Intact revision rotator cuff repair stabilizes muscle atrophy and fatty infiltration after minimum follow up of two years.

BACKGROUND: The extent of fatty infiltration and rotator cuff (RC) atrophy is crucial for the clinical results after rotator cuff repair (RCR). The purpose of this study was to evaluate changes in fatty infiltration and RC atrophy after revision RCR and to correlate them with functional outcome parameters. METHODS: Patients who underwent arthroscopic revision RCR for symptomatic recurrent full-thickness tear of the supraspinatus tendon between 2008 and 2014 and were retrospectively reviewed with a minimum follow up of 2 years. Magnetic resonance imaging (MRI) was performed pre- and postoperatively to assess 1) tendon integrity after revision RCR according to Sugaya classification, (2) RC atrophy according to Thomazeau classification, and (3) fatty infiltration according to Fuchs MRI classification. Constant score (CS) and the American Shoulder and Elbow Surgeon (ASES) score were used to correlate functional outcome, tendon integrity, and muscle degeneration. RESULTS: 19 patients (17 males and 2 females) with a mean age of 57.5 years (range, 34 to 72) were included into the study at a mean follow-up of 50.3 months (range, 24 - 101). At final evaluation, 9 patients (47%) presented with intact RCR and 10 patients (53%) suffered a re-tear after revision repair. No progress of fatty infiltration was observed postoperatively in the group with intact RC, atrophy progressed in only 1 out of 9 patient (11%). Fatty infiltration progressed in 5/10 patients (50%) and RC atrophy increased in 2/10 patients (20%) within the re-tear group. CS (42.7 ± 17.7 preop, 65.2 ± 20.1 postop) and ASES (47.7 ± 17.2 preop, 75.4 ± 23.7 postop) improved significantly from pre- to postoperatively (p < 0.001). A positive correlation between fatty infiltration and RC integrity was detected (r = 0.77, p < 0.01). No correlation between clinical outcome and tendon integrity or RC atrophy was observed. CONCLUSION: Arthroscopic revision RCR leads to reliable functional outcomes even in case of a recurrent RC retear. An intact RCR maintains the preoperative state of fatty infiltration and muscle atrophy but does not lead to muscle regeneration. LEVEL OF EVIDENCE: Level IV; Therapeutic study.

Center of pressure (COP) measurement in patients with confirmed successful outcomes following shoulder surgery show significant sensorimotor deficits.

PURPOSE: To determine the sensorimotor and clinical function of patients with confirmed successful outcome after either undergoing acromioclavicular joint (ACJ) stabilization, Bankart repair (BR), or rotator cuff repair (RC), and to compare these measures to the contralateral, healthy side without history of previous injuries or surgeries of the upper extremity. It was hypothesized that patients of each interventional group would have inferior sensorimotor function of the shoulder joint compared to the contralateral, healthy side, while presenting with successful clinical and functional outcomes. METHODS: Three intervention groups including ten patients who had confirmed successful clinical and functional outcomes after either undergoing ACJ stabilization, BR, or RC were evaluated postoperatively at an average follow-up of 31.7 ± 11.6 months. Additionally, a healthy control group (CG) of ten patients was included. Clinical outcomes were assessed using the Constant-Murley (CM) and American Shoulder and Elbow Surgeons (ASES) Score. Pain was evaluated using the visual analogue scale (VAS). Sensorimotor function was assessed by determining the center of pressure (COP) of the shoulder joint in a one-handed support task in supine position on a validated pressure plate. RESULTS: Each interventional group demonstrated excellent clinical outcome scores including the CM Score (ACJ 83.3 ± 11.8; BR 89.0 ± 10.3; RC 81.4 ± 8.8), ASES Score (ACJ 95.5 ± 7.0; BR 92.5 ± 9.6; RC 96.5 ± 5.2), and VAS (ACJ 0.5 ± 0.9; BR 0.5 ± 0.8; RC 0.5 ± 0.8). Overall, the CG showed no significant side-to-side difference in COP, whereas the ACJ-group and the BR-group demonstrated significantly increased COP compared to the healthy side (ACJ 103 cm vs. 98 cm, p = 0.049; BR: 116 cm vs. 102 cm, p = 0.006). The RC-group revealed no significant side-to-side difference (120 cm vs. 108 cm, n.s.). CONCLUSION: Centre of pressure measurement detected sensorimotor functional deficits following surgical treatment of the shoulder joint in patients with confirmed successful clinical and functional outcomes. This may indicate that specific postoperative training and rehabilitation protocols should be established for patients who underwent surgery of the upper extremity. These results underline that sensorimotor training should be an important component of postoperative rehabilitation and physiotherapeutic activities to improve postoperative function and joint control. LEVEL OF EVIDENCE: IV.

Patients return to sports and to work after successful treatment of septic arthritis following anterior cruciate ligament reconstruction.

