Anconeus-sparing minimally invasive approach for lateral ulnar collateral ligament reconstruction using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow.

BACKGROUND: Surgical treatment helps to restore stability of the elbow in patients with posterolateral rotatory instability (PLRI). The anconeus muscle is one of the most important active stabilizers against PLRI. A minimally invasive anconeus-sparing approach for lateral ulnar collateral ligament (LUCL) reconstruction using a triceps tendon autograft has been previously described. The purpose of this study was to evaluate the outcome of this intervention and identify risk factors that influenced the clinical and patient-reported outcomes. METHODS: Sixty-one patients with chronic PLRI and no previous elbow surgery who underwent surgical reconstruction of the LUCL using a triceps tendon autograft in a minimally invasive anconeus-sparing approach during 2012 and 2018 were evaluated. Outcome measures included a clinical examination and the Oxford Elbow Score (OES) and the Mayo Elbow Performance Score (MEPS) questionnaires. Subjective patient outcomes were evaluated with the visual analog scale (VAS) for pain and the Subjective Elbow Value (SEV). Integrity of the common extensor tendons and centering of the radial head were assessed preoperatively on standardized magnetic resonance images (MRIs). RESULTS: Fifty-two patients were available at final follow-up. The mean age of patients was 51 ± 12 years with a mean follow-up of 53 ± 14 months (range 20-76). Clinical examination after surgery (n = 41) showed no clinical signs of instability in 98% of the patients (P < .001) and a nonsignificant improvement in range of motion. OES, MEPS, and VAS scores averaged 40 ± 10 of 48 points, 92 ± 12 of 100 points, and 1 ± 2 points, respectively, all corresponding with good or excellent outcomes. The SEV was 88%, indicating very high satisfaction with the surgery. Only 1 patient had revision surgery due to pain, and there were no reported postoperative complications in this cohort. A radial head subluxation in the MRI correlated significantly with worse postoperative outcomes. CONCLUSIONS: The anconeus-sparing minimally invasive technique for posterolateral stabilization of the elbow using a triceps tendon autograft is an effective and safe treatment for chronic posterolateral instability of the elbow with substantial improvements in elbow function and pain relief with a very low rate of persistent clinical instability.

Biomechanical Stability of Lateral Ulnar Collateral Ligament Reconstruction and Repair of the Elbow: The Role of Ligament Bracing on Gap Formation and Stabilization.

BACKGROUND: Augmented (internal braced) lateral ulnar collateral ligament (LUCL) repair has been biomechanically compared with reconstruction techniques in the elbow. However, LUCL repair alone has not yet been compared with augmented repair and reconstruction techniques. HYPOTHESIS: Internal bracing of LUCL repair would improve time-zero stabilization regarding gap formation, stiffness, and residual torque as compared with repair alone and reconstruction techniques to restore native elbow stability. STUDY DESIGN: Controlled laboratory study. METHODS: Overall, 24 cadaveric elbows were used for either internal braced LUCL repair (Repair-IB) or single- and double-strand ligament reconstruction with triceps (Recon-TR) and palmaris longus tendon graft (Recon-PL), respectively. Laxity testing in external rotation was consecutively performed at 90° of elbow flexion on the intact, dissected, and repaired conditions and with the previously assigned techniques. First, intact elbows were loaded to 7.0-N·m external torque to evaluate time-zero ligament rotations at 2.5, 4.0, 5.5, and 7.0 N·m. Rotation-controlled cycling was performed (total of 1000 cycles) for each surgical condition. Gapping, stiffness, and residual torque were analyzed. Finally, these and 8 additional intact elbows underwent torque-to-failure testing (30 deg/min). RESULTS: The dissected state showed the highest gap formation and lowest peak torques (P < .001). While gap formation of Repair-IB (P < .021) was significantly lower than that of repair without internal bracing at all rotation levels, gaps of Recon-PL were similar to and Recon-TR were significantly higher than those of Repair-IB except for the highest torsion level. Residual peak torques at specific rotation angles between native state and Recon-TR (α2.5), Recon-PL (α4.0), and Repair-IB (α5.5) were similar; all other comparisons were significantly different (P < .027). Torsional stiffness of Repair-IB was significantly higher at all rotation angles measured. Analysis of covariance showed significantly less gap formation over residual peak torques for Repair-IB (P < .001) as compared with all other groups. The native state failure load was significantly higher than Recon-PL and Recon-TR failure loads, with similar stiffness to all other groups. CONCLUSION: Repair-IB and Recon-PL of the LUCL showed increased rotational stiffness relative to the intact elbow for restoring posterolateral stability to the native state in a cadaveric model. Recon-TR demonstrated lower residual peak torques but provided near-native rotational stiffness. CLINICAL RELEVANCE: Internal bracing of LUCL repair may reduce suture-tearing effects through tissue and provide sufficient stabilization for healing throughout accelerated and reliable recovery without the need for a tendon graft.

