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Background:. Although a certain degree of tension in bridging sutures is required for proper tendon healing following suture-bridge rotator cuff repair, excessive suture tension may be detrimental to tendon healing. This study aimed to investigate the effects of bridging suture tension on clinical outcomes and tendon healing. We hypothesized that fixed, low tension of the bridging sutures would improve the tendon healing rate and clinical outcomes compared with maximum manual tensioning. Methods:. A group of 39 patients with a rotator cuff tear were treated with arthroscopic suture-bridge rotator cuff repair, in which the bridging sutures were uniformly tensioned to 20 N (group A). A separate group of 37 patients was treated with the same suture construct, but the sutures were tensioned by maximum manual pulling (mean tension, 36.1 N; group B). The visual analog scale (VAS) score for pain, active anterior elevation, external and internal rotation, and Constant score were compared between the groups preoperatively and at 1, 3, and 6 months and 1 and 2 years postoperatively. Anatomical healing was evaluated using magnetic resonance imaging (MRI) at 1 year after surgery. Results:. At 6 months postoperatively, all clinical values had improved in both groups. The Constant score (p < 0.001), VAS pain score (p < 0.001), and anterior elevation (p = 0.004) were significantly better in group A than in group B. Two years postoperatively, there was no significant difference between groups A and B in the Constant score (p = 0.847), VAS pain score (p = 0.991), and anterior elevation (p = 0.855). Group A demonstrated a significantly lower retear rate (3 of 39, 7.7%) than group B (9 of 37, 24.3%) (p = 0.0467). Conclusions:. Double-row suture-bridge repairs with fixed, low tension led to superior clinical outcomes at 6 months and a superior tendon healing rate at 1 year compared with repairs with higher suture tension. However, the clinical outcomes did not differ significantly at 2 years between the 2 tensioning methods. Level of Evidence:. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Chronic expanding hematoma (CEH) is a rare anatomical condition that gradually expands due to trauma or surgery. We report the case of a 56-year-old woman who developed CEH 25 years after metal-on-polyethylene total hip arthroplasty. She presented with swelling and radiating pain in the right inguinal region. Tocilizumab was administered for treating rheumatoid arthritis and renal amyloid A amyloidosis. Diagnostic imaging and partial resection revealed a soft tissue mass and a CEH, respectively. The symptoms recurred 6 months later; dialysis was initiated, and the CEH was resected under general anesthesia, leading to improvement. This case report emphasizes the importance of prompt diagnosis and intervention in CEH management for preventing further complications and improving the patient's quality of life.

Background:. Although reverse shoulder arthroplasty (RSA) for rotator cuff arthropathy reliably restores anterior elevation (AE), restoration of external rotation (ER) had been unreliable using traditional Grammont-type designs, which has been addressed by lateralizing the center of rotation. This study investigated whether sequential lateralization based on the intraoperatively measured glenoid-humeral axis interval (GHI) results in better outcomes than RSA with a uniform amount of lateralization irrespective of the GHI. Methods:. Fifty-four shoulders were treated with a nonlateralized Grammont-type implant between 2016 and 2018 (group A). Forty shoulders were treated with the same Grammont-type implant with 8.0-mm-thick bony increased offset (BIO) between 2014 and 2016 (group B). Fifty consecutive shoulders were treated with a different Grammont-type implant with glenoid-side prosthetic lateralization based on the GHI between 2019 and 2020 (group C). Group C was further stratified into 3 subgroups: group C1 (GHI < 20.0 mm, n = 12) was lateralized by +3.4 mm; C2 (20.0 ≤ GHI ≤ 24.0 mm, n = 25), by +5.4 mm; and C3 (GHI > 24.0 mm, n = 13), by +7.4 mm. Active ER with the arm at the side (ER0) and abducted to 90° (ER90) as well as functional outcomes including active AE and Constant and UCLA scores were evaluated at 2 years postoperatively. Results:. The mean age, height, and body mass index and the percentage of male patients were not significantly different between groups A, B, and C. However, the patients in subgroup C1 were the shortest (151.3 ± 3.9 cm) and most elderly (77.5 ± 4.1 years) and had the highest proportion of female patients (91.7%). The patients in subgroup C3 were the tallest (161.1 ± 5.6 cm) and had the highest proportion of male patients (69.2%). ER0, ER90, and the Constant score were significantly larger in group C than in group A. AE, ER0, and the Constant and UCLA scores were significantly larger in group C than in group B. Conclusions:. Rather than using a single ideal offset, the optimal lateralization may be better determined according to the body size, the muscle volume, or perhaps the excursion of the musculotendinous unit of each individual patient. Level of Evidence:. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Knee osteoarthritis with patellar dislocation is a rare and difficult-to-treat condition. Several reports of total knee arthroplasty (TKA) combined with various realignment procedures have been published. A 77-year-old man with knee pain was referred to our hospital. Plain radiography revealed a laterally dislocated patella, with osteoarthritic changes in the femorotibial joint. He simply underwent TKA via a lateral parapatellar approach without realignment. We devised methods of exposure and closure to maximize the effect of lateral release by the lateral parapatellar approach. TKA using the lateral parapatellar approach might be effective in treating knee osteoarthritis with patellar dislocation.

