Operative vs. conservative treatment of AC-Joint Dislocations Rockwood grade ≥ III -An economical and clinical evaluation.

INTRODUCTION: Acromioclavicular joint dislocations (ACD) are one of the most common shoulder injuries. There is no consensus in how to treat higher graded ACD ≥ Rockwood grade III. This study compares operative versus conservative treatment regarding costs and clinical outcome parameters. MATERIALS AND METHODS: This retrospective, consecutive case-control-study includes 14 patients. Seven operatively treated patients were matched, by Rockwood grade, with seven conservatively treated patients. The cost was extracted out of the clinical- and insurance-based cost sheets and furthermore these include the loss of earnings. Clinical examination, demographic data as well as different outcome-questionnaires were recorded. RESULTS: There were no significant differences between operative and conservative treated patients for outcome Questionnaires. Of note, there was a significantly higher incidence of tenderness over the AC-joint (p = 0.0038) postoperatively. As expected, economical evaluation showed various findings in favor of the conservative treatment. The costs for medical services (11012.39vs.1163.81USD; p = 0.0061), days of hospitalization (3.3vs.0days; p < 0.0001); total cost for medical treatment (30262.17 vs. 7833.82 USD; p = 0.0358) were significantly higher in the operative group. CONCLUSION: Even with a limited case number and a retrospective study design almost all clinical results were equal in both groups. Operative therapy of higher graded ACDs (Rockwood > III) compared to conservative is economically inefficient. Under consideration of clinical comparable results, indications for operative treatment should be set very carefully.

Plantar Plating in the Modified Lapidus Procedure: Evaluation of Function and Impairment of the Tibialis Anterior Tendon.

The modified "Lapidus" procedure (MLP) describes the arthrodesis of the first tarsometatarsal joint. We investigate if there are detectable changes of the tendon or the function of the muscle and clinical outcome after MLP. We reviewed 22 feet. All patients underwent magnetic resonance imaging (MRI) at an average of 27 (range, 12-49) months. Clinical outcome was evaluated using the European Foot and Ankle Society score. Strength was measured and complications were assessed. MRI revealed signs of tendinopathy of the tibialis anterior tendon in 13 feet (59%). The mean total European Foot and Ankle Society score at final follow-up was 17 (range, 6-24) points. The mean postoperative Visual Analog Scale score was 1.4 (range, 0-5). Range of motion and force data were not significantly different to the contralateral side. In conclusion, MRI showed signs of tendinopathy in 59%, which does not seem to affect clinical outcome, but has to be considered when choosing the desired implant and placement. MLP leads to high patient satisfaction rates and significant improvement at midterm follow up.

The Metatarsal Cortical Index as an Indicator of Insufficiency Fracture of the Foot.

The diagnosis of metatarsal stress fractures is challenging. Standard imaging often shows false-negative results. The aim of this study was to create reliable radiologic outcome parameters to predict insufficiency fractures of the metatarsals. We performed an age- and sex-matched case-control study of patients with (n = 18) and without insufficiency fracture (n = 18) of the foot. The metatarsal cortical index (MCI) for each metatarsal was developed to predict an insufficiency fracture. The MCI of each metatarsal was significantly decreased in the insufficiency fracture group compared with the control group (p < .01). The MCI of the fourth ray yielded the highest area under the curve among the analyzed MCI values (area under the curve, 0.79; 95% confidence interval, 0.61-0.90). A cut-off value of 1.62 for the MCI of the fourth ray yielded a sensitivity of 78% and a specificity of 78% to predict insufficiency fracture of the foot (odds ratio, 12.25; 95% confidence interval, 2.54-58.97), and enabled accurate allocation to the insufficiency fracture group versus the control group in 74% of cases. In conclusion, a decreased MCI is associated with metatarsal insufficiency fractures and enables an accurate diagnosis in 3 out of 4 cases. The MCI might aid clinicians in identifying insufficiency fracture, and raise the suspicion of the diagnosis without additional imaging studies.

Scarf osteotomy for hallux valgus deformity: Radiological outcome, metatarsal length and early complications in 118 feet.