Infraspinatus shift for massive, posterosuperior tears yields good clinical outcome.

AIM: To evaluate the functional outcome of partial reconstruction margin convergence in the treatment of massive, irreparable posterosuperior rotator cuff tear (RCT). METHODS: This retrospective, single-center study included all patients that were operated by means of a partial repair and infraspinatus shift for a massive, posterosuperior cuff tear between 2009 and 2016, either in arthroscopic or mini-open technique. Outcome measures included sex- and age-adapted Constant Score (saCS), Western Ontario Rotator Cuff (WORC) Index, Disabilities of Arm, Shoulder and Hand Scores (DASH), and relative effect per patient (REPP). RESULTS: Fifty-six shoulders in 54 patients (mean age: 66 ± 7 years) were evaluated at a mean follow-up of 40 ± 9 months. The mean tear size was Bateman 3.1 ± 0.7 and Patte 2.3 ± 0.4. All clinical scores showed improvement. The saCS improved from 64.1 ± 13.4 to 90.4 ± 13.7 (p < 0.0001), the DASH score from 51.8 ± 9.4 to 10.2 ± 13.4 (p < 0.0001) and the WORC index from 47.1% ± 8.6 to 87.9% ± 13.7 (p < 0.0001). The abduction strength of the affected side (1.7 ± 1.6 kg) was not restored to the same level as the contralateral side (5.4 ± 2.7 kg, p < 0.0001). CONCLUSION: Partial cuff repair for posterosuperior, massive cuff tears yields good clinical outcome with a low rate of complications and high proportion of good and excellent responders. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Cell-based therapy of the elbow: evidence for lateral tendinopathy-a review on current treatments.

PURPOSE: Cell-based therapies are on the rise in treating intra and extraarticular pathologies, trying to avoid surgical intervention and support local repair processes. Therefore, the aim was to summarize current evidence-based treatment options for a cell-based therapy around the elbow. METHODS: Through a literature review up-to date treatment algorithms and therapies have been identified and have been rated according to their evidence level for clinical recommendation. RESULTS: Regarding the four extraarticular anatomical regions of the elbow (anterior, medial, posterior and lateral) and the joint itself, the lateral elbow and its´ tendinopathies as well as the use of cell-based treatment options have been extensively studied and, therefore, allow for clear and evidence-based recommendations. The remaining three regions as wells as the intraarticular application do not show enough evidence for a clinical recommendation. CONCLUSION: In conclusion the cell-based approach for treating elbow pathologies can only be recommended for the lateral elbow, as there has been shown sufficient evidence for the extraarticular application. It has to be mentioned, that the results from the lateral elbow maybe transferred to other extra-articular tendinopathies, as the lack of evidence may be due to the rare appearance of posterior, medial and anterior tendon affection. No recommendation can be given for intra-articular use. LEVEL OF EVIDENCE: IV.

Cement pressurizing reduces radiolucent lines at glenoid: A randomized, multicentric study.

BACKGROUND: The hypothesis of this study is that cement pressurization into the glenoid reduces the rate of radiolucent lines in total shoulder arthroplasty in the mean 25.5 months after the operation. METHODS: To examine this effect, a multicentric prospective randomized study (level of evidence 1) was initiated: one group (group P, n = 24) received intraoperative pressurization of cement into the cancellous bone of the glenoid, the other cement without pressure (group NoP, n = 27). Inclusion criteria were an osteoarthritis with glenoid erosion <15° and an intact rotator cuff. RESULTS: There were no significant differences preoperatively between the groups regarding age (mean age 66 ± 10 years (range 44-81)), gender, range of motion, scores and pathomorphology. Both groups had a significant improvement of the scores, strength, motion and satisfaction 25.5 months after the intervention. The scores were similar between the groups (ns). However, cement pressurization at the glenoid side significantly reduced the incidence of radiolucent lines (p < 0.027). CONCLUSION: This supports the use of this simple technique to improve long-term survival of total shoulder arthroplasty.Level of evidence: 1.

