Clinical Outcomes of Arthroscopic Superior Capsular Reconstruction Using Fascia Lata Autograft Versus Reverse Shoulder Arthroplasty in Patients 65 Years and Older With Irreparable Rotator Cuff Tears: A Retrospective Cohort Study.

Background: Arthroscopic superior capsular reconstruction (ASCR) and reverse shoulder arthroplasty (RSA) have both shown favorable outcomes in patients with irreparable rotator cuff tears (IRCTs). Purpose: To (1) compare the clinical outcomes of ASCR versus RSA in patients aged ≥65 years with IRCTs and (2) compare serial changes in clinical outcomes between treatment groups. Study Design: Cohort study; Level of evidence, 3. Methods: This study included patients with IRCTs without glenohumeral osteoarthritis who underwent either ASCR or RSA between March 2013 and December 2020 and had at least 2 years of follow-up data. We assessed active range of motion, a visual analog scale (VAS) pain score, the American Shoulder and Elbow Surgeons (ASES) score, and the Single Assessment Numeric Evaluation (SANE) score at the preoperative, short-term (postoperative 6-12 months), and final follow-up times. Results: In total, 64 patients (ASCR, 31 patients; RSA, 33 patients) were included. The mean age of patients was 71.3 ± 4.4 and 72.9 ± 4.1 years, and the mean final follow-up duration was 42 ± 21.8 and 37.7 ± 21.7 months in the ASCR and RSA groups, respectively. At the short-term follow-up, RSA achieved significant improvements in all clinical outcomes, except for internal rotation (IR), while ASCR only showed significant improvements in VAS pain, ASES, and SANE scores. Compared with the preoperative period, both ASCR and RSA achieved significant improvements in all clinical outcomes, except for IR in the RSA group at the final follow-up. The ASCR group achieved better IR and ASES scores at the final follow-up, while the time taken to recover from pseudoparalysis was shorter after RSA. The ASCR group showed a 67.8% graft healing rate at the 1-year follow-up, while the RSA group showed 12.1% of scapular notching at the final follow-up. No other postoperative complications were observed in either group. Conclusion: ASCR and RSA achieved favorable clinical outcomes in the study cohort. At the short-term follow-up, RSA showed significant improvements in all clinical outcomes, except for IR, while ASCR only showed significant improvements in VAS pain, ASES, and SANE scores. At the final follow-up, however, ASCR had better IR and ASES scores compared with RSA.

Superior Capsular Reconstruction Combined With Lower Trapezius Tendon Transfer Improves the Biomechanics in Posterosuperior Massive Rotator Cuff Tears.

BACKGROUND: Surgical treatments for chronic posterosuperior massive rotator cuff tear (MRCT) are still controversial. Superior capsular reconstruction (SCR), which provides a static stabilizer to decrease superior humeral head translation, and lower trapezius tendon transfer (LTTT) with centralization of the humeral head, which prevents superior humeral head migration, are potential surgical options. To date, SCR combined with LTTT has not been fully investigated. HYPOTHESIS: Restoration of static stabilizer and dynamic stabilizer together would effectively improve shoulder kinematics in posterosuperior MRCT. STUDY DESIGN: Controlled laboratory study. METHODS: A custom-made shoulder mechanics testing system was used to test 8 fresh-frozen cadaveric shoulders. The testing conditions were as follows: (1) intact; (2) posterosuperior MRCT (supraspinatus and infraspinatus removed); (3) SCR using the fascia lata; (4) LTTT; and (5) SCR combined with LTTT. The total rotational range of motion (ROM), superior translation, anteroposterior translation, and peak subacromial contact pressure were evaluated at 0°, 30°, and 60° of shoulder abduction. Repeated-measures analysis of variance and Tukey post hoc tests were performed. RESULTS: The total rotational ROM, superior translation, anteroposterior translation, and peak subacromial contact pressure increased in posterosuperior MRCTs (all, P < .05). The rotational ROM, superior translation, anteroposterior translation, and peak subacromial contact pressure at 0° and 30° of shoulder abduction decreased in SCR (all, P < .05). However, there was no significant improvement in rotational ROM, superior translation, and peak subacromial contact pressure at 60° of shoulder abduction (P > .05). LTTT resulted in a significant decrease in the superior translation, anteroposterior translation, and peak subacromial contact pressure at 0°, 30°, and 60° of shoulder abduction (P < .05). SCR combined with LTTT restored the total rotational ROM, superior translation, anteroposterior translation, and peak subacromial contact pressure at 0°, 30°, and 60° of shoulder abduction (all, P < .05). CONCLUSION: In the cadaveric model, SCR combined with LTTT showed improved shoulder kinematics and contact pressures in the posterosuperior MRCT model compared with SCR or LTTT alone. CLINICAL RELEVANCE: SCR combined with LTTT may be regarded as an alternative surgical procedure for posterosuperior MRCTs.

