Full-thickness Group Research Articles

Single slice MR image estimation of 3D supraspinatus intramuscular fatty infiltration in older adults: relevance for clinical practice and research.

(1) To compare older adults stratified by supraspinatus tendon tear status (STT status)-no tear (Intact), partial-thickness (PT) tear, full-thickness (FT) tear-by 3D Dixon fat fraction (3D-FF); 2D fat fraction (2D-FF); and 2D Goutallier grade (2D-GG) at the Y-shaped view, and 1.4cm and 2.8cm medial to the Y-shaped view. Stratified by STT status to determine (2) correlation of 3D-FF with 2D-FF and 2D-GG and (3) inter-rater reliability at and medial to the Y-shaped view. Forty-five volunteers ≥ 60years recruited prospectively received shoulder MRI. 3D-FF and 2D-FF were measured on 6-point-Dixon MRI by three trainees. Goutallier grade was assessed on T1-weighted MRI by three fellowship-trained diagnostic radiologists. Descriptive, reliability, and correlation analyses were performed. Groups showed no difference in age. The FT group showed higher (p < 0.05) mean 3D-FF (14.09% ± 10.99%), mean 2D-FF (1.4cm medial to Y-shaped view, 14.91% ± 12.11%; 2.8cm medial to Y-shaped view, 13.32% ± 9.48%), and mean 2D-GG (Y-shaped view, 1.71 ± 0.78; 1.4cm medial to Y-shaped view, 1.71 ± 0.69; 2.8cm medial to Y-shaped view, 1.71 ± 0.72), relative to Intact/PT groups. 3D-FF showed strong correlation with 2D-FF among all groups/all analyses (rho, 0.80-0.98; p < 0.001). 3D-FF showed strong correlation with 2D-GG for all FT group analyses (rho, 0.85-0.91; p < 0.05). 3D-FF showed moderate-to-strong correlation considering all Intact/PT group analyses (rho, 0.51-0.79; p < 0.50). Dixon fat fraction showed excellent reliability for all groups (≥ 0.884, intraclass correlation coefficient). Goutallier grade showed excellent reliability for FT group (0.771, weighted Fleiss's kappa) but poor (0.294) and fair (0.502) for Intact and PT groups, respectively. Single slice MR image estimation of 3D supraspinatus intramuscular fatty infiltration has merit for continued use in clinical populations requiring potential rotator-cuff-repair surgery. However, Dixon fat fraction should be prioritized for use in research over Goutallier grade due to superior reliability.

L’angle critique de l’épaule et l’indice acromial sont-ils corrélés à la taille des lésions de la coiffe des rotateurs

PurposeScapular morphology is an extrinsic factor playing role in rotator cuff tear (RCT) etiology. The objective of this study was to evaluate the relationship between critical shoulder angle (CSA) and acromion index (AI) with partial-bursal side and full thickness RCT and the size of the RCT. HypothesisThe hypothesis was that CSA and AI would be greater in partial bursal-side RCT and full-thickness RCT patients and would increase with the size of the RCT. MethodsThis retrospective study assessed 218 patients who had standard shoulder radiographs and magnetic resonance imaging. Patients were divided into three groups: intact rotator cuff (68), partial bursal-side RCT (34) and full-thickness RCT (116). In the second part, full-thickness RCT patients were divided into four groups according to RCT size; small (<1cm), medium (1–3cm), large (3–5cm) and massive (>5cm). AI and CSA measurements were evaluated from radiographs. ResultsThe mean CSA was 32.8° in control group, 34.3° in partial group and 36.9° in full-thickness group. The mean AI was 0.66, 0.68 and 0.72, respectively. Significant difference was found in AI and CSA between full thickness RCT and intact RC group (p<0.01), and partial RCT and full thickness RCT group (p<0.05) in paired comparisons. In full thickness RCT size groups, the mean CSA was 34.2°, 36.4°, 39.0° and 40.8° and mean AI was 0.70, 0.71, 0.73 and 0.79, respectively. Significant difference was found between small-large, small-massive and medium-massive groups for CSA in paired comparisons and between small-massive, medium-massive groups for AI. ConclusionCSA and AI were significantly greater in full-thickness RCT patients and the size of the RCT increased with CSA and AI. The greater CSA and AI could be predictors for larger RCT. Level of evidenceIII; cross-sectional design; prognosis study.

