Radiologic Evaluation of the Distal End Radius Indices in Indian Paediatric Population

Background

The distal end radius's bony anatomy in relation to three variables-Radial Inclination, Volar tilt, and radial height-has been discussed commonly in the adult population and is not very well defined in the growing skeleton. In children aged 8-16 years old, we measured the osseous distal end radius according to radiography standards. The research comprised 130 patients, 65 males and 65 females aged 8-16. In each child, the norms for radial inclination, volar tilt, and radial epiphyseal height were established. This research defines these radiographic parameters for the paediatric population in India for the first time.

Methods

This research is an Unicentric Cross-sectional observational analytical study. We studied 130 normal wrist posteroanterior and lateral radiographs of the Indian paediatric population aged 8-16 years who reported to our OPD and calculated the three parameters-(1) Radial height, (2) Volar Tilt, and (3) Radial Inclination. Mean measurement values were analysed statistically.

Results

The Mean distal end radius volar tilt is 10.92° ± 1.76° SD with a range from 4° to 15°. The Mean distal end radial inclination is 21.04° ± 2.10° SD with a range from 15° to 25°. The Mean distal end radial height is 11.93 ± 1.44 mm SD with a range from 9.0 to 14.50 mm.

Conclusion

In true Postero-anterior and lateral wrist radiographs of the Indian paediatric population, we have established normal values that may be utilized as a guide for the evaluation and treatment of a variety of traumatic and non-traumatic problems in Indian children.

Clinical management and innovation in fracture non-union

INTRODUCTION

With the introduction and continuous improvement in operative fracture fixation, even the most severe bone fractures can be treated with a high rate of successful healing. However, healing complications can occur and when healing fails over prolonged time, the outcome is termed a fracture non-union. Non-union is generally believed to develop due to inadequate fixation, underlying host-related factors, or infection. Despite the advancements in fracture fixation and infection management, there is still a clear need for earlier diagnosis, improved prediction of healing outcomes and innovation in the treatment of non-union.

AREAS COVERED

This review provides a detailed description of non-union from a clinical perspective, including the state of the art in diagnosis, treatment, and currently available biomaterials and orthobiologics.Subsequently, recent translational development from the biological, mechanical, and infection research fields are presented, including the latest in smart implants, osteoinductive materials, and in silico modeling.

EXPERT OPINION

The first challenge for future innovations is to refine and to identify new clinical factors for the proper definition, diagnosis, and treatment of non-union. However, integration of in vitro, in vivo, and in silico research will enable a comprehensive understanding of non-union causes and correlations, leading to the development of more effective treatments.

Comparison of the Efficacy of Different Combined Therapies Based on Modified Core Decompression for the Treatment of Early-stage Nontraumatic Osteonecrosis of the Femoral Head: A Retrospective Clinical Study

OBJECTIVE

Osteonecrosis of the femoral head (ONFH) is a severe orthopedic disease, which may cause severe hip dysfunction in later stage. Therefore, it is necessary to treat nontraumatic ONFH during the early stages. The aim of this study was to evaluate the clinical efficacy and survival rates of different combined therapies based on modified core decompression (CD) for early-stage nontraumatic ONFH.

METHODS

This retrospective cohort study assessed 397 hips with ONFH who underwent different combined therapies based on modified CD in our institution between January 2010 and December 2017. Patients were classified into six groups based on treatment modalities, and were followed up at 1 year and 5 years postoperatively. Clinical outcomes, including Harris hip score (HHS) and Western Ontario and McMaster Universities osteoarthritis index (WOMAC), were compared to evaluate the hip function and quick rehabilitation effect. Radiographic progression of ONFH and the incidence of total hip arthroplasty were analyzed to evaluate the survival rate of ONFH postoperatively. Statistical analyses were mainly performed with Kruskal-Wallis test, chi-square test and Kaplan-Meier method.

RESULTS

HHS increased significantly in all groups but showed no significant differences among the six groups in the first years. The nonvascularized allogeneic fibula with bone grafting (NVAF + BG) and percutaneous femoral neck-head fenestration with bone grafting via the direct anterior approach (DAA + BG) groups had significantly higher HHS (p = 0.010; p = 0.025) and WOMAC function score (p < 0.001; p = 0.012) than the CD group 5 years postoperatively. Compared with the CD group, all the other groups showed statistically significant differences in radiographic progression (p < 0.001) and a higher survival rate with no significant difference (p = 0.569).

CONCLUSION

Our study demonstrates the potential use of NVAF + BG and DAA + BG, may serve as a promising combined therapy for the treatment of early-stage nontraumatic ONFH.

Investigation of Novel Radiological Parameters to Predict Treatment Failure and Ideal Surgical Interventions in Young Femoral Neck Fractures Treated with Triple Cannulated Screw: A Retrospective Analysis

Introduction

Treatment failure remains a challenge in young femoral neck fractures treated with triple cannulated screws (TCS). This study aims to identify novel radiological parameters that can predict treatment failure and propose surgical techniques to enhance the success of TCS or aid in selecting alternative methods.

Patients and methods

We conducted a retrospective analysis of 87 patients who underwent surgery for femoral neck fractures between February 2014 and June 2022, meeting the inclusion criteria. Patients achieving union were categorized as Non-Fail (Group 1), while those experiencing nonunion were categorized as Fail (Group 2). Various demographic and clinical factors were assessed, including age, gender, fracture side, and fracture classification (Garden and Pauwels). Radiological parameters such as fragmentation in the medial cortex, postoperative fracture displacement in the calcar region, collo-diaphyseal angle (CDA) difference (varus/valgus alignment), and several newly defined parameters (modified tip apex distance (m-TAD), tip cortex distance (TCD), upper-lower screw-cortex distance/neck diameter, the calcar screw-cortex distance/neck diameter (Buyukdogan index), and sub-capital area/basocervical area (Dogan index) were evaluated. Patients developing nonunion were studied to establish potential cut-off values based on radiological parameters.

Results

Of the patients, 61 were classified as Non-Fail (Group 1) and 26 as Fail (Group 2). Both groups exhibited similar distributions in terms of gender, fracture side, Pauwels classification, and follow-up times (p > 0.05). However, Group 2 had a higher mean age than Group 1 (p = 0.006). There was a significant difference between the two groups in terms of Garden classification (p = 0.0003). Furthermore, postoperative calcar displacement, varus alignment, m-TAD, TCD, upper-lower screw-cortex distance/neck diameter ratio, Buyukdogan index, and Dogan index showed significant differences between the groups (p < 0.05). Conversely, medial calcar fragmentation did not differ significantly between the groups (p > 0.05).

Conclusions

The Dogan index (≤ 0.5) can serve as an independent preoperative predictor of treatment failure, aiding in the selection of more effective surgical interventions than TCS. Varus alignment (> 10 degrees), the upper-lower screw-cortex distance to the neck diameter (> 0.45) and Buyukdogan index (> 0.2) are influenced by the surgical technique of TCS application and should be considered to decrease the success of TCS.

Restoration of internal rotation after reverse shoulder arthroplasty may vary depending on etiology in patients younger than 60 ​years of age: a multicenter retrospective study

BACKGROUND

Reverse shoulder arthroplasty (RSA) offers promising functional outcomes for young patients, yet challenges persist in restoring internal rotation (IR). This study aimed to assess the restoration of IR after RSA in patients younger than 60 years of age and analyze the factors affecting IR recovery.

METHODS

A retrospective multicenter study was conducted, examining the functional outcome of patients who underwent RSA, with a minimum follow-up period of 2 years. Two subgroups of patients who underwent primary RSA were analyzed separately with respect to active internal rotation with the elbow at the side (AIR1): "difficult AIR1" and "easy AIR1."

RESULTS

The study included 136 patients (overall series) with a mean age of 51.6 years. The overall series showed statistically significant improvement in active range of motion (RoM), pain, and Constant scores, especially with active IR (p ​< ​0.01). According to etiology, statistically significant improvement (p ​< ​0.05) in active IR was observed for fracture sequelae, primary osteoarthritis, and rheumatoid arthritis, whereas no statistically significant improvement in IR was observed for tumor, revision, and cuff-tear arthropathy (p ​> ​0.05). In subgroup analysis, patients with easy AIR1 displayed a statistically significant lower body mass index and better Constant score mobility, as well as improved motion in forward elevation and active IR (p ​< ​0.05). No statistically significant associations were found between improved IR and prosthetic design or subscapularis repair. Scapular notch, lysis of the graft, and teres minor atrophy were significantly associated with better active IR (p ​< ​0.05).

CONCLUSION

RSA improves active RoM, pain, and functional outcomes in patients aged under 60. However, the degree of improvement in IR may vary depending on several factors and the underlying etiologies. These insights are crucial for patient selection and counseling, guiding RSA optimization efforts.

LEVEL OF EVIDENCE

IV.

Pediatric Wrist

Pediatric wrist injuries pose unique diagnostic challenges due to distinct bone characteristics in children and their diverse injury patterns. The dynamic development of the wrist, marked by changes in bone age and emerging ossification centers, is crucial to evaluate growth and identify potential pathologies. The skeletal composition, rich in cartilage, renders bones relatively weaker yet more elastic, impacting their susceptibility to fracture. Forearm fractures display diverse patterns influenced by torsional forces. Scaphoid fractures, less common in children, differ from those in adults. Conditions like Madelung's deformity and ulnar variance are more common wrist disorders in the pediatric population. In addition, the scarcity and nonspecificity of symptoms in those with tendon injuries and triangular fibrocartilage complex lesions can be diagnostically challenging. This article reviews pediatric wrist injuries, emphasizing ossification patterns, common fracture types, and developmental variants. Grasping these complexities in pediatric wrist development and associated pathologies is essential for precise diagnosis and treatment.

The addition of mesenchymal stem cells in a bioabsorbable scaffold does not enhance tendon healing after a repair of rotator cuff tear

PURPOSE

The purpose of the study is to evaluate the healing potential of a full-thickness tendon defect in the rotator cuff of rabbits using a bioabsorbable scaffold impregnated with bone marrow-mesenchymal stem cells (BM-MSCs) or rotator cuff-derived mesenchymal stem cells (RC-MSCs).

METHODS

Sixteen adult rabbits were subjected to a full-thickness rotator cuff deficit. Rabbits were randomly assigned to four groups of four animals. In Group 0 (control), the deficit was left untreated. In Group 1, the deficit was treated with a single synthetic scaffold alone. In Group 2, the deficit was treated with the previous scaffold loaded with allogeneic BM-MSCs. In Group 3, the deficit was treated with the previous scaffold loaded with allogenic RC-MSCs. After animal sacrifice, tissue samples were subjected to histological and immunohistochemical analysis.

