Clinical and Radiographic Outcomes Of Primary Versus Revision Arthroscopic Anatomic Glenoid Reconstruction with Distal Tibial Allograft For Anterior Shoulder Instability With Bone Loss.

PURPOSE: The purpose of this study was to assess the clinical and radiographic outcomes of arthroscopic anatomic glenoid reconstruction (AAGR) used for primary versus revision surgery for addressing anterior shoulder instability with bone loss. METHODS: We performed a retrospective review on consecutive patients who underwent AAGR from 2012 to 2020. Patients who received AAGR for anterior shoulder instability with bone loss and had a minimum follow-up of two-years were included. Exclusion criteria included patients with incomplete primary patient reported outcome scores (PROs), multi-directional instability, glenoid fracture, non-rigid fixation and concomitant HAGL, or rotator cuff repair. Our primary outcome was measured using the Western Ontario Shoulder Instability Index (WOSI) scores. Secondary outcomes included postoperative Disabilities of Arm, Shoulder, Hand (DASH) scores, complications, recurrence of instability and CT evaluation of graft position, resorption, and healing. RESULTS: There were 73 patients (52 primary and 21 revision) finally included. Both groups had comparable demographics and preoperative WOSI and DASH scores. The primary group had significantly better postoperative WOSI and DASH scores at final follow-up when compared to the revision group (WOSI: 21.0 vs 33.8, p=0.019; DASH: 7.3 vs 17.2, p=0.001). The primary group also showed significantly better WOSI scores than the revision group at 6-month, 1-year and 2-year time points (p=0.029, 0.022 and 0.003; respectively). The overall complication rate was 9.6% (5/52) in the primary group and 23.8% (5/21) in the revision group. Both groups showed good graft healing and placement in the A to P and ML orientation and had a similar rate of graft resorption/remodeling. There was no difference between the groups in the remainder of the CT measurements. CONCLUSION: Functional outcome scores and stiffness were significantly worse in patients undergoing an AAGR procedure after a failed instability surgery when compared with patients undergoing primary AAGR. There were no differences in postoperative recurrence of instability or radiographic outcomes. As a result, AAGR should be considered as a primary treatment option within current treatment algorithms for shoulder instability.

Arthroscopic Treatment of Cam-Type Impingement for Femoroacetabular Impingement Using Patient's Own 1:1 Three-Dimensional Printed Hip Model Without the Use of Fluoroscopy.

The arthroscopic treatment of femoroacetabular impingement (FAI) has increased greatly in popularity over the past decades. Treatment involves the resection of abnormal bony morphology of the femoral head/neck (cam-type) and the acetabulum (pincer-type), which otherwise create damage from the pathologic contact between the 2 structures. More recently, in evaluating the postoperative success of FAI surgery, unsuccessful resection of the cam impingement has been identified as a leading cause for revision. To evaluate adequate cam resection intraoperatively, C-arm fluoroscopy is most commonly used. However, fluoroscopy has disadvantages, including its limited availability in smaller surgical centers, radiation exposure, and it only provides 2-dimensional information of a 3-dimensional problem. With the recent implementation of ultrasound-guided portal placement, a technique for adequate cam resection is the last barrier to eliminating the need for intraoperative imaging for FAI. We present a technique that uses a 1:1 3-dimensional printed model made from computed tomography scans that have the patient's unique anatomy, to better identify and quantify the resection of cam-type impingements. This technique is reproducible and can lead to better understanding of the cam resection for each individual patient. Further, when combined with ultrasound-guided portal placement, it eliminates the need for intraoperative fluoroscopy.

Retrograde closure of post-infarct ventricular septal rupture to avoid moderator band entanglement.

A 63-year-old man presented with delayed inferior ST-elevation myocardial infarction complicated with ventricular septal rupture (VSR). He developed cardiogenic shock and respiratory failure requiring intubation and Impella (Abiomed) support.

Short-Term Outcomes of ACURATE neo2.