Are critical shoulder angle and acromion index correlated to the size of a rotator cuff tear

PurposeScapular morphology is an extrinsic factor playing role in rotator cuff tear (RCT) etiology. The objective of this study was to evaluate the relationship between critical shoulder angle (CSA) and acromion index (AI) with partial-bursal side and full thickness RCT and the size of the RCT. HypothesisThe hypothesis was that CSA and AI would be greater in partial bursal-side RCT and full-thickness RCT patients and would increase with the size of the RCT. MethodsThis retrospective study assessed 218 patients who had standard shoulder radiographs and magnetic resonance imaging. Patients were divided into three groups: intact rotator cuff (68), partial bursal-side RCT (34) and full-thickness RCT (116). In the second part, full-thickness RCT patients were divided into four groups according to RCT size; small (<1cm), medium (1-3cm), large (3-5cm) and massive (>5cm). AI and CSA measurements were evaluated from radiographs. ResultsThe mean CSA was 32.8̊ in control group, 34.3̊ in partial group and 36.9̊ in full-thickness group. The mean AI was 0.66, 0.68 and 0.72 respectively. Significant difference was found in AI and CSA between full thickness RCT and intact RC group (p<0.01), and partial RCT and full thickness RCT group (p<0.05) in paired comparisons. In full thickness RCT size groups the mean CSA was 34.2̊, 36.4̊, 39.0̊ and 40.8̊ and mean AI was 0.70, 0.71, 0.73 and 0.79 respectively. Significant difference was found between small-large, small-massive, medium-massive groups for CSA in paired comparisons and between small-massive, medium-massive groups for AI. ConclusionCSA and AI were significantly greater in full-thickness RCT patients and the size of the RCT increased with CSA and AI. The greater CSA and AI could be predictors for larger RCT. Level of evidenceIII; Cross-Sectional Design; Prognosis Study.

Is Cartilage Thickness Important in Cartilage Tympanoplasty? A Systematic Review and Meta-analysis.

Cartilage is used as a grafting material for tympanoplasty. The rigidity of the cartilage is the main concern. There are debates regarding slicing the cartilage when it is used as a graft. Therefore, this systematic review and meta-analysis aimed to compare the hearing results of full vs. partial-thickness cartilages in patients undergoing cartilage tympanoplasty. We systematically searched google scholar, PubMed, Cochrane, Ovid, Scopus, and gray literature including the references of the selected studies, and conference abstracts which were published up to 6 May 2020. The search syntax for identifying studies was: ((Cartilage) AND (tympanoplasty) AND (thickness)). The literature search found 1047 articles. After eliminating duplicates, 908 studies remained; from these, we excluded observational studies, reviews, case reports, and non-randomized trials, and 12 studies remained. Finally, only 5 articles were included for analysis. The pooled standardized mean difference (SMD) for the post-operative gap was -0.87 95% CI: (-1.66, -0.08) (I2 = 87.1%, p < 0.001). The pooled SMD of the reduction in gap in the full-thickness group was 2.84, 95% CI (1.39-4.3), I2 = 93.2%, p < 0.001). The pooled SMD of the reduction in gap in the partial-thickness group was 4.02, 95% CI (1.97-6.02), I2 = 95.3%, p < 0.001). The pooled results of this systematic review showed that partial-thickness cartilage graft has better hearing outcomes than full-thickness in patients undergoing cartilage tympanoplasty.

Full versus partial thickness flap to determine differentiation and over keratinization of non‐keratinized mucosa. A 3‐year split mouth randomized pilot study

ObjectivesIt was shown, that Connective Tissue Grafts (CTG) retrieved from the tuberosity tends to determine hyperplastic responses and may induce a beneficial over‐keratinization of non‐keratinized mucosa. Clinically evaluate and compare CTG from tuberosity ability to increase soft tissue thickness and the keratinization potential after recipient area is either prepared using split or full thickness flap in edentulous mandible.Materials and methodsFourty implants were placed in 10 edentulous patients with atrophied mandible (Class IV of Misch) presenting less than 1.0 mm of keratinized tissue using a flapless approach and immediately restored with acrylic temporary bridge on multi‐unit abutments. The surgical sites were split‐mouth randomized and prepared as CTG recipients by a tunneling procedure. Twenty benefited of a partial thickness approach and 20 of a full thickness one. The CTG was placed buccally using partial thickness or full thickness flap according to the randomization schedule. The width of keratinized tissue (KT), the horizontal soft tissue thickness (STT), the marginal hard and soft tissue levels as well as the implant success parameters were collected and analyzed.ResultsAfter a 3 year follow‐up period the increase of KT was statistically significantly (p < 0.001) larger in the partial thickness group from 0.6(0.6) to 5.1(0.72) mm, while full thickness group showed very little improvement from 0.5(0.51) to 1(0.57) mm (p < 0.001). STT was significantly increased in both groups over time: from 2.4(0.88) to 5.4(0.68) mm in full thickness group and from 2.5(0.51) to 5.8(0.41) mm in partial thickness group without any significant difference between the groups.ConclusionThe increase of soft tissue thickness by using CTG from tuberosity was found in both groups, while keratinization of non‐keratinized mucosa appeared more in the partial thickness group.

