Defining Minimal Clinically Important Difference, Patient Acceptable Symptomatic State and Substantial Clinical Benefit for the Visual Analog Scale Pain Score After Arthroscopic Rotator Cuff Repair.

INTRODUCTION: Patient satisfaction after arthroscopic rotator cuff repair (RCR) is commonly assessed with patient-reported outcome measures (PROMs), and there is an increased need to establish clinical relevance within these measures. The purpose of this study was to (1) define Minimal Clinically Important Difference (MCID), Patient Acceptable Symptomatic State (PASS) and Substantial Clinical Benefit (SCB) for the visual analog scale (VAS) pain score in patients undergoing arthroscopic RCR, and (2) identify preoperative predictors of achieving each of these threshold values. METHODS: Data from consecutive patients who underwent primary arthroscopic rotator cuff repair study between 2010 and 2016 were prospectively collected. Baseline data and VAS pain scores were collected preoperatively and at 1 year and 2 years postoperatively. MCID, PASS and SCB were determined using an anchor-based approach, with anchor questions assessing postoperative satisfaction and expectation fulfilment. Multivariate logistic regression analysis was also used to identify preoperative predictors for achieving MCID, PASS and SCB. RESULTS: A total of 286 patients were included in the final analysis, with an average age of 60.2 ± 10.4 and the majority being female (61.2%). The values for VAS pain score identified to represent MCID, PASS, and SCB, respectively at 1-year postoperatively were: 5, 2 and 1. The rates of achieving clinically significant improvement based on VAS were 60.5%, 63.3% and 57.2% respectively. A higher preoperative VAS was predictive for achieving MCID (odds ratio [OR], 1.84; P<0.01). CONCLUSION: This study identified threshold VAS pain scores of 5, 2 and 1 for achieving MCID, PASS, and SCB, respectively, at 1-year follow-up after arthroscopic rotator cuff repair. A higher preoperative VAS pain score was also identified as a statistically significant predictor of attaining MCID after arthroscopic rotator cuff repair. LEVEL OF EVIDENCE: II.

Short- to medium-term outcomes and future direction of reverse shoulder arthroplasty: Current concepts.

Reverse shoulder arthroplasty is typically indicated for patients with severe shoulder osteoarthritis, rotator cuff tear arthropathy, or proximal humerus fractures that have failed to heal properly. The primary goal of reverse shoulder arthroplasty is to improve shoulder function and reduce pain, while also restoring the ability to perform daily activities. There is a growing body of evidence supporting the effectiveness of reverse shoulder arthroplasty in improving shoulder function and reducing pain in patients with severe shoulder osteoarthritis or rotator cuff tear arthropathy. Reverse shoulder arthroplasty is associated with significant improvements in shoulder function and pain reduction compared to non-surgical treatments. This paper aims to summarize current knowledge, practices and present a summary of the long-term effects of reverse shoulder arthroplasty (RSA) on patient outcomes, including how these outcomes are defined and what measures are typically used to assess them. It will also cover newer definitions of outcomes for RSA that have been developed in recent years in order to better understand the long-term effects of the procedure on patient-reported outcomes and functional ability, as well as information on revision surgery and implant survivorship, and the future of RSA (3D-navigation, patient-specific instrumentation, robotics and artificial intelligence) and its effects on outcomes.

Treatment of Chronic Dislocated Patella in a Skeletally Mature Down Syndrome Patient: A Case Report.

CASE: A 55-year-old man with Down syndrome (DS) suffered from chronic irreducible right patellar dislocation. Imaging studies showed an attenuated appearance of the medial patellar retinaculum, and the tibial tubercle to trochlear groove distance measured 1.6 cm. Right medial patellofemoral ligament reconstruction (MPFLR) and lateral lengthening (LL) with proximalization of the tibial tubercle (PTT) were performed with good surgical outcomes. CONCLUSION: The combination of MPFLR, LL, and PTT is a viable option for treating a skeletally mature DS patient with patellofemoral instability causing recurrent patellar dislocation.

Determining the Minimal Clinically Important Difference on the Oxford Shoulder Instability Score in Patients Undergoing Arthroscopic Bankart Repair for Shoulder Instability.

