Aims. Advances in arthroscopic techniques for rotator cuff repair have made the mini-open approach less popular. However, the mini-open approach remains an important technique for repair for many surgeons. The aims of this study were to compare the integrity of the repair, the function of the shoulder and satisfaction post-operatively using these two techniques in patients aged > 50 years. Patients and Methods. We identified 22 patients treated with mini-open and 128 patients treated with arthroscopic rotator cuff repair of July 2007 and June 2011. The mean follow-up was two years (1 to 5). Outcome was assessed using the American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test (SST) scores, and satisfaction. The integrity of the repair was assessed using ultrasonography. A power analysis ensured sufficient enrolment. Results. There was no statistically significant difference between the age, function, satisfaction, or pain scores (p > 0.05) of the two groups. The integrity of the repair and the mean SST scores were significantly better in the mini-open group (91% of mini-open repairs were intact versus 60% of arthroscopic repairs, p = 0.023; mean SST score 10.9 (standard deviation (. sd. ) 1.3) in the mini-open group; 8.9 (. sd. 3.5) in arthroscopic group; p = 0.003). The ASES scores were also higher in the mini-open group (mean ASES score 91.0 (. sd. 10.5) in mini-open group; mean 82.70 (. sd. 19.8) in the arthroscopic group; p = 0.048). Conclusion. The integrity of the repair and function of the shoulder were better after a mini-open repair than after arthroscopic repair of a rotator cuff tear in these patients. The functional difference did not translate into a difference in satisfaction. Mini-open rotator cuff repair remains a useful technique despite advances in arthroscopy. Cite this article: Bone Joint J 2017;99-B:245–9

Standard approaches to thoracic intradural tumors often involve a large incision and significant tissue destruction. Minimally invasive techniques have been applied successfully for a variety of surgical decompression procedures, but have rarely been used for the removal of intradural thoracolumbar tumors. Here we compare the clinical outcome of mini-open resection of intradural thoracolumbar tumors to a standard open technique. We retrospectively reviewed our series of twelve mini-open thoracolumbar intradural tumor resection cases and compared the outcome to a profile matched cohort of six cases of open intradural tumor resection cases. Operative statistics, functional outcome, and complications were compared. Tumors were extirpated successfully with both approaches. There was no statistical difference in operating times, ASIA score improvement, or back pain VAS score improvement between groups. However, the mini-open group had a statistically significantly lower estimated blood loss (146 cc vs. 392 cc) and a significantly shorter length of hospitalization (3.6 vs 7.8 days). There was one complication of pseudomeningocoele formation in the mini-open cohort and no complications in the open cohort. Mean follow-up length was 13 months in the miniopen group compared to 23 months in the open group. The mini-open approach allows for adequate treatment of intradural thoracolumbar tumors with comparable outcomes to standard, open approaches. The mini-open approach is associated with a lower blood loss and a shorter length of stay compared with standard open surgery

Standard approaches to thoracic intradural tumors often involve a large incision and significant tissue destruction. Minimally invasive techniques have been applied successfully for a variety of surgical decompression procedures, but have rarely been used for the removal of intradural thoracolumbar tumors. Here we compare the clinical outcome of mini-open resection of intradural thoracolumbar tumors to a standard open technique. We retrospectively reviewed our series of twelve mini-open thoracolumbar intradural tumor resection cases and compared the outcome to a profile matched cohort of six cases of open intradural tumor resection cases. Operative statistics, functional outcome, and complications were compared. Tumours were extirpated successfully with both approaches. There was no statistical difference in operating times, ASIA score improvement, or back pain VAS score improvement between groups. However, the mini-open group had a statistically significantly lower estimated blood loss (146 cc vs. 392 cc) and a significantly shorter length of hospitalization (3.6 vs 7.8 days). There was one complication of pseudomeningocoele formation in the mini-open cohort and no complications in the open cohort. Mean follow-up length was 13 months in the miniopen group compared to 23 months in the open group. The mini-open approach allows for adequate treatment of intradural thoracolumbar tumors with comparable outcomes to standard, open approaches. The mini-open approach is associated with a lower blood loss and a shorter length of stay compared with standard open surgery

