Treating pathological metastatic fractures of the humerus by compound osteosynthesis: a retrospective cohort study.

Background: The number of malignant tumors is increasing as are bone metastases, such as those in the humerus. Arm function is important for an independent everyday life. In this study, compound osteosynthesis of metastatic fractures of the humerus is examined for its suitability in light of the competing risk of death. Methods: This retrospective monocentric study includes a cohort of tumor patients who underwent primary compound osteosynthesis for pathological humeral fractures. The main endpoint was the continued existence of compound osteosynthesis using competing risk analysis to contrast failure and death. Failure was defined as mechanical failure of the osteosynthesis construct like refracture or plate-and-screw dislocation or loosening, which provides an indication for reintervention. Other complications are also described. Results: We included 36 consecutive patients (64% male, mean age: 71.6 yr) from September 2007 to October 2020. In 58% of the cases, the left humerus was fractured. Lung carcinoma was the most common cause of bone metastases (27.8%). Compound osteosynthesis was performed with a median delay of 5 days after diagnosis of the pathologic fracture. Postoperative complications occurred in 7 of the 36 patients (19.4%): radial nerve palsy (n = 3), postoperative hematoma (n = 2), refracture (n = 2), and screw loosening (n = 1). Few mechanical failures (8.3%) occurred within the first year; only 1 patient needed revision of the osteosynthesis (2.8%). Median patient survival after compound osteosynthesis was 26.6 weeks. Competing risk analysis showed that for up to 2 years, the risk of death is clearly dominant over the risk of osteosynthesis failure from surgery. Conclusion: Our study shows that compound osteosynthesis of the humerus is a suitable option for patients with pathologic humerus fractures. Compound osteosynthesis of the humerus usually survives the duration of malignant tumor disease.

[Sleep behavior after reverse shoulder replacement in comparison to a healthy control group : An exploratory cross-sectional study]. / Schlafverhalten von Personen nach Implantation einer inversen Schulterprothese im Vergleich zu einer gesunden Kontrollgruppe : Eine explorative Querschnittsstudie.

BACKGROUND: Individuals with shoulder pathologies frequently report sleep problems. Improving sleep quality is a treatment focus of shoulder arthroplasty. So far, it is unclear whether altered anatomy and biomechanics in reversed total shoulder arthroplasty affect sleep quality in the long term. In addition to a subjective evaluation, a reliable assessment can be obtained by recording objective sleep parameters. With the help of actigraphy, body movements are registered and divided into active and inactive phases by means of threshold values. Thanks to the valid correspondence with waking and sleeping phases, the calculation of objective sleep parameters is successful. OBJECTIVES: The aims of the study were to investigate whether objective sleep parameters differ in persons with reversed total shoulder arthroplasty (RTSA) 1 year postoperatively compared to a healthy control group and to explore what the reasons are. MATERIAL AND METHODS: The present work is an exploratory cross-sectional study with one measurement time point. 29 study participants (15 in the RTSA-group, 14 in the control group) collected objective sleep parameters and body position data during seven nights using actigraphy. The Mann-Whitney-U test was used for the mean comparison of sleep parameters. In addition, reasons for wakefulness were explored. RESULTS AND CONCLUSIONS: The groups showed no significant differences in all objective sleep parameters with nearly identical sleep efficiency (p = 0.978). In the RTSA-group, 11% lay on the operated side and 65% on the back. This is just above the significance level compared to the control group with 45% in the supine position (p = 0.056). The increased use of the supine position could promote sleep-related medical conditions such as sleep apnoea and requires further research.

Reversed total shoulder arthroplasty for rotator cuff arthropathy is associated with increased scapulothoracic motion: A longitudinal two-year kinematic study.