BACKGROUND: Scarf osteotomy has been widely used to restore axial orientation of the first ray in the treatment of hallux valgus deformity. The aim of the study was to present our radiological outcomes of bunion reconstruction, identify surgical complications in early follow-up, and assess to what extent a shortening of the first metatarsal is present after surgery as a possible cause of postoperative metatarsalgia. METHODS: We enrolled 106 patients (118 feet) and assessed patients' pre- and postoperative measurements of hallux valgus and intermetatarsal angles on weightbearing X-ray images. Three different methods of measuring metatarsal length were compared and early postoperative complications noted. RESULTS: Hallux valgus angle decreased significantly by an average of 18.7 degrees and the intermetatarsal angle by 7.8 degrees. Using three methods of measuring metatarsal length, all showed significant shortening of the first metatarsal. Mean relative lengthening of the second metatarsal averaged 0.45mm. The Coughlin method showed the highest interrater reliability (ICC=0.96). CONCLUSIONS: Significant reduction of the hallux valgus angle and intermetatarsal angle was demonstrated with a low complication rate. There was significant shortening of the first metatarsal. The Coughlin method clearly demonstrated an excellent interrater reliability. LEVEL OF EVIDENCE: Level IV.

Whole spine localizers of magnetic resonance imaging detect unexpected vertebral fractures.

BACKGROUND: Whole spine localizers (WS-loc) of magnetic resonance imaging (MRI) are performed for enumeration of the vertebrae but they can be also used for the evaluation of the spine. PURPOSE: To assess the accuracy of fracture detection using WS-locs of MRI and compare the findings with standard high-resolution short tau inversion recovery (STIR) sequences, and to determine whether the review of WS-locs is useful and if additional information can be gained by assessing the thoracic spine section of the WS-locs. MATERIAL AND METHODS: A total of 298 magnetic resonance (MR) examinations of the lumbar spine with WS-locs were evaluated. Two independent readers reviewed the images. In case of fracture detection, further characterization of the fracture was performed. To assess inter-reader agreement, unweighted Cohen's kappa with 95% confidence intervals (CI) and Phi coefficients were calculated. RESULTS: The study sample included 187 female and 111 male patients (age range = 65-94 years; median age = 75.0 years). The WS-locs detected 42 fractures of the lumbar spine and 36 of the thoracic spine. Inter-reader agreement for fracture detection in the lumbar and thoracic spine was strong (K = 0.87, 95% CI = 0.78-0.95, Phi = 0.87, and K = 0.88, 95% CI = 0.79-0.96, Phi = 0.88, respectively). CONCLUSION: WS-locs from MR examinations of the lumbar spine provide a good diagnostic tool for the detection and evaluation of unsuspected vertebral fractures. WS-locs show strong inter-reader agreement for fracture detection in the thoracic and lumbar spine.

Anatomy-based MRI assessment of the iliopsoas muscle complex after pertrochanteric femoral fracture.

OBJECTIVE: To evaluate the quality of the iliopsoas muscle complex after pertrochanteric femoral fracture, using MRI; to propose an anatomy-based evaluation of the iliopsoas muscle complex; and to determine the inter-reader reliability of two classifications of fatty muscle degeneration. MATERIALS AND METHODS: We included adult patients with a displaced lesser trochanter following pertrochanteric femoral fracture. Muscle quality was evaluated using the Goutallier and Slabaugh classifications at three levels (L4/L5, L5/S1, and the anterior inferior iliac spine). Two radiologists independently reviewed the MRIs, and force measurement was performed on both hips. Linear mixed-effects models were used to determine the effect of fracture on muscle quality and strength, and Cohen's kappa statistic was used to assess inter-reader agreement. RESULTS: In the 18 patients included, the iliopsoas muscle complex showed higher grades of fatty muscle degeneration on the fractured side than on the non-fractured side. The mean difference between muscle strength on the fractured vs the non-fractured side was -12 N (p > 0.05). Inter-reader agreement for the Goutallier and Slabaugh classifications was good and very good respectively (weighted K = 0.78 and 0.85 respectively). CONCLUSION: Fatty muscle degeneration of the iliopsoas muscle complex after pertrochanteric femoral fracture was evident using both classification systems; however, fatty muscle degeneration resulted in only a minimal reduction of muscle strength. To provide a thorough assessment of iliopsoas muscle complex quality, we suggest evaluating it at different anatomical levels. Regarding inter-reader agreement, the Slabaugh classification was superior to the Goutallier classification.

