Functional and MRI Outcomes After In Situ Repair Versus Tear Completion Before Repair of Bursal-Side Partial-Thickness Rotator Cuff Tears

Objective

The optimal repair method for bursal-side partial-thickness rotator cuff tears (PTRCTs) involving >50% of the thickness remains a controversial topic. The study was aimed to compare the functional and magnetic resonance imaging (MRI) outcomes after in situ repair or tear completion before repair of bursal-side PTRCTs.

Methods

A retrospective clinical study was conducted involving 58 patients who underwent in situ repair or tear completion before repair of bursal-side PTRCTs between January 2019 and December 2020. These patients were divided into two groups: the in situ repair group and the tear completion before repair group. Functional assessment consisted of active range of motion (ROM), visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, and Constant–Murley score. The percentages of patients in each group achieving the minimal clinical important difference (MCID) of the functional scores were determined. The healing status of the rotator cuff was assessed by postoperative MRI.

Results

There were no statistically significant differences between the two groups in terms of demographic data. The mean follow-up period was 14.53 ± 2.64 months in the in situ repair group and 15.40 ± 2.66 months in the tear completion before repair group. At the final follow-up, the forward elevation, external rotation, and internal rotation improved significantly in both groups. The VAS, ASES score, and Constant–Murley score improved significantly in the in situ repair group (5.17 ± 2.00 points to 0.11 ± 0.41 points, p = 0.001; 44.04 ± 17.40 points to 95.47 ± 4.32 points, p = 0.001; 49.50 ± 14.38 points to 93.50 ± 3.49 points, p = 0.001) and in the tear completion before repair group (5.43 ± 3.32 points to 0.03 ± 0.18 points, p = 0.001; 41.50 ± 19.59 points to 95.94 ± 2.68 points, p = 0.001; 47.54 ± 17.13 points to 93.97 ± 2.61 points, p = 0.001). Postoperative MRI revealed that the re-tear rate was 7.1% (2/28) in the in situ repair group and 3.3% (1/30) in the tear completion before repair group. No significant differences were observed in terms of the functional scores, the percentages of patients achieving the MCID of the functional scores, and the re-tear rate between the two groups (p > 0.05).

Conclusions

Both in situ repair and tear completion before repair yielded satisfactory clinical outcomes for patients with bursal-side PTRCTs. No significant differences were observed in the functional and MRI outcomes between the two groups.     

Prognosefaktoren für das klinische Outcome nach arthroskopischer Schulterarthrolyse

Aim

Which clinical and functional parameters affect the outcome of arthroscopic panglenoidal release in refractory frozen shoulders? Does an accessory deep posterior approach (7 o’clock) facilitate the arthroscopic procedure?

Method

A total of 44 patients (23 women, 21 men) with refractory shoulder stiffness underwent an arthroscopic capsular release performed by radiofrequency electrode through a posterior, an anterior and a deep posterior approach (7 o’clock). Prior conservative treatment took at least 3–4 months. A standard aftercare protocol (free passive and active motion, physiotherapy) was started on the first postoperative day. An intraarticular pain catheter for 2 days accompanied by oral analgetics was used for pain treatment. Average age was 57 (range: 37 to 84). The mean duration of follow-up was 11 months (range: 3 to 21). Three distinct etiologies were identified: idiopathic in 19, metabolic (diabetes, hyperthyreoidism) in 15, and postoperative/postfracture in 10. Five different age cohorts were identified: 30–40 years in 4 patients, 41–50 in 8, 51–60 in 17, 61–70 in 10 and >71 in 5. Furthermore, the point of time of follow-up examination was classified: <6 months in 11 patients, 7–12 months in 14, 13–18 months in 13 and >18 months in 6. Patients were also divided in 3 groups concerning preoperative range of motion for anteversion: 31–60° in 24, 61–90° in 10 and 91–120° in 8. Finally we divided the group into those who received subacromial decompression (n=32) and those who did not (n=12). Subacromial decompression was only performed in case of bursitis or acromial spur. The retrospective outcome evaluation included the median Constant Murley Score (CMS) and median Visual Analog Score (VAS). Statistical analysis was performed by Wilcoxon and Mann-Whitney tests. P values less than 0.05 were considered significant.