PURPOSE: To determine specific return to sports (RTS) and return to work (RTW) rates of patients with septic arthritis following anterior cruciate ligament reconstruction (ACLR), and to assess for factors associated with a diminished postoperative return to physical activity after successful eradication of the infection. METHODS: In this study, patients who were treated for postoperative septic arthritis of the knee following anterior cruciate ligament reconstruction between 2006 and 2018 were evaluated at a minimum follow-up (FU) of 2 years. Patients' outcomes were retrospectively analyzed using standardized patient-reported outcome scores including the Lysholm score and the subjective IKDC score, as well as return to sports and return to work questionnaires to assess for the types, number, and frequency of sports performed pre- and postoperatively and to evaluate for potential occupational changes due to septic arthritis following ACLR. To assess for the signifiance of the graft at follow-up, outcomes were compared between patients with a functioning graft at FU and those without, as well as between patients with initial graft retention and those with graft removal and consecutive revision ACLR. RESULTS: Out of 44 patients eligible for inclusion, 38 (86%) patients at a mean age of 36.2 ± 10.3 years were enrolled in this study. At a mean follow-up of 60.3 ± 39.9 months, the Lysholm score and the subjective IKDC score reached 80.0 ± 15.1 and 78.2 ± 16.6 points, respectively. The presence of a graft at FU yielded statistically superior results only on the IKDC score (p = 0.014). There were no statistically significant differences on the Lysholm score (n.s.) or on the IKDC score (n.s.) between patients with initial graft retention and those with initial removal who had undergone revision ACLR. All of the included 38 patients were able to return to sports at a median time of 8 (6-16) months after their last surgical intervention. Among patients who performed pivoting sports prior to their injury, 23 (62.2%) returned to at least one pivoting sport postoperatively. Overall, ten patients (26.3%) returned to all their previous sports at their previous frequency. The presence of a graft at FU resulted in a significantly higher RTS rate (p = 0.010). Comparing patients with initial graft retention and those with graft removal and consecutive revision ACLR, there was no statistically significant difference concerning the RTS rate (n.s.). Thirty-one patients (83.8%) were able to return to their previous work. CONCLUSION: Successful eradication of septic arthritis following anterior cruciate ligament reconstruction allows for a postoperative return to sports and a return to work particularly among patients with ACL-sufficient knees. However, the patients' expectations should be managed carefully, as overall return rates at the pre-injury frequency are relatively low. LEVEL OF EVIDENCE: IV.

Clinical Outcomes, Tendon Integrity, and Shoulder Strength After Revision Rotator Cuff Reconstruction: A Minimum 2 Years' Follow-up.

BACKGROUND: The retear rate after primary rotator cuff (RC) reconstruction is high and commonly leads to poorer clinical outcomes and shoulder function. In the case of primary failure, revision RC reconstruction (RCR) has become increasingly important to re-create RC integrity and improve outcomes. To date, clinical and structural outcomes after RCR have not been sufficiently investigated and described at midterm follow-up. Hypothesis/Purpose: The purpose was to evaluate the clinical and radiological outcomes after revision RCR. It was hypothesized that revision RCR significantly improves clinical outcomes and that the outcomes positively correlate with tendon integrity on magnetic resonance imaging (MRI). STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who underwent revision RCR between 2008 and 2014 were retrospectively evaluated with a minimum follow-up of 2 years. Outcomes were assessed by a clinical examination, a visual analog scale for pain (VAS), the Constant Score (CS), the American Shoulder and Elbow Surgeons (ASES) score, and the Disabilities of the Arm, Shoulder and Hand (DASH) score. Tendon integrity was determined using 3-T MRI and graded according to the Sugaya classification. RESULTS: Thirty-one of 40 patients (77.5%) were available for the final assessment at a mean follow-up of 50.3 ± 20.4 months. Clinical outcome scores significantly improved from preoperatively to postoperatively for the CS (39.7 ± 16.7 to 65.1 ± 19.7; P < .001), ASES (44.2 ± 17.7 to 75.2 ± 24.8; P < .001), and DASH (68.6 ± 15.1 to 21.5 ± 19.1; P < .001). The VAS score decreased from 6.1 ± 1.8 preoperatively to 1.3 ± 1.8 at final follow-up ( P < .001). MRI demonstrated a retear rate of 55.5%. No differences in CS, ASES, and DASH scores were detected between patients with an intact repair and failure. Abduction strength was not significantly different in patients with an intact repair and retears (55.5 N vs 44.0 N, respectively, P = .52). CONCLUSION: Revision RCR improves clinical outcomes and shoulder function at midterm follow-up. The clinical outcome scores were comparable in patients with an intact repair and those with failed RC healing. Therefore, tendon integrity was not correlated with better clinical outcomes after revision RCR at final follow-up.

The effectiveness of conservative and surgical treatment for shoulder stiffness: a systematic review of current literature.

