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Osteoarthritis (OA) can lead to a significant functional disability. Poly[2-(methacryloyloxy)ethyl phosphorylcholine] (pMPC) liposomes are a novel treatment modality for OA, intended to restore the natural lubrication properties of articular cartilage. Here, we report on two studies aimed to assess the local and systemic safety and toxicity of pMPCylated liposomes in comparison with physiological saline, in Sprague-Dawley (SD) rats and in sheep after a single intra-articular (IA) injection. The animals were sacrificed after 1 and 6 weeks (rats) and 3 and 6 weeks (sheep). No signs of toxicity or abnormal clinical findings were observed. Histopathological evaluation revealed no signs of reactivity or abnormal findings in the injected joints or in any other organs. In conclusion, a single IA injection of the pMPCylated liposomes demonstrated an excellent safety profile and did not result in local reactivity or systemic toxicity, thus supporting its further development for use in humans.

Background Little information exists to guide the choice of exercise for regaining shoulder range of motion (ROM). The purpose of this study was to compare the maximal ROM reached, pain and difficulty associated with 4 commonly prescribed exercises. Methods Forty (9 females) patients with various shoulder disorders and a limited flexion ROM performed 4 exercises for regaining shoulder flexion ROM in a randomized order. Exercises included the self-assisted flexion, forward bow, table slide and rope-and-pulley. Participants were videotaped while performing all exercises and the maximal flexion angle reached during each exercise was recorded using Kinovea motion analysis freeware (Kinovea 0.8.15). Pain intensity and the perceived level of difficulty associated with each exercise were also recorded. Results The forward bow and table slide generated significantly greater ROM compared with the self-assisted flexion and rope-and-pulley (P ≤ 0.005). The self-assisted flexion was associated with a greater pain intensity compared with the table slide and rope-and-pulley (P = 0.002) and a greater perceived level of difficulty compared with the table slide (P = 0.006). Conclusions Due to the greater ROM allowed, and similar or even lower level of pain or difficulty, clinicians may wish to initially recommend the forward bow and table slide for regaining shoulder flexion ROM.

Aims Rotator cuff (RC) tears are common musculoskeletal injuries which often require surgical intervention. Noninvasive pulsed electromagnetic field (PEMF) devices have been approved for treatment of long-bone fracture nonunions and as an adjunct to lumbar and cervical spine fusion surgery. This study aimed to assess the effect of continuous PEMF on postoperative RC healing in a rat RC repair model. Methods A total of 30 Wistar rats underwent acute bilateral supraspinatus tear and repair. A miniaturized electromagnetic device (MED) was implanted at the right shoulder and generated focused PEMF therapy. The animals’ left shoulders served as controls. Biomechanical, histological, and bone properties were assessed at three and six weeks. Results Extension of the tendon from preload to the maximum load to failure was significantly better in the PEMF-treated shoulders at three weeks compared to controls (p = 0.038). The percentage strain was significantly higher in the PEMF group at both timepoints (p = 0.037). Collagen organization was significantly better (p = 0.034) as was tissue mineral density in the PEMF-treated group at three weeks (p = 0.028). Tendon immunohistochemistry revealed a prominent increase in type I collagen at the repair site at three weeks following continuous PEMF treatment compared with controls. None of the other tested parameters differed between the groups. Conclusion MED-generated PEMF may enhance early postoperative tendon-to-bone healing in an acute rat supraspinatus detachment and repair model. Superior biomechanical elasticity parameters together with better collagen organization suggest improved RC healing. Cite this article: Bone Joint Res 2021;10(5):298–306.

Anterior shoulder instability is typically characterized by detachment of the anteroinferior labrum (Bankart lesion). Some patients also sustain a superior labrum anterior-to-posterior (SLAP) injury. The purpose of this study was to compare the medium-term clinical results of isolated anterior Bankart repairs (ABR) with those of combined Bankart and SLAP repair (ABR + SLAP).Data on all patients treated surgically for recurrent anterior shoulder instability between 2006 and 2011 were retrospectively collected from medical charts. The minimum follow-up was 5 years. Patients were interviewed to assess patient-reported outcome measurements (PROM) as determined by the American Shoulder and Elbow Surgeons Score (ASES), the Subjective Shoulder Score (SSV), and the Disabilities of the Arm, Shoulder, and Hand Score (DASH), as well as their quality of life (QOL: SF12 questionnaire). Information on complications, re-operations, and recurrent instability was recorded and evaluated as well.A total of 150 patients (88% males) with a mean age 23.7 years (range 15-40) were included. Forty-two patients following ABR + SLAP repair were compared to 108 patients following ABR alone, with a mean follow-up of 7.8 years (range 5-10.7). The rate of re-dislocation was similar in both groups (26% for ABR + SLAP vs 20% for ABR, p = .44). There were no significant differences in functional outcome between the ABR + SLAP and the ABR alone groups (SSV 86.7 vs 86.5, p = .93, ASES 89.6 vs 86.5, p = .11, and DASH 4.9 vs 7, p = .17), or in QOL outcome (SF12 physical 95.6 vs 93.3, p = .27, SF12 mental 84.4 vs 85.7, p = .63).Surgical repair for anterior shoulder instability and a coexisting SLAP lesion yields clinical results as good as those of isolated ABR, as evidenced by similar PROM and re-dislocation rates after medium-term follow-up.III.

Background The delivery of orthopaedic care via telemedicine services has the potential to promote accessibility and decrease medical care expenses, while facilitating the control of infectious disease spreading. The purpose of this study was to assess agreement regarding diagnosis, recommended course of management and the perceived need for additional diagnostic testing between a video examination (VE) and a face to face (FTF) assessment of patients with shoulder disorders. Methods Forty-seven (18 females) patients presenting to a shoulder surgery clinic were assessed consecutively by VE and a FTF examination. All assessments were conducted by a shoulder specialist. Agreement regarding the established diagnosis, the recommended course of management and the need for additional diagnostic tests was assessed using percent agreement and kappa (95% CI) coefficient. Differences in the content, duration and satisfaction between the two examination modes were also assessed. Results Percent agreement and kappa (95% CI) coefficient for agreement regarding diagnosis were 85.1% and 0.82 (0.69–0.94), respectively. Percent agreement and kappa (95% CI) coefficient regarding the recommended course of management and the need for additional diagnostic testing were 61.7% and 0.43 (0.22–0.63), and 74.5% and 0.49 (0.25–0.74), respectively. The VE resulted in collection of less physical examination information, took longer to complete and was associated with less satisfaction by both patient and examiner. Conclusions Video examination of patients with shoulder disorders may present a valid alternative to FTF examination. Nevertheless, the content of the video-based physical examination may need to be modified to facilitate a clearer detection of indications for specific interventions or diagnostic tests.

To prospectively compare the effectiveness of three methods for self-assisted shoulder reduction demonstrated using a smartphone video link. Anterior shoulder dislocation is very common among young adults. Patients often seek medical assistance in the emergency department to reduce their shoulder. Many techniques for shoulder reduction had been described, some of which do not require professional assistance and can be performed by patients themselves. Patients admitted with anterior shoulder dislocation were randomized to either the Stimson, Milch or the Boss–Holtzach–Matter technique. Each patient was given a link to watch a short instructional video on his smartphone and instructed to attempt self-reduction. Success of the reduction, pain level, patient satisfaction and complications were recorded. The study cohort consisted of 58 patients (mean age was 31.6 (18–66, median = 27), 82% males, 88% right hand dominant). Success rate using Boss–Holtzach–Matter (10 of 19, 53%) and self-assisted Milch (11 of 20, 55%) were significantly higher than with the self-assisted Stimson method (3 of 19, 16%), p

The objective was to test the influence of a pulsed electromagnetic field (PEMF) on bacterial biofilm colonization around implants incorporated with healing abutments. Healing abutments with (test ...