Results

No instability or nerve damage occurred after capsular release using two posterior approaches. Inferior capsular release, up to the triceps tendon, is relieved easily by using the deep posterior approach. The study population showed significant improvement (P<0.001) for both scores (VAS decreased from 76 to 19 and CMS increased from 26 to 66). Each age cohort showed a significant improvement for both scores (P<0.001), without a significant difference (P>0.05) in the between group comparisons. The same significant improvement (P<0.001) was shown for each point of time of follow-up, with a significantly better outcome (P<0.05) between the <6 month group and the 7–12 month group, and the 7–12 month group and the >18 month group for the CMS. VAS showed only a significant better outcome (P<0.05) between the <6 month group and the 7–12 month group. All three groups of different etiologies showed a significant improvement (P<0.001) for both scores, with the difference of a significant better outcome (P<0.05) between the idiopathic and the metabolic group compared to the postfracture/posttraumatic group, for both scores. No significant difference exists between the idiopathic and metabolic group. Patients who underwent subacromial decompression (n=32) showed a non-significant (P>0.05) outcome, compared to the patients without subacromial decompression. Subdividing the patients into groups concerning the preoperative motion for anteversion showed an expected significant improvement from the 31–60° group to the 61–90° group, and for the 61–90° group to the 91-120° group for the preoperative parameters in CMS, but no significance (P>0.05) for the postoperative parameters between the three groups in CMS. Significant improvement for VAS was shown not only between the 31–60°°group and the 91–120°°group, but also for the postoperative parameters. The improvement from pre- to postoperative parameters, within each group, was significant (P<0.001) for both scores.

Conclusion

An accessory deep posterior approach for inferior capsular release is a safe and simple method to complete the capsular release up to the triceps tendon. Patient’s age or preoperative motion do not alter the postoperative outcome. The duration of continuous clinical improvement takes at least 1 year. During this time, patients should be encouraged to practice stretching exercises at home. Regardless of etiology, arthroscopic capsular release resulted in improvement. Patients suffering from idiopathic or metabolic frozen, stiff shoulder improve better than those suffering from postoperative or postfracture shoulder stiffness. Subacromial decompression should not be performed regularly, but only in case of bursitis or acromial spur.     

Mid-Term Outcomes of Arthroscopic Rotator Cuff Repair in Patients with Rheumatoid Arthritis

Objective

The effectiveness of arthroscopic rotator cuff repair (ARCR) on rheumatoid arthritis (RA) patients remains a controversial topic. This study investigates the mid-term outcomes of ARCR in RA patients and identifies the factors influencing clinical efficacy.

Methods

This retrospective study enrolled RA patients with small or medium rotator cuff tears (RCTs) between February 2014 and February 2019. Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons (ASES), and Constant–Murley scores were collected at each follow-up time. Ultimately, magnetic resonance imaging (MRI) and X-ray were employed to assess rotator cuff integrity and progression of shoulder bone destruction, respectively. Statistical methods used two-way repeated-measures ANOVA or generalized estimation equations.

Results

A total of 157 patients were identified and divided into ARCR (n = 75) and conservative treatment (n = 82) groups. ARCR group continued to be divided into small tear (n = 35) and medium tear (n = 40) groups. At the final, all scores were better in ARCR group than in the conservative treatment group (p < 0.05). A radiographic evaluation of the final follow-up demonstrated that the progression rate in ARCR group (18.67%) was significantly lower than that of the conservative treatment group (39.02%, p < 0.05). In the comparison of the small tear and medium tear groups, all scores increased significantly after surgery (p < 0.05), and the final follow-up scores were better than preoperative scores (p < 0.05) but worse than those of the 6-month postoperative follow-up (p < 0.05). Comparison between the two groups revealed that all scores of the small tear group were significantly better than those of the medium tear group at 6-month postoperative follow-up (p < 0.05). Although the scores of small tear group remained better than those of the medium group at the final postoperative follow-up, the difference was not statistically significant (p > 0.05). Radiographic assessment of the final follow-up demonstrated that the progression rate in the small tear group (8.57%) was significantly lower than that in the medium group (27.50%, p < 0.05), and the retear rate of small tear group (14.29%) was significantly lower than that of the medium tear group (35.00%, p < 0.05).

Conclusion

ARCR could effectively improve the quality of life for RA patients with small or medium RCTs, at least in the medium term. Despite the progression of joint destruction in some patients, postoperative retear rates were comparable to those in the general population. ARCR is more likely to benefit RA patients than conservative treatment.     

Early arthroscopic release in stiff shoulder

Purpose:

To evaluate the results of early arthroscopic release in the patients of stiff shoulder

Methods:

Twenty patients of stiff shoulder, who had symptoms for at least three months and failed to improve with steroid injections and physical therapy of 6 weeks duration, underwent arthroscopic release. The average time between onset of symptoms and the time of surgery was 4 months and 2 weeks. The functional outcome was evaluated using ASES and Constant and Murley scoring systems.

Results:

All the patients showed significant improvement in the range of motion and relief of pain by end of three months following the procedure. At 12 months, mean improvement in ASES score is 38 points and Constant and Murley score is 4O.5 points. All patients returned to work by 3-5 months (average -4.5 months).

Conclusion:

Early arthroscopic release showed promising results with reliable increase in range of motion, early relief of symptoms and consequent early return to work. So it is highly recommended in properly selected patients.

