Retrospective analysis of the subscapularis-sparing approach for reverse total shoulder arthroplasty.

PURPOSE: The influence of the subscapularis tendon on reverse total shoulder arthroplasty (RTSA) has been discussed controversially. The aim of the study was to investigate the subscapularis-sparing approach for RTSA and the effect of the intact subscapularis tendon. METHODS: This retrospective comparative study included 93 patients. Among these, 55 underwent the deltopectoral subscapularis-sparing approach, and in 38 cases, the standard deltopectoral approach with subscapularis tenotomy was applied. At the final follow-up, representative shoulder scores were measured, radiographs were taken in two planes, and shoulder sonography was performed. RESULTS: The subscapularis-sparing group showed a significantly higher Constant score (71.8 vs. 65.9 points) and adapted Constant score if the subscapularis tendon was shown to be intact in the postoperative sonography (85.2% vs. 78.6%) (p = 0.005; p = 0.041). Furthermore, these patients had improved abduction (128.2 vs. 116.8, p = 0.009) and external rotation (34.6 vs. 27.1, p = 0.047). However, no significant differences were found for the degree of internal rotation and internal rotation strength. No dislocation or infection was observed. The degree of scapular notching was not significantly different between the two groups (p = 0.082). However, independently from the integrity of the subscapularis the subscapularis-sparing approach showed no difference in clinical and radiographic outcome (Constant score scapularis-sparing 70.0 points vs. tenotomy 66.8 points; p = 0.27). CONCLUSION: The subscapularis-sparing approach RTSA showed improved clinical outcome, abduction, and external rotation, if the subscapularis was shown to be intact at time of follow-up. Both groups showed no difference in internal rotation.

Biomechanical comparison of single versus double plate osteosynthesis in acromion type III fractures.

Background: One of complications of the reverse shoulder arthroplasty is acromion fractures, and its therapy is controversial. The aim of the study was to investigate the double-plate osteosynthesis for these fractures. Methods: An acromion type III fracture according to classification of Levy was simulated in 16 human shoulder cadavers, and the specimens were randomly divided into two groups. Single-plate osteosynthesis was performed in the first group (locking compression plate) and double-plate osteosynthesis (locking compression plate and one-third tubular locking plate) in the second group. Biomechanical testing included cycling load and load at failure on a material testing machine. During the test, the translation was measured using an optical tracking system. Results: The load at failure for the single-plate osteosynthesis was 167 N and for the double-osteosynthesis 233.7 N (P = 0.328). The average translation was 11.1 mm for the single-plate osteosynthesis and 16.4 mm for the double-plate osteosynthesis (P = 0.753). The resulting stiffness resulted in 74.7 N/mm for the single-plate osteosynthesis and 327.9 N/mm for the double-plate osteosynthesis (P = 0.141). Discussion: Results of the biomechanical study showed that double-plate osteosynthesis had biomechanical properties similar to those of single-plate osteosynthesis for an acromion type III fracture at time point zero. The missing advantages of double-plate osteosynthesis can be explained by the choice of plate configuration.

Does glenoid inclination affect the anterior stability of reverse total shoulder arthroplasty? A biomechanical study.

PURPOSE: The anterior stability of reverse total shoulder arthroplasty is affected by multiple factors. However, the effect of glenosphere inclination on stability has rarely been investigated, which is what this study aims to look into. METHODS: Reverse shoulder arthroplasty was performed on 15 cadaveric human shoulders. The anterior dislocation forces and range of motion in internal rotation in the glenohumeral joint (primary measured parameters) were tested in a shoulder simulator in different arm positions and implant configurations, as well as with a custom-made 10° inferiorly inclined glenosphere. The inclination and retroversion of the baseplate as well as the distance between the glenoid and coracoid tip in two planes (secondary measured parameters) were evaluated on CT scans. RESULTS: In biomechanical testing, the custom-made inclined glenosphere showed no significant influence on anterior stability other than glenoid lateralisation over all arm positions as well as the neck-shaft angle in two arm positions. The 6 mm lateralised glenosphere reduced internal rotation at 30° and 60° of glenohumeral abduction. In 30° of glenohumeral abduction, joint stability was increased using the 155° epiphysis compared with the 145° epiphysis. The mean inclination was 16.1°. The inclination was positively, and the distance between the glenoid and coracoid tip in the anterior-to-posterior direction was negatively correlated with anterior dislocation forces. CONCLUSIONS: The custom-made inferiorly inclined glenosphere did not influence anterior stability, but baseplate inclination itself had a significant effect on stability.

