Chondrocyte Isolation from Loose Bodies-An Option for Reducing Donor Site Morbidity for Autologous Chondrocyte Implantation.

Loose bodies (LBs) from patients with osteochondritis dissecans (OCD) are usually removed and discarded during surgical treatment of the defect. In this study, we address the question of whether these LBs contain sufficient viable and functional chondrocytes that could serve as a source for autologous chondrocyte implantation (ACI) and how the required prolonged in vitro expansion affects their phenotype. Chondrocytes were isolated from LBs of 18 patients and compared with control chondrocyte from non-weight-bearing joint regions (n = 7) and bone marrow mesenchymal stromal cells (BMSCs, n = 6) obtained during primary arthroplasty. No significant differences in the initial cell yield per isolation and the expression of the chondrocyte progenitor cell markers CD44 + /CD146+ were found between chondrocyte populations from LBs (LB-CH) and control patients (Ctrl-CH). During long-term expansion, LB-CH exhibited comparable viability and proliferation rates to control cells and no ultimate cell cycle arrest was observed within 12 passages respectively 15.3 ± 1.1 mean cumulative populations doublings (CPD). The chondrogenic differentiation potential was comparable between LB-CH and Ctrl-CH, but both groups showed a significantly higher ability to form a hyaline cartilage matrix in vitro than BMSC. Our data suggest that LBs are a promising cell source for obtaining qualitatively and quantitatively suitable chondrocytes for therapeutic applications, thereby circumventing donor site morbidity as a consequence of the biopsies required for the current ACI procedure.

The acetabular roof reinforcement plate for the treatment of displaced acetabular fractures in the elderly: results in 59 patients.

INTRODUCTION: Open reduction and internal fixation is considered the gold standard of treatment for displaced acetabular fractures in younger patients. For elderly patients with osteoporotic bone quality, however, primary total hip arthroplasty (THA) with the advantage of immediate postoperative mobilization might be an option. The purpose of this study was to evaluate the clinical and radiological outcomes of surgical treatment of displaced osteoporotic acetabular fractures using the acetabular roof reinforcement plate (ARRP) combined with THA. MATERIALS AND METHODS: Between 2009 and 2019, 84 patients were operated using the ARRP combined with THA. Inclusion criteria were displaced osteoporotic fractures of the acetabulum with or without previous hemi- or total hip arthroplasty, age above 65 years, and pre-injury ability to walk at least with use of a walking frame. Of the 84 patients, 59 could be followed up after 6 months clinically and radiographically. Forty-nine (83%) were primary fractures and 10 (17%) periprosthetic acetabular fractures. RESULTS: The mean age was 80.5 years (range 65-98 years). The average time from injury to surgery was 8.5 days (range 1-28). Mean time of surgery was 167 min (range 100-303 min). Immediate postoperative full weight bearing (FWB) was allowed for 51 patients (86%). At the 6-month follow-up, all 59 patients except one showed bony healing and incorporation of the ARRP. One case developed a non-union of the anterior column. No disruption, breakage or loosening of the ARRP was seen. Additional CT scans performed in 18 patients confirmed bony healing. Twenty-six patients (44%) had regained their pre-injury level of mobility. Complications requiring revision surgery occurred in 8 patients. Five of them were suffering from a prosthetic head dislocation, one from infection, one from hematoma and one from a heterotopic ossification. CONCLUSIONS: The ARRP has proven to provide sufficient primary stability to allow for immediate FWB in most cases and represents a valuable option for the surgical management of displaced acetabular fractures in this challenging patient group.

Long-term results after arthroscopic treatment of symptomatic Ellman grade 2 PASTA lesions.