BACKGROUND: Reversed total shoulder arthroplasty (RTSA) is a standard surgical procedure for the treatment of rotator cuff tear arthropathy (CTA), aimed at restoring active arm elevation. Shoulder elevation relies on both scapulothroacic (ST) and glenohumeral (GH) motion, but RTSA computer planning primarily focuses on the GH joint due to challenges in visualizing scapulothroacic (ST) motion. RESEARCH QUESTION: Does the scapulohumeral rhythm, by means of the relative contributions of ST rotation and GH elevation per degree of arm elevation, in a longitudinal setting for up to two years postoperatively after RTSA for CTA change? METHODS: In a prospective longitudinal study, shoulder kinematics were studied in 20 patients (22 shoulders) before and at three, six, 12, and 24 months after RTSA implantation for CTA. Skin markers were tracked using 3D motion analysis. The relative ST and GH contributions per degree of arm elevation were assessed and were compared using statistical non-parametric mapping with Bayesian inference. RESULTS: Mean arm elevation was 89 ± 33° preoperatively, 135 ± 28° at 3 months, 161 ± 20° at 6 months, 169 ± 18° at 12 months, and 165 ± 19° at 24 months. Between 48-66°, 62-93°, 53-94°, 60-97° and 72-104° of arm elevation at the measurement time points pre, 3-months, 6-months, 12-months and 24-months postoperatively, respectively, the ST rotation had a significantly greater contribution to arm elevation compared to GH elevation; a pattern that was not found in controls. SIGNIFICANCE: While RTSA successfully restored active arm elevation through improved GH and ST motion, the scapulohumeral rhythm exhibited a consistent pattern up to two years postoperatively, resembling the preoperative state. In the midrange of motion, ST rotation dominated over GH elevation, potentially contributing to muscular fatigue and explaining the documented decline in functional outcomes over time after RTSA. The findings highlight the importance of incorporating ST kinematics into modern computer planning for RTSA.

The effects of length and width of the stem on proximal humerus stress shielding in uncemented primary reverse total shoulder arthroplasty.

INTRODUCTION: To preserve humeral bone during RTSA, stems have been made shorter and cement avoided whenever possible. However, with the increased use of uncemented RTSA, a phenomenon comparable to the stress shielding of the hip has been described for the proximal humerus. The aim of this study was to investigate the influence of stem length and width on proximal humeral bone resorption after primary uncemented RTSA. MATERIALS AND METHODS: The prospective shoulder arthroplasty database of our institution was reviewed for all primary uncemented RTSAs from 2017 to 2020 in osteoarthritis and cuff tear arthropathy cases with > 2-year follow-up. We compared the clinical and the radiographic 2-year outcome of the short and standard length stems of the same prosthesis design. This allowed us to assess the effects of stem length and width with regard to stress shielding. Furthermore, we defined a cut-off value for the filling ratios to prevent stress shielding. RESULTS: Fifty patients were included in the analysis, nineteen were in the short stem group (SHORT) and thirty-one in the standard stem group (STANDARD). After 2 years, SHORT showed a relative Constant Score of 91.8% and STANDARD of 98.3% (p = 0.256). Stress shielding was found in 4 patients (21%) in SHORT and in 16 patients (52%) in STANDARD (p = 0.03); it occurred more frequently in patients with higher humeral filling ratios (p < 0.05). The calculated cut-off to prevent stress shielding was 0.7 (± 0.03) for the metaphyseal and distal filling ratio. CONCLUSION: While short and standard stems for RTSA have good results after 2 years, we found a significant negative effect of higher length and width of the stem with regard to stress shielding. Even though the clinical effects of stress shielding have to be assessed, short stems should be chosen with a filling ratio at the metaphyseal and distal position below 0.7. LEVEL OF EVIDENCE (A RETROSPECTIVE CASE-CONTROL STUDY): III.

Blunt rupture of the biceps brachii muscle - The "parachute injury" in a wake surfer - A case report.

Case: A 40-year-old man fell while wake surfing and his left arm got tangled in the rope. This caused a closed complete rupture of the M. biceps brachii. A primary muscle suture led to unrestricted function and excellent patient satisfaction after two years. Conclusions: The mentioned muscle rupture is a rare injury mainly described for paratroopers. As it has also been described for wakeboarding, this is the first description in wake surfing. Whereas in wakeboarding mainly experts are at risk during jumps, in wake surfing beginners are in danger and must be advised accordingly. Generally, the muscle suture leads to excellent function in these patients.

Glenoid component placement in reverse shoulder arthroplasty assisted with augmented reality through a head-mounted display leads to low deviation between planned and postoperative parameters.