Comparison of Superior Capsular Reconstruction and Partial Infraspinatus Repair: A Matched-Pair Analysis of Irreparable Rotator Cuff Tears.

BACKGROUND: Superior capsular reconstruction (SCR) represents a new option for the treatment of irreparable rotator cuff tears. PURPOSE/HYPOTHESIS: This study aimed to evaluate the clinical and radiologic outcomes of SCR and compare them with the outcomes of partial repair (PR) of the infraspinatus tendon. The hypothesis was that there would be no significant differences between the clinical and radiologic outcome parameters of SCR and PR after a minimum follow-up of 2 years. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Of 21 patients who underwent SCR, 20 patients were matched in a 1:1 ratio according to sex, age, and tear configuration with 20 of 60 patients who had undergone PR; all patients were prospectively evaluated for a minimum follow-up of 2 years. The investigated outcome measures included the Constant score; Western Ontario Rotator Cuff (WORC) index; Disabilities of the Arm, Shoulder and Hand (DASH) score; and radiologic analysis of acromiohumeral distance (AHD) and humeral head centralization (HHC). RESULTS: There were no differences in the demographic data between the SCR and PR groups. The mean age of both groups was 62.3 years (range, 47-79 years), the mean tear configuration was Bateman 3.0 and Patte 2.8, and the mean follow-up period was 29.4 months (range, 24-53 months). At final follow-up, no significant differences were seen between the SCR and PR groups with regard to Constant score (77.1 vs 82.7), age- and sex-adapted Constant score (85.5% vs 91.4%), DASH score (15.6 vs 7.8), or WORC index (81.1 vs 90.4). No significant differences in the AHD or HHC were seen between the groups. The reoperation rate was 4.8% (1/21) in the SCR cohort and 15% (9/60) in the PR cohort. CONCLUSION: Both SCR and PR resulted in significant improvements in patient-reported outcomes at 2-year follow-up, with no significant differences in clinical outcomes between the 2 techniques. Further follow-up is needed to determine whether there are long-term differences in HHC and development of cuff tear arthropathy. Further investigations should also focus on the cost-effectiveness of the respective procedures.

Immobilization in External Rotation and Abduction Versus Arthroscopic Stabilization After First-Time Anterior Shoulder Dislocation: A Multicenter Randomized Controlled Trial.

BACKGROUND: Treatment of first-time shoulder dislocation (FSD) is a topic of debate. After high rates of recurrent instability after nonoperative management were reported in the literature, primary repair of FSD significantly increased. At the same time, new concepts were proposed that had promising results for immobilization in external rotation (ER) and abduction (ABD). PURPOSE: The aim of this study was to evaluate the recurrence rates (primary outcome) and clinical outcomes (secondary outcome parameters) of immobilization in ER+ABD versus arthroscopic primary stabilization after FSD. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: In a multicenter randomized controlled trial, patients with FSD were randomized to either treatment with immobilization in 60° of ER plus 30° of ABD (group 1) or surgical treatment with arthroscopic Bankart repair (group 2). Clinical evaluation was performed 1, 3, and 6 weeks as well as 6, 12, and 24 months postoperatively or after reduction, including range of motion, instability testing, subjective shoulder value, Constant-Murley score, Rowe score, and Western Ontario Shoulder Instability Index. Recurrent instability events were prospectively recorded. RESULTS: Between 2011 and 2017, a total of 112 patients were included in this study. Of these, 60 patients were allocated to group 1 and 52 to group 2. At the 24-month follow-up, 91 patients (81.3%) were available for clinical examination. The recurrence rate was 19.1% in group 1 and 2.3% in group 2 (P = .016). No significant differences were found between groups regarding clinical shoulder scores (P > .05). Due to noncompliance with the immobilization treatment protocol, 4 patients (6.7%) were excluded. CONCLUSION: Immobilization in ER+ABD versus primary arthroscopic shoulder stabilization for the treatment of FSD showed no differences in clinical shoulder scores. However, recurrent instability was significantly higher after nonoperative treatment.

The Loop Tenodesis Procedure-From Biomechanics to First Clinical Results.

