Influence of age-related bone density changes on primary stability in stemless shoulder arthroplasty: A multi-implant finite element study.

BACKGROUND: Stemless implants were introduced to prevent some of the stem-related complications associated with the total shoulder arthroplasty. Although general requirements for receiving these implants include good bone quality conditions, little knowledge exists about how bone quality affects implant performance. The goal of this study was to evaluate the influence of age-induced changes in bone density, as a metric of bone quality, in the primary stability of five anatomic stemless shoulder implants using 3D finite element (FE) models. METHODS: The implant designs considered were based on the Global Icon, Sidus, Simpliciti, SMR, and Inhance stemless implants. Shoulder arthroplasties were virtually simulated in Solidworks. The density distributions of 20 subjects from two age groups, 20 to 40 and 60 to 80 years old, were retrieved from medical image data and integrated into three-dimensional FE models of a single humerus geometry, developed in Abaqus, to avoid confounding factors associated with geometric characteristics. For the designs which do not have a solid collar covering the entire bone surface, i.e., the Sidus, Simpliciti, SMR, and Inhance implants, contact and non-contact conditions between the humeral head component and bone were considered. Primary stability was evaluated through the assessment of micromotions at the bone-implant interface considering eight load cases related to rehabilitation activities and demanding tasks. Three research variables, considering 20 µm, 50 µm, and 150 µm as thresholds for osseointegration, were used for a statistical analysis of the results. RESULTS: The decreased bone density registered for the 60-80 age group led to larger micromotions at the bone-implant interface when compared to the 20-40 age group. The Global Icon-based and Inhance-based designs were the least sensitive to bone density, whereas the Sidus-based design was the most sensitive to bone density. The establishment of contact between the humeral head component and bone for the implants that do not have a solid collar led to decreased micromotions. DISCUSSION: Although the age-induced decline in bone density led to increased micromotions in the FE models, some stemless shoulder implants presented good overall performance regardless of the osseointegration threshold considered, suggesting that age alone may not be a contraindication to anatomic total shoulder arthroplasty. If only primary stability is considered, the results suggested superior performance for the Global Icon-based and Inhance-based designs. Moreover, the humeral head component should contact the resected bone surface when feasible. Further investigation is necessary to combine these results with the long-term performance of the implants and allow more precise recommendations.

Knotted or knotless double-row rotator cuff repair retear rates: a systematic review and meta-analysis.

Background: Arthroscopic rotator cuff tear repair techniques used to rely on knot-tying double row techniques, but the advent of knotless transosseous equivalent procedures introduced a new variable to the debate. The purpose of this study is to determine which technique is associated with lower retear rates. For its' biomechanical advantages, the authors' hypothesis is that knotless techniques would have lower retear rates. Methods: A systematic literature search was performed via PubMed and Google Scholar by two independent reviewers following PRISMA guidelines. Papers reporting retear rates after rotator cuff arthroscopic repair using knotted double-row or knotless transosseous equivalent techniques, evaluated by magnetic resonance imaging at least 6 months after surgery, were retrieved. Studies that do not differentiate between techniques and nonclinical reports were excluded. Eligible data was analyzed with Review Manager 5.4.1 using Mantel-Haenszel statistics with a fixed effect model. Results: The authors' initial literature search retrieved 511 reports. After the selection process, 24 articles were available for this review, and 9 were eligible for meta-analysis. A comparison of 1888 subjects from noncomparative reports and a meta-analysis of reports in which both techniques were studied could not show a statistically significant difference in technique retear rates. Discussion and conclusion: The current report revealed no significant difference in retear rates between the two arthroscopic repair techniques. Studies' quality was a limitation. Only two reported level 1 evidence. This review could not control variables such as cuff tear size, tissue quality, or individual comorbidities. Larger and longer follow-up studies could be helpful to further investigate this topic.

Chemotherapy Regimens for Non-Metastatic Conventional Appendicular Osteosarcoma: A Literature Review Based on the Outcomes.

