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.

Three-dimensional planning, navigation, patient-specific instrumentation and mixed reality in shoulder arthroplasty: a digital orthopedic renaissance.

Accurate component placement in shoulder arthroplasty is crucial for avoiding complications, achieving superior biomechanical performance and optimizing functional outcomes. Shoulder and elbow surgeons have explored various methods to improve surgical understanding and precise execution including preoperative planning with 3D computed tomography (CT), patient-specific instrumentation (PSI), intraoperative navigation, and mixed reality (MR). 3D preoperative planning facilitated by CT scans and advanced software, enhances surgical precision, influences decision-making for implant types and approaches, reduces errors in guide pin placement, and contributes to cost-effectiveness. Navigation demonstrates benefits in reducing malpositioning, optimizing baseplate stability, improving humeral cut, and potentially conserving bone stock, although challenges such as varied operating times and costs warrant further investigation. The personalized patient care and enhanced operational efficiency associated with PSI are not only attractive for achieving desired component positions but also hold promise for improved outcomes in complex cases involving glenoid bone loss. Augmented reality (AR) and virtual reality (VR) technologies play a pivotal role in reshaping shoulder arthroplasty. They offer benefits in preoperative planning, intraoperative guidance, and interactive surgery. Studies demonstrate their effectiveness in AR-guided guidewire placement, providing real-time surgical advice during reverse total shoulder arthroplasty (RTSA). Additionally, these technologies show promise in orthopedic training, delivering superior realism and accelerating learning compared to conventional methods.

MicroRNA expression analysis in peripheral blood and soft-tissue of patients with periprosthetic hip infection.

Aims: Current diagnostic tools are not always able to effectively identify periprosthetic joint infections (PJIs). Recent studies suggest that circulating microRNAs (miRNAs) undergo changes under pathological conditions such as infection. The aim of this study was to analyze miRNA expression in hip arthroplasty PJI patients. Methods: This was a prospective pilot study, including 24 patients divided into three groups, with eight patients each undergoing revision of their hip arthroplasty due to aseptic reasons, and low- and high-grade PJI, respectively. The number of intraoperative samples and the incidence of positive cultures were recorded for each patient. Additionally, venous blood samples and periarticular tissue samples were collected from each patient to determine miRNA expressions between the groups. MiRNA screening was performed by small RNA-sequencing using the miRNA next generation sequencing (NGS) discovery (miND) pipeline. Results: Overall, several miRNAs in plasma and tissue were identified to be progressively deregulated according to ongoing PJI. When comparing the plasma samples, patients with a high-grade infection showed significantly higher expression levels for hsa-miR-21-3p, hsa-miR-1290, and hsa-miR-4488, and lower expression levels for hsa-miR-130a-3p and hsa-miR-451a compared to the aseptic group. Furthermore, the high-grade group showed a significantly higher regulated expression level of hsa-miR-1260a and lower expression levels for hsa-miR-26a-5p, hsa-miR-26b-5p, hsa-miR-148b-5p, hsa-miR-301a-3p, hsa-miR-451a, and hsa-miR-454-3p compared to the low-grade group. No significant differences were found between the low-grade and aseptic groups. When comparing the tissue samples, the high-grade group showed significantly higher expression levels for 23 different miRNAs and lower expression levels for hsa-miR-2110 and hsa-miR-3200-3p compared to the aseptic group. No significant differences were found in miRNA expression between the high- and low-grade groups, as well as between the low-grade and aseptic groups. Conclusion: With this prospective pilot study, we were able to identify a circulating miRNA signature correlating with high-grade PJI compared to aseptic patients undergoing hip arthroplasty revision. Our data contribute to establishing miRNA signatures as potential novel diagnostic and prognostic biomarkers for PJI.

Diagnosis and treatment of posterior shoulder instability based on the ABC classification.

