Displaced proximal humerus fractures in older patients: reverse total shoulder arthroplasty or nonoperative treatment?

BackgroundReverse total shoulder arthroplasty (RTSA) for proximal humerus fractures (PHFs) in older patients has been shown to be an effective treatment modality. Recent studies have questioned the superiority of RTSA over nonoperative treatment. The purpose of this study was to compare outcomes after RTSA and nonoperative treatment of PHF.MethodsA retrospective case-matched review of 72 displaced PHFs who underwent either RTSA or nonoperative treatment between August 2016 and August 2019 was conducted. Nine RTSA and 6 nonoperative patients were excluded. Thirty-seven RTSAs in 36 patients (1 bilateral) were compared to twenty patients who met operative criteria for RTSA but did not elect to undergo surgery.ResultsMean VAS pain scores decreased significantly in both groups at the final follow-up. Although there was no statistically significant difference in VAS scores at the time of most-recent follow-up between the two cohorts (1.5 RTSA vs. 1.9 nonop, P = .49), patients who underwent RTSA had a more rapid improvement in pain than nonoperative patients. RTSA patients had significantly lower VAS scores at 2 weeks (2.7 ± 3.1 vs. 5.6 ± 3.2, P = .03), 6 weeks (1.7 ± 2.8 vs. 4.1 ± 3.4, P = .02), and 3 months (1.6 ± 2.8 vs. 3.7 ± 3.2, P = .04) postoperatively. RTSA patients also had better forward flexion (125.4 ± 26.4° vs. 92.1 ± 35.1°, P = 0.001) and abduction (87.1 ± 11.6° vs. 75 ± 13.4°, P = .002) than nonoperative patients at the final follow-up (minimum 6 months). There was a statistically significant difference in mean American Shoulder and Elbow Surgeons scores after RTSA compared with nonoperative patients at the time of final follow-up for acute RTSA and for 3- and 4-part fracture subgroups. Eight patients (21.6%) experienced a complication after RTSA, of which 3 required revision surgery.Discussion/ConclusionOlder patients with displaced PHF have significant improvement in pain and function after both RTSA and nonoperative treatment although RTSA does come with a greater risk of complications. Patients who undergo RTSA have a greater increase in overhead motion and abduction and experience a more rapid improvement in pain, with significantly lower pain scores in the early postoperative period.     

Allografts are not necessary for displaced proximal humeral fractures in patients less than 65 years old,a retrospective cohort study

IntroductionDisplaced proximal humeral fractures (PHF) are frequently treated with locking plates to achieve osteosynthesis. Bone grafts are used as augmentation techniques to improve stability in osteoporotic patients. However, there has been little research into whether bone grafts are necessary for patients younger than 65 years old. This study compared radiographic and clinical outcomes between PHFs augmented with bone grafts or not in a younger population.MethodsBetween January 2016 and June 2020, 91 patients treated with a locking plate alone (LP), and 101 patients treated with locking plates augmented with bone grafts (BG) were analyzed. Potential confounding factors for outcomes were adjusted by propensity score-matching analyses. For the retrospective cohort study, 62 patients from each group were evaluated for radiographic outcomes and clinical outcomes and compared.ResultsSixth-two patients in each group, both with a mean age of 52 years old, were with a mean follow-up time of 25 months in the LP group and 26 months in the BG group. There was no difference in demographic or surgical characteristics between the two groups after propensity score-matching. With regard to radiographic outcomes, the changes in neck-shaft angle (−5.1 ± 4.9 vs. −3.1 ± 5.3, p = 0.015) and humeral head height (−1.5 ± 2.5 vs. −0.4 ± 2.7, p = 0.002) were more obvious in the BG group. However, regarding functional outcomes, there were no significant differences between the two groups in DASH score, Constant–Murley score, or VAS score. Moreover, the complication rate was not significantly different between two groups.DiscussionAllografts only provide minor improvements of stability in radiography for patients less than 65 years old after locking plate fixation of PHFs, but don't improve shoulder function, relieve pain or reduce complications. We concluded that allografts are unnecessary for younger patients with displaced PHFs.     

The results of tension band rotator cuff suture fixation of locked plating of displaced proximal humerus fractures