Level of evidence:

Level IV     

A Modified Arthroscopic Outside-in Shoulder Release Approach for Severe Shoulder Stiffness

Objective

Arthroscopic release is effective for patients with shoulder stiffness, but the traditional inside-out procedure cannot effectively alleviate the mobility of some severe stiff shoulder and even cause itrogenic injuries sometimes. The aim of this study is to evaluate the clinical efficacy and advantages of a modified outside-in shoulder release approach for severe shoulder stiffness.

Methods

Included in this retrospective study were 15 patients (five male and 10 female) with severe shoulder stiffness who underwent modified outside-in shoulder release surgery at our hospital between June 2019 and March 2021. Of them, 10 patients had a primary frozen shoulder and five had secondary shoulder stiffness, involving the right shoulder in six cases and the left shoulder in nine cases. The mean age of the 15 patients was 56.7 (34–69) years. The patients were instructed to exercise passively from second-day post-operation and enhance the rehabilitation exercise gradually. All patients received a range of motion (ROM) examination before and after surgery. The American Shoulder and Elbow Surgeon's Score (ASES), Constant Score (CS), and Visual Analog Scale (VAS) score for pain were recorded. All data were tested by normal distribution first and then by paired T test, otherwise by Wilcoxon rank sum test.

Results

The mean follow-up period was 18.2 (12–33) months. Compared with the preoperative value, the mean ASES score at the final follow-up improved from 38.4 ± 7.37 to 88.13 ± 6.33 points; the mean CS score from 43.27 ± 6.71 to 78.74 ± 6.93 points; the mean VAS score from 5.07 ± 1.03 to 0.81 ± 0.83 points; forward flexion from 81.93° ± 11.45° to 156.73° ± 9.12°; abduction from 65.93° ± 16.82° to 144.80° ± 8.83°; neutral external rotation from 13.53° ± 10.38° to 51.20° ± 4.77°; internal rotation from the buttock to waist (L3), all showing a significant difference (P < 0.0001). No serious complication was observed in any patient during the postoperative follow-up periods.

Conclusion

The present study has demonstrated that the modified arthroscopic outside-in shoulder release approach can improve ROM of patients and alleviate pain effectively, proving it to be an appropriate surgical option for the treatment of severe shoulder stiffness.     

Effect of nonoperative concomitant intraarticular pathologies on the outcome of arthroscopic capsular release for adhesive capsulitis of the shoulder

Objective

The aim of this study was to investigate whether coexistent intraarticular lesions are negative prognostic factors for the results of arthroscopic capsular release in frozen shoulder patients.

Das chronisch instabile Schultergelenk nach operativer Rekonstruktion

Introduction

Shoulder stability is supported by active and passive stabilization structures. Shoulder stability due to dislocation can be restored by various surgical procedures. Nevertheless, all known techniques are associated with a certain percentage of failures. Under these circumstances, secondary procedures are challenging, especially when anatomic reconstruction is not possible. The aim of the study was to evaluate the outcome of patients with chronic unilateral anterior shoulder instability, having received a coracoid transfer according to Laterjet-Patte with a follow-up time of 19 months.

Patients and methods

From 2005 to 2007, 6 patients with anterior shoulder instability underwent shoulder reconstruction by coracoid transfer, after two or more former operations had been unsuccessful. According to the classification for shoulder instability by Gerber, 4 patients were assigned to group II and 2 patients to group III. The mean age was 34.8 years (range: 19–43 months), the mean follow-up time was 19.2 months (13–37 months) in this retrospective, clinical evaluation. The follow-up consisted of clinical evaluation using Constant Murley, Disabilities of the Arm, Shoulder and Hand (DASH) and Rowe scores and radiological evaluation (X-ray, CT, and MRI scan pre- and postoperative).

Results

The mean Constant Murley score was 92.7 (85–100), corrected for Katolik 100.4 (95.8–106.8) and correlated to the opposite side 94.4 (87.6–99.0). The 4 main criteria of the Constant Murley score did not differ significantly compared to the non-operated side. Furthermore, the DASH score and Rowe score revealed no significant limitations in daily living and working conditions. The mean transverse glenohumeral index (TGHI) increased from 0.54 to 0.73 postoperativly. To date, there was neither an event of complete or subdislocation nor non-union of the coracoid or a failure of the fixation material. There was no evidence of arthrosis at follow-up.

Conclusion

Coracoid transfer is an effective and safe method to stabilize a chronically unstable shoulder joint, especially if prior treatment failed to achieve stability or anatomic reconstruction. Assuming an experienced surgeon, the risk of postoperative complications and iatrogenic arthrosis is rare after coracoid transfer.     

