Clinical and radiographic long-term outcomes of hemiarthroplasty for complex proximal humeral fractures.

BACKGROUND: Hemiarthroplasty (HA) is a treatment option for complex proximal humeral fractures not suitable for conservative treatment or open reduction-internal fixation. Long-term outcomes using a large-metaphyseal volume prosthesis in the management of proximal humeral fractures have not been reported thus far. METHODS: Between 2006 and 2010, 41 patients with proximal humeral fractures were treated with HA at our institution (average age, 62 years; age range, 38-85 years). Nine patients underwent revision surgery, 3 were lost to follow-up, and 7 died unrelated to the index surgical procedure. Twenty-two patients were reviewed clinically and radiographically after a mean period of 10.4 years (range, 9-13 years). RESULTS: Of the 9 HA failures, 7 occurred within the first 2 postoperative years: 2 patients had infections and 5 had greater tuberosity nonunions or malunions. The other 2 patients underwent revision for rotator cuff deficiency >5 years after initial surgery. Among the patients available for final follow-up, the implant survival rate was 71% (22 of 31 patients). At final follow-up, these patients showed a mean relative Constant score of 76% (range, 49%-96%), mean active elevation of 116° (range, 60°-170°), and mean external rotation of 28° (range, 0°-55°). The majority had good or excellent internal rotation, with internal rotation to the 12th thoracic vertebra in 13 patients (59%) and to the eighth thoracic vertebra in 7 (31%). The mean Subjective Shoulder Value was 76% (range, 40%-100%). Clinical outcomes did not significantly deteriorate over a period of 10 years, except for flexion (P < .001) and internal rotation (P = .002). On analysis of greater tuberosity healing, 1 patient had a nonunion and 10 patients (45%) had a malunion, whereas the greater tuberosity had healed in an anatomic position in 12 patients (55%). Patients with a displaced malunion of the greater tuberosity did not have inferior clinical results at last follow-up. Only 2 patients showed glenoid erosion, and in no patients could stem loosening be identified at final follow-up. CONCLUSION: The revision rate following large-metaphyseal volume HA to treat a proximal humeral fracture was 29% after 10 years postoperatively, with failure within 2 years largely related to greater tuberosity nonunion or malunion and failure later related to rotator cuff insufficiency. Patients with a retained implant showed good clinical and radiographic long-term results, without relevant deterioration over time even when the greater tuberosity healed in a nonanatomic position.

Extension of the shoulder is essential for functional internal rotation after reverse total shoulder arthroplasty.

BACKGROUND: Disabling loss of functional internal rotation (fIR) after reverse total shoulder arthroplasty (RTSA) is frequent but not well understood. This study tested the hypothesis that limitation of fIR after RTSA is not primarily related to a deficit in internal rotation. METHODS: Fifty patients (mean age at RTSA, 74 ± 11.7 years) who were consecutively seen at a yearly follow-up visit at 1-10 years (median, 4 years) after RTSA were prospectively examined with special attention to fIR. Patients with axillary nerve or deltoid dysfunction were excluded. Relative (age- and sex-adjusted) Constant-Murley scores (CSs) and Subjective Shoulder Values were assessed preoperatively and at final follow-up. In addition, active extension and 4 postoperative activities of daily living (ADLs) requiring fIR were tested at follow-up. Rotator cuff fatty infiltration and notching were evaluated radiographically. For analysis, patients were divided into a group with poor fIR (fIR-, n = 19), defined as ≤2 internal-rotation points in the CS, and a group with good fIR (fIR+, n = 31), defined as ≥4 internal-rotation points in the CS. RESULTS: Active extension of the contralateral shoulders was comparable in the fIR- group (mean, 60.3° [standard deviation (SD), 11.2°]) and fIR+ group (66.1° [SD, 14.2°]). Postoperatively, a difference in active extension between the unaffected and operated sides was present in both groups and averaged 16° (55° [SD, 14.3°] in fIR+ group and 39.1° [SD, 10.8°] in fIR- group; P < .001). No patient in the fIR+ group had active extension < 40° (range, 40°-85°). Shoulders with extension ≥ 40° but unsatisfactory fIR had restricted passive internal rotation in extension. The ability to perform ADLs behind the back correlated better with shoulder extension than with so-called fIR measurements in the CS. CONCLUSION: Functional internal rotation after RTSA requires at least 40° of shoulder extension. If fIR is unsatisfactory despite 40° of extension, passive restriction of internal rotation in full extension is the limiting factor. It is crucial to preserve or restore active shoulder extension to allow ADLs involving internal rotation.

Clinical results of conservative versus operative treatment of acromial and scapular spine fractures following reverse total shoulder arthroplasty.

