[Conservative treatment of frozen shoulder]. / Konservative Therapie der "frozen shoulder".

Idiopathic shoulder stiffness (i.e. frozen shoulder, FS) is a common pathology of the glenohumeral joint characterized by a sudden onset of pain syndrome and progressive restriction of the range of motion. While the histological changes of FS are accompanied by synovial inflammation and increasing capsular fibrosis, the underlying cause of FS is still unknown. The treatment options for FS are multifarious and include medication, local steroid injection, physiotherapy, hydrodistension, manipulation under anesthesia, arthroscopic and open capsular release. As the disease is usually self-limiting and the symptoms resolve after 2-3 years, especially conservative treatment measures are often clinically applied; however, in this context there is still no scientifically based consensus on which treatment measures are most likely to contribute to symptom relief in which phase of the disease. For this reason, this article focuses on the description of the scientifically investigated conservative treatment methods in FS and their temporal classification into the classical three-phase course of the disease.

[Acute injury of the posterior cruciate ligament with femoral avulsion : Arthroscopic ligament repair and bracing]. / Akute Verletzung des hinteren Kreuzbandes mit femoraler Avulsion : Banderhaltende arthroskopische Refixation und Bracing.

OBJECTIVE: The aim of arthroscopic bracing of the posterior cruciate ligament (PCL) is to restore anatomic and biomechanic function in acute PCL tears. Therefore, primary augmentation of the PCL by using a stable suturing system is used. INDICATIONS: Acute tears of the PCL, femoral avulsions, isolated or combined in cases of multiligament injuries (knee dislocations of Schenk types II-IV). CONTRAINDICATIONS: Chronic instabilities of the PCL, infection of the knee joint. SURGICAL TECHNIQUE: Arthroscopic preparation of the femoral PCL footprint. Suturing of the PCL stump with non-resorbable sutures. Placement of the femoral and tibial tunnel with a specific arthroscopic PCL guide. Femoral fixation of the bracing system and the PCL augmenting sutures extracortical via a button or intraarticular with a suture anchor. Tibial fixation via a button has to be performed in a minimum of 80° of flexion and under permanent anterior drawer tension. POSTOPERATIVE MANAGEMENT: Brace in full extension with posterior support 24 h/day, range of motion (ROM) restricted up to 90° of flexion and limited weight bearing with 20 kg for the first 6 weeks postoperatively. After 6 weeks, weight bearing and ROM can be increased and a solid frame brace with posterior support is recommended for the next 6 weeks.

Retrograde fixation of the lesser trochanter in the adolescent: new surgical technique and clinical results of two cases.

INTRODUCTION: Avulsions of the lesser femoral trochanter are rare injuries in the adolescent population. An acute avulsion causes severe functional impairment with compromised hip flexion. Recent literature reports the superiority of surgical treatment for apophyseal avulsion fractures of the pelvis in adolescents. Unfortunately, there are no guidelines for an evidence-based treatment of lesser trochanter avulsions established. We present the cases of two adolescent athletes treated operatively. MATERIALS AND METHODS: Two adolescent males, 12 and 16 years old, suffered an avulsion of the lesser trochanter during soccer. They reported immobilizing groin pain with subjective impairment in daily activities and inability to perform sports. Surgical treatment with a new retrograde technique by applying an adapted mini-open anterior approach was performed. Intraoperatively, both cases showed an intact musculo-tendinous unit attached to the avulsed fragment. RESULTS: Both patients showed excellent postoperative results and were satisfied with the clinical outcome. In the postoperative follow-up an adequate consolidation of the lesser trochanter was visible. No complications were postoperatively reported at final follow-up. CONCLUSIONS: The retrograde fixation technique has led to an excellent outcome without complications in two adolescents with acute lesser trochanter apophyseal avulsions. Further clinical use may support the value of this new surgical technique.

[Osteoarthritis of the shoulder: pathogenesis, diagnostics and conservative treatment options]. / Omarthrose: Pathogenese, Diagnostik und konservative Therapieoptionen.

PATHOGENESIS: Osteoarthritis of the shoulder is characterized by a progressive degenerative process, which is based on chronic inflammation with intra-articular release of different cytokines and proteolytic enzymes. The main predisposing factors are a history of trauma or surgery, as well as chronic overuse or instability of the glenohumeral joint. Affected patients especially suffer from impaired joint function and pain, which are often associated with cognitive and psychosocial restrictions. DIAGNOSTICS: Possible co-pathologies have to be evaluated carefully both clinically and radiologically as they must be taken into account in the therapeutic procedure. If arthroplasty of the shoulder is planned, a pre-operative CT scan is mandatory in order to evaluate the bone stock of the glenoid, which has a decisive influence on the choice of implant. TREATMENT: Conservative treatment options are oral pain medication, physical therapy, and intra-articular injections, whereby, in comparison to corticosteroids, hyaluronic acid seems to be advantageous especially with respect to the duration of a positive clinical effect.