Application of Cinematic Rendering in Clinical Routine CT Examination of Ankle Sprains.

OBJECTIVE: Cinematic rendering technique is used to generate almost photorealistic 3D reconstructions of volumetric data. The purpose of this study was to evaluate the feasibility of cinematically rendered reconstructions in routine CT examinations of ankle sprains. CONCLUSION: Cinematic rendering technique may be primarily used to deliver visual information to patients, physicians, and virtual anatomy classes. Postprocessing requires more time than traditional methods do, which can be a hindrance in clinical work.

No difference in flexion power despite iliopsoas fatty degeneration in healed hip fractures with large lesser trochanter displacement.

OBJECTIVE: To evaluate iliopsoas atrophy and loss of function after displaced lesser trochanter fracture of the hip. DESIGN: Cohort study. SETTING: District hospital. PATIENTS: Twenty consecutive patients with pertrochanteric fracture and displacement of the lesser trochanter of > 20 mm. INTERVENTION: Fracture fixation with either an intramedullary nail or a plate. OUTCOME MEASUREMENTS: Clinical scores (Harris hip, WOMAC), hip flexion strength measurements, and magnetic resonance imaging findings. RESULTS: Compared with the contralateral non-operated side, the affected side showed no difference in hip flexion force in the supine upright neutral position and at 30° of flexion (205.4 N vs 221.7 N and 178.9 N vs. 192.1 N at 0° and 30° flexion, respectively). However, the affected side showed a significantly greater degree of fatty infiltration compared with the contralateral side (global fatty degeneration index 1.085 vs 0.784), predominantly within the psoas and iliacus muscles. CONCLUSION: Severe displacement of the lesser trochanter (> 20 mm) in pertrochanteric fractures did not reduce hip flexion strength compared with the contralateral side. Displacement of the lesser trochanter in such cases can lead to fatty infiltration of the iliopsoas muscle unit. The amount of displacement of the lesser trochanter did not affect the degree of fatty infiltration. LEVEL OF EVIDENCE: II.

[Frozen Shoulder - a short review for the practice].

INTRODUCTION: The Frozen Shoulder is a frequently encountered pathology in clinical practice. This condition often coexists with various comorbidities and is characterized by severe pain and a significantly restricted motion of the affected shoulder. A limited passive external rotation with the arm in adduction, with no signs of any other pathology that could explain the finding, such as shoulder osteoarthritis or an undetected posterior dislocation, is pathognomonic. The course of the disease typically spans over one to two years and is usually self-limiting. In the vast majority of cases, this condition can be managed conservatively. Keywords: shoulder, shoulder stiffness, shoulder pain, conservative therapy.

Proximal anterior cruciate ligament tears: the healing response technique versus conservative treatment.

The healing response technique (HRT) is a nonreconstructive method to promote healing in proximal anterior cruciate ligament (ACL) tears. The study reviews clinical and radiological long-term results. Thirty patients (average age 31 years) were treated according to the protocol described by Steadman et al. For comparison, an age- and gender-matched control group of conservatively treated patients (CST; n = 127) was selected. At follow-up (mean: 4 years), all patients were evaluated using Kneelax-3-arthrometer, magnetic resonance imaging (MRI), and by clinical examination. Two HRT patients were lost to follow-up and 10 (36%) patients needed definitive ACL reconstruction. The rate of secondary ACL reconstruction in the initial CST group was 56% (71 of 127). Nineteen of the conservatively treated patients were selected according to above-mentioned criteria. The average Lysholm score in the HRT group was 91 (CST group = 90), and the Orthopaedische Arbeitsgemeinschaft Knie score was 93 (CST group = 92). Tegner score decreased from 6.8 before injury to 5.7 at the time of follow-up (CST group: 6.0 to 5.1). Kneelax-3-arthrometer showed a significant higher anterior knee laxity compared with the noninjured side in both groups. MRI showed improvement of the ACL in both groups. HRT in adult patients is associated with a high revision rate of 36% secondary ACL reconstruction, comparable with primary conservative treatment (p = 0.056). For the remaining patients (64%), HRT did not result in better outcomes than conservative treatment.