IntroductionThe purpose of this study was to assess 1-year outcomes of patients with displaced proximal humerus fractures who underwent treatment with locked plate fixation with rotator cuff suture augmentation.MethodsA total of 86 patients who had sustained 2, 3 and 4-part displaced proximal humerus fractures underwent locked plate fixation with multiple sutures placed in the cuff tendons. Clinical outcome variables included active forward elevation (AFE), active external rotation (AER), and Constant and American Shoulder and Elbow Surgeons (ASES) scores. Post-operative variables included the following complications: varus re-collapse, loss of fixation, osteonecrosis of the humeral head (AVN), screw cut out, hardware failure and infection.ResultsForty-one patients were available with minimum of 1-year follow-up. Mean AFE was 142 ± 17.0° and AER was 41 ± 13.0°. The overall complication rate was 14.6%, with osteonecrosis being the most common (12.2%). Of the 21 patients (51.2%) that initially had varus displacement, all but one maintained anatomic reduction and fixation. Mean ASES score was 78.2 ± 20.0 and average Constant score was 72.7 ± 17.6. Bivariate analyses demonstrated that pre-operative medial comminution (p = 0.297) or varus collapse (p = 0.95) were not associated with an increased likelihood of sustaining a complication.ConclusionsFollow-up of patients in this series demonstrated a low overall complication rate and excellent functional outcomes. We believe suture augmentation of the rotator cuff can counteract varus forces on proximal humerus fractures fixed with locked plates, and should be performed routinely in displaced 2, 3 and 4 part fractures.     

Anatomic vs. reverse shoulder arthroplasty for glenohumeral osteoarthritis with intact rotator cuff: a retrospective comparison of patient-reported outcomes using the systems outcomes database with up to 5-year follow-up

BackgroundThe growing enthusiasm for the use of reverse shoulder arthroplasty (RSA) in the treatment of primary glenohumeral osteoarthritis (GHOA) with an intact rotator cuff is based on data derived from single-center studies with limited generalizability and follow-up. This study compared patient-reported outcomes (PROs) between RSA and total shoulder arthroplasty (TSA) for the treatment of primary GHOA with up to 5-year follow-up and examined temporal trends in the treatment of GHOA between 2012 and 2021.MethodsA retrospective review was performed on patients with primary GHOA undergoing primary arthroplasty surgery from the Surgical Outcomes System global registry between 2012 and 2021. PROs including the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, and visual analog scale (VAS) for pain were compared between RSA and TSA at 1, 2, and 5 years postoperatively.ResultsA total of 4451 patients were included, with 2693 (60.5%) undergoing TSA and 1758 (39.5%) undergoing RSA. Both RSA and TSA provided clinically excellent outcomes at 1 year postoperatively (ASES: 80.8 ± 17.9 vs. 85.9 ± 15.2, respectively; SANE: 74.8 ± 24.7 vs. 79.5 ± 22.9; VAS pain: 1.3 ± 2.0 vs. 1.1 ± 1.7; all P < .05) that were maintained at 2 years (ASES: 81.3 ± 19.3 vs. 87.3 ± 14.9; SANE: 74.8 ± 26.2 vs. 79.7 ± 24.7; VAS pain: 1.3 ± 2.1 vs. 1.0 ± 1.6; all P < .05) and 5 years (ASES: 81.7 ± 16.5 vs. 86.9 ± 15.3; SANE: 71.6 ± 28.5 vs. 78.2 ± 25.9; VAS pain: 1.0 ± 1.7 vs. 1.0 ± 1.7; all P < .05), with statistical significance favoring TSA. After controlling for age and sex, there was an adjusted difference of 4.5 units in the ASES score favoring TSA (P = .005) at 5 years postoperatively but no differences in adjusted SANE (P = .745) and VAS pain (P = .332) scores. The use of RSA for GHOA grew considerably over time, from representing only 17% of all replacements performed for GHOA in 2012 to nearly half (47%) in 2021 (P < .001).ConclusionRSA as a treatment for GHOA with an intact rotator cuff seems to yield PROs that are largely clinically equivalent to TSA extending to 5 years postoperatively. The observed statistical significance favoring TSA appears to be of marginal clinical benefit based on established minimal clinically important differences and may be a result of the large sample size. Further research using more granular clinical data and examining differences in range of motion and complications is warranted as it may change the value analysis.     

Intra-articular corrective osteotomy for intra-articular malunion of distal radius fracture using three-dimensional surgical computer simulation and patient-matched instrument

BackgroundCorrective osteotomy of malunited intra-articular distal radius fracture is challenging. In this study, we investigated the results in patients with malunited intra-articular distal radius fracture who underwent intra-articular corrective osteotomy through an extra-articular approach using three-dimensional (3-D) computer simulation and a patient-matched instrument (PMI).MethodsWe retrospectively studied five consecutive patients with symptomatic malunited intra-articular distal radius fracture who underwent corrective osteotomy using a PMI. The maximal step-off on computed tomography and the deformity angle on plain radiographs were evaluated. The clinical examination parameters included range of motion (ROM), grip strength, pain according to visual analog scale (VAS), and Patient-Rated Wrist Evaluation (PRWE) score.ResultsThe maximal step-off was significantly reduced from 4.9 ± 1.8 to 1.0 ± 0.2 mm (p = 0.008). The absolute differences between the affected side and the normal contralateral side in radial inclination were significantly reduced from 5.4° ± 3.4°–1.2° ± 1.1° (p = 0.043). These differences were not significantly reduced postoperatively in the volar tilt and ulnar variance. VAS was significantly reduced from 4.1 ± 1.6 to 0.9 ± 0.7 cm (p = 0.006). The PRWE score significantly improved from 41.6 ± 22.0 to 15.7 ± 19.5 (p = 0.043). Grip strength was significantly increased from 54.0% ± 14.8%–85.8% ± 18.8% (p = 0.003). The preoperative and postoperative total arc of the wrist and forearm ROM were not significantly different.ConclusionsIntra-articular corrective osteotomy using PMI could be one of the reliable treatment options for intra-articular malunion. PMI has exceptionally high precision performance, and it is also anticipated to yield superior surgical results.     