Partial and full-thickness rotator cuff tears in patients younger than 45 years.

The aim of this study was to evaluate the results of the arthroscopic repair in patients with partial and full thickness rotator cuff tears and less than 45 years of age. Fifty patients (26 women and 24 men; mean age: 41.4±3.96 years; range: 31-45) with rotator cuff tear, and who were treated with the arthroscopic repair, were included in the study. Twenty patients had full thickness and 30 had partial-thickness tears. The final functional evaluation was conducted at a mean of 42.4 months (range, 24 to 95 months; SD:13.3). The American Shoulder and Elbow Surgeon (ASES) self-report score and the University of California at Los Angeles Shoulder Score (UCLA Shoulder Score) were used as validated scoring systems. At the final follow-up, the mean ASES and UCLA scores improved significantly to 72.3 and 26.5, respectively, in the full-thickness group (p<0.01). The mean ASES and UCLA scores improved significantly to 70.7 and 25.3, respectively, in the bursal-side group (p<0.01). The mean ASES and UCLA scores improved significantly to 75.3 and 27.1, respectively, in the joint-side group (p<0.01). There were no significant differences between the groups according to the postoperative ASES score (p>0.06) and UCLA score (p<0.37). The arthroscopic repair of the joint-sided tears and bursal-sided tears has good functional outcomes as full thickness rotator cuff tears, and the surgical option should be considered in younger population if the conservative treatment fails. Level IV, Therapeutic study.

Full- versus partial-thickness sutures: experimental models of corneal injury repair.

To evaluate the performance of full-thickness (FT) versus partial-thickness (PT) sutures in a full-thickness corneal wound in an animal model. This is a prospective, experimental, comparative, longitudinal study. A 6-mm linear, full-thickness corneal incision was performed on the right eye of eight domestic pigs. Eyes were randomly assigned for repair with interrupted PT (80-90% depth) sutures or FT 10-0 nylon sutures. Anterior segment OCT, corneal pachymetry and clinical photographs were obtained 1, 4 and 8weeks postoperatively. Corneal thickness, depth of suture placement, perilesional edema, coaptation of wound edges and complications were noted. Histopathologic examination was performed at 8weeks. 100% of the eyes with FT sutures developed a linear, less opaque scar. 100% of the eyes with PT developed a dense, opaque stromal scar (p = 0.02). Vascularization of the cornea was present in 75% of PT group and 25% in the FT group (p = 0.50). As the corneas healed, there was a marked trend toward thicker corneas in the PT group versus FT group with a median difference of - 63µm at week 1 [median 788µm vs. 725µm, (p = 0.11)], - 38µm at week 4, (724µm vs. 686µm, (p = 0.63)) and - 47µm median difference at week 8 with (670µm vs. 623µm, (p = 0.06)). Histopathology showed disorganization of the collagen fibers and the formation of a retrocorneal fibrous membrane in the PT group. The FT group presented less corneal edema at week 8 with a more linear and less opaque scar. Histopathology showed a better-organized scar and endothelialization without the formation of a fibrous membrane.

The clinical and prognostic implication of deep stromal invasion in cervical cancer patients undergoing radical hysterectomy.

Background: To evaluate the patterns of recurrence and survival related to deep stromal invasion (DSI) in cervical cancer patients who underwent the radical surgery.Methods: Patients with International Federation of Gynaecology and Obstetrics (FIGO) 2009 stage IB and IIA and definite pathology-confirmed deep stromal invasion between 03/2006 and 06/2014 were collected. A subcategorization of deep stromal invasion (inner full-thickness, full-thickness and outer full-thickness) were performed. Disease-free survival (DFS) and overall survival (OS) were compared by Kaplan-Meier analysis and independent predictors were identified using Cox regression analysis.Results: A total of 3,298 cervical cancer patients were included. The proportion of patients with outer 1/3 to full-thickness invasion, full-thickness invasion and outer-full-thickness invasion were 60.6%, 33.5% and 5.9%, respectively. Deep stromal invasion strongly correlated with patients' age, stage, menopause status, tumor diameter, lymphovascular space invasion (LVSI), nodal metastasis, parametrial and vaginal involvement, as well as the site of recurrence. However, no connection was found between the DSI and tumor histologic type. Upon further analysis, patients with full- and outer-full-thickness invasion exhibited significantly higher recurrence rates compared to inner full-thickness group. Both DFS and OS was independently associated with the depth of deep stromal invasion. By subgroup analysis, multivariate analysis revealed that only adjuvant radiotherapy was independent risk factors for both DFS and OS in isolated full-thickness invasion patients.Conclusions: This study indicated that the depth of deep stromal invasion is an important prognostic factor in patients with cervical cancer. Patients with full-thickness invasion should receive customized adjuvant treatment.

