Comparison of Patients' and Surgeons' Expectations before Shoulder Arthroplasty.

Background: Patients suffering from osteoarthritis particularly complain about pain during day and night as well as loss of function. This consequently leads to impaired quality of life and therefore psychological stress. The surgical therapy of choice is joint replacement. Regarding the outcome after operation, expectations might differ between the patient and the surgeon. This can lead to dissatisfaction on both sides. This study aimed to document patients' expectations of a planned shoulder joint replacement. The results were compared with assessments made by shoulder surgeons. Methods: In total, 50 patients scheduled for operative shoulder joint replacement were included in this study, as well as 10 shoulder surgeons. Patients were requested to fill out questionnaires preoperatively to provide sociodemographic data, PROMS (Patient-Reported Outcome Measures) with regard to the pathology and their expectations about surgery in terms of pain relief, gain of range of motion, strength as well as the impact on activities of daily and professional life and sports. In addition, surgeons were asked what they thought their patients expect. Results: The most important goal to achieve for patients was to relieve daytime pain, followed by improvement of self-care and the ability to reach above shoulder level. The most important factors for patients to achieve after operation were 'pain relief' in first place, 'movement' in second and 'strength' in third. This also applied to shoulder surgeons, who ranked 'pain relief' first, followed by 'movement' and 'strength'. When patients where asked what is most important when it comes to choosing their surgeon, 68% voted for 'surgical skills', 28% for 'age/experience', followed by 'empathy', 'sympathy' and 'appearance'. For surgeons, 'age/experience' obtained rank one, 'surgical skills' was ranked second, followed by 'sympathy', 'empathy' and 'appearance'. Surgeons significantly underrated the factor 'empathy' in favor of 'sympathy'. Conclusions: This study shows that patients' expectations for shoulder joint replacement and surgeons' assessments do not differ significantly. Relief from pain and better shoulder movement were crucial for patients to achieve after operation, which was in line with surgeons' expectations. The most important factor for choosing the surgeon was 'surgical skills' for patients, while surgeons thought they would care more about 'age and experience'. This underlines that patients' expectations should be taken into account within the preoperative medical interview. This might allow an optimization of compliance of the patients and lead to a better satisfaction on both sides.

Neuromuscular Electrical Stimulation-Enhanced Physical Therapist Intervention for Functional Posterior Shoulder Instability (Type B1): A Multicenter Randomized Controlled Trial.

OBJECTIVE: Functional posterior shoulder instability (FPSI) (type B1) is a severe type of instability, mainly in teenagers and young adults, that leads to loss of function, pain, and stigmatization among peers. An experimental nonsurgical treatment protocol based on neuromuscular electrical stimulation (NMES) showed very promising early results in the treatment of FPSI. The hypothesis of this study was that NMES-enhanced physical therapy leads to better outcomes than physical therapy alone as the current gold standard of treatment in patients with FPSI. METHODS: In this multicenter randomized controlled trial, patients with FPSI were randomly allocated in a 1:1 ratio to either 6 weeks of physical therapy or 6 weeks of physical therapy with simultaneous motion-triggered NMES. Baseline scores as well as outcome scores at 6 weeks, 3 months, 6 months, and 12 months after the intervention were obtained. The predefined primary outcome of this trial was the Western Ontario Shoulder Instability Index (WOSI) at the 3-month time point. RESULTS: Forty-nine patients were randomized and eligible for the trial. The group that received physical therapy with simultaneous motion-triggered NMES showed a significantly better main outcome measurement in terms of the 3-month WOSI score (64% [SD = 16%] vs 51% [SD = 24%]). Two-thirds of the patients from the physical therapist group crossed over to the group that received physical therapy with simultaneous motion-triggered NMES due to dissatisfaction after the 3-month follow-up and showed a significant increase in their WOSI score from 49% [SD = 8%] to 67% [SD = 24%]. The frequency of instability episodes showed a significant improvement in the group that received physical therapy with simultaneous motion-triggered NMES at the 3-month follow-up and beyond, while in the physical therapist group, no significant difference was observed. CONCLUSION: The current study shows that NMES-enhanced physical therapy led to statistically significant and clinically relevant improvement in outcomes in the treatment of FPSI compared to conventional physical therapy alone-from which even patients with prior unsatisfactory results after conventional physical therapy can benefit. IMPACT: Based on the results of this study, NMES-enhanced physical therapy is an effective new treatment option for FPSI, a severe type of shoulder instability. NMES-enhanced physical therapy should be preferred over conventional physical therapy for the treatment of patients with FPSI.

Prospective Multicenter Randomized Controlled Trial of Surgical Versus Nonsurgical Treatment for Acute Rockwood Type 3 Acromioclavicular Injury.