Differences in Osseous Shoulder Morphology, Scapulothoracic Orientation, and Muscle Volume in Patients With Constitutional Static Posterior Shoulder Instability (Type C1) Compared With Healthy Controls.

BACKGROUND: Constitutional static posterior humeral decentering (type C1 according to ABC Classification) has been recognized as a pre-osteoarthritic deformity that may lead to early-onset posterior decentering osteoarthritis at a young age. Therefore, it is important to identify possible associations of this pathologic shoulder condition to find more effective treatment options. PURPOSE: To perform a comprehensive analysis of all parameters reported to be associated with a C1 shoulder-including the osseous shoulder morphology, scapulothoracic orientation, and the muscle volume of the shoulder girdle in a single patient cohort. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A retrospective, comparative study was conducted analyzing 17 C1 shoulders in 10 patients who underwent magnetic resonance imaging (MRI) with the complete depiction of the trunk from the base of the skull to the iliac crest, including both humeri. The mean age of the patients was 33.5 years, and all patients were men. To measure and compare the osseous shoulder morphology (glenoid version, glenoid offset, humeral torsion, anterior acromial coverage, posterior acromial coverage, posterior acromial height, and posterior acromial tilt) and scapulothoracic orientation (scapular protraction, scapular internal rotation, scapular upward rotation, scapular translation, scapular tilt, and thoracic kyphosis), these patients were matched 1 to 4 according their age, sex, and affected side with shoulder-healthy patients who had received positron emission tomography (PET)-computed tomography. To measure and compare the muscle volume of the shoulder girdle (subscapularis, infraspinatus/teres minor, supraspinatus, trapezius, deltoid, latissimus dorsi/teres major, pectoralis major, and pectoralis minor), patients were matched 1 to 2 with patients who had received PET-MRI. Patients with visible pathologies of the upper extremities were excluded. RESULTS: The C1 group had a significantly higher glenoid retroversion, increased anterior glenoid offset, reduced humeral retrotorsion, increased anterior acromial coverage, reduced posterior acromial coverage, increased posterior acromial height, and increased posterior acromial tilt compared with controls (P < .05). Decreased humeral retrotorsion showed significant correlation with higher glenoid retroversion (r = -0.742; P < .001) and higher anterior glenoid offset (r = -0.757; P < .001). Significant differences were found regarding less scapular upward rotation, less scapular tilt, and less thoracic kyphosis in the C1 group (P < .05). The muscle volume of the trapezius and deltoid was significantly higher in the C1 group (P < .05). CONCLUSION: Patients with C1 shoulders differ from healthy controls regarding osseous scapular and humeral morphology, scapulothoracic orientation, and shoulder girdle muscle distribution. These differences may be crucial in understanding the delicate balance of glenohumeral centering.

Short-term results of a new anatomic stemless shoulder arthroplasty - A prospective multicentre study.

Background: Anatomic total shoulder arthroplasty (TSA) has been continuously developed and current designs include stemless or canal-sparing humeral components. In the literature stemless and canal sparing TSA showed good clinical and radiographic results, which were comparable to stemmed TSA. Objective: The aim of this study was to determine the short-term clinical and radiological outcomes of a new stemless TSA design. Methods: A prospective multicentre study including 154 total shoulder arthroplasty patients with a follow up of 12 months was performed. At the time of follow up 129 patients were available for review. The adjusted Constant Murley score,1 Oxford Shoulder Score, EQ-5D-5L score and radiographs were examined preoperatively, 3 and 12 months after the implantation of the new stemless TSA implant GLOBAL ICON™ (DePuy Synthes, Warsaw, IN, USA). Complications were documented. Results: Implant Kaplan-Meier survivorship was 98.7% at 12 months. From baseline to 12 months follow-up, all scores showed a progressive significant mean improvement. The mean adjusted Constant score increased from 42.3 to 96.1 points (p<0.001). The Oxford Shoulder Score showed an increase of 21.6 points (p<0.001). The postoperative radiographs showed no continuous radiolucent lines, subsidence, aseptic loosening or progressive radiolucency, but one osteolytic lesion was observed. Only 2 prostheses were revised. Conclusion: The new GLOBAL ICON stemless TSA showed good clinical and radiographic results at short-term follow up which were comparable to early results of other stemless TSA. Further studies with longer follow up are needed in the future.

