Subacromial Balloon Spacer Does Not Reduce the Retear Rate for Massive Rotator Cuff Tears: A Comparative Study.

PURPOSE: To determine whether a subacromial spacer decreases the recurrent rotator cuff tear rate in arthroscopically managed massive rotator cuff tears (MRCTs) with 1 year of follow-up. METHODS: We selected all patients who met the following criteria: (1) an MRCT excluding Collin type A, (2) Goutallier stage equal or less than 2, and (3) complete arthroscopic repair of the MRCT. Patients were allocated into 2 groups: A (without subacromial spacer) or B (with subacromial spacer) for a prospective evaluation 1 year after surgery. The primary outcome was the retear rate, determined with magnetic resonance imaging (MRI) according to the classification of Sugaya. Secondary outcome measures were the functional outcomes using visual analog score, Shoulder Subjective Value, and Constant-Murley Score. Preoperative rotator cuff characteristics such as number of tendons involved and the tear retraction also were evaluated. Patient-related data such as sex, age, laterality, history of smoking, and diabetes mellitus were analyzed. RESULTS: In total, 31 patients were included in group A and 33 in group B. Preoperatively, only 2 differences were found between both groups: a significant (but not clinical) greater Constant score in group A (P = .034) and a slightly greater retraction of the supraspinatus in group B (P = .0025). The overall retear rate between the 2 groups was similar regarding the number of patients (P = .746) and the total number of tendons involved in the recurrent tear (P = .112). At 1-year follow-up, no differences were found in VAS (P = .397), SSV (P = .309), and Constant score (P = .105). CONCLUSIONS: In reparable massive rotator cuff tears (excluding Collin type A), the augmentation of repair with a subacromial spacer did not significantly reduce the number of patients with recurrent rotator cuff tears identified by MRI. It was also ineffective in reducing the number of re-ruptured tendons in these patients. No patient-reported or clinically significant findings were noted in Constant, SSV, and VAS scores at 1-year postoperative follow-up. Patients with MRI findings of a healed rotator cuff (Sugaya 1-3) had better clinical outcomes compared with those without. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Nonoperative treatment of acromial fractures following reverse shoulder arthroplasty: clinical and radiographic outcomes.

BACKGROUND: Acromion/scapular spine fractures (ASFs) remain a challenging complication following reverse shoulder arthroplasty (RSA). Historically, nonoperative management has been the treatment of choice, with variable results. The purpose of this study is to report on both clinical and radiographic outcomes of nonoperative treatment. A new subclassification of Levy type II acromion fractures will be proposed, and outcomes will be evaluated in relation to the modified Levy classification. METHODS: Forty-four patients diagnosed with ASF following RSA were matched 1:3 to a control group based on gender, age, and preoperative function. All ASF patients were treated nonoperatively. Patient-reported outcome measures, consisting of American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Simple Shoulder Test, Single Assessment Numerical Evaluation, visual analog scale pain and function scores, satisfaction, and active range of motion were gathered preoperatively and at the most recent follow-up. Outcomes were stratified based on fracture type. Radiographic findings including fracture union, scapular rotation, progressive notching, and osteolysis were reviewed from latest follow-up and compared with initial postoperative films. RESULTS: ASFs were identified at a median of 2 months following RSA (8 type I; 22 type II; 14 type III), followed for a median of 37 months and compared to 108 matched controls. Patients with ASF had inferior clinical outcomes with a higher rate of dissatisfaction (27.8%) when compared to controls. Lateral fracture subtypes (I and IIA) were similar to controls and had little impact on outcomes. However, medial fracture subtypes (type IIB, IIC, and III) demonstrated inferior outcomes when compared to controls, with type III fracture patients demonstrating no improvement from baseline. The overall nonunion rate was 61.4%, with high rates of scapular rotation and osteolysis in medial fracture subtypes. Nonunion was associated with a higher incidence of secondary radiographic findings, including scapular rotation, progressive notching, and osteolysis. CONCLUSION: Results of nonoperative treatment of ASF following RSA differs based on fracture location. Fractures that occur at or medial to the glenoid face (IIB, IIC, III) demonstrate high rates of unsatisfactory results and worse clinical outcomes. Concerning radiographic findings of scapular tilt, progressive scapular notching and osteolysis were seen at a higher rate with medial fracture types and fracture nonunions.

Operative Intervention for a Chronic Fifth Carpometacarpal Dislocation: A Case Report and Review of Literature.

INTRODUCTION: Carpometacarpal (CMC) dislocations are infrequent hand injuries that are often missed in the acute care setting, resulting in inappropriate treatment and significant morbidity. CMC dislocations occur in a volar or dorsal direction, and volar dislocations are traditionally subclassified as either volar-ulnar or volar-radial. While various treatment methods and injury identification techniques have been reported in the literature, there remains a lack of standardization in the treatment of these injuries. This case report reviews the current literature on the subject in an attempt to further our knowledge on the subject. CASE REPORT: A 73-year-old right hand dominant male presented to the clinic complaining of persistent pain on the ulnar aspect of his left hand for the past 3 months. The injury had been missed in the urgent care and emergency settings before his arrival to the office. Radiographs demonstrated a volar-ulnar dislocation of the fifth CMC joint. The patient subsequently underwent open reduction with internal fixation to correct his deformity. Post-operative QuickDASH and grip strength measurements were gathered at post-operative visits. CONCLUSION: This paper provides a literature review on the diagnostic techniques and management options of the fifth CMC dislocations. It further provides a treatment algorithm for a chronic volar-ulnar fifth CMC dislocation being amenable to open reduction and Kirschner wire fixation with an excellent outcome.

