Subscapularis tear classification implications regarding treatment and outcomes: consensus decision-making.

Background: Several classifications have been proposed for subscapularis tendon tearing (SCTs); however, there remains a poor agreement between orthopedic surgeons regarding the diagnosis and management of these lesions. Distinguishing the various tear patterns and classifying them with some prognostic significance may aid the operating surgeon in planning appropriate treatment. Purpose: The purpose of this study was to outline the current literature regarding SCT classification and treatment and conduct a survey among shoulder and elbow surgeons to identify the approaches regarding surgical decision-making for these injuries. Methods: In this systematic review, we analyzed 12 articles regarding the subscapularis tendon tear classification and implications regarding treatment plans and outcomes. In addition, 4 international experts in subscapularis repair surgery participated in the development of a questionnaire form that was distributed to 1161 ASES members. One hundred sixty five surgeons participated and chose whether they agree, disagree, or abstain for each of the 32 statements in 4 parts including indications/contraindications, treatment plan, and the factors affecting outcomes in the survey. Results: Classification criteria were extremely variable with differing recommendations and descriptions of tear morphology; most were based on tear size, associated shoulder pathology, or lesser tuberosity footprint exposure. Considering the multiple classification systems and the overall poor agreement regarding SCT management, our study found that the most widely agreed upon (more than 80%) statements included early surgery is advised for traumatic SCT, chronic degenerative SCT (without fatty infiltration) associated with acute supraspinatus tear is a candidate for repair, and rotator cuff arthropathy is a contraindication for SCT repair. Conclusion: Our study was able to identify both patient and tear characteristics that are well agreed upon among surgeons in the treatment of these injuries. Lafosse classification is generally widely accepted; however, it needs to be improved by some additions. Continued collaboration among surgeons is needed to establish an acceptable and broadly applicable classification system for the management of these injuries.

Descriptive analysis of recurrences of nasal intestinal-type adenocarcinomas after radiotherapy.

BACKGROUND: Despite adjuvant radiotherapy, rates of recurrences of endoscopically operated nasal intestinal-type adenocarcinomas (ITAC) have not been improved in successive series. To better understand how to improve local control, we aimed to investigate the site of local recurrences of ITACs. METHODS: Retrospective study in a reference center in sinonasal malignancies. For all patients with a local recurrence, radiotherapy plans were retrieved and compared to the delineation of local recurrences. RESULTS: Of 63 patients, 54 underwent adjuvant radiotherapy of which 14 (25.9%) had a local recurrence. Eleven of them had their onset in an optimally irradiated area. Difficulty to dissect the cribriform plate and/or the lateral lamina was reported for 11 patients with local recurrences in the operative reports (p <0.0001). CONCLUSIONS: Most of recurrences arose in an optimally irradiated area. A close cooperation between surgeons and radiotherapists is required to define areas at risk and adapt treatment.

Is Revision Surgery Necessary for Patients With High Risk of Recurrence After Parotidectomy? A Multicenter Retrospective Study.

OBJECTIVES: Close margin is a frequent situation after parotidectomy. The need for systematic prophylactic revision surgery is a question that arises regularly for malignant tumors, as it exposes to a high risk of facial palsy, while oncological benefits are unclear. STUDY DESIGN: retrospective study. SETTING: Multicentric. SUBJECTS AND METHODS: We included all patients operated for systematic revision surgery in case of close margins after parotidectomy for a malignant tumor and analyzed the rate of tumor residue and its risk factors. RESULTS: A tumor residue was identified in 43.5% of 23 cases, but none in case of initial complete excision with supra-millimetric margins. Invaded lymph nodes were identified in 6 cases, but none in case of low-grade tumors. CONCLUSIONS: Systematic revision seems mandatory in case of infra-millimetric margins and high-grade tumors or positive lymph node; further studies are needed to confirm whether it can be spared for T1-T2/N0 low-grade tumors, with close margins but complete initial excision.

Characteristics of obstructive sleep apnea syndrome in patients with partial laryngectomy.