Introduction: Currently, no therapeutic intervention is universally accepted, and the most effective management for restoring motion and diminishing pain in patients with shoulder stiffness has yet to be defined. This systematic review analyses outcomes of conservative and surgical interventions to treat shoulder stiffness. Source of data: A systematic review of literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, Ovid and Google Scholar databases using various combinations of the keywords 'shoulder', 'shoulder stiffness', 'stiff shoulder', 'conservative', since inception of databases to June 2018 was performed. Areas of agreement: Shoulder stiffness could be treated with conservative means including nonsteroidal anti-inflammatory medications, corticosteroid injections, or transcutaneous electrical nerve stimulation, manipulation under anaesthesia, and arthroscopic capsular release. Areas of controversy: No therapeutic intervention is universally accepted, and the most effective management to restore motion and diminish pain in patients with shoulder stiffness has yet to be defined. Growing points: The rate of failure after treatment for stiff shoulder is higher in the surgical group than in the conservative group. Areas timely for developing research: There is insufficient evidence to establish whether surgical or conservative management is the best choice to manage shoulder stiffness. Prospective, randomized studies are needed to establish whether surgical or conservative management produce a clinically relevant difference in functional outcome.

Septic Arthritis After Anterior Cruciate Ligament Reconstruction: How Important Is Graft Salvage?

BACKGROUND: Septic arthritis (SA) of the knee after anterior cruciate ligament reconstruction (ACLR) is a rare but potentially devastating condition. In certain cases, graft removal becomes necessary. PURPOSE: To evaluate clinical, subjective, and radiologic outcomes of patients with SA after ACLR and assess whether graft retention has superior clinical results as compared with graft removal. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All patients who were at least 12 months out from arthroscopic treatment of SA after isolated ACLR at our institution were eligible for inclusion. Patients were categorized into 2 groups: group 1, patients with initial graft retention; group 2, patients with initial graft removal. Group 2 was subdivided into 2 groups: group 2a, patients with graft reimplantation; group 2b, patients without graft reimplantation. Objective and subjective assessments were obtained at follow-up, including the International Knee Documentation Committee (IKDC) knee examination form, KT-1000 arthrometer measurements, WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score, Lysholm score, and IKDC subjective evaluation. Radiologic assessment was performed with pre- and postoperative magnetic resonance imaging. RESULTS: Of the 41 patients included, 33 (81%) were available for follow-up at a mean ± SD 54.7 ± 24.4 months at an age of 28.4 ± 9.3 years. When compared with patients from group 2 (n = 12), patients from group 1 (n = 21) obtained significantly better results on the objective IKDC score (normal or nearly normal: group 1, 66.6%; group 2, 36.4%; P = .047) and KT-1000 measurements (group 1, 1.3 ± 1.0 mm; group 2, 2.9 ± 1.5 mm; P = .005). Group 1 also scored better than group 2 on the Lysholm ( P = .007), IKDC subjective ( P = .011), and WOMAC ( P = .069) measures. Between groups 2a (n = 4) and 2b (n = 8), no significant differences in outcomes could be detected ( P values, .307-.705), although patients with anterior cruciate ligament graft reimplantation showed a clear tendency toward better results in objective and not subjective parameters. Magnetic resonance imaging evaluation showed higher rates of cartilage damage and meniscal tears among patients with graft resection versus graft retention. CONCLUSION: Patients with graft retention showed superior postoperative results when compared with patients who underwent initial graft resection, although subanalysis showed comparable outcomes between graft retention and reimplantation. Thus, while graft-retaining protocols should have the highest priority in the treatment of SA after ACLR, graft reimplantation should be performed in cases where graft resection becomes necessary, to avoid future cartilage and meniscal lesions. Finally, further studies with larger numbers of patients are needed to gain a better understanding of the outcomes of patients with SA after ACLR.

Rehabilitation following rotator cuff repair: A work of the Commission Rehabilitation of the German Society of Shoulder and Elbow Surgery e. V. (DVSE) in collaboration with the German Association for Physiotherapy (ZVK) e. V., the Association Physical Therapy, Association for Physical Professions (VPT) e. V. and the Section Rehabilitation-Physical Therapy of the German Society for Orthopaedics and Trauma e. V. (DGOU).

BACKGROUND: Tears and lesions of the rotator cuff are a frequent cause of shoulder pain and disability. Surgical repair of the rotator cuff is a valuable procedure to improve shoulder function and decrease pain. However, there is no consensus concerning the rehabilitation protocol following surgery. OBJECTIVES: To review and evaluate current rehabilitation contents and protocols after rotator cuff repair by reviewing the existing scientific literature and providing an overview of the clinical practice of selected German Society of Shoulder and Elbow Surgery e. V. (DVSE) shoulder experts. MATERIALS AND METHODS: A literature search for the years 2004-2014 was conducted in relevant databases and bibliographies including the Guidelines International Network, National Guidelines, PubMed, Cochrane CentralRegister of Controlled Trials, Cochrane Database of Systematic Reviews, and the Physiotherapy Evidence Database. In addition, 63 DVSE experts were contacted via online questionnaire. RESULTS: A total of 17 studies, four reviews and one guideline fulfilled the inclusion criteria. Based on these results and the obtained expert opinions, a four-phase rehabilitation protocol could be developed.

Single versus double row suture anchor fixation for greater tuberosity fractures - a biomechanical study.