Patient-Reported Outcomes After Use of a Bioabsorbable Collagen Implant to Treat Partial and Full-Thickness Rotator Cuff Tears

To collect outcomes data on patients treated with a bioinductive collagen implant designed to induce rotator cuff healing in partial- and full-thickness cuff tears and to assess the safety and efficacy of the device. Fifteen surgeons in 15 centers in the United States enrolled patients between April 2016 and August 2017 and collected standardized outcomes data. Patients 21years of age and older, able to read and speak English, and with partial- or full-thickness tears of the rotator cuff documented by magnetic resonance imaging were included in the study. Patients were assessed preoperatively with visual analogue scale (VAS), single-assessment numeric evaluation (SANE), Veterans RAND 12-Item (VR-12), American Shoulder and Elbow Surgeons (ASES), and Western Ontario Rotator Cuff (WORC) outcomes measures. Postoperative assessment was made at 2, 6, and 12weeks, 6months, and 1year. Patients underwent a standardized operative procedure with the implant. Patient demographics, comorbidities, tear types, and concomitant operative procedures were recorded. Patients in both groups experienced statistically significant improvement in VAS, SANE, VR-12 PCS, ASES, and WORC scores (mean values 1.1, P < .001; 86.0, P < .001; 49.7, P < .001; 85.6, P < .001; and 84.4, P < .001 for partial tears and 1.2, P < .001; 80.7, P < .001; 45.7, P < .001; 83.8, P < .0001; and 80.1, P < .001 for full-thickness tears, respectively). For the partial tear group, average times for return to driving, work, and nonoverhead athletic activity were 14.6, 37.3, and 65.6days, and for the full-thickness group, 24.5, 50.7, and 119.2days, respectively. In the partial-thickness group, 84% and 83% of patients reported improvement in their VAS pain and ASES scores, respectively, that met or exceeded each measure's minimal clinically important difference. In the full-thickness group, 72% and 77% of the patients met or exceeded the minimal clinically important differences for VAS pain and ASES, respectively. Outcomes after repair of partial- and full-thickness rotator cuff tears using a bioinductive implant show safety and efficacy at 1-year follow-up. Retrospective case series, level IV evidence.

Synovial fluid biomarkers: association with chronic rotator cuff tear severity and pain

We tested the hypothesis that biomarkers in the synovial fluid of the glenohumeral (shoulder) joint are correlated with visual analog scale (VAS) scores, functional scores, and ultrasound findings of chronic rotator cuff tear (RCT) severity. We measured biomarkers in shoulder joint synovial fluid of 42 patients with partial-thickness (21), nonmassive full-thickness (10), and massive full-thickness (11) RCTs. Pain duration, tear severity, and VAS and functional scores were compared with interleukin (IL) 1β, IL-6, matrix metalloproteinase (MMP) 1, and MMP-13 levels. Both MMP-1 and MMP-13 levels were significantly highest in the massive full-thickness group. MMP-13 levels were significantly different between groups, but proinflammatory cytokine IL-1β and IL-6 levels were not. However, IL-1β levels were significantly positively correlated with VAS (r = 0.66; P <.01) and functional scores (r = 0.61; P <.01), but IL-6, MMP-1, and MMP-13 levels were not. IL-1β levels in shoulder synovial fluid correlated positively with shoulder pain and functional scores in patients with chronic RCTs. Both MMP-1 and MMP-13 levels were altered and increased with cuff tear severity.

Higher critical shoulder angle increases the risk of retear after rotator cuff repair

No evaluation has been done on the relationship of the critical shoulder angle (CSA) with retear after rotator cuff repair. Our purpose was to evaluate whether a higher CSA is associated with retear after rotator cuff repair. This was a retrospective review of 76 patients who had undergone rotator cuff repair with postoperative ultrasound examination. Ultrasound findings were graded no retear (NT), partial-thickness (PT) retear, or full-thickness (FT) retear. Preoperative radiographs were used to measure CSA, glenoid inclination, lateral acromion angle, and acromion index. Average age was 61.9 years (45.3-74.9 years). On ultrasound examination, 57 shoulders (74.0%) had NT, 11 (14.2%) had PT retears, and 8 (10.3%) had FT retears. There was no significant difference in retear rate by age, gender, or tension of repair. Average CSA was significantly lower for the NT group at 34.3° ± 2.9° than for the FT group at 38.6° ± 3.5° (P < .01). If CSA was >38°, the odds ratio of having an FT retear was 14.8 (P < .01). In addition, higher CSA inversely correlated with postoperative American Shoulder and Elbow Surgeons scores (P < .03). Average glenoid inclination was significantly lower in the NT group at 12.3° ± 2.7° compared with 17.3° ± 2.6° in the FT group (P < .01). If glenoid inclination was >14, the odds ratio of having a FT retear was 15.0 (P < .01). At short-term follow-up, higher CSA significantly increased the risk of an FT retear after rotator cuff repair. Also, increasing CSA correlated with worse postoperative American Shoulder and Elbow Surgeons scores. This radiographic marker may help manage expectations for rotator cuff tear patients.