Effect of tuberosity repair on functional outcome of reverse shoulder arthroplasty in proximal humerus fractures

PurposeUnsatisfactory results of hemiarthroplasty in Neer's 3- and 4-part proximal humerus fractures in elderly, have led to the shift towards reverse shoulder arthroplasty (RSA). The objective of our study was to repair the tuberosities that are generally overlooked during RSA and observe its impact on the functional outcome and shoulder scores.MethodsWe include elderly patients with acutely displaced or dislocated 3- or 4-part proximal humerus fractures from July 2013 to November 2019 who were treated with RSA along with tuberosity repair by non-absorbable sutures and bone grafting harvested from the humeral head. Open injuries and cases with neuro-muscular involvement of the deltoid muscle were excluded. According to the tuberosity healing on radiographs of the shoulder at 9th postoperative month, the patients were divided into 2 groups, as the group with successful tuberosity repair and the other with failed tuberosity repair. Statistical analysis of the functional outcome and shoulder scores between the 2 groups were done by independent t-test for normally distributed parameters and Mann-Whitney test for the parameters, where data was not normally distributed.ResultsOf 41 patients, tuberosity healing was achieved in 28 (68.3%) and failed in 13 (31.7%) cases. Lysis of the tuberosity occurred in 5 patients, tuberosity displacement in 2, and nonunion in 2. Mean age was 70.4 years (range 65 – 79 years) and mean follow-up was 58.7 months (range 18 – 93 months). There were no major complications. Group with successful tuberosity repair showed improvement in mean active range of movements, like anterior elevation (165.1° ± 4.9° vs. 144.6° ± 9.4°, p < 0.000), lateral elevation (158.9° ± 7.2° vs. 138.4° ± 9.6°, p < 0.000), external rotation (30.5° ± 6.9° vs. 35.0° ± 6.3°, p = 0.367), internal rotation (33.7° ± 7.5° vs. 32.6° ± 6.9°, p = 0.671) and in mean shoulder scores including Constant score (70.7 ± 4.1 vs. 55.5 ± 5.7, p < 0.000), American shoulder and elbow surgeons score (90.3 ± 2.4 vs. 69.0 ± 5.7, p < 0.000), disability of arm shoulder and hand score (22.1 ± 2.3 vs. 37.6 ± 2.6, p < 0.000).ConclusionSuccessful repair and tuberosity healing around the RSA prosthesis is associated with statistically significant improvement in postoperative range of motion, strength and shoulder scores. Standardized repair technique and interposition of cancellous bone grafts, harvested from the humeral head can improve the rate of tuberosity healing.     

Continuous adductor canal block following total knee arthroplasty provides a better analgesia compared to single shot: A prospective randomized controlled trial

ObjectiveThe aim of this study was to compare single-shot adductor canal block and continuous infusion adductor canal block techniques in total knee arthroplasty patients.MethodsWe prospectively randomized 123 patients who were scheduled for unilateral primary total knee arthroplasty surgery into single shot (n = 60; mean age: 67.1 ± 6.9 years) and continuous (n = 63; mean age: 66.9 ± 6.8 years) adductor canal block groups. Postoperative visual analog scale pain scores, need for additional opioids and functional results as; timed up and go test, the 30-s chair stand test, 5 times sit-to-stand test, the 6-min walking test, the time to active straight leg raise, time to walking upstairs, maximal flexion at the time of discharge, duration of stay in hospital were compared between the two groups.ResultsPain scores were lower in the continuous adductor canal block group as compared to the single-shot adductor canal block group throughout the postoperative period (p = 0.001). Rescue analgesia was required for 6 (10%) patients in the single shot group and for 1 (1.59%) patient in the continuous group (p = 0.044). Patients in the continuous adductor canal block group displayed better functional results than the single-shot adductor canal block group with respect to active straight-leg rise time (25.52 ± 4.56 h vs 30.47 ± 8.07 h, p = 0.001), 6-min walking test (74.52 ± 29.38 m vs 62.18 ± 33.32 m, p = 0.035) and maximal knee flexion degree at discharge (104.92 ± 5.35° vs 98.5 ± 7.55°, p = 0.001). There was no significant difference between the two groups for other functional and ambulation scores.ConclusionPain control following total knee arthroplasty was found to be better in those patients treated with continuous adductor canal block as compared to those treated with single-shot adductor canal block. Patients treated with continuous adductor canal block also displayed better ambulation and functional recovery following total knee arthroplasty.Level of evidenceLevel I, Therapeutic Study.     

