Arthroscopic repair of posterosuperior rotator cuff tears with bioabsorbable patch augmentation: a magnetic resonance-controlled case series with 1-year follow-up.

BACKGROUND: Among many advances in the treatment of rotator cuff tears, arthroscopic augmentation techniques with patches of various biological and synthetic graft materials have been introduced to reinforce the repair. However, structural and functional outcomes after patch augmentation vary, and reinforcing the tendon healing remains a challenge. The aim of this study was to evaluate clinical and radiologic outcomes 1 year after arthroscopic posterosuperior (PS) rotator cuff repair with bioabsorbable patch augmentation. METHODS: From October 2014 to December 2017, all patients with PS rotator cuff tears undergoing arthroscopic repair with patch augmentation using a resorbable, biologically derived poly-4-hydroxybutyrate patch (Biofiber; Wright, Memphis, TN, USA) were enrolled in this study. Only full-thickness PS lesions with ≥1 of the following tear patterns were augmented with a patch and were the subject of this study: large U- and L-shaped tear, transtendinous tear, delamination, and fraying of the bursal layer. Patients were examined preoperatively and at 1 year postoperatively with a standardized examination protocol and magnetic resonance imaging (MRI). RESULTS: Sixteen patients were included in this study; 1 patient was lost to follow-up. One patient only underwent clinical follow-up. We detected 1 repair failure (6.7%) with dislocation of the lateral-row anchors on computed tomography scanning at 3 months postoperatively. MRI was performed in 14 patients after 1 year; in all of them, the cuff repair was intact. The Sugaya tendon integrity score was 1.7 ± 0.9. The Constant-Murley score improved from 44 to 89 points (P < .001). Muscular strength improved in the supraspinatus (from 2.6 to 4.8), infraspinatus (from 3.2 to 4.9), and subscapularis (from 4 to 4.9) (all P < .001). Overall, patient satisfaction was high (3.6 ± 0.6). DISCUSSION: This small-sized case series is the first to prospectively assess clinical and radiologic outcomes after patch augmentation of PS rotator cuff tears using bioabsorbable poly-4-hydroxybutyrate patches. Good to excellent structural and functional outcomes were observed with a low retear rate (6.7%) and good tendon integrity on 1-year postoperative MRI, and the graft did not cause any complications. The use of bioabsorbable patches could be beneficial when unfavorable PS tear patterns are encountered in which a stable repair of the full tendon thickness at its insertion is otherwise difficult to reach.

Cementless Stem for Femoral Neck Fractures in a Patient's 10th Decade of Life: High Rate of Periprosthetic Fractures.

BACKGROUND: Subsidence of cementless femoral stems in hemiarthroplasty (HA) and increased fracture rates are ongoing concerns of orthopedic surgeons when treating fractures in very old patients. Additionally, bone cement implantation syndrome may result in perioperative cardiac or pulmonary complications, especially in older patients, leading to morbidity and mortality. This study was performed to analyze possible subsidence and intraoperative fractures in a cohort of very old patients treated with cementless stems. METHODS: We retrospectively analyzed a consecutive cohort of patients aged ≥90 years with femoral neck fractures treated by uncemented HA and an anterior minimally invasive approach. Immediate full-weight bearing was allowed postoperatively. Pelvic radiographs were examined for subsidence immediately postoperatively and 6 weeks later. RESULTS: We treated 109 patients (74% women; mean age, 93 years; range, 90-102 years) by HA from January 2010 to March 2016. The 30-day mortality rate was 16%, and the morbidity rate was 47%. There were 11 (12%) intraoperative fractures: 8 (Vancouver B2) had to be addressed immediately during the primary operation, while 3 (1 Vancouver B1 and 2 Vancouver AG) were treated conservatively. One periprosthetic femoral fracture (Vancouver B1) was documented during follow-up. In 17 patients, subsidence of >2.0 mm (median, 3.9 mm; range, 2.5-9.0 mm) was documented. CONCLUSION: Early subsidence was low in this very old cohort treated with an uncemented stem and not showing a periprosthetic fracture. The risk of intraoperative periprosthetic fractures was high. The use of uncemented implants in osteoporotic bone continues to be an intervention with high risk and should only be performed by experienced surgeons. LEVEL OF EVIDENCE: Level III, Therapeutic study.

Arthroscopic Repair of Massive Cuff Tears With Large Subscapularis Tendon Ruptures (Lafosse III/IV): A Prospective Magnetic Resonance Imaging-Controlled Case Series of 26 Cases With a Minimum Follow-up of 1 Year.