Oncologic Outcomes of Invasive Squamous Cell Carcinoma of the Scalp Requiring Resection of Cranial Bone.

Objectives To identify the recurrence rates and survival outcomes of patients with invasive squamous cell carcinoma of the scalp. Methods This study was a retrospective chart review of eight patients that had squamous cell carcinoma of the scalp with either periosteal or skull invasion on clinical and/or radiographic evaluation. Results The disease-free survival was 62.5% (5/8 patients) with a local control rate of 75% (6/8 patients) for the entire group. The two patients with full-thickness craniectomy had a local control rate of 100% (2/2 patients); the patients with outer cortex removal had a local control rate of 66.7% (4/6 patients). The disease-free survival of the full-thickness group was 50% (1/2 patients ), and the disease-free survival of the outer cortex removal patients was 66.7% (4/6 patients). Conclusion Despite the invasive nature of this disease, a high degree of local control can be achieved in this high-risk group with multiple comorbidities using outer cortex drilldown, and, in properly selected patients, full-thickness calvarial resection. We conclude that for patients without evidence of medullary involvement that outer table drilldown offers a well-tolerated approach with reasonable oncologic control.

Fatigue strength of bilayered ceramics under cyclic loading as a function of core veneer thickness ratios

Statement of problemMinimal evidence is available concerning the appropriate thickness of each layer in bilayered ceramic systems. PurposeThe purpose of this in vitro study was to examine the effect of core-veneer thickness ratios on the fatigue strength of a bonded bilayered ceramic system. Material and methodsSpecimens of Ivoclar Porcelain System (IPS) e.max lithium disilicate were fabricated with core/veneer thicknesses of 0.5/1.0 mm, 0.75/0.75 mm, 1.0/0.5 mm, and 1.5/0.0 mm. All specimens were cemented to bases of a dentin-like material. Each specimen was cyclically loaded by a 2-mm–diameter G10 piston in water. Loads ranging from 10 N to the target load were applied at a frequency of 20 Hertz for 500 000 cycles. If cracked, the next specimen was cycled at a lower load; if not cracked, at a higher load (step size of 25 N). ResultsMean and standard deviations of fatigue loads for the different core thicknesses were 0.5-mm core 610.94 N ±130.11; 0.75-mm core 600.0 N ±132.80; 1.0-mm core 537.50 N ±41.67; a Nd 1.5-mm core 501.14 N ±70.12. All veneered groups were significantly stronger than the full thickness group (ANOVA, P<.001; 95% post hoc). Cone cracking was observed only in the 2 thinner core groups (χ2 test, P<.05), possibly indicating residual stresses. ConclusionsResults indicate that the addition of veneering porcelain to lithium disilicate cores increases the fatigue strength of the biceramic system.

Comparison of a superficial suturing device with a full-thickness suturing device for transoral outlet reduction (with videos)

Larger gastrojejunal (GJ) anastomosis aperture is one independent predictor for weight regain after Roux-en-Y gastric bypass. Transoral outlet reduction (TORe) has proven safe and effective for treatment of weight regain by using a superficial-thickness (ST) suturing device. Full-thickness (FT) suturing devices are now available, potentially providing more effective results. To compare effectiveness of superficial-thickness with full-thickness TORe. Matched cohort study: patients were matched sequentially by GJ anastomosis aperture, body mass index, and age. Tertiary-care center. A total of 59 consecutive patients undergoing full-thickness TORe were matched with 59 patients undergoing superficial-thickness TORe. All had GJ anastomosis apertures >20 mm. Transoral outlet reduction. Weight loss and rate of adverse events. Post-TORe GJ anastomosis apertures were similar between groups (ST 6.9 ± 0.2 mm vs FT 7.1 ± 0.3 mm). Weight loss was greater at 6 months in the FT group (10.6 ± 1.8 kg in FT vs 4.4 ± 0.8 kg in ST; P < .01) and at 1 year (8.6 ± 2.5 kg in FT vs 2.9 ± 1.0 kg in ST; P < .01). Excess weight loss was greater in the FT group at 6 months (20.4 ± 3.3% in FT vs 8.1 ± 2.5% in ST; P < .01) and at 1 year (18.9 ± 5.4% in FT vs 9.1 ± 2.3% in ST; P = .03). This was a single-center, retrospective, cohort study. There is level 1b evidence for effectiveness of TORe by using a superficial mucosal suturing device. This matched cohort study compared TORe by using the same ST suturing device with TORe by using a newer, FT suturing device and the same operative methods. FT TORe resulted in significantly more weight loss than ST TORe at 6 months and at 1 year. Full-thickness TORe is a significant improvement over ST TORe for endoscopic therapy of weight regain in patients with dilated GJ anastomosis.