BACKGROUND: The literature on minimal clinically important differences (MCIDs) for patient-reported outcome measures assessing shoulder instability is limited, with none addressing the Oxford Shoulder Instability Score (OSIS). The OSIS was developed to provide a standardized method for assessing shoulder function after surgery for shoulder instability, and previous studies have demonstrated its high reliability, low interrater variability, and ease of administration. PURPOSE: To identify the MCID for the OSIS after arthroscopic Bankart repair for recurrent shoulder instability. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A longitudinally maintained institutional registry was queried for patients who underwent arthroscopic Bankart repair from 2010 to 2016 for recurrent shoulder instability secondary to a Bankart lesion without significant glenoid bone loss. The OSIS was completed preoperatively and at 1 year postoperatively. Patients were categorized into "expectations met" and "expectations unmet" groups using a questionnaire evaluating expectation fulfilment. The MCID of the OSIS at 1 year was calculated using 3 anchor-based approaches and a distribution-based approach. The 3 anchor-based approaches comprised (1) simple linear regression analysis, (2) receiver operating characteristic curve analysis, and (3) calculation of mean differences in change for the OSIS between the "expectations met" and "expectations unmet" groups. RESULTS: The study cohort comprised 68 men and 11 women aged 29.9 ± 12.7 years (mean ± SD). Duration of follow-up for all patients exceeded 1 year. The MCIDs for the OSIS based on the 4 calculation approaches yielded a narrow range of values, ranging from 7.7 to 8.5 for the anchor-based methods and 8.6 for the distribution-based method. CONCLUSION: Study results indicated that patients with recurrent shoulder instability without significant bone loss who undergo primary arthroscopic Bankart repair and have at least 8.6 points of improvement on their OSIS experience a clinically significant change at 1 year postoperatively.

Arthroscopic Management of Scapulothoracic Bursitis: Clinical Outcomes and Assessment of Novel Bony Parameters on Magnetic Resonance Imaging.

BACKGROUND: Scapulothoracic bursitis is a significant clinical condition that limits day-to-day function. Arthroscopic scapular debridement and resection have provided satisfactory outcomes; however, techniques, approaches, and recommendations remain varied. Novel bony parameters have also gained increasing interest owing to their value in preoperative planning. PURPOSE: To assess midterm clinical outcomes after the arthroscopic management of scapulothoracic bursitis and to identify and measure novel bony parameters on preoperative magnetic resonance imaging. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 8 patients underwent arthroscopic scapular debridement and bursectomy; 5 of the 8 patients underwent additional medial scapulectomy. There were 5 male (62.5%) and 3 female (37.5%) patients with a mean age of 30.1 ± 12.3 years (range, 19-58 years). Inclusion criteria for surgery were patients with symptomatic scapulothoracic bursitis for whom extensive nonoperative modalities had been utilized for at least 6 months but failed. Outcome measures included the Oxford Shoulder Score (OSS), University of California Los Angeles (UCLA) shoulder rating scale, Constant Shoulder Score (CSS), and visual analog scale (VAS) for pain. The bony parameters included scapular shape, anterior offset, costomedial angle, and medial scapular corpus angle (MSCA). RESULTS: The follow-up duration was at least 2 years for all patients (mean follow-up, 25.0 ± 4.1 months [range, 24-35 months]). The majority of patients had a concave-shaped scapula (62.5%). The mean anterior offset was 24.3 ± 3.4 mm, and the mean costomedial angle was 132.3° ± 9.6°. Half the patients had a positive MSCA, while the other half had a negative MSCA. A statistically significant improvement was observed in the OSS, UCLA, CSS, and VAS scores from preoperatively to 2-year follow-up (P < .001 for all). No complications were observed. CONCLUSION: Arthroscopic scapular debridement and resection provided satisfactory midterm clinical outcomes for the treatment of scapulothoracic bursitis.

No difference in long-term outcomes between men and women undergoing medial fixed-bearing cemented unicompartmental knee arthroplasty: A retrospective cohort study with minimum 10-year follow up.