Surgical results of concomitant treatment of deltoid contracture and rotator cuff tear

Background

Contracture of the deltoid muscle is an uncommon disorder. The symptoms usually are nonspecific and the diagnosis may be missed, especially when combined with other shoulder disorders, such as rotator cuff lesions. Few reports have described the surgical treatment of combined deltoid contracture and a torn rotator cuff. The purpose of this study was to share our experiences in the diagnosis and treatment of patients, who sustained deltoid contracture combined with rotator cuff tearing.

Materials and methods

Between April 2001 and December 2006, 18 consecutive patients underwent concomitant treatment for distal release of deltoid contracture and repair of a torn rotator cuff. The mean age at operation was 55.1 years. There were eight female and ten male patients. The acromial type, winging angle of the scapula and thickest diameter of the deltoid fibrotic band were measured using preoperative magnetic resonance imaging studies. The abduction-contracture angle, extension-contracture angle, horizontal-adduction angle and Constant and Murley scores were measured preoperatively and at the latest follow-up.

Results

There were nine complete rotator cuff tears and nine partial tears. At an average of 5 years and 3 months’ follow-up, the mean abduction-contracture angle significantly improved from 27° to 0° (p < 0.001), the mean extension-contracture angle improved from 13° to 0° (p < 0.001), and, the mean horizontal-adduction angle improved from 8° to 44° (p < 0.001). The mean Constant score also improved from 69 points to 95 points (p < 0.001).

Conclusions

If a symptomatic torn rotator cuff and deltoid contracture co-exist, simultaneous operative treatment of both conditions is highly recommended.     

Indikationsspezifische mittelfristige Ergebnisse der anatomischen Kurzschaft-Schulterprothese

Background

The stemless shoulder prosthesis is a new concept in shoulder arthroplasty. To date, only few studies have investigated the results of this prosthesis. The aim of this study was to investigate the clinical and radiological midterm results of this implant with respect to different indications.

Materials and Methods

The Constant Murley score (CMS), the disabilities of the arm, shoulder, and hand (DASH) score, active range of motion (abduction, anteversion, external rotation) and radiological results were examined in 86?patients (31?male/55?female, age 65.4?±?8.7?years) with the TESS? stemless shoulder prosthesis. The average follow-up time was 31?±?4?months.

Results

The overall mean CMS improved significant (p?<?0.001) from 36.2?±?9.5?points preoperatively to 66.0?±?14.4?points after surgery and, as suspected, shows significant differences between the various patient groups (CMS after surgery: primary omarthrosis 73.3?±?11.4?points, posttraumatic omarthrosis 56.6?±?12.8?points, humeral head necrosis 62.7?±?9.8?points, rheumatoid arthritis 50.2?±?11.0?points, rotator cuff tear arthropathy 44.7?±?3.7?points). Regarding pain relief, there were no significant differences within the patient groups. In contrast, the functional results were significantly better in patient with primary omarthrosis and humerus head necrosis as compared to the other indications.

Conclusions

Depending on the indication, the use of stemless shoulder prostheses leads to good results that are comparable to those of conventional anatomic shoulder prostheses at mid-term follow-up.     

Uncemented metal-back glenoid component in revision of aseptic glenoid loosening: a prospective study of 10 cases with a minimum follow-up of 2 years

Introduction

Glenoid component loosening comprises 25 % of all complications related to total shoulder arthroplasties (TSA). This prospective study was undertaken to assess the accuracy of an uncemented metal-back glenoid component in cases of revision of aseptic glenoid loosening.

Materials and methods

Between September 2007 and January 2010, a total of ten patients with symptomatic glenoid loosening after TSA (7 cemented and 3 non-cemented) underwent revision surgery with an uncemented metal-back glenoid component (MB). The rotator cuff was functional in all cases. The reconstruction of the glenoid was obtained using an iliac crest graft (8 patients) or synthetic bone substitute (2 patients). The non-cemented glenoid component was fixed into the glenoid native bone, thus stabilizing the graft reconstruction. A clinical and radiological checkup was performed at the long-term follow-up and compared with the preoperative values. The patients were also asked to quantify their pain and satisfaction.

Results

There were no intraoperative complications. In all cases, the radiological evaluation showed a good integration of the bone graft with no radiolucency or new glenoid loosening. In one patient, the revision surgery was indicated for the dissociation between MB and polyethylene. After more than 2 years of follow-up, all patients were satisfied or highly satisfied with the outcomes. The pain VAS score (0–10) decreased from 5.1 to 0.6 (p < 0.001). The simple shoulder test increased from 3.4 to 7.9 points (gain 4.5; p < 0.001). The Constant and Murley score increased from 39.4 to 71 points (gain 31.6; p < 0.001). The gain in anterior elevation was 31°, from 118° to 149° (p < 0.001). External rotation elbow to the body (ER1) increased from an average of 34° preoperatively to 47° after surgery (p < 0.001) and external rotation at 90° of abduction from 43° to 66° (p < 0.001).