Effects of partial or complete laser-assisted hatching on the hatching of mouse blastocysts and their cell numbers

BackgroundIt is still debatable whether a full-thickness assisted hatching (AH) is better than the partial zona thinning. In this research, we used a mouse model to study the effect of partial and complete laser-AH on the rate of completely hatched blastocyst and their cell numbers.MethodsIn experiment 1, mouse morulae had 0, 1, 2 or 3 full-thickness openings of 10 microns created in the zona pellucida with an infrared laser beam. In the second experiment, 0, 1 and 2 openings of 20 microns were studied. In the third experiment, a full-thickness opening of 20 microns or quarter-thinning of the zonal circumference to a depth of 90% was compared with non-AH controls.ResultsNo difference in blastocyst formation was found in laser-treated groups and in the controls. In experiment 1, the rate of completely hatched blastocysts was significantly lower than the controls. In experiment 2 when the size of the opening was increased, blastocysts completely hatched at a significantly higher rate than that in the controls. In experiment 3, the rate of completely hatched blastocysts was the highest in the full-thickness group. Cell numbers in completely hatched blastocysts from both AH groups were significantly fewer than those in the controls.ConclusionsFull-thickness opening resulted in a higher rate of completely hatched blastocysts than quarter zonal-thinning and controls, but the cell numbers were significantly decreased.

Results of Arthroscopic Repair of Partial- or Full-Thickness Longitudinal Medial Meniscal Tears by Single or Double Vertical Sutures Using the Inside-Out Technique

Background: Although numerous studies have assessed arthroscopic repair of meniscal tears, no study has described the repair of partial- or full-thickness longitudinal medial meniscal tears using single or double vertical sutures. Purpose: To present the intermediate-term results of medial meniscal tears repaired with single or double vertical sutures. Study Design: Case series; Level of evidence, 4. Methods: The authors evaluated the results of 112 longitudinal medial meniscal tears treated with inside-out single or double vertical sutures, with or without anterior cruciate ligament (ACL) reconstruction, based on the clinical resolution of symptoms, the Lysholm knee scoring scale, and the Tegner activity scale. Re-examination was also performed by magnetic resonance imaging after the repair. The length of the tears was evaluated arthroscopically. Eighty-five tears of 112 were >2 cm in length, and 27 were tears ≤2 cm. Eighty-nine (79.4%) of the 112 repairs were performed in conjunction with ACL reconstructions, and the remaining 23 (20.6%) repairs were performed in ACL-intact knees. The tear type of the menisci in our study was full thickness in 66 (58.9%) cases and partial thickness in 46 (41.1%) cases. Double vertical sutures were used for full-thickness tears, and single vertical sutures were used for partial-thickness tears. Results: The cases were evaluated after a mean follow-up duration of 49.3 months (range, 12-88 months). Clinical and radiological examination results determined that 99 (88.4%) meniscal repairs had healed, and the remaining 13 cases (10.6%) were considered to be failures. The healing rate of the full-thickness group was 80.3%, while in the partial-thickness group, the rate was 100%. The mean Lysholm score improved significantly from a preoperative value of 63.8 to a postoperative value of 89.5 (P < .001). The mean Tegner activity score was 3.3 preoperatively and 6.7 postoperatively (P < .001). Logistic regression analysis found that concurrent ACL reconstruction, tear length, and smoking as factors had a significant effect on meniscal healing. Conclusion: Single or double vertical sutures using the inside-out technique provide a high rate of healing in longitudinal medial meniscal tears.

Beware of the Small Finger and/or the Proximal Interphalangeal Joint? Skin Lacerations following Collagenase Injection in Dupuytren Contracture