(1) Introduction: Several surgical therapy options for the treatment of pathologies of the long biceps tendon (LHB) have been established. However, tenotomy, as well as established tenodesis techniques, has disadvantages, such as cosmetic deformities, functional impairments and residual shoulder pain. This study presents the first clinical and structural results of the recently introduced loop tenodesis procedure for the LHB, developed to overcome these issues. (2) Methods: 37 patients (11 women, 26 men, mean age 52 years), who underwent loop tenodesis of the LHB were examined six months after surgery. For the clinical evaluation the Constant score, as well as the LHB score, were used, complemented by elbow flexion and supination strength measurements. The integrity of the tenodesis construct was evaluated indirectly by sonographic detection of the LHB in the bicipital groove. (3) Results: Both, the overall Constant score as well as the LHB score showed significant improvements six months postoperatively, as compared to the preoperative value. Fourteen patients (38%) presented an examiner-dependent upper arm deformity, although only five patients (13%) reported subjective cosmetic deformities. Both, flexion and supination strength were preserved compared to the preoperative level. In 35 patients (95%), the tenodesis in the bicipital groove was proofed sonographically. (4) Conclusion: The loop tenodesis of the LHB provides good-to-excellent overall clinical results after a short-term follow-up of six month. The incidence of cosmetic deformities was inferior compared to conventional therapy options (tenotomy and anchor tenodesis).

3D-Analysis of the Proximal Humeral Anatomy Before and After Stemless Shoulder Arthroplasty-A Prospective Case Series Study.

BACKGROUND: Stemless shoulder arthroplasty (SSA) is used to anatomically reconstruct proximal humerus geometry and preserve proximal humerus bone stock. The current literature lacks 3D-analysis of pre- and postoperative proximal humeral anatomy after SSA. The aim of this study was to prospectively analyze the humeral head anatomy using a computer-assisted topography mapping technique after SSA in relation to the preoperative status and the contralateral (not affected) side. METHODS: Twenty-nine patients (mean age: 63.5 ± 11.7 years) affected by primary shoulder osteoarthritis and treated with SSA were included. Preoperative and postoperative CT scans of the affected and contralateral sites were analyzed regarding joint geometry. Clinical outcome was assessed by Constant and Disabilities of the Arm, Shoulder and Hand (DASH) score shortly before and one year after surgery. RESULTS: Clinical outcome improved significantly. No correlation between clinical outcome and the evaluated anatomical parameters was found. There was a significant decrease of the humeral head height (p < 0.01) and radius (p = 0.03) in the preoperative versus the postoperative joint geometry. The comparison to the contralateral site showed also a significant decrease of the humeral head height (p < 0.01). All other parameters showed no significant differences. CONCLUSION: Proximal humeral anatomy can be almost anatomically reconstructed by SSA. Solely the humeral head height differs significantly to the preoperative as well as contralateral morphology.

Reversed shoulder arthroplasty leads to significant histological changes of the deltoid muscle: a prospective intervention trial.

INTRODUCTION: Reverse shoulder arthroplasty (RSA) shows promising short- and mid-term results in cuff tear arthropathy. However, functional impairments are described in long-term findings. Micromorphological changes in the periarticular musculature could be in part responsible for this, but have not yet been analysed. Thus, histological changes of the deltoid muscle and their association to the functional outcome were evaluated in this study. MATERIAL AND METHODS: A total of 15 patients treated with RSA were included in this prospective study. Functional outcome was assessed using the Constant Score (CS) and the DASH (disabilities of the arm, shoulder and hand) Score before RSA and after a mean follow-up of 12 months. Deltoid muscle biopsies were harvested intraoperatively and 12 months postoperatively. Mean deltoid muscle fibre area (MMFA) was calculated histologically after haematoxylin-eosin staining. RESULTS: Postoperative shoulder function significantly improved within 12 months (CS: Δ 37.4 ± 22.6, p = 0.001; DASH: Δ 27.1 ± 29.1, p = 0.006). The MMFA significantly decreased (p = 0.02), comparing the results from the intraoperative biopsy (MMFA: 8435.8 µm2, SD ± 5995.9 µm2) to the 12 months biopsy (MMFA: 5792. µm2, SD ± 3223.6 µm2). No correlation could be found between the functional score results and MMFA. CONCLUSION: Signs of deltoid muscle changes in terms of a reduced MMFA can be detected 1 year after RSA and thus already a long time before long-term functional impairments become apparent. Further studies with larger patient series and longer follow-up periods as well as extended histological assessments and simultaneous radiological examinations are required.