[Flexion and extension osteotomy of the knee]. / Flexions- und Extensionsosteotomien am Kniegelenk.

OBJECTIVES: Flexion and extension osteotomy of the knee for symptomatic malalignment in the sagittal plane. INDICATIONS: Congenital/posttraumatic bony deficiencies in flexion/pathologic hyperextension in the knee. Additional treatment for ligament reconstruction. CONTRAINDICATIONS: Absolute: Infection, critical soft tissue situation, circulatory disorders. Relative: Osteoporosis, heavy smoker, obesity, reduced patient compliance. SURGICAL TECHNIQUE: Diagnostic arthroscopy of the knee. If the malposition is located at the proximal tibia, an extending or flexing high tibial osteotomy with correction of the tibial slope is carried out. If the malalignment is referred to the distal femur, the adjustment is performed by a distal femoral osteotomy. POSTOPERATIVE MANAGEMENT: Partial weight bearing with 20 kg for the first 6 postoperative weeks. Due to the tuberositas tibiae osteotomy, it is necessary to restrict the movement of the knee for the first 6 weeks. RESULTS: Between 2015 and 2016, 11 patients (2 female, 9 male) were treated with a flexion or extension osteotomy of the knee. Of these patients, 2 had symptomatic hyperflexion, 7 had restriction of movement with an exaggerated tibial slope, and 2 patients had an extension deficiency according to a malalignment of the distal femur. After surgery, the symptomatic pathologic movement of the knee was improved in every patient. One patient had pseudarthrosis during the healing process, which required a second operation with reosteosynthesis and bony grafting. These results are also reflected in an improvement of the preoperative IKDC score from 52.7 (range 37-82) to 1 year postoperative 75.8 (range 67-84). The Lysholm score increased from preoperative 40.2 (range 15-73) to postoperative 84.3 (range 68-91).

[Arthroscopic refixation of acute proximal anterior cruciate ligament rupture using suture anchors]. / Arthroskopische Refixation einer akuten proximalen vorderen Kreuzbandruptur mittels knotenlosem Fadenanker.

OBJECTIVE: Arthroscopic assisted suture anchor refixation combined with microfracturing of the femoral ACL insertion zone in cases of acute proximal anterior cruciate ligament (ACL) rupture to restore anatomical and biomechanical properties of the native ACL. INDICATIONS: Acute proximal ACL rupture/avulsion, multiligament injury of the knee CONTRAINDICATIONS: Chronic (>6 weeks) proximal ACL rupture, intraligamentary rupture, as well as previous ACL surgery. SURGICAL TECHNIQUE: Arthroscopic examination of the knee joint, debridement of the femoral insertion zone, examination of the ligament quality by a probe, insertion of a curved lasso through the ACL to place the sutures and use of a drill guide to place the anchor in the middle of the femoral ACL insertion. Microfracturing holes around the femoral footprint were made by an awl to enhance healing properties of the ACL. POSTOPERATIVE MANAGEMENT: Partial weight bearing was permitted and crutches were used for 6 weeks, knee brace limited for the first 2 weeks 0­0-0°, then 0­0-90° for the following 4 weeks. RESULTS: A total of 20 patients who underwent acute proximal ACL suture anchor refixation were evaluated after a mean follow-up of 28 months. Regarding stability, mean values of the KT-1000 arthrometer indicated stable results (<3 mm), 3 patients had a 1+ Lachman and 4 patients had a 1+ pivot shift. IKDC (International Knee Documentation Committee) score indicated that 17 cases were very good to good (12A, 4B) and in 3 cases the results were satisfactory (3C). Magnetic resonance imaging showed that the ALC was found to be intact in 17 cases. The total rate of revision was 15 % (3/20) because of recurrent instability.

[Surgical treatment of anterosuperior impingement of the shoulder]. / Die operative Therapie des anterosuperioren Schulterimpingements.