BACKGROUND: Fractures of the humeral greater tuberosity (GT) are a frequent injury progressively treated with arthroscopic suture anchor repair. Yet, no biomechanical study has been performed comparing fixation strength of arthroscopic single- (SR) vs. double row (DR) fixation. METHODS: Standardized fractures of the greater tuberosity were created in 12 fresh frozen proximal humeri. After random assignation to the SR or DR group the fixed humeri were tested applying cyclic loading to the supraspinatus and infraspinatus tendon. Load to failure and fragment displacement were assessed by means of an electrodynamic material testing machine using an optical tracking system. RESULTS: Load to failure values were higher in the DR group (649 N; ±176) than in the SR group (490 N; ±145) however without statistical significance (p = .12). In greater tuberosity displacement of 3-5 mm surgical treatment is recommended. The fixing constructs in this study did not reach displacement landmarks of 3 or 5 mm before construct failure as shown in previous studies. Thus the applied traction force (N) at 1 mm displacement was analyzed. In the SR group the load at 1 mm displacement was 277 N; ±46 compared to 260 N; ±62 in the DR group (p = .65). CONCLUSION: The results suggest that both techniques are viable options for refixation of greater tuberosity fractures. LEVEL OF EVIDENCE: Laboratory study.

Five-Year Outcomes After Treatment for Acute Instability of the Tibiofibular Syndesmosis Using a Suture-Button Fixation System.

BACKGROUND: Suture-button repair is a widely accepted surgical treatment for acute and isolated ankle syndesmosis injuries. To our knowledge, midterm results have not previously been reported. PURPOSE: To evaluate the clinical, qualitative, and quantitative radiological midterm outcomes of suture-button repair after acute isolated ankle syndesmosis injuries. STUDY DESIGN: Retrospective case series; Level of evidence, 4. METHODS: Clinical outcomes were measured using the Foot and Ankle Disability Index (FADI) and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Three-tesla magnetic resonance imaging (MRI) was performed bilaterally at the ankle. Besides morphological sequences for evaluation of the syndesmosis and degenerative changes of the ankle using the Ankle Osteoarthritis Scoring System (AOSS), the MR protocol included a coronal 2-dimensional multislice multiecho sequence for quantitative cartilage T2-weighted mapping. Spearman correlations and paired t tests were used for statistical analysis. RESULTS: This retrospective study included 19 consecutive patients (mean age, 29.7 ± 11.5 years) with acute isolated syndesmosis injuries treated with a suture-button system between January 2006 and June 2014, with a mean follow-up of 5.1 ± 2.6 years. Postoperatively, the median FADI score was 136 (range, 78-136), and the median AOFAS score was 100 (range, 87-100). Seventeen (89.5%) patients reported to have reached their preinjury level of sports activities. MRIs of 16 patients were obtained and all showed intact anterior and posterior syndesmotic ligaments; however, in most patients, the previously injured syndesmotic ligament was thickened compared with the uninjured ankle. Average width of the anterior (P = .81) and posterior (P = .60) syndesmosis was not significantly different between the ipsilateral (3.2 ± 1.2 and 4.4 ± 0.9 mm) and contralateral ankles (3.0 ± 0.6 and 4.2 ± 0.7 mm). The median AOSS score was 1.5 (range, 0-11) for the ipsilateral ankle and 0 (range, 0-6) for the contralateral ankle. T2 values of articular cartilage did not significantly differ between the involved and the uninjured ankle (P = .68). Five patients needed hardware removal due to persistent skin irritation, and 1 patient suffered from reinstability of the ankle resulting in revision surgery 2 years after the index surgery. CONCLUSION: Suture-button fixation is an excellent treatment for acute and isolated syndesmosis injuries, resulting in stable ankles without early or advanced osteoarthritic changes at midterm follow-up.

No correlation between radiolucency and biomechanical stability of keeled and pegged glenoid components.

BACKGROUND: The purpose of this study was to examine biomechanical properties and the degree of radiolucency of two cemented basic glenoid designs for total shoulder arthroplasty. Our hypothesis was that a component with increased micro-motion in the laboratory at time zero would also exhibit a greater amount of radiolucency in patients at a minimum of 2 years post total shoulder arthroplasty. METHODS: Thirty cadaveric shoulders were divided into 2 groups (keel vs. peg). The glenoid components were first loaded with a single axial eccentric force of 196 N in all orientations and then with a transversal load of 49 N to simulate in vivo loads with abduction. Displacement of the glenoid component was determined with four different linear variable-differential transducers. In the second phase, 56 antero-posterior x-rays of 52 patients with either the same keeled (n = 24) or pegged (n = 32) glenoid component with a minimum of 24 months follow-up were evaluated for radiolucency. RESULTS: Biomechanically the pegged glenoid showed a significant increase in micro-motion during eccentric axial loading as well as during combined loading in the anterior, posterior, and inferior position as compared to the keeled glenoid (p < 0.05). In contrast all results were significant with greater radiolucency for the keeled glenoid component (p = 0.001). CONCLUSION: While the pegged component exhibited a greater amount of micro-motion during biomechanical testing, radiolucency was greater in patients with a keeled component. These findings provide support for both components from different perspectives and highlight the need for well-constructed studies to determine whether glenoid design has an effect on clinical outcome, because influences are multifactorial and biomechanical forces may not recreate forces seen in vivo.