BACKGROUND: Navigated augmented reality (AR) through a head-mounted display (HMD) may lead to accurate glenoid component placement in reverse shoulder arthroplasty (RSA). The purpose of this study is to evaluate the deviation between planned, intra- and postoperative inclination, retroversion, entry point, depth, and rotation of the glenoid component placement assisted by a navigated AR through HMD during RSA. METHODS: Both shoulders of 6 fresh frozen human cadavers, free from fractures or other bony pathologies, were used. Preoperative computed tomography (CT) scans were used for the 3-dimensional (3D) planning. The glenoid component placement was assisted using a navigated AR system through an HMD in all specimens. Intraoperative inclination, retroversion, depth, and rotation were measured by the system. A postoperative CT scan was performed. The pre- and postoperative 3D CT scan reconstructions were superimposed to calculate the deviation between planned and postoperative inclination, retroversion, entry point, depth, and rotation of the glenoid component placement. Additionally, a comparison between intra- and postoperative values was calculated. Outliers were defined as >10° inclination, >10° retroversion, >3 mm entry point. RESULTS: The registration algorithm of the scapulae prior to the procedure was correctly completed for all cases. The deviations between planned and postoperative values were 1.0° ± 0.7° for inclination, 1.8° ± 1.3° for retroversion, 1.1 ± 0.4 mm for entry point, 0.7 ± 0.6 mm for depth, and 1.7° ± 1.6° for rotation. The deviation between intra- and postoperative values were 0.9° ± 0.8° for inclination, 1.2° ± 1.1° for retroversion, 0.6 ± 0.5 mm for depth, and 0.3° ± 0.2° for rotation. There were no outliers between planned and postoperative parameters. CONCLUSION: In this study, the use of a navigated AR system through an HMD for RSA led to low deviation between planned and postoperative values and between intra- and postoperative parameters.

Demographic changes and surgery caseloads for hip arthroplasty over the last 50 years: a retrospective study.

AIMS OF THE STUDY: Data on the demographic changes over time for hip arthroplasty are rare in Switzerland. The aim of the study was to evaluate the influence of these changes on the distribution of age, gender, operated hip side, place of residence and caseload per surgeon over the last 50 years of hip arthroplasty at the Kantonsspital St. Gallen. METHODS: For this retrospective explorative study, data were collected from the operating theatre journals of hip replacements performed at Kantonsspital St. Gallen from 1969 to 2019. Every fifth year was included, which resulted in 5-year sampling rate over the observation period. The journals were handwritten until 1999 and digital from 2004 to 2019. The following data were obtained: age, sex, type of hip arthroplasty, side of operated hip, place of residence and name of main surgeon. Apart from overall descriptive statistics, we applied the Mann-Whitney U-test to test for differences in age and the binomial test for categorical variables. A linear regression model was applied to investigate the relationship between patients' ages and historical data of life expectancy of the Swiss population. RESULTS: We included 2,963 patients, of whom 1,318 were men (median age = 67 yr., p25 = 59 yr., p75 = 74 yr.) and 1,608 women (median age = 72 yr., p25 = 63 yr., p75 = 79 yr.). Overall, women were significantly older than men, irrespective of whether they received primary total hip arthroplasty (median age = 70 yr. vs 66 yr., p25 = 61 yr. vs 58 yr., p75 = 77 yr. vs 73 yr., p <0.001), hemiarthroplasty (median age = 84 yr. vs 78.5 yr., p25 = 78 yr. vs 71 yr., p75 = 89 yr. vs 85 yr., p <0.001) or total revision arthroplasty (median age = 71 yr. vs 70 yr., p25 = 64.25 yr. vs 63 yr., p75 = 78 yr. vs 75 yr., p = 0.036). A trend toward rising median age is evident looking at the whole period observed from 1969 to 2019. Except for women in the total revision arthroplasty group (r = 0.226), a high correlation between increasing median age of patients undergoing hip replacement and life expectancy was found (r ≥0.663). Significantly more primary total hip prostheses (p = 0.003) and hip hemiprostheses (p <0.001) were implanted in women than in men between 1969 and 2019. Overall, no significant difference in side distribution was seen in the primary total hip arthroplasty (p = 0.061), total revision arthroplasty (p = 1.000) and hemiarthroplasty (p = 0.365) group. In contrast to earlier years, most patients in recent years are operated on by high-volume surgeons (>50 operations per surgeon per year). CONCLUSIONS: Demographic changes of patients undergoing total hip replacement reflect the overall demographic changes in the Swiss population. Over the last 50 years the indication for prosthetic hip replacements has not been extended to younger ages. The caseload in hip arthroplasty has changed over the last 50 years towards high-volume surgeons.