Posterior shoulder instability (PSI) is less common than anterior shoulder instability, accounting for 2-12% of total shoulder instability cases. However, a much higher frequency of PSI has been recently indicated, suggesting that PSI accounts for up to 24% of all young and active patients who are surgically treated for shoulder instability. This differentiation might be explained due to the frequent misinterpretation of vague symptoms, as PSI does not necessarily present as a recurrent posterior instability event, but often also as mere shoulder pain during exertion, limited range of motion, or even as yet asymptomatic concomitant finding. In order to optimize current treatment, it is crucial to identify the various clinical presentations and often unspecific symptoms of PSI, ascertain the causal instability mechanism, and accurately diagnose the subgroup of PSI. This review should guide the reader to correctly identify PSI, providing diagnostic criteria and treatment strategies.

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.

Information videos posted on Instagram by orthopaedics and sports traumatology surgeons mostly explain surgical technique, and the least mentioned topics are injury prevention and complications.

PURPOSE: Social media has become the new information acquisition platform for all content producers. In the current literature, there are no studies examining the content quality and the strengths and weaknesses of videos on Instagram that explain anterior cruciate ligament (ACL) injuries, which is the most discussed topic of sports surgery. The aim of this study was to evaluate the quality, strengths and weaknesses of information pertaining to ACL surgery that is disseminated on Instagram. METHOD: An Instagram search was conducted from 30 May 2023 to 30 January 2024. The search encompassed six languages (English, Spanish, German, French, Italian and Turkish) and was performed by six different observers. The investigation focused on eight subheadings derived from current literature on the ACL. These subheadings were addressed in Instagram videos, covering ACL biology or biomechanics, injury mechanism, injury prevention, injury evaluation, surgical technique, injury or surgery complications, injury rehabilitation process and return to sport or work. RESULT: The content was assessed of 127 videos from 127 Instagram accounts, spanning six different languages. Across the review of eight subheadings, the average number covered for the entire group was 3 (range, 0-8). Further analysis revealed that surgical technique was the most frequently mentioned subheading for the whole group (68.5%), followed by injury evaluation (54.3%). Prevention (10.2%) and complications (19.6%) were the least mentioned subheadings. The number of followers showed a correlation with video content quality. CONCLUSION: Although the video quality scores were found to be moderate, the content often focused on surgery and evaluation subheadings. The prevalence of incomplete information underscores the importance of developing strategies to ensure more comprehensive and accurate dissemination of medical knowledge. LEVEL OF EVIDENCE: Level V.

The latissimus dorsi creates a dynamic track for the inferior angle of the scapula during arm abduction in humans.

BACKGROUND: The importance of several scapulothoracic muscles, including trapezius and serratus anterior, in maintaining physiological scapula kinematics has been highlighted in the past. However, the relationship between the scapula and the latissimus dorsi muscle remains unclear. Our clinical surgical observation is that the latissimus dorsi does not directly attach but rather runs superficial to the inferior angle of the scapula. Based on this observation, we hypothesise that the latissimus dorsi creates a dynamic track on which the scapula glides under the muscle belly during elevation of the arm, creating the latissimus-scapula overlap (LSO). METHODS: All consecutive patients who had a whole-body computed tomography scan (CT) in case of polytrauma evaluation between 2018 and 2021, with complete depiction of the scapula and latissimus dorsi muscle, were analysed. 150 shoulders in 90 patients with arms up were matched according to their age (within five years), gender, and affected side with 150 shoulders in 88 patients with arms down. Patients with pathologies of the upper extremities or thorax that potentially could alter LSO measurements were excluded. LSO was calculated as a ratio of the measured area of the latissimus dorsi projection on the scapula and the total scapula area. RESULTS: The mean age of the 178 patients (48 females; 13 males) was 60 years. The arms-up group showed a significantly higher LSO than the arms-down group (19.9 ± 6.3% vs. 2.7 ± 2.2%; p < 0.0001). In the arms-up group, approximately one fifth of the scapula was overlapped inferiorly by the muscle belly of the latissimus dorsi, contrary to the almost non-existing LSO in the arms-down group. CONCLUSION: With arms up, humans show a significantly higher LSO in comparison to arms down indicating that the latissimus dorsi indeed creates a dynamic track on which the scapula is forced to travel during abduction of the arm. This finding of increased LSO during the elevation of the arm warrants further consideration of the role of the latissimus dorsi in scapula kinematics and potentially scapular dyskinesis. LEVEL OF EVIDENCE: Level two diagnostic study.

