Aim: Narrative Review of the current knowledge of scapular dyskinesis in the presence of rotator cuff tears.
Background: Scapular dyskinesis (SD) is defined by the altered rest position and dysfunctional motion of the scapula and can be present in asymptomatic individuals as in patients with shoulder pathology. It is no consensual if the altered patterns of scapular kinematics cause or exacerbate rotator cuff tears pathology. Methods: For this work was performed an electronic database search using PubMed, Web of Science, and Scopus for studies published from 01-01-2015 until 31-12-2020, with the search terms: “shoulder”, “kinematics”, “scapular dyskinesis”, “rotator cuff tear”, “treatment” and “outcome”. Studies that were more relevant to the subject were retrieved. Results: There is a four-type classification for SD, based on the aspect of the medial border of the scapula with the arm at rest or during arm motion in forward flexion. SD impairs shoulder function, worsens the symptoms, compromises the clinical intervention success, and can cause or be the consequence of rotator cuff tear. The first recommended treatment for rotator cuff tears is physical therapy, and it should address SD whenever it is present. Surgery is reserved for non-responsive cases. Post-surgical physical therapy protocols after rotator cuff repair must consider SD to improve the outcomes. Conclusions: Further evidence is needed to clarify abnormal scapular kinematics present with rotator cuff tears and investigate the changes in scapular muscle activation patterns. As well is necessary to establish rehabilitation strategies and protocols.

Introduction : Accurate evaluation of glenoid inclination is important to avoid superior tilt of the glenoid implant in reverse total shoulder arthroplasty. The aim of this study was to evaluate a new radiographic parameter for glenoid inclination which can be easily recognized in plain radiographs.
Methods : Glenoid anterior-posterior(AP) radiographs of 200 shoulders(100 men and 100 women) from hand & upper extremity center at our hospital. Three angles (A, B, C) were calculated for each shoulder. Angle A is composed line 1 (connecting the superior-most point and the inferior-most point on the glenoid rim) and the floor of supraspinatus fossa. Angle B is composed line 1 and line 2 (cortical border of the medial margin of the scapular). Angle C composed line 1 and line 3(connecting the inferior-most point on glenoid rim and the point which the floor of the supraspinatus fossa meets the lateral base of coracoid process). Each angle was measured 2 times by 2 independent observers.
Results : There was no significant difference in intra- and inter-observer reliability between the angle A, B and C. Angle A and angle B values were relatively in consistent tendency. Each angle was form a regular distribution. There was no significant difference related age, gender, the direction of the shoulders.
Conclusion: Angle A by Maurer et al. has been known as reliable parameter in glenoid inclination. Angle B & C also showed good reliability comparable to Angle A and could be used as new parameters of glenoid inclination.

INTRODUCTION: Frozen shoulder or adhesive capsulitis is the restriction in shoulder movement (both passive and active) without intrinsic shoulder disorder. Patients with diabetes mellitus have a higher rate of recurrence. Manipulation under anaesthesia was cost effective when compared with arthroscopic release and physiotherapy.METHODS: We looked at patients treated with manipulation under anaesthesia (MUA) +/- steroid injection and arthroscopic capsular release from 2010 to 2020. We divided these patients into two groups. Patients who had MUA +/- steroid injection were group A and patients who had arthroscopic capsular release were group B. We looked at recurrence, need for further invention, complications, clinical and cost effectiveness.RESULTS: A total of 312 patients were reviewed. 84 patients were excluded as the had further procedures for impingement (subacromial decompression, acromioclavicular joint excision). A total of 222 patients had manipulation under anaesthesia with or without steroid injection and 6 patients had arthroscopic release. There were 37 patients who had manipulation under anaesthesia had recurrence 16.6%. 19.3% of patients who had either manipulation under anaesthesia (+/- steroid injection)/ arthroscopic capsular release had diabetes mellitus.
CONCLUSION: Manipulation under anaesthesia was found to be the most cost effective, our recurrence rate 16.6% (literature 17.8% to 36%) when compared with physiotherapy, arthroscopic capsular release. Distension arthrogram has a lower recurrence rate of 7.6% but there is the need to have dedicated musculoskeletal radiologist. Availability of a musculoskeletal radiologist will to an extent determine the treatment choice and act in accordance to the NICE guidelines before venturing down the operative route.

