Tendinopathy, a degenerative condition of tendon collagen protein, is a common sports injury among elite athletes. Despite its prevalence, the manifestation and progression of tendinopathy remain unclear, and the efficiency of diagnosis and treatment modalities is uncertain. Artificial intelligence and machine learning (ML) have shown positive results in disease diagnosis and treatment evaluation. This systematic review examined many ML methods and their diagnostic yield in predicting tendinopathy. A comprehensive search of electronic databases, including Ovid Medline, EMBASE, PubMed and the Web of Science, was conducted. The quality of the studies was assessed using the Newcastle–Ottawa scale. The statistical analysis was performed using mada package on R software. Four studies were considered eligible for this meta-analysis, constituting outcomes from 12,611 patients. The ML methods used in the selected studies included random forest, convolutional neural networks and linear support vector machines. The results showed that all selected studies demonstrated the relevance of ML in moderately (Reviewer 2, Comment 2) predicting tendinopathy. The pooled diagnostic yield of the ML algorithms estimated an overall sensitivity of 0.74 (95

Massive, irreparable posterosuperior rotator cuff tears, particularly those involving the infraspinatus, remain challenging to manage. In recent years, superior capsular reconstruction (SCR) and lower trapezius transfer (LTT) have been two techniques that have gained popularity. Superior capsular reconstruction aims to restore superior glenohumeral stability, but on its own, it may not restore the dynamic anteroposterior force couple, particularly in cases with significant infraspinatus dysfunction. Lower trapezius tendon transfer provides dynamic external rotation and replicates the posterior force couple by providing a line of pull that mimics native infraspinatus, but it may not restore superior stability, especially in early abduction. We describe a combined technique integrating arthroscopically assisted LTT with SCR using the long head of the biceps tendon as a biological graft. This method seeks to combine the static stability benefits of SCR with the dynamic rotational advantages of LTT, in a cost-effective and reproducible approach.

Background Surgical intervention for lateral epicondylitis remains a controversial topic, with its purpose being debated. Recent guidelines have concluded no benefit from surgery when compared to conservative management. Methods An electronic database search of Ovid Medline via PubMed, EMBASE and the Web of Science was performed to understand the published literature further. Results 35 studies incorporating 1564 patients were included. This included 12 trials and 23 observational studies. Most studies reported the benefits of surgery in pain and function despite the majority of studies using a variety of outcome measures. Conclusion Surgery is reported to treat lateral epicondylitis successfully. However, multicenter studies have yet to be published, and the low number of included patients means that further evidence is required to conclude management.

Clavicular brachial plexus blocks are a popular method to provide analgesia in upper limb surgery. Two common approaches include the infraclavicular (IC) and supraclavicular (SC) blocks. These two techniques have been compared previously; however, it is still being determined from the current literature whether one should be favoured. A search was performed on the following databases: Ovid Medline, EMBASE and the Web of Science from inception until 30.04.2023. All RCTs comparing SC and IC approaches in upper limb orthopaedic surgery were included. The primary outcome was block success rate. Eighteen RCTs comprising 1389 patients were included. The success rate of IC blocks was higher than SC blocks, odds ratio 0.61 (95

Numerous surgical techniques have been developed to address recurrent anterior shoulder instability, with the Bankart repair and the Latarjet procedure emerging as dominant. With recent advancements in keyhole surgery, there's been a surge in popularity for all-arthroscopic procedures. Our systematic review aims to determine if there's justification for incorporating these techniques into a classification system for guiding treatment of traumatic anterior recurrent instability. We identified and analysed a variety of key studies, including 12 systematic reviews, three prospective studies, seven nonrandomized prospective and retrospective studies, along with one biomechanical study. Our study sheds light on the wide range of procedures available to shoulder surgeons dealing with traumatic anterior recurrent instability. We introduce a novel classification system (BoTH) designed to simplify the decision-making process in this context.

PURPOSE:To assess the impact of the COVID-19 pandemic on the outcomes of the patients who underwent trauma surgery during the peak of the pandemic.METHODS:The UKCoTS collected the postoperative outcomes of consecutive patients who underwent trauma surgery across 50 centres during the peak of the pandemic (April 2020) and during April 2019.RESULTS:Patients who were operated on during 2020 were less likely to be followed up within a 30-day postoperative period (57.5% versus 75.6% p <0.001). The 30-day mortality rate was significantly higher during 2020 (7.4% versus 3.7%, p <0.001). Likewise, the 60-day mortality rate was significantly higher in 2020 than in 2019 (p <0.001). Patients who were operated on during 2020 had lower rates of 30-day postoperative complications (20.7% versus 26.4%, p <0.001).CONCLUSIONS:Postoperative mortality was higher during the first wave of the COVID-19 pandemic compared to the same period in 2019, but with lower rates of postoperative complications and reoperation.