Proton Density Fat-Fraction of Rotator Cuff Muscles Is Associated With Isometric Strength 10 Years After Rotator Cuff Repair: A Quantitative Magnetic Resonance Imaging Study of the Shoulder.

BACKGROUND: Quantitative muscle fat-fraction magnetic resonance (MR) imaging techniques correlate with semiquantitative Goutallier scores with failure after rotator cuff (RC) repair. PURPOSE: To investigate the relationship of proton density fat fraction (PDFF) of the RC muscles with semiquantitative MR scores, cartilage T2 relaxation times, and clinical isometric strength measurements in patients 10 years after unilateral RC repair. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Bilateral shoulder MR imaging was performed in 13 patients (11 male, 2 female; age, 72 ± 8 years) 10.9 ± 0.4 years after unilateral autologous periosteal flap augmented RC repair (total shoulders assessed, N = 26). Goutallier classification, muscle atrophy, RC tendon integrity, and cartilage defects were determined based on morphological MR sequences. A paracoronal 2D multi-slice multi-echo sequence was used for quantitative cartilage T2 mapping. A chemical shift-encoding-based water-fat separation technique (based on a 6-echo 3D spoiled gradient echo sequence) was used for quantification of the PDFF of RC muscles. Isometric shoulder abduction strength was measured clinically. Mean and SD, Pearson correlation, and partial Spearman correlation were calculated. RESULTS: There were 6 RC full-thickness retears in ipsilateral shoulders and 6 RC full-thickness tears in contralateral shoulders. Isometric shoulder abduction strength was not significantly different between ipsilateral and contralateral shoulders (50 ± 24 N vs 54 ± 24 N; P = .159). The mean PDFF of RC muscles was 11.7% ± 10.4% (ipsilateral, 14.2% ± 8.5%; contralateral, 9.2% ± 7.8%; P = .002). High supraspinatus PDFF correlated significantly with higher Goutallier scores ( R = 0.75, P < .001) and with lower isometric muscle strength ( R = -0.49, P = .011). This correlation remained significant after adjustment for muscle area measurements and tendon rupture ( R = -0.41, P = .048). More severe cartilage defects at the humerus were significantly associated with higher supraspinatus PDFF ( R = 0.44; P = .023). Cartilage T2 values did not correlate with muscle PDFF ( P > .05). CONCLUSION: MR imaging-derived RC muscle PDFF is associated with isometric strength independent of muscle atrophy and tendon rupture in shoulders with early and advanced degenerative changes. It therefore provides complementary, clinically relevant information in tracking RC muscle composition on a quantitative level.

Long-term Results After Arthroscopic Repair of Isolated Subscapularis Tears.

BACKGROUND: Although some reports have presented short- to midterm results after arthroscopic repair of isolated subscapularis (SSC) tendon tears, long-term evaluation is still lacking. HYPOTHESIS: Long-term results after arthroscopic repair of isolated SSC tears are comparable with the functional and radiological short- to midterm outcomes described in the literature. STUDY DESIGN: Case series, Level of evidence, 4. METHODS: This study assessed 17 patients (5 females and 12 males; mean age, 45.6 years) with isolated SSC tears (Fox and Romeo classification types 2-4) who underwent all-arthroscopic suture anchor repair. The mean interval from symptom onset to the time of surgery was 5.3 months in 16 patients (94.1%). One patient (5.9%) was symptomatic for a prolonged period (104 months) before surgery. All patients were assessed with a clinical examination preoperatively. SSC function was investigated using specific clinical tests and common scoring systems, including Constant, American Shoulder and Elbow Surgeons (ASES), Disabilities of the Arm, Shoulder and Hand (DASH), and Simple Shoulder Test (SST) scores. At follow-up, muscular strength was evaluated using an electronic force-measuring plate. Structural integrity of the repair was assessed using magnetic resonance imaging (MRI). RESULTS: At a mean follow-up of 98.4 ± 19.9 months, the mean Constant score improved from 47.8 preoperatively to 74.2 postoperatively ( P = .001). Higher Constant ( P = .010) and ASES ( P = .001) scores were significantly associated with a shorter time from symptom onset to surgery. The size of the SSC lesion did not correlate with any clinical score outcome ( P = .476, .449, .985, and .823 for Constant, ASES, DASH, and SST scores, respectively). Three patients (17.6%) had persistent positive clinical test results (belly-press/lift-off). Compared with the uninjured contralateral side, SSC strength was significantly reduced in the belly-press position ( P = .031), although active internal ( P = .085) and external ( P = .093) rotation was not affected. In 1 patient, a rerupture was detected by MRI. Six patients had cranial SSC atrophy. Overall, 88.2% of patients were "very satisfied" or "satisfied" with their results. CONCLUSION: Arthroscopic repair of isolated SSC tears results in significant clinical improvements and enduring tendon integrity, although SSC strength remains reduced in the long term. Early surgical treatment seems to be a relevant factor allowing good shoulder function.

Biomechanical Analysis of Intra-articular Pressure After Coracoclavicular Reconstruction.

