No healing improvement after rotator cuff reconstruction augmented with an autologous periosteal flap.

PURPOSE: To show descriptive clinical and magnetic resonance (MR) imaging results after an additional periosteal flap augmentation in mini-open rotator cuff reconstruction and to evaluate potential healing improvement at long-term follow-up. METHODS: Twenty-three patients with degenerative rotator cuff tears were followed after receiving a mini-open single-row repair with a subtendinous periosteal flap augmentation. Data were collected preoperatively, after 12 months and after 11 years. Clinical examination, simple shoulder test (SST), Constant-Murley Score (CS), ultrasonography examination and 3T MR imaging were performed. RESULTS: Out of 23 patients, 20 were available for short-term and 19 for final follow-up at a median of 11.5 years (range 10.4-13.0). Questions answered with "yes" in SST improved from baseline 5.0 (range 1.0-8.0) to short 10.5 (range 8.0-12.0) and final follow-up 12.0 (range 7.0-12.0). CS improved from 53.5 (range 25.0-66.0) to 80.8 (range 75.9-89.3) and finally to 79.8 points (range 42.3-95.4). Improvement was highly significant (p < 0.05). Severe retears were found in 9/19 patients. Ossifications along the refixed tendon were noticed in 8/19 cases. Ossifications did not correlate with clinical outcome. At final follow-up, patients with retears seemed likely to have lower strength values in CS (mean ± SD) than patients without retears (7.3 ± 4.1 vs. 12.8 ± 5.3; p < 0.05). CONCLUSION: No positive effect on improving healing response in rotator cuff refixation with a periosteal flap augmentation could be found. Retear rate is comparable to that of conventional rotator cuff refixation in the published literature. Ossifications along the tendon, without negatively affecting the clinical outcome, were seen. This invasive technique cannot be advised and should not be used anymore. LEVEL OF EVIDENCE: IV.

[Arthroscopic double-row reconstruction of high-grade subscapularis tendon tears]. / Arthroskopische Doppelreihenrekonstruktion hochgradiger Rupturen der Subskapularissehne.

OBJECTIVE: Reconstruction of tendon integrity to maintain glenohumeral joint centration and hence to restore shoulder functional range of motion and to reduce pain. INDICATIONS: Isolated or combined full-thickness subscapularis tendon tears (≥upper two-thirds of the tendon) without both substantial soft tissue degeneration and cranialization of the humeral head. CONTRAINDICATIONS: Chronic tears of the subscapularis tendon with higher grade muscle atrophy, fatty infiltration, and static decentration of the humeral head. SURGICAL TECHNIQUE: After arthroscopic three-sided subscapularis tendon release, two double-loaded suture anchors are placed medially to the humeral footprint. Next to the suture passage, the suture limbs are tied and secured laterally with up to two knotless anchors creating a transosseous-equivalent repair. POSTOPERATIVE MANAGEMENT: The affected arm is placed in a shoulder brace with 20° of abduction and slight internal rotation for 6 weeks postoperatively. Rehabilitation protocol including progressive physical therapy from a maximum protection phase to a minimum protection phase is required. Overhead activities are permitted after 6 months. RESULTS: While previous studies have demonstrated superior biomechanical properties and clinical results after double-row compared to single-row and transosseous fixation techniques, further mid- to long-term clinical investigations are needed to confirm these findings.

Bone-mediated anteroinferior glenohumeral instability : Current concepts.

Recurrent anterior shoulder instability is commonly associated with defects of the anterior glenoid rim. Substantial osseous defects significantly diminish the glenohumeral stability and require a bony augmentation, either by a coracoid transfer or free bone grafting procedure. Both reconstructive techniques have been applied for a long time and evaluated biomechanically and clinically. Although neither treatment option has been recognized as clearly superior, both comprise certain advantages and disadvantages. The Latarjet technique enables a biomechanically superior stabilization through the additional sling effect at time zero, but constitutes an extra-anatomical procedure with a broad spectrum and relatively high incidence of complications. Free bone grafting techniques enable an anatomical reconstruction of the glenoid concavity, offer the advantage of an unlimited graft size and show generally less severe and more easily manageable complications. The indications need to be carefully considered depending on the specific defect type, the glenoid track concept in cases of bipolar lesions as well as the individual patient characteristics. For both reconstructive procedures, open and arthroscopic approaches have been described with very good results, allowing a selection based on individual surgical skills and experience levels.

[The ABC guide for the treatment of posterior shoulder instability]. / Das ABC der posterioren Schulterstabilisierung.