We report a case of a 40-year-old man who presented with left shoulder pain and marked functional impairment two days after receiving the second dose of the Pfizer COVID-19 vaccine. Advanced imaging demonstrated focal avascular necrosis (AVN) of his humeral head. Initial management included simple analgesics, activity modification, and an ultrasound-guided intra-articular hydrodilatation injection. The patient subsequently had an improved range of motion but persistent severe shoulder pain. He has now been offered surgical intervention. Despite having risk factors for developing AVN previously, the patient did not demonstrate any recent risk factors for developing the disease. COVID-19 vaccination is known to cause severe joint pain and stiffness rarely. However, avascular necrosis is not a known or documented side effect. His symptoms arose directly after the administration of the vaccine, with no other demonstrable cause. Therefore, we are reporting COVID-19 vaccination as a potential new risk factor for AVN of the humeral head.

Background: This study aims to demonstrate the impact of the COVID-19 pandemic on providing trauma services at our district general hospital. We aim to identify the impact on specific areas of theatre delay to help optimize theatre efficiency and generate better protocols and improve patient flow for future pandemic waves. Methods: Patients who underwent orthopaedic trauma surgery at our hospital between July-August 2019 (pre-COVID-19) and 2020 (first UK wave of COVID-19) were identified retrospectively and grouped by year of operation. Type of operation was recorded, including time for sending, anaesthetic induction, surgical preparation, operating time, and time for transfer to recovery. The two groups were compared for analysis. Results: Case numbers were similar in both 2019 and 2020 (215vs.213 operations), with a similar proportion being hip fractures (39.1% and 36.6%), respectively. Median sending time (40vs.23 minutes, P <0.00001) and induction time (13vs.8 minutes, P<0.00001) were increased in 2020, a 74% and 63% increase compared to 2019, respectively. Median surgical preparation time (35vs.37 minutes, P=0.06) and operating time (56vs.50 minutes, P=0.16) were not statistically significant. Transfer time in 2020 (16vs.13 minutes, P<0.00001) was significantly increased. Overall case time increased in 2020 (2:40vs.2:11, P<0.00001) by 29 minutes. Conclusion: COVID-19 had a significant impact on theatre efficiency in our hospital, causing multiple points of delay. As hospitals across the UK restart crucial elective services, focus should be given to maximizing theatre efficiency by providing rapid access COVID-19 testing for patients undergoing emergency surgery. We have proposed and implemented several steps for better theatre utilization.

Anterior shoulder instability with bone loss is a challenging condition. The two most performed procedures, Bankart repair & Latarjet, are not without issues. We describe a technique where arthroscopic free bone grafting was performed in conjunction with remplissage. We feel that this combined arthroscopic procedure offers advantages that include reduced risk of conventional Latarjet complications, including neurological deficits and metal hardware complications while preserving subscapularis and coracoid. Furthermore, these advantages may not come at the cost of compromised outcomes, particularly recurrence rate, as the remplissage may compensate for the possible lack of "sling effect" with free bone graft reconstruction.

Background Structural failure rate in rotator cuff repairs is still high. The purpose of the study is to assess the structural integrity of a series of augmented rotator cuff repairs with porcine matrix patch and report the functional outcomes. Methods Between 2014 and 2017, 44 consecutive patients underwent arthroscopic double-row repair of medium to massive rotator cuff tears with extracellular porcine dermal matrix augmentation. At one-year follow-up, magnetic resonance imaging scan was performed to assess the integrity of the repair. Oxford Shoulder Score (OSS), Constant Score (CS) and Visual Analogue Scale pain score, together with range of motion were used to assess patients. Results Patients mean age was 68 (53–82); mean follow-up was 17.2 (12–24) months. On magnetic resonance imaging scans, seven rotator cuff repair failures (15.9%) were observed: tear size was an independent predictor of re-rupture at one-year follow-up. Clinical scores showed a statistically significant improvement at three months and until final follow-up (p< 0.001). No complications occurred. Conclusion Observed structural failure rate of 15.9% is lower than those reported in the literature for standard rotator cuff repair of medium to massive tears in similar cohorts to ours. Extracellular matrix augmentation for rotator cuff repair was shown to be a safe and reliable support to the repairs and patients recovered good shoulder function. Level of Evidence: Level IV.

