Surgical repair versus conservative treatment and subacromial decompression for the treatment of rotator cuff tears

Aims

The purpose of this study was to compare the effectiveness of surgical repair to conservative treatment and subacromial decompression for the treatment of chronic/degenerative tears of the rotator cuff.

Materials and Methods

PubMed, Cochrane database, and Medline were searched for randomized controlled trials published until March 2018. Included studies were assessed for methodological quality, and data were extracted for statistical analysis. The systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

Results

Six studies were included. Surgical repair resulted in a statistically significantly better Constant–Murley Score (CMS) at one year compared with conservative treatment (mean difference 6.15; p = 0.002) and subacromial decompression alone (mean difference 5.81; p = 0.0004). In the conservatively treated group, 11.9% of patients eventually crossed over to surgical repair.

Conclusion

The results of this review show that surgical repair results in significantly improved outcomes when compared with either conservative treatment or subacromial decompression alone for degenerative rotator cuff tears in older patients. However, the magnitude of the difference in outcomes between surgery and conservative treatment may be small and the ‘success rate’ of conservative treatment may be high, allowing surgeons to be judicious in choosing those patients who are most likely to benefit from surgery. Cite this article: Bone Joint J 2019;101-B:1100–1106.

The use of dorsal distraction plating for severely comminuted distal radius fractures: A review and comparison to volar plate fixation

INTRODUCTION

Optimal fixation for highly comminuted distal radius fractures remains a major treatment challenge for orthopaedic surgeons. Dorsal distraction plating can serve as an improved fixation technique by allowing reduction under ligamentotaxis, providing a dorsal buttress, addressing proximal comminution, and allowing for early weightbearing in polytrauma patients. The aim of this study was to review current literature regarding treatment of distal radius fractures treated with dorsal distraction plating.

METHODS

We performed a literature search in Pubmed and EMBASE databases to identify all studies analyzing use of dorsal distraction plating. Case reports, biomechanical and anatomic cadaver studies were excluded from analysis. Primary outcome measures were range of motion (ROM) at final follow up, grip strength, and radiographic parameters.

RESULTS

Eight studies were included in the final analysis. Pooled mean ROM after dorsal distraction plating was found to be 47.6° of flexion, 50.5° of extension, 76.0° of pronation, and 74.2° of supination. Pooled mean grip strength was 79.1% compared to the uninjured contralateral limb. Pooled mean volar tilt was 3.6°. Overall radial height was maintained at an average of 10.5 mm with a pooled mean loss of only 3.8 mm in length. Mean radial inclination was found to be 19.4 mm with patients having a mean ulnar variance of 0.5 mm.

DISCUSSION & CONCLUSION

Treatment of comminuted intra-articular distal radius fractures with dorsal distraction plating yielded excellent outcomes with very low complication rates, and has several advantages over volar plating and/or external fixation for these fractures. Necessity of plate removal remains a negative feature of this technique.

Design and preliminary results of FRENSHOCK 2016: A prospective nationwide multicentre registry on cardiogenic shock

BACKGROUND

Most data on the epidemiology of cardiogenic shock (CS) have come from patients with acute myocardial infarction admitted to intensive cardiac care units (ICCUs). However, CS can have other aetiologies, and could be managed in intensive care units (ICUs), especially the most severe forms of CS.

AIM

To gather data on the characteristics, management and outcomes of patients hospitalized in ICCUs and ICUs for CS, whatever the aetiology, in France in 2016.

METHODS

We included all adult patients with CS between April and October 2016 in metropolitan France. CS was defined (at admission or during hospitalization) by: low cardiac output, defined by systolic blood pressure<90mmHg and/or the need for amines to maintain systolic blood pressure>90mmHg and/or cardiac index<2.2L/min/m²; elevation of the left and/or right heart pressures, defined by clinical, radiological, biological, echocardiographic or invasive haemodynamic overload signs; and clinical and/or biological signs of malperfusion (lactate>2mmol/L, hepatic insufficiency, renal failure).

