The effect of cellular nuclear function alteration on the pathogenesis of shoulder adhesive capsulitis: an immunohistochemical study on lamin A/C expression.

BACKGROUND: The network of intermediate filament proteins underlying the inner nuclear membrane forms the nuclear lamina. Lamins have been associated with important cellular functions: DNA replication, chromatin organization, differentiation of the cell, apoptosis and in maintenance of nuclear structure. Little is known regarding the etiopathogenesis of adhesive capsulitis (AC); recently, a dysregulating fibrotic response starting from a subpopulation has been described within the fibroblast compartment, which suddenly turns on an activated phenotype. Considering the key role of A-type lamins in the regulation of cellular stability and function, our aim was to compare the lamin A/C expression between patients with AC and healthy controls. MATERIALS AND METHODS: A case-control study was performed between January 2020 and December 2021. Tissue samples excised from the rotator interval were analysed for lamin A/C expression by immunohistochemistry. Patients with AC were arbitrarily distinguished according to the severity of shoulder flexion limitation: ≥ 90° and < 90°. Controls were represented by samples obtained by normal rotator interval excised from patients submitted to shoulder surgery. The intensity of staining was graded, and an H-score was assigned. Statistical analysis was performed (Chi-square analysis; significance was set at alpha = 0.05). RESULTS: We enrolled 26 patients [12 male and 14 female, mean age (SD): 52.3 (6.08)] and 15 controls [6 male and 9 female, mean age (SD): 57.1 (5.3)]. The expression of lamin A/C was found to be significantly lower in the fibroblasts of patients with adhesive capsulitis when compared with controls (intensity of staining: p: 0.005; H-score: 0.034); no differences were found regarding the synoviocytes (p: > 0.05). Considering only patients with AC, lamin A/C intensity staining was found to be significantly higher in samples where acute inflammatory infiltrate was detected (p: 0.004). No significant changes in levels of lamin A/C expression were documented between the mild and severe adhesive capsulitis severity groups. CONCLUSIONS: Our study demonstrated that the activity of lamin A/C in maintaining nuclear structural integrity and cell viability is decreased in patients with adhesive capsulitis. The phase of the pathogenetic process (freezing and early frozen) is the key factor for cell functionality. On the contrary, the clinical severity of adhesive capsulitis plays a marginal role in nuclear stability. LEVEL OF EVIDENCE: III.

Arthroscopic capsular release is more effective in pain relief than conservative treatment in patients with frozen shoulder.

BACKGROUND: Frozen shoulder is a common medical condition, but the ideal therapeutic method is yet to be determined. Our aim was to analyze the pain-relieving effect of different treatment options used for the management of this disease. METHODS: Medical records of 59 patients (22 male, 37 female, average age: 55.5 years ±9.9) with early stage primary frozen shoulder were evaluated, their demographic data, physical examination, concomitant diseases and treatment specific data were registered. Life quality and the level of pain were assessed using the Oxford Shoulder Score (OSS) and Numeric Rating Scale (NRS). Different treatment modalities and their effect on pain relief were recorded. Any existing correlation between life quality, pain and demographic data, concomitant diseases or the therapeutic method used was investigated. RESULTS: The level of pain measured on NRS improved from 7.9 ± 1.6 to 1.9 ± 2.2. The most effective therapeutic method in terms of pain relief was surgery, followed by physiotherapy and intraarticular steroid injection (NRS score after treatment: 2 - p < 0.0001; 3.3 - p < 0.0001; 4.9 - p < 0.0001, respectively). Non-steroidal anti-inflammatory drugs (NSAIDs) did not reduce pain significantly. OSS improved from 24 to 43.6 and was not affected by the investigated variables, time to recovery was not influenced by the demographic data, the type of treatment or concomitant diseases. CONCLUSIONS: Arthroscopic capsular release, physiotherapy and intraarticular steroid injection outperformed physical therapy and NSAID treatment in terms of pain relief. Despite of slight but persistent post-therapeutic pain found in half of the cases, treatment was considered satisfactory by the patients. Nor patient specific neither therapy specific data had a significant effect on the course of the disease.

High satisfaction rate and range of motion can be expected in frozen shoulder after awake manipulation with brachial plexus block.

