Midterm outcome of superior capsular reconstruction using doubled acellular human dermal allograft for irreparable rotator cuff tear.

BACKGROUND: Thicker (folded) facia lata autografts have been shown to be superior to thinner grafts and single-layered acellular human dermal (HD) allografts for superior capsular reconstruction (SCR) in biomechanical studies. The aim of this study was to evaluate the midterm clinical outcomes following SCR for irreparable supraspinatus tears using doubled (folded) HD allograft. METHODS: Thirty-two patients who had undergone SCR using doubled HD allograft between February 2012 and January 2020 were recruited in a continuous manner in this retrospective study. The inclusion criteria were SCR performed for irreparable supraspinatus tear and a minimum of 2 years' follow-up. The primary outcome measure was the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score. The secondary outcome measures were complications and revision surgery. A subgroup analysis was performed between patients who received a "standard" graft of mean 3-mm thickness or a "thick" graft of mean 4.4-mm thickness. RESULTS: One patient was lost to follow-up. A total of 31 patients (31 shoulder joints) were analyzed with a mean follow-up duration of 48 months (range, 25-96 months). Following surgery, there was significant improvement in the ASES score from 18.1 ± 14.3 (preoperative) to 76.3 ± 25.1 (postoperative) (P < .001), with a satisfactory clinical outcome obtained in 83.8% of the patients. In a subset of 8 patients completing 5 years' follow-up, the clinical improvements were sustained. The percentage of patients with a clinically successful outcome was higher among those with thick grafts compared to those with standard grafts, although this failed to reach statistical significance (94.4% vs. 69.2%, risk ratio 1.36, 95% confidence interval 0.93-1.99, P = .13). One patient within the standard group underwent revision surgery. CONCLUSION: SCR for irreparable rotator cuff tears with doubled HD allograft results in improved clinical outcomes and low reoperation at midterm follow-up duration.

A pilot randomised controlled trial assessing standard versus dermal patch-augmented rotator cuff repair found no adverse effects and suggest future trials need a minimum of 150 patients.

PURPOSE: The aims of this pilot randomised controlled trial (RCT) were to assess the safety and efficacy of a human dermal allograft patch and assess the feasibility of a future RCT comparing retear rate and functional outcome 12 months following standard and augmented double-row rotator cuff repair. METHODS:  A pilot RCT was conducted among patients undergoing arthroscopic repair of rotator cuff tear measuring between 1 and 5 cm. They were randomised to either augmented (double-row repair with human acellular dermal patch) or standard (double-row repair only). The primary outcome was rotator cuff retear determined on MRI scan at 12 months using the Sugaya's classification (grade 4 or 5). All adverse events were recorded. Functional assessment was performed at baseline and 3, 6, 9, and 12 months post-surgery using clinical outcome scores. Safety was assessed by complications and adverse effects, and feasibility by recruitment, follow-up rate and proof of concept statistical analyses of a future trial. RESULTS: Between 2017 and 2019, 63 patients were considered for inclusion. Twenty-three patients were excluded, leaving 40 patients (20 per group) in the final study population. The mean tear sizes were 3.0 cm in the augmented and 2.4 cm in the standard group. There was one adhesive capsulitis in the augmented group, with no other adverse events. Retear was observed in 4/18 (22%) of patients in the augmented and 5/18 (28%) in the standard group. In both groups, functional outcome improved significantly which was clinically meaningful for all scores, with no difference between groups. Retear rate increased with tear size. Future trials are feasible but need a minimum total sample size of 150 patients. CONCLUSION:  Clinically meaningful improved function without adverse effects was found with human acellular dermal patch-augmented cuff repairs. LEVEL OF EVIDENCE: Level II.

Age-adjusted Charlson comorbidity index as a novel guideline for patient selection between unilateral versus bilateral simultaneous total knee arthroplasty.