Biomechanical Functional Elbow Restoration of Acute Ulnar Collateral Ligament Tears: The Role of Internal Bracing on Gap Formation and Repair Stabilization.

BACKGROUND: Biomechanical studies have compared augmented primary repair with internal bracing versus reconstruction techniques of the anterior ulnar collateral ligament (aUCL) in the elbow. However, aUCL repair alone has not been compared with augmented repair or reconstruction techniques. HYPOTHESIS: Internal bracing of aUCL repair provides improved time-zero stabilization in terms of gap formation, torsional stiffness, and residual torque compared with both repair alone and the modified docking technique, with enhanced valgus stability restoration to that of the native ligament. STUDY DESIGN: Controlled laboratory study. METHODS: We randomized 8 matched pairs of cadaveric elbows to undergo either augmented aUCL repair or a modified docking technique through use of the palmaris longus tendon. Valgus laxity testing was consecutively performed at 90° of flexion on the intact, torn, and repaired conditions as well as the previously assigned techniques. First, intact elbows were loaded up to 10 N·m valgus torque to evaluate time-zero ligament rotations at valgus moments of 2.5, 5.0, 7.5, and 10 N·m. Rotation controlled cycling was performed (total 1000 cycles) for each surgical condition. Gap formation, stiffness, and residual torque were analyzed. Finally, these elbows and 8 additional intact elbows underwent torque to failure testing (30 deg/min). RESULTS: Repair alone revealed low torsional resistance and gapping, similar to the torn state. The augmented repair technique showed significantly higher torsional stiffness (P < .001) and residual torque (P < .001) compared with all other conditions and restored native function. Although reconstruction revealed similar initial stiffness and residual torque compared with an intact ligament, a steady decrease of torsional resistance led to a completely loose state at higher valgus rotations. Analysis of covariance between all groups showed significantly less gap formation for augmented repair (P < .001). The native failure load and stiffness were significantly higher and were similar to those of augmented repair (P = .766). CONCLUSION: Internal bracing of aUCL repair restored valgus stability to the native state with statistically improved torsional resistance, loading capability, and gap formation compared with reconstruction, especially at the upper load range of native aUCL function in the elbow. CLINICAL RELEVANCE: We found that aUCL repair with an internal brace effectively improves time-zero mechanical characteristics and may provide stabilized healing with accelerated and reliable recovery without the need for a tendon graft.

Anconeus-Sparing Minimally Invasive Approach for Lateral Ulnar Collateral Ligament Reconstruction in Posterolateral Elbow Instability.

Posterolateral elbow instability with an insufficiency of the lateral ulnar collateral ligament commonly results from elbow trauma. However, other etiologies such as iatrogenic injuries after primary surgical treatment for lateral epicondylitis or repetitive corticosteroid injections also may lead to a lateral ulnar collateral ligament insufficiency. In these cases, surgical treatment can help to restore posterolateral stability of the elbow. Besides the stabilizing effect of the ligamentous structures, the anconeus muscle is the most import active stabilizer against posterolateral elbow instability. Therefore, the aim of the present technique is to present an anconeus-sparing, minimally invasive approach to restore posterolateral stability. This technique may serve as an alternative for typically used all open access.

Novel implant-free loop Tenodesis vs. simple Tenotomy of the long biceps tendon - a biomechanical investigation.

BACKGROUND: Simple tenotomy and anchor tenodesis are commonly used in treatment of long biceps tendon (LHB) pathologies. The tenotomy can result in biceps distalization or cosmetic deformities. A novel loop Tenodesis Technique (LTD) could prevent a distalization of the biceps muscle without the risk of implant associated complications. The purpose of this study was to investigate the biomechanical aspects of the novel LTD compared to a standard tenotomy of the LHB. It has been hypothesized that the novel technique will show biomechanical superiority in terms of resistance and distalization. METHODS: Seven paired adult human cadaveric shoulder joints were assigned to one of the two study groups: Loop tenodesis (LTD); simple tenotomy (STT). In both groups load-to-failure testing was performed. The load-displacement curve was used to determine the maximum load (N), the degree of distalization of the LHB (mm) and the stiffness (N/mm). Additionally, the mode of failure was registered. RESULTS: The LTD group achieved a significantly higher ultimate load to failure (LTD: 50.5 ± 12.5 N vs. STT: 6.6 ± 3.9 N; p = 0.001). Significantly less distalization of the tendon could be detected for the LTD group (LTD: 8 ± 2.3 mm vs. STT: 22.4 ± 2.4 mm; p = 0.001). Stiffness was 7.4 ± 3.9 N/mm for the LTD group and 0.23 ± 0.16 N/mm for the STT group (p = 0.001). In all specimens of the LTD group a tendon rupture was found as mode of failure, while the STT group failed because of pulling out the LHB through the bicipital groove. CONCLUSION: The novel loop Tenodesis Technique shows biomechanically higher stability as well as less distalization compared to a simple tenotomy of the long biceps tendon.