Does application of hydrogen peroxide to the dermis reduce incidence of Cutibacterium acnes during shoulder arthroplasty: a randomized controlled trial.

INTRODUCTION: Prosthetic joint infections (PJIs) following shoulder arthroplasty are a major source of morbidity and are most commonly caused by Cutibacterium acnes, a bacteria found concentrated in the dermis. Skin preparation using hydrogen peroxide has been shown to reduce positive cultures; however, direct application to the dermis has not been investigated. The purpose of this study is to determine whether the application of hydrogen peroxide to the dermis affects the incidence of positive C acnes cultures. METHODS: A prospective, randomized controlled trial of patients undergoing primary shoulder arthroplasty by a single fellowship-trained surgeon was performed between February and November 2020. Enrolled patients were randomized to either receive standard skin preparation and antibiotic prophylaxis with or without an additional application of hydrogen peroxide to the dermis following incision. Culture samples were taken from the skin, dermis, glenohumeral joint, and air. Laboratory personnel and patients were blinded to randomization, and all cultures were held for 14 days. Culture positivity rate along with culture site, day of culture positivity, and bacterial abundance of positive cultures were analyzed. Stratified analysis by gender and age of ≤69 years was also performed. RESULTS: Sixty patients undergoing primary arthroplasty were randomized. The group receiving hydrogen peroxide (n =30) and the control group (n = 30) were similar in age (71.1 ± 7.1 vs. 73.4 ± 9.8; P = .30), body mass index (29.4 ± 5.7 vs. 28.5 ± 6.0; P = .57), gender (P = .64), hand dominance (P = .65), and surgery type (P = .90). The overall rate of at least 1 positive culture was 18%. All positive cultures were C acnes. The positive culture rate in the hydrogen peroxide (20%) and control group were similar (16%; P > .99). There were no positive glenohumeral joint cultures and no wound complications. There was no significance difference in the culture site, day of culture positivity, and bacterial abundance. Stratification analysis by gender and age also demonstrated similar rates of C acnes between study groups. CONCLUSION: Standard skin preparation and antibiotic prophylaxis results in an overall low rate of skin and dermis culture positivity. The use of hydrogen peroxide after initial incision did not significantly alter the rate of positive C acnes cultures during shoulder arthroplasty and did not increase wound complications.

The Palmaris Longus and Its Association with Carpal Tunnel Syndrome.

Background The palmaris tendon inserts into the palmar fascia and is positioned in close association with the transverse carpal ligament. Loading of this tendon has been demonstrated to increase carpal tunnel pressures. Purpose The purpose of this study was to determine if a relationship exists between the palmaris tendon, carpal tunnel syndrome (CTS), and handedness. The sensitivity, specificity, positive predictive value, and negative predictive value for Schaeffer's test were calculated. Methods A retrospective review of patient charts undergoing endoscopic carpal tunnel release was performed. Rates of palmaris longus agenesis (PLA) were compared to a population matched data set. Statistical analysis was performed using a one-proportion z -test. Schaeffer's test for the palmaris longus tendon was performed on all patients and compared to intraoperative confirmation. Results A total of 520 carpal tunnel releases were performed in 389 consecutive patients. The frequency of PLA in this surgical cohort was significantly lower compared to the population matched dataset. No correlation between handedness and laterality of CTS or PLA was found. Schaeffer's test was evaluated to yield sensitivity (93.6%), specificity (100%), positive predictive value (100%), and negative predictive value (50.8%). Conclusion The palmaris tendon was more prevalent in a population of patients undergoing carpal tunnel release. These findings can be used to provide further insight into the pathophysiology of CTS. While Schaeffer's test was accurate in detecting the palmaris longus tendon, a negative test was frequently incorrect. Further imaging is recommended in patients with a negative Schaeffer's test when the palmaris longus is desired for surgical utilization. Level of Evidence This is a Level III, prognostic study.

Local injection of liposomal bupivacaine combined with intravenous dexamethasone reduces postoperative pain and hospital stay after shoulder arthroplasty.

BACKGROUND: Alternative techniques have been developed to address pain after shoulder arthroplasty and are well documented. We evaluated the effect of adding intraoperative liposomal bupivacaine and intravenous dexamethasone during shoulder arthroplasty. METHODS: We retrospectively reviewed 2 consecutive cohorts undergoing elective shoulder arthroplasty. The 24 patients in cohort 1 and the 31 patients in cohort 2 received perioperative multimodal management with preoperative and postoperative intravenous and oral narcotics, gabapentin, nonsteroidal anti-inflammatory drugs, acetaminophen, and single-injection interscalene block. Cohort 2 also received 8 to 10 mg of intravenous dexamethasone intraoperatively after the skin incision and liposomal bupivacaine injected at surgery. Patients who did and did not use preoperative narcotics were analyzed together and separately. We evaluated hospitalization length of stay, narcotic use, and visual analog scale pain before and after the change in the perioperative protocol. RESULTS: Cohort 1 was hospitalized longer (2 vs. 1 day; P < .001), required more narcotics on postoperative day 1 (21.0 vs. 10.0 mg; P < .001) and days 0 and 1 cumulatively (30.5 vs. 17.5 mg; P = .001), and had more pain on postoperative days 0 (6.5 vs. 3.5; P < .001) and 1 (7.5 vs. 3.5; P < .001) than cohort 2. In patients using preoperative narcotics, cohort 2 had less pain on postoperative day 1 (3.5 vs. 7.0; P = .006), less cumulative narcotic use (20 vs. 58.5 mg; P = .03), and shorter hospitalization (1 vs. 2 days; P = .052) than cohort 1. CONCLUSION: These changes to the perioperative shoulder arthroplasty protocol decreased hospitalization length of stay, narcotic requirement, and pain.