PURPOSE: The aim of this study was to validate the age-adjusted Charlson comorbidity index as a clinical practice guideline for patient selection between unilateral total knee arthroplasty (UTKA) and bilateral simultaneous total knee arthroplasty (BSTKA). METHODS: A consecutive series of 1016 patients undergoing UTKA (402 patients) or BSTKA (614 patients) was analysed. The age-adjusted Charlson comorbidity index (ACCI) was measured for all the patients and graded as low (0-2 score), moderate (3-4 score) and high risk (≥ 5 score). The complications occurring within 3 months of surgery were compared between UTKA and BSTKA recipients. RESULTS: Following surgery, the complication rate was comparable between both the groups. However, among high-risk patients, there was significant difference in the complication rates between UTKA and BSTKA groups (12% versus 30.76%, minor; 8% versus 23.07%, major complication). The high-risk patients who had bilateral surgery were at more than three times greater risk of developing major and minor complications than those who had unilateral surgery. CONCLUSION: The BSTKA procedure is associated with significantly higher risk of post-operative complications than UTKA procedure in patients with ≥ 5 ACCI scores.

Sharpened lateral acromion morphology (SLAM sign) as an indicator of rotator cuff tear: a retrospective matched study.

BACKGROUND: Bigliani types of acromion and critical shoulder angle (CSA) have been implicated as indicators of rotator cuff disease. A sharpened inferolateral edge of acromion (termed as Sharpened Lateral Acromion Morphology or SLAM sign) is frequently observed in anteroposterior radiographs of the glenohumeral joint in patients with rotator cuff tears (RCT). We aimed to evaluate the association of the SLAM sign with RCT in comparison to high CSA (≥35°) and Bigliani type 3 (hooked) acromion. METHODS: A cohort of 100 consecutive patients undergoing non-arthroplasty surgery for RCT and 106 patients with primary frozen shoulder were matched manually in 1:1 ratio based on age and gender to yield study population with 50 patients in each group. The 2 groups were compared for the presence of the SLAM sign, high CSA, and type 3 acromion on the radiographs. RESULTS: All the 3 parameters were found more prevalent in the RCT group than the frozen shoulder group (SLAM, 46% vs. 0; high CSA, 60% vs. 40%; type 3 acromion, 18% vs. 4%) (P < .05). The SLAM sign showed stronger correlation with RCT than high CSA and type 3 acromion (Ps = 0.562 vs. 0.220 vs. 0.224 respectively). CONCLUSION: The SLAM sign is a simple and easily identifiable radiological predictor of rotator cuff disease.

Does statin-treated hyperlipidemia affect rotator cuff healing or muscle fatty infiltration after rotator cuff repair?

BACKGROUND: Hyperlipidemia is linked to poor tendon-to-bone healing and progression of fatty infiltration after rotator cuff repair. Statins effectively treat hyperlipidemia, but it is unknown if they have any potential detrimental effects following rotator cuff repair. The aim of this study was to evaluate the effect of statins on rotator cuff healing and fatty infiltration following repair. METHODS: A total of 77 patients undergoing arthroscopic rotator cuff repair were recruited prospectively, 38 patients who were prescribed a statin for hyperlipidemia (statin group) and 39 patients who were not taking a statin (control group). Patients who did not have both preoperative and 1-year postoperative magnetic resonance imaging (MRI) scans were excluded from the study. Patient-reported outcome measures, namely the Western Ontario Rotator Cuff (WORC) index, Constant-Murley score, American Shoulder and Elbow Surgeons (ASES) score, and Disabilities of the Arm, Shoulder and Hand (DASH) score, were collected preoperatively and at 1 year. Fatty infiltration was assessed on MRI according to the Goutallier grade preoperatively and at 12 months; rotator cuff healing was assessed at 12 months according to the Sugaya classification. Following propensity score weighting to adjust for baseline imbalances, 12-month outcomes were compared between the 2 groups. RESULTS: At 12 months, all patient-reported outcome measures had improved significantly compared with baseline (WORC score, 85.9 vs. 32.5, P < .001; ASES score, 87.3 vs. 37.5, P < .001; Constant-Murley score, 77 vs. 31, P < .001; and DASH score, 13.6 vs. 61.4, P < .001). There was no significant difference in postoperative scores in the statin group vs. the control group (WORC score, 84.9 vs. 89.6, P = .94; ASES score, 87.5 vs. 86.6, P = .40; Constant-Murley score, 77 vs. 81, P = .90; and DASH score, 14.4 vs. 11.4, P = .14), and for 3 of these scores, the 95% confidence intervals excluded a clinically meaningful difference. Similarly, rotator cuff healing at 12 months and Goutallier fatty infiltration grades were comparable between the 2 groups. Retears were seen in 6 patients (15.8%) in the statin group and 8 (20.5%) in the control group. Progression of fatty infiltration was seen in 4 patients (10.5%) in the statin and 4 (10.3%) in the control group. Statin use did not demonstrate a significant association with either retear risk (P = .41) or progression of fatty atrophy (P = .69). CONCLUSION: Patient-reported outcomes, rotator cuff retear rate, and fatty infiltration on MRI at 12 months after rotator cuff repair in patients with hyperlipidemia treated with statins are similar to those in a control group.