Background:. Irreparable massive rotator cuff tears are characterized by a poor prognosis with high failure rates following repair. Numerous strategies, such as partial repair, graft interposition, latissimus dorsi (LD) transfer, balloon arthroplasty, and superior capsular reconstruction, have been proposed. We have adopted a graft-augmented LD-transfer procedure, in which partial repair, graft interposition, and LD transfer are performed simultaneously. Methods:. Thirty-nine patients underwent the graft-augmented LD-transfer procedure using autologous fascia lata from 2007 to 2016. All patients underwent a 5-year assessment at a mean (and standard deviation) of 54.8 ± 3.5 months. Of 20 patients with a history of >10 years, 14 underwent a 10-year assessment at a mean of 112.6 ± 5.6 months. To characterize the therapeutic effects of the procedure, the patients were divided into 3 groups according to the tear pattern: superior-posterior tears (Group A), superior-anterior tears (Group B), and global tears (Group C). Results:. The overall mean Constant-Murley score improved from 33.8 ± 5.3 preoperatively to 63.1 ± 9.4 at the 5-year assessment (p < 0.001). The overall mean active anterior elevation (AE) improved from 57.3° ± 13.2° preoperatively to 131.3° ± 18.2° at 5 years (p < 0.001). Preoperatively, AE was significantly different between Groups A and C (p < 0.001) and between Groups B and C (p < 0.001), reflecting the difference in cuff tear patterns. Postoperatively, AE was significantly higher in Group A than in Groups B (p < 0.001) and C (p < 0.001). The present study also showed that AE was electromyographically synchronized to the contraction of the transferred LD. The transferred LD was kinetically more potent at a slower speed, but it was easier to exhaust, than the native rotator cuff. Osteoarthritis progression was radiographically found to occur during the first 5 years. Conclusions:. The graft-augmented LD-transfer procedure may be a treatment option for massive rotator cuff tears, especially for active patients who are

Background:. Large posterior glenoid defects pose problems in reverse shoulder arthroplasty (RSA). We have adopted a sequential approach to the management of posterior glenoid defects using asymmetrical reaming, the placement of a ring graft around the central peg (bony-increased offset, or BIO), or structural bone-grafting, depending on the amount of glenoid retroversion. Furthermore, we have devised multiple bioresorbable pinning (MBP)-assisted bone-grafting, in which as many bioresorbable pins as required are inserted, from whichever aspects of the graft necessary, to achieve initial stability. Methods:. We reviewed 52 shoulders with posterior glenoid defects undergoing RSA between 2014 and 2019 (mean follow-up, 4.8 years; range, 2 to 6 years). Twenty (38.5%) of the shoulders had glenoid retroversion of

Background:. Reverse shoulder arthroplasty (RSA) is a recognized therapeutic modality for a massive rotator cuff tear. Some authors recommend lateralization of the center of rotation by bony increased offset (BIO) of the glenoid for improvement of external rotation, while others refute its effects. RSA through the conventional deltopectoral approach sacrifices the subscapularis tendon during the approach. We hypothesized that a lateral approach (LA) for RSA, with less soft-tissue resection, would restore external rotation by allowing retensioning of the remaining rotator cuff with use of a BIO graft. Methods:. We retrospectively investigated 36 nonlateralized inlay RSAs performed through a lateral approach (LA non-BIO group) and 40 inlay RSAs performed through a lateral approach with BIO (LA BIO group) for a massive rotator cuff tear. There were 5 patients with a combined loss of active elevation and external rotation (CLEER) in the LA non-BIO group and 6 in the LA BIO group. The Constant score, the UCLA (University of California Los Angeles) score, and range of motion, in particular, external rotation with the arm at 0° (ER0) and at 90° of abduction (ER90), were compared. Results:. The mean ER90 in the LA BIO group improved significantly, from 45.8° ± 21.6° to 65.9° ± 15.8° (p = 0.012). Postoperative ER90 in the LA BIO group was significantly higher than in