Calcium pyrophosphate crystal deposition with rotator cuff tear-A case report.

Calcium pyrophosphate dihydrate (CPPD) deposition disease is an inflammatory arthritis induced by calcium pyrophosphate (CPP) crystals and clinically it is called pseudogout. It usually deposits in articular cartilage and in periarticular soft tissues. But no cases of pseudogout in the rotator cuff without cartilage deposition or destruction have been reported so far. We present a case of a 57-year-old woman who was diagnosed as pseudogout with rotator cuff tear.

Biomechanical Comparison of 1.2-mm Suture Tape, 2.0-mm Suture Tape, and 0.5-mm Suture Using Various Arthroscopic Knot Techniques.

Background: The biomechanical properties of the 1.2-mm suture tape have outperformed conventional sutures in previous studies. Purpose: To compare the loop and knot security of 2 tape-type and 1 cord-type sutures using different arthroscopic knot techniques. Study Design: Controlled laboratory study. Methods: The biomechanical characteristics of the 1.2-mm tape, 2.0-mm tape, and 0.5-mm No. 2 suture were compared using 4 different knot types: 2 sliding knots (Samsung Medical Center [SMC] and Tennessee) and 2 nonsliding knots (2-throw surgeon's and 2-throw square) with 2 and 3 additional reverse half-hitches on alternating posts (RHAPs) in a closed-loop system on a materials testing device. Each configuration was tested for loop security (maximal load applied between 0 and 3 mm of displacement), knot security (ultimate failure load), and failure mode with cyclical loading (30 N load for 20 cycles at 1 cycle per sec until failure). Loop and knot security among the configurations were compared using an analysis of variance. Results: With 2 RHAPs, the 2.0-mm tape showed significantly greater loop security than the 1.2-mm tape and suture (P = .001). With 3 RHAPs, the loop security of the suture was significantly superior compared with the 1.2-mm tape (P = .010). Regarding knot security, with 2 RHAPs, the 2.0-mm tape was significantly better than the 1.2-mm tape and suture (P < .001), while with 3 RHAPs, the suture was significantly superior to the 1.2-mm tape (P = .012). Using a square knot with 2 RHAPs, the 2.0-mm tape had significantly greater loop security (P = .001) and better knot security (P = .001) to the 1.2-mm tape and suture. Using the Tennessee knot with 2 RHAPs, the 1.2-mm tape had less loop security (P = .011) and knot security (P = .005) than the suture. Using the SMC knot with 3 RHAPs, the 2.0-mm tape and suture were significantly superior in loop security (P = .001) and knot security (P < .001) to the 1.2-mm tape. There was no significant difference in the failure mode between tapes and sutures with 2 and 3 RHAPs. Conclusion: With 2 RHAPs, the 2.0-mm tape demonstrated greater resistance to suture loop displacement and better knot security compared with the 1.2-mm tape and suture. However, with 3 RHAPs, the 1.2-mm tape manifested weaker loop and knot security compared with the suture.

Types and doses of anti-adhesive agents injected into subacromial space do not have an effect on the clinical and anatomical outcomes after arthroscopic rotator cuff repair.

PURPOSE: Joint stiffness after arthroscopic rotator cuff repair is a major concern for orthopaedic surgeons. Various antiadhesive agents are commonly administered after rotator cuff repair for its prevention. This study aimed to compare the outcomes among patients injected with different types and amounts of anti-adhesive agents after rotator cuff repair. It was hypothesized that the outcomes might differ depending on the use of the anti-adhesive agent and its type and dose. METHODS: A total of 267 patients who underwent arthroscopic rotator cuff repair with or without subacromial injection of anti-adhesive agents were enrolled. The first group (group A; 51 patients) were injected with 3 mL of poloxamer/sodium alginate-based anti-adhesive agent. The second group (group B; 93 patients) were injected with 3 mL of sodium hyaluronate-based anti-adhesive agent. The third group (group C; 82 patients) were injected with 1.5 mL of sodium hyaluronate-based anti-adhesive agent. Finally, the last group (group D; 41 patients) who did not use anti-adhesive agents served as the control. The range of motion (ROM) and pain VAS scores were measured preoperatively and at 5 weeks, 3 months, 6 months, and 1 year postoperatively. Functional outcomes were evaluated using American Shoulder and Elbow Surgeons and Constant scores, whereas cuff integrity was assessed via MRI or ultrasonography at least 6 months postoperatively. RESULTS: All ROM measurements, pain VAS scores, and functional scores were significantly improved regardless of the use, type, and dose of the anti-adhesive agents. In addition shoulder ROM and rotator cuff healing did not significantly differ among the groups (all n.s.). CONCLUSIONS: No significant differences were found in the clinical and anatomical outcomes according to the type and dose of the anti-adhesive agents subacromially injected after rotator cuff repair. LEVEL OF EVIDENCE: III.