BACKGROUND: Adhesive capsulitis (AC) is a disease of the glenohumeral joint that is characterized by pain and both passive and active global stiffness with a slow and insidious onset. The disease can occur spontaneously (primary AC) or it can be secondary to other comorbidities, surgery, or trauma, such as fracture or dislocation. Multiple treatment approaches have been suggested: intra-articular steroid injection, physical therapy, manipulation under total anesthesia, and arthroscopic or open surgery. Shoulder manipulation under anesthesia is usually proposed to patients that suffer from severe AC and have already undergone several nonoperative treatments without benefit. Different techniques have been proposed. This study presents our manipulation technique and the clinical results we achieved after shoulder mobilization under brachial plexus block in patients with phase III primary AC. MATERIALS AND METHODS: A retrospective cohort study was performed on a sample of 110 patients with phase III AC who were treated with this manipulation and followed up for 1 year. Patients underwent two assessments-before the procedure (T0) and 4 months after it (T1)-based on the Numerical Rating Scale, Simple Shoulder Test, and joint range of motion to assess shoulder pain, function, and joint articulation, respectively. Furthermore, the patients had to express their degree of satisfaction with the procedure and the results achieved. RESULTS: Positive and statistically significant results were recorded in terms of pain reduction (ΔNPRS = - 5.4; p < 0.01) and improved functionality (Simple Shoulder Test Δ = 5; p < 0.01). Passive range of motion was statistically significantly increased for each movement at T1. Large increases were observed in extrarotation range of motion (ROM): R1 (Δ = 77.5°) and R2 (Δ = 70°), whereas little improvements were observed in intrarotation ROM. Patients achieved satisfying functional and articular recovery in all cases. Complications that needed further treatment occurred in three cases: a brachial plexus injury, a glenoid flake fracture, and persistent pain and stiffness. CONCLUSIONS: In this study, we proposed a standardized method of manipulation under brachial plexus block for patients affected by phase III adhesive capsulitis. The technique was applied among a large cohort of patients, who reported a high satisfaction rate and range-of-motion recovery after 4 months. This could represent an alternative treatment to surgery that has a shorter timeline and does not require patient hospitalization. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Establishing the Minimal Clinically Important Difference and Patient Acceptable Symptom State Thresholds Following Arthroscopic Capsular Release for the Treatment of Idiopathic Shoulder Adhesive Capsulitis.

PURPOSE: To determine the minimal clinically important difference (MCID) and the patient acceptable symptom state (PASS) threshold for the visual analog scale (VAS), Constant, Single Assessment Numeric Evaluation (SANE), and American Shoulder and Elbow Surgeons (ASES) scores following arthroscopic capsular release for the treatment of idiopathic shoulder adhesive capsulitis. METHODS: A retrospective review of prospective collected data was performed in patients undergoing arthroscopic capsular release for the treatment of idiopathic adhesive capsulitis at a single institution from January 2018 through January 2019. Patient-reported outcome measures were collected preoperatively and 6 months' postoperatively. Delta was defined as the change between preoperative and 6 months' postoperative scores. Distribution-based and anchored-based (response to a satisfaction question at 1 year) approaches were used to estimate MCIDs and PASS, respectively. The optimal cut-off point where sensitivity and specificity were maximized (Youden index) and the percentage of patients achieving those thresholds were also calculated. RESULTS: Overall, a total of 100 patients without diabetes who underwent arthroscopic capsular release and completed baseline and 6-month patient-reported outcome measures were included. The distribution-based MCID for VAS, Constant, SANE, and ASES were calculated to be 1.1, 10.1, 9.3, and 8.2, respectively. The rate of patients who achieved MCID thresholds was 98% for VAS, 96% for Constant, 98% for SANE, and 99% for ASES. The PASS threshold values for VAS, Constant, and ASES were ≤2, ≥70, ≥80, and ≥80, respectively. The rate of patients who achieved PASS thresholds was 84% for VAS, 84% for Constant, 89% for SANE, and 78% for ASES. CONCLUSIONS: In patients without diabetes and idiopathic adhesive capsulitis, high rates of MCID and PASS thresholds can be achieved with arthroscopic anteroinferior capsular release LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Shoulder Adhesive Capsulitis Prior to Total Knee Arthroplasty is Associated With Increased Rates of Postoperative Stiffness Requiring Manipulation Under Anesthesia and Arthroscopic Lysis of Adhesions.