Results of Arthroscopic Revision Rotator Cuff Repair for Failed Open or Arthroscopic Repair: A Prospective Multicenter Study on 100 Cases.

BACKGROUND: Retears after rotator cuff repair (RCR) have been associated with poor clinical results. Meaningful data regarding the role of arthroscopic revision RCR are sparse thus far. PURPOSE/HYPOTHESIS: To investigate results after arthroscopic revision RCR. We hypothesized that (1) arthroscopic revision RCR would lead to improved outcomes, (2) the clinical results would be dependent on tendon integrity and (3) tear pattern, tendon involvement, and repair technique would influence clinical and structural results. STUDY DESIGN: Case series; Level of evidence 4. METHODS: During a 40-month period, 100 patients who underwent arthroscopic revision RCR were prospectively enrolled in this multicenter study. Outcomes were evaluated preoperatively, at 6 months (6M), and at 24 months (24M) using the Constant score (CS), the Oxford Shoulder Score (OSS), and the Subjective Shoulder Value (SSV). Tendon integrity at 2 years was analyzed using magnetic resonance imaging. A total of 13 patients (13%) were lost to follow-up, and 14 patients (14%) had a symptomatic retear before the 24M follow-up. RESULTS: All clinical scores improved significantly during the study period (CS: preoperative, 44 ± 16; 6M, 58 ± 22; 24M, 69 ± 19 points; OSS: preoperative, 27 ± 8; 6M, 36 ± 11; 24M, 40 ± 9 points; SSV: preoperative, 43% ± 18%; 6M, 66% ± 24%; 24M, 75% ± 22%) (P < .01). At 2 years, a retear rate of 51.8% (43/83) and a surgical revision rate of 12.6% (11/87) were observed. Mean full-thickness tear size decreased from 5.00 ± 1.61 cm2 to 3.25 ± 1.92 cm2 (P = .041). Although the Sugaya score improved from 4.5 ± 0.9 to 3.7 ± 1.4 (P = .043), tendon integrity did not correlate with better outcome scores. Previous open RCR, involvement of the subscapularis, chondral lesions of Outerbridge grade ≥2, and medial cuff failure were correlated with poorer SSV scores at 2 years (P≤ .047). Patients with traumatic retears had better CS and OSS scores at 2 years (P≤ .039). CONCLUSION: Although arthroscopic revision RCR improved shoulder function, retears were frequent but usually smaller. Patients with retears, however, did not necessarily have poorer shoulder function. Patient satisfaction at 2 years was lower when primary open RCR was performed, when a subscapularis tear or osteoarthritis was present, and when the rotator cuff retear was located at the musculotendinous junction. Patients with traumatic retears showed better functional improvement after revision.

Biomechanical Comparison of Two Fixation Techniques for Lateral Ulnar Collateral Ligament Repair With Ligament Bracing.

PURPOSE: Ligament bracing is a technique of suture reinforcement that can be used to augment lateral ulnar collateral ligament repair in the treatment of posterolateral rotatory instability of the elbow, thereby improving early stability of the repair. However, multiple failures of the ulnar anchor during implantation have been documented. We hypothesized that the use of a cortical button for ulnar fixation of the ligament brace would be biomechanically comparable to a suture anchor construct. METHODS: Sixteen elbows were tested with a materials testing machine. The intact, dissected, and repaired lateral collateral ligament complex was tested with a cyclic varus rotational torque of 0.5-3.5 Nm in 120°, 90°, 60°, and 30° elbow flexion. For the repair, the specimens were randomized into 2 groups: ulnar fixation of the ligament bracing using a suture anchor and ulnar fixation of the ligament bracing using a cortical button. The number of implant failures was documented. A load-to-failure protocol was conducted in 90° elbow flexion. RESULTS: Load to failure was comparable and was found to be 20.7 Nm in the suture anchor group and 21.8 Nm in the cortical button group. Laxity after ligament bracing did not differ significantly between suture anchor and cortical button fixation. Compared with the native ligament, the laxity was significantly reduced after ligament bracing. The failure mode was slippage of the suture tape through the humeral anchor in all cases. Additionally, the capitellum was damaged in 9 of 16 cases. CONCLUSIONS: A cortical button for ulnar fixation of the ligament bracing was comparable with a suture anchor fixation with regard to biomechanical properties such as laxity and load to failure. CLINICAL RELEVANCE: A cortical button fixation is less prone to failure of insertion. This would improve the implantation technique, while clinical results are expected to be comparable.

