Does the subscapularis refixation affect the clinical outcome after primary reverse shoulder arthroplasty?

BACKGROUND: Reverse shoulder arthroplasty is an established procedure for patients with rotator cuff tear arthropathy. However, the refixation of the subscapularis tendon remains a controversial and frequently discussed topic. This prospective randomized study was conducted to evaluate the clinical benefit of the subscapularis refixation after reverse shoulder arthroplasty. METHODS: Fifty patients (f: 36, m:14) were randomized and assigned to either the "repaired" (rep) or the "not repaired" (nrep) cohort. Intraoperatively, the subscapularis tendon was reattached in the rep-cohort with four tendon-to-tendon sutures, whereas no refixation was performed in the nrep-cohort. The Constant-Murley Score (CS) and the range of motion was evaluated preoperatively as well as 12 and 36 months postoperatively. The Subjective Shoulder Value (SSV) and the Lift-off test were performed 36 months postoperatively. The postoperative subscapularis integrity was assessed sonographically. RESULTS: Twelve months postoperatively the rep-cohort presented better results in the CS (rep: 71 vs. nrep: 66, p: 0.037). The normalized CS was 80% in the rep-cohort and 75% in the nrep-cohort (p: 0.114). At our last follow-up after 36 months we did not find significant differences between the rep-cohort and the nrep-cohort in the CS (rep: 76 vs. nrep: 75, p: 0.285) and normalized CS (rep: 91% vs. nrep: 91%, p: 0.388). Concerning internal rotation (in points) the rep-cohort achieved better results than the nrep-cohort (rep: 7.3 vs. nrep: 6.6, p: 0.040). Flexion (rep: 145° vs. nrep: 151°, p: 0.826), abduction (rep: 135° vs. nrep: 137° p: 0.816), external rotation (rep: 34° vs. nrep: 37°, p: 0.817) and the SSV (rep: 81% vs. nrep: 77%, p: 0.398) presented no significant differences between the cohorts. The ultrasound examination after 36 months displayed an intact tendon in 70%. CONCLUSION: While the subscapularis refixation effects the postoperative internal rotation positively, there were no differences in mid-term follow-up concerning the overall results after rTSA. Further, the external rotation is not affected by the refixation of the subscapularis tendon.

Converting to reverse shoulder arthroplasty from primary anatomic shoulder arthroplasty and fracture hemiarthroplasty: a radiographic and clinical outcome analysis at 8-years.

INTRODUCTION: Revision shoulder arthroplasty can be challenging. One of the main considerations for surgeons is the type of implant that was placed in the initial surgery. Anatomic shoulder arthroplasty (ASA) is used for cases of osteoarthritis as well as for fractures of the humeral head. Hemiarthroplasty can be used for complex proximal humerus fractures. The purpose of this study is to determine whether there is a difference in clinical and radiographic outcomes between patients that failed primary fracture hemiarthroplasty (FHA), or ASA for osteoarthritis and then required reoperation with a conversion to reverse shoulder arthroplasty (RSA). METHODS: Patients with failed anatomic shoulder replacement, who had undergone conversion to RSA, were enrolled after a mean follow-up of 107 (85-157) months. Two different groups, one with failed ASA implanted for osteoarthritis and one with failed FHA, were created. At follow-up patients were assessed with standard radiographs and clinical outcome scores. RESULTS: Twenty-nine patients (f = 17, m = 12; 51%) suffered from a failed ASA (Group A), while the remaining 28 patients (f = 21, m = 74; 49%) had been revised due to a failed FHA (Group B). Patients of Group B had a poorer Constant score (Group A: 60 vs. Group B: 46; p = 0.02). Abduction (Group A: 115° vs. Group B: 89°; p = 0.02) was worse after conversion of a failed FHA to RSA in comparison to conversions of failed ASA. The mean bone loss of the lateral metaphysis was higher in patients with failed FHA (Group A: 5 mm vs. Group B: 20 mm; p = 0.0). CONCLUSION: The initial indication for anatomic shoulder arthroplasty influences the clinical and radiological outcome after conversion to RSA. Conversion of failed FHA to RSA is related to an increased metaphyseal bone loss, decreased range of motion and poorer clinical outcomes when compared to conversions of failed ASA implanted for osteoarthritis. LEVEL OF EVIDENCE: III Retrospective Cohort Comparison Study.