OBJECTIVES: The impacts of partial laryngectomy on sleep-disordered breathing were rarely investigated and reported in a limited number of patients. The aim of this study was to assess the prevalence of obstructive sleep apnea-hypopnea syndrome (OSAHS) in patients with partial laryngectomy. STUDY DESIGN: Case series. METHODS: All patients undergoing partial laryngectomy by open approach (frontolateral vertical partial laryngectomy and supracricoid horizontal partial laryngectomy) for squamous cell carcinoma of the larynx between January 2006 and December 2019 were enrolled. Listed patients were contacted via telephone to propose participating in the study and plan a sleep study: self-assessments of sleep quality using the Pittsburgh Sleep Quality Index (PSQI) following a home sleep recording using respiratory polygraphy. Daytime sleepiness was also self-assessed by using the Epworth sleepiness scale. RESULTS: Twenty patients with sleep record were included to the analyses. There were 11/20 patients (55%) diagnosed with moderate to severe OSASH. No relationship between OSAHS severity and age as well as body mass index (BMI) was observed. The Epworth sleepiness score was not necessarily high in patients with moderate/severe OSASH. Type of partial laryngectomy did not influence apnea-hypopnea index (AHI) results. There was no difference in terms of age, BMI, gender, type of partial laryngectomy, and the presence of adjuvant radiotherapy between two groups AHI < 15/h and AHI ≥ 15/h. CONCLUSION: A sleep study screening for OSAHS should be considered in patients with partial laryngectomy in order to improve their sleep quality and quality of life even though they did not exhibit daily sleepiness and obesity.

Impact of Neck Dissection in Head and Neck Squamous Cell Carcinomas of Unknown Primary.

PURPOSE: Management of head and neck cancers of unknown primary (HNCUP) combines neck dissection (ND) and radiotherapy, with or without chemotherapy. The prognostic value of ND has hardly been studied in HNCUP. METHODS: A retrospective multicentric study assessed the impact of ND extent (adenectomy, selective ND, radical/radical-modified ND) on nodal relapse, progression-free survival (PFS) or survival, taking into account nodal stage. RESULTS: 53 patients (16.5%) had no ND, 33 (10.2%) had lymphadenectomy, 116 (36.0%) underwent selective ND and 120 underwent radical/radical-modified ND (37.3%), 15 of which received radical ND (4.7%). With a 34-month median follow-up, the 3-year incidence of nodal relapse was 12.5% and progression-free survival (PFS) 69.1%. In multivariate analysis after adjusting for nodal stage, the risk of nodal relapse or progression was reduced with lymphadenectomy, selective or radical/modified ND, but survival rates were similar. Patients undergoing lymphadenectomy or ND had a better PFS and lowered nodal relapse incidence in the N1 + N2a group, but the improvement was not significant for the N2b or N2 + N3c patients. Severe toxicity rates exceeded 40% with radical ND. CONCLUSION: In HNCUP, ND improves PFS, regardless of nodal stage. The magnitude of the benefit of ND does not appear to depend on ND extent and decreases with a more advanced nodal stage.

Labral Repair Augmentation by Labroplasty and Simultaneous Trans-Subscapular Transposition of the Long Head of the Biceps.

Chronic traumatic anteroinferior instability is a common pathology of the shoulder joint. In case of glenoid bone defects, the Latarjet or bone block technique is the method of choice. The arthroscopic Bankart procedure and its modifications remain the preferred methods of treating patients without substantial bone damage of the glenoid and humeral head; however, there is a high recurrence of instability after the Bankart procedure, even for optimal indications. One of the main causes of recurrence is poor quality and weakness of the glenohumeral ligaments and labrum. We describe an alternative technique that provides triple mechanisms of stabilization like the Latarjet procedure. In our procedure, the long head of the biceps tendon is used for a sling effect, dynamic stabilization is achieved by trans-subscapular tenodesis with simultaneous plasty of the anterior segment of the labrum, and subsequent resuspension of the glenohumeral ligaments is performed using the same anchors. In patients without substantial bone loss, this procedure has numerous advantages over the arthroscopic Latarjet procedure. By creating triple mechanisms of stability like the Latarjet procedure (the bumper effect, reinforcement of ligaments, and sling effect), our procedure can significantly reinforce the Bankart procedure in cases of poor-quality glenohumeral ligaments.

Can anatomical assessment of hypopharyngolarynx in awake patients predict obstructive sleep apnea?

