Non-steroidal Anti-inflammatory Drugs and Cyclooxygenase-2 Inhibitors Do Not Affect Healing After Rotator Cuff Repair: A Systematic Review and Meta-analysis.

PURPOSE: To determine whether non-steroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors affect healing rate, functional outcomes, and patient satisfaction after rotator cuff repair. METHODS: Medline, EMBASE, PsychINFO and the Cochrane Library were searched for randomized controlled trials (RCTs) investigating the use of NSAIDs and COX-2 inhibitors after arthroscopic rotator cuff repair. Primary outcomes included healing and retear rate, determined by radiological imaging. Secondary outcomes included shoulder-specific outcome measures and the visual analog scale (VAS). Risk of bias was graded using the Cochrane risk-of-bias v2.0 tool. The GRADE framework was used to assess certainty of findings. RESULTS: Seven RCTs with a total of 507 patients were included (298 randomized to NSAID/COX-2 vs 209 randomized to control). NSAIDs use did not yield a difference in retear rate (P = .77). NSAIDs were shown to significantly reduce pain in the perioperative period (P = .01); however, no significant difference was present at a minimum of 6 months (P = .11). COX-2 inhibitors did not significantly reduce pain (P = .15). Quantitative analysis of ASES and UCLA scores showed NSAIDs significantly improved functional outcomes versus control (P = .004). COX-2 inhibitors did not significantly improve functional outcomes (P = .15). Two trials were deemed "low" risk of bias, four trials were graded to have "some concerns", and one trial was graded to have "high" risk of bias. Retear rate and functional PROMs were deemed to have "low" certainty. VAS pain scale was graded to have "moderate" certainty. CONCLUSIONS: This systematic review and meta-analysis indicates that NSAIDs do not affect healing rate after arthroscopic rotator cuff repair, but they do significantly improve postoperative pain and functional outcomes. No significant difference was seen in pain or functional outcomes with the use of COX-2 inhibitors. LEVEL OF EVIDENCE: Level I, meta-analysis of randomized controlled trials.

Paget-Schroetter Syndrome in a Patient With Posterior Shoulder Subluxation: A Case Report.

ABSTRACT: Paget-Schroetter syndrome describes a primary thrombosis of the subclavian vein induced by effort. In most cases, the clinical presentation includes painful swelling, discoloration, and visible collateral circulation in the arm. Paget-Schroetter syndrome is treated with anticoagulation, rest, and physical therapy. In certain cases, invasive treatment such as thrombolysis and decompression surgery (first rib resection) may be necessary. We present the case of a 28-year-old healthy male patient with effort-induced deep vein thrombosis of the upper extremity after posterior shoulder subluxation. Anticoagulation, rest, and physical therapy were used to treat the patient, who became asymptomatic and was able to resume normal activities without restriction. To our knowledge, this is the first case of effort-induced upper extremity deep vein thrombosis after posterior shoulder subluxation. Paget-Schroetter syndrome is rare diagnosis that requires vigilance during musculoskeletal assessment for shoulder pain and swelling. The early detection, radiological confirmation, and prompt initiation of treatment are essential to successful management of Paget-Schroetter syndrome. The impact of associated posterior shoulder subluxation remains unclear.

Navigated augmented reality through a head-mounted display leads to low deviation between planned, intra- and post-operative parameters during glenoid component placement of reverse shoulder arthroplasty: a proof-of-concept case series.