This randomized clinical trial utilizing the validated rotator cuff disease specific quality of life outcome measure (RC-QOL) and adequate power demonstrates no difference in outcome for full thickness rotator cuff tears comparing open to mini-open surgical techniques. The purpose of the study was to compare standard open rotator cuff repair versus mini-open rotator cuff repair by measuring the disease specific quality of life in patients with rotator cuff injury. This randomized clinical trial utilizing a validated disease specific outcome measure and adequate power demonstrates no difference in outcome for full thickness rotator cuff tears comparing open to mini-open surgical techniques. The miniopen approach utilizing an arthroscoic acromioplasty provides no additional beneifit to the patient undergoing a rotator cuff repair. The mean one year RC-QOL score for the open and mini-open groups were 85.3 (SD = 15.6) and 87.4 (SD = 12.0) out of a maximum of one hundred, respectively. This difference was not statistically significant (p = 0.572). Seventy-two patients (forty-eight males/twenty-four females) with an average age of 56.4 years (thirty-three to eighty-two years) consented to participate in the study. Inclusion criteria involved: unremitting pain, failed conservative treatment of at least three months, weakness of rotator cuff, and positive diagnostic imaging indicating a full-thickness rotator cuff tear. Massive rotator cuff tears were excluded. Prior to surgery, patients were randomized to either open or mini-open rotator cuff repair. Patients were assessed and outcomes were collected at three, six and twelve months after surgery. Primary Outcome Measure: Patient quality of life was quantified using the validated disease specific, reliable and responsive Rotator Cuff Quality of Life Questionnaire (RC-QOL) measured on a one hundred point visual analogue scale format. Secondary Outcomes: Range of motion, strength, American Shoulder and Elbow Surgeons Score, and the Shoulder Rating Questionnaire

Purpose: Controversy remains regarding the results of all arthroscopic rotator cuff repairs compared to the mini-open approach. The purpose of this study was to perform a comprehensive literature search and meta-analysis of clinical trials comparing the results of all arthroscopic rotator cuff repairs and mini-open rotator cuff repairs with two years of follow-up data. Method: A computerized search of articles published between 1966 and July 2006 was performed using Medline and PubMed. Additionally, a search of abstracts from four major annual meetings each held between 2000 and 2005, was performed to identify Level I to III studies comparing the results of arthroscopic rotator cuff repair and mini-open repair. Studies that included follow-up of at least two years and included the use of one of four validated functional outcome scores used to study shoulder pathology were included in the present meta-analysis. All outcome scores were normalized to a 100-point scale to allow outcome comparison. Results: Five studies that met the inclusion criteria were identified. There was no difference in functional outcome scores between the arthroscopic and mini-open repair groups. There was a trend toward fewer complications in the arthroscopic repair group, however, this did not meet statistical significance. Conclusion: In studies with at least two years of follow-up data, there was no significant difference in functional outcome scores between the arthroscopic and mini-open rotator cuff repair techniques. The arthroscopic repair technique is a useful and successful alternative to the mini-open repair technique

Background. Operative fixation of acute tendo-achilles ruptures remains controversial. Standard surgical exposure is associated with and increased risk of wound breakdown and infections. The mini-open technique was developed to minimise these risks and provide anatomical reduction/apposition of the tendon rupture. Methods. We present a retrospective case series of 27 patients who were treated operatively for acute Achilles tendon rupture in the hands of 1 surgeon, between 4–6 years post operatively, using Achillon instrumentation. Post operatively they were treated with an air cast boot and 3 wedges, bringing the foot into neutral by 6 weeks followed by a rehabilitation programme. The patients were contacted via telephone and consent was obtained. The complications, Leppilahti score and ATRS score were then calculated. Results. 2 patients underwent a further operation (one for a retained suture and another for a re-rupture in an uncompliant patient), in total there were 2 re-ruptures (another patient sustained a partial rupture which was treated conservatively). There were no patients who sustained a wound problem or infection (other than the patient already mentioned). There were 3 patients who complained of ongoing altered sensation in the sural nerve distribution, and 4 who had paraesthesia post operativeley that completely resolved within 3 months. There were no DVT/PE reported and the average Leppilahti score was 85.7/100 (excellent outcome) and ATRS 93.3/100 (excellent outcome). Conclusion. This study shows that the mini-open technique can be used successfully to treat acute tendo-Achilles ruptures with excellent long term outcome