BACKGROUND: The purpose of this retrospective study was to evaluate the clinical and radiologic long-term results of medium-sized (Ellman grade 2) partial-thickness articular-sided supraspinatus tendon avulsion (PASTA) lesions treated arthroscopically. METHODS: Of 22 patients, 18 (82%) were available for follow-up evaluation after a mean of 15 ± 2 years (range, 12-17 years). The mean age at time of surgery was 55 ± 9 years (range, 35-66 years). The Constant score was used as the primary outcome instrument to evaluate shoulder function. Furthermore, the University of California-Los Angeles shoulder score, the American Shoulder and Elbow Surgeons score, and the Subjective Shoulder Value were collected. The patients' satisfaction with the outcome was investigated. Tendon integrity of the affected shoulder at final follow-up was assessed with magnetic resonance imaging or ultrasound in 89% of the cohort. RESULTS: Overall, 94% of the patients were very satisfied or satisfied with the outcome. The average Constant score of the affected shoulder was 78 ± 21 points; the University of California-Los Angeles score, 31 ± 7 points; the American Shoulder and Elbow Surgeons score, 85 ± 24 points; and the Subjective Shoulder Value, 83% ± 21%. Radiologic evaluation showed progression to a full-thickness rotator cuff tear in 6% (1/16), and 60% of the patients (6/10) showed persistent signs of partial tearing evaluated by magnetic resonance imaging. CONCLUSION: At long-term follow-up, arthroscopic treatment of medium-sized PASTA lesions resulted in good clinical results together with a high satisfaction level of the patients.

Long-term results after arthroscopic transosseous rotator cuff repair.

BACKGROUND: The purpose of this study was to evaluate the long-term clinical and radiologic results after arthroscopic transosseous rotator cuff repair (TORCR). METHODS: A total of 69 patients with full-thickness supraspinatus tendon tears with or without infraspinatus tendon tears treated with arthroscopic TORCR by a single surgeon between 1998 and 2003 were included. Among them, 56 patients (81%) with a mean age of 58 ± 5 years (range, 42-70 years) were available for final follow-up examination after an average of 15 ± 2 years (range, 12-18 years). The Subjective Shoulder Value, Constant score (CS), University of California at Los Angeles score, and American Shoulder and Elbow Surgeons score were recorded. Magnetic resonance imaging (MRI) was performed to visualize tendon integrity in 66% of patients. RESULTS: At final follow-up, the mean CS was 84 ± 8 points; mean University of California at Los Angeles score, 33 ± 2 points; mean American Shoulder and Elbow Surgeons score, 92 ± 10 points; and mean Subjective Shoulder Value, 89% ± 17%. MRI revealed asymptomatic repair failure in 9 patients (27%). Moreover, 4 patients (7%) underwent revision surgery because of a symptomatic rerupture, resulting in an overall retear rate of 33%. Patients with intact repairs at final follow-up showed a significantly higher CS (P = .019) and abduction strength (P = .016) than patients with retears. CONCLUSION: Arthroscopic TORCR for the treatment of full-thickness rotator cuff tears provided good clinical results 12 to 18 years after surgery. Cuff integrity on follow-up MRI scans had a positive effect on the clinical outcome.

Neer Award 2019: Latarjet procedure vs. iliac crest bone graft transfer for treatment of anterior shoulder instability with glenoid bone loss: a prospective randomized trial.

BACKGROUND: The Latarjet and iliac crest bone graft transfer (ICBGT) procedures are competing treatment options for anterior shoulder instability with glenoid bone loss. METHODS: In this bicentric prospective randomized study, 60 patients with anterior shoulder instability and glenoid bone loss were included and randomized to either an open Latarjet or open ICBGT (J-bone graft) procedure. Clinical evaluation was completed before surgery and 6, 12, and 24 months after surgery, including the Western Ontario Shoulder Instability index, Rowe score, Subjective Shoulder Value, pain level, satisfaction level, and work and sports impairment, as well as assessment of instability, range of motion, and strength. Adverse events were prospectively recorded. Radiographic evaluation included preoperative, postoperative, and follow-up computed tomography analysis. RESULTS: None of the clinical scores showed a significant difference between the 2 groups (P > .05). Strength and range of motion showed no significant differences except for diminished internal rotation capacity in the Latarjet group at every follow-up time point (P < .05). A single postoperative traumatic subluxation event occurred in 2 ICBGT patients and 1 Latarjet patient. The type and severity of other adverse events were heterogeneous. Donor-site sensory disturbances were observed in 27% of the ICBGT patients. Computed tomography scans revealed a larger glenoid augmentation effect of the ICBGTs; this, however, was attenuated at follow-up. CONCLUSION: The Latarjet and ICBGT procedures for the treatment of anterior shoulder instability with glenoid bone loss showed no difference in clinical and radiologic outcomes except for significantly worse internal rotation capacity in the Latarjet group and frequently noted donor-site sensory disturbances in the ICBGT group.

Joint-preserving treatment for type 3 sequelae following fracture of the proximal humerus with small head fragments.