Defining maximal outcome improvement thresholds for patient satisfaction after reverse total shoulder arthroplasty: a minimum two-year follow-up study

BackgroundPrevious research has investigated the percentage of maximal outcome improvement (MOI) for the American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test scores after reverse total shoulder arthroplasty (rTSA); however, few other outcome scores have been validated. The purpose of this study was to establish thresholds of MOI percentage for the Single Assessment Numeric Evaluation (SANE) and subjective Constant-Murley (Constant) scores associated with patient satisfaction at 2 years following rTSA.MethodsA retrospective review of institutional registry data for all patients who underwent primary rTSA between 09/2016 and 02/2018 was performed. All patients completed the ASES, SANE, and Constant outcome measures preoperatively and at a minimum of 2 years postoperatively. Changes were assessed with Wilcoxon signed-rank tests. MOI percentage was defined as the score improvement from baseline divided by the highest possible improvement from baseline based on the maximum value of the outcome score used. Receiver operating characteristic (ROC) analyses were used to determine optimal MOI percentage thresholds associated with postoperative satisfaction. Stepwise multivariate logistic regression was performed to identify variables associated with achieving the MOI.ResultsA total of 105 patients were included in the final analysis, with a mean (±standard deviation) age of 70.0 ± 7.5 years and BMI of 28.9 ± 5.6 kg/m². The majority of patients were satisfied postoperatively (81.0%). Statistically significant increases were observed from baseline to 2 years postoperatively for the outcome measures assessed (P < .001 for all). ROC analysis demonstrated that the optimal MOI percentage threshold for achieving satisfaction was 66.9% for ASES ([Area under curve, AUC]: 0.87), 71.0% for SANE (AUC: 0.89), and 37.5% for Constant (AUC: 0.85). The linear regression model fit between the proportion of satisfied patients and the calculated MOI percentages was moderate for SANE (r² = 0.313, P < .001) and weak for Constant (r² = 0.228, P < .001). Multivariate logistic regression demonstrated that comorbid diabetes was associated with a decreased likelihood of MOI achievement for SANE ([Odds Ratio, OR]: 0.66, P = .020) and Constant (OR: 0.72, P = .027). Preoperative diagnosis of rotator cuff arthropathy (OR: 0.84, P = 0.049) was associated with a decreased likelihood of MOI achievement for Constant. No factors were significantly associated with MOI achievement for ASES.ConclusionAchieving 66.9%, 71.0%, and 37.5% of the MOI for the ASES, SANE, and Constant scores is associated with postoperative satisfaction following rTSA. Comorbid diabetes and diagnosis of rotator cuff arthropathy were significantly associated with a decreased likelihood of MOI achievement.Level of evidenceLevel III; Retrospective Case Series (Prognostic)     

Accuracy of cup placement using computed tomography-based navigation system in total hip arthroplasty through the direct anterior approach

BackgroundThis study aimed to elucidate the accuracy of cup placement with the computed tomography (CT)-based navigation system (CTN) in the direct anterior approach (DAA)-total hip arthroplasty (THA) in the supine position compared with the mechanical cup alignment guide (MG) or the fluoroscopy (FS).MethodsA total of 171 hips of 156 patients undergone primary THA were classified into the following three groups (the MG group: 63 hips, the FS group: 58 hips, the CTN group: 50 hips). Comparing the preoperative planning with postoperative CT measurement by three-dimensional templating software, the accuracy of cup placement was investigated in the three groups.ResultsThere were significant differences in the mean absolute error of radiographic inclination (RI) between the MG group (4.4° ± 3.2°) and the CTN group (2.8° ± 2.5°) (p = 0.01). The mean absolute error of radiographic anteversion (RA) also showed significant differences between the CTN group (2.8° ± 1.9°) and the MG group (5.8° ± 4.7°) (p = 0.0001) or the FS group (4.8° ± 4.1°) (p = 0.02). Regarding the cup center position, the mean absolute error of vertical position from preoperative planning was the smallest in the CTN group (1.8 ± 1.4 mm) compared with those in other groups (MG: 3.3 ± 3.2 mm, p = 0.007, FS: 3.2 ± 3.0 mm, p = 0.017).ConclusionThe CTN guarantees accurate cup placement in the DAA-THA in the supine position compared with the MG and FS groups.     