RESULTS

Over a 6-month period, 772 patients were included in the survey (mean age 65.7±14.9 years; 71.5% men) from 49 participating centres (91.8% were public, and 77.8% of these were university hospitals). Ischaemic trigger was the most common cause (36.3%).

CONCLUSIONS

To date, FRENSHOCK is the largest CS survey; it will provide a detailed and comprehensive global description of the spectrum and management of patients with CS in a high-income country.

A novel experimental thrombotic myocardial infarction and primary angioplasty model in swine

AIMS

We sought to develop a reproducible animal model for acute myocardial infarction (AMI) in adult atherosclerosis-prone pigs.

METHODS AND RESULTS

A coil was placed in the right coronary artery or the left anterior descending artery in 26 downsized spontaneously hypercholesterolaemic pigs and left untreated until thrombotic occlusion. Then, we crossed the thrombotic occlusion with a guidewire, followed by predilatation, thrombus visualisation with optical coherence tomography (OCT) imaging and, finally, deployment of a stent and repeated OCT. After revascularisation, we calculated the index of microcirculatory resistance (IMR). After a feasibility phase (six animals), acute thrombotic occlusion was achieved in all 20 pigs. Eighteen animals were successfully revascularised and survived until sacrifice. Thrombus formation was confirmed by OCT, measurement of thrombin-antithrombin complexes and pathology examination. Myocardial necrosis was confirmed by troponin T elevation, myocardial staining and pathology examination. Distal thrombotic embolisation and microvascular obstruction were supported by increased IMR and pathology examination.

CONCLUSIONS

A porcine model of thrombotic occlusion AMI in miniaturised adult spontaneously atherosclerosis-prone pigs is feasible by percutaneous intracoronary placement of a coil. The reperfusion by angioplasty completed this model which mirrors human pathological conditions with myocardial infarction, necrosis and distal embolisation.

Bone marrow stimulation decreases retear rates after primary arthroscopic rotator cuff repair: a systematic review and meta-analysis

BACKGROUND

Despite the optimization of biomechanical and patient factors in the setting of rotator cuff repair (RCR), postoperative retear rates remain high in many series reported in the literature. Preclinical studies have suggested bone marrow stimulation (BMS) at the rotator cuff footprint may reduce the rate of retear after RCR. The objective of this meta-analysis was to analyze the clinical evidence investigating the effect of arthroscopic RCR, with and without BMS, on rotator cuff healing and functional outcomes.

METHODS

PubMed, MEDLINE, Embase, and the Cochrane Library were searched through December 2017. Two reviewers selected studies based on the inclusion criteria and assessed methodologic quality. Pooled analyses were performed for continuous and binomial variables where appropriate.

RESULTS

Four studies (365 patients), including 2 Level I randomized controlled trials and 2 Level III retrospective comparative cohort studies were included. There was no statistical difference in the Disabilities of the Arm, Shoulder and Hand score, University of California Los Angeles Shoulder Rating Scale score, or the Constant score between the BMS and conventional repair groups. The pooled retear rates were 18.4% (28 of 152) and 31.8% (56 of 176) for patients treated with and without BMS, respectively. The pooled analysis of rotator cuff retear rates from the 4 studies (328 patients) showed a statistically significant difference favoring BMS over conventional repair (odds ratio, 0.42; 95% confidence interval, 0.25-0.73; P = .002; I² = 0%).

CONCLUSION

BMS reduces the retear rate after RCR but shows no difference in functional outcomes compared with conventional repair. This study provides evidence for the use of BMS as a potential cost-effective biological approach toward improving rotator cuff healing.

Sources, Quality, and Reported Outcomes of Superior Capsular Reconstruction: a Systematic Review

PURPOSE

Superior capsular reconstruction (SCR) has gained attention as a potential treatment option for those with massive irreparable rotator cuff tears without significant arthritis. The aim of this systematic review is to review and evaluate the current sources and quality of SCR literature as well as reported outcomes.

METHODS

Three databases (PubMed, Ovid [MEDLINE], and EMBASE) were searched independently and in duplicate to systematically screen the literature. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist guided the reporting and data abstraction. The results are presented in a narrative summary fashion using descriptive statistics.

