Do multiple fractures affect risk of fixation failure after surgical treatment of midshaft clavicle fracture? A retrospective cohort study.

BACKGROUND: Surgical treatment of midshaft clavicle fractures is associated with quick recovery and low risk of non-union. However, fixation failure may occur in case of severe comminution fractures. Moreover, clinical outcomes may be affected when clavicle fractures occur in combination with other injuries, particularly those involving the lower extremities, as the use of crutches or walkers may hinder the process of rehabilitation by adding strain on the acromioclavicular (AC) joint, resulting in possible fixation failure. This study aims to identify risk factors for fixation failure of midshaft clavicle fractures and elucidate the role of combined fractures in treatment outcomes. METHODS: This study included patients diagnosed with midshaft clavicle fractures who underwent initial surgery between January 2012 and November 2021 at a designated regional trauma center hospital. Retrospective evaluation of fixation failure was carried out in 352 patients with midshaft clavicle fractures using standard clinical evaluation protocols and conventional radiographs. The prevalence of fixation failure and the effects of several demographic variables on the risk of fixation failure and non-union were examined. Multivariate logistic regression analysis was carried out to identify independent risk factors for fixation failure. RESULTS: Fixation failure occurred in 40 patients (11.4%). Multivariate analysis identified comminution [odds ratio (OR) 3.532, p value = 0.003, 95% confidence interval (CI) 1.55-8.05)] and fewer number of screws (OR 0.223, p value = 0.022, 95% CI 0.06-0.80) as risk factors for fixation failure. Surgical techniques using wire cerclage reduced the chances of fixation failure in comminuted fractures (OR 0.63, p value = 0.033, 95% CI 0.05-0.80). Combined fractures that required rehabilitation using walkers or crutches increased the risk of non-union (OR 19.043, p value = 0.032, 95% CI 1.28-282.46). CONCLUSIONS: Additional fixation of comminuted fractures using cerclage can reduce the risk of treatment failure, while multiple fractures or rehabilitation for ambulation increases the risk of the same. LEVEL OF EVIDENCE: III.

Comparison of the Analgesic Efficacy between Arthroscopically Placed Continuous Suprascapular Nerve Block and Ultrasound-guided Continuous Superior Trunk Block: A Double-blinded Randomized Controlled Trial.

BACKGROUND: Single-shot suprascapular nerve block and superior trunk block have been reported to provide a noninferior analgesic effect after shoulder surgery with a lesser incidence of hemidiaphragmatic paresis compared with interscalene brachial plexus block. This study hypothesized that continuous suprascapular nerve block provides noninferior analgesia with minimal effects on diaphragmatic movement compared with continuous superior trunk block in patients undergoing arthroscopic shoulder surgery. METHODS: 100 patients were randomized undergoing arthroscopic shoulder surgery between December 2020 and October 2021 into continuous suprascapular nerve block and continuous superior trunk block groups. Before the surgery, patients received either a single-shot superior trunk block or subomohyoid suprascapular nerve block. Thereafter, a superior trunk catheter was inserted by anesthesiologists in patients in the continuous superior trunk block group, and a posterior suprascapular nerve catheter was inserted with arthroscopic assistance during the surgery by surgeon in the continuous suprascapular nerve block group. The primary outcome was the postoperative pain score at postoperative 24 h, and the incidence of hemidiaphragmatic paresis was also compared. RESULTS: Overall, 98 patients were included in the final analysis. The worst and resting pain scores at postoperative 24 h in the continuous suprascapular nerve block group were inferior compared with those in the continuous superior trunk block group in the test with a noninferiority margin of 1 (worst pain score: mean difference, 0.9; 95% CI, 0.1 to 1.7; resting pain score: mean difference, 0.5; 95% CI, 0.0 to 1.0). However, the continuous suprascapular nerve block group had a significantly lower incidence of hemidiaphragmatic paresis at postoperative 24 h than the continuous superior trunk block group. CONCLUSIONS: Continuous suprascapular nerve block provides statistically inferior analgesia compared to the continuous superior trunk block; however, the continuous suprascapular nerve block had a minimal effect on the phrenic nerve function.

Remplissage in Addition to Arthroscopic Bankart Repair for Shoulder Instability With On-Track Hill-Sachs Lesions Reduces Residual Apprehension Without External Rotation Limitation.

