Rotator Cuff Repair Augmented With Interpositional Nanofiber Scaffold.

Despite advances in arthroscopic rotator cuff repair, failure rates up to 94% have been reported in the literature for large tears, with rates as high as 36% for small and medium tears. One strategy for improving outcomes is augmentation with a patch, which has typically been incorporated onto the bursal portion of the repaired tendon and been made up of either dermal or bovine collagen tissue. The Rotium wick (Atreon Orthopedics, Columbus, OH)-an interpositional augmentation-is a nanofiber scaffold that is meant to be sandwiched between the rotator cuff and humerus at the bone-tendon interface and is currently the only implant approved by the US Food and Drug Administration to be used in this manner. The scaffold works to improve the cellular organization of the basement membrane during tendon healing at the enthesis and, in a recent sheep study, has been shown to better replicate the natural Sharpey-like fibers similar to the native tendon and increase the strength of the repair more rapidly. The purpose of this Technical Note is to describe the means for use of an interpositional nanofiber scaffold for arthroscopic rotator cuff repair.

Determination of rotator cuff tear reparability: an ultrasound-based investigation.

Background: The use of ultrasound as a viable diagnostic tool for routine office visit evaluation of rotator cuff integrity is slowly gaining acceptance in orthopedic practice. However, the reliability of accurately assessing rotator cuff tear reparability by ultrasound has limited evidence in the literature. The purpose of this study was to compare preoperative assessment of cuff tear reparability via ultrasound with the arthroscopic determination of reparability at the time of surgery. Methods: We prospectively collected preoperative ultrasound and arthroscopic imaging data on 145 patients (80 or 55% men and average age of 60.7 years) who underwent arthroscopic posterior superior rotator cuff repair. Three independent experienced orthopedic surgeons retrospectively reviewed all ultrasound studies and arthroscopic imaging and determined if the posterior superior rotator cuff tendon edge was able to be viewed via ultrasound and determined with the arthroscopic images if the tear was reparable. Results: On review of the ultrasound and arthroscopic data, if the edge of the rotator cuff tendon was able to be viewed on the coronal ultrasound image, it was most likely reparable with a positive predictive value of 97.6% and a positive likelihood ratio of 5.8. Sensitivity was 84.4%, and specificity was 76.9%. The negative predictive value was 37.5%, and the negative likelihood ratio was 0.17. The interobserver reliability was 0.63, and the observers were unanimous in determining the tendon edge was able to be visualized in 99 of 145 cases (68%). Conclusion: Preoperative ultrasound evaluation of the shoulder for posterior superior rotator cuff tears is a useful tool for assessing rotator cuff integrity and may help predict intraoperative reparability of the tendon. This study demonstrates that if the cuff tear edge is able to be visualized, there is a high probability of successful arthroscopic restoration of the tendon to its native attachment. Conversely, if the tear edge is unable to be visualized, there is a moderate chance of the tear being irreparable. These results help expand the knowledge base of the usefulness of in-office ultrasound performed by the surgeon in predicting the results of surgical intervention for rotator cuff tears.

Use of a Nanofiber Resorbable Scaffold During Rotator Cuff Repair: Surgical Technique and Results After Repair of Small- to Medium-Sized Tears.