BACKGROUND: Although nonunions of the proximal humerus are rare, they cause significant disability to patients. Surgical reconstruction is challenging, especially with small and excavated head fragments. A promising surgical option is open reduction and stabilization using the Humerusblock device along with tension wires. The aim of this retrospective investigation was to evaluate the clinical and radiological results of this procedure. MATERIALS AND METHODS: Fifteen patients with symptomatic surgical neck nonunions were treated with open reduction and internal fixation using the Humerusblock device without bone grafting. All patients showed a loss of bone stock, leading to excavated head fragments. The mean interval from injury to the described treatment was 6.2 months (range, 3.4-10.7). At a mean follow-up of 40.5 months, the Constant-Murley score was documented, pain and patient satisfaction were evaluated using a visual analogue scale, and x-rays were taken in two planes. RESULTS: The patients' mean age was 69.7 years (range, 52-83). The mean Constant-Murley score improved from 24 points before surgery to 62 points at follow-up, which was an average of 80.8% of the score obtained for the contralateral arm. Radiological examination confirmed bony healing in 14 patients. All but one patient felt satisfied with the results. Three patients required revision surgery because of a hematoma, and early metal removal was performed in one patient because of infection. CONCLUSION: Nonunions of humeral surgical neck fractures can be successfully treated by fixation using the Humerusblock device along with tension wires without the need for additional bone grafting. Especially in patients with flat, concave head fragments, this procedure remains a promising reconstructive option to arthroplasty. LEVEL OF EVIDENCE: Level IV; Therapeutic retrospective case series.

Arthroscopic Versus Open Iliac Crest Bone Grafting in Recurrent Anterior Shoulder Instability With Glenoid Bone Loss: A Computed Tomography-Based Quantitative Assessment.

PURPOSE: To assess the iliac crest bone graft (ICBG) position in the en-face view and axial plane comparing arthroscopic with open procedures. METHODS: A total of 40 consecutive patients with recurrent anterior shoulder instability and glenoid bone loss over 10% treated by 2 independent orthopaedic departments were included. Two independent observers analyzed preoperative and immediate postoperative computed tomography scans of 20 open (group O) and 20 arthroscopic (group A) procedures. Defect and ICBG characteristics of the J-shaped graft in the en-face view and axial plane were manually assessed by multiplanar reconstructed computed tomography scans. Variances in terms of graft positioning were analyzed. RESULTS: No significant variances in arthroscopic graft positioning were observed. The graft position in the en-face view was comparable in both groups, with the superior extent of the arthroscopic graft (40° ± 9° [inferior extent, 139° ± 16°]) lying significantly higher than the superior extent in group O (50° ± 13°, P = .005 [inferior extent, 147° ± 21°; P = .178]). The covered glenoid defect size was above 95% (98% ± 1% in group O vs 95% ± 2% in group A, P = .001). The arthroscopic graft in the axial plane showed a significantly steeper impaction angle (34.8° ± 7.8° vs 26.9° ± 9.9°, P = .010), with a significantly increased medial offset compared with group O (6.6 ± 1.7 mm vs 5.4 ± 1.3 mm, P = .024). The mediolateral step formation, however, was not significantly different (2.9 ± 1.1 mm in group A vs 3.2 ± 0.8 mm in group O, P = .289). The interobserver reliability was very good for all measurements (R = 0.969; 95% confidence interval, 0.965-0.972). CONCLUSIONS: Positioning of the arthroscopic ICBG in the en-face view and axial plane is comparable to that of the open technique. Good glenoid defect coverage and glenoid concavity reconstruction can be achieved with the arthroscopic technique. The main difference compared with the open procedure is the significantly steeper impaction angle. LEVEL OF EVIDENCE: Level III, case-control study.

Treatment of recurrent anterior shoulder instability with the Latarjet or Bristow procedure in older patients.