Structural and Functional Results of Subscapularis and Conjoint Tendon After Latarjet Procedure at 8-Year Average Follow-up.

BACKGROUND: The Latarjet procedure involves initial dissection through a longitudinal split of the subscapularis tendon with only a final partial closure to accommodate the transferred coracoid bone. Furthermore, by transferring the coracoid bone block to the anterior glenoid, the surgeon completely alters the resting and dynamic route of the attached conjoint tendon. The eventual structural and functional integrity of the subscapularis and conjoint tendons is currently unknown. PURPOSE: To examine the structural and functional integrity of the subscapularis and the conjoint tendon after the Latarjet procedure at an 8-year average follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty patients with anterior shoulder instability at a mean age of 30 years (range, 19-50 years) underwent the open Latarjet procedure. Clinical examination at the final follow-up included quantitative isometric measurement of abduction and internal rotation strength compared with the nonoperative side. Patients were assessed via radiograph examination and preoperative computed tomography. Final position and healing of the transferred coracoid bone block were evaluated using standard radiographs. At follow-up, the subscapularis and conjoint tendon were evaluated via magnetic resonance imaging (MRI) with metal artifact reduction techniques and via ultrasound. RESULTS: Nineteen of the 20 shoulders remained stable at the final follow-up; there was 1 redislocation (5%) after 14 months. The mean Rowe score was 83 points (SD, 17.9 points), the mean Constant score was 85 points (SD, 8.1 points), and the Subjective Shoulder Value was 80% (SD, 18%). The mean abduction strength of the operative shoulder was 7.41 ± 2.06 kg compared with 8.33 ± 2.53 kg for the nonoperative side (P = .02). The mean internal rotation strength at 0° for the operative shoulder was 8.82 ± 3.47 kg compared with 9.06 ± 3.01 kg for the nonoperative side (P = .36). The mean internal rotation strength in the belly-press position for the operative shoulder was 8.12 ± 2.89 kg compared with 8.50 ± 3.03 kg (P = .13). Four of 20 shoulders showed mild tendinopathic changes of the subscapularis tendon but no partial or complete tear. One patient exhibited fatty degeneration Goutallier stage 1. Conjoint tendon was in continuity in all 20 shoulders on MRI scans. CONCLUSION: Abduction, but not internal rotation strength, was slightly reduced after the Latarjet procedure at a mean of 8 years of follow-up. The subscapularis tendon was intact based on ultrasound examination, and the conjoint tendon was intact based on MRI scans. Subscapularis muscle girth relative to the supraspinatus muscle remained intact from preoperative measurements based on MRI scans.

Long-Term Clinical and Radiological Results After Hook Plate Osteosynthesis of Lateral Clavicle Fractures.

OBJECTIVES: To assess both clinical and radiological long-term outcomes after hook plate osteosynthesis for Neer type II lateral clavicle fractures. DESIGN: Retrospective case series. SETTING: Level-1 trauma center. PATIENTS/PARTICIPANTS: Patients who underwent open reduction internal fixation with a hook plate for displaced fractures of the lateral third of the clavicle (Neer type II) at a single trauma hospital were identified. INTERVENTION: Lateral clavicle open reduction internal fixation with a hook plate. MAIN OUTCOME MEASURES: At the first of 2 long-term follow-up appointments, bilateral magnetic resonance imaging (MRI) scans and strength measurements were performed, Constant-Murley score, subjective shoulder value (SSV), and Oxford shoulder score (OSS) of both shoulders were obtained. At the second follow-up, specific acromioclavicular (AC) score, SSV, and OSS were obtained. RESULTS: Twenty-one patients (mean age, 29.5 ± 9.7 years) could be included who were available for at least 1 of 2 follow-ups after 7.4 years (±2.3) and 13.9 years (±2.2). Bony union was achieved in all patients (100%) at an average of 3.4 months (±1.4). The hook plate was removed at an average of 5.5 months (±3.3) after initial surgery in all patients. No significant side-to-side differences were found in OSS, Constant-Murley score, SSV, and specific AC score and for strength testing and MRI scans. CONCLUSIONS: Long-term outcome after hook plate fixation of Neer type II lateral clavicle fractures demonstrated good clinical results and shoulder strength without higher radiographic rates of AC joint osteoarthritis, subacromial impingement, or rotator cuff lesions. That may be related to a standardized early plate removal after bony fracture union. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Characterization of Deposits in Calcific Tendinitis of the Shoulder: Deposits Are Composed of Large Aggregates of Highly Crystalline, Rod-Like Crystals.