BACKGROUND: Acromial and scapular spine fractures are common complications after reverse total shoulder arthroplasty (RTSA). There is limited information on the treatment outcome of these fractures. Therefore, the purpose of this study was to compare the clinical outcome of operative and conservative treatment of patients with acromial or scapular spine fractures. METHODS: A total of 1146 RTSAs were performed in our institution between 1999 and 2016. In 23 patients (2%), we identified an acromial fracture, and in 7 cases (0.6%), a scapular spine fracture in the postoperative course. Of those patients, 7 patients (23%) were treated with open reduction and internal fixation and 23 (77%) were treated conservatively. We compared the outcome of operative vs. conservative treatment assessing the Constant score (CS), range of motion, and subjective shoulder value (SSV). Fractures were classified by the system of Crosby. Radiographic assessment consisted of measuring the healing rate, time to heal, and the displacement of the acromion before and immediately after the fracture as well as after treatment. RESULTS: There were no statistically significant differences between operative and conservative treatment. The mean preoperative CS in the operative group was 32 points and improved to 45 points after surgery, whereas it was 35 points in the conservative group and improved to 61 points at the final follow-up. The mean SSV improved from 20 to 50 points in the operative group and from 22 to 58 points in the conservative group. Mean active flexion changed from 59° to 75°, mean abduction from 68° to 67°, and external rotation from 25° to 13° in the operative group and from 75° to 91°, 67° to 92°, and 28° to 24° in the conservative group. CONCLUSIONS: In our study, operative treatment was not superior to conservative treatment, neither for CS, SSV, or range of motion. Both treatment forms, however, resulted in inferior results to those previously reported for RTSA without postoperative acromion fractures. Before better surgical methods have been developed, conservative treatment of acromial fractures may be the better treatment option for acromial fractures after RTSA.

Long-term results after posterior open glenoid wedge osteotomy for posterior shoulder instability associated with excessive glenoid retroversion.

BACKGROUND: Treatment of posterior shoulder instability (PSI) associated with excessive glenoid retroversion is a rare, challenging problem in shoulder surgery. One proposed technique is posterior open wedge glenoid osteotomy to correct excessive glenoid retroversion as described by Scott. However, this operation is rarely performed, and limited long-term outcomes using this approach are available. The goal of this study was to analyze the long-term outcomes of posterior open wedge glenoid osteotomy for PSI associated with excessive glenoid retroversion. METHODS: Six consecutive patients (7 shoulders) with a mean age of 24 years (range 19-34) were treated with posterior open wedge glenoid osteotomy for PSI associated with a glenoid retroversion greater than 15° and followed up clinically and radiographically at a mean age of 15 years (range 10-19). RESULTS: Recurrent, symptomatic PSI was observed in 6 of 7 shoulders (86%). One necessitated revision with a posterior (iliac crest) bone block procedure and was rated as a failure and excluded from functional analysis. One patient rated his result as excellent, 3 as good, 1 as fair, and 1 as unsatisfactory. Mean relative Constant Score (CS%) was unchanged from preoperation to final follow-up (CS% = 72%) and pain did not significantly decrease (Constant Score = 7-10 points; P = .969). The mean Subjective Shoulder Value (SSV) improved postoperatively, but with 6 patients the improvement did not reach statistical significance (SSV = 42%-67%, P = .053) and the total Western Ontario Shoulder Instability Index averaged 30% at the final follow-up. Mean glenoid retroversion of all 7 shoulders was corrected from 20° (range 16°-26°) to 3° (range -3° to +8°) (P = .018). In the 5 shoulders with preoperative static posterior subluxation of the humeral head, the humeral head was not recentered. All 7 shoulders showed progression of glenoid arthritic changes. CONCLUSIONS: Posterior open wedge glenoid osteotomy for PSI associated with excessive glenoid retroversion neither reliably restored shoulder stability nor recentered the joint or prevent progression of osteoarthritis. Alternative treatments for PSI associated with excessive glenoid retroversion have to be developed and evaluated.

Reverse total shoulder arthroplasty in patients with type B2, B3, and type C glenoids: comparable clinical outcome to patients without compromised glenoid bone stock-a matched pair analysis.

