[Humeral and glenoid bone loss in shoulder arthroplasty : Classification and treatment principles]. / Humerale und glenoidale Knochendefekte in der Schulterendoprothetik : Klassifikation und Behandlungsprinzipien.

TECHNIQUE: The treatment of bone defects in primary shoulder arthroplasty has evolved due to more detailed diagnostic tools, 3D planning and expanded indications for reverse shoulder arthroplasty. Glenoid bone defects combined with chronic posterior subluxation of the humeral head are gradually being treated by glenoid reconstruction and reverse implants even if the rotator cuff is still intact. The treatment of advanced bone loss due to glenoid loosening has been facilitated by bone augmentation using a cementless fixation as proposed by Norris. Precise pre-operative planning using reformatted computed tomography (CT) and dedicated instruments is recommended in primary and revision arthroplasty. RESULTS: Revision rates and complications are high for revision surgery in extended glenoid and humeral bone loss. Functional results are limited in these cases, particularly after multiple operations and damage of the soft tissue envelope.

Pyrocarbon interposition shoulder arthroplasty in advanced collapse of the humeral head.

BACKGROUND: Pyrocarbon (PyC) interposition shoulder arthroplasty can be used to treat advanced collapse of the humeral head after avascular necrosis. OBJECTIVES: We examined outcomes for this bone-preserving implant which has a PyC coating and a novel biomechanical concept. MATERIALS AND METHODS: For a minimum of 2 years, we followed 10 patients (4 men, 6 women, 55.6 ± 12.9 years) treated with a free interposition PyC arthroplasty ("snookerball") due to advanced humeral head collapse but with an intact glenoid and rotator cuff. Anteroposterior radiographs, the Constant score (CS), adjusted CS, DASH score, and the EuroQol 5D-5L score from the preoperative and the latest follow-up presentation were compared. RESULTS: At a mean of 3.6 years (±15 months), the mean absolute CS was 70.6 (±13.6; adjusted CS 81.4 ± 16.4), the DASH score was 25.6 (±16.1), the mean EQ subjective VAS score was 72.6 (±15.9), and the EQ index score was 0.9 (±0.11). Scores improved: CS: +63.2 ± 12.9; adjusted CS: +72.9 ± 15.5; DASH: +47.2 ± 14.7; EQ VAS: +42.6 ± 16.8; EQ index score +0.52 ± 0.23. Mean glenoid erosion was 1.4 mm (±1.3 mm), thinning of the tuberosities was -0.8 mm (±3.3 mm), and superior migration of the implant was 2.0 mm (±2.2). A thin radiolucent zone around the implant with bone densification on the metaphyseal side was observed in all cases (mean 1.8 ±â€¯0.6 mm). CONCLUSIONS: Excellent improvement of function and quality of life which are comparable to total shoulder arthroplasty data were observed. Significant bone remodeling occurs in the metaphysis around the implant. Further studies are needed to evaluate longevity and applicability of the implant. These results indicate that advanced collapse of the humeral head with an intact glenoid and rotator cuff are an optimal indication for this implant.

[Destruction of the radial head : Endoprosthesis, autologous reconstruction or anconeus arthroplasty?] / Destruktion des Radiuskopfes : Endoprothese, autologer Aufbau oder Anconeusplastik?

BACKGROUND: Radiocapitellar arthritis or defects most often result from trauma. Most of the patients are young and have high functional demands with high load capacities. Therefore, endoprosthetic options should be postponed for as long as possible. If conservative treatment cannot relieve symptoms sufficiently, radial head preservation, resection or replacement options are at the surgeon's disposal. In early stages of radiocapitellar arthritis, radial head preservation options can be taken into account. The chances ofgood results decrease with increasing cartilage damage. TREATMENT OPTIONS: In addition to radial head preservation options this article discusses radial head resection with and without anconeus interposition and radial head as well as radiocapitellar replacement. Clinical data are rare. The advantages and disadvantages of each option must be discussed with the patient and the decision should be made individually on the basis of patient specific factors. The aim must be to postpone endoprosthetic options - especially total elbow arthroplasty - for as long as possible, while assuring a functional range of motion with an acceptable pain level.