Bone marrow aspirate concentrate (BMAC) is an autologous cell composition that is obtained through a needle aspiration from the iliac crest. The purpose of this study was to evaluate the outcomes of patients treated with open reduction and internal fixation with BMAC supplementation for clavicle fracture nonunion. This was a retrospective case series of 21 consecutive patients with clavicle fracture nonunion that were treated with ORIF and BMAC supplementation between 2013 and 2020. Patients were evaluated for fracture union, time to union, complications related to surgical and donor site, and functional outcome using the Quick Disability of the Arm Shoulder and Hand (QDASH), subjective shoulder value (SSV), and pain. The mean age was 41.8 years. The mean follow-up was 36 months. Twenty (95.2%) patients demonstrated fracture union, with a mean time to union of 4.5 months. Good functional scores were achieved: SSV, 74.3, QDASH, 23.3, pain level, 3.1. There were no complications or pain related to the iliac crest donor site. Supplementary BMAC to ORIF in the treatment of clavicle fracture nonunion is a safe method, resulting in high rates of fracture union and good functional outcomes with minimal complications and pain.

A commonly used method of fixation of the transferred coracoid in the traditional Latarjet–Bristow procedure (open or arthroscopic) is by two bicortical screws. Although mechanically effective, screw fixation is also a major source of hardware and neurologic complications. This study aimed to compare the biomechanical performances of traditional metal screws and endobuttons as fixators of the Latarjet–Bristow procedure. Nine fresh-frozen cadaveric human scapulae with the conjoined tendon attached to the coracoid process were used for the Latarjet–Bristow procedure. The specimens were randomly assigned one of two groups: fixation using two 4.5-mm cannulated partially threaded Latarjet–Bristow experience screws or fixation using a suture-button construct. Specimens were secured in a material testing machine and cyclically preconditioned from 2 to 10 N at 0.1 Hz for ten cycles. They were then pulled to failure at a normalized displacement rate of 400% of the measured gauge length per minute. The maximal load-to-failure, stiffness and stress were calculated using a custom script. The failure mechanism and site were recorded for each specimen. There were no significant differences in the maximal load-to-failure or other biomechanical properties of the two fixation techniques, but the failure mechanisms were unique to each one. Four specimens fixated with screws underwent graft failures (fracture) through the proximal or distal drill hole. Five specimens fixated with endobuttons underwent failure due to glenoid bone fractures. A single endobutton fixation appears to be biomechanically comparable to screw fixation in the Latarjet–Bristow procedure and provides a lower risk for graft fracture. Further studies with more numerous specimens are warranted to conclusively validate these findings.

Introduction Direct oral anticoagulation agents (DOACs) are increasingly prescribed to older adults. Concerns for perioperative blood loss dictate cessation of anticoagulation treatment and postponement of surgery until the coagulation system returns to normal state. The goal of this study is to compare the estimates of perioperative blood loss and mortality between patients using DOACs and patients receiving no anticoagultaion, in order to challenge the existing policy and question the need for surgery deferral. Materials and methods This is a retrospective cohort of patients (age > 65) with proximal hip fractures treated with either closed reduction internal fixation (CRIF, n = 1143; DOAC use n = 60) or hemiarthroplasty (HA, n = 571; DOAC use n = 29). Baseline patient characteristics included age, gender, ASA score, socioeconomic level, type of surgica#1: In general a l treatment, duration of surgery and time from admission to surgery. The effect of anticoagulant prescription on percentage of hemoglobin change, odds of receiving blood transfusions and one-month and one-year mortality was evaluated separately for CRIF and HA patients. Results Patients receiving DOACs had similar perioperative hemoglobin change, transfusion rates and mortality, compared to subjects without anticoagulants in both CRIF and HA cohorts. DOAC patients undergoing CRIF had a longer delay to surgery (40.2 ± 26.9 vs 31.2 ± 22.2, p = 0.003) and higher mortality rates at one year postoperatively (26.7% vs 16.1%, p = 0.015). Conclusions DOAC use was not associated with an increased perioperative blood loss or mortality compared to controls. However, they had to wait longer for surgery, which itself was an independent predictor of mortality. It may be safe to shorten waiting time for surgery in patients using anticoagulation, with the goal to minimize surgery delay.

This study was designed to investigate the efficacy of the InSpace balloon spacer with a specific focus on clinical and patient-related parameters, functional scores InSpace durability, and satisfaction in patients with massive irreparable rotator cuff tears (IRCT) at minimum one year follow-up.Between 2010 and 2018, patients with symptomatic IRCTs were treated with InSpace balloon implantation. Demographic characteristics, concomitant procedures, and patient's reported outcomes (PROMs) were obtained as well as satisfaction rate and willingness to undergo the procedure again. Need for subsequent surgery and conversion to reverse total shoulder arthroplasty (RTSA) and time to conversion were also evaluated.Seventy-eight patients (mean age of 70 years, range 46-86) who underwent an InSpace (OrthoSpace, Inc., Caesarea, Israel) balloon implantation were included. Mean follow-up was 56 months (median = 49.6, range 16-129 months). Sixteen out of our 29 pseudoparalytic patients (55.2%) exceed 90° of forward flexion post-surgery with mean improvement of 73° (20-150). Patients older than 65 years of age displayed a statistically significant improved ASES score (60.6 to 46.4, P 0.05). Patients who underwent a subscapularis (SSC) repair demonstrated a superior ASES score (63.4 compared to 50.4, P = 0.06).Based on the current study, spacer implantation is a low-risk, clinically effective treatment for the patients with IRCTs. Patient-specific parameters such as age, BMI, and gender should be considered during patient selection process. SSC tendon tears should be repaired if needed. Improvement in function and symptoms from this procedure may negate or delay the need for RTSA even for some of the pseudoparalytic patients.

The objective was to test the influence of a pulsed electromagnetic field (PEMF) on bacterial biofilm colonization around implants incorporated with healing abutments. Healing abutments with (test group) and without (control group) active PEMF devices were placed in a multispecies biofilm consisting of 31 different bacterial species. The biofilm composition and total bacterial counts (x10

Hyaluronan (HA)-lipid layers on model (mica) surfaces massively reduce friction as the surfaces slide past each other, and have been proposed, together with lubricin, as the boundary layers accounting for the extreme lubrication of articular cartilage. The ability of such HA-lipid complexes to lubricate sliding biological tissues has not however been demonstrated. Here we show that HA-lipid layers on the surface of an intrasynovial tendon can strongly reduce the friction as the tendon slides within its sheath. We find a marked lubrication synergy when combining both HA and lipids at the tendon surface, relative to each component alone, further enhanced when the polysaccharide is functionalized to attach specifically to the tissue. Our results shed light on the lubricity of sliding biological tissues, and indicate a novel approach for lubricating surfaces such as tendons and, possibly, articular cartilage, important, respectively, for alleviating function impairment following tendon injury and repair, or in the context of osteoarthritis. STATEMENT OF SIGNIFICANCE: Lubrication breakdown between sliding biological tissues is responsible for pathologies ranging from dry eye syndrome to tendon-injury repair impairment and osteoarthritis. These are increasing with human longevity and impose a huge economic and societal burden. Here we show that synergy of hyaluronan and lipids, molecules which are central components of synovial joints and of the tendon/sheath system, can strongly reduce friction between sliding biological tissues (the extrasynovial tendon sliding in its sheath), relative to untreated tissue or to either component on its own. Our results point to the molecular origins of the very low friction in healthy tendons and synovial joints, as well as to novel treatments of lubrication breakdown in these organs.