Sir:FigureWe read with great interest the recent Viewpoint by Dr. Hallock highlighting a skin laceration of the small finger necessitating full-thickness skin grafting following collagenase injection in Dupuytren contracture.1 As reported in the Collagenase Option for Reduction of Dupuytren's I randomized controlled trial, skin lacerations occurred in 10.8 percent of all collagenase-treated patients.2 In addition, ecchymosis occurred in every fourth treated patient in the Collagenase Option for Reduction of Dupuytren's I study, and blood blisters occurred in 3.4 percent. In addition, two flexor tendon ruptures have been reported in the Collagenase Option for Reduction of Dupuytren's I study, both occurring at the small finger following proximal interphalangeal joint–targeted collagenase injections.3 The reported skin laceration in Dr. Hallock's case also occurred following proximal interphalangeal joint–targeted collagenase injection. One is tempted to ask whether the small finger proximal interphalangeal joint in Dupuytren contracture is a hazardous area. After the European approval of collagenase histolyticum in May of 2011, we have so far encountered two skin lacerations in collagenase-treated patients. The first female patient treated in our institution presented with a long-standing fourth ray Dupuytren contracture of 135 degrees following 15 Gy of radiotherapy. Immediately following cord breaking, a blood blister and subsequently a skin laceration occurred over her proximal phalanx. Using Steri-Strips and a custom-made plaster, healing by secondary intention was achieved within 10 days, surprisingly, in the previously irradiated hand. The second patient suffering with a skin laceration following collagenase injection was a 58-year-old man who had been previously operated on, with a fixed contracture of 120 degrees following selective fasciectomy of his ring finger (Fig. 1, above, left). A colleague had previously suggested ring finger amputation. He was treated with collagenase injection and, during cord breaking, a skin laceration occurred near the proximal interphalangeal joint of his ring finger. (See Video, Supplemental Digital Content 1, which demonstrates skin laceration during cord breaking 24 hours after collagenase injection in a male patient with recurrent Dupuytren contracture of this ring finger following selective fasciectomy, https://links.lww.com/PRS/A519.) Using Repithel ointment and daily dressing changes on a customized Dupuytren glove (Fixxglove) (Fig. 1, above, right, and below, left), the wound healed within 10 days albeit with exposed flexor tendons using a McCash open palm4 analogon (Fig. 1, below, right).Fig. 1: (Above, left) Male patient with recurrent Dupuytren contracture of his ring finger before collagenase injection. (Above, right) Forty-eight hours after skin laceration during cord breaking. (Below, left) Customized Fixxglove for postinterventional splinting following collagenase injection. (Below, right) Ten days after skin laceration with exposed flexor tendons at the proximal interphalangeal joint, complete reepithelialization following collagenase injection is shown.Video: Supplemental Digital Content 1 demonstrates skin laceration during cord breaking 24 hours after collagenase injection in a male patient with recurrent Dupuytren contracture of this ring finger following selective fasciectomy, https://links.lww.com/PRS/A519.In 2004, the Journal published an interesting prospective though nonrandomized clinical comparison of the McCash open palm technique and full-thickness skin grafting.5 Disabilities of the Arm, Shoulder and Hand scores improved in both groups from 37 to 30. Healing time was significantly faster in the full-thickness skin graft group compared with the McCash group (28 days versus 40 days). Furthermore, the recurrence rate was 50 percent for the McCash open palm group and 0 percent for the full-thickness group. Similar results in terms of reduced recurrence rates following full-thickness skin grafts have been reported by a number of authors in nonrandomized trials.6,7 However, a randomized trial with 79 patients with proximal interphalangeal joint Dupuytren contractures randomized to either firebreak full-thickness skin grafting or fasciectomy did not find any significant difference in recurrence rates at 3-year follow-up.8 Coming back to Dr. Hallock's case, it is tempting to speculate on how the recurrence rate will be influenced, if at all, by full-thickness skin grafting for skin lacerations following collagenase injections. The published 8-year follow-up results of eight patients report a 66 percent metacarpophalangeal joint and a 100 percent proximal interphalangeal joint recurrence rate.9 Therefore, we should follow the patients especially following skin lacerations with or without skin grafting in the future to elucidate the aforementioned question. Karsten Knobloch, M.D., Ph.D. Peter M. Vogt, M.D., Ph.D. Plastic, Hand, and Reconstructive Surgery and, Burn Center, Hannover Medical School, Hannover, Germany DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.

A Comparison of Outcomes After Arthroscopic Repair of Partial Versus Small or Medium-Sized Full-Thickness Rotator Cuff Tears

