Improved outcomes of older patients with acute and displaced proximal humerus fractures treated with window bone ingrowth fracture-specific stem reverse shoulder arthroplasty.

BACKGROUND: The optimal treatment of displaced proximal humerus fractures (PHFs) in the older people population remains controversial. Reverse shoulder arthroplasty (RSA) is a popular surgical treatment option that provides improved and reproducible results. However, the relevance of fracture-specific stem designs for RSA to improve tuberosity consolidation and shoulder function remains debatable. METHODS: This study included all patients 70 years or older with acute and displaced PHFs primarily treated with RSA at a single institution in Portugal, between January 2010 and December 2019 who participated in a minimum follow-up of 2 years. RESULTS: A total of 112 patients (15 men and 97 women) with a median clinical follow-up of 52 months were included. The mean age at the time of fracture was 78.6 years. All fractures were classified as Neer types 3 and 4 (n = 50 and n = 62, respectively). A window bone ingrowth fracture-specific stem was used for 86 patients, and a conventional humeral stem was used for 26 patients. Regarding the tuberosity fixation technique, 76 tuberosities were attached using technique A (according to Boileau's principles), 36 tuberosities were attached using technique B (not following Boileau's principles) and 11cases were classified as technique C (if fixation was not possible). The overall survival rate during the 2-year follow-up was 88.2%; however, this decreased to 79% at 5 years. Only three patients had complications (two infections and one dislocation) requiring revision surgery. In the multivariable analysis, the tuberosity fixation technique (P = 0.012) and tuberosity anatomical consolidation (P < 0.001) were associated with improved Constant scores (median Constant Score 62.67 (technique A), 55.32 (technique B), 49.70 (technique C). Fracture-specific humeral implants (P = 0.051), the tuberosity fixation technique (P = 0.041), tuberosity anatomical consolidation (P < 0.001), and dementia influenced the achievement of functional mobility (P = 0.014). Tuberosity anatomic consolidation was positively associated with bone ingrowth fracture-specific humeral implants (P < 0.01) and a strong tuberosity fixation technique (P < 0.01). CONCLUSION: RSA is used for complex and displaced fractures of the proximal humerus in older patients. Dementia was negatively correlated with functional outcomes. A window bone ingrowth fracture-specific stem combined with strong tuberosity fixation can yield better clinical and radiological results. LEVEL OF EVIDENCE: Level II; prospective comparative study; treatment study.

Type IX Superior Labrum Anterior and Posterior Lesion in a Professional Football Player: A Rare Pattern of Shoulder Instability in a Non-throwing Athlete.

Anterior shoulder instability is the most frequent type of glenohumeral instability, especially among young athletes. Superior labral anterior-posterior (SLAP) injuries involve the superior glenoid labrum where the long head of the biceps tendon (LHBT) inserts. There is still some debate regarding the pathogenesis, clinical presentation, and treatment of these lesions. We report a clinical case of an 18-year-old male professional football player with a rare type IX SLAP lesion. Given the recurrence of instability after prior nonoperative management, surgical treatment was seen as the best option, and a pan-labral arthroscopic repair suture anchor fixation was performed. Three months after undergoing a personalized postoperative rehabilitation program, he was able to return to full sport with the same competitive level, and no recurrent instability or other symptoms were reported throughout the 18-month follow-up period.

Improved Clinical Outcomes After Lateralized Reverse Shoulder Arthroplasty: A Systematic Review.