A pulsed electromagnetic field (PEMF) has been shown to contribute to heightening bone regeneration in a range of clinical areas, including dentistry. Due to the scarcity of studies using PEMF in oral implantology, the present experiment scrutinized the effect of PEMF can lead to improving the stability of the implant. A total of 19 subjects (40 implants in total) were selected to participate in the current study and were randomly allocated to either the PEMF group or control group. Subjects in the PEMF group received an activated miniaturized electromagnetic device (MED) while the control group received a sham healing cup. Implants stability was assessed by resonance frequency analyses (RFA) via implant stability quotient (ISQ) calculations. RFA were recorded as following: immediately after procedure, and then 2, 4, 6, 8 and 12 weeks later. Radiographic analysis was performed at baseline, 6 and 12 weeks after implant placement. Proinflammatory cytokines were evaluated in peri-implant crevicular fluid (PICF). The PEMF group presented higher ISQ mean values when compared to the control group. The primary stability time frame (the first 2 weeks) MED group depicted an increase in stability of 6.8%, compared to a decrease of 7.6% in the control group related to the baseline. An overall stability increase of 13% was found in MED treated group (p = 0.02), in contrast, the overall stability in the control group decreased by 2% (p = 0.008). TNF-&alpha, concentration during first 4 weeks was lower in the MED treated group. The data strongly suggests that MED generated continuing a PEMF may be considered as a new way to stimulate the stability of the implants at the early healing period.

This study was designed to compare the results of clavicle fracture open reduction internal fixation (ORIF) with standard horizontal incision versus vertical incision. ORIF surgery performed between October 2012 and August 2016 was included. The surgical approach was chosen according to surgeon preference as vertical or horizontal. Functional outcomes, fracture union, complications, scar appearance, skin irritation, and denervation around the scar were assessed at a minimum follow-up of three months. Thirty-eight patients, age 39 ± 12 years, were operated upon, 22 through vertical incisions and 16 through horizontal incisions. There were no significant group differences in functional scores, fracture union, or complications. Two patients in the vertical incision group had a post-operative haematoma. The scar length was significantly shorter when a vertical incision was used (6.75 ± 1.25 cm vs 8.9 ± 2.3 cm, P = 0.001). The typical distribution of hypoesthetic skin area distal and lateral to the scar represented iatrogenic damage to the supraclavicular nerves and was found in 66% of patients. The mean hypoesthetic surface area was smaller in the vertical incision group (38 ± 29 cm2 vs 48 ± 28 cm2, P = non-significant). Vertical incision results in shorter scars but may be associated with increased incidence of haematomas. Meticulous closure of the subcutaneous tissue is recommended.

Repeated attempts of closed reduction of distal radius fractures (DRF) are performed in the emergency department setting to optimize fracture alignment and avoid surgery. The additional manipulation of the fracture may, however, increase dorsal comminution and lead to loss of reduction in the cast. This retrospective cohort study has investigated the effect of second reduction attempt on fracture alignment and comminution. Six-hundred-eighteen patients with DRF were treated in the medical center in 2007–2010. Seventy-six (12.3%) DRF who underwent two reductions were included in the study. Radiographs taken after the first and second reduction attempts were reviewed for changes in fracture alignment parameters (radial height, radial inclination, volar tilt) and dorsal comminution length. Patients were also followed retrospectively to determine the rates of secondary displacement in a cast. A second closed reduction attempt improved mean radial height by 1.43 mm, mean radial inclination by 1.62° and mean volar tilt by 8.75°. Mean dorsal comminution length increased by 1.6 mm. Of the 19 (25%) patients with acceptable alignments after two reduction attempts, follow-up radiographs were available for 12, which showed successful reduction in four cases (33.3 or 5.2% of total 76 patients). A second closed reduction attempt improved immediate fracture alignment, but also worsened dorsal comminution. Only 5.2% of patients who underwent two reduction attempts had an acceptable final alignment and did not require surgery. Increased dorsal comminution may further compromise fracture stability, complicate surgery and have negative effect on the postoperative course.

Intraoperative hairline longitudinal fractures were recently reported in association with distal radius volar plating. Our aim was to further analyze this newly described complication. A retrospective radiographic and chart review was performed on 225 patients who underwent distal radius plating between June 2013 and June 2015. The Acu-Loc/Acu-Loc2© plating system (Acumed, Hillsboro, OR, USA) was used in 208 cases, and the VariAx© plating system (Stryker, Kalamazoo, MI, USA) was used in 17 cases. Three independent reviewers performed a blind evaluation of all relevant radiographs for the occurrence of longitudinal fractures around the plate, and validity was considered only when there was agreement among all three of them. Hairline longitudinal fractures were identified in 57 cases (25%), 55 with the Acu-Loc/Acu-Loc2© system and 2 with the VariAx© system. All fractures occurred with volar plating. Fracture occurrence was associated with age over 59 years, female gender, extra-articular fractures, and the use of Hexalobe screws (Acu-Loc/Acu-Loc2© system). We believe that the source of fracture occurrence lies within the screw design and that better screw design and possibly tapping in patients at risk may reduce the occurrence of intraoperative hairline longitudinal fractures. Further clinical and biomechanical research is needed to better understand this newly reported complication.

Arthroscopic rotator cuff (RC) repair incorporates suture anchors to secure torn RC tendons to the greater tuberosity (GT) bone. RC repair strength depends on the anchor-bone interface and on the quality of the GT. We evaluated the effect of single and multiple corticosteroid injections on the pullout strength of suture anchors.Fifty rats were divided into those receiving saline solution injection (control group), a single methylprednisolone acetate (MTA) injection (MTA1 group), or 3 once-weekly MTA injections (MTA3 group). Rats were killed humanely at 1 or 4 weeks after the last injection. A mini-suture anchor was inserted into the humeral head through the GT. Specimens were tested biomechanically.At 1 week after the last injection, the mean maximal pullout strength was significantly reduced in the MTA1 group (63.5%) and MTA3 group (56%) compared with the control group (P .05 for both). Mean stiffness decreased significantly in both treatment groups compared with controls (P .05). At 4 weeks after the last injection, there was a significant increase in the mean maximal pullout strength after single and triple MTA injections compared with values recorded at the 1-week time point (P .05). At 4 weeks, the mean maximal pullout strength after a single MTA injection was 92.8% of the pullout strength measured in the control group.We showed a significant detrimental effect of corticosteroid exposure on the pullout strength of a suture anchor at 1 week. However, this effect was transient and resolved within a relatively short period. These findings indicate that a waiting period is required between subacromial corticosteroid injection and RC repair surgery that involves the use of suture anchors.

Background The infraspinatus test is often used to determine the presence of shoulder external rotator strength deficits. As the accuracy of this test has not been established adequately, the purpose of this study was to determine the accuracy of the infraspinatus test in detecting shoulder external rotator strength deficits. Methods Sixty-two patients with a unilateral shoulder disorder underwent the infraspinatus test followed by instrumented assessment of shoulder external rotator muscle strength. The infraspinatus test was rated positive or negative based on the presence or absence of a strength deficit on the involved compared with the uninvolved shoulder. The instrumented strength assessment was rated positive or negative based on 4 cutoff thresholds for the presence of a strength deficit on the involved side: ≥10%, ≥15%, ≥20%, or ≥30%. The Sensitivity, specificity, positive and negative likelihood ratio of the infraspinatus test was determined based on each cutoff threshold. Results Sensitivity ranged from 52.5 to 61.1%, specificity ranged from 72.7 to 90.9%, the positive likelihood ratio ranged from 2.24 to 5.77, while the negative likelihood ratio ranged from 0.52 to 0.59. Conclusions As considerable external rotator strength deficits may frequently exist among patients with a negative infraspinatus test, this test may not serve a good screening test for external rotator strength deficits. Contrarily, clinicians can be reasonably certain of the presence of an external rotator strength deficit given a positive infraspinatus test.