PURPOSE: To evaluate the role of remplissage as an adjunct to Bankart repair in patients with recurrent anterior shoulder dislocation combined with on-track Hill-Sachs lesion. METHODS: Arthroscopic Bankart repair with remplissage data (December 2018-2020) were collected (BR group). Inclusion criteria were (1) recurrent anterior shoulder dislocation, (2) on-track Hill-Sachs lesion, (3) minimal/subcritical glenoid bone loss (<17%), and (4) postoperative follow-up >1 year. Exclusion criteria were (1) revision surgery, (2) first dislocation with acute glenoid rim fracture, and (3) combined with other surgery. The control group was identified in Bankart repair-only cohort (B group). All patients were evaluated preoperatively, and at 3 weeks, 6 weeks, 3 months, 6 months, and then annually postoperatively. Visual analogue scale for pain, Self-Assessment Numerical Evaluation, American Shoulder and Elbow Surgeons Shoulder score, ROWE, and Western Ontario Shoulder Instability were evaluated at preoperative and final follow-up. Residual apprehension experience and external rotation deficit were evaluated. Patients, who were followed-up for more than 1 year, were asked how often they experienced any subjective apprehension in 4 grades (1: always, 2: frequently, 3: occasionally, 4: never). Patients who had a history of recurrent dislocation or revision surgery were investigated. RESULTS: In total, 53 patients (B, 28; BR, 25) were included. At final follow-up, both groups showed improvement in 5 clinical scores postsurgery (P < .001). The BR group showed greater ROWE scores than the B group (B: 75.2 ± 13.6, BR: 84.4 ± 10.8; P = .009). Residual apprehension patient ratio (B: 71.4% [20/28], BR: 32% [8/25]; P = .004) and the mean subjective apprehension grade (B: 3.1 ± 0.6, BR: 3.6 ± 0.6; P = .005) showed statistically significant difference, whereas no patients in either group experienced external rotation deficit (B: 14.8 ± 12.9°, BR: 18.0 ± 15.2°, P = .420). Only 1 patient in the B group had not responded to surgery, with dislocation recurrence (P = .340). CONCLUSIONS: Remplissage with arthroscopic Bankart repair in on-track Hill-Sachs lesion has a role in reducing residual apprehension without external rotation limitation. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic trial.

Extracellular Vesicles Delivered by Injectable Collagen Promote Bone-Tendon Interface Healing and Prevent Fatty Degeneration of Rotator Cuff Muscle.

PURPOSE: This study aimed (1) to confirm the maintenance of the extracellular vesicles (EVs) delivered via injectable collagen at the application site, and (2) to evaluate the effect of EVs derived from the human umbilical cord-derived mesenchymal stem cells and loaded in an injectable collagen gel after rotator cuff repair (RCR). METHODS: Rabbits (n = 20) were assigned to normal (N), repair-only (R), and those administered with injectable collagen after repair (RC), and EV-laden injectable collagen after repair (RCE) groups. The EVs isolated by ultra-centrifugation from the human umbilical cord-derived mesenchymal stem cells spent medium were mixed with collagen and administered accordingly. After 12 weeks, the rabbits were sacrificed to evaluate the healing of the bone-to-tendon junction and the fatty degeneration of muscle. Histomorphometric scoring for bone-tendon interface, fatty infiltration (%), and biomechanical tests were performed. Separately, groups of 3 rabbits were assigned to 3 different time points to evaluate maintenance of green fluorescence-labeled EVs with injectable collagen via tracking on the bursal side of the rotator cuff (3 groups: 3 days, 2, and 4 weeks). RESULTS: The EVs delivered by injectable collagen remained until 4 weeks at the bursal side of the cuff tissue. The RCE group showed a significantly greater histomorphometric total score (P < .001, and P = .013, respectively) and significantly lower fatty degeneration than the RC and R groups (P = .001, and P = .013, respectively). The biomechanical tests revealed significant growing trends in load-to-failure and stiffness (P = .002, and P = .013, respectively), in the R, RC, RCE, and N groups. CONCLUSIONS: EVs mounted in injectable collagen remained at the repair site for at least 4 weeks after application. Furthermore, they effectively promote bone-to-tendon healing via collagen maturation in bone-tendon interface and preventing fatty degeneration of rotator muscle after RCR as compared with collagen-only or repair-only groups. CLINICAL RELEVANCE: The combination of collagen with EVs significantly promotes rotator cuff healing demonstrating potential clinical application during partial rotator cuff tear or after RCR.

Patient-specific instrumentation improves the reproducibility of preoperative planning for the positioning of baseplate components with reverse total shoulder arthroplasty: a comparative clinical study in 39 patients.