Evaluation of a New MRI-Based Classification of Graft Status After Superior Capsule Reconstruction.

Background: A classification system for the graft state after superior capsule reconstruction (SCR) using magnetic resonance imaging (MRI) has not been described previously. Purpose: To introduce a new, MRI-based classification system for graft integrity after SCR and to evaluate the system according to postoperative outcomes. Study Design: Cohort study (diagnosis); Level of evidence, 3. Method: Included were 62 consecutive patients who underwent SCR using autologous fascia lata graft between January 2013 and April 2021. Postoperative outcomes were assessed (American Shoulder and Elbow Surgeons [ASES] score, Constant score, pain visual analog scale [pVAS], range of motion [ROM], acromiohumeral distance [AHD], Hamada grade). Graft status was classified by 2 orthopaedic surgeons on postoperative MRI in accordance with the signal intensity and the presence or extent of the tear, as follows: type 1 (hypointense signal without tear), type 2 (hyperintense signal without tear), type 3 (partial-thickness tear), type 4 (full-thickness tear with partial continuity), and type 5 (full-thickness tear with complete discontinuity). Intra- and interobserver agreement were assessed using Cohen kappa. The correlation between postoperative outcomes (ASES score, Constant score, pVAS, ROM, AHD, and Hamada grade) and the SCR graft classification system was assessed with the Pearson correlation coefficient, and the outcomes were compared according to classification type. Results: Patients were classified according to the new system as follows: type 1 (n = 15), type 2 (n = 20), type 3 (n = 7), type 4 (n = 8), and type 5 (n = 12). There was excellent interobserver agreement (κ = 0.819) and intraobserver agreement (κ = 0.937 and 0.919). The classification system showed a moderate to high correlation with the ASES score (r = -0.451; P = .001), pVAS (r = 0.359; P = .005), AHD (r = -0.642; P < .001), and Hamada grade (r = 0.414; P < .001). Patients classified as having types 1 and 2 showed better outcomes in terms of ASES score, pVAS, ROM, and AHD compared with type 5 patients (P ≤ .021 for all). Conclusion: The new classification system was highly reproducible and showed clinical utility for both radiological and clinical evaluation after SCR.

Prevalence, Timing, Locational Distribution, and Risk Factors for Heterotopic Ossification After Elbow Arthroscopy.

BACKGROUND: Arthroscopic techniques aim to reduce complications and accelerate recovery of the elbow after treatments for posttraumatic stiffness, arthritis diseases, lateral epicondylitis, ligament reconstruction, and elbow trauma. However, data on the true prevalence and characteristics of heterotopic ossification (HO) formation after elbow arthroscopy are limited. PURPOSE: To investigate the prevalence, timing, locational distribution, and risk factors of HO after elbow arthroscopy. STUDY DESIGN: Cohort study; Level of evidence, 4. METHODS: Data on 205 patients undergoing elbow arthroscopy by a single senior elbow surgeon at a single institution between May 2011 and January 2022 were retrospectively reviewed. The patients were evaluated at 2 weeks, 8 weeks, 6 months, and then annually after surgery or more frequently if HO developed, with a minimum of 1 year of postoperative follow-up. Postoperative anteroposterior and lateral elbow radiographs were taken at 2 weeks to rule out fracture and at 8 weeks to identify HO. The clinical outcomes were evaluated based on the pain visual analog scale; the shortened version of the Disabilities of the Arm, Shoulder and Hand score; Mayo Elbow Performance Score; and the Single Assessment Numeric Evaluation scores before and after surgery. Bivariate logistic regression analyses were used to determine factors affecting HO prevalence. RESULTS: Thirteen (12 male, 1 female) of 205 (6.3%) patients developed HO, with 10 (76.9%) with HO that formed on the medial compartment of the elbow. Ten (76.9%) patients were diagnosed at 8 weeks after arthroscopic surgery, 1 (7.7%) at 6 months after surgery, and 2 (15.4%) at 12 months after surgery. HO was not found at 2 weeks after surgery in any patient. The mean follow-up time was 3.5 years (range, 1.0-11.8 years). Eleven asymptomatic patients were treated nonoperatively, and 2 symptomatic patients underwent HO excision arthroscopically or had a combination of open surgery and arthroscopy. Age was a protective factor for HO formation (odds ratio [OR], 0.953; 95% CI, 0.910-0.999; P = .047). The risk factors for HO formation were tourniquet time (OR, 1.042; 95% CI, 1.019-1.065; P < .001) and surgical time (OR, 1.026; 95% CI, 1.011-1.041; P < .001). CONCLUSION: Among 205 patients who underwent elbow arthroscopy, HO was a minor complication of elbow arthroscopy, with a prevalence rate of 6.3%, and was usually located on the medial compartment of the elbow. Although the presence of HO may not affect the clinical outcomes in most patients, it should be carefully monitored for a minimum of 8 weeks postoperatively. Younger age, longer tourniquet time, and longer surgical time contributed to HO formation after elbow arthroscopy.