Results after primary reverse shoulder arthroplasty with and without subscapularis repair: a prospective-randomized trial.

INTRODUCTION: Indications for reverse shoulder arthroplasties (rTSA) have increased since their development by Paul Grammont in 1985. Prosthesis design was enhanced over time, but the management of the tendon of the M. subscapularis (SSC-tendon) in primary rTSA is still a controversial subject with regard to perform a refixation or not. METHODS: 50 patients were randomized in a refixation group (A) and a non-refixation-group (B) of the SSC-tendon in a double-blinded fashion. SSC-function was assessed at baseline before surgery, such as 3 and 12 months after surgery. Constant-Murley-Shoulder Score (CS), American Shoulder and Elbow Surgeons Score (ASES), strength, range of motion (ROM), and pain on numeric rating scale (NRS) were measured in all examinations. An ultrasound examination of the shoulder was performed for evaluation of subscapularis tendon integrity at 3 and 12 month follow-up visits. Pain was evaluated on NRS via phone 5 days after surgery. Surgery was performed by a single experienced senior surgeon in all patients. RESULTS: Patients with a refixation of the SSC-tendon and primary rTSA had improved internal rotation [40° (20°-60°) vs. 32° (20°-45°); p = 0.03] at 12 months of follow-up. Additionally, the A-group had increased CS [74 (13-90) vs. 69.5 (40-79); p = 0.029] 1 year after surgery. Results were strengthened by subgroup analysis of successful refixation in ultrasound examination vs. no refixation. No differences were seen in ASES and NRS 1 year after rTSA. CONCLUSION: SSC-tendon repair in rTSA improves CS and internal rotation 12 months after surgery.

Single-Portal Proximal Biceps Tenodesis Using an All-Suture Anchor.

The long head of the biceps is an important pain generator of the shoulder joint. Pathologies of the long head of the biceps involve superior labrum anterior to posterior lesions, pulley lesions, partial tears of the biceps tendon, biceps tendonitis, and medial biceps subluxation caused by full-thickness subscapularis tendon tears. Treatment of an inflamed or injured long head of the biceps by either tenotomy or tenodesis is often mandatory during shoulder arthroscopy to avoid persisting pain and possible revision procedures. In comparison with a tenotomy of the biceps tendon, a biceps tenodesis preserves the tension, anatomy, and cosmesis of the biceps muscle. The presented technique demonstrates a single portal technique for a proximal biceps tenodesis in the bicipital groove using an all-suture anchor.

Treatment of proximal humerus fractures using reverse shoulder arthroplasty: do the inclination of the humeral component and the lateral offset of the glenosphere influence the clinical outcome and tuberosity healing?

INTRODUCTION: The employment of reverse shoulder arthroplasty for dislocated proximal humerus fractures of elderly patients becomes increasingly relevant. The standard inclination angle of the humeral component was 155°. Lately, there is a trend towards smaller inclination angles of 145° or 135°. Additionally, there has been an increased focus on the lateralization of the glenosphere. This retrospective comparative study evaluates clinical and radiological results of patients treated for proximal humerus fractures by reverse shoulder arthroplasty with different inclination angles of the humeral component, which was either 135° or 155°. Additionally, a different lateral offset of the glenosphere, which was either 0 mm or 4 mm, was used. METHODS: For this retrospective comparative analysis, 58 out of 66 patients treated by reverse total shoulder arthroplasty for proximal humerus fractures were included. The minimum follow-up was 24 months. Thirty (m = 3, f = 27; mean age 78 years; mean FU 35 months, range 24-58 months) were treated with a standard 155° humeral component and a glenosphere without lateral offset (group A), while 28 patients (m = 2, f = 26; mean age 79 years; mean FU 30 months, range 24-46 months) were treated with a 135° humeral component and a glenosphere with a 4 mm lateral offset (group B). We determined range of motion, Constant score, and the American Shoulder and Elbow Surgeons Shoulder score as clinical outcomes and evaluated tuberosity healing as well as scapula notching. RESULTS: Neither forward flexion (A = 128°, B = 121°; p = 0.710) nor abduction (A = 111°, B = 106°; p = 0.327) revealed differences between the groups. The mean Constant Score rated 63 in group A, while it was 61 in group B (p = 0.350). There were no differences of the ASES Score between the groups (A = 74, B = 72; p = 0.270). There was an increased risk for scapula notching in group A (47%) in comparison to group B (4%, p = 0.001). Healing of the greater tuberosity was achieved in 57% of group A and in 75% of group B (p = 0.142). The healing rate of the lesser tuberosity measured 33% in group A and 71% in group B (p = 0.004). CONCLUSIONS: Both inclination angles of the humeral component are feasible options for the treatment of proximal humerus fractures in elderly patients. Neither the inclination angle nor the lateral offset of the glenosphere seem to have a relevant influence on the clinical outcome. The healing rate of the lesser tuberosity was higher in implants with a decreased neck-shaft angle. There is an increased risk for scapula notching, if a higher inclination angle of the humeral component is chosen. LEVEL OF EVIDENCE: III. Retrospective comparative study.