OBJECTIVE: Therapy of intraarticular lesions and elimination of structural risk factors for those suffering from clinical manifest anterosuperiorer impingement (ASI) of the shoulder. This includes as a maximum version the arthroscopic repair of supraspinatus (SST) and subscapularis tendon (SCT) tears with subsequent subpectoral tenodesis of the long head of the biceps tendon (LBT) and arthroscopic coracoplasty. INDICATIONS: Clinical manifest anterosuperiorer impingement of the shoulder with anterior shoulder pain, failed conservative treatment and clear intraarticular damage in radiological imaging. This involves in detail lesions of the SST, SCT and damage to the LBT. CONTRAINDICATIONS: Lack of structural intraarticular lesions or massive osteoarthritis. Persistent dysfunction of active and passive glenohumeral and scapulathoracal motion, due to neurologic deficits or stiff shoulder. A hypertrophic or deformed healed coracoid process is seen as a structural risk factor for suffering from ASI and should be addressed surgically when causing impingement. SURGICAL TECHNIQUE: Arthroscopic tenotomy of the LBT with subsequent repair of the SST and SCT. Arthroscopic coracoplasty if indicated and subpectoral tenodesis of the long head of the biceps. POSTOPERATIVE MANAGEMENT: No biceps activity and intermittent immobilization in sling for 6 weeks. Limitation of abduction, flexion and external rotation for 6 weeks depending on rotator cuff tendon repair. Start of sport-specific training after 3 months, over-head sports 6 months postoperatively. RESULTS: The arthroscopic repair of anterosuperior rotator cuff tears provides reliable results for improvement in function, decreases in pain and improvement in shoulder scores. The overall rate of adverse events is low.

[Open-wedge osteotomy of the glenoid for treatment of posterior shoulder instability with increased glenoid retroversion]. / Open-wedge-Glenoidosteotomie als Therapie bei posteriorer Schulterinstabilität aufgrund vermehrter Glenoidretroversion.

OBJECTIVE: Treatment of posterior shoulder instability with increased retroversion of the glenoid using open-wedge osteotomy of the glenoid neck stabilized with an autologous bone block. INDICATIONS: Symptomatic, atraumatic posterior shoulder instability with increased retroversion (>20°) of the glenoid and previously failed conservative or surgical treatment. CONTRAINDICATIONS: General contraindications against surgery. Relative contraindications: osteoporosis, nicotine abuse, or suspected patient noncompliance. SURGICAL TECHNIQUE: Posterior approach with a 7 cm long incision starting medial of the posterolateral corner of the acromion heading to the posterior axillary fold and subsequent preparation of the deltoid muscle and the infraspinatus muscle. The posterior glenohumeral capsule is incised by performing a capsular T­shift. The osteotomy is performed intracapsulary medial to the genoid rim. The wedge bone graft, harvested from spina scapulae or iliac spine, is placed "press fit" in position. Additional fixation of the graft is not necessary if the anterior cortex is intact. For reinforcing the posterior capsule, a posterior capsule shift should be performed. Insertion of extracapsular wound drainage. Successive wound closure. POSTOPERATIVE MANAGEMENT: Postoperative immobilization in a 0° shoulder orthesis for 6 weeks; avoidance of horizontal abduction for 8 weeks. After removing the wound drainage, start of limited active-assisted range of motion. Over-head sports after 6 months. RESULTS: From 2009-2015, 6 posterior open wedge glenoid osteotomies were performed. Postoperative retroversion of the glenoid was 11.2 ± 9.4° compared to 26.0 ± 8.6° before surgery. Of 6 shoulders, 2 showed postoperative signs of persistent posterior instability; the other 4 shoulders were free of complaints. No revision surgery was needed.

[The mini-open Latarjet procedure for treatment of recurrent anterior instability of the shoulder]. / Die Mini-open-Latarjet-Technik als Therapie bei rezidivierender vorderer Instabilität des Schultergelenks.

OBJECTIVE: Shoulder stabilization. INDICATIONS: Symptomatic recurrent anterior shoulder instability combined with glenoid bone loss of approximately 20-35 % of the glenoid surface, engaging Hill-Sachs lesion and/or previously failed arthroscopic Bankart repair. In patients with a high risk of redislocation (contact sports) or irreparable soft tissue injury the Latarjet procedure can be considered as a first-line treatment. CONTRAINDICATIONS: Contraindicated if arthroscopic Bankart repair is possible. Irreparable damage of subscapularis tendon. Bony defect >35 % of the glenoid that cannot be filled with coracoid bone block. Arbitrary shoulder dislocation. Young patients with open growth plates (relative contraindication). SURGICAL TECHNIQUE: Mini-open deltopectoral approach of approximately 6 cm. Preparation of the coracoid process and the conjoined tendons. Osteotomy of the coracoid process at its base using a 90° sawblade. Split of the subscapularis tendon. Preparation of the glenoid defect and implantation of 2-3 suture anchors where appropriate. Drilling of two parallel holes through the coracoid process. Fixation of the bone block with cannulated screws at the anterior glenoid rim and refixation of the joint capsula, if necessary with the help of the suture anchors. Wound drainage and closure in layers. POSTOPERATIVE MANAGEMENT: Intermittent immobilization in a sling for 6 weeks with limited abduction, flexion and external rotation. Sport-specific training after 3 months, over-head sports after 6 months. RESULTS: Since 2009 64 mini-open Latarjet procedures (61 patients) performed. In all, 9.4 % of patients suffered from persistent instability (dislocations and subluxations); only 1 patient needed revision surgery due to instability.