Varus malposition relates to functional outcomes following open reduction and internal fixation for proximal humeral fractures: A retrospective comparative cohort study with minimum 2 years follow-up

Background: The aim of this study was to evaluate functional outcomes in patients with varus malposition following open reduction and internal fixation of displaced proximal humeral fractures.Methods: Data of 685 patients with a mean age of 67±15.8 years (67% female), that were treated by open reduction and internal fixation for a displaced proximal humeral fracture at a level 1 trauma center, were analyzed. On standardized x-ray imaging, the degree of varus displacement was measured over a minimum of two years follow-up and patients were divided into three groups. Group A: anatomic or <10° of varus or valgus malposition, group B: 10–20° of varus malposition and group C: >20° varus malposition, while anatomic head-shaft-angle was defined 135° The groups were compared with regards to functional outcomes by means of the Constant Score (CS).Results: In 565 patients with anatomic to minor <10° varus or valgus malposition (Group A), the mean CS was 72.5 ± 18.8 points. The %CS to the uninjured side was 87.2 ± 24.1 and the age and gender normalized nCS was 84.7 ± 21.7. In comparison, in group B (10–20° varus) the mean CS was 64.7 ± 16.9, the mean %CS was 84.5 ± 18.3 and the mean nCS was 76.2 ± 20.6. In group C (>20° varus) the mean CS was 54.1 ± 19.5, the mean was %CS: 72.3 ± 26.4 and the mean nCS was 64.8 ± 23.8 (p = 0.02, p = 0.03, p = 0.01). Overall, the CS, %CS and nCS correlated significantly with the degree of varus position (Pearson correlation, r = 0.23, r = 0.21, r = 0.25).Conclusion: Varus malposition is related to inferior functional outcomes compared to anatomic healing in patients treated by open reduction and internal fixation for proximal humeral fractures. The data supports suggestions to prevent varus malposition in open reduction and internal fixation. In severe >20° of varus malposition, revision surgery should be considered.     

Comparison of surgical outcomes for laparoscopic liver resection of large hepatocellular carcinomas: A retrospective observation from single-center experience

Background/purposeAlthough laparoscopic liver resection (LLR) is a common surgical procedure for hepatocellular carcinoma (HCC), its suitability for large HCCs (≥5 cm) remains controversial. This study compared surgical outcomes of open hepatectomy with LLR for large HCCs.MethodsA total of 313 patients with HCC who underwent hepatectomy between January 2010 and June 2017 were analyzed retrospectively. Demographic data, short-term outcomes, and long-term survivals were analyzed.ResultsAmong patients with large HCCs (n = 122), the open group (n = 85) had larger tumor sizes (10.91 ± 4.72 vs. 7.45 ± 2.95 cm; p < 0.001) and more advanced stages (stages 3/4: 71.8% vs. 45.9%; p = 0.029) than the LLR group (n = 37), while LLR group achieved less blood loss (623.24 ± 841.75 mL vs. 1091.76 ± 1004.72 mL, p = 0.014) and shorter LOS (9.00 ± 5.13 d vs. 12.82 ± 8.51 d, p = 0.013). There were no significant differences in complication and mortality rates between groups. The 5-year overall and recurrence-free survival rates between the two groups were not significantly different (p = 0.408 and 0.644 respectively). The surgical outcomes showed equal benefit of the two operation types.ConclusionWith sufficient surgeon experience and appropriate patient selection, LLR is a feasible treatment choice for large HCCs.     

Patients can accurately self-report their elbow range of motion following surgery for trauma

IntroductionThere is an increased demand of telemedicine in the recent century, especially with the outbreak of Covid-19. The aim of this study was to investigate patients' reliability in self-assessing own elbow range of motion following surgery for trauma.MethodsAll patients of age ≥16 years who underwent surgery for elbow trauma at the local trauma unit between March 2015 to Aug 2018 were reviewed retrospectively. Identified cohort was invited to self-assess their elbow range of motion (ROM) using questionnaire with image instruction. They were then followed up with a clinical review for objective measurements by the lead clinician. Independent T-test was used to compare the measurements between patients and clinician. The power of the study was calculated using G1Power software.ResultsThirty-five patients were enrolled in the study with mean age of 41 years. 11 of 35 patients had an associated elbow fracture dislocation associated. Mean patient reported total ROM was 105.7° ± 32.8°, with mean extension of 24.6° ± 18.9° to mean flexion of 130.3° ± 18.2°. Mean objective ROM measured by lead clinician was 112.6° ± 18.3°, with mean extension 22.4° ± 10.9° to mean flexion 135.0° ± 10.8°. No statistical significance was found between self-reported and clinician-based extension (p = 0.36), flexion (p = 0.076), and overall range of motion (p = 0.12).ConclusionPatients can self-assess their elbow range of motion following surgery for trauma accurately. In the midst of increasing demands for telemedicine, we suggest the application of patients' self-reporting outcome in clinical settings.     