BACKGROUND: The application of patient-specific instrumentation (PSI) for reverse total shoulder replacement has been rapidly increasing, which could reduce errors in implant positioning. Although PSI theoretically holds promise, evidence of the accuracy and reliability of PSI in shoulder replacement surgery is limited. METHODS: Thirty-nine shoulders that underwent reverse total shoulder arthroplasty were included in this study and categorized into two groups: the conventional (n = 20) and PSI (n = 19) groups. Screw (length and angle) and baseplate (version, inclination, translation, and rotation) positioning were calculated based on postoperative computed tomography images using a three-dimensional measurement tool. The difference between the values of the preoperative target and postoperative measurement was calculated to evaluate the reproducibility of preoperative planning. Screw involvement in the suprascapular and spinoglenoid notches was assessed. Thus, the correlation between the position of the baseplate and the screws was assessed. RESULTS: The mean differences between the planned length and angle (anteroposterior and superoinferior angles) and postoperative measurement in the PSI group were significantly smaller than those in the conventional group. Similarly, the mean difference in baseplate rotation between the planned and postoperative measurements in the PSI group was significantly lower than that in the conventional group (4.5° vs 10.6°; P < .001). The spinoglenoid notch was involved in 10 cases in the conventional group and 2 cases in the PSI group, and this difference was significant (P = .014). Overall, the mean difference between the preoperative and postoperative version, inferior inclination, and rotation values for the baseplate position was significantly correlated with the values for screw position (length and angle). CONCLUSIONS: PSI improves the reproducibility of preoperative planning for baseplate and screw positioning and reduces the risk of neurovascular injury in reverse total shoulder arthroplasty.

Retear bigger than preoperative tear size would lead to treatment failure after rotator cuff repair.

BACKGROUND: This study aimed to (1) define treatment failure using the referred patient acceptable symptomatic state (PASS) values for pain visual analog scale (PVAS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Single Assessment Numeric Evaluation (SANE) clinical scores and (2) identify the factors that lead to patient dissatisfaction after arthroscopic rotator cuff repair (ARCR). METHODS: We analyzed the arthroscopic rotator cuff surgery registry data from January 2015 to December 2016. Patients were followed for ≥2 years and categorized as dissatisfied or satisfied based on our own definition of treatment failure at 2 years postoperatively. For defining treatment failure, the referred PASS values for the PVAS, ASES, and SANE scores were used. Patients who failed to attain the PASS value for the PVAS, ASES, or SANE score were categorized into the dissatisfied group. Pre- and postoperative imaging and basic demographic data were compared between groups. Univariable and multivariable logistic regression analyses were performed to identify the factors affecting patient satisfaction at 2 years after rotator cuff repair. RESULTS: Of 117 patients, 30 (25.6%) were defined as the dissatisfied group (mean follow-up period, 37.5 months). Seventeen patients (14.5%) had confirmed retear on follow-up magnetic resonance imaging. In the univariate analysis, sex significantly differed between the groups (female, satisfied vs. dissatisfied groups: 39 [44.8%] vs. 22 [73.3%]; P = .010). Retear alone did not affect patient satisfaction in the univariate analysis (P = .11). Progressed retear size featured a significantly higher risk of patient dissatisfaction (P = .024; odds ratio 6.430, 95% confidence interval 1.270-32.541) in the multivariable analysis using symptom duration, sex, preoperative ASES score, preoperative tear size, retear, and progressed retear size as variables. Moreover, female sex had an increased odds for dissatisfaction (odds ratio 4.646, 95% confidence interval 1.590-13.578; P = .005). CONCLUSION: Two years after ARCR, most patients (74.4%) reported satisfaction with their outcomes. However, satisfaction levels can be altered by female sex or progressed retear size compared with the preoperative state.

Is reverse total shoulder arthroplasty (rTSA) more advantageous than anatomic TSA (aTSA) for osteoarthritis with intact cuff tendon? A systematic review and meta-analysis.