BACKGROUND: In the current literature, deposits in calcific tendinitis are described as amorphous masses of hydroxyapatite with a size in the range of 5 to 20 µm. Theoretically, these are too big to be phagocytized by macrophages and induce an inflammatory reaction. PURPOSE: To better characterize the deposits seen in calcific tendinitis. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Included in the study were 6 patients with a history of at least 1 year of shoulder pain (range, 1-14 years). Shoulder arthroscopy was performed under general anesthesia, and calcium deposits from the supraspinatus tendon and biopsies from the adjacent subacromial bursa were taken. Samples were analyzed by light microscopy and immunostained for macrophages. Scanning electron microscopy and energy-dispersive x-ray (EDX) analysis were used to assess the morphology and chemical composition of the calcific deposits. RESULTS: Light microscopy showed round and bulky calcium deposits partially surrounded by activated CD68-positive macrophages within inflammatory tissue. Some hemosiderin positive mononuclear cells, indicative for (micro-) hemorrhage, were seen. Scanning electron microscopy revealed that the large calcific deposits (1-20 µm) were composed of rod-like structures. These highly crystalline rods had a size of approximately 100 nm in length and 20 nm in width. Chemical composition by EDX analysis showed that crystals were composed of mainly calcium, oxygen, and phosphorus, equaling the chemical composition of hydroxyapatite. CONCLUSION: Deposits in calcific tendinitis of the rotator cuff are not amorphous but composed of highly crystalline structures. Fragmentation of these aggregates and subsequent release of the needle-like nanocrystals might initiate the strong inflammatory reaction often seen in patients with calcifying tendinitis of the rotator cuff.

How Should We Grade Cervical Disk Degeneration? A Comparison of Two Popular Classification Systems.

INTRODUCTION: Despite being originally developed for the evaluation of lumbar disk degeneration, the Pfirrmann classification has emerged as the most popular classification system for cervical disk degeneration. However, with the Suzuki classification, a new classification system that is specifically tailored for the evaluation of cervical disk disease was introduced. In this study, we aim to evaluate differences in inter- and intraobserver reliability of both classifications in a head-to-head comparison. METHODS: In total, we have evaluated 120 cervical disks within 40 patients via magnetic resonance imaging according to the Pfirrmann and Suzuki classification. The degree of disk degeneration was evaluated by two independent musculoskeletal radiologists. After 6 months, the classification was reassessed to evaluate the intraobserver reliability. The inter- and intraobserver reliabilities were then calculated using Cohen's kappa. RESULTS: The inter- and intraobserver reliability provided a significant agreement between all ratings in Pfirrmann as well as the Suzuki classification (p>0.001). The interobserver reliability was determined to be fair in both the Suzuki classification (κ=0.290) and the Pfirrmann classification (κ=0.265). The intraobserver reliability was substantial in the Suzuki classification (κ=0.798), while it was almost perfect in the Pfirrmann classification (κ=0.858). CONCLUSIONS: Although not designed for the evaluation of cervical disk degeneration, the Pfirrmann classification yielded equal inter- and higher intraobserver reliability. Both classification systems are viable options for the grading of cervical disk degeneration. While the Pfirrmann classification has the advantage of being better established, the Suzuki classification may be clinically superior due to a better representation of cervical disk degeneration and the consideration of disk bulging for the classification of cervical disk degeneration.

Plate Fixation for Irreducible Proximal Humeral Fractures in Children and Adolescents-A Single-Center Case Series of Six Patients.