BACKGROUND: Navigated augmented reality (AR) through a head-mounted display (HMD) has led to accurate glenoid component placement in reverse shoulder arthroplasty (RSA) in an in-vitro setting. The purpose of this study is to evaluate the deviation between planned, intra-, and postoperative inclination, retroversion, entry point and depth of the glenoid component placement during RSA, assisted by navigated AR through a HMD, in a surgical setting. METHODS: A prospective, multicenter study was conducted. All consecutive patients undergoing RSA in two institutions, between August 2021 and January 2023, were considered potentially eligible for inclusion in the study. Inclusion criteria were: age >18 years, surgery assisted by AR through a HMD, and postoperative computed tomography (CT) scans at six weeks. All participants agreed to participate in the study and an informed consent was provided in all cases. Preoperative CT scans were undertaken for all cases and used for three-dimensional (3D) planning. Intra-operatively, glenoid preparation and component placement were assisted by a navigated AR system through a HMD in all patients. Intraoperative parameters were recorded by the system. A postoperative CT scan was undertaken at 6 weeks, and 3D reconstruction was used for obtaining postoperative parameters. The deviation between planned, intra-, and postoperative inclination, retroversion, entry point, and depth of the glenoid component placement was calculated. Outliers were defined as >5° for inclination and retroversion and >5 mm for entry point. RESULTS: 17 patients (9 females, 12 right shoulders) with a mean age of 72.8±9.1 years old (range, 47.0 to 82.0) met inclusion criteria. The mean deviation between intra- and postoperative measurements was 1.5°±1.0° (range, 0.0° to 3.0°) for inclination, 2.8°±1.5° (range, 1.0° to 4.5°) for retroversion, 1.8±1.0 mm (range, 0.7mm to 3.0mm) for entry point, and 1.9±1.9 mm (range, 0.0mm to 4.5mm) for depth. The mean deviation between planned and postoperative values was 2.5°±3.2° (range, 0.0° to 11.0°) for inclination, 3.4°±4.6° (range, 0.0° to 18.0°) for retroversion, 2.0±2.5 mm (range, 0.0° to 9.7°) for entry point, and 1.3±1.6 mm (range, 1.3mm to 4.5mm) for depth. There were no outliers between intra- and postoperative values and there were three outliers between planned and postoperative values. The mean time (minutes:seconds) for the tracker unit placement and the scapula registration was 03:02 (range, 01:48 to 04:26) and 08:16 (range, 02:09 to 17:58), respectively. CONCLUSION: The use of a navigated AR system through a HMD in RSA led to low deviations between planned, intra-operative and postoperative parameters for glenoid component placement.

Editorial Commentary: Acute Treatment Including Cerclage Result in Best Surgical Outcomes for High-Grade Acromioclavicular Joint Separations.

Despite years of research, optimal treatment of acute high-grade acromioclavicular joint (ACJ) separations remains controversial. ACJ separations occur in a "multiplanar" fashion and identification of horizonal plane instability is paramount to differentiate between high-grade versus low-grade injuries. As surgeons, we treat a self-selected group of patients referred for surgery, and our physiotherapy colleagues may rehabilitate many patients with both "low-grade" and "high-grade" separations who compensate. Of importance, ACJ separations stabilized <3 weeks after injury have the best chance of healing in a close-to anatomic position. The addition of the ACJ cerclage augmentation improves horizontal plane stability while the soft tissues heal and likely improves outcome.

Clinical and radiologic outcomes of Lima ProMade custom 3D-printed glenoid components in primary and revision reverse total shoulder arthroplasty with severe glenoid bone loss: a minimum 2-year follow-up.

