Long-lasting decreased pain threshold negatively affects functional recovery after arthroscopic rotator cuff repair.

PURPOSE: The relationship between sensitization and postoperative function in patients undergoing arthroscopic rotator cuff repair (ARCR). The purpose of this study was to evaluate the effect of pre-and postoperative reductions in the pressure pain threshold (PPT) on postoperative clinical outcomes in patients with ARCR and investigate changes in PPT and clinical outcomes resulting from postoperative administration of weak opioids activating the central inhibitory system. METHODS: This retrospective study included patients who underwent primary ARCR, categorized into Group A (excellent/good Constant scores) and B (fair/poor Constant scores). In a complementary study, patients were randomized to the Control or Tramadol groups. Both studies evaluated the PPT, visual analog scale, active range of motion (ROM), Constant score, and retear rates pre-and postoperatively. RESULTS: In the primary study with 158 patients, those with poor clinical outcomes exhibited significantly lower PPT at the affected shoulder preoperatively at 3 months postoperatively compared to those with good outcomes. The PPT of the affected side was lower than that of the uninvolved side not only at 1 and 3 months but also preoperatively and at 6 months in the poor outcome group. In the secondary study involving 96 patients, weak opioid administration was associated with increased PPT for 3 months, improved ROM at 3 months postoperatively, and reduced postoperative pain 1 year postoperatively. CONCLUSION: Patients experiencing poor postoperative clinical outcomes exhibited prolonged lowered PPT. Lowered PPT due to sensitization may adversely affect functional recovery and pain perception. Elevating PPT using weak opioids improved clinical outcomes during the acute perioperative period after ARCR. LEVEL OF EVIDENCE: III.

Anatomic restoration of the articular deep layer is a definitive factor for repair status in delaminated rotator cuff tear.

BACKGROUND: Recent studies have focused on the deep layer in delaminated rotator cuff tears. However, no studies have discussed the relationship between repair success and the properties of the deep layer. Herein, we aimed to analyze the intraoperative repair tension of the deep layer with respect to clinical outcomes and repair integrity and to evaluate the clinical results of delaminated rotator cuff tears after dual layer-specific repair. METHODS: A total of 202 patients with delaminated rotator cuff tears had undergone dual layer-specific suture bridge repair; the mean follow-up duration was 28.6 (24-72) months. Intraoperatively, the repair tension of the deep layer was measured using a tensiometer, and mobility was ranked as easy or tight. After repair of the deep layer, the superficial layer tension was measured and ranked in a similar fashion. Clinical outcomes were evaluated using the Constant score, American Shoulder and Elbow Surgeons score, and subjective shoulder values. The relationship between retear and intraoperative qualitative factors of tendons was investigated. Prognostic factors for retear were analyzed using multiple logistic regression analyses. RESULTS: Postoperative retears occurred in 11 (5.4%) patients. With regard to the deep layer, the tight mobility group had greater tear size, tendon retraction, and fatty infiltration of the supraspinatus and infraspinatus than the easy mobility group. No intergroup difference in postoperative retear rate was observed between the tight and easy deep-layer groups. Logistic regression analysis showed that fatty infiltration of the infraspinatus (odds ratio, 3.1; 95% confidence interval, 1.3-7.7; P = .013) and mobility of the superficial layer after deep layer repair (odds ratio, 8.1; 95% confidence interval, 1.7-38.1; P = .008) were predictors of retear. CONCLUSION: Intraoperative mobility in the deep layer was not directly related to postoperative retear. Conversely, the quality of the infraspinatus concomitant with mobility of the superficial layer after deep layer repair significantly influenced repair integrity. Good clinical results were obtained even in cases with high repair tension of the deep layer.

High diagnostic accuracy of magnetic resonance imaging in detecting subscapularis tendon tears by focusing on the most superior portion of the subscapularis tendon.

PURPOSE: This study aimed to test the hypothesis that identifying the exact location of the most superior portion of the subscapularis tendon using magnetic resonance imaging (MRI) provides high diagnostic accuracy in detecting subscapularis tendon tears. METHODS: This study included 157 patients who underwent primary arthroscopic rotator cuff repair between 2014 and 2017. All patients underwent conventional 1.5-T MRI in our hospital, within 3 months before surgery. We retrospectively compared the diagnosis of subscapularis tendon tears using MRI based on an anatomical concept focusing on the superior-most insertion point of the subscapularis tendon with intraoperative arthroscopic findings. RESULTS: Subscapularis tendon tears were detected in 80 (51.0%) of the 157 patients during arthroscopic evaluation. The overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the MRI examination were 90, 83, 85, 89, and 87%, respectively. With a kappa score of 0.83, the concordance rate between the two raters was almost perfect (95% confidence interval, 0.75-0.92). The sensitivities of the oblique-sagittal and axial sequences were 84 and 79%, respectively. CONCLUSIONS: Preoperative MRI evaluation focusing on the most superior portion of the subscapularis tendon demonstrated high diagnostic accuracy in detecting subscapularis tendon tears. To find the most superior portion of the subscapularis tendon tears, it was essential to check the slice at the level of the lesser tubercle tip and its adjacent slice. In addition, the combined observation of oblique-sagittal and axial sequences helped to detect subscapularis tendon tears with higher sensitivity.