Biomechanical comparison of lateral collateral ligament reconstruction with and without additional internal bracing using a three-dimensional elbow simulator.

BACKGROUND: Although an additional internal bracing significantly increases stability in a repair of the lateral ulnar collateral ligament, it remains unclear whether it also does in reconstruction. Aim of this study was to implement a three-dimensional elbow simulator for testing posterolateral rotatory instability. We hypothesized that (1) reconstruction with and without internal bracing is comparable in biomechanical properties, and (2) there would be higher load-to-failure with internal bracing. METHODS: Posterolateral rotatory instability was tested by imitating the lateral pivot shift test in 16 elbows. Valgus and supination torques were simultaneously increased stepwise up to 1.2 Nm. Specimens were tested at 30°, 60°, 90°, and 120° elbow flexion with an intact lateral collateral ligament complex, dissected complex, and after reconstruction with or without internal bracing. Outcome measures included joint gapping, laxity, and load to failure. FINDINGS: With the implemented elbow simulator no significant difference was observed for gapping or laxity between both treatment groups. Comparing treatment and native ligament, gapping was reduced, especially with increased elbow flexion. Laxity was also reduced at some flexion angles. The mean load-to-failure was 8.1 ± 2.7 Nm without and 9.6 ± 3.6 Nm with internal bracing (P = 0.645). INTERPRETATION: Both treatments were comparable in biomechanical properties but did not fully restore the native state. Although the additional augmentation of the LUCL reconstruction tends to increase the maximum load to failure, this difference was not statistically significant. Still, reconstruction with internal bracing seems to be a reasonable option in selected primary reconstructions. It could also be useful in revision reconstruction.

Suture tape augmentation of the lateral ulnar collateral ligament increases load to failure in simulated posterolateral rotatory instability.

PURPOSE: Simple elbow dislocations are accompanied with lateral ulnar collateral ligament ruptures. For persisting instability, surgery is indicated to prevent chronic posterolateral rotatory instability. After lateral collateral ligament (LCL) complex repair the repair is protected by temporary immobilization, limited range of motion and hinged bracing. Internal bracing is an operative alternative augmenting the LCL repair using non-absorbable suture tapes. However, the stability of LCL repair with and without additional augmentation remains unclear. The hypothesis was that LCL repair with additional suture tape augmentation would improve load to failure. Secondary goal of this study was to evaluate different humeral fixation techniques. A humeral fixation using separate anchors for the LCL repair and the augmentation was not expected to provide superior stability compared to using only one single anchor. METHODS: Twenty-one elbows were tested. A cyclic varus rotational torque of 0.5-3.5 Nm was applied in 90°, 60°, 30°, and 120° elbow flexion to the intact, torn, and repaired LCLs. The specimens were randomized into three groups: repair alone (group I), repair with additional internal bracing using two anchors (group II), repair using one humeral anchor (group III). A load-to-failure protocol was conducted. RESULTS: Load to failure was significantly higher in groups II (26.6 Nm; P = 0.017) and III (23.18 Nm; P = 0.038) than in group I (12.13 Nm). No significant difference was observed between group II and III. All specimens lost reduction after LCL dissection by a mean of 4.48° ± 4.99° (range 0.66-15.82). The mean reduction gain after repair was 7.21° ± 4.97° (2.70-21.23; mean over reduction, 2.73°). The laxity was comparable between the intact and repaired LCLs (n.s.), except for varus movements at 30° in group II (P = 0.035) and 30° (P = 0.001) and 120° in group III (P = 0.008) with significantly less laxity. Inserting the ulnar suture anchor showed failure in the thread in 10 cases. CONCLUSION: LCL repair with additional internal bracing yielded higher load to failure than repair alone. Repair with additional internal bracing for the humeral side using one anchor was sufficient. A higher primary stability would facilitate postoperative management and allow immediate functional treatment. Reducing the number of humeral anchors would save costs.