Sonographic Measurement of Dynamic Horizontal Instability in Acromioclavicular Joint Instability: Description of a Simple Technique and Correlation to Radiographic Parameters.

OBJECTIVE: Dynamic horizontal instability is considered to be the main reason for poor outcome after treatment for acromioclavicular (AC) joint instability. In this study, we describe a simple technique to quantify this pathology via sonography. METHODS: Thirty-six shoulders from 18 patients with ac joint instabilities were examined using modified Alexander views and a standardized sonographic examination. On the Alexander views, overlap of acromion and clavicle (OLAC), glenoid center to posterior clavicle distance (GCPC), and lateral extension (LE) were measured. Afterwards, the results were analyzed and compared with sonography. Posterior translation of the clavicle and the difference of translation between healthy and injured shoulder were evaluated. RESULTS: The mean age of the patients was 39 ± 14 years (range 19-61 years). We included 4 (22%) Rockwood type 3, 1 (6%) Rockwood type 4, and 13 (72%) Rockwood type 5 lesions. Four (22%) patients were female and 14 (78%) male patients. Posterior clavicle translation of the injured shoulder correlated strongly between OLAC and sonography (r = -0.514, P = .029), and the difference of translation between healthy and injured shoulder correlated very strongly between LE and sonography (r = 0.737, P < .001). CONCLUSION: The sonographic measurement technique for horizontal instability presented in this work could help detect horizontal instabilities. While the observation of dynamic horizontal displacement is a strength of this technique, measurements are hindered in cases of high coracoclavicular distances. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Treating cuff tear arthropathy by reverse total shoulder arthroplasty: do the inclination of the humeral component and the lateral offset of the glenosphere influence the clinical and the radiological outcome?

PURPOSE: Reverse total shoulder arthroplasty is widely used for the treatment of cuff tear arthropathy. Standard implants consist of a humeral component with an inclination angle of 155° and a glenosphere without lateral offset. Recently, lower inclination angles of the humeral component as well as lateralized glenospheres are implanted to provide better rotation of the arm and to decrease the rate of scapular notching. This study investigates the clinical and radiological results of a standard reverse total shoulder in comparison with an implant with an inclination angle of 135° in combination with a 4 mm lateralized glenosphere in context of cuff tear arthropathy. MATERIAL AND METHODS: For this retrospective comparative analysis 42 patients treated by reverse total shoulder arthroplasty for cuff tear arthropathy were included. Twenty-one patients (m = 11, f = 10; mean age 76 years; mean follow-up 42 months) were treated with a standard 155° humeral component and a standard glenosphere with caudal eccentricity (group A), while twenty-one patients (m = 5, f = 16; mean age 72 years; mean follow-up 34 months) were treated with a 135° humeral component and 4 mm lateral offset of the glenosphere (group B). At follow-up patients of both groups were assessed with plain X-rays (a.p. and axial view), Constant Score, adjusted Constant Score, the subjective shoulder value and the range of motion. RESULTS: The clinical results were similar in both groups concerning the Constant Score (group A = 56.3 vs. group B = 56.1; p = 0.733), the adjusted CS (group A = 70.4% vs. group B = 68.3%; p = 0.589) and the SSV (group A = 72.0% vs. group B = 75.2%; p = 0.947). The range of motion of the operated shoulders did not differ significantly between group A and group B: Abduction = 98° versus 97.9°, p = 0.655; external rotation with the arm at side = 17.9° versus 18.7°, p = 0.703; external rotation with the arm positioned in 90° of abduction = 22.3° versus 24.7°, p = 0.524; forward flexion = 116.1° versus 116.7°, p = 0.760. The rate of scapular notching was higher (p = 0.013) in group A (overall: 66%, grade 1: 29%, grade 2: 29%, grade 3: 10%, grade 4: 0%) in comparison to group B (overall: 33%, grade 1: 33%, grade 2: 0%, grade 3: 0%, grade 4: 0%). Radiolucency around the humeral component was detected in two patients of group B. Stress shielding at the proximal humerus was observed in six patients of Group A (29%; cortical thinning and osteopenia in zone M1 and L1) and two patients of group B (10%; cortical thinning and osteopenia in zone M1 and L1). Calcifications of the triceps origin were observed in both groups (group A = 48% vs. group B = 38%). CONCLUSION: Theoretically, a lower inclination angle of the humeral component and an increased lateral offset of the glenosphere lead to improved impingement-free range of motion and a decreased rate of scapular notching, when compared to a standard reverse total shoulder implant. This study compared two different designs of numerous options concerning the humeral component and the glenosphere. In comparison to a standard-fashioned implant with a humeral inclination of 155° and a standard glenosphere, implants with a humeral inclination angle of 135° and a 4 mm lateralized glenosphere lead to comparable clinical results and rotatory function, while the rate of scapular notching is decreased by almost 50%. While the different implant designs did not affect the clinical outcome, our results indicate that a combination of a lower inclination angle of the humeral component and lateralized glenosphere should be favored to reduce scapular notching. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Elective shoulder surgery during the coronavirus disease 2019 pandemic in Germany: the patients' perspective.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has impeded the treatment of elective shoulder patients all over the world. Owing to the constraints in personnel and operation theater capacities, many patients who should undergo planned surgeries could not receive medical care. In our study, we examined the status quo of elective shoulder arthroscopy during the pandemic in Germany. METHODS: Using a nonprofit database, 40 shoulder units that performed the most arthroscopic rotator cuff repairs in Germany in 2018 were identified. Following a standardized protocol, the web pages of these units were screened, and their strategy for elective procedures during the COVID-19 pandemic was analyzed. Special emphasis was put on the use of new digital technologies. RESULTS: At the time of the study, no unit had stopped scheduling appointments for elective shoulder patients because of the pandemic. Almost all units (97.5%) offered explicit information about COVID-19 and their strategies toward it. The possibilities of visiting patients in shoulder units varied owing to local restrictions. Two units (5%) offered digital consultations. CONCLUSION: At the time of the study, elective shoulder procedures could be planned and carried out at the largest centers in Germany. Local restrictions had a great influence on the organization of the procedure and hospital stay during the COVID-19 pandemic. Digital consultations were not available in every unit.

[Arthroscopically-assisted treatment of acute and chronic dislocations of the acromioclavicular joint : A prospective clinical trial]. / Die arthroskopisch-assistierte Versorgung akuter und chronischer Sprengungen des Akromioklavikulargelenks : Eine prospektive Beobachtungsstudie.

BACKGROUND: Injuries of the acromioclavicular joint (ACJ) are frequent and often occur during sports. While arthroscopically-assisted stabilization of acute injuries of the ACJ is a well-established procedure, there is not much data available for arthroscopically-assisted stabilization of chronic injuries of the ACJ. OBJECTIVES: This study assesses clinical and radiological results of arthroscopically-assisted stabilization of acute and chronic injuries of the ACJ. MATERIALS AND METHODS: Thirty-six patients with acute and chronic injuries of the ACJ were assessed in a prospective clinical trial. Twenty-five patients with acute injuries (group A) and eleven patients with chronic injuries (group B) were included in this study. Patients of group A were operated using two suture-button systems, while patients of group B received one suture-button system and an autologous gracilis tendon graft. RESULTS: In group A, the mean preoperative Constant score rated 38, and the ASES score rated 34. At follow-up the Constant score (92) and the ASES score (89) had improved. Panorama views revealed an increased coracoclavicular distance of the affected shoulder (15.8 mm) in comparison to the contralateral shoulder (10.9 mm). In group B, the preoperative Constant score measured 57. It improved to 72 points at follow-up. The ASES score improved from 39 to 72 points in the same period. Panorama views revealed an increased coracoclavicular distance of the affected shoulder (18.9 mm) in comparison to the contralateral shoulder (12.4 mm). CONCLUSIONS: Stabilization of acute injuries of the ACJ with two suture-button systems is related to very good shoulder function after one year. The native coracoclavicular distance cannot be restored with this procedure. Stabilization of chronic injuries of the ACJ with a suture-button system and an autologous gracilis tendon graft is related to improved shoulder function after one year. However, shoulder function cannot be fully restored with the stabilization technique presented.