Progressive glenoid bone loss caused by erosion in humeral head resurfacing.

BACKGROUND: Cementless surface replacement of the shoulder represents an alternative to conventional stemmed anatomic prostheses. Glenoid erosion is a well-known complication in hemiarthroplasty. However, there is limited data concerning radiographic evaluation and prognostic factors for this phenomenon. OBJECTIVES: The aim of our study was to determine the development of glenoid erosion following shoulder resurfacing using a new measurement technique and detect potential prognostic factors. MATERIALS AND METHODS: We performed a retrospective analysis on 38 shoulders undergoing humeral head resurfacing with a mean follow-up of 65.4 ± 43 months. Clinical and radiographic evaluation followed a standardized protocol including pre- and postoperative Constant score, active range of motion, and X­rays in true anteroposterior view. Three independent observers performed measurements of glenoid erosion. RESULTS: We found good interobserver reliability for glenoid erosion measurements (intraclass correlation coefficient [ICC] 0.74-0.78). Progressive glenoid erosion was present in all cases, averaging 5.5 ± 3.9 mm at more than 5 years' follow-up. Male patients demonstrated increased glenoid bone loss within the first 5 years (p < 0.04). The mean Constant score improved to 55.4 ± 23.6 points at the latest follow-up. Younger age was correlated to increased functional outcome. Revision rate due to painful glenoid erosion was 37%. CONCLUSIONS: Glenoid erosion can be routinely expected in patients undergoing humeral head resurfacing. Painful glenoid erosion leads to deterioration in functional outcome and necessitates revision surgery in a high percentage of cases.

[Results from the German shoulder- and elbow arthroplasty register (SEPR) : Anatomic or reverse shoulder arthroplasty in B2-glenoids?] / Ergebnisse des deutschen Schulter- und Ellenbogenprothesenregisters (SEPR) : Anatomische oder inverse Prothese bei B2-Glenoid?

BACKGROUND: Anatomic shoulder arthroplasty in osteoarthritis with biconcave glenoid wear results in decreased functional results and a higher rate of early glenoid loosening. AIM: The aim of the data analysis of the German shoulder arthroplasty register was to clarify whether reverse shoulder arthroplasty can provide better functional results and a lower complication rate than anatomic arthroplasty in osteoarthritis with biconcave glenoid wear. METHODS: The analysis included 1052 completely documented primary implanted arthroplasties with a minimum follow-up of 2 years. In 119 cases, a B2-type glenoid was present. Out of these cases, 86 were treated with an anatomic shoulder arthroplasty, and in 33 cases a reverse shoulder arthroplasty was implanted. The mean follow-up was 47.6 months. RESULTS: The Constant score with its subcategories, as well as the active range of movement improved significantly after anatomic and after reverse shoulder arthroplasty. DISCUSSION: We observed no difference in functional results between both types of arthroplasty; however, reverse arthroplasty showed a significant higher revision rate (21.2%) (3% glenoid loosening, 6% prosthetic instability) than anatomic shoulder arthroplasty (12.8%) (11.6% glenoid loosening, 1.2% prosthetic instability), whereas anatomic shoulder arthroplasty showed a higher rate of glenoid loosening. Functional and radiographic results of both types of arthroplasty are comparable with the results reported in the literature, although our analysis represents results from an implant registry (data pertaining to medical care quality).

[Olecranon osteotomy]. / Die Olekranonosteotomie.

In recent years the increase of interest for surgery of the elbow has fostered the development of new and modified triceps sparing approaches. Olecranon osteotomy is a widely accepted method especially for open reduction and internal fixation of displaced intra-articular fractures because it provides excellent exposure of the joint surfaces. Due to several reports describing numerous complications, the enthusiasm for this procedure is currently limited. Several intra-articular and extra-articular techniques for refixation of the olecranon have been developed to limit these complications and good results have been obtained. This paper describes various techniques, analyzes advantages and disadvantages and shows alternative ways and solutions for different indications.