The Arthroscopic Loop Tenodesis Procedure: An Implant-Free Technique to Treat Long Biceps Tendon Pathologies.

Different surgical techniques are available to treat pathologies of the long biceps tendon. Although simple tenotomy of the tendon can result in distalization of the biceps muscle, implant-associated complications can occur after bony tendon fixation within a biceps tenodesis. This article describes the arthroscopic loop tenodesis procedure. The technique is based on an enlargement of the proximal tenotomized tendon by creating a tendon loop, which subsequently blocks itself at the entrance to the bicipital groove and prevents distalization of the biceps muscle. This procedure can be performed arthroscopically, resulting in a stable fixed tendon without an anchor or other foreign materials, and might be suitable for young and old patients with biceps tendon pathologies.

The throwing shoulder in youth elite handball: soft-tissue adaptations but not humeral retrotorsion differ between the two sexes.

PURPOSE: In youth handball players, knowledge about the development of soft-tissue adaptation and humeral retrotorsion is limited. The purpose of this study was to investigate differences in adaptations in the glenohumeral rotational range of motion and humeral retrotorsion of the throwing arm between male and female youth elite handball players. METHODS: One-hundred and thirty-eight youth elite handball players (mean age: 14.1 ± 0.7 years) were assessed for glenohumeral external (ER) and internal (IR) rotational ranges of motion and humeral retrotorsion (HRT) by means of a manual goniometer and a portable ultrasound device. Sports-specific adaptations between the dominant and non-dominant shoulders and between male and female adolescents were calculated. RESULTS: Handball players showed side-to-side differences in IR and ER in the throwing shoulder. HRT did not correlate with the measurements of rotational ROM of the throwing arm. Male athletes showed a more pronounced glenohumeral internal rotation deficit than female athletes (13.1° ± 22.8° vs. 5.1° ± 14.0°, p = 0.014). Adaptations in HRT but no sex differences could be seen in the throwing shoulder (16.5° ± 9.6°) compared to the non-throwing shoulder (13.5° ± 9.4°, p < 0.001). CONCLUSION: Loss of internal rotation and gain in external rotation in youth handball players seem to be more related to adaptive changes in the soft-tissues than to HRT. Male athletes showed stronger throwing-related adaptations in the rotational range of motion but not in humeral torsion in their dominant shoulder than female athletes. LEVEL OF EVIDENCE: Cross-sectional study, Level II.

Repair and augmentation of the lateral collateral ligament complex using internal bracing in dislocations and fracture dislocations of the elbow restores stability and allows early rehabilitation.

PURPOSE: Most elbow dislocations can be treated conservatively, with surgery indicated in special circumstances. Surgical options, apart from fracture fixation, range from repair or reconstruction of the damaged ligaments to static external fixation, usually entailing either a long period of immobilization followed by carefully monitored initiation of movement or dynamic external fixation. In general, no consensus regarding surgical treatment has been reached. A new method of open ligament repair and augmentation of the lateral ulnar collateral ligament using a non-absorbable suture tape in cases of acute and subacute elbow instability following dislocations has been described here, which allows an early, brace-free initiation of the full range of motion. This is the first description of the technique of internal bracing of the lateral elbow with preliminary patient outcome parameters for acute treatment of posterolateral rotatory instability. METHODS: Seventeen patients (14 males and 3 females) with acute or subacute posterolateral elbow instability as a result of dislocation or fracture dislocation were treated in our centre (Sporthopaedicum, Straubing, Regensburg, Germany) from 2014 to 2015 with open LUCL re-fixation and non-absorbable suture tape augmentation. The elbows were actively mobilized immediately after the operation and a maximum bracing period of 3 days. RESULTS: At 10 month median follow-up, none of the patients showed clinically apparent signs of instability or suffered subluxation or re-dislocation. One patient required re-operation for heterotopic ossification. The median range of motion was from 10° (0-40) to 130° (90-50) and median Oxford, Mayo Elbow Performance score, Simple Elbow Value, and DASH Scores were 41(29-48), 100 (70-100), 83% (60-95), and 18.5 (1.6-66), respectively. All patients reported a complete return to pre-injury level of activity. CONCLUSION: Augmentation with a non-absorbable suture tape acting as an 'Internal Brace' following an elbow dislocation is a safe adjunct to primary ligament repair and may allow the early mobilization and recovery of elbow stability and range of motion. LEVEL OF EVIDENCE: IV.

