Analysis of three different reverse shoulder arthroplasty designs for cuff tear arthropathy - the combination of lateralization and distalization provides best mobility.

BACKGROUND: The two major reverse shoulder arthroplasty (RSA) designs are the Grammont design and the lateralized design. Even if the lateralized design is biomechanically favored, the classic Grammont prosthesis continues to be used. Functional and subjective patient scores as well as implant survival described in the literature so far are comparable to the lateralized design. A pure comparison of how the RSA design influences outcome in patients has not yet been determined. The aim of this study was a comparison focused on patients with cuff tear arthropathy (CTA). METHODS: We analyzed registry data from 696 CTA patients prospectively collected between 2012 and 2020 in two specialized orthopedic centers up to 2 years post-RSA with the same follow-up time points (6,12 24 months). Complete teres minor tears were excluded. Three groups were defined: group 1 (inlay, 155° humeral inclination, 36 + 2 mm eccentric glenosphere (n = 50)), group 2 (inlay, 135° humeral inclination, 36 + 4 mm lateralized glenosphere (n = 141)) and group 3 (onlay, 145° humeral inclination, + 3 mm lateralized base plate, 36 + 2 mm eccentric glenosphere (n = 35)) We compared group differences in clinical outcomes (e.g., active and passive range of motion (ROM), abduction strength, Constant-Murley score (CS)), radiographic evaluations of prosthetic position, scapular anatomy and complications using mixed models adjusted for age and sex. RESULTS: The final analysis included 226 patients. The overall adjusted p-value of the CS for all time-points showed no significant difference (p = 0.466). Flexion of group 3 (mean, 155° (SD 13)) was higher than flexion of group 1 (mean, 142° (SD 18) and 2 (mean, 132° (SD 18) (p < 0.001). Values for abduction of group 3 (mean, 145° (SD 23)) were bigger than those of group 1 (mean, 130° (SD 22)) and group 2 (mean, 118° (SD 25)) (p < 0.001). Mean external rotation for group 3 (mean, 41° (SD 23)) and group 2 (mean, 38° (SD 17)) was larger than external rotation of group 1 (mean, 24° (SD 16)) (p < 0.001); a greater proportion of group 2 (78%) and 3 (69%) patients reached L3 level on internal rotation compared to group 1 (44%) (p = 0.003). Prosthesis position measurements were similar, but group 3 had significantly less scapular notching (14%) versus 24% (group 2) and 50% (group 1) (p = 0.001). CONCLUSIONS: Outcome scores of different RSA designs for CTA revealed comparable results. However, CTA patients with a lateralized and distalized RSA configuration were associated with achieving better flexion and abduction with less scapular notching. A better rotation was associated with either of the lateralized RSA designs in comparison with the classic Grammont prosthesis. LEVEL OF EVIDENCE: Therapeutic study, Level III.

Lateralization and distalization shoulder angles do not predict outcomes in reverse shoulder arthroplasty for cuff tear arthropathy.

BACKGROUND: In reverse shoulder arthroplasty (RSA), there are a plethora of measurements regarding implant lateralization and distalization to optimize the center of rotation. Two specific measurements known as the "lateralization shoulder angle" (LSA) and "distalization shoulder angle" (DSA) have been the recent focus of studies to assess their association with RSA and postoperative function. The aim of this study was to evaluate the prognostic clinical value of the LSA and DSA in a large cohort of patients with cuff tear arthropathy (CTA) who were treated with different RSA systems. METHODS: Two local shoulder arthroplasty registries were reviewed for all RSA patients documented to have undergone a radiologic assessment and complete 2-year follow-up examination. The main inclusion criterion was primary RSA in patients with CTA. Patients with either a complete teres minor tear, os acromiale, or acromial stress fracture reported between the time of surgery and the 24-month follow-up were excluded. Five RSA implant systems with 4 neck-shaft angles (NSAs) were assessed. The Constant score, Subjective Shoulder Value, and range of motion at 2 years were correlated with both the LSA and DSA assessed on 6-month anteroposterior radiographs. Linear and parabolic univariable regressions were calculated for both shoulder angles, for each prosthesis system, and for the entire patient cohort. RESULTS: Between May 2006 and November 2019, there were a total of 630 CTA patients who had undergone primary RSA. Of this large cohort of patients, 270 were treated with the Promos Reverse prosthesis system (NSA, 155°); 44, Aequalis Reversed II (NSA, 155°); 62, Lima SMR Reverse (NSA, 150°); 25, Aequalis Ascend Flex (NSA, 145°); and 229, Univers Revers (NSA, 135°). The mean LSA was 78° (standard deviation [SD], 10°; range, 6°-107°), and the mean DSA was 51° (SD, 10°; range, 7°-91°). The average Constant score at 24 months' follow-up was 68.1 points (SD, 13 points; range, 13-96 points). Neither the linear nor parabolic regression calculations for the LSA or DSA revealed significant associations with any of the clinical outcomes. CONCLUSION: Different patients may achieve different clinical outcomes despite having identical LSA and DSA values. There is no association between angular radiographic measurements and 2-year functional outcomes after RSA.