RESULTS

Group 1 showed the highest mean tendon maturing score (15.3 ± 0.9) postoperatively, being significantly higher, in comparison to groups 0, 2 and 3 (p = 0.01, 0.02 and 0.01, respectively). Group 1 showed the highest mean collagen I/collagen III ratio (1.4 ± 0.8) postoperatively but without any statistical significance.

CONCLUSIONS

The utilization of MSCs in rotator cuff repair in a rabbit model has not been associated with an enhancement in tendon healing in 16 weeks postoperatively, in comparison to controls and bioabsorbable scaffolds. The addition of MSCs does not result in better rotator cuff healing.

LEVEL OF EVIDENCE

Not applicable. This is an animal study.

Reverse Shoulder Arthroplasty for Proximal Humerus Fractures: A Review of Current Evidence

PURPOSE OF REVIEW

The aim of this review is to summarize information published in the recent peer-reviewed literature on reverse shoulder arthroplasty (RSA) for proximal humerus fractures.

RECENT FINDINGS

Although there is still some debate regarding which may be the best treatment for proximal humerus fractures in certain age ranges, RSA seems to offer more predictable results than other surgical treatments for elderly patients. Successful tuberosity healing seems to correlate with better outcomes. Recent trends indicate interest in cementless fixation, fracture-specific stems and a 135-degree polyethylene opening angle. RSA provides a successful surgical solution for selected proximal humerus fractures. Indications, design features, and surgical execution have continued to evolve over the last few years.

Gouty destruction of a patellar tendon reconstruction and novel revision reconstruction technique: A case report

BACKGROUND

Gout is a disease characterized by hyperuricemia, and resultant deposition of uric acid crystals in tissues. While typically manifested as intraarticular crystals or tophi, gout can also cause pathology at entheses. Gouty deposition within tendinous structures put them at risk for traumatic and degenerative rupture. Furthermore, allografts can also be at risk of rupture in the setting of severe gout. We present the case of a 56-year-old female with severe gouty disease who sustained a re-rupture of a patellar tendon allograft reconstruction.

CASE SUMMARY

A 56-year-old female presented to clinic after feeling her left knee pop and collapse beneath her while descending stairs. She had a history of tophaceous gout and left patellar tendon rupture with reconstruction and multiple revisions over the course of 19 years. This patient presented with pain and extensor lag. A magnetic resonance image demonstrated a ruptured patellar tendon allograft reconstruction and avulsion fracture at the tibial tubercle. The patient was treated with a novel intervention of Achilles allograft with bone block in a unique configuration with a dermal allograft incorporated into the reconstruction. She was made non-weight bearing in the operative extremity in extension for the first four weeks postoperatively and was then progressed to active flexion over the course of eight weeks. At twelve weeks, she was able to fully extend her operative knee and at five months she was resuming her normal activities and exercises.

CONCLUSION

Failed patellar tendon reconstruction due to gouty infiltration is treated with dermal allograft augmented Achilles tendon reconstruction with bone block.

Higher rates of intraoperative fractures with compaction broaching compared to conventional broaching during hip hemiarthroplasty for femoral neck fractures

PURPOSE

Intraoperative periprosthetic femoral fracture (IPFF) is a known iatrogenic complication during hemiarthroplasty (HA) which may lead to inferior outcomes. The risk factors for IPFF during HA in displaced femoral neck fractures (FNF) remains to be fully elucidated. This study aims to compare IPFF rates between compaction broaching and conventional broaching techniques for cementless HA in FNF.

METHODS

We retrospectively reviewed institutional surgical data of patients who underwent cementless HA for displaced FNF from January 2010 to January 2022. Patients were stratified into two groups based on the broaching system: conventional broaching and compaction broaching. The presence, location, and treatment of IPFF were assessed for both groups. Effect of IPFF on postoperative weight-bearing status, mortality readmission and revision rates were compared between groups.

RESULTS

A total of 1,586 patients included in the study. 1252 patients (78.9%) in the conventional broaching group and 334 patients (21.1%) in the compaction broaching group. A total of 104 IPFF were found (6.5%). As compared to conventional broaching, compaction broaching was associated with significant higher IPFF rates (12.9% vs. 4.9%, p < 0.001, OR 2.84, CI 1.88-4.30). The location of the IPFF was similar between groups (p = 0.366), as well as the intraoperative treatment (p = 0.103) and postoperative weight-bearing status (p = 0.640). Surgical time, mortality rates, readmission rates and revision rates were comparable between groups. In a multivariate regression analysis, compaction broaching (OR, 4.24; p < 0.001) was independently associated with IPFF.

CONCLUSIONS

This study reveals higher rates of IPFF associated with compaction broaching. Although this finding may have minimal clinical relevance, surgeons should consider these results when considering implant selection.

Retention of the posterior cruciate ligament stabilizes the medial femoral condyle during kneeling using a tibial insert with ball-in-socket medial conformity

PURPOSE

Resecting the posterior cruciate ligament (PCL) increases posterior laxity and increases the flexion gap more than the extension gap in the native (i.e. healthy) knee. These two effects could lead to significant anterior displacement of the medial femoral condyle in kneeling following total knee arthroplasty even when using a tibial insert with a high degree of medial conformity. Using an insert with ball-in-socket medial conformity and a flat lateral articular surface, the primary purpose was to determine whether the medial femoral condyle remained stable with and without PCL retention during kneeling.

METHODS

Two groups of patients were studied, one with PCL retention (22 patients) and the other with PCL resection (25 patients), while kneeling at 90º flexion. Following 3D model-to-2D image registration, A-P displacements of both femoral condyles were determined relative to the dwell point of the medial socket.

RESULTS

With PCL resection versus PCL retention, the medial femoral condyle was 5.1 ± 3.7 mm versus 0.8 ± 2.1 mm anterior of the dwell point (p < 0.0001). Patient-reported function scores were comparable (p ≥ 0.1610) despite a significantly shorter follow-up of 7.8 ± 0.9 months with PCL retention than 19.6 ± 4.9 months with PCL resection (p < 0.0001). Range of motion was 126 ± 8° versus 122 ± 6° with and without PCL retention, respectively (p = 0.057).

CONCLUSION

Surgeons that use a highly conforming tibial insert design can stabilize the medial femoral condyle during kneeling by retaining the PCL. In patients with PCL resection, the 9 mm high anterior lip of the insert with ball-in-socket medial conformity was insufficient to prevent significant anterior displacement of the medial femoral condyle when weight-bearing on the anterior tibia.

Starting Up a Lateral Unicompartmental Knee Arthroplasty Practice - Is Outcome Affected?

INTRODUCTION

In the past, the utilization of lateral unicompartmental knee arthroplasty (UKA) has been limited at national levels, despite the fact that an estimated 10% of patients who have an indication for arthroplasty, present with isolated lateral compartment osteoarthritis (OA). Units dedicated to UKA have reported good outcomes. Identifying patients for the procedure has been less clear, and the procedure has been perceived to be technically more demanding than medial UKA. This may result in a reluctance to start a lateral UKA practice and challenge the early phase. Therefore, this paper aimed to present the outcomes and learning curve when starting up a lateral UKA practice, as this theme remains unelucidated.

METHODS

There were 85 primary fixed-bearing lateral UKAs, with a minimum of 1-year follow-up, performed between 2016 and 2022 by two arthroplasty surgeons with existing UKA practices. The indications were primary (n = 79) or post-traumatic (n = 6) osteoarthritis. Patient-reported outcome measures (PROMs) were assessed at 3, 12, and 24 months. A cumulative sum (CUSUM) analysis was used to evaluate surgical duration and the 12-month Oxford Knee Score (OKS).

RESULTS

Median (Interquartile range (IQR)) 12-month OKS, Activity and Participation Questionnaire (APQ), and Forgotten Joint Score (FJS) were 43 (37.5 to 46), 78 (42.5 to 98.5), and 72 (55 to 90), respectively. The OKS outcomes did not reveal adverse effects from the learning curve. A performance shift in surgical duration was observed around case 33. Kaplan-Meier implant survival reached 95.4% at 7 years for the endpoint "implant revision," and 93.5% for "implant revision/implant addition."

CONCLUSION

Starting up a lateral UKA practice is safe and efficient for surgeons who have prior medial UKA experience, provided strict adherence to indications. While surgical duration indicated a learning curve over approximately 33 cases, PROMs remained stable, suggesting proficient outcomes irrespective of the learning curve.

Linking Patient-Reported Outcome Measure Scores to Adverse Event Data to Gain Insight into Overestimation of Postoperative Patient-Reported Outcome Measure Improvement After Total Hip Arthroplasty and Total Knee Arthroplasty Due to Selective Nonresponse

BACKGROUND

The purpose of the study was to gain insight into how clinically relevant improvement in patient-reported outcome measure scores after total hip arthroplasty (THA) and total knee arthroplasty (TKA) may be underestimated or overestimated, we compared patient-reported outcome measure respondents and nonrespondents on their adverse event rates and assessed whether adverse event occurrence was associated with clinically relevant patient-reported outcome measure improvement from those without adverse events.

METHODS

All primary THAs and TKAs performed in 19 Dutch hospitals between January 2017 and December 2019 were included. The hip disability and osteoarthritis outcome score-physical function short form (HOOS-PS) and knee injury and osteoarthritis outcome score-physical function short form (KOOS-PS) were used to assess the physical function after THA and TKA, respectively. Adverse events included 1-year revision, 30-day readmission, 30-day complications, and long (ie, >75th percentile) length of stay. A clinically relevant improvement was defined as at least a 10-point decrease in HOOS-PS and 9 points in KOOS-PS scores. Associations between adverse events and clinically relevant HOOS-PS and KOOS-PS improvement were assessed using binary logistic regression models adjusted for patient characteristics and clustering of patients within hospitals.

RESULTS

There were 20,338 THA and 18,082 TKA procedures included. Adverse events occurred more frequently in HOOS-PS and KOOS-PS nonrespondents than in respondents. The THA patients experiencing revision, complications, or long length of stay were less likely to experience clinically relevant HOOS-PS improvements (odds ratios of 0.11 [0.06 to 0.20], 0.44 [0.30 to 0.63], and 0.66 [0.50 to 0.88], respectively). The TKA patients experiencing revision or long length of stay were less likely to experience clinically relevant KOOS-PS improvements (odds ratios of 0.26 [0.12 to 0.55] and 0.63 [0.50 to 0.80], respectively).

CONCLUSIONS

Clinically relevant HOOS-PS and KOOS-PS improvements are likely overestimated, as nonrespondents had higher adverse event rates which were associated with lower likelihood to achieve clinically relevant HOOS-PS and KOOS-PS improvements.