BACKGROUND: Posterior glenohumeral instability (PGHI) is an often unrecognized or misdiagnosed type of shoulder instability due to its heterogenic clinical and radiological presentation. CLASSIFICATION: The ABC classification for PGHI is based on the different pathomechanisms and recommended treatment standards and is therefore a guide to finding the correct diagnosis and therapy for affected patients. There are different types of PGHI: A (first time), B (dynamic), C (static). These groups are further classified based on pathomechanical principles: A1: subluxation, A2: dislocation; B1: functional, B2: structural; C1: constitutional, C2: acquired. THERAPY: In patients with type 1 PGHI (A1, B1, C1) conservative treatment is recommended while in patients with type 2 PGHI (A2, B2, C2) surgical treatment can be considered based on structural defects, clinical symptoms, chronicity, age, functional demand, and patient-specific health status. In addition it has to be considered, that there is the possibility of coexisting or overlapping subtypes as well as the chance of progression from one category into another over time.

[Arthroscopic rotator cuff surgery : New and established methods]. / Arthroskopische Rotatorenmanschettenchirurgie : Neues und Bewährtes.

This present article summarizes established and current developments and aspects of rotator cuff surgery. Achieved milestones as well as current approaches are presented and assessed with respect to their clinical and radiographic impact. Despite biomechanical and technical improvements in modern rotator cuff repair techniques, re-defect and re-tearing rates could not be fully eliminated. Meanwhile, the importance of biological processes around successful tendon-bone reintegration has been increasingly recognized. Hence, this article presents the current scientific standing regarding biological growth factors, platelet-rich plasma and rotator cuff augmentation techniques (with allogenic/autologous grafts). In summary, there are clear biomechanical advantages as well as many promising approaches to biological augmentation; however, the latter have not yet been transferred into regular clinical application.

[Initial management of traumatic ventral shoulder dislocation]. / Initiales Management der traumatischen ventralen Schultererstluxation.

BACKGROUND: In the current literature a consensus on the specific management of primary anterior traumatic shoulder instability has not been reached. While the steps of the initial diagnostic and therapeutic procedures are mostly well-defined, a variety of factors need to be considered for the planning of further treatment. OBJECTIVE: This article aims at giving an overview of the essential aspects of the initial management in the rescue center, clinical and radiological diagnostic procedures and the subsequent treatment options. MATERIAL AND METHODS: The content of this article is based on our own clinical experiences in combination with a systematic literature search for relevant clinical and baseline studies. RESULTS: Besides a detailed anamnesis and clinical examination, X­rays in two planes are important for the diagnosis. Potential nerve injuries or fractures need to be borne in mind before and after reduction of the joint and documented accordingly. The Matsen's maneuver can be recommended as it enables a careful repositioning. In rare cases of an irreducible shoulder dislocation due to soft tissue or bony articular interpositions, an open reduction might be necessary. Further therapeutic concepts should be adapted to patient age, activity level and accompanying pathologies, which determine the risk of a recurrent dislocation. A surgical approach for stabilization of the shoulder is highly recommended in cases of concomitant bony defects as well as in young and physically active patients. CONCLUSION: A well-structured treatment plan is essential for the initial management of primary anterior traumatic shoulder instability. A generally applicable algorithm for further management is not yet established. The treatment should therefore be individually planned based on patient-specific characteristics.

[Arthroscopic tenodesis or tenotomy of the long head of the biceps tendon in preselected patients : Does it make a difference?] / Arthroskopische Tenodese oder Tenotomie der langen Bizepssehne bei vorselektionierten Patienten : Macht es einen Unterschied?

BACKGROUND: Are there clinical, cosmetic and/or structural differences between tenotomy and tenodesis of the long head of the biceps tendon (LHB) in patients selected according to commonly used indication criteria? MATERIAL AND METHODS: A total of 85 patients were included in this study. An LHB tenodesis (LHB-TD) was performed in 49 patients and a tenotomy (LHB-TT) in 36 patients. In addition to a standardized examination, the age and gender adjusted Constant score (aCS), the LHB score and the subjective shoulder value (SSV) were assessed. The cosmetic result was evaluated by both patient and examiner. In all patients the elbow flexion and supination strength were measured and compared between sides and sonography of the affected shoulder was performed. RESULTS: Both groups showed significant differences concerning age, body mass index (BMI) and requirements for shoulder function. The aCS and the LHB score showed good to excellent results without any significant differences between the groups and the SSV also did not reveal any significant differences between the two groups. In 34 patients of the LHB-TD group and 25 patients of the LHB-TT group a mild upper arm asymmetry could be detected (n. s.). Only three patients of the LHB-TD group and two patients of the LHB-TT group confirmed the presence of a subjective popeye deformity (n. s.). Both flexion and supination strength showed significantly better results for the LHB-TD group in comparison to the LHB-TT group. The LHB could not be sonographically detected in the bicipital groove in five patients of the LHB-TD group and in one patient of the LHB-TT group. CONCLUSION: In patients preselected according to routinely used indication parameters (e.g. age, BMI and functional requirements of the shoulder) both LHB-TD and LHB-TT can achieve good to very good functional and cosmetic results with high patient satisfaction.