Subpectoral biceps tenodesis with BicepsButton fixation in the young population: which technique works best?

BACKGROUND: Injuries of the long head of the biceps (LHB) tendon are a prevalent source of anterior shoulder pain and are commonly treated with tenodesis. Not only a stable fixation of the LHB but also anatomic restoration of the length-tension relationship plays a central role in providing satisfactory functional and cosmetic outcomes, especially in young patients. We report the clinical outcomes of 2 different subpectoral tenodesis techniques using unicortical button fixation. METHODS: Patients aged ≤ 50 years who were treated between April 2015 and January 2020 with 1 of the 2 following subpectoral tenodesis techniques were retrospectively selected and enrolled to undergo a follow-up examination at least 2 years after surgery: subpectoral in situ tenodesis followed by resection of the intra-articular portion leaving a residual tendon stump in the bicipital groove (group I) vs. tenotomy followed by resection of the stump and subpectoral tenodesis (group II). Patients who underwent concomitant rotator cuff repair, subsequent shoulder surgery, or contralateral biceps surgery were excluded. Clinical outcomes were evaluated using the LHB score and the Constant-Murley Score (CMS), as well as measurements of isometric elbow flexion and forearm supination strength. Sonographic evaluation included assessment of the integrity of the LHB and tenodesis, examination for signs of inflammation within the sulcus or around the tendon, and measurements of the distalization of the myotendinous junction of the LHB compared with the nonoperative side. RESULTS: A total of 34 patients comprising group I (24 men; mean age at time of surgery, 40.3 years; mean follow-up period, 57.2 months) and 24 patients comprising group II (19 men; mean age at time of surgery, 39.8 years; mean follow-up period, 51.9 months) were evaluated. The total CMS, as well as the scores for each CMS subcategory, did not reveal significant differences between the groups. The overall LHB score was on average 10 points higher in group I (mean, 94 points) than in group II (mean, 84 points) (P = .016). Regarding the LHB score subcategories, group I showed significantly better results for patient-dependent cosmesis (mean, 15 points in group I vs. 12 points in group II; P = .005) and examiner-dependent cosmesis (mean, 14 points in group I vs. 10 points in group II; P = .001). This finding was substantiated by a significantly higher distalization of the myotendinous junction in group II (mean, 3.0 cm in group I vs. 3.8 cm in group II; P = .030). CONCLUSION: This study shows that subpectoral in situ tenodesis of the LHB followed by arthroscopic resection of the intra-articular portion provides higher LHB scores and better cosmetic outcomes compared with proximal intra-articular tenotomy followed by subpectoral tenodesis.

Is it worth the risk? Clinical and radiographic outcomes 24 months after reverse shoulder arthroplasty in an advanced geriatric population.