Comparison of tissue pharmacokinetics of esflurbiprofen plaster with flurbiprofen tablets in patients with knee osteoarthritis: A multicenter randomized controlled trial.

This open-label, multicenter, prospective, randomized controlled trial aimed to determine the effectiveness of esflurbiprofen plaster (SFPP) and flurbiprofen tablets (FPTs) on knee osteoarthritis in patients scheduled for total knee arthroplasty by comparing the transfer of esflurbiprofen and flurbiprofen to tissues and fluids. Thirty-eight patients were randomly assigned in a 1:1 ratio to receive SFPP or FPT. Both groups were then divided into four subgroups, according to whether they received the final dose of SFPP or FPT at 2, 7, 12, or 24 h before planned surgery. The primary endpoints were the esflurbiprofen concentrations in synovium, synovial fluid, and plasma. Areas under concentration-time curves (AUC0-24 h ) of esflurbiprofen were calculated for each group. Pain was assessed using a numeric rating scale (NRS) 7 days before and immediately before surgery. The AUC0-24 h in the synovium were 4401.24 and 4862.70 ng·h/g in the SFPP and FPT groups, respectively. Maximum esflurbiprofen concentrations were observed in the synovium, synovial fluids, and plasma after SFPP application for 12 h. The NRS results indicated a long-lasting effect of SFPP. The AUC of the synovial esflurbiprofen concentration of SFPP indicated that the SFPP is transferred to the synovium and synovial fluid in high concentration. The efficient deep-tissue transfer of esflurbiprofen suggests that its pharmacokinetic characteristics differ from those of conventional topical NSAIDs. This study was prospectively registered in the Japan Registry of Clinical Trials (registration number: jRCTs031180228).

Osteointegration of a Biocomposite Suture Anchor After Arthroscopic Shoulder Labral Repair.

PURPOSE: To evaluate osteoconductivity of a poly-L-lactide co-glycolide (PLG)-calcium sulfate (CS)-ß-tricalcium phosphate (ß-TCP) biocomposite suture anchor after arthroscopic shoulder labral repair. METHODS: The subjects of this study were patients who participated in a clinical trial for acquisition of marketing approval of a PLG-CS-ß-TCP biocomposite anchor in Japan. They underwent arthroscopic labral repair using the anchor, and computed tomographic (CT) images of the glenoid were obtained 2 years after surgery. Osteoconductivity at the anchor sites was evaluated with the CT images using the established ossification quality score. Shoulder function scores including the Rowe score and Japanese Shoulder Society shoulder instability score were also assessed 2 years after surgery. RESULTS: CT images and functional scores were obtained from 37 patients, comprising 29 men and 8 women with a mean age of 29 years (range, 25-33 years) at surgery. A total of 148 anchors were implanted in the 37 shoulders. Osteoconductivity was seen in 133 of 148 anchor sites (90.0%) 2 years after implantation. No significant differences in osteoconductivity were found by anchor diameter or position. The Rowe score significantly improved from 39.9 points (95% confidence interval [CI], 33.8-45.9 points) preoperatively to 96.6 points (95% CI, 95.1-98.1 points) at 2 years postoperatively (P < .001). The Japanese Shoulder Society shoulder instability score also significantly improved, from 63.1 points (95% CI, 58.4-67.7 points) preoperatively to 96.3 points (95% CI, 94.7-97.8 points) at 2 years postoperatively (P < .001). CONCLUSIONS: Biocomposite suture anchors made of PLG, CS, and ß-TCP exhibited some osteoconductivity 2 years after arthroscopic labral repair, as well as good clinical outcomes. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The anatomy of the coracohumeral ligament and its relation to the subscapularis muscle.