Systematic Review of Modular Bicompartmental Knee Arthroplasty for Medio-Patellofemoral Osteoarthritis.

BACKGROUND: We aimed to locate, appraise, and synthesize the available literature to assess the functional outcome of modular bicompartmental knee arthroplasty (BKA) compared to total knee arthroplasty (TKA) for medio-patellofemoral osteoarthritis. METHODS: After an extensive literature search based on electronic databases such as MEDLINE, EMBASE, CINAHL, and PubMed, and grey literature, 9 articles satisfied our selection criteria which included 1 randomized controlled trial, 1 prospective cohort, 3 retrospective cohort, and 4 case series. Narrative synthesis was performed due to clinical, methodological, and statistical heterogeneity among the included studies. RESULTS: There were 331 participants (341 knees) in this systematic review. BKA group included 229 patients (239 knees) and TKA group included 102 patients (102 knees). The quality of included studies ranged from moderate to very low as per GRADE (grading of recommendations, assessment, development, and evaluation working group) score with low to high risk of bias. Most of the studies showed comparable functional outcome in BKA compared to TKA such as Knee Society Score, Knee Osteoarthritis and Outcome Score, Short Form-36 score, and revision surgery in short-term to midterm follow-up. BKA patients achieved better range of movement and forgotten knee status than TKA patients. It resulted in longer operative time, but less intraoperative blood loss. Long-term series showed 95.1% survivorship of BKA at 5 years and 58% at 17 years. CONCLUSION: Current evidence suggests that modular BKA provides comparable functional outcome to TKA at short-term to midterm follow-up, however, with poor long-term survivorship.

Prosthetic knee joint infection due to Mycobacterium abscessus.

Infected total knee arthroplasty (TKA) due to Mycobacterium abscessus is very rare with only three such cases described in literature. Only one case was managed successfully, however, with a prolonged course of anti tubercular therapy. In this case report, we present an elderly lady with infected TKA after 2 years of the primary procedure. Although initially it grew different bacteriae, M. abscessus was isolated during the second debridement. She was successfully treated with total of 5 months of second line anti tubercular drugs with revision prosthesis performed during chemotherapy. Two years followup revealed satisfactory outcome with no relapse.

Impact of Charlson indices and comorbid conditions on complication risk in bilateral simultaneous total knee arthroplasty.

BACKGROUND: The purpose of this study was to evaluate the influence of Charlson indices and comorbid conditions on the risk of perioperative complications in bilateral simultaneous total knee arthroplasty (BSTKA). METHODS: In our retrospective analysis, 556 patients including 133 males and 423 females (mean age 65.8years), who had undergone bilateral simultaneous total knee arthroplasty between 2011 and 2014 were included. Risk factors (Charlson comorbidity index (CCI), age-adjusted Charlson comorbidity index (ACCI), and comorbid illnesses) and perioperative complications were noted, and subsequently, statistical tests were applied. RESULTS: There was significant association between Charlson indices and most of the complications (P<0.05) with high-risk ACCI groups (a score>5) bearing maximum odds for cumulative major complication (OR 4.165, P<0.001, 95% CI 1.874 to 9.256). In addition, hypertension, non-ischemic cardiac illness, and moderate to severe chronic kidney disease proved be to be determinants for major complications (P=0.031, P=0.041, and P=0.014, respectively). We also found significant associations between organ-specific illnesses and complications such as cardiac, pulmonary, neurological and renal complications (P<0.05). CONCLUSIONS: Both CCI and ACCI are predictors of post-operative complications with ACCI being the better predictive determinant. Hence, these predictors should be used for risk stratification prior to patient selection for BSTKA. The influence of hypertension, non-ischemic cardiac illness and moderate to severe chronic kidney disease should also be considered during patient selection. Moreover, optimum organ function at the time of surgery should be a priority to avoid these complications.