BACKGROUND: The purpose of this study is to report the clinical and radiologic outcomes of patients undergoing primary or revision reverse total shoulder arthroplasty using custom 3D-printed components to manage severe glenoid bone loss with a minimum of 2-year follow-up. METHODS: Following ethical approval, patients were identified and invited to participate. Inclusion criteria were (1) severe glenoid bone loss necessitating the need for custom implants and (2) patients with definitive glenoid and humeral components implanted more than 2 years prior. Included patients underwent clinical assessment using the Oxford Shoulder Score (OSS), Constant-Murley score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and the quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH). Radiographic assessment included anteroposterior and axial projections. Patients were invited to attend a computed tomography (CT) scan to confirm osseointegration. Statistical analysis used descriptive statistics (mean and standard deviation [SD]) and paired t test for parametric data. RESULTS: Eleven patients declined to participate. Five patients were deceased prior to study commencement, leaving 42 remaining patients in this analysis. Three patients had revision surgery before the 2-year follow-up; of these, 2 retained their custom glenoid components. Mean follow-up was 31.6 months from surgery (range 24-52 months). All 4 scores improved: OSS from a mean 15 (SD 8.4) to 36 (SD 12) (P < .001), Constant-Murley score from a mean 15 (SD 11.2) to 52 (SD 20.1) (P < .001), QuickDASH from a mean 70 (SD 21) to 31 (SD 24.8) (P = .004), and the ASES score from a mean 22 (SD 17.8) to 71 (SD 23.3) (P = .007). Radiologic evaluation demonstrated good osseointegration in all but 1 included patient. CONCLUSION: The utility of custom 3D-printed components for managing severe glenoid bone loss in primary and revision reverse total shoulder arthroplasty yields significant clinical improvements in this complex cohort. Large complex glenoid bone defects can be managed successfully with custom 3D-printed glenoid components.

Validation of three classification systems for posterior malleolus fractures of the ankle.

PURPOSE: A number of classification systems exist for posterior malleolar ankle fractures. The user reliability of these classification systems remains unclear. The primary aim of this study was to evaluate the reliability of three commonly utilised classification systems for fractures of the posterior malleolus. METHODS: Imaging of 60 patients across 2 hospitals with ankle fractures including a posterior malleolar fragment was identified. All patients had undergone plain radiographs and computed tomography of their injured ankle as part of their normal standard of care. 9 surgeons including pre-resident/registrar level, resident/registrar level, and attending/consultant level applied the Haraguchi, Bartonícek, and Mason classifications to these fractures, at two timepoints, at least 4 weeks apart. The order was randomised between assessments. Inter-rater reliability was assessed using Fleiss' κ and standard error (SE). Intra-rater reliability was assessed using Cohen's κ and standard error (SE). RESULTS: Inter-rater reliability (Fleiss' κ) was calculated for the Haraguchi classification as 0.588 (SE 0.023), for the Bartonícek classification as 0.626 (SE 0.019), and the Mason classification as 0.541 (SE 0.098). Intra-rater reliability (Cohen's κ) was 0.761 (SE 0.098) for the Haraguchi classification, 0.761 (SE 0.091) for the Bartonícek, classification, and 0.724 (SE 0.096) for the Mason classification. CONCLUSIONS: This study reports the inter-rater and intra-rater reliability for three classification systems for posterior malleolus fractures. Based on definitions by Landis and Koch (Biometrics 33:159-174, 1977), inter-rater reliability was rated as 'moderate' for the Haraguchi and Mason classifications and 'substantial' for the Bartonícek classification. Similarly, the intra-rater reliability was rated as 'substantial' for all three classifications.

Editorial Commentary: Causes of Failure After Arthroscopic Rotator Cuff Repair.

Causes of failure after arthroscopic rotator cuff repair include patient factors, tear factors, and surgical factors. Failure may occur at the suture-tendon interface, the bone-tendon interface, or the bone-anchor interface. Low bone mineral density (BMD) in the greater tuberosity has been reported as a prognostic factor for recurrent tears following rotator cuff repair, and although most studies suggest the tendon-to-suture interface as the "weakest link," patients with low BMD may have lower suture anchor pull-out strength. A potential alternative cause of failure is the suture cutting through the greater tuberosity bone in patients with low BMD. Knotless suture bridge constructs or single-row constructs may be more susceptible to a suture cutting through the bone. The knotted suture bridge technique, wherein the medial mattress sutures are tied, may to some extent "shield" against complete cut-through. When bone quality appears poor, a common response is to change the type of anchor, size of anchor, or the location of the anchor. Other factors, such as bone preparation, suture type, suture tensioning, and anchor type (e.g., internal vs external locking), may all potentially affect suture cutting through weak bone.