BACKGROUND: Arthrofibrosis following total knee arthroplasty (TKA) and adhesive capsulitis (AC) of the shoulder develop via a similar pathologic process. The purpose of this study was to examine the relationship between these two conditions. METHODS: This was a retrospective cohort study using a large nationwide claims database. Patients who had a history of shoulder AC prior to TKA were compared to TKA patients who did not have AC history comparing rates of postoperative stiffness, manipulation under anesthesia (MUA), arthroscopic lysis of adhesions (LOAs), and revision arthroplasty at postoperative timepoints (3 months, 6 months, 1 year, and 2 years). RESULTS: Within 3 months, 6 months, 1 year, and 2 years of their TKAs, patients who had a history of AC prior to TKA were significantly more likely to experience stiffness (OR [odds ratio] = 1.29, 1.28, 1.32, and 1.36, respectively) and LOAs (OR = 6.78, 3.65, 2.99, and 2.81, respectively). They also showed increased risk of MUA within 6 months, 1 year, and 2 years (OR = 1.15, 1.15, and 1.16, respectively) of their TKAs. Patients having a preoperative diagnosis of AC did not have an increased risk of undergoing revision surgery 1 year or 2 years after their TKAs (P > .05). CONCLUSIONS: Patients diagnosed with AC prior to TKA experience higher rates of postoperative stiffness, resulting in additional interventions such as MUA and LOAs. These findings identify a particularly high-risk patient population that may benefit from additional interventions prior to and following TKA. LEVEL OF EVIDENCE: This is a level III prognostic study.

Functional results of Circumferential Capsular Release in adhesive shoulder capsulitis. Comparative study of patients over and under fifty years of age.

INTRODUCTION: The aim of our study is to evaluate the functional and mobility outcomes in patients who have undergone arthroscopic circumferential arthrolysis of the shoulder and to find out if there are differences in the results in relation to the patient's age. MATERIALS AND METHODS: This is a retrospective case series of patients with idiopathic adhesive capsulitis treated by arthroscopic 360º circumferential capsulotomy in lateral position and followed for a minimum of 2 years. Range of motion (ROM), functional outcomes using the Constant Score (CS), health-related quality of life outcomes with the EuroQol Five Dimensions tool (EQ-5D), pain using the Visual Analogue Scale (VAS). RESULTS: A total of 26 shoulders were included, 10 men (41.7%) and 14 women (58.3%), with 2 patients being bilateral. The mean age was 48.64 ± 7.5 years, and the mean follow-up was 50.2 months. Postoperative ROM improved significantly compared to preoperative ROM (p < 0.05). Shoulder forward flexion improved by 38.6° (95%CI 22.3-54.9, p < 0.01), abduction by 35.2° (95%CI 17.6-52.8, p < 0.01) and external rotation by 21.9° (95%CI 12.8-30.9, p < 0.01 p < 0.01). Median internal rotation improved from buttock to T12 (p < 0.01). The mean improvement in CS was 54.3 ± 24.4 points (p < 0.01). The EQ-5D and VAS scores at the end of follow-up were 0.73 ± 0.23 and 2.73 ± 2.55, respectively. There were no statistical differences between young patients and patients aged 50 years or older in ROM or functional results. CONCLUSIONS: Patient age did not affect outcomes significantly, with patients older than 50 years showing similar results to younger patients.

Clinical Efficacy of Small Needle Knife Therapy on Stage I-II Frozen Shoulder.

Frozen shoulder is a kind of aseptic inflammatory disease of the shoulder caused by strain, trauma, and other reasons, resulting in shoulder joint pain and limited function. The protocol presented here demonstrates the operation of a small needle knife in treating frozen shoulders, including patient management, material preparation, positioning, operation, and postoperative care. The purpose of this protocol is to relieve the pain and functional limitations and improve the living ability of patients with frozen shoulders. In our study, 76 stage I-II frozen shoulder patients who met the inclusion criteria were randomly divided into a control group and a treatment group (n=38). Patients in the control group received functional exercise, while the treatment group received small needle knife therapy with functional exercise. The visual analogue scores (VAS), the Constant and Murley scores (CMS), and the thickness of the coracohumeral ligament (CHL) under ultrasound were evaluated. After small needle knife therapy, the VAS score was significantly lower in the treatment group (5.11 ± 0.89) than in the control group (5.49 ± 0.65; t=-2.065, p<0.05); the CMS score was significantly higher in the treatment group (64.72 ± 4.78) than in the control group (60.97 ± 6.00; t=2.947, p<0.05); the CHL thickness was significantly decreased in the treatment group (2.38 ± 0.36) than in the control group (2.57 ± 0.42; t=-2.117, p<0.05). These results indicate that the small needle knife significantly relieved the pain symptoms, improved the shoulder function, reduced the CHL thickness, and improved the quality of life and, therefore, had significant therapeutic efficacy in stage I-II frozen shoulder patients.