Lack of correlation between hip osteoarthritis and anatomical spinopelvic parameters obtained in supine position on MRI

PurposeHip osteoarthritis (HOA) is known to have a multifactorial pathogenesis. Recent studies suggest that spinopelvic alignment may represent an important additional pathogenic abnormality resulting in HOA. This study aims to assess the correlation between spinopelvic parameters (pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS) and lumbar lordosis (LL)) obtained in the supine position on MRI and HOA, lateral center edge (LCE) angle, and patient reported back pain.MethodsAsymptomatic participants from the whole-body MRI cohort (FF4) from the cross-sectional case-control “Cooperative Health Research in the Region of Augsburg” study (KORA) were included. Whole-body MRI was performed in a standardized fashion in each case, on which hip osteoarthritis (HOA), anatomical spinopelvic parameters and lateral center edge angle were measured. Presence of back pain was assessed using a standardized questionnaire. Correlations were estimated by logistic regression models providing odds ratio.ResultsAmong 340 subjects (mean age 56.3 ± 9.3 years; 56.5% male), HOA was present in 89.1% (male: 87.0%, female: 91.7%, p = 0.17). The LCE angle was 30.0° ± 5.5 (men: 29.8° ± 5.9; women: 30.1° ± 5.1; p = 0.696). Mean PI was 54.0° ± 11.3°, PT was 13.7° ± 5.9°, SS was 40.3° ± 8.8° (significantly smaller in women p<0.05) and LL was 36.4° ± 9.6° (significantly greater in women p<0.05). None of the spinopelvic parameters correlated significantly with hip osteoarthritis or LCE angle. HOA was not correlated with back pain.ConclusionSpinopelvic parameters as measured in the supine position on MRI, do not correlate with hip osteoarthritis or lateral center edge angle.     

Evaluating Alternate Registration Planes for Imageless,Computer-Assisted Navigation During Total Hip Arthroplasty

BackgroundImageless computer navigation improves component placement accuracy in total hip arthroplasty (THA), but variations in the registration process are known to impact final accuracy measurements. We sought to evaluate the registration accuracy of an imageless navigation device during THA performed in the lateral decubitus position.MethodsA prospective, observational study of 94 patients undergoing a primary THA with imageless navigation assistance was conducted. Patient position was registered using 4 planes of reference: the patient’s coronal plane (standard method), the long axis of the surgical table (longitudinal plane), the lumbosacral spine (lumbosacral plane), and the plane intersecting the greater trochanter and glenoid fossa (hip-shoulder plane). Navigation measurements of cup position for each plane were compared to measurements from postoperative radiographs.ResultsMean inclination from radiographs (41.5° ± 5.6°) did not differ significantly from inclination using the coronal plane (40.9° ± 3.9°, P = .39), the hip-shoulder plane (42.4° ± 4.7°, P = .26), or the longitudinal plane (41.2° ± 4.3°, P = .66). Inclination measured using the lumbosacral plane (45.8° ± 4.3°) differed significantly from radiographic measurements (P < .0001). Anteversion measured from radiographs (mean: 26.1° ± 5.4°) did not differ significantly from the hip-shoulder plane (26.6° ± 5.2°, P = .50). All other planes differed significantly from radiographs: coronal (22.6° ± 6.8°, P = .001), lumbosacral (32.5° ± 6.4°, P < .0001), and longitudinal (23.7° ± 5.2°, P < .0001).ConclusionPatient registration using any plane approximating the long axis of the body provided a frame of reference that accurately measured intraoperative cup position. Registration using a plane approximating the hip-shoulder axis, however, provided the most accurate and consistent measurement of acetabular component position.     

The influence of mental health on outcomes following total shoulder arthroplasty

BackgroundAnxiety and depression symptoms have been associated with higher pain and lower functional scores in patients with glenohumeral osteoarthritis (GHOA). The influence of mental health on outcomes following total shoulder arthroplasty (TSA) for GHOA has not been fully investigated .MethodsThis observational cohort study included 143 shoulders in 135 subjects undergoing TSA for GHOA. Preoperative imaging was assessed for glenoid wear pattern. Patients completed preoperative and postoperative American Shoulder and Elbow Surgeons (ASES) score, Visual Analog Pain Scale (VAS), and PROMIS Upper Extremity (UE), Physical Function (PF), and Pain Interference (PI) scores. The Western Ontario Osteoarthritis Score (WOOS) was collected postoperatively. Mean postoperative pain and functional scores, improvement from preoperative scores, and surgical regret were compared between varying severity of anxiety or depression and pattern of glenoid wear.ResultsCompared to subjects without anxiety, those with moderate-to-severe anxiety reported worse postoperative ASES (p=0.019), WOOS (p<0.01) and PROMIS UE (p=0.02) and higher PROMIS PI scores (p<0.01). Compared to those without depression, those with moderate-to-severe depression reported worse postoperative ASES and WOOS and higher VAS and PROMIS Pain scores (p<0.01). Linear regression showed that anxiety and concentric glenoid wear were associated with worse postoperative PROMIS scores. There were no significant differences in pre-to-postoperative improvement in any outcome measures among those with and without anxiety or depression. Patients with moderate-to-severe depression were less likely to want to undergo the same procedure again (p=0.035).DiscussionPatients with anxiety and depression report similar improvements in pain and function following TSA similar to those without depression or anxiety. Despite the similar improvement, those with moderate-to-severe depression and anxiety symptoms reported persistently lower functional and higher pain scores. Though most patients are satisfied following TSA, those with moderate-to-severe depression may be more likely to regret undergoing surgery. Future studies should identify mental health symptoms preoperatively and evaluate the effect of preoperative intervention on postoperative outcomes following TSA.     