Glenoid lateralization in reverse shoulder arthroplasty: metal vs. bone offset in different implant designs

Background

Higher bone or metal glenoid offset in reverse shoulder arthroplasty (RSA) reduces scapular notching, improves range of motion (ROM), and reduces postoperative instability. This retrospective multicenter study compared two implant designs to evaluate the short-term clinical and radiologic results of bone increased offset RSA (BIO-RSA) and metal increased offset RSA (MIO-RSA) in reverse shoulder. We hypothesized no difference between groups.

Methods

This study analyzed n = 62 BIO-RSA and n = 90 MIO-RSA cases with a mean follow-up of 29.7 ± 6.0 months (BIO-RSA, range 24-49 months) and 24.0 ± 1.1 months (MIO-RSA, range 22-28 months). A 145°-onlay humeral stem was utilized in BIO-RSA cases, while a 135°-semi-inlay humeral stem was implanted in all MIO-RSA cases. Preoperative and postoperative radiologic imaging was reviewed to identify signs of scapular notching. Additionally, lateralization was evaluated according to Erickson et al. The constant score, subjective shoulder value, and ROM were evaluated during the baseline and follow-up consultations, and the findings of both groups were subsequently compared.

Results

Scapular notching was observed in 7.0% (n = 8) of MIO-RSA cases and 8.1% (n = 5) of BIO-RSA cases (P = .801). MIO-group had a higher lateralization angle (P = .020) and the BIO-group had a higher distalization angle (P = .005). At baseline, mean constant score in the MIO-RSA group was higher than in the BIO-RSA group (P < .001), and it significantly increased to 67.8 ± 12.1P (MIO-RSA) and 69.5 ± 12.3P (BIO-RSA) to a similar level (P = .399). ROM improved in both groups with no significant difference between the two groups at follow-up.

Conclusion

BIO-RSA and MIO-RSA in two distinct implant designs provide comparable short-term outcomes with a similar increase in shoulder function with notable variations in the lateralization and distalization angles between both implants. Scapular notching was rarely seen and unaffected by the method of glenoid lateralization. Follow-up investigations of both techniques are necessary to complement and track changes in the long-term outcome.

A Posterior Acromial Bone Block Augmentation Is Biomechanically Effective at Restoring the Force Required To Translate the Humeral Head Posteriorly in a Cadaveric, Posterior Glenohumeral Instability Model

PURPOSE

To assess the biomechanical utility of a posterior acromial bone block (PABB) for the treatment of posterior glenohumeral instability.

METHODS

Ten fresh-frozen cadaveric specimens were obtained based upon an a priori power analysis. A 2.5-cm scapular spine autograft was harvested from all shoulders. A custom robot device was used to apply a 50-N compressive force to the glenohumeral joint. The humeral head was translated 10 mm posteroinferiorly at 30 degrees from the center of the glenoid at a rate of 1.0 mm/s in 6 consecutive conditions: (1) intact specimen, (2) intact with PABB, (3) posterior capsulolabral tear, (4) addition of the PABB, (5) removal of the PABB and repair of the capsulolabral tear (LR), and (6) addition of the PABB with LR. The maximum force required to obtain this translation was recorded. Paired t tests were performed to compare relevant testing conditions.

RESULTS

Ten cadavers with a mean ± SD age of 54.4 ± 13.1 years and mean ± SD glenoid retroversion of 6.5 ± 1.0 degrees were studied. The PABB provided greater resistance force to humeral head translation compared to the instability state (instability, 29.3 ± 15.3 N vs PABB, 47.6 ± 21.0 N; P = .001; 95% confidence interval [CI], -27.6 to -10.0). When comparing PABB to LR, the PABB produced higher resistance force than LR alone (PABB, 47.6 ± 21.0 N; LR, 34.2 ± 20.5 N; P = .012; 95% CI, -23.4 to -4.1). An instability lesion treated with the PABB, with LR (P = .056; 95% CI, -0.30 to 20.4) or without LR (P = .351; 95% CI, -6.8 to 15.7), produced resistance forces similar to the intact specimen.

CONCLUSIONS

A PABB is biomechanically effective at restoring the force required to translate the humeral head posteriorly in a cadaveric, posterior glenohumeral instability model. A posterior acromial bone block is a biomechanically feasible option to consider in patients with recurrent posterior instability.

CLINICAL RELEVANCE

Augmentation of the posterior acromion may be a biomechanically feasible option to treat posterior shoulder instability.

Safety and efficacy of second-generation all-suture anchors in labral tear arthroscopic repairs: prospective, multicenter, 1-year follow-up study

Background

This study's primary aim was to assess the safety and performance of second-generation all-soft suture anchors following arthroscopic labral tear repair.

Methods

This prospective, multicenter study was conducted by 6 surgeons at 6 sites in Europe and the United States between November 2018 and August 2020. Patients who required shoulder arthroscopic repair, for a range of labral injuries, were treated with a second-generation all-soft suture anchor. The primary outcome was clinical success rate (percentage of patients without signs of failure and/or reintervention) at 6 months. Secondary outcomes included clinical success rate at 12 months, intraoperative anchor deployment success rate, and patient-reported outcomes (PROs) at 6 and 12 months, including visual analog scale (VAS) pain assessment, VAS satisfaction assessment, EQ-5D-5L Index Score, EQ-5D-5L VAS Health Score, Rowe Shoulder Score for Instability, American Shoulder and Elbow Surgeons score, and Constant-Murley Shoulder Score. Serious adverse events and serious adverse device effects were collected throughout the study.

Results

Forty-one patients were enrolled (mean age, 28.2 years; 87.8% male, 12.2% female). Clinical success was achieved in 27/28 and 31/32 patients at 6 months and 12 months, respectively. Anchor deployment had a 100% success rate. Significant improvements over baseline were reported for all PROs except Constant-Murley Shoulder (6 months) and VAS Satisfaction Score (12 months). One patient experienced 1 serious adverse event and 1 patient experienced 1 serious adverse device effect.

Conclusion

Second-generation all-soft suture anchors used in this study demonstrated a high clinical success rate, a favorable safety profile, and patients exhibited significant improvement in PROs.

Which factor is more associated with survival of patients with hip fracture over 90 years: Type of fracture or treatment modality?

OBJECTIVE

We aimed to analyze prognostic factors affecting the mortality and to evaluate whether the fracture type (collum femoris or intertrochanteric fracture) or treatment method (proximal femoral nail or hemiarthroplasty) affects the mortality in patients with hip fractures and older than 90 years old.

METHODS

In our study, we retrospectively reviewed the patients aged >90 years and operatively treated hip fractures. Patients were categorized according to fracture type and treatment method. Finally, three groups were created. Demographic values, laboratory values were analyzed for prognostic factors and determining independent factors associated with survival for each group.

RESULTS

A total of 193 patients were included with an average age of 92.5±2.4 (range, 90-104) years. There were 144 women and 49 men. There were 126 (65.2%) patients with intertrochanteric fracture and 67 (34.8%) patients with collum femoris fracture. At the time of this study, 142 (73.5%) patients had deceased. Staying in intensive care unit for collum femoris group, general anesthesia for intertrochanteric fracture treated with hemiarthroplasty group and delay to surgery and preoperative albumin level for intertrochanteric fracture treated with proximal femoral nail group were associated with poor survival.

CONCLUSION

Staying intensive care unit, general anesthesia, delay to surgery and preoperative albumin levels should be carefully evaluated for patients aged over 90 years with hip fractures. Our study showed that both fracture type and treatment modality were not associated with poor overall survival of the patients aged >90 years following hip fracture surgery.

A Case Report Emphasizing the Advantageous Effect of Mulligan Mobilization Technique in the Management of Rotator Cuff Syndrome to Enhance Functional Recovery in a 65-Year-Old Farmer

Adults with shoulder pain often have partial rotator cuff injuries (RCIs) as the underlying cause. RC partial tears are one of the common conditions that can have a major influence on a wide range of people, including sportspeople, workers, and sedentary adults with rotator cuff syndrome (RCS). Any injury, disease, or deteriorating condition that affects the shoulder's RC muscles and tendons is recognized as RCS. Subacromial bursitis, RC tendonitis, subacromial impingement syndrome (SIS), rotator cuff tears (RCTs), etc., are a few disorders linked to RCS. For partial RCT, nonoperative treatment options include physical therapy, anti-inflammatories, analgesics, medication, rest or activity adjustments, and corticosteroid injections. We present the case of a 65-year-old male farmer by occupation, suffering from an RCI on the right side. Following a history of trauma to the right shoulder from a collision with a bull on his farm, the patient complained of pain and limitations in his right shoulder joint. The goal of the rehabilitation program was to maximize the patient's recovery through pain management, range-of-motion (ROM) restoration, muscle strength building, and functional activities. To improve muscular strength and preserve the ROM, strengthening exercises and isometrics were all incorporated into the rehabilitation regimen at the same time. The patient's progress was monitored at scheduled times during rehabilitation using the disabilities of arm, shoulder, and hand (DASH) score, visual analog scale (VAS), goniometer for normal ROM, and the upper extremity functional scale (UEFS). In this case study, the care and recovery of a patient with RC tendinopathy who received physical therapy are examined.

SECEC Didier Patte Prize 2023: the ABC classification of posterior shoulder instability

BACKGROUND

The ABC classification has recently been proposed as a comprehensive classification system for posterior shoulder instability (PSI). The purpose of this study was to analyze the comprehensiveness as well as inter-rater and intrarater reliability of the ABC classification.

METHODS

All consecutive patients presenting with unidirectional PSI from June 2019 to June 2021 were included in a prospective study. No patients were excluded, leaving a consecutive series of 100 cases of PSI in 91 patients. All recorded clinical and imaging data were used to create anonymized clinical case vignettes, which were evaluated twice according to the ABC classification at the end of the recruitment period in random sequential order by 4 independent raters (2 experienced shoulder surgeons and 2 orthopedic residents) to analyze the comprehensiveness as well as inter-rater and intrarater reliability of the ABC classification for PSI and to describe differences in characteristics among subtypes. Group A was defined as a first-time singular PSI event <3 months in the past regardless of etiology and is further subdivided into type 1 and type 2 depending on the occurrence of a subluxation (A1) or dislocation (A2). Group B comprises recurrent dynamic PSI regardless of time since onset and is further subdivided by the cause of instability into functional (B1) and structural (B2) dynamic PSI. Group C includes chronic static PSI with posterior humeral decentering that can be either constitutional (C1) or acquired (C2).