Cemented vs. uncemented reverse total shoulder arthroplasty for the primary treatment of proximal humerus fractures in the elderly-a retrospective case-control study.

BACKGROUND: Uncemented reverse total shoulder arthroplasty (RTSA) for the primary treatment of proximal humerus fractures (PHF) in elderly patients was introduced at our institution in 2017. Recent reports have raised concerns about increased rates of early bone resorption at the proximal humerus with uncemented fracture stems. The aim of this study was to find out whether there was any difference in functional or radiographic outcomes between cemented and uncemented RTSA for PHF. METHODS: Seventeen consecutive patients who underwent uncemented RTSA (group nC) in 2017 and 2018 were age and sex matched (propensity score matching 1:2) to 34 patients with cemented RTSA implanted between 2011 and 2016 (group C) for the primary treatment of PHF. These two groups were compared in terms of clinical and radiographic outcomes at 2 years after the index surgery. RESULTS: The mean bone quality was low in both groups: in group nC the deltoid tuberosity index (DTI) was 1.43 (1.22-1.72) and in group C 1.42 (1.22-1.67). At the final 2 year follow-up, the relative CS was 98.3% (71-118) in group nC and 97.9% (36-125) in group C (p = 0.927); the absolute CS was 70.2 (49-89) in group nC and 68.0 (30-94) in group C (p = 0.509). Lucent lines at the humeral site were seen in 8 cases (47%) in group nC and in 13 cases (38%) in group C (p = 0.056). Compared to 3% in group C, all patients in group nC showed at least grade 1 and 65% showed grade 3 bone resorption at the proximal humerus (p < 0.001). CONCLUSION: Compared to cemented RTSA bone resorption at the proximal humerus was significantly more frequent in patients with uncemented RTSA for PHF. So far, this is rather a radiographic than a clinical finding, because both groups showed very satisfying functional outcomes and low revision rates at the 2 year follow-up. LEVEL OF EVIDENCE III: A retrospective case-control study.

Patient-specific instrumentation reduces deviations between planned and postosteotomy humeral retrotorsion and height in shoulder arthroplasty.

BACKGROUND: Patient-specific instrumentation (PSI) may potentially improve humeral osteotomy in shoulder arthroplasty. The purpose of this study was to compare the deviation between planned and postosteotomy humeral inclination, retrotorsion, and height in shoulder arthroplasty, using PSI vs. standard cutting guides (SCG). METHODS: Twenty fresh-frozen cadaveric specimens were allocated to undergo humeral osteotomy using either PSI or SCG, such that the 2 groups have similar age, gender, and side. Preosteotomy computed tomography (CT) scan was performed and used for the 3-dimensional (3D) planning. The osteotomy procedure was performed using a PSI designed for each specimen or an SCG depending on the group. A postosteotomy CT scan was performed. The preosteotomy and postosteotomy 3D CT scan reconstructions were superimposed to calculate the deviation between planned and postosteotomy inclination, retrotorsion, and height. Outliers were defined as cases with 1 or more of the following deviations: >5° inclination, >10° retrotorsion, and >3 mm height. The deviation and outliers in inclination, retrotorsion, and height were compared between the 2 groups. RESULTS: The deviations between planned and postosteotomy parameters were similar among the PSI and SCG groups for inclination (P = .260), whereas they were significantly greater in the SCG group for retrotorsion (P < .001) and height (P = .003). There were 8 outliers in the SCG group, compared with only 1 outlier in the PSI group (P = .005). Most outliers in the SCG group were due to deviation >10° in retrotorsion. CONCLUSION: After 3D planning, PSI had less deviation between planned and postosteotomy humeral retrotorsion and height, relative to SCG.

Osteochondral Shearing Fracture of the Humeral Head Associated with Traumatic Anterior Shoulder Dislocation: A Case Report.