Usefulness of strain cardiac magnetic resonance for the exposure of mild left ventricular systolic abnormalities in pectus excavatum

BackgroundSystolic dysfunction in pectus excavatum (PEX) is usually very subtle and mainly focused on the right ventricle (RV), leading to normal or unremarkable cardiac imaging findings unless involving exercise stress.ObjectivesWe evaluated systolic function in PEX using longitudinal strain cardiac magnetic resonance (CMR), a validated parameter for the assessment of the systolic deformation of subendocardial fibers.MethodsThis prospective registry comprised consecutive patients with PEX who were referred to CMR to define treatment strategies or to establish surgical candidacy. We also included a control group of 15 healthy volunteers without chest wall abnormalities. Using dedicated software, we evaluated the endocardial global longitudinal strain (GLS) of both ventricles and the endocardial global circumferential strain (GCS) of the left ventricle (LV).ResultsA total of 50 patients with PEX comprised the study population, with a mean age of 19.9 ± 8.0 years. The right ventricular ejection fraction (RVEF) of patients with PEX was significantly lower compared to the control group both at end-expiration (59.5 ± 6.8 vs. 64.7 ± 4.7%, p = 0.008) and end-inspiration (56.7 ± 7.2%, vs. 62.7 ± 4.4, p = 0.004); as well as the pulmonary stroke distance (12.6 ± 2.5, vs. 15.0 ± 2.0 cm, p = 0.001). The LV volumetric analysis revealed no differences between PEX and the control group (p > 0.05 for all) regardless of the respiratory cycle, with a mean expiratory LV ejection fraction (LVEF) of 61.4 ± 6.0%. In contrast, the GLS of the LV was significantly lower in PEX compared to controls (-21.2 ± 3.2 vs. -23.7 ± 3.0%, p = 0.010), whereas GCS was similar either at expiration (-28.5 ± 4.0%, vs. -29.5 ± 2.8, p = 0.38) or inspiration (-29.3 ± 4.1%, vs.-28.9 ± 2.3, p = 0.73).ConclusionsIn this study, we demonstrated that longitudinal strain analysis might enable the detection of very subtle left ventricular systolic function abnormalities in patients with PEX, that are commonly overlooked using the conventional assessment.Level of evidenceII     

The effects of a short-term perioperative duloxetine treatment on post-colectomy pain: A randomized,controlled clinical trial

Study objectiveTo test the hypothesis that duloxetine reduces postoperative morphine consumption and pain intensity in patients undergoing major colonic surgeries.DesignSingle-center, prospective, double-blinded, randomized, controlled trial.SettingTertiary university hospital, from December 2019 to September 2021.PatientsSixty 18–85 years old, ASA I – III patients undergoing elective open major colonic surgeries were randomly allocated into duloxetine (duloxetine) or placebo (placebo) groups (n = 30 per group).InterventionsDuloxetine 60 mg or placebo was administered orally 2 h before and 24 h after surgery.MeasurementsPCA morphine consumption, surgical pain at rest, and movement measured on 10-cm visual analog scales (VAS), Ramsay sedation scores, and the incidence of adverse effects potentially associated with duloxetine were assessed at patients' admission to the post-anesthesia care unit (PACU), 6, 24, and 48 h postoperatively (PO).Main resultsAfter adjusting for age, BMI, ASA physical status, education level, and incision type, no differences were found between groups in PCA morphine consumption 24 PO h (duloxetine = 5.44 ± 2.06 mg; placebo = 10.33 ± 2.06 mg, p = 0.62) or 48 h PO (duloxetine = 9.18 ± 2.06 mg, placebo = 12.93 ± 2.06, p = 1). Pain at rest also did not differ between groups at 24 h PO (duloxetine = 1.76 ± 0.67 cm; placebo = 1 ± 0.67 cm, p = 1) or at 48 h PO (duloxetine = 0.84 ± 0.67 cm; placebo = 0.49 ± 0.67 cm, p = 1). Similarly, groups did not differ regarding pain on movement at 24 h PO (duloxetine = 2.09 ± 0.68 cm; placebo = 1.80 ± 0.68, p = 1) or at 48 h PO (duloxetine = 1.16 ± 0.68 cm; placebo = 0.88 ± 0.68 cm, p = 1). Sedation scores and adverse effects also did not differ between groups.ConclusionUnder this study's conditions, short-term duloxetine did not reduce total opioid consumption or pain intensity during the initial 48 h following major colon surgery.     