BACKGROUND: Primarily posterior bone deficient (dysplastic) (Walch type C) or secondarily eroded (Walch type B2 or B3) glenoids represent a surgical challenge for shoulder arthroplasty. Due to the posteriorly static decentered head, reverse total shoulder arthroplasty (RTSA) is often considered as the treatment of choice. The purpose of this study is to report the clinical and radiographic outcomes, complications and reoperations of RTSA for posteriorly deficient glenoids. MATERIALS AND METHODS: All patients who underwent RTSA for osteoarthritis secondary to underlying glenoid deficiency (Walch type B2, B3 and C) between 2005 and 2018 (study group), were identified from our institutional shoulder arthroplasty database and gender- and age-matched to a cohort of patients with normal glenoid bone stock (control group). Longitudinal pre- and postoperative clinical [Constant-Murley (CS) score, Subjective Shoulder Value (SSV)] and radiographic outcomes were assessed. RESULTS: We included 188 patients (94 in each group). The median follow-up was 43 ± 26 (24-144) months in the study group and 59 ± 32 (24-124) months in the control group. The glenoid deficiency was addressed by using glenoid bone reconstruction. The surgical site complication and revision rate of RTSA in patients with bony deficient glenoids were 17% and 7%. Although glenoid loosening was slightly higher in the study group (5 vs. 2), overall no significant differences were found between the study and control groups in satisfaction scores, preoperative and postoperative absolute and relative Constant scores, complication and revision rates, respectively. CONCLUSION: Reverse total shoulder arthroplasty (RTSA) seems to be a valuable treatment option for patients with primary (dysplasia) or secondary (wear) posterior glenoid deficiency. Although severe glenoid bone loss seems to be a risk factor for glenoid component failure, the overall complication and revision rates as well as clinical and radiographic outcome are comparable to RTSA in patients without compromised glenoid bone stock. LEVEL OF EVIDENCE: Level III: case-control study.

Targeting Ion Channel TRPM4.

The transient receptor potential melastatin 4 (TRPM4) ion channel is ubiquitously expressed. Dysregulation and/or functional mutations of TRPM4 lead to several diseases. Within our studies, we screened for TRPM4 inhibitors and identified small molecules that block TRPM4 in the low µM range. Furthermore, we investigated the pathophysiology of TRPM4 in cardiac conditions, immune diseases and cancer using these novel inhibitors, molecular biology techniques and functional assays.

Down-Regulation of Mitochondrial Metabolism after Tendon Release Primes Lipid Accumulation in Rotator Cuff Muscle.

Atrophy and fat accumulation are debilitating aspects of muscle diseases and are rarely prevented. Using a vertical approach combining anatomic techniques with omics methodology in a tenotomy-induced sheep model of rotator cuff disease, we tested whether mitochondrial dysfunction is implicated in muscle wasting and perturbed lipid metabolism, speculating that both can be prevented by the stimulation of ß-oxidation with l-carnitine. The infraspinatus muscle lost 22% of its volume over the first 6 weeks after tenotomy before the area-percentage of lipid increased from 8% to 18% at week 16. Atrophy was associated with the down-regulation of mitochondrial transcripts and protein and a slow-to-fast shift in muscle composition. Correspondingly, amino acid levels were increased 2 weeks after tendon release, when the levels of high-energy phosphates and glycerophospholipids were lowered. l-Carnitine administration (0.9 g/kg per day) prevented atrophy over the first 2 weeks, and mitigated alterations of glutamate, glycerophospholipids, and carnitine levels in released muscle, but did not prevent the level decrease in high-energy phosphates or protein constituents of mitochondrial respiration, promoting the accumulation of longer lipids with an increasing saturation. We conclude that the early phase of infraspinatus muscle degeneration after tendon release involves the elimination of oxidative characteristics associated with an aberrant accumulation of lipid species but is largely unrelated to the prevention of atrophy with oral l-carnitine administration.

Posterior Open-wedge Osteotomy and Glenoid Concavity Reconstruction Using an Implant-free, J-shaped Iliac Crest Bone Graft in Atraumatic Posterior Instability with Pathologic Glenoid Retroversion and Dysplasia: A Preliminary Report.

