Evaluation of the Circles Measurement and the ABC Classification of Acromioclavicular Joint Injuries.

BACKGROUND Acromioclavicular joint (ACJ) injuries are common. Despite this, it remains unclear how best to assess, classify, and manage these cases. A simple, reliable, valid, and accurate radiographic parameter to measure ACJ displacement would allow improved consistency of diagnosis and subsequent treatment pathways. PURPOSE To evaluate "the circles measurement" and associated "ABC classification" as a tool for assessing ACJ displacement and injury classification. STUDY DESIGN Descriptive laboratory study. METHODS The circles measurement is taken from a lateral Alexander radiograph of the shoulder. The measurement is the center-to-center distance between 2 circles drawn to define the lateral extent of the clavicle and the anteromedial extent of the acromion; it is independent of the displacement plane, judging total ACJ displacement in any direction rather than trying to quantify vertical and/or horizontal displacement. When utilized clinically, the circles measurement is a single measurement calculated as the difference between values recorded for the injured and uninjured sides. Validation of the circles measurement was performed using lateral Alexander radiographs (including ±20° projection error in all planes) and computed tomography of standardized ACJ injury simulations. We assessed inter- and intrarater reliability, convergent validity, and discriminant validity of the circles measurement and subsequently generated a classification of ACJ injury based on displacement. RESULTS Reliability and validity of the circles measurement was excellent throughout. Interrater reliability (ICC [intraclass correlation coefficient] [2,1], 95% CI; n = 78; 4 observers) was 0.976 (0.964-0.985). Intrarater reliability (ICC [2,1]; 95% CI; n = 78; 2 measures) was 0.998 (0.996-0.998). Convergent validity (Pearson correlation coefficient, r) was 0.970 for ideal radiographs and 0.889 with ±20° projection error in all planes. Discriminant validity, with 1-way analysis of variance, showed a P value of <.0001 and effect size (η2) of 0.960, with the ability to distinguish between the previously defined stable (Rockwood IIIA) and unstable (Rockwood IIIB) injuries. The results permitted objective, statistically sound parameters for the proposed ABC classification system. CONCLUSION The circles measurement is a simple, reliable, valid, accurate, and resilient parameter for assessing ACJ displacement and can be used in conjunction with the proposed ABC classification to define ACJ injuries more accurately and objectively than previously described. CLINICAL RELEVANCE This novel parameter has the potential to standardize the initial assessment and possibly the subsequent clinical management of ACJ injuries, in addition to providing a standardized measure for future research

Recurrence Rate After Wide Resection of Plantar Fibromatosis: A Case Series and Systematic Literature Review.

BACKGROUND The aim was to assess the recurrence rate and clinical outcome after wide resection for plantar fibromatosis. METHODS A total of 12 patients, 2 to 13 years after wide resection, were assessed for local and magnetic resonance imaging tomographic signs of recurrence at the clinical follow-up. In addition, a systematic review of the literature was conducted. RESULTS After 7.8 years (2-13), 2 patients (17%) suffered a recurrence. At the last follow-up, median Foot Functional Index was 1 (0-66) and American Orthopaedic Foot and Ankle Society score was 95 (44-100). Six studies with 109 feet (92 patients) were included in the systematic review. The recurrence rate depends on the width of the resection: 67% after local resection, 42% after wide resection, and 27% after fasciectomy. CONCLUSION In patients with symptomatic plantar fibromatosis, we recommend a wide resection or fasciectomy over a local resection because of the inferior recurrence rate. LEVELS OF EVIDENCE Level IV: Retrospective case series

Massive Rotator Cuff Tears With Short Tendon Length Can Be Successfully Repaired Using Synthetic Patch Augmentation.