Automated 3-dimensional MRI segmentation for the posterosuperior rotator cuff tear lesion using deep learning algorithm.

INTRODUCTION: Rotator cuff tear (RCT) is a challenging and common musculoskeletal disease. Magnetic resonance imaging (MRI) is a commonly used diagnostic modality for RCT, but the interpretation of the results is tedious and has some reliability issues. In this study, we aimed to evaluate the accuracy and efficacy of the 3-dimensional (3D) MRI segmentation for RCT using a deep learning algorithm. METHODS: A 3D U-Net convolutional neural network (CNN) was developed to detect, segment, and visualize RCT lesions in 3D, using MRI data from 303 patients with RCTs. The RCT lesions were labeled by two shoulder specialists in the entire MR image using in-house developed software. The MRI-based 3D U-Net CNN was trained after the augmentation of a training dataset and tested using randomly selected test data (training: validation: test data ratio was 6:2:2). The segmented RCT lesion was visualized in a three-dimensional reconstructed image, and the performance of the 3D U-Net CNN was evaluated using the Dice coefficient, sensitivity, specificity, precision, F1-score, and Youden index. RESULTS: A deep learning algorithm using a 3D U-Net CNN successfully detected, segmented, and visualized the area of RCT in 3D. The model's performance reached a 94.3% of Dice coefficient score, 97.1% of sensitivity, 95.0% of specificity, 84.9% of precision, 90.5% of F1-score, and Youden index of 91.8%. CONCLUSION: The proposed model for 3D segmentation of RCT lesions using MRI data showed overall high accuracy and successful 3D visualization. Further studies are necessary to determine the feasibility of its clinical application and whether its use could improve care and outcomes.

Latarjet procedure for failed Bankart repair provides better stability and return to sports, but worse postoperative pain and external rotation limitations with more complications, compared to revision Bankart repair: a systematic review and meta-analysis.

PURPOSE: This study aimed to compare the clinical results of revision Bankart repair versus the Latarjet procedure for failed Bankart repair. METHODS: A literature search was performed in databases, such as Pubmed, Embase, and Scopus Library. The studies were appraised using the Methodological Index for Non-randomized Studies tool. Studies for failed Bankart repair with revision Bankart repair or Latarjet procedure were included. The pain VAS, ROWE score, rate of return to sports and preinjury level of sports, recurrent instability, range of motion, and complications were compared. Additionally, the pain VAS, ROWE score, forward flexion, and external rotation at side were subjected to a meta-analysis. RESULTS: Twenty-four articles were included in the systematic review. The functional outcomes in terms of the ROWE score, recurrent instability, return to sports, and the preinjury level of sports was better in the Latarjet procedure group than those in the revision Bankart repair group (ROWE score, 91 vs. 86.7; recurrent instability rate, 3.5% vs. 14.4%; return to sports rate, 100% vs. 87.9%; return to preinjury level of sports rate, 89.9% vs. 74.9%; all P < 0.001). However, the results of postoperative pain and the postoperative limitation of external rotation at side were worse in the Latarjet procedure group than those in the revision Bankart repair group (pain VAS, 1.4 vs. 0.8; postoperative external rotation at side, 38° vs. 60°; all P < 0.001). In addition, the majority of the complications occurred in the Latarjet procedure group. In the meta-analysis, the postoperative ROWE score was significantly higher in the Latarjet procedure group than that in the revision Bankart group (revision Bankart repair: 95% CI 88.9-80.9, I2 = 65.70; Latarjet procedure: 95% CI 95.8-88.1, I2 = 93.37; P = 0.014). However, the pain VAS, forward flexion, and external rotation at side did not reach the significant level in the meta-analysis. CONCLUSION: Compared with revision Bankart repair, the Latarjet procedure for failed Bankart repair showed better ROWE scores, stability, and return to sports or preinjury level of sports; however, the postoperative pain and the limitation of external rotation at side were worse with more complications. IRB NO: KUMC 2022-01-024. LEVEL OF EVIDENCE: Level IV.

Transient postoperative inferior subluxation of the shoulder after surgical stabilization of recurrent anterior dislocation in a patient with myasthenia gravis: a case report.