BACKGROUND: Atraumatic posterior shoulder instability in patients with pathologic glenoid retroversion and dysplasia is an unsolved problem in shoulder surgery. QUESTIONS/PURPOSES: In a preliminary study of a small group of patients with atraumatic posterior shoulder instability associated with glenoid retroversion ≥ 15° and glenoid dysplasia who underwent posterior open-wedge osteotomy and glenoid concavity reconstruction using an implant-free, J-shaped iliac crest bone graft, we asked: (1) What proportion of the patients had persistent apprehension? (2) What were the improvements in patient-reported shoulder scores? (3) What were the radiographic findings at short-term follow-up? METHODS: Between 2016 and 2018, we treated seven patients for atraumatic posterior shoulder instability. We performed this intervention when posterior shoulder instability symptoms were unresponsive to physiotherapy for at least 6 months and when it was associated with glenoid retroversion ≥ 15° and dysplasia of the posteroinferior glenoid. All seven patients had a follow-up examination at a minimum of 2 years. The median (range) age at surgery was 27 years (16 to 45) and the median follow-up was 2.3 years (2 to 3). Apprehension was assessed by a positive posterior apprehension and/or posterior jerk test. Patient-reported shoulder scores were obtained and included the subjective shoulder value, obtained by chart review (and scored with 100% representing a normal shoulder; minimum clinically important difference [MCID] 12%), and the Constant pain scale score (with 15 points representing no pain; MCID 1.5 points). Radiographic measurements included glenohumeral arthropathy and posterior humeral head subluxation, bone graft union, correction of glenoid retroversion and glenoid concavity depth, as well as augmentation of glenoid surface area. All endpoints were assessed by individuals not involved in patient care. RESULTS: In four of seven patients, posterior apprehension was positive, but none reported resubluxation. The preoperative subjective shoulder value (median [range] 40% [30% to 80%]) and Constant pain scale score (median 7 points [3 to 13]) were improved at latest follow-up (median subjective shoulder value 90% [70% to 100%]; p = 0.02; median Constant pain scale score 15 points [10 to 15]; p = 0.03). Posterior glenoid cartilage erosion was present in four patients (all four had Walch Type B1 glenoids) preoperatively and showed no progression until the final follow-up examination. The median (range) humeral head subluxation index decreased from 69% (54% to 85%) preoperatively to 55% (46% to 67%) postoperatively (p = 0.02), and in two of four patients with preoperative humeral head subluxation (> 65% subluxation), it was reversed to a centered humeral head. CT images showed union in all implant-free, J-shaped iliac crest bone grafts. The median preoperative retroversion was corrected from 16° (15° to 25°) to 0° postoperatively (-5° to 6°; p = 0.02), the median glenoid concavity depth was reconstructed from 0.3 mm (-0.7 to 1.6) preoperatively to 1.2 mm (1.1 to 3.1) postoperatively (p = 0.02), and the median preoperative glenoid surface area was increased by 20% (p = 0.02). No intraoperative or postoperative complications were recorded, and no reoperation was performed or is planned. CONCLUSION: In this small, retrospective series of patients treated by experienced shoulder surgeons, a posterior J-bone graft procedure was able to reconstruct posterior glenoid morphology, correct glenoid retroversion, and improve posterior shoulder instability associated with pathologic glenoid retroversion and dysplasia, although four of seven patients had persistent posterior apprehension. Although no patients in this small series experienced complications, the size and complexity of this procedure make it likely that as more patients have it, some will develop complications; future studies will need to characterize the frequency and severity of those complications, and we recommend that this procedure be done only by experienced shoulder surgeons. The early results in these seven patients justify further study of this procedure for the proposed indication, but longer term follow-up is necessary to continue to assess whether it is advantageous to combine the reconstruction of posterior glenoid concavity with correction of pathological glenoid retroversion and increasing glenoid surface compared with traditional surgical techniques such as the posterior opening wedge osteotomy or simple posterior bone block procedures. LEVEL OF EVIDENCE: Level IV, therapeutic study.

The critical shoulder angle does not change over time: a radiographic study.

BACKGROUND: The anatomy of the scapula may predispose individuals to develop shoulder pathologies. The purpose of this study was to determine if the scapular anatomy, in particular the critical shoulder angle (CSA), changes over a long-term follow-up, or if it is a stable parameter. We hypothesized that increasing age would not influence the scapular morphology. METHODS: We analyzed shoulder radiographs in our database from 2002 to 2019 to extract radiographs at an interval of at least 10 years. Radiographic analysis included measuring the CSA and assessing the acromion type according to Bigliani and Morrison, the posterior acromial height and the posterior acromial tilt. RESULTS: A total of 41 patients (47 shoulders) with a mean age of 53 years (range, 15-76; standard deviation [SD], ±14) fulfilled the inclusion criteria. The mean interval between the 2 sets of radiographs was 12 years (range, 10-16; SD ±2).The mean CSA did not change significantly with 34° (range, 20-41; SD ±4) at the first and 34° (range, 19-44; SD ±5) (P = .597) at the second assessment. On the initial lateral radiographs ("Neer view"), there were 11 type 1 (24%), 32 type 2 (70%), and 3 type 3 (6%) acromia according to Bigliani and Morrison. At the second assessment, there were 16 type 1 (34%), 28 type 2 (60%), and 3 type 3 (7%). Between both sets of radiographs, 11 were different (23%), without a trend in the type of change being discernible. The posterior acromial height was stable with 19 mm (range, 2-36; SD ±8) at the first and 18 mm (range, 5-38; SD ±8) at the second assessment (P = .186). The posterior acromion tilt changed from 59° (range, 34-81; SD ±10) to 62° (range, 30-81; SD ±10) (P < .001). Among 6 cases with rotator cuff tears (RCTs) already at the first assessment, the CSA did not change significantly at 10 years' follow-up (P = .414). Among the 10 cases with new RCTs at the second assessment, the CSA did not change significantly at 10 years' follow-up from 34° (range, 25-41; SD ±5) to 35° (range, 24-44; SD ±6) (P = .510). In the group of 31 shoulders without RCT, the mean CSA at the first assessment of 34° (range, 28-41; SD ±3) stayed also stable with 34° (range, 28-40; SD ±3) (P = .796). CONCLUSION: The CSA is an anatomical parameter of the scapula that does not change in size after closure of the physes.