OBJECTIVES/HYPOTHESIS: To assess the relationships between laryngeal and hypopharyngeal morphology and obstructive sleep apnea-hypopnea syndrome (OSAHS) in awake patients. STUDY DESIGN: Prospective study. METHODS: Awake flexible fiberoptic laryngoscopy and sleep studies were performed in 80 patients for snoring or OSAHS suspicion. Endoscopic videos were reviewed by two examiners to assess morphological characteristics of hypopharynx and larynx using a standardized examination of appearance, shape and position of epiglottis, shape of retropharyngeal-epiglottic aerospace (RPEA), modified Cormack-Lehane score, and length ratios of the hypopharynx and epiglottis. The multivariate logistic regression model was used to assess independent predictors of moderate/severe OSAHS. RESULTS: The interrater agreements were moderate for epiglottis appearance (κ = 0.52), epiglottis form (κ = 0.66), and epiglottis position (κ = 0.49), but fair for the shape of RPEA (κ = 0.26) and modified Cormack-Lehane scoring (κ = 0.38). The presence of a mega-epiglottis was significantly correlated with the severity of OSAHS (P < .05). By multivariate logistic regression analysis, independent predictors of moderate/severe obstructive sleep apnea were mega-epiglottis (adjusted odds ratio [aOR]: = 4.78, 95% confidence interval [CI]: 1.23-18.56, P = .024), modified Cormack-Lehane score of 2 (aOR: 15.3, 95% CI: 1.8-130.3, P = .012), or modified Cormack-Lehane score of 3 (aOR: 10.03, 95% CI: 1.3-78.2, P = .03) and aging (aOR = 1.07, 95% CI: 1.01-1.14, P = .025). CONCLUSIONS: Routine flexible fiberoptic laryngoscopy performed by otorhinolaryngologists in awake patients may help to detect some predictors of OSAHS such as presence of mega-epiglottis, and modified Cormack-Lehane score of 2 or more. Investigation of sleep disorders should be proposed in these patients. LEVEL OF EVIDENCE: 2 Laryngoscope, 129:2782-2788, 2019.

Relationship between subscapularis tears and injuries to the biceps pulley.

PURPOSE: The purpose of this study was to analyse the relationship between long head of the biceps brachii (LHBT) lesions and subscapularis tears. The hypothesis was that a bicipital pulley might remain intact, even in the case of a subscapularis tear. METHODS: Between 2010 and 2011, all patients who had a primary arthroscopic repair of a subscapularis tear were potentially included in this prospective study. The outcome of interest was the prevalence and type of arthroscopic lesions of the LHBT and bicipital pulley. Furthermore, the supposed pathomechanics of injury and the treatment proposed (conservative, pulley repair, tenodesis, tenotomy, etc.) was recorded. The following baseline characteristics were assessed: age, sex, shoulder side, and limb dominance. RESULTS: Of the 218 patients, the superior glenohumeral ligament/coracohumeral ligament (SGHL/CHL) complex was normal in 54 patients (25%), stretched in 84 patients (39%), and absent in 77 patients (35%). Below the SGHL/CHL complex in the bicipital groove, the medial wall of the LHBT sheath was normal in 25%, partially torn in 39%, and completely torn in 35%. In 25 of the 218 patients (11%), a pathologic LHBT with an intact SGHL/CHL complex was observed. In these cases, the medial wall of the bicipital sheath was torn in 92%. CONCLUSIONS: The biceps pulley system, including the SGHL/CHL complex and subscapularis tendon, merits recognition as an important anatomical structure, and its lesions contribute to shoulder pathology. The subscapularis tendon is very important for the stability of the LHBT and should be included in the pulley system. In cases of a tear associated with a lesion of the SGHL/CHL complex, the LHBT is nearly always unstable and pathologic. LEVEL OF EVIDENCE: II.

Estimating the number of sudden cardiac deaths attributable to the use of domperidone in France.

PURPOSE: The aim of this study was to estimate of the number of sudden cardiac deaths attributable to the use of domperidone in France in 2012 METHODS: Computation of the attributable fraction, function of the increase in risk of sudden cardiac death induced by domperidone and of the exposure prevalence. Multiplying the attributable fraction by the risk of sudden cardiac death in the French population gives an estimation of the number of sudden cardiac deaths attributable to domperidone. RESULTS: The use of domperidone in France is the cause of 231 deaths per year in the population aged 18 years or over. CONCLUSIONS: This risk should be taken into consideration by clinicians when prescribing a drug which provides a minor benefit.

Arthroscopic treatment of anterosuperior rotator cuff tears.