Aerosol generating procedures in trauma and orthopaedics in the era of the Covid-19 pandemic; What do we know?

PURPOSE: COVID-19 pandemic has created havoc all over the globe and spared no one regardless of status, gender, location and ethnicity. There were questions raised if trauma and orthopaedic (T&O) procedures actually generated aerosols? The need for a review of literature highlighting the nature and impact of aerosol generation within T&O surgery was noted. METHODS: A comprehensive online search was performed for all published articles in the English language, evaluating AGPs in T&O surgery and the relevant personal protection equipment used. RESULTS: The search strategy populated 43 studies. Six studies were identified as duplicates. The shortlisted 37 studies were screened and nine studies were included in the review. An additional four studies were included from the bibliography review. CONCLUSION: Most orthopaedic procedures are high-risk aerosol generating procedures (AGPs). Conventional surgical masks do not offer protection against high-risk AGPs. In the current era of COVID-19 pandemic, there is a significant risk to the transmission of infection to the theatre staff. For protection against airborne transmission, appropriate masks should be used. These need proper fitting and sizing to ensure full protection when used.

Determining the rate of full-thickness progression in partial-thickness rotator cuff tears: a systematic review.

BACKGROUND: Partial-thickness rotator cuff tears are likely at least as common as full-thickness rotator cuff tears, and it is critical for surgeons to have knowledge of the tear progression rate of partial-thickness rotator cuff tears when determining surgical or nonsurgical treatment. However, a systematic review investigating the rate of tear progression of partial-thickness rotator cuff tears has not been performed. Therefore, the purpose of this study was to systematically review the literature and determine the rate of full-thickness progression in nonoperatively treated partial-thickness rotator cuff tears. METHODS: A systematic review of the literature was performed following the PRISMA guidelines and checklist using the PubMed, MEDLINE, and Cochrane Library databases. English-language studies of Level I through IV evidence examining partial-thickness rotator cuff tears with description of the change in tear size were included. Studies using imaging modalities other than magnetic resonance imaging (MRI) or ultrasonography (US) for serial imaging and studies without description of the number of tears that progressed to full-thickness tears were excluded. The primary outcome was to determine the per-month progression rate from a partial-thickness tear to a full-thickness tear confirmed on either MRI or US. The progression rates, which were divided into 3 groups-symptomatic, asymptomatic and combined (asymptomatic + symptomatic)-were calculated using a random effects model with binomial within-study variance. RESULTS: Four studies were included, and 257 tears were analyzed statistically for tear progression. The average follow-up was 34 months (standard deviation, 19 months). The overall rate of progression to a full-thickness tear was 0.26% per month (95% confidence interval [CI], 0.15%-0.36% per month). In the symptomatic and asymptomatic groups, the rates were 0.22% per month (95% CI, 0.09%-0.34% per month) and 0.32% per month (95% CI, 0.15%-0.49% per month), respectively, which showed no significant difference (P =.341). CONCLUSIONS: This study demonstrated that partial-thickness tears progress to full-thickness tears over time but at a relatively low rate at short- to intermediate-term follow-up. There was no significant difference in the per-month rates of full-thickness progression between symptomatic and asymptomatic tears.

The Bankart repair: past, present, and future.

Arthur Sidney Blundell Bankart was a London-based orthopedic surgeon who discovered the essential lesion in recurrent anterior shoulder instability in 1923. He pioneered a technique, the Bankart repair, to re-establish stability to the glenohumeral joint, without sacrificing native joint motion. In this article, the original Bankart repair is compared to the modern arthroscopic Bankart repair, accompanied by a surgical video of Blundell Bankart performing the Bankart repair in 1951, shortly before his death. Bankart's original description included an open repair with a coracoid osteotomy and subscapularis tenotomy and repair. The history of the technique, its utility in present day, and the future of the Bankart repair are discussed.