Background: The application of reverse shoulder arthroplasty (RSA) has risen in the past decades especially due to its excellent long-term outcomes. With this positive trend, the indications for RSA have gradually extended to a broader age spectrum. The objective of this study was to identify the benefits of primary RSA in an advanced geriatric population with considerable comorbidity burden and higher perioperative risk. Methods: For this observational study using data collected from our local RSA register, we identified 73 patients (77% female) with a minimum age of 85 years (range: 85-93 years) at the time of surgery and a complete 24-month postoperative follow-up. Clinical evaluations of pain, Subjective Shoulder Value, Constant score, Shoulder Pain and Disability Index, quality of life (European Quality-of-Life 5-Dimension 5-Level utility), and patient satisfaction were made. Radiographic evaluation followed an international consensus core set. Adverse events were documented according to a core event set. Results: Preexisting medical conditions categorized following the American Society of Anesthesiologists physical status classification system indicated only 22% of patients with mild comorbidities (American Society of Anesthesiologists I-II), whereas severe (American Society of Anesthesiologists III-IV) comorbidities were common (78%). Indications for surgery were rotator cuff deficiency (72%), post-traumatic conditions (18%), and primary arthrosis (10%). There was significant improvement in all clinical evaluations up to 24 months post RSA: mean pain levels decreased from 6.2 to 1.6 points, where 0 indicates no pain (P < .001) and Subjective Shoulder Value, Constant score, Shoulder Pain and Disability Index, and European Quality of Life 5 Dimensions 5 Level increased from 36% to 76%, 26 to 61 points, 29 to 74 points, and 0.58 to 0.79, respectively (P < .001). Most patients (88%) opted in favor of undergoing the same surgery again based on their personal outcome. There were no signs of early loosening, migration or dislocation at 24 months postsurgery. However, 6 periprosthetic fractures were identified, 5 of which were treated conservatively. Adverse events were reported for 39% of patients, yet rarely led to the need for revision surgery (1.8%) or hospital readmission (3.6%). Conclusion: Despite an advanced age over 85 years and numerous associated comorbidities, our geriatric population showed a distinct clinical improvement in their daily activities with high rates of patient satisfaction. Radiographic analysis at 24 months after surgery identified adequate implant stability. RSA is a safe procedure, even in these elderly patients, with an acceptable risk of unfavorable medical and surgical events.

[Treatment of subscapularis tendon lesions]. / Therapie von Subskapularissehnenrupturen.

The further development of minimally invasive techniques in recent years, enables adequate intraoperative visualization, mobilization and stable reconstruction even of larger subscapularis tears resulting in good to excellent clinical and structural results. Chronic tears of the subscapularis tendon with high grade muscle atrophy and advanced fatty infiltration can be treated with a muscle tendon transfer (e.g. pectoralis major or latissimus dorsi transfer). If pseudoparalysis and/or signs of anterosuperior decentration of the humeral head or defect arthropathy are present, in most cases a reverse shoulder arthroplasty represents the only surgical option.

[Anatomical fracture endoprosthesis-who and how?] / Anatomische Frakturendoprothese ­ wer und wie?

The aim of this review article is to present the indications for an anatomical fracture prosthesis, mostly as a shoulder hemiprosthesis (SHEP) and its value in comparison to other procedures. The healing of the tuberosities in the anatomical position and an intact rotator cuff are particularly important for the successful implantation of a SHEP after proximal humeral fractures. For older patients (> 70 years), the use of reverse shoulder arthroplasty achieves more reliable results and is associated with a lower revision rate. The indications for implantation of a SHEP in non-reconstructible proximal humeral fractures, usually with a head split, should be carefully considered and can be used in cases with well-preserved large tuberosities and in younger patients. Complications of SHEP, such as secondary rotator cuff insufficiency, tuberosity dislocation or resorption and secondary glenoid wear, can be treated using a conversion or a change to reverse shoulder arthroplasty.

[Anatomy and diagnostics of subscapularis tendon lesions]. / Anatomie und Diagnostik von Subskapularissehnenrupturen.

Among lesions of the rotator cuff, subscapularis tendon tears are one of the less common injuries and mostly occur in combination with additional lesions of the posterosuperior rotator cuff and the long biceps tendon. If a subscapularis tendon rupture is suspected in the initial clinical testing, the primary diagnostics should include modern cross-sectional magnetic resonance imaging to assess the tendon lesion and to detect concomitant pathologies. Nevertheless, subscapularis tendon lesions are often initially overlooked and first correctly diagnosed during shoulder arthroscopy.

Reverse Shoulder Arthroplasty for Proximal Humerus Head-Split Fractures-A Retrospective Cohort Study.