[Simultaneous surgical treatment of the long head of the biceps tendon during operative treatment of proximal humeral fractures]. / Simultane Versorgung der langen Bizepssehne im Rahmen der operativen Therapie proximaler Humerusfrakturen.

BACKGROUND: Pathologic conditions of the long biceps tendon can be found within treatment of proximal humeral fractures or as a source of pain after surgery. However, simultaneous surgical treatment at the index surgical intervention is so far not well established. The purpose of this study is to evaluate the results of a simultaneous biceps treatment during plate osteosynthesis of proximal humeral fractures. MATERIALS AND METHODS: Twenty-seven patients were included into this study. In 14 patients (high cosmetic and functional shoulder demand) a biceps tenodesis (LHB-TD) was carried out (7 women, 7 men; ø57 years). In 13 patients (12 women, 1 man; ø72 years) a biceps tenotomy (LHB-TT) was performed. In addition to the range of motion (ROM), the Constant score and the LHB score were evaluated. RESULTS: All 27 patients were investigated after a mean follow-up of 25 months (range: 18-32 months). The ROM did not reveal any significant differences in either group. The Constant score was significantly decreased compared to the non-affected side (CS) without differences between the groups (LBS-TT 77 ± 9 vs. LBS-TD 77 ± 14; LBS-TT (CS) 82 ± 4 vs. LBS-TD (CS) 87 ± 4). The LHB score showed excellent results for both groups without significant differences (LBS-TT 98 ± 3 vs. LBS-TD 93 ± 10). In one patient of each group, an examiner-dependent upper arm deformity was detected. No patient complained of a subjective cosmetic deformity. CONCLUSION: The simultaneous surgical treatment of the LHB during plate osteosynthesis of proximal humeral fractures shows good clinical and cosmetic results. In a preselected patient population (cosmetic and functional demand) the kind of treatment (LHB tenotomy or LHB tenodesis) is indifferent.

[Distal biceps tendon rupture : Overview and own procedure]. / Distale Bizepssehnenruptur : Überblick und eigenes Vorgehen.

Mainly males in their 40s and 50s suffer from distal biceps tendon rupture. The diagnosis is made by clinical evaluation and is usually confirmed by magnetic resonance imaging. Different approaches and reconstruction techniques have been described in the past, and the clinical results are mostly good and excellent. Thereby the decision regarding which technique to use lies with the surgeon. However, specific complications have been described and should be considered.

[Rotator cuff avulsion fractures. Current concepts in the surgical treatment]. / Knöcherne Ausrisse der Rotatorenmanschette. Aktuelle Behandlungskonzepte zur operativen Versorgung.

Rotator cuff avulsion fractures represent rare lesions in younger individuals and are caused by different trauma mechanisms. The present article outlines current concepts regarding diagnosis, indications, and surgical approaches to the treatment of greater and lesser tuberosity fractures, as discussed in the international literature. Modified arthroscopic double-row rotator cuff repair techniques allow for the anatomical reduction and retention of fragments and the treatment of concomitant intra-articular lesions at the same time. Moreover, the article provides practical hints on different surgical repair techniques, their respective limitations and results from the literature.

Using the LHB score for assessment of LHB pathologies and LHB surgery: a prospective study.