CASE: Osteochondral shearing fracture of the humeral head after an anterior shoulder dislocation is a condition that has rarely been reported in literature. We report a case of a large posteriorly located fragment of such a fracture in a 23-year-old man. We performed open reduction and internal fixation with resorbable pins through a deltopectoral approach and subscapularis tenotomy. CONCLUSION: In our case of a large osteochondral fracture of the posterior humeral head, treatment by open reduction and internal fixation showed an excellent radiographic result at 1 year and clinical result up to 5 years postoperatively.

Outcomes of Management of Proximal Humeral Fractures with Patient-Specific, Evidence-Based Treatment Algorithms.

BACKGROUND: Previous studies have identified risk factors for different types of treatment of proximal humeral fracture (PHF) and allowed the development of a patient-specific, evidence-based treatment algorithm with the potential of improving overall outcomes and reducing complications. The purpose of this study was to evaluate the results and complications of treating PHF using this algorithmic approach. METHODS: All patients with isolated PHF between 2014 and 2017 were included and prospectively followed. The initial treatment algorithm (Version 1 [V1]) based on patients' functional needs, bone quality, and type of fracture was refined after 2 years (Version 2 [V2]). Adherence to protocol, clinical outcomes, and complications were analyzed at a 1-year follow-up. RESULTS: The study included 334 patients (mean age, 66 years; 68% female): 226 were treated nonoperatively; 65, with open reduction and internal fixation (ORIF); 39, with reverse total shoulder arthroplasty (RTSA); and 4, with hemiarthroplasty. At 1 year, the preinjury EuroQol 5-Dimension (EQ-5D) values were regained (0.88 and 0.89, respectively) and the mean relative Constant Score (CS) and Subjective Shoulder Value (SSV) (and standard deviation [SD]) were 96% ± 21% and 85% ± 16%. Overall complications and revision rates were 19% and 13%. Treatment conforming to the algorithm outperformed non-conforming treatment with respect to relative CS (97% versus 88%, p = 0.016), complication rates (16.3% versus 30.8%, p = 0.014), and revision rates (10.6% versus 26.9%, p < 0.001). CONCLUSIONS: Treating PHF using a patient-specific, evidence-based algorithm restored preinjury quality of life as measured with the EQ-5D and approximately 90% normal shoulders as measured with the relative CS and the SSV. Adherence to the treatment algorithm was associated with significantly better clinical outcomes and substantially reduced complication and revision rates. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Swiss-wide multicentre evaluation and prediction of core outcomes in arthroscopic rotator cuff repair: protocol for the ARCR_Pred cohort study.

INTRODUCTION: In the field of arthroscopic rotator cuff repair (ARCR), reporting standards of published studies differ dramatically, notably concerning adverse events (AEs). In addition, prognostic studies are overall methodologically poor, based on small data sets and explore only limited numbers of influencing factors. We aim to develop prognostic models for individual ARCR patients, primarily for the patient-reported assessment of shoulder function (Oxford Shoulder Score (OSS)) and the occurrence of shoulder stiffness 6 months after surgery. We also aim to evaluate the use of a consensus core event set (CES) for AEs and validate a severity classification for these events, considering the patient's perspective. METHODS AND ANALYSIS: A cohort of 970 primary ARCR patients will be prospectively documented from several Swiss and German orthopaedic clinics up to 24 months postoperatively. Patient clinical examinations at 6 and 12 months will include shoulder range of motion and strength (Constant Score). Tendon repair integrity status will be assessed by ultrasound at 12 months. Patient-reported questionnaires at 6, 12 and 24 months will determine functional scores (subjective shoulder value, OSS), anxiety and depression scores, working status, sports activities, and quality of life (European Quality of Life 5 Dimensions 5 Level questionnaire). AEs will be documented according to a CES. Prognostic models will be developed using an internationally supported regression methodology. Multiple prognostic factors, including patient baseline demographics, psychological, socioeconomic and clinical factors, rotator cuff integrity, concomitant local findings, and (post)operative management factors, will be investigated. ETHICS AND DISSEMINATION: This project contributes to the development of personalised risk predictions for supporting the surgical decision process in ARCR. The consensus CES may become an international reference for the reporting of complications in clinical studies and registries. Ethical approval was obtained on 1 April 2020 from the lead ethics committee (EKNZ, Basel, Switzerland; ID: 2019-02076). All participants will provide informed written consent before enrolment in the study. TRIAL REGISTRATION NUMBER: NCT04321005. PROTOCOL VERSION: Version 2 (13 December 2019).