Primary reverse total shoulder arthroplasty in patients older than 80 years: clinical and radiologic outcome measures.

BACKGROUND: The use of reverse total shoulder arthroplasty (RTSA) has spread worldwide as a result of an expansion of indications and an aging society. However, the value of RTSA for very old patients is rarely analyzed. This study was conducted to investigate the outcome of primary RTSA in patients older than 80 years. METHODS: We identified 171 shoulders (159 patients) treated with RTSA at an age of more than 80 years between January 2005 and March 2018. The primary outcome parameters were Subjective Shoulder Value (SSV) and the Constant-Murley score, mortality, complications, and reoperation rates. Secondary outcomes were adverse radiographic outcomes. A minimum follow-up of 1 year was accepted in 14 patients (8%) because of these patients' older age. RESULTS: We included 171 cases (159 patients; 120 female) with a mean age of 84 ± 3 years (range 80.1-94). The main indication for RTSA was cuff tear arthropathy (43%), isolated rotator cuff tear (22%), and fracture (21%). A total of 136 patients (79%) were eligible for physical examination with a mean follow-up of 41 ± 25 months (12-121). Relative Constant-Murley scores improved significantly from 39% ± 19% to 77% ± 16% and SSV from 31% ± 18% to 74% ± 22%. The range of motion and force improved significantly as well. The surgical site complication rate was 30%, with a reoperation rate of 8% (13 patients) mainly due to fracture and glenoid loosening. The overall mortality was 16% with a mean time to death of 53 ± 31 months (95% confidence interval 15, 120), thereby no higher than the age-adjusted, expected mortality rate without this procedure. CONCLUSION: Despite a quite high postoperative complication rate, RTSA is a valid therapeutic option in patients older than 80 years, with an unexpectedly low medical complication rate and good to excellent improvement of shoulder function and pain.

Mid-term results of arthroscopically assisted latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears.

BACKGROUND: With progress in arthroscopic surgery, latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears (RCTs) has become a reliable all-arthroscopic or arthroscopically assisted procedure. The mid-term results of arthroscopically assisted latissimus dorsi transfer (aLDT) are scarce in the literature. The purpose of this study was to report our clinical and radiographic mid-term results of aLDT for irreparable posterosuperior RCTs. METHODS: Thirty-one consecutive patients with a mean age of 55.5 years (range, 38-73 years) at the time of aLDT were evaluated after a mean of 3.5 years (range, 2-5 years). All patients had irreparable, full-thickness tears of at least the complete supraspinatus, with or without infraspinatus tendons, and 12 patients (39%) had undergone previous rotator cuff repair (RCR). A concomitant upper-third subscapularis repair was needed at the time of aLDT in 7 patients (23%). Mid-term results were assessed clinically and radiographically (including magnetic resonance imaging). RESULTS: At final follow-up, 4 patients with failure (13%) had undergone revision to reverse total shoulder arthroplasty (RTSA) essentially for untreatable pain. Patients with revision to RTSA had significantly higher preoperative pain levels (Constant pain score, 6 points vs. 11 points; P = .032) and lower Constant activity scores (2 points vs. 5 points, P = .017) than the remaining 27 patients. Patients with failed previous RCRs had significantly inferior results compared with patients without previous repair (mean Subjective Shoulder Value, 67% vs. 88%; P = .035). For the 27 patients without revision, the mean relative Constant score improved from 63% to 76% (P = .032), the Constant pain score, from 10.5 to 12.7 points (P = .012), and the Subjective Shoulder Value, from 43% to 77% (P < .001). Significant progression of glenohumeral arthropathy by 2 or more grades according to the Hamada classification was observed in 13 of the 27 patients (48%), but there was no significant difference in clinical outcomes between the patients with arthropathy (n = 13) and those without it (n = 14, P = .923). CONCLUSIONS: The mid-term results of aLDT for irreparable posterosuperior RCTs were associated with significant improvements in objective and subjective outcome measures. The failure rate leading to conversion to RTSA was relatively high in this cohort. The failures were associated with unusually intense pain in low-demand individuals and/or revision of failed RCR. Long-term results of aLDT are needed to evaluate the effect of this procedure on the progression of osteoarthritis.

Stand-alone coracoclavicular suture repair achieves very good results in unstable distal clavicle fractures at a minimum follow-up of 1 year.