Osteosarcoma is a rare condition with a complex treatment. Most protocols include neoadjuvant chemotherapy, surgery, and consolidation chemotherapy as the standard of treatment. However, the use of neoadjuvant chemotherapy lacks scientific evidence proving superiority in opposition to the use of isolated chemotherapy in an adjuvant regimen after surgery. We conducted a review for studies published in English between 1980 and 2020, using the MEDLINE/PubMed and Scopus electronic databases, to evaluate the outcomes when using neoadjuvant chemotherapy or adjuvant chemotherapy strategies in the treatment of non-metastatic appendicular osteosarcoma, as well as the toxicity associated with different chemotherapeutic regimens. Patients were divided into a neoadjuvant chemotherapy group (NAC) and adjuvant chemotherapy group (ACT), depending on the chemotherapy regimen used in association with surgery. A total of 1254 articles in English were screened by title and abstract, and 146 were pre-selected for full reading and analysis. A total of 24 assays matching the inclusion criteria were selected: 10 prospective and 14 retrospective studies. This review points to an absence of significative differences in outcomes, namely overall survival, disease-free survival/event-free survival rates, or toxicity, regarding neoadjuvant or single adjuvant chemotherapy strategies used in the treatment of appendicular non-metastatic osteosarcomas. However, there is a significative difference in population dimensions between the NAC and the ACT groups. Additionally, clinical presentation, tumor localization, tumor volume, or histological type were not considered, with these variables presenting the potential to influence these results. Despite these limitations, our findings should allow a re-thinking of our current practice and promote new opportunities to optimize treatment, always looking towards better survival and lower complications rates.

Bilateral Sprengel Deformity With Bilateral Omovertebral Bone: An Unusual Case in an Adult Patient: A Case Report.

CASE: We describe an adult patient with bilateral Sprengel deformity (BSD) with bilateral omovertebral bone and thoracic spinal failure of segmentation (T2-T4) successfully surgically treated only at 19-year-old. After resection of the bilateral omovertebral bone and simultaneous relocation of the scapula, disabilities of the arm, shoulder, and hand score improved from 26.7 preoperatively to 2.5 at the 3-year follow-up. CONCLUSION: The surgical treatment of Sprengel deformity is typically recommended between 3 and 7 years of age when significant shoulder impairment and/or severe cosmetic concerns are present. The authors were able to achieve a successful surgical outcome in a patient with BSD despite an unusual late presentation.

Ultrasound findings and prognosis of shoulder pain: A role for Doppler signal?

PURPOSE: To find ultrasound prognostic factors for shoulder pain. METHODS: This was an observational, prospective study, comparing the evolution of ultrasound findings with clinical outcomes, in patients with shoulder pain. Data were collected in two appointments, from February 2018 to March 2021. Two-tailed non-parametric statistics were used, and p values <0.05 were considered significant. RESULTS: A total of 79 participants were included in this study (median age 59 years, range 24-70, 61 women). A positive Doppler signal on tendons (p = 0.002) and absent tendon heterogeneity (p = 0.01) were associated with the patient's self-reported improvement. Tendon calcifications with poorly defined contours (p = 0.03) and sparse distribution (p = 0.001) were associated with VAS improvement. A reduction in the number of calcifications (p = 0.004), in the supraspinatus tendon thickness (p = 0.01), in subacromial effusions (p = 0.03), and in color Doppler grade (p = 0.02), between initial and follow-up exams, was found in patients with an improved DASH outcome. CONCLUSION: A positive Doppler signal on shoulder tendons can be a marker for a better prognosis in shoulder pain. Poorly defined and sparsely distributed calcifications can also indicate a better course of the disease.

Local bone metabolism balance regulation via double-adhesive hydrogel for fixing orthopedic implants.