Percutaneous repair of a ruptured Achilles tendon has been shown to reduce wound healing problems but it has a high incidence of injury to the sural nerve. The Achillon Suture System is a new method utilising a small longitudinal incision. It passes a suture through the Achilles tendon leaving the suture purely within the tendon. The aim of this prospective study was to investigate the results of a new mini-open technique utilising a horizontal incision and early active mobilisation. Following ethical committee approval 25 patients underwent repair of their ruptured Achilles tendon using the Achillon System. Rather than the longitudinal incision we used a horizontal incision and an accelerated rehabilitation program with a brace for six weeks post-operatively. Patients were followed up at six weeks, three and six months and one year post-op using the AOFAS and Leppilahti scoring systems. There were no wound complications, re-ruptures or sural nerve injuries. All patients returned to work or their previous daily activities by six weeks (mean 22 days) post op. All patients had returned to driving by six weeks. One patient had 10° restriction in dorsiflexion at three months, which prevented her return to running. She was back to running and had a full range of movement at six months. All other patients returned to sporting activities at three months but jumping sports such as basketball were discouraged until six months post-op. We suggest that this modification of using a horizontal incision and early mobilisation enhances wound healing and allows early return to normal activities and sports. It is technically simple, utilises a small incision (still enabling visual confirmation that the tendon ends have been approximated) and reduces the risk of sural nerve injury seen in other mini-open or percutaneous techniques

Percutaneous repair of a ruptured Achilles tendon has been shown to reduce wound healing problems but it has a high incidence of injury to the sural nerve. The Achillon Suture System is a new method utilising a small longitudinal incision. It passes a suture through the Achilles tendon leaving the suture purely within the tendon. The aim of this prospective study was to investigate the results of a new mini-open technique utilising a horizontal incision and early active mobilisation. Following ethical committee approval 25 patients underwent repair of their ruptured Achilles tendon using the Achillon System. Rather than the longitudinal incision we used a horizontal incision and an accelerated rehabilitation program with a brace for 6 weeks post-operatively. Patients were followed up at 6 weeks, 3 months and 6 months post-op using the AOFAS and Leppilahti scoring systems. There were no wound complications, re-ruptures or sural nerve injuries. All patients returned to work or their previous daily activities by 6 weeks (mean 22 days) post op. All patients had returned to driving by 6 weeks. One patient had 10° restriction in dorsiflexion at 3 months which prevented her return to running. She was back to running and had a full range of movement at 6 months. All other patients returned to sporting activities at 3 months but jumping sports such as basketball were discouraged until 6 months post-op. We suggest that this modification of using a horizontal incision and early mobilisation enhances wound healing and allows early return to normal activities and sports. It is technically simple, utilises a small incision (still enabling visual confirmation that the tendon ends have been approximated) and reduces the risk of sural nerve injury seen in other mini-open or percutaneous techniques

Introduction:. Percutaneous fixation of intraarticular calcaneal fractures adequately restore the subtalar joint with lower soft tissue complications and equivalent short-term results compared to open fixation. However, studies have largely focused on less severe fracture types (Sanders types 2/3). We report our initial experience of this relatively new Mini-open Arthroscopic-assisted Calcaneal Osteosynthesis (MACO) technique for more comminuted calcaneal fractures (Sanders types 3/4). Methods:. We prospectively studied consecutive patients with intraarticular calcaneal fractures requiring surgical fixation between April 2012 and June 2013. MACO involves initial subtalar arthroscopic debridement, with subsequent fluoroscopic-assisted, mini-open reduction and fixation of depressed fragments using cannulated screws. Outcome scores (Manchester-Oxford Foot(MOXFQ), AOFAS Hindfoot and SF-36 questionnaires) and radiological parameters were recorded with a mean follow-up of 12 months (7–13). Results:. There were 9 patients (7 M:2 F) with a mean age of 45.4 years (24–70). All had intra-articular joint depression-type fractures: 5 Sanders type 3 and 4 Sanders type 4. Mean time to surgery was 6.6 days (1–13), operating time was 89.4 minutes (66–130) and inpatient stay was 1.7 days (1–4). All wounds healed without complication and one patient required change of a long screw 11 days post-operatively. There were significant post-operative improvements in the mean Bohler's angle (−2°[−27.2–14.8] to 30°[10.2–41.3], p<0.0002) and angle of Gissane (95°[66.2–111.7] to 111°[101.6–120], p=0.004). Mean outcome scores were 60.8(41–86) for MOXFQ and 75.3(55–92) for AOFAS Hindfoot, with 55.9% developing moderate/severe subtalar joint stiffness. Mean physical and mental SF-36 summary scores were 35.5(24.5–41.5) and 51.7(40.8–61.7) respectively. Conclusion:. We describe the MACO technique for Sanders types 3/4 calcaneal fractures. There were no soft tissue complications with good short-term outcomes, despite a reduction in hindfoot mobility. Restoration of the joint and bone stock without infection is desirable in the event of subsequent arthrodesis. We propose MACO is a valuable alternative technique to open fixation

