The results of using a tendon autograft as a new rotator cable for patients with a massive rotator cuff tear:a technical note and comparative outcome analysis

Background: Several surgical reconstructive options are available to treat massive rotator cuff tears (MRCTs). The rotator cable has an important function and we evaluated the clinical result after arthroscopic reconstruction of the rotator cable with an autograft tendon. Methods: A prospective pilot study was performed with inclusion of four patients, average age of 64 years, with an irreparable MRCT. The patients underwent an arthroscopic reconstruction of the rotator cable with the use of the long head of biceps tendon autograft, except for one which was reconstructed with a hamstring tendon. Pre- and postsurgically, the Constant-Murley Score (CMS), Western Ontario Rotator Cuff Index (WORC), Simple Shoulder Test (SST), visual analog scale (VAS) scores, and an MRI was performed. Clinical results of the study group were compared with clinical results of comparable cohort of patients with a MRCT, treated non-operatively with physiotherapy. Results: The CMS score increased after surgery in three of the four patients. The improvement of CMS score was comparable to the improvement of the CMS score encountered in a comparable cohort. The MRI at 12 months follow-up showed that the reconstructed rotator cable was disintegrated in all patients and the rotator cuff was detached and retracted. Conclusions: In our pilot study, arthroscopic reconstruction of the rotator cable using a tendon autograft failed over time and showed no clinical benefit in comparison to the non-operative treatment with physiotherapy. Trial registration: The regional Medical Ethical Committee (Zwolle) gave approval at 14th of October 2016 and assigned no. 16.06100

Using the Long Head of Biceps Tendon Autograft as an Anatomical Reconstruction of the Rotator Cable:An Arthroscopic Technique for Patients With Massive Rotator Cuff Tears

The treatment of massive rotator cuff tears (MRCT) is challenging. Insufficient tissue quality, size, and retraction of the cuff often lead to failures of repair. Different techniques like direct repair, partial repair, and graft applications have been developed, but results are not yet predictable. In this arthroscopic technique the objective is not to reconstruct the rotator cuff as a tissue layer but to restore the biomechanical function of the rotator cable with an autograft of the long head of the biceps tendon. After glenohumeral inspection, the long head of the biceps tendon is harvested and the retracted cuff is released and, if possible, closed partially side-to-side. The biceps graft is positioned from the posterior aspect of the greater tubercle to the superior part of the lesser tubercle and fixed with 2 biotenodesis anchors. Finally, the cuff remnants are securely sutured to the biceps graft with standard cuff repair sutures. This arthroscopic technique has several advantages because the biceps autograft is easily harvested, autologous, and rich in collagen. Previous studies show use of the biceps tendon differently for reconstruction of the rotator cuff, with promising results. Future studies are needed to evaluate clinical outcomes

Arthroscopic isolated long head of biceps tenotomy in patients with degenerative rotator cuff tears:mid-term clinical results and prognostic factors

INTRODUCTION: The long head of biceps tendon is frequently involved in degenerative rotator cuff tears. Therefore, this study explored the clinical results of an isolated biceps tenotomy and identified prognostic factors for improvement in pain and function. MATERIALS AND METHODS: Between 2008 and 2017, an arthroscopic isolated biceps tenotomy was performed on 64 patients with a degenerative rotator cuff tear (> 65 years). Primary outcome was patient-perceived improvement in pain and function. Potential prognostic factors for improvement in pain and function were identified. RESULTS: A perceived improvement in pain was reported in 78% of the patients at three months after surgery and in 75% at a mean follow-up of 4.2 years (1-7 years; n = 55). A perceived improvement in function was observed in 49% of patients at three months and in 76% of patients at follow-up. Patients with a preoperatively normal acromiohumeral distance (> 10 mm) reported an improvement in pain and function significantly more often. Retraction of the supraspinatus tendon Patte 3 was significantly associated with worse functional outcome. CONCLUSIONS: A biceps tenotomy can be a reliable treatment option for patients with symptomatic degenerative cuff tears who fail conservative treatment and have a normal acromiohumeral distance (> 10 mm)

Topical use of MMC in the upper aerodigestive tract: a review on the side effects