BACKGROUND: The coracoid transfer procedure is commonly and successfully used to treat shoulder instability in young patients. However, there is concern that the outcome of this procedure might be inferior in older patients because of decreased bone graft quality and the potential concomitant presence of irreparable rotator cuff tears (RCTs). METHODS: All patients older than 40 years treated with a coracoid transfer procedure between 1998 and 2013 because of anterior shoulder instability were included. Surgical indication criteria were anterior glenoid bone defects and/or the presence of an irreparable yet functionally compensated RCT. Of 27 consecutive patients, 25 (93%) were followed up after an average of 9 years (2-15 years) clinically as well as by means of computed tomography scans. Mean age at surgery was 62 years (40-85 years). RESULTS: Nine patients (36%) were revised during the follow-up period. The average Western Ontario Shoulder Instability Index of the nonrevised patients was 556; Rowe score, 77; American Shoulder and Elbow Surgeons score, 75; Constant score, 65; and subjective shoulder value, 70%. The average preoperative instability arthropathy score of 0.7 increased to 2.0 (P < .001). An irreparable RCT showed no significant effect on the clinical outcome scores or revision rate but was associated with the development of cuff arthropathy (R = 0.89; P = .01). An increased grade of preoperative cuff arthropathy was associated with a higher revision rate (R = 0.55; P = .04). CONCLUSION: The coracoid transfer procedure represents a joint-preserving treatment option for anterior shoulder instability in older patients with glenoid bone defects or concomitant irreparable yet functionally compensated RCTs. However, bone graft- and hardware-related complications as well as required revision operations are frequent.

A 1-Year Prospective Analysis of Ice Climbing Injuries.

OBJECTIVE: To describe rates, patterns, and causes of acute injuries in an increasingly popular outdoor sport. DESIGN: Prospective cohort study. SETTING: One winter season ranging from November 2011 to March 2011. PARTICIPANTS: Seventy ice climbers from 13 different countries and various performance levels. MAIN OUTCOME MEASURES: Participants were asked to complete a monthly Internet-based survey regarding their completed hours of training and competitions and eventual sustained injuries. RESULTS: During 4275 hours of ice climbing, 42 injuries occurred, of which 81.0% were defined as mild, 16.6% as moderate, and 2.4% as severe. The calculated injury rate was 9.8 injuries per 1000 hours of sports exposure. Intermediate ice climbers had a significantly higher injury risk compared with advanced ice climbers (odds ratio, 2.55; 95% confidence intervals, 1.17-5.54; P = 0.018). About 73.8% of all injuries occurred on a frozen waterfall, icicles, or icefalls, whereas 4.8% occurred on artificial ice walls. The head was the most injured body part (47.6%), followed by the knee (14.3%) and the shoulder (11.9%). The most common types of injuries were abrasions (38.1%), contusions (35.7%), and joint sprains (7.1%). Falling ice was the main circumstance leading to injury (59.5%). All athletes with a head injury wore a helmet; however, only 35.0% mentioned they used protective goggles. CONCLUSION: Ice climbing is a sport with moderate risk for injury with most of the reported injuries being of minor severity. However, severe and fatal injuries, although less common, also occur. Advanced ice climbers with greater experience and skill level have a lower overall injury risk.

Posterior open wedge osteotomy of the scapula neck for the treatment of advanced shoulder osteoarthritis with posterior head migration in young patients.

BACKGROUND: Treatment of young, active patients with symptomatic glenohumeral osteoarthritis, excessive glenoid retroversion, and static posterior humeral subluxation is challenging. Correction of glenoid retroversion may lead to centric loading and perhaps recenter the humeral head. We describe the functional and radiologic outcomes after corrective osteotomy of the glenoid in this population of patients. MATERIALS AND METHODS: In this retrospective study, we included 10 shoulders (8 patients) that were observed for a mean of 33.4 months (range, 24-52 months) after corrective osteotomy of the glenoid. The mean age at surgery was 41.5 years (range, 24-51 years). On standardized axial images, glenoid retroversion and posterior static humeral subluxation were measured preoperatively and postoperatively and at the final follow-up. At final follow-up, anterior and posterior axial radiographs were performed to determine humeral head position in different arm positions. Clinical follow-up included Constant-Murley score, subjective shoulder value, and patient satisfaction. RESULTS: The mean Constant-Murley score improved significantly from 45.1 points (range, 24-71) to 64.1 points (range, 44-92; P < .001). The average degree of anterior flexion improved significantly from 117° (range, 50°-160°) to 143° (range, 110°-180°; P = .006). The mean glenoid retroversion changed from 16° (range, 11°-31°) preoperatively to 5° (range, 13° anteversion-16° retroversion; P = .003) at the final follow-up. The mean posterior static subluxation of the humeral head changed from 5 mm (range, 0-10 mm) preoperatively to 6 mm (range, 0-14 mm; P = .259) at the final follow-up. CONCLUSIONS: This study shows that posterior open wedge osteotomy of the glenoid neck provides excellent correction of glenoid retroversion.