Functional and Radiologic Outcomes of Degenerative Versus Traumatic Full-Thickness Rotator Cuff Tears Involving the Supraspinatus Tendon.

BACKGROUND: Arthroscopic rotator cuff repair (ARCR) is among the most commonly performed orthopaedic procedures. Several factors-including age, sex, and tear severity-have been identified as predictors for outcome after repair. The influence of the tear etiology on functional and structural outcome remains controversial. PURPOSE: To investigate the influence of tear etiology (degenerative vs traumatic) on functional and structural outcomes in patients with supraspinatus tendon tears. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients undergoing ARCR from 19 centers were prospectively enrolled between June 2020 and November 2021. Full-thickness, nonmassive tears involving the supraspinatus tendon were included. Tears were classified as degenerative (chronic shoulder pain, no history of trauma) or traumatic (acute, traumatic onset, no previous shoulder pain). Range of motion, strength, the Subjective Shoulder Value, the Oxford Shoulder Score (OSS), and the Constant-Murley Score (CMS) were assessed before (baseline) and 6 and 12 months after ARCR. The Subjective Shoulder Value and the OSS were also determined at the 24-month follow-up. Repair integrity after 12 months was documented, as well as additional surgeries up to the 24-month follow-up. Tear groups were compared using mixed models adjusted for potential confounding effects. RESULTS: From a cohort of 973 consecutive patients, 421 patients (degenerative tear, n = 230; traumatic tear, n = 191) met the inclusion criteria. The traumatic tear group had lower mean baseline OSS and CMS scores but significantly greater score changes 12 months after ARCR (OSS, 18 [SD, 8]; CMS, 34 [SD,18] vs degenerative: OSS, 15 [SD, 8]; CMS, 22 [SD, 15]) (P < .001) and significantly higher 12-month overall scores (OSS, 44 [SD, 5]; CMS, 79 [SD, 9] vs degenerative: OSS, 42 [SD, 7]; CMS, 76 [SD, 12]) (P≤ .006). At the 24-month follow-up, neither the OSS (degenerative, 44 [SD, 6]; traumatic, 45 [SD, 6]; P = .346) nor the rates of repair failure (degenerative, 14 [6.1%]; traumatic 12 [6.3%]; P = .934) and additional surgeries (7 [3%]; 7 [3.7%]; P = .723) differed between groups. CONCLUSION: Patients with degenerative and traumatic full-thickness supraspinatus tendon tears who had ARCR show satisfactory short-term functional results. Although patients with traumatic tears have lower baseline functional scores, they rehabilitate over time and show comparable clinical results 1 year after ARCR. Similarly, degenerative and traumatic rotator cuff tears show comparable structural outcomes, which suggests that degenerated tendons retain healing potential.

SECEC Didier Patte Prize 2023: the ABC classification of posterior shoulder instability.

BACKGROUND: The ABC classification has recently been proposed as a comprehensive classification system for posterior shoulder instability (PSI). The purpose of this study was to analyze the comprehensiveness as well as inter-rater and intrarater reliability of the ABC classification. METHODS: All consecutive patients presenting with unidirectional PSI from June 2019 to June 2021 were included in a prospective study. No patients were excluded, leaving a consecutive series of 100 cases of PSI in 91 patients. All recorded clinical and imaging data were used to create anonymized clinical case vignettes, which were evaluated twice according to the ABC classification at the end of the recruitment period in random sequential order by 4 independent raters (2 experienced shoulder surgeons and 2 orthopedic residents) to analyze the comprehensiveness as well as inter-rater and intrarater reliability of the ABC classification for PSI and to describe differences in characteristics among subtypes. Group A was defined as a first-time singular PSI event <3 months in the past regardless of etiology and is further subdivided into type 1 and type 2 depending on the occurrence of a subluxation (A1) or dislocation (A2). Group B comprises recurrent dynamic PSI regardless of time since onset and is further subdivided by the cause of instability into functional (B1) and structural (B2) dynamic PSI. Group C includes chronic static PSI with posterior humeral decentering that can be either constitutional (C1) or acquired (C2). RESULTS: None of the cases was deemed unsuitable to be classified based on the proposed system by the observers. After consensus agreement between the 2 expert raters, 16 cases were attributed to group A (8 type A1 and 8 type A2); 64, to group B (33 type B1 and 31 type B2); and 20, to group C (11 type C1 and 9 type C2). The expert raters agreed on the classification subtypes in 99% and 96% of the cases during the first rating and second rating, respectively (intraclass correlation coefficients [ICCs], 0.998 and 0.99, respectively). The intraobserver reliability was excellent for both raters. The beginners reached the same conclusion as the consensus agreement in 94% of the cases (ICC, 0.99) and 89% of the cases (ICC, 0.97) during the first round and 94% each (ICC, 0.97) during the second round. The intraobserver reliability was excellent for both beginners. Overall, discrepancies between raters were found between groups B1 and B2 (n = 14), groups B2 and C2 (n = 4), groups B1 and C1 (n = 1), and groups A1 and B2 (n = 1). In general, each subtype showed distinctive clinical and imaging characteristics that facilitated the diagnosis. CONCLUSION: The presented ABC classification for PSI is a comprehensive classification with a high reliability and reproducibility. However, a gradual transition and potential progression between the subtypes of PSI must be considered. The reliable distinction between different subtypes of PSI based on etiology and pathomechanism provides a standardized basis for future investigations on treatment recommendations.