The number of patients undergoing shoulder arthroplasty is increasing yearly.To evaluate the results of a consecutive series of patients who underwent shoulder replacement for a variety of indications in a single medical center in Israel.All shoulder arthroplasties performed in our institution between 2006 and 2015 were retrospectively reviewed. The functional outcomes and satisfaction of 180 shoulder arthroplasties were evaluated for objective and subjective parameters using the American Shoulder and Elbow Surgeons Shoulder Score (ASES), the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure, and the Short Form Health Survey (SF-12).The indications for surgery were osteoarthritis (n=35), rotator cuff arthropathy (n=32), fractures (n=99), and other reasons (n=14). The mean follow-up was 52 months. The scores improved markedly among the patients who underwent surgery later in the study period. The mean DASH score before 2012 was 48.8 and improved to 37.2 after 2013. The respective ASES also improved from 54.2 to 68.6. The use of hemiarthroplasty decreased from 85% to 33% as of 2013, while the use of total shoulder arthroplasty increased.Shoulder arthroplasty represents an effective treatment modality with satisfactory functional outcomes. Our current study demonstrates a shift from hemiarthroplasty to total shoulder arthroplasty, with the number of procedures increasing yearly. Surgeon experience and the expanding volume of operations had a direct positive effect on the functional outcomes of shoulder arthroplasties.

Background: Humeral avulsion of the glenohumeral ligament (HAGL) is an uncommon condition but a major contributor to shoulder instability and functional decline. Purpose: To describe the pre- and postoperative HAGL lesion presentations of instability, pain, and functionality and the return-to-sports activities in patients managed arthroscopically for anterior and posterior HAGL lesions. Study Design: Case series; Level of evidence, 4. Methods: Data on patients with HAGL lesions treated with arthroscopic repair between 2009 and 2018 were retrospectively retrieved from medical charts, and the patients were interviewed to assess their level of postoperative functionality. The Rowe; Constant; University of California, Los Angeles; Oxford; and pain visual analog scale (VAS) scores were obtained for both pre- and postoperative status. Return-to-sports activities and level of activities after surgery were compared with the preinjury state, and complications, reoperations, and recurrent instability were recorded and evaluated. Results: There were 23 study patients (12 females and 11 males; mean age, 24 years). The mean follow-up duration was 24.4 months (range, 7-99 months; median, 17 months). In 7 (30.4%) of the patients, HAGL lesions were diagnosed only intraoperatively. A significant improvement was seen in all examined postoperative functional scores and VAS. At the last follow-up visit, 2 patients (8.7%) reported residual instability with no improvement in pain levels and declined any further treatment, and 3 others (13.0%) required revision surgeries for additional shoulder pathologies (reoperations were performed 18-36 months after the index procedure). The remaining 18 patients (78.3%) were free of pain and symptoms. There was a mean of 0.65 coexisting pathologies per patient, mostly superior labral anterior-posterior, Bankart, and rotator cuff lesions. Conclusion: HAGL lesions are often missed during routine workup in patients with symptoms of instability, and a high level of suspicion is essential during history acquisition, clinical examination, magnetic resonance imaging arthrogram interpretation, and arthroscopic evaluation. Arthroscopic repair yields good pain and stability results; however, some high-level athletes may not return to their preinjury level of activity.

Several techniques and procedures have been described to treat long head of the biceps pathology; however, tenodesis and tenotomy are the 2 most common procedures performed. This study evaluated the initial fixation strength of the biceps tenodesis triple loop suture (TLS) technique and compared it with that of the simple suture technique (SST).Twenty fresh frozen cadaveric human shoulders (humeral head and neck with attached biceps tendons) were harvested. The biceps tendon was tenotomized proximally before reattachment to the bicipital groove of the matching humerus using suture anchors. Tenodesis was performed using the SST or the TLS technique. Specimens were tested biomechanically for load to failure, stress, and stiffness. The mechanism of failure was evaluated and compared between the 2 suture techniques.Maximal load to failure was significantly greater using the TLS technique (122.2 ± 26.73 N) than the SST (46.12 ± 14.37 N, P .001). There was no difference in the mean stiffness (SST: 7.33 ± 4.41 N/mm, TLS: 7.46 N/mm ± 2.67, P = .94). The failure mechanism in all SST samples occurred by suture cutout through the longitudinal fibers of the tendon. In all TLS samples, the failure occurred by suture slippage.This study demonstrated superior load to failure of the TLS compared with the SST technique for biceps tenodesis. Furthermore, this study provides the first description of the TLS technique as a possible application in biceps tenodesis. Clinical application of the TLS must be carefully considered, because although it achieved a superior biomechanical profile, experience with this stitch is limited.

Angiotensin (1–7) [Ang 1–7] is a 7 amino acid peptide generated predominantly from Ang II by the action of Ang-converting enzyme 2. We previously showed that Ang 1–7 reduced plasma aldosterone and plasma renin activity in high fructose–fed rats, and that the reduction in circulating aldosterone seemed to accord a parallel reduction in plasma renin activity. Here, we tested the possibility that Ang 1–7 affects aldosterone secretion acting directly in glomerulosa cells. First, as detected by immunofluorescence, the receptor for Ang 1–7, Mas1 is localized predominantly at the rat adrenal subcapsular region. Second, in isolated rat glomerulosa cells incubates, Ang 1–7 attenuated the aldosterone response to Ang II, with the strongest effect seen on Ang II (10 −9 M) (control 22±2.5 pg/10 5 cells; Ang II [10 −9 M] 189±11 pg/10 5 cells; Ang II [10 −9 M]+Ang 1–7 [10 −6 M] 33±3.6 pg/10 5 cells; P −8 M) (control 30±3.4 pg/10 5 cells; ACTH [10 −8 M] 409±32.5 pg/10 5 cells; ACTH [10 −8 M]+Ang 1–7 [10 −6 M] 280±12.5 pg/10 5 cells; P + ). In rats subjected to a low-salt diet for 7 days, continuous infusion of Ang 1–7 (576 μg/kg per day) resulted in a lesser rise in aldosterone (salt deplete+Ang 1–7, 16.4±4.8 ng/dL) compared with rats receiving vehicle (salt deplete+vehicle, 27.6±5.3 ng/dL; P

Background: Arthroscopic Bankart repair (ABR) and the Latarjet procedure are surgical techniques commonly used to treat anterior shoulder instability. There is no consensus among shoulder surgeons regarding the indications for choosing one over the other. Purpose: To compare the results of the Latarjet procedure with those of ABR for the treatment of anterior shoulder instability. Study Design: Cohort study; Level of evidence, 3. Methods: Data on all patients who were treated surgically for recurrent anterior shoulder instability between 2006 and 2011 were retrospectively collected at 4 medical centers. The minimum follow-up was 5 years. Data were retrieved from medical charts, and patients were interviewed to assess their level of satisfaction (range, 0-100), functional outcomes (using the American Shoulder and Elbow Surgeons shoulder score; the Subjective Shoulder Value; and the Disabilities of the Arm, Shoulder and Hand score), and quality of life (using the 12-Item Short Form Health Survey [SF-12]). Information on return to sports activities and postoperative level of activity compared with that of the preinjury state, complications, reoperations, and recurrent instability were recorded and evaluated. Results: A total of 242 patients were included. The Latarjet procedure was performed in 27 shoulders, and ABR was performed in 215 shoulders. Patients in the ABR group had significantly higher rates of redislocation (18.5%; P = .05) and subluxation (21.4%; P = .43) but a lower rate of self-reported apprehension (43.0%; P = .05) compared with patients in the Latarjet group (3.7%, 14.8%, and 63.0%, respectively). There were 5 patients in the ABR group who underwent reoperation with the Latarjet procedure because of recurrent instability. The functional scores in the Latarjet group were better than those in the ABR group. The SF-12 physical score was significantly better in the Latarjet group than in the ABR group (98.1 vs 93.9, respectively; P = .01). Patient satisfaction and subjective scores were similar in both groups. Conclusion: These results support recently published data on the Latarjet procedure that showed its superiority over ABR in midterm stability (dislocations or subluxations). The contribution of self-reported apprehension to the broad definition of stability is not clear, and apprehension rates were not correlated with satisfaction scores or the recurrence of dislocation or subluxation.