Lunotriquetral (LT) ligament tear, usually in combination with an adjacent carpal ligament injury, can result in complete LT dissociation and VISI (Volarflexed Intercalated Segment Instability). Operative techniques for the management of instability are highly variable with many described in literature, although there is little evidence to demonstrate the superiority of one definitive therapeutic technique of repair and reconstruction. In this paper, we discuss our proposed technique for performing LT ligament repair using an augmented internal brace, which addresses triquetral extension and lunate flexion. The internal brace construct also provides biomechanical superiority as it includes the augmentation of the ligament and capsule repair. We use figures and references from our case example to demonstrate this technique.

Background Repair of massive rotator cuff tears remains a challenging process with mixed success. There is a growing interest in the use of patches to augment the repair construct and the potential to enhance the strength, healing, and associated clinical outcomes. Such patches may be synthetic, xenograft, or autograft/allograft, and a variety of techniques have been tried to biologically enhance their integration and performance. The materials used are rapidly advancing, as is our understanding of their effects on rotator cuff tissue. This article aims to evaluate what we currently know about patch augmentation through a comprehensive review of the available literature. Methods We explore the results of existing clinical trials for each graft type, new manufacturing methods, novel techniques for biological enhancement, and the histological and biomechanical impact of patch augmentation. Results There are promising results in short-term studies, which suggest that patch augmentation has great potential to improve the success rate. In particular, this appears to be true for human dermal allograft, while porcine dermal grafts and some synthetic grafts have also had promising results. Conclusion However, there remains a need for high-quality, prospective clinical trials directly comparing each type of graft and the effect that they have on the clinical and radiological outcomes of rotator cuff repair.

This systematic review of the literature aims to analyse current knowledge to inform choice between hemiarthroplasty (HA) and reverse total shoulder arthroplasty (rTSA) for managing proximal humerus fractures (PHF) in elderly patients; the aim is to understand if rTSA can be considered the gold standard for treating PHF in the elderly when surgical fixation or conservative treatment is not viable options. Studies reporting outcomes and complications of PHF treated with shoulder arthroplasty in the elderly were included. Studies were in English and published after 2008. Evidence levels I, II, III and IV were included. According to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a comprehensive literature search was conducted using Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and PubMed search engines, as well as the Cochrane Central Register of Controlled Trials. General data collected were study design, number of patients treated with HA and rTSA, age of patients (mean, mean and SD, mean and range), length of follow-up, type of implant, and clinical outcomes. rTSA can be regarded as the gold standard for surgical management of displaced 3 and 4-part fractures in the elderly. However, the literature offers mostly low-quality studies, thereby requiring further work to achieve a full understanding of this important topic.

PURPOSE:Posterior fracture-dislocation of shoulder is an infrequent traumatic event; however, most orthopaedic surgeons may face the challenge of treating it. The aim of this study is to review and summarise systematically the current principles of the management of this complex injury, and create a treatment algorithm.METHODS:Both PubMed and Scopus Databases were systematically searched for the terms "posterior shoulder fracture-dislocation" or "posterior glenohumeral fracture-dislocation" or "posterior glenoid fracture-dislocation" for articles written in English and published in the last decade.RESULTS:A total of 900 articles were identified, of which 13 were retained for analysis. A total of 153 patients (161 shoulders) were identified. These patients were treated either with open reduction and internal fixation, modified McLaughlin procedure, allograft/autograft humeral head reconstruction or shoulder arthroplasty. The mean age was 40.15 years. The mean postoperative Constant score in cases treated by open reduction and internal fixation was 86.45, whereas by bone graft was 84.18. Further, the mean postoperative Constant score was between 79.6 and 67.1 in those that were managed by modified McLaughlin and arthroplasty procedure, respectively.CONCLUSION:The management of posterior shoulder fracture-dislocation may be challenging, and the best surgical option depends on many variables such as the chronicity of the injury, the presence of a fracture at the level of the surgical neck or tuberosities and the extend of the Hill-Sachs lesion if any. A treatment algorithm is proposed, based on the current literature in an effort to create a consensus for these injuries. For the acute shoulder fracture-dislocations, an open reduction should be performed. For the chronic fracture/dislocations in the elderly low-demand patients, conservative treatment should be performed. For the rest of the patients, depending on the severity of the Hill-Sachs lesion different surgical options are available such as the McLaughlin technique, the use of an allograft, osteotomy or arthroplasty.