The authors present a case of transient postoperative inferior subluxation of the shoulder after arthroscopic surgical stabilization for recurrent anterior dislocation. The patient was a 61-year-old woman with myasthenia gravis (MG). The first anterior shoulder dislocation occurred because of a fall to the ground. Despite a successful closed reduction, two more dislocations occurred in 3 weeks. Magnetic resonance imaging revealed an anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion, an engaging Hill-Sachs lesion, and large tears of the supraspinatus and infraspinatus tendons. The patient underwent arthroscopic rotator cuff repair and ALPSA repair with a remplissage procedure. Intraoperatively, no tendency for instability was found; however, a widened glenohumeral joint space and inferior subluxation of the humeral head without functional compromise was observed on the day after surgery and disappeared spontaneously on radiographs 2 weeks later. To the authors' knowledge, this is the first report documenting the occurrence of transient postoperative inferior subluxation of the shoulder in a patient with MG.

Biceps Tenodesis Versus Superior Labral Anterior and Posterior (SLAP) Lesion Repair for the Treatment of SLAP Lesion in Overhead Athletes: A Systematic Review and Meta-analysis.

BACKGROUND: Superior labral anterior and posterior (SLAP) lesions are common injuries in overhead athletes. As a surgical treatment for SLAP lesions, SLAP repair has been traditionally performed. Recently, biceps tenodesis has been performed as an alternative treatment option; however, there is no review for outcome comparisons between these 2 procedures in overhead athletes. PURPOSE: The aim of this study was to compare the outcomes of SLAP repair versus biceps tenodesis, especially in overhead athletes with SLAP lesions. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: An electronic literature search was performed in Medline, Embase, Scopus, and the Cochrane Library. The studies were appraised using the Methodological Index for Non-randomized Studies (MINORS) tool. Studies that had a minimum follow-up of 2 years, included only patients with SLAP lesions without other major shoulder pathologies, and included only patients who engaged in overhead sports were included. The functional outcomes of the American Shoulder and Elbow Surgeons (ASES) score, rate of return to sport, rate of return to preinjury level of sport, and complication rate were subjected to meta-analysis. RESULTS: A total of 332 articles were identified, and 13 were included in the systematic review. Even though the postoperative ASES scores were slightly higher in the biceps tenodesis group than in the SLAP repair group, no statistically significant differences were found between the groups (biceps tenodesis, 95% CI = 91.71-96.75, I2 = 0.00; SLAP repair, 95% CI = 85.47-94.46, I2 = 16.3; P = .085) The rate of return to sport and the return to preinjury level of sport were slightly higher in the biceps tenodesis group than in the SLAP repair group; however, in meta-analysis these factors did not reach statistical significance (return to sport: biceps tenodesis, 95% CI = 0.66-0.91, I2 = 0.00; SLAP repair, 95% CI = 0.68-0.93, I2 = 70.23; P = .94) (return to preinjury level of sport: biceps tenodesis, 95% CI = 0.61-0.89, I2 = 17.78; SLAP repair, 95% CI = 0.53-0.82, I2 = 58.07; P = .37). The biceps tenodesis group showed a lower complication rate compared with the SLAP repair group without statistical significance (biceps tenodesis, 95% CI = 0.013-0.145, I2 = 0.00; SLAP repair, 95% CI = 0.049-0.143, I2 = 0.00; P = .25). CONCLUSION: The results of biceps tenodesis, compared with SLAP repair, were not inferior in the surgical treatment of overhead athletes with SLAP lesions with regard to the ASES score, rate of return to sport, rate of return to preinjury level of sport, and complication rate. Further high-level, randomized controlled studies are needed to confirm this result.

Rotator cuff retear after repair surgery: comparison between experienced and inexperienced surgeons.

BACKGROUND: We hypothesized in this study that the characteristics of retear cases vary according to surgeon volume and that surgical outcomes differ between primary and revision arthroscopic rotator cuff repair (revisional ARCR). METHODS: Surgeons performing more than 12 rotator cuff repairs (RCRs) per year were defined as high-volume surgeons, and those performing fewer than 12 RCRs were considered low-volume surgeons. Of the 47 patients who underwent revisional ARCR at our clinic enrolled in this study, 21 cases were treated by high-volume surgeons and 26 cases by low-volume surgeons. In all cases, the interval between primary surgery and revisional ARCR, degree of "acromial scuffing," number of anchors, RCR technique, retear pattern, fatty infiltration, retear size, operating time, and clinical outcome were recorded. RESULTS: During primary surgery, significantly more lateral anchors (p=0.004) were used, and the rate of use of the double-row repair technique was significantly higher (p<0.001) in the high- versus low-volume surgeon group. Moreover, the "cut-through pattern" was observed significantly more frequently among the cases treated by high- versus low-volume surgeons (p=0.008). The clinical outcomes after revisional ARCR were not different between the two groups. CONCLUSIONS: Double-row repair during primary surgery and the cut-through pattern during revisional ARCR were more frequent in the high- versus low-volume surgeon groups. However, no differences in retear site or size, fatty infiltration grade, or outcomes were observed between the groups.