Background: Evidence for the superiority of surgical versus nonsurgical treatment of Rockwood type 3 acromioclavicular joint (ACJ) dislocation is still lacking. Hypothesis: It was hypothesized that surgical treatment will outperform nonsurgical treatment. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A prospective randomized trial involving 4 study centers was performed from January 1, 2011, to March 31, 2016. A total of 85 patients with acute Rockwood type 3 ACJ dislocations were allocated randomly to receive either nonsurgical or surgical treatment. A total of 70 patients were treated as allocated, and 8 patients made an early crossover from nonsurgical to surgical treatment, leaving 47 patients treated surgically and 31 patients nonsurgically. All patients were followed up longitudinally, including clinical evaluation using the Constant score and standardized radiographic evaluation, with final follow-up after 2 years. Results: At no follow-up time point was there a significant difference in Constant score between the surgically and nonsurgically treated patients. Radiographic analysis showed not only an inferior coracoclavicular distance at all follow-up points for surgical treatment but also a higher incidence of posttraumatic osteoarthritis and heterotopic ossifications, without any negative clinical correlation. With regard to complications, 1 patient (3%) in the nonsurgical group underwent secondary surgical ACJ stabilization. The revision rate after surgical treatment was 17% (P < .001). Neither primary horizontal instability nor younger age were associated with inferior clinical outcomes after nonsurgical treatment. Conclusion: Surgical treatment of ACJ Rockwood type 3 injuries did not lead to superior functional outcomes. Neither younger age nor horizontal instability were associated with inferior outcomes after nonsurgical treatment. Surgical treatment led to a slower recovery and to higher complication and revision rates. Registration: ISRCTN registry (study ID: ISRCTN92265154).

Acromioclavicular Joint Lesions in Adolescents-A Systematic Review and Treatment Guidelines.

True acromioclavicular joint (ACJ) injuries are rare in children and adolescents due to the strength of ligaments in this age group. However, a standardized management guideline for these injuries is currently lacking in the literature. This systematic review aims to provide an organized overview of associated injuries and propose a management algorithm for pediatric ACJ injuries. Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review was conducted. Two independent observers searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus databases for ACJ injuries in children and adolescents. The extracted data were analyzed (due to the limited number of publications and inhomogeneity of data, no formal statistical analysis was conducted), and cases were categorized based on injury frequency and pattern, leading to the formulation of a treatment algorithm. The risk of bias was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist. A total of 77 articles were identified, and 16 articles (4 case series and 12 case reports) met the inclusion criteria. This study included 37 cases in 36 patients (32 males, 4 females) with a mean age of 13 years (9-17 years). Six injury categories were described. Surgical management was performed in 27 ACJ injuries (25 open, 2 arthroscopic). Various surgical implants were used including K wires, polydioxanone sutures (PDS), screws, hook plates, suture anchors, and suture button devices. Most cases achieved good to excellent outcomes, except for one case of voluntary atraumatic dislocation of the ACJ. This systematic review provides the first comprehensive analysis of ACJ injury management in adolescents with open physis. It categorizes injury patterns and presents a treatment algorithm to enhance the understanding of these injuries. The review's findings contribute valuable insights for clinicians dealing with pediatric ACJ injuries.

Clinical outcomes in latissimus dorsi transfer single- versus double-incision technique.

BACKGROUND/HYPOTHESIS: In patients with irreparable postero-superior rotator cuff lesions, a latissimus dorsi transfer (LDT) is performed. For this surgery, different techniques are used. In this study, we aim to compare the patient's functional outcome after treatment with modified L'Episcopo "single-incision" and modified Gerber "double-incision" technique for LDT. METHODS: 44 patients with irreparable postero-superior rotator cuff ruptures, refractory to physiotherapeutic treatment were included. 21 patients were treated using a modified L'Episcopo "single-incision", 23 patients with modified Gerber "double-incision" surgical approach. All patients had full-thickness tears of at least two complete tendons, and all had fully functioning deltoid and subscapularis muscles. Preoperatively, there were statistically significant differences between the two groups in all preoperative CMS sub-parameters except "power" and "pain". In the postoperative follow-up, a functional assessment using "Constant-Murley Score" (CMS) and "Age- and gender-related CMS" was conducted. STUDY DESIGN: Retrospective-comparative trial. RESULTS: There were no statistically significant differences between age, sex and time of follow-up between the two study groups (p > 0.05). The mean age was 59.2(± 6.3) years, and the mean follow-up time was 45.4(± 9.3) months for both groups taken together. Mean CMS improved for both groups together from 24.2 ± 8.2 points prior to surgery, to 62.8 ± 17.4 points after a mean follow-up time of 45.4 ± 9.3 months post surgery. The patients treated with "single-incision" surgery (n = 21) gained significantly (p < 0.001) more in CMS and all CMS-sub-scoring parameters except power and pain, compared to the patients treated with "double-incision" technique (n = 23). CONCLUSION: This survey shows appealing post-operative functional outcome in patients with irreparable postero-superior rotator cuff lesions treated with two different techniques for LDT. We believe that the presentation of these methods and their results might encourage shoulder surgeons to implement these techniques. Especially the "single-incision" LDT surgery might be a more accustomed technique for many shoulder surgeons well trained in the deltopectoral approach.