Anatomic factors influencing the anterior stability of reverse total shoulder arthroplasty.

BACKGROUND: Several factors affect the stability of the reverse shoulder arthroplasty. The influence of bony anatomy on anterior stability remains unclear. This study aimed to identify the correlations between bony anatomy and anterior dislocation forces. METHODS: The differences in anterior dislocation force in reverse total shoulder arthroplasty reported in a previous biomechanical study were used to analyze the anatomic factors influencing anterior stability. The critical shoulder angle, glenocoracoid distance in 2 planes, and glenoid inclination were measured in the tested specimens using 3-dimensional computed tomographic scans and radiographs. Anatomic parameters were then correlated with the anterior dislocation forces. RESULTS: The critical shoulder angle had no correlation with anterior stability. The glenocoracoid distance in anteroposterior direction showed a negative correlation with the stability of a reverse shoulder arthroplasty with a 9-mm lateralized glenosphere and 155° humeral inclination in 30° and 60° glenohumeral abduction with the arm in 30° external rotation (r = -0.662, P = .004; r = -0.794, P = .011) and 30° glenohumeral abduction with neutral rotation (r = -0.614, P = .009). Using the same hardware configuration, the anterior stability had a negative correlation with the glenocoracoid distance in the mediolateral direction in 30° of glenohumeral abduction with the arm in 0° and 30° of external rotation (r = -0.542, P = .025; r = -0.497, P = .042). CONCLUSION: The distance between the coracoid tip and glenoid in 2 planes had a significant negative correlation with the anterior stability of the reverse shoulder arthroplasty with a lateralized glenosphere and 155° humeral inclination. The findings suggest that only glenoid lateralization is influenced by the bony anatomy.

Clinical evaluation of double-plate osteosynthesis for olecranon fractures: A retrospective case-control study.

INTRODUCTION: Single, dorsal plating is a commonly used technique for treating olecranon fractures. Double-plate osteosynthesis is an alternative treatment. Aim of this study was to present the surgical technique using this novel double-plate implant for olecranon fractures and review clinical results, complication rates and revision surgeries. Results were compared to single, dorsal plating. HYPOTHESIS: Does double-plate osteosynthesis for olecranon fractures improve material's tolerance with respect to osteosynthesis by single dorsal plating? PATIENTS AND METHODS: Between February 2011 and March 2015, we retrospectively evaluated 47 patients who were included in this study: 25 were treated with a low-profile double-plate osteosynthesis and 22 with an anatomically pre-shaped 3.5mm locking compression plate (LCP). The 2 groups were the result of a change of implants in our department in 2013. Patient satisfaction, range of motion, patient related outcome scores (Mayo Elbow Performance Score [MEPS], Disabilities of Arm, Shoulder and Hand Score [DASH]), complications and revision surgeries were evaluated. Results between both implant types were statistically compared using the Mann-Whitney U test. RESULTS: After a mean follow-up of 41 months (range: 25-61), the low-profile double-plate group showed a range of motion of 127°, MEPS of 94 and DASH of 6. The 3.5mm LCP group was found to have a range of motion of 130°, MEPS of 96 and DASH of 8. No clinical difference was found between groups. A total of 9 revision surgeries after double-plate osteosynthesis were recorded including seven implant removals and two intraarticular screws. One loosening of a screw without revision surgery was reported. The 3.5mm LCP group had 9 revision surgeries including eight implant removals and one intraarticular screw. DISCUSSION: Low-profile double-plate osteosynthesis is a safe and effective alternative treatment of olecranon fractures. Subjective and objective clinical outcome measures revealed a low complication rate and excellent results. Still, implant removal due to soft tissue irritation remains an issue. These findings were comparable to common dorsal plate osteosynthesis. LEVEL OF EVIDENCE: III, retrospective case-control study.

Effect of the humeral neck-shaft angle and glenosphere lateralization on stability of reverse shoulder arthroplasty: a cadaveric study.