INTRODUCTION: The long head of biceps tendon (LHB) score was designed to clinically assess LHB pathologies. Purpose of this study was to prospectively assess patients with LHB pathologies preoperatively and after LHB surgery using the LHB score. MATERIALS AND METHODS: Fifty-seven patients (29 f/28 m, Ø age 61.0 years), showing clinical signs of LHB pathologies, were prospectively included into this study. In 43 patients LHB pathologies could be confirmed intraoperatively. Among these, in 26 patients a biceps tenodesis (group I; 8 f/18 m, Ø age 61.2 years), and in 17 patients a biceps tenotomy was performed (group II; 12 f/5 m, Ø age 64.2 years). In 14 patients no intraoperative correlate concerning the biceps symptoms could be found (group III; 9 f/5m, Ø age 56.8 years). In these patients no further LHB treatment was carried out. The clinical evaluation contained the Constant score (CS) as well as the LHB score preoperatively and 2 years postoperatively. RESULTS: The CS improved significantly in all the three groups [group I: 41.7 (20-70) to 81.3 (62-100); group II: 42.2 (18-66) to 75.3 (41-84); group III: 45.7 (22-77) to 72.9 (48-85)] (p < 0.05). Also the LHB score increased significantly in all three groups [group I: 74.3 (41-97) to 94.2 (80-100); group II: 73.4 (57-97) to 84.2 (49-100); group III: 71.1 (58-80) to 90.8 (70-100)] (p < 0.05). Compared to group II, group I showed significant better results in the total LHB score and in the cosmetic result (p < 0.05). CONCLUSIONS: We recommend that patients with LHB pathologies are evaluated using the LHB score, since it provides LHB related information and is a proper tool to assess the clinical outcome after surgery. However, the score is not appropriate to detect LHB pathologies preoperatively. LEVEL OF EVIDENCE: II.

[Injuries of the acromioclavicular joint in athletes]. / Verletzungen des Schultereckgelenks bei Sportlern.

Acromioclavicular joint (ACJ) dislocation is a common injury to the shoulder girdle, especially in contact and high velocity sports. Besides the severity of the injury, and particularly in competitive and elite athletes and the type of sports, individual career plans and in and out of season injuries have to be taken into account when advising treatment for athletes. Conservative treatment is reserved for low-grade dislocations and in-season athletes. The aim is fast pain relief and a safe return to competitive sport. High-grade ACJ dislocations in athletes should be treated surgically. Arthroscopic and arthroscopically-assisted techniques can offer a lower risk of infection, a higher patient acceptance in terms of cosmetic perspectives and the potential to treat concomitant glenohumeral lesions and may avoid potential disadvantages of open techniques, such as secondary obligatory implant removal and extensive soft tissue preparation with a relevant approach morbidity.

[The gymnastics shoulder]. / Die Turnerschulter.

BACKGROUND: Adult gymnasts show a high prevalence of various shoulder pathologies. Due to the specific equipment used in gymnastics and the high training schedule with weekly training times up to 32 h, the shoulders of gymnasts are mostly subjected to symmetrical bilateral weight bearing. This is in contrast to overhead throwing, racket and martial arts sport forms in which the load is mainly located on the dominant side. CAUSES OF INJURY: Structural lesions of the shoulder and shoulder girdle in male gymnasts can arise due to high repetitive support and swing forces during exercises on the six specific types of apparatus and particularly the rings. INJURY PATTERNS: These lesions particularly affect the biceps tendon anchor, the long head of the biceps tendon and the tendon of the supraspinatus muscle. Because possible pathologies can increasingly occur even in younger gymnasts, awareness of the treating physician and also the trainer should be increased. THERAPY: Early initiation of intensive conservative treatment and arthroscopic interventions in cases of failure of non-operative management are relevant for satisfying results. Modern arthroscopic reconstructive techniques are available for treating structural lesions. CONCLUSION: Nevertheless, in almost 30 % of the patients the occurrence of shoulder pain or the necessity for surgical interventions will prevent them from achieving the national or international level of competition. This underlines the necessity for development of prevention programs.

[Acute and overuse injuries of the shoulder in sports]. / Akutverletzungen und Überlastungsschäden der Schulter im Sport.

BACKGROUND: During sports the shoulder complex is exposed to considerable load especially where throwing is important and various pathological changes can occur. In the last two decades the shoulder in athletes has become a special term in clinical sports medicine METHODS: Selective literature review in PubMed and consideration of personal experience, research results as well as national and international recommendations RESULTS: In general acute lesions of the shoulder caused by sudden sport injuries, such as traumatic luxation, acromioclavicular (AC) joint disruption, traumatic tendon ruptures, labral lesions, cartilage defects and fractures have to be distinguished from chronic or long-standing pathologies due to recurrent microtrauma, such as overuse bursitis and tendinitis, as well as secondary forms of impingement along with rotator cuff tears and labral lesions. Besides common pathological changes that can be observed in almost all overhead-sports, there are also injuries that are more sport-specific due to the particular load profile in each sport. These injuries are especially common in racquet and throwing sports (e.g. golf, tennis, handball and volleyball) as well as in individual and artistic sports (e.g. swimming, gymnastics, dancing and rowing), contact and extreme sports (e.g. judo, mixed martial arts, bodybuilding, weightlifting, motocross and downhill mountain biking). CONCLUSION: Knowledge about sport-specific load profiles as well as about the variety of treatment options is crucial for successful treatment of these injuries.