BACKGROUND: The treatment of unstable (Neer type IIB and V) extra-articular distal clavicle fractures remains challenging, especially when encountering a small lateral fragment which does not allow for sufficient screw purchase. It was the purpose of this study to present the clinical and radiologic outcome of a consecutive series of patients treated by a stand-alone coracoclavicular stabilization using a so-called cow-hitch technique with a suture anchor. METHODS: Nineteen patients were treated with a specific surgical technique for distal clavicle fractures (11 left, 8 right) with either rupture or bony avulsion of the coracoclavicular ligaments. Fourteen patients were examined in our outpatient clinic for the purpose of this study after a mean follow-up of 5 years (1-12.2 years). The examination included scoring according to Constant Murley score (CMS), the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), the Subjective Shoulder Value (SSV), and follow-up radiographs. Two additional patients were amenable to a telephone interview. RESULTS: All patients reported very good subjective results, with a mean SSV of 92% and a mean ASES score of 96%. The CMS resulted in average absolute values of 92 points. Fractures consolidated in 95% of cases. One patient developed an asymptomatic pseudarthrosis. The coracoclavicular distance was restored from 21 mm preoperatively to 11 mm at the final follow-up and finally showed an average side-to-side difference of +1.8 mm. Sports activities were fully resumed after an average of 4.7 months. CONCLUSION: The coracoclavicular stand-alone cow-hitch suture repair for unstable distal clavicle fractures is a minimally invasive fixation technique without prominent hardware that allows for an anatomic reduction and stable fixation with a low complication and high bony union rate. Both radiographic and clinical long-term results are very satisfactory.

Health problems in youth competitive alpine skiing: A 12-month observation of 155 athletes around the growth spurt.

Alpine ski racing is known as a high-risk sport; however, little is known on the health problems occurring at youth level. The purpose of this study was to investigate the prevalence of health problems in youth competitive alpine skiers with respect to sex, age, and season differences, to describe their severity and location and to assess the influence of biological maturation. Over a 12-month period, 155 youth competitive alpine skiers around the growth spurt were prospectively monitored for health problems using the Oslo Sports Trauma Research Centre (OSTRC) questionnaire. These data were verified by supplemental interviews at the end. Biological maturation was estimated by a non-invasive, anthropometric-based assessment method. During competition season, 42.2% of the skiers suffered from health problems and 19.8% reported their problem being substantial. Females had significantly higher rates of acute and overuse injuries compared to males, while there was no sex difference in duration, severity, and time loss. Skiers of the category U15 showed higher prevalence of acute and overuse injuries than U14 skiers. During preparation season, health problem prevalence was substantially lower. The knee was found to be the most affected body part for both acute and overuse injuries. There was a direct association between the offset to the age at peak height velocity (APHV) and the occurrence and severity of acute injuries. In conclusion, youth competitive alpine skiers suffer from a large number of health problems. Since sex, age, and biological maturation are important, effective injury prevention should already start before reaching the APHV.

Radiographic performance depends on the radial glenohumeral mismatch in total shoulder arthroplasty.

BACKGROUND: Optimal radii of curvature of the articulating surfaces of the prosthetic components are factors associated with the longevity of cemented glenoid components in anatomical total shoulder arthroplasty. It was the purpose of this study, to evaluate the radiographic and clinical performance of an anatomical glenoid component of a total shoulder arthroplasty (TSA) with respect to radial mismatch of the glenoid and humeral component. METHODS: In a retrospective study 75 TSA were analyzed for their clinical and radiographic performance with computed tomography by independent examiners using an established methodology. The study group was divided in two groups, one with mismatch < 4.5 mm (n:52) the others with mismatch ≥4.5 mm (n:23) and analyzed for confounding variables as indication, primary or revision surgery, age, gender, glenoid morphology and implant characteristics. RESULTS: The mean glenohumeral radial mismatch was 3.4 mm (range 0.5-6.9). At median follow-up of 41 months (range 19-113) radiographic loosening (defined as modified Molé scores ≥6) was present in 7 cases (9.3%). Lucencies around the glenoid pegs (defined as modified Molé score ≥ 1) were present in 34 cases (45%). Radiolucencies were significantly associated with a radial mismatch < 4.5 mm (p = 0.000). The pre- to postoperative improvements in Subjective Shoulder Value and absolute Constant Score were significantly better in the group with a mismatch ≥4.5 mm (p = 0.018, p = 0.014). CONCLUSION: A lower conformity of the radii of humerus and glenoid seems to improve the loosening performance in TSA. Perhaps cut-off values regarding the recommended mismatch need to be revalued in the future.

Suprascapular nerve decompression in addition to rotator cuff repair: a prospective, randomized observational trial.