BACKGROUND: Lateralizing the glenosphere and decreasing the humeral neck-shaft angles are implant design parameters that reduce the risk of scapular impingement. The effects of these parameters on joint stability remain unclear. This study evaluated the effect of glenosphere lateralization and humeral neck-shaft angle on joint stability by quantifying the anterior dislocation force in different arm positions. METHODS: Reverse shoulder arthroplasty was performed on 19 human shoulder specimens. Anterior dislocation force and maximum external rotation were evaluated using a robot-based shoulder simulator. By varying the neck-shaft angle and magnitudes of glenosphere lateralization, 12 configurations were analyzed with the glenohumeral joint in 30° and 60° of abduction, in neutral, and in 30° of external rotation. RESULTS: At 30° of abduction, measurements showed significantly higher dislocation forces for the 9-mm and 6-mm lateralized glenosphere than for the 0-mm (P < .0001, P = .007) nonlateralized glenosphere. At 60° of abduction, measurements showed significantly higher dislocation forces for the 9-mm and 6-mm lateralized glenosphere than for the 0-mm (P < .0001, P = .0007) and 3-mm (P = .0003, P = .04) glenosphere. Configurations with a neck-shaft angle of 135° showed significantly higher dislocation forces than configurations with a neck-shaft angle of 145° (P = .02) or 155° (P = .02) at 30° of abduction in 30° of external rotation. Neck-shaft angle and glenosphere lateralization had no influence on maximum external rotation capability. CONCLUSION: Glenosphere lateralization significantly increased anterior stability of the glenohumeral joint without influencing the range of passive external rotation. The humeral neck-shaft angle only had a minor effect on anterior stability.

Reverse shoulder arthroplasty for fracture sequelae: Clinical outcome and prognostic factors.

BACKGROUND: The reverse total shoulder arthroplasty (RTSA) is a common therapy for the fracture sequelae (FS) of the proximal humerus. The aim of this study was to show the short and midterm clinical outcome of the RTSA for FS and to identify prognostic factors. METHODS: Data from 46 patients with chronic FS who underwent RTSA were analysed. The clinical follow-up included the Constant score and radiographic examination. Patients were divided into groups based on the Boileau classification of FS, and the degree of metaphyseal bone loss was measured (Boileau type I 9 patients; type II 3 patients; type III 8 patients and type IV 16 patients). Scapular notching was assessed according to the classification of Sirveaux. RESULTS: The mean postoperative Constant score was 57. Clinical outcomes were similar among the various FS groups, as defined according to the Boileau classification, but patients who had undergone revision arthroplasty had a significantly inferior mean Constant score than patients with type IV FS. There were no significant differences between patients who were initially managed with conservative therapy and those treated surgically. Patients with metaphyseal bone loss >3 cm showed inferior clinical scores. Inferior scapular notching was seen in 25 patients, and had a negative effect on the clinical outcome. Complications included five infections and one dislocation. CONCLUSION: Metaphyseal bone loss was unfavourable prognostic factors in patients with FS treated with RTSA. However, the Boileau classification did not serve as a prognostic criterion. Previous operative or conservative treatment had no influence on the outcome and scapular notching was associated with inferior clinical results.

Diagnosing periprosthetic hip joint low-grade infection via arthroscopic neo synovium biopsies.

BACKGROUND: There is currently a lack of consensus regarding the most effective diagnostic algorithm for cases of supposed low-grade infection after total hip arthoplasty (THA). OBJECTIVE: The aim of this study was to assess reliability in the use of biopsies, obtained by hip arthroscopy, to detect a periprosthetic hip joint infection (PJI). METHODS: From 2012 to 2016, diagnostic arthroscopy of the hip joint was performed in 20 patients with a supposed PJI following THA. In 10 of these patients, the THA was revised for various reasons after diagnostic arthroscopy. The microbiological and histological findings of the biopsies obtained by arthroscopy were compared to findings from intraoperative samples of the revision arthroplasty. RESULTS: For arthroscopic biopsies, we detected a sensitivity of 1.00 (95% confidence interval [CI] 0.40-1.00), a specificity of 0.83 (95% CI 0.36-1.00), a positive predictive value of 0.80 (95% CI 0.28-1.00), and a negative predictive value of 1.00 (95% CI 0.48-1.00). The accuracy was 0.90. CONCLUSIONS: The analysis of arthroscopic biopsies represents a helpful tool to verify or rule out a PJI in selected patients. Nevertheless, minimally invasive diagnostic tools (e.g., laboratory analysis and aspiration) should be utilized beforehand.

[Options in joint-preserving surgical treatment of osteoarthritis]. / Optionen der gelenkerhaltenden operativen Omarthrosetherapie.