The "triple dislocation fracture": anterior shoulder dislocation with concomitant fracture of the glenoid rim, greater tuberosity and coracoid process-a series of six cases.

BACKGROUND: A combined fracture of the glenoid rim, greater tuberosity, and coracoid process after anterior shoulder dislocation is a rare event. Only 1 patient has been reported in the literature. METHODS: All patients with a first-time traumatic anterior shoulder dislocation in a level A trauma center were retrospectively reviewed. Among the 2068 patients treated between 1998 and 2013, we identified 6 patients (0.3%; 1 female, 5 male) with "triple dislocation fracture" (anterior shoulder dislocation with concomitant fracture of the glenoid rim, greater tuberosity, and coracoid process). All patients underwent surgery and had computed tomography scans before surgery and the first postoperative day. Mean follow-up time was 59 months. Clinical and radiographic evaluation, Constant-Murley Score, Simple Shoulder Test, and Subjective Shoulder Value were performed at the final follow-up. RESULTS: Surgery was determined individually according to the radiologic findings, patient's age, and personal demands. Glenoid reconstruction was performed in all 6 patients, greater tuberosity refixation in 4 patients, and coracoid process refixation in 3. Two patients needed revision surgery due to loss of reduction. At the final follow-up, mean abduction was 133°, mean anterior flexion was 138°; the mean Constant-Murley Score was 72 points; the mean Simple Shoulder Test was 9 points; and the mean Subjective Shoulder Value was 72%. No recurrent instability occurred. CONCLUSIONS: A "triple dislocation fracture," especially coracoid process fractures, can easily be overlooked in radiographs. Computed tomography scans are strongly recommended in patients with a first-time traumatic shoulder dislocation. Because recurrent joint instability and secondary arthropathy are serious complications after anterior shoulder dislocation, surgery should be considered and provides satisfying to excellent results.

CD3+ lymphocytosis in the peri-implant membrane of 222 loosened joint endoprostheses depends on the tribological pairing.

Background and purpose - The most frequent cause of arthroplasty failure is aseptic loosening-often induced by particles. Abrasion material triggers inflammatory reactions with lymphocytic infiltration and the formation of synovial-like interface membranes (SLIM) in the bone-implant interface. We analyzed CD3 quantities in SLIM depending on articulating materials and possible influences of proven material allergies on CD3 quantities. Patients and methods - 222 SLIM probes were obtained from revision surgeries of loosened hip and knee arthroplasties. SLIM cases were categorized according to the SLIM-consensus classification and to the particle algorithm. The CD3 quantities were analyzed immunohistochemically, quantified, and correlated to the particle types. Results - Metal-metal pairings showed the highest CD3 quantities (mean 1,367 counted cells). CD3 quantities of metal-polyethylene (mean 243), ceramic-polyethylene (mean 182), and ceramic-ceramic pairings (mean 124) were significantly smaller. Patients with contact allergy to implant materials had high but not statistically significantly higher CD3 quantities than patients without allergies. For objective assessment of the CD3 response as result of a pronounced inflammatory reaction with high lymphocytosis (adverse reaction), a defined CD3 quantity per high power field was established, the "CD3 focus score" (447 cells/0.3 mm2, sensitivity 0.92; specificity 0.90; positive predictive value 0.71; negative predictive value 0.98). Interpretation - The high CD3 quantities for metal-metal pairings may be interpreted as substrate for previously described adverse reactions that cause severe peri-implant tissue destruction and SLIM formation. It remains unclear whether the low CD3 quantities with only slight differences in the various non-metal-metal pairings and documented contact allergies to implant materials have a direct pathogenetic relevance.

Effect of glenoid concavity loss on shoulder stability- a case report in a professional wrestler.