Inferior outcomes with ACURATE neo, a self-expanding transcatheter heart valve (THV) for the treatment of severe aortic stenosis, were mainly driven by higher rates of moderate/severe paravalvular leak (PVL). To overcome this limitation, the next-generation ACURATE neo2 features a 60% larger external sealing skirt. Data on long-term performance are limited; however, clinical evidence suggests improved short-term performance which is comparable to contemporary THVs. This report reviews data on short-term clinical and echocardiographic outcomes of ACURATE neo2. A PubMed search yielded 13 studies, including 5 single arm and 8 nonrandomized comparative studies with other THVs which reported in-hospital or 30-day clinical and echocardiographic outcomes. In-hospital or 30-day all-cause mortality was ≤3.3%, which is comparable to other contemporary THVs. The rates of postprocedural ≧moderate PVL ranged 0.6%-4.7%. In multicenter propensity-matched analyses, neo2 significantly reduced the rate of ≧moderate PVL compared to neo (3.5% vs. 11.3%, p < 0.01), whereas rates were comparable to Evolut Pro/Pro+ (Neo2: 2.0% vs. Pro/Pro+: 3.1%, p = 0.28) and SAPIEN 3 Ultra (Neo2: 0.6% vs. Ultra: 1.1%, p = 0.72). The rate of permanent pacemaker implantation with neo2 was consistently low (3.3%-8.6%) except in one study, and in propensity-matched analyses were significantly lower than Evolut Pro/Pro+ (6.7% vs. 16.7%, p < 0.01), and comparable to SAPIEN 3 Ultra (8.1% vs. 10.3%, p = 0.29). In conclusion, ACURATE neo2 showed better short-term performance by considerably reducing PVL compared to its predecessor, with short-term clinical and echocardiographic outcomes comparable to contemporary THVs.

Surgical Management of Massive Irreparable Cuff Tears/Management of Rotator Cuff Disease: Interpositional Graft for Irreparable Posterosuperior Rotator Cuff Tears.

PURPOSE OF REVIEW: Increasingly, massive irreparable rotator cuff tears present a treatment challenge due to their high re-tear rates. The reparability of such tears depends on factors like tear size, the number of involved tendons, tendon retraction extent, muscular atrophy, fatty infiltration, and the presence or absence of arthritis. There are non-surgical and several surgical treatment options described each with their specific indications, contraindications, pros, and cons. Bridging reconstruction restores the superior rotator cuff tissue and arrests humeral head superior migration. The purpose of his review is to explore the existing literature on interpositional graft mechanics, indications, surgical technique, and clinical outcomes. It aims to understand how these parameters can facilitate the incorporation of bridging reconstruction using interpositional grafts into a surgeon's practice for managing massive irreparable rotator cuff tears. RECENT FINDINGS: Interpositional grafts for irreparable massive rotator cuff tears can either be auto-, allo-, xenografts, or synthetic material and are best suited for patients who are relatively younger, no glenohumeral arthritis, and minimal to no fatty infiltration and muscle atrophy. Short to medium term outcome studies available report good functional, clinical, and radiological improvements with bridging reconstruction utilizing acellular dermal matrix allograft. Interpositional grafts for management of irreparable posterosuperior cuff tears provides improved clinical and radiological outcomes with minimal complications and thus a viable and valuable surgical technique for a shoulder surgeon's armamentarium.

Comprehensive identification of pathogenic microbes and antimicrobial resistance genes in food products using nanopore sequencing-based metagenomics.

Foodborne pathogens, particularly antimicrobial-resistant (AMR) bacteria, remain a significant threat to global health. Given the limitations of conventional culture-based approaches, which are limited in scope and time-consuming, metagenomic sequencing of food products emerges as a promising solution. This method provides a fast and comprehensive way to detect the presence of pathogenic microbes and antimicrobial resistance genes (ARGs). Notably, nanopore long-read sequencing provides more accurate bacterial taxonomic classification in comparison to short-read sequencing. Here, we revealed the impact of food types and attributes (origin, retail place, and food processing methods) on microbial communities and the AMR profile using nanopore metagenomic sequencing. We analyzed a total of 260 food products, including raw meat, sashimi, and ready-to-eat (RTE) vegetables. Clostridium botulinum, Acinetobacter baumannii, and Vibrio parahaemolyticus were identified as the top three foodborne pathogens in raw meat and sashimi. Importantly, even with low pathogen abundance, higher percentages of samples containing carbapenem and cephalosporin resistance genes were identified in chicken and RTE vegetables, respectively. In parallel, our results demonstrated that fresh, peeled, and minced foods exhibited higher levels of pathogenic bacteria. In conclusion, this comprehensive study offers invaluable data that can contribute to food safety assessments and serve as a basis for quality indicators.