BACKGROUND: Only a few reports describe the extension of the coracohumeral ligament to the subscapularis muscle. The purposes of this study were to histo-anatomically examine the structure between the ligament and subscapularis and to discuss the function of the ligament. METHODS: Nineteen intact embalmed shoulders were used. In 9 shoulders, the expansion of the ligament was anatomically observed, and in 6 of these 9, the muscular tissue of the supraspinatus and subscapularis was removed to carefully examine the attachments to the tendons of these muscles. Five shoulders were frozen and sagittally sectioned into 3-mm-thick slices. After observation, histologic analysis was performed on 3 of these shoulders. In the remaining 5 shoulders, the coracoid process was harvested to investigate the ligament origin. RESULTS: The coracohumeral ligament originated from the horizontal limb and base of the coracoid process and enveloped the cranial part of the subscapularis muscle. The superficial layer of the ligament covered a broad area of the anterior surface of the muscle. Laterally, it protruded between the long head of the biceps tendon and subscapularis and attached to the tendinous floor, which extended from the subscapularis insertion. Histologically, the ligament consisted of irregular and sparse fibers abundant in type III collagen. CONCLUSION: The coracohumeral ligament envelops the whole subscapularis muscle and insertion and seems to function as a kind of holder for the subscapularis and supraspinatus muscles. The ligament is composed of irregular and sparse fibers and contains relatively rich type III collagen, which would suggest flexibility.

Serial Assessment of Factors Associated With Patient-Reported Outcomes up to 2 Years After ACL Reconstruction Using Autologous Hamstring Tendon: Results From the TMDU MAKS Study.

Background: Understanding the factors related to patient-reported outcomes (PROs) after anterior cruciate ligament reconstruction (ACLR) can lead to more effective interventions. Purpose/Hypothesis: The purpose of this study was to identify factors associated with PRO scores after ACLR. It was hypothesized that concomitant meniscal treatment and postoperative range of motion (ROM) would be associated with early postoperative PRO scores and that postoperative physical findings would be associated with 2-year postoperative PRO scores. Study Design: Cohort study; Level of evidence, 2. Methods: We examined the data from the Tokyo Medical and Dental University Multicenter Arthroscopic Knee Surgery (TMDU MAKS) Study for patients who underwent primary ACLR with autologous hamstring tendon grafts; 1252 patients in the TMDU MAKS Study were eligible for inclusion. The International Knee Documentation Committee (IKDC) subjective score, Knee injury and Osteoarthritis Outcome Score (KOOS), and Lysholm score of the patients at 3 months (n = 675), 1 year (n = 660), and 2 years (n = 375) postoperatively were assessed using multiple regression to evaluate the strength of the relationship between PRO scores and the following predictor variables: patient-specific factors, treatment-specific factors, and physical findings. Results: Improvement in all PROs significantly exceeded the minimal important change at 1 and 2 years postoperatively. Older age and female sex were predictive of lower PRO scores up to 2 years postoperatively. Concurrent meniscal treatment and limited range of knee motion were predictive of lower PRO scores at 3 months and 1 year postoperatively. A tighter knee (ie, less anterior translation) on the injured side compared with the contralateral knee was predictive of lower KOOS-Quality of Life and IKDC scores at 2 years postoperatively. At all 3 postoperative time points, greater side-to-side difference in knee ROM was predictive of lower PRO scores. Conclusion: Inferior PRO scores were associated with concomitant meniscal treatment and limited postoperative ROM until 1 year postoperatively and with older age and female sex up to 2 years postoperatively. PRO scores were associated with knee stability at all assessed time points.

Locking versus non-locking neutralization plates for treatment of lateral malleolar fractures: a randomized controlled trial.

PURPOSE: The reduction of periosteal compression through the use of a locking plate may minimize disturbances of bone blood supply and may improve the rate of bone union. A single-centre, assessor blinded randomized controlled trial was conducted to compare the clinical effectiveness of a locking plate and a non-locking plate. METHODS: A total of 52 patients with AO/OTA 44B lateral malleolar fractures were included in this study. All patients underwent surgical fixation using a lag screw and neutralization plate. An identical treatment protocol was used in all patients, with exception of plate selection. The rate of radiographic bone union, defined as the complete disappearance of fracture lines confirmed through anteroposterior, lateral, and internal oblique views was compared at three, six, and 12 months following surgery. In addition, the Medical Outcomes 36-Item Short-Form Health Survey (SF-36) score, the time required for resolution of tenderness at the fracture site and the complication rate were evaluated. RESULTS: Twenty-three patients were randomly assigned to undergo fixation using a locking plate, and 29 patients were assigned to undergo fixation using a non-locking plate. Intention-to-treat analysis showed no difference in the radiographic bone union rate of fibula, SF-36 score, the time for resolution of tenderness at the fracture site and complication rates. CONCLUSION: No differences were observed in patients with AO/OTA 44B lateral malleolar fractures undergoing fixation with a locking versus non-locking neutralization plate.