Surgical revision of radial head fractures: a multicenter retrospective analysis of 466 cases.

BACKGROUND: Radial head fractures lead to persisting disability in a considerable number of cases. This study aimed to investigate their most common revision causes and procedures. METHODS: This multicenter retrospective study reviewed the cases of 466 adult patients who had undergone surgical revision after operative or nonoperative treatment of a radial head fracture. The initial diagnosis was a Mason type I fracture in 13.0%, Mason type II fracture in 14.6%, Mason type III fracture in 22.8%, Mason type IV fracture in 20.9%, terrible-triad injury in 12.8%, Monteggia-like lesion in 13.1%, and Essex-Lopresti lesion in 2.0%. Initial treatment was nonoperative in 30.2%, open reduction and internal fixation (ORIF) in 44.9%, radial head arthroplasty in 16.6%, radial head resection in 3.7%, sole treatment of concomitant injuries in 2.6%, and fragment excision in 2.0%. Up to 3 revision causes and procedures were recorded per case. RESULTS: The most common complications were stiffness (67.4%), instability (36.5%), painful osteoarthritis (29.2%), ORIF related (14.8%), nonunion or necrosis (9.2%), radial head arthroplasty related (7.5%), ulnar neuropathy (6.0%), and infection (2.6%). Revision procedures frequently included arthrolysis (42.1%), arthroplasty (24.9%), implant removal (23.6%), ligament repair or reconstruction (23.0%), débridement (14.2%), repeated ORIF (8.2%), and/or radial head resection (7.7%). Mason type I or II fractures were primarily revised because of stiffness and painful osteoarthritis. Complications after Mason type III fractures were predominantly ORIF related. Fracture-dislocations showed a wide range of complications, with instability and stiffness comprising the most common causes of revision. CONCLUSIONS: The complications of radial head fractures are characteristic to their classification. Knowledge of these findings might guide surgeons in treating these injuries and may help counsel patients accordingly.

Reverse shoulder arthroplasty: the role of physical therapy on the clinical outcome in the mid-term to long-term follow-up.

INTRODUCTION: Reverse shoulder arthroplasty shifts the rotational center of the shoulder joint caudally and medially to restore shoulder function in a rotator cuff deficient shoulder. Despite promising results in early- and mid-term follow-up, long-term loss in shoulder function has been described in the literature. A lack of exercise in elderly patients may be one reason for this loss in function. This study examines the functional benefits of physical therapy in the mid-term to long-term follow-up regarding the subjective and objective shoulder function. MATERIALS AND METHODS: Twenty patients with a mean age of 73 years were included in this series. The study was performed as a single-center, prospective study. Initial indications for reverse shoulder arthroplasty were cuff tear arthropathy, failed anatomical shoulder arthroplasty, and fracture sequelae. The patients were clinically examined at a mean follow-up of 62 months using the Constant score (CS) and the DASH score for the operated and the non-operated shoulder. They were reevaluated using the same scores following a standardized physical therapy program of 6 weeks' duration. RESULTS: The mean CS as well as the mean age- and gender-adjusted CS of the affected shoulder improved significantly from 53.5 to 59.3 points, and 72.7-80.8%, respectively. The subcategories activities of daily living (ADL) and range of motion (ROM) of the CS improved significantly, whereas no significant improvement was observed for the subcategories pain and strength. Evaluating the contralateral shoulder, no significant change was observed for the age- and gender-adjusted CS and the CS as well as its subcategories. We found no significant difference in the CS comparing the different etiologies prior to physical therapy. DISCUSSION: Physical therapy plays an important role subsequent to reverse shoulder arthroplasty. It also has an effect in the mid-term to long-term follow-up regarding the range of motion as well as activities of daily living. However, physical therapy seems to have limited effect on the strength and the residual pain level. LEVEL OF EVIDENCE: Level III.