Clinical Outcomes of Interposition Graft Versus Superior Capsular Reconstruction in Patients With Irreparable Rotator Cuff Tears: A Systematic Review and Meta-analysis.

BACKGROUND: Interposition grafting (IG), also called bridging grafting, and superior capsular reconstruction (SCR) are the most commonly used joint-preserving surgical methods for irreparable rotator cuff tears (RCTs). PURPOSE: To compare the effectiveness of IG versus SCR to treat patients with irreparable RCTs. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A literature search was performed in MEDLINE, Embase, and Scopus. Included in this review were clinical studies evaluating the effect of IG or SCR in patients with irreparable RCTs with a minimum follow-up of 1 year. Various clinical results from the studies were extracted and compared between IG and SCR, and among them, the results of the American Shoulder and Elbow Surgeons score, graft retear rate, and complication rate were included in the meta-analysis. RESULTS: Of 1638 identified articles, 17 (10 studies of IG involving 321 patients and 7 studies of SCR involving 357 patients) were selected. Both surgical methods showed significantly improved clinical outcomes in all but 1 study; however, the IG group had lower pain visual analog scale score, higher Constant score, and bigger active forward flexion and internal rotation compared with the SCR group (all P < .001). The meta-analysis showed no difference in the American Shoulder and Elbow Surgeons score between groups (P = .44), but showed a significantly lower complication rate in the IG group compared with the SCR group (1.12% vs 8.37%, respectively; P < .001). The graft retear rate was not significantly different between groups (IG = 10.64% vs SCR = 12.67%; P = .79). The meta-analysis of graft type indicated no difference between groups in retear rate (autograft: 95% CI, 0.045-0.601; I 2 = 93.28 [IG], 91.27 [SCR]; P = .22; allograft: 95% CI, 0.041-0.216; I 2 = 80.39 [IG], 69.12 [SCR]; P = .64) or complication rate (autograft: 95% CI, 0.009-0.150; I 2 = 0 [IG], 65.89 [SCR]; P = .25; allograft: 95% CI, 0.012-0.081; I 2 = 0 [IG], 30.62 [SCR]; P = .09). CONCLUSION: Both IG and SCR techniques resulted in improvement in patients with irreparable RCTs. Meta-analysis showed a lower complication rate in the IG group; however, the lack of randomized studies limited our conclusions.

Delayed Anticipatory Muscle Activation in Rotator Cuff Tendinopathy.

BACKGROUND: Previous research investigating rotator cuff (RC) tendinopathy has usually focused on pathoanatomy. The pathologic response to anticipatory postural adjustments (APAs) has not yet been investigated. PURPOSE/HYPOTHESIS: To explore changes in APAs as detected by pre-emptive activation of shoulder muscles during ball catching. It was hypothesized that anticipatory muscle activation (AMA) would be present in the unaffected shoulder but delayed or absent in the affected shoulder in patients with RC tendinopathy. STUDY DESIGN: Controlled laboratory study. METHODS: This study included 21 RC tendinopathy patients with a mean age of 49.5 years. Patients were required to grab a ball embedded with an electromyography sensor when it dropped on their hand, and surface electromyography signals were recorded from the infraspinatus, upper trapezius, anterior deltoid, and biceps. The trials utilized 2 balls, weighing 200 g and 500 g. Each ball was used in 2 trials, 1 involving a number count preceding the ball drop (predictable) and the other involving a sudden drop (unpredictable). The onsets of AMA between the affected and unaffected limbs were compared. RESULTS: Regardless of the experimental condition, significantly delayed AMA onsets were identified in all investigated muscles of the affected side compared with those of the unaffected side, except for the biceps muscle in the 500-g predictable trial. For the infraspinatus, the mean onset time in the 200-g predictable trial was -141.0 ± 60.2 ms on the affected side and -211.9 ± 67.1 ms on the unaffected side (P < .001); in the 200-g unpredictable trial this value was -139.5 ± 54.9 ms on the affected side and -199.5 ± 56.2 ms on the unaffected side (P < .001). CONCLUSION: Delayed AMA was observed in the affected shoulder compared with the unaffected shoulder in patients with RC tendinopathy, not only in the RC muscle but also in the periscapular and upper arm muscles. This may indicate that central hypoexcitability is partly responsible. CLINICAL RELEVANCE: The basis for RC tendinopathy treatment should not be limited to the tendon pathoanatomy. Delayed AMA around the shoulder joint could provide insight into potential mechanisms related to the central nervous system.