Background: The rate of retear after primary rotator cuff failure remains unacceptably high (up to 36% for small- to medium-sized tears). Augmentation of cuff repair with scaffold devices has been reported to improve healing after cuff repair. Purpose/Hypothesis: To describe the surgical technique of using an interpositional nanofiber scaffold during rotator cuff repair and report on a retrospective series of patients regarding functional outcomes and postoperative healing on magnetic resonance imaging (MRI). We hypothesized that augmentation of cuff repair with an interpositional scaffold would result in a high rate of tendon healing and excellent functional outcomes. Study Design: Case series; Level of evidence, 4. Methods: A total of 33 patients underwent arthroscopic rotator cuff repair augmented with a nanofiber, bioresorbable polymer patch secured as an inlay between the tendon and underlying bone. Patients were evaluated preoperatively and postoperatively with the Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) shoulder score, and active range of motion (ROM) measurements. Postoperative MRI was used to evaluate repair status. Results: At a minimum follow-up of 6 months, the patients showed significant improvement on SST and ASES scores (P < .0001 for both). ROM in forward flexion, abduction, internal rotation, and external rotation significantly improved at 6 months postoperatively (P < .05 for all). MRI at an average of 11 months postoperatively showed healing in 91% of patients; one patient had a recurrent tear with transtendon failure, and another patient had retear at the insertional site. The patch was not visible on postoperative imaging, suggesting complete resorption in all patients. No adverse events were associated with the patch. Conclusion: Our results demonstrate the preliminary safety and efficacy of a novel, bioresorbable synthetic scaffold for rotator cuff repair. The use of the scaffold resulted in a 91% tendon healing rate and significant improvements in functional and patient-reported outcome measures. The results are promising for improving the current unacceptably high rate of rotator cuff repair failure.

Trends in outpatient shoulder arthroplasty during the COVID-19 (coronavirus disease 2019) era: increased proportion of outpatient cases with decrease in 90-day readmissions.

BACKGROUND: The COVID-19 (coronavirus disease 2019) pandemic has placed an increased burden on health care resources, with hospitals around the globe canceling or reducing most elective surgical cases during the initial period of the pandemic. Simultaneously, there has been an increased interest in performing outpatient total joint arthroplasty in an efficient manner while maintaining patient safety. The purpose of this study was to investigate trends in total shoulder arthroplasty (TSA) during the COVID-19 era with respect to outpatient surgery and postoperative complications. METHODS: We conducted a retrospective chart review of all primary anatomic and reverse TSAs performed at our health institution over a 3-year period (January 2018 to January 2021). All cases performed prior to March 2020 were considered the "pre-COVID-19 era" cohort. All cases performed in March 2020 or later comprised the "COVID-19 era" cohort. Patient demographic characteristics and medical comorbidities were also collected to appropriately match patients from the 2 cohorts. Outcomes measured included type of patient encounter (outpatient vs. inpatient), total length of stay, and 90-day complications. RESULTS: A total of 567 TSAs met the inclusion criteria, consisting of 270 shoulder arthroplasty cases performed during the COVID-19 era and 297 cases performed during the pre-COVID-19 era. There were no significant differences in body mass index, American Society of Anesthesiologists score, smoking status, or distribution of pertinent medical comorbidities between the 2 examined cohorts. During the COVID-19 era, 31.8% of shoulder arthroplasties were performed in an outpatient setting. This was significantly higher than the percentage in the pre-COVID-19 era, with only 4.5% of cases performed in an outpatient setting (P < .0001). The average length of stay was significantly reduced in the COVID-19 era cohort (0.81 days vs. 1.45 days, P < .0001). There was a significant decrease in 90-day readmissions during the COVID-19 era. No significant difference in 90-day emergency department visits, 90-day venous thromboembolism events, or 90-day postoperative infections was observed between the 2 cohorts. CONCLUSION: We found a significant increase in the number of outpatient shoulder arthroplasty cases being performed at our health institution during the COVID-19 era, likely owing to a multitude of factors including improved perioperative patient management and increased hospital burden from the COVID-19 pandemic. This increase in outpatient cases was associated with a significant reduction in average hospital length of stay and a significant decrease in 90-day readmissions compared with the pre-COVID-19 era. The study data suggest that outpatient TSA can be performed in a safe and efficient manner in the appropriate patient cohort.

Single-Shot Liposomal Bupivacaine Reduces Postoperative Narcotic Use Following Outpatient Rotator Cuff Repair: A Prospective, Double-Blinded, Randomized Controlled Trial.