RESULTS

None of the cases was deemed unsuitable to be classified based on the proposed system by the observers. After consensus agreement between the 2 expert raters, 16 cases were attributed to group A (8 type A1 and 8 type A2); 64, to group B (33 type B1 and 31 type B2); and 20, to group C (11 type C1 and 9 type C2). The expert raters agreed on the classification subtypes in 99% and 96% of the cases during the first rating and second rating, respectively (intraclass correlation coefficients [ICCs], 0.998 and 0.99, respectively). The intraobserver reliability was excellent for both raters. The beginners reached the same conclusion as the consensus agreement in 94% of the cases (ICC, 0.99) and 89% of the cases (ICC, 0.97) during the first round and 94% each (ICC, 0.97) during the second round. The intraobserver reliability was excellent for both beginners. Overall, discrepancies between raters were found between groups B1 and B2 (n = 14), groups B2 and C2 (n = 4), groups B1 and C1 (n = 1), and groups A1 and B2 (n = 1). In general, each subtype showed distinctive clinical and imaging characteristics that facilitated the diagnosis.

CONCLUSION

The presented ABC classification for PSI is a comprehensive classification with a high reliability and reproducibility. However, a gradual transition and potential progression between the subtypes of PSI must be considered. The reliable distinction between different subtypes of PSI based on etiology and pathomechanism provides a standardized basis for future investigations on treatment recommendations.

A novel anatomical locked medial femoral condyle plate: a biomechanical study

BACKGROUND

Fixation with a distal lateral femoral plate is a standard approach in treating osteoporotic or comminuted supracondylar femur fractures. However, in clinical practice, this method may prove inadequate, necessitating the application of a plate on the medial side of the distal femur. The aim of this study is to perform a biomechanical evaluation of the newly manufactured anatomically locked plate applied to the distal medial femoral condyle.

MATERIALS AND METHODS

The plate underwent 2 biomechanical tests by simulating an AO/OTA 33A3 type supracondylar fracture model on synthetic femur bones. The samples were divided into three groups. Fracture fixations were carried out on the medial side using the distal femur medial anatomical locking plate (DFMALP) in group A samples, on the lateral side using the distal femur lateral anatomical locking plate in group B samples, and on both sides in group C samples.

RESULTS

In the axial compression test, stability was preserved 23% more in group C than in group B. During the cyclic axial compression test, total displacement was 21% less in group C than in group B. Group A was collapsed at early cycle degrees.

CONCLUSION

In our study, it was observed that the application of DFMALP in conjunction with the lateral plate in AO/OTA 33A3 fragmented supracondylar femur fractures significantly enhanced biomechanical fracture stability.

LEVEL OF EVIDENCE

This is a Level 2 prospective, randomized controlled study.

Metallic Lateralized-Offset Glenoid Reverse Shoulder Arthroplasty

Background

Metallic lateralized-offset glenoid reverse shoulder arthroplasty (RSA) for cuff tear arthropathy combines the use of a metallic augmented baseplate with a metaphyseally oriented short stem design that can be applied at a 135° or 145° neck-shaft angle, leading to additional lateralization on the humeral side. Lateralization of the center of rotation decreases the risk of inferior scapular notching and improves external rotation, deltoid wrapping, residual rotator cuff tensioning, and prosthetic stability1-4. Metallic increased-offset RSA (MIO-RSA) achieves lateralization and corrects inclination and retroversion while avoiding graft resorption and other complications of bony increased-offset RSA (BIO-RSA)5-8. Reducing the neck-shaft angle from the classical Grammont design, in combination with glenoid lateralization, improves range of motion9,10 by reducing inferior impingement during adduction at the expense of earlier superior impingement during abduction2,11. Lädermann et al.12 investigated how different combinations of humeral stem and glenosphere designs influence range of motion and muscle elongation. They assessed 30 combinations of humeral components, as compared with the native shoulder, and found that the combination that allows for restoration of >50% of the native range of motion in all directions was a 145° onlay stem with a concentric or lateralized tray in conjunction with a lateralized or inferior eccentric glenosphere. In addition, the use of a flush-lay or a slight-onlay stem design (like the one utilized in the presently described technique) may decrease the risk of secondary scapular spine fracture13,14. The goal of this prosthetic design is to achieve an excellent combination of motion and stability while reducing complications.

Description

This procedure is performed via a deltopectoral approach with the patient in the beach-chair position under general anesthesia combined with a regional interscalene nerve block. Subscapularis tenotomy and capsular release are performed, the humeral head is dislocated, and any osteophytes are removed. An intramedullary cutting guide is placed for correct humeral resection. The osteotomy of the humeral head is performed in the anatomical neck with an inclination of 135° and a retroversion of 20° to 40°, depending on the anatomical retroversion. The glenoid is prepared as usual. The lateralized, augmented baseplate is assembled with the central screw and the baseplate-wedge-screw complex is placed by inserting the screw into the central screw hole. Four peripheral screws are utilized for definitive fixation. An eccentric glenosphere with inferior overhang is implanted. The humerus is dislocated, and the metaphysis is prepared. Long compactors are utilized for proper stem alignment, and an asymmetric trial insert is positioned before the humerus is reduced. Stability and range of motion are assessed. The definitive short stem is inserted and the asymmetric polyethylene is impacted, resulting in a neck-shaft angle of 145°. Following reduction, subscapularis repair and wound closure are performed.

Alternatives

BIO-RSA is the main alternative to MIO-RSA. Boileau et al.15 demonstrated satisfactory early and long-term outcomes of BIO-RSA for shoulder osteoarthritis. A larger lateral offset may also be achieved with a thicker glenosphere2,16. Mark A. Frankle developed an implant that addressed the drawbacks of the Grammont design: a lateralized glenosphere combined with a 135° humeral neck-shaft angle. The 135° neck-shaft angle provides lateral humeral offset, preserving the normal length-tension relationship of the residual rotator cuff musculature, which optimizes its strength and function. The lateralized glenosphere displaces the humeral shaft laterally, minimizing the potential for impingement during adduction2,9,17,18. The advantage of BIO-RSA and MIO-RSA over lateralized glenospheres is that the former options provide correction of angular deformities without excessive reaming, which can lead to impingement19.

Rationale

BIO-RSA has been proven to achieve excellent functional outcomes15,20,21; however, the bone graft can undergo resorption, which may result in early baseplate loosening. Bipolar metallic lateralized RSA is an effective strategy for achieving lateralization and correction of multiplanar defects while avoiding the potential complications of BIO-RSA6,7,22-24. MIO-RSA also overcomes another limitation of BIO-RSA, namely that BIO-RSA is not applicable when the humeral head is not available for use (e.g., humeral head osteonecrosis, revision surgery, fracture sequelae).

Expected Outcomes

A recent study evaluated the clinical and radiographic outcomes of metallic humeral and glenoid lateralized implants. A total of 42 patients underwent primary RSA. Patients were documented prospectively and underwent follow-up visits at 1 and 2 years postoperatively. That study demonstrated that bipolar metallic lateralized RSA achieves excellent clinical results in terms of shoulder function, pain relief, muscle strength, and patient-reported subjective assessment, without instability or radiographic signs of scapular notching23. Kirsch et al.25 reported the results of primary RSA with an augmented baseplate in 44 patients with a minimum of 1 year of clinical and radiographic follow-up. The use of an augmented baseplate resulted in excellent short-term clinical outcomes and substantial deformity correction in patients with advanced glenoid deformity. No short-term complications and no failure or loosening of the augmented baseplate were observed. Merolla et al.7 compared the results of 44 patients who underwent BIO-RSA and 39 patients who underwent MIO-RSA, with a minimum follow-up of 2 years. Both techniques provided good clinical outcomes; however, BIO-RSA yielded union between the cancellous bone graft and the surface of the native glenoid in <70% of patients. On the other hand, complete baseplate seating was observed in 90% of MIO-RSA patients.

Important Tips

When performing subscapularis tenotomy, leave an adequate stump to allow end-to-end repair.Tenotomize the superior part of the subscapularis tendon in an L-shape, sparing the portion below the circumflex vessels.As glenoid exposure is critical, perform a 270° capsulotomy.Continuously check the orientation of the baseplate relative to the prepared hole and reamed surface to ensure accurate implantation of the full wedge baseplate to achieve a proper fit.Aim for 70% to 80% seating of the baseplate onto the prepared glenoid surface. Avoid overtightening or excessive advancement of the baseplate into the subchondral bone. Gaps between the baseplate and glenoid surface should also be avoided.In order to avoid varus or valgus malpositioning of the final implant, obtain proper diaphyseal alignment by following "the three big Ls": large, lateral, and long. Use a large metaphyseal component to fill the metaphysis. Place the guide pin for the reaming of the metaphysis slightly laterally into the resected surface of the humerus. Use long compactors for diaphyseal alignment to avoid varus or valgus malpositioning of the final implant.Use an intramedullary cutting guide for correct humeral resection.Utilize the correct liner in order to obtain proper tensioning and avoid instability.

Acronyms and Abbreviations

K wire = Kirschner wireROM = range of motion.

Are glenoid retroversion, humeral subluxation, and Walch classification associated with a muscle imbalance?

BACKGROUND

The etiology of humeral posterior subluxation remains unknown, and it has been hypothesized that horizontal muscle imbalance could cause this condition. The objective of this study was to compare the ratio of anterior-to-posterior rotator cuff and deltoid muscle volume as a function of humeral subluxation and glenoid morphology when analyzed as a continuous variable in arthritic shoulders.

METHODS

In total, 333 computed tomography scans of shoulders (273 arthritic shoulders and 60 healthy controls) were included in this study and were segmented automatically. For each muscle, the volume of muscle fibers without intramuscular fat was measured. The ratio between the volume of the subscapularis and the volume of the infraspinatus plus teres minor (AP ratio) and the ratio between the anterior and posterior deltoids (APdeltoid) were calculated. Statistical analyses were performed to determine whether a correlation could be found between these ratios and glenoid version, humeral subluxation, and/or glenoid type per the Walch classification.

RESULTS

Within the arthritic cohort, no statistically significant difference in the AP ratio was found between type A glenoids (1.09 ± 0.22) and type B glenoids (1.03 ± 0.16, P = .09), type D glenoids (1.12 ± 0.27, P = .77), or type C glenoids (1.10 ± 0.19, P > .999). No correlation was found between the AP ratio and glenoid version (ρ = -0.0360, P = .55) or humeral subluxation (ρ = 0.076, P = .21). The APdeltoid ratio of type A glenoids (0.48 ± 0.15) was significantly greater than that of type B glenoids (0.35 ± 0.16, P < .01) and type C glenoids (0.21 ± 0.10, P < .01) but was not significantly different from that of type D glenoids (0.64 ± 0.34, P > .999). When evaluating both healthy control and arthritic shoulders, moderate correlations were found between the APdeltoid ratio and both glenoid version (ρ = 0.55, P < .01) and humeral subluxation (ρ = -0.61, P < .01).