PURPOSE: We aimed to compare the outcomes and complications of anatomical shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) for primary glenohumeral osteoarthritis with intact cuff tissue. MATERIALS AND METHODS: The MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies published before March 2, 2021 using the PRISMA guidelines. Studies were included if they directly compared aTSA and rTSA for treating primary glenohumeral arthritis. A meta-analysis was performed using six studies that compared radiologic outcomes, functional scores, and range of motion (ROM). All the data were pooled using a random-effects model. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated as dichotomous data, while continuous data were analyzed using mean differences with 95% CIs. RESULTS: Two independent researchers reviewed 1,061 studies. Six studies met the inclusion criteria. The range of motion, especially external rotation, was better for aTSA than for rTSA (MD = - 10.28, 95% CI: - 16.69 to - 3.88, P = 0.002). Functional scores showed no difference between aTSA and rTSA. Glenoid loosening (OR = 0.17, 95% CI: 0.06-0.50, P = 0.001) was more common with aTSA, and scapula notching (OR = 10.63, 95% CI: 1.73-65.27, P = 0.01) with rTSA. In the mid-term follow-up, the overall revision rate showed no difference between aTSA and rTSA, with a pooled OR of 0.33 (95% CI: 0.07-1.57, P = 0.16). CONCLUSION: A better ROM was achieved after aTSA than after rTSA. There was no difference in the revision rate at mid-term follow-up between aTSA and rTSA. Glenoid loosening was more common with aTSA, and scapula notching with rTSA. LEVEL OF EVIDENCE: Level IV, Meta-analysis.

Postoperative Pain Control After Arthroscopic Rotator Cuff Repair: Arthroscopy-Guided Continuous Suprascapular Nerve Block Versus Ultrasound-Guided Continuous Interscalene Block.

PURPOSE: To compare the clinical efficacy and safety of arthroscopy-guided continuous suprascapular nerve block and ultrasound-guided continuous interscalene block in postoperative analgesia in patients undergoing arthroscopic rotator cuff repair. METHODS: A prospective study was performed between March and November 2020. In total, 76 patients were enrolled and divided into 2 groups: in the 38 patients of group 1 (arthroscopy-guided continuous suprascapular nerve block), an indwelling catheter was introduced via the Neviaser portal under arthroscopic view before closing the portal at the end of the surgery; and in the 38 patients of group 2 (ultrasound-guided continuous interscalene block), an indwelling catheter was inserted and directed toward the interscalene brachial plexus prior to the surgery under ultrasound guidance. The primary outcome was the pain score measured by the visual analog scale at postoperative 24 hours during admission. Comparisons were conducted at different time points (postoperative 4, 8, 24, and 48 hours). The secondary outcome was any of these events: neurologic complications, such as sensory/motor change in the upper extremities; hemidiaphragmatic paresis; dyspnea; dysphonia; and Horner's syndrome. Opioid usage until postoperative 3 weeks was compared between the groups. RESULTS: The visual analog scale scores in groups 1 and 2 were comparable at each postoperative time point (analysis of variance, P = .919; trends, P = .132). Neurologic deficits were more common in group 2 than in group 1 (8 vs 32 patients, P < .001). Decreased excursion of the diaphragm was more common in group 2 (partial or complete paresis of the hemidiaphragm: 1 vs 29 patients, P < .001). Opioid consumption was similar in both groups (morphine milligram equivalents per kilogram; 1.75 vs 1.55, P = .195). CONCLUSIONS: Our findings show that arthroscopy-guided continuous suprascapular nerve block is not inferior to ultrasound-guided continuous interscalene block for postoperative pain control after arthroscopic rotator cuff repair while showing fewer temporary neurologic complications. LEVEL OF EVIDENCE: Level II, prospective cohort study, interventional study.

The contact area of the radiocapitellar joint under pronation and supination with axial load using a 3-dimensional computed tomography: an in vivo study.

OBJECTIVE: To evaluate the contact area of the radiocapitellar joint with forearm pronation and supination under axial loading. MATERIALS AND METHODS: Six healthy volunteers (2 males and 4 females, mean age: 44.6 years) were included in the study. A computed tomography scan of the extended elbow joints was obtained at 4 positions of forearm: full pronation with or without load and full supination with or without load. Mimics, 3-matic Medical, Geomagic, and Photoshop were used to reconstruct 3-dimensional models. The contact area of the radiocapitellar joint was measured. Shifting of the center of the contact area of the radiocapitellar joint was measured. RESULTS: The axial load added 8.6% and 10.5% contact area to pronation and supination without load, respectively. From pronation without load, the center of contact area significantly shifted 2.4 ± 1.1 mm anteromedially to supination without load and shifted by 1.0 ± 0.5 mm to the center of the radial head compared with the pronation with load. The center of the contact area significantly shifted 2.4 ± 1.5 mm anteromedially from the pronation to the supination under loading. The contact area of the tuberosity anterior in the radial head significantly increased by 14% (without load) and 8% (with load) from pronation to supination. CONCLUSION: Axial loading increases the contact area of the radiocapitellar joint. The center of the contact area of the radiocapitellar joint changed according to loading and shifted to the anterior tuberosity of the radial head from forearm pronation to supination.

Determination of the patient acceptable symptomatic state after osteocapsular arthroplasty for primary elbow osteoarthritis.

