Greater Tuberosity Fractures after RTSA: A Matched Group Analysis

Periprosthetic fractures, such as acromial and spine fractures, are known complications following implantation of reverse shoulder arthroplasty (RTSA). The entity of greater tuberosity fractures (GTF) has rarely been studied in the literature. The purpose of this study was to analyze the outcome of postoperative greater tuberosity fractures after RTSA compared to a matched control group. The main findings of this study are that a GTF after RTSA is associated with worse clinical outcome scores (mean absolute CS 50 ± 19 (p = 0.032); SSV 63% ± 26 (p = 0.022); mean force 1 kg ± 2 kg (p = 0.044)) compared with the control group (mean absolute CS 62 ± 21; SSV 77% ± 29; mean force 2 kg ± 2 kg). In terms of postoperative range of motion, the fracture group was significantly worse in terms of external rotation (17° ± 19° vs. 30° ± 19° (p = 0.029)). Internal rotation, flexion, as well as abduction of the shoulder appear to be unaffected (internal rotation GTF 4 ± 2, control group 5 ± 3 (p = 0.138); flexion GTF 102° ± 28°, control group 114° ± 27° (p = 0.160); abduction GTF 109° ± 42°, control group 120° ± 39° (p = 0.317))

Stability of novel cow-hitch suture button coracoid bone graft fixation in Latarjet procedures: a biomechanical study

BACKGROUND The Latarjet procedure is widely used to address anterior shoulder instability, especially in case of glenoid bone loss. Recently, cortical suture button fixation for coracoid transfer has been used to mitigate complications seen with screw placement. The aim of this biomechanical study was to evaluate the stability of a novel and cost-effective cow-hitch suture button technique, designed to be performed through a standard open deltopectoral approach, and compare this to a well-established double suture button technique. MATERIALS AND METHODS We randomly assigned 12 fresh frozen cadaveric shoulders to undergo the Latarjet procedure with either 4 suture button (S&N EndoButton) fixations (SB group; n = 6, age 72 ± 9.8 years) or cow-hitch suture button technique using a 1.7-mm FiberTape looped sequentially in 2 suture buttons (Arthrex Pectoralis Button) placed from anterior on the posterior glenoid (CH-SB group; n = 6, age 73 ± 9.3 years). After fixation, all shoulders underwent biomechanical testing with direct loading on the graft via a material testing system. Cyclic loading was performed for 100 cycles (10-100 N) to determine axial displacement with time; each graft was then monotonically loaded to failure. RESULTS The maximum cyclic displacement was 4.3 ± 1.6 mm for the cow-hitch suture button technique and 5.0 ± 1.7 mm for the standard double suture button technique (P = .46). Ultimate load to failure and stiffness were, respectively, 190 ± 82 N and 221 ± 124 N/mm for the CH-SB technique and 172 ± 48 N and 173 ± 34 N/mm for the standard double SB technique (P = .66 and .43). The most common failure mode was suture cut-through at the anteroinferior aspect of the glenoid for both fixation groups. CONCLUSIONS The cow-hitch suture button technique resulted in a similar elongation, stiffness, and failure load compared to an established double suture button technique. Therefore, this cost-effective fixation may be an alternative, eligible for open approaches, to the established double suture button techniques

Partial sacrectomy with patient-specific osteotomy guides

Background Chordomas are rare, locally aggressive, malignant tumors. Surgical resection with sufficient margins defines the outcome. However, the necessity for wide margins often leads to sacrifice of important neurological structures. 3D-printed osteotomy guides are a promising solution for precise execution of surgical resection. We present probably the first sacrococcygeal chordoma resection with 3D-printed guides. Methods The case of a 49-year-old woman with a sacrococcygeal chordoma, resected with help of 3-D pre-operative planning and patient-specific 3D-printed osteotomy guides, is reported in detail. Results A sufficient tumor excision could be performed successfully while sparing nerve root S4. The planed margin has been exactly maintained, as confirmed by histology. The patient demonstrated an excellent clinical outcome with no evidence of local recurrence. Conclusions 3-D pre-operative planning and patient-specific osteotomy guides can be used for planning and performing en-bloc surgical resection of sacral chordomas

