BACKGROUND: Avascular necrosis of the humeral head (AVN) is characterized by osteonecrosis secondary to disrupted blood flow to the glenohumeral joint. Following collapse of the humeral head, arthroplasty, namely total shoulder arthroplasty (TSA) or humeral head arthroplasty (hemiarthroplasty) is recommended standard of care. The literature is limited to underpowered and small sample sizes in comparing arthroplasty modalities. Therefore, the aims of this study were (1) to compare the 10-year survivorship of TSA and hemiarthroplasty in the treatment of AVN of the humeral head and (2) to identify differences in their revision etiologies.
METHODS: Patients who underwent primary TSA and hemiarthroplasty for AVN were identified using the PearlDiver database. TSA patients were matched by age, gender, and Charlson Comorbidity Index (CCI) to the hemiarthroplasty cohort in a 4:1 ratio since TSA patients were generally older, sicker, and more often female. The 10-year cumulative incidence rate of all-cause revision was determined using Kaplan-Meier survival analysis. Multivariable analysis was conducted using Cox Proportional Hazard modeling. Chi-squared analysis was conducted to compare the indications for revisions between matched cohorts including periprosthetic joint infection (PJI), dislocation, mechanical loosening, broken implants, periprosthetic fracture, and stiffness.
RESULTS: In total, 4,825 patients undergoing TSA and 1,969 patients undergoing hemiarthroplasty for AVN were included in this study. The unmatched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 7.0% and 7.7%, respectively. The matched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 6.7% and 8.0%, respectively. When comparing the unmatched cohorts, TSA patients were at significantly higher risk of 10-year all-cause revision (HR: 1.39; P = 0.017) when compared to hemiarthroplasty patients. After matching, there was no significant difference in risk of 10-year all-cause revision (HR: 1.29; P = 0.148) and no difference in the observed etiologies for revision (P > 0.05 for all).
CONCLUSIONS: After controlling for confounders, only 6.7% of TSA and 8.0% hemiarthroplasties for humeral head AVN were revised within 10-years of index surgery. The demonstrated high and comparable long-term survivorship for both modalities supports the utilization of either for the AVN induced humeral head collapse.

BACKGROUND: Aseptic loosening is one of the most common complications of total elbow arthroplasty (TEA). Modern implants, such as the Nexel, have been designed in an attempt to decrease loosening. The present study aims to report implant survivorship, radiographic assessment of loosening and lucency, and patient-reported outcome measures (PROMs) in patients treated with the Nexel TEA at mid-term follow-up.
METHODS: Consecutive series of adult patients underwent TEA using the Nexel by a single surgeon via standardized technique. Patients with minimum 3 year follow-up with radiographic and PROM data were included. Survivorship was defined by the absence of revision. Loosening was assessed via Wrightington method by three independent fellowship-trained shoulder and elbow surgeons. Lucency was analyzed across individual radiographic zones on orthogonal radiographs. PROMs included the Quick Dash (QDASH), Patient Rated Elbow Evaluation (PREE), and EuroQoL (EQ5D).
RESULTS: 38 consecutive patients (22 female, 16 male) with mean age of 67 underwent TEA via triceps-sparing isolated medial window approach. Mean follow-up was 5.5 years (range 3-9). Primary diagnoses were: 19 osteoarthritis (OA), 9 rheumatoid arthritis (RA), 9 post-traumatic arthritis (PA), 1 conversion of elbow arthrodesis. Overall survivorship was 97.4%, with one patient undergoing revision for infection. Loosening was found in 5.3% of elbows, averaged across three observers. Lucency was most pronounced at the level of the humeral condyles. PROMs demonstrated significant and clinically meaningful improvements in 76%, 92%, and 73% of patients for QDASH, PREE, and EQ5D, respectively. No significant correlations were found between patient age, gender, loosening, lucency, and PROMs.
CONCLUSIONS: At mid-term follow-up, the Nexel TEA demonstrated excellent overall survivorship and low rate of implant loosening. The single failure requiring revision for infection was conversion of a prior elbow arthrodesis. PROMs overall exhibited marked and consistent improvement from preop to final postop follow-up. Although promising, these results should be interpreted with some caution as long term data regarding this prosthesis are still lacking.

Drug-resistant epilepsy is a common complaint in dogs and affects up to 30% of dogs with idiopathic epilepsy. Experimental data suggest that targeting cyclooxygenase-2 (COX-2) mediated signaling might limit excessive excitability and prevent ictogenesis. Moreover, the role of COX-2 signaling in the seizure-associated induction of P-glycoprotein has been described. Thus, targeting this pathway may improve seizure control based on disease-modifying effects as well as enhancement of brain access and efficacy of the co-administered antiseizure medication. The present open-label non-controlled pilot study investigated the efficacy and tolerability of a COX-2 inhibitor (firocoxib) add-on therapy in a translational natural occurring chronic epilepsy animal model (client-owned dogs with phenobarbital-resistant idiopathic epilepsy). The study cohort was characterized by frequent tonic-clonic seizures and cluster seizures despite adequate phenobarbital treatment. Enrolled dogs (n = 17) received a firocoxib add-on therapy for 6 months. Tonic-clonic seizure and cluster seizure frequencies were analyzed at baseline (6 months) months during the study (6 months). The responders were defined by a substantial reduction of tonic-clonic seizure and cluster seizure frequency (≥50%). In total, eleven dogs completed the study and were considered for the statistical analysis. Two dogs (18%, 2/11) were classified as responders based on their change in seizure frequency. Interestingly, those two dogs had the highest baseline seizure frequency. The overall tolerability was good. However, given the low percentage of responders, the present data do not support an overall considerable efficacy of COX-2 inhibitor add-on therapy to overcome naturally occurring phenobarbital-resistant epilepsy in dogs. Further translational evaluation should only be considered in the canine patients with a very high baseline seizure density.