Head-split fractures are proximal humerus fractures (PHF) that result from fracture lines traversing the articular surface. While head-split fractures are rare, surgical treatment of these complex injuries can be extremely challenging and is associated with high rates of complications. Treatment using primary reverse shoulder arthroplasty (RSA) has been associated with moderate complication rates and reproducible clinical results. The aim of this study was to evaluate clinical and radiographic outcomes, and complication rates of RSA for head-split PHF. Twenty-six patients were evaluated based on Constant Score (CS) and range of motion of both shoulders and Subjective Shoulder Value (SSV). Radiographic analysis evaluated tuberosity healing, prosthetic loosening and scapular notching. Patients achieved good clinical results with a CS of 73.7 points and SSV of 82% after a mean follow-up of 50 months. The relative CS comparing operated versus the unaffected shoulder was 92%. Greater tuberosity healing was achieved in 61%. Patients who suffered a high-energy trauma reached a significantly greater functional outcome. Patients who suffered multifragmentation to the humeral head performed the worst. There were no cases of loosening; scapular notching was visible in two cases. The complication rate was 8%. RSA is an adequate treatment option with for head-split PHF in elderly patients.

Lateralized vs. classic Grammont-style reverse shoulder arthroplasty for cuff deficiency Hamada stage 1-3: does the design make a difference?

BACKGROUND: Reverse shoulder arthroplasty (RSA) with a lateralized design is thought to improve outcomes. Our aim was to compare RSA with the classic Grammont prosthesis against a prosthesis with 135° inclination and a lateralized glenosphere for cuff-deficient shoulders. METHODS: Patients with irreparable massive posterosuperior rotator cuff tear Hamada grade 1-3 underwent RSA and were documented prospectively up to 24 months postsurgery. Comparative RSA groups were "lateralized" (L), with 135° humeral inclination and 36+4-mm lateralized glenosphere (n = 44), and "Grammont" (G), with 155° humeral inclination and 36+2-mm eccentric glenosphere (n = 23). Range of motion including the Apley scratch test, abduction strength, Constant-Murley score (CS), and Shoulder Pain and Disability Index (SPADI) were assessed. Anteroposterior and axial radiographs were evaluated at 24 months, and additional measurements of scapular neck and glenoid anatomy, baseplate and glenosphere position, center of rotation, humeral offset, and lateralization and distalization shoulder angles were made. Linear regression and mixed models adjusted for sex differences and preoperative values were applied. RESULTS: Overall CS and SPADI outcomes were not significantly different between groups (P ≥ .654). For group L, external rotation remained stable up to the 2-year follow-up and was higher than for group G (P = .012 ); a greater proportion of group L patients could reach the lumbar vertebra 3 (L3) (70% vs. 48% in group G) (P = .26). Group G had a higher inferior glenosphere overhang (P = .020) and center of rotation (COR) medialization (P < .001), whereas group L had higher humeral offset (P < .001) and lateralization shoulder angle (P < .001) with a trend toward higher baseplate positioning (P = .045). The rate of scapular notching was 2.9 times higher for group G than group L (P = .001). CONCLUSION: RSA with 135° humeral inclination and a lateralized glenosphere shows similar outcome scores as the classic Grammont design but enables better preservation of external rotation and reduces the rate of scapular notching compared with the classic Grammont design in Hamada 1-3 patients with irreparable posterosuperior tears.

Minced Cartilage Procedure for One-Stage Arthroscopic Repair of Chondral Defects at the Glenohumeral Joint.

Chondral defects of the glenohumeral joint are common but still remain a diagnostic and management challenge. Whereas arthroplasty is a reasonable treatment option in the elderly and low-demand population, joint preservation should be aimed for the remaining patients. For larger defects the current gold standard of treatment is autologous chondrocyte implantation. However, disadvantages such as high cost, the restriction in availability of specialized laboratories, and the 2-stage surgical design need to be accounted for if choosing this option. Showing first good clinical results for the knee joint, minced cartilage implantation is moreover a cost-effective procedure bringing autologous cartilage chips harvested from the defect walls and bringing them into the area of damage in a single-step open or arthroscopic approach. We describe an arthroscopic strategy of this technique to treat chondral defects at the glenohumeral joint.