RESULTS

Overall, 58 studies were identified, including 304 different patients. There was a rapid increase in the number of publications observed over the past 3 years, with the most dramatic single-year increase noted from 2017 to 2018 (175% increase). There are no level 1 studies, and 95% of the included studies were level 4 and 5 evidence. Comparing pre-operative to post-operative pooled-weighted mean outcome scores, the American Shoulder and Elbow Surgeons score improved from 44.2 to 84.8, the Visual Analogue Scale from 5.0 to 1.5, and acromiohumeral distance from 6.5 to 8.4 mm, respectively. Range of motion in forward elevation also improved from 111° to 152°. Among studies reporting, the complication rate was 13.4% with a revision surgery rate of 4.3%.

CONCLUSION

Over the past 3 years there has been considerable growth in the number of publications of publications related to SCR. Despite a lack of high-quality clinical evidence, preliminary available evidence does suggest promising results both functionally and radiographically. There is a need for future higher-quality research such as large randomized controlled trials to improve our current understanding of the benefits of SCR.

Impact of renal dysfunction on the management and outcome of acute heart failure: results from the French prospective, multicentre, DeFSSICA survey

OBJECTIVES

Cardiorenal syndrome (CRS) is the combination of acute heart failure syndrome (AHF) and renal dysfunction (creatinine clearance (CrCl) ≤60 mL/min). Real-life data were used to compare the management and outcome of AHF with and without renal dysfunction.

DESIGN

Prospective, multicentre.

SETTING

Twenty-six academic, community and regional hospitals in France.

PARTICIPANTS

507 patients with AHF were assessed in two groups according to renal function: group 1 (patients with CRS (CrCl ≤60 mL/min): n=335) and group 2 (patients with AHF with normal renal function (CrCl >60 mL/min): n=172).

RESULTS

Differences were observed (group 1 vs group 2) at admission for the incidence of chronic heart failure (56.42% vs 47.67%), use of furosemide (60.9% vs 52.91%), insulin (15.52% vs 9.3%) and amiodarone (14.33% vs 4.65%); additionally, more patients in group 1 carried a defibrillator (4.78% vs 0%), had ≥2 hospitalisations in the last year (15.52% vs 5.81%) and were under the care of a cardiologist (72.24% vs 61.63%). Clinical signs were broadly similar in each group. Brain-type natriuretic peptide (BNP) and BNP prohormone were higher in group 1 than group 2 (1157.5 vs 534 ng/L and 5120 vs 2513 ng/mL), and more patients in group 1 were positive for troponin (58.2% vs 44.19%), had cardiomegaly (51.04% vs 37.21%) and interstitial opacities (60.3% vs 47.67%). The only difference in emergency treatment was the use of nitrates, (higher in group 1 (21.9% vs 12.21%)). In-hospital mortality and the percentage of patients still hospitalised after 30 days were similar between groups, but the median stay was longer in group 1 (8 days vs 6 days).

CONCLUSIONS

Renal impairment in AHF should not limit the use of loop diuretics and/or vasodilators, but early assessment of pulmonary congestion and close monitoring of the efficacy of conventional therapies is encouraged to allow rapid and appropriate implementation of alternative therapies if necessary.

Healing, Pain and Function after Midshaft Clavicular Fractures: A Systematic Review of Treatment with Immobilization and Rehabilitation

OBJECTIVE

To systematically evaluate the scientific literature examining the efficacy of nonoperative management for midshaft clavicular fractures, specifically looking at the effect of immobilization and/or functional rehabilitation. TYPE: Systematic review.

LITERATURE SURVEY

MEDLINE (PubMed), EMBASE, CINAHL databases were searched.

METHODOLOGY

Inclusion criteria included adult patients enrolled in a controlled study evaluating bony healing, pain and/or function-related improvements after a strict nonoperative treatment plan for management of midshaft clavicle fractures.

