Arthroscopic management of isolated partial-thickness rotator cuff tears.

PURPOSE: The aim of the present study is to provide a comprehensive review on the surgical outcomes following arthroscopic treatments of partial-thickness rotator cuff tears (PT-RCTs) and to compare the postoperative American Shoulder and Elbow Surgeons (ASES) score following in situ transtendon repair and tear completion, followed by repair. METHODS: Medline, EMBASE, Scopus, CINAHL and CENTRAL bibliographic databases were searched. Papers including patients with PT-RCTs of any grade who underwent treatment using debridement, in situ transtendon repair, tear completion and repair or bioinductive collagen implants were reviewed. Primary PT-RCTs were the sole indication for surgery. Primary postoperative outcomes assessed included the ASES score, the Absolute Constant-Murley score, the Simple Shoulder Test, the Visual Analogue Scale, the University of California-Los Angeles Shoulder Scale, the Western Ontario Rotator Cuff Score, range of motion, complications and revisions. A meta-analysis of comparative studies compared the postoperative ASES score between patients treated with in situ transtendon repair versus tear completion repair. RESULTS: Twenty-eight studies were included. The ASES score was reported by four comparative studies with contrasting results. The heterogeneity was high (I2 = 86%), and effect sizes ranged from -0.49 in favour of the tear completion and repair technique to an effect size of +1.07 favouring in situ transtendon repair. The overall effect size of 0.02 suggests an equivalence between the two techniques in terms of the ASES score. Two studies with a total sample size of 111 patients reported on debridement, and four studies with a total sample size of 155 patients reported on bioinductive collagen implants. CONCLUSION: Debridement alone is suitable for Ellman grades I-II PT-RCTs. In situ transtendon and tear completion repair techniques yield similar postoperative outcomes. Bioinductive collagen implants hold promise but lack long-term efficacy data. High-quality comparative studies are needed to determine the best treatment for PT-RCTs. LEVEL OF EVIDENCE: Level IV.

Augmented versus non-augmented locking-plate fixation in proximal humeral fractures.

Aims: Proximal humeral fractures are the third most common fracture among the elderly. Complications associated with fixation include screw perforation, varus collapse, and avascular necrosis of the humeral head. To address these challenges, various augmentation techniques to increase medial column support have been developed. There are currently no recent studies that definitively establish the superiority of augmented fixation over non-augmented implants in the surgical treatment of proximal humeral fractures. The aim of this systematic review and meta-analysis was to compare the outcomes of patients who underwent locking-plate fixation with cement augmentation or bone-graft augmentation versus those who underwent locking-plate fixation without augmentation for proximal humeral fractures. Methods: The search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Articles involving patients with complex proximal humeral fractures treated using open reduction with locking-plate fixation, with or without augmentation, were considered. A meta-analysis of comparative studies comparing locking-plate fixation with cement augmentation or with bone-graft augmentation versus locking-plate fixation without augmentation was performed. Results: A total of 19 studies were included in the qualitative synthesis, and six comparative studies were included in the meta-analysis. Overall, 120 patients received locking-plate fixation with bone-graft augmentation, 179 patients received locking-plate fixation with cement augmentation, and 336 patients received locking-plate fixation without augmentation. No statistically relevant differences between the augmented and non-augmented cohorts were found in terms of the Disabilities of the Arm, Shoulder and Hand questionnaire score and Constant-Murley Score. The cement-augmented group had a significantly lower rate of complications compared to the non-augmented group. Conclusion: While locking-plate fixation with cement augmentation appears to produce a lower complication rate compared to locking-plate fixation alone, functional outcomes seem comparable between augmented and non-augmented techniques.

Role of the Gut Microbiota in Osteoarthritis, Rheumatoid Arthritis, and Spondylarthritis: An Update on the Gut-Joint Axis.