[Endoprosthesis infections of the shoulder: diagnosis and therapy algorithm]. / Endoprotheseninfektionen der Schulter : Diagnose und Therapiealgorithmus.

Periprosthetic shoulder joint infections are encountered by orthopedic surgeons mainly as complex situations which are highlighted by difficult treatment modalities. In a confirmed infection the general therapeutic principle is a surgical procedure. Several strategies orientate on the cause of an infection, the time course of postoperative symptoms, the pathogenicity of the isolated species and the specific comorbidities of the patient. An arthroscopic joint lavage with open debridement and component change may suffice in selected acute cases whereas a two-stage revision augmented by an articulating antibiotic spacer is mandatory in chronic infections. Early recognition is of paramount importance in order to prevent further spread, sepsis or even fatal outcome. Low grade infections are challenging conditions in terms of diagnosis and treatment. This article summarizes the principles of current classification, detection and treatment strategies for periprosthetic shoulder joint infections.

[Classification of elbow stiffness and indications for surgical treatment]. / Einteilung der Ellenbogensteifen und Indikation zur operativen Behandlung.

An elbow can become stiff for a variety of reasons, such as intra-articular or extra-articular fractures, soft-tissue trauma, prolonged immobilization, thermal injury, infection, inflammatory arthritis, osteoarthrosis and heterotopic bone formation. Elbow stiffness is usually classified into extrinsic (affecting the capsule and extra-articular soft tissues), intrinsic (affecting the synovial and intra-articular structures) and mixed forms. Indications for operative treatment have to be considered in cases of failed conservative treatment with severe functional deficits. The choice of operative treatment has to be based on a thorough analysis of the underlying cause, the affected structures, the pathogenesis and the individual needs. Options are an arthroscopic or open arthrolysis, endoprostheses, hinged external fixators, interposition arthroplasty or combinations of these procedures.

[Cementless humeral head replacement for dislocation arthropathy of the shoulder joint]. / Zementfreier Oberflächenersatz bei Dislokationsarthropathie des Schultergelenks.

BACKGROUND: Only a few reports in the literature describe that total shoulder replacement provides better functional results in dislocation arthropathy than hemiarthroplasty. Nevertheless, the risk of aseptic loosening in young and active patients is high after long-term follow-up. We evaluated the results of cementless humeral head resurfacing in this group. METHODS: We evaluated 29 patients with dislocation arthropathy who had been followed up for a mean of 39 months. The mean age at the time of operation was 43.7±14.7 years. Preoperatively, cuff deficiency was seen in 11 cases. RESULTS: The mean adjusted Constant score improved from 16.8±15.2% to 78.1±21.9%. Negative prognostic factors turned out to be female sex, age, cuff tears especially of the subscapularis tendon, and previous bone block procedures. Revision was performed in five patients, and two developed painful glenoid erosion which required conversion to total shoulder arthroplasty. CONCLUSION: Cementless humeral head replacement is a viable option in the treatment of dislocation arthropathy. Revision can be performed easily since the bone stock has been preserved. On the basis of our data, humeral head replacement in patients <40 years with dislocation arthropathy offers promising short- to midterm results with an acceptable complication rate.

[Complication management after unsuccessful operative shoulder stabilization]. / Komplikationsmanagement nach fehlgeschlagener operativer Schulterstabilisierung.

Operative repair of shoulder instability may fail because of multiple causes: a constitutional predisposition, a new trauma, incorrect diagnosis, inadequate operative techniques or inappropriate rehabilitation can be involved. The key to successful revision surgery is a thorough analysis of errors of the primary repair and the revision also has to deal with the decisive pathological factors. The management of revision surgery after failed surgery for patients with instability has to focus on the decisive pathological factors and has to take a higher complication rate and lower success rate than primary repairs into account.In agreement with the literature a retrospective investigation of 61 open revision surgeries after an average follow up of more 4 years showed recurrent dislocations in 6 patients (9.8%). One of these patients had an adequate trauma and a seizure as the cause of dislocation. After thorough examination three patients revealed signs of a primarily overlooked connective tissue disorder.