Not much is known about the side effects of mitomycin C (MMC), an anti-fibrogenetic agent, in the upper aerodigestive tract. However, its use in ophthalmology is widely known and without quantitatively important side effects. A literature review was performed for side effects of MMC in the upper aerodigestive tract. Forty-six articles, describing the use of MMC to prevent scarring, were retracted from PubMed. Thirty-two are human studies. MMC is used in different concentrations (0.1–10 mg/ml) with different application times (2–5 min) and frequencies (up to 4 times). Five hundred and thirty-eight patients were included in those publications, of whom 19 developed side effects (3.53%). No side effects developed in studies, where post-application irrigation with saline was reported. The longest mean follow-up period is 75.5 months. Direct relations between the reported side effects and MMC seem absent in most studies. Serious complications seem to occur when MMC is used in high concentrations. Unfortunately, sometimes crucial information is lacking. One patient was described who supposedly developed laryngeal carcinoma after repeated treatment of hyperkeratosis and anterior commissure webbing. Animal studies show that excessive fibrin production can lead to acute airway obstruction. In conclusion, topical application of MMC on a wound with consecutive irrigation with saline can be performed safely to prevent scar formation in circular structures of the upper aerodigestive tract. Long-term yearly control of the application site seems advisable

Identification of regulatory variants associated with genetic susceptibility to meningococcal disease.

Non-coding genetic variants play an important role in driving susceptibility to complex diseases but their characterization remains challenging. Here, we employed a novel approach to interrogate the genetic risk of such polymorphisms in a more systematic way by targeting specific regulatory regions relevant for the phenotype studied. We applied this method to meningococcal disease susceptibility, using the DNA binding pattern of RELA - a NF-kB subunit, master regulator of the response to infection - under bacterial stimuli in nasopharyngeal epithelial cells. We designed a custom panel to cover these RELA binding sites and used it for targeted sequencing in cases and controls. Variant calling and association analysis were performed followed by validation of candidate polymorphisms by genotyping in three independent cohorts. We identified two new polymorphisms, rs4823231 and rs11913168, showing signs of association with meningococcal disease susceptibility. In addition, using our genomic data as well as publicly available resources, we found evidences for these SNPs to have potential regulatory effects on ATXN10 and LIF genes respectively. The variants and related candidate genes are relevant for infectious diseases and may have important contribution for meningococcal disease pathology. Finally, we described a novel genetic association approach that could be applied to other phenotypes

Biceps Autograft Augmentation for Rotator Cuff Repair:A Systematic Review

Purpose: To improve surgical outcomes in patients with massive cuff defects, different techniques and augmentations are proposed. The biceps tendon is easily available as an autograft. Our aim was to conduct a qualitative systematic review of various methods and surgical techniques that use a biceps autograft (BAG) for rotator cuff repair. Functional outcomes are also reported. We hypothesized that by using a BAG to treat massive rotator cuff tears, a more anatomic and biomechanical reconstruction could be achieved compared with other techniques. Methods: A qualitative systematic review was conducted (MEDLINE and Embase databases) to inventory surgical techniques for use of a BAG for rotator cuff repair. The following search terms were used for MEDLINE: biceps AND (augment* OR autograft* OR transplantation* OR (cuff AND graft*) OR biceps-incorporat*). Studies were included if the following criteria were fulfilled: description of surgical technique, only human subjects, functional outcomes noted, all study designs except technical notes, and no restrictions on study date. The quality of the studies was assessed in a standardized manner using a tool based on the Cochrane handbook. Results: We identified 981 studies; among these, 8 case series met the inclusion criteria. We identified 6 studies as high quality and 2 as medium quality. Different techniques for harvest and augmentation were used. Some studies left the proximal or distal portion intact, whereas others used it as a free graft. The clinical results of these studies showed significantly improved function, pain relief, and range of motion at follow-up, although this was not compared with a control group. The constructs were intact on magnetic resonance imaging in most patients (82%) within 2 years. Conclusions: It can be concluded that use of a BAG is an option for augmentation in massive rotator cuff tears, although no definitive recommendations can be given. This is based on Level IV medium- and high-quality studies