Outcomes of intra-articular calcaneal fractures: surgical treatment of 114 consecutive cases at a maximum care trauma center.

BACKGROUND: The aim of this retrospective monocentric study was to investigate the outcomes of surgically treated intra-articular calcaneus fractures in a maximum care trauma center. METHODS: One hundred forty patients who had undergone surgery for intra-articular calcaneal fractures between 2002 and 2013 were included. One hundred fourteen cases with 129 fractures were eligible to participate in the study of which 80 were available for a clinical and radiological follow-up. 34 patients were followed up by telephone interview only. Outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, Short Form 36 Health Status Survey (SF-36), complications, and subsequent surgeries. RESULTS: Mean follow-up was 91 months (range 12-183). The overall complication rate was 29% (37/129 ft). Disturbed wound healing (11%) and infection (5%) occurred most commonly. Non-union (4%) only occurred in smokers (p = 0.02). A high rate of posttraumatic subtalar arthritis (77%) and need for subsequent subtalar fusion (18%) without independent risk factors for subsequent subtalar fusion was found. The revision rate was high (60%) after primary fusion. Mean AOFAS-hindfoot score was 74 (Sanders I: 99, Sanders II: 74, Sanders III: 77, Sanders IV: 70). The postoperative Boehler angle improved significantly in all subgroups (p < 0.01). Patients with a decreased Boehler angle between postoperative images and the follow-up had significantly lower AOFAS hindfoot scores (p < 0.01). CONCLUSIONS: Our data can aid decision-making in the treatment of calcaneal fractures. We advocate to use primary subtalar fusion with caution due to the high revision rate. Smoking status should always be considered. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

The Impact of Surgical Strategy and Rifampin on Treatment Outcome in Cutibacterium Periprosthetic Joint Infections.

BACKGROUND: Cutibacterium species are common pathogens in periprosthetic joint infections (PJI). These infections are often treated with ß-lactams or clindamycin as monotherapy, or in combination with rifampin. Clinical evidence supporting the value of adding rifampin for treatment of Cutibacterium PJI is lacking. METHODS: In this multicenter retrospective study, we evaluated patients with Cutibacterium PJI and a minimal follow-up of 12 months. The primary endpoint was clinical success, defined by the absence of infection relapse or new infection. We used Fisher's exact tests and Cox proportional hazards models to analyze the effect of rifampin and other factors on clinical success after PJI. RESULTS: We included 187 patients (72.2% male, median age 67 years) with a median follow-up of 36 months. The surgical intervention was a 2-stage exchange in 95 (50.8%), 1-stage exchange in 51 (27.3%), debridement and implant retention (DAIR) in 34 (18.2%), and explantation without reimplantation in 7 (3.7%) patients. Rifampin was included in the antibiotic regimen in 81 (43.3%) cases. Infection relapse occurred in 28 (15.0%), and new infection in 13 (7.0%) cases. In the time-to-event analysis, DAIR (adjusted hazard ratio [HR] = 2.15, P = .03) and antibiotic treatment over 6 weeks (adjusted HR = 0.29, P = .0002) significantly influenced treatment failure. We observed a tentative evidence for a beneficial effect of adding rifampin to the antibiotic treatment-though not statistically significant for treatment failure (adjusted HR = 0.5, P = .07) and not for relapses (adjusted HR = 0.5, P = .10). CONCLUSIONS: We conclude that a rifampin combination is not markedly superior in Cutibacterium PJI, but a dedicated prospective multicenter study is needed.

Comparing major joint injuries, interventions and late sequelae in elite male handball players with an age-matched control group.