This study evaluated pre- and postoperative clinical and structural outcome data on anterosuperior rotator cuff tears involving the supraspinatus and subscapularis treated by arthroscopic methods. Between June 2006 and October 2007, a total of 155 consecutive patients underwent an arthroscopic repair for a supraspinatus or supraspinatus and infraspinatus (superior) rotator cuff tear. Of these, 44 (28%) were identified on preoperative imaging to have involvement of the subscapularis. Confirmation of subscapularis tears occurred during arthroscopic repair of the superior rotator cuff. If the subscapularis was found to be torn, it was documented, and an arthroscopic repair was performed. Postoperative clinical and radiographic outcomes were assessed with the belly press and lift-off tests, range of motion, strength, pain score, Constant score, and either a magnetic resonance imaging arthrogram or a computed tomography arthrogram at an average of 15 months postoperatively. Failure was determined based on rotator cuff integrity on radiologic studies. Sixteen of the 44 anterosuperior rotator cuff tears identified on preoperative imaging were found to have a full-thickness subscapularis tear requiring repair on arthroscopic examination. On preoperative imaging, subscapularis tears were all either grade 1 or grade 2 (no complete grade 3 tears). Mean follow-up was 16.9 months (range, 13-24 months). Compared with preoperative values, significant postoperative improvements occurred in Constant scores, forward flexion, strength, and pain scores (P<.01). Patients also showed significant improvements in both the lift-off and belly press tests (P<.001). Mean postoperative patient satisfaction was 7.9 (range, 5-10) with 10 (59%) of 17 patients being extremely satisfied. Two of the 17 patients with an anterosuperior rotator cuff tear had confirmed retears of the supraspinatus (1 partial and 1 full-thickness) with no radiographic evidence of retear of any of the subscapularis repairs at most recent follow-up.

The role of radiation therapy in pediatric mucoepidermoid carcinomas of the salivary glands.

OBJECTIVE: To investigate the role of radiation therapy in rare salivary gland pediatric mucoepidermoid carcinoma (MEC). STUDY DESIGN: A French multicenter retrospective study (level of evidence 4) of children/adolescents treated for MEC between 1980 and 2010 was conducted. RESULTS: Median age of the 38 patients was 14 years. Parotid subsite, low-grade, and early primary stage tumors were encountered in 81%, 82%, and 68% of cases, respectively. All except 1 patient were treated by tumoral surgical excision, and 53% by neck dissection (80% of high grades). Postoperative radiation therapy and chemotherapy were performed in 29% and 11% of cases. With a median 62-month follow-up, overall survival and local control rates were 95% and 84%, respectively. There was 1 nodal relapse. Lower grade and early stage tumors had better survival. Postoperative radiation therapy and chemotherapy were associated with similar local rates. Patients with or without prior cancer had similar outcomes. CONCLUSIONS: Pediatric salivary gland MEC carries a good prognosis. Low-intermediate grade, early-stage tumors should be treated with surgery alone. Neck dissection should be performed in high-grade tumors. Radiation therapy should be proposed for high grade and/or advanced primary stage MEC. For high-grade tumors without massive neck involvement, irradiation volumes may be limited to the primary area, given the risk of long-term side effects of radiation therapy in children. Pediatric MEC as second cancers retain a similar prognosis. Long-term follow-up is needed to assess late side effects and second cancers.

BRAF, p53 and SOX2 in anaplastic thyroid carcinoma: evidence for multistep carcinogenesis.

AIMS: The aim of this study was to genotype a series of papillary thyroid carcinomas (PTCs) and anaplastic thyroid carcinomas (ATCs) for BRAF mutation, and to evaluate p53 and SOX2 expression as factors implicated in tumour progression. METHODS: The study included 17 PTCs and 14 ATCs. Analysis of the exon 15 of BRAF was based on direct sequencing. Immunohistochemistry was used to evaluate p53 and SOX2 expression. RESULTS: V600E (c.1799T>A) mutation was observed in 53% (9/17) of PTCs. Two cases of ATCs (2/14; 14%), both with PTC component, harboured BRAF mutation: the classical V600E mutation and an undocumented duplication of codon 599 (c.1795_1797dup; p.Thr599dup). These mutations were present in ATC as well as PTC tumour cells. Overexpression of p53 and SOX2 was depicted respectively in 64% (9/14) and 29% (4/14) of ATCs, and absent in PTCs. CONCLUSION: We confirm that V600E mutation is a frequent and specific event in PTC. BRAF-mutated ATCs are associated with a PTC component displaying the same mutation. We describe a new mutation of BRAF, T599dup, in a case of ATC with tall cell PTC component. Moreover, progression from PTC to ATC could be favoured by further TP53 mutation and SOX2 expression.