Editorial Commentary: Anterior Shoulder Stabilization Combining Arthroscopic Bankart and Inferior Capsular Shift Avoids Open Surgery in Athletes Without Critical Glenoid Bone Loss.

Traumatic anterior shoulder dislocations can cause a myriad of injuries, each with their own unique set of challenges with respect to surgical management. The debate of whether open or arthroscopic management is the superior approach is one that predates most currently practicing orthopaedic surgeons yet remains one of the most actively researched areas of orthopaedics. Current trends favor arthroscopic management for anterior instability secondary to a Bankart lesion in patients without other risk factors for instability, such as critical glenoid bone loss. However, excellent results are not guaranteed following arthroscopic Bankart repair, particularly in athletes, due to high rates of recurrence. While the technique of inferior to superior capsular shift is not new, transitioning a historically open technique to the arthroscopic world may represent another tool in the glenohumeral instability management toolbox. While perspectives are evolving, more evidence supporting arthroscopic techniques like the capsular shift are needed to better identify appropriate patient populations.

SRPK2 Mediates HBV Core Protein Phosphorylation and Capsid Assembly via Docking Interaction.

Members of the serine-arginine protein kinase (SRPK) family, SRPK1 and SRPK2, phosphorylate the hepatitis B core protein (Cp) and are crucial for pregenomic RNA encapsidation during viral nucleocapsid assembly. Among them, SRPK2 exhibits higher kinase activity toward Cp. In this study, we identified Cp sites that are phosphorylated by SRPK2 and demonstrated that the kinase utilizes an SRPK-specific docking groove to interact with and regulate the phosphorylation of the C-terminal arginine rich domain of Cp. We determined that direct interaction between the docking groove of SRPK2 and unphosphorylated Cp inhibited premature viral capsid assembly in vitro, whereas the phosphorylation of the viral protein reactivated the process. Pull-down assays together with the new cryo-electron microscopy structure of the HBV capsid in complex with SRPK2 revealed that the kinases decorate the surface of the viral capsid by interacting with the C-terminal domain of Cp, underscoring the importance of the docking interaction in regulating capsid assembly and pregenome packaging. Moreover, SRPK2-knockout in HepG2 cells suppressed Cp phosphorylation, indicating that SRPK2 is an important cellular kinase for HBV life cycle.

Primary Rotator Cuff Bridging Reconstruction Shows Better Clinical and Radiographic Results Than Revision Bridging Reconstruction.

Purpose: To evaluate the outcome of revision rotator cuff bridging reconstruction (BR) as compared to primary BR in a large cohort of patients. Methods: A retrospective chart review was conducted for patients who underwent BR using dermal allograft for large/massive rotator cuff tears between 2010 and 2018. Patients who completed Western Ontario Rotator Cuff Index (WORC) and Disability of the Arm, Shoulder, and Hand (DASH) scores both pre- and postoperatively were included. Pre- and postoperative magnetic resonance imaging scans were compared to assess for differences in fatty infiltration, muscle atrophy, and graft status. Results: Eighty patients met the inclusion criteria, including 43 patients who underwent BR as a primary surgery and 37 patients who underwent revision BR. The mean follow-up duration was 5.7 ± 1.9 years in the primary group and 5.8 ± 2.0 years in the revision group. Both WORC and DASH scores significantly improved from pre- to postoperatively for both the primary and revision groups (P < .05). The primary group had significantly better postoperative WORC and DASH scores at 6 months, 1 year, and final follow-up (P < .05). Failure rate of the graft was higher in the revision group compared to primary group (14.3% vs 6.1%, respectively; P = .337), and the amount of fatty infiltration of supraspinatus and infraspinatus muscles significantly improved in patients who received primary BR compared to revision BR (P < .05). Conclusions: BR using dermal allograft for large/massive irreparable rotator cuff tears showed improvement of functional outcomes, with primary cases resulting in better improvement in patient-reported outcomes compared to revision cases. Primary BR was also associated with better postoperative fatty infiltration of supraspinatus and infraspinatus muscles. Level of Evidence: Level III, retrospective cohort study.

Arthroscopic capsular shift from inferior to superior has an exceptional safety profile and short-term outcomes.