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.

Position of scapula and clavicle in acute acromioclavicular joint dislocations: depressed scapula or elevated distal clavicle?

Background: Increased coracoclavicular distance due to acute acromioclavicular joint (ACJ) instability is often described as a pseudoelevation of the clavicle due to inferior hanging of the scapula, while the distal clavicle remains in its position. The aim of this study was to analyze whether the elevation of the distal clavicle, depression of the scapula, or both are associated with vertical instability and to evaluate the impact of weighted stress radiographs on the clavicle and scapular position in acute ACJ instabilities. Methods: The cohort consisted of 505 patients (f = 52, m = 453; mean age 46 years) which presented to our emergency department or outpatient clinic and treated in our institution from 2006 to 2019 displaying an acute ACJ injury. The panorama views that displayed at least two vertebraes with their spinous processes were retrospectively evaluated. Two raters assessed the panorama views twice regarding the clavicular and coracoidal angle of both sides in relation to the cervicothoracal spine and the difference in height of both clavicles and coracoids. Results: In our cohort, five types of displacement were distinguished: type A, only clavicle is elevated (N = 46); B, only scapula depressed (N = 36); C, the clavicle elevated and the scapula depressed (N = 67); D, both depressed (N = 133); and E, both elevated (N = 223). 123 patients had non-weighted radiographs and 353 patients stress views with 10 kg of axial load, whereas 29 patients had both radiological modalities. Among these 29 patients, a significant increase in coracoclavicular distance difference, clavicle, and scapula height (P < .05, respectively) was observed, when non-weighted radiographs were compared with weighted. A total of 13 shifts could be observed during the Rockwood type comparison of non-weighted radiographs with the weighted: six from Rockwood type II to III, two from type III to V, and five from type V to type III. Conclusion: Acute injury to the ACJ does not exclusively lead to a depression of the scapula or an elevated distal clavicle but rather leads to various vertical displacement combinations, however mostly to the elevation of both structures possibly due to muscle spasm and pain. Comparing both radiological modalities of the same patients, the routine use of weighted views should be questioned, since often a shift of Rockwood stage can be observed might lead to on the one hand inadequate conservative treatment for underestimated injuries however on the other hand unnecessary surgery for overestimated dislocations.

Gram negative periprosthetic hip infection: nearly 25% same pathogen infection persistence at a mean of 2 years.