Radiologically severe osteoarthritis is related to worse clinical outcomes after arthroscopic osteocapsular arthroplasty in primary elbow osteoarthritis at medium-term follow-up: a retrospective cohort study.

HYPOTHESIS: This study aimed to compare the clinical outcomes after arthroscopic osteocapsular arthroplasty (OCA) at medium-term follow-up according to the radiologic severity of primary elbow osteoarthritis (OA) and assess serial changes in clinical outcomes in each group. METHODS: Patients treated from January 2010 to April 2019 with arthroscopic OCA for primary elbow OA with a minimum of 3 years' follow-up were retrospectively assessed regarding range of motion (ROM), visual analog scale (VAS) pain score, and Mayo Elbow Performance Score (MEPS) preoperatively, at short-term follow-up (3-12 months postoperatively), and at medium-term follow-up (≥3 years after surgery). Preoperative computed tomography was performed to evaluate the radiologic severity of OA using the Kwak classification. Clinical outcomes were compared according to the radiologic severity of OA by their absolute values and the number of patients achieving the patient acceptable symptomatic state (PASS). Serial changes in the clinical outcomes in each subgroup were also assessed. RESULTS: Of the 43 patients, 14, 18, and 11 were classified as the stage I, II, and III groups, respectively; the mean follow-up duration was 71.3 ± 28.9 months, and the mean age was 56.5 ± 7.2 years. At medium-term follow-up, the stage I group had a better ROM arc (stage I, 114° ± 14°; stage II, 100° ± 23°; and stage III, 97° ± 20°; P = .067) and VAS pain score (stage I, 0.9 ± 1.3; stage II, 1.8 ± 2.1; and stage III, 2.4 ± 2.1; P = .168) than the stage II and III groups without reaching statistical significance, whereas the stage I group had a significantly better MEPS (stage I, 93.2 ± 7.5; stage II, 84.7 ± 11.9; and stage III, 78.6 ± 15.2; P = .017) than the stage III group. The percentages of patients achieving the PASS for the ROM arc (P = .684) and VAS pain score (P = .398) were comparable between the 3 groups; however, the percentage achieving the PASS for the MEPS was significantly higher in the stage I group than in the stage III group (100.0% vs. 54.5%, P = .016). During serial assessment, all clinical outcomes tended to improve at the short-term follow-up. Compared with the short-term period, the ROM arc tended to decrease at the medium-term follow-up whereas the VAS pain score and MEPS overall did not show significant changes. CONCLUSION: After arthroscopic OCA, the stage I group showed an overall better ROM arc and pain score than the stage II and III groups at medium-term follow-up, whereas the stage I group showed a significantly better MEPS and higher percentage of patients achieving the PASS for the MEPS than the stage III group.

Clinical and Radiological Outcomes of Arthroscopic Superior Capsular Reconstruction Versus Primary Rotator Cuff Repair in Massive Rotator Cuff Tears: A Propensity Score-Matched Study.