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: Conservative antibiotic treatment (CAT) for uncomplicated acute appendicitis (AUA) in children has been proven safe and efficacious. However, as data accumulate, high rates of recurrent appendicitis and subsequent appendectomy have been reported. This prospective longitudinal study evaluated risk-factors for recurrent AUA after CAT in a large cohort, with long-term follow-up.
METHODS: Children ages 5 to 16 years admitted to the Department of Pediatric Surgery from 2014 through 2018, diagnosed with AUA were eligible for CAT. We recorded their age, appendix outer diameter, white blood cell counts, C-reactive protein and other related signs and symptoms associated with AUA. Clinical and ultrasonographic follow-up was carried out until follow-up data collection ceased according to the study design (2014-2019).
RESULTS: The cohort included 646 children who were initially treated successfully with CAT. Among them, 180 (28%) were readmitted for recurrent acute appendicitis during the follow-up period and 138 (21%) eventually had appendectomy. Overall success of 79% for CAT was recorded in this cohort. A multivariable model including; age, sex, appendiceal diameter, WBC and CRP, found the factors of older age, larger outer appendiceal diameter and high WBC counts significantly related to appendectomy during the follow-up period. We offer a decision tree model to predict appendectomy probabilities for patients based on their prognostic measurements.
CONCLUSIONS: CAT in AUA in children should consider older age, larger outer appendiceal diameter and high WBC counts as risk-factors for recurrent AUA and subsequent appendectomy. The proposed decision tree model may help both clinicians and parents before CAT is chosen.
METHODS: Level 2.

Patients with complex regional pain syndrome suffer from chronic neuropathic pain and also show a decrease in sensorimotor performance associated with characteristic central and peripheral neural system parameters. In the brain imaging domain, these comprise altered functional sensorimotor representation for the affected hand side. With regard to neurophysiology, a decrease in intracortical inhibition for the sensorimotor cortex contralateral to the affected hand has been repetitively verified, which might be related to increased primary somatosensory cortex functional activation for the affected limb. Rare longitudinal intervention studies in randomized controlled trials have demonstrated that a decrease in primary somatosensory cortex functional MRI activation coincided with pain relief and recovery in sensorimotor performance. By applying a randomized wait-list control crossover study design, we tested possible associations of clinical, imaging and neurophysiology parameters in 21 patients with complex regional pain syndrome in the chronic stage (>6 months). In more detail, we applied graded motor imagery over 6 weeks to relieve movement pain of the affected upper limb. First, baseline parameters were tested between the affected and the non-affected upper limb side and age-matched healthy controls. Second, longitudinal changes in clinical and testing parameters were associated with neurophysiological and imaging parameters. During baseline short intracortical inhibition, as assessed with transcranial magnetic stimulation, was decreased only for hand muscles of the affected hand side. During movement of the affected limb, primary somatosensory cortex functional MRI activation was increased. Hand representation area size for somatosensory stimulation in functional MRI was smaller on the affected side with longer disease duration. Graded motor imagery intervention but not waiting, resulted in a decrease of movement pain. An increase of somatosensory hand representation size over graded motor imagery intervention was related to movement pain relief. Over graded motor imagery intervention, pathological parameters like the increased primary somatosensory cortex activation during fist movement or decreased short intracortical inhibition were modified in the same way as movement pain and hand performance improved. No such changes were observed during the waiting period. Overall, we demonstrated characteristic changes in clinical, behaviour and neuropathology parameters applying graded motor imagery in patients with upper limb complex regional pain syndrome, which casts light on the effects of graded motor imagery intervention on biomarkers for chronic neuropathic pain.