PURPOSE: While gram negative (GN) periprosthetic joint infections (PJI) have previously been described as difficult to treat pathogens with high rates of reinfection, limited investigations have addressed midterm outcomes and risk of infection persistence by the same pathogen. This study analyzed (1) baseline demographics, treatment strategy, and midterm outcomes of GN PJIs, as well as (2) differences in reinfection and relapse rates compared to gram positive (GP) PJIs. METHODS: We identified 29 patients that were revised for 30 GN PJIs of total hip arthroplasties (THAs) between 2010 and 2020 using a university-based hip registry. Mean age was 77 years, 63% were females (19), and mean BMI was 27 kg/m2. Major causative pathogens included Escherichia coli (12), Klebsiella pneumoniae (5), Pseudomonas aeruginosa (5), and Enterobacter cloacae complex (5). Mean follow-up was 3.5 years. Study outcomes included (1) Kaplan-Meier survivorship analyses of all 30 GN PJIs, and (2) comparison of 18 two-stage exchanges for GN PJIs and 104 two-stage exchanges for GP PJIs, performed during the time from 2013 to 2017. RESULTS: (1) The 5-year survivorship free of recurrent PJI was 69%, and there were 7 recurrent PJIs at a mean of 2 years. There were 2 further suprafascial wound infections, resulting in a 61% survivorship free of any infection at 5-years. At a mean of 2 years, there were 7 patients with reinfection by the same GN pathogen (6 PJIs, one wound infection) as at index revision (23%). (2) Following two-stage exchange, the 5-year survivorship free of recurrent PJI (GN: 74%; GP: 91%; p = 0.072), any infection (GN: 61%; GP: 91%; p = 0.001), and reinfection by the same pathogen was significantly lower among GN PJIs (GN: 73%; GP: 98%; p < 0.001). CONCLUSIONS: Patients revised for GN PJIs are at increased risk of reinfection as opposed to GP infections. Affected patients must be counseled on the exceptionally high risk of infection persistence with one in four developing relapses. LEVEL OF EVIDENCE: Therapeutic Level III.

Inter-Observer and Intra-Observer Reliability Assessment of the Established Classification Systems for Periprosthetic Shoulder Fractures.

This study evaluated the reliability and comprehensiveness of the Unified classification system (UCPF), Wright & Cofield, Worland and Kirchhoff classifications and related treatment recommendations for periprosthetic shoulder fractures (PPSFx). Two shoulder arthroplasty specialists (experts) and two orthopaedic residents (non-experts) assessed 20 humeral-sided and five scapula-sided cases of PPSFx. We used the unweighted Cohen's Kappa (κ) for measuring the intra-observer reliability and Krippendorff's alpha (α) for measuring the inter-observer reliability. The inter-rater reliabilities for the Wright & Cofield and Worland classifications were substantial for all groups. The expert and non-expert groups for UCPF also showed substantial inter-rater agreement. The all-rater group for the UCPF and the expert and non-expert group for the Kirchhoff classification revealed moderate inter-rater reliability. For the Kirchhoff classification, only fair inter-rater reliability was found for the non-expert group. Almost perfect intra-rater reliability was measured for all groups of the Wright & Cofield classification and the all-rater and expert groups of the UCPF. All groups of the Kirchhoff and Worland classifications and the group of non-experts for the UCPF had substantial intra-rater reliabilities. Regarding treatment recommendations, substantial inter-rater and moderate intra-rater reliabilities were found. Simple classification systems for PPSFx (Wright & Cofield, Worland) show the highest inter- and intra-observer reliability but lack comprehensiveness as they fail to describe scapula-sided fractures. The complex Kirchhoff classification shows limited reliability. The UCPF seems to offer an acceptable combination of comprehensiveness and reliability.

Arthroscopic Posterior Capsulolabral Repair With Suture-First Versus Anchor-First Technique in Patients With Posterior Shoulder Instability (Type B2): Clinical Midterm Follow-up.