Introduction: There remains much debate regarding the optimal method for surgical management of patients with long head of biceps pathology. The study aim was to compare the outcomes of tenotomy versus tenodesis. Methods: This meta-analysis was registered on PROSPERO (ref: CRD42020198658). Electronic databases searched included EMBASE, Medline, PsycINFO, and Cochrane Library. Randomised controlled trials (RCTs) comparing tenotomy versus tenodesis were included. Risk of bias within studies was assessed using the Cochrane risk of bias v2.0 tool and Jadad score. The primary outcome included patient reported functional outcome measures pooled using standardised mean difference (SMD) and a random effects model. Secondary outcome measures included visual analogue scale (VAS), rate of cosmetic deformity (Popeye sign), range of motion, operative time, and elbow flexion strength. Results: 751 patients from 10 RCTs demonstrated (369 tenotomy vs 382 tenodesis) were included in the meta-analysis. Pooled analysis of all PROMs data demonstrated comparable outcomes between tenotomy vs tenodesis (SMD 0.17 95% CI -0.02 to 0.36, p=0.09). Sensitivity analysis comparing RCTs involving patients with and without an intact rotator cuff did not change the result. Secondary outcomes including VAS, shoulder external rotation, and elbow flexion strength did not reveal any significant difference. Tenodesis resulted in a lower rate of Popeye deformity (OR 0.27 95% CI 0.16 to 0.45, p<0.00001). Conclusion: Aside from a lower rate of cosmetic deformity, tenodesis yielded no measurable significant benefit to tenotomy for addressing pathology in the long head of biceps. This finding was irrespective of the whether the rotator cuff was intact.

Introduction: Tranexamic acid (TXA) has been shown to be effective in trauma, spinal surgery, and lower limb arthroplasty. The aim of this study is to investigate the clinical effectiveness of TXA in shoulder surgery on bleeding and non-bleeding related outcomes. Methods: This study was registered on PROSPERO (ref: CRD42020185482). A meta-analysis of randomised controlled trials (RCTs) investigating use of TXA versus placebo in any type of shoulder surgery. Electronic databases searched included MEDLINE, EMBASE, PsychINFO, and Cochrane Library. Risk of bias within studies was assessed using the Cochrane risk of bias tool and Jadad score. Certainty of findings were reported using the GRADE approach. The primary outcome was total blood loss. Secondary outcomes included patient reported outcome measures, adverse events, and rate of blood transfusion. Results: 708 patients were randomized across eight studies (406 received TXA, 302 received placebo). Pooled analysis demonstrated significant reduction in perioperative bleeding with TXA compared to controls; estimated total blood loss (mean difference [MD], -209.66; 95% CI -389.11 to -30.21; p=0.02), and post-operative blood loss (via drain output) (MD, -84.8ml; 95% CI, -140.04 to -29.56; p=0.003). A mean difference in Visual Analogue Scale of 2.93 was noted in favour of TXA (95% CI 0.2 to 5.66; p=0.04). Conclusion: Whilst noting some risk of bias within studies, TXA was effective in reducing blood loss and pain in shoulder surgery. There may be a benefit of TXA in both open and arthroscopic shoulder procedures. Larger, low risk of bias, RCTs for specific surgical shoulder procedures are required.

Introduction: Principles of fixation of comminuted olecranon fractures include anatomical reduction of the articular surface and restoration of ulnohumeral joint motion. However, comminution sometimes may not permit anatomical fixation of fracture fragments, resulting in inadvertent olecranon lengthening after plate fixation. The aim of our study is to investigate the relationship between olecranon lengthening following plate fixation and loss of elbow extension. Materials and methods: Transverse olecranon osteotomies were performed on 8 cadaveric elbows. The osteotomy sites were then fixed with olecranon plates. Lengthening of the osteotomy sites were simulated by placement of 2mm, 4mm, 6mm and 8mm blocks. Lateral view photographs of the elbows were taken after each degree of lengthening. These photographs were then printed and measurements of elbow extension were performed with a goniometer with average values taken. The measurements were tabulated and statistical analysis performed to determine the relationship between degree of elbow extension loss and amount of olecranon lengthening. Results: Average values of each degree of lengthening (at 2mm, 4mm, 6mm and 8mm) were taken and compared with the baseline measurement (at 0mm). Cluster analysis showed that for every increment in osteotomy length of 2mm, there is a corresponding increase of 0.79˚ of elbow extension loss (p<0.01, 95% confidence level 0.55˚-1.03˚). Conclusion: Lengthening of olecranon by increments of 2mm correlates positively with loss of elbow extension. This shows that inadvertent intra-operative olecranon lengthening post-fixation may result in limited range of motion and possible loss of elbow function post-operatively.