BACKGROUND: Liposomal bupivacaine (LB) theoretically is longer-acting compared with conventional bupivacaine. The purpose of this study was to compare conventional bupivacaine combined with dexamethasone (control group), LB combined with conventional bupivacaine (LB group), and LB combined with dexamethasone and conventional bupivacaine (LBD group) in a perineural interscalene nerve block during ambulatory arthroscopic rotator cuff repair to determine if LB decreased postoperative narcotic consumption and pain. The effect of supplemental dexamethasone on prolonging the analgesic effect of LB was also assessed. METHODS: This was a prospective, double-blinded, randomized controlled trial of 76 consecutive patients who underwent outpatient arthroscopic rotator cuff repair. Patients were randomized into the 3 interscalene-block treatment groups: control group (n = 26), LB group (n = 24), and LBD group (n = 26). Outcome measures included pain measured with a visual analog scale (VAS; 0 to 10) and narcotic consumption measured in oral morphine milligram equivalents (MME). Both were measured daily on postoperative day 0 through postoperative day 4. RESULTS: Generalized estimating equation modeling revealed that narcotic consumption across all time points (postoperative days 0 to 4) was significantly lower in the LB group compared with the control group (mean difference, -8.5 MME; 95% confidence interval, -15.4 to -1.6; p = 0.015). Narcotic consumption was significantly higher in the control group on postoperative days 2 and 3 compared with the LB group (p = 0.004 and p = 0.02, respectively) and the LBD group (p = 0.01 and p = 0.003, respectively). There was no difference in narcotic consumption between the LBD and LB groups on any postoperative day. VAS pain scores in all groups were similar across all postoperative days. CONCLUSIONS: Among patients undergoing outpatient arthroscopic rotator cuff repair, the addition of LB to conventional bupivacaine in interscalene nerve blocks appeared to be effective in controlling postoperative pain. Because LB with and without dexamethasone decreased postoperative narcotic use, LB should be considered for use in preoperative interscalene nerve blocks to reduce the reliance on narcotics for pain management. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Short-Term Clinical Outcomes and Comparison of Ultrasound Versus Magnetic Resonance Imaging of Superior Capsular Reconstruction.

PURPOSE: To evaluate the short-term outcomes of 10 patients with irreparable massive rotator cuff tears treated with arthroscopic superior capsular reconstruction (SCR) using dermal allograft. METHODS: Between 2016 and 2018, patients with symptomatic irreparable rotator cuff tears were prospectively enrolled for treatment with arthroscopic SCR. Investigational review board approval was achieved. All patients were treated by a single fellowship-trained shoulder surgeon. Minimum follow-up was 1 year. Range of motion and functional outcome according to visual analog scale pain, American Shoulder and Elbow Surgeons, and Simple Shoulder Test scores were assessed preoperatively and at routine follow-up intervals. Magnetic resonance imaging (MRI) and ultrasound were obtained at a minimum of 1 year to assess graft integrity and to correlate clinical outcomes. RESULTS: Ten patients with a mean age of 58.6 years had a minimum follow-up of 1 year. In all patients, preoperatively to postoperatively, mean forward flexion improved from 141° to 173° (P = .018), mean visual analog scale pain score decreased from 6.5 to 1 (P = .004), and mean American Shoulder and Elbow Surgeons score improved from 43 to 87 (P = .005). At 1 year, ultrasound evaluation identified graft failure in 1 patient (10%), whereas MRI diagnosed graft failure in 7 patients (70%). Of the 7 failures diagnosed by MRI, 4 failed at the level of the glenoid, 2 failed mid-graft, and 1 failed at the humerus. CONCLUSIONS: Although clinical outcomes are statistically improved following arthroscopic SCR using a dermal allograft, the early high failure rates of the graft raise concerns about the long-term outcomes of the procedure. Furthermore, the use of ultrasound alone to validate an intact graft should be used with caution, as failures can occur at the glenoid and can be missed without MRI correlation. LEVEL OF EVIDENCE: Level IV, Therapeutic case series.