Long-Term Outcomes of Ultrasound-Guided Hydrodistension for Adhesive Capsulitis: A Prospective Observational Study.

Ultrasound-guided hydrodistention has been established as an effective minimally invasive treatment option for glenohumeral joint adhesive capsulitis (AC). Nonetheless, the long-term outcomes of the procedure have not yet been established. A total of 202 patients with AC were prospectively recruited and followed up for a total of 2 years. Pain and functionality were assessed with the use of the visual analogue scale (VAS) and the disabilities of the arm, shoulder, and hand (DASH) score, respectively, at the beginning and the end of the follow-up period. The relapse of AC over the 2-year period and the effect of diabetes were also evaluated in the treatment cohort. The Mann-Whitney U test was used to compare mean scores at the two time points, and Cox survival analysis and χ2 test were used to assess the effect of diabetes on AC relapse. VAS and DASH scores were significantly lower at 2 years compared with the beginning of the follow-up period (p < 0.001). Diabetes was diagnosed in 38/202 patients (18.8%) and was found to be significantly associated with recurrence of the disease (p < 0.001). In conclusion, in this observational study, we have demonstrated that ultrasound-guided hydrodistention is linked to excellent long-term outcomes for the treatment of AC, which are significantly worse in patients with diabetes.

Arthroscopic capsular release for frozen shoulder: when etiology matters.

PURPOSE: No therapeutic intervention is universally accepted for frozen shoulder, and the most effective management to restore motion and diminish pain has yet to be defined. The aim of this study was to investigate functional and psychological outcomes in patients who underwent arthroscopic capsular release for a frozen shoulder. METHODS: A retrospective study with prospective data collection was conducted with 78 patients suffering from frozen shoulder resistance to conservative treatment. Considering the etiology, there were 36 (46.2%) idiopathic, 31 (39.7%) postoperative, and 11 (14.1%) posttraumatic cases. Preoperatively, each patient was evaluated with the range of motion (ROM) assessment and the Constant-Murley score (CMS). At follow-up, the 4-point subjective satisfaction scale (SSS), the ROM assessment, the SF-12 questionnaire, the numerical rating scale (NRS) for the subjective assessment of pain, the CMS and the Hospital Anxiety and Depression Scale (HADS) were assessed. RESULTS: After a mean follow-up of 54.2 ± 22.3 months, ROM and CMS showed a statistically significant improvement between pre- and postoperative values (all p < 0.001). Before surgery, the mean CMS was 36.9% that of sex- and age-matched healthy individuals, and all patients showed a CMS lower than the normative data. At the final follow-up visit, the mean CMS was 99.9% that of sex- and age-matched healthy individuals, and 49 (62.8%) patients showed a CMS equal to or higher than the normative data. The mean increase in the CMS was 56.1 ± 8.3 points. The mean SSS, HADS-A, HADS-D, and NRS were 3.7 ± 0.5, 2.5 ± 1.6, 2.2 ± 1.3, and 2.2 ± 1.0, respectively. All patients returned to their previous level of work and sports activity after 2 and 2.5 months, respectively. The multivariate analysis showed the association between a higher postoperative CMS and the idiopathic etiology of a frozen shoulder (p = 0.004, ß = 3.971). No intraoperative complications occurred. Postoperatively, four patients (5.1%) were treated with intra-articular steroid injections to manage residual symptoms. One patient (1.3%) with a postoperative frozen shoulder showed persistent symptoms and underwent a new successful arthroscopic capsular release. CONCLUSION: High patient satisfaction and statistically significant ROM and CMS recovery can be achieved after arthroscopic capsular release to manage frozen shoulder. Better functional outcomes are expected when the etiology is idiopathic. Results can help surgeons identify the patients who will most benefit from surgery and should be discussed with the patient. LEVEL OF EVIDENCE: III.

Percutaneous Ultrasound-Guided Tenotomy of the Iliotibial Band for Trochanteric Pain Syndrome: A Longitudinal Observational Study With One-Year Durability Results.