Conclusion

This study suggests that revision with a non-cemented glenoid component associated with a bone graft can solve the difficult challenge of glenoid loosening, provided that the rotator cuff is functional and the glenoid is reconstructable.

Level of evidence and study type

Cohort studies (prospective) without controls, Level IV.     

Reverse shoulder arthroplasty in revision of failed shoulder arthroplasty—outcome and follow-up

Purpose

The number of shoulder arthroplasties has increased over the last decade, which can partly be explained by the increasing use of the reverse total shoulder arthroplasty technique. However, the options for revision surgery after primary arthroplasty are limited in cases of irreparable rotator cuff deficiency, and tuberosity malunion, nonunion, or resorption. Often, conversion to a reverse design is the only suitable solution. We analysed the functional outcome, complication rate and patient satisfaction after the revision of primary shoulder arthroplasty using an inverse design.

Methods

Over a ten-year period 57 patients underwent revision surgery for failed primary shoulder arthroplasty using a reverse design. Of the 57 patients, 50 (mean age, 64.2 years) were available after an average follow-up of 51 months. Clinical evaluation included the Constant Murley Score, the UCLA score, and the Simple Shoulder Test, whereas radiological evaluation included plain radiographs in standard projections. Patients were also requested to rate their subjective satisfaction of the final outcome as excellent, good, satisfied or dissatisfied.

Results

Compared to the preoperative status, the overall functional outcome measurements based on standardised outcome shoulder scores improved significantly at follow-up. The overall mean Constant Murley score improved from 18.5 to 49.3 points, the mean UCLA score improved from 7.1 to 21.6 points, and the mean simple shoulder test improved from 1.2 to 5.6 points. The average degree of abduction improved from 40 to 93° (p < 0.0001), and the average degree of anterior flexion improved from 47 to 98° (p < 0.0001). The median VAS pain score decreased from 7 to 1. Complications occurred in 12 cases (24 %).A total of 32 (64 %) patients rated their result as good or excellent, six (12 %) as satisfactory and 12 (24 %) as dissatisfied.

Conclusion

In revision shoulder arthroplasty after failed primary shoulder arthroplasty an inverse design can improve the functional outcome, and patient satisfaction is usually high. However, the complication rate of this procedure is also high, and patient selection and other treatment options should be carefully considered.     

Factors affecting results of patients with humeral proximal end fractures undergoing primary hemiarthroplasty: A retrospective study in 42 patients

Aim

Our study reports long-term results and factors related to patient satisfaction in the case of primary hemiarthroplasty for humeral proximal end fractures.

Patients and methods

We retrospectively evaluated 42 patients with humeral proximal end fractures who underwent primary hemiarthroplasty in our clinic from February 1994 to March 2004. Of the 42 patients, 14 (33%) were male and 28 (67%) female. The mean age was 68.9 ± 5.57 years (age range: 59–81 years). The mean follow-up period was 78.8 ± 26.6 months (range: 48–118 months). We evaluated the following parameters: fracture type according to the Neer classification, the time interval between the fracture and the operation, postoperative radiological examination, the Neer outcome assessment criteria for patient satisfaction and functions, according to the Constant and Murley Scoring (CMS) system.

Results

We found good-to-excellent outcomes in 36 (85.7%) and poor outcome in six (14.3%) patients according to the Neer criteria. The average values for CMS score, anterior elevation and external rotation were 73.59 ± 17.95 (25–94), 121.30 ± 42.99° (range: 30–170°) and 30° (range: 0–80°), respectively. The patients who had been operated in the early period (within 2 weeks) had better functional outcomes (p < 0.001) and had significant pain relief. There was a strong positive correlation between the humeral offset (distance between the head and the tuberosities) and the degree of elevation (r = 0.872, p < 0.001). There was a strong negative correlation between the height of the humeral head and the degree of elevation (r = −0.853, p < 0.001).

Conclusion

In humeral proximal end fractures, primary hemiarthroplasty in the early period with the anatomic reconstruction of bone and soft tissues of the shoulder joint and long-term regular rehabilitation programme are important factors contributing to increased patient satisfaction.     

Short-term Clinical Outcome of Dual Plate Fixation in the Treatment of Proximal Humerus Fractures with Calcar Comminution

Objective

Calcar comminution has been considered to be the main cause of the failure of internal fixation and fracture nonunion in proximal humerus surgery. Anatomical reduction and increasing the strength of internal fixation is the key to success. The purpose of this study was to investigate the short-term clinical effect of dual plate fixation in the treatment of proximal humeral fractures with calcar comminution.