BACKGROUND: Arthroscopic superior capsular reconstruction (aSCR) has emerged as a treatment option for managing massive rotator cuff tears (MRCTs) given the unpredictable results after an arthroscopic rotator cuff repair (aRCR). Yet, few comparative studies of aSCR and aRCR have been conducted. PURPOSE: To compare the clinical and radiological outcomes between aRCR and aSCR in patients with MRCT. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 163 cases of MRCT from 2010 to 2020 with follow-up ≥2 years were retrospectively reviewed. Among them, 102 had aRCR and 61 had aSCR using fascia lata autograft. Propensity score matching was used to select controls matched for age, sex, diabetes mellitus, osteoporosis, preoperative American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, Constant score, pain visual analog scale (pVAS) score, range of motion (ROM), tear size, global fatty degeneration index, and acromiohumeral distance (AHD). Last, 33 cases in each group were selected after propensity score matching. Radiological assessment was conducted using serial postoperative magnetic resonance imaging. Pre- and postoperative findings-including American Shoulder and Elbow Surgeons, pVAS, Single Assessment Numeric Evaluation, and Constant scores and ROM-were assessed to compare clinical outcomes. For radiological outcomes, global fatty degeneration index, AHD, and healing rate were evaluated. Healing failure was defined as Sugaya classification IV or V in the aRCR group, as compared with a full-thickness tear of the graft in the aSCR group, which corresponded to Sugaya classification IV or V. RESULTS: Postoperative clinical outcomes were significantly improved at the final follow-up in both groups. In the aSCR group, postoperative forward flexion, pVAS, and AHD were significantly improved as compared with the aRCR group (mean, 161° vs 148° [P = .02]; 1.03 vs 1.64 [P = .047]; 7.00 vs 5.23 mm [P < .001], respectively). The healing rate was 20 of 33 (60.6%) for aRCR and 29 of 33 (87.9%) for aSCR (P = .022). CONCLUSION: aSCR and aRCR are effective and reliable treatment options for MRCT. However, when compared with aRCR, aSCR showed improved clinical outcomes, including pVAS score, postoperative ROM, and favorable radiological findings, including AHD and a higher healing rate.

Clinical Outcomes of Revision Arthroscopic Osteocapsular Arthroplasty in Primary Elbow Osteoarthritis: A Retrospective Cohort Study.

BACKGROUND: Arthroscopic osteocapsular arthroplasty (OCA) achieves significant medium-term outcomes in patients with primary elbow osteoarthritis (OA); however, outcomes after revision arthroscopic OCA are not well known. PURPOSE: To assess clinical outcomes after revision arthroscopic OCA as compared with those after primary surgery in patients with OA. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who underwent arthroscopic OCA attributed to primary elbow OA between January 2010 and July 2020 were enrolled. Range of motion (ROM), visual analog scale (VAS) pain score, and Mayo Elbow Performance Score (MEPS) were assessed. Operation time and complications were assessed by chart review. Clinical outcomes between the primary and revision surgery groups were compared, and subgroup analysis for radiologically severe OA was performed. RESULTS: Data from 61 patients were analyzed (primary, n = 53; revision, n = 8). The mean ± SD age was 56.3 ± 8.5 and 54.3 ± 8.9 years in the primary and revision groups, respectively. The primary group had significantly better ROM arcs preoperatively (89.9°± 20.3° vs 71.3°± 22.3°; P = .021) and postoperatively (112.4°± 17.1° vs 96.9°± 16.5°; P = .019) than the revision group; however, the degree of improvement was comparable (P = .445). Postoperative VAS pain score (P = .164) and MEPS (P = .581) were comparable between the groups, as were the degrees of improvement in VAS pain score (P = .691) and MEPS (P = .604). The revision group required a significantly longer operative time than the primary group (P = .004) and had a nonsignificant higher complication rate (P = .065). Subgroup analysis showed that radiologically severe cases in the primary group had significantly better preoperative (P = .010) and postoperative (P = .030) ROM arcs than the revision group and a comparable postoperative VAS pain score (P = .155) and MEPS (P = .658). CONCLUSION: Revision arthroscopic OCA is a favorable treatment option for primary elbow OA with recurrent symptoms. Postoperative ROM arc was worse after revision surgery as compared with primary surgery; however, the degree of improvement was comparable. Postoperative VAS pain score and MEPS were comparable with primary surgery.

Serial Changes in Clinical Outcomes After Arthroscopic Osteocapsular Arthroplasty for Primary Elbow Osteoarthritis: A Medium-term Follow-up Study.