BACKGROUND: Lateralized reverse shoulder arthroplasty (RSA) has emerged as an attempt to improve on some of the drawbacks of conventional RSA, such as glenoid notching and decrease in ROM. Although this new design is being used in clinical practice, the evidence is mostly limited to case series and has not been systematically reviewed. QUESTIONS/PURPOSES: (1) How much did patient-reported outcome measures (PROMs) and ROM improve among patients who receive a lateralized RSA implant? (2) What proportion of shoulders experience complications, revision surgery, or scapular notching? METHODS: The PubMed and EMBASE databases were searched from database inception to January 31, 2020. We included clinical studies that reported the PROMs and/or ROM of patients with insufficient rotator cuffs undergoing RSA with a lateralized implant. All other types of studies and those including patients with fractures, instability or escape, infection, rheumatologic disease, neurologic disease, or revision surgeries as an indication for RSA were excluded. PROMs and ROM were collected and are reported as mean values and ranges. Complications, revision surgery, and scapular notching are presented as proportions. The percentage of the mean change relative to the minimum clinically important difference (MCID) was calculated using the anchor-based value for each outcome. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. The initial search yielded 678 studies; 61 full-text articles were analyzed according to our eligibility criteria. After a detailed analysis, we included nine studies that evaluated 1670 patients (68% of whom [1130] were women) with a mean age of 71.8 ± 0.6 years. The mean follow-up period was 41.1 ± 5.6 months. The mean MINORS score was 12 ± 4. RESULTS: Active ROM improved for forward flexion (mean change 47° to 82°; MCID 12°), abduction (mean change 43° to 80°; MCID 7°), external rotation (mean change 8° to 39°; MCID 3°), and internal rotation (mean change -2 to 1 points). PROM scores also improved, including the American Shoulder and Elbow Surgeons score (mean change 20 to 50; MCID 20.9 points), Constant score (mean change 28 to 40; MCID 5.7 points), Simple Shoulder Test score (mean change 3 to 7; MCID 2.4 points), and VAS score (mean change -1.8 to -4.9; MCID -1.6 points). The proportion of shoulders with complications ranged from 0% (0 of 44) to 21% (30 of 140), and the proportion of shoulders with scapular notching ranged from 0% (0 of 76) to 29% (41 of 140). The proportion of patients undergoing revision ranged from 0% (0 of 44) to 13% (10 of 76) at short-term follow-up. CONCLUSION: Lateralized RSA is a reasonable alternative to medialized implants for patients with rotator cuff insufficiency because it might reduce the likelihood of scapular notching without apparently compromising PROMs or ROM. More studies are required to determine whether there is a direct correlation between the amount of lateralization and PROMs or ROM.

Proximal and mid-thigh fascia lata graft constructs used for arthroscopic superior capsule reconstruction show equivalent biomechanical properties: an in vitro human cadaver study.

BACKGROUND: The proximal fascia lata (FL) graft construct used for arthroscopic superior capsule reconstruction (ASCR) is openly harvested, whereas the mid-thigh FL graft construct is minimally invasively harvested. The purpose of the current study was to compare the biomechanical properties of proximal thigh and mid-thigh-harvested FL graft constructs used for ASCR. The hypothesis was that, despite the different morphological characteristics of the proximal thigh and mid-thigh FL graft constructs used for ASCR, their biomechanical properties would not significantly differ. This information may assist orthopedic surgeons in the choice of the harvest location, technique, and type of graft construct for ASCR. METHODS: Forty FL specimens, 20 proximal thigh and 20 mid-thigh, were harvested from the lateral thighs of 10 fresh human cadavers (6 male, 4 female; average age, 58.60 ± 17.20 years). The thickness of each 2-layered proximal thigh and 6-layered mid-thigh FL graft construct was measured. Each construct was mechanically tested in the longitudinal direction, and the stiffness and Young's modulus were computed. Data were compared by Welch's independent t-test and analysis of variance, and statistical significance was set at P < .05. RESULTS: The average thickness of the proximal thigh FL graft construct (7.17 ± 1.97 mm) was significantly higher than that of the mid-thigh (5.54 ± 1.37 mm) [F (1,32) = 7.333, P = .011]. The average Young's modulus of the proximal thigh and mid-thigh graft constructs was 32.85 ± 19.54 MPa (range, 7.94 - 75.14 MPa; 95% confidence interval [CI], 23.71 - 42.99) and 44.02 ± 31.29 MPa (range, 12.53 -120.33 MPa; 95% CI, 29.38 - 58.66), respectively. The average stiffness of the proximal thigh and mid-thigh graft constructs was 488.96 ± 267.80 N/mm (range, 152.96 - 1086.49 N/mm; 95% CI, 363.63 - 614.30) and 562.39 ± 294.76 N/mm (range, 77.46 - 1229.68 N/mm; 95% CI, 424.44 - 700.34), respectively. There was no significant difference in the average Young's modulus or stiffness between the proximal thigh and mid-thigh graft constructs (P = .185 and P = .415, respectively). CONCLUSION: Despite the different morphological characteristics of the proximal thigh and mid-thigh FL graft constructs used for ASCR, their Young's modulus and stiffness did not significantly differ.

Clinical Importance of Graft Integrity in Arthroscopic Superior Capsular Reconstruction Using a Minimally Invasively Harvested Midthigh Fascia Lata Autograft: 3-Year Clinical and Magnetic Resonance Imaging Outcomes.