Dysregulation of the gut microbiota and their metabolites is involved in the pathogenic process of intestinal diseases, and several pieces of evidence within the current literature have also highlighted a possible connection between the gut microbiota and the unfolding of inflammatory pathologies of the joints. This dysregulation is defined as the "gut-joint axis" and is based on the joint-gut interaction. It is widely recognized that the microbiota of the gut produce a variety of compounds, including enzymes, short-chain fatty acids, and metabolites. As a consequence, these proinflammatory compounds that bacteria produce, such as that of lipopolysaccharide, move from the "leaky gut" to the bloodstream, thereby leading to systemic inflammation which then reaches the joints, with consequences such as osteoarthritis, rheumatoid arthritis, and spondylarthritis. In this state-of-the-art research, the authors describe the connections between gut dysbiosis and osteoarthritis, rheumatoid arthritis, and spondylarthritis. Moreover, the diagnostic tools, outcome measures, and treatment options are elucidated. There is accumulating proof suggesting that the microbiota of the gut play an important part not only in immune-mediated, metabolic, and neurological illnesses but also in inflammatory joints. According to the authors, future studies should concentrate on developing innovative microbiota-targeted treatments and their effects on joint pathology as well as on organizing screening protocols to predict the onset of inflammatory joint disease based on gut dysbiosis.

The influence of gut microbiome on periprosthetic joint infections: State-of-the art.

Early periprosthetic joint infection constitutes one of the most frightening complications of joint replacement. Recently, some evidence has highlighted the potential link between dysregulation of the gut microbiota and degenerative diseases of joints. It has been hypothesized that microbiome dysbiosis may increase the risk of periprosthetic joint infection by facilitating bacterial translocation from these sites to the bloodstream or by impairing local or systemic immune responses. Although the processes tying the gut microbiome to infection susceptibility are still unknown, new research suggests that the presurgical gut microbiota-a previously unconsidered component-may influence the patient's ability to resist infection. Exploring the potential impact of the microbiome on periprosthetic joint infections may therefore bring new insights into the pathogenesis and therapy of these disorders. For a successful therapy, a proper surgical procedure in conjunction with an antibacterial concept is essential. As per the surgical approach, different treatment strategies include surgical irrigation, debridement, antibiotic therapy, and implant retention with or without polyethylene exchange. Other alternatives could be one-stage or two-stage revisions surgery. Interventions that either directly target gut microbes as well as interventions that modify the composition and/or function of the commensal microbes represent an innovative and potentially successful field to be explored. In recent times, innovative therapeutic methods have arisen in the realm of microbiome restoration and the management of gut-related ailments. These progressive approaches offer fresh perspectives on tackling intricate microbial imbalances in the gastrointestinal tract. These emerging therapies signify a shift towards more precise and individualized approaches to microbiome restoration and the management of gut-related disorders. Once a more advanced knowledge of the pathways linking the gut microbiota to musculoskeletal tissues is gained, relevant microbiome-based therapies can be developed. If dysbiosis is proven to be a significant contributor, developing treatments for dysbiosis may represent a new frontier in the prevention of periprosthetic joint infections.

Debridement, antibiotics, and implant retention (DAIR) for the early prosthetic joint infection of total knee and hip arthroplasties: a systematic review.

PURPOSE: Early periprosthetic joint infection (PJI) represents one of the most fearsome complications of joint replacement. No international consensus has been reached regarding the best approach for early prosthetic knee and hip infections. The aim of this updated systematic review is to assess whether debridement, antibiotics, and implant retention (DAIR) is an effective choice of treatment in early postoperative and acute hematogenous PJI. METHODS: This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The diagnostic criteria defining a PJI, the most present pathogen, and the days between the index procedure and the onset of the PJI were extracted from the selected articles. Additionally, the mean follow-up, antibiotic regimen, and success rate of the treatment were also reported. RESULTS: The articles included provided a cohort of 970 patients. Ten studies specified the joint of their cohort in PJIs regarding either hip prostheses or knee prostheses, resulting in 454 total knees and 460 total hips. The age of the patients ranged from 18 to 92 years old. Success rates for the DAIR treatments in the following cohort ranged from 55.5% up to a maximum of 90% (mean value of 71%). CONCLUSION: Even though the DAIR procedure is quite limited, it is still considered an effective option for patients developing an early post-operative or acute hematogenous PJI. However, there is a lack of studies, in particular randomized control trials (RCTs), comparing DAIR with one-stage and two-stage revision protocols in the setting of early PJIs, reflecting the necessity to conduct further high-quality studies to face the burden of early PJI.

Evaluating the Minimum Clinically Important Difference and Patient Acceptable Symptom State for the Womac Osteoarthritis Index after Unicompartmental Knee Arthroplasty.