Effect of shape and size of supraspinatus tears on rotator cuff strain distribution: an in vitro study.

BACKGROUND: The impact of the size and shape of a supraspinatus tear on the strain of the intact rotator cuff and the kinematics of the shoulder is still unknown. This, however, can be relevant when deciding whether surgical reconstruction is required to prevent an increase in a tendon defect. In this study, the effect of tear width and shape on rotator cuff strain and glenohumeral kinematics was evaluated during active abduction. METHODS: Twelve fresh-frozen cadaveric shoulders with intact rotator cuffs were used in this study. We created 50% and 100% wide (full-thickness) crescent-shaped (CS) tears (n = 6) and reverse L-shaped (rLS) tears (n = 6) in the supraspinatus tendon and measured strain and kinematics during active humeral elevation until 30°. RESULTS: Both tear shapes and sizes led to an increase in internal rotation, supraspinatus loading force, and superior translation of the humerus. For the 100% wide tear size, anterior translation was observed in the CS tear group, whereas in the rLS tear group, this translation occurred mainly in the posterior direction. Strain was higher in the infraspinatus during the first 25° of abduction in comparison with the supraspinatus tendon in both tear shape groups. An analysis of the anterior and posterior tear borders showed a higher strain concentration on the same side of the tear in the CS tear group with 50% and 100% wide tears. CONCLUSIONS: The influence of different tear shapes on translation in the anterior-posterior direction was evident as both CS and rLS tears led to an oppositely directed translation of the humeral head. The strain analysis showed a stress-shielding effect of the infraspinatus at the beginning of abduction. Therefore, special attention must be paid to correctly identify the tear extension and adequately reconstruct the rotator cuff footprint. Moreover, the constant location of maximum strain in the CS tear group may lead to an earlier progression than in the rLS tear group.

[Winter sports injuries to the elbow joint]. / Wintersportverletzungen des Ellenbogengelenks.

BACKGROUND: Elbow injuries occur quite often when practicing winter sports. Due to the high sports dynamics and risk of fall the elbow joint is prone to injuries. Hereby, the most common injury is the dislocation of the elbow. TREATMENT: Isolated ligamentous instabilities can usually be treated non-operatively when the joint is centered on post-reduction imaging. In the case of persistent symptomatic instability, secondary ligament reconstruction surgery is associated with reliable and good results. Most fractures of the elbow involve the radial head in terms of postero-lateral rotation instability, whereas distal humerus and olecranon fractures are more likely to occur in high-energy or direct trauma. Indication for surgical treatment is given according to common guidelines, including involvement of the joint line, fragment dislocation and instability with risk of secondary fracture dislocation. Minimally invasive techniques for the radial head as well as anatomic preformed locking plate systems seem to have reached a wide acceptance.

Different expectations of patients and surgeons with regard to rotator cuff repair.

BACKGROUND: Rotator cuff lesions are a common shoulder pathology mainly affecting patients aged >50 years. This condition is accompanied by not only pain and loss of function but also impaired quality of life and psychological stress. A frequently employed treatment option is arthroscopic repair. But expectations regarding the outcome after surgery might differ between patients and surgeons and therefore lead to dissatisfaction on both sides. The aim of this study was to document patient expectations of a planned arthroscopic rotator cuff repair and compare the results with the assessment of shoulder surgeons. MATERIALS AND METHODS: A total of 303 patients and 25 surgeons were involved in this study. Patients with partial- or full-thickness tear of the rotator cuff scheduled for arthroscopic repair were included in this study. Preoperatively, they were asked to fill out questionnaires inquiring sociodemographic data, scores of the underlying pathology, as well as expectations regarding the operation with regard to pain relief, gain of range of motion and strength, as well as the effect on activities of daily life, work, and sports. Furthermore, 25 surgeons were surveyed on what they think their patients expected using the same standardized questions. RESULTS: Among the patients, 43.9% considered gain of range of motion to be the most important goal after rotator cuff repair, followed by pain relief (30.6%) and gain of force (13.7%). Among the surgeons, 72% believed pain relief to be the most important for their patient followed by movement (20%) and strength (8%). When asked which parameter was the most important to achieve after operation, for patients, movement was on first place, pain second, and strength third. For shoulder specialists, the ranking was pain, movement, and strength. Surgeons significantly overrated pain relief when ranking against movement compared with their patients. CONCLUSION: The expectations of patients regarding their operation differ from the surgeon's assessment. Whereas gaining range of motion was more important for patients, surgeons clearly voted for pain relief. Different expectations should therefore be discussed within the pretreatment interview and taken into account when planning the right therapy. This might lead to better satisfaction on both sides.