Introduction:Proximal humerus fractures (PHFs) are a common fragility fracture and have been shown to increase mortality in elderly patients. In the last decade, reverse total shoulder arthroplasty (RTSA) was introduced as a reliable operative treatment option for this indication. In other fragility fractures, most notably hip fractures, urgent surgical treatment can reduce mortality. The purpose of this study is to evaluate whether treatment with RTSA can reduce 1-year mortality in elderly patients with complex displaced PHFs.Materials and Methods:A retrospective study was performed to compare 1-year mortality between 2 groups of elderly patients (>75 years old) who presented to a level 1 trauma center emergency department with complex displaced PHFs. The conservative treatment group (n = 83; mean age, 83.7 years) presented from 2008 to 2010 when RTSA was not yet available, and treatment was nonoperative. The surgical treatment group (n = 62; mean age, 82.2 years) presented from 2012 to 2015 and underwent RTSA.Results:One-year mortality was 8.1% (male 7.1%; female 8.3%) in the surgical treatment group and 10.8% (male 18.8%; female 9.0%) in the conservative treatment group. The reduction in mortality in the surgical treatment group was not significant (entire cohort P = .56; males P = .35; females P = .59).Discussion:Recent studies failed to show better functional results after surgical treatment with RTSA when compared to conservative treatment. This study suggests that a benefit of surgical treatment with RTSA that was not examined until now might exist—a reduction in the increased mortality risk associated with PHFs.Conclusions:There was no significant difference in 1-year mortality between the groups, although there was a trend showing lower mortality with RTSA, mostly in men. Further studies with larger populations and longer follow-up times are needed to determine whether this trend is of clinical significance.

Objective Assess the frequency of a positive scapular assistance test (SAT) in different shoulder disorders and establish its association with scapular dyskinesis. Design Cross-sectional. Setting Shoulder clinic. Participants Seventy-four patients. Main outcome measures The SAT and visual assessment of scapular movement were performed by a physical therapist. An orthopaedic surgeon classified participants into 4 diagnostic categories: rotator cuff disease, superior labrum anterior posterior lesion (SLAP), shoulder instability, and other. Results Twenty-seven (36.5%) participants presented with a positive SAT. The SAT was positive among 9 of 28 participants (32.1%) with rotator cuff disease, 7 of 23 participants (30.4%) with SLAP lesions, 9 of 21 participants (42.9%) with shoulder instability, and 2 of 2 participants (100.0%) with other pathologies. The frequency of a positive SAT did not differ between the various diagnostic categories (P = 0.64). The SAT was more frequently positive among participants with scapular dyskinesis (48.5% versus 26.8%, P = 0.05). Conclusions The SAT is found similarly positive among patients with various common shoulder disorders. Although associated with scapular dyskinesis, the SAT was positive in less than half of those demonstrating scapular dyskinesis suggesting the SAT may help identify patients in whom altered scapular movement is contributing to shoulder pain.

Background The use of video examinations (VE) may improve patient care by offering them a low-cost and easy access to physicians, save traveling expenses and shorten waiting time. The aim of this study was to validate the use of Smartphones for distant assessment of shoulder function by comparing the Constant scores (CS) of patients obtained by both VE and conventional face-to-face (FTF) examination. Methods Fifty-one subjects (age 19–80 years; women:men 18:33) who presented to a shoulder clinic with a variety of complaints were prospectively recruited and underwent FTF and VE in alternating order. CS obtained by the two methods were compared. Four patients were unable to complete the VE due to technical problems or non-compliance. Results Forty-seven (92%) subjects successfully completed both examinations. The mean difference in CS was −0.53 points (95%CI: −2.6:1.6), with limits of agreement of −7.7:6 points. Agreement of correlation coefficient, accuracy and precision were 0.91 (95%CI: 0.86:0.96), 0.99 (95%CI: 0.92:1.00) and 0.91 (95%CI: 0.86:0.96), respectively. Conclusion VE can obtain a reliable estimate of shoulder function. The mean video CS was only −0.53 points from the mean frontal CS. Individual variations of CS did not exceed a 7-point distance from the “gold standard” estimate.

Methylphenidate (MP) use is highly prevalent among children and young adults. Previous basic and epidemiological research demonstrated an adverse effect of MP on bone mass. Studies in military recruits have shown that history of MP use before conscription was a risk factor for stress fractures (SF) during the service.This study is part of the project in which the association between MP use and incidence of SF was retrospectively investigated in a cohort of healthy conscripts aged 18-25, who served for at least 12 months between 2008 and 2017. Baseline information included sex, age, weight, height, geographic origin, socioeconomic status, and education. Subjects were divided into five groups: subjects without ADHD; untreated subjects with ADHD; and subjects with ADHD and prescriptions of 1-90, 91-180, or 181+ tablets during the study period. The primary outcome was at least one diagnosis of stress fracture during the study.Among 682,110 subjects (409,175 men [60%]), 29,888 (4.4%) had fractures. MP was used by 1681 (0.4%) men and 2828 (1%) women. In both men and women, SF incidence was significantly higher among subjects with untreated ADHD (7.9% and 5.4%, respectively) and significantly lower in subjects with treated ADHD (1.9-3%; 0.3-4.3%), compared to healthy controls (5.3% and 2.9%). After multivariate adjustment, subjects with untreated ADHD remained at an increased risk of fracture (men OR = 1.66, p 0.001 and women OR = 1.33, p = 0.007), whereas only subjects with highest exposure to MP (180+ tablets) had significantly lower chances for fracture (men OR = 0.49, p = 0.08 and women OR = 0.09, p = 0.02), compared to healthy controls.The study has demonstrated lower risk of stress fractures with concurrent MP use. The findings in this population challenge our understanding of the MP effect on bone integrity and prompt further basic research.

The Mayo metaphysical conservative femoral stem (Zimmer, Warsaw, Indiana) is a wedge-shaped implant designed to transfer loads proximally, reduce femoral destruction, and enable the preservation of bone stock in the proximal femur. Thus, it is a potentially preferred prosthesis for active, non-elderly patients who may require additional future surgeries. This retrospective case study analyzed the outcomes of consecutive patients who underwent total hip replacements with this stem between May 2001 and February 2013. All patients underwent clinical assessment, radiological evaluation for the presence and development of radiolucent lines, and functional assessment (numerical analog scale, Harris hip score, and Short Form-12 questionnaire). Ninety-five hips (79 patients) were available for analysis. The patients' mean age was 43 years (range, 18–64 years), and the mean follow-up was 97 months (range, 26.9–166 months). The postoperative clinical assessments and functional assessments revealed significant improvements. Sixteen patients (20.3%) had 18 orthopedic complications, the most common of which were an intraoperative femoral fracture and implant dislocation requiring revision surgeries in 10 hips (10.5%). Radiological analysis revealed evidence of femoral remodeling in 64 (67.4%) implants, spot welds (neocortex) in 35 (36.8%), and osteolysis in 3 (3.2%). These results suggest that the conservative hip femoral implant has an unacceptable complication rate for non-elderly patients. [ Orthopedics . 2018; 41(4):e516–e522.]