Large and massive rotator cuff tears can cause persistent pain and significant disability. These tears are often chronic with substantial degeneration of the involved tendons. Surgical treatment is challenging and the functional outcome after repair less predictable then for smaller tears. The aim of this study was to determine the functional outcome and rate of re-rupture after mini-open repair of symptomatic large and massive rotator cuff tears using a modified two-row technique. Twenty-four patients, who were operated on under the care of a single surgeon between 2003 and 2006, were included in this study. Patients were assessed prospectively before and at a mean of 27 months after surgery using Constant Score and Oxford Shoulder Score. This assessment was carried out by an independent physiotherapist specialising in shoulder rehabilitation. At follow-up an ultrasound was carried out by a musculoskeletal radiographer to determine the integrity of the rotator cuff repair. Patient satisfaction was assessed using a simple questionnaire. The mean Constant Score improved significantly from 36 preoperatively to 68 postoperatively (p< 0.0001), the mean Oxford Shoulder Score from 39 to 20 (p< 0.0001). Four patients (16.7%) had a re-rupture diagnosed by ultrasound. 87.5% of patients were satisfied with the outcome of their surgery. Tear size and repair integrity did not significantly influence functional outcome. 87.5% of patients were satisfied or very satisfied with the outcome of their surgery. This study shows that the two-row repair of large and massive rotator cuff tears using a mini-open approach is an effective method of repair with a comparatively low re-rupture rate. It significantly improves the functional outcome and leads to a very high patient satisfaction. We conclude that these results justify repair of large to massive rotator cuff tears when possible, irrespective of chronicity of symptoms

The median nerve compression in the carpal tunnel is the most common compression syndrome of the upper limb. In most cases it is idiopathic but may also occur from anatomical, traumatic, endocrine, rheumatic or tumoral causes. Chow's endoscopic technique was initially used to treat this disease and then modified to a mini-open approach through a single palmar incision. This incision is similar to the one used in endoscopic release by Agee. After exposing the proximal part of the transverse carpal ligament a meniscus knife is advanced until there is a complete section of the ligament, without endoscopic equipment. Between 2004 and 2006, 200 hands in 179 patients with a diagnosis based on clinical and electromyographic criteria were operated by this mini-open technique. The mean follow-up was 49 months (minimum of 34 months and a maximum of 70 months). 50 randomly selected patients were submitted to the self-administered Boston questionnaire. 50 patients treated by the minimal-incision decompression during the same period were also given the questionnaire. The aesthetic satisfaction was registered as well as if they would have surgery on the other hand or would recommend the procedure. This mini-open technique is another technique available to the surgeon that allows very similar functional results to endoscopic surgery, without use of specific material and with a shorter surgical time

This study compared the clinical outcomes following mini-open rotator cuff repair (MORCR) between early mobilisation and usual care, involving initial immobilisation. In total, 189 patients with radiologically-confirmed full-thickness rotator cuff tears underwent MORCR and were randomised to either early mobilisation (n = 97) or standard rehabilitation (n = 92) groups. Patients were assessed at six weeks and three, six, 12 and 24 months post-operatively. Six-week range of movement comparisons demonstrated significantly increased abduction (p = 0.002) and scapular plane elevation (p = 0.006) in the early mobilisation group, an effect which was not detectable at three months (p > 0.51) or afterwards. At 24 months post-operatively, patients who performed pain-free, early active mobilisation for activities of daily living showed no difference in clinical outcomes from patients immobilised for six weeks following MORCR. We suggest that the choice of rehabilitation regime following MORCR may be left to the discretion of the patient and the treating surgeon.

Cite this article: Bone Joint J 2015;97-B:1257–63.