A traumatic superficial temporal artery aneurysm after a bicycle accident

A male cyclist presented with a swelling on the forehead. Six weeks before, he fell of his bike and smashed his head on the ground while wearing a helmet. A smooth lump of 1 cm had evolved on the temporal side of his forehead in a few weeks. Duplex ultrasonography demonstrated a dilated vessel with a minor defect in the luminal wall. Surgical exploration revealed an aneurysm of the superficial temporal artery (STA). The aneurysm was surgically removed and the patient recovered uneventfully. Owing to its superficial course, the STA is vulnerable to blunt head trauma. Traumatic aneurysms of the STA should be a differential diagnostic consideration in patients with a history of trauma and a swelling on their head

Appropriate care for orthopedic patients: effect of implementation of the Clinical Practice Guideline for Diagnosis and Treatment of Subacromial Pain Syndrome in the Netherlands

Background and purpose — The multidisciplinary Clinical Practice Guideline for diagnosis and treatment of subacromial pain syndrome (SAPS) was created in 2012 by the Dutch Orthopedic Association. In brief, it stated that SAPS should preferably be treated nonoperatively. We evaluated the effect of the implementation of the guideline on the number of shoulder surgeries for SAPS in the Netherlands (17 million inhabitants). Patients and methods — An observational study was conducted with the use of aggregated data from the national database of the Dutch Health Authority from 2012 to 2016. Information was collected on patients referred to and seen at orthopedic departments. Data from the following Diagnoses Related Groupings were analyzed: 1450 (tendinitis supraspinatus) and 1460 (rotator cuff tear). Results — In 2016 fewer patients were diagnosed with tendinitis supraspinatus than in 2012—a decrease from 49,491 to 44,662 (10%). Of the patients diagnosed with tendinitis, 14% were treated surgically in 2012; this number dropped to 9% by 2016. More patients with a rotator cuff tear were diagnosed in 2016 than in 2012, an increase from 17,793 to 23,389 (32%), fewer were treated surgically: 30% in 2012, compared with 25% in 2016. Interpretation — After introducing the multidisciplinary Clinical Practice Guideline “Diagnosis and treatment of subacromial pain syndrome,” a decrease in shoulder surgeries for related diagnoses was observed in the Netherlands. The introduction and dissemination of this guideline seems to have contributed to the implementation of more appropriate health care and prevention of unnecessary surgeries

Long-term clinical outcome of arthroscopic Bankart repair with suture anchors

Background: The most common surgical technique in traumatic anterior shoulder instability is the arthroscopic Bankart repair, which has excellent short-term results. The long-term results of the arthroscopic Bankart repair are less frequently studied, with a high recurrence rate of 23% to 35%. The aim of this study was to evaluate the medium-term to long-term results of arthroscopic Bankart repair using suture anchors and to identify specific risk factors for recurrent instability. Methods: Included were 147 patients after traumatic anterior shoulder dislocation who underwent an arthroscopic Bankart repair. The primary outcome was recurrent instability, defined as dislocation or subluxation as perceived by the patients. The secondary outcome was subjective shoulder stability and function as well as quality of life, evaluated using the Western Ontario Shoulder Instability Index, the Simple Shoulder Test, and the 12-Item Short Form Health Survey. Prognostic factors for recurrent instability were analyzed. Results: Recurrent instability occurred in 22% of patients with a mean follow-up of 6.3 years. Survival at 5 and 10 years without recurrent instability was 79% and 78%, respectively (95% confidence interval, 72%-85% and 71%-85%, respectively). The Western Ontario Shoulder Instability Index score, the Simple Shoulder Test score, and the 12-item Short Form Physical Component Summary improved significantly in the nonrecurrence group (P <.001, P = .004, and P = .002, respectively). Younger age and use of fewer than 3 anchors were associated with a higher risk of recurrent dislocation (P = .008 and P = .039, respectively). Conclusion: We found an overall recurrent instability rate of 22% (dislocation or subluxation). Good long-term results were observed after arthroscopic Bankart repair in patients older than 20 years with 3 or more suture anchors used. (C) 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved