Anterior shoulder pain （anterior shoulder pain） is the most common form around the shoulder， occurring in up to 30% of patients and lasting for a year or more in 40%.Causes of pain include rotator cuff injury， shoulder impingement syndrome， glenolabial injury， and injury of the biceps long tendon（long head tendon）.As a receptor of shoulder joint pain and pressure， the long head tendon is an important cause of shoulder joint motor dysfunction， manifesting as inflammation， edema， dislocation， tear， etc.The injury can occur alone and is often accompanied by other structural injuries， such as supraspinatus and subscapular tendon injuries.Previous literature has confirmed a high correlation between biceps long tendon injury and rotator cuffinjury.Singaraju et al.showed that the correlation between supraspinatus tendon tear and biceps long tendon injury was as high as 78.5%， and with every 1 cm increase in supraspinatus tendon injury， the incidence of biceps long tendon lesions increased by 1.7 times.Tendinopathy combined with rotator cuff repair is the most commonly used technique for treating anterior shoulder pain caused by rotator cuff injury combined with a long head tendon injury.Tendinopathy can be performed using various surgical techniques， and tendon fixation locations are often selected according to the doctor's surgical preference， the patient's age， and functional requirements.Proximal fixation of intertubercular sulcus has the advantages of being a simple technique， having fast speed and few incisions， but the postoperative pain relief may be incomplete due to residual pathological tendon tissue.Some studies have suggested no significant difference in functional outcome between the intertubercular sulcus's proximal fixation and the pectoralis major's upper margin.However， researchers who support the fixation of the upper margin of the pectoralis major believe that the slide of the long head tendon in the sheath formed by the transverse humeral ligament is the primary source of pain.Hence， the removal of this lesion is particularly important， but this method of fixation is complicated and carries the risk of humeral fracture and neurovascular damage.In recent years， a large number of studies have compared tenodesis.However，due to confounding factors such as the difference between endoscopic and open surgery， long head tendon injury combined with different follow-ups， there is no consensus on the optimal fixation position for long head tendon surgery.Therefore， this study only included patients with typical clinical injuries of long head tendon combined with rotator cuff injury to make the study closer to clinical practice and give full play to the clinical guiding role of the study.At the same time， the type of rotator cuff injury was limited to Ellmann type I supraspinatus tendon degenerative tear to reduce the impact of accompanying injury and its severity on pain and mobility in the study results.Reduce potential bias from other subtypes.
Objective
To compare and analyze the initial clinical efficacy of arthroscopic anterior clearance， proximal intertubercular sulcus fixation， and upper margin pectoralis major fixation combined with rotator cuff repair in the treatment of Ellmann Type I supraspinatus tendon tear complicated with longhead tendon injury.
Methods
The clinical data of 36 patients with Ellmann type I supraspinatus tendon tear and long head tendon injury resulting in anterior shoulder pain were retrospectively analyzed.They were divided into anterior clearance + rotator cuffrepair group （AR group， n=15）， proximal intertubercular sulcus fixation + rotator cuff repair group （IR group， n=10）， fixed upper border of pectoralis major + rotator cuff repair group （SR group， n=11）.VAS，ASES， CMS， UCLA， and SST scores， the incidence of intertubercular sulci tenderness， and the improvement of shoulder active/passive motion were compared before and at least 3 to 6 months after surgery.MRI and physical examination measured the incidence of complications and rotator cuff healing at 3 and 6 months after surgery.
Results
All 36 patients were observed and followed up for at least 3 - 6 months.MRI showed that the rotator cuff healed well in all patients， and no complications such as Popeye deformity occurred.Postoperative shoulder joint scores of patients in the three groups were significantly improved compared with those before surgery； postoperative ASES scores in the AR group were significantly increased compared with those before surgery （P＜0.01）； preoperative UCLA scores in the IR and SR groups were significantly increased compared with those before surgery （P＜ 0.01）； postoperative VAS and SST scores in the SR group were significantly decreased compared with those before surgery （P=0.02， P=0.04）； The active forward flexion activity of IR group was significantly improved after operation （P=0.01）， and the active forward flexion， passive forward flexion and passive abduction activity of IR group were significantly greater than those of AR group （P=0.01， P＜0.01， P=0.05）； The positive rate of internodal groove tenderness after operation was significantly lower than that before operation （P=0.01， P=0.03， P＜ 0.01）， IR and SR groups were significantly better than AR group （P=0.02，P=0.04）.
Conclusion
The three operations combined with rotator cuff repair for Ellmann Type I supraspinatus tendon degeneration tear combined with long head tendon injury can effectively relieve shoulder pain and improve shoulder joint function 3 to 6 months after surgery.The pain improvement is more evident after the upper margin of pectoralis major muscle fixation， and the mobility is better after the proximal intertubercular sulci fixation.
With the increasing aging of society， the incidence， disability rate，mortality rate， and related medical costs of proximal humeral fracture （PHF） are all showing a rising trend， which has become a public health problem that cannot be ignored.According to epidemiological investigations， PHF has become the third most common fracture type in older adults after hip and distal radius fractures.For severely displaced PHF， surgical treatment aims to achieve ideal reduction and fixation，stabilize the fracture end， and facilitate the patients to perform shoulder joint functional exercises in the early stage.However， surgical treatment is often faced with many difficulties， such as the inability to use a tourniquet， osteoporosis， bone defects， difficulty reduction， etc.， which increase the risk of intraoperative bleeding.For elderly patients， intraoperative bleeding may not only increase the need for postoperative blood transfusion but also directly threaten the life safety of patients and increase perioperative mortality.Tranexamic acid （TXA）， an anti-fibrinolytic drug， has been widely used in joint surgery.According to relevant studies， TXA can effectively reduce perioperative blood loss and transfusion volume in hip and knee replacement surgery patients.However， there are few reports on the application of TXA in elderly patients undergoing PHF surgery.
Objective
To investigate the efficacy and safety of preoperative intravenous administration of TXA in elderly patients undergoing internal fixation for PHF.
Methods
This study retrospectively analyzed the clinical data of 75 elderly patients with PHF who underwent open reduction and internal fixation surgery in Beijing Chaoyang Hospital， Capital Medical University， from December 2017 to December 2021.Patients were divided into a TXA group （45 cases） and a control group （30 cases）according to whether they received preoperative intravenous TXA therapy.Patients in the TXA group were given 1 g TXA intravenously 30 minutes before surgery， while those in the control group were not given TXA.We compared baseline characteristics， perioperative blood loss （including total， overt， recessive， and intraoperative blood loss）， transfusion rate， postoperative hematological indicators （hemoglobin， hematocrit，and platelet count）， and postoperative complications between the two groups.Statistical significance was determined by P＜0.05.
Results
Compared with the control group， the TXA group significantly reduced perioperative blood loss.The total blood loss in the TXA group was substantially lower than that in the control group （P＜0.01）， and the dominant blood loss （P＜0.01） and recessive blood loss （P＜0.01） were also significantly reduced.Although there was no significant difference in intraoperative blood loss between the two groups （P＞0.05）， the postoperative drainage flow and drainage tube removal time in the TXA group were significantly lower than those in the control group （P＜0.01）.The hemoglobin level of the TXA group was higher than that of the control group on day 1， day 3， and day 5 after the operation， especially on day 1（P=0.01）.Regarding hematocrit， the TXA group was significantly higher than the control group on day 1 and day 3 after surgery （P=0.01 and P=0.006）， but there was no significant difference in hematocrit level on day 5.There was no significant difference in platelet count between the two groups （P＞0.05）.In addition，the length of hospitalization in the TXA group was significantly shorter than that in the control group（P＜0.01）.The incidence of postoperative complications was similar between the two groups， and there were no adverse events such as thromboembolism.
Conclusion
Preoperative intravenous application of TXA can effectively reduce perioperative blood loss in elderly patients with PHF， maintain good postoperative hemoglobin and hematocrit levels， and significantly shorten hospital stay， which is conducive to rapid postoperative recovery of patients and has good clinical effectiveness and safety.
The proximal humerus is a common site for osteoporotic fractures.The measurement of bone mineral density （BMD） of the proximal humerus is essential for the diagnosis and evaluation of the therapeutic effect of osteoporosis.Dual-energy X-ray Absorptiometry （DXA） is the gold standard for the diagnosis of osteoporosis， but there is no clear threshold for the diagnosis of proximal humerus osteoporosis.Quantitative Computed Tomography （QCT） measures bone trabeculae's volumetric BMD on a two-dimensional CT cross-section.However， when QCT is used to measure BMD， a calibrated body model is required to obtain the lumbar vertebra's bone mineral content （BMC）.However， this body model cannot be used for bone mineral density measurement of the humerus， and this method cannot be used for retrospective bone mineral density measurement.As an advanced technology， Dual-energy Computed Tomography （DECT） has been widely applied in clinical practice， such as virtual noncalcium （VNCa）reconstruction algorithm.It has been used to analyze substances such as iron， calcium， and fat quantitatively.The single energy reconstruction algorithm of energy spectrum purification can also evaluate shoulder joint ligament and rotator cuff structure morphology and continuity.
Objective
To investigate the feasibility of measuring the cortical thickness of the proximal humerus in predicting the local bone mineral density of the proximal humerus combined with the quantitative bone mineral density measurement method of the upper humerus.
Methods
A total of 65 patients （mean age 49.5±15.2 years old， male： female =32：33， right：left=30：35） were included in the retrospective study of shoulder joint orthographic radiographs and dualsource CT images of trauma patients from Shanghai First People's Hospital.Cortical bone thickness （CBT）of the proximal humerus was measured on the program and reconstructed coronal CT images， and the mean value of the cortical index （CBTavg） and the standard value of the cortical index （CBTg） was calculated.The dual-energy CT data of the shoulder joint were imported into Syngo.via post-processing workstation and the middle plane between the greater tubercle plane of the humerus and the surgical neck was taken as the reference plane.The two ends of the articular surface of the humerus head were connected as vertical bisector lines， thus dividing the humeral head into four parts.The relative CT values of calcium （CaCT） and the regular CT value （rCT） between the four components were measured.The correlation between CaCT， rCT， CBTavg， and CBTg was studied.