BACKGROUND: The study aimed (1) to determine patient acceptable symptomatic state (PASS) values for the pain visual analog scale (PVAS), range-of-motion (ROM) scale difference, Mayo Elbow Performance Score (MEPS), and Self-evaluation Elbow (SEE) following osteocapsular arthroplasty for primary elbow osteoarthritis and (2) to determine factors for achieving the PASS. METHODS: The study analyzed retrospectively collected osteocapsular arthroplasty registry data from January 2010 to April 2019. Fifty patients were evaluated, and anchor questions for deriving PASS values were administered at a 1-year follow-up. PASS values for the PVAS score, ROM difference, MEPS, and SEE score were derived using a sensitivity- and specificity-based approach. Univariate and multivariate logistic regression analyses were performed to determine factors for achieving the PASS. A subgroup comparison analysis based on age was also conducted. RESULTS: The PASS value was 1.0 for the PVAS score, 15° for ROM difference, 75 for the MEPS, and 60 for the SEE score. Older age (≥65 years) showed significantly lower odds ratios for achieving the PASS for the PVAS score (0.888; 95% confidence interval, 0.804-0.981; P = .032) and ROM (0.861; 95% confidence interval, 0.760-0.976; P = .020). CONCLUSION: Reliable PASS values were derived for the PVAS score, ROM difference, MEPS, and SEE score after osteocapsular arthroplasty. The PASS values defined in this study can be implemented as clinically relevant targets in patients undergoing osteocapsular arthroplasty. An analysis of factors that affect clinical symptom improvement showed that older age (≥65 years) was significantly correlated with lower PASS values for the PVAS score and ROM.

The elbow plica: a systematic review of terminology and characteristics.

BACKGROUND: There has been a lack of evidence regarding the structure of the elbow plica, or synovial fold. Inconsistency remains regarding the correct terminology, prevalence, and investigation used to understand this anatomic structure. METHODS: For this systematic review, we searched the PubMed, Ovid-MEDLINE, Cochrane, Google Scholar, and Embase databases using keywords as well as medical subject headings for English-language studies. We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RESULTS: We included 27 articles in this review. "Plica" was the most commonly used terminology (33%). The prevalence of plicae in asymptomatic and symptomatic patients was 77% and 97%, respectively. Provocative factors were sporting activities (57%), including those performed by professional athletes, and heavy labor (43%). Lateral elbow pain represented the most common symptom (49%). Magnetic resonance imaging was the most commonly used diagnostic modality (64%). On the magnetic resonance imaging scans of symptomatic patients, the most common location of the plica was the posterolateral region (54%) and its thickness was a minimum of 3 mm. In 2 studies that included symptomatic patients, the plica was found to cover more than one-third of the radial head. CONCLUSION: Plicae are prevalent in both asymptomatic and symptomatic patients. Consideration of the pathologies associated with an elbow plica helped identify the following: (1) its thickness is >3 mm and (2) its location is in the posterolateral aspect and/or it covers more than one-third of the radial head quadrant.

Topography of sensory receptors within the human glenohumeral joint capsule.

BACKGROUND AND HYPOTHESES: Sensory receptors in the joint capsule are critical for maintaining joint stability. However, the distribution of sensory receptors in the glenohumeral joint of the shoulder, including mechanoreceptors and free nerve endings, has not been described yet. This study aimed to describe the distributions of different sensory receptor subtypes in the glenohumeral joint capsule. Our hypotheses were as follows: (1) Sensory receptor subtypes would differ in density but follow a similar distribution pattern, and (2) the anterior capsule would have the highest density of sensory receptors. METHODS: Six glenohumeral joint capsules were harvested from the glenoid to the humeral attachment. The capsule was divided into 4 regions of interest (anterior, posterior, superior, and inferior) and analyzed using modified gold chloride stain. Sensory receptors as well as free nerve endings were identified and counted under a light microscope from sections of each region of interest. The density of each sensory receptor subtype was calculated relative to capsule volume. RESULTS: Sensory receptors were distributed in the glenohumeral joint capsule with free nerve endings. The anterior capsule exhibited the highest median density of all 4 sensory receptors examined, followed by the superior, inferior, and posterior capsules. The median densities of these sensory receptor subtypes also significantly differed (P = .007), with type I (Ruffini corpuscles) receptors having the highest density (2.97 U/cm3), followed by type IV (free nerve endings, 2.25 U/cm3), type II (Pacinian corpuscles, 1.40 U/cm3), and type III (Golgi corpuscles, 0.24 U/cm3) receptors. CONCLUSION: Sensory receptor subtypes are differentially expressed in the glenohumeral joint capsule, primarily type I and IV sensory receptors. The expression of sensory receptors was dominant in the anterior capsule, stressing the important role of proprioception feedback for joint stability. The surgical procedure for shoulder instability should consider the topography of sensory receptors to preserve or restore the proprioception of the shoulder joint.