BACKGROUND: The clinical importance of graft type and integrity in arthroscopic superior capsular reconstruction (ASCR) remains controversial. PURPOSE: To assess 3-year clinical and magnetic resonance imaging (MRI) outcomes of ASCR using a minimally invasively harvested fascia lata autograft (FLA) for irreparable rotator cuff tears (IRCTs) and to determine the clinical importance of graft integrity and whether the results change from year 2 to 3. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 22 consecutive patients who underwent ASCR with a minimally invasively harvested FLA were enrolled in a prospective single-arm study. At 3 years, the patients answered a satisfaction questionnaire and underwent a clinical examination and MRI. The MRI scans were independently reviewed by 3 raters to determine the graft integrity, acromiohumeral interval, supraspinatus atrophy, and fatty degeneration of the rotator cuff muscles. Reliability statistics were calculated, and the outcomes were compared across subgroups of patients with and without complete graft tears. RESULTS: Overall, 21 patients (95.5%) answered the questionnaire, 20/21 (95.2%) were satisfied, 4/20 (20.0%) reported donor site pain, and 19 patients (86.4%) underwent examinations. From preoperatively to 3 years, the mean improvement was 73.68° in elevation (95% CI, 47.59°-99.77°), 89.21° in abduction (95% CI, 66.56°-111.86°), 24.74° in external rotation (95% CI, 4.72°-34.75°), 3.00 in internal rotation (95% CI, 2.36-3.64), 2.61 kg in abduction strength (95% CI, 1.76-3.45 kg), 50.79 on the Constant score (CS; 95% CI, 41.99-59.58), 7.47 on the Simple Shoulder Test (SST; 95% CI, 5.19-9.75), and 36.05% on the subjective shoulder value (SSV; 95% CI, 23.19%-48.92%), which were all significant (P < .05). From 2 to 3 years, the mean improvement in abduction was 20.26° (95% CI, 5.44°-35.09°), which was significant (P = .010). At 3 years, the raters perfectly agreed (kappa = 1; P = .000013) that 4 patients (21.1%) had complete graft tears; this subgroup of patients had decreased external rotation strength at 90° of abduction (1.77 ± 0.17 vs 4.45 ± 2.55 kg, respectively; P = .027) and increased grades of infraspinatus (3.50 ± 0.58 vs 2.20 ± 1.01, respectively; P = .030) and teres minor fatty degeneration (3.25 ± 0.96 vs 1.53 ± 0.64, respectively; P = .005) compared with those without a complete graft tear, but the mean CS, SST, and SSV scores did not differ from those of the overall group (69.50 ± 5.20 vs 69.63 ± 18.25; 9.00 ± 2.31 vs 9.74 ± 4.73; and 72.50 ± 15.00 vs 71.58 ± 26.70, respectively). CONCLUSION: The 3-year clinical outcomes of ASCR using a minimally invasively harvested FLA for IRCTs were good, despite donor site morbidity. Active abduction improved significantly from 2 to 3 years. Complete graft tears were correlated with significantly decreased external rotation strength at 90° of shoulder abduction and increased grades of infraspinatus and teres minor fatty degeneration. REGISTRATION: NCT03663036 (ClinicalTrials.gov identifier).

Cryptococcus magnus Periprosthetic Shoulder Infection: A Case Report.

CASE: We present a 68-year-old diabetic man with a periprosthetic shoulder infection (PSI) by Cryptococcus magnus. The fungus was identified 4 weeks after a revision surgery for a chronic bacterial PSI. Treatment was successful with a 2-week course of intravenous liposomal amphotericin B (5 mg/kg) followed by 6 weeks of fluconazole (200 mg/d). CONCLUSION: To the best of our knowledge, only 2 periprosthetic infections due to Cryptococcus neoformans have been previously reported. This is the first report of cryptococcal involvement of a prosthetic shoulder, and the first identified osteoarticular infection ever by C. magnus.

Fascia Lata Autograft Versus Human Dermal Allograft in Arthroscopic Superior Capsular Reconstruction for Irreparable Rotator Cuff Tears: A Systematic Review of Clinical Outcomes.