Arthroscopic and open partial arthroplasty for the treatment of focal grade IV cartilage defects of the humeral head.

INTRODUCTION: Focal Outerbridge grade IV cartilage defects of the proximal humerus may lead to pain and an impaired shoulder function. In cases of failed operative or conservative treatment options such as intraarticular injections or arthroscopic microfracturing of the subchondral bone, partial arthroplasty of the humeral may restore the articular surface of the humeral head without altering the anatomy. This study evaluates mid-term results of open and arthroscopic partial resurfacing of the humeral head in the context of focal grade IV cartilage defects. METHODS: Eighteen patients (f = 3, m = 15, mean age = 57.7 years) out of 22 patients were available for follow-up after 65 (24-116) months. Thirteen patients were treated with a partial humeral head prosthesis in an open technique and five patients received a partial humeral head prosthesis in an arthroscopic technique. The patients were followed-up clinically using the Constant-Score, the ASES Score as well as the range of motion. Plain radiographs (anterior-posterior and axial view) were carried out for radiologic assessment. RESULTS: At follow-up the mean CS rated 79.5. The mean ASES Score was 85.8 points. Mean active forward flexion measured 163.8°, while mean active abduction was 160.0°. The average pain level on a visual analogue scale (VAS) made out 0.7 out of 10. Patients treated with an arthroscopically implanted prosthesis achieved a mean CS of 88.8 points and a mean ASES Score of 92.6 points. The patients with openly implanted prosthesis had a CS of 75.3 points and an ASES Score of 83 points. There were no intraoperative or immediate postoperative complications. Until the final follow-up one patient needed to be converted to total shoulder arthroplasty due to progressive glenohumeral osteoarthritis. Nine patients (50%) showed progressive glenohumeral osteoarthritis. Aseptic loosening of the implants was not observed. CONCLUSION: Partial arthroscopic or open arthroplasty of the humeral head is related to good functional results after mid-term follow-up. Resurfacing of the humeral head is a safe procedure without any implant-related complications. There is a risk for progression of glenohumeral osteoarthritis, which may require surgical revision with conversion to anatomic shoulder arthroplasty. LEVEL OF EVIDENCE: Level IV (retrospective study).

Tuberosity healing improves functional outcome following primary reverse shoulder arthroplasty for proximal humeral fractures with a 135° prosthesis.

INTRODUCTION: Reverse shoulder arthroplasty (RSA) is a common treatment for proximal humeral fractures (PHFs) in the elderly. This study evaluates the influence of tuberosity healing (TH) on functional outcome following a 135° humeral inclination RSA for PHFs. METHODS: Retrospectively, all patients with an acute PHF treated with a 135° humeral inclination RSA at four centers during a three-year period were followed up. Constant score (CS), TH and glenoid notching were analyzed. RESULTS: Sixty-four of 100 patients (64%) with a mean age of 76 ± 7 years were available for follow-up at 22 ± 8 months. The mean-adjusted CS was 72%. TH of the greater tuberosity (GT) was 77% and resulted in significantly improved forward flexion (128° vs. 92°; p = 0.003), external rotation (33° vs. 17°; p = 0.03) and adjusted CS (78% vs. 54%, p < 0.005). GT healing rate was 86% with neutral, 70% with lateralized and 33% with an inferior eccentric glenosphere. TH of the lesser tuberosity was 79%. There was 8% complication and 3% revision rate; implant survival was 100%. CONCLUSION: RSA with 135° humeral inclination for PHFs leads to good functional outcome, reproducible results and a high rate of TH. The short-term revision rate is low. TH is associated with improved ROM and functional outcome. LEVEL OF EVIDENCE: III.

Traumatic Tear of the Latissimus Dorsi Tendon in a CrossFit Athlete: Surgical Management.