BACKGROUND: Recent biomechanical and clinical studies have demonstrated the effectiveness of suture button and pulley-type fixations for surgical treatment of acromioclavicular instability. Concerns remain that such procedures can "overconstrain" (overreduce the lateral clavicle in relation to the acromion to a nonphysiological position) the joint. Purpose/Hypothesis: The purpose of this study was to investigate the intra-articular pressure of native and reconstructed acromioclavicular (AC) joints in relation to the configuration of the joint. Anatomic (0 mm), overconstrained (-3 mm), and underconstrained (+3 mm) AC joint reconstructions were simulated. The hypothesis was that reconstructions using suture pulley systems do not increase the intra-articular pressure of the AC joint. STUDY DESIGN: Controlled laboratory study. METHODS: Eleven fresh-frozen cadaveric shoulders were used in this study (mean age ± SD, 60.8 ± 6.7 years). Each specimen underwent radiographic analysis by using a Zanca view to determine the basic configuration of the AC joint. A pressure Tekscan sensor was inserted in the AC joint. A servohydraulic materials testing system was used for testing. The specimens were kept in the testing machine, and the native AC position was marked at 0 mm. This allowed moving the clavicle during the surgical procedure with reference to the native anatomic position. Intra-articular pressure in the native AC joint during cyclic loading (1000 cycles; 1 Hz) was measured. After native testing, the AC ligaments and coracoclavicular ligaments were cut and reconstructed using a cortical button technique. Anatomic, -3 mm, and +3 mm positions, relative to the acromion, were cyclically loaded, and intra-articular pressure was documented. RESULTS: According to the AC joint classification of inclination, we identified five type 1 (46%), four type 2 (36%), one type 3 (9%), and one incongruous (9%) configurations. Changes in superior displacement across the 4 conditions were not statistically significant (0.5 ± 0.8 [native], 0.01 ± 0.00 [0 mm repair], 0.02 ± 0.02 [-3 mm repair], and 0.01 ± 0.01 [+3 mm repair]; P = .162). Before testing (time point 1), pressure in the -3 mm repair (62.9 ± 70.1) differed between the native state (11.3 ± 21.8; P = .042) and the +3 mm repair (7.1 ± 18.4; P = .023). All other changes at time points 2 (after cyclic loading unloaded) and 3 (after cyclic loading loaded) in pressure were not significant. ( P = .086 and .226, respectively). CONCLUSION: AC joint reconstruction (within -3 to +3 mm of reduction) with a coracoclavicular suture button device does not significantly increase the intra-articular pressure of the AC joint after cyclic loading in our experimental cadaveric setup. CLINICAL RELEVANCE: Recent biomechanical and clinical studies have demonstrated the effectiveness of suture button and pulley-type fixations for coracoclavicular reconstruction of the joint. Concerns remain that such procedures would "overconstrain" the joint because of the high rigidity of these pulley systems and the preservation of the lateral clavicle. This overconstraining may potentially result in pain at the lateral end of the clavicle, osteolysis, or a later increased risk of early osteoarthritis. Therefore, our results indicate that within a range of ±3 mm to the anatomic position, overconstraining may not result in a higher intra-articular pressure.

Surgical treatment of two adolescent athletes with dislocated avulsion fracture of the anterior superior iliac spine (ASIS).

INTRODUCTION: Avulsion fractures of the anterior superior iliac spine are rare. Therefore, evidence-based treatment guidelines do not exist. The therapeutic options are either conservative treatment or surgical intervention. The decision depends on grade of dislocation, age of the patient, and his sportive demands and competitive requirements. MATERIALS AND METHODS: We present the cases of two young athletes suffering from traumatic avulsion fractures of the anterior superior iliac spine. In both cases, the musculotendinous unit (sartorius muscle and tensor of the fascia lata) remained attached to the loose dislocated fragment. Both patients were treated by means of open reduction with a new surgical technique using suture anchors. RESULTS: Both patients were pain-free 4 weeks after surgery and had full range of motion. They were able to return to their preoperative sportive activity levels 10 weeks after surgery. No complications were reported at final follow-up 18 months postoperatively. CONCLUSION: Operative treatment of avulsion fracture of the ASIS using suture anchors shows excellent clinical outcome and a short convalescence period. The patients achieve their preinjury sportive levels within 3 months.

Hill-Sachs Off-track Lesions as Risk Factor for Recurrence of Instability After Arthroscopic Bankart Repair.

PURPOSE: To evaluate the effect of "off-track" Hill-Sachs lesions, according to the glenoid track concept, as a risk factor for recurrent instability and need for revision surgery after arthroscopic Bankart repair. METHODS: We retrospectively reviewed 254 patients with anteroinferior glenohumeral instability who were managed with an arthroscopic stabilization procedure between 2006 and 2013. Preoperative magnetic resonance imaging and/or computed tomography scans were available for 100 of these patients to calculate the glenoid track and the presence of "on-track" or off-track Hill-Sachs lesions. Recurrence of instability was evaluated at a mean follow-up of 22.4 months. RESULTS: Of 100 patients whose magnetic resonance imaging and/or computed tomography scans were available, 88 had an on-track Hill-Sachs lesion and 12 had an off-track Hill-Sachs lesion. Revision surgery for recurrent instability was performed in 5 patients (6%) with an on-track Hill-Sachs lesion and in 4 patients (33%) with an off-track Hill-Sachs lesion (odds ratio, 8.3; 95% confidence interval, 1.85-37.26; P = .006). CONCLUSIONS: An off-track Hill-Sachs lesion is a significant and important risk factor for recurrence of instability and need for revision surgery after arthroscopic Bankart repair when compared with an on-track Hill-Sachs lesion. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Defect Characteristics of Reverse Hill-Sachs Lesions.