Patient-Reported Outcome Measures (PROMs) are standardized questionnaires that gather information on health-related quality of life directly from patients. Since a significant statistical mean change may not correspond to a clinical improvement, there is a need to calculate a considerable change in scores. This is done by the Minimum Clinically Important Difference (MCID) and Patient Acceptable Symptom State (PASS). The objective of this article is to report the MCID and the PASS values of the WOMAC (Western Ontario and McMaster University) osteoarthritis index for patients undergoing Unicompartmental Knee Arthroplasty (UKA). A total of 37 patients (25 females and 12 males; mean age 68 ± 8.1 years and mean BMI 28.7 ± 4) who underwent UKA were enrolled. All patients were assessed using the WOMAC and the Oxford Knee Score (OKS) questionnaires before and six months following the procedure. To measure the cut-off values for MCID, distribution methods and anchor methods were applied, while the PASS was assessed only via anchor approaches. The MCID related to the WOMAC average global score was 90.7 ± 7.6, the average pain dimension score was 93.2 ± 6.6, the average stiffness dimension score was 92.6 ± 17, and the average physical function dimension score was 89.7 ± 7.6. In terms of PASS, the normalized WOMAC was 82.8, the pain dimension was 87.5, the stiffness dimension was 93.7, and the functional dimension was 83.1. A 34.5 amelioration in the WOMAC score, from initial evaluation to final follow-up, using change in OKS > 5 as anchor, indicates that the patients' health state improved to a clinically significant degree. A value at least of 82.8 in WOMAC score after treatment denotes that the symptom state is deemed acceptable by most of the patients.

Application of Machine Learning Algorithms for Prognostic Assessment in Rotator Cuff Pathologies: A Clinical Data-Based Approach.

AIM: The overall aim of this proposal is to ameliorate the care of rotator cuff (RC) tear patients by applying an innovative machine learning approach for outcome prediction after arthroscopic repair. MATERIALS AND METHODS: We applied state-of-the-art machine learning algorithms to evaluate the best predictors of the outcome, and 100 RC patients were evaluated at baseline (T0), after 1 month (T1), 3 months (T2), 6 months (T3), and 1 year (T4) from surgical intervention. The outcome measure was the Costant-Murley Shoulder Score, whereas age, sex, BMI, the 36-Item Short-Form Survey, the Simple Shoulder Test, the Hospital Anxiety and Depression Scale, the American Shoulder and Elbow Surgeons Score, the Oxford Shoulder Score, and the Shoulder Pain and Disability Index were considered as predictive factors. Support vector machine (SVM), k-nearest neighbors (k-NN), naïve Bayes (NB), and random forest (RF) algorithms were employed. RESULTS: Across all sessions, the classifiers demonstrated suboptimal performance when using both the complete and shrunken sets of features. Specifically, the logistic regression (LR) classifier achieved a mean accuracy of 46.5% ± 6%, while the random forest (RF) classifier achieved 51.25% ± 4%. For the shrunken set of features, LR obtained a mean accuracy of 48.5% ± 6%, and RF achieved 45.5% ± 4.5%. No statistical differences were found when comparing the performance metrics of ML algorithms. CONCLUSIONS: This study underlines the importance of extending the application of AI methods to new predictors, such as neuroimaging and kinematic data, in order to better record significant shifts in RC patients' prognosis. LIMITATIONS: The data quality within the cohort could represent a limitation, since certain variables, such as smoking, diabetes, and work injury, are known to have an impact on the outcome.

Minimal Clinically Important Difference (MCID), Substantial Clinical Benefit (SCB), and Patient Acceptable Symptom State (PASS) of the Shoulder Disability Questionnaire (SDQ) in Patients Undergoing Rotator Cuff Repair.

The Shoulder Disability Questionnaire (SDQ) is a Patient-Reported Outcome Measure (PROM) applied to evaluate shoulder surgery outcomes. The purpose of this study is to identify the accurate Minimal Clinically Important Difference (MCID), Substantial Clinical Benefit (SCB) and Patient Acceptable Symptom State (PASS) values for the SDQ score. A total of 35 patients (21 women and 16 men, mean age 76.6 ± 3.2 years) were followed up at 6 months postoperatively. To assess the patient's health satisfaction and symptoms, anchor questions were used. The MCID and SCB values of the SDQ score for patients who underwent arthroscopic rotator cuff repair from inception to final follow-up were 40.8 and 55.6, respectively. A change of 40.8 in the SDQ score at 6 months after surgery shows that patients achieved a minimum clinically important improvement in their state of health, and a 55.6 change in the SDQ score reflects a substantial clinically important improvement. The PASS cut-off of the SDQ score at 6 months postoperatively ranged from 22.5 to 25.8. If an SDQ score of 22.5 or more is attained after surgery, the health condition can be recognized as acceptable by the majority of patients. These cut-offs will help with understanding specific patient results and allow clinicians to personally assess patient improvement after rotator cuff repair.