Conservative treatment of acute traumatic posterior shoulder dislocations (Type A) is a viable option especially in patients with centred joint, low gamma angle, and middle or old age.

PURPOSE: Purpose of this study was to evaluate the mid- to long-term outcome after conservatively treated first-time posterior shoulder dislocations and to determine structural defects associated with failure. METHODS: In this multi-centric retrospective study, 29 shoulders in 28 patients with first-time acute posterior shoulder dislocation (Type A1 or A2 according to the ABC classification) and available cross-sectional imaging were included. Outcome scores as well as radiological and magnetic resonance imaging were obtained at a mean follow-up of 8.3 ± 2.7 years (minimum: 5 years). The association of structural defects with redislocation, need for secondary surgery, and inferior clinical outcomes were analysed. RESULTS: Redislocation occurred in six (21%) shoulders and nine shoulders (31%) underwent secondary surgery due to persistent symptoms. The posttraumatic posterior glenohumeral subluxation was higher in the redislocation group compared to the no redislocation group; however, statistical significance was not reached (61.9 ± 12.5% vs. 50.6 ± 6.4%). Furthermore, a higher adapted gamma angle was observed in the failed conservative treatment group versus the conservative treatment group, similarly without statistically significant difference (97.8° ± 7.2°, vs. 93.3° ± 9.7°). The adapted gamma angle was higher than 90° in all patients of failed conservative therapy and the redislocation group. An older age at the time of dislocation showed a significant correlation with better clinical outcomes (SSV: r = 0.543, p = 0.02; ROWE: r = 0.418, p = 0.035 and WOSI: r = 0.478, p = 0.045). Posterior glenohumeral subluxation after trauma correlated with a worse WOSI (r = - 0.59, p = 0.02) and follow-up posterior glenohumeral decentring (r = 0.68, p = 0.007). The gamma angle (r = 0.396, p = 0.039) and depth of the reverse Hill-Sachs lesion (r = 0.437, p = 0.023) correlated significantly with the grade of osteoarthritis at follow-up. CONCLUSION: Conservative treatment is a viable option in patients with an acute traumatic posterior shoulder dislocation with good outcome after mid- and long-term follow-up especially in patients with centred joint, low gamma angle, and middle or old age. LEVEL OF EVIDENCE: IV.

Distal humerus fracture in patients over 70 years of age: results of open reduction and internal fixation.

BACKGROUND: Due to the complexity of distal humerusfractures and often poor bone quality in elderly patients, these entities remain a challenge. However, because of a high rate of complications related to total elbow prostheses, reconstruction of distal humerus fractures should still be considered a therapeutic option, also in the elderly patient. The purpose of the present study was to investigate the clinical outcomes after open reduction and internal fixation and to evaluate whether the results justify reconstruction even in elderly patients. We hypothesized that despite advanced age, reasonable clinical results can be achieved, using a standardized surgical technique and aftertreatment protocol for the treatment of distal humerus fractures in elderly patients. METHODS: Between 2004 and 2012, 30 patients with a mean age of 78 years at the time of injury with a recent distal humerus fracture were evaluated. All patients underwent the identical aftertreatment protocol with no weight bearing for 6 weeks and weekly increasing range of motion. Follow-up rate was 90%. 22 patients were treated with double plate, 4 with single plate, and 1 with screw fixation only. Patients were evaluated based on clinical criteria. Primary outcome measures were Mayo Elbow Performance Score, VAS and joint range of motion, secondary was radiological evaluation. RESULTS: After a mean follow-up period of 3.8 years (min. 1 year, max. 9 years, SD ± 2), the average range of motion was flexion of 127° (min. 100°; max. 150°; SD ± 16.5) and average loss of extension of 20.9° (min. 5°; max. 40°; SD ± 11). Average pronation and supination was 68.3° (min. 0°; max. 90°; SD ± 25.3) and 75.3° (min. 0°; max. 90°; SD ± 19.7), respectively. Average Mayo Elbow Performance (MEPS) score was 88.7 (min. 60; max. 100; SD ± 12.1). 6 patients developed heterotopic ossification without significant effect on the clinical outcome. 7 patients had radiological evidence of at least partial non-union with one requiring revision, 2 discrete hardware dislocations were treated conservatively. There were no infections in the presented cohort. Our results regarding the surgical approach showed significantly higher patient satisfaction scores in the osteotomy group, compared to the group with Triceps-On Approach (PTOA). CONCLUSION: The present data support indication for open reduction internal fixation (ORIF) even in the elderly patient. Advanced age should not be seen as a contraindication for ORIF of fractures of the distal humerus. Although the rate of complications is higher than in younger patients, complications such as non-union are often asymptomatic, patient satisfaction scores are high, and the possible devastating complications of failed elbow replacement can be evaded. LEVEL OF EVIDENCE: IV.