Rotator cuff repair with biological graft augmentation causes adverse tissue outcomes.

Background and purpose - Biological patches can be used to augment rotator cuff tendon repair in an attempt to improve healing and reduce rates of re-rupture. However, little is known about the in vivo tissue response to these patches. We assessed native rotator cuff tissue response after surgical repair and augmentation with 2 commercially available extracellular matrix (ECM) patches. Patients and methods - Patients underwent a rotator cuff repair augmented with either GraftJacket (Wright Medical), Permacol (Zimmer Biomet), or no patch (Control), applied using an onlay technique. A sample of supraspinatus tendon was collected intraoperatively and 4 weeks post-surgery, using ultrasound-guided biopsy. Histology and immunohistochemistry were performed on all samples. Results - The Permacol group (n = 3) and GraftJacket group (n = 4) demonstrated some changes in native tendon ECM compared with the control group (n = 3). Significant disruption of the extracellular matrix of the repaired native supraspinatus, underlying both patches, was observed. The patches did not generally increase cellularity, foreign body giant cell count, or vascularity compared to the control group. 1 patient in the Permacol group had an adverse tissue immune response characterized by extensive infiltration of IRF5+, CD68+, and CD206+ cells, suggesting involvement of macrophages with a pro-inflammatory phenotype. No significant differences in protein expression of CD4, CD45, CD68, CD206, BMP7, IRF5, TGFß, and PDPN were observed among the groups. Interpretation - Histological and immunohistochemical analysis of native tendon tissue after patch augmentation in rotator cuff repair raises some concerns about a lack of benefit and potential for harm from these materials.

An audit of clinical training exposure amongst junior doctors working in Trauma & Orthopaedic Surgery in 101 hospitals in the United Kingdom.

BACKGROUND: There are concerns regarding early years' training for junior doctors in Trauma & Orthopaedic Surgery (T&O) in the United Kingdom. Our primary objective was to audit the clinical activities undertaken by junior doctors working in Trauma & Orthopaedic (T&O) surgery in the National Health Service (NHS) in a typical workweek. A secondary objective was to audit the clinical exposure of junior surgeons in training to the Joint Committee on Surgical Training (JCST) standards for minimum weekly clinical exposure in T&O surgery. METHODS: We recruited collaborators in 101 T&O surgery departments in NHS hospitals to participate in this study. Clinical activity diaries from 935 doctors working in T&O surgery in the 101 participating NHS hospitals were involved. All junior doctors covering the junior on call tier were included. Collaborators collected clinical activity data from 08:00 18/01/2015 to 20:00 22/01/2015. Clinical activities recorded in sessions (morning, afternoon, evening) depending on what activity that doctor undertook for the majority of that session. Clinical activities were grouped into operating theatre/room, outpatient clinic, on call, "not in work" (i.e. leave, sickness), teaching, and ward cover sessions. The weekly clinical activity of Core Surgical Trainees (CSTs) were analyzed in accordance to two JCST standards for minimum weekly clinical exposure. RESULTS: Overall, junior doctors working in T&O surgery attended a theatre list session 8.5% of the time, an outpatient clinic 3.2%, were on call 14.8%, a teaching session 1.7%, providing ward cover 34.6%, and on a zero session 20.7% of the time. Only 5% of core surgical trainees (n = 200) met both the JCST standards for minimum weekly clinical exposure in the specialty. CONCLUSIONS: Junior surgeons in training, working in Trauma & Orthopaedic surgery in the United Kingdom are not meeting the minimum weekly clinical sessions laid out by the JCST. Further work to develop models allowing for enhanced training experiences and improved clinical exposure to operating lists and outpatient clinics would be beneficial.

Correction to: An audit of clinical training exposure amongst junior doctors working in Trauma & Orthopaedic Surgery in 101 hospitals in the United Kingdom.