CONCLUSION

This in vitro study supports the use of software for fully automated 3-dimensional reconstruction of the 4 rotator cuff muscles and the deltoid. Compared with previous 2-dimensional computed tomography scan studies, our study did not find any correlation between the anteroposterior muscle volume ratio and glenoid parameters in arthritic shoulders. However, once deformity occurred, the observed APdeltoid ratio was lower with type B and C glenoids. These findings suggest that rotator cuff muscle imbalance may not be the precipitating etiology for the posterior humeral subluxation and secondary posterior glenoid erosion characteristic of Walch type B glenoids.

Safety and Efficacy of Bone-Marrow Aspirate Concentrate in Hip Osteoarthritis: A Systematic Review of Current Clinical Evidence

Introduction

Hip osteoarthritis (OA) is one of the leading causes of disability and morbidity worldwide. It is estimated to affect 9.2% individuals globally with age over 45 years. Conventional treatment modalities have limitations and side-effects. To overcome these limitations, over the last decade, there has been an increased interest in the use of orthobiologics derived from autologous sources including platelet-rich plasma (PRP), bone-marrow aspirate concentrate (BMAC) and adipose tissue derived formulations. This review qualitatively presents the in-vitro, pre-clinical, clinical and on-going clinical studies exploring the safety and efficacy of BMAC for management of hip OA.

Materials and methods

The electronic database search was done through PubMed, Embase, Web of Science, Scopus, ProQuest and Google Scholar till February 2024. The search terms used were "osteoarthritis" OR "hip osteoarthritis" OR "orthobiologics" OR "efficacy or use of orthobiologic treatment" OR "bone-marrow concentrate" OR "bone-marrow aspirate concentrate", AND "BMAC". The inclusion criteria were clinical studies of any level of evidence written in the English language, published till February 2024, evaluating the safety and efficacy of intra-articular administration of BMAC for the management of hip OA.

Results

A total of 5 studies were included in this review for qualitative data synthesis. The total number of patients who participated in the study was 182, ranging from 4 to 112 in a single study. No adverse events were reported throughout the duration of the study. In addition, intra-articular administration of BMAC led to reduced pain, and improved function and overall quality of life (QoL).

Conclusion

The results from this review demonstrated that administration of BMAC is safe and potentially efficacious in terms of reducing pain, improving function and overall QoL of patients with hip OA in short- and mid-term average follow-up based on the included studies. Nonetheless, more adequately powered, multi-center, prospective, double-blind, non-randomized and randomized controlled trials with long-term follow-up are warranted to establish long-term safety and efficacy of BMAC for management of hip OA and justify its routine clinical use.

Rotator Cuff Arthropathy: A Comprehensive Review

Rotator cuff arthropathy is a spectrum of disease states secondary to full-thickness cuff tears classified by rotator cuff insufficiency and degenerative disease within the shoulder joint. Diagnosis can be made through standard physical exam and radiographic films demonstrating varying levels of weakness, along with acetabularization, femoralization, and superior migration of the humeral head. Severity of disease is classified through both the Hamada and Seebauer grading systems, which are used clinically to determine the appropriate treatment algorithm. Treatment exists along the spectrum from conservative therapy with physical therapy to a definitive treatment with total joint replacement. Depending on a patient's progression and other comorbidities, arthroscopic treatments may additionally be used in specific circumstances as joint-sparing techniques. In recent years, reverse total shoulder arthroplasty has produced increasingly favorable outcomes with improvements in pain and function while simultaneously diminishing complication rates, making it generally accepted as standard of care. This disease limits quality of life for a large population of patients and efforts toward optimization of the treatment regimen is critical. This review provides an overview on the diagnostic criteria, classification, pathoanatomic changes, biomechanics, treatment options, outcomes, and complications of rotator cuff arthropathy.

Augmented versus non-augmented locking-plate fixation in proximal humeral fractures

Aims

Proximal humeral fractures are the third most common fracture among the elderly. Complications associated with fixation include screw perforation, varus collapse, and avascular necrosis of the humeral head. To address these challenges, various augmentation techniques to increase medial column support have been developed. There are currently no recent studies that definitively establish the superiority of augmented fixation over non-augmented implants in the surgical treatment of proximal humeral fractures. The aim of this systematic review and meta-analysis was to compare the outcomes of patients who underwent locking-plate fixation with cement augmentation or bone-graft augmentation versus those who underwent locking-plate fixation without augmentation for proximal humeral fractures.

Methods

The search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Articles involving patients with complex proximal humeral fractures treated using open reduction with locking-plate fixation, with or without augmentation, were considered. A meta-analysis of comparative studies comparing locking-plate fixation with cement augmentation or with bone-graft augmentation versus locking-plate fixation without augmentation was performed.

Results

A total of 19 studies were included in the qualitative synthesis, and six comparative studies were included in the meta-analysis. Overall, 120 patients received locking-plate fixation with bone-graft augmentation, 179 patients received locking-plate fixation with cement augmentation, and 336 patients received locking-plate fixation without augmentation. No statistically relevant differences between the augmented and non-augmented cohorts were found in terms of the Disabilities of the Arm, Shoulder and Hand questionnaire score and Constant-Murley Score. The cement-augmented group had a significantly lower rate of complications compared to the non-augmented group.

Conclusion

While locking-plate fixation with cement augmentation appears to produce a lower complication rate compared to locking-plate fixation alone, functional outcomes seem comparable between augmented and non-augmented techniques.

Balloon Spacer Implant is an "Intermediate Value" Innovation Relative to Partial Repair for Full-Thickness Massive Rotator Cuff Repairs: A Cost-Utility Analysis

PURPOSE

The purpose of this study was to evaluate the cost-utility of a Balloon Spacer implant relative to partial repair (PR) for the surgical treatment of full-thickness massive rotator cuff tears (MRCT).

METHODS

A decision-analytic model comparing Balloon Spacer versus PR was developed using data from a prospective, randomized, single-blinded, multi-center controlled trial of 184 randomized patients. Our model was constructed based on the various event pathways a patient could have after the procedure. The probability that each patient progressed to a given outcome and the quality-adjusted life years (QALY) associated with each outcome were derived from the clinical trial data. Incremental cost utility ratio (ICUR) and incremental net monetary benefit (INMB) were calculated based on a probabilistic sensitivity analysis using Monte Carlo simulations of 1,000 hypothetical patients progressing through the decision-analytic model. One-way sensitivity and threshold analyses were performed by varying cost, event probability, and QALY estimates.

RESULTS

Balloon Spacer had an ICUR of $106,851 (95% CI, $96,317 to $119,143) relative to PR for surgical treatment of MRCT. Across all patients, Balloon Spacer was associated with greater 2-year QALY gain compared to PR (0.20 ± 0.02 for Balloon Spacer versus 0.18 ± 0.02 for PR), but with substantially higher total 2-year cost ($9,701 ± $939 for Balloon Spacer versus $6,315 ± $627 for PR). PR was associated with a positive INMB of $1,802 (95% CI, $1,653 to $1,951) over Balloon Spacer at the $50,000/QALY willingness-to-pay (WTP) threshold.

CONCLUSIONS

Compared to PR, Balloon Spacer is an "intermediate value" innovation for treatment of MRCT over a 2-year postoperative period with an ICUR value that falls within the $50,000 to $150,000 WTP threshold.

Comparison of functional outcomes following early and delayed arthroscopic repair for traumatic and non-traumatic rotator cuff injuries

BACKGROUND

The effects of the timing of surgical repair on the outcomes of traumatic and non-traumatic rotator cuff injuries (RCI) remain elusive. Thus, this study aimed to compare differences in outcomes following the repair of traumatic and non-traumatic RCI at varying time points.

METHODS

The study population comprised 87 patients with traumatic and non-traumatic RCI who underwent arthroscopic rotator cuff repair and were followed up for a minimum of 6 months. Next, the trauma and the non-trauma groups were stratified into subgroups according to the time of injury (early repair: occurring within 3 months; delayed repair: occurring after 3 months). Measurements before and after surgical interventions were compared to evaluate the effect of the duration of RCI on the functional status of patients in the trauma and non-trauma groups. Primary evaluation indices included the Visual Analog Scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, Constant shoulder function score, and the University of California, Los Angeles (UCLA) shoulder score. Secondary evaluation indices consisted of shoulder range of motion (ROM), postoperative rotator cuff retear rate, and incidence of joint stiffness.

RESULTS

Among the 40 patients in the trauma group, 22 underwent early repair, whereas the remaining 18 underwent delayed repair. In the non-trauma group consisting of 47 patients, 18 underwent early repair, whereas the remaining 29 underwent delayed repair. The minimum clinical follow-up time was 6 months, with an average follow-up time of 10.2 months. During postoperative follow-up, 1 and 6 patients who underwent early and delayed repair experienced re-tear in the trauma group, respectively. Contrastingly, 3 and 8 patients who underwent early and delayed repair presented with re-tear in the non-trauma group, respectively.

CONCLUSION

Early repair of traumatic RCI yielded superior outcomes, including improved range of motion, lower pain symptoms, and lower risk of postoperative re-tears compared to delayed repair. Additionally, non-surgical treatment is recommended as the preferred approach for patients with non-traumatic RCI.

Impact of COVID-19 pandemic-induced surgical restrictions on operational performance: a case study at the University Hospital of Ulm

INTRODUCTION

The operating room (OR) is a high-cost and high-revenue area in a hospital comprising extremely complex process steps to treat patients. The perioperative process quality can be optimized through an efficiency-oriented central OR management based on performance indices. However, during the COVID-19 pandemic with the corresponding OR restrictions, there was a significant nation- and worldwide decline in the performance, which may have a lasting impact. Therefore, we proposed the hypothesis that COVID-19 pandemic-related OR restrictions could reduce operative performance in the long term.

METHODS

A retrospective, descriptive analysis of perioperative processing times was conducted exemplarily at the University Hospital Ulm using a pre-post design, examining the corresponding second quarters of 2019 to 2022. In total, n = 18,489 operations with n = 314,313 individual time intervals were analyzed. The statistical analyses included the Kruskal-Wallis test adjusted for multiple testing, and the significance level was set at p < 0.01.

RESULTS

The results revealed not only a significant decrease in the case volume by 31% (2020) and 23% (2021) during the COVID-19 crisis years, but also significant time delays in various process steps; e.g. the median patient's OR occupancy time (column time) rose from 65 min (2019) to 87 min (2020) and remained elevated (72 min in 2021 and 74 min in 2022, respectively). Even in 2022, beyond the pandemic, the net anaesthesia time was permanently enhanced by 9 min per case. Furthermore, both, the incision-to-closure time and surgeon attachment time were each significantly prolonged by 7 additional minutes, and the time from the end of anaesthesia to the release of the next patient was extended by 4 min. Selected standardized index operations showed only a trend towards these changes, even with a decrease in the incision-to-closure time over time.

CONCLUSION

Overall, long-term changes were found in essential perioperative process times even after retraction of the COVID-19 restrictions, indicating some processual "slow down" after the Covid-19-induced "shut down". Further analyses are needed to determine the appropriate targeted control measures to improve processing times and increase the process quality.

Distal nerve transfers for peripheral nerve injuries: indications and outcomes

Distal nerve transfer is a refined surgical technique involving the redirection of healthy sacrificable nerves from one part of the body to reinstate function in another area afflicted by paralysis or injury. This approach is particularly valuable when the original nerves are extensively damaged and standard repair methods, such as direct suturing or grafting, may be insufficient. As the nerve coaptation is close to the recipient muscles or skin, distal nerve transfers reduce the time to reinnervation. The harvesting of nerves for transfer should usually result in minimal or no donor morbidity, as any anticipated loss of function is compensated for by adjacent muscles or overlapping cutaneous territory. Recent years have witnessed notable progress in nerve transfer procedures, markedly enhancing the outcomes of upper limb reconstruction for conditions encompassing peripheral nerve, brachial plexus and spinal cord injuries.

A novel post-processing technique for correcting symmetric implant ambiguity in measuring total knee arthroplasty kinematics from single-plane fluoroscopy

Recent advancements in computer vision and machine learning enable autonomous measurement of total knee arthroplasty kinematics through single-plane fluoroscopy. However, symmetric components present challenges in optimization routines, causing "symmetry traps" and ambiguous poses. Achieving clinically robust kinematics measurement requires addressing this issue. We devised an algorithm that converts a "true" pose to its corresponding "symmetry trap" orientation. From a dataset of nearly 13,000 human supervised kinematics, this algorithm constructs an augmented dataset of "true" and "symmetry trap" kinematics, used to train eight classification machine learning algorithms. The outputs from the highest-performing algorithm classify kinematics sequences as 'obviously true' or 'potentially ambiguous.' We construct a spline through 'obviously true' poses, and 'ambiguous' poses are compared to the spline to determine correct orientation. The machine learning algorithms achieved 88-94% accuracy on our internal test set and 91-93% on our external test set. Applying our spline algorithm to kinematics sequences yielded 91.1% accuracy, 94% specificity, but 67% sensitivity. The accuracy of standard ML algorithms for implants within 5 degrees of a pure-lateral view was 71%, rising to 88% beyond 5 degrees. This pioneering study systematizes addressing model-image registration issues with symmetric tibial implants. High accuracy suggests potential use of ML algorithms to mitigate shape-ambiguity errors in pose measurements from single-plane fluoroscopy. Our results also suggest an imaging protocol for measuring kinematics that favors more oblique viewing angles, which could further disambiguate "true" and "symmetry trap" poses.

Arthroscopic Modified Double-Pulley Suture-Bridge Repair of Medium-Sized Supraspinatus Tendon Tears

At present, the repair patterns for medium-sized supraspinatus tendon tears are double- and single-row repairs. However, the limitations of double-row repair include excessive anchor implantation and incremental surgical cost and time, whereas a deficient tendon-bone contact area exists with single-row repair. The modified double-pulley suture-bridge repair presented in this study is an arthroscopic technique using 3 double-loaded suture anchors combined with a double-pulley technique to form a hybrid repair pattern with a double row as the mainstay and a single row as the supplement. In the treatment of medium-sized tendon tears, the modified double-pulley suture-bridge repair can not only maximize the tendon-bone contact area but also lower the surgical cost and shorten the operative time. The surgical technique is described, including pearls and pitfalls, as well as advantages and disadvantages.

Kinematic Performance of Medial Pivot Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) implants have continued to evolve to accommodate new understandings of knee mechanics. The medial-pivot implant is a newer design, which is intended to limit anterior-posterior translation in the medial compartment while allowing lateral compartment translation. However, evidence for a generalized medial-pivot characteristic across all activities is limited. The purpose of the study was to quantify and compare in vivo knee joint kinematics using high-speed stereo radiography during activities of daily living in patients who have undergone a TKA with a cruciate sacrificing medial-pivot implant to age-matched and sex-matched native controls.

METHODS

Fifteen participants (7 patients, 4 women, mean age 70 years and 8 nonsymptomatic controls, 4 women, mean age 64 years) performed 6 functional tasks in high-speed stereo radiography: deep-knee lunge, chair rise, step down, gait, gait with 90° turn, and seated knee extension. Translational differences between groups (surgical versus control) were assessed for the medial and lateral condyle, while pivot location was normalized to subject-specific tibial plateau geometry.

RESULTS

The surgical cohort displayed a more constrained medial condyle that provided greater stability of the medial compartment and did not result in the paradoxical anterior translation at mid-flexion angles during weight-bearing activities, but was associated with less condylar translation than native knees. Additionally, the transverse tibial pivot location occurs most commonly in the middle third of the tibial plateau and secondarily on the medial third.

CONCLUSIONS

Some variability in pivot location occurs between activities and is more in nonsymptomatic, native knee controls.

Current perspectives on peripheral nerve repair and management of the nerve gap

From the first surgical repair of a nerve in the 6th century, progress in the field of peripheral nerve surgery has marched on; at first slowly but today at great pace. Whether performing primary neurorrhaphy or managing multiple large nerve defects, the modern nerve surgeon has an extensive range of tools, techniques and choices available to them. Continuous innovation in surgical equipment and technique has enabled the maturation of autografting as a gold standard for reconstruction and welcomed the era of nerve transfer techniques all while bioengineers have continued to add to our armamentarium with implantable devices, such as conduits and acellular allografts. We provide the reader a concise and up-to-date summary of the techniques available to them, and the evidence base for their use when managing nerve transection including current use and applicability of nerve transfer procedures.

Postoperative outcomes of third-generation shoulder hemiarthroplasties for three-and four-part proximal humeral fractures: A systematic review of published studies from 2012 to 2022

Background

The aim of this study was to provide up-to-date evidence on the outcomes for hemiarthroplasties (HAs) that were performed using modern third-generation prostheses (post-2004) for isolated (excluding head-splits and fracture-dislocations) three-and four-part proximal humerus fractures (PHFs).

Methods

PubMed, Medline, Embase and the Cochrane register were searched from January 1, 2012, to November 15, 2022, conforming to the PRISMA guidelines. The outcome measures were the complication rates, revision rates, surgery-related postoperative mortality, post-operative clinical outcome scores and radiological outcomes.

Results

432 hemiarthroplasties in 432 patients were performed across the 11 eligible studies (two prospective and 9 retrospective). Three studies compared HA versus reverse shoulder replacement (RSR); one study compared HA with locking plate fixation (LPF) and RSR; one study compared HA with LPF. 61.1 % and 19.4 % of hemiarthroplasties were performed using cemented and uncemented techniques respectively, while cementing data was ill-defined in 19.4 % of shoulders. The results for the outcome measures have been derived directly from the included studies and no statistical pooling was performed, due to heterogeneity in the different study designs and outcomes. Descriptive data synthesis from the included studies showed that third generation HAs have higher overall postoperative complication rates, with similar revision and mortality rates when compared to RSR and LPF for three-and four-part PHFs. RSR and LPF showed better statistically significant improvements than HA for the Constant-Murley score, Quick DASH, forward flexion and abduction. Mixed results were observed for the DASH score, ASES score and internal rotation ROM between RSR/LPF versus HA.

Conclusion

Low to moderate quality evidence from this review showed that even third-generation HA prostheses provided worse overall outcomes than RSR and LPF for three-and four-part PHFs.

Three-Dimensional Magnetic Resonance Imaging Fast Field Echo Resembling a Computed Tomography Using Restricted Echo-Spacing Sequence Is Equivalent to 3-Dimensional Computed Tomography in Quantifying Bone Loss and Measuring Shoulder Morphology in Patients With Shoulder Dislocation

PURPOSE

To evaluate the equivalence of 3-dimensional (3D) magnetic resonance imaging (MRI) (FRACTURE [Fast field echo Resembling A CT Using Restricted Echo-spacing]) and 3D computed tomography (CT) in quantifying bone loss in patients with shoulder dislocation and measuring morphologic parameters of the shoulder.

METHODS

From July 2022 to June 2023, patients with anterior shoulder dislocation who were aged 18 years or older and underwent both MRI and CT within 1 week were included in the study. The MRI protocol included an additional FRACTURE sequence. Three-dimensional reconstructions of MRI (FRACTURE) and CT were completed by 2 independent observers using Mimics software (version 21.0) through simple threshold-based segmentation. For bone defect cases, 2 independent observers evaluated glenoid defect, percentage of glenoid defect, glenoid track, Hill-Sachs interval, and on-track/off-track. For all cases, glenoid width, glenoid height, humeral head-fitting sphere radius, critical shoulder angle, glenoid version, vault depth, and post-processing time were assessed. The paired t test was used to assess the differences between 3D CT and 3D MRI (FRACTURE). Bland-Altman plots were constructed to evaluate the consistency between 3D CT and 3D MRI (FRACTURE). Interobserver and intraobserver agreement was evaluated with the interclass correlation coefficient. The paired χ2 test and Cohen κ statistic were used for binary variables (on-track/off-track).

RESULTS

A total of 56 patients (16 with bipolar bone defect, 5 with only Hill-Sachs lesion, and 35 without bone defect) were ultimately enrolled in the study. The measurements of 21 bone defect cases showed no statistically significant differences between 3D CT and 3D MRI: glenoid defect, 4.05 ± 1.44 mm with 3D CT versus 4.16 ± 1.39 mm with 3D MRI (P = .208); percentage of glenoid defect, 16.21% ± 5.95% versus 16.61% ± 5.66% (P = .199); glenoid track, 18.02 ± 2.97 mm versus 18.08 ± 2.98 mm (P = .659); and Hill-Sachs interval, 14.29 ± 1.93 mm versus 14.35 ± 2.07 mm (P = .668). No significant difference was found between 3D CT and 3D MRI in the diagnosis of on-track/off-track (P > .999), and diagnostic agreement was perfect (κ = 1.00, P < .001). There were no statistically significant differences between the 2 examination methods in the measurements of all 56 cases, except that the post-processing time of 3D MRI was significantly longer than that of 3D CT: glenoid height, 34.56 ± 1.98 mm with 3D CT versus 34.67 ± 2.01 mm with 3D MRI (P = .139); glenoid width, 25.32 ± 1.48 mm versus 25.45 ± 1.47 mm (P = .113); humeral head-fitting sphere radius, 22.91 ± 1.70 mm versus 23.00 ± 1.76 mm (P = .211); critical shoulder angle, 33.49° ± 2.55° versus 33.57° ± 2.51° (P = .328); glenoid version, -3.25° ± 2.57° versus -3.18° ± 2.57° (P = .322); vault depth, 37.43 ± 1.68 mm versus 37.58 ± 1.75 mm (P = .164); and post-processing time, 89.66 ± 10.20 seconds versus 360.93 ± 26.76 seconds (P < .001). For all assessments, the Bland-Altman plots showed excellent consistency between the 2 examination methods, and the interclass correlation coefficients revealed excellent interobserver and intraobserver agreement.

