Rotator cuff repair with an interposition polypropylene mesh: A biomechanical ovine study.

BACKGROUND: Chronic large to massive rotator cuff tears are difficult to treat and re-tears are common even after surgical repair. We propose using a synthetic polypropylene mesh to increase the tensile strength of rotator cuff repairs. We hypothesize that using a polypropylene mesh to bridge the repair of large rotator cuff tears will increase the ultimate failure load of the repair. AIM: To investigate the mechanical properties of rotator cuff tears repaired with a polypropylene interposition graft in an ovine ex-vivo model. METHODS: A 20 mm length of infraspinatus tendon was resected from fifteen fresh sheep shoulders to simulate a large tear. We used a polypropylene mesh as an interposition graft between the ends of the tendon for repair. In seven specimens, the mesh was secured to remnant tendon by continuous stitching while mattress stitches were used for eight specimens. Five specimens with an intact tendon were tested. The specimens underwent cyclic loading to determine the ultimate failure load and gap formation. RESULTS: The mean gap formation after 3000 cycles was 1.67 mm in the continuous group, and 4.16 mm in the mattress group (P = 0.001). The mean ultimate failure load was significantly higher at 549.2 N in the continuous group, 426.4 N in the mattress group and 370 N in the intact group (P = 0.003). CONCLUSION: The use of a polypropylene mesh is biomechanically suitable as an interposition graft for large irreparable rotator cuff tears.

What is the optimal surgical intervention for patients with frozen shoulder and a concomitant partial-thickness rotator cuff tear?

BACKGROUND: Patients with recalcitrant frozen shoulder traditionally undergo arthroscopic capsular release. Some patients may have a concomitant partial-thickness rotator cuff tear (PTT). There is limited evidence if these PTT require repair at the same setting. We aim to compare if patients undergoing concomitant rotator cuff repair do better than patients undergoing capsular release alone. Secondarily, we aim to determine if outcomes after arthroscopic capsular release differ for patients with and without PTT. METHODS: A retrospective review of patients with frozen shoulders undergoing arthroscopic capsular release between 2012 and 2016 was performed. Patients with partial-thickness tears and patients without rotator cuff tears were included. Clinical outcomes were collected preoperatively and at 3, 6, 12 months after operation. RESULTS: There were 33 patients with PTT-15 underwent capsular release without repair (CR group), whereas 18 underwent capsular release with rotator cuff repair (RCR group). A total of 62 control patients without rotator cuff tears (No Tear) underwent arthroscopic capsular release only. For patients with PTT, there were no significant differences in preoperative demographics and function between the CR and RCR group. The CR group had significantly worse preoperative pain. At 1-year follow-up, the RCR group had significantly better internal rotation, lesser pain, and better function than the CR group. For patients undergoing capsular release only, the No Tear group had better internal rotation, lesser pain, and better function at 1 year compared with the CR group. CONCLUSION: Patients with a stiff, frozen shoulder and concomitant PTT do benefit from arthroscopic rotator cuff repair with capsular release. The benefit is evident at 1-year follow-up.

Simultaneous bilateral hallux valgus surgery: Percutaneous or conventional? Early results of a matched study from a tertiary institution.

BACKGROUND: Hallux valgus is bilateral in up to 84 % of cases. In the setting of simultaneous bilateral correction, we aim to evaluate if minimally invasive percutaneous surgery (MIS) provides any advantage compared to conventional open surgery. METHODS: 52 feet (26 patients) undergoing simultaneous bilateral MIS surgery were matched by severity of deformity to 52 feet (26 patients) undergoing simultaneous conventional open surgery. Patients were followed for a minimum of six months. Pre- and post-operative radiographs and clinical records were reviewed. RESULTS: There were no significant differences in pre-operative function or pain between both groups. Post-operatively, the mean hallux valgus angle (HVA) was significantly lower in the MIS group. (HVA MIS - 8.6; Open - 11.8, P = 0.013). There were no significant differences in post-operative outcome and patient satisfaction between both groups. CONCLUSION: This study demonstrates that simultaneous bilateral MIS hallux valgus surgery can be considered for patients with bilateral symptomatic hallux valgus.