CORRECTION: Following publication of the original article [1], the corresponding author wrote to say that he had missed the names of some of the collaborators in the list he sent to the typesetters. In addition, there was a spelling error in one of the author's names: instead of Nagriz Seyidova it should read Nargiz Seyidova. The complete list of collaborators is as follows.

Intra-operative fluoroscopic radiation exposure in orthopaedic trauma theatre.

INTRODUCTION: Radiation exposure from intra-operative fluoroscopy in orthopaedic trauma surgery is a common occupational hazard. References for fluoroscopy use in the operating room for commonly performed operations have not been reported adequately. This study aimed to report appropriate intra-operative fluoroscopy use in orthopaedic trauma and compare the effect of surgery type and surgeon grade on radiation exposure. METHODS: Data on 849 cases over an 18-month period were analysed retrospectively. Median and 75th centile values for dose area product (DAP), screening time (ST), and number of fluoroscopy images were calculated for procedures where n > 9 (n = 808). RESULTS: Median DAP for dynamic hip screws for extracapsular femoral neck fractures was 668 mGy/cm2 (ST 36 s), 1040 mGy/cm2 (ST 49 s) for short proximal femoral nail, 1720 mGy/cm2 (ST 2 m 36 s) for long femoral nail for diaphyseal fractures, 25 mGy/cm2 (ST 25 s) for manipulation and Kirschner wire fixation in distal radius fractures, and 27 mGy/cm2 (ST 23 s) for volar locking plate fixation in distal radius fractures. These represented the five commonest procedures performed in the trauma operating room in our hospital. Experienced surgeons utilized less radiation in the operating room than junior surgeons (DAP 90.55 vs. 366.5 mGy/cm2, p = 0.001) and took fewer fluoroscopic images (49 vs. 66, p = 0.008) overall. CONCLUSIONS: This study reports reference values for common trauma operations. These can be utilized by surgeons in the operating room to raise awareness and perform clinical audits of appropriate fluoroscopy use for orthopaedic trauma, using this study as guidance for standards. We demonstrated a significant reduction in fluoroscopy usage with increasing surgeon experience.

Increasing age and tear size reduce rotator cuff repair healing rate at 1 year.

Background and purpose - There is a need to understand the reasons why a high proportion of rotator cuff repairs fail to heal. Using data from a large randomized clinical trial, we evaluated age and tear size as risk factors for failure of rotator cuff repair. Patients and methods - Between 2007 and 2014, 65 surgeons from 47 hospitals in the National Health Service (NHS) recruited 447 patients with atraumatic rotator cuff tendon tears to the United Kingdom Rotator Cuff Trial (UKUFF) and 256 underwent rotator cuff repair. Cuff integrity was assessed by imaging in 217 patients, at 12 months post-operation. Logistic regression analysis was used to determine the influence of age and intra-operative tear size on healing. Hand dominance, sex, and previous steroid injections were controlled for. Results - The overall healing rate was 122/217 (56%) at 12 months. Healing rate decreased with increasing tear size (small tears 66%, medium tears 68%, large tears 47%, and massive tears 27% healed). The mean age of patients with a healed repair was 61 years compared with 64 years for those with a non-healed repair. Mean age increased with larger tear sizes (small tears 59 years, medium tears 62 years, large tears 64 years, and massive tears 66 years). Increasing age was an independent factor that negatively influenced healing, even after controlling for tear size. Only massive tears were an independent predictor of non-healing, after controlling for age. Interpretation - Although increasing age and larger tear size are both risks for failure of rotator cuff repair healing, age is the dominant risk factor.

Arthroscopic "Remplissage" for shoulder instability: a systematic review.