Background:Heterotopic ossification (HO) after hip arthroscopic surgery is a common complication and may be associated with clinical sequelae such as pain, impingement, and decreased range of motion. Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used medications for reducing or preventing HO.Hypothesis/Purpose:The purpose of this study was to evaluate the effectiveness of short-term selective cyclooxygenase-2 (COX-2) inhibitors used for HO prophylaxis after hip arthroscopic surgery. The hypothesis was that postoperative HO prophylaxis with 600 mg etodolac once daily for 2 weeks would significantly reduce the incidence of HO after hip arthroscopic surgery when compared with no prophylaxis.Study Design:Cohort study; Level of evidence, 3.Methods:Between July 2010 and April 2014, a total of 263 consecutive patients underwent hip arthroscopic surgery, performed by a single surgeon, for various pathological abnormalities at 1 medical center. The initial 163 patients received no postoperative NSAID prophylaxis for HO, and the subsequent 100 patients received 600 mg etodolac once daily for 2 weeks postoperatively. Prophylaxis compliance data, gastrointestinal side effects, and postoperative radiographs for HO were monitored.Results:A total of 100 control patients and 63 study patients met the inclusion criteria. The mean follow-up period was 12.88 months. No significant differences were observed in terms of age, sex, follow-up, or procedures performed. No gastrointestinal bleeding was observed. Radiographic findings of HO were present in 36 of 100 control patients with 17, 15, and 4 classified as having Brooker grades 1, 2, and 3, respectively. No patients in the study group presented with HO, and a significant difference in the HO rate between groups was observed ( P < .0001).Conclusion:HO after hip arthroscopic surgery is a relatively common complication, with a rate of 19% for Brooker grade ≥2 in the patients who did not receive NSAID prophylaxis. No HO was found in the patients who received short-term COX-2 inhibitor prophylaxis. The short-term administration of 600 mg etodolac once daily for 2 weeks was found to be safe and effective in preventing HO in patients undergoing hip arthroscopic surgery. HO prophylaxis protocols based on short-term etodolac treatment may be considered after hip arthroscopic surgery.

The most frequent complications after rotator cuff repair (RCR) are non-healing and re-tear. Age and gender are both proven risk factors for faulty RCR. This study analyzed the effects of female sex steroids and calciotropic hormones on tendon-derived cell characteristics.Tendon-derived cells from rat supraspinatus were treated with estradiol-17β (E2); soy isoflavones (daidzein, genistein, biochainin A); raloxifene and estrogen receptors α and β agonists and antagonists; and less-calcemic vitamin-D analog, parathyroid hormone, and vehicle control for 24 h. Cell proliferation and mRNA expression of estrogen receptor α and β, vitamin-D receptor (VDR), scleraxis, and collagen-1 were assessed.E2, Biochainin A, raloxifene, and vitamin-D significantly increased tendon-derived cell proliferation. Estrogen receptor α antagonists neutralized tendon-derived cells response to estradiol 17-β; however, estrogen receptor β antagonists did not have an effect. Scleraxis expression decreased following estradiol 17-β and vitamin-D treatments. Vitamin-D significantly reduced collagen-1 expression, while estradiol 17-β had no effect. Vitamin-D and estradiol 17-β upregulated VDR expression.Significant tendon-derived cell proliferation can be achieved with commonly prescribed female sex and calciotropic hormones. However, collagen-1 expression remained constant or decreased following the administration of these hormones. Female sex steroids and vitamin-D promoted tendon-derived cell proliferation via estrogen receptor α and VDR, not estrogen receptor β. Amplified cell proliferation was not associated with increased scleraxis and collagen-1 expression. These results have important implications to the properties of healing tendon and possible pharmaceutical therapies for patients with torn RC. Further research is warranted to expose the underling mechanisms of these effects.

The medial collateral ligament (MCL) is the most frequently injured ligament of the knee. Platelet-rich plasma (PRP) is a relatively new treatment option developed to enhance the healing response after injury to different tissue types. This study aimed at investigating whether the addition of PRP to MCL tears in rats would alter healing both biomechanically and histologically. Bilateral full-thickness tears of the MCL were surgically induced in the knees of 32 rats. Right ligament was saturated with PRP (n = 32, study group), and the left ligament was saturated with saline (n = 32, control group). The animals were killed 3 weeks later and the surgical sites were evaluated by gross inspection, biomechanically and histologically. There was no gross difference in the mass of granulation tissue, load to failure, stiffness and displacement between the study and control groups. Histological examination by means of maturity score revealed no significant differences between the study and control groups. The addition of PRP to a healing MCL did not improve any of the outcome measures in this model.

Background Lung contusion, which can occur in patients with blunt thoracic trauma, is a leading risk factor for development of acute lung injury (ALI) and acute respiratory distress syndrome. Statins are lipid-lowering drugs with many beneficial antiinflammatory and antioxidative effects. We therefore hypothesized that the administration of statins immediately after trauma will inhibit the production of inflammatory mediators, and thereby alleviate the severity of lung injury. Methods A model of blunt chest injury in rat was employed. The effects of statins (rosuvastatin) and cyclooxygenase-2 (COX-2) inhibitors (meloxicam) on ALI were assessed by measuring inflammatory mediator levels in the serum and in the bronchoalveolar space. Animals were killed at the end of day 3. Histologic evaluation of lung tissue was performed to confirm the presence and severity of lung contusion as well as the effects of statins, nonsteroidal antiinflammatory drugs, and their combination. Results Administration of meloxicam after lung contusion decreased the amount of neutrophil infiltration; however, marked hemorrhage and edema were still noticed. Administration of rosuvastatin decreased significantly cytokine levels that were increased after the blunt chest trauma. Rosuvastatin increased the expression of inducible nitric oxide (iNOS), COX-2, heme oxygenase-1 (HO-1), and prostaglandin E2 (PGE-2) in the bronchoalveolar lavage fluid of the rat contused lungs. Coadministration of meloxicam prevented these changes. Conclusion Rosuvastatin treatment after lung contusion attenuated several features of ALI. The enhanced activity of iNOS, COX-2, and HO-1 in the lung may reflect the advent of protective processes that took place in the contused lung. To our knowledge, this is the first demonstration that prostaglandin pathways play an essential role in the effects of statins in lung injury.

Drilling through bone is a complex action that requires precise motor skills of an orthopedic surgeon. In order to minimize plunging and soft tissue damage, the surgeon must halt drill progression precisely following penetration of the far cortex. The purpose of this study was to create a low-cost and easy-to-use drilling simulator to train orthopedic residents in reducing the drill plunging depth.This prospective observational study was performed in the division of orthopedic surgery of a single tertiary medical center. The participants included 13 residents and 7 orthopedic specialists. The simulator consisted of a synthetic femur bone model and ordinary modeling clay, and the training unit consisted of a disposable plastic tube (∼US$14), clamps (∼US$58), and a power drill + drill bit (standard hospital equipment). Plunging depths were measured by the simulator and compared between orthopedic specialists, the 6 "senior residents" (3+ years) and the 7 "junior residents" during a training session. Measurements were taken again 2 weeks following the training session.Initially, the plunging depths of the junior residents were significantly greater compared to those of the orthopedic specialists (7.00 mm vs. 5.28 mm, respectively, p0.038). There was no similarly significant difference between the senior residents and the orthopedic experts ([6.33 mm vs. 5.28 mm, respectively; p = 0.18). The senior residents achieved plunging depths of 5.17 mm at the end of the training session and 4.7 mm 2 weeks later compared to 7.14 mm at the end of the training session and 6 mm 2 weeks later for the junior residents.This study demonstrated the capability of a low-cost drilling simulator as a training model for reducing the plunging depth during the drilling of bone and soft tissue among junior and senior residents.

Pulsed electromagnetic fields (PEMFs) have been considered a potential treatment modality for fracture healing, however, the mechanism of their action remains unclear. Mammalian target of rapamycin (mTOR) signaling may affect osteoblast proliferation and differentiation. This study aimed to assess the osteogenic differentiation of mesenchymal stem cells (MSCs) under PEMF stimulation and the potential involvement of mTOR signaling pathway in this process. PEMFs were generated by a novel miniaturized electromagnetic device. Potential changes in the expression of mTOR pathway components, including receptors, ligands and nuclear target genes, and their correlation with osteogenic markers and transcription factors were analyzed. Involvement of the mTOR pathway in osteogenesis was also studied in the presence of proinflammatory mediators. PEMF exposure increased cell proliferation and adhesion and the osteogenic commitment of MSCs even in inflammatory conditions. Osteogenic-related genes were over-expressed following PEMF treatment. Our results confirm that PEMFs contribute to activation of the mTOR pathway via upregulation of the proteins AKT, MAPP kinase, and RRAGA, suggesting that activation of the mTOR pathway is required for PEMF-stimulated osteogenic differentiation. Our findings provide insights into how PEMFs influence osteogenic differentiation in normal and inflammatory environments.