UNASSIGNED: Advances in statistical methods and computing power have led to a renewed interest in addressing the statistical analysis challenges posed by Small-N Designs (SND). Linear mixed-effects modeling (LMEM) is a multiple regression technique that is flexible and suitable for SND and can provide standardized effect sizes and measures of statistical significance.
UNASSIGNED: Our primary goals are to: 1) explain LMEM at the conceptual level, situating it in the context of treatment studies, and 2) provide practical guidance for implementing LMEM in repeated measures SND.
UNASSIGNED: We illustrate an LMEM analysis, presenting data from a longitudinal training study of five individuals with acquired dysgraphia, analyzing both binomial (accuracy) and continuous (reaction time) repeated measurements.
UNASSIGNED: The LMEM analysis reveals that both spelling accuracy and reaction time improved and, for accuracy, improved significantly more quickly under a training schedule with distributed, compared to clustered, practice. We present guidance on obtaining and interpreting various effect sizes and measures of statistical significance from LMEM, and include a simulation study comparing two p-value methods for generalized LMEM.
UNASSIGNED: We provide a strong case for the application of LMEM to the analysis of training studies as a preferable alternative to visual analysis or other statistical techniques. When applied to a treatment dataset, the evidence supports that the approach holds up under the extreme conditions of small numbers of individuals, with repeated measures training data for both continuous (reaction time) and binomially distributed (accuracy) dependent measures. The approach provides standardized measures of effect sizes that are obtained through readily available and well-supported statistical packages, and provides statistically rigorous estimates of the expected average effect size of training effects, taking into account variability across both items and individuals.

OBJECTIVE: Hoarding disorder (HD) was recognized as a psychiatric disorder in 2013. Existing literature suggests room for improvement in its treatment. The current pilot study aimed to provide an initial evaluation on the potential of compassion-focused therapy (CFT) as an intervention for HD, with the primary aim being assessing its feasibility and acceptability, and the secondary being evaluating its effects.
METHODS: Both CFT and a second round of the current standard of treatment and cognitive behavioural therapy (CBT) were investigated in the current study as follow-up treatment options for individuals who had completed CBT but were still significantly symptomatic.
METHODS: Forty eligible individuals were enrolled (20 in each treatment). Treatment feasibility and acceptability were assessed by quantitative and qualitative measures. To explore treatment effects, HD symptom severity, HD-related dysfunctions, and their underlying mechanisms were assessed pre-treatment and post-treatment.
RESULTS: Retention rates were 72% for CFT and 37% for CBT. All participants and 79% of the participants rated CFT and CBT, respectively, as good or excellent. After receiving CFT as a follow-up treatment, HD symptom severity dropped below the cut-off point for clinically significant HD for 77% of the treatment completers, and 62% achieved clinically significant reduction in symptom severity. In contrast, after completing a second course of CBT, 23% had HD symptom severity dropped below the cut-off threshold, and 29% achieved clinically significant symptom reduction.
CONCLUSIONS: The current study showed satisfactory feasibility and acceptability of CFT. Moreover, it also found promising effects of CFT in addressing hoarding-related mechanisms that may not have been sufficiently addressed by CBT. The results suggest promising potential of CFT as a treatment for HD. Further investigation on this intervention is needed.
UNASSIGNED: CFT may be a promising treatment option, particularly for those who do not respond well to CBT. Improving emotion regulation and negative self-perception by applying CFT interventions may help relieve hoarding symptoms. Generalization of the findings should be applied with caution given the small convenience sample of the current study. Statistical comparison on treatment effect measures between CFT and CBT as follow-up treatments was not available due to small sample size. Therefore, the comparative conclusions based on this pilot study should be made with caution.

The purpose of this study was to compare clinical outcomes and retear rate between arthroscopic double row (DR) and suture bridge (SB) repair for rotator cuff tears. Postoperative Constant score and MRI findings were compared between 52 patients underwent DR repair and 63 patients underwent SB repair with medium tear of the supraspinatus. There was no significant difference in Constant score between the two groups. Postoperative MRI revealed that retear rate of SB group was significantly lower than DR group. This study suggests that SB repair can provide better clinical and structural outcomes compared with DR repair.

BACKGROUND: Bilateral reverse shoulder arthroplasty (RSA) is controversial because of potential rotational deficits impairing daily living activities. We assessed achievement of insufficient internal rotation (IR) and associated factors in bilateral RSA patients.
METHODS: Fifty-seven staged bilateral RSA patients with a minimum of 1 year of follow-up after the second intervention were identified from our local monocentric register. Shoulder range of motion (including IR using the Apley scratch test), strength, and Constant and Shoulder Pain and Disability Index scores were assessed preoperatively and 6, 12, and 24 months postoperatively.
RESULTS: Before surgery, both shoulders were similar regarding imaging parameters, but first operated shoulders tended to have poorer function. One year after the first RSA, 21% of patients had insufficient IR (not reaching the lumbosacral junction) compared with 33% after the second intervention (P = .180). At 2 years, 5% of patients had insufficient IR on both sides. Patients with insufficient IR on the second side at baseline (relative risk [RR], 1.8 [1.0-3.2]) and patients with insufficient IR 1 year after the first RSA (RR, 3.0 [1.6-5.6]) were more likely to have insufficient IR 1 year after the second RSA. Constant and Shoulder Pain and Disability Index scores and abduction of the second side were significantly worse 1 year after the second RSA (P ≤ .047); at 2 years, there were no differences in functional outcome between shoulders.
CONCLUSIONS: A minority of bilateral RSA patients did not achieve sufficient IR on at least 1 side. Staged surgery is justified, particularly when the outcome of the initial operation is satisfactory.