Little is known about the outcomes after repair of partial-thickness rotator cuff tears. The aim of this study was to assess the outcome after repair of partial-thickness rotator cuff tears compared with full-thickness tears. Our hypothesis was that repair of partial-thickness tears leads to more shoulder stiffness but fewer retears compared with repair of full-thickness tears. A group of 105 consecutive patients who had a full-thickness tear measuring <3 cm2 was compared with a group of sixty-four patients who had a partial-thickness tear. All tears were repaired with use of a knotless single-row arthroscopic repair. The American Shoulder and Elbow Surgeons (ASES) score and standardized patient and examiner-determined outcomes were obtained preoperatively and at six, twelve, and twenty-four weeks and at two years after surgery. Rotator cuff integrity was determined by ultrasound examination at six months and two years after surgery. Examiner-determined postoperative stiffness at six weeks was common in both groups (50% of those with a partial-thickness tear and 47% of those with a full-thickness tear) but was decreased compared with preoperative findings in both groups to 21% and 19%, respectively, at three months and to 15% and 14% at six months. The ultrasound-determined retear rate was small (5% in the partial-thickness group and 10% in the full-thickness group) at six months, but increased to 10% and 20%, respectively, at twenty-four months. The ASES score, patient-determined overall shoulder function, and all pain scores were superior to preoperative scores at six months (p < 0.001) and at twenty-four months (p < 0.001) in both groups. Arthroscopic repair of partial-thickness and small and medium-sized full-thickness rotator cuff tears was associated with excellent medium-term clinical outcomes with low retear rates. The data did not support our hypothesis: the differences in retear rate and postoperative shoulder stiffness rate found between the two groups did not reach significance.

Full-thickness supraspinatus tears are associated with more synovial inflammation and tissue degeneration than partial-thickness tears

The objective of this study was to determine whether the tear size of a supraspinatus tendon correlated with synovial inflammation and tendon degeneration in patients who underwent shoulder arthroscopy for rotator cuff repair. We hypothesized that increased synovial inflammation would correlate with greater tear size of the supraspinatus tendon at the time of surgery. Tissue from the synovium, bursa, torn supraspinatus tendon, and subscapularis tendon was obtained from patients during shoulder arthroscopy to evaluate the messenger RNA expression of proinflammatory cytokines, tissue remodeling, and angiogenesis factors in the tendon, bursa, and synovium. Additional tissue was fixed to determine histologic changes including inflammation, vascular ingrowth, and collagen organization. Increased expression of interleukin 1β, interleukin 6, cyclooxygenase 2, matrix metalloproteinase (MMP) 9, and vascular endothelial growth factor was found in the synovium of patients with full-thickness tears versus partial-thickness tears (P < .05). In the supraspinatus tendon, increased expression of MMP-1, MMP-9, MMP-13, and vascular endothelial growth factor was found in the full-thickness group. The upregulation of these genes in the full-thickness group was consistent with enhanced synovial inflammation, greater vascular ingrowth, and the loss of collagen organization in both supraspinatus and subscapularis tendons as determined by histology. Increased synovial inflammation and tissue degeneration correlate with the tear size of the supraspinatus tendon. A better understanding of the relationship between synovial inflammation and theprogression of tendon degeneration can help in the design of novel and effective treatments to limit the advancement of rotator cuff disease and to improve their clinical outcomes.

Incomplete Healing of the Uterine Incision After Caesarean Section: Is it Preventable?

It is not unusual for a wedge-shaped distortion to compromise the integrity of a uterine incision scar resulting from cesarean section. Although it has been implicated in later uterine rupture, ectopic pregnancy, abnormal uterine bleeding, and dysmenorrhea, little is known about its cause or how to prevent it. This prospective, randomized trial compared 2 suturing techniques, full-thickness suturing that included the endometrial (decidual) layer of the uterine wall and split-thickness suturing that excluded the endometrial layer. Of the 78 nulliparous women in the study, 45 were in labor at the time of operative delivery and 33 had an elective cesarean. The Kerr technique was used for the uterine incision. Forty patients were assigned to full-thickness suturing and 38 to the split-thickness method. Transvaginal ultrasonography, with transverse and longitudinal sections, was scheduled 40 to 42 days postoperatively. A lack of complete apposition of the cranial and caudal edges of the incision, resulting in ballooning out toward the anterior abdominal wall, was considered evidence of incomplete healing. The final analysis included 38 women having full-thickness closure and 32 having the split-thickness procedure. The 2 groups were comparable in all respects. There were no immediate postoperative complications. Sonography demonstrated a wedge-type healing defect at the site of the uterine incision in 69% of the split-thickness and 45% of the full-thickness groups, a statistically significant difference (odds ratio, 2.72; 95% confidence interval, 1.02-7.27). Women whose scar healed incompletely had significantly less cervical dilation preoperatively as well as a thinner anterior and a thicker posterior uterine wall. On logistic regression analysis, significant factors in the state of healing 40 days postoperatively included the method used to suture the uterine incision, the degree of cervical dilation, and the thickness of the anterior and posterior uterine walls. In addition to the method used to suture the uterine scar at cesarean section, the degree of cervical dilation and possibly the contractile strength of uterine muscle influence the completeness of healing. When the cervix is closed, drainage of the uterine cavity may depend on vigorous uterine activity that leads to a thicker posterior uterine wall and thinning at the uterine incision site, particularly if the relatively strong endometrial layer is not included when repairing the uterine incision.