Plate Fixation for Irreducible Proximal Humeral Fractures in Children and Adolescents-A Single-Center Case Series of Six Patients.

BACKGROUND: Recommended treatment for severely displaced proximal humeral fractures in children is the closed reduction and percutaneous fixation by K-wires or intramedullary nailing. METHODS: From January 2016 to January 2017 6, 21 children/adolescents (range 8 to 16 years) with proximal humeral fractures were treated surgically for severe displacement. In these six patients, several attempts of closed reduction were unsuccessful, and an open reduction was performed. The humeral head was fixed with a 3.5 mm T-plate without affecting the growth plate. Plate removal was performed at a mean interval of 132 days after initial surgery. Two years after initial surgery, the clinical outcome was assessed by the Constant-Murley score and QuickDASH score (including sport/music and work) and the shoulder joint was evaluated with a standardized sonographic examination for the rotator cuff and the conjoint tendon. RESULTS: In all six patients, dorsal displacement of the fracture was irreducible due to the interposition of tendinous or osseous structures. Intraoperatively, the interposed structures were the long biceps tendon in two, periosteal tissue in two, a bony fragment in one, and the long biceps tendon together with the conjoint tendon in one case. At mean follow-up of 26 months (range 22 months to 29 months), patients showed very good clinical results with an excellent mean Constant-Murley score of 97.5 (range 91 to 100) and mean QuickDASH score (including sport/music and work) of 5.5 (range 0-20.8). An X-ray follow-up 6 weeks after surgery demonstrated early consolidation and correct alignment in all patients. A sonographic evaluation at 2 years post injury showed that the biceps and the conjoined tendon were intact in all patients. CONCLUSIONS: If a proximal humeral fracture is not reducible by closed means, a tissue entrapment (most likely biceps tendon) should be considered. Treatment with an open reduction and plate fixation yields very good clinical and radiological results and preserves interposed structures as the biceps and conjoint tendon.

Glenoid Component Loosening in Anatomic Total Shoulder Arthroplasty: Association between Radiological Predictors and Clinical Parameters-An Observational Study.

The mechanisms of glenoid component loosening in anatomic total shoulder arthroplasty (aTSA) are still unclear, and it remains undetermined which specific radiographic features are associated with clinical outcomes. Patients with primary osteoarthritis who underwent aTSA with a stemless implant and a pegged glenoid between January 2011 and December 2016 were extracted from a local registry. Anteroposterior radiographs were evaluated at six, 12, 24 months, and five years post-TSA for lateral humeral offset (LHO), joint gap (JG), acromiohumeral distance (AHD), and radiolucency (modified Franklin score); 147 patients were included. Mixed-model linear regression was used. Both constant score (CS) and subjective shoulder value (SSV) markedly decreased at five years follow-up compared to one year (p < 0.001 for both). AHD, LHO, and JG all showed a consistent and statistically significant decline over time, with the joint gap decreasing by half. Consistently, smaller JG and AHD were correlated with lower SSV (p = 0.03 and p = 0.07, respectively). Massive loosening was associated with a 14.5 points lower SSV (p < 0.01). Finally, narrowing of the JG was significantly correlated with increased radiolucency (p < 0.001) and tended toward worse SSV (p = 0.06). In summary, radiographic parameters displaying medialization and cranialization after aTSA with a cemented pegged glenoid are useful predictors of impaired shoulder function.

Arthroscopically Assisted Stabilization of Chronic Acromioclavicular Joint Instability.