Biceps Brachii Alterations Following the Latarjet Procedure: A Prospective Multicenter Study.

PURPOSE: To prospectively investigate the postoperative forearm supination and elbow flexion strength of both upper extremities and popeye deformity in patients who underwent a mini-open Latarjet procedure for anterior shoulder instability. METHODS: Patients who underwent a mini-open Latarjet procedure at two specialized shoulder centers were prospectively evaluated preoperatively (T0) and at least 6 months (T1) after surgery. Subjects were tested for elbow flexion and forearm supination strength of both upper extremities using an isometric dynamometer and customized torque dynamometer. Clinical outcome was assessed by the Constant Score (CS), American Shoulder and Elbow Score (ASES) and Simple Shoulder test (SST). Popeye deformity was defined as a distalization of the greatest circumference of the biceps muscle belly towards the lateral epicondyle of the elbow. RESULTS: A total of 20 patients with a mean age of 27 ± 6 years were included in the study. At a mean follow-up of 10 ± 3 months, the elbow flexion strength was restored to the preoperative state (p = 0.240). Forearm supination strength significantly decreased at final follow-up, to 88 % in the surgical arm (p = 0.015) vs. 90 % in the non-surgical arm (p = 0.023). There was no statistical difference when comparing both arms concerning elbow flexion strength (p = 0.510) and forearm supination strength (p = 0.495). No significant popeye deformity was observed in both arms (p = 0.111 vs. p = 0.508). Clinical outcome scores improved significantly from 73 ± 18 to 82 ± 13 (p = 0.014) for CS and 76 ± 22 to 89 ± 12 (p = 0.008) for ASES score preoperatively to final follow-up. No difference in the SST was documented (p = 0.10). CONCLUSION: The Latarjet procedure showed to preserve elbow flexion strength and provided comparable forearm supination strength compared to the uninjured arm with reliable clinical outcome in this study population. However, a decrease of forearm supination strength in both arms was persistent at a mean of 10 months postoperatively. No popeye deformity was noted in the postoperative examinations. LEVEL OF EVIDENCE: Case series, Level III.

Differences in Patients' and Surgeons' Expectations before Shoulder Stabilization Surgery.

PURPOSE: The primary goal of shoulder stabilization procedures is to re-establish stability and many surgeons measure the success after shoulder stabilization surgery only by the absence of re-dislocation. However, patients might also suffer from pain, loss of range of motion and strength as well as anxiety and stigmatization and therefore have other expectations from a stabilization surgery than just a stable shoulder. Purpose of this study was to analyze if surgeons know what their patients typically expect from a shoulder stabilization surgery. Furthermore, the aim was to analyze the influence of various factors on patients' expectations. MATERIALS AND METHODS: 204 patients with a diagnosis of shoulder instability scheduled for surgical treatment were included in this prospective multicentric study. Preoperatively, objective and subjective scores were obtained and patients were asked about their postoperative expectations. Additionally, 25 surgeons were interviewed with regard to what they think their patients expect from the surgery using standardized questions. RESULTS: With regard to postoperative expectations surveyed by the Hospital for Special Surgery questionnaire (HSS), the most important goal to achieve for the patients was 'stopping the shoulder from dislocation', followed by 'to improve the ability to exercise or participate in sports' and 'being the shoulder to be back the way it was before the issue started'. The ranking of factors for patients was 'stability' as the most important to achieve, followed by 'movement', 'strength', 'pain' and 'cosmetics'. For surgeons, the order was 'stability' (p = 0.004 **), 'movement' (p = 0.225), 'pain' (p = 0.509), 'strength' (p = 0.007 **) and 'cosmetics' (p = 0.181). There was a significant difference between patients and surgeons with regard to gaining stability at the cost of movement (p = 0.001 **). CONCLUSION: Patients and surgeons expectations regarding outcome after surgical shoulder stabilization procedures are quite similar with limited topics of disagreement. Generally, surgeons tend to overrate the importance of stability at the costs of other factors.

A classification for partial subscapularis tendon tears.