BACKGROUND: Upper lateral hip pain is a common complaint in adults and is referred to as greater trochanteric pain syndrome (GTPS) and is more prevalent among older women. This is a debilitating condition that could result in lower physical activity and quality of life, and higher unemployment rate. GTPS is a clinical diagnosis, and many cases improve with conservative medical management (CMM). However, there is still a gap between patients not responding to CMM and those who are not good surgical candidates. Thus, percutaneous ultrasound tenotomy (PUT) may be a valuable treatment option to limit this gap. OBJECTIVES: Demonstration of the one-year pain and functional outcomes, including sit to stand. SETTING: Academic tertiary care medical center. METHODS: Forty-eight consecutive patients with refractory trochanteric pain due to iliotibial band (ITB) tendinopathy. Fifty-six hips were treated; 8 patients underwent bilateral procedures. Electronic medical record review of consecutive patients who underwent ITB TENEX® was performed at Montefiore Medical Center from December 2019 to December 2021. Institutional guidelines recommended TENEX® for greater trochanteric pain refractory to conservative treatment and ultrasound (US) confirmed ITB tendinopathy (hypoechogenicity or thickened tendon > 6 mm). Pain level, as well as sit-to-stand, side-lying, and walking tolerance levels were evaluated at baseline preprocedure visit and one-year visit. Follow-up was performed by independent practitioners and corroborated by chart review. RESULTS: Numeric Rating Scale (NRS-11) improved by 4 points across all patients. Seventy percent of patients endorsed pain relief at one-year visit. Median preprocedure NRS-11 was 9. The reported median NRS-11at one year was 5 (Wilcoxon signed rank NRS-11 demonstrated a Z score of -6.042 with P < 0.001). One-year analysis among all patients revealed 57%, 78%, and 66% improvement in side-lying, sit-to-stand, and walking tolerance levels, respectively. LIMITATIONS: We believe that our results must be confirmed with a randomized control trial with a control arm and more patients included. CONCLUSIONS: PUT of the ITB using the TENEX® tissue remodeling device could be a safe and effective treatment for ITB tendinopathy-associated GTPS.

Relationship between the Arthroscopic Findings and Pathology of Greater Trochanteric Pain Syndrome.

In recent publications on greater trochanteric pain syndrome (GTPS), the pathology receiving the most attention has been gluteus medius muscle tendinous injury, and surgical techniques such as gluteus medius tendon repair and their outcomes for GTPS have been reported. In our department-related facilities, arthroscopic surgeries are routinely performed for the patients with recalcitrant GTPS. A total of 51 patients were diagnosed with GTPS. Surgical treatment was carried out 22 patients (24 joints; 4 males and 18 females; mean age at surgery of 52.0 years). Arthroscopic findings confirmed bursitis in all 24 joints. In all cases, debridement of the greater trochanter bursa provided rapid relief of greater trochanter pain. The Numerical Rating Scale showed significant improvement, from the preoperative mean of 7.8 (range, 6-10) to the postoperative day 7 mean of 1.6 (range, 0-3). The modified Harris Hip Score was significantly improved from the preoperative mean of 65.5 (range, 52.5-78.3) to the final follow-up (average 2.9 months) mean of 96.0 (range, 85.2-100). Fascial damage of the gluteus medius muscle was observed in 21 joints while only 2 patients had a gluteus medius tendinous injury. Greater trochanteric bursitis and fascia or muscle-fiber injury of the gluteus medius muscle are the most common pathologies in patients with lateral hip pain.

Clinical Outcomes After Concomitant Hip Arthroscopy and Iliotibial Band Lengthening With Trochanteric Bursectomy Compared to a Matched Cohort.

PURPOSE: This study sought to determine the clinical outcomes of patients that underwent hip arthroscopy for femoroacetabular impingement (FAI) and concomitant arthroscopic iliotibial (IT) band lengthening with trochan- teric bursectomy (TB group) as well as a matched cohort of patients undergoing hip arthroscopy for isolated FAI symptoms (NTB group) from baseline to a minimum of 2-year follow-up. METHODS: Patients who were diagnosed with FAI and symptomatic trochanteric bursitis and who failed con- servative measures and underwent hip arthroscopy and arthroscopic IT band lengthening with trochanteric bur- sectomy were identified. These patients were matched by age, sex, and body mass index (BMI) to a group of patients who underwent surgery for FAI without trochanteric bur- sitis symptoms. Patients were separated into two groups: iliotibial band lengthening with trochanteric bursectomy (TB) and non-trochanteric bursectomy (NTB). The patient reported outcomes (PROs) recorded were the modified Har- ris Hip Score (mHHS) and Non-Arthritic Hips Score (NAHS), which were obtained with a minimum of 2-years follow-up. RESULTS: Each cohort was composed of 22 patients. The TB cohort was composed of 19 females (86%) with a re- ported mean age of 49.3 ± 11.6 years. The NTB cohort was composed of 19 females (86%) with a reported mean age of 49.0 ± 11.7 years. Both cohorts showed significant improve- ment from baseline in the mHHS and NAHS. There was no significant difference in the mHHS and NAHS between the two groups. There was no significant difference between TB and NTB groups with respect to achieving minimal clinically important difference (MCID), [19 (86%) vs. 20 (91%), p > 0.99] or patient acceptable symptom state (PASS), [13 (59%) vs. 14 (64%), p = 0.76]. CONCLUSIONS: There was no difference in PROs of patients with FAI and trochanteric bursitis who underwent hip ar- throscopy with concomitant arthroscopic IT band lengthen- ing with trochanteric bursectomy compared to patients with isolated FAI who underwent hip arthroscopy.