BACKGROUND: The treatment of glenohumeral arthritis represents a major challenge in highly active younger patients. In these patients, an endoprosthetic treatment often achieves only unsatisfactory results with a limited lifetime of the implant. OBJECTIVES: The aim of the study was to identify joint-preserving therapies for glenohumeral arthritis. MATERIALS AND METHODS: For this study, an extensive and selective literature search was performed. RESULTS: There are several options available for joint-preserving treatment of glenohumeral arthritis. In addition to arthroscopic debridement with treatment of concomitant pathologies, CAM procedures (CAM: comprehensive arthroscopic management) according to Millett, as well as the interposition of allografts are other options. For all therapy options, an improved range of motion and pain reduction is described. A joint gap of <2 mm, bipolar cartilage lesions and age are described as risk factors for failure of the therapies. DISCUSSION: Short and mid-term results have been described for arthroscopic debridement, but there are no long-term and high-quality studies to enable us to make clear recommendations. The CAM procedure and the interposition of an allograft are demanding procedures that should be reserved for experienced arthroscopists. The therapies are an option for younger patients in accordance with individual decisions and realistic expectations.

Arthroscopic posterior bone block stabilization-early results of an effective procedure for the recurrent posterior instability.

PURPOSE: In the current study the clinical outcome of an arthroscopic posterior bone block augmentation in combination with a posterior capsular repair was investigated. METHODS: Twenty-four shoulders (18 patients) with unidirectional posterior shoulder instability were treated with an arthroscopic posterior bone block and capsular reconstruction. The mean follow up period was 26 months. The patients were examined pre- and postoperatively using the Constant-Murley score, the Rowe score, Walch-Duplay score and Western Ontario Shoulder index. RESULTS: At the follow up examination 21 shoulders were classified to be stable, while one patient reported a single redislocation and two further patients reported recurrent posterior subluxation or posterior apprehension. Thus, the recurrence rate was defined to be 12.5%. The Rowe-Score significantly improved from 50 points preoperatively to 75 points postoperatively (p = 0.0003). The WOSI-score significantly improved from 37% preoperatively to 66% postoperatively (p = 0.0001). Revision surgery commonly was required for screw removal. CONCLUSION: The early clinical results of this arthroscopic bone block augmentation and capsular repair are promising. LEVEL OF EVIDENCE: IV.

The effect of rotator cuff malreduction on tendon tension: an evaluation of a custom-made digital tensiometer clamp.

INTRODUCTION: Rotator cuff tears are common and good-to-excellent clinical outcome is reported after subsequent repair. However, the retear rate of rotator cuff repairs has been shown to be as high as 20%. The reasons for retear seem to be multifactorial, mainly comprised by mechanical and biological aspects. Regarding mechanical causes, the role of the tendon tension and malreduction is so far unknown. First, we hypothesized that the tendon tension depends on the technique of tendon reposition and that malreduction of the tendon results in an increased tendon tension. Second, we aimed to demonstrate the inter- and intraobserver reliability of a novel custom-made digital tensiometer clamp. MATERIALS AND METHODS: A tendon defect of posterosuperior rotator cuff (reverse L-shaped) was simulated in seven cadaveric human shoulder specimens. By use of a custom-made tensiometer clamp, the supraspinatus tendon was reduced by pulling it in (1) an anterolateral direction (anatomical reduction) and (2) in a straight lateral direction (malreduction) until the footprint was completely covered. The reduction procedure was consecutively repeated to evaluate the inter- and intraobserver reliability. RESULTS: The mean traction forces for anatomical reduction and malreduction were 16.02 N (SD 8.06) and 19.52 N (SD 9.95), respectively. The difference between the two groups was statistically significant (p = 0.028). The interobserver reliability showed a correlation of r = 0.757 [95% confidence interval (CI) 0.092-0.955]. The intraobserver reliability of the three surgeons was observed to be between r = 0.905 and 0.986. CONCLUSIONS: The malreduction of the rotator cuff has a significant influence on the tendon tension and may therefore affect the healing rate of the tendon after the repair, so that a tension-balanced repair could improve the clinical results. Furthermore, the application of a novel custom-made tensiometer clamp showed good interobserver and excellent intraobserver reliabilities.