Background The overall success and predictability of dental implant treatment hinge on the primary stability, direct bone-to implant contact formation, and quantity and/or quality of residual bone. Pulsed electromagnetic field has been reported to increase bone regeneration in various clinical situations. Therefore, it was hypothesized that devices which could locally generate a Pulsed electromagnetic field would stimulate bone healing and increase bone density surrounding implants. Objective To retrospectively assess the effects of the miniaturized electromagnetic device (MED) on the implants stability for the first time in human subjects, in a prospective case controlled series. Methods Twelve consecutive patients (28 implants) were included in the study.Twelve MED healing caps and 16 regular control healing caps were inserted. Resonance frequency analysis (RFA) was performed at implant placement and abutment connection and an implant stability quotient value was given for each implant. Results Twenty-eight dental implants were included in the current study. Maxillary implants stability was significantly higher with MED healing cups compared with controls at 15 days postimplantation (66.2 vs 62.1, P = .0008). Resonance frequency analysis test performed at 30 days postimplantation demonstrated significantly increased stability in MED as compared with the control 73.5 ± 3.2 vs 66.7 ± 4.8 in mandibular implants and 74 ± 1.7 vs 65 ± 2.3 in maxillary implants. At the 50 days postimplantation, RFA tests revealed markedly higher stability of the maxillary implants with MED active healing caps compared with nonactive 75.4 ± 5.1 vs 68.5 ± 8.5, respectively. Conclusions We conclude that MED-abutment implants demonstrated a superior stability during the early phase of healing as compared with standard implants.

Olecranon bursitis (OB) is a benign but disturbing condition that may adversely affect a military recruit's combat preparedness. This study was designed to assess incidence, risk factors, and associated medical burden of OB in the Israel Defense Forces.This is a retrospective study drawing on medical records of all Israel Defense Forces soldiers diagnosed as having OB between 2005 and 2015. OB was classified as septic and noninfectious. Crude incidence rates and duty-specific incidence rates were calculated. Medical burden was defined by the number of physician visits, referrals to orthopedic specialist consultations, duration of symptoms, and duration of pharmaceutical treatment. Demographic and occupational information (age, sex, height, weight, socioeconomic status, country of origin, type of military service, time of presentation to medical services) was used to identify risk factors for septic bursitis and longer duration of symptoms. Statistical analysis was performed in R statistical software. Risk factors were evaluated using the Chi-square test for categorical variables and Pearson correlation coefficients were used for continuous variables. The study was approved by the Israeli Defense Force IRB.A total of 2,692 soldiers were diagnosed with OB during the study period. The crude annual incidence rate of OB was 29/100,000 person-years (PY). Combat duty had an incidence of 97/100,000 PY, and noncombat duties had an incidence of 12/10,000 PY (p0.001). Female incidence (8.4/100,000 PY) was similar to male incidence (11/100,000 PY) in administrative duties (p = 0.54). More cases were diagnosed during summer and autumn than in other seasons (p = 0.016). Septic bursitis constituted 24% of all cases, was more frequent in combat soldiers (32%), and on average presented earlier in service than noninfectious OB (13 vs. 17 weeks since recruitment). The mean duration of symptoms was estimated at 17.58 weeks, with a mean of 1.75 physician visits per soldier. About 19% received a specialist referral. Origin from the former USSR was associated with a higher duration of symptoms (p = 0.012).Type of military service was the principal risk factor for OB, as indicated by a higher incidence of the disorder among combat compared to noncombat units, possibly the result of field training without protective gear and repetitive trauma to elbows. The greater number of diagnoses of OB during summer and autumn, when training is more intensive, support that explanation. Sex did not affect incidence of OB in administrative units. The medical burden appears to be relatively low, since most of the soldiers had only one physician visit. OB is highly prevalent in military compared to civilian populations. Outdoor training involving crawling is a probable explanation for the much higher rates among combat units and increased number of diagnoses during warm summer and autumn months. Prevention by use of protective gear seems to be the most promising intervention.

There is evidence that pneumoperitoneum induces transient changes in renal function in healthy individuals. Its effect on malfunctioning kidneys is not well known. We investigated effects caused by pneumoperitoneum in animals with impaired renal function.Male Wistar rats underwent subtotal (5/6) nephrectomy in 2 sequential steps to induce renal failure. Two and 10 weeks postoperatively rats were classified with acute and chronic kidney injury, respectively. At those time points all rats were exposed to 0, 5 and 8 mm Hg pneumoperitoneum for 60 minutes. Changes in creatinine, blood urea nitrogen and creatinine clearance were measured. Histopathological changes and apoptosis were also evaluated in the subgroups.A total of 18 rats with acute and 18 with chronic kidney injury completed the study. Creatinine and blood urea nitrogen did not change after applying pneumoperitoneum in the different pressure subgroups but creatinine clearance significantly decreased in the 5 and 8 mm Hg subgroups in rats with acute and chronic kidney injury. Histopathological findings in the acute kidney injury subgroups that underwent 5 and 8 mm Hg pressure revealed ischemic changes while compensatory hypertrophy was noticed in the chronic injury pressurized subgroups. The apoptotic count was significantly higher in the chronic injury subgroups compared to their acute injury pressurized counterparts.Pneumoperitoneum seems feasible in rats with impaired baseline renal function. Particularly chronic cases should not be considered a contraindication to pneumoperitoneum while in acute cases pneumoperitoneum might be detrimental.

Pulmonary ischemia-reperfusion (IR) is a biopathological event detectable in several clinical conditions, including lung transplantation, cardiopulmonary bypass, resuscitation, and pulmonary embolism. The understanding behind the activation of various inflammatory mediators regulating the apoptotic pathways remains largely unknown. We investigated the temporal expression of endothelial nitric oxide (eNOS), inducible (iNOS), and cyclooxygenase-2 (COX-2) proteins following lung-IR injury.Lung IR was induced in anesthetized rats. One hour ischemia was performed by clamping the left hilum. eNOS, iNOS, and COX-2 levels in the bronchoalveolar lavage (BAL) were measured at different time points after restoring lung perfusion in conjunction with histological changes and cellular apoptosis.BAL-eNOS levels were increased as early as 3 hours post IR, attaining the highest values (5.5 U/mL) at 3 hours, compared to non-IR values (2.8 U/mL). BAL-iNOS increased at 3-hour post-IR (3 U/mL). iNOS reached the highest levels at 24 hours (4.5 U/mL) as compared to nonischemic lungs (1.8 U/mL). COX-2 peaked at 12 hours (.025 U/mL) compared to 3, 24, and 48 hours. Highest apoptotic rates were detected at 12 and 48 hours following IR.The time-associated involvement of eNOS, iNOS, and COX-2 enzymes during the evolution of IR injury may point to an early reaction of the NOSs system versus the COX-2. Similar patterns of enzymatic activity were previously shown in the context of lung IR injury. This temporal activation may indicate an involvement of eNOS in an early reparative response, and possibly the late-pathological response, mediated by the coinduction of iNOS-COX-2.