BACKGROUND: Current glenoid defect measurement techniques only quantify bone loss in terms of defect diameter or surface. However, the glenoid depth plays an important role in shoulder stabilization by means of concavity compression. CASE PRESENTATION: We present a case of a professional wrestler who suffered from anterior shoulder instability after sustaining a bony Bankart lesion without loss of glenoid surface area but flattening of the concavity due to medialization of the fragment. The patient's glenoid concavity was reconstructed arthroscopically by reduction and percutaneous screw fixation of the bony fragment along with a capsulo-ligamentous shift. Changes of the glenoid concavity with according alterations in the Bony Shoulder Stability Ratio (BSSR) were analyzed on pre-op, post-op, and follow-up CT scans. Postoperative CT scans revealed a deepened concavity (3.3 mm) and improved BSSR (46.1 %) compared to pre-op scans (0.7 mm; 11.3 %). Follow-up CT scans showed a slight remodeling of the glenoid concavity (3.2 mm) with steady BSSR (44.7 %). CONCLUSION: This case shows that the passive stabilizing effect of the glenoid can be compromised by loss of concavity despite the absence of loss of articular surface. Therefore, addressing the concavity loss and resulting reduction of the BSSR is recommended in these cases. Bony Bankart repair was successful in restoring the BSSR of the patients shoulder as determined by mathematical calculations based on CT scans.

S100B serum protein cannot predict secondary intracranial haemorrhage after mild head injury in patients with low-dose acetylsalicylic acid prophylaxis.

INTRODUCTION: The goal of this study was to investigate if S100B serum protein could predict secondary intracranial haemorrhagic events (SIHEs) after mild head injury (mHI) in patients taking low-dose acetylsalicylic acid (LDA), making routinely repeated head computed tomography (RRHCT) scans unnecessary. METHODS: Three hundred and eight-two patients with mHI, older than 60 years and taking LDA prophylaxis were enrolled. Primary head CT and RRHCT scans within 3 and 48 hours to trauma were performed. Additionally, S100B serum protein levels were evaluated at admission and predictive power for SIHEs was analysed. RESULTS: Fifty-nine per cent were female and the mean age of all included patients was 81.8 ± 8.9 years. In four patients SIHEs were diagnosed. Sensitivity and the negative predictive value of S100B serum protein (cut-off value 0.10 µg l(-1)) were 75.0% and 98.6%, respectively. Specificity was 19.0% and the positive predictive value 1.0% (306 false positive values). In patients without bleeding, the median S100B value was 0.18 (IQR = 0.12-0.34) and in the ones with SIHEs, the median was 0.11 (IQR = 0.10-1.16) (p > 0.05). The discriminatory power of S100B in the ROC analysis was 0.399 (95% CI = 0.079-0.720; p > 0.05). CONCLUSION: S100B cannot be considered as an effective diagnostic tool in the prediction or exclusion of SIHE in older patients with mHIs taking LDA prophylaxis.

Scapular dyskinesis after Latarjet procedure.

BACKGROUND: Because of detachment of the pectoralis minor and variation of the vector of the conjoint tendons, we hypothesized that the Latarjet procedure may alter scapular position and motion. The purpose of this study was to evaluate scapular position and motion in patients who underwent a Latarjet or a modified iliac crest bone graft transfer (ICBGT) procedure (J-bone graft). METHODS: Forty-six consecutive patients treated for recurrent anterior shoulder dislocation between 2010 and 2012 were retrospectively enrolled. Twenty-three were treated with a Latarjet and 23 with an ICBGT procedure. Twenty Latarjet and 20 ICBGT patients were available at a mean follow-up of 20 months (min, 12; max, 60). We recorded the Western Ontario Instability Index, the Rowe Score, and the Subjective Shoulder Value. Scapulothoracic position was studied according to the dyskinesis yes/no method. Intraobserver and interobserver reliability of the dyskinesis assessment was assessed. RESULTS: Intraobserver and interobserver reliability of scapula dyskinesis assessment was high (Latarjet: intratester, κ = 0.84; intertester, κ = 0.75; ICBGT: intratester, κ = 0.78; intertester, κ = 0.71). Scapular dyskinesis was observed after 5 of 20 Latarjet and after 0 of 20 ICBGT procedures (P = .047). Patients with dyskinesis had lower scores (Western Ontario Instability Index, P = .043; Rowe, P = .047; Subjective Shoulder Value, P = .046), but no statistically significant difference was found between the Latarjet and ICBGT groups. Two of the 5 scapular dyskinesis patients reached the SICK (Scapular malposition, Inferior medial scapular winging, Coracoid tenderness, and scapular dysKinesis) scapula syndrome definition. CONCLUSIONS: Scapular dyskinesis was found in 5 of 20 patients who underwent a Latarjet procedure. Dyskinesis may be related to the detachment of the pectoralis minor, and variation of the vector and the working length of the coracobrachialis and the short head of the biceps.

Classification of proximal humeral fractures based on a pathomorphologic analysis.