OBJECTIVES: Arthroscopic Bankart for anterior shoulder instability has a good safety profile but with a relatively high recurrence index. Open surgery has been used to decrease recurrence rates but with a higher complication rate. Arthroscopic capsular shift from inferior to superior (ACSIS) was designed to decrease the recurrence rates without the added morbidity of open surgery. METHODS: An observational retrospective study was conducted to analyze perioperative complications and patient reported outcomes of patients treated with ACSIS to determine the safety profile of the procedure. The patients with anterior traumatic shoulder instability treated with ACSIS between January 2015 and December 2021 were included for the study. The analysis was conducted using SPSS (Version 27). The pre vs. postoperative Western Ontario Shoulder Instability Index scores were compared using a paired sample t-test or Wilcoxon signed ranks test depending on the results of the normality test and Levene's test. The significance level was 0.05 in all analyses. Thirty-six patients were included in this study, the mean age of the population is 30.8 â€‹± â€‹11.4 years, with a male dominance of 86.1% (N â€‹= â€‹31), and a mean clinical follow-up of 2.7 â€‹± â€‹1.2 years. RESULTS: No intraoperative complications, including bleeding or neurovascular injury, were noted. Additionally, no early postoperative complications, including infection or hospital readmission, were noted. During the follow-up, one patient (3%) had persistent apprehension. The mean Western Ontario Shoulder Instability index decreased from 66.6 â€‹± â€‹13.10% to 27.9 â€‹± â€‹22% postoperatively (P â€‹< â€‹0.001). CONCLUSIONS: ACSIS procedure is safe and has good short-term outcomes with a low recurrence rate at 1-year minimum follow-up. LEVEL OF EVIDENCE: 3 (Observational study).

Venovenous extracorporeal membrane oxygenation for respiratory failure refractory to high frequency percussive ventilation.

BACKGROUND: High frequency percussive ventilation (HFPV) has demonstrated improvements in gas exchange, but not in clinical outcomes. OBJECTIVES: We utilize HFPV in patients failing conventional ventilation (CV), with rescue venovenous extracorporeal membrane oxygenation (VV ECMO) reserved for failure of HFPV, and we describe our experience with such a strategy. METHODS: All adult patients (age >18 years) placed on HFPV for failure of CV at a single institution over a 10-year period were included. Those maintained on HFPV were compared to those that failed HFPV and required VV ECMO. Survival was compared to expected survival after upfront VV ECMO as estimated by VV ECMO risk prediction models. RESULTS: Sixty-four patients were placed on HFPV for failure of CV over a 10-year period. After HFPV initiation, the P/F ratio rose from 76mmHg to 153.3mmHg in the 69 % of patients successfully maintained on HFPV. The P/F ratio only rose from 60.3mmHg to 67mmHg in the other 31 % of patients, and they underwent rescue ECMO with the P/F ratio rising to 261.6mmHg. The P/F ratio continued to improve in HFPV patients, while it declined in ECMO patients, such that at 24 h, the P/F ratio was greater in HFPV patients. The strongest independent predictor of failure of HFPV requiring rescue VV ECMO was a lower pO2 (p = .055). Overall in-hospital survival (59.4 %) was similar to that expected with upfront ECMO (RESP score: 57 %). CONCLUSIONS: HFPV demonstrated significant and sustained improvements in gas exchange and may obviate the need for ECMO and its associated complications.

Arthroscopy Association of Canada Position Statement on Opioid Prescription After Arthroscopic Surgery.

Background: Despite the ongoing opioid epidemic, most patients are still prescribed a significant number of opioid medications for pain management after arthroscopic surgery. There is a need for consensus among orthopaedic surgeons and solutions to aid providers in analgesic strategies that reduce the use of opioid pain medications. Purpose: This position statement was developed with a comprehensive systematic review and meta-analysis of exclusively randomized controlled trials (RCTs) to synthesize the best available evidence for managing acute postoperative pain after arthroscopic surgery. Study Design: Position statement. Methods: The Embase, MEDLINE, PubMed, Scopus, and Web of Science databases were searched from inception until August 10, 2022. Keywords included arthroscopy, opioids, analgesia, and pain, and associated variations. We included exclusively RCTs on adult patients to gather the best available evidence for managing acute postoperative pain after arthroscopic surgery. Patient characteristics, pain, and opioid data were extracted, data were analyzed, and trial bias was evaluated. Results: A total of 21 RCTs were identified related to the prescription of opioid-sparing pain medication after arthroscopic surgery. The following recommendations regarding noninvasive, postoperative pain management strategies were made: (1) multimodal oral nonopioid analgesic regimens-including at least 1 of acetaminophen-a nonsteroidal anti-inflammatory drug-can significantly reduce opioid consumption with no change in pain scores; (2) cryotherapy is likely to help with pain management, although the evidence on the optimal method of application (continuous-flow vs ice pack application) is unclear; (3) and (4) limited RCT evidence supports the efficacy of transcutaneous electrical nerve stimulation and relaxation exercises in reducing opioid consumption after arthroscopy; and (5) limited RCT evidence exists against the efficacy of transdermal lidocaine patches in reducing opioid consumption. Conclusion: A range of nonopioid strategies exist that can reduce postarthroscopic procedural opioid consumption with equivalent vocal pain outcomes. Optimal strategies include multimodal analgesia with education and restricted/reduced opioid prescription.