A systematic analysis of preprints in Trauma & Orthopaedic surgery

AIMS Preprint servers allow authors to publish full-text manuscripts or interim findings prior to undergoing peer review. Several preprint servers have extended their services to biological sciences, clinical research, and medicine. The purpose of this study was to systematically identify and analyze all articles related to Trauma & Orthopaedic (T&O) surgery published in five medical preprint servers, and to investigate the factors that influence the subsequent rate of publication in a peer-reviewed journal. METHODS All preprints covering T&O surgery were systematically searched in five medical preprint servers (medRxiv, OSF Preprints, Preprints.org, PeerJ, and Research Square) and subsequently identified after a minimum of 12 months by searching for the title, keywords, and corresponding author in Google Scholar, PubMed, Scopus, Embase, Cochrane, and the Web of Science. Subsequent publication of a work was defined as publication in a peer-reviewed indexed journal. The rate of publication and time to peer-reviewed publication were assessed. Differences in definitive publication rates of preprints according to geographical origin and level of evidence were analyzed. RESULTS The number of preprints increased from 2014 to 2020 (p < 0.001). A total of 38.6% of the identified preprints (n = 331) were published in a peer-reviewed indexed journal after a mean time of 8.7 months (SD 5.4 (1 to 27)). The highest proportion of missing subsequent publications was in the preprints originating from Africa, Asia/Middle East, and South America, or in those that covered clinical research with a lower level of evidence (p < 0.001). CONCLUSION Preprints are being published in increasing numbers in T&O surgery. Depending on the geographical origin and level of evidence, almost two-thirds of preprints are not subsequently published in a peer-reviewed indexed journal after one year. This raises major concerns regarding the dissemination and persistence of potentially wrong scientific work that bypasses peer review, and the orthopaedic community should discuss appropriate preventive measures.Cite this article: Bone Jt Open 2022;3(7):582-588

Why is female gender associated with poorer clinical outcome after reverse total shoulder arthroplasty?

INTRODUCTION: There is a lack of gender-specific research after reverse total shoulder arthroplasty (RTSA). While previous studies have documented worse outcome in women - a more thorough understanding of why outcome may differ is needed. We therefore asked: (1) Are there gender-specific differences in pre- and postoperative clinical scores, complications, surgery-related parameters and demographics? (2) Is female gender an independent risk factor for poorer clinical outcome after RTSA? (3) If so, why is female gender associated with poorer outcome after RTSA? MATERIALS AND METHODS: Between 2005 and 2019, 987 primary RTSAs were performed in our institution. After exclusion criteria were applied, data of 422 female and 271 male patients were analyzed. Clinical outcome (absolute/relative Constant Score (a/rCS) and Subjective Shoulder Value (SSV)), complications (intra- and/or postoperative fracture, loosening), surgery-related parameters (indication, implant related characteristics) and demographics (age, gender, body mass index (BMI) and number of previous surgeries) were evaluated. Pre- and postoperative radiographs were analyzed (Critical Shoulder Angle (CSA), Deltoid-Tuberosity Index (DTI), Reverse Shoulder Angle (RSA), Lateralization (LSA) and Distalization Shoulder Angle (DSA)). RESULTS: Preoperative clinical scores (aCS, rCS, SSV and pain level) as well as postoperative clinical outcome (aCS, rCS) were significantly worse in women. However, the improvement between pre- and postoperative outcome was significantly higher in female patients for rCS (p=0.037), internal rotation (p<0.001) and regarding pain (p<0.001). Female patients had a significantly higher number of intraoperative as well as postoperative fractures (24.9% vs. 11.4%, p<0.001). The proportion of female patients with a DTI<1.4 was significantly higher than in males (p=0.01). Female gender was an independent negative predictor for postoperative rCS (p=0.047, Coefficient -0.084) and pain (p=0.017, Coefficient -0.574). In addition to female sex per se being a predictive factor of worse outcome, females were significantly more likely to meet two of the three most significant predictive factors: (1) significantly worse preoperative clinical scores and (2) higher rate of intra- and/or postoperative fractures. CONCLUSIONS: Female sex is a very weak, but isolated, negative predictive factor that negatively affects objective clinical outcome (rCS) after RTSA. However, differences did not reach the minimal clinically important difference (MCID) and it is not a predictor for subjective outcome (SSV). The main reason for worse outcome in female patients seems to be a combination of higher preoperative disability and higher incidence of fractures. To improve the outcome of women, all measures that contribute to the reduction of perioperative fracture risk should be utilized

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Are molecular tools clarifying or confusing our understanding of the public health threat from zoonotic enteric protozoa in wildlife?