PURPOSE: To determine the clinical outcomes of arthroscopic superior capsular reconstruction (ASCR) using either fascia lata autograft or human dermal allograft for irreparable rotator cuff tears (IRCTs). METHODS: A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines by searching the MEDLINE, Embase, and Cochrane Library databases through January 31, 2019. The inclusion criteria were as follows: 5 or more consecutive patients who underwent ASCR for IRCTs; clinical outcome measures reported at a minimum follow-up of 12 months; and magnetic resonance imaging assessment at a minimum follow-up of 6 months. The methodologic quality was evaluated using the Methodological Index for Non-randomized Studies (MINORS). A narrative synthesis of data was performed. Mean outcome improvements were compared with minimal clinically important differences. RESULTS: We identified 7 eligible studies that included 344 shoulders in 338 patients who underwent ASCR for IRCTs (all Level IV studies). The mean MINORS score was 12.3 ± 1.60. Of the 7 studies, 5 had a high risk of bias (MINORS score ≤12): 2 studies using only fascia lata autograft and 3 studies using only human dermal allograft. The mean age of patients ranged from 59.4 to 66.9 years. The mean follow-up time ranged from 12 to 48 months. All studies reported statistically significant and clinically important mean improvements in active elevation (range of means, 28°-56°), the Constant score (range of means, 12-47.1 points), or the American Shoulder and Elbow Surgeons score (range of means, 29.3-56 points). In total, 218 shoulders underwent postoperative magnetic resonance imaging. The graft tear rate reported in studies using fascia lata autograft (181 shoulders) ranged from 5% to 32%, whereas the values reported in studies using human dermal allograft (37 shoulders) ranged from 20% to 75%. CONCLUSIONS: ASCR using either fascia lata autograft or human dermal allograft leads to significant and clinically important improvements in clinical outcomes in IRCT patients at 12 months or later. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Is Bony Morphology and Morphometry Associated With Degenerative Full-Thickness Rotator Cuff Tears? A Systematic Review and Meta-analysis.

PURPOSE: To scope the scientific literature and analyze the influence of bony risk factors for degenerative full-thickness primary rotator cuff tear. METHODS: A systematic review of databases PubMed, Scopus, EMBASE, and Cochrane Library was performed up to June 30, 2018. Meta-analysis was performed with mean difference (MD) or risk ratio for degenerative full-thickness rotator cuff injury, and when there were ≥3 studies for the considered potential risk factor. Methodologic quality was assessed using the Newcastle-Ottawa scale. RESULTS: We analyzed 34 studies comprising 5,916 shoulders (3,369 shoulders with rotator cuff tear and 2,546 controls) and identified 19 potential risk factors for degenerative full-thickness rotator cuff tears. There was moderate evidence that a higher critical shoulder angle (MD = 4.41, 95% confidence interval [CI] 3.43 to 5.39), higher acromion index (MD = 0.06, 95% CI 0.04 to 0.09), and lower lateral acromion angles (MD = -7.11, 95% CI -8.32 to -5.90) were associated with degenerative full-thickness rotator cuff tears compared with controls. Moderate evidence showed that a type III acromion significantly increases the risk for full-thickness degenerative rotator cuff tear (risk ratio = 2.26, 95% CI 1.38 to 3.70). CONCLUSION: There is moderate evidence that larger critical shoulder angle, higher acromion index, lower lateral acromion angles, and a type III acromion are significantly associated with degenerative full-thickness rotator cuff tears. Other potential risk factors identified showed insufficient evidence. LEVEL OF EVIDENCE: Level IV, systematic review of level II to IV studies.

Meniscus Subluxation Retensioning: "Autotransplant".

Knee osteoarthritis (OA) is a common condition in the older population and is characterized by several articular dysfunctions with consequent anatomic abnormalities including osteochondral degenerative changes and meniscal extrusion. Meniscal damage with extrusion is one of the strongest identified risk factors for the development and progression of knee OA and represents an important factor in the long-term health of the joint. Meniscal extrusion can alter normal knee biomechanics and dramatically inhibit meniscal function. We present a surgical technique for the treatment of early knee OA in association with an extruded meniscus to restore the meniscal anatomic position and preserve its native physiological function related to cartilage preservation. Meniscal retensioning, or a "meniscal autotransplant," can increase meniscal coverage in the compromised compartment, prevent cartilage degeneration, decrease subchondral bone exposure, and restore the compartmental space and, consequently, can relieve patients' symptoms related to early OA.

Anatomic and non-anatomic reconstruction improves post-operative outcomes in chronic acromio-clavicular instability: a systematic review.