Arthroscopic Excision of Pigmented Villonodular Synovitis of the Trochanteric Bursa.

Trochanteric bursitis is a common disorder affecting middle-aged adults and usually presents with lateral-based hip pain and swelling. It usually responds to conservative measures, including adductor stretching, abductor strengthening, and select injections of corticosteroid or platelet-rich plasma. For refractory cases, excision, open or arthroscopic, is usually recommended. We observed a 55-year-old woman who had lateral hip pain and longstanding swelling consistent with refractory trochanteric bursitis. Her persistent symptoms, coupled with atypical findings on imaging, prompted an arthroscopic evaluation. Arthroscopic examination of the peritrochanteric space revealed a fulminant bursal inflammation that pierced through the iliotibial band. The bursal inflammation was excised arthroscopically and biopsy of the tissue revealed a diagnosis of pigmented villonodular synovitis (PVNS). The patient had an uneventful recovery and had a full resolution of symptoms with no recurrence noted at 3-year follow-up. This is the first reported case of arthroscopic excision of PVNS of the trochanteric bursa. Given that it may mimic trochanteric bursitis, it is important for clinicians to be aware of the possibility of this progressive condition for appropriate clinical intervention. [Orthopedics. 2023;46(6):e381-e383.].

Septic inflammation of the bicipital bursa: clinical, imaging, and surgical findings in nine horses.

OBJECTIVE: To describe the etiologies, clinicopathologic findings, diagnostic modalities employed, treatments, and outcome associated with cases of septic bicipital bursitis. ANIMALS: 9 horses. CLINICAL PRESENTATION AND PROCEDURES: Medical records of horses diagnosed with septic bicipital bursitis between 2000 and 2021 were reviewed. Horses were included if synoviocentesis of the bicipital bursa revealed a total nucleated cell count of ≥ 20,000 cells/µL with a neutrophil proportion of ≥ 80%, a total protein concentration of ≥ 4.0 g/dL, and/or the presence of bacteria on cytology, or positive culture of the synovial fluid. Information retrieved from medical records included signalment, history, clinicopathologic variables, diagnostic imaging findings, treatment, and outcome. RESULTS: Trauma was the most common inciting cause (n = 6). Synoviocentesis using ultrasonographic guidance was performed in all cases and showed alterations consistent with septic synovitis. Radiography identified pathology in 5 horses, whereas ultrasonography identified pathology in all horses. Treatment consisted of bursoscopy (n = 6) of the bicipital bursa of which 1 was performed under standing sedation, through-and-through needle lavage (3), bursotomy (2), or medical management alone (2). Five (55.6%) horses survived to discharge. Long-term follow-up was available for 3 horses and all were serviceably sound, with 2 in training as pleasure horses and 1 case continuing retirement. CLINICAL RELEVANCE: Ultrasonography was the most informative imaging modality and paramount in obtaining synovial fluid samples for definitive diagnosis of septic bicipital bursitis. Bursoscopy performed under standing sedation is a feasible treatment option. Horses treated for bicipital septic bursitis have a fair prognosis for survival and may return to some level of athletic performance.

Retrospective Comparison of Isolated Haglund's Deformity Surgery Versus Combined With Gastrocnemius Recession.