Role of inferomedial supporting screws for secondary varus deformity in non-osteoporotic proximal humerus fracture: A biomechanical study.

INTRODUCTION: The purpose of this study was to evaluate the effect of a medial support screw through a proximal humerus fracture. For this purpose, we verified whether the biomechanics are different according to the position of the screw while using the same number of screws. In addition, we tried to verify whether the insertion of additional inferomedial screws would make a difference in stability. MATERIALS AND METHODS: Twenty-four proximal humerus bones were included in the study. A two-part fracture was created and fixed using a locking plate. Cyclic loading and load-to-failure test were applied to three groups: group A (proximal 6 screws + calcar screws), group B (proximal 6 screws), and group C (proximal 4 screws + calcar screws). Interfragmentary gaps were measured following cyclic loading and compared. The failure was defined when the bone breakage or medial gap closing was observed during ultimate failure load applied. The load-to-failure, maximum displacement, stiffness, and yield load were recorded and compared. RESULTS: The interfragmentary gap was differently reduced by 0.29 ± 0.14 mm, 0.73 ± 0.25 mm, and 0.53 ± 0.09 mm following 1000 cyclic loading for groups A, B, and C, respectively. The load-to-failure was 945.22 ± 101.02 N, 941.40 ± 148.90 N, and 940.58 ± 91.78 N in groups A, B, and C, respectively. The stiffness of group A (214.76 ± 34.0 N/mm) was superior when compared to that of group C (171.12 ± 23.0 N/mm; p = 0.025). The maximum displacement prior to failure, yield load, showed no significant difference between comparative groups. CONCLUSION: Our study did not show any additional biomechanical effects with the use of inferomedial supporting screws in non-osteoporotic proximal humerus fracture, besides making the fracture-plate construct stiff. The role of the inferomedial supporting screw was also unclear. However, the groups that used increased screw fixation and inferomedial screw insertion seemed to be more resistant to cyclic loading.

Loosening and revision rates after total shoulder arthroplasty: a systematic review of cemented all-polyethylene glenoid and three modern designs of metal-backed glenoid.

BACKGROUND: Several modern designs of metal-backed glenoids (MBG) have been devised to overcome flaws such as loosening and a high failure rate. This review aimed to compare rates of complications and revision surgeries between cemented polyethylene glenoid (PEG) and three examples of modern MBG designs. METHODS: Literature search was carried out using PubMed, Cochrane Library, EMBASE, and Google Scholar using MeSH terms and natural keywords. A total of 1186 articles were screened. We descriptively analyzed numerical data between the groups and statistically analyzed the categorical data, such as the presence of radiolucent line, loosening, and revision surgery (failure). Articles were divided into three groups based on follow-up duration: < 36-month, 36-72-month, and > 72-month subgroups. RESULTS: This study included 35 articles (3769 shoulders); 25 on cemented PEG and ten on the modern MBG. Mean age was 66.4 (21-93) and 66.5 years (31-88). The mean duration of follow-up was 73.1 (12-211) and 56.1 months (24-100). Overall, the rate of the radiolucent line was 354/1302 (27%) and 47/282 (17%), the loosening rate was 465/3185 (15%) and 22/449 (5%), and the failure rate was 189/3316 (6%) and 11/457 (2%), for PEG and MBG, respectively. The results of < 36-month and 36-72-month subgroups showed lower rates of radiolucency and loosening in the cemented PEG group, but there was no significant difference in failure rate (P = 0.754 and 0.829, respectively). In the > 72-month subgroup, MBG was better in terms of loosening (P < 0.001) and failure rates (P = 0.006). CONCLUSIONS: The modern MBG component, especially TM glenoid, seems to be a promising alternative to cemented PEGs, based on subgroup revision rates according to the follow-up duration and overall results of ROM and clinical scores. All polyethylene glenoids tend to increase loosening and failure over time. Three modern MBG designs seem to have no difference in failure, at least in the < 36-month and 36-72-month subgroups compared to the cemented PEG. More long-term follow-up studies on modern MBG should be ultimately conducted. LEVEL OF EVIDENCE: Level IV, systematic review.

Navigation-assisted anchor insertion in shoulder arthroscopy: a validity study.