INTRODUCTION: Handball is a contact sport which involves throwing and jumping, exposing players to serious physical stress. There is a high risk of injuries leading to possible long-term sequelae. The aim of this study was to assess the incidence of musculoskeletal injuries in elite male handball players compared with an age-matched control group. PATIENTS AND METHODS: Former elite handball players, who had played on the Swiss national team between 1980 and 1985, answered a questionnaire about injuries, surgical interventions and their current health status. A total of 34 athletes were compared with 58 age-matched volunteers, who only engaged in recreational sports or no sports at all. RESULTS: The mean age of the athletes was 58.4 years (range 52-68 years) and did not differ significantly from the mean age of the control group of 58.7 years (range 53-69 years). In the control group, 70 % engaged in recreational sports. There was no statistical difference regarding the life-long incidence of shoulder injuries and surgical interventions, sequelae or persistent shoulder pain. Athletes had more interventions after elbow injuries (0.09 vs. 0, p = 0.047), but the difference with respect to chronic pain or late sequelae was not statistically significant. For knee injuries, there were no significant differences regarding the incidence of injuries or interventions, the prevalence of secondary consequences or persistent pain. Concerning the foot and ankle, there was a significantly higher incidence of injuries (0.5 vs. 0.03, p < 0.001) and interventions (0.5 vs. 0.09, p < 0.001) in athletes, but no statistical difference regarding sequelae or persistent pain. Overall quality of life had identical ratings in both groups (athletes mean 85.9 %, controls mean 85.8 %). DISCUSSION: Top handball players did not sustain more shoulder or knee injuries than the age-matched control group. The elbow was more at risk in these top athletes, but long-term consequences appeared to be less severe. The most distinctive difference was seen in foot and ankle injuries. CONCLUSIONS: A career as an elite handball player had no adverse effect on the overall quality of life of elite handball players 25 to 30 years after retiring from professional sports.

No difference in long-term outcome between open and arthroscopic rotator cuff repair: a prospective, randomized study.

BACKGROUND: Arthroscopic rotator cuff repair techniques have almost replaced open repairs. Short- and mid-term studies have shown comparable outcomes, with no clear superiority of either procedure. The aim of this study was to compare the long-term clinical and imaging outcomes following arthroscopic or open rotator cuff repair. METHODS: Forty patients with magnetic resonance imaging (MRI)-documented, symptomatic supraspinatus or supraspinatus and infraspinatus tears were randomized to undergo arthroscopic or open rotator cuff repair. Clinical and radiographic follow-up was obtained at 6 weeks, 3 months, 1 year, 2 years, and >10 years postoperatively. Clinical assessment included measurement of active range of motion, visual analog scale score for pain, functional scoring according to the Constant-Murley score (CS), and assessment of the Subjective Shoulder Value. Imaging included conventional radiography and MRI for the assessment of cuff integrity and alteration of the deltoid muscle. RESULTS: We enrolled 20 patients with a mean age of 60 years (range, 50-71 years; standard deviation [SD], 6 years) in the arthroscopic surgery group and 20 patients with a mean age of 55 years (range, 39-67 years; SD, 8 years) in the open surgery group. More than 10 years' follow-up was available for 13 patients in the arthroscopic surgery group and 11 patients in the open surgery group, with mean follow-up periods of 13.8 years (range, 11.9-15.2 years; SD, 1.1 years) and 13.1 years (range, 11.7-15 years; SD, 1.1 years), respectively. No statistically significant differences in clinical outcomes were identified between the 2 groups: The median absolute CS was 79 points (range, 14-84 points) in the arthroscopic surgery group and 84 points (range, 56-90 points) in the open surgery group (P = .177). The median relative CS was 94% (range, 20%-99%) and 96% (range, 65%-111%), respectively (P = .429). The median Subjective Shoulder Value was 93% (range, 20%-100%) and 93% (range, 10%-100%), respectively (P = .976). MRI evaluation showed a retear rate of 30% equally distributed between the 2 groups. Neither fatty infiltration of the deltoid muscle, deltoid muscle volume, nor the deltoid origin were different between the 2 groups. CONCLUSION: In a small cohort of patients, we could not document any difference in clinical and radiographic outcomes at long-term follow-up between arthroscopic and open rotator cuff repair. The postulated harm to the deltoid muscle with the open technique could not be confirmed.

How Do Scapulothoracic Kinematics During Shoulder Elevation Differ Between Adults With and Without Rotator Cuff Arthropathy?