Methods

The data of 37 patients with proximal humeral fractures with calcar comminution, treated in our departments from July 2018 to April 2020, were retrospectively analyzed. These patients were treated with anterior plate and lateral PHILOS plate, and followed up for more than 12 months, including 25 cases in Tianjin Hospital and 12 cases in Shanghai General Hospital. The patients included 12 males and 25 females, their age was 54.89 ± 13.59 years (range from 32–79 years), and 21 patients had dominant hand injury. According to the Neer classification, there were 11 two-part fractures, 22 three-part fractures, and four four-part fractures. The range of motion of the shoulder joint, visual analog scale (VAS), American Shoulder and Elbow Surgeons Shoulder Score (ASES), Constant–Murley shoulder score, neck-shaft angle, anterior–posterior angle, and other complication scores were recorded at the last follow-up.

Results

All 37 patients were followed up after operation, and the follow-up time was 21.81 ± 7.35 months (range from 12–36 months). The fractures of all 37 patients had healed at the last follow-up visit. The neck-shaft angle measured immediately after operation was 132.59° ± 8.34°, and the neck-shaft angle measured at the last follow-up visit was 132.38 ± 8.53°. The anterior–posterior angle measured immediately after surgery was 3.45° ± 0.81°, and the anterior–posterior angle at the last follow-up visit was 3.66° ± 0.77°. The range of motion of the shoulder joint was as follows: the shoulder joint could be forward elevated by 158.11° ± 13.09° (range: 140°–180°), rotated externally by 38.38° ± 7.55° (range: 20°–45°), and internally rotated to T4-L4 level. The VAS score was 0.46 ± 0.87 (range: 0–3), the ASES was 86.58 ± 8.79 (range: 56.7–100), and the Constant–Murley score was 88.76 ± 8.25 (range: 60–100). Thirty-three cases were excellent, and four cases were good. No obvious complications occurred.

Conclusion

The combination of anterior plate and lateral PHILOS plate in the treatment of proximal humeral fractures with calcar comminution can achieve stable fixation, and the postoperative clinical and imaging outcome was satisfactory. Firstly, the anterior plate can provide temporary stability when the Kirschner wires are removed, which can provide space for lateral plate placement during fracture reduction and fixation. Secondly, additional support by the anterior plate can provide higher stability in complex fractures with calcar comminution.     

Meta-analysis of joint preservation versus arthroplasty for the treatment of displaced 3- and 4-part fractures of the proximal humerus

Purpose

This meta-analysis compares the clinical outcomes of joint preservation versus arthroplasty in the treatment of displaced proximal humerus fractures.

Methods

Medline, CINAHL, and EMBASE were searched for studies published between 1970 and 2011 reporting outcomes of the treatment of 3- or 4-part proximal humerus fractures using the Constant–Murley score in skeletally mature patients. Randomised and cohort studies with ≥1-year follow-up were included. Two individuals independently extracted data, and study results were divided into subgroups based on type of treatment.

Results

A meta-analysis with meta regressions was performed on the mean Constant score. Of 610 total participants in the studies analysed, 340 were treated with joint-preserving techniques. The random-effects mean Constant score across all treatment types was 62.7 (95% CI, 61.6–63.9, P < 0.001), with joint-preserving treatments demonstrating higher scores than arthroplasty (70 vs. 49, P < 0.001). The studies displayed significant heterogeneity (Q statistic = 516, P < 0.001, I² = 94.8). In the meta-regression analyses, Constant scores decreased significantly with increasing age, fracture severity, and rate of osteonecrosis (P < 0.001).

Conclusions

In the existing literature, displaced proximal humerus fractures demonstrate improved Constant scores when treated with joint-preserving options. Age, fracture pattern, and complication rate are significant predictors of the Constant score independent of the selected treatment. Given the observed heterogeneity and variance in treatment techniques in the included studies, more comparative studies are needed to definitively recommend joint-preserving techniques versus arthroplasty for specific fracture patterns.     

Periprostatic nerve block (PNB) alone vs PNB combined with an anaesthetic‐myorelaxant agent cream for prostate biopsy: a prospective,randomized double‐arm study

OBJECTIVE

To compare the efficacy of periprostatic nerve block (PNB) alone vs PNB combined with the local administration of a 1.5% lidocaine/0.3% nifedipine cream (Antrolin®, Bracco, Milan, Italy).

PATIENTS AND METHODS

In a prospective, randomized, double‐arm study, 200 patients were randomized to receive PNB alone (group A, 100) or PNB combined with a previous administration of the topical anaesthetic Antrolin (group B, 100). The PNB was applied by infiltrating bilaterally a solution of 5 mL lidocaine 1% and naropine 0.75%. Patients were asked to complete visual analogue scale (VAS) questionnaire (0–10) to score pain and discomfort during probe insertion (VAS1), PNB (VAS2), cores (VAS3), 30 min after biopsy (VAS4), the evening of the procedure (VAS5), and the day after biopsy (VAS6).