BACKGROUND: Tear and retraction of the supraspinatus (SS) and infraspinatus (IS) musculotendinous units and/or their repair may be associated with traction damage to the suprascapular nerve, potentially responsible for pain or weakness of the rotator cuff (RC). Arthroscopic release of the transverse scapular ligament at the suprascapular notch has been advocated to prevent or treat suprascapular nerve impairment associated with RC retraction and/or repair. The effect of this procedure on preoperative normal nerve function is, however, not well studied.We hypothesize that (1) decompression of the suprascapular nerve without preoperative pathologic neurophysiological findings will not improve clinical or imaging outcome and (2) suprascapular decompression will not measurably change suprascapular nerve function. METHODS: Nineteen consecutive patients with a magnetic resonance arthrography documented RC tear involving SS and IS but normal preoperative electromyography (EMG)/nerve conduction studies of the SS and IS were enrolled in a prospective, controlled trial involving RC repair with or without suprascapular nerve decompression at the suprascapular notch. Nine patients were randomized to undergo, and 10 not to undergo, a decompression of the suprascapular nerve. Patients were assessed clinically (Constant score, mobility, pain, strength, subjective shoulder value), with magnetic resonance imaging and neurophysiology preoperatively and at 3- and 12-month follow-up. RESULTS: There was no clinically relevant difference between the release and the non-release group in any clinical parameter at any time point. At magnetic resonance imaging, there was a slightly greater increase of fatty infiltration of the IS in the release group without any other differences between the 2 groups. Electromyographically, there were no pathologic findings in the non-release group at any time point. Conversely, 3 of the 9 patients of the release group showed pathologic EMG findings at 3 months, of whom 2 had recovered fully and 1 only partially at 12 months. CONCLUSION: In the presence of normal EMG findings, suprascapular nerve release added to arthroscopic RC repair is not associated with any clinical benefit, but with electromyographically documented, postoperative impairment of nerve function in 1 of 3 cases. Suprascapular nerve release does not therefore seem to be justified as an adjunct to RC repair if preoperative EMG findings document normal suprascapular nerve function. Based on these findings, the ongoing prospective randomized trial was terminated.

Salvage reverse total shoulder arthroplasty for failed operative treatment of proximal humeral fractures in patients younger than 60 years: long-term results.

HYPOTHESIS: Is salvage reverse total shoulder arthroplasty (RTSA) a justifiable treatment for failed operative treatment (open reduction-internal fixation [ORIF] or primary and secondary hemiarthroplasty) of proximal humeral fractures in patients younger than 60 years? METHODS: Thirty patients (mean age, 52 years; age range, 30-59 years) were reviewed after a mean follow-up period of 11 years (range, 8-18 years). Of the patients, 7 (23%) underwent RTSA for failed ORIF and 23 (77%) for failed hemiarthroplasty. Clinical and radiographic outcomes were assessed longitudinally. RESULTS: At final follow-up, the mean relative Constant score had improved from 25% (±12%) to 58% (±21%, P < .001). Significant improvements were seen in the mean Subjective Shoulder Value (20% to 56%), active elevation (45° to 106°), abduction (42° to 99°), pain scores, and strength (P < .001). Clinical outcomes did not significantly deteriorate over a period of 10 years. Patients with salvage RTSA for failed secondary hemiarthroplasty (n = 8) vs. those for failed ORIF (n = 6) showed significantly inferior active abduction (77° vs. 116°, P = .023). Patients with a healed greater tuberosity (n = 9) showed significantly better external rotation than patients with a resorbed/resected greater tuberosity (n = 13, 21° vs. 3°, P = .025). One or more complications occurred in 18 shoulders (60%), and 6 (20%) resulted in explantation of the RTSA. CONCLUSIONS: Salvage RTSA in patients younger than 60 years is associated with a high complication rate. It leads nonetheless to substantial and durable improvement beyond 10 years, provided the complications can be handled with implant retention. Inferior shoulder function is associated with greater tuberosity resorption or resection and inferior overhead elevation with the diagnosis of failed hemiarthroplasty.

Clinical and structural outcome 20 years after repair of massive rotator cuff tears.

BACKGROUND: Short- and mid-term outcomes after massive cuff tear repair are well reported, but there is no documentation of the clinical and structural outcomes at 20 years of follow-up. The hypothesis of the present study was that at 20 years, deterioration of the shoulder would have occurred and led to a substantial number of reoperations. METHODS: The authors retrospectively recalled all 127 patients operated for massive rotator cuff tears in 1994 at 6 different centers. At the 20-year follow-up, 26 patients died and 35 were lost to follow-up. Thirteen (10.2%) had been reoperated. This left 53 patients for personal clinical assessment. Forty-nine consented to standardized radiographic evaluation for assessment of osteoarthritis, 36 patients underwent magnetic resonance imaging, allowing assessment of tendon healing, atrophy, and fatty infiltration (FI) of the cuff muscles. RESULTS: The final Constant-Murley score (CS) was 68 ± 17.7 (range, 8-91) vs. 44 ± 15.3 (range, 13-74) preoperatively (P < .05). The final Subjective Shoulder Value (SSV) was 73% ± 23% (range, 0-100). Retears (Sugaya IV and V) were found in 17 cases (47%). Nine patients (17%) had cuff tear arthropathy (Hamada stage 4). The CS and SSV for the shoulders with FI stages III or IV were significantly inferior (53 ± 19 points and 65% ± 14% respectively) than for those with FI stages 0-II (respectively, 71.6 ± 6 points and 73% ± 4%) (P < .05). CONCLUSIONS: Twenty years after surgical repair of massive rotator cuff tears, the functional scores remain satisfactory, and the rate of revision is low.