Background: Arthroscopic osteocapsular arthroplasty (OCA) shows promising short-term outcomes for primary elbow osteoarthritis (OA). However, serial changes in clinical outcomes for medium-term follow-up are not well known. Purpose: To evaluate clinical outcomes after arthroscopic OCA in primary elbow OA from preoperative to short- and medium-term follow-up and to analyze the correlation between the time from short- to medium-term follow-up and the changes in clinical outcomes between the periods. Study Design: Case series; Level of evidence, 4. Methods: Patients with primary elbow OA who were treated with arthroscopic OCA between January 2010 and April 2020 were evaluated. Elbow range of motion (ROM), visual analog scale (VAS) for pain, and Mayo Elbow Performance Score (MEPS) were assessed preoperatively and at short-term (3-12 months) and medium-term (≥2 years) follow-up. The correlation between the time from short- to medium-term follow-up and the changes in clinical outcomes was analyzed using the Pearson correlation coefficient. Results: Included were 56 patients who underwent short-term follow-up (mean [range], 5.9 [3-12] months) and medium-term follow-up (62.2 [24-129] months) after arthroscopic OCA. When compared with preoperative values, significant improvements were seen at short-term follow-up: ROM (from 89.4° to 111.7°; P < .001), VAS for pain (from 4.9 to 2.0; P < .001), and MEPS (from 62.3 to 83.7; P < .001). From short- to medium-term follow-up, ROM decreased (from 111.7° to 105.4°; P = .001) while VAS for pain (from 2.0 to 1.4; P = .031) and MEPS (from 83.7 to 87.8; P = .016) improved. All outcomes improved significantly at medium-term follow-up as compared with preoperative values (P < .001 for all). The time between short- and medium-term follow-up had a significant positive correlation with decreased ROM (r = 0.290; P = .030) and a significant negative correlation with improvement in MEPS (r = -0.274; P = .041). Conclusion: Serial assessment of patients with primary elbow OA who underwent arthroscopic OCA showed that the clinical outcomes improved from preoperative assessment to short- and medium-term follow-up, although ROM decreased between short- and medium-term follow-up. VAS for pain and MEPS showed continued improvement until medium-term follow-up.

Postoperative HbA1c Level as a Predictor of Rotator Cuff Integrity After Arthroscopic Rotator Cuff Repair in Patients With Type 2 Diabetes.

Background: In patients with type 2 diabetes mellitus (DM), preoperative glycosylated hemoglobin (HbA1c) is associated with outcomes after arthroscopic rotator cuff repair (ARCR); however, the relationship between outcomes and postoperative serum glycosylated hemoglobin (HbA1c) after ARCR has not been investigated. Purpose: To evaluate outcomes after ARCR in patients (1) with and without DM and (2) with DM according to their pre- and postoperative HbA1c levels. Study Design: Cohort study; Level of evidence, 3. Method: Included in this study were 148 patients without DM and 35 patients with type 2 DM who underwent ARCR between January 1, 2017, and December 31, 2019. Clinical and radiological outcomes were evaluated preoperatively and at the latest clinical follow-up. Postoperative magnetic resonance imaging was performed after 12 months. In patients with type 2 DM, HbA1c levels were evaluated preoperatively as well as 6 and 12 months postoperatively; patients with an HbA1c level of ≥7% were defined as having uncontrolled DM. Multivariate logistic regression analyses were performed to determine the factors for retears after ARCR. Results: The retear rates after ARCR were 22.9% (8/35) and 16.9% (25/148) in patients with and without DM, respectively. The retear rates were significantly higher in the 6-month postoperative uncontrolled DM group than in the controlled DM and non-DM groups (50% vs 8.7% and 16.8%; P < .05). The odds ratio for retears in the postoperative uncontrolled DM group was 5.555 (P =0.01) compared with the non-DM group. Among the patients with DM, in the uncontrolled DM group, 6-month postoperative hyperglycemia was superior in accuracy, sensitivity, and specificity for predicting retears after ARCR than preoperative hyperglycemia (77.1% vs 62.9%, 75% vs 37.5%, and 77.8% vs 70.4%, respectively). Conclusion: This study demonstrated the association between uncontrolled postoperative DM and an increased risk of retears compared with no DM or controlled DM. Furthermore, postoperative HbA1c values were correlated more closely with the risk of retears than preoperative HbA1c values.