Treatment of atrophic diaphyseal humeral nonunions with compressive locked plating and augmented with an intramedullary strut allograft.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of thorough debridement and locked compression plating augmented with an intramedullary fibular allograft for the treatment of atrophic diaphyseal humeral nonunions. DESIGN: The study involved a level 4 retrospective case series. SETTING: This study was conducted at a level 1 university trauma center. PATIENTS: Twenty patients with painful atrophic nonunions of the humeral diaphysis were examined. INTERVENTION: This involved a thorough debridement and locked compression plating augmented with an intramedullary fibular allograft. MAIN OUTCOME MEASURES: These were union rate, shoulder range of motion, visual analog scale (VAS) pain, VAS function, patient satisfaction, and American Shoulder and Elbow Surgeons score at latest follow-up. METHODS: Clinical and radiographic examinations were performed preoperatively and postoperatively. VAS pain and function scores were collected preoperatively and postoperatively. Patient satisfaction and ASES scores were recorded at the time of the most recent follow-up. RESULTS: : Bony union was achieved in 19 of 20 patients (95%). The patients demonstrated an average improvement in forward elevation from 65 to 144° (P = 0.001), abduction from 48 to 133° (P < 0.001), external rotation from 34 to 70° (P = 0.05), and internal rotation from S1 to T12 (P = 0.025). VAS pain scores improved from 6.05 to 1.88 (P = 0.032). VAS function scores improved from 2.06 to 7.75 (P = 0.003). The average postoperative ASES score was 76, and the average patient satisfaction was rated 9.3/10. CONCLUSIONS: Atrophic nonunions of the humerus can be successfully treated with debridement of the nonunion, coupled with the use of a fibular allograft and locked compression plating. This technique leads to predictable healing without the morbidity associated with autograft. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Results of surgical treatment for unstable distal clavicular fractures.

HYPOTHESIS: Delayed surgical treatment of unstable distal clavicle fractures is associated with a higher complication rate. MATERIALS AND METHODS: Between 1998 and 2008, a retrospective study of 38 patients (average age, 42.9 year) with Neer type II clavicular fractures was performed. Fractures were treated with a hook-plate (22 patients) or with superior locked plate with suture augmentation (16 patients). Patients were divided into acute (27 patients) or delayed (11 patients) treatment groups based on the timing of surgical intervention before or after 4 weeks. All had clinical and radiographic follow-up for 1 year or until fracture union. RESULTS: Union was achieved in 36 of 38 patients (94.7%). The acute treatment group had an average American Shoulder and Elbow Surgeons score of 77.9 compared with 65.0 in the delayed group. Six complications occurred (15.8%) including 2 infections (5.3%), 1 hardware failure (2.6%), and 3 peri-implant fractures (7.9%). The complication rate was 36.4% in the delayed group vs 7.4% in the acutely treated group (P = .047). DISCUSSION: A high rate of union was observed in all cases regardless of timing or method of fixation. Despite a high rate of union, the results of treatment in the delayed group were more problematic. Patients treated with a hook-plate in a delayed fashion had more complications than those treated in an acute fashion (P = .039). Peri-implant fractures occurred only in patients treated with hook-plates. CONCLUSION: Surgical timing played a critical role in the outcome and complication rate in treatment of unstable distal third clavicle fractures.

Large coronal shear fractures of the capitellum and trochlea treated with headless compression screws.

BACKGROUND: The purpose of this study is to retrospectively evaluate the clinical outcomes of 18 patients with large coronal shear fractures of the capitellum and lateral trochlea that underwent open reduction and internal fixation with headless compression screws. METHODS: Eighteen patients were identified (16 women, 2 men) with an average age of 45 years and an average follow-up of 26 months. Fractures were classified according to the Dubberley classification as 11 type-1A injuries and 7 type-2A injuries. RESULTS: All patients, with the exception of 1, had good to excellent functional results by the Broberg-Morrey scale (mean score, 93.3). Average arc of motion was 128 degrees in flexion/extension and 176 degrees in pronation/supination. Radiographically, 3 patients had subsequent development of avascular necrosis and 5 developed arthrosis. No significant negative correlation was noted between the development of avascular necrosis and clinical outcome. Minor complications occurred in 2 patients, but there were no re-operations. CONCLUSION: Headless compression screw fixation allows for stable fixation in patients with large coronal shear fractures of the distal humerus without posterior comminution. LEVEL OF EVIDENCE: 4.