the LA non-BIO group (mean, 65.9° ± 15.8° compared with 53.0° ± 12.3°; p = 0.026). The mean ER0 for the patients with CLEER status significantly improved in the LA BIO group, from −15.8° ± 9.8° to 11.0° ± 15.6° (p = 0.0072). The mean postoperative anterior elevation, UCLA score, and Constant score in the LA BIO group and the LA non-BIO group improved significantly, but there was no difference between the 2 groups (anterior elevation: 131.5° ± 17.6° compared with 121.5° ± 14.1°, p = 0.07; UCLA: 25.5 ± 6.4 compared with 23.4 ± 5.4, p = 0.2; Constant: 74.3 ± 12.0 compared with 73.6 ± 10.1, p = 0.43). Conclusions:. LA BIO-RSA was associated with a significant improvement in range of motion, particularly external rotation. Improvements in anterior elevation, the Constant score, and the UCLA score were not significantly different from those noted for LA non-BIO-RSA. Level of Evidence:. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background:. The Latarjet procedure is a commonly used treatment for recurrent shoulder instability. However, its neurological complication rate has been reported to be as high as 10%. During the Latarjet procedure, the neurovascular structures are relocated inferiorly and medially. I hypothesized that the risk of nerve injury would be reduced by assisting the inferior-medial relocation of the neurovascular structures intraoperatively. Methods:. Seventeen consecutive patients with shoulder instability accompanied by glenoid bone loss were treated with an all-arthroscopic Latarjet procedure assisted by the novel low-profile SaSumata (SS) guide. The SS guide is inserted through a portal made above the coracoid process and is attached to the coracoid process by 2 pre-fix screws (i.e., temporary pre-fixation screws). Unlike previous techniques, the SS guide is not shuttled from 1 portal to the other to redirect the bone graft from the donor site to the recipient site; instead, it remains attached to the graft throughout the procedure. The SS guide brings the coracoid graft along an inferior-medial trajectory, pushing aside the neurovascular structures with the help of a switching stick. Owing to its semicircular pronged head, the SS guide holds the graft until the pre-fix screws are exchanged with permanent screws. All patients were clinically assessed and underwent computed tomography (CT) scans. Results:. This maneuver was performed arthroscopically in 17 patients, with no conversion to open surgery and no neurological injuries. No patient had recurrence of dislocation after follow-up for a minimum of 24 months. The mean Subjective Shoulder Value was 87.5% ± 11.7%. The mean Rowe score was 88 ± 15.7. The bone block was optimally positioned between 3 o’clock and 5 o’clock and was flush with the glenoid facet in 16 of the 17 patients. There was 1 fracture of the bone block. The mean operation time after the first 5 patients was 125 ± 23 minutes. Conclusions:. The SS guide was a useful tool for performing the arthroscopically assisted Latarjet procedure for recurrent anterior shoulder instability, with good functional results. Level of Evidence:. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Prolonged dislocation of the patella is a rare condition and is often related to severe osteoarthritis (OA) of the femorotibial (FT) joint. For this condition's treatment, numerous surgical techniques using total knee arthroplasty (TKA) have been published. To the best of our knowledge, this case report is the first description of the use of lateral release alone to treat recurrent patellar subluxation with TKA. An interesting point in this case is that the patient had a good recovery after TKA in spite of quite a long-term (a duration of almost 55 years) dislocation of her patella and development of secondary OA. We describe a case that we treated by TKA for FT-OA with a prolonged patellar dislocation. We were able to obtain good patellar reduction without additional surgery by performing adequate lateral release of the patellar retinaculum. This clinical case indicates the usefulness of lateral patellar retinaculum release for obtaining stable patellar tracking in TKA for FT-OA with remaining lateral patellar dislocation. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).