RESULTS

Pain during probe insertion in group B was significantly less than in group A (VAS1 0.82 vs 2.9; P < 0.001). Pain during periprostatic infiltration was also lower in group B than group A (VAS2 1.4 vs 3.48; P < 0.001). Pain control was similar during biopsy in the two groups (VAS3 1.28 vs 1.2; P = 0.69). The pain scored at VAS4 was significantly less in group B (0.7 vs 1.86, P < 0.001), as was VAS5 (0.68 vs 1.3, P < 0.001). There was no difference in pain perception the day after biopsy (VAS6, 0.32 vs 0.22, P = 0.14).

CONCLUSIONS

Antrolin placed with PNB is better than PNB alone in reducing pain and discomfort during transrectal‐ultrasonography guided prostate biopsy.     

Clinical Outcomes of Open-Door Laminoplasty Combined with Bilateral Lateral Mass Screw Fixation for Multi-Level Cervical Spinal Stenosis with Traumatic Cervical Instability and Spinal Cord Injury: A Retrospective Study

Objectives

The prevalence of multi-level cervical spinal stenosis complicated with traumatic cervical instability and spinal cord injury (MCSS-TCISCI) is low, and the optimal surgical approach remains unclear. Open-door laminoplasty combined with bilateral lateral mass screw fixation (ODL-BLMSF) is a relatively new surgical technique; however, its clinical effectiveness in managing MCSS-TCISCI has not been well-established. This study aims to assess the clinical value of ODL-BLMSF against MCSS-TCISCI.

Methods

We retrospectively analyzed 20 cases of MCSS-TCISCI treated with ODL-BLMSF from July 2016 to June 2020. Radiographic alterations of all included patients were measured using plain radiographs, CT scans, and MRI scans. Cervical lordosis was evaluated using C2-C7 Cobb angle and cervical curvature index (CCI) on lateral radiographs, and Pavlov ratio at the C5 level. Neurological functional recovery was assessed using Japanese Orthopaedic Association (JOA) scores and Nurick grade, while neck and axial symptoms were assessed using the neck disability index (NDI) and the visual analog scale (VAS). The paired t-test was utilized for statistical analysis.

Results

All included patients were followed up for an average period of 26.5 months (range: 24–30 months) after ODL-BLMSF. The average Pavlov ratio at the C5 level significantly improved from 0.57 ± 0.1 preoperatively to 1.13 ± 0.1 and 1.12 ± 0.04 at 6 months postoperatively and at the last follow-up (t = 16.347, 16.536, p < 0.001). Importantly, this approach significantly increased the JOA score from 5.0 ± 2.6 before surgery to 11.65 ± 4.3 and 12.1 ± 4.3 at 6 months postoperatively and at the last follow-up (t = 9.6, −9.600, p < 0.001), with an average JOA recovery rate of 59.1%; and the average Nurick disability score decreased from 3.0 ± 1.3 (preoperative) to 1.65 ± 1.22 and 1.5 ± 1.2 (6 months postoperatively and at last follow-up) (t = 5.111, 1.831, p < 0.001). Meanwhile, the NDI score decreased from 30.3 ± 4.3 preoperatively to 13.2 ± 9.2 at 6 months (t = 12.305, p < 0.001), and to 12.45 ± 8.6 at the final follow-up (t = 13.968, p < 0.001), while the VAS score decreased from 4.0 ± 1.5 preoperatively to 1.5 ± 0.7 at 6 months (t = 9.575, p < 0.001), and to 1.15 ± 0.7 at the final follow-up (t = 10.356, p < 0.001).

Conclusion

ODL-BLMSF can effectively dilate the stenotic spinal canal to decompress the spinal cord, maintain good cervical alignment and stability, and improve the recovery of neurological function and neck function. This technique is suitable for treating selected cases of MCSS-TCISCI.     

AO extra-articular distal humerus locking plate: extended spectrum of usage in intra-articular distal fractures with metaphyseal extension—our experience with 20 cases

Background

LCP extra-articular plate designed by AO has been used in extra-articular fractures of the distal humerus, mal-unions, and nonunions of the distal humerus. They provide anatomically shaped and angular stable fixation system for extra-articular fractures of the distal humerus. We extended the usage spectrum of this plate to the extra-articular with intra-articular distal humerus fractures and compared it with the standard orthogonal locking plate fixation.

Methods

We included 22 consecutive distal humerus intra-articular fractures with metaphyseal and diaphyseal extension into the study. Each case underwent osteosynthesis with LCP extra-articular plate fixation and augmented the intra-articular fragments with 4.0 mm partially threaded cancellous screws. The cost, surgical time, VAS, Modified Mayo Clinic Performance Index for elbow, and postoperative complications were recorded. The radiological union and postoperative elbow range of motion were assessed at 6 weeks, 6, and 12 months of follow-up. Twenty cases completed the scheduled follow-up. The results were compared with retrospective data of 20 cases from our institute where similar fractures were treated with standard orthogonal LCP distal humerus plate (LCPDHP).