INTRODUCTION: Traumatic tears of the latissimus dorsi tendon (LDT) are a rare sports injury that may occur during exercises involving horizontal and vertical pulling. A standardized treatment algorithm for this injury does not yet exist. CASE REPORT: A 30-year old male CrossFit Athlete experienced sudden unbearable pain in his right posterior shoulder during a bar muscle-up exercise. The contour of his right posterior shoulder had changed immediately, and the patient could not do any more exercises involving his right shoulder. BMagnet resonance imaging (MRI) revealed an isolated tear of the LDT. The repair of the tendon was performed using a posterior approach in the lateral decubitus position. After arming the tendon with non-absorbable sutures it was reinserted onto the crest of the lesser tuberosity of the proximal humerus with two monocortical suture buttons. Postoperatively, the patient was immobilized with an abduction pillow for 6 weeks. After 9 months he reported a 90% function of his shoulder. MRI showed complete anatomical reinsertion of the LDT. The patient was able to master 15 pull-ups in a row. CONCLUSIONS: Surgical repair of the LDT may achieve good functional results as well as an acceptable recovery period.

All-Extra-articular Repair of Anterosuperior Rotator Cuff Tears.

Anterosuperior rotator cuff tears involve the subscapularis tendon, supraspinatus tendon, and rotator interval. The long head of the biceps is usually affected and unstable in these complex lesions. Arthroscopic repair of anterosuperior rotator cuff tears often consists of 2 different procedures. Whereas the subscapularis tendon is reconstructed under intra-articular visualization, the supraspinatus tendon is reconstructed under extra-articular visualization. The rotator interval is often sacrificed to improve visualization and instrumentation. The presented technique uses an all-extra-articular approach, which helps to reconstruct these complex rotator cuff lesions in their whole extent without switching from the inside to the outside of the shoulder joint. The preservation of the rotator interval leads to a more stable and anatomic reconstruction.

Subacromial spacer implantation for massive rotator cuff tears: Clinical outcome of arthroscopically treated patients.

BACKGROUND: Massive rotator cuff tears (MRCT) can be treated arthroscopically by partial reconstruction, tenotomy/tenodesis of the long head of the biceps, and debridement. A new treatment option is the additional implantation of a biodegradable spacer (InSpace Balloon®; ISB) into the subacromial space, which reduces subacromial shear forces to keep the humeral head centered in the glenoid. The aim of this study is to investigate the clinical outcome of patients with MRCT who were treated arthroscopically with or without an additional ISB. METHODS: The clinical outcome of patients treated with conventional arthroscopic techniques (n = 11, group A, partial repair, biceps tenotomy, and debridement) and that of patients treated with a supplementary ISB (n = 12, group B) was retrospectively analyzed. Preoperatively and postoperatively, shoulder function was assessed with the Constant and American Shoulder and Elbow Surgeons (ASES) scores. At follow-up after a mean of 22 months, patients filled out a questionnaire about their subjective satisfaction. RESULTS: Preoperative shoulder function was lower in patients treated with an ISB (ASES score: group A, 59.1; group B, 31.5; Constant score: group A, 60.7; group B, 36.8). At follow-up, both groups had improved shoulder function (Constant score: group A, 60.7-77.6; p < 0.001; group B, 36.8-69.5; p < 0.001; ASES score: group A, 59.1-88.6; p < 0.001; group B, 31.5-85.7; p < 0.001). Patients in both groups were subjectively satisfied with their outcome. CONCLUSION: The ISB is a feasible treatment option for MRCT, providing subjective pain relief and improved shoulder function. Further studies with larger patient collectives and longer follow-up are needed to confirm whether it is a safe and cost-effective treatment.

Conversions from anatomic shoulder replacements to reverse total shoulder arthroplasty: do the indications for initial surgery influence the clinical outcome after revision surgery?