BACKGROUND: Some studies have suggested that women have poorer short-term outcomes after unicompartmental knee arthroplasty (UKA) due to a higher incidence of implant overhang. This study aimed to compare patient-reported outcome measures (PROMs) between men and women after UKA at a minimum follow-up of 10 years. METHODS: Patients who underwent medial fixed-bearing UKA by two arthroplasty surgeons were identified from an institutional joint registry. Men and women were matched for age, body mass index, Charlson Comorbidity Index, American Society of Anesthesiologists class, range-of-motion and baseline PROMs using propensity scores. PROMs were compared at 2 and 10 years. Patients also completed a satisfaction questionnaire during these visits. Radiographic outliers were defined as > 2 mm of overhang. RESULTS: A total of 128 patients were included. There was no difference in complications, length of stay or readmissions. Women had poorer Knee Society functional scores, Short-Form 36 physical and mental component scores (SF-36 MCS) at 2 years. No difference in PROMs was found at 10 years, except for poorer SF-36 MCS in women (P = 0.041). At 10 years, 96% of women and 92% of men were satisfied (P = 0.243). Fifteen-year survivorship free from any revision was 96% in each group. There were more medial-tibial outliers in women (9%) compared with men (5%) (P = 0.018). However, no association between outliers and outcomes or survivorship was found on multivariate analyses. CONCLUSION: There was nodifference in clinical outcomes between men and women undergoing UKA at a minimum follow-up of 10 years. While women had a higher incidence of medial tibial overhang, this was not associated with long-term outcomes or survivorship.

Knee subchondroplasty for management of subchondral bone cysts: a novel treatment method.

Knee subchondroplasty (SCP) is one of the most novel minimally invasive methods for treating bone marrow lesions. The literature suggests that it is safe, with few complications and good outcomes. However, no studies have documented its usage for managing large subchondral bone cysts. This article outlines a case report and details the pearls and pitfalls of SCP in treating large subchondral bone cysts. Our patient underwent arthroscopic debridement with medial femoral condyle SCP. Mild posterior extravasation of synthetic bone substitute was observed on Postoperative Day 1, which was immediately rectified on revision arthroscopy. Gradual escalation of weight bearing and good pain relief were subsequently achieved, and the patient has remained complication-free after two years. No further extravasation were observed on repeat radiography. SCP is a feasible temporising measure that may help to delay the need for bone allograft or immediate knee arthroplasty in younger patients while retaining function and delaying loss of productivity.

Incidence of deep vein thrombosis and pulmonary embolism in Asian patients after direct anterior total hip arthroplasty.

OBJECTIVE: Venous thromboembolism (VTE), comprising either deep vein thrombosis (DVT) and pulmonary embolism (PE), is one of the most significant complications after Total Hip Arthroplasty (THA). The incidence of VTE after Direct Anterior Approach (DAA) hip arthroplasty is not known. Preceding studies have shown that internal femoral rotation used in the posterior approach leads to "scissoring" of the femoral vein and complete occlusion of flow. In contrast, external femoral rotation, utilized in an anterior approach, does not lead to any limitation in venous flow. We hypothesize that the rate of VTE post-operatively after DAA THA is comparable, if not lower, to other conventional approaches. METHODS: Retrospective analysis of medical records was examined to identify the incidence of symptomatic DVT within 6 months post-surgery, yielding 196 cases of elective primary DAA after THAs between 2015 and 2019. Aspirin was administered post-operatively. Corresponding imaging was performed for cases with high clinical suspicion of either DVT or PE based on Well's criteria. RESULTS: There were no cases of symptomatic DVT or fatal PE within 1 year of THA. There was 1 case of non-fatal subsegmental pulmonary embolism, treated with warfarin, which made an uneventful recovery. The overall incidence of symptomatic DVT and PE after DAA THA was 0% and 0.5% respectively in our study population. CONCLUSION: Cumulative rate of symptomatic DVT and PE was less than 1%, demonstrating that incidence of VTE after DAA THA is low. DAA is a viable approach in Asian patients undergoing THA, in view of lower incidence of post-operative VTE compared values cited in other conventional surgical approaches. Further large scale studies involving use of routine post-operative venography for assessment will further validate our results.

Unicompartmental knee arthroplasty in patients with Parkinson's disease.