Eighty-eight consecutive patients with symptomatic rotator cuff tears were entered in to a prospect study with a novel technique of open double row repair using a ‘Capstan’ screw technique. The medial row has standard anchors, but the lateral suture row is a 35mm × 6.5mm ‘Capstan' screw. This allows up to 28 suture bridges to be taken from the medial row to the lateral row compressing the footprint and spreading the load. This creates a very robust repair or ‘bulletproof repair’. This was used for medium to large isolated supraspinatus tears

Each patient had a pre and post operative Oxford Shoulder Score (OSS), American Shoulder and Elbow Score (ASES Score). The mean pre-operative OSS was 22 (maximum 48) and the mean post-operative OSS was 45, (p < 0.0001). Flexion improved from a mean of 117° to 172° (p < 0.0001). The clinical re-tear rate was 3.4%. 95% were satisfied with the procedure. There were no deep infections. 18% had transient stiffness, 6% stiffness at one year but none severe enough to warrant release. There were no instances of deltoid dysfunction.

This demonstrates excellent results in terms of OSS, patient satisfaction and function. Clinical re-tear rate is markedly reduced in comparison to previous literature.

Objectives. The incidence of acute Achilles tendon rupture appears to be increasing. The aim of this study was to summarize various therapies for acute Achilles tendon rupture and discuss their relative merits. Methods. A PubMed search about the management of acute Achilles tendon rupture was performed. The search was open for original manuscripts and review papers limited to publication from January 2006 to July 2017. A total of 489 papers were identified initially and finally 323 articles were suitable for this review. Results. The treatments of acute Achilles tendon rupture include operative and nonoperative treatments. Operative treatments mainly consist of open repair, percutaneous repair, mini-open repair, and augmentative repair. Traditional open repair has lower re-rupture rates with higher risks of complications. Percutaneous repair and mini-open repair show similar re-rupture rates but lower overall complication rates when compared with open repair. Percutaneous repair requires vigilance against nerve damage. Functional rehabilitation combining protected weight-bearing and early controlled motion can effectively reduce re-rupture rates with satisfactory outcomes. Biological adjuncts help accelerating tendon healing by adhering rupture ends or releasing highly complex pools of signalling factors. Conclusion. The optimum treatment for complete rupture remains controversial. Both mini-open repair and functional protocols are attractive alternatives, while biotherapy is a potential future development. Cite this article: X. Yang, H. Meng, Q. Quan, J. Peng, S. Lu, A. Wang. Management of acute Achilles tendon ruptures: A review. Bone Joint Res 2018;7:561–569. DOI: 10.1302/2046-3758.710.BJR-2018-0004.R2

Eighteen Arthroscopic and nine mini-open Rotator Cuff repairs were evaluated at an average of 31.5 months post-operatively. The tears were classified as small, moderate and massive with all the massive tears in the mini-open group. The arthroscopic group showed 94% patient satisfaction with the Western Ontario Rotator Cuff Index scale (WORC) of 89.6% and the University of California at Los Angeles (UCLA) score of 32.4/35. The mini-open technique showed 100% patient satisfaction, 83.7% with the WORC and 27.7/35 with the UCLA. This study showed both procedures were effective. It is one of the first to report on the use of the WORC index for evaluation. The purpose of this study was to evaluate the mid term results of arthroscopic and mini-open (arthroscopic assisted) rotator cuff repairs using the Western Ontario Rotator Cuff Index (WORC) and the University of California at Los Angeles (UCLA) validated assessment systems. Patients with classic rotator cuff tears were identified retrospectively and then seen for a one-time evaluation and scoring, using the WORC and UCLA index. The tears were classified as small- < 2 cm, moderate 2– 5 cm, and massive > 5cm. 27/33 (82%) responded, eighteen arthroscopic, nine mini-open with all the massive tears falling into the mini-open category. The average time frame from operation was 31.5 months, average age, 57.7 years. Overall results for the arthroscopic technique were, 94% (17/18) patient satisfaction, WORC 89.6%, UCLA 32.4/35. Overall result for the mini-open technique was 100% patient satisfaction, WORC 83.7%, UCLA 27.7/35. The size of the tear was found to be statistically significant only with respect to the degree of external rotation achieved at the final evaluation. WCB patients (three) showed a discrepancy between subjective and objective outcomes. Arthroscopic and mini-open Rotator Cuff repairs are associated with a very high level of patient satisfaction, and high scores when evaluated by the WORC and UCLA indexes. This study shows that arthroscopic, and mini-open repairs (for the massive tears), are very effective procedures. It is one of the first to utilize the WORC index for evaluation along with the UCLA which has been more commonly used