BACKGROUND Choosing the optimal treatment for massive rotator cuff tears (MRCT) still poses a surgical problem. In MRCT with good muscle quality, but short tendon length, non-augmented repairs lead to high failure rates of up to 90%. AIM The aim of the study was to evaluate mid-term clinical and radiological outcomes of massive rotator cuff tears with good muscle quality, but short tendon length, which were repaired with synthetic patch augmentation. METHODS A retrospective study of patients who underwent arthroscopic or open rotator cuff repairs with patch augmentation between 2016 and 2019 was performed. We included patients older than 18 years, who presented with MRCT confirmed by an MRI arthrogram showing good muscle quality (Goutallier ≤II) and short tendon length (length <15mm). Constant-Murley score (CS), subjective shoulder value (SSV) and range of motion (ROM) were compared pre- and postoperatively. We excluded patients older than 75 years or with presence of rotator cuff arthropathy Hamada ≥ 2a. Patients were followed up for two years minimum. Clinical failures were defined by re-operation, forward flexion <120 or a relative CS < 70. Structural integrity of the repair was assessed using an MRI. Comparison between different variables and outcomes was performed using Wilcoxon-Mann-Whitney and Chi square tests. RESULTS Fifteen patients (mean age 57 years, 13 (86.7%) male, 9 (60%) right shoulders) were reevaluated with a mean follow-up of 43.8 months (27-55 months). There was a significant improvement in the absolute CS (from 33 to 81 points, p=0.03), the relative CS (from 41% to 88%, p=0.04), the SSV (from 31% to 93% p=0,007) and forward flexion (from 111° to 163°, p=0.004) but not in external rotation (from 37° to 38°, p=0.5). There were three clinical failures (one atraumatic, two traumatic) with re-operations (two reverse total shoulder arthroplasties and one refixation). Structurally, there were three Sugaya grade 4 and five Sugaya grade 5 re-ruptures resulting in a retear rate of 53%. The presence of a complete or partial re-rupture was not associated with inferior outcomes compared to intact cuff repairs. There were no correlations between the grade of retraction, muscle quality or rotator cuff tear configuration and re-rupture or functional outcomes. CONCLUSION Patch augmented cuff repair leads to a significant improvement of functional and structural outcomes. Partial re-ruptures were not associated with inferior functional outcomes. Prospective randomized trials are needed to confirm the results found in our study

Fully Automatic Analysis of Posterosuperior Full-Thickness Rotator Cuff Tears from MRI

Rotator cuff tears (RCT) are one of the most common sources of shoulder pain. Many factors can be considered to choose the right surgical treatment procedure. Of the most important factors are the tear retraction and tear width, assessed manually on preoperative MRI. A novel approach to automatically quantify a rotator cuff tear, based on the segmentation of the tear from MRI images, was developed and validated. For segmentation, a neural network was trained and methods for the automatic calculation of the tear width and retraction from the segmented tear volume were developed. The accuracy of the automatic segmentation and the automated tear analysis were evaluated relative to manual consensus segmentations by two clinical experts. Variance in the manual segmentations was assessed in an interrater variability study of two clinical experts. The accuracy of the tear retraction calculation based on the developed automatic tear segmentation was 5.3 mm ± 5.0 mm in comparison to the interrater variability of tear retraction calculation based on manual segmentations of 3.6 mm ± 2.9 mm. These results show that an automatic quantification of a rotator cuff tear is possible. The large interrater variability of manual segmentation-based measurements highlights the difficulty of the tear segmentations task in general

Functional and Radiologic Outcomes of Degenerative Versus Traumatic Full-Thickness Rotator Cuff Tears Involving the Supraspinatus Tendon.