This video article demonstrates biological and synthetic acromioclavicular (AC) and coracoclavicular stabilization with use of a hamstring tendon graft and a low-profile TightRope implant (Arthrex). The low-profile TightRope reduces soft-tissue irritation due to knot stacks1. The tendon graft is wrapped around the clavicle and the coracoid to avoid weakening of the osseous structures as a result of clavicular and coracoidal tunnel placement2. Description: For this procedure, the patient is placed in the beach chair position. After establishing standard posterior, anteroinferior, and anterolateral (transtendinous) portals, the arthroscopic preparation of the coracoid base is performed. Next, transcoracoidal-transclavicular drilling is performed, and a nitinol suture passing wire is utilized to aid the placement of the TightRope later in the procedure. The graft passage around the clavicle and the coracoid is then set up by placing 2 additional nitinol suture passing wires. Following this, coracoclavicular stabilization is performed with use of the low-profile TightRope device, after which the graft is shuttled around the clavicle and the coracoid with the help of the passing wires. After the acromial drilling, the graft is shuttled laterally transacromially and subcutaneously back to the clavicle, completing the AC cerclage. Finally, the graft ends are sewn together under tension. The deltotrapezial fascia is closed above the graft, incorporating the tendon ends into the suture. Finally, the skin can be closed. Alternatives: In case of chronic AC joint injuries, many surgical stabilization techniques have been described. On the one hand there are rigid stabilization techniques like the hook-plate or temporary Kirschner wire fixation. On the other hand, there are dynamic stabilization techniques like the modified Weaver-Dunn procedure or solitary synthetic coracoclavicular reconstruction with use of pulley-like devices, with or without additional AC stabilization3. As for nonsurgical alternatives, physiotherapy with periscapular stabilization and muscle strengthening may be an option4. Rationale: For the treatment of chronic AC joint instability, many techniques5-9 have been described that utilized horizontal and vertical stabilization with a tendon graft combined with a synthetic pulley-like device. Usually, multiple transclavicular and transcoracoidal drill holes are utilized for the graft passage, which could weaken the bone and may result in postoperative fractures of the coracoid and clavicle10. Considering this, we present a modified technique that focuses on the optimization of the graft passage. In contrast to other aforementioned techniques, this procedure requires only 1 transcoracoidal-transclavicular tunnel for the TightRope and another transacromial tunnel for the passage of the AC cerclage. By forming a loop of the graft around the coracoid and the clavicle, the graft passage is managed without any additional coracoidal or clavicular drilling. Expected Outcomes: A dedicated study investigating the specific clinical and radiographic results of our technique will be part of future research. Because the biomechanical principle of reconstruction of our technique is very similar to the technique described by Kraus et al., we refer to their clinical and radiographic results regarding the expected outcome. As shown in the chart in the video, Kraus et al. demonstrated good clinical and radiographic results with their biologic and synthetic AC-stabilization technique at a median follow-up of 24 months. The outcomes measured in that study were the Constant score, Subjective Shoulder Value, AC Joint Instability Score, and Taft score. Patients were divided into 2 groups. Group 1 included patients with failed prior conservative treatment, and group 2 included those with failed prior surgical treatment. Overall, the authors report complete dynamic posterior translation in 1 patient and partial dynamic posterior translation in 5 patients. Although there was no notable enlargement of the TightRope drill hole, the authors of that study found a significant enlargement of the clavicular graft tunnels. However, the enlargement had no clinical relevance10. Important Tips: Utilize a low-profile TightRope device to minimize the risk of suture irritation from knot stacks.The tendon graft should be ≥24 cm in length. If the graft is too short, perform an end-to-end anastomosis of 2 grafts.Utilize an image intensifier to ensure correct drill hole placement and avoid damage to neurovascular structures.The graft passage around the clavicle and the coracoid can be dilated by hand with the use of differently sized drill bits.Incorporate the graft into fascial closure at the end of the procedure.

Pain during Cast Wedging of Forearm Shaft and Distal Forearm Fractures in Children Aged 3 to 12 Years-A Prospective, Observational Study.