The effect of stromal vascular fraction in an experimental frostbite injury model

BackgroundDespite current treatment modalities, frostbite remains an injury with a poor prognosis which may cause functional morbidities. Several experimental and clinical studies have demonstrated that stromal vascular fraction is an autologous mixture, which can improve wound healing and vasculogenesis. The aim of this study was to show the beneficial effects of stromal vascular fraction on experimental frostbite healing.Material and methodsStromal vascular fraction (SVF) was harvested from 5 rats after excision of the inguinal fat pads. Another 20 rats were separated into 2 groups of 10 as the SVF group and the control group. A frostbite injury was created on each rat using a cryoprobe frozen with liquid nitrogen (?196 °C). SVF was applied to the SVF group and phosphate-buffered saline to the control group. All injections were performed subcutaneously within the frostbite injury area. Biopsies were performed on days 5 and 14 for histopathological and immunochemical evaluations. The tissue perfusion rates of both groups were assessed on day 14 using indocyanine green angiography (SPY system).ResultsThe increase in mean tissue perfusion was 373.3% ( ± 32.1) in the SVF group and 123.8% ( ± 16.3) in the control group (p < 0.001). The macroscopic wound reduction rates of the SVF and control groups were 25.5% ( ± 19.1) and 18.0% ( ± 5.9), respectively on day 5%, and 78.2% ( ± 9.2) and 57.3% ( ± 16.7) on day 14 (p = 0.007; p = 0.003). Acute inflammation and the fibrosis gradient were significantly decreased in the SVF group compared to the control group (p = 0.004, p = 0.054 respectively on day 14). Granulation tissue amount, re-epithelialization score and neovascularization were significantly increased in the SVF group (p = 0.006, p = 0.010 and p = 0.021, respectively on day 14).ConclusionsThe study results demonstrated that SVF increases frostbite wound healing by increasing tissue perfusion rate, neovascularization and re-epithelialization, and modulating acute inflammation and fibrosis.     

Outcomes of nonoperative management of acromial stress fractures after reverse shoulder arthroplasty

IntroductionAcromial stress fractures (ASF) and stress reactions (ASR) are common complications after reverse shoulder arthroplasty (RSA), and have been shown to compromise outcomes. The purpose of this study was to determine the functional outcomes of patients with ASF and ASR treated nonoperatively.MethodsA total of 958 patients that underwent RSA were retrospectively reviewed. 43 (4.5%) were found to have ASF and 56 (5.7%) were found to have ASR. ASF were defined by tenderness over the acromion with identified fracture on radiographic imaging, and ASR was defined as tenderness without radiographic evidence of fracture. Functional outcomes were assessed via American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), Simple Shoulder Test (SST) and VAS (Visual Analog scale) pain at a minimum of 2 years after RSA and one year from diagnosis of acromial pathology. The ASF patients were matched 3:1 to RSA controls without acromial pathology based on age, sex, indication, and implant.ResultsTwenty seven ASF and 35 ASR patients met inclusion criteria with a mean follow-up of 50.3 months after surgery (range: 24-108 months). Symptom onset after RSA occurred at 8.1 ± 8.9 months (range: 0.8-49.8) in ASFs and 7.5 ± 6.8 months (range: 1.0-41.3) in ASRs (P = .700). The ASF group included 20 (74%) females with an average age of 71.8 years, and the ASR group included 30 (86%) females with an average age of 72.9 years. ASF patients had inferior outcomes compared to controls in ASES (57.8 vs. 76.0, P = .001), SANE (59.1 vs. 78.8, P = .001), SST (5.1 vs. 7.5, P = .001), and VAS (3.3 vs. 1.2, P = .002). Additionally, ASF patients had significantly worse scores compared to ASR patients by VAS Pain (3.3 vs 1.7, P = .020), ASES (57.8 vs. 76.7, P = .001), SANE (59.1 vs. 81.1, P = .001), and SST (5.1 vs. 7.5, P = .001). Patients with ASR had comparable pain and function to controls in ASES (P = .858), SANE (P = .508), SST (P = .956), and VAS (P = .264) scores. Twenty-one (77.7%) ASF patients experienced fracture displacement and 13 (48.1%) went on to nonunion.ConclusionEarly follow-up of patients treated nonsurgically for ASF after RSA demonstrated worse pain and function compared to controls. The majority demonstrated further displacement after diagnosis and almost half developed a nonunion. Patients with ASR experienced temporary dysfunction with little impact on final outcome. Strategies to prevent and treat ASFs remain an area in need of innovation.Level of evidenceLevel IV; Case series