BACKGROUND: Rotator cuff arthropathy with loss of active arm elevation can be successfully treated with nonanatomic reverse total shoulder arthroplasty to restore active elevation. Shoulder kinematics in this context predominantly focus on glenohumeral motion, neglecting scapular motion, although both substantially contribute to global shoulder motion. Because scapular kinematics are difficult to assess clinically and in the laboratory, they are not well understood and therefore are often reduced to glenohumeral models with a static scapula. QUESTIONS/PURPOSES: (1) Does the scapulohumeral rhythm (scapular rotation/glenohumeral elevation ratio) change during arm elevation? (2) Is there any scapular motion before arm elevation becomes clinically visible? (3) How do scapulothoracic kinematics during shoulder elevation differ between adults with and without rotator cuff arthropathy? METHODS: This was a comparative kinematics study of 20 young adult volunteers (reference group) without rotator cuff impairment (seven females, 13 males; mean age: 27 ± 3.5 years) and 20 patients (22 shoulders) with cuff tear arthropathy (10 females, 10 males; mean age: 74 ± 6.2 years). We used a three-dimensional (3-D) motion analysis system from Vicom with eight high-speed infrared cameras (frame rate 200 Hz) and 25 skin markers. Kinematics were studied for scapulothoracic and glenohumeral movements using the Upper Limb Evaluation in Movement Analysis (ULEMA) open-source model. The main motion studied was active arm elevation in the scapular plane. After data cleaning, modeling, and normalization, changes of scapulohumeral rhythm and scapular motion at the beginning of arm elevation were analyzed qualitatively, and statistical parametric mapping was applied to study the difference in scapulothoracic kinematics between adults with and without rotator cuff arthropathy. RESULTS: The scapular rhythm changes continuously during elevation. Whereas in people without rotator cuff arthropathy, a homogenous proportional relative angular contribution between 85° and 120° could be observed, this regular pattern was disturbed in patients with rotator cuff arthropathy. We observed medial scapular rotation before arm elevation became visible, followed by low lateral or even medial scapular rotation (approximately up to 25°) at the beginning of arm elevation. Patients with rotator cuff arthropathy exhibited more scapulothoracic motion between 50° and 93° of elevation than the reference group. CONCLUSIONS: Our study introduces a double-normalized data analysis that allows for a more detailed assessment of complex scapular kinematics in a noninvasive way. Scapulothoracic motion is more complex than previously reported, especially in patients with rotator cuff arthropathy. The scapulohumeral rhythm changes dynamically throughout arm elevation. There is counter-directed scapular rotation because of muscular engagement before clinically visible arm elevation. Compared with the homogenous shoulder kinematics in the reference group, patients with rotator cuff arthropathy show a different pattern with predominantly scapular motion in the range between 50° and 93° of arm elevation. CLINICAL RELEVANCE: The findings of this study suggest that there is a specific pattern of scapular motion during arm elevation in patients with rotator cuff arthropathy. Our study introduces a new noninvasive method that allows for simultaneous analysis of glenohumeral and scapular kinematics. This will enable to investigators explore whether active arm elevation and the physiological motion pattern can be restored after, for example, reverse total shoulder arthroplasty despite a nonanatomic prosthesis configuration.

Bone mineral density, mechanical properties, and trabecular orientation of cancellous bone within humeral heads affected by advanced shoulder arthropathy.

The mechanical properties of cancellous bone in the humeral head are increasingly interesting due to the increased popularity of stemless prosthetic fixation in the cancellous bone of the metaphysis. Age or pathology-related systemic osteoporosis, inactivity, or pathology of the shoulder joint may influence the primary bonding of implants that rely on good cancellous bone quality. We assessed the bone mineral density (BMD) and anisotropy using micro-computed tomography (micro-CT) (0.04 mm voxel size) and correlated the results with indentation load/displacement response. Resected parts of humeral heads (from patients undergoing total shoulder replacement, n = 18) were used as probes. The region of interest was defined as 2 mm medial from the resection plane, presuming that it mirrored the bone quality lateral to the resection plane. The indentation tests were performed with a large probe (diameter 10 mm) in a single destructive loading procedure. The BMD and trabecular orientation were determined by micro-CT. Our results showed a correlation between the BMD and the slope of the load/displacement curve. Furthermore, the trabeculae were predominantly oriented orthogonal to the joint surface. In conclusion, the predominant factor determining the bone quality and mechanical resistance to pressure appears to be the BMD, while trabecular orientation could not be related to load/displacement response. Statement of clinical significance: Bone quality predominately determines the mechanical properties of cancellous bone. This might be crucial when prosthetic implants need to be anchored in metaphyseal bone. Therefore, clinical decision-making processes should also include local BMD measurements.