BACKGROUND: The purpose of this study was to analyze the pathomorphology of proximal humeral fractures to determine relevant and reliable parameters for fracture classification. METHODS: A total of 100 consecutive acute proximal humeral fractures in adult patients were analyzed by 2 non-independent observers from a single shoulder department using a standardized protocol based on biplane radiographs and 3-dimensional computed tomography scans. A fracture classification system based on the most reliable key features of the pathomorphologic analysis was created, and its reliability was tested by 6 independent shoulder experts analyzing another 100 consecutive proximal humeral fractures. RESULTS: The head position in relation to the shaft (varus, valgus, sagittal deformity) and the presence of tuberosity fractures showed a higher interobserver reliability (κ > 0.8) than measurements for medial hinge, shaft, and tuberosity displacement, metaphyseal extension, fracture impaction, as well as head-split component identification (κ < 0.7). These findings were used to classify nondisplaced proximal humeral fractures as type 1, fractures with normal coronal head position but sagittal deformity as type 2, valgus fractures as type 3, varus fractures as type 4, and fracture dislocations as type 5. The fracture type was further combined with the fractured main fragments (G for greater tuberosity, L for lesser). Interobserver and intraobserver reliability analysis for the fracture classification revealed a κ value (95% confidence interval) of 0.700 (0.631-0.767) and 0.917 (0.879-0.943), respectively. CONCLUSION: The new classification system with emphasis on the qualitative aspects of proximal humeral fractures showed high reliability when based on a standardized imaging protocol including computed tomography scans.

Reverse shoulder arthroplasty after failed pectoralis major tendon transfer with a minimum follow-up of 5 years. A case series.

BACKGROUND: Treatment strategies after failed pectoralis major tendon transfer (PMTT) are scarce in literature and no information is available for patients treated with reverse shoulder arthroplasty (RSA) for failed PMTT. METHODS: We performed a retrospective outcome study of all patients who underwent revision with RSA after failed PMTT at our institution. From 1999 to 2009 we included 8 patients (8 shoulders). The minimum follow-up was 5 years with a mean follow-up time of 97 months (range, 64-134). Clinical and radiological evaluation comprised range of motion, Constant Murley score (CMS), Simple Shoulder Test (SST) as well as standard X-rays in 2 planes. Pain was measured using VAS pain scale. The patients were asked to rate their satisfaction at final follow-up. RESULTS: All outcome measures improved significantly post-surgical compared to pre-surgical, including the CMS (17.8-62.8), SST (1.8-7.3) and VAS (7.1-1). Active abduction and anterior flexion improved significantly (p < .001) from 65.6° to 125° and from 62.5° to 136.3°, respectively. There were 2 complications. One patient sustained transient musculocutaneous nerve palsy that resolved completely after 5 months and one patient sustained postoperative hematoma and had to be revised 4 days after surgery. 4 (50%) patients rated their results as excellent and 4 (50%) rated them as good. CONCLUSIONS: RSA is a good option for treating patients after failed pectoralis major tendon transfer. After a minimum follow-up of 5 years, functional outcome is good and patient satisfaction is high. LEVEL OF EVIDENCE: Level IV, Case series, Treatment study.

Short to mid-term results of stemless reverse shoulder arthroplasty in a selected patient population compared to a matched control group with stem.

PURPOSE: Little scientific evidence on the clinical and radiological outcome after stemless reverse shoulder arthroplasty (RSA) exists. The hypothesis of this study was that stemless RSA has an inferior outcome compared to RSA with stem. METHODS: All cases of cuff-arthropathy fullfilling strict selection criteria (selection rate 18.4 %) were treated with stemless RSA between 2009 and 2013. Twenty nine of 37 cases (78.4 %) were clinically and radiologically examined by an independent observer. Twenty four of the 29 cases could be matched with 24 patients that underwent conventional stemmed RSA at a different institution based on the following criteria: indication (cuff-arthropathy), age (within 5 years), gender, and time of follow-up (within 2 years). Clincial and radiological outcomes of both groups were compared. RESULTS: After mean follow-up of 35 months (range 24-75) no significant difference regarding constant score, ASES, subjective shoulder value, pain score, patient satisfaction, strength, and range of motion was detected. One case of traumatic dislocation was observed in the stemless RSA group. Scapular notching grade 1 was detected in two cases of the stemless group while in the stemmed group five cases with grade 1 and four cases with grade 2 notching were observed. Average post-operative humeral component inclination (neck-shaft angle) in the stemless RSA group (134.4°) was significantly steeper than in the stemmed RSA group (155°) (p < 0.001). No loosening of the humeral component was observed in both groups. CONCLUSION: At short to mid-term follow-up, stemless RSA does not feature inferior clinical or radiological outcomes in a strictly selected patient population.