BACKGROUND: This study aimed to compare conventional and navigation-assisted arthroscopic rotator cuff repair in terms of anchor screw insertion. METHODS: The surgical performance of five operators while using the conventional and proposed navigation-assisted systems in a phantom surgical model and cadaveric shoulders were compared. The participating operators were divided into two groups, the expert group (n = 3) and the novice group (n = 2). In the phantom model, the experimental tasks included anchor insertion in the rotator cuff footprint and sutures retrieval. A motion analysis camera system was used to track the surgeons' hand movements. The surgical performance metric included the total path length, number of movements, and surgical duration. In cadaveric experiments, the repeatability and reproducibility of the anchor insertion angle were compared among the three experts, and the feasibility of the navigation-assisted anchor insertion was validated. RESULTS: No significant differences in the total path length, number of movements, and time taken were found between the conventional and proposed systems in the phantom model. In cadaveric experiments, however, the clustering of the anchor insertion angle indicated that the proposed system enabled both novice and expert operators to reproducibly insert the anchor with an angle close to the predetermined target angle, resulting in an angle error of < 2° (P = 0.0002). CONCLUSION: The proposed navigation-assisted system improved the surgical performance from a novice level to an expert level. All the experts achieved high repeatability and reproducibility for anchor insertion. The navigation-assisted system may help surgeons, including those who are inexperienced, easily familiarize themselves to of suture anchors insertion in the right direction by providing better guidance for anchor orientation. LEVEL OF EVIDENCE: A retrospective study (level 2).

Arthroscopic osteocapsular arthroplasty for advanced-stage primary osteoarthritis of the elbow using a computed tomography-based classification.

HYPOTHESIS: Arthroscopic osteocapsular arthroplasty for stage III osteoarthritis (advanced stage) shows worse clinical and radiologic outcomes compared with stage I or II according to computed tomography (CT)-based classification. METHODS: Clinical and radiologic outcomes in 65 patients treated with arthroscopic osteocapsular arthroplasty were retrospectively analyzed for range of motion (ROM) arc, functional score (Mayo Elbow Performance Score [MEPS]), and pain score (visual analog scale [VAS]). Patients were classified into stage I or II (n = 44) and stage III (n = 21) groups according to CT-based classification, and postoperative clinical outcomes and complications were analyzed. RESULTS: Mean follow-up duration was 32.9 ± 13.7 months (range, 24-69). The average patient age was 52 ± 10 years (range, 40-63). Improvements from preoperative to final follow-up were seen in the overall ROM-flexion from 94° ± 19° to 129° ± 14° (P < .01), ROM-extension from 25° ± 12° to 14° ± 7° (P < .01), MEPS from 45 ± 13 to 78 ± 14 (P < .01), and VAS score from 6.3 ± 1.6 to 3.1 ± 1.4 (P < .01). Subgroup analysis using the CT-based classification revealed that stage III led to worsened VAS score and MEPS than stage I or II. CONCLUSIONS: Arthroscopic osteocapsular arthroplasty can be recommended for its favorable overall treatment outcomes for elbow osteoarthritis. However, stage III shows worse clinical and radiologic outcomes compared with stage I or II according to CT-based classification.

The Effect of Povidone-Iodine Lavage in Preventing Infection After Total Hip and Knee Arthroplasties: Systematic Review and Meta-Analysis.

BACKGROUND: Dilute povidone-iodine (PI) lavage, a simple disinfection method, could reduce postoperative infection risk. However, there is no clinical consensus regarding its efficacy in total joint arthroplasties (TJAs). This systematic review and meta-analysis evaluated PI lavage's efficacy in preventing infection after TJA. METHODS: MEDLINE, Embase, and the Cochrane Library were systematically searched for studies published before November 22, 2019, that compared postoperative infection rates in patients who underwent TJA with or without PI lavage before wound closure. Subgroup analyses were designed to identify the differences in infection site (overall or deep), type of surgery (total hip arthroplasty or total knee arthroplasty), time until diagnosis of infection (3 or 12 months postoperatively), and primary/aseptic revision arthroplasties. RESULTS: We included 7 studies with 31,213 TJA cases, comprising 8861 patients who received PI lavage and 22,352 who did not. Pooled odds ratio for overall infection rate for the PI and non-PI lavage groups was 0.67 (95% confidence interval, 0.38-1.19, P = .17) and for the deep infection rate was 0.90 (95% confidence interval, 0.27-2.98, P = .86). Subgroup analyses revealed no differences in postoperative infection rates between the PI and non-PI lavage groups in terms of total hip arthroplasty and total knee arthroplasty, diagnosis of infection at 3 and 12 months postoperatively, or primary and aseptic revision arthroplasties. CONCLUSION: We detected no differences in the overall postoperative infection rates between the PI and non-PI lavage groups before wound closure in TJA including all studies in the subgroup analyses.