The effective osteointegration of orthopedic implants is a key factor for the success of orthopedic surgery. However, local metabolic imbalance around implants under osteoporosis condition could jeopardize the fixation effect. Inspired by the bone structure and the composition around implants under osteoporosis condition, alendronate (A) was grafted onto methacryloyl hyaluronic acid (H) by activating the carboxyl group of methacryloyl hyaluronic acid to be bonded to inorganic calcium phosphate on trabecular bone, which is then integrated with aminated bioactive glass (AB) modified by oxidized dextran (O) for further adhesion to organic collagen on the trabecular bone. The hybrid hydrogel could be solidified on cancellous bone in situ under UV irradiation and exhibits dual adhesion to organic collagen and inorganic apatite, promoting osteointegration of orthopedic implants, resulting in firm stabilization of the implants in cancellous bone areas. In vitro, the hydrogel was evidenced to promote osteogenic differentiation of embryonic mouse osteoblast precursor cells (MC3T3-E1) as well as inhibit the receptor activator of nuclear factor-κ B ligand (RANKL)-induced osteoclast differentiation of macrophages, leading to the upregulation of osteogenic-related gene and protein expression. In a rat osteoporosis model, the bone-implant contact (BIC) of the hybrid hydrogel group increased by 2.77, which is directly linked to improved mechanical stability of the orthopedic implants. Overall, this organic-inorganic, dual-adhesive hydrogel could be a promising candidate for enhancing the stability of orthopedic implants under osteoporotic conditions.

Arthroscopic-Assisted Acromioclavicular Joint Dislocation Repair: A Modified Technique for Horizontal Stabilization Using Suture Anchors.

Acromioclavicular (AC) dislocation is a common lesion often resulting from a sports injury. Nowadays, treatment is still controversial mainly in grade III lesions according to the Rockwood classification. For most surgically treated AC acute dislocations, treatment is performed with an arthroscopic procedure that anatomically reconstructs the coracoclavicular ligaments. Increasing knowledge about AC joint biomechanics has underlined the importance of its horizontal stability through the superior and inferior AC ligaments. Moreover, the pattern of lesion tends to repeat itself, with the superior AC ligament being torn most frequently from the clavicular side in a peeling fashion. Therefore, the purpose of this note is to describe the technical aspects of additional horizontal stability through superior AC ligament repair using suture anchors.

Sternoclavicular Septic Arthritis: Partial Resection is Still an Option - A Case Report.

Introduction: Sternoclavicular joint (SCJ) infection is rare. Delayed diagnosis might lead to severe complications. Optimal surgical management is still under debate however extended resection of the joint requiring muscle flap coverage appears to be the favored approach nowadays in the cases with bony involvement. Case Presentation: A 58-year-old man complained of isolated left shoulder and anterior chest pain for over a month. Careful examination revealed a mass over the SCJ. A Computed tomography scan confirmed joint effusion and adjacent bone erosion, with no retrosternal involvement, consistent with SCJ septic arthritis with significant bony involvement. Conclusion: This case illustrates how a heightened index of suspicion is essential for diagnosis and prompt treatment, and how partial resection was effective and resulted in complete recovery of range of motion and pain resolution, despite bony involvement. There were no signs of recurrence 1 year after surgery.

Short-term results (1 year) of vented versus solid polyetheretherketone anchors in treatment of rotator cuff tears.

BACKGROUND: Due to the rotator cuff retear after being surgically repaired, some strategies have been developed. The authors verified that the possibility of polyetheretherketone (PEEK) vented anchors promoted a better clinical and healing process than PEEK solid anchors. METHODS: A prospective and randomized study was designed with 38 patients treated with PEEK anchors, 18 of whom with vented anchors and 20 with solid ones. Demographic, clinical and radiologic data were collected before and during surgery (time 0) and at 12 months of follow-up. RESULTS: In the final follow-up (12 months), there was no difference in the visual analogic scale (VAS) scale between groups (1.7 points vs 1.9 points; p = 0.731), neither in the DASH score (34.2 points vs 23.9 points; p = 0.268), nor in absolute Constant score (76.9 points vs 77.3 points; p = 0.910). In MRI, 10 patients had their cuff tear healed in the vented group and 15 in the solid group (p = 0.173). CONCLUSION: The new designed vented anchors do not add any advantage when compared to solids ones, at least within the first year after surgery.