Rupture of the spleen following thoracoscopic spine surgery in a patient with chronic pancreatitis.

PURPOSE: To highlight the perioperative risk of intracapsular haematoma of the spleen or splenic ruptures during thoracoscopic spine surgery in patients with chronic pancreatitis. METHODS: A 38-year-old patient with an L1 burst fracture (AO A3.3) underwent a standard thoracoscopic corpectomy and replacement of the vertebral body with an extendable vertebral body replacement 10 days after posterior instrumentation of T12-L2. In patients history chronic abusive alcoholism with related diseases such as pancreatitis, followed by hemipancreatectomy was found. Six hours after the surgery, the patient became hemodynamically unstable. An emergency CT scan revealed a splenic rupture. Emergent splenectomy was performed. RESULTS: After surgical treatment of the L1 burst fracture, a rupture of the spleen was detected. An immediate splenectomy was performed. At the 18-month follow-up, an unchanged stable position of the cage was observed on CT. CONCLUSIONS: Due to its proximity to the thoracolumbar junction, the spleen is vulnerable to injury during spine surgery. If the patient has undergone previous intra-abdominal operations or chronic inflammation of the pancreas is found, special care of the spleen during the operation is necessary.

Construct stability of an instrumented 2-level cervical corpectomy model following fatigue testing: biomechanical comparison of circumferential antero-posterior instrumentation versus a novel anterior-only transpedicular screw-plate fixation technique.

INTRODUCTION: A high rate of complications in multilevel cervical surgery with corpectomies and anterior-only screw-and-plate stabilization is reported. A 360°-instrumentation improves construct stiffness and fusion rates, but adds the morbidity of a second approach. A novel ATS-technique (technique that used anterior transpedicular screw placement) was recently described, yet no study to date has analyzed its performance after fatigue loading. Accordingly, the authors performed an analysis of construct stiffness after fatigue testing of a cervical 2-level corpectomy model reconstructed using a novel anterior transpedicular screw-and-plate technique (ATS-group) in comparison to standard antero-posterior instrumentation (360°-group). MATERIALS AND METHODS: Twelve fresh-frozen human cervical spines were mounted on a spine motion tester to analyze restriction of ROM under loading (1.5 Nm) in flexion-extension (FE), axial rotation (AR), and lateral bending (LB). Testing was performed in the intact state, and after instrumentation of a 2-level corpectomy C4 + C5 using a cage and the constructs of ATS- and 360°-group, after 1,000 cycles, and after 2,000 cycles of fatigue testing. In the ATS-group (n = 6), instrumentation was achieved using a customized C3-C6 ATS-plate system. In the 360°-group (n = 6), instrumentation consisted of a standard anterior screw-and-plate system with a posterior instrumentation using C3-C6 lateral mass screws. Motion data were assessed as degrees and further processed as normalized values after standardization to the intact ROM state. RESULTS: Specimen age and BMD were not significantly different between the ATS- and 360°-groups. After instrumentation and 2,000 cycles of testing, no specimen exhibited a ROM greater than in the intact state. No specimen exhibited catastrophic construct failure after 2,000 cycles. Construct stiffness in the 360°-group was significantly increased compared to the ATS-group for all loading conditions, except for FE-testing after instrumentation. After 2,000 cycles, restriction of ROM under loading in FE was 39.8 ± 30% in the ATS-group vs. 2.8 ± 2.3% in the 360°-group, in AR 60.4 ± 25.8 vs 15 ± 11%, and in LB 40 ± 23.4 vs 3.9 ± 1.2%. Differences were significant (p < 0.05). CONCLUSION: 360°-instrumentation resembles the biomechanical standard of reference for stabilization of 2-level corpectomies. An ATS-construct was also shown to confer high construct stiffness, significantly reducing the percentage ROM beyond that of an intact specimen after 2,000 cycles. This type of instrumentation might be a clinical valuable and biomechanically sound adjunct to multilevel anterior surgical procedures.