Alpha-defensin lateral flow test does not appear to be useful in predicting shoulder periprosthetic joint infections.

PURPOSE: Periprosthetic joint infections (PJIs) remain a challenging complication after shoulder arthroplasty. The antimicrobial peptide α-defensin has been proposed as a new synovial fluid biomarker in diagnosing PJIs. To date, only little data are available on the diagnostic accuracy of α-defensin in shoulder PJIs; thus, we aimed to evaluate its diagnostic value in a cohort of patients with a suspected shoulder PJI. METHODS: Between June 2016 and June 2018, we prospectively enrolled patients with a diagnostic shoulder aspiration due to painful shoulder arthroplasty or planned revision surgery. PJI diagnostics were performed according to the Musculoskeletal Infection Society (MSIS) criteria. All patients with an antibiotic therapy within two  weeks before enrollment, insufficient amount of synovial aspirate, or bloody aspiration were excluded. α-Defensin was measured in the synovial fluid using the α-defensin lateral flow (ADLF) test (Synovasure®). RESULTS: Out of 60 patients, we could include 29 (59% female) patients with a mean age of 70 (range, 50-92) years. A shoulder PJI was detected in five cases (Staphylococcus aureus, n = 2; Staphylococcus epidermidis, n = 2; Cutibacterium acnes, n = 1). The ADLF test was positive in seven out of 29 cases. According to the MSIS criteria, the ADLF test was false-negative in two patients and false-positive in four patients, resulting in sensitivity, specificity, and positive and negative predictive value of 60%, 83%, 43%, and 91%, respectively. The overall accuracy was 79%. CONCLUSION: The ALDF test does not appear to be useful in predicting shoulder PJIs but may be used as an additional diagnostic factor in rejecting these infections.

Neurectomy preserves fast fibers when combined with tenotomy of infraspinatus muscle via upregulation of myogenesis.

INTRODUCTION: We evaluated the contribution of denervation-related molecular processes to rotator cuff muscle degeneration after tendon release. METHODS: We assessed the levels of myogenic (myogenin and myogenic differentiation factor [myoD]) and proadipogenic (peroxisome proliferator-activated receptor γ) transcription factors; the denervation-associated proteins tenascin-C, laminin-2, and calcium/calmodulin-dependent kinase II (CaMKII); and cellular alterations in sheep after infraspinatus tenotomy (TEN), suprascapular neurectomy (NEU), or both (TEN-NEU). RESULTS: Extracellular ground substance increased at the expense of contractile tissue 16 weeks after surgery, correlating with CaMKII isoform levels. Sheep undergoing NEU and TEN-NEU had exaggerated infraspinatus atrophy and increased fast fibers compared with TEN sheep. The ßMCaMKII isoform levels increased with TEN, and myoD levels tripled after denervation and were associated with slow fibers. DISCUSSION: In sheep, denervation did not affect muscle-to-fat conversion after TEN of the infraspinatus. Furthermore, concurrent NEU mitigated the loss of fast fibers after TEN by inducing a fast-contractile phenotype. Muscle Nerve 59:100-107, 2019.

Chronic anterior sternoclavicular instability: technique and results of corrective clavicular osteotomy.

BACKGROUND: Chronic anterior sternoclavicular (SC) instability is a rare but potentially disabling condition. It can arise in conjunction with trauma or hyperlaxity, or both. Numerous surgical techniques have been described, but no gold standard exists. SC instability is often position-dependent and can be reduced with the arm in a specific position. METHODS: To directly address this issue, we used a technique of corrective osteotomy of the clavicle with the goal to reorient the articular portion of the medial end of the clavicle so that it remains stable in all functional positions of the arm. To illustrate the technique and the correction in space, we performed postoperative 3-dimensional computed tomography analyses of the shoulder girdle of 4 patients. Clinical scores were obtained at the final follow-up and compared with preoperative scores. RESULTS: Mean follow-up was 64 months (range, 19-191 months). The mean Constant score improved from 58 (range, 45-68) preoperatively to 73 (range, 69-84) postoperatively and the Subjective Shoulder Value from 42 (range, 15-80) to 79 (range, 50-100). All patients reported good or very good stability of the SC joint at the last follow-up. We recorded no intraoperative or direct postoperative complications. During follow-up, 3 patients underwent removal of the plate, 1 of them for plate breakage. The mean postoperative correction for combined rotations is given as a 3-dimensional angle and averaged 28.0° (range, 8.6°-39.7°). CONCLUSION: In this pilot study, medial corrective clavicular osteotomy using the described technique treated anterior SC instability with improvement of clinical shoulder function scores and good patient satisfaction. The technique appears simple and safe and deserves further evaluation.