SYNTHESIS

A total of 10 articles were included in the study. Only four studies contained level I evidence; four studies were prospective case series without a control, and one was a retrospective case series without a control. Half of studies used a strict immobilization period, and most utilized a period of functional rehabilitation. There were no direct comparisons between rehabilitation protocols. Studies without a strict immobilization period had a nonunion rate of 5% to 24% and residual pain in 35% to 83% of patients compared to studies with a strict immobilization period with a nonunion rate of 3% to 29% and residual pain in 14% to 49% of patients. Studies including functional rehabilitation protocol reported functional as measured by the Constant Shoulder Score of 87.8 to 96, out of a maximum of 100 representing no functional limitations, and nonunion rates of 12% to 25% compared to 81 to 85 and 3% to 29% in those without a rehabilitation protocol.

CONCLUSIONS

No studies directly examine the effect of immobilization and functional rehabilitation on clinical outcomes for midshaft clavicular fractures. Future studies are needed to better elucidate the most effective treatment.

LEVEL OF EVIDENCE

I.

Admissions to intensive cardiac care units in France in 2014: A cross-sectional, nationwide population-based study

Geographic variation in admission to the intensive cardiac care unit (ICCU) might question about the efficiency and the equity of the healthcare system. The aim was to explain geographic variation in the rate of admission to ICCU for coronary artery disease (CAD) or heart failure (HF) in France.We conducted a retrospective study based on the French national hospital discharge database. All inpatient stays for CAD or HF with an admission to an ICCU in 2014 were included. We estimated population-based age and sex-standardized ICCU admission rates at the department level. We separately modeled the department-level admission rates for HF and CAD using generalized linear models.In all, 61,010 stays for CAD and 27,828 stays for HF had at least 1 ICCU admission. The ICCU admission rates were explained by the admission rate for CAD, by the diabetes prevalence, by the proportion of the population >75 years, and by the drive time to the ICCU.This work sheds light on the finding of substantial geographic variation in the ICCU admission rates for CAD and HF in France. This variation is explained by both the age and the health status of the population and also by the drive time to the closest ICCU for HF. Moreover, ICCU admission for HF might be more prone to unwarranted variations due to medical practice patterns.

Short-term Outcomes of Arthroscopic Debridement and Selected Acromioplasty of Bursal- vs Articular-Sided Partial-Thickness Rotator Cuff Tears of Less Than 50

Background:

While it is believed that good results can be achieved by arthroscopic debridement of partial-thickness tears (PTTs) of <50% tendon thickness, few studies have directly compared the treatment of articular- versus bursal-sided PTTs of <50%.

Purpose:

To compare the postoperative outcomes of patients with articular- versus bursal-sided PTTs of <50% tendon thickness that were treated with arthroscopic debridement and selective acromioplasty (for type II or III acromions).

Study Design:

Cohort study; Level of evidence, 3.

Methods:

An analysis was performed with data from 76 consecutive patients diagnosed with a PTT <50% tendon width (Ellman grade II) who had undergone arthroscopic debridement and selective acromioplasty (for type II or III acromions). Outcome measures included the short version of the Western Ontario Rotator Cuff index, the American Shoulder and Elbow Surgeons score, and the relative Constant-Murley score, as well as strength of the affected shoulder. A statistical paired t test (preoperative vs 2 years postoperative) and an independent t test were utilized to compare outcomes between patients with bursal- and articular-sided tears.

Results:

Between 2001 and 2010, there were 40 (53%) articular- and 36 (47%) bursal-sided tears treated with debridement and selective acromioplasty. The mean patient age was 55 years (range, 36-77 years) for the bursal group and 56 years (range, 33-81 years) for the articular group. The mean follow-up was 24 months (range, 22-26 months). Both groups showed significant improvement in the short version of the Western Ontario Rotator Cuff index, American Shoulder and Elbow Surgeons score, and relative Constant-Murley score 2 years after surgery (P < .0001) as well as in strength (P < .0001 for bursal tears, P = .006 for articular tears). There was no statistically significant difference between groups in any of the postoperative outcome measures at 2 years.