Total Hip Replacement: Psychometric Validation of the Italian Version of Forgotten Joint Score (FJS-12).

BACKGROUND: One million Total Hip Replacements (THA) are thought to be performed annually. To measure prosthesis awareness throughout daily activities, the FJS-12 patient-reported outcome scale was developed. This article's goal is to undertake a psychometric validation of the Italian FJS-12 among a sample of related THA patients. METHODS: Between January and July 2019, data from 44 patients were retrieved. The participants were required to complete the Italian version of FJS-12 and of the WOMAC at preoperative follow-up, after two weeks, 1, 3, and 6 months postoperatively. RESULTS: The Pearson correlation coefficient between the FJS-12 and WOMAC was 0.287 (p = 0.002) at preoperative follow-up, r = 0.702 (p < 0.001) at 1 month, r = 0.516 (p < 0.001) at 3 months and r = 0.585 (p < 0.001) at 6 months. The ceiling effect surpassed the acceptable range (15%) for FJS-12 in 1 month (25.5%) and WOMAC in 6 months follow-up (27.3%). CONCLUSIONS: The psychometric validation of the Italian version of this score for THA was executed with acceptable results. FJS-12 and WOMAC reported no ceiling and floor effects. Therefore, to distinguish between patients who had good or exceptional results following UKA, the FJS-12 could be a reliable score. Under the first four months, FJS-12 had a smaller ceiling effect than WOMAC. It is recommended to use this score in clinical research concerning the outcomes of THA.

Establishing the Minimum Clinically Significant Difference (MCID) and the Patient Acceptable Symptom Score (PASS) for the Hospital Anxiety and Depression Scale (HADS) in Patients with Rotator Cuff Disease and Shoulder Prosthesis.

Insufficiently treated shoulder pain may cause mental disturbances, including depression and anxiety. The Hospital Anxiety and Depression Scale (HADS) is a patient-reported outcome measure (PROM) that aims to identify depression and anxiety in patients in nonpsychiatric wards. The aim of this study was to identify the minimum clinically important difference (MCID) and patient acceptable symptom state (PASS) scores for the HADS in a cohort of individuals with rotator cuff disease. Using the HADS, participants' degrees of anxiety and depression were assessed at inception and at their final assessment 6 months after surgery. To calculate the MCID and the PASS, distribution and anchor approaches were employed. The MCID from inception to final assessment was 5.7 on the HADS, 3.8 on the HADS-A, and 3.3 on the HADS-D. A 5.7 amelioration on the HADS score, 3.8 on the HADS-A, and 3.3 on the HADS-D, from inception to final assessment, meant that patients had reached a clinically meaningful improvement in their symptom state. The PASS was 7 on the HADS, 3.5 on the HADS-A, and 3.5 on the HADS-D; therefore, for the majority of patients, a score of at least 7 on the HADS, 3.5 on the HADS-A, and 3.5 on the HADS-D at final evaluation was considered a satisfactory symptom state.

Minimum Clinically Important Difference (MCID) and Patient Acceptable Symptomatic State (PASS) Applied to the SF-36 in Patients Who Underwent Arthroscopic Rotator Cuff Repair.

The 36-Item Short-Form Health Survey questionnaire (SF-36) is a reliable tool to assess the health-related quality of life of patients. If a mean difference between pre-operative evaluation and final follow-up is found to be statistically significant, then the change in score is not random. However, a statistically significant mean change may not correspond to a clinical amelioration for the patient or mean that the patient's state of health is to be considered acceptable. For this reason, interest in the concepts of minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) has grown within recent years. The goal of the present work of research was to determine the MCID and PASS values for the SF-36 in patients who received rotator cuff repair (RCR). Forty-six patients (18 women and 28 men, mean age 58.5 ± 12.9) previously diagnosed with rotator cuff disease were enrolled. All of these patients underwent RCR. They were evaluated pre-operatively and six months after the surgical intervention as a final follow-up. The SF-36 questionnaire was assessed at each evaluation. The MCID cut-offs of the total, physical, and mental dimensions of the SF-36 for patients who underwent RCR were 23.1, 32.5, and 18.1, respectively. A 23.1 improvement in the SF-36 score at six months following RCR can be correlated with patients having reached a clinically significant improvement in health status. If 81.9 or more is attained in the SF-36 score after surgical repair, the symptom state can be judged as satisfactory by the majority of patients.