BackgroundThe aim of our study is to report the clinical and radiological outcomes of a series of prospectively enrolled patients who have had double-row transosseous equivalent rotator cuff repairs, where all-suture anchors were used as medial-row anchors, with a minimum follow-up of 1 year.MethodsTwenty-two consecutive patients underwent arthroscopic transosseous equivalent double-row rotator cuff repair using all-suture anchors as medial-row anchors. Oxford Shoulder Score, Constant Score and Visual Analogue Scale pain score, together with shoulder range of motion, were used preoperatively and at 3 months, 6 months and final follow-up. Radiological evaluation was performed with magnetic resonance imaging at one-year post surgery to assess the structural integrity of the repair and the rate of cyst formation in greater tuberosity.ResultsThe patient mean age was 61 years (range 46-75). Minimum follow-up was 1 year, and the mean final follow-up was 15 months (range 12-24). Healing failure in our patients was less than 5% (1/22 patients). There were significant improvements in shoulder function outcome scores at final follow-up. The Constant and Oxford scores were 78 and 44 at final follow-up respectively. There were similar magnitudes of improvement in range of motion (combined abduction and rotation), pain score and supraspinatus strength at final follow up. The improvements in outcome scores were already statistically significant at 3 months (P<.001). Using Kim's classification for cyst formation on T2-weighted MRI images, we observed no fluid or minimal fluid collection in 85% of the patients (17/22 patients). There were no correlations between the grade of bone changes and the clinical outcomes.ConclusionIt is safe to use all-suture anchors as medial-row anchors when performing double-row anchor transosseous equivalent rotator cuff repairs. The purported advantages of all-suture anchors may outweigh their perceived disadvantages in rotator cuff repair surgery.

Background Reverse shoulder arthroplasty (RSA) has revolutionized the management of many shoulder pathologies. Lateralization has become favourable to combat complications (e.g. notching, compromised external rotation), using a metallic, or autogenous bone-graft baseplates – bony increased-offset reverse shoulder arthroplasty (BIO-RSA). We systematically reviewed the literature to determine: Does BIO-RSA improve range of motion and outcome scores? Are notching rates decreased? Does the graft heal? Methods All available prospective studies, trials and case series reporting on BIO-RSA were included. Outcomes were grouped into outcome scores, range of motion and radiographic outcomes. Data were pooled and statistical analysis performed. Results Eight studies reported on 385 RSA – 235 BIO-RSA and 150 standard-RSA (STD-RSA). Follow-up was 20–36 months; average age 74 years. Outcome scores: Constant-Murley and SSV scores showed statistically significant post-operative benefit of BIO-RSA (mean-difference 4.0 (95% confidence interval (CI): 0.79,7.1) and 6.8 (95% CI: 3.8, 9.9)). No Minimal Clinically Importance Difference was surpassed. Range of motion: No difference was found in any direction. Notching: Notching was less likely with BIO-RSA (odds ratio 0.19 (95% CI: 0.10, 0.38)). Healing and loosening: 92% grafts fully healed/incorporated. Loosening rate was 2.4%. Conclusions Literature on BIO-RSA is limited with only one randomised controlled trial (RCT). Weak evidence exists for improved outcome scores. Range of motion is equivocal. Notching rates are significantly lower in BIO-RSA. The graft usually heals.

Despite profound advancements in arthroscopic rotator cuff repair (RCR) techniques, radiologic failure rates may be in excess of 60% with repairs of large and massive tears in the elderly population. One of the strategies to improve these healing rates has been "patch" augmentation of the cuff repair. At the same time, superior capsular reconstruction (SCR) has gained significant popularity as an option for irreparable rotator cuff (RC) tears. Some have also advocated performing SCR in addition to arthroscopic RCR to reinforce the repair and improve healing rates. Techniques involving the use of fascia lata, ECM patches, and long head of the biceps (LHB) for SCR to reinforce the cuff repair have all been elegantly described. In this article, we propose a technique that enables a combination of the aforementioned procedures and involves performing RCR with patch augmentation, as well as SCR using LHB. In doing so, the repaired RC is bordered by the patch over its bursal surface and the LHB on the articular surface (functioning as the superior capsule), thus giving us the name "Hamburger technique" (a 3-layered construct).