[Glenoid reconstruction in revision shoulder arthroplasty]. / Glenoidrekonstruktion bei Wechseloperationen an der Schulter.

OBJECTIVE: The aim of the surgical technique is the stable fixation of a glenoid baseplate and reconstruction of bone loss with correction of version, inclination, and medialization of the joint line. INDICATIONS: Significant glenoid bone loss due to glenoid loosening or wear in revision shoulder arthroplasty. CONTRAINDICATIONS: Active infection, inoperability due to poor health condition. SURGICAL TECHNIQUE: Reconstruction of advanced glenoid bone stock in case of glenoid loosening of total shoulder arthroplasty can be performed either with autografts and allografts or metallic augmentation together with reverse baseplates in a one- or two-stage procedure. The preferred fixation mode was a transfixation technique using autograft and baseplates with extra-long coated or threaded post with 2-4 locking screws. Baseplates with an extended post and locking screws adjustable in various inclination are required to achieve fixation along the "3-column concept" which is used by the authors based on a recently introduced classification algorithm, which is based on the remaining bone stock available for fixation of the post in native bone stock. POSTOPERATIVE MANAGEMENT: The standard protocol with an abduction brace for 6 weeks and passive exercises is modified, depending on the extent of reconstruction on the humeral and glenoid side, and the type of implant. RESULTS: In all, 145 cases of revision total shoulder arthroplasty suffering from moderate or advanced bone loss were retrospectively evaluated and 95 followed up for a mean of 2.7 years (range 1-7 years). We classified the remaining bone stock as grade 4 or 5 in 61 patients and grade 2 and 3 in 84 patients. Our preferred surgical technique was cementless fixation of structural bone grafts using a reverse baseplate in transfixation technique. In all, 56 cases required substantial iliac crest bone grafts, of which 36 patients were operated on in a 2-stage procedure. In 20 patients the bone defect in the iliac crest was secured by a locking plate in order to avoid a fatigue fracture of the anterior iliac spine. Only in 5 cases with intact rotator cuff was an anatomical "platform" component used; the remaining cases were converted to reverse shoulder arthroplasty. A success rate of more than 90% for both one- and two-stage reconstructions, which is mainly related to the high rate of incorporation of autografts taken from the iliac crest, is comparable to the majority of data published in the literature.

The inflamed biceps tendon as a pain generator in the shoulder: A histological and biomolecular analysis.

INTRODUCTION: The long head of the biceps (LHB) is often resected in shoulder surgery. However, its contribution to inflammatory processes in the shoulder remains unclear. In the present study, inflamed and noninflamed human LHBs were comparatively characterized for features of inflammation. MATERIALS AND METHODS: Twenty-two resected LHB tendons were classified into inflamed ( n = 11) and noninflamed ( n = 11) samples. For histological examination, samples were stained with hematoxylin eosin, Azan, van Gieson, and Masson Goldner trichrome. Neuronal tissue was immunohistochemically visualized. In addition, specific inflammatory marker gene expression of primary LHB-derived cell cultures were analyzed. RESULTS: Features of tendinopathy, such as collagen disorganization, infiltration by inflammatory cells, neovascularization, and extensive neuronal innervation were found in the tendinitis group. Compared to noninflamed samples, inflamed LHBs showed a significantly increased inflammatory marker gene expression. CONCLUSION: Structural and biomolecular differences of both groups suggest that the LHB tendon acts as an important pain generator in the shoulder joint. These findings can, on the one hand, contribute to the understanding of the biomolecular genesis of LHB tendinitis and, on the other hand, provide possibilities for new therapeutic approaches.

The effect of suture materials and techniques on the outcome of repair of the rotator cuff: a prospective, randomised study.