CONCLUSIONS

Three-dimensional MRI (FRACTURE) is equivalent to 3D CT in quantifying bone loss in patients with shoulder dislocation and measuring shoulder morphologic parameters.

LEVEL OF EVIDENCE

Level II, development of diagnostic criteria (consecutive patients with consistently applied reference standard and blinding).

Current research trends on the effect of diabetes mellitus on rotator cuff tendon healing/tendinopathy

Rotator cuff tendon tears are a leading cause of shoulder pain. They are challenging to treat, and tendon-bone healing has a high failure rate despite successful surgery. Tendons connect the muscles and bones, which make them important for the body's overall mobility and stability. Metabolic diseases, including diabetes or high blood pressure, can affect the healing process after repair of a damaged tendon. With a global incidence of 9.3%, diabetes is considered as a significant risk factor for rotator cuff tendon healing because it causes structural, inflammatory, and vascular changes in the tendon. However, the mechanisms of how diabetes affects tendon healing remain unknown. Several factors have been suggested, including glycation product accumulation, adipokine dysregulation, increased levels of reactive oxygen species, apoptosis, inflammatory cytokines, imbalanced matrix-metalloproteinase-to-tissue-inhibitor ratio, and impaired angiogenesis and differentiation of the tendon sheath. Despite the effects of diabetes on tendon function and healing, few treatments are available to improve recovery in these patients. This review summarizes the current literature on the pathophysiological changes of the tendon in diabetes and hyperlipidemia. Preclinical and clinical evidence regarding the association between diabetes and tendon healing is presented. Moreover, current approaches to improve tendon healing in patients with diabetes are reviewed.

Surgical and Biological Treatment with a Platelet-Rich Fibrin Matrix for Patellar Tendinopathy: Clinical Outcomes and Return to Sport at 2-Year Follow-Up

BACKGROUND

Patellar tendinopathy (PT) involves anterior knee pain and functional. Platelet-rich fibrin matrix (PRFM) is a promising biological therapy for tendinopathies. We examined a cohort of PT patients treated with tendon debridement and autologous PRFM at the 24-month follow-up to assess whether the combined treatment facilitated return to sports and yielded satisfactory clinical and functional scores.

METHODS

Baseline and 24-month visual analogue scale (VAS), Victorian Institute of Sport Assessment Scale for Patellar Tendinopathy (VISA-P), Tegner Activity Scale (TAS), and Blazina scores were compared to evaluate treatment effectiveness. The Friedman test was used to compare repeated observations of VAS, VISA-P, TAS, and Blazina Score values. Return to sport rate, Tampa Scale of Kinesiophobia (TKS) score and patient satisfaction were collected at 24 months.

RESULTS

The postoperative clinical scores demonstrated significant improvement compared with their preoperative values (all p < 0.001). Specifically, the VISA-P score was 80.32 (±20.58), 92.10% of patients had resumed sports activities and patient satisfaction was 9.21 (±1.21) at 24 months.

CONCLUSIONS

Surgical debridement and autologous PRFM application in patients with chronic PT resulted in a higher rate of return to sports when compared to solely surgical treatment, significantly improved clinical outcomes and excellent patient satisfaction at 24 months.

A New Approach to Postoperative Rehabilitation following Mosaicplasty and Bone Marrow Aspiration Concentrate (BMAC) Augmentation

BACKGROUND

Chondral defects in the knee present a significant challenge due to their limited self-healing capacity, often leading to joint degeneration and functional disability. Current treatments, including surgical approaches like mosaicplasty and regenerative therapies such as bone marrow aspirate concentrate (BMAC) augmentation, aim to address these defects and improve patient outcomes.

MATERIALS AND METHODS

This study conducted a single-center, randomized controlled trial to evaluate the efficacy of different treatment approaches and rehabilitation protocols for chondral defects. Thirty-seven subjects presenting with symptomatic chondral or osteochondral defects (>3 cm2) in the weight-bearing region of the femoral condyle were partitioned into three groups, and underwent mosaicplasty with or without BMAC augmentation, followed by either a 6-week or 12-week rehabilitation program. Group 1 (n = 10) received mosaicplasty combined with BMAC augmentation and engaged in a twelve-week two-phase rehabilitation protocol. Group 2 (n = 15) underwent mosaicplasty alone and participated in the same twelve-week two-phase rehabilitation regimen. Meanwhile, Group 3 (n = 12) underwent mosaicplasty and underwent a shorter six-week one-phase rehabilitation program. Clinical assessments were performed using the visual analog scale (VAS) for pain, goniometry for the knee's range of motion (ROM), manual muscle testing (MMT) for quadricep strength, and the Western Ontario and McMaster University Arthritis Index (WOMAC) for functional evaluation in three test phases.

RESULTS

Significant differences in WOMAC scale scores were observed between the three groups at the intermediate (F(2, 34) = 5.24, p < 0.010) and final (F(2, 34) = 111, p < 0.000) stages, with post hoc Tukey tests revealing variations shared among all three groups. The between-group analysis of the VAS scale demonstrated no statistically significant difference initially (F(2, 34) = 0.18, p < 0.982), but significant differences emerged following the intermediate (F(2, 34) = 11.40, p < 0.000) and final assessments (F(2, 34) = 59.87, p < 0.000), with post hoc Tukey tests revealing specific group variations, notably between Group 1 and both Group 2 and Group 3, and also between Group 3 and Group 2. The between-group analysis of quadricep muscle strength using MMT scores revealed no statistically significant differences initially (F(2, 34) = 0.376, p < 0.689) or following the intermediate assessment (F(2, 34) = 2.090, p < 0.139). The one-way ANOVA analysis showed no significant difference in the knee ROM initially (F(2, 34) = 1.037, p < 0.366), but significant differences emerged following intermediate (F(2, 34) = 9.38, p < 0.001) and final assessments (F(2, 34) = 11.60, p < 0.000). Post hoc Tukey tests revealed significant differences between Groups 1 and 2, Groups 1 and 3, and Groups 2 and 3 at intermediate and final assessments.

CONCLUSIONS

The patients who received BMAC augmentation and completed a 12-week rehabilitation protocol had significantly better outcomes in pain relief, knee function, and ROM when compared to those who did not receive BMAC augmentation or those who completed a shorter rehabilitation period. Our findings suggest that combining mosaicplasty with BMAC augmentation and a comprehensive rehabilitation program can lead to superior clinical outcomes for patients with chondral defects in the knee.

Percutaneous bone marrow concentrate and platelet products versus exercise therapy for the treatment of rotator cuff tears: a randomized controlled, crossover trial with 2-year follow-up

BACKGROUND

Surgical repair is recommended for the treatment of high-grade partial and full thickness rotator cuff tears, although evidence shows surgery is not necessarily superior to non-surgical therapy. The purpose of this study was to compare percutaneous orthobiologic treatment to a home exercise therapy program for supraspinatus tears.

METHODS

In this randomized-controlled, crossover design, participants with a torn supraspinatus tendon received either 'BMC treatment', consisting of a combination of autologous bone marrow concentrate (BMC) and platelet products, or underwent a home exercise therapy program. After three months, patients randomized to exercise therapy could crossover to receive BMC treatment if not satisfied with shoulder progression. Patient-reported outcomes of Numeric Pain Scale (NPS), Disabilities of the Arm, Shoulder, and Hand, (DASH), and a modified Single Assessment Numeric Evaluation (SANE) were collected at 1, 3, 6, 12, and 24 months. Pre- and post-treatment MRI were assessed using the Snyder Classification system.

RESULTS

Fifty-one patients were enrolled and randomized to the BMC treatment group (n = 34) or the exercise therapy group (n = 17). Significantly greater improvement in median ΔDASH, ΔNPS, and SANE scores were reported by the BMC treatment group compared to the exercise therapy group (-11.7 vs -3.8, P = 0.01; -2.0 vs 0.5, P = 0.004; and 50.0 vs 0.0, P < 0.001; respectively) after three months. Patient-reported outcomes continued to progress through the study's two-year follow-up period without a serious adverse event. Of patients with both pre- and post-treatment MRIs, a majority (73%) showed evidence of healing post-BMC treatment.

CONCLUSIONS

Patients reported significantly greater changes in function, pain, and overall improvement following BMC treatment compared to exercise therapy for high grade partial and full thickness supraspinatus tears.

TRIAL REGISTRATION

This protocol was registered with www.

CLINICALTRIALS

gov (NCT01788683; 11/02/2013).

Total Hip Arthroplasty in Patients Who Have Crowe Type IV Developmental Dysplasia of the Hip: A Systematic Review

BACKGROUND

Developmental dysplasia of the hip (DDH) is one of the principal causes of secondary hip osteoarthritis, giving rise to considerable pain, impaired mobility, and a reduced quality of life. The optimal approach to managing individuals who have Crowe type IV DDH remains controversial. This study aimed to review the existing literature on the application of total hip arthroplasty (THA) as a treatment modality for Crowe type IV DDH, assessing its efficacy in addressing this severe hip deformity.

METHODS

A comprehensive search across the PubMed, Scopus, and Web of Science databases identified relevant studies. Inclusion criteria encompassed investigations reporting outcomes of THA in Crowe type IV DDH patients. Data extraction and quality assessment were performed independently by 2 reviewers. Utilizing R software, the prevalence of THA complications was analyzed through proportion analysis, employing the inverse variance method.

RESULTS

In this systematic review, a total of 74 studies were included, comprising a collective sample size of 2,829 patients (3,356 hips) diagnosed with Crowe type IV DDH. The posterior or posterolateral approach was the most commonly utilized surgical approach, followed by the lateral Hardinge and direct lateral approaches. The majority of studies have employed subtrochanteric osteotomies. Notably, post-THA, leg length discrepancy decreased, Trendelenburg sign resolved, and back pain was reduced. Patient-reported outcome measures like the Harris Hip Score improved significantly. The pooled prevalence rates of major postoperative complications were also assessed, including dislocation (7.2%), revision (8.7%), intraoperative fractures (10.5%), loosening (5.7%), nerve paralysis (5.6%), deep vein thrombosis (3.6%), infection (3.8%), heterotopic ossification grade 2 and above (6.1%), and a complicated patient rate of 11.0%.