Early Postoperative MRI Evaluation of a Fascia Lata Autograft With and Without Polypropylene Mesh Augmentation After Superior Capsular Reconstruction.

BACKGROUND: Recently, a polypropylene mesh has been introduced and reported to improve clinical outcomes after superior capsular reconstruction (SCR) using a fascia lata autograft (FLA). However, mesh-related events such as a foreign body response may trigger inflammation, which might affect graft healing and remodeling. PURPOSE/HYPOTHESIS: The aim was to investigate whether the healing and remodeling of an FLA were affected by the use of a mesh by comparing the signal intensity of an FLA-alone group vs an FLA + Mesh group on postoperative magnetic resonance imaging (MRI). The hypothesis was that the use of a mesh would decrease the MRI signal intensity of FLA during the early postoperative phase. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who had undergone SCR using an FLA with or without a mesh between March 2013 and August 2021 were retrospectively analyzed. Follow-up MRI was performed at 3 months. A total of 78 patients (24 in the FLA group and 54 in the FLA + Mesh group) with intact grafts were included. Graft remodeling was evaluated by analyzing the signal-to-noise quotient (SNQ) at the humeral, mid-substance, and glenoid sites. Theoretically, lower SNQ ratios indicate higher strength and better healing of the graft. RESULTS: The mean SNQ was 30.603 (range, 11.790-72.710) in the FLA group and 18.367 (range, 4.464-69.500) in the FLA + Mesh group (P < .001). Furthermore, significant differences were found between the 2 groups at the humeral and mid-substance sites (37.863 [range, 5.092-81.187] vs 15.512 [range, 1.814-80.869], P < .001; and 29.168 [range, 6.103-73.900] vs 16.878 [range, 2.454-92.416], P = .003; respectively). However, there was no difference between the 2 groups at the glenoid site (25.346 [range, 7.565-86.353] vs 20.354 [range, 3.732-88.468], P = .057). CONCLUSION: At the 3-month follow-up, the FLA + Mesh group showed a lower MRI signal intensity than the FLA group. The healing and remodeling of an FLA may be enhanced when a mesh is used.

Postoperative MRI signal intensity correlates functional outcomes after superior capsular reconstruction.

PURPOSE: Superior capsular reconstruction (SCR) using fascia lata autograft has been performed for irreparable rotator cuff tear recently. The signal-to-noise quotient (SNQ) of the graft on magnetic resonance imaging (MRI) may reflect the degree of graft maturity and healing. However, how SNQ changes with graft remodelling and time and whether this change correlates with postoperative clinical outcomes after SCR remain unknown. This study aimed to explore the correlation between SNQ of the fascia lata autograft and clinical functional outcomes after SCR. METHODS: Patients with irreparable posterosuperior rotator cuff tear undergoing SCR using fascia lata autograft between 2013 and 2017 were retrospectively analysed. For clinical outcomes, the American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, Single Assessment Numeric Evaluation (SANE), and Visual Analogue Scale (VAS) for pain and range of motion (ROM; forward flexion and external rotation) were evaluated at postoperative 6 and 12 months. Signal intensity of the humeral, mid-substance, and glenoid sites and background were measured to calculate the SNQ values on follow-up MRI at 3 and 12 months. The correlations between clinical outcomes and SNQ at different time points were then analysed. RESULTS: A total of 15 patients were enrolled in the study. The mean postoperative VAS score significantly increased at postoperative 6 months and significantly decreased at postoperative 12 months. Except for forward flexion, all other functional outcomes were improved at postoperative 6 months. Analysis of MRI showed SNQ at the humeral (SNQh), mid-substance, and glenoid sites decreased from postoperative 3 to 12 months with a statistical significance detected in SNQh (P < 0.01). Correlation analyses showed that the SNQh values negatively correlated with VAS, ASES, Constant-Murley score, SANE, ROM (forward flexion), and ROM (external rotation) (all P < 0.05). CONCLUSION: SNQ of the fascia lata autograft decreased with time in patients receiving SCR. SNQ at the humeral site was negatively correlated with clinical outcomes. LEVEL OF EVIDENCE: III.

Effect of Fatty Infiltration of the Infraspinatus Muscle on Outcomes and Graft Failure After Arthroscopic Superior Capsule Reconstruction for Irreparable Posterosuperior Rotator Cuff Tears.