Background: Isolated soft tissue injuries of the posterior capsulolabral complex can be addressed arthroscopically, with various anchor systems available for repair. Purpose: To evaluate clinical and patient-reported outcomes after arthroscopic capsulolabral repair in patients with posterior shoulder instability (PSI) and to compare differences in outcomes between patients treated with a suture-first technique (PushLock anchor) and an anchor-first technique (FiberTak all-suture anchor). Study Design: Cohort study; Level of evidence, 3. Methods: Included were 32 patients with dynamic structural PSI (type B2 according to the ABC classification) treated with an arthroscopic posterior capsulolabral repair. After a mean follow-up time of 4.8 ± 3.4 years (range, 2-11) patients were evaluated clinically, and standardized outcome scores were obtained for the Subjective Shoulder Value (SSV), the Western Ontario Shoulder Instability Index (WOSI), Rowe, Kerlan-Jobe Orthopaedic Clinic (KJOC), patient satisfaction (0-5 [best]), and pain on a visual analog scale (VAS; 0-10 [worst]). Results: The overall satisfaction level with the outcome of the surgery was 4.6 ± 0.5 (range, 4-5). No patient suffered from instability events. The mean VAS level for pain was 0.4 ± 0.9 (range, 0-4) at rest and 1.9 ± 2.0 (range, 0-6) during motion. The mean SSV was 80 ± 17 (range, 30-100), the mean postoperative WOSI score 75% ± 19% (range, 18-98), the mean Rowe score 78 ± 20 (range, 10-100), and the mean KJOC score was 81 ± 18 (range, 40-100) for the entire cohort. There was no significant difference between the techniques with regard to range of motion, strength, or clinical outcome scores. Conclusion: Arthroscopic posterior capsulolabral repair was a satisfactory method to treat structural PSI type B2 with regard to stability, pain relief, and functional restoration. The majority of patients had good outcomes. No differences in outcomes were observed between the anchor-first and suture-first techniques.

No clinical consequence of liner malseating in dual-mobility THAs at short term: a systematic review.

BACKGROUND: Liner malseating is well described in ceramic-on-ceramic total hip arthroplasties (THAs). However, limited information is known on this complication among dual-mobility articulations. As such, this systematic review analyzed liner malseating in dual-mobility THAs concerning prevalence, clinical implications, and associated risk factors. METHODS: A PRISMA criteria-based systematic review was performed, and PubMed, Web of Science, MEDLINE, and Cochrane used as data bases. All original studies from 1980 to 2022 were considered eligible for inclusion, and Methodological Index for Nonrandomized Studies (MINORS) used for quality assessment. RESULTS: In total, five retrospective cohort studies with 2330 patients (2673 dual-mobility THAs) were included. Mean age was 66.9 years, mean BMI was 29.8 kg/m2, and 35% of patients were female. Rates of malseating ranged from 0.15% to 5.8%, with a total of 53 malseated liners identified throughout all studies (1.98%). Based on THA manufacturer, malseating occurred in 48 Stryker (1.96%) and 5 Biomet Zimmer (2.14%) THAs. Mean clinical follow-up was 2.2 years (mean range, 1.3 to 6.4 years). Except one patient reporting of pain at 2 years, no revision or negative clinical implication was noted in any of the malseated liners, including normal ranged metal ions measured in four cases. A smaller acetabular component size was identified as a statistically significant risk factor for malseating in one study. Mean MINORS score was 9.8. CONCLUSIONS: Liner malseating is a rare finding in patients undergoing THAs with dual-mobility articulations. While prelim results demonstrate no negative clinical consequences to date, existing studies are limited, refer to short-term outcomes only, and do not prospectively follow-up affected patients. LEVEL OF EVIDENCE: IV.

Practical considerations for determination of scapular internal rotation and its relevance in reverse total shoulder arthroplasty planning.

BACKGROUND: Scapulothoracic orientation, especially scapular internal rotation (SIR) may influence range of motion in reverse total shoulder arthroplasty (RTSA) and is subjected to body posture. Clinical measurements of SIR rely on apical bony landmarks, which depend on changes in scapulothoracic orientation, while radiographic measurements are often limited by the restricted field of view (FOV) in CT scans. Therefore, the goal of this study was (1) to determine whether the use of CT scans with a limited FOV to measure SIR is reliable and (2) if a clinical measurement could be a valuable alternative. METHODS: This anatomical study analyzed the whole-body CT scans of 100 shoulders in 50 patients (32 male and 18 female) with a mean age of 61.2 ± 20.1 years (range 18; 91). (1) CT scans were rendered into 3D models and SIR was determined as previously described. Results were compared to measurements taken in 2D CT scans with a limited FOV. (2) Three apical bony landmarks were defined: (the angulus acromii (AA), the midpoint between the AA and the coracoid process tip (C) and the acromioclavicular (AC) joint. The scapular axis was determined connecting the trigonum scapulae with these landmarks and referenced to the glenoid center. The measurements were repeated with 0°, 10°, 20°, 30° and 40° anterior scapular tilt. RESULTS: Mean SIR was 44.8° ± 5.9° and 45.6° ± 6.6° in the 3D and 2D model, respectively (p < 0.371). Mean difference between the measurements was 0.8° ± 2.5° with a maximum of 10.5°. Midpoint AA/C showed no significant difference to the scapular axis at 0° (p = 0.203) as did the AC-joint at 10° anterior scapular tilt (p = 0.949). All other points showed a significant difference from the scapular axis at all degrees of tilt. CONCLUSION: 2D CT scans are reliable to determine SIR, even if the spine is not depicted. Clinical measurements using apical superficial scapula landmarks are a possible alternative; however, anterior tilt influenced by posture alters measured SIR.