Bone adaptation impact of stemless shoulder implants: a computational analysis.

BACKGROUND: Despite stemless implants showing promising functional and radiologic clinical outcomes, concerning signs of complications, such as bone resorption, have been reported. The aim of this study was to investigate the influence of 5 stemless designs on the bone adaptation process of the humerus. METHODS: Three-dimensional finite element models of shoulder arthroplasties were developed considering stemless designs based on the Eclipse, Global Icon, SMR, Simpliciti, and Sidus stemless systems. For the designs not possessing a collar that covers the entire resected surface of the humerus, conditions of contact and no contact were simulated between the humeral head components and the bone surface. By use of a bone remodeling model, computational simulations were performed considering 6 load cases of standard shoulder movements. The bone adaptation process was evaluated by comparing differences in bone density between the implanted models and the intact model of the humerus. RESULTS: Overall, the design of the stemless implants had a relevant impact on the bone adaptation process of the humerus. The Eclipse-based design caused the largest bone mass loss, whereas the SMR-based design caused the least. When contact was simulated between the humeral head components of the SMR-, Simpliciti-, and Sidus-based designs and the resected bone surface, bone resorption increased. DISCUSSION: Considering only the bone adaptation process, the results suggest that the SMR-based implant presents the best performance and that contact between the humeral head component and the resected bone surface should be avoided. However, because other factors must be considered, further investigation is necessary to allow definite recommendations.

How to measure a Hill-Sachs lesion: a systematic review.

Quantifying bone loss is important to decide the best treatment for patients with recurrent anterior glenohumeral instability. Currently, there is no standard method available to make a precise evaluation of the Hill-Sachs lesion and predict its engagement before the surgical procedure. This literature review was performed in order to identify existing published imaging methods quantifying humeral head bone loss in Hill-Sachs lesions.Searches were undertaken in Scopus and PubMed databases from January 2008 until February 2018. The search terms were "Hill-Sachs" and "measurement" for the initial search and "Hill-Sachs bone loss" for the second, to be present in the keywords, abstracts and title. All articles that presented a method for quantifying measurement of Hill-Sachs lesions were analysed.Several methods are currently available to evaluate Hill-Sachs lesions. The length, width and depth measurements on CT scans show strong inter and intra-observer correlation coefficients. Three-dimensional CT is helpful for evaluation of bony injuries; however, there were no significant differences between 3D CT and 3D MRI measurements. The on-track off-track method using MRI allows a simultaneous evaluation of the Hill-Sachs and glenoid bone loss and also predicts the engaging lesions with good accuracy. Cite this article: EFORT Open Rev 2019;4:151-157. DOI: 10.1302/2058-5241.4.180031.

Evaluation and Management of Failed Shoulder Instability Surgery.

BACKGROUND: Failed shoulder instability surgery is mostly considered to be the recurrence of shoulder dislocation but subluxation, painful or non-reliable shoulder are also reasons for patient dissatisfaction and should be considered in the notion. METHODS: The authors performed a revision of the literature and online contents on evaluation and management of failed shoulder instability surgery. RESULTS: When we look at the reasons for failure of shoulder instability surgery we point the finger at poor patient selection, technical error and an additional traumatic event. More than 80% of surgical failures, for shoulder instability, are associated with bone loss. Quantification of glenoid bone loss and investigation of an engaging Hill-Sachs lesion are determining facts. Adequate imaging studies are determinant to assess labrum and capsular lesions and to rule out associated pathology as rotator cuff tears. CT-scan is the method of choice to diagnose and quantify bone loss. Arthroscopic soft tissue procedures are indicated in patients with minimal bone loss and no contact sports. Open soft tissue procedures should be performed in patients with small bone defects, with hiperlaxity and practicing contact sports. Soft tissue techniques, as postero-inferior capsular plication and remplissage, may be used in patients with less than 25% of glenoid bone loss and Hill-Sachs lesions. Bone block procedures should be used for glenoid larger bone defects in the presence of an engaging Hill-Sachs lesion or in the presence of poor soft tissue quality. A tricortical iliac crest graft may be used as a primary procedure or as a salvage procedure after failure of a Bristow or a Latarjet procedure. Less frequently, the surgeon has to address the Hill-Sachs lesion. When a 30% loss of humeral head circumference is present a filling graft should be used. CONCLUSION: Reasons for failure are multifactorial. In order to address this entity, surgeons must correctly identify the causes and tailor the right solution.