Evaluation of static and dynamic MRI for assessing response of bone sarcomas to preoperative chemotherapy: Correlation with histological necrosis.

OBJECTIVES: Preoperative chemotherapy plays a key role in management of bone sarcomas. Postoperative evaluation of histological necrosis has been the gold standard method of assessing response to preoperative chemotherapy. This study was done to evaluate the efficacy of static and dynamic magnetic resonance imaging (MRI) for assessing response preoperatively. MATERIALS AND METHODS: Our study included 14 patients (12 osteosarcomas and 2 malignant fibrous histiocytomas) with mean age of 21.8 years, treated with preoperative chemotherapy followed by surgery. They were evaluated with static and dynamic MRI twice, before starting chemotherapy and again prior to surgery. Change in tumor volume and slope of signal intensity - time curve were calculated and correlated with percentage of histological necrosis using Pearson correlation test. RESULTS: The change in dynamic MRI slope was significant (P = 0.001). Also, ≥60% reduction in slope of the curve proved to be an indicator of good histological response [positive predictive value (PPV) =80%]. Change in tumor volume failed to show significant correlation (P = 0.071). Although it showed high negative predictive value (NPV = 85.7%), PPV was too low (PPV = 57.14%). CONCLUSIONS: Dynamic MRI correctly predicts histological necrosis after administration of preoperative chemotherapy to bone sarcomas. Hence, it can be used as a preoperative indicator of response to neoadjuvant chemotherapy. On the other hand, volumetric assessment by static MRI is not an effective predictor of histological necrosis. This study proves the superiority of dynamic contrast-enhanced study over volumetric study by MRI.

Streptococcus pyogenes Associated Post-traumatic Brodie's Abscess of Cuboid: A Case Report and Review of Literature.

INTRODUCTION: Brodie's abscess of cuboid bone is one of the rarest diagnosis in children which most often is hematogenous in origin. Although Streptococcus pyogenes has been uncommonly implicated as causative organism in other bones, it is not yet reported in the cuboid. CASE REPORT: We report the case of 14-year-old boy who presented with a lytic lesion in the cuboid bone. It was preceded by a penetrating injury with a small iron nail. He was treated with simple curettage without the addition of bone graft. Frank pus present in the cavity in the cuboid bone grew S. pyogenes on bacterial culture. Symptoms resolved after 6 weeks of antibiotics, however, complete radiological healing was obtained after 9 months. CONCLUSION: Although very rare, S. pyogenes associated Brodie's abscess should strongly be suspected in a posttraumatic lytic lesion in the cuboid bone and bone grafting is not always required for bone healing even in presence of large pus-filled cavity.

Role of dynamic MRI and clinical assessment in predicting histologic response to neoadjuvant chemotherapy in bone sarcomas.

BACKGROUND: Neoadjuvant chemotherapy has become the first-line therapy in management of malignant bone tumors. Response to it is best assessed with evaluation of tumor necrosis postoperatively. This study was carried out to evaluate the role of clinical parameters and dynamic magnetic resonance imaging (MRI) to predict the histologic response before surgery. MATERIALS AND METHODS: Our study included 14 patients (12 osteosarcoma and 2 malignant fibrous histiocytoma) with mean age of 21.8 years, treated with neoadjuvant chemotherapy followed by surgery, who were evaluated clinically and with dynamic MRI twice, before starting chemotherapy and before surgery. Clinical parameters (pain, tumor girth, maximum tumor diameter, surface temperature, and consistency) and dynamic MRI parameter (slope of signal intensity-time curve) were correlated with histologic response (percentage of necrosis) using Pearson and Spearman correlation test. RESULTS: Significant correlation with histologic necrosis was seen in change in pain, tumor girth, maximum tumor diameter, surface temperature, and dynamic MRI slope (P<0.01). Change in consistency did not show significant correlation (P>0.05). Complete relieve of pain with reduction of >4 grades, ≥5% reduction in tumor girth, ≥8% reduction in tumor diameter, attainment of normal body temperature or decrease of ≥2°F temperature, and ≥60% reduction in slope proved to be an indicator of good histologic response. CONCLUSIONS: Both dynamic MRI and clinical evaluation are reliable methods of assessment of response of the bone tumors to neoadjuvant chemotherapy.