PURPOSE: To systematize the surgical outcomes of anatomic and non-anatomic reconstruction in patients with chronic acromio-clavicular joint (ACJ) instability and determine which technique is superior. METHODS: This review was conducted according to the PRISMA guidelines. PubMed and Cochrane Library databases were searched up to April 30th, 2018 for original articles that assessed the outcomes of one or more surgical techniques of anatomic and non-anatomic reconstruction in patients with chronic ACJ instability. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. Pre-to-post meta-analysis was performed for both anatomic and non-anatomic reconstructions. RESULTS: Twenty-eight studies were included comprising 799 patients (mean age of 36.6 years old and 84% males) with a mean follow-up of 34.6 months (range 13 to 74). Surgical techniques included anatomic (tendinous or synthetic grafts/constructs) and non-anatomic reconstruction (Weaver-Dunn or Modified Weaver-Dunn, conjoined tendon transfer, or temporary hook plate). There were significant pre-to-post improvements on the constant score with an average improvement ranging from 11.1 to 50.7 (p < 0.01). Average failure rate was 7.6% (7.5% for anatomic and 8.5% for non-anatomic reconstruction). Non-comparative studies had a mean MINORS score of 9 points (out of 16) and comparative studies 17 (out of 24) with excellent interrater agreement (k = 0.910). CONCLUSION: Both anatomic and non-anatomic ACJ reconstructions provide significant post-operative improvements, but definitive conclusions on optimal technique remain elusive. Notwithstanding, comparative studies support the use of anatomic ACJ reconstruction which should be preferably used. However, until superiority is demonstrated by robust studies, surgeons should supplement their decision-making with experience and patient preference. LEVEL OF EVIDENCE: IV.

Mesenchymal Stem Cell Secretome Improves Tendon Cell Viability In Vitro and Tendon-Bone Healing In Vivo When a Tissue Engineering Strategy Is Used in a Rat Model of Chronic Massive Rotator Cuff Tear.

BACKGROUND: Massive rotator cuff tears (MRCTs) represent a major clinical concern, especially when degeneration and chronicity are involved, which highly compromise healing capacity. PURPOSE: To study the effect of the secretome of mesenchymal stem cells (MSCs) on tendon cells (TCs) followed by the combination of these activated TCs with an electrospun keratin-based scaffold to develop a tissue engineering strategy to improve tendon-bone interface (TBi) healing in a chronic MRCT rat model. STUDY DESIGN: Controlled laboratory study. METHODS: Human TCs (hTCs) cultured with the human MSCs (hMSCs) secretome (as conditioned media [CM]) were combined with keratin electrospun scaffolds and further implanted in a chronic MRCT rat model. Wistar-Han rats (N = 15) were randomly assigned to 1 of 3 groups: untreated lesion (MRCT group, n = 5), lesion treated with a scaffold only (scaffold-only group, n = 5), and lesion treated with a scaffold seeded with hTCs preconditioned with hMSCs-CM (STC_hMSC_CM group, n = 5). After sacrifice, 16 weeks after surgery, the rotator cuff TBi was harvested for histological analysis and biomechanical testing. RESULTS: The hMSCs secretome increased hTCs viability and density in vitro. In vivo, a significant improvement of the tendon maturing score was observed in the STC_hMSC_CM group (mean ± standard error of the mean, 15.6 ± 1.08) compared with the MRCT group (11.0 ± 1.38; P < .05). Biomechanical tests revealed a significant increase in the total elongation to rupture (STC_hMSC_CM, 11.99 ± 3.30 mm; scaffold-only, 9.89 ± 3.47 mm; MRCT, 5.86 ± 3.16 mm; P < .05) as well as a lower stiffness (STC_hMSC_CM, 6.25 ± 1.74 N/mm; scaffold-only, 6.72 ± 1.28 N/mm; MRCT, 11.54 ± 2.99 N/mm; P < .01). CONCLUSION: The results demonstrated that hMSCs-CM increased hTCs viability and density in vitro. Clear benefits also were observed when these primed cells were integrated into a tissue engineering strategy with an electrospun keratin scaffold, as evidenced by improved histological and biomechanical properties for the STC_hMSC_CM group compared with the MRCT group. CLINICAL RELEVANCE: This work supports further investigation into the use of MSC secretome for priming TCs toward a more differentiated phenotype, and it promotes the tissue engineering strategy as a promising modality to help improve treatment outcomes for chronic MRCTs.

Reverse shoulder arthroplasty for irreparable massive rotator cuff tears: a systematic review with meta-analysis and meta-regression.