PURPOSE:
To explore the effectiveness and operative methods to treat various mal-united Pilon fractures with joint-sparing osteotomy.
METHODS:
Between January 2011 and October 2019, 32 patients with mal-united Pilon fractures were treated with joint-sparing osteotomy. There were 21 males and 11 females with an average age of 40.6 years (range, 22-63 years). 19 were left feet and 13, right. The time from injury to reconstructive operation was 4 months to 10 years. 21 received operative treatment previously, and 11 were treated by plaster fixation. According to Rüedi-Allgöwer classification, 19 were rated as type Ⅱ (including 8 medial Pilon fractures, 6 anterior, 5 posterior) and 13, type Ⅲ. All patients received standardized postoperative managements.
RESULTS:
All patients were followed up for more than 1 year. All the fractures were reunited in an average time of 14.8 weeks (range 9 to 22 weeks). The mean visual analogue scale (VAS) score was 2.21 (range 0 to 5) and the mean ankle and hindfoot scale of the American Orthopaedic Foot and Ankle Society (AOFAS) score was 80.21(range 60 to 92) 6 months after operation. The VAS score was 5.17 (range 2 to 8) and the AOFAS score was 50.78 (range 12 to 83) before. Comparing to preoperative data, statistically significant difference was found postoperatively (P<0.05).
CONCLUSION:
Results by joint-sparing osteotomy to realign and reconstruct articular surfaces of ankles are acceptable. Functions and symptoms are improved significantly after operation. Joint-sparing osteotomy can be a considerable option for treating mal-united Pilon fractures.

Background: Intractable hallucal ganglion cysts (HGC) is often a symptomatic and recurrent condition. Its connection with the ankle joint is not well understood.
Objective: To evaluate the relationship between tenosynovitis of the flexor hallucis longus (FHL) tendon at the level of the ankle with formation of an HGC. Additionally, the authors sought to analyze the outcomes of cystectomy combined with ankle capsulorrhaphy.
Methods: Nineteen patients with HGC who underwent surgical intervention were included, between June 2016 and June 2019. Eight of them were previously intractable with known recurrences. Ankle arthrography and cystectomy was performed for all patients. Clinical evaluations included the American Orthopaedic Foot & Ankle Society (AOFAS) scores, visual analogue scale (VAS), and postoperative complications.
Results: Thirteen of the nineteen HGC (68.4%) had connection with the FHL tendon sheath. Combined with ankle capsulorrhaphy, there was no recurrence after the cystectomy. The mean follow-up period was 16.5±8.6 months. The VAS score decreased from 2.05±1.51 to 0.37±0.76 and AOFAS score significantly improved from 84.32±8.67 to 97.42±5.17 at final follow-up (P＜0.001).
Conclusions: The results of the current study demonstrate the connection between a HGC and the ankle joint. Ankle arthrography appeared to be useful for diagnosis and cystectomy combined with ankle capsulorrhaphy is an effective treatment measure to limit cyst recurrence.

Introduction: Despite the low incidence of pilon fractures, their high impact nature presents difficulties in surgical management/recovery. Current literature is varied, with no universal treatment algorithm. Methods: 135 patients over a 5-year period were included. AO/OTA classification: closed fractures (43-A:n=12, 43-B:n=18, 43-C:n=55); open fractures (43-A:n=11, 43-B:n=12, 43-C:n=27). Primary outcome was AOFAS score at 3,6 and 12-months post-injury. Secondary outcomes include time to partial weight-bear (PWB) and full weight-bear (FWB), bone union time, follow-up time. Interobserver agreement was high for bone union time (kappa=0.882) and AO/OTA class (kappa=0.807). Results: Generally, there was a tendency towards higher AOFAS scores in ORIF groups of both open and closed fractures, compared to fixed wire fixator(FWF) groups. However, the difference was not statistically significant apart from 12-month AOFAS score of 43-C open fractures (p=0.001), and in 43-B closed fractures 3 and 6 months post-injury (p<0.001 and p<0.001, respectively). The majority of ORIF subgroups, open and closed fractures, also had shorter time to PWB, FWB, time to union, and follow-up. ORIF-treated 43-B closed fracture subgroup had shorter time to PWB and FWB (p<0.001 and p=0.001, respectively). ORIF-treated 43-C closed fractures had shorter time to bone union (p<0.001). Common complications (closed:open) were deep infection(7%:10%), post-traumatic arthritis(25%:16%), non-union (11%:24%); all occurred more frequently in FWF-treated patients. Conclusion: The use of staged approach involving temporary external fixation, followed by ORIF or FWF, achieved low complication rates and good functional recovery. Compared to FWF groups, ORIF groups in either closed or open pilon fractures showed better primary and secondary outcomes.