Emerging infectious diseases are frequently zoonotic, often originating in wildlife, but enteric protozoa are considered relatively minor contributors. Opinions regarding whether pathogenic enteric protozoa may be transmitted between wildlife and humans have been shaped by our investigation tools, and has led to oscillations regarding whether particular species are zoonotic or have host-adapted life cycles. When the only approach for identifying enteric protozoa was morphology, it was assumed that many enteric protozoa colonized multiple hosts and were probably zoonotic. When molecular tools revealed genetic differences in morphologically identical species colonizing humans and other animals, host specificity seemed more likely. Parasites from animals found to be genetically identical - at the few genes investigated - to morphologically indistinguishable parasites from human hosts, were described as having zoonotic potential. More discriminatory molecular tools have now sub-divided some protozoa again. Meanwhile, some infection events indicate that, circumstances permitting, some “host-specific” protozoa, can actually infect various hosts. These repeated changes in our understanding are linked intrinsically to the investigative tools available. Here we review how molecular tools have assisted, or sometimes confused, our understanding of the public health threat from nine enteric protozoa and example wildlife hosts (Balantoides coli - wild boar; Blastocystis sp. - wild rodents; Cryptosporidium spp. - wild fish; Encephalitozoon spp. - wild birds; Entamoeba spp. - non-human primates; Enterocytozoon bieneusi - wild cervids; Giardia duodenalis - red foxes; Sarcocystis nesbitti - snakes; Toxoplasma gondii - bobcats). Molecular tools have provided evidence that some enteric protozoa in wildlife may infect humans, but due to limited discriminatory power, often only the zoonotic potential of the parasite is indicated. Molecular analyses, which should be as discriminatory as possible, are one, but not the only, component of the toolbox for investigating potential public health impacts from pathogenic enteric protozoa in wildlife

Genome-Wide Identification of the Aconitase Gene Family in Tomato (Solanum lycopersicum) and CRISPR-Based Functional Characterization of SlACO2 on Male-Sterility

Tomato (Solanum lycopersicum) is one of the most cultivated vegetables in the world due to its consumption in a large variety of raw, cooked, or processed foods. Tomato breeding and productivity highly depend on the use of hybrid seeds and their higher yield, environmental adaption, and disease tolerance. However, the emasculation procedure during hybridization raises tomato seed production costs and labor expenses. Using male sterility is an effective way to reduce the cost of hybrid seeds and ensure cultivar purity. Recent developments in CRISPR genome editing technology enabled tomato breeders to investigate the male sterility genes and to develop male-sterile tomato lines. In the current study, the tomato Acotinase (SlACO) gene family was investigated via in silico tools and functionally characterized with CRISPR/Cas9-mediated gene disruption. Genome-wide blast and HMM search represented two SlACO genes located on different tomato chromosomes. Both genes were estimated to have a segmental duplication in the tomato genome due to their identical motif and domain structure. One of these genes, SlACO2, showed a high expression profile in all generative cells of tomato. Therefore, the SlACO2 gene was targeted with two different gRNA/Cas9 constructs to identify their functional role in tomatoes. The gene was mutated in a total of six genome-edited tomato lines, two of which were homozygous. Surprisingly, pollen viability was found to be extremely low in mutant plants compared to their wild-type (WT) counterparts. Likewise, the number of seeds per fruit also sharply decreased more than fivefold in mutant lines (10&ndash;12 seeds) compared to that in WT (67 seeds). The pollen shape, anther structures, and flower colors/shapes were not significantly varied between the mutant and WT tomatoes. The mutated lines were also subjected to salt and mannitol-mediated drought stress to test the effect of SlACO2 on abiotic stress tolerance. The results of the study indicated that mutant tomatoes have higher tolerance with significantly lower MDA content under stress conditions. This is the first CRISPR-mediated characterization of ACO genes on pollen viability, seed formation, and abiotic stress tolerance in tomatoes

A systematic analysis of preprints in Trauma & Orthopaedic surgery

Aims: Preprint servers allow authors to publish full-text manuscripts or interim findings prior to undergoing peer review. Several preprint servers have extended their services to biological sciences, clinical research, and medicine. The purpose of this study was to systematically identify and analyze all articles related to Trauma & Orthopaedic (T&O) surgery published in five medical preprint servers, and to investigate the factors that influence the subsequent rate of publication in a peer-reviewed journal. Methods: All preprints covering T&O surgery were systematically searched in five medical preprint servers (medRxiv, OSF Preprints, Preprints.org, PeerJ, and Research Square) and subsequently identified after a minimum of 12 months by searching for the title, keywords, and corresponding author in Google Scholar, PubMed, Scopus, Embase, Cochrane, and the Web of Science. Subsequent publication of a work was defined as publication in a peer-reviewed indexed journal. The rate of publication and time to peer-reviewed publication were assessed. Differences in definitive publication rates of preprints according to geographical origin and level of evidence were analyzed. Results: The number of preprints increased from 2014 to 2020 (p < 0.001). A total of 38.6% of the identified preprints (n = 331) were published in a peer-reviewed indexed journal after a mean time of 8.7 months (SD 5.4 (1 to 27)). The highest proportion of missing subsequent publications was in the preprints originating from Africa, Asia/Middle East, and South America, or in those that covered clinical research with a lower level of evidence (p < 0.001). Conclusion: Preprints are being published in increasing numbers in T&O surgery. Depending on the geographical origin and level of evidence, almost two-thirds of preprints are not subsequently published in a peer-reviewed indexed journal after one year. This raises major concerns regarding the dissemination and persistence of potentially wrong scientific work that bypasses peer review, and the orthopaedic community should discuss appropriate preventive measures. Cite this article: Bone Jt Open 2022;3(7):582–588

