The effectiveness of surgical vs conservative interventions on pain and function in patients with shoulder impingement syndrome. A systematic review and meta-analysis

Objective To assess the effectiveness of surgical vs conservative interventions on pain and function in patients with subacromial impingement syndrome. Design Systematic review and meta-analysis of randomized controlled trials. Setting Clinical setting. Participants Patients 18 years and older with subacromial impingement syndrome. Intervention/Comparison Surgical intervention plus postoperative physiotherapy / placebo surgery plus physiotherapy or physiotherapy only. Main outcome measures Pain and function. Results 11 RCTs (n = 919) were included. The pooled results displayed no statistically or clinically different between surgery plus physiotherapy vs physiotherapy alone on pain levels at 3-, 6-months, 5- and 10 years follow up (moderate quality, 3 RCTs, 300 patients, WMD -0.39, 95% CI: -1.02 to 0.23, p = 0.22; moderate quality, 3 RCTs, 310 patients, WMD -0.36, 95% CI: -1.02 to 0.29, p = 0.27; low quality, 1 RCT, 109 patients, WMD -0.30, 95% CI: -1.54 to 0.94, p = 0.64; low quality, 1 RCT, 90 patients, WMD -1.00, 95% CI: -0.24 to 2.24, p = 0.11) respectively. Similarly, the pooled results were not statistically or clinically different between groups for function at 3-, 6-month and 1-year follow ups (very low quality, 2 RCTs, 184 patients, SMD 0.11, 95% CI: -0.57 to 0.79, p = 0.75; moderate quality, 3 RCTs, 310 patients, SMD 0.15, 95% CI: -0.14 to 0.43, p = 0.31; very low quality, 2 RCTs, 197 patients, SMD 0.11, 95% CI: -0.46 to 0.69, p = 0.70) respectively. Conclusion The effects of surgery plus physiotherapy compared to physiotherapy alone on improving pain and function are too small to be clinically important at 3-, 6-months, 1-, 2-, 5- and \u3e= 10-years follow up

A biomechanical assessment of superior shoulder translation after reconstruction of anterior glenoid bone defects: The Latarjet procedure versus allograft reconstruction

BACKGROUND: The coracoacromial ligament (CAL) is an important restraint to superior shoulder translation. The effect of CAL release on superior stability following the Latarjet is unknown; therefore, our purpose was to compare the effect of two Latarjet techniques and allograft reconstruction on superior instability. MATERIALS AND METHODS: Eight cadaveric specimens were tested on a simulator. Superior translation was monitored following an axial force in various glenohumeral rotations (neutral, internal, and external) with and without muscle loading. Three intact CAL states were tested (intact specimen, 30% glenoid bone defect, and allograft reconstruction) and two CAL deficient states (classic Latarjet (classicLAT) and congruent-arc Latarjet (congruentLAT)). RESULTS: In neutral without muscle loading, a significant increase in superior translation occurred with the classicLAT as compared to 30% defect (P = 0.046) and allograft conditions (P = 0.041). With muscle loading, the classicLAT (P = 0.005, 0.002) and the congruentLAT (P = 0.018, 0.021) had significantly greater superior translation compared to intact and allograft, respectively. In internal rotation, only loaded tests produced significant results; specifically, classicLAT increased translation compared to all intact CAL states (P < 0.05). In external rotation, only unloaded tests produced significant results with classicLAT and congruentLAT allowing greater translations than intact (P ≤ 0.028). For all simulations, the allograft was not significantly different than intact (P > 0.05) and no differences (P = 1.0) were found between classicLAT and congruentLAT. DISCUSSION: In most simulations, CAL release with the Latarjet lead to increased superior humeral translation. CONCLUSION: The choice of technique for glenoid bone loss reconstruction has implications on the magnitude of superior humeral translation. This previously unknown effect requires further study to determine its clinical and kinematic outcomes