Proximal humeral nonunions treated with fixed-angle locked plating and an intramedullary strut allograft.

OBJECTIVE: To determine if the use of a fixed-angle locked plate plus an intramedullary allograft in the treatment of proximal humeral nonunions resulted in improved union. DESIGN: Retrospective clinical analysis of patients' medical charts and radiographs. SETTING: Clinical practice of senior authors. PATIENTS/PARTICIPANTS: Eighteen patients who presented to the senior authors' clinic between 2001 and 2007 with clinical and radiographic evidence of symptomatic proximal humeral nonunions that were treated with the described method were included for analysis. Patients with severe humeral head bone loss, avascular necrosis, evidence of arthrosis, and less than 12-month clinical follow-up were excluded. INTERVENTION: All patients with a symptomatic viable nonunion of the proximal humerus were treated with a fixed-angle locked plate and an intramedullary cortical allograft. MAIN OUTCOME MEASUREMENT: Patients were followed until radiographic union was achieved, with this being the principle determinant of a successful outcome. RESULTS: Radiographic union was achieved in 17 of 18 patients (94%). The average follow-up was 26.5 months (range 12-49 months). The average time from surgery to radiographic union was 5.4 months (range 2.5-8.8 months). There was 1 failure of fixation, and 2 patients developed transient neurologic sequelae. Range of motion measurements obtained from the most recent clinical follow-up were 115 degrees (range 20-180 degrees) active forward elevation, 37 degrees (range 0-70 degrees) passive external rotation, and active internal rotation was to the 10th thoracic vertebrae. American Shoulder and Elbow Surgeon scores improved from a level of 40 preoperatively to 81 postoperatively, and visual analog scale scores improved from 6.7 to 1.5. CONCLUSION: Intramedullary strut allograft insertion combined with fixed-angle plating is an effective technique for treating viable nonunions of the proximal humerus and was successful in achieving union in 94% of our patients.

Radiation exposure with use of the mini-C-arm for routine orthopaedic imaging procedures.

BACKGROUND: The use of mobile fluoroscopic devices during orthopaedic procedures is associated with substantial concern with regard to the radiation exposure to surgeons and support staff. The perceived increased risks associated with large c-arm devices have been well documented. However, no study to date has documented the relative radiation risk associated with the use of a mini-c-arm device. The purpose of the current study was to determine the amount of radiation received by the surgeon during the use of a mini-c-arm device and to compare this amount with documented measurements associated with the large c-arm device. METHODS: With use of a radiation dosimeter, measurements were carried out with tissue-equivalent anthropomorphic phantoms to quantitatively determine exposure rates at various locations and distances from the mini-c-arm for two common upper and lower extremity procedures. RESULTS: Regardless of position, distance, or relative duration of exposure, exposure rates resulting from the use of the mini-c-arm device were one to two orders of magnitude lower than those reported in the literature in association with the use of the large c-arm device. CONCLUSIONS: The mini-c-arm device should be utilized whenever feasible in order to eliminate many of the concerns associated with use of the large c-arm device, specifically those related to cumulative radiation hazards, positioning considerations, relative distance from the beam, and the need for protective shielding.

Spinal injury considerations in the competitive diver: a case report and review of the literature.

BACKGROUND CONTEXT: Despite significant literature associated with spinal injuries and recreational diving, few articles exist regarding competitive diving injuries, with no reports pertaining specifically to spinal injuries. As a result, a case report of a collegiate diver with C5-C6 ligamentous instability requiring operative stabilization is currently presented in addition to a review of the literature. PURPOSE: Present a case report of cervical C5-C6 ligamentous instability in a collegiate diver. STUDY DESIGN: Case report and literature review. METHODS: Not applicable. RESULTS: Not applicable. CONCLUSIONS: Diving injuries pertaining to competitive diving do occur but to a lesser extent than would be expected given the large forces the spine experiences. Training, experience and appropriate technique greatly minimize potential spinal hazards. Persistent complaints of neck pain after a competitive diving injury mandate aggressive evaluation and further workup.