Optical Motion Capture Systems for 3D Kinematic Analysis in Patients with Shoulder Disorders.

Shoulder dysfunctions represent the third musculoskeletal disorder by frequency. However, monitoring the movement of the shoulder is particularly challenging due to the complexity of the joint kinematics. The 3D kinematic analysis with optical motion capture systems (OMCs) makes it possible to overcome clinical tests' shortcomings and obtain objective data on the characteristics and quality of movement. This systematic review aims to retrieve the current knowledge about using OMCs for 3D shoulder kinematic analysis in patients with musculoskeletal shoulder disorders and their corresponding clinical relevance. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used to improve the reporting of the review. Studies employing OMCs for 3D kinematic analysis in patients with musculoskeletal shoulder disorders were retrieved. Eleven articles were considered eligible for this study. OMCs can be considered a powerful tool in orthopedic clinical research. The high costs and organizing complexities of experimental setups are likely outweighed by the impact of these systems in guiding clinical practice and patient follow-up. However, additional high-quality studies on using OMCs in clinical practice are required, with standardized protocols and methodologies to make comparing clinical trials easier.

The Role of Humeral Neck-Shaft Angle in Reverse Total Shoulder Arthroplasty: 155° versus <155°­A Systematic Review

The aim of this study was to have updated scrutiny of the influence of the humeral neck-shaft angle (HNSA) in patients who underwent reverse shoulder arthroplasty (RSA). A PRISMA-guided literature search was conducted from May to September 2021. Clinical outcome scores, functional parameters, and any complications were reviewed. Eleven papers were identified for inclusion in this systematic review. A total of 971 shoulders were evaluated at a minimum-follow up of 12 months, and a maximum of 120 months. The sample size for the "HNSA 155°" group is 449 patients, the "HNSA 145°" group involves 140 patients, and the "HSNA 135°" group comprises 291 patients. The HNSA represents an important variable in choosing the RSA implant design for patients with rotator cuff arthropathy. Positive outcomes are described for all the 155°, 145°, and 135° HSNA groups. Among the different implant designs, the 155° group show a better SST score, but also the highest rate of revisions and scapular notching; the 145° cohort achieve the best values in terms of active forward flexion, abduction, ASES score, and CMS, but also the highest rate of infections; while the 135° design obtains the best results in the external rotation with arm at side, but also the highest rate of fractures. High-quality studies are required to obtain valid results regarding the best prosthesis implant.

Medialized versus Lateralized Center of Rotation in Reverse Total Shoulder Arthroplasty: A Systematic Review and Meta-Analysis.

One of the original biomechanical principles of reverse total shoulder arthroplasty (RTSA) is medialization of the center of rotation (COR) relative to the native level of the glenoid. Several authors have proposed the lateralized center of rotation, which is characterized by a lateralized (L) glenoid and medialized (M) humeral component. The aim of this review is to compare the clinical and functional outcomes of COR in medialized (M-RTSA) and lateralized (L-RTSA) RTSA in patients with uniform indications and treatment through a meta-analysis. A PRISMA-guided literature search of PubMed, Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Cochrane Clinical Answers was conducted from April to May 2021. Twenty-four studies were included in the qualitative synthesis, and 19 studies were included in the meta-analysis. Treatment with RTSA resulted in positive post-operative outcomes and low complication rates for both groups. Statistically relevant differences between L-RTSA group and M-RTSA group were found in post-operative improvement in external rotation with arm-at-side (20.4° and 8.3°, respectively), scapular notching rates (6.6% and 47.7%) and post-operative infection rates (1% and 7.7%). Both lateralized and medialized designs were shown to improve the postoperative outcomes. Nevertheless, a lateralized COR resulted in greater post-operative external rotation.