Footprint preparation with nanofractures in a supraspinatus repair cuts in half the retear rate at 1-year follow-up. A randomized controlled trial.

PURPOSE: To evaluate if adding nanofractures to the footprint of a supraspinatus tear repair would have any effect in the outcomes at one-year follow-up. METHODS: Multicentric, triple-blinded, randomized trial with 12-months follow-up. Subjects with isolated symptomatic reparable supraspinatus tears smaller than 3 cm and without grade 4 fatty infiltration were included. These were randomized to two groups: In the Control group an arthroscopic supraspinatus repair was performed; in the Nanofracture group the footprint was additionally prepared with nanofractures (1 mm wide, 9 mm deep microfractures). Clinical evaluation was done with Constant score, EQ-5D-3L, and Brief Pain Inventory. The primary outcome was the retear rate in MRI at 12-months follow-up. Secondary outcomes were: characteristics of the retear (at the footprint or at the musculotendinous junction) and clinical outcomes. RESULTS: Seventy-one subjects were randomized. Two were lost to follow-up, leaving 69 participants available for assessment at 12-months follow-up (33 in the Control group and 36 in the Nanofracture Group). The Nanofracture group had lower retear rates than the Control group (7/36 [19.4%] vs 14/33 [42.4%], differences significant, p = 0.038). Retear rates at the musculotendinous junction were similar but the Nanofracture group had better tendon healing rates to the bone (34/36 [94.4%] vs. 24/33 [66.71%], p = 0.014). Clinically both groups had significant improvements, but no differences were found between groups. CONCLUSION: Adding nanofractures at the footprint during an isolated supraspinatus repair lowers in half the retear rate at 12-months follow-up. This is due to improved healing at the footprint. LEVEL OF EVIDENCE: Level I.

Increased fatigue of the biceps after tenotomy of the long head of biceps tendon.

PURPOSE: The aim of this study is to evaluate the biomechanical parameters of biceps fatigue (time to claudication during elbow flexion) and strength between the shoulder where the tenotomy has been performed and the healthy arm. The hypothesis of this study was that measuring biceps fatigue may be more useful for determining functionality after tenotomy. METHODS: 52 patients from 2 hospitals were selected to undergo biomechanical tests of healthy and pathological arms, before and 12 months after surgery. The test consisted of (1) isometric measurement of maximal voluntary contraction (MVC) in elbow flexion and forearm supination (MVS) at baseline conditions. (2) Biceps fatigue test was performed by a submaximal contraction to 33% of MVC maintained at a time as well recorded to the time to claudication. (3) After claudication, measurements of the MVC and MVS were recorded. In addition, the Constant score, SSI functional scale, VAS scale and perceived symptoms were evaluated. RESULTS: Of the 52 patients included in the study, 26 met the selection criteria. Two patients were lost to follow-up. The mean age was 55 ± 5.6 years. Popeye sign was observed in 58.3% of the cases. Two patients were not satisfied with the results. Preoperatively, MVC was 193.6 ± 55.2 N, which significantly improved after tenotomy to 252.1 ± 61.2 N, but this value was less than the healthy arms (280 ± 68 N). The fatigue time decreased from 141.9 ± 69.7 s preoperatively to 94.2 ± 29.9 s after tenotomy. There was also an improvement in the strength of the arm after the fatigue test. No differences in supination force were found. The Constant, SSI and VAS rating scales improved significantly. CONCLUSIONS: Despite functional improvements of the long head of biceps tendon (LHBT) after tenotomy, this study demonstrates that the shoulder where the tenotomy has been performed will fatigue more quickly than it did preoperatively. Despite this, an improvement in the isometric contraction in flexion of the elbow with respect to the preoperative values. However, this improvement did not reach the flexion power of the contralateral healthy arm. No changes were observed in the supination force of the forearm. LEVEL OF EVIDENCE: III.

Arthroscopic Scapholunate Capsuloligamentous Repair: Suture With Dorsal Capsular Reinforcement for Scapholunate Ligament Lesion.

Scapholunate ligament (SLL) injury is the most frequent injury of the intrinsic carpal ligaments. The dorsal part of the SLL is the most important part for the stability of the scapholunate joint, and tears of this part and at least one of its secondary capsular attachments cause scapholunate dissociation. The arthroscopic technique most frequently used for acute injuries is reduction and fixation with Kirschner wires, and techniques that involve a primary repair of the injured ligament are performed by open surgery with efficient results. However, they lead to significant stiffness of the wrist due to injury to the soft tissue caused by damage to the secondary dorsal stabilizers; the dorsal blood supply; and in many cases, the proprioceptive innervation of the posterior interosseous nerve. We present an all-arthroscopic technique for the direct repair of acute injuries of the dorsal part of the SLL using bone anchors, complemented by a dorsal arthroscopic plication that reconstructs the dorsal capsulo-scapholunate septum of the scapholunate complex.

Nonunion of the humeral shaft: long lateral butterfly fracture--a nonunion predictive pattern?

Retrospective review of 30 patients with nonunion of the humeral shaft treated from 1984-1999 revealed nine patients with an initial fracture pattern which to our knowledge was not described previously. Humeral fractures originated at the junction of the proximal and middle thirds of the diaphysis as an hemitransverse medial fracture that extended with a great lateral butterfly third fragment with its distal portion long and sharp. The patients were women approximately 60 years old. Eight fractures progressed to nonunion after initial conservative treatment. All fractures followed the same pattern: the proximal humeral fragment healed with the proximal portion of the third fragment, but an atrophic nonunion between the proximal humeral fragment, the distal humeral fragment, and the distal portion of the third fragment developed. The treatment required a technique adapted to this type of nonunion consisting of retrograde flexible intramedullary nailing, cerclage wires, and bone grafts.