BACKGROUND: Superior capsule reconstruction (SCR) was developed as an alternative treatment for irreparable rotator cuff tears to restore superior stability of the glenohumeral joint. Although fatty infiltration (FI) of the rotator cuff muscles, especially the infraspinatus, has been implicated as a predictor of outcomes and graft integrity after rotator cuff repair, it has not been fully investigated in cases of SCR. PURPOSE: To evaluate the effect of FI of the infraspinatus muscle on clinical and radiological outcomes after SCR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 55 consecutive patients with irreparable posterosuperior rotator cuff tears who underwent SCR between January 2013 and August 2020 were included retrospectively. Preoperative and postoperative clinical and radiological findings (median follow-up of >2 years), including magnetic resonance imaging results, were thoroughly reviewed. The patients were divided into 2 groups: group 1 with mild FI of the infraspinatus (Goutallier grades 0-2) and group 2 with severe FI of the infraspinatus (Goutallier grades 3-4). The American Shoulder and Elbow Surgeons score, Constant score, visual analog scale score for pain, and range of motion were evaluated. Acromiohumeral distance and rotator cuff tear arthropathy using the Hamada classification were assessed on plain radiography. Postoperative graft integrity was evaluated by magnetic resonance imaging. Graft failure was defined as complete discontinuity. Univariate and multivariable logistic regression analyses were performed to evaluate clinical and radiological findings that might be associated with successful SCR. RESULTS: Clinical and radiological outcomes significantly improved after SCR. Graft failure was noted in 15 (27.3%) patients and was more frequent in group 2 than in group 1 (50.0% vs 14.3%, respectively; P = .004). Univariate analysis indicated a significant association between severe FI in the infraspinatus (group 2) and graft failure after SCR (odds ratio, 6.00 [95% CI, 1.65-21.80]; P = .006). Multivariable analysis indicated that FI of the infraspinatus was the only factor associated with graft failure (odds ratio, 6.37 [95% CI, 1.63-24.90]; P = .008). CONCLUSION: Severe FI of the infraspinatus muscle was a factor indicating a poor prognosis for graft integrity after SCR. Preoperative evaluation of FI in the rotator cuff muscles can help predict postoperative outcomes and may help guide therapeutic options.

Patient Acceptable Symptom State, Minimal Clinically Important Difference, and Substantial Clinical Benefit After Arthroscopic Superior Capsular Reconstruction.

BACKGROUND: Patient Acceptable Symptom State (PASS), minimal clinically important difference (MCID), and substantial clinical benefit (SCB) have rarely been assessed after arthroscopic superior capsular reconstruction (ASCR) with fascia lata autograft. PURPOSE: (1) To investigate PASS, MCID, and SCB values for pain visual analog scale (pVAS), American Shoulder and Elbow Surgeons (ASES) score, Constant score, and Single Assessment Numeric Evaluation (SANE) after ASCR with fascia lata autograft, (2) to investigate factors for achieving PASS, MCID, and SCB. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: We retrospectively collected data from patients who underwent ASCR between June 2013 and October 2020. A total of 88 patients were included, and anchor questions for deriving PASS, MCID, and SCB values were applied at a minimum 1-year follow-up postoperatively. PASS, MCID, and SCB were derived using sensitivity- and specificity-based approaches. Univariable and multivariable logistic regression analyses were performed to determine factors for achieving PASS, MCID, and SCB. RESULTS: Based on receiver operating characteristic curves, all 4 scores had acceptable area under the curve values (>0.7) for PASS, MCID, and SCB values. The PASS, MCID, and SCB values were 1.5, 2.5, and 4.5 for pVAS; 81.0, 19.0, and 27.5 for the ASES score; 60.5, -0.5, and 5.5 for the Constant score; and 75.0, 27.5, and 32.5 for SANE, respectively. Poor preoperative scores were related to significantly higher odds ratios (ORs) for achieving MCID and SCB. Wide acromiohumeral distance and dominant side were related to higher ORs for achieving PASS for the ASES score, and subscapularis tear was related to lower ORs for achieving PASS for pVAS and SCB for the Constant score. CONCLUSION: Reliable PASS, MCID, and SCB values were achieved for at least 1 year after ASCR surgery. Poor preoperative score, wide acromiohumeral distance, and dominant side all demonstrated higher ORs for at least one value, but a subscapularis tear demonstrated lower ORs for achieving PASS for pVAS and SCB for the Constant score.