First Metatarsophalangeal Joint Arthrodesis: A Retrospective Comparison of Crossed-screws, Locking and Non-Locking Plate Fixation with Lag Screw.

BACKGROUND: Locking plate fixation is increasingly used for first metatarsophalangeal joint (MTP-I) arthrodesis. There are still few comparable clinical data regarding this procedure. In this study we aimed to compare the clinical and radiographical outcomes of crossed-screws, locking and non-locking plate fixation with lag screw for first metatarsophalangeal joint arthrodesis. METHODS: A total of 60 patients who had undergone arthrodesis of the MTP-I between January 2008 and June 2010 were retrospectively evaluated. Locking plate fixation with lag screw as well as arthrodesis with crossed-screws or with a non-locking plate with lag screw was performed on three groups of 20 patients. RESULTS: There were four non-unions in patients with crossed-screws and one in non-locked plate group. All patients in locking plate group achieved union. 90% of the patients were completely or mildly satisfied in locking plate group, whereas this rate was 80% for patients in both crossed-screws and non-locking plate groups. CONCLUSION: Use of dorsal plating for arthrodesis of MTP-I joint, either locking or non-locking, were associated with high union rate and acceptable and comparable functional outcome. Although the rate of nonunion was higher with two crossed-screws, however, the functional outcome was not significantly different compared to dorsal plating.

The value of arthroscopic neosynovium biopsies to diagnose periprosthetic knee joint low-grade infection.

INTRODUCTION: The diagnostic algorithm in cases of assumed low-grade infection after total knee arthroplasty is discussed controversial. The aim of this study was to evaluate the reliability of neosynovium biopsies via knee arthroscopies in predicting a periprosthetic knee joint infection (PJI). METHODS: From 2010 to 2015, 56 consecutive patients received a diagnostic arthroscopy of the knee joint by reason of an assumed PJI. In 34 cases, a revision arthroplasty was performed after the diagnostic arthroscopy. The microbiologic and histologic results from neosynovium biopsies were compared to intraoperative findings of the consecutively performed revision arthroplasty. RESULTS: The arthroscopic neosynovium biopsies had a sensitivity of 0.88 (0.47-1.0 95 % confidence interval), a specificity of 0.88 (0.7-0.98), a positive predictive value of 0.7 (0.35-0.93), and a negative predictive value of 0.96 (0.79-1.0). The accuracy was 0.88. We determined a higher sensitivity of neosynovium biopsies compared to C-reactive protein (p = 0.038) and white blood cell count (p < 0.001) in serum. The itemized evaluation of histologic results showed a significant higher sensitivity compared to microbiologic results (p = 0.045) and a higher accuracy. CONCLUSIONS: The analysis of arthroscopic neosynovium biopsies can be helpful to verify or exclude a PJI in selected patients. Especially, histologic assessment showed a high accordance with final results. Level of evidence IV, retrospective study.

Anterior stability of the reverse shoulder arthroplasty depending on implant configuration and rotator cuff condition.

INTRODUCTION: The aim of this study was to investigate the stabilizing influence of the rotator cuff as well as the importance of glenosphere and onlay configuration on the anterior stability of the reverse total shoulder replacement (RTSR). MATERIALS AND METHODS: A reverse total shoulder replacement was implanted into eight human cadaveric shoulders, and biomechanical testing was performed under three conditions: after implantation of the RTSR, after additional dissection of the subscapularis tendon, and after additional dissection of the infraspinatus and teres minor tendon. Testing was performed in 30° of abduction and three rotational positions: 30° internal rotation, neutral rotation, and 30° external rotation. Furthermore, the 38-mm and 42-mm glenospheres were tested in combination with a standard and a high-mobility humeral onlay. A gradually increased force was applied to the glenohumeral joint in anterior direction until the RTSR dislocated. RESULTS: The 42-mm glenosphere showed superior stability compared with the 38-mm glenosphere. The standard humeral onlay required significantly higher anterior dislocation forces than the more shallow high-mobility onlay. External rotation was the most stable position. Furthermore, isolated detachment of the subscapularis and combined dissection of the infraspinatus, teres minor, and subscapularis tendon increased anterior instability. CONCLUSIONS: This study showed superior stability with the 42-mm glenosphere and the more conforming standard onlay. External rotation was the most stable position. Detachment of the subscapularis as well as dissection of the complete rotator cuff decreased anterior stability.