Is single stage capsular release and rotator cuff repair suitable for rotator tears with concomitant stiffness?

INTRODUCTION: It is common for patients with a rotator cuff tear to present with shoulder stiffness. There is no consensus on the acceptable level of stiffness at time of rotator cuff repair.We aim to determine if patients with stiffness undergoing rotator cuff repair and concomitant capsular release have different outcome than those with no stiffness undergoing rotator cuff repair alone. We hypothesize that patients with stiffness will not have poorer outcome than patients with no stiffness. METHOD: We conducted a retrospective study of prospectively collected data for 47 patients who underwent arthroscopic rotator cuff repair under a single surgeon from 2010 to 2015. 25 patients were considered stiff (Stiff group) and 22 patients were considered to have no pre-operative stiffness (Non-stiff group).Range of motion and functional outcomes were collected preoperatively and post-operatively at two-years. RESULTS: There were no significant differences in gender distribution, age and cuff tear size between both groups. Pre-operatively, patients in the Stiff group had significantly poorer active range of motion (Forward flexion - Stiff 74.8° vs Non-stiff 100.2°, P = 0.001) and poorer function (Constant score - Stiff 23.5 vs Non-stiff 43.2, P < 0.001). Post-operatively, both groups of patients had increased range of motion, strength and reported lesser pain compared to pre-operation. There were no significant differences in post-operative outcomes between both groups. CONCLUSION: Single-stage surgery combining capsular release and rotator cuff repair is effective for patients with stiffness as they are able to achieve similar results to those without shoulder stiffness.

Women Do Not Have Poorer Outcomes After Minimally Invasive Lumbar Fusion Surgery: A Five-Year Follow-Up Study.

BACKGROUND: Women undergoing lumbar spine surgery report greater preoperative pain and disability and have less improvement after surgery. There is a paucity of literature on sex-related differences after minimally invasive surgery transforaminal lumbar interbody fusion (MIS TLIF) surgery. We aim to determine whether sex influences outcome after MIS TLIF at 5-year midterm follow-up. METHODS: Prospectively collected registry data for 907 patients who underwent MIS TLIF at a single institution from 2004 to 2013 were reviewed. Of these, 296 patients (94 males and 202 females) were reviewed at 5-year follow-up. All patients were assessed preoperatively and postoperatively at 2 and 5 years. Data recorded included patient demographics, Oswestry Disability Index (ODI), Short-Form 36 Physical and Mental component scores (SF-36 PCS and MCS), and the North American Spine Society lumbar spine outcome assessment instrument. RESULTS: Females who underwent MIS TLIF were generally younger (females, 52.2 years; males, 56.1 years; P = .04). Females had significantly poorer preoperative ODI (females, 49.5; males, 41.5; P < .001) and SF-36 PCS (females, 31.9; males, 35.6; P < .01) and MCS (females, 44.9; males, 49.2; P < .01) scores. At 2-year and 5-year follow-up, there were no significant differences in ODI, SF-36, and pain scores between sexes. Both groups reported similar proportions that returned to work and returned to function. There were no differences in proportion of patients who were satisfied or had their expectations fulfilled. CONCLUSIONS: Women who undergo MIS TLIF have poorer preoperative function and quality of life than men. However, women demonstrated greater improvement after surgery, attaining similar clinical outcomes at 5-year follow-up. LEVEL OF EVIDENCE: 3.

The effect of gender in hallux valgus surgery. A propensity score matched study.

