partial-thickness rotator cuff-tear repair gave satisfactory results in terms of pain scores, range of motion, and functional outcomes. The retear rate was still considerably high (10.9%), necessitating better understanding of the basic science, such as molecular mechanisms during adaptation, to improve the surgical technique.

Open Reduction on very late-presenting unreduced posterior elbow dislocation: Still promising treatment option.

BACKGROUND: Neglected dislocation of the elbow is associated with instability, pain, and limitation of elbow function. In developing countries, neglected dislocations of the elbow are quite common, and most patients initially go to local bonesetters, which only aggravates the problem. PRESENTATION OF CASE: Two patients with a history of unreduced posterior elbow dislocation for more than 1 year and were treated by a traditional bonesetter were included in this case study. The first case was a 65-year-old female with a history of injury around her right elbow around 12 months before admission. The patient underwent open reduction with triceps lengthening and immobilization with plaster of paris for 3 weeks. The second case was a 53-year-old male with a history of injury caused by a fall on an outstretched hand around 18 months before admission. The patient underwent arthrolysis followed by triceps lengthening, internal fixation with transarticular k-wire, and immobilization with elbow slab for 3 weeks. DISCUSSION: To optimize treatment goals and patient function, various surgical approaches have been described for treating chronic elbow dislocations. The benefit of the VY triceps lengthening is to simplify the reduction procedure, especially in the elbow dislocations with greater chronicity. The downside of the VY lengthening is possible triceps weakness, delayed physiotherapy, and increased postsurgical pain. On the basis of this study, open reduction should remain a treatment option for patients regardless of age and chronicity of injury. CONCLUSION: Operative treatment of late-presenting, unreduced elbow dislocation is effective in restoring the joint to a painless, stable, and functional limb.

Traumatic Inferior Glenohumeral Dislocation Associated With Rotator Cuff Avulsion Fracture: Arthroscopic-Assisted Fixation: A Technical Note.

Traumatic inferior glenohumeral dislocation with rotator cuff avulsion fracture rarely occurs and may cause chronic pain and diminished shoulder function. Several treatment options are available for this injury, such as open reduction internal fixation and arthroscopic-assisted reduction internal fixation. This technique describes a step-by-step technique to manage traumatic inferior glenohumeral dislocation with rotator cuff avulsion fracture using the simultaneous closed reduction procedure for traumatic inferior glenohumeral dislocation and the arthroscopic procedure with suture bridge technique for the treatment of rotator cuff avulsion fracture.

Autologous tendon graft for non-union distal clavicle fracture in a patient with chronic kidney disease.

BACKGROUND: Fracture of distal-end accounts for 20% of all clavicle fracture. In the situation of impaired bone healing environment such as chronic kidney disease (CKD), nonunion rates after surgery might increase. In the case where bone healing is unexpected, biological healing with tendon graft could be an alternative method to maintain bone reduction. PRESENTATION OF CASE: A 62-year old male with a history of end-stage CKD presented to the hospital with pain, wound, and deformity on the right shoulder. The patient have had surgery in the past 4 months and resulted in a non-union fracture of the distal third right clavicle. The patient underwent implant removal and continued with coracoclavicular ligament reconstruction with autologous tendon grafts of semitendinosus tendon and mini-plate augmentation. DISCUSSION: The Distal clavicle has a high rate of delayed and nonunion even without the presence of comorbidity. A compromised bone quality frequently leads to failed osteosynthesis in patients with end-stage renal failure. In the advanced stages of kidney disease, problems with a renal clearance of phosphate and low 1ɑ-hydroxylase levels resulting in increased serum phosphate levels and low serum calcium levels. Given these circumstances, we considered the idea to maintain fracture reduction by biologic soft tissue healing of the graft to replace the coracoclavicular ligaments as we can not rely on normal bone strength and healing capacity. CONCLUSION: In the situation where bone healing is unexpected, biological healing with tendon graft may be necessary. The use of autologous tendon graft and mini-plate suture augmentation could help to maintain bone reduction in such environment.