INTRODUCTION: The most frequent indications for anatomic shoulder replacement are glenohumeral osteoarthritis and fractures of the humeral head. If anatomic shoulder prostheses fail, reverse total shoulder arthroplasty is often the only remaining treatment option. This study evaluates the influence of indications for primary shoulder arthroplasty on the clinical outcome after conversion to reverse total shoulder arthroplasty. MATERIALS AND METHODS: From 2010 to 2012, 44 failed shoulder arthroplasties were converted to reverse total shoulder arthroplasty. Forty-four patients were available for follow-up after a mean of 24 months (14-36 months). Twenty-three of them had received an initial shoulder replacement because of osteoarthritis, while the remaining 21 patients had been treated for a fracture of the humeral head. At follow-up, patients were assessed with X-rays, constant-, and ASES scores. RESULTS: The total number of observed complications was higher in patients revised because of failed fracture arthroplasty (24 vs. 9%). Patients initially treated for osteoarthritis achieved a higher ASES score (71 vs. 59 points; p = 0.048). The normalized constant score was not different between the two observed groups (osteoarthritis 73% vs. fracture 67%: p = 0.45). Complications occurred more often in patients who had initially suffered from a fracture of the humeral head (fracture 23.8% vs. osteoarthritis 8.7%). Scapular notching was more frequent after initial fracture arthroplasty (33 vs. 14%). CONCLUSION: Indications for initial shoulder replacement have an influence on the clinical outcome after conversion to reverse total shoulder arthroplasty. Patients initially treated for a fracture of the humeral head have a lower subjective outcome and a higher complication rate in comparison with patients initially treated for osteoarthritis. LEVEL OF EVIDENCE: IV (Retrospective study).

Knowledge transfer of spinal manipulation skills by student-teachers: a randomised controlled trial.

PURPOSE: To assess the use of peer-assisted learning (PAL) of complex manipulative motor skills with respect to gender in medical students. METHODS: In 2007-2010, 292 students in their 3rd and 4th years of medical school were randomly assigned to two groups [Staff group (SG), PAL group (PG)] led by either staff tutors or student-teachers (ST). The students were taught bimanual practical and diagnostic skills (course education module of eight separate lessons) as well as a general introduction to the theory of spinal manipulative therapy. In addition to qualitative data collection (Likert scale), evaluation was performed using a multiple-choice questionnaire in addition to an objective structured clinical examination (OSCE). RESULTS: Complex motor skills as well as palpatory diagnostic competencies could in fact be better taught through professionals than through ST (manipulative OSCE grades/diagnostic OSCE score; SG vs. PG; male: P = 0.017/P < 0.001, female: P < 0.001/P < 0.001). The registration of theoretical knowledge showed equal results in students taught by staff or ST. In both teaching groups (SG: n = 147, PG: n = 145), no significant differences were observed between male and female students in matters of manipulative skills or theoretical knowledge. Diagnostic competencies were better in females than in males in the staff group (P = 0.041) Overall, students were more satisfied with the environment provided by professional teachers than by ST, though male students regarded the PAL system more suspiciously than their female counterparts. CONCLUSIONS: The peer-assisted learning system does not seem to be generally qualified to transfer such complex spatiotemporal demands as spinal manipulative procedures.

Peer teaching: a randomised controlled trial using student-teachers to teach musculoskeletal ultrasound.

OBJECTIVES: This study (a post-intervention assessment) was designed to assess the effectiveness of peer-assisted learning (PAL) using student-teachers (STs) with limited training to teach complicated technical skills for interpreting ultrasound images of the shoulder. METHODS: Students in Years 3 and 4 of medical school were randomly assigned to two groups. In the PAL group (PG), teaching was delivered by a group of nine STs from Years 3 and 4, who undertook a 30-minute general training and 1 week of self-teaching. In the staff-led group (SG), students were taught by a group of three ultrasound-experienced doctors. Exposure took place in two separate lessons (each of 120 minutes) and introduced eight standard sectional planes (EULAR) using a 10-MHz Nemio XG system (Toshiba Medical Systems GmbH). The theoretical and practical learning outcomes were tested using a multiple-choice question (MCQ) test and an objective structured clinical examination (OSCE). Qualitative differences were evaluated using Likert scale-based items. RESULTS: Evaluation of differences between the PG (n = 75) and SG (n = 76) in the theoretical (MCQ score; P = 0.644) and practical (total OSCE score; P = 0.133) outcomes showed no difference between the two groups. However, the STs themselves showed significantly better results overall (P < 0.05). Staff members were rated more highly than STs, especially on items relating to competence (P < 0.05). CONCLUSIONS: Complicated technical skills can be adequately taught to students using the PAL system by STs with limited training. Self-teaching learning strategies are successful in contexts of limited teacher training. However, despite positive objective results, STs still face prejudice from students with regard to competency.