BACKGROUND: Recommended treatment for severely displaced proximal humeral fractures in children is the closed reduction and percutaneous fixation by K-wires or intramedullary nailing. METHODS: From January 2016 to January 2017 6, 21 children/adolescents (range 8 to 16 years) with proximal humeral fractures were treated surgically for severe displacement. In these six patients, several attempts of closed reduction were unsuccessful, and an open reduction was performed. The humeral head was fixed with a 3.5 mm T-plate without affecting the growth plate. Plate removal was performed at a mean interval of 132 days after initial surgery. Two years after initial surgery, the clinical outcome was assessed by the Constant-Murley score and QuickDASH score (including sport/music and work) and the shoulder joint was evaluated with a standardized sonographic examination for the rotator cuff and the conjoint tendon. RESULTS: In all six patients, dorsal displacement of the fracture was irreducible due to the interposition of tendinous or osseous structures. Intraoperatively, the interposed structures were the long biceps tendon in two, periosteal tissue in two, a bony fragment in one, and the long biceps tendon together with the conjoint tendon in one case. At mean follow-up of 26 months (range 22 months to 29 months), patients showed very good clinical results with an excellent mean Constant-Murley score of 97.5 (range 91 to 100) and mean QuickDASH score (including sport/music and work) of 5.5 (range 0-20.8). An X-ray follow-up 6 weeks after surgery demonstrated early consolidation and correct alignment in all patients. A sonographic evaluation at 2 years post injury showed that the biceps and the conjoined tendon were intact in all patients. CONCLUSIONS: If a proximal humeral fracture is not reducible by closed means, a tissue entrapment (most likely biceps tendon) should be considered. Treatment with an open reduction and plate fixation yields very good clinical and radiological results and preserves interposed structures as the biceps and conjoint tendon.

Cervical disc degeneration reduces distance between vertebral artery and surgical landmarks.

PURPOSE: Anterior cervical decompression surgery exposes the vertebral artery to the risk of injury. This risk can increase if the natural course of the vertebral artery is altered. Therefore, this study evaluated if the distance between surgical landmarks and the vertebral artery decrease with the progression of cervical disc degeneration. METHODS: This study analyzed 40 patients with cervical magnetic resonance imaging. We evaluated the distance between the uncinate process and the vertebral artery in axial-plane T2 weighted sequences of the cervical levels C3-C6. The cervical disc degeneration was graded according to the Pfirrmann- and Suzuki classification. The decrease of the distance was evaluated using a one-way ANOVA. RESULTS: The distance between the uncinate process and the vertebral artery decreased with increasing disc degeneration (p ≤ 0.015). ROC analysis provided an acceptable area under the curve in both classifications for the detection of a vertebral artery to the uncinate process distance of zero. The presence of Pfirrmann grade V had a positive predictive value of 69% for the presence of contact between the uncinate process and the vertebral artery. CONCLUSION: High-grade cervical disc degeneration according to the Pfirrmann- and the Suzuki classification decrease the distance between the uncinate process and the vertebral artery. High-grade disc degeneration therefore should raise the awareness of the surgeon for the loss of the distance between surgical landmarks and the vertebral artery. However, screening for high-grade disc degeneration alone cannot substitute the thorough evaluation of the anatomical course of the vertebral artery before surgery.

Non-Adherence to Pain Medication Increases Risk of Postoperative Frozen Shoulder.

BACKGROUND: Postoperative frozen shoulder (FS) or adhesive capsulitis is a relatively frequent complication (5-20%), even after simple arthroscopic shoulder surgeries. The pathophysiology is still unclear, but psychological factors may play a pivotal role. From clinical experience, we hypothesized that patients, who are reluctant to take medications, particularly "pain-killers," have an increased incidence of postoperative FS. METHODS: We identified twenty patients who underwent limited arthroscopic operations of the shoulder and developed postoperative FS. Twenty patients with matching type of surgery, age, and gender served as control group (n = 20). All patients were at least one year postoperative and asymptomatic at the time of examination. Demographic data, the patient's adherence to self-medication (including self-medicating scale, SMS), development the Quality of life (QoL), and depression scale (PHQ-4-questionnaire) were assessed. RESULTS: Patients with FS had a 2-fold longer rehabilitation and 3-fold longer work inability compared to the patients without FS (P < 0.009 and P < 0.003, respectively). Subjective shoulder value SSV (P = 0.075) and post-operative improvement of QoL (P = 0.292) did not differ among the groups. There was a trend-but not significant-toward less coherence to self-medication in the FS-group (26.50 vs. 29.50; P = 0.094). Patients with postoperative FS significantly more often stated not to have "taken pain-killers as prescribed" (P = 0.003). CONCLUSIONS: Patients reporting unwillingness to take the prescribed pain medications had a significantly higher incidence of postoperative FS. It remains unclear whether the increased risk of developing FS is due to reduced postoperative analgesia or a critical attitude toward taking medication. However, patients who are reluctant to take painkillers should strongly be encouraged to take medications as prescribed.