BACKGROUND: Little scientific evidence regarding reverse Hill-Sachs lesions (RHSLs) in posterior shoulder instability exists. Recently, standardized measurement methods of the size and localization were introduced, and the biomechanical effect of the extent and position of the defects on the risk of re-engagement was determined. PURPOSE: To analyze the characteristics and patterns of RHSLs in a large case series using standardized measurements and to interpret the results based on the newly available biomechanical findings. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In this multicenter study, 102 cases of RHSLs in 99 patients were collected from 7 different shoulder centers between 2004 and 2013. Patient- as well as injury-specific information was gathered, and defect characteristics in terms of the size, localization, and depth index were determined on computed tomography or magnetic resonance imaging scans by means of standardized measurements. Additionally, the position (gamma angle) of the posterior defect margin as a predictor of re-engagement was analyzed. RESULTS: Three types of an RHSL were distinguished based on the pathogenesis and chronicity of the lesion: dislocation (D), locked dislocation (LD), and chronic locked dislocation (CLD). While the localization of the defects did not vary significantly between the subgroups (P = .072), their mean size differed signficantly (D: 32.6° ± 11.7°, LD: 49.4° ± 17.2°, CLD: 64.1° ± 20.7°; P < .001). The mean gamma angle as a predictor of re-engagement was similarly significantly different between groups (D: 83.8° ± 14.5°, LD: 96.5° ± 17.9°, CLD: 108.7° ± 18.4°; P < .001). The orientation of the posterior defect margin was consistently quite parallel to the humeral shaft axis, with a mean difference of 0.3° ± 8.1°. CONCLUSION: The distinction between the 3 different RHSL types based on the pathogenesis and chronicity of the defect helps identify defects prone to re-engagement. The gamma angle as a measurement of the position of the posterior defect margin and therefore a predictor of re-engagement varies significantly between the defect types.

Severe heterotopic ossifications after Rockwood type II acromioclavicular joint injury: a case report.

INTRODUCTION: Heterotopic ossification (HO) is a benign condition of abnormal bone formation in soft tissue. It is frequently asymptomatic, though it manifests as decreased range of motion in the affected joints that may occur in the shoulder after a substantial traumatic injury and can complicate the functional outcome of the affected upper extremity. However, severe HO is an extremely rare event following acromioclavicular joint (ACJ) injury. MATERIALS AND METHODS: We are presenting a case of a 29-year-old male patient who had a trauma with resultant Rockwood type II injury. He subsequently complained of left shoulder pain with decreased range of motion 3 years later. HO was diagnosed after X-rays and the severity was assessed with a computerized tomography scan and magnetic resonance imaging. The patient was treated with a combination of pre-operative radiotherapy, surgical excision, mobilization under anesthesia, non-steroidal anti-inflammatory drug (NSAID) therapy and physiotherapy. RESULTS: At 6-month follow-up, excellent clinical and radiological outcomes were achieved with a Constant score of 92 points, DASH score of 24%, and ASES score 100%, with a full range of motion of the left shoulder. Furthermore, there was no more radiological evidence of HO on plain radiographs. CONCLUSION: Severe heterotopic ossification after a Rockwood type II ACJ injury in this case was successfully treated with combination of pre-operative radiotherapy, surgical excision and manipulation under anesthesia as well as NSAID therapy and physiotherapy.

Long-term effects on subscapularis integrity and function following arthroscopic shoulder stabilization with a low anteroinferior (5:30 o'clock) portal.

PURPOSE: The use of a low anteroinferior (5:30 o'clock) portal for arthroscopic shoulder stabilization allows an anatomical refixation of the capsulolabral complex. This anteroinferior portal, however, penetrates the inferior subscapularis (SSC), which is criticized. Therefore, the aim of the study was to evaluate the functional and structural properties of the SSC in patients with anteroinferior shoulder stabilization. The hypothesis was that it does not harm the SSC by demonstrating full muscular function and imaging-based normal structure at a long-term follow-up. METHODS: Twenty patients were examined (14 males and six females; mean age 37.0 years) retrospectively after a mean follow-up of 9.6 years. At final follow-up, clinical examination and clinical scores (ASES, Constant-Murley, WOSI, and Rowe score) were documented. Additionally, SSC strength was evaluated with a custom-made electronic force measurement plate. All patients underwent bilateral magnetic resonance imaging to assess structural integrity and fatty infiltration (grading according to Fuchs et al.) of the SSC. Furthermore, vertical and transversal (superior and inferior) diameters of the muscle and the muscle area in a parasagittal plane were measured. RESULTS: Clinical scores revealed good-to-excellent long-term results (ASES 92 points, Constant-Murley 82 points, WOSI 85 %, and Rowe 84 points). Force measurement in comparison with the contralateral side showed no significant (p > 0.05) differences for the 'belly-press' test (ipsilateral 102 N vs. contralateral 101 N) and the 'lift-off' test (73 vs. 69 N). There were also no significant differences between the mean diameters and the areas of the SSC muscle belly (vertical diameter ipsilateral 92 mm vs. contralateral 94 mm; superior transversal 28 vs. 29 mm; inferior transversal 34 vs. 34 mm; area 2336 vs. 2526 mm(2)). CONCLUSION: Arthroscopic labral repair with a low anteroinferior portal demonstrates no signs of structural and functional impairment of the SSC after 9.6 year follow-up. For clinical relevance, the lower part of the SSC can be penetrated for an optimal anchor placement in shoulder instabilities or Bankart fractures without concerns of a negative long-term effect on the SSC. LEVEL OF EVIDENCE: Case series, Level IV.