PURPOSE: To prospectively assess arthroscopic repair of massive cuff tears (MCT) in a highly selective patient group with large subscapularis (SSC) tendon tears by means of clinical results and magnetic resonance imaging (MRI) studies. METHODS: Between April 2009 and December 2010, 26 patients with MCT were treated with arthroscopic rotator cuff repair. Only lesions involving a large tear of the SSC tendon (Lafosse III or IV) in combination with a complete tear of the supraspinatus (SSP) tendon and a tear of at least the anterior third of the infraspinatus (ISP) tendon were included. Minimum follow-up was 1 year. Pre- and postoperative assessment included a standardized clinical examination, subjective patient outcome, and MRI (structural integrity, fatty muscle infiltration, and muscular mass). RESULTS: Mean follow-up was 17 months (range, 12 to 34 months). MRI was performed in 25 patients. In 21 (84%) the cuff repair was intact. A partial retear of the SSC was found in 2 patients (8%). In 2 patients (8%) a full-thickness retear of the posterosuperior cuff was observed (1 SSP, 1 SSP/ISP). A significant increase of the muscle mass and decrease of fatty infiltration was observed for the SSC and SSP but not for the ISP. The mean Constant-Murley score improved from 36 to 86 points (P < .001) with all its subscores as well (P < .001). Muscular strength improved for the SSC (4.9 v 3.0, P < .001), SSP (4.6 v 2.9, P < .001), and ISP (4.8 v 3.4, P < .001). Overall patient satisfaction was high (3.6 ± 0.8). CONCLUSIONS: Arthroscopic repair of MCT involving the ISP, SSP, and large tears of the SSC provides a reliable tendon healing, in particular for the SSC tendon, combined with good functional results. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Arthroscopic repair of traumatic isolated subscapularis tendon lesions (Lafosse Type III or IV): a prospective magnetic resonance imaging-controlled case series with 1 year of follow-up.

PURPOSE: The purpose of this study was to prospectively assess the efficacy of arthroscopic repair of isolated high-grade subscapularis (SSC) tendon lesions by means of clinical follow-up combined with magnetic resonance imaging investigations. METHODS: Between January 2008 and September 2010, 11 patients (9 men and 2 women; mean age, 45 ± 10 years) with Lafosse type III or IV traumatic isolated SSC tendon lesions underwent arthroscopic repair including tenodesis of the long head of the biceps tendon. All patients were preoperatively assessed by clinical examination (Constant-Murley score [CMS]) and contrast-enhanced magnetic resonance arthrography. At 1 year of follow-up, specific clinical SSC tests, the CMS, and the loss of external rotation were evaluated. A native magnetic resonance investigation was performed to assess the structural integrity of the repair. The SSC muscle was compared with its preoperative condition regarding fatty infiltration and size (cross-sectional area). Patient satisfaction was graded from 1 (poor) to 4 (excellent). RESULTS: The mean time interval from trauma to surgery was 3.7 months. A concomitant lesion of the biceps tendon was observed in 10 patients (91%). The mean CMS improved from 44 to 89 points (P < .001). The functional tests showed a significant increase in strength (P < .05) (belly-press test, 4.8 v 2.9; lift-off test, 4.8 v 2.9). The mean loss of external rotation at 0° of abduction was 10° compared with the contralateral side (P < .05). Patient satisfaction was high. Magnetic resonance imaging evaluation showed complete structural integrity of the tendon repair in all studies. The SSC showed a significant decrease in fatty infiltration and increase in the cross-sectional area. CONCLUSIONS: Arthroscopic repair of higher-grade isolated SSC lesions provides reliable tendon healing accompanied by excellent functional results 1 year after surgery. LEVEL OF EVIDENCE: Level IV, prospective therapeutic case series.

Primary Hemiarthroplasty for Proximal Humeral Fractures in the Elderly: Long-Term Functional Outcome and Social Implications.

BACKGROUND: Primary shoulder hemiarthroplasty is an established treatment modality for complex fractures of the proximal humerus. Long-term functional outcome is often disappointing. However, little is known about social implications particularly in the elderly. METHODS: A single-institution case series of consecutive geriatric patients (age > 70 years) treated with shoulder hemiarthroplasty for complex fractures of the proximal humerus between 1994 and 1997 was analysed. Postoperative morbidity, long-term function, radiological outcome and social implications were evaluated. RESULTS: Seventy-seven patients fulfilled the study criteria. Median age at the time of operation was 80 years (range 70-93 years). Systemic and local postoperative complications were observed in 8% including 2 patients (3%) with revision surgery. Postoperative mortality was 1%. Forty-eight patients (62%) were available for follow-up (median 49 months, range 25-80 months), 22 (29%) died from causes unrelated to hemiarthroplasty before follow-up and 7 patients (9%) did not attend follow-up examination. Median Constant-Murley score was 41 points (range 17-77 points). Long-term results concerning pain were satisfying. The Oxford shoulder score ranged from 14 to 40 (median 30). Forty-one patients (85%) still lived in their original environment and managed their daily life independently despite poor shoulder function. Four patients (8%) lived in a retirement home and 3 (6%) in a nursery home. Eighty percent of our patients were still able to use public transportation, do the daily shopping and wash their whole body by themselves. CONCLUSION: Most patients managed their daily life independently despite poor shoulder function.

Elastic stable intramedullary nailing for midclavicular fractures in athletes: indications, technical pitfalls and early results.

This prospective consecutive case series was done to evaluate indications, technical pitfalls and functional outcome of elastic stable intramedullary nailing of displaced midclavicular fractures in 14 athletes. Constant score and radiographs were evaluated after 1 and 6 weeks, 3 months and 6 months in 13 patients. Mean age was 28 years. The average follow-up was 17 months. Mean operation time was 62 minutes. Open reduction through an additional small incision was necessary for 7 fractures. Mean hospital stay was 1.2 days. Secondary fracture displacement was observed in 1 patient. The Constant score averaged 81 after 1 week, 96 after 6 weeks and 98 after 6 months. Compared to the contralateral side, average shortening of the clavicle was 1.7 mm. Overall, elastic stable intramedullary nailing provided good restoration of the length of the clavicle and allowed immediate active mobilisation with early return to normal activity. Functional results were excellent.