Improvement in scapular dyskinesis after rotator cuff repair and subacromial decompression.

PURPOSE: To investigate the incidence of scapular dyskinesis (SD) in patients with rotator cuff tears using pre- and postoperative 3D computed tomography, analyze the changes in scapular kinematics that occur after arthroscopic rotator cuff repair, and identify the contributing clinical factors. METHODS: Thirty-five patients (mean age, 62.5 ± 8.4 years) were included. Four scapular angles (upward rotation, internal rotation, protraction, and posterior tilt) were measured. The patients were categorized into three pre-existing SD types according to the difference in measured scapular angles between the affected and unaffected sides (type 1 SD, posterior tilt angle difference < - 5°; type 2 SD, internal rotation angle difference > 5°; and type 3 SD, upward rotation angle difference > 5°). The prevalence, factors influencing SD, and outcomes were compared between the improved and sustained SD groups. RESULTS: Twenty three of the 35 patients (65.7%) with rotator cuff tears had SD (type 1, 11; type 2, six; type 3, six). Of the 23 preoperative SD patients, 12 (52.1%) showed improved SD postoperatively. Most of the patients with improved SD (9/12) had type 1 SD (p = 0.021) and a significantly improved posterior tilt angle (p = 0.043). The improvement in SD was correlated with a higher range of motion of forward flexion and higher Constant scores (all p < 0.05). No healing failure occurred in the improved SD group (p = 0.037). CONCLUSION: The prevalence of SD was high in patients with degenerative rotator cuff tears. More than half of the SD cases, especially type 1 SD, improved postoperatively. SD recovery correlated with better function and successful rotator cuff healing. LEVEL OF EVIDENCE: IV.

Metastasis of renal cell carcinoma around suture anchor implants.

We present an unusual case of bone metastases from renal cell carcinoma around orthopedic implants in a 78-year-old female with osteolytic, expansile, highly vascularized, malignant infiltration around suture anchors in the proximal humerus. The patient had undergone arthroscopic rotator cuff repair using suture anchor implants 6 years previously. After diagnosis of bone metastasis, she was successfully treated with metastasectomy and internal fixation using a plate and screws, with cement augmentation. This report is the first to document metastases around a suture anchor in a bone and suggests the vulnerability of suture anchor implants to tumor metastasis.

Evaluation of the Electromyographic Amplitude-to-Work Ratio in the Infraspinatus Muscle During External Shoulder Rotation Exercises: A Comparison of Concentric Isotonic and Isokinetic Exercises.

BACKGROUND: Isotonic exercise is commonly adopted for shoulder rehabilitation, but the efficacy of isokinetic exercise for rehabilitation has not been evaluated. PURPOSE: To evaluate the efficacy of isotonic and isokinetic external shoulder rotation exercises. STUDY DESIGN: Controlled laboratory study. METHODS: Using surface electromyography (EMG) and the Biodex system, we investigated the EMG amplitude of the infraspinatus (IS), total work (tWK), and EMG(IS)/tWK ratio and examined the relative IS and posterior deltoid (PD) contributions to all exercises. A total of 24 healthy participants without musculoskeletal injuries were included. Participants performed isotonic external shoulder rotation at 10%, 20%, 30%, 40%, and 50% of the maximum voluntary isometric contraction (MVIC) as well as isokinetic external shoulder rotation at angular velocities of 60, 120, 180, 240, and 300 deg/s. Levels of intensity were classified from 1 to 5: level 1 corresponded to 10% of the MVIC and a 300-deg/s angular velocity; level 2 corresponded to 20% MVIC and 240 deg/s; level 3 corresponded to 30% MVIC and 180 deg/s; level 4 corresponded to 40% MVIC and 120 deg/s; and level 5 corresponded to 50% MVIC and 60 deg/s. Normalized IS and tWK amplitudes were calculated for each exercise. RESULTS: During isotonic exercise, the EMG(IS)/tWK ratio significantly decreased from level 5 to 3, 2, and 1; from level 4 to 2 and 1; and from level 3 to 1. During isokinetic exercise, the EMG(IS)/tWK ratio at level 3 was greater than that at all other levels except level 1. Statistical differences were found between isotonic and isokinetic modes at levels 1, 2, and 3. The IS/PD activation ratios were not significantly different between exercise modes at any level. CONCLUSION: Isokinetic resistance may provide more effective stimulation of the IS muscle compared with isotonic resistance. CLINICAL RELEVANCE: Isokinetic exercise needs to be considered as a method of rehabilitation that effectively increases infraspinatus muscle activity.