Introduction

The optimal management for Achilles Tendon (AT) ruptures continues to encourage debate. Historically, the operative repair was favoured secondary to its lower re-rupture rates. More recently, we have seen promising results and with conservative management, particularly in a functional weight-bearing orthosis (VacoPed®). However, results for complete AT ruptures are still unclear. This study aims to evaluate the functional outcomes of early weight-bearing in a functional orthosis for conservatively managed, complete AT ruptures.

Methodology

In this prospective study, we have analysed data from 41 patients with US diagnosed compete AT ruptures, with a gap of less than 5 cm. Every patient was treated in a functional weight-bearing orthosis (VACOped®) for 8 weeks with early weight-bearing following a specific treatment protocol, followed by rehabilitation with a trained physiotherapist. At 1-year post-injury, the followings were measured: the ATRS score, calf girth, single-leg heel raise height (SHRH) and single heel raise repetitions (SHRR).

Result

The mean ATRS score was 82.1, with a re-rupture rate of only 2%. The average calf bulk difference was 1.6 cm, the average HRH difference was 1.8cm and a SHRR difference of 6. There was a statistically significant correlation between ATRS score and calf muscle girth (p=0.02). However, there was no significant correlation between ATRS score and SHRH or SHRR.

Conclusion

Early weight-bearing in a functional orthosis provides excellent functional outcomes for conservatively managed, complete AT ruptures, and is associated with very low re-rupture rates. A multidisciplinary approach with a guided rehabilitation programme is essential for optimising functional outcome.

First metatarsophalangeal joint congruency in hallux valgus includes congruous and incongruous conditions. Our purpose of study was analyzing the difference between congruous and incongruous joint, and finding out hallux valgus parameters different in two different conditions.
[Methods] From October 2017 to June, 2018, a cohort of patients were included into our study. These patients were symptomatic hallux valgus patients who had a weight bearing CT scan. After recording the inter metatarsal angle, hallux valgus angle, metatarsal adducts angle, first metatarsal distal articular angle, first metatarsal α angle, and anteroposterior tibial sesamoid grading, coronal plane sesamoid grading.[Results]There were 117 female patients included in our study, totally 211 feet. The average age were 55.0±12.6 years old. The means of IMA was 14.1±3.0 degree，HVA was 33.1±10.5 degree，DMAA was 18.7±7.9 degree, MAA was 15.7±5.3 degree, and first metatarsal α angle was 23.2±7.2 degree. IMA, HVA, MAA, DMAA and sesamoids grading between congruous group and incongruous group had significantly difference. But first metatarsal rotation on coronal plane had no difference between two groups. Correlation calculation show sesamoids grading had correlations to all parameters. But in coronal plane sesamoids grading only correlated to HVA.
[Conclusion]
A incongruous hallux valgus was a severe deformed hallux valgus. Incongruous joint had larger IMA, HVA, DMAA, and higher sesamoids grading in frontal and coronal plane than congruous joint. But joint congruency did not affect first metatarsal pronation angle, which need to be derotated during hallux valgus surgical treatment. DMAA angle changing correlated to IMA, first metatarsal rotation and HVA.

Introduction
This paper shows in a case series, exceptional cartilage lesions with pathological changes. The indications, strategies for osteotomies and the treatment strategies in malaligned bipolar, cystic and gross cartilage lesions is explained.

Material &Technique:
35 patients with severe circumscript varus/valgus arthritis have been operated by supramalleolar osteotomy (SMOT).
70 patients presented bipolar (tibial & talar “kissing”) lesions with correct hindfoot axis.
18 patients had a gross cystic lesion and were additionally treated with filling of the cysts.
Follow-up consisted of a clinical evaluation with assessment of the Foot and Ankle Outcome Score (FAOS) and the VAS Score for pain, function and satisfaction.