Discoid lateral meniscus: a simple horizontal tear was associated with less articular cartilage degeneration compared to other types of tear.

PURPOSE: The relationship between the tear type of discoid lateral meniscus (DLM) and articular cartilage degeneration has not been well studied. METHODS: Data from patients with DLM tears who underwent arthroscopic surgery, between 2008 and 2016, were reviewed retrospectively. Demographic variables were obtained from medical records. The types of DLM and meniscal tear and status of cartilage were assessed using operation records and arthroscopic images. Patients were assigned to horizontal or non-horizontal tear groups according to the types of the tear. Factors affecting cartilage degeneration of the lateral femoral condyle (LFC) and lateral tibial plateau (LTP) were identified using logistic regression analysis. The horizontal tear group was divided into two subgroups on the basis of the median value of duration of symptoms and difference in cartilage degeneration between the two subgroups was evaluated. RESULTS: Overall, 355 knees were enrolled and assigned to the horizontal (n = 53) or the non-horizontal (n = 302) tear groups. The incidence of International Cartilage Repair Society grades 2-4 cartilage lesions of the LFC (0%, P < 0.001) and LTP (24.5%, P < 0.001) was significantly lower in the horizontal tear group than in the non-horizontal tear group. Horizontal tear [LFC, odds ratio (OR) = 0.02, P < 0.001; LTP, OR = 0.27, P < 0.001] and age (LFC, OR = 1.04, P < 0.001; LTP, OR = 1.03, P < 0.001) were significantly related to cartilage status. There was no difference in cartilage degeneration between the two subgroups in the horizontal tear group. CONCLUSIONS: A simple horizontal tear was associated with less articular cartilage degeneration compared to other types of tear in the DLM. In the case of simple horizontal tear, there was no difference in the degree of cartilage degeneration according to the duration of symptoms. Therefore, it is not necessary to perform surgical treatment promptly in cases of simple horizontal tears unless the patient's symptoms are severe. LEVEL OF EVIDENCE: III, Case-Control Study.

Effect of osteoporosis on the clinical and radiological outcomes following one-level posterior lumbar interbody fusion.

BACKGROUND: Cage subsidence or pedicle screw loosening following lumbar fusion surgery is frequently reported in osteoporotic patients. However, few studies have analyzed clinical as well as radiological outcomes after such surgeries as a function of bone mineral density. We aimed to evaluate the impact of osteoporosis on the clinical and radiological outcomes of patients who underwent one-level posterior lumbar interbody fusion (PLIF). METHODS: Fifty-five non-osteoporotic (T-score ≥ -1.0) and 31 osteoporotic (T-score ≤ -2.5) patients who underwent one-level PLIF were followed up for >2 years. Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and EuroQol 5-Dimension (EQ-5D) parameters were assessed. Fusion success was identified with dynamic plain radiographs and computed tomography. Pedicle screw loosening and cage subsidence were evaluated. The clinical and radiological parameters were compared between osteoporotic and non-osteoporotic patients. Subgroup analysis was performed on cage subsidence or screw loosening. RESULTS: Although VAS score for back pain was higher in osteoporotic patients than in non-osteoporotic patients at 6 months postoperatively (3.3 vs. 2.2, P = 0.062), this difference disappeared at 1 year postoperatively (2.9 vs. 2.5, P = 0.606). However, no differences were noted between the groups in ODI and EQ-5D grades. Cage subsidence (65.4% vs. 17.6%, P < 0.001) and screw loosening rates (32.3% vs. 12.7%, P = 0.029) were significantly higher in osteoporotic patients than in non-osteoporotic patients, but fusion rate did not differ between the groups. Although clinical outcomes did not differ between those who had cage subsidence or screw loosening and those who did not, fusion rate was lower in those who showed screw loosening than those who did not (71.4% vs. 93.9%, P = 0.038). CONCLUSIONS: Higher cage subsidence and pedicle screw loosening rates in osteoporotic patients did not significantly affect the clinical outcomes, but screw loosening, which occurred more frequently in older patients, significantly reduced the fusion success rate. Thus, PLIF procedure may be a good surgical treatment option to achieve good clinical outcomes, even in osteoporotic patients despite higher rates of cage subsidence and pedicle screw loosening. However, surgeons should monitor screw loosening because of its significant association with non-union.