Valgus stress ultrasound for medial ulnar collateral ligament injuries in athletes: is ultrasound alone enough for diagnosis?

BACKGROUND: We hypothesized that valgus stress ultrasound would be useful for both identifying medial ulnar collateral ligament (MUCL) tears and assessing the severity of the tears. Hence, we performed valgus stress ultrasound of the elbow in athletes with MUCL injuries, confirmed by magnetic resonance imaging (MRI), to determine whether ultrasound can be used as a diagnostic tool. METHODS: Stress ultrasound and MRI data from 146 athletes with medial elbow pain were compared prospectively. MRI findings for MUCL injuries were classified into 3 levels as follows: low-grade partial tear (≤50%), high-grade partial tear (>50%), and complete tear. The degree of joint laxity on stress ultrasound was evaluated by measuring joint gapping after applying a 2.5-kg load to the wrist. Joint gapping was measured at 30° and 90° of elbow flexion for the dominant arm and nondominant arm, and the differences between the dominant and nondominant arms were determined. RESULTS: A higher degree of MUCL injury on MRI was associated with greater joint gapping in the medial elbow on stress ultrasound. At 30° of elbow flexion, the cutoff value for complete MUCL rupture was 0.5 mm (P < .001), with a sensitivity and specificity of 88.1% and 61.5%, respectively. At 90° of elbow flexion, the cutoff value for complete MUCL rupture was 1.0 mm (P < .001), with a sensitivity and specificity of 81.0% and 66.4%, respectively. CONCLUSION: Stress ultrasound can be used to diagnose complete MUCL tears in athletes when joint gapping is greater than 0.5 mm at 30° of elbow flexion and greater than 1 mm at 90° of elbow flexion.

Three-Dimensional Analysis of Scapular Kinematics During Arm Elevation in Baseball Players With Scapular Dyskinesis: Comparison of Dominant and Nondominant Arms.

BACKGROUND: The knowledge of 3-dimensional scapular kinematics is essential for understanding the pathological lesions of the shoulder and elbow in throwing athletes. Many studies about alterations of the resting scapular position, dynamic scapular motion, or scapular dyskinesis (SD) have been conducted, yet none of them have identified a consistent pattern of altered scapular kinematics in throwing athletes. Hypothesis/Purpose: To analyze the 3-dimensional scapular kinematics of dominant and nondominant arms in baseball players with a pathological condition of the shoulder or elbow. STUDY DESIGN: Cross-sectional study. METHODS: Bilateral scapular positions, consisting of upward rotation (UR), superior translation (ST), internal rotation (IR), protraction (PRO), and anterior tilting (AT) with an arm at rest and at 150° forward elevation, were measured among 319 baseball players with SD using 3-dimensional computed tomography. Angular values of scapula were compared between dominant and nondominant arms with statistical analysis. LEVEL OF EVIDENCE: Level III, diagnostic study. RESULTS: The scapular position of dominant arms showed significantly more AT, less ST at rest and more UR and IR and less ST, PRO, and AT at 150° full forward elevation compared with the nondominant arms. The magnitude of mean change of UR, IR, PRO, and AT during arm elevation increased significantly between the paired arms (P value: UR, ST, PRO, and AT: <.001 and IR: .001). CONCLUSION: When compared with the nondominant arms, UR, AT, and PRO with the arm at 150° forward elevation of dominant symptomatic arms in baseball players tilted toward positive compensation, whereas IR altered toward negative decompensation. In addition, the angular increment of the scapula increased significantly in dominant symptomatic arms compared with the nondominant arms.

Does anchor insertion angle or placement of the suture anchor affect glenoid rim fracture occurrence after arthroscopic Bankart repair?