The Rotator Cuff Registry is a unique initiative of the New Zealand Shoulder & Elbow Society. The aim of the study was to enrol nationwide all patients undergoing rotator cuff repair over a 22 month period to provide best practice guidelines for management of rotator cuff tears. To qualify for the Registry patients have to undergo surgical repair of either a partial or full thickness rotator cuff tear. Prior to surgery patients fill out a registration document as well as a pain score and Flex-SF function score. The Surgeon completes an operating day questionnaire detailing operative findings and repair methods. Follow-up is by pain and Flex-SF function scores returned at six, twelve and twenty-four months from surgery. By the 31st December 2010 3000 patients had been recruited. Analysis of the first 2684 patients for the purpose of this abstract showed 70% Male and 30% female. The dominant arm was involved in 65%. 19% of patients were in high demand occupations, 27% in medium demand and 33% low demand occupations. 16% of patients were treated with all arthroscopic repair, 40% were mini-open and 44% open. Comparing pre-op and one year post-op activity scores by surgical approach the Flex-SF improved by 12.97 points in the arthroscopic group, 13.3 in the mini-open and 12.72 in the open (NSS). Pre-op, 6 mth and 12mth pain scores were arthroscopic 4.60, 1.81 and 1.57, mini-open 4.34, 2.15 and 1.52 and open 4.82, 2.27 and 1.86. Preoperatively, the open approach had statistically more pain than the mini-open. At 6 months the arthroscopic group had statistically less pain than the open and at twelve months the mini-open had statistically less pain than the open group. For all tear sizes significant improvements in Fex-SF were seen both from preoperative levels to 6 month follow-up and from 6–12 month follow-up. A labral tear was present in 12% and repaired in 25% of these. No difference was seen in outcome between these groups Biceps tenolysis was undertaken in 27% and tenodesis in 23%. A single row repair was selected in 44% and a double row in 56%. Double row repair resulted in better Flex-SF scores in the large tears. Six, twelve and some twenty-four month data will be presented. Outcome was unaffected by the surgical approach with arthroscopic, mini-open and open results essentially identical

Abstract. Introduction. Fractures of the articular surface of the patella or the lateral femoral condyle usually occur following acute dislocation of the patella. This study looked at the radiological and functional outcomes of fixation of osteochondral fractures. Methods. Twenty-nine patients (18 male, 11 female) sustained osteochondral fractures of the knee following patellar dislocation. All patients had detailed radiographic imaging and MRI scan of the knee preoperatively. An arthroscopic assessment was done, followed by fixation using bio-absorbable pins or headless screws either arthroscopically or mini-open arthrotomy. VMO plication or MPFL repair were done if necessary. MRI scan was done at follow-up to assess for healing of the fixed fragment prior to patient discharge. Results. The mean age of the patients was 21 yrs (9–74), 11 had osteochondral fracture of the patella (38%), while 18 were from the lateral femoral condyle (62%). 13 patients needed additional VMO plication. Mean follow up period was 7.7 years (1 to 12 years). As per Tegner activity scale, all patients returned to their pre-injury activity level (Mean score 7) and sports. None of the patients had a further episode of patellar dislocation. Mean postoperative IKDC score was 86.5 (SD 17.3), Kujala was 91.1(SD 15.5) and Tegner- lysholm was 88.7 (SD 14.4). All patients had statistically significant (p < 0.05) improvement. Post-operative MRI scan showed satisfactory union in all cases (100%). Conclusion. It is extremely important to identify this group of injury and treat them early to have satisfactory knee function and avoid long term complications of arthritis

