Variability in breast reconstruction methods provides an opportunity to investigate whether a method is superior to another with regard to cost, quality, or both. We performed a cost-effectiveness analysis (CEA) study based on tertiary endpoint data from a randomized clinical trial to compare the cost-effectiveness of delayed breast reconstruction by either a latissimus dorsi flap (LD) or a thoracodorsal artery perforator flap (TAP).
A total of 50 women were included for unilateral delayed breast reconstruction and were randomized to reconstruction by either the LD flap (n = 18) or the TAP flap (n = 22). The CEA was based on differences in shoulder function after the reconstruction. Direct and indirect costs relating to the two procedures were assessed by the Danish Diagnosis-Related Groups tariffs.
Our analysis showed a significant positive effect of introducing the TAP flap on the total shoulder score with an additional cost of $2779. The incremental cost-effectiveness ratio was $4481 and based on a willingness to pay (WTP) $500, we found an estimated net benefit of $519, which was statistically significant (p = 0.0375). The cost-effectiveness acceptability curve indicated that there is a 96.3% probability for the TAP flap being cost-effective to the LD flap at a WTP threshold of $500.
From a societal perspective, our cost-effective analysis demonstrated that the TAP flap is the more cost-effective method of breast reconstruction compared to the LD flap with respect to patient-reported shoulder-related disability.

BACKGROUND: Two popular methods used to treat distal-third clavicle fractures are the traditional hook plate and the anatomically contoured locking plate. No consensus exists on whether one method is more effective than the other. Therefore, the aim of this study was to compare the efficacy of a traditional hook plate with that of an anatomically contoured locking plate augmented with coracoclavicular fixation in the treatment of distal-third clavicle fractures.
METHODS: Enrolled patients were randomly assigned to either the hook plate group (n = 13) or the locking plate group (n = 17). Follow-up assessments (clinical and radiologic) were performed at 6 and 12 months postoperatively.
RESULTS: In both groups, union was achieved in 91% of cases at 6 months and 100% at 12 months. No differences in Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley shoulder scores were noted between the hook plate and locking plate groups at 12 months. From 6 to 12 months, DASH scores improved in the hook plate group (P = .007) and Constant-Murley shoulder scores tended to improve (P = .075). Surgical time was longer in the locking plate group than in the hook plate group (P < .001).
CONCLUSIONS: Similar functional outcomes and union rates were achieved in both groups at 12 months postoperatively. However, the improvement in DASH scores in the hook plate group from 6 to 12 months suggests that patients treated with an anatomically contoured locking plate make a quicker recovery than patients treated with a hook plate.

BACKGROUND: Based on the contradictory results about the effect of an intramedullary nail in the treatment of humeral shaft fracture, in this study, we aim to evaluate the outcomes of patients with humeral fracture treated with PHILOS plaque.
METHODS: In this cross-sectional study, which was performed to evaluate the recovery rate of patients with humeral fracture treated with PHILOS plaque referred to Shahid Beheshti Hospital in Abadan-Iran during 2015-2019. Constant Shoulder Score was evaluated six months and one year after the operation.
RESULTS: The mean constant shoulder score was increased significantly after 1 year compared to 6 months (P<0.001). The means of constant shoulder score 6 months in type 4 of fracture was significantly higher than type 3 of fracture (P=0.03) but there was no significant relationship between the means of constant shoulder score 1 year after surgery and type of fracture.
CONCLUSIONS: We suggest that orthopedic surgeons should pay more attention to the usage of PHILOS plate in patients with humerus fractures especially the type 4 fracture.

BACKGROUND: This randomized controlled trial (RCT) investigates differences in shoulder-related morbidity after delayed breast reconstruction by either a latissimus dorsi (LD) flap or a thoracodorsal artery perforater (TAP) flap.
METHODS: In accordance with the CONSORT guidelines, we included women for unilateral delayed breast reconstruction. Patients were randomized to reconstruction by either of the two flaps. Shoulder-function was assessed at baseline and at 3, 6 and 12 months after surgery. The primary endpoint was patient-reported shoulder-related pain. A further objective assessment by the Constant Shoulder Score (CSS) was included as secondary endpoints.
RESULTS: A total of 50 women were enrolled over a two-year period and allocated to reconstruction, with 25 patients in each group. Patient-reported shoulder-related pain was significantly lower in the TAP group at 12 months after surgery when adjusting for pain at baseline: OR = 0.05 95%CI(0.005-0.51), p-value = 0.011. The estimated effect on the total CSS at 12 months, when applying the TAP flap instead of the LD flap and adjusting for the baseline score, was 6.2 points with 95%CI(0.5-12.0), p-value 0.033. The TAP flap seems to have a statistically significant positive effect on pain and activity in daily life (ADL), while there were no significant effect on range of motion and strength after one year.
CONCLUSIONS: Patient reconstructed by the TAP flap are less likely to experience shoulder-related pain and have a better shoulder-function one year after the reconstruction. Harvest of the LD flap carries a higher risk of shoulder-function impairment, chronic pain and reduced ADL.

BACKGROUND: Degenerative changes and inflammation in the rotator cuff (RC) are the most important causes of shoulder pain. The aim of the present study was to determine the effectiveness of platelet-rich plasma (PRP) in patients with chronic RC tendinopathy.
METHODS: This study was an open-label study performed at Kashani Hospital between April 2012 and June 2014. Patients with a <1 cm partial tearing of the bursal side of RC with no or little response to conservative management were included. PRP injection was done using ultrasonography guide via posterior subacromial approach. Demographic data were obtained in all patient before the study, and shoulder function was evaluated using Constant shoulder score (CSS) before and 3 months after PRP injection.
RESULTS: A total number of 17 patients were enrolled. The mean of CSS before and after intervention was 37.05 ± 11.03 and 61.76 ± 14.75, respectively (P < 0.001). There was no statistically significant correlation between the pain score before the study and the improvement in CSS (P = 0.45, r = 0.03). Significant relation was observed between the individuals\' age and improvement of CSS (P = 0.02, r = -0.49). There was no significant difference in CSS improvement between genders (P = 0.23).
CONCLUSIONS: Single injection of PRP is effective to reduce pain and improve range of motion in patients with bursal side partial tearing of RC who failed to respond to conservative treatments.

BACKGROUND: Clavicle fractures are common and usually heal without complications. In this study, we evaluated the outcomes of non-operative versus operative management of displaced fractures.
METHODS: In a prospective clinical trial study, sixty-five patients with displaced clavicle mid-shaft fractures were non-randomly divided in two treatment groups. The first group underwent non-operative treatment with figure of 8 bandage (30 patients), and the other underwent operative treatment with plate fixation (35 patients). Figure of 8 bandage and 3.5 millimeter DCP plate with at least six cortical screws were used in non-operative and operative groups respectively. We followed up all patients at weeks 2, 6 and 12, and at month sixth. In addition to clinical examination and x-ray evaluation, we assessed satisfaction, DASH and Constant Shoulder Score for each individual.
RESULTS: The average durations of union were 19.3 and 24.4 weeks in operative and non-operative groups respectively (P=0.006). Satisfaction with operative treatment was 74.3% and with non-operative treatment was 66.7%, showing no significant difference (P=0.500). The non-union rate was 5.7% in the operative group and 13.3% in the non-operative group (P=0.518). A significant difference between the two groups in terms of DASH and Constant Shoulder Scores after the six-month follow-up was not found (P=0.352).
CONCLUSIONS: According to our results, we recommend operative treatment in mid-shaft clavicle fractures only when there is a definitive indication.