In a prospective, randomised study on the repair of tears of the rotator cuff we compared the clinical results of two suture techniques for which different suture materials were used. We prospectively randomised 100 patients with tears of the rotator cuff into two groups. Group 1 had transosseous repair with No. 3 Ethibond using modified Mason-Allen sutures and group 2 had transosseous repair with 1.0 mm polydioxanone cord using modified Kessler sutures. After 24 to 30 months the patients were evaluated clinically using the Constant score and by ultrasonography. Of the 100 patients, 92 completed the study. No significant statistical difference was seen between the two groups: Constant score, 91% vs 92%; rate of further tear, 18% vs 22%; and revision, 4% vs 4%. In cases of further tear the outcome in group 2 did not differ from that for the intact repairs (91% vs 91%), but in group 1 it was significantly worse (94% vs 77%, p = 0.005). Overall, seven patients had complications which required revision surgery, in four for pain (two in each group) and in three for infection (two in group 1 and one in group 2).

The stabilizing sling for the long head of the biceps tendon in the rotator cuff interval. A histoanatomic study.

A histoanatomic study of the rotator cuff interval was done in 13 cadaveric specimens to investigate the relation of its ligamentous structures to the long head of the biceps tendon, with a special focus on revealing a stabilizing function. After macroscopic evaluation, the lateral half of the rotator cuff interval capsule was cut into three sections: medial, middle, and lateral. These sections were embedded in methacrylate, and then serial sections were made and stained for polarized light microscopy. The superior glenohumeral ligament was seen to form a fold having the macroscopic appearance of a U-shaped anterior suspension sling for the long head of the biceps tendon. Microscopic evaluation revealed an important role of the fasciculus obliquus in the roof of this sling. Fibers of the supraspinatus tendon join the posterosuperior part of the sling. The subscapularis tendon is not involved in this suspensory mechanism. As a result of these observations, we determined that the superior glenohumeral ligament and the fasciculus obliquus are the most important ligamentous reinforcements of a stabilizing sling for the long head of the biceps tendon in the rotator cuff interval. Their histologic appearance indicates they function to protect the long head of the biceps against anterior shearing stress. A lesion of this sling might lead to anterior instability of the biceps tendon.

[Arthrography, ultrasound and MRI in rotator cuff lesions: a comparison of methods in partial lesions and small complete ruptures]. / Arthrographie, Ultraschall und MRT bei Rotatorenmanschettenläsionen--ein Methodenvergleich bei Partialläsionen und kleinen kompletten Rupturen.

PURPOSE: To evaluate the accuracy of arthrography, ultrasound and MR imaging in rotator cuff disease. METHODS: 40 patients suffering from subacromial impingement syndrome for at least three months and who were selected for surgery, underwent ultrasound, double-contrast arthrography and MR imaging. Patient preselection focused on partial and small complete tears. RESULTS: 13/26 surgically confirmed tears were partial tears (articular surface: 10, bursal surface: 2, intra-substance tearing: 1). Arthrography, ultrasound and MR imaging yield a sensitivity for complete tears of 91%, 69% and 92% with a specificity of 100%, 93% and 93%. For partial tears sensitivity was 50%, 69% and 69% with a specificity of 100%, 79% and 86%. Concerning evaluation of localisation, extent and correct classification ultrasound was correct in 17/26 cases, MR in 21/26 cases. CONCLUSION: Arthrography is not helpful in detecting partial tears. Ultrasound and MR imaging yield comparable accuracy. MR imaging has advantages concerning better evaluation of extent, location and classification as well as for the detection of associated pathologies.

Os acromiale associated with tear of the rotator cuff treated operatively. Review of 33 patients.

Os acromiale is a rare anatomical abnormality and treatment is controversial. Our retrospective study analyses the outcome of excision, acromioplasty and bony fusion of the os acromiale when it is associated with a tear of the rotator cuff. After a mean follow-up of 41 months, 33 patients were radiologically and clinically assessed using the Constant score. The surgical procedure was to repair the rotator cuff together with excision of the os acromiale in six patients, acromioplasty in five, and fusion in 22. Of the 22 attempted fusions seven failed radiologically. The Constant scores were 82%, 81%, 81% and 84% for patients who had excision, acromioplasty, successful fusion and unsuccessful fusion respectively. There were no statistically significant differences. We conclude that a small mobile os acromiale can be resected, a large stable os acromiale treated by acromioplasty and a large unstable os acromiale by fusion to the acromion. Even without radiological fusion the clinical outcome can be good.