PURPOSE: The aim of the study was to analyze partial subscapularis tendon (SSC) tears and provide a descriptive classification. METHODS: The retrospective study included 50 patients with arthroscopically confirmed partial SSC tears. Internal rotation (IR) force measurements and IR ROM have been made and compared to the healthy contralateral side. Then the footprint of the SSC was routinely investigated by arthroscopy with standardized measurement of the bony footprint lesion. The partial tears were classified according to the mediolateral and craniocaudal extension of the rupture in the transverse and coronal plane, respectively. RESULTS: Partial SSC tears could be classified into split lesions (type 1, n = 11) and 3 further groups depending on the mediolateral peeled-off length of the bony footprint (type 2: < 10 mm, n = 20; type 3: 10-15 mm, n = 10; type 4: > 15 mm, n = 9). Type 2-4 could be further divided depending on the craniocaudal peeled-off length of the bony footprint (group A: < 10 mm, group B: 10-15 mm, group C: > 15 mm). Significantly decreased IR strength was shown for types 2-4 (p < 0.05) but not for split lesions as compared to healthy side. Types 1-4 showed significant decreased active IR ROM and all except type 3 (n.s.) which showed decreased passive IR ROM compared to the healthy side (p < 0.05). CONCLUSION: We present a novel classification for partial SSC tears for a more detailed and reproducible description. This can help to improve the current knowledge about the appropriate treatment. It could be shown that partial tears of the subscapularis can have an impact on IR strength and motion. LEVEL OF EVIDENCE: III.

Prospective midterm results of a new convertible glenoid component in anatomic shoulder arthroplasty: a cohort study.

PURPOSE: The purpose of our study was to evaluate the clinical and radiological results of a new anatomic convertible cementless glenoid component. METHODS: Forty-eight patients with a mean age of 67.3 years were clinically and radiologically followed-up with a mean of 49 months. Indications for glenoid replacement were A2 glenoid wear in 21.7%, B1 glenoid wear in 28.3%, B2 glenoid wear in 28.3%, B3 glenoid wear in 13%, D glenoid wear in 2.2%, and glenoid component loosening in 6.5%. RESULTS: The Constant-Murley score improved significantly (p < 0.0001) from 50% pre-OP to 103% post-OP. Patients with a B3 glenoid type according to Walch achieved a significant (p = 0.044) lower Constant-Murley Sscore post-OP compared to patients with a B1 glenoid type (88% vs 106%). The mean subluxation index changed significantly (p < 0.0001) from 0.54 pre-OP to 0.46 post-OP. At the metal-back bone interface an incomplete radiolucent line < 1 mm was observed in two cases (4.2%) and an incomplete radiolucent line < 2 mm was observed in another two cases (4.2%). PE dissociation occurred in two cases. No glenoid loosening was observed. The implant related revision rate was 4.2% (2 cases). All components (n = 612.5%) requiring conversion to reverse were converted without any further complications or loosening. CONCLUSION: Good functional results can be achieved in cases with a B1 and a B2 glenoid after anatomic shoulder arthroplasty using the described metal back glenoid. A conversion from an anatomic to a reverse glenoid component were possible in all cases without any further complications. Conversion of the anatomic glenoid component to a reverse system alleviates revision surgery.

Comparison of Structural Subscapularis Integrity After Latarjet Procedure Versus Iliac Crest Bone Graft Transfer.

BACKGROUND: Although clinical outcome scores are comparable after coracoid transfer procedure (Latarjet) and iliac crest bone graft transfer (ICBGT) for anterior shoulder instability with glenoid bone loss, a significant decrease in internal rotation capacity has been reported for the Latarjet procedure. HYPOTHESIS: The subscapularis (SSC) musculotendinous integrity will be less compromised by ICBGT than by the Latarjet procedure. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We retrospectively analyzed pre- and postoperative computed tomography (CT) scans at short-term follow-up of 52 patients (26 Latarjet, 26 ICBGT) previously assessed in a prospective randomized controlled trial. Measurements included the preoperative glenoid defect area and graft area protruding the glenoid rim at follow-up and tendon thickness assessed through SSC and infraspinatus (ISP) ratios. Fatty muscle infiltration was graded according to Goutallier, quantified with muscle attenuation in Hounsfield units, and additionally calculated as percentages. We measured 3 angles to describe rerouting of the SSC musculotendinous unit around the bone grafts. RESULTS: SSC fatty muscle infiltration was 2.0% ± 2.2% in the Latarjet group versus 2.4% ± 2.2% in ICBGT (P = .546) preoperatively and showed significantly higher values in the Latarjet group at follow-up (5.3% ± 4.5% vs 2.3% ± 1.7%; P = .001). In total, 4 patients (15.4%) in the Latarjet group showed a progression from grade 0 to grade 1 at follow-up, whereas no changes in the ICBGT group were noted. The measured rerouting angle of the SSC muscle was significantly increased in the Latarjet group (11.8° ± 2.1°) compared with ICBGT (7.5° ± 1.3°; P < .001) at follow-up, with a significant positive correlation between this angle and fatty muscle infiltration (R = 0.447; P = .008). Ratios of SSC/ISP tendon thickness were 1.03 ± 0.3 in the Latarjet group versus 0.97 ± 0.3 (P = .383) in ICBGT preoperatively and showed significantly lower ratios in the Latarjet group (0.7 ± 0.3 vs 1.0 ± 0.2; P < .001) at follow-up. CONCLUSION: Although clinical outcome scores after anterior shoulder stabilization with a Latarjet procedure and ICBGT are comparable, this study shows that the described decline in internal rotation capacity after Latarjet procedure has a radiographic structural correlate in terms of marked thinning and rerouting of the SSC tendon as well as slight fatty degeneration of the muscle.