PURPOSE: Large Hill-Sachs lesions engaging the glenoid rim predispose to recurrent anterior instability and failure of isolated labrum repairs. In arthroscopic remplissage, the posterior capsule and infraspinatus are sutured into the humeral defect to limit such engagement. This systematic review assessed the outcomes and complications of arthroscopic remplissage for anterior shoulder instability. METHODS: A search of the MEDLINE, EMBASE and evidence-based medicine Cochrane databases was conducted. Data were extracted by two reviewers in a standardised manner. Redislocation, instability and complication rates were calculated and expressed as percentages with 95 % confidence intervals. RESULTS: Of 4,284 studies identified, eight articles with a total of 207 patients were analysed. Mean redislocation rate was 4.2 ± 3.9 % (range 0-15 %), and mean recurrent instability rate 3.2 ± 3.8 % (0-15 %). Posterosuperior shoulder pain and stiffness were the only complications described. Overall, there was a mean reduction in external rotation in adduction of 5.6° (-40 to +30), reduction in external rotation in abduction of 11.3° (-50 to +7) and reduction in internal rotation of 0.9 (-4 to 0) vertebral levels. CONCLUSIONS: Arthroscopic remplissage alongside anterior labrum repair seems successful in treating recurrent shoulder instability in the presence of large or engaging Hill-Sachs lesion. However, the available literature consists mainly of heterogeneous case series. There is a need for a high-quality randomised trial to compare remplissage with other commonly used techniques for recurrent instability associated with substantial Hill-Sachs defects such as the Latarjet procedure. LEVEL OF EVIDENCE: Systematic review, Level IV.

The sound of orthopaedic surgery--the application of acoustic emission technology in orthopaedic surgery: a review.

Acoustic emission technology has been developed and extensively used as a non-destructive method of testing within engineering. In recent years, acoustic emission has gained popularity within the field of Orthopaedic research in a variety of situations. It is an attractive method in the detection of flaws within structures due its high sensitivity and non-destructive nature. The aim of this article is firstly to critically review the research conducted using acoustic emission testing in a variety of Orthopaedic-related situations and to present the technique to the wider Orthopaedic community. A summary of the principles and practical aspects of using acoustic emission testing are outlined. Acoustic emission has been validated as a method of early detection of aseptic loosening in femoral components in total hip arthroplasty in several well-conducted in vitro studies [1-3]. Other studies have used acoustic emission to detect microdamage in bone and to assess the biomechanical properties of bone and allografts [9]. Researchers have also validated the use of acoustic emission to detect and monitor fracture healing [4]. Several studies have applied acoustic emission to spinal surgery and specifically to assess the biomechanical environment in titanium mesh cages used in spinal surgery [10, 11]. Despite its growing popularity within Orthopaedic research, acoustic emission remains are relatively unfamiliar technique to the majority of Orthopaedic surgeons.

Subacromial Balloon Spacer for the Massive Irreparable Cuff Tear.

PURPOSE OF REVIEW: The purpose of the review is to provide an updated overview of a relatively novel but controversial surgical device (InSpace subacromial balloon, Stryker, Kalamazoo, MI) that can be readily incorporated into the armamentarium of the shoulder surgeon. The authors review the critical clinical and surgical decision-making aspects of InSpace. A recommended surgical technique and rehabilitation protocol are outlined. The authors present a nuanced view of the balloon spacer in the continuum of care of the irreparable rotator cuff tear. RECENT FINDINGS: Within the last year, two Level I clinical trials have been published, and the data from these studies offer conflicting evidence regarding the utility of the subacromial balloon spacer. The current review contrasts these two recent studies and offers a framework by which the available evidence can be practically understood with respect to clinical decision-making. The literature currently supports a limited indication for use of InSpace: the elderly, low-demand patient with preserved active range of motion with an operatively irreparable, posterosuperior rotator cuff tear with an intact subscapularis. The InSpace subacromial balloon spacer is a simple device that can yield substantial improvements in clinical outcomes among a subset of patients with irreparable rotator cuff tears. InSpace is not a panacea for the complex, irreparable rotator cuff tear. Individualized decision-making is necessary in this diverse and challening patient population.