BACKGROUND: The purposes were to compare the characteristics of 2 groups of patients who underwent revision Bankart repair with and without glenoid rim fractures and to examine risk factors for glenoid rim fractures. METHODS: We retrospectively analyzed 39 patients who needed revision surgery after arthroscopic Bankart repair and identified 19 patients with and 20 patients without glenoid rim fractures. The insertion angle of the suture anchor, anchor position on the glenoid, and demographic data were compared between the groups. RESULTS: The mean anchor insertion angles in the glenoid fracture group (group F) at the 2-, 3-, 4-, and 5-o'clock positions were 64°, 58°, 55°, and 55°, respectively; those in the no-fracture group (group R) were 60°, 63°, 60°, and 55°, respectively (P = .630, P = .207, P = .166, and P = .976, respectively). At the 5-o'clock position, anchors were fixed to the glenoid face in 13 cases in group F and in 3 cases in group R (P = .040). Although age (P = .529) and sex (P = 1.0) did not differ between the groups, elite and professional athletes had a significantly higher incidence of glenoid rim fractures (P = .009). CONCLUSION: The anchor insertion angle did not affect glenoid rim fracture occurrence after arthroscopic Bankart repair. However, the placement of the suture anchor at the 5-o'clock position on the glenoid face could increase the risk of glenoid rim fracture after trauma. Athletes were more likely to have glenoid rim fractures owing to major trauma after arthroscopic Bankart repair.

Effects of remote ischemic preconditioning on regional cerebral oxygen saturation in patients in the beach chair position during shoulder surgery: A double-blind randomized controlled trial.

STUDY OBJECTIVE: The beach chair position for shoulder surgery induces cerebral hypoperfusion. We evaluated the effects of remote ischemic preconditioning (RIPC) prior to surgery to ameliorate cerebral desaturation in a double-blind randomized fashion. DESIGN: Blinded, prospective, randomized study. SETTING: Operating room & postoperative recovery room, tertiary university hospital. PATIENTS: Seventy patients scheduled for shoulder surgery were recruited. After excluding 7 patients according to the exclusion criteria, 63 patients were randomized into two groups (control and RIPC). INTERVENTIONS: Remote ischemic preconditioning was applied by briefly inflating a tourniquet on the thigh three times just after inducing anesthesia in the RIPC group. MEASUREMENTS: The changes in regional cerebral oxygen saturation, hemodynamic values, laboratory values, and serum levels of cytokines including interleukin (IL)-1ß, IL-6, IL-10 and transforming growth factor-ß were measured. MAIN RESULTS: The remote ischemic preconditioning group had higher regional cerebral oxygen saturation just after establishment of the beach chair position (P = 0.002) and lower cerebral desaturation (P = 0.007) during operation than the control group. Hemodynamic and laboratory values did not differ between the groups. There were no significant intergroup differences in cytokine levels. CONCLUSION: Remote ischemic preconditioning before surgery ameliorates cerebral desaturation in patients in the beach chair position during shoulder surgery. Trial Registry Number: KCT0001384 (http://cris.nih.go.kr).

Factors associated with needle breakage of antegrade suture passer and effect of intratendinous remnant needle tip on clinical outcomes after arthroscopic rotator cuff repair.

OBJECTIVE: The aim of this study was to evaluate factors associated with the needle breakage of antegrade suture passer and the effect of intratendinous remnant needle tip on clinical outcomes after rotator cuff repair. METHODS: We retrospectively reviewed 283 patients (138 men and 145 women; mean age: 59.7 ± 9.3 years) who underwent arthroscopic repair for full-thickness rotator cuff tear. We evaluated the characteristics of 16 patients in whose needle tip had been broken and embedded and remained in the rotator cuff (remnant needle group) and compared them with the remaining 267 patients (control group). Afterwards, another 64 patients were selected from control group (1:4 matching) after propensity score matching (PSM). The groups were compared anatomically with MRI or ultrasonography and functionally (serial pain VAS and ROM; ASES, Constant, UCLA and SST scores) at a minimum follow-up of 1 year. RESULTS: The remnant needle group showed preoperative thicker tendon (6.72 mm vs 5.33 mm, p = 0.047), higher tendinosis (mean grade, 1.88 vs. 1.43, p = 0.029), and more frequent delaminated tears (p = 0.035) compared with control group. When we compare the clinical outcomes after PSM, the initial pain VAS of the remnant needle tip group was higher up to 3 months (pain VAS: 4.13 ± 2.07 vs 2.48 ± 1.61 (p = 0.032) at 5 weeks and 3.79 ± 2.12 vs 2.25 ± 1.76 (p = 0.044) at 3 months), however the difference disappeared after 6 months postoperatively. In final evaluation, there was no significant differences in every outcome parameters (all p > 0.05). CONCLUSION: Breakage of the needle of the antegrade suture passer occurred more frequently in the thicker tendon, higher tendinosis, and delaminated tears. The retained broken needle tip was associated with higher pain scores during the early postoperative period, but revealed no difference in final outcomes by using PSM. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Comparison of Clinical and Radiographic Outcomes of Vertical Simple Stitch Versus Modified Mason-Allen Stitch in Arthroscopic Bankart Repairs: A Prospective Randomized Controlled Study.