Modified Eden-Lange procedure for iatrogenic lateral scapular winging.

INTRODUCTION: Lateral winging scapula is rare and generated by the trapezius paralysis. It is most likely iatrogenic from procedures involving the posterior cervical triangle. The modified Eden-Lange procedures one of the options by restoring the major actions of a flaccid trapezius. This case report aims to evaluate the outcomes. CASE REPORT: A 34-year-old female came with right lateral scapular winging after radical neck tumor dissection and miss diagnosed by another hospital and underwent shoulder surgery. We performed a physical examination and showed lateral winging scapula. The best management therapy for this patient used modified Eden-Lange procedure. DISCUSSION: Conservative treatments for Lateral scapular winging caused by spinal accessory nerve injury might be successful in early 20 months. However, our patient was injured 26 months before surgery which made Eden-Lange Procedures was the best choice for the patient. Modifications to this procedure allowed her to achieve excellent results. CONCLUSION: Correction of the lateral scapular winging by modified Eden-Lange procedure combined with physical therapy for patient's trapezius palsy to gain adequate stability for daily activities.

Bipolar fracture dislocation of clavicle: A report of osteosynthesis and early soft tissue reconstruction.

INTRODUCTION: Bipolar dislocation of the clavicle, also called bifocal or pan-articular dislocation or floating clavicle, is an uncommon traumatic injury. The injury of this case is also concomitant with distal third clavicle and coracoid fracture. This article aimed to report the experience of performing osteosynthesis and early soft tissue reconstruction on these injuries. CASE REPORT: We reported a case of bipolar clavicle fracture-dislocation in concomitant with coracoid fracture in a man, aged 32 years old, successfully treated 24days after accident by fixation of both fractures and early simultaneous reconstruction of sternoclavicular- acromioclavicular-coracoclavicular joints. DISCUSSION: These injuries are rare and capable of causing many complications if they are treated improperly. It is compulsory to carefully assess any fractured clavicle along its whole length, both clinically and radiologically. Various options, from non-operative to operative, have been reported to manage such of these cases. Early bony fixation and soft tissue reconstruction can correct the alignment of clavicle and recover the function of sterno-clavicular and acromio-clavicular- joints promptly. CONCLUSION: Fracture osteosynthesis and early soft tissue reconstruction can be regarded as an option treatment for bipolar fracture-dislocation of the clavicle to facilitate prompt treatment and early rehabilitation.

Effect of Lead Nanoparticles Inhalation on Bone Calcium Sensing Receptor, Hydroxyapatite Crystal and Receptor Activator of Nuclear Factor-Kappa B in Rats.

This study aimed to investigate whether Pb nanoparticle exposure affects the bone calcium sensing receptor (CaSR), hydroxyapatite crystal, and receptor activator of nuclear factor-kappa B (RANK) in rats exposed to subchronic and chronic inhalation. Thirty two rats were randomly divided into eight groups. One group is a non-exposed group. While three groups were exposed to nanoparticles Pb at the following doses 6.25; 12.5; or 25 mg/m3 an hour daily for 28 days. Another three groups were exposed to nanoparticles Pb at following doses 6.25; 12.5; and 25 mg/m3 one hour daily for 6 months. The expression of trabecular CaSR was significantly decreased at the all doses subchronic exposure compared to the control group (P < 0.05). The CaSR expression significantly decreased in second and third doses subchronic exposure groups compared to the control groups (P < 0.05). With subchronic exposure, the crystal size was increased in second dose group and decreased in lowest and highest doses compared to the control (untreated) group. The crystal size and c-axis were decreased in all dose chronic exposures compared to the control (untreated) group. The expression of cortical RANK was significantly lower at the two lowest dose chronic exposures compared to the control group (P < 0.05). In conclusion, Pb nanoparticle inhibit hydroxyapatite crystal growth at least a part via down regulation of CaSR and RANK.