Aim. Diagnosis of periprosthetic shoulder infections (PSI) is difficult as they are mostly caused by low-virulent bacteria and patients do not show typical infection signs, such as elevated blood markers, wound leakage, or red and swollen skin. Ultrasound-guided biopsies for culture may therefore be an alternative for mini-open biopsies as less costly and invasive method. The aim of this study was to determine the diagnostic value and reliability of ultrasound-guided biopsies for cultures alone and in combination polymerase chain reaction (PCR), and/or synovial markers for preoperative diagnosis of PSI in patients undergoing revision shoulder surgery. Method. A prospective explorative diagnostic cohort study was performed including patients undergoing revision shoulder replacement surgery. A shoulder puncture was taken preoperatively before incision to collect synovial fluid for interleukin-6 (IL-6), calprotectin, WBC, polymorphonuclear cells determination. Prior to revision surgery, six ultrasound-guided synovial tissue biopsies were collected for culture and two additional for PCR analysis. Six routine care tissue biopsies were taken during revision surgery and served as reference standard. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV; primary outcome measure), and accuracy were calculated for ultrasound-guided biopsies, and synovial markers, and combinations of these. Results. Fifty-five patients were included. In 24 patients, routine tissue cultures were positive for infection. Cultures from ultrasound-guided biopsies diagnosed an infection in 7 of these patients, yielding a sensitivity, specificity, PPV, NPV, and accuracy of 29.2%, 93.5%, 77.8%, 63.0%, and 65.6%, respectively. Ultrasound-guided biopsies in combination with synovial WBC increased the NPV to 76.7% and accuracy to 73.8%. When synovial WBC and calprotectin were combined with ultrasound-guided biopsies, it resulted in a better diagnostic value: sensitivity 69.2%, specificity 80.0%, PPV 69.2%, NPV 80.0%, and accuracy 75.8%. Ultrasound-guided biopsies in combination with calprotectin and ESR yielded a sensitivity of 50.0%, specificity of 93.8%, PPV of 80.0%, NPV of 78.9%, and accuracy of 79.2%. Synovial fluid was obtained in 42 patients. Sensitivities of WBC, PMN, IL-6, and calprotectin were between 25.0% and 35.7%, specificities between 89.5% and 95.0%, PPVs between 60.0% and 83.3%, NPVs between 65.4% and 69.4%, and accuracies between 64.5% and 70.6%. Conclusions. In this prospective study we showed that ultrasound-guided biopsies for cultures alone and in combination with PCR and/or synovial markers are not reliable enough to use in clinical practice for the preoperative diagnosis of low grade PSI

Introduction. Active patients may benefit from surgical repair of the achilles tendon with the aim of preserving functional length and optimising push-off power. A mini-open device assisted technique has the potential to reduce wound complications, but risks nerve injury. We present the largest published series of midsubstance achilles tendon repairs using the Achillon® device. Methods. A prospective cohort study was run at the Princess Royal Devon & Exeter Hospital between 2008 and 2015. We included all patients who presented with a midsubstance Achilles tendon rupture within 2 weeks of injury, and device assisted mini-open repair was offered to a young active adult population. All patients in the conservative and surgical treatment pathway had the same functional rehabilitation protocol with a plaster for 2 weeks, and a VACOped boot in reducing equinus for a further 8 weeks. Results. 354 patients presented with a midsubstance achilles tendon rupture over a 7-year period, of which 204 had conservative treatment and 150 patients had surgical repair with the Achillon device. Patients were assessed clinically for a minimum of 10 weeks, with long-term notes surveillance for late complications. The rerupture rate for conservative treatment was 1.5%, with no reruptures in the Achillon group. Infections in the surgical group were superficial in 2 cases (1.3%) and deep in 3 cases (2%). Pulmonary embolus occurred in 2 Achillon cases (1.3%), and 1 conservatively managed case (0.5%). There was 1 case of temporary sural nerve irritation in each group. Discussion. Our series show encouraging results for the Achillon® repair with no reruptures and a low complication profile. Functional rehabilitation is likely to have contributed to the low rerupture rate. Studies are emerging that show earlier and improved calf muscle strength in those having surgical repair, suggesting a role for device assisted mini open repair in a selected population

The aim of this study was to determine the functional outcome and rate of re-tears following mini-open repair of symptomatic large and massive tears of the rotator cuff using a two-row technique. The 24 patients included in the study were assessed prospectively before and at a mean of 27 months (18 to 53) after surgery using the Constant and the Oxford Shoulder scores. Ultrasound examination was carried out at follow-up to determine the integrity of the repair. Patient satisfaction was assessed using a simple questionnaire. The mean Constant score improved significantly from 36 before to 68 after operation (p < 0.0001) and the mean Oxford Shoulder score from 39 to 20 (p < 0.0001). Four of the 24 patients (17%) had a re-tear diagnosed by ultrasound. A total of 21 patients (87.5%) were satisfied with the outcome of their surgery. The repair remained intact in 20 patients (83%). However, the small number of re-tears (four patients) in the study did not allow sufficient analysis to show a difference in outcome in relation to the integrity of the repair