Computer-assisted versus non-computer-assisted preoperative planning of corrective osteotomy for extra-articular distal radius malunions: a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Malunion is the most common complication of distal radius fracture. It has previously been demonstrated that there is a correlation between the quality of anatomical correction and overall wrist function. However, surgical correction can be difficult because of the often complex anatomy associated with this condition. Computer assisted surgical planning, combined with patient-specific surgical guides, has the potential to improve pre-operative understanding of patient anatomy as well as intra-operative accuracy. For patients with malunion of the distal radius fracture, this technology could significantly improve clinical outcomes that largely depend on the quality of restoration of normal anatomy. Therefore, the objective of this study is to compare patient outcomes after corrective osteotomy for distal radius malunion with and without preoperative computer-assisted planning and peri-operative patient-specific surgical guides.</p> <p>Methods/Design</p> <p>This study is a multi-center randomized controlled trial of conventional planning versus computer-assisted planning for surgical correction of distal radius malunion. Adult patients with extra-articular malunion of the distal radius will be invited to enroll in our study. After providing informed consent, subjects will be randomized to two groups: one group will receive corrective surgery with conventional preoperative planning, while the other will receive corrective surgery with computer-assisted pre-operative planning and peri-operative patient specific surgical guides. In the computer-assisted planning group, a CT scan of the affected forearm as well as the normal, contralateral forearm will be obtained. The images will be used to construct a 3D anatomical model of the defect and patient-specific surgical guides will be manufactured. Outcome will be measured by DASH and PRWE scores, grip strength, radiographic measurements, and patient satisfaction at 3, 6, and 12 months postoperatively.</p> <p>Discussion</p> <p>Computer-assisted surgical planning, combined with patient-specific surgical guides, is a powerful new technology that has the potential to improve the accuracy and consistency of orthopaedic surgery. To date, the role of this technology in upper extremity surgery has not been adequately investigated, and it is unclear whether its use provides any significant clinical benefit over traditional preoperative imaging protocols. Our study will represent the first randomized controlled trial investigating the use of computer assisted surgery in corrective osteotomy for distal radius malunions.</p> <p>Trial registration</p> <p>NCT01193010</p

Intraosseous foreign body granuloma in rotator cuff repair with bioabsorbable suture anchor

Biodegradable implants lead to problems such as cyst formation, soft-tissue inflammation, loose implant fragments or local osteolysis. This report represents the first published case of an intraosseous foreign body granuloma in the humeral head after arthroscopic rotator cuff tear fixation with a poly-l-lactide (PLLA) suture anchor. A 48-year-old female patient presented with pain in her right shoulder. A refixation of her right supraspinatus tendon with a biodegradable suture anchor was performed 11 months ago at an external hospital. Laboratory tests showed normal values for C-reactive protein, leukocytes and the erythrocyte sedimentation rate. No signs of infection or instability were noted. The visual analogue scale (VAS) was 8, the simple shoulder test (SST) was 4 and the American shoulder and elbow surgeons score (ASES) was 44. Plain radiographs showed high lucency in the area of the tuberculum majus. MRI showed an intra- and extraosseous mass surrounded by fluid in this area. Surgical care involved arthroscopic debridement and removal of the suture anchor. Histological examination revealed a foreign body granuloma. At the 18-month follow-up the patient was nearly pain-free. The VAS was 2, SST was 10 and ASES was 88. Foreign body granulomas are a well known but rarely described complication that arises after the use of biodegradable suture anchors in shoulder surgery. Every patient presenting with shoulder pain after usage of a biodegradable fixation material should be evaluated closely. Orthopaedic surgeons should be aware of the possibility of delayed foreign body reactions, especially after using PLLA anchors

Brown Planthopper (N. lugens Stal) Feeding Behaviour on Rice Germplasm as an Indicator of Resistance

BACKGROUND: The brown planthopper (BPH) Nilaparvata lugens (Stal) is a serious pest of rice in Asia. Development of novel control strategies can be facilitated by comparison of BPH feeding behaviour on varieties exhibiting natural genetic variation, and then elucidation of the underlying mechanisms of resistance. METHODOLOGY/PRINCIPAL FINDINGS: BPH feeding behaviour was compared on 12 rice varieties over a 12 h period using the electrical penetration graph (EPG) and honeydew clocks. Seven feeding behaviours (waveforms) were identified and could be classified into two phases. The first phase involved patterns of sieve element location including non penetration (NP), pathway (N1+N2+N3), xylem (N5) [21] and two new feeding waveforms, derailed stylet mechanics (N6) and cell penetration (N7). The second feeding phase consisted of salivation into the sieve element (N4-a) and sieve element sap ingestion (N4-b). Production of honeydew drops correlated with N4-b waveform patterns providing independent confirmation of this feeding behaviour. CONCLUSIONS/SIGNIFICANCE: Overall variation in feeding behaviour was highly correlated with previously published field resistance or susceptibility of the different rice varieties: BPH produced lower numbers of honeydew drops and had a shorter period of phloem feeding on resistant rice varieties, but there was no significant difference in the time to the first salivation (N4-b). These qualitative differences in behaviour suggest that resistance is caused by differences in sustained phloem ingestion, not by phloem location. Cluster analysis of the feeding and honeydew data split the 12 rice varieties into three groups: susceptible, moderately resistant and highly resistant. The screening methods that we have described uncover novel aspects of the resistance mechanism (or mechanisms) of rice to BPH and will in combination with molecular approaches allow identification and development of new control strategies