Lesions of the biceps pulley: a prospective study and classification update.

HYPOTHESIS: The purpose of the study was to investigate which anatomic structures are affected in a series of patients with pulley lesions and whether all lesions can be classified according to the Habermeyer classification. METHODS: One hundred consecutive patients with pulley lesions were prospectively studied. During arthroscopy, lesions of the superior glenohumeral ligament (SGHL), medial coracohumeral ligament (MCHL) and/or lateral coracohumeral ligament (LCHL), adjacent rotator cuff, and biceps (long head of the biceps) were recorded. All lesions were then classified according to the Habermeyer classification. The χ2 test was used for statistical analysis. RESULTS: There were 3 lesions in group 1, 20 in group 2, 6 in group 3, and 35 in group 4 according to the Habermeyer classification. Thirty-six lesions were not classifiable because of an intact SGHL. A lateral pulley sling (LCHL) lesion was found in 95% of the patients, and a medial pulley sling (MCHL-SGHL) lesion was noted 64%. An isolated lesion of the MCHL and/or SGHL was present in 5%, and an isolated lesion of the LCHL was found in 36%. Combined medial-lateral sling lesions were correlated with complete subscapularis tears and biceps fraying. CONCLUSION: The lateral pulley sling is more often affected than the medial sling. The SGHL is not always affected, and isolated lesions of the medial sling are rare. Lesions of both slings correlated with complete subscapularis tears and fraying of the long head of the biceps. An updated classification of direct pulley lesions is proposed: type 1, lesion of the medial pulley (MCHL and/or SGHL); type 2, lesion of the lateral pulley (LCHL); and type 3, lesion of the medial and lateral pulley slings. Concomitant lesions of the indirect pulley stabilizers can be mentioned additionally according to the well-known classifications.

Short-term safety, function, and quality of life in patients treated with Univers Revers prosthesis: a multicenter 2-year follow-up case series.

BACKGROUND: The use of reverse total shoulder arthroplasty (RTSA) has dramatically increased in recent years with the advent of new prosthesis designs regularly entering the market. We define the rate of local complications during the first 2 years after RTSA with the Univers Revers prosthesis and describe the changes in radiologic outcomes, as well as function, pain, satisfaction, and quality of life. METHODS: This multicenter, prospective case series included rotator cuff tear arthropathy patients who underwent RTSA with the Univers Revers. Incidence percentages of complications and pathologic radiographic changes were documented. Mixed-model linear regression was used to examine changes in range of motion, shoulder function (Constant score, Shoulder Pain and Disability Index, Subjective Shoulder Value), and quality of life (EQ-5D-5L [European Quality of Life 5 Dimensions 5 Level] and EQ-VAS [EuroQol Visual Analog Scale]). RESULTS: Of 187 patients, 59.4% were women, and the mean age was 75.3 years (range, 56-91 years). Twenty-five percent of patients had a postoperative complication; 5 complications were severe (2.7%, 5 of 187), whereby 2 were implant related (1.1%; 95% confidence interval [CI], 0.1%-3.8%). The incidence of scapular notching was 10.6% (95% CI, 6.5%-16%). After 2 years, abduction, flexion, and abduction strength improved by 54° (95% CI, 50°-58°), 57° (95% CI, 53°-60°), and 5 kg (95% CI, 4-5 kg), respectively (P < .001), whereas external rotation at 0° (1°; 95% CI, -1° to 3°) did not improve (P = .4). The Constant score improved by 39 (95% CI, 38-41); Shoulder Pain and Disability Index, by 50 (95% CI, 47-52); and Subjective Shoulder Value, by 43 (95% CI, 41-45) (P < .001). Furthermore, the EQ-5D-5L index value improved by 0.31 (95% CI, 0.30-0.33), and the EQ-VAS score improved by 16 (95% CI, 14-18) (P < .001). CONCLUSION: Our case series showed a low complication rate with a consistent clinically relevant and statistically significant improvement across most clinical and patient-reported outcomes for the Univers Revers. Long-term safety requires further investigation.