No Difference in Risk of Amputation or Frequency of Surgical Interventions Between Patients With Diabetic and Nondiabetic Charcot Arthropathy

BACKGROUND The cause of Charcot neuro-osteoarthropathy (CN) is diabetes in approximately 75% of patients. Most reports on the clinical course and complications of CN focus on diabetic CN, and reports on nondiabetic CN are scarce. No study, to our knowledge, has compared the clinical course of patients initially treated nonoperatively for diabetic and nondiabetic CN. QUESTIONS/PURPOSES Among patients with CN, are there differences between patients with diabetes and those without in terms of (1) the frequency of major amputation as ascertained by a competing risks survivorship estimator; (2) the frequency of surgery as ascertained by a competing risks survivorship estimator; (3) frequency of reactivation, as above; or (4) other complications (contralateral CN development or ulcers)? METHODS Between January 1, 2006, and December 31, 2018, we treated 199 patients for diabetic CN. Eleven percent (22 of 199) were lost before the minimum study follow-up of 2 years or had incomplete datasets and could not be analyzed, and another 9% (18 of 199) were excluded for other prespecified reasons, leaving 80% (159 of 199) for analysis in this retrospective study at a mean follow-up duration since diagnosis of 6 ± 4 years. During that period, we also treated 78 patients for nondiabetic Charcot arthropathy. Eighteen percent (14 of 78) were lost before the minimum study follow-up and another 5% (four of 78 patients) were excluded for other prespecified reasons, leaving 77% (60 of 78) of patients for analysis here at a mean of 5 ± 3 years. Patients with diabetic CN were younger (59 ± 11 years versus 68 ± 11 years; p < 0.01), more likely to smoke cigarettes (37% [59 of 159] versus 20% [12 of 60]; p = 0.02), and had longer follow-up (6 ± 4 years versus 5 ± 3 years; p = 0.02) than those with nondiabetic CN. Gender, BMI, overall renal failure, dialysis, and presence of peripheral arterial disease did not differ between the groups. Age difference and length of follow-up were not considered disqualifying problems because of the later onset of idiopathic neuropathy and longer available patient follow-up in patients with diabetes, because our program adheres to the follow-up recommendations suggested by the International Working Group on the Diabetic Foot. Treatment was the same in both groups and included serial total-contact casting and restricted weightbearing until CN had resolved. Then, patients subsequently transitioned to orthopaedic footwear. CN reactivation was defined as clinical signs of the recurrence of CN activity and confirmation on MRI. Group-specific risks of the frequencies of major amputation, surgery, and CN reactivation were calculated, accounting for competing events. Group comparisons and confounder analyses were conducted on these data with a Cox regression analysis. Other complications (contralateral CN development and ulcers) are described descriptively to avoid pooling of complications with varying severity, which could be misleading. RESULTS The risk of major amputation (defined as an above-ankle amputation), estimated using a competing risks survivorship estimator, was not different between the diabetic CN group and nondiabetic CN group at 10 years (8.8% [95% confidence interval 4.2% to 15%] versus 6.9% [95% CI 0.9% to 22%]; p = 0.4) after controlling for potentially confounding variables such as smoking and peripheral artery disease. The risk of any surgery was no different between the groups as estimated by the survivorship function at 10 years (53% [95% CI 42% to 63%] versus 58% [95% CI 23% to 82%]; p = 0.3), with smoking (hazard ratio 2.4 [95% CI 1.6 to 3.6]) and peripheral artery disease (HR 2.2 [95% CI 1.4 to 3.4]) being associated with diabetic CN. Likewise, there was no between-group difference in CN reactivation at 10 years (16% [95% CI 9% to 23%] versus 11% [95% CI 4.5% to 22%]; p = 0.7) after controlling for potentially confounding variables such as smoking and peripheral artery disease. Contralateral CN occurred in 17% (27 of 159) of patients in the diabetic group and in 10% (six of 60) of those in the nondiabetic group. Ulcers occurred in 74% (117 of 159) of patients in the diabetic group and in 65% (39 of 60) of those in the nondiabetic group. CONCLUSION Irrespective of whether the etiology of CN is diabetic or nondiabetic, our results suggest that orthopaedic surgeons should use similar nonsurgical treatments, with total-contact casting until CN activity has resolved, and then proceed with orthopaedic footwear. A high frequency of foot ulcers must be anticipated and addressed as part of the treatment approach. LEVEL OF EVIDENCE Level III, prognostic study