BACKGROUND: Parkinson's disease (PD) adversely affects physical function after joint replacement. The biomechanical advantages of unicompartmental knee arthroplasty (UKA) may be particularly beneficial for these patients who suffer from gait and kinetic abnormalities. We aimed to describe the functional outcomes, complications and survivorship after UKA in patients with PD. METHODS: Ten patients (11 knees) undergoing primary fixed-bearing UKA for medial osteoarthritis were studied. Knee Society Knee (KSKS) and Function Scores (KSFS), as well as the Short-Form-36 (SF-36) Mental (MCS) and Physical Component Scores (PCS) were assessed preoperatively, at six months and at two years postoperatively. Complications, survivorship and all-cause mortality were analyzed. RESULTS: No perioperative complications occurred. Length of stay was 5 ± 2 days and no patients were discharged to rehabilitation or readmitted. Nine of 11 knees had a flexion contracture preoperatively and this remained unchanged at two years. KSKS and SF-36 PCS improved significantly. However, there was no improvement in KSFS or SF-36 MCS. All patients achieved minimal clinically important difference for KSKS, six of 11 for KSFS and nine of 11 for SF-36 PCS. At mean 10 ± 5 years, there was one revision for progression of osteoarthritis. Seven of 10 patients progressed in Hoehn and Yahr stage and only three were able to ambulate independently at last follow-up. CONCLUSIONS: Patients suffering from osteoarthritis and PD can experience a substantial improvement in knee pain with low morbidity after UKA. However, the improved kinematics of UKA did not translate to an improved range of motion or knee function postoperatively.

Dyslipidemia With Perioperative Statin Usage Is Not Associated With Poorer 24-Month Functional Outcomes After Arthroscopic Rotator Cuff Surgery.

BACKGROUND: Current literature suggests a higher rate of rotator cuff disease development in patients with dyslipidemia (DL). Moderate to high levels of DL are associated with higher rates of retear and revision surgery after arthroscopic rotator cuff repair. Statins protect against development of rotator cuff disease and mitigate the need for rotator cuff repair. PURPOSE: We aimed to investigate the influence of DL and statin use on postoperative functional outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Between 2010 and 2016, 266 patients underwent arthroscopic double-row rotator cuff repair for atraumatic full-thickness tears. Evaluation was conducted preoperatively and at 3, 6, 12, and 24 months postoperatively. Three functional outcome measures were used (Constant Shoulder Score [CSS], Oxford Shoulder Score [OXF], and University of California, Los Angeles, Shoulder Rating Scale [UCLASS]), as well as a visual analog scale (VAS) for pain. DL and non-DL were classified through screening of health and assessment of lipid levels within 6 months of surgery (triglycerides, total cholesterol, low-density lipoprotein, and high-density lipoprotein). Patients with DL were divided into statin users and nonusers. Types and dosages of statins were recorded, and intensity and equivalency charts were employed for standardization. Mann-Whitney U test and Pearson chi-square test were used for analysis. Generalized estimating equations and linear mixed models were used to examine the influence of DL and statin dosage, respectively on percentage change of postoperative outcome scores. RESULTS: Increased age was associated with a higher incidence of DL (P < .001), and 86% of the DL group was taking statins. The DL group also exhibited poorer scores preoperatively (CSS, P = .001; OXF, P = .032). No significant difference in scores was elicited between the DL and non-DL groups at 24 months. However, patients with DL experienced greater percentage improvement of CSS and OXF from preoperative baseline than did patients without DL (P = .008 and P = .034, respectively) at 24 months. There was no significant difference in 24-month functional outcomes between statin users and nonusers. No statistically significant change of CSS; OXF; UCLASS; or VAS was noted with increasing statin doses at 24 months. CONCLUSION: Patients with DL with perioperative statin usage did not have poorer 24-month functional outcomes after arthroscopic rotator cuff surgery compared with those in patients without DL.

Induced Membrane Bone Grafting Technique for Treatment of Large Postinfectious Acetabular Bone Defects.

Management of large acetabular bone defects is challenging. The Masquelet technique has successfully reconstructed segmental defects in long bones arising from trauma, tumors, or infection but not been described for large acetabular defects. We present 3 cases of large acetabular bone defects arising from chronic prosthetic joint infection, treated via a novel induced membrane bone grafting technique, drawn from the Masquelet technique. All cases showed satisfactory clinical and radiological outcomes at midterm follow-up. This technique holds promise and can be an alternative means when treating large acetabular bone defects.