Cerebrospinal fluid proteome shows disrupted neuronal development in multiple sclerosis.

Despite intensive research, the aetiology of multiple sclerosis (MS) remains unknown. Cerebrospinal fluid proteomics has the potential to reveal mechanisms of MS pathogenesis, but analyses must account for disease heterogeneity. We previously reported explorative multivariate analysis by hierarchical clustering of proteomics data of MS patients and controls, which resulted in two groups of individuals. Grouping reflected increased levels of intrathecal inflammatory response proteins and decreased levels of proteins involved in neural development in one group relative to the other group. MS patients and controls were present in both groups. Here we reanalysed these data and we also reanalysed data from an independent cohort of patients diagnosed with clinically isolated syndrome (CIS), who have symptoms of MS without evidence of dissemination in space and/or time. Some, but not all, CIS patients had intrathecal inflammation. The analyses reported here identified a common protein signature of MS/CIS that was not linked to elevated intrathecal inflammation. The signature included low levels of complement proteins, semaphorin-7A, reelin, neural cell adhesion molecules, inter-alpha-trypsin inhibitor heavy chain H2, transforming growth factor beta 1, follistatin-related protein 1, malate dehydrogenase 1 cytoplasmic, plasma retinol-binding protein, biotinidase, and transferrin, all known to play roles in neural development. Low levels of these proteins suggest that MS/CIS patients suffer from abnormally low oxidative capacity that results in disrupted neural development from an early stage of the disease.

Swiss-wide multicentre evaluation and prediction of core outcomes in arthroscopic rotator cuff repair: protocol for the ARCR_Pred cohort study.

INTRODUCTION: In the field of arthroscopic rotator cuff repair (ARCR), reporting standards of published studies differ dramatically, notably concerning adverse events (AEs). In addition, prognostic studies are overall methodologically poor, based on small data sets and explore only limited numbers of influencing factors. We aim to develop prognostic models for individual ARCR patients, primarily for the patient-reported assessment of shoulder function (Oxford Shoulder Score (OSS)) and the occurrence of shoulder stiffness 6 months after surgery. We also aim to evaluate the use of a consensus core event set (CES) for AEs and validate a severity classification for these events, considering the patient's perspective. METHODS AND ANALYSIS: A cohort of 970 primary ARCR patients will be prospectively documented from several Swiss and German orthopaedic clinics up to 24 months postoperatively. Patient clinical examinations at 6 and 12 months will include shoulder range of motion and strength (Constant Score). Tendon repair integrity status will be assessed by ultrasound at 12 months. Patient-reported questionnaires at 6, 12 and 24 months will determine functional scores (subjective shoulder value, OSS), anxiety and depression scores, working status, sports activities, and quality of life (European Quality of Life 5 Dimensions 5 Level questionnaire). AEs will be documented according to a CES. Prognostic models will be developed using an internationally supported regression methodology. Multiple prognostic factors, including patient baseline demographics, psychological, socioeconomic and clinical factors, rotator cuff integrity, concomitant local findings, and (post)operative management factors, will be investigated. ETHICS AND DISSEMINATION: This project contributes to the development of personalised risk predictions for supporting the surgical decision process in ARCR. The consensus CES may become an international reference for the reporting of complications in clinical studies and registries. Ethical approval was obtained on 1 April 2020 from the lead ethics committee (EKNZ, Basel, Switzerland; ID: 2019-02076). All participants will provide informed written consent before enrolment in the study. TRIAL REGISTRATION NUMBER: NCT04321005. PROTOCOL VERSION: Version 2 (13 December 2019).