BACKGROUND: Massive rotator cuff tears (MRCTs) are very large tears that are often associated with an uncertain prognosis. Indeed, some MRCTs even without osteoarthritis are considered irreparable, and nonanatomic solutions are needed to improve the patient's symptoms. Reverse shoulder arthroplasty (RSA) is an option that can provide a more predictable pain relief and recovery of function. Nonetheless, outcomes after RSA for irreparable MRCTs have not been well defined. The aim of this study was to quantitatively aggregate the findings associated with the use of RSA in this subset of patients and analyze the effect on patient functional status and pain. METHODS: A comprehensive search was performed until October 2015 using MEDLINE, Scopus, Cochrane Database of Systematic Reviews, and Central Register of Controlled Trials databases. Studies that assessed the outcomes of RSA in patients with irreparable MRCT without osteoarthritis (with at least 2 years of follow-up) were included. If the results of MRCT without osteoarthritis were not possible to subgroup, the study was excluded. Methodologic quality was assessed using the Coleman Methodology Score. RESULTS: Included were 6 studies (266 shoulders) with a follow-up ranging from 24 to 61.4 months. The mean Coleman Methodology Score was 58.2 ± 11.8 points. There was an overall improvement from preoperative to postoperative assessments of the clinical score (Cohen d = 1.35, P < .001), forward flexion (d = 0.50, P = .009), external rotation (d = 0.40, P < .001), function (d = 1.04, P < .001), and pain (d = -0.89, P < .001). CONCLUSION: Patients with irreparable MRCT without presence of osteoarthritis have a high likelihood of achieving a painless shoulder and functional improvements after RSA.

Mesenchymal Stem Cell Secretome: A Potential Tool for the Prevention of Muscle Degenerative Changes Associated With Chronic Rotator Cuff Tears.

BACKGROUND: Massive rotator cuff tears (MRCTs) are usually chronic lesions with pronounced degenerative changes, where advanced fatty degeneration and atrophy can make the tear irreparable. Human mesenchymal stem cells (hMSCs) secrete a range of growth factors and vesicular systems, known as secretome, that mediates regenerative processes in tissues undergoing degeneration. PURPOSE: To study the effect of hMSC secretome on muscular degenerative changes and shoulder function on a rat MRCT model. STUDY DESIGN: Controlled laboratory study. METHODS: A bilateral 2-tendon (supraspinatus and infraspinatus) section was performed to create an MRCT in a rat model. Forty-four Wistar-Han rats were randomly assigned to 6 groups: control group (sham surgery), lesion control group (MRCT), and 4 treated-lesion groups according to the site and periodicity of hMSC secretome injection: single local injection, multiple local injections, single systemic injection, and multiple systemic injections. Forelimb function was analyzed with the staircase test. Atrophy and fatty degeneration of the muscle were evaluated at 8 and 16 weeks after injury. A proteomic analysis was conducted to identify the molecules present in the hMSC secretome that can be associated with muscular degeneration prevention. RESULTS: When untreated for 8 weeks, the MRCT rats exhibited a significantly higher fat content (0.73% ± 0.19%) compared with rats treated with a single local injection (0.21% ± 0.04%; P < .01) or multiple systemic injections (0.25% ± 0.10%; P < .05) of hMSC secretome. At 16 weeks after injury, a protective effect of the secretome in the multiple systemic injections (0.62% ± 0.14%; P < .001), single local injection (0.76% ± 0.17%; P < .001), and multiple local injections (1.35% ± 0.21%; P < .05) was observed when compared with the untreated MRCT group (2.51% ± 0.42%). Regarding muscle atrophy, 8 weeks after injury, only the single local injection group (0.0993% ± 0.0036%) presented a significantly higher muscle mass than that of the untreated MRCT group (0.0794% ± 0.0047%; P < .05). Finally, the proteomic analysis revealed the presence of important proteins with muscle regeneration, namely, pigment epithelium-derived factor and follistatin. CONCLUSION: The study data suggest that hMSC secretome effectively decreases the fatty degeneration and atrophy of the rotator cuff muscles. CLINICAL RELEVANCE: We describe a new approach for decreasing the characteristic muscle degeneration associated with chronic rotator cuff tears. This strategy is particularly important for patients whose tendon healing after later surgical repair could be compromised by the progressing degenerative changes. In addition, both precise intramuscular local injection and multiple systemic secretome injections have been shown to be promising delivery forms for preventing muscle degeneration.

Modified Elmslie-Trillat Procedure for Distal Realignment of Patella Tendon.