BACKGROUND: Although fracture displacement in children is easily treated by cast wedging, no data on pain associated with the procedure are available. We hypothesized that there is no clinically relevant difference in pain before and after cast wedging in children between 3 and 12 years of age. PATIENTS AND METHODS: This international, multicenter, prospective, observational study included 68 children (39 male, 29 female) aged 3 to 12 years (median age 8 years) with forearm fractures. Cast wedging was performed 5 to 10 days after the injury. Before starting the procedure, we administered a single oral dose of sodium metamizole (10 mg/kg body weight), and the children inhaled a nitrous oxide/oxygen mixture (50%/50%) during the wedging procedure. Pain was rated on a visual analog scale (VAS) 5 to 10 min before incision of the cast as well as 3 to 5 min and 30 min (maximum remembered pain) after inhalation stop. The degree of bending was judged either by the surgeon or was determined on the basis of first signs of pain expressed by the patient. We assessed the effectiveness of the procedure by obtaining X-ray images in two planes after 3 to 9 days. RESULTS: Among the 68 patients, median VAS score before cast wedging was 0. This increased to a score of 1 (p = 0.015) at 3 to 5 min after the procedure. Median VAS score for the maximum remembered pain measured after 30 min was 0. Median differences in angulation between proximal and distal bone fragments before and after the intervention were 0° (p < 0.0001) in the a.p. view and 8.4° (p < 0.0001) in the lateral view. CONCLUSION: Cast wedging improved the position of forearm fracture fragments at the expense of minimal short-term pain.

[Ruptures of the Distal Biceps and Triceps Tendon]. / Distale Bizepssehnen- und Trizepssehnenrupturen.

Ruptures of the distal biceps and triceps tendon are rare. Most frequently these injuries occur in men, athletes and patients with physically demanding work activities. This review article describes aetiology and pathogenesis as well as diagnostics, treatment options, the expected outcome and provides insights in our own approach.

Arthroscopic Knotless-Anchor Rotator Cuff Repair.

The most common type of rotator cuff lesion is a tear of the supraspinatus tendon, with arthroscopic rotator cuff repair representing an established treatment option1-3. Several double-row techniques have been described to achieve complete coverage of the rotator cuff footprint. Among these is the bridging, double-row, transosseous-equivalent rotator cuff repair, which has become one of the most popular techniques for its maximized contact area and initial fixation strength4-9. However, medial cuff failure is a common complication following this procedure9-14. To reduce medial strangulation and overall surgical time, all-knotless anchor repair has been introduced as an alternative technique15. The arthroscopic knotless, bridging, double-row, transosseous-equivalent technique is performed with the patient in the beach-chair position via lateral operative and viewing portals. A medial row of suture anchors is placed in the usual fashion. The tendon is then perforated twice per anchor with use of a suture-passer device, after which the suture limbs are bridged over the tendon and fixed in a lateral row of anchors. Excellent functional outcomes as well as satisfaction in >90% of patients have been reported with the supraspinatus knotted double-row, bridging, transosseous-equivalent repair4,9,11,13,16-19. No significant differences have been reported for clinical results and tendon integrity on magnetic resonance imaging when comparing knot-tying and knotless double-row transosseous-equivalent rotator cuff repair; however, the rate of medial cuff failure was lower among knotless procedures1,12,16,17,20-25. The major steps of the procedure, which are demonstrated in this video article, include (1) diagnostic arthroscopy; (2) supraspinatus tear visualization and debridement; (3) decortication of the footprint on the greater tuberosity; (4) placement of the medial row of anchors loaded with nonabsorbable suture tape; (5) separate suture passage of each limb, perforating the tendon with use of a suture passer; (6) fixation of the tape in the lateral row of anchors, creating a bridging configuration; and (7) anterolateral acromioplasty with use of an arthroscopic burr. Complications are rare following this procedure. As postoperative rehabilitation is essential for tendon healing, the operative arm should be placed in an abduction brace for 6 weeks, with only passive mobilization.

Biological Augmentation With Subacromial Bursa in Arthroscopic Rotator Cuff Repair.

Rotator cuff tears can be associated with significant shoulder dysfunction and pain. Despite improved surgical techniques and new materials for rotator cuff reconstruction, there is no significant reduction in the re-rupture rate. Innovative approaches for enhanced tendon healing are required. The potential of biologically optimized tendon integration has probably been insufficiently explored so far. The existing practice of debridement might eliminate repair tissue and a major source of cells and blood vessels necessary for tendon healing. Biological augmentation may be an option to improve the healing process. The subacromial bursa is a highly proliferative tissue with mesenchymal stem cells capable of differentiating into various cell lines and is easily accessible during rotator cuff repair. We describe the technique of bursal augmentation in arthroscopic double-row SutureBridge repair of a posterosuperior rotator cuff tear with the aim of improving tendon-to-bone healing.