We analysed the effects of commonly used medications on human osteoblastic cell activity in vitro, specifically proliferation and tissue mineralisation. A list of medications was retrieved from the records of patients aged > 65 years filed in the database of the largest health maintenance organisation in our country (> two million members). Proliferation and mineralisation assays were performed on the following drugs: rosuvastatin (statin), metformin (antidiabetic), metoprolol (β-blocker), citalopram (selective serotonin reuptake inhibitor [SSRI]), and omeprazole (proton pump inhibitor (PPI)). All tested drugs significantly stimulated DNA synthesis to varying degrees, with rosuvastatin 5 µg/ml being the most effective among them (mean 225% (sd 20)), compared with metformin 10 µg/ml (185% (sd 10)), metoprolol 0.25 µg/ml (190% (sd 20)), citalopram 0.05 µg/ml (150% (sd 10)) and omeprazole 0.001 µg/ml (145% (sd 5)). Metformin and metoprolol (to a small extent) and rosuvastatin (to a much higher extent) inhibited cell mineralisation (85% (sd 5)). Our results indicate the need to evaluate the medications prescribed to patients in terms of their potential action on osteoblasts. Appropriate evaluation and prophylactic treatment (when necessary) might lower the incidence and costs associated with potential medication-induced osteoporosis. Cite this article: Bone Joint J 2013;95-B:1575–80.

Recurrent patella subluxation may be secondary to excessive external tibial torsion. The purpose of this study is to evaluate the clinical and radiographic outcome of patients undergoing tibial derotation osteotomy and tibial tuberosity transfer for recurrent patella subluxation in association with excessive external tibial torsion.A combined tibial derotation osteotomy and tibial tuberosity transfer was performed in 15 knees (12 patients) with recurrent patella subluxation secondary to excessive external tibial torsion. Clinical evaluation was carried out using preoperative and post-operative Knee Society Score (KSS), Kujala Patellofemoral score, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire, the short form-12 (SF-12) and a visual analogue score (VAS) pain scale.The median follow-up period was 84 months (range 15-156) and median patient age was 34 years (range 19-57 years). The median preoperative external tibial torsion was 62° (range 55°-70°), with a median rotational correction of 36° (range 30°-45°) after surgery. Significant improvement (p0.05) was found in the KSS part I (37 ± 14 to 89 ± 11 points), KSS part II (25 ± 26 to 85 ± 14 points), Kujala score, the SF-12 outcome, WOMAC score and VAS score (8.8 ± 1.9 to 2.4 ± 1.5). Two patients had a nonunion of the tibial osteotomy site; one patient required bone grafting, while another patient required revision to total knee arthroplasty.Patients presenting with recurrent patella subluxation secondary to excessive external tibial torsion45° who underwent tibial derotation osteotomy and tibial tuberosity transfer achieved a satisfactory outcome in terms of pain relief and improved function. A significant complication was seen in 2/15 patients.Case series, Level IV.

Background: This study compared the radiological outcomes of adult closed distal radius fractures (DRFs) reduction with and without fluoroscopy. We hypothesized that fluoroscopy-assisted reduction would not improve radiographic alignment or decrease the need for surgery. Methods: Hospital medical records and radiographic images of all patients who presented with DRFs between April to June 2009 and April to June 2013 were reviewed. All patients underwent closed reduction and immobilization with or without fluoroscopic assistance. Reduction attempts were noted and pre- and postreduction posteroanterior and lateral radiographs were reviewed for fracture stability. Results: Eighty-four patients underwent reduction without fluoroscopy (group 1), and 90 patients underwent reduction with the aid of fluoroscopy (group 2). According to accepted radiographic guidelines, nonsurgical treatment was indicated for 62% of patients in group 1 and 56% of patients in group 2 ( P = .44). In addition, no significant difference between the groups was observed in any postreduction radiographic parameters ( P > .53) or postreduction alignment of unstable fractures ( P = .47). Conclusions: Reduction without the use of fluoroscopy demonstrated noninferiority when compared with fluoroscopy-assisted reduction in the emergency department for closed adult DRFs.

Anticoagulant therapy is a mainstay of treatment subsequent to major orthopedic surgeries. Evidence linking anticoagulant therapy, osteoporosis, and delayed fracture healing is not conclusive. We have previously reported that rivaroxaban significantly inhibited cell growth and energy metabolism in a human osteoblastic cell line. This study analyzed the response of primary female osteoblast cells to rivaroxaban in combination with various bone-modulating hormones.Bone samples were taken from both premenopausal (pre-Ob) and postmenopausal (post-Ob) women. Cells were isolated from each sample and cultured to sub-confluence. Each sample was then treated with Rivaroxaban (10 µg/ml) in combination with the following hormones or with the hormones alone for 24 hours: 30nM estradiol-17β (E2), 390nM estrogen receptor α (ERα) agonist PPT, 420nM estrogen receptor β (ERβ) agonist DPN, 50nM parathyroid hormone (PTH), and 1nM of vitamin D analog JKF.No effects were observed after exposure to rivaroxaban alone. When pre-Ob and post-Ob cells were exposed to the bone-modulating hormones as a control experiment, DNA synthesis and creatine kinase (CK)-specific activity was significantly stimulated with a greater response in the pre-Ob cells. When the cells were exposed to rivaroxaban in combination with bone-modulating hormones, the increased DNA synthesis and CK-specific activity previously observed were completely attenuated.Rivaroxaban significantly inhibited the stimulatory effects of bone-modulating hormones in both pre-Ob and post-Ob primary human cell lines. This finding may have clinical relevance for patients at high risk of osteoporosis managed with rivaroxaban or other factor Xa inhibitors.

The aim of the present study was to determine whether the type of protein ingested influences the efficiency of catch-up (CU) growth and bone quality in fast-growing male rats. Young male Sprague–Dawley rats were either fed ad libitum (controls) or subjected to 36 d of 40 % food restriction followed by 24 or 40 d of re-feeding with either standard rat chow or iso-energetic, iso-protein diets containing milk proteins – casein or whey. In terms of body weight, CU growth was incomplete in all study groups. Despite their similar food consumption, casein-re-fed rats had a significantly higher body weight and longer humerus than whey-re-fed rats in the long term. The height of the epiphyseal growth plate (EGP) in both casein and whey groups was greater than that of rats re-fed normal chow. Microcomputed tomography yielded significant differences in bone microstructure between the casein and whey groups, with the casein-re-fed animals having greater cortical thickness in both the short and long term in addition to a higher trabecular bone fraction in the short term, although this difference disappeared in the long term. Mechanical testing confirmed the greater bone strength in rats re-fed casein. Bone quality during CU growth significantly depends on the type of protein ingested. The higher EGP in the casein- and whey-re-fed rats suggests a better growth potential with milk-based diets. These results suggest that whey may lead to slower bone growth with reduced weight gain and, as such, may serve to circumvent long-term complications of CU growth.

The popularity of bicycle riding for recreation, exercise and transportation has grown enormously in recent years, which has led to an increased incidence of bicycle-related injuries. While these injuries involve mainly the musculoskeletal system, data on shoulder-specific injuries incurred while bike riding are lacking. Classifying these shoulder injuries may provide insight and assistance in the creation and implementation of effective protective gear and measures.To investigate the types and mechanisms of shoulder injuries among cyclists.This study retrospectively examined all cyclists who incurred shoulder injuries while riding and were admitted to the emergency department and shoulder clinic between January 2008 and November 2013. The study included 157 subjects with various bicycle-related shoulder injuries treated with either conservative or surgical measures.Eighty-four percent of injuries were caused by a direct blow to the shoulder, 7% by falling on an outstretched hand, 6% were traction injuries, and 3% were due to hyperabduction. Nine different clinical types of injury were observed; the most common injuries were clavicle fractures (32%), followed by acromioclavicular joint dislocations (22%), rotator cuff tears (22%), and humeral fractures (8%). Fifty-one percent of subjects were managed with conservative care and the remaining patients required surgical interventions.Shoulder injuries incurred while riding a bicycle span the entire spectrum of shoulder injuries and often result in debilitating conditions. Although the use of helmets is increasing, there is currently no effective protective gear or measures to prevent riders from suffering shoulder injuries.