Patellofemoral dysfunction, due to either a patellofemoral malalignment or patellar instability, is a complex and debilitating condition that significantly decreases the knee function. Conservative management may yield significant clinical outcomes; however, when morphologic anomalies are identified, the surgical approach should be employed. Hence, several surgical procedures have been described in the scientific literature aiming the correction of underlying extensor mechanism malalignments. Still, the rate of complications is higher than desirable. The described technique is based on the principles of transferring the tibial tubercle medially as described in the Elmslie-Trillat technique. However, a curvilinear horizontal cut is made prior to the vertical cut, which raises a thick osseous fragment and allows the formation of a gutter when the osseous fragment is moved medially. Whereas the horizontal gutter provides stability to the bone fragment, the thicker dimension of the osseous fragment and retention of the distal attachment significantly enhances the osteotomy union. Hence, adequate pain relief and stability with very low postoperative morbidity could be achieved. The purpose of this surgical note is to describe a modification to the Elmslie-Trillat technique to treat patellofemoral dysfunctions, achieving a higher osseous stability and decreased postoperative morbidity.

Augmentation of Patellar Tendon Repair With Autologous Semitendinosus Graft-Porto Technique.

Patellar tendon ruptures can lead to significant functional deficiency of the extensor mechanism of the knee. These injuries, because of their inherent nature and associated complications, may require a complex treatment and remains a challenge for orthopaedic surgeons. Current surgical techniques present significant complications, including patellar fracture, damage to patellar articular cartilage, and abnormal patella height. This note describes a surgical technique to provide an additional reinforcement to the patellar tendon repair with a semitendinous autograft, without the necessity to perform any transosseous tunnels at the patella bone. First, the patellar tendon is repaired with an end-to-end technique and the semitendinous tendon is harvested. A transosseous tunnel at the tibial tubercle is drilled and 2 rents are made, both medial and lateral to the retinaculum at the level of the intermedial segment of the patella close to the patellar margin. The graft is passed through the tunnel and rents in a U-shaped form. The graft is sutured along the length of the patellar tendon on both margins in tension at 30° of knee flexion. Fluoroscopy imaging is performed to assess the patella height. This technique provides a significant augmentation of patellar tendon, avoiding the potential patella bone tunnel complications.

Surgical Adjustment of the Guide Pin to Perform a Correct Tibial Tunnel in Anatomical Anterior Cruciate Ligament Single-Bundle Reconstruction.

Anatomical positioning of the graft in anterior cruciate ligament reconstruction is important to restore normal knee kinematics and prevent early joint degeneration. Inadequate position of a first attempt to place the guide pin within the center of the tibial footprint may occur. Therefore, its adjustment is important to achieve the anatomical positioning of the graft within the tibial footprint. When the guide pin exits eccentrically in an inadequate position, it is possible to correct it to the center of the footprint. A small tunnel with a 4.5-mm reamer is made and the guide pin is shifted to the center of the footprint. The center of the tunnel can be corrected until 50% and in all direction in relation to the initial drilled tunnel, without additional associated morbidity. Once the correct position of the center is achieved, the guide pin is fixed in the femoral notch roof to guarantee the accurate correction of the axis, without toggling of the guide pin inside the tunnel and metal dusting. The final tunnel is then drilled with the same size of the graft. With this technique it is possible to adjust an eccentrically misplaced guide pin to the center of the footprint without additional morbidity.

Assessment of rotatory laxity in anterior cruciate ligament-deficient knees using magnetic resonance imaging with Porto-knee testing device.

PURPOSE: Objective evaluation of both antero-posterior translation and rotatory laxity of the knee remains a target to be accomplished. This is true for both preoperative planning and postoperative assessment of different ACL reconstruction emerging techniques. The ideal measurement tool should be simple, accurate and reproducible, while enabling to assess both ''anatomy'' and ''function'' during the same examination. The purpose of this study is to evaluate the clinical effectiveness of a new in-house developed testing device, the so-called Porto-knee testing device (PKTD). The PKTD is aimed to be used on the evaluation of both antero-posterior and rotatory laxity of the knee during MRI exams. METHODS: Between 2008 and 2010, 33 patients with ACLdeficient knees were enrolled for the purpose of this study. All patients were evaluated in the office and under anesthesia with Lachman test, lateral pivot-shift test and anterior drawer test. All cases were studied preoperatively with KT-1000 and MRI with PKTD, and examinations performed by independent observers blinded for clinical evaluation. During MRI, we have used a PKTD that applies antero-posterior translation and permits free tibial rotation through a standardized pressure (46.7 kPa) in the proximal posterior region of the leg. Measurements were taken for both knees and comparing side-to-side. Five patients with partial ruptures were excluded from the group of 33. RESULTS: For the 28 remaining patients, 3 women and 25 men, with mean age of 33.4 ± 9.4 years, 13 left and 15 right knees were tested. No significant correlation was noticed for Lachman test and PKTD results (n.s.). Pivot-shift had a strong positive correlation with the difference in anterior translation registered in lateral and medial tibia plateaus of injured knees (cor. coefficient = 0.80; p\0.05), and with the difference in this parameter as compared to side-to-side (cor. coefficient = 0.83; p\0.05). Considering the KT-1000 difference between injured and healthy knees, a very strong positive correlation was found for side-to-side difference in medial (cor. coefficient = 0.73; p\0.05) and lateral (cor. coefficient = 0.5; p\0.05) tibial plateau displacement using PKTD. CONCLUSION: The PKTD proved to be a reliable tool in assessment of antero-posterior translation (comparing with KT-1000) and rotatory laxity (compared with lateral pivotshift under anesthesia) of the ACL-deficient knee during MRI examination. LEVEL OF EVIDENCE: Therapeutic studies, Level IV.