Surgical Treatment of Rotator Cuff Tears After 65 Years of Age: A Systematic Review.

INTRODUCTION: The objective of this study was to analyze current evidence regarding surgical management of rotator cuff tears in patients of 65 years of age and above. Our hypothesis was that surgical repair of rotator cuff tears, in patients older than 65 years, conveys good outcome scores. We have not found a similar systematic review in current literature. MATERIAL AND METHODS: Medline®, PubMed, Scopus, and the Cochrane Register of Controlled Trials were searched from January 1999 unto December 2015 for studies, regardless of language, including the words 'rotator cuff' and '65 years' or '70 years'. Inclusion criteria were studies (level I to IV) that reported clinical outcomes in patients older than 65 years, having undertaken surgical repair of a symptomatic rotator cuff tears. Arthroscopic, mini open and open techniques were included. Exclusion criteria were: studies with patients younger than 65 years, studies that did not use validated outcome evaluation scores as primary assessment tools and those with follow up under one year. This work followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - PRISMA guidelines. Data abstracted included patient demographics, tear pattern, surgical procedures, clinical and repair results. Outcome scores were converted to percentages, allowing comparison of data between studies. RESULTS: After deep analysis, 14 studies met the inclusion criteria: 11 level IV studies, 1 level III study and 2 level II studies. Seven studies found statistically significant outcome improvements between pre and postoperative evaluations. All studies reported good or excellent surgical outcomes. DISCUSSION: Better results would probably be achieved if all studies had rigorous and homogeneous patient selection criteria, but the fact is, that even though this was not the case, the clinical scores remained favorable, and with statistically significant outcome improvement in all studies with prospectively collected data. CONCLUSION: Based on current literature, rotator cuff repair in patients older than 65 years imparts favorable improvement in clinical outcome scores and overall patient satisfaction.

Introdução: O objetivo deste estudo, é o de analisar a evidência atual no que respeita ao tratamento cirúrgico de roturas da coifa dos rotadores, em doentes com mais de 65 anos de idade. A hipótese proposta foi que o tratamento cirúrgico de roturas da coifa dos rotadores, em doentes com 65 anos ou mais, acarreta bons resultados funcionais. Não existe, na literatura atual, uma revisão sistemática com os mesmos parâmetros que esta. Material e Métodos: Recorremos à Medline®, PubMed, Scopus, e Cochrane Register of Controlled Trials, na procura de estudos entre janeiro de 1999 e dezembro de 2015, independentemente da língua, que incluíssem as palavras: 'rotator cuff' e '65 years' ou '70 years'. Como critérios de inclusão estipulámos, estudos (nível I a IV) que reportassem os resultados funcionais de doentes com 65 anos ou mais, submetidos à reparação cirúrgica de uma rotura da coifa dos rotadores sintomática. Foram incluídas técnicas artroscópicas, mini-invasivas e abertas. Os critérios de exclusão estipulados foram, estudos que incluíssem doentes com menos de 65 anos, estudos que não recorressem a escalas de avaliação funcional validadas, como ferramenta de aferição primária, e aqueles com tempo de seguimento inferior a um ano. Este trabalho seguiu as orientações da Preferred Reporting Items for Systematic Reviews and Meta-Analyses - PRISMA. A informação colhida incluiu dados demográficos, padrões de rotura, procedimentos cirúrgicos realizados e resultados, clínicos e das reparações efectuadas. Os resultados funcionais foram convertidos em percentagens, permitindo a comparação de dados entre os estudos. Resultados: Quatorze estudos cumpriram os critérios de inclusão: 11 estudos nível IV, um estudo nível III e dois estudos nível II. Sete estudos reportaram melhorias com significado estatístico entra as avaliações funcionais pré e pós operatórias. Todos os estudos reportaram resultados funcionais bons ou excelentes. Discussão: É provável que seriam obtidos resultados mais consistentes, se todos os estudos incluídos tivessem critérios de selecção mais homogéneos e rigorosos. Apesar de tal não se ter verificado, os resultados clínicos foram, todavia, favoráveis. Isto traduziu-se numa melhoria dos resultados funcionais, com significado estatístico, em todos os estudos prospectivos incluídos. Conclusão: Com base na literatura atual, a reparação de roturas da coifa dos rotadores em doentes com 65 anos ou mais, está associada à melhoria dos resultados funcionais e a um bom grau de satisfação com o procedimento.