My Approach to Failed Rotator Cuff Repair.

Failed rotator cuff repairs pose several challenges due to the high incidence rate, complexity, and range of symptoms. We propose an overview for assessing and treating failed rotator cuff repairs. For active young patients, attempt revision repair with patch augmentation if possible. When anatomic revision is not viable, but muscle is retained, consider partial repair with interposition bridging. Isolated, irreparable supraspinatus tears may benefit from superior capsule reconstruction. Tendon transfer is suitable for patients with significant atrophy and multiple irreparable cuff tears. Low-demand elderly patients or those with substantial glenohumeral arthritis may consider reverse total shoulder arthroplasty if conservative management fails. There are a variety of reported outcomes in the literature but long-term studies with larger cohorts are needed to improve the management of failed rotator cuff repair.

Ruptured chordae during percutaneous mitral commissurotomy: immediate recognition by intracardiac echocardiography.

Traditionally, percutaneous mitral commissurotomy (PMC) is performed under fluoroscopy only. In difficult cases, general anesthesia with transesophageal echocardiography (TEE) guidance is needed. Intracardiac echocardiography (ICE) enables operators to perform PMC under local anesthesia while providing intra-procedural imaging guidance, as in TEE. Hereby, we describe a case of PMC guided by ICE to allow early detection of complications.

Free Bone Block Procedures for Glenoid Reconstruction in Anterior Shoulder Instability.

Advances in the understanding and management of bone loss in shoulder instability have led to the development of free bone block techniques as an alternative to the Latarjet procedure. These techniques have been proposed as a theoretically safer option to Latarjet, and there is growing clinical enthusiasm in their use. The purpose of this article was to contextualize the utilization of free bone block procedures in the current treatment paradigm of anterior shoulder instability and to review the history and common types of bone autograft (eg, iliac crest, distal clavicle, scapular spine) and allograft (eg, distal tibia, preshaped blocks) techniques and approaches, as well as their clinical effectiveness and safety.

Identification of microbial community in the urban environment: The concordance between conventional culture and nanopore 16S rRNA sequencing.

Introduction: Microbes in the built environment have been implicated as a source of infectious diseases. Bacterial culture is the standard method for assessing the risk of exposure to pathogens in urban environments, but this method only accounts for <1% of the diversity of bacteria. Recently, full-length 16S rRNA gene analysis using nanopore sequencing has been applied for microbial evaluations, resulting in a rise in the development of long-read taxonomic tools for species-level classification. Regarding their comparative performance, there is, however, a lack of information. Methods: Here, we aim to analyze the concordance of the microbial community in the urban environment inferred by multiple taxonomic classifiers, including ARGpore2, Emu, Kraken2/Bracken and NanoCLUST, using our 16S-nanopore dataset generated by MegaBLAST, as well as assess their abilities to identify culturable species based on the conventional culture results. Results: According to our results, NanoCLUST was preferred for 16S microbial profiling because it had a high concordance of dominant species and a similar microbial profile to MegaBLAST, whereas Kraken2/Bracken, which had similar clustering results as NanoCLUST, was also desirable. Second, for culturable species identification, Emu with the highest accuracy (81.2%) and F1 score (29%) for the detection of culturable species was suggested. Discussion: In addition to generating datasets in complex communities for future benchmarking studies, our comprehensive evaluation of the taxonomic classifiers offers recommendations for ongoing microbial community research, particularly for complex communities using nanopore 16S rRNA sequencing.