Osteochondral transplantation using autografts from the upper tibio-fibular joint for the treatment of knee cartilage lesions.

PURPOSE: Treatment of large cartilage lesions of the knee in weight-bearing areas is still a controversy and challenging topic. Autologous osteochondral mosaicplasty has proven to be a valid option for treatment but donor site morbidity with most frequently used autografts remains a source of concern. This study aims to assess clinical results and safety profile of autologous osteochondral graft from the upper tibio-fibular joint applied to reconstruct symptomatic osteochondral lesions of the knee. METHODS: Thirty-one patients (22 men and 9 women) with grade 4 cartilage lesions in the knee were operated by mosaicplasty technique using autologous osteochondral graft from the upper tibio-fibular joint, between 1998 and 2006. Clinical assessment included visual analog scale (VAS) for pain and Lysholm score. All patients were evaluated by MRI pre- and post-operatively regarding joint congruency as good, fair (inferior to 1 mm incongruence), and poor (incongruence higher than 1 mm registered in any frame). Donor zone status was evaluated according to specific protocol considering upper tibio-fibular joint instability, pain, neurological complications, lateral collateral ligament insufficiency, or ankle complaints. RESULTS: Mean age at surgery was 30.1 years (SD 12.2). In respect to lesion sites, 22 were located in weight-bearing area of medial femoral condyle, 7 in lateral femoral condyle, 1 in trochlea, and 1 in patella. Mean follow-up was 110.1 months (SD 23.2). Mean area of lesion was 3.3 cm2 (SD 1.7), and a variable number of cylinders were used, mean 2.5 (SD 1.3). Mean VAS score improved from 47.1 (SD 10.1) to 20.0 (SD 11.5); p = 0.00. Similarly, mean Lysholm score increased from 45.7 (SD 4.5) to 85.3 (SD 7.0); p = 0.00. The level of patient satisfaction was evaluated, and 28 patients declared to be satisfied/very satisfied and would do surgery again, while 3 declared as unsatisfied with the procedure and would not submit to surgery again. These three patients had lower clinical scores and kept complaints related to the original problem but unrelated to donor zone. MRI score significantly improved at 18-24 months comparing with pre-operative (p = 0.004). No radiographic or clinical complications related to donor zone with implication in activity were registered. CONCLUSIONS: This work corroborates that mosaicplasty technique using autologous osteochondral graft from the upper tibio-fibular joint is effective to treat osteochondral defects in the knee joint. No relevant complications related to donor zone were registered. LEVEL OF EVIDENCE: Case series, Level IV.

Reverse shoulder arthroplasty: does reduced medialisation improve radiological and clinical results?

The purpose of this retrospective study was to assess the effect of the reduced medialisation of the Arrow reverse shoulder prosthesis on short-term clinical and radiological results. The clinical and radiological results of 47 Delta III reverse prostheses and 49 Arrow reverse prostheses were retrospectively compared at a minimum of twelve months follow-up. There was a significant increase (p < 1.10(-4)) in range of motion from the preoperative range in the two groups except for internal rotation in the Delta III group (p = 0.1). Radiological analysis on anteroposterior view in neutral position showed greater lateralisation (p < 0.001) with the Arrow prosthesis. Scapular notching was noted in 32 patients with a Delta III prosthesis, and in no instance with an Arrow prosthesis. Complication rates were 14.9% for the Delta group and 10.2% for the Arrow group. The design features of the Arrow prosthesis--reduced medialisation of the center of rotation with lateralisation of the humerus--were found to be associated with slight improvement in range of motion and absence of scapular notching.