Autoimmune findings resembling connective tissue disease in a patient with Castleman's disease.

Multicentric angiofollicular lymphnode hyperplasia (multicentric Castleman's disease) may be associated with acute phase reaction and several autoimmune features. Since lymphadenopathy is a common feature in connective tissue disease, a clear distinction between the different disease entities may be difficult. We describe a 26-year-old male patient with predominant cervical lymphadenopathy, hepatosplenomegaly and polyserositis, diagnosed as collagen disease. He showed several autoimmune features including autoimmune haemolytic anaemia, cryoglobulinaemia, positive antinuclear and anti smooth muscle antibodies, serum immune complexes and a sensorimotor polyneuropathy. Under immunosuppressive therapy with prednisolone and azathioprine, only partial remission was achieved. Repeated lymph node biopsy together with the clinical features led to the diagnosis of multicentric Castleman's disease in this patient nine years later. Interleukin-6 (IL-6) seems to play an important role in the pathogenesis of clinical and serum biochemical features in patients with Castleman's disease.

[Prospective observational study of surgical therapy of renal hyperparathyroidism]. / Prospektive Beobachtungsstudie zur operativen Therapie des renalen Hyperparathyreoidismus.

A prospective long-term follow-up study in patients who had had surgical therapy for renal hyperparathyroidism was launched to investigate the results of surgical treatment and to evaluate possible correlations between preoperative laboratory values and the course of symptoms. From August 1987 to December 1995, 79 patients underwent surgery for renal hyperparathyroidism. It was the first neck exploration for 72 patients. Total parathyroidectomy with autotransplantation to a forearm was our preferred procedure (n = 67). The postoperative course of all patients is know. We carried out one to nine reexaminations (median 4) in 74 of 79 patients. The follow-up period ranged from 1 month to 5 years with a median of 18 months. After the operation transient hypocalcaemia occurred in 84.4% of patients. Postoperative hypocalcaemia correlated negatively with the preoperative levels of alkaline phosphatase and intact parathyroid hormone. Within the first month after surgery 60% of the preoperatively affected patients completely recovered from pruritus, whereas the skeletal syndrome took longer to disappear. One year after surgery 75% of the patients with pruritus and 79% of those with skeletal syndrome had became asymptomatic. After total parathyroidectomy with autotransplantation, patients with preoperatively elevated concentrations of alkaline phosphatase (> 200 U/I) experienced faster relief from joint pain than patients with preoperatively normal concentrations (P = 0.0297). To date 4.5% of the patients developed recurrent hyperparathyroidism after total parathyroidectomy with autotransplantation. Morbidity of surgery for renal hyperparathyroidism is influenced by patients' risk factors. Postoperative hypocalcaemia correlates negatively with the grade of renal osteopathy at the time of operation. Preoperative concentrations of alkaline phosphatase influence the rapidity of the relief from joint pain.

Biomechanik der Schulter.

The shoulder joint takes a special position among all the||| other joints of the human body because of its special requirements of stability||| and mobility. Knowledge of the biomechanics of the shoulder joint forms the||| basis for the development of modern concepts of reconstructive surgery and||| arthroplasty. Most of the biomechanical findings are the result of research||| performed on cadaver shoulders using increasingly sophisticated methods of||| measurement. These studies elucidate the interaction of the static and dynamic||| factors which contribute to the delicate balance of the glenohumeral joint.||| Recently performed research is increasingly being focussed on more detailed||| analyses of muscle forces and stress distribution in the subchondral bone and||| periarticular soft tissues. The efficiency of the computer systems now||| available has enabled the development of complex, virtual shoulder models and||| three-dimensional finite element analyses. In the future a pure mechanical||| understanding has to be modified to extend to a concept which includes more||| data obtained from living subjects, especially with regard to muscle activity||| under varying loads and neuromuscular feedback systems which currently are||| difficult to assess.