Reverse shoulder arthroplasty: the role of physical therapy on the clinical outcome in the mid-term to long-term follow-up.

INTRODUCTION: Reverse shoulder arthroplasty shifts the rotational center of the shoulder joint caudally and medially to restore shoulder function in a rotator cuff deficient shoulder. Despite promising results in early- and mid-term follow-up, long-term loss in shoulder function has been described in the literature. A lack of exercise in elderly patients may be one reason for this loss in function. This study examines the functional benefits of physical therapy in the mid-term to long-term follow-up regarding the subjective and objective shoulder function. MATERIALS AND METHODS: Twenty patients with a mean age of 73 years were included in this series. The study was performed as a single-center, prospective study. Initial indications for reverse shoulder arthroplasty were cuff tear arthropathy, failed anatomical shoulder arthroplasty, and fracture sequelae. The patients were clinically examined at a mean follow-up of 62 months using the Constant score (CS) and the DASH score for the operated and the non-operated shoulder. They were reevaluated using the same scores following a standardized physical therapy program of 6 weeks' duration. RESULTS: The mean CS as well as the mean age- and gender-adjusted CS of the affected shoulder improved significantly from 53.5 points to 59.3 points, and 72.7-80.8%, respectively. The subcategories activities of daily living and range of motion of the CS improved significantly, whereas no significant improvement was observed for the subcategories pain and strength. Evaluating the contralateral shoulder, no significant change was observed for the age- and gender-adjusted CS and the CS as well as its subcategories. We found no significant difference in the CS comparing the different etiologies prior to physical therapy. DISCUSSION: Physical therapy plays an important role subsequent to reverse shoulder arthroplasty. It also has an effect in the mid-term to long-term follow-up regarding the range of motion as well as activities of daily living. However, physical therapy seems to have limited effect on the strength and the residual pain level. LEVEL OF EVIDENCE: Level III.

Local rhBMP-12 on an Absorbable Collagen Sponge as an Adjuvant Therapy for Rotator Cuff Repair-A Phase 1, Randomized, Standard of Care Control, Multicenter Study: Part 2-A Pilot Study of Functional Recovery and Structural Outcomes.

BACKGROUND: The high failure rate of rotator cuff repairs requires the development of methods to enhance healing at the tendon-bone junction of the repair site. PURPOSE: To assess functional recovery and structural outcomes in detail after implanting recombinant human bone morphogenetic protein-12 (rhBMP-12)/absorbable collagen sponge (ACS) as adjuvant treatment during open rotator cuff repair in patients over a 1-year postoperative follow-up. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: A total of 20 patients were randomized into 2 groups, rhBMP-12/ACS and standard-of-care (SOC) control, with 16 and 4 patients, respectively. The patients underwent open repair of a rotator cuff tear at least 2 to 4 cm wide; in the rhBMP-12/ACS group, this was augmented with a bioscaffold containing rhBMP-12. Follow-up assessments were conducted with a 100-mm visual analog scale (VAS) for pain and active and passive ranges of motion (ROMs) including forward flexion, elevation in the scapular plane, abduction, and external rotation at 12, 16, 26, 39, and 52 weeks after surgery; isometric strength in scapular abduction and external rotation at 16, 26, 39, and 52 weeks; and magnetic resonance imaging (MRI) at 12 and 52 weeks. RESULTS: The mean VAS score decreased from 37.9 mm preoperatively to 13.8 mm at week 52, and ROM and isometric strength recovered at week 52 in the rhBMP-12/ACS group. The mean VAS score decreased from 48.3 mm preoperatively to 1.5 mm at week 52, and ROM (excluding external rotation) and isometric strength recovered by week 52 in the SOC control group. Of the 16 patients in the rhBMP-12/ACS group, 14 showed an intact repair at week 12; the MRI scans of the other 2 patients could not be evaluated because of artifacts. In the SOC control group, 1 patient showed repair failure. At week 52, 14 repairs in the rhBMP-12/ACS group and 2 repairs with available MRI scans in the SOC control group remained intact. CONCLUSION: Functional recovery and structural outcomes in patients in whom rhBMP-12/ACS was used as adjuvant therapy in rotator cuff repair justify conducting future, larger, multicenter, prospective studies. REGISTRATION: NCT00936559, NCT01122498 (ClinicalTrials.gov identifier).