Older Age, Poor Preoperative Quadriceps Muscle Strength, and Residual Pain as Risk Factors for Poor Quadriceps Muscle Strength Recovery at 1 Year After ACL Reconstruction: A TMDU MAKS Study of 402 Patients.

Background: Poor postoperative quadriceps muscle strength recovery after anterior cruciate ligament reconstruction (ACLR) leads to delayed return to sports and lower patient satisfaction. Purpose/Hypothesis: The purpose of this study was to examine factors that affect quadriceps muscle strength 1 year after ACLR. It was hypothesized that older age, poor preoperative quadriceps muscle strength, and residual pain would be risk factors for poor quadriceps muscle strength recovery. Study Design: Case-control study; Level of evidence, 3. Methods: Included were patients from multiple institutions who underwent primary ACLR using autologous hamstring tendon grafts between August 1, 2013, and March 31, 2018, and who had at least 1 year of follow-up data. Patients with past ligamentous injuries in the affected knee, previous injuries or operations in the contralateral knee, accompanying ligament injuries of grade 2 or 3, or inflammatory or other types of osteoarthritis were excluded. Patients were categorized as having muscle strength ≥80% (good strength recovery) or <80% (poor strength recovery) compared with the contralateral leg at 1 year postoperatively. Multivariate logistic regression analysis was performed to investigate the factors influencing postoperative quadriceps muscle strength. In addition, a categorical analysis was conducted based on factors extracted by the multivariate logistic regression analysis. Results: A total of 402 patients were included. Multivariate logistic regression analysis revealed that age at surgery (P = .020), preoperative quadriceps muscle strength (P = .006), and postoperative Knee injury and Osteoarthritis Outcome Score (KOOS)-Pain score (P = .002) were significantly associated with quadriceps muscle strength at 1 year postoperatively. The odds of poor muscle strength recovery according to categorical analysis were 5.0-fold higher for patients aged >40 versus ≤20 years, 4.2-fold higher for those with preoperative quadriceps muscle index <60% versus ≥80%, and 7.7-fold higher for those with a postoperative KOOS-Pain score of <85 versus 100. Conclusion: Older age, poor preoperative quadriceps muscle strength, and low postoperative KOOS-Pain score were risk factors for poor quadriceps muscle strength 1 year after primary ACLR. Surgical indications, including age, preoperative active rehabilitation, and pain control, should be considered for optimization of postoperative quadriceps muscle strength recovery.

Anatomical Repair of a Femoral-Sided Avulsion Fracture of the Anterior Cruciate Ligament: A Case Report.

CASE: We report a rare case of femoral-sided avulsion fracture of both the anteromedial and posterolateral bundle attachments of the anterior cruciate ligament (ACL). We performed an arthroscopic double-bundle pull-out repair. At the 1-year follow-up, the patient had no deformity, laxity of the knee, and no limitations when engaging in various sports activities. CONCLUSION: An avulsion fracture of both the anteromedial and posterolateral bundle attachments is a rare injury. Arthroscopically assisted reduction and fixation demonstrated successful achievement of both bone union and good ACL function.

Degradation of Cylindrical Poly-Lactic Co-Glycolide/Beta-Tricalcium Phosphate Biocomposite Anchors After Arthroscopic Bankart Repair: A Prospective Study.

The purpose of this study was to examine widening and ossification of anchor holes after arthroscopic Bankart repair with the use of cylindrical biocomposite anchors made of 70% poly-L-lactide-co-glycolide acid (PLGA) and 30% beta-tricalcium phosphate (ß-TCP). Twenty-two patients were enrolled in a clinical trial to acquire marketing approval of a PLGA/ß-TCP biocomposite suture anchor in Japan and underwent arthroscopic Bankart repairs with the anchors. Eleven of 22 patients had computed tomography scans after 2-year follow-up. Three surgeons independently evaluated width and ossification of anchor holes in 4 grades using computed tomography scans. When the evaluations disagreed, the final grade was determined based on the 3 surgeons' consensus. Seven men and 4 women were evaluated at a mean of 30 months (range, 28-32 months) after surgery, and a total of 47 anchors were implanted. Anchor holes were narrowed in 39 (83%) of 47 anchor sites and were almost or completely filled in (type 3 or 4) in 21 (45%) of 47 anchor sites. Ossification was seen in 46 (98%) of 47 anchor sites and was nearly complete or complete (type 3 or 4) in 16 (34%) of 47 anchor sites. There were no significant differences in both anchor hole width and ossification score on comparison of the anteroinferior (4- to 6-o'clock positions in the right shoulder) with other anchor sites. Cylindrical biocomposite anchors made of 70% PLGA/30% ß-TCP showed a low incidence of anchor hole widening and excellent ossification regardless of anchor site. [Orthopedics. 2018; 41(3):e348-e353.].