BACKGROUND Arthroscopic rotator cuff repair (ARCR) is among the most commonly performed orthopaedic procedures. Several factors-including age, sex, and tear severity-have been identified as predictors for outcome after repair. The influence of the tear etiology on functional and structural outcome remains controversial. PURPOSE To investigate the influence of tear etiology (degenerative vs traumatic) on functional and structural outcomes in patients with supraspinatus tendon tears. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Patients undergoing ARCR from 19 centers were prospectively enrolled between June 2020 and November 2021. Full-thickness, nonmassive tears involving the supraspinatus tendon were included. Tears were classified as degenerative (chronic shoulder pain, no history of trauma) or traumatic (acute, traumatic onset, no previous shoulder pain). Range of motion, strength, the Subjective Shoulder Value, the Oxford Shoulder Score (OSS), and the Constant-Murley Score (CMS) were assessed before (baseline) and 6 and 12 months after ARCR. The Subjective Shoulder Value and the OSS were also determined at the 24-month follow-up. Repair integrity after 12 months was documented, as well as additional surgeries up to the 24-month follow-up. Tear groups were compared using mixed models adjusted for potential confounding effects. RESULTS From a cohort of 973 consecutive patients, 421 patients (degenerative tear, n = 230; traumatic tear, n = 191) met the inclusion criteria. The traumatic tear group had lower mean baseline OSS and CMS scores but significantly greater score changes 12 months after ARCR (OSS, 18 [SD, 8]; CMS, 34 [SD,18] vs degenerative: OSS, 15 [SD, 8]; CMS, 22 [SD, 15]) (P < .001) and significantly higher 12-month overall scores (OSS, 44 [SD, 5]; CMS, 79 [SD, 9] vs degenerative: OSS, 42 [SD, 7]; CMS, 76 [SD, 12]) (P≤ .006). At the 24-month follow-up, neither the OSS (degenerative, 44 [SD, 6]; traumatic, 45 [SD, 6]; P = .346) nor the rates of repair failure (degenerative, 14 [6.1%]; traumatic 12 [6.3%]; P = .934) and additional surgeries (7 [3%]; 7 [3.7%]; P = .723) differed between groups. CONCLUSION Patients with degenerative and traumatic full-thickness supraspinatus tendon tears who had ARCR show satisfactory short-term functional results. Although patients with traumatic tears have lower baseline functional scores, they rehabilitate over time and show comparable clinical results 1 year after ARCR. Similarly, degenerative and traumatic rotator cuff tears show comparable structural outcomes, which suggests that degenerated tendons retain healing potential

Swiss-wide multicentre evaluation and prediction of core outcomes in arthroscopic rotator cuff repair: protocol for the ARCR_Pred cohort study

Introduction In the field of arthroscopic rotator cuff repair (ARCR), reporting standards of published studies differ dramatically, notably concerning adverse events (AEs). In addition, prognostic studies are overall methodologically poor, based on small data sets and explore only limited numbers of influencing factors. We aim to develop prognostic models for individual ARCR patients, primarily for the patient-reported assessment of shoulder function (Oxford Shoulder Score (OSS)) and the occurrence of shoulder stiffness 6 months after surgery. We also aim to evaluate the use of a consensus core event set (CES) for AEs and validate a severity classification for these events, considering the patient’s perspective.Methods and analysis A cohort of 970 primary ARCR patients will be prospectively documented from several Swiss and German orthopaedic clinics up to 24 months postoperatively. Patient clinical examinations at 6 and 12 months will include shoulder range of motion and strength (Constant Score). Tendon repair integrity status will be assessed by ultrasound at 12 months. Patient-reported questionnaires at 6, 12 and 24 months will determine functional scores (subjective shoulder value, OSS), anxiety and depression scores, working status, sports activities, and quality of life (European Quality of Life 5 Dimensions 5 Level questionnaire). AEs will be documented according to a CES. Prognostic models will be developed using an internationally supported regression methodology. Multiple prognostic factors, including patient baseline demographics, psychological, socioeconomic and clinical factors, rotator cuff integrity, concomitant local findings, and (post)operative management factors, will be investigated.Ethics and dissemination This project contributes to the development of personalised risk predictions for supporting the surgical decision process in ARCR. The consensus CES may become an international reference for the reporting of complications in clinical studies and registries. Ethical approval was obtained on 1 April 2020 from the lead ethics committee (EKNZ, Basel, Switzerland; ID: 2019-02076). All participants will provide informed written consent before enrolment in the study.Trial registration number NCT04321005.Protocol version Version 2 (13 December 2019)