[ß-Tricalcium Phosphate in the Surgical Treatment of Proximal Humeral Fractures]. / Fosfato ß-Tricálcico Monobloco no Tratamento de Fraturas Proximais do Ãmero Cirúrgicas.

INTRODUCTION: The proximal humeral fractures are becoming more frequent, with a greater tendency for its surgical treatment by osteosynthesis with plate and locked screws. The mechanical and biological failure in these fractures and devices, despite the evolution of this type of implants, highlighted the synthetic bone grafts became an option. MATERIAL AND METHODS: Over a period of 96 months, patients considered were those with proximal humeral fractures treated surgically with a plate and locked screws, and in which ß-tricalcium phosphate bone graft had been used. Functional results were evaluated by the shoulder range of motion as the radiological results. RESULTS: In 19 patients, with a medial follow up of 53 months, we obtained an average shoulder range of motion of 140º in abduction, 142º in forward flexion, 37º in external rotation and L3 hand position in internal rotation for a cefalo-diaphyseal angle of 136º. DISCUSSION: The ß-tricalcium phosphate synthetic bone graft allows the maintenance of reduction after fixation of proximal humeral fractures stabilized with plate and locked screws. This reduction which means the maintenance of cefalo-diaphyseal angle is in close relationship with functional results as shown by shoulder range of motion in all planes. CONCLUSION: The ß-tricalcium phosphate synthetic bone graft should be seen as an adjuvant therapy in extramedullary fixation of proximal humeral fractures, especially those with greater comminution of the medial calcar.

Introdução: As fraturas proximais do úmero são cada vez mais frequentes, com maior tendência para o seu tratamento cirúrgico, predominado a utilização da osteossíntese com placa e parafusos bloqueados. Pela falência mecânica e biológica, apesar da evolução deste tipo de implantes, a utilização de enxertos ósseos sintéticos passaram a ser uma opção. Material e Métodos: Num período de 96 meses, avaliámos os doentes com fraturas proximais do úmero, tratados cirurgicamente com placa e parafusos bloqueados e nos quais foi usado enxerto ósseo sintético de fosfato ß-tricálcico. Avaliaram-se os resultados funcionais pelo arco de mobilidade e pelos exames radiográficos. Resultados: Nos 19 doentes avaliados, para um follow-up médio de 53 meses, obteve-se um arco de mobilidade com valores médio de abdução de 140º, flexão anterior de 142º, rotação externa de 37º e rotação interna com mão a L3, para um ângulo cefalo-diafisário de 136º. Discussão: A utilização de enxerto ósseo sintético de fosfato ß-tricálcico permite a estabilização da redução após fixação das fraturas proximais do úmero estabilizadas com placa e parafusos bloqueados. Esta redução que se traduz na manutenção do ângulo cefalodiafisário, permite a obtenção de bons resultados funcionais como o demonstra o arco de mobilidade nos vários planos. Conclusão: O enxerto ósseo sintético de fosfato ß-tricálcico deverá ser encarado como uma terapêutica auxiliar na osteossíntese extramedular das fraturas proximais do úmero, principalmente naquelas com maior dificuldade de manutenção da redução pela maior cominução do calcar medial.