Results
The average CBTavg-Xray was （0.6±0.11）cm， and the average CBTavg-DECT was （0.74±0.11）cm.There were statistical differences between CBTavg-Xray and CBTavg-DECT and CBTg-Xray and CBTg-DECT （P＜0.001）.There was a correlation between CBTavg-Xray and CBTavg-DECT and CBTg-Xray and CBTg-DECT.r values were 0.679 and 0.747，respectively， and P values were all ＜ 0.001.CBTavg-Xray， CBTg-Xray， CBTavg-DECT， and CBTg-DECT were not strongly correlated with CaCT and rCT values in regions 1-4 （r values were all ＜ 0.6）.
Conclusion
The cortical thickness of the proximal humerus had a poor correlation with the bone calcium value of the proximal humerus， so it could not accurately predict the bone calcium value of the proximal humerus.The CaCT and rCT values of the proximal humerus can be measured by dual-energy CT to guide the surgeon in selecting the appropriate internal fixation area.
Cubital tunnel syndrome is one of the most common peripheral nerve entrapment diseases， which is often caused by an inflammatory reaction of repeated friction of the ulnar nerve at the cubital canal， leading to clinical syndrome.In the stage of severe cubital tunnel syndrome， the aseptic inflammatory reaction caused by friction and ischemia of the ulnar nerve leads to the thickening of the epineural membrane and pathological progression such as inter-fascicular scar and fibrotic tissue hyperplasia， which leads to further compression of nerve fiber tissue， formation of permanent scar tissue，and further reduction of local nerve sheath fluid and nerve blood supply.It leads to Waller's degeneration of myelinated nerve fibers， which has serious consequences for the recovery of nerve function.Failure to receive timely treatment will lead to patients' hypoaesthesia， muscle atrophy， and even joint contracture， and surgical intervention can improve clinical effects.At present， releasing local nerves trapped by anatomical structures is one of the surgical methods used to treat elbow tunnel syndrome.There are many discussions on the anterior ulnar nerve release， and various surgical methods have advantages and focus.Some surgical methods have been eliminated due to unsatisfactory efficacy.The protection of accompanying vessels during the anatomic dissociation of the ulnar nerve has not been discussed in detail.However， anatomical studies on accompanying vessels of the ulnar nerve in the elbow have made it clear that the ulnar nerve has three blood vessels supplying to the cubital canal， and the accompanying vessels of the ulnar nerve can move forward together with the ulnar nerve to the ulnar nerve sulci， with no tension in the previa vessels.This study mainly focused on the main blood supply of the ulnar nerve near the cubital canal， including the small branches of the inferior collateral ulnar artery and the recurrent ulnar artery entering the fascia around the ulnar nerve and the outer membrane of the ulnar nerve， and finally reaching the nutrition of the ulnar nerve.With this focus， the ulnar nerve preposition operation with the inferior collateral ulnar artery of the elbow and the fascia around the ulnar nerve was designed to treat severe cubital tunnel syndrome.
Objective
To investigate the operative methods and clinical effects of ulnar nerve preposition with the ulnar inferior collateral artery and the fascia around the ulnar nerve and ulnar nerve preposition with ulnar inferior collateral artery in treating severe cubital tunnel syndrome.
Methods
From October 2022 to September 2024， 30 patients with severe cubital tunnel syndrome admitted to our hospital were randomly divided into two groups， which were divided into the ulnar nerve preposition group with the ulnar inferior collateral artery of the elbow and the peripheral fascia of the ulnar nerve by different surgical methods and the ulnar nerve preposition group with the ulnar inferior collateral artery of the elbow.The elbow joint was fixed at 90-120°flexion by plaster or brace after surgery.The braking time was 3 weeks.Michelin alleviated the nerve edema， and a mecobalamine tablet was used for nerve nutrition.Outcome measures： According to the functional evaluation criteria of the upper limb，the postoperative autonomous sensation of the hand， the muscle strength of the internal muscle of the hand，the discernibility of two points in the abdomen of the little finger， and the electromyography nerve conduction velocity of the elbow were compared between the two groups.
Results
The 30 patients were followed for 6 to 24 months （mean 13.2 months）.The superior rate of ulnar nerve preposition with inferior ulnar artery and fascia around the ulnar nerve （study group） was 86.67%.The excellent and good rate of ulnar nerve preposition with the inferior ulnar artery of the elbow （control group） was 73.33%.There was no significant difference between the two groups in the changes of ulnar nerve conduction velocity， hand autonomic sensation， and two-point discernible sense of the distal finger of the little finger before and after surgery（P＞0.05）.However， the relief rate of postoperative hand numbness， pain， and other symptoms， as well as the surgical satisfaction of patients， significantly increased.
Conclusion
The ulnar nerve preposition with the inferior ulnar artery of the elbow and the fascia around the ulnar nerve can more completely protect the blood supply of the local ulnar nerve of the elbow， which is a reliable surgical treatment for severe cubital tunnel syndrome and obtain better therapeutic effect and patient satisfaction.