Debridement, antibiotics, and implant retention in infected shoulder arthroplasty caused by Serratia marcescens: a case report.

Periprosthetic joint infection (PJI) is one of the most devastating complications that can occur after shoulder arthroplasty. Although staged revision arthroplasty is the standard treatment in many cases, surgical intervention with debridement, antibiotics, and implant retention (DAIR) can be an effective option for acute PJI. We report a complex case of infected reverse shoulder arthroplasty (RSA) in a 73-year-old male. The patient had been previously treated for infected nonunion of a proximal humerus fracture caused by methicillin-resistant Staphylococcus epidermidis. He presented with a sinus tract 16 days after the implantation of RSA and was diagnosed with PJI caused by Serratia marcescens. The patient was successfully treated with DAIR and was free of infection at the last follow-up visit at 4 years postoperatively.

A case of dystrophic calcification in the masseter muscle.

BACKGROUND: Dystrophic calcification can occur in any soft tissue with the absence of a systemic mineral imbalance and is often associated with trauma, infection, or inflammation. It is easily found in the site of the heart and skeletal muscles and rarely appears in the head and neck area. CASE REPORT: We present a rare case of multiple calcified masses in the left masseter muscle of a 26-year-old female with a history of trauma in the area. In computed tomography, multiple radiopaque masses were observed inside the left masseter muscle and blood test results were normal. The calcified masses were diagnosed as dystrophic calcification and removed by surgery without any complications. CONCLUSION: Different types of calcifications may occur in the cheek area, and they need to be distinguished from dystrophic calcification. Thorough clinical examination and history taking is required together with blood testing and radiographic examinations.

Survey of Preferences in Patients Scheduled for Carpal Tunnel Release Using Conjoint Analysis.

BACKGROUND: This study aimed to investigate the preferences of patients scheduled for carpal tunnel release using conjoint analysis and also introduce an example of how to apply a conjoint analysis to the medical field. The use of conjoint analysis in this study is new to the field of orthopedic surgery. METHODS: A total of 97 patients scheduled for carpal tunnel release completed the survey. The following four attributes were predefined: board certification status, distance from the patient's residency, medical costs, and waiting time for surgery. Two plausible levels for each attribute were assigned. Based on these attributes and levels, 16 scenarios were generated (2 × 2 × 2 × 2). We employed 8 scenarios using a fractional factorial design (orthogonal plan). Preferences for scenarios were then evaluated by ranking: patients were asked to list the 8 scenarios in their order of preference. Outcomes consisted of two results: the average importance of each attribute and the utility score. RESULTS: The most important attribute was the physician's board certificate, followed by distance from the patient's residency to the hospital, waiting time, and costs. Utility estimate findings revealed that patients had a greater preference for a hand specialist than a general orthopedic surgeon. CONCLUSIONS: Patients considered the physician's expertise as the most important factor when choosing a hospital for carpal tunnel release. This suggests that patients are increasingly seeking safety without complications as interest in medical malpractice has increased.

A case of acute disseminated encephalomyelitis associated with hepatitis C virus infection.

Acute disseminated encephalomyelitis (ADEM) is a monophasic autoimmune demyelinating disease of the central nervous system, which typically follows acute viral or bacterial infection or vaccination. We report a case of ADEM associated with hepatitis C virus (HCV) infection with positive serum and cerebrospinal fluid (CSF) anti-HCV antibody. After steroid treatment, neurologic symptoms were improved. Virus triggers autoimmunity or direct viral invasion plays a part in the genesis of ADEM. This is the first reported case of ADEM with anti-HCV antibody in the CSF.

Treatment of spontaneous cervical spinal subdural hematoma with methylprednisolone pulse therapy.

We report herein a case of hyperacute onset of spontaneous cervical spinal subdural hematoma treated with methylprednisolone pulse therapy that showed good results. A 57-year-old man was admitted for posterior neck pain and paraparesis which occurred an hour ago. MRI revealed a ventral subdural hematoma distributed from the level of C1 down to T3, compressing the spinal cord. Conservative management with methylprednisolone pulse therapy was administered considering the patient's poor general condition. Although emergent surgical decompression is necessary in most cases of spinal subdural hematoma, conservative management with steroid therapy could be effective.