Conclusion:

The results of this study demonstrate that good outcomes can be achieved with arthroscopic debridement and selective acromioplasty among patients with articular- or bursal-sided PTT of <50% tendon thickness. No difference was observed between groups at 2-year follow-up.

Shoulder physiotherapy exercise recognition: machine learning the inertial signals from a smartwatch

OBJECTIVE

Participation in a physical therapy program is considered one of the greatest predictors of successful conservative management of common shoulder disorders. However, adherence to these protocols is often poor and typically worse for unsupervised home exercise programs. Currently, there are limited tools available for objective measurement of adherence in the home setting. The goal of this study was to develop and evaluate the potential for performing home shoulder physiotherapy monitoring using a commercial smartwatch.

APPROACH

Twenty healthy adult subjects with no prior shoulder disorders performed seven exercises from an evidence-based rotator cuff physiotherapy protocol, while 6-axis inertial sensor data was collected from the active extremity. Within an activity recognition chain (ARC) framework, four supervised learning algorithms were trained and optimized to classify the exercises: k-nearest neighbor (k-NN), random forest (RF), support vector machine classifier (SVC), and a convolutional recurrent neural network (CRNN). Algorithm performance was evaluated using 5-fold cross-validation stratified first temporally and then by subject.

MAIN RESULTS

Categorical classification accuracy was above 94% for all algorithms on the temporally stratified cross validation, with the best performance achieved by the CRNN algorithm (99.4%). The subject stratified cross validation, which evaluated classifier performance on unseen subjects, yielded lower accuracies scores again with CRNN performing best (88.9%).

SIGNIFICANCE

This proof of concept study demonstrates the technical feasibility of a smartwatch device and supervised machine learning approach to more easily monitor and assess the at-home adherence of shoulder physiotherapy exercise protocols.

Arthroscopic-Assisted Latissimus Dorsi Tendon Transfer for Massive Rotator Cuff Tears: A Systematic Review

Background:

Arthroscopic-assisted latissimus dorsi tendon transfer (LDTT) has shown promising results with good outcomes in patients with massive rotator cuff tears (MRCTs), as reported by individual studies. However, to the best of the authors’ knowledge, no systematic review has been performed to assess the collective outcomes of these individual studies.

Purpose/Hypothesis:

The primary purpose of this study was to assess patient outcomes after arthroscopic-assisted LDTT for the management of MRCTs. The secondary objectives were to report on the management of MRCTs, including diagnostic investigations, surgical decision making, and arthroscopic techniques, as well as to evaluate the quality of evidence of the existing literature. It was hypothesized that nearly all patients were satisfied with arthroscopic-assisted LDTT and that they experienced improvements in pain symptoms, function, and strength after the procedure, with an overall complication rate of less than 10%.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

The databases MEDLINE, Embase, and PubMed were searched from database inception (1946) until August 18, 2017, with titles, abstracts, and full-text articles screened independently by 2 reviewers. Inclusion criteria were English-language studies investigating arthroscopic-assisted LDTT for the management of MRCTs on patients of all ages. Conference papers, book chapters, review articles, and technical reports were excluded. The quality of the included studies was categorized by level of evidence and the Methodological Index for Non-Randomized Studies (MINORS) checklist.

Results:

In total, 8 studies (7 case series [median MINORS score, 7 of 16] and 1 prospective comparative study [median MINORS score, 14 of 24]) were identified; the studies included 258 patients (258 shoulders) with MRCTs treated with LDTT using arthroscopic-assisted techniques. The decision to pursue surgery was based on both clinical findings and investigations in 5 studies, investigations only in 2 studies, and clinical findings only in 1 study. Overall, 88% of patients were satisfied with the results of surgery and experienced significant improvement in their symptoms, including shoulder pain, strength, range of motion, and overall function, over a mean follow-up period of 34.3 months. Overall, there was a low rate of complications (7%) associated with the procedure.

Conclusion:

Arthroscopic-assisted LDTT for MRCTs provides patients with marked improvement in shoulder pain, strength, and function, and the procedure is associated with a low risk of complication. Further high-quality comparative studies are warranted to validate these findings in comparison with other operative techniques.