CONCLUSIONS

Synthesizing diverse study data, an overview of THAs performance emerges, demonstrating significant enhancements in function, pain reduction, quality of life, and the correction of substantial leg length discrepancy. While THA has shown positive outcomes, instances of complications have been reported. The decision to undergo THA should involve a collaborative assessment between the surgeon and the patient, considering potential benefits and complications.

One- vs. Two-Stage Revision for Periprosthetic Shoulder Infections: A Systematic Review and Meta-Analysis

Periprosthetic shoulder infection (PSI) remains a challenging complication after shoulder arthroplasty. Therapeutic options include one- or two-stage revision, irrigation and debridement, and resection arthroplasty. With our systematic review and meta-analysis, we aimed to compare one- and two-stage revisions for periprosthetic shoulder joint infections and determine the most appropriate therapeutic procedure. We performed an extensive literature search in PubMed, Ovid Medline, Cochrane Library, Web of Science, and CINAHL and filtered out all relevant studies. The meta-analysis was performed using the random-effects model, heterogeneity was analyzed using I2, and publication bias was assessed using the Egger's test. A total of 8 studies with one-stage revisions, 36 studies with two-stage revisions, and 12 studies with both one-stage and two-stage revisions were included. According to the random-effects model, the reinfection rate for the entirety of the studies was 12.3% (95% Cl: 9.6-15.3), with a low-to-moderate heterogeneity of I2 = 47.72%. The reinfection rate of the one-stage revisions was 10.9%, which was significantly lower than the reinfection rate of the two-stage revisions, which was 12.93% (p = 0.0062). The one-stage revision rate was significantly lower with 1.16 vs. 2.25 revisions in the two-stage revision group (p < 0.0001). The postoperative functional outcome in one-stage-revised patients was comparable but not statistically significant (p = 0.1523). In one- and two-stage revisions, most infections were caused by Cutibacterium acnes. In summary, our systematic review and meta-analysis show the superiority of single-stage revision regarding reinfection and revision rates in periprosthetic shoulder joint infection.

Nonoperative and Operative Soft-Tissue, Cartilage, and Bony Regeneration and Orthopaedic Biologics of the Elbow and Upper Extremity: An Orthoregeneration Network Foundation Review

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and, optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electromagnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the elbow and upper extremity, including the tendons (lateral epicondylitis, medial epicondylitis, biceps tendonitis, triceps tendonitis), articular cartilage (osteoarthritis, osteochondral lesions), and bone (fractures, nonunions, avascular necrosis, osteonecrosis). Promising and established treatment modalities include hyaluronic acid; botulinum toxin; corticosteroids; leukocyte-rich and leukocyte-poor platelet-rich plasma; autologous blood; bone marrow aspirate comprising mesenchymal stromal cells (alternatively termed medicinal signaling cells and frequently mesenchymal stem cells [MSCs]) and bone marrow aspirate concentrate; MSCs harvested from adipose and skin (dermis) sources; vascularized bone grafts; bone morphogenic protein scaffold made from osteoinductive and conductive β-tricalcium phosphate and poly-ε-caprolactone with hydrogels, human MSCs, and matrix metalloproteinases; and collagen sponge. Autologous blood preparations such as autologous blood injections and platelet-rich plasma show positive outcomes for nonresponsive tendinopathy. In addition, cellular therapies such as tissue-derived tenocyte-like cells and MSCs show a promising ability to regulate degenerative processes by modulating tissue response to inflammation and preventing continuous degradation and support tissue restoration.

A case series utilizing bone marrow aspirate concentrate, cancellous bone autograft, platelet-rich plasma and autologous fibrin for the treatment of femur nonunions

Aim: To assess the efficacy of a bioregenerative scaffold derived from bone marrow aspirate, cancellous bone autograft, platelet-rich plasma and autologous fibrin in treating supracondylar femur nonunions. Methods & materials: Three patients with nonunions following multiple surgical failures underwent bone stabilization and the application of a novel bioregenerative scaffold. x-rays and subjective scales were collected before surgery and at 6, 12 and 24 months post-surgery. Results: All nonunions exhibited healing with sufficient callus formation, as confirmed radiologically. After 6 months, all patients resumed full weight-bearing walking without pain. Statistical analysis showed improvements in all scales compared with pre-surgical values. Conclusion: This method presents itself as an option for treating supracondylar femur nonunions following multiple surgical failures.

Unicompartmental knee replacement: controversies and technical considerations

BACKGROUND

Unicompartmental knee replacement (UKR) is one of the effective interventions for the treatment of symptomatic knee osteoarthritis. Moreover, it has multiple advantages over total knee arthroplasty (TKA), including reduced intraoperative blood loss, decreased risk of transfusion, and faster recovery. This study aimed to discuss critical technical considerations regarding UKR and some of the controversies and updates.

METHODS

We conducted a review to provide an overview of the controversies and technical considerations about UKR in several aspects. Only peer-reviewed articles were included, up to December 2023 using PubMed, Google Scholar, ERIC, and Cochrane database for systematic reviews databases.

RESULT

UKR is associated with superior patient-reported clinical and functional outcomes, as well as shorter hospital stays, fewer postoperative complications, and revealed favorable outcomes in patients' return to sport. The choice between mobile- and fixed-bearing prostheses depends, in part, on the surgeon's preference. The mobile-bearing UKR is a less constrained prosthesis and can potentially result in less wear, but it is more technically demanding. While no significant difference between mobile-bearing versus fixed-bearing prostheses, cementless is superior to cemented design. Furthermore, UKR can be a good alternative for high tibial osteotomy (HTO) and still can be considered after a failed HTO. Lastly, recent reviews have shown a revision rate comparable to that of TKA. This is probably influenced by Improved comprehension of the best indications, patient selection criteria, as well as of the design, materials, and technological advances.

CONCLUSION

UKR treatment for unicompartmental knee osteoarthritis is secure and effective. Based on clinical and functional outcomes, decreased morbidity and mortality, and cost-effectiveness, long-term studies suggest that UKR is superior to TKA. Further investigation in this area is warranted.

Use of a Spinal Needle Through the Deep Rotator Cuff Tissue to Treat Rotator Cuff Tears Under Direct Articular Vision

Achieving sufficient attachment of deep rotator cuff tissue to the footprint area on the greater tubercle of the humerus is essential for functional recovery, yet the optimal approach remains uncertain. We introduce a surgical technique for rotator cuff tear repair using a spinal needle to penetrate deep rotator cuff tissue under direct arthroscopic visualization. After trimming the torn edge, an arthroscope is inserted into the joint cavity through a posterior portal, and a hole is drilled into the humeral head cartilage margin using an upper approach, facilitating the implantation of an internal shoulder row nail. A spinal needle is used to introduce a No. 2 polydioxanone (PDS; Johnson & Johnson) line through sufficient deep rotator cuff tissue. Graspers are then used to extract the stitch and PDS together through the anterolateral opening. Once the PDS is knotted, the stitch is introduced into the rotator cuff. This process is replicated to insert additional stitches into the rotator cuff. Our proposed technique, involving a spinal needle under direct visualization, ensures sufficient coverage of the deep rotator cuff tissue over the footprint area and promotes the healing of the repaired rotator cuff. This method is safe, effective, convenient, and reproducible.

Outcome of hip resurfacing revision through the Hueter-anterior approach

BACKGROUND

The Hueter-Anterior Approach (HAA) with its limited soft tissue and internervous dissection has been shown to be an effective approach for primary total hip and hip resurfacing arthroplasty (HRA). The purpose of this study is to evaluate the clinical outcome of patients requiring revision of HRA to total hip replacement using the HAA, assessing function and complications.

METHODS

We performed a retrospective review of a prospectively maintained research database. Between 2006 and 2015, 555 primary metal-on-metal (MoM) HRAs were performed via the HAA; we identified 33 hips in 30 patients that required revisions for aseptic causes to THA: aseptic loosening of acetabulum in 12 and femoral in 7, 10 for pseudotumour/ALTR, 4 for femoral neck fracture. All revision surgeries were performed through a HAA by a single surgeon who had also performed the index operation. PROMs were collected preoperatively and yearly at various timepoints postoperatively.

RESULTS

The mean age at time of revision was 48.9 years (±5.3 SD) for 22 males (67%) and 11 females (33%). The mean time to revision surgery/failure of hip resurfacing was 3.3 years (±2.4 SD). There were 5 major reoperations with 3 infections, 1 acetabular loosening and 1 trunnionosis. There were significant improvements in multiple PROMs.

CONCLUSIONS

The HAA is a viable surgical approach for revision of HRA with smaller initial HRA acetabular components generally requiring a relatively larger acetabular compoent at time of revision. Patients reported improvement in symptoms and function and a lower risk of subsequent reoperation than what has previously been reported for failed MoM bearings.

Tendon Transfers, Nerve Grafts, and Nerve Transfers for Isolated Radial Nerve Palsy: A Systematic Review and Analysis

BACKGROUND

Isolated radial nerve palsy is a debilitating injury that may potentially be reconstructed with either tendon transfers, nerve grafts, or nerve transfers. Currently, there is no consensus on the optimal technique for reconstruction. We performed a systematic review and analysis to determine which surgical intervention provides the best clinical outcomes.

METHODS

A systematic review was conducted according to PRISMA guidelines. Twenty-nine papers met inclusion criteria. Grading scales of function and strength were converted into a tripartite scoring system to compare outcomes between techniques. χ2 analyses were performed with a P value < .05.

RESULTS

Seven hundred fifty-four patients were analyzed. Tendon transfers resulted in the highest percentage of good outcomes (82%) and the lowest percentage of poor outcomes (9%). Tendon transfers were superior to nerve grafts and nerve transfers for restoration of wrist extension. Nerve transfers for wrist extension were superior to nerve transfers for finger extension. Nerve grafts and nerve transfers had equivalent rates of good and poor clinical outcomes.

CONCLUSIONS

This study analyzed reported outcomes of tendon transfers, nerve grafts, and nerve transfers for reconstruction of isolated radial nerve palsy. On pooled analysis, tendon transfers had higher rates of superior clinical outcomes as compared with nerve transfers and nerve grafts. Tendon transfers should be considered first-line reconstruction for isolated radial nerve palsy as nerve-based reconstruction is less predictable and reproducible.