Results

The radiological union rates and the range of motion at 6 weeks, 6, and 12 months in both the groups were comparable and did not vary significantly (p > 0.05). The cost and operative time with the LCP extra-articular plates were significantly less (p < 0.05) when compared to the group LCPDHP.

Conclusion

The usage spectrum of extra-articular distal humerus locking plate can be extended to intra-articular fractures. It provides good results and significantly reduces the cost and operative time.     

An uncemented metal-backed glenoid component in total shoulder arthroplasty for osteoarthritis: factors affecting survival and outcome

Background

The reported survivorship of total shoulder replacement (TSR) is variable. This is probably related to implant design. We report the outcome and survivorship of the uncemented glenoid in patients with osteoarthritis receiving a TSR with an intact or repairable rotator cuff at surgery.

Methods

Thirty-two consecutive patients were analysed after TSR using a screw-fixed porous coated metal-back glenoid performed by a single surgeon, with a minimum follow-up of five years. Thirty-three TSRs in 32 patients (19 women) with a mean age of 67 years were analysed, two of whom died before five years of follow-up. Thirty patients (31 shoulders) were monitored for a mean of 95 months (60–173 months).

Results

The Constant score improved by 22 points (p < 0.001). The only significant predictor of outcome on logistic regression analysis was the preoperative Constant score, with better scores resulting in a lesser improvement at last follow-up (p < 0.0001). Implant survivorship at ten years was 93 %. Three were revisions: two for polyethylene wear (both at six years) but with a well-fixed glenoid, and another for loosening of the glenoid at 11 years postoperatively. Univariate analysis identified that younger age (56 year vs. 68 years, p = 0.03) and a higher combined preoperative Constant score (35.7 vs. 21.5, p = 0.03) were both predictors of failure.

Conclusion

The uncemented glenoid performs well in the medium term for osteoarthritis of the shoulder in older patients, giving improved and sustained functional outcome. Age and preoperative level of function are predictors of outcome and survival.     

Comparison of arthroscopic capsular release in diabetic and idiopathic frozen shoulder patients

Introduction  

The clinical results of arthroscopic capsular release for frozen shoulder in diabetic (group 1) and idiopathic (group 2) patients were compared. Surgery was performed on 28 shoulders of 26 patients (24 women, 2 men) with frozen shoulder unresponsive to conservative treatment. The mean age was 50 (range 40–65). A total of 14 patients were included in group 1, and 12 were in group 2. The average duration of complaints was 10 and 7 months in groups 1 and 2, respectively. The evaluation of shoulder functions was made according to the University of California, Los Angeles (UCLA) and Constant Scoring Systems. Duration of complete pain relief and for regaining range of motion (ROM) after surgery were also noted in their final follow-up examination.     

Treatment of bone marrow edema syndrome with intravenous Ibandronate

Background

In this pilot study, we investigated the therapeutic efficacy of intravenous Ibandronate compared to pain medication on the outcome of bone marrow edemas (BME) of the knee and talus.

Patients and methods

Fifteen patients with a painful BME of the knee and 15 patients with a BME of the ankle, confirmed on MRI, were enrolled and treated with three ambulatory infusions of each 6?mg Ibandronate (group 1). A control group (group 2) of 10 patients with a BME of the knee and 10 patients with a BME of the talus was treated with pain medication and partial weight bearing. Patients were evaluated clinically at baseline and at 1, 3, 6 and 12?months after therapy start with a visual analog pain-scale (VAS) and specific joint scores (Larson knee- and Mazur ankle-score). BMEs were assessed with MRI at baseline and after 6?months in both groups.

Results

In the knee group, the mean VAS pain score decreased from 8.5 at baseline to 1.2 at 12?months (p?<?0.0001) in patients treated with Ibandronate and, respectively, from 8.1 to 4.0 in the control group (p?<?0.001). In the ankle group, the mean VAS pain score decreased from 8.2 at baseline to 0.9 at 12?months (p?<?0.0001) in patients treated with Ibandronate and, respectively, from 7.9 to 3.9 in the control group (p?<?0.001). The mean Mazur ankle score increased from 51 to 91?points (p?<?0.001) in group 1, and from 52 to 72?points in group 2 (p?<?0.01). The mean Larson knee score increased from 54 to 89?points (p?<?0.001) at 12?months in group 1, and from 51 to 70?points in group 2 (p?<?0.01). For both joints, we observed a significant clinical improvement in the Ibandronate treatment group and in the control group, but functional results were significantly more improved in the Ibandronate treatment group. Only the Ibandronate treatment group showed a significant BME regression at the 6?months MRI follow-up.

Conclusions

Intravenous Ibandronate therapy showed significantly better clinical results and BME regression rates on MR-imaging compared to analgesic medication in combination with partial weight bearing in the treatment of BME of the knee and talus and shortens the natural course of the disease.