[Infiltration therapies for lateral epicondylopathy]. / Infiltrationstherapien am Ellenbogengelenk bei Epicondylopathia humeri radialis.

The therapy of the lateral epicondylopathy (tennis elbow) includes drug injection into the extensor tendon insertion in chronic cases. The choice of medication and the type of injection is decisive for the success of therapy. Furthermore, accurate application is indispensable for therapy success (e.g. peppering injection technique, ultrasound-supported injection technique). Corticosteroid injection is often associated with short-term success, so that other options have found their way into everyday practice. Objectification of treatment success is usually defined by Patient-Reported Outcome Measurements (PROM). With the introduction of Minimal Clinically Important Differences (MCID), statistically significant results are put into perspective in terms of clinical significance. Therapy for lateral epicondylopathy was considered effective if the mean difference in score results between baseline and follow-up exceeded 1.5 points for the Visual Analogue Scale (VAS), 16 points for Disabilities of Arm, Shoulder and Hand Score (DASH), 11 points for Patient-Rated Tennis Elbow Evaluation (PRTEE), and 15 points for Mayo Elbow Performance Score (MEPS). However, the effectiveness must still be critically questioned according to meta-analytical evaluations, in which healing within 12 months was found in 90% of the cases of untreated chronic tennis elbow in the placebo groups. The use of substances, such as Traumeel (Biologische Heilmittel Heel GmbH, Baden-Baden, Germany), hyaluronic acid, botulinum toxin, platelet rich plasma (PRP), autologous blood or polidocanol, are based on various mechanisms. In particular, the use of PRP or autologous blood for the treatment of musculotendinous and degenerative articular pathologies has become popular, although the studies regarding effectiveness are inconsistent. PRP can be divided into leukocyte-rich (LR-PRP) and leukocyte-poor plasma (LP-PRP) according to its preparation. In contrast to LP-PRP, LR-PRP incorporates the middle and intermediate layers, but there is no standardized preparation described in the literature. Conclusive data regarding effective efficacy are still pending.

Corynebacterium periprosthetic joint infection: a systematic review of 52 cases at 2.5 years follow-up.

INTRODUCTION: While large progress has been achieved in identifying and treating the most common pathogens involved in periprosthetic joint infections (PJI), there remains limited knowledge on atypical pathogens such as Corynebacterium. For that reason, we analyzed infection and diagnostical characteristics, as well as treatment outcome in Corynebacterium PJI. METHODS: A systematic review was performed based on a structured PubMed and Cochrane Library analysis using the PRISMA algorithm. The search was performed by 2 independent reviewers, and articles from 1960 to 2022 considered eligible for inclusion. Out of 370 search results, 12 studies were included for study synthesis. RESULTS: In total, 52 cases of Corynebacterium PJI were identified (31 knees, 16 hips, 4 elbows, 1 shoulder). Mean age was 65 years, with 53% females, and a mean Charlson Comorbidity Index of 3.9. The most common species was Corynebacterium striatum in 37 cases (71%). Most patients were treated with two-stage exchange (40%), isolated irrigation and debridement (21%), and resection arthroplasty (19%). Mean duration of antibiotic treatment was 8.5 weeks. At a mean follow-up of 2.5 years, there were 18 reinfections (33%), and 39% were for Corynebacterium. Initial infection by Corynebacterium striatum species was predictive of reoperation (p = 0.035) and reinfection (p = 0.07). CONCLUSION: Corynebacterium PJI affects multimorbid and elderly patients, with one in three developing a reinfection at short term. Importantly, the relative majority of reinfections was for persistent Corynebacterium PJI.