[Abduction/external rotation immobilization after primary traumatic anterior shoulder dislocation: which ortheses are suitable?]. / Abduktions-/Außenrotationsimmobilisation nach primärtraumatischer anteriorer Schulterluxation: Welche Orthesen sind geeignet?

BACKGROUND: Immobilization of the shoulder in 60 ° external rotation and 30 ° abduction after primary anterior shoulder dislocation has been shown to allow anatomical reduction and potential healing of the capsule-labrum complex. The purpose of the present study was to evaluate commercially available shoulder braces concerning functionality and comfort as well as for potential problems. METHODS: In this study ten healthy subjects (6 female, 4 male and average age 23 years) tested four braces: 1. Omo Immobil (Ottobock), 2. Quadrat (DJO Global), 3. MP Airplane Axilla (Horst Rattenhuber GmbH) and 4. ARC XR (Bledsoe Brace Systems) with respect to functionality and comfort. Each subject completed simulated activities of daily living (ADLs) and a the end of each ADL the subject evaluated comfort, difficulty of the activities and potential pain on a points scale. The position or the change of the position were controlled by digital photographs. Additionally it was checked whether the subjects could actively change the position of the brace contrary to the desired position. RESULTS: Braces 3 and 4 were rated significantly more comfortable (p < 0.05). Even the difficulty of the activities was rated lower and in particular putting on and taking off the braces was assessed to be significantly easier in comparison to braces 1 and 2. In addition, differences of potential pain were statistically significant and pain was experienced only with braces 1 and 2. The measuring of the position showed no significant differences (p > 0.05). For braces 1 and 2 the active change of the position by subjects was significantly higher and the arm could be rotated more against the favored position (p < 0.05). Between braces 3 and 4, there were no statistical differences during the whole evaluation. CONCLUSIONS: Ortheses where the main joint is positioned in and not in front of the axilla or which can ensure a jointless stabilization of the shoulder or which allow an improved position by an additional sling on the opposite shoulder, are most qualified for immobilization of the shoulder in an external rotation/abduction position with respect to functionality and comfort.

[Conservative therapy of acute locked posterior shoulder dislocation: clinical and radiological long-term results]. / Konservative Therapie der akuten verhakten posterioren Schultergelenkluxation: Klinische und radiologische Langzeitergebnisse.

BACKGROUND: Long-term results of conservative treatment of acute locked posterior shoulder dislocation with a reverse Hill-Sachs defect (Malgaigne lesion) <25% are rare. The aim of the present study was to evaluate the clinical and radiological results of patients after conservative treatment. MATERIAL AND METHODS: In this study 8 patients (8 male, average age 58.4 years) after non-operative treatment consisting of closed reduction and immobilization in 15° of external rotation were retrospectively clinically and radiologically examined (true anteroposterior, axillary and y view) The Constant score (CS), Rowe score (RS), Western Ontario shoulder instability index (WOSI) and the subjective shoulder value (SSV) were evaluated. RESULTS: After a mean follow-up of 5.4 years (range 5-7 years) no patient reported a redislocation or resubluxation or a persistent feeling of instability. None of the patients stated that they had to avoid certain movements or were limited in their everyday life. The clinical tests for posterior instability (jerk test/Kim test) were negative in all patients. The mean CS was 87.4 (range 42-98) points, the RS 96.4 (range 55-100) points, the WOSI 89.1% (range 41-100%) and the SSV 89.1% (range 50-98%). The radiological evaluation of the affected shoulder in true anteroposterior, axillary and y views showed signs of osteoarthritis (grade II according to Samilson and Prieto) in two cases. The humeral head was centered in all eight cases. CONCLUSIONS: Non-operative treatment of acute locked posterior shoulder dislocation demonstrated good to excellent clinical and radiological long-term results in this study. It represents the treatment of choice in patients with a reverse Hill-Sachs defect (Malgaigne lesion) < 25% and a duration of dislocation < 3 weeks.

[Reverse shoulder arthroplasty for fracture sequelae]. / Inverse Schulterendoprothetik bei Frakturfolgezuständen.

Posttraumatic fracture sequelae of the proximal humerus represent an extremely heterogeneous pathology. In severe cases they are often associated with marked soft tissue scarring, osseous defects and insufficiency of the rotator cuff, resulting in a static instability of the humeral head. The aim of this article is to demonstrate the possibilities and early results of reverse shoulder arthroplasty for the operative management of this complex injury pattern.