BACKGROUND: Males and females who undergo hallux valgus (HV) surgery have different expectations. METHODS: Data from 439 patients, with 26 males, were prospectively collected between 2007-2015. Propensity score matching (PSM) of one male to two females was performed using logistic regression of six variables to minimize selection bias. Hallux visual analogue scale (VAS) scores, AOFAS scores, SF-36, satisfaction and expectation scores were analysed at two years. RESULTS: There were no significant differences in patient demographics after PSM. At two years, males and females attained similar VAS and AOFAS scores but males had significantly lower SF-36 general health score (males 68.7, females 79.3). 26.9% of males and 21.2% of females were not satisfied after surgery. Higher proportion of males did not have their expectations fulfilled (males 19.2%, females 5.8%) although this was not statistically significant. CONCLUSIONS: Both genders attain similar outcome at two years. There is a trend towards lower expectation fulfilment in males after surgery.

Unexplained Pain Post Total Knee Arthroplasty With an Oxford Knee Score ≥20 at 6 Months Predicts Good 2-Year Outcome.

BACKGROUND: Total knee arthroplasty (TKA) is an effective procedure for end-stage osteoarthritis of the knee. Some patients experience persistent unexplained pain post-TKA despite normal investigations. The purpose of this study is to identify which of these patients are likely to improve without any surgical intervention. We hypothesize that patients with unexplained persistent pain and a poor 6-month Oxford knee score (OKS) post-TKA can improve at 2 years. METHODS: Prospectively collected data for all primary unilateral TKA performed from June 2004 to January 2012 were analyzed to identify which patients with unexplained pain at 6 months will improve at 2 years. Patients were included if they had persistent pain and an OKS <27 at 6 months; normal radiological and clinical investigations; no infection identified; surgery performed for primary osteoarthritis. Two hundred sixty patients with OKS <27 at 6 months were analyzed. These patients were subdivided into 2 groups (group 1: 6-month OKS 20-26, group 2: 6-month OKS less than 20). RESULTS: One hundred ninety-one out of 208 (92%) patients in group 1 experienced improvement in pain and outcome at 2 years. Most of the group 1 patients attained a minimal clinically important difference in OKS of at least 5 (P < .001) at 2 years. Group 1 patients also reported better Knee Society Functional Score and Short Form Survey 36 mean scores at 2 years. CONCLUSION: In patients with unexplained pain, an OKS of at least 20 at 6 months predicts good functional outcome at 2 years.

Accelerometer-Based Navigation Is as Accurate as Optical Computer Navigation in Restoring the Joint Line and Mechanical Axis After Total Knee Arthroplasty: A Prospective Matched Study.

The Zimmer iASSIST system is a novel accelerometer-based navigation system for TKA. 76 patients (76 knees) were prospectively matched for age, BMI, gender, diagnosis, and pre-operative scores, and underwent TKA using the iASSIST (n=38) or optical CAS (n=38). There were no significant differences in clinical outcomes or satisfaction rates at six months post-operatively (P>0.05). Mechanical axis was 1.8±1.3° in the iASSIST cohort versus 2.1±1.6° in the CAS cohort (P=0.543). There were no significant differences in number of outliers for mechanical axis (P=1.000), coronal femoral-component angle (P=0.693), coronal tibial-component angle (P=0.204) or joint line deviation (P=1.000). The duration of surgery was significantly longer in the CAS group (P<0.001), while the added cost of accelerometer-based navigation was approximately $1000 per operation.

Intra-operative correction of volar tilt of distal radius fractures using volar locking plate as reduction tool: review of 24 cases.

In surgical fixation of distal radius fractures with metaphyseal comminution, volar tilt can be restored using an anatomical volar locking plate as a reduction tool. The purpose of our study is to assess the degree of over or under correction of volar tilt that can result with our 'lift' technique and to determine the ratio between theoretical and actual angular correction. We retrospectively reviewed 24 patients who underwent distal radius fracture fixation using this technique and assessed intra-operative radiographs for parameters including pre-'lift' and post-'lift' volar tilt and pre-'lift' plate-shaft angles. The ratio between actual angular correction and theoretical angular correction was calculated. The 'lift' technique is found to be reliable in restoring volar tilt in most fractures. Over- or under-correction does occur due to errors in visual estimation and actual angular correction is generally less than the theoretical angular correction.