Results
The over all mean time from initial surgery to follow-up was 29.4±5.7 months. The subscales of the FAOS Score for symptoms, pain, function in daily living, function in sport and recreation and quality of live improved from 25.7±4.0, 39.6±3.3, 46.5±4.4, 20.8±3.4 and 13.2±2.9 preoperatively to postoperative 71.8±5.5, 72.2±4.3, 74.8±5.7, 25.9±2.8 and 50.8±4.5 respectively in patients with kissing lesions. All improvements with significance (p<0.05) excepting in in sports and recreation. The VAS scores improved significantly (p<0.05) in pain from 8.2±3.9 to 3.4±2.8, in function from 2.1±1.8 to 6.4±4.1 and in satisfaction from 2.7±1.9 to 7.1±3.5. In patients with SMOT and in cystic lesions, improvements were observed in all scores, but not all with significance.

Conclusions
This cases series have shown the possibilities for a successfull managing of this severe cartilage lesions and offers also its limit in the over all results.

Background :Osteotomies appear to be the best choice for symptomatic flatfoot in skeletally immature patients.The purpose of this study was to compare the clinical and radiographic outcome of the calcaneo-cuboid-cuneiform osteotomies (3C) and the calcaneal-lengthening osteotomy (CLO) in the treatment of Symptomatic Flexible Flatfoot in skeletally immature patients.Methods:A prospective review was led on 42 prospectively enrolled patients with symptomatic flatfoot.A single surgeon performed the surgeries.The clinical and radiographic outcome was evaluated in 34 feet (21P) with a 3C osteotomy and 36 feet (21p) with a CLO.We used the Kitaoka score.We measured and compared 5 parameters on the anteroposterior and lateral weight-bearing radiographs.Results:Average age at the time of surgery was significant difference (3C: 12.53±2.23 y,CLO: 11.17±2.12 y, P=0.01). Average follow-up was 2.29±1.05 years in the 3C group and 2.26±1 years in the CLO group.There were no significant differences in the Kitaoka (AOFAS) score,(3C: 85.76±4.57, : 86.39±3.97, P=0.52) CLO.We found significant differences in all of the 5 radiographic measurements: anteroposterior talocalcaneal angle (3C: 27.24±2.31, CLO: 22.76±3.94, P=0.001) and TN coverage (3C: 19.38±4.34, CLO: 22.9±5, P<0.002).and lateral T-first MTT angle (3C: 10.81±2.06, CLO: 11.93±1.9, P<0.02)and TH angle(3C: 27.18±4.11, CLO: 20.21±3.93,P<0.001),and C-pitch(3C: 23.75±2.68, CLO: 21.35±2.53,P<0.001).There were 1(2.9%) complications in the 3C group and 2(5.5%) complications in the CLO group.calcaneocuboid subluxation was present in 18 (50%) feet of the CLO group. Conclusions:both osteotomies obtain good clinical and radiographic results in the treatment of symptomatic idiopathic flexible flatfoot in a pediatric population.CLO achieves better improvement of the relationshipof the navicular to the head of the talus

The Achilles tendon rupture is usually considered chronic at 4 to 6 weeks, these lesions are a therapeutic challenge for the Orthopedic surgeon. The aim of this study was to evaluate the functional outcome of chronic Achilles tendon rupture repair.
A retrospective revision of all chronic Achilles tendon rupture repair between 2014 and 2018 at our institution was performed and the AOFAS hind foot score was used to evaluate the functional outcome.
15 patients were treated, 13 males and 2 females, with a mean age of 49 years (35-70). Diagnosis were based on clinical examination, MRI was used to confirm the diagnosis and evaluate gap length. The mean gap in preoperatively MRI was 3,4cm(3-7,6), in contrast to 9,7cm(3,5-15) intraoperatively. Mean time to surgery was 30 weeks, mean follow-up time was 18 months. These patients received different surgical techniques based on rupture pattern and surgeon preference: V-Y tendon plasty(4), Bosworth(1) and Lindholm methods(2), flexor hallucis longus(4) and peroneus brevis transfers(4). The AOFAS score improved from a mean of 62 preoperatively to 92 at the end of follow up, without significant difference between surgical options. The mean time for patient return to daily activities was 3,6 months(3,2-5). Five patients returned to sport activities. There were two superficial infections successfully treated with antibiotics.
There is no evidence based guideline for deciding on the type of surgical technique to treat this injury. Thus, decision must be based on intraoperatively findings and surgeon experience, a satisfactory final clinical outcome can be achieved.