Structural and biomechanical changes in shoulders of junior javelin throwers: a comprehensive evaluation as a proof of concept for a preventive exercise protocol.

PURPOSE: The purpose of this study was to develop a preventive exercise protocol based on structural and functional changes present in shoulder joints of young throwing athletes. As a proof of concept, these changes were previously evaluated in a cross-section of high-performance junior javelin throwers. METHODS: Thirteen members of the German and Bavarian junior javelin squad (mean age 17.5 ± 0.8 years) completed a systematic clinical examination, shoulder range of motion (ROM) measurement, and were scored with standardized clinical tools. 3.0 tesla magnetic resonance imaging (MRI) was conducted on both shoulders. Bilateral three-dimensional analysis of the scapulothoracic motion during multiplanar humeral elevation and isokinetic strength testing of the shoulder internal and external rotators was accomplished. Based on the findings, a preventive exercise protocol was confirmed. RESULTS: Dominant internal ROM was significantly decreased (dominant 48° ± 20° vs. non-dominant 57° ± 19°; P = 0.006) and dominant external ROM increased (dominant 117° ± 15° vs. non-dominant 107° ± 10°; P = 0.008). MRI revealed posterosuperior intraosseous cysts of the humeral head with a size larger than >3 mm in 69 % of the dominant shoulders and only in 15 % in the non-dominant shoulders. Motion analysis of the static scapular resting position was significantly different between dominant and non-dominant sides regarding anterior tilt (dominant > non-dominant, mean difference 4.2°, P = 0.010) and retraction (dominant > non-dominant, mean difference 2.4°, P = 0.038). Dominant scapular anterior tilt during flexion and abduction was significantly increased (-4.3°, P = 0.006; -3.4°, P = 0.046). Dominant retraction was significantly increased during abduction (-2.3°, P = 0.040). Isokinetic outcome parameters presented nonsignificant bilateral differences. CONCLUSIONS: Elite junior javelin throwers already present structural (humeral intraosseous cysts) and biomechanical changes (ROM deficits and asymmetric scapulothoracic motion patterns), even if they have no history of major shoulder pain or injury. A novel exercise protocol was developed in order to address the complex of alterations in a comprehensive way. Preventive diagnostics in combination with a systematic all-year preventive exercise intervention might be one option to detect and control risk factors of a symptomatic throwing shoulder at an early stage. LEVEL OF EVIDENCE: IV.

Multidirectional Instability of the Shoulder: A Systematic Review.

PURPOSE: To analyze outcomes of surgical and conservative treatment options for multidirectional instability (MDI). METHODS: A systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. A comprehensive search of the PubMed, MEDLINE, CINAHL, Cochrane, EMBASE, and Google Scholar databases using various combinations of the keywords "shoulder," "multidirectional instability," "dislocation," "inferior instability," "capsulorrhaphy," "capsular plication," "capsular shift," "glenoid," "humeral head," "surgery," and "glenohumeral," over the years 1966 to 2014 was performed. RESULTS: Twenty-four articles describing patients with open capsular shift, arthroscopic treatment, and conservative or combined management in the setting of atraumatic MDI of the shoulder were included. A total of 861 shoulders in 790 patients was included. The median age was 24.3 years, ranging from 9 to 56 years. The dominant side was involved in 269 (58%) of 468 shoulders, whereas the nondominant side was involved in 199 (42%) shoulders. Patients were assessed at a median follow-up period of 4.2 years (ranging from 9 months to 16 years). Fifty-two of 253 (21%) patients undergoing physiotherapy required surgical intervention for MDI management, whereas the overall occurrence of redislocation was seen in 61 of 608 (10%) shoulders undergoing surgical procedures. The redislocation event occurred in 17 of 226 (7.5%) shoulders with open capsular shift management, in 21 of 268 (7.8%) shoulders with arthroscopic plication management, in 12 of 49 (24.5%) shoulders undergoing arthroscopic thermal shrinkage, and in 11 of 55 (22%) shoulders undergoing arthroscopic laser-assisted capsulorrhaphy. CONCLUSIONS: Arthroscopic capsular plication and open capsular shift are the best surgical procedures for treatment of MDI after failure of rehabilitative management. Arthroscopic capsular plication shows results comparable to open capsular shift. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.