Upper limb amputation due to a brachial arterial embolism associated with a superior mesenteric arterial embolism: a case report.

BACKGROUND: Acute mesenteric ischemia due to an embolism of the superior mesenteric artery is associated with a high mortality rate. Over 20 percent of acute mesenteric embolism cases consist of multiple emboli, and the long-term prognosis depends on the incidence of subsequent embolic events at other sites. The incidence of emboli in the upper extremity associated with a superior mesenteric arterial embolism has rarely been described. The signs and symptoms of ischemic change in the upper limb can be masked by other circumstances, such as postoperative conditions or complications. In these cases, a late presentation or delayed diagnosis and treatment can result in limb loss. CASE PRESENTATION: We present a rare case of a 67-year-old Japanese woman with atrial fibrillation who developed an embolic occlusion of the brachial artery associated with a superior mesenteric arterial embolism. She developed gangrene in her right hand, which had progressed to the point that amputation was necessary by the time the gastrointestinal surgeon had consulted the Department of Orthopedic Surgery. The brachial arterial embolism diagnosis was delayed by the severe abdominal symptoms and shock conditions that followed the emergency enterectomy, resulting in amputation of the upper limb despite anticoagulation therapy. In this case, multiple infarctions of the spleen were also observed, indicating a shower embolism. CONCLUSIONS: When treating a superior mesenteric arterial embolism in a patient with atrial fibrillation, the possibility of recurrent or multiple arterial thromboembolic events should be considered, even after the procedure is completed.

Synovial mesenchymal stem cells accelerate early remodeling of tendon-bone healing.

Tendon-bone healing is important for the successful reconstruction of the anterior cruciate ligament by using the hamstring tendon. Mesenchymal stem cells (MSCs) have attracted much interest because of their self-renewing potential and multipotentiality for possible clinical use. We previously reported that MSCs derived from synovium had a higher proliferation and differentiation potential than the other MSCs that we examined. The purpose of this study was to investigate the effect and mechanism of the implantation of the synovial MSCs on tendon-bone healing in rats. Half of the Achilles' tendon grafts of rats were inserted into a bone tunnel from the tibial plateau to the tibial tuberosity with a suture-post fixation. The bone tunnel was filled with MSCs labeled with fluorescent marker DiI or without MSCs as the control. The tendon-bone interface was analyzed histologically, and collagen fibers were quantified. At 1 week, the tendon-bone interface was filled with abundant DiI-positive cells, and the proportion of collagen fiber area was significantly higher in the MSC group than in the control group. By 2 weeks, the proportion of oblique collagen fibers, which appeared to be Sharpey's fibers, was significantly higher in the MSC group than in the control group. At 4 weeks, the interface tissue disappeared, and the implanted tendon appeared to attach to the bone directly in both groups. DiI-labeled cells could no longer be observed. Implantation of synovial MSCs into bone tunnel thus accelerated early remodeling of tendon-bone healing, as shown histologically.

Comparison of rat mesenchymal stem cells derived from bone marrow, synovium, periosteum, adipose tissue, and muscle.

Mesenchymal stem cells (MSCs) are increasingly being reported as occurring in a variety of tissues. Although MSCs from human bone marrow are relatively easy to harvest, the isolation of rodent MSCs is more difficult, thereby limiting the number of experiments in vivo. To determine a suitable cell source, we isolated rat MSCs from bone marrow, synovium, periosteum, adipose, and muscle and compared their properties for yield, expansion, and multipotentiality. After two passages, the cells in each population were CD11b (-), CD45 (-), and CD90 (+). The colony number per nucleated cells derived from synovium was 100-fold higher than that for cells derived from bone marrow. With regard to expansion potential, synovium-derived cells were the highest in colony-forming efficiency, fold increase, and growth kinetics. An in vitro chondrogenesis assay demonstrated that the pellets derived from synovium were heavier, because of their greater production of cartilage matrix, than those from other tissues, indicating their superiority in chondrogenesis. Synovium-derived cells retained their chondrogenic potential after a few passages. The Oil Red-O positive colony-rate assay demonstrated higher adipogenic potential in synovium- and adipose-derived cells. Alkaline phosphatase activity was greater in periosteum- and muscle-derived cells during calcification. The yield and proliferation potential of rat MSCs from solid tissues was much better than those from bone marrow. In particular, synovium-derived cells had the greatest potential for both proliferation and chondrogenesis, indicating their usefulness for cartilage study in a rat model.