BACKGROUND: In spite of the probable advantages of Bankart repair with modified Mason-Allen technique, there has been no study to evaluate the clinical outcomes of the modified Mason-Allen technique for Bankart repair. PURPOSE: To prospectively compare the anatomic and clinical outcomes between the vertical simple stitch and the modified Mason-Allen stitch with respect to the labral height, retear rate, redislocation/apprehension, and various functional outcome scores. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: Patients who underwent arthroscopic Bankart repair with double-loaded suture anchors were randomly allocated to 1 of 2 groups: the vertical simple stitch method (SS; n = 45) or the Bankart repair using modified Mason-Allen technique (BRUMA; n = 41). All patients underwent computed tomography arthrography at 6 months postoperatively and various functional outcome measurements at least 2 years postoperatively. The labral height and width at the 3-, 4-, and 5-o'clock positions were measured preoperatively and at 6 months after surgery on axial computed tomography arthrography; the redislocation/apprehension rate, the retear rate, and various functional outcome scores were evaluated at each follow-up visit. RESULTS: Postoperative labral height and width were significantly increased at all locations (all P < .001) in both groups, but they were not statistically different between groups (all P > .05). Two patients in the SS group (4.4%) and 2 in the BRUMA group (4.9%) experienced redislocation after surgery, and 4 patients in the SS group (8.9%) and 2 in the BRUMA group (4.9%) group showed apprehension after surgery. Additionally, 5 patients in the SS group (11.1%) and 2 in the BRUMA group (4.9%) showed retear at 6 months ( P = .239). There were no differences in any functional outcome scores (all P > .05). CONCLUSION: There was no difference in the radiologic outcomes at 6 months and the clinical outcomes assessed at least 2 years after surgery between the groups.

Does a Partial Rotator Cuff Tear Affect Pitching Ability? Results From an MRI Study.

BACKGROUND: Numerous studies have examined changes in the athletic performance of baseball pitchers after rotator cuff surgery. However, only a few studies have evaluated changes in athletic performance caused by partial rotator cuff tears that are not treated surgically. PURPOSE: To examine the course of partial-thickness rotator cuff tears and its possible effect on the athletic performance of professional pitchers. STUDY DESIGN: Case series; Level of evidence, 4. METHOD: Of 191 professional pitchers who attended our clinic between January 2009 and October 2018, 52 individuals had partial-thickness tears with at least 2 years of follow-up magnetic resonance imaging (MRI) scans and were included in this study. All initial MRI examinations were performed when a season was finished or during the off-season for regular medical check-up purposes. Hence, any abnormal finding on MRI, which suggests damage to the rotator cuff tendon, was assumed to have occurred during the previous season. The mean follow-up MRI period was 40.8 months (range, 24.4-100.9 months). We defined the year before an athlete's first MRI at our clinic as the year of damage, and we evaluated athletic performance during the season before the damage (pre-damage year 1), the season of the damage (damage year), and 1 and 2 seasons after the damage (post-damage years 1 and 2). We evaluated the changes in 5 statistical performance indicators: earned run average (ERA), fielding independent pitching (FIP), walks plus hits divided by innings pitched (WHIP), winning percentage (WPCT), and innings pitched (IP). RESULTS: The partial-thickness tears progressed in 39 of 52 (75%) patients. Of these 39 patients, 34 (87%) were grade 1 in severity and 5 (12.8%) were grade 2 or higher. The ERA of the pitchers did not increase significantly immediately after damage or at post-damage years 1 and 2. WPCT increased significantly compared with pre-damage year 1 (P < .001), and IP decreased significantly during the follow-up period (P < .001). Although no significant decrease in pitching ability was noted based on these 3 indices, significant increases were observed for FIP and WHIP. CONCLUSION: A partial-thickness rotator cuff tear does not have significant influence on the athletic performance of professional baseball pitchers in the short term based on conventional performance indicators. Our findings suggest that WHIP and IP decline significantly at 2 years after damage is noticed.