Insertional Achilles tendonitis is a common pathology treated by foot and ankle surgeons that may require surgical intervention. Literature has shown good outcomes following detachment and reattachment of the Achilles for removal of the exostosis. However, there is minimal literature showing the impact of adding a gastrocnemius recession to the Haglund's resection. The goal of the present study was to retrospectively review the outcomes of an isolated Haglund's resection versus a Haglund's resection combined with a gastrocnemius recession. A retrospective chart review of 54 operative extremities was performed: 29 with isolated Haglund's resection and 25 with a Strayer gastrocnemius recession. We found similar decreases in pain between the 2 groups, 6.1 to 1.5 and 6.8 to 1.8 in the isolated Haglund's and Strayer's group, respectively. We found decreased postoperative Achilles rupture and reoperation rates in the Strayer group but this did not reach statistical significance. We found a statistically significant decreased rate of wound healing complications in the Strayer group, 4% in the Strayer group and 24% in the isolated procedure. In conclusion, adding a Strayer to a Haglund's resection was found to have a statistically significant decrease in wound complications. We recommend future randomized controlled studies to compare the use of a Strayer procedure on postoperative complications.

A Comparison Between Preoperative and Intraoperative Measurement and Classification of the Size of Rotator Cuff Tears / Uma comparação entre a medição e a classificação da ruptura do manguito rotador no pré-operatório e no intraoperatório

Abstract Purpose To evaluate the agreement in tear size obtained through preoperative imaging and intraoperative measurement, and to determine the accuracy of preoper-ative imaging in the classification of tear size and identification of tears in each rotator cuff tendon. Methods Data from 44 patients recruited to a randomized controlled trial were reviewed retrospectively. Size and location of the rotator cuff tears were confirmed by either ultrasound or magnetic resonance imaging scans preoperatively and evaluated during surgery. A t-test and Bland and Altman plot were used to determine the agreement between the preoperative and intraoperative measurements. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for tear size and involvement of the rotator cuff tendon. Results There was good agreement in terms of the measurements (91%) and classification (89%) of the tear size preoperatively and during surgery. When classifying tear size, the sensitivity and PPV were high for medium-sized tears (100%) and lower for large tears (75%), reflecting that all medium-sized tears but not all large tears were identified preoperatively. For the preoperative identification of the tears, the sensitivity and PPV were highest for the supraspinatus (84%), with progressively lower sensitivities and PPV for the infraspinatus (57%), subscapularis (17%) and teres minor (0%). Conclusions Through preoperative imaging, the measurement or classification of the tear size can be accurately performed. Where there is disagreement, it is unclear whether the tear size is either underestimated on the scan or overestimated during surgery. The high sensitivity demonstrates that a supraspinatus tear is usually detected by scan. The lower sensitivities for the infraspinatus and subscapularis indicate that the identification of tears in these tendons is less accurate.

Resumo Objetivo Avaliar a concordância no tamanho de ruptura obtido por imagem préoperatória e por medição intraoperatória, e determinar a precisão da imagem préoperatória na classificação do tamanho da ruptura e na identificação de rupturas em cada tendão do manguito rotador. Métodos Os dados de 44 pacientes recrutados para um ensaio controlado randomizado foram revisados retrospectivamente. O tamanho e a localização do manguito rotador foram confirmados por ultrassom ou ressonância magnética préoperatórios, e avaliados durante a cirurgia. Um teste t e o gráfico de Bland e Altman foram usados para determinar a concordância entre as medições pré-operatória e intraoperatória. Sensibilidade, especificidade, valor preditivo positivo (VPP) e valor preditivo negativo (VPN) foram calculados para o tamanho do rompimento e o envolvimento do tendão do manguito rotador. Resultados Houve boa concordância para medidas de tamanho da ruptura (91%) e classificação (89%) pré-operatória e durante a cirurgia. Ao classificar o tamanho da ruptura, a sensibilidade e o VPP foram elevados para rupturas de tamanho médio (100%), e menor para rupturas grandes (75%), o que indica que todas as rupturas de tamanho médio, mas nem todas as grandes, foram identificadas pré-operatoriamente. Para a identificação de rupturas, a sensibilidade pré-operatória e o VPP foram maiores para o supraespinal (84%), com sensibilidade e VPP progressivamente menores para o infraespinal (57%), o subescapular (17%), e o redondo menor (0%). Conclusões Por meio da imagem pré-operatória, pode-se medir ou classificar com precisão o tamanho da ruptura. Quando há discordância, não está claro se o tamanho da ruptura é subestimado no exame ou superestimado durante a cirurgia. A alta sensibilidade demonstra que uma ruptura do supraespinal é geralmente detectada por escaneamento. As sensibilidades mais baixas para o infraespinal e o subescapular indicam que a identificação de rupturas nestes tendões é menos precisa.

Intraoperative Greater Trochanteric Fractures During Revision Total Hip Arthroplasty May Not Always Need Surgical Fixation.