Periprosthetic hip infection in octogenarians : a single institution experience of 33 cases.

AIMS: Periprosthetic joint infection (PJI) in total hip arthroplasty in the elderly may occur but has been subject to limited investigation. This study analyzed infection characteristics, surgical outcomes, and perioperative complications of octogenarians undergoing treatment for PJI in a single university-based institution. METHODS: We identified 33 patients who underwent treatment for PJIs of the hip between January 2010 and December 2019 using our institutional joint registry. Mean age was 82 years (80 to 90), with 19 females (57%) and a mean BMI of 26 kg/m2 (17 to 41). Mean American Society of Anesthesiologists (ASA) grade was 3 (1 to 4) and mean Charlson Comorbidity Index was 6 (4 to 10). Leading pathogens included coagulase-negative Staphylococci (45%) and Enterococcus faecalis (9%). Two-stage exchange was performed in 30 joints and permanent resection arthroplasty in three. Kaplan-Meier survivorship analyses were performed. Mean follow-up was five years (3 to 7). RESULTS: The two-year survivorship free of any recurrent PJI was 72% (95% confidence interval (CI) 56 to 89; 18 patients at risk). There were a total of nine recurrent PJIs at a mean of one year (16 days to eight years), one for the same pathogen as at index infection. One additional surgical site infection was noted at two weeks, resulting in a 69% (95% CI 52 to 86; 17 patients at risk) survivorship free of any infection at two years. There were two additional revisions for dislocations at one month each. As such, the two-year survivorship free of any revision was 61% (95% CI 42 to 80; 12 patients at risk). In addition to the aforementioned revisions, there was one additional skin grafting for a decubitus ulcer, resulting in a survivorship free of any reoperation of 54% (95% CI 35 to 73; ten patients at risk) at two years. Mean Clavien-Dindo score of perioperative complications was two out of five, with one case of perioperative death noted at six days. CONCLUSION: Octogenarians undergoing surgery for PJI of the hip are at low risk of acute mortality, but are at moderate risk of other perioperative complications. One in two patients will undergo a reoperation within two years, with 70% attributable to recurrent infections.Cite this article: Bone Joint J 2023;105-B(2):135-139.

Periprosthetic knee infection in octogenarians: a single institution experience at midterm outcome.

PURPOSE: Periprosthetic joint infections (PJI) of total knee arthroplasties (TKAs) in the elderly is among the clinically most challenging scenarios given multimorbidity combined with poor bone and soft tissue quality. Despite increasing prevalence, limited is known on PJI among this unique group of patients. As such, this study analyzed PJI characteristics, implant survivorship and non-surgical complications of octogenarians revised PJI for the knee. METHODS: We identified 31 patients that were revised for PJIs of the knee between 2010 and 2019 using a single university-based registry. Mean age was 83 years (range 80-87), 48% were females, and mean BMI was 29 kg/m2. Mean age adjusted Charlson Comorbidity Index was 7, and mean ASA score was 3. Major causative pathogens included Coagulase-negative Staphylococci (26%), Staphylococcus aureus (13%), and Streptococci (13%). Two-stage exchange was performed in 30 patients, permanent resection arthroplasty in one joint. Kaplan-Meier survivorship analyses were performed. Mean follow-up was 4 years. RESULTS: The 2-year survivorship free of any recurrent PJI was 96%, and there was one PJI relapse noted at 6 months. Moreover, there were three additional revisions for aseptic loosening, and one further revision for fracture. As such, the 2-year survivorship free of any revision was 87%. In addition to the aforementioned revisions, there was one additional plate osteosynthesis for a Vancouver C fracture, resulting in a 79% survivorship free of any reoperation at 2 years. Mean perioperative complication score according to the Clavien-Dindo classification was 2 out of 5. A total of three patients died: one patient 40 days after resection arthroplasty, two others 4 months and 8 months after reimplantation. CONCLUSIONS: Octogenarians revised for PJI of the knee are at low risk of recurrent infection and overall revision at 2 years. However, moderate rates of perioperative complications and mortality at short term must acknowledge before deciding upon procedure. LEVEL OF EVIDENCE: Therapeutic level IV.