Risk Factors for Rotator Cuff Disease: An Experimental Study on Intact Human Subscapularis Tendons.

Although several studies revealed a multifactorial pathogenesis of degenerative rotator cuff disorders, the impact and interaction of extrinsic variables is still poorly understood. Thus, this study aimed at uncovering the effect of patient- and pathology-specific risk factors that may contribute to degeneration of the rotator cuff tendons. Between 2015 and 2018, 54 patients who underwent arthroscopic shoulder surgery at three specialized shoulder clinics were prospectively included. Using tendon samples harvested from the macroscopically intact subscapularis (SSC) tendon, targeted messenger RNA expression profile analysis was performed in the first cohort (n = 38). Furthermore, histological analyses were conducted on tendon tissue samples obtained from a second cohort (n = 16). Overall, both study cohorts were comparable concerning patient demographics. Results were then analyzed with respect to specific extrinsic factors, such as patient age, body mass index, current as well as previous professions and sport activities, smoking habit, and systemic metabolic diseases. While patient age, sports-activity level, and preexisting rotator cuff lesions were considered to contribute most strongly to tendinopathogenesis, no further coherences were found. With regards to gene expression analysis, change in expression correlated most strongly with patient age and severity of the rotator cuff pathology. Further, chronic disorders increased overall gene expression variation. Taken together, our study provides further evidence that tendon degeneration is the consequence of a multifactorial process and pathological changes of the supraspinatus tendon affect the quality of SSC tendon and most likely vice versa. Therefore, the rotator cuff tendons need to be considered as a unit when managing rotator cuff pathologies. © 2019 The Authors. Journal of Orthopaedic Research® published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society J Orthop Res 38:182-191, 2020.

[Shoulder Osteoarthritis-pathogenesis, classification, diagnostics and treatment]. / Omarthrose ­ Pathogenese, Klassifikation, Diagnostik und Therapie.

Primary osteoarthritis of the shoulder represents a destructive joint disease with associated synovitis, which in the first line seems to be genetically determined. Clinically, patients suffer from shoulder pain with progressive impairment of both active and passive range of motion. The diagnostics include a clinical examination, imaging by native radiography and magnetic resonance imaging (MRI) for assessment of the rotator cuff. Current classification systems consider the formation of humeral osteophytes, glenoid morphology and loss of humeral sphericity. Non-surgical measures include, apart from topical and oral analgesics, injection of corticosteroids and hyaluronic acid supported by physiotherapeutic measures. After failure of non-surgical therapeutic measures, arthroscopic joint-preserving arthroplasty in terms of the comprehensive arthroscopic management (CAM) procedure can be performed in young patients with early stage osteoarthritis, whereas in advanced stages endoprosthetic joint replacement is indicated.

Arthroscopically assisted acromioclavicular joint stabilization leads to significant clavicular tunnel widening in the early post-operative period.

PURPOSE: Arthroscopically assisted acromioclavicular joint (ACJ) stabilization techniques use bone tunnels in the clavicle and coracoid process. The tunnel size has been shown to have an impact on the fracture risk of clavicle and coracoid. The aim of the present study was to radiographically evaluate the alterations of the clavicular tunnel size in the early post-operative period. It was hypothesized that there would be a significant increase of tunnel size. METHODS: Twenty consecutive patients with acute high-grade ACJ (Rockwood type IV-V) injury underwent arthroscopic-assisted ACJ stabilization. The median age of the patients was 40 (26-66) years. For all patients, a single tunnel button-tape construct was used along with an additional ACJ tape cerclage. Radiologic measurements were undertaken on standardized Zanca films at two separate time points, immediate post-operative examination (IPO) and at late post-operative examination (> 4 months; LPO). The LPO radiographs were taken at a median follow-up period of 4.5 (3-6) months. Clavicular tunnel width (CT) and coracoclavicular distance (CCD) were measured using digital calipers by two independent examiners and the results are presented as median, range, and percentage. RESULTS: The median CCD increased significantly from 9.5 (8-13) mm at IPO to 12 (7-20) mm at LPO (p < 0.05). Median tunnel size showed significant difference from 3 (3-4) mm at IPO to 5 (4-7) mm at LPO (p < 0.05). Despite a significant increase of 2 mm (66.6%) of the initial tunnel size, there was no correlation between tunnel widening and loss of reduction. CONCLUSION: Arthroscopic ACJ stabilization with the use of bone tunnels led to a significant increase of clavicular tunnel size in the early post-operative period. This phenomenon carries a higher fracture risk, especially in high-impact athletes, which needs to be considered preoperatively. LEVEL OF EVIDENCE: IV.