Many fixation techniques have been described to manage intraoperative greater trochanteric (GT) fractures during revision total hip arthroplasty (rTHA), but complications such as broken hardware and bursitis are common. The purpose of this study was to determine whether surgical fixation of an intraoperative GT fracture resulted in improved outcomes in rTHA. We reviewed a consecutive series of 1442 rTHA patients at our institution from 2008 to 2019. We identified all patients with an intraoperative GT fracture and noted whether the fracture was fixed surgically or left without fixation. Demographics, comorbidities, complications, radiographic union, and dislocations were compared between the groups. Of the 44 (3%) intra-operative GT fractures identified, 23 (52%) underwent fixation, most commonly with claw plates (8 patients) and cables (10 patients). There were no differences in the rates of radiographic union (86% vs 100%, P=.100), dislocations (4% vs 10%, P=.599), or re-revision (10% vs 13%, P=1.000) between the groups. Patients undergoing fixation had a higher rate of bursitis postoperatively, but it was not significant with the numbers available (35% vs 10%, P=.072). Our cohort of GT fractures at a large revision referral institution represents the largest reported series of GT fractures during rTHA. Surgical fixation in rTHA did not show improved outcomes in terms of dislocation, re-revision, and radiographic union compared with those fractures that were not fixed. There was a trend toward increased postoperative bursitis in the group undergoing surgical fixation. Further research is needed on this topic, as the number of rTHAs continues to increase. [Orthopedics. 2023;46(5):297-302.].

Defining Haglund's deformity radiographically by incorporating the biomechanics of ankle motion.

BACKGROUND: Haglund's deformity is clinically defined by the presence of retrocalcaneal tenderness, with previous radiographic parameters relying on calcaneal anatomic parameters that did not considering the influence of ankle motion on posterior calcaneal-Achilles impingement METHODS: Standing foot radiographs from 55 patients with clinically defined Haglund's deformity were compared to 50 control patients using previously described measurements and 2 new angular measurements based on the linkage between ankle rotation and posterior calcaneal-Achilles impingement. The ability of each measure to distinguish between Haglund's and control patients was assessed. RESULTS: The combination of the angles to account for both increased calcaneal tubercle height and increased posterior calcaneal prominence could distinguish between the two patient groups (p = .018, Area under the curve = 63.2%). None of the previously published radiographic criteria were different between the two patient groups. CONCLUSIONS: The proposed radiographic criteria were more predictive than previous criteria that did not address the role of ankle motion.

A comparison of two surgical methods in the treatment of shoulder adhesive capsulitis.

OBJECTIVE: The purpose of the study was to compare the outcomes of arthroscopic capsular release surgery and manipulation of patients with resistant primary adhesive capsulitis (AC) under anesthesia. PATIENTS AND METHODS: The study comprised forty-four patients who had surgery after being given a diagnosis of primary AC. Patients who had both passive and active glenohumeral and scapulothoracic movements equal to or less than 100° elevation and less than 50% of external rotation compared to the contralateral side were considered to have resistant adhesive capsulitis and were included in the study. Conservative treatments such as intra-articular steroid injections and physical therapy had failed to relieve the pain in these patients for at least six months. The patients who took part in the trial underwent manipulation under anesthesia (group 1) and arthroscopic capsular release (group 2) operations. The chosen surgical procedure was chosen at random and based on the surgeon's preferences. examining the patients' demographic information. After treatment, the patients were examined at three-month, six-month, and one-year intervals. Joint range of motion, visual analogue scale (VAS), and Constant-Murley shoulder scores were all recorded. Statistics were used to compare the outcomes of the two surgical techniques in this study both before and after the procedure. RESULTS: The study's participants' gender, side, extra procedure, and age factors did not show a statistically significant difference between groups 1 and 2 (p<0.05). According to the age, gender, side, additional process, and homogeneous distribution throughout the groups. No statistically significant difference was discovered between groups 1 and 2 in any of the measurements taken from study participants during the follow-up period: Pre-op visual pain scores (VPS), Post-op 3rd month VPS, Post-op 1st year VPS, Pre-op Constant score, Post-op 6th month Constant score, and Post-op 1st year Constant score (p<0.05). The change in VPS and Constant Score values over time did not show a statistically significant difference between the groups (p<0.05). A statistically significant difference between the groups was discovered in each of the Pre-op period and Post-op 6th month VPS assessments (p<0.05). CONCLUSIONS: Although there was no statistically significant difference between the two studied therapies, the surgical method was shown to be more beneficial in both groups the shorter the pre-op period was between the onset of the complaints and the operation.