Return-to-activity after anatomical reconstruction of acute high-grade acromioclavicular separation.

BACKGROUND: To evaluate return-to-activity (RtA) after anatomical reconstruction of acute high-grade acromioclavicular joint (ACJ) separation. METHODS: A total of 42 patients with anatomical reconstruction of acute high-grade ACJ-separation (Rockwood Type V) were surveyed to determine RtA at a mean 31 months follow-up (f-u). Sports disciplines, intensity, level of competition, participation in overhead and/or contact sports, as well as activity scales (DASH-Sport-Module, Tegner Activity Scale) were evaluated. Functional outcome evaluation included Constant score and QuickDASH. RESULTS: All patients (42/42) participated in sporting activities at f-u. Neither participation in overhead/contact sports, nor level of activity declined significantly (n.s.). 62 % (n = 26) of patients reported subjective sports specific ACJ integrity to be at least the same as prior to the trauma. Sporting intensity (hours/week: 7.3 h to 5.4 h, p = .004) and level of competition (p = .02) were reduced. If activity changed, in 50 % other reasons but clinical symptoms/impairment were named for modified behavior. QuickDASH (mean 6, range 0-54, SD 11) and DASH-Sport-Module (mean 6, range 0-56, SD 13) revealed only minor disabilities at f-u. Over time Constant score improved significant to an excellent score (mean 94, range 86-100, SD 4; p < .001). Functional outcome was not correlated with RtA (n.s.). CONCLUSION: All patients participated in sporting activities after anatomical reconstruction of high-grade (Rockwood Type V) ACJ-separation. With a high functional outcome there was no significant change in activity level (Tegner) and participation in overhead and/or contact sports observed. There was no correlation between functional outcome and RtA. Limiting, there were alterations in time spent for sporting activities and level of competition observed. But in 50 % those were not related to ACJ symptoms/impairment. Unrelated to successful re-established integrity and function of the ACJ it should be considered that patients decided not return-to-activity but are very content with the procedure.

[Open anatomic reconstruction of chronic acromioclavicular instability]. / Offen anatomische Rekonstruktion der chronischen Akromioklavikularinstabilität.

OBJECTIVE: The aim of open anatomic reconstruction of the acromioclavicular (AC) joint is combined reconstruction of the AC and coracoclavicular ligaments using a tendon graft. INDICATIONS: Symptomatic instabilities of the AC joint > type III. CONTRAINDICATIONS: Asymptomatic instabilities < type III and general contraindication against elective surgery. SURGICAL TECHNIQUE: Through the open surgical approach, the exact anatomical insertion sites of the ligamentous structures can be reproduced. In addition, this approach enables accurate repositioning of the AC joint under direct vision (including possible debridement of the intraarticular discus) and an additional fixation of deltotrapezoidal fascia. POSTOPERATIVE MANAGEMENT: Postoperatively, the arm is positioned in an abduction brace for 6-8 weeks. Passive exercises in flexion up to 90° and in external rotation up to 30° are permitted during this period. After 6-8 weeks, free and active motion is allowed. RESULTS: Between January 2003 and December 2010, 46 patients (9 women and 37 men, mean age 42 ± 13 years) underwent AC combined reconstruction. Complete outcome data were available for 25 patients. Mean length of follow-up was 31 ± 26 months. The mean preoperative coracoclavicular distance was 20.1 ± 5.6 mm; postoperatively the mean distance was 7.1 ± 3.0 mm (p < 0.001) The mean clinical scores also statistically improved (p < 0.001): American Shoulder and Elbow Score improved from 53.4 ± 18.7 points preoperatively to 80.6 ± 25.7 points postoperatively and the Constant Murley Score improved from 60.0 ± 16.7 points preoperatively to 85.2 ± 22.8 points postoperatively.

In vivo evaluation of the kinematics of the long head of the biceps tendon within the pulley: a 3 T MRI motion analysis.

INTRODUCTION: To evaluate the kinetic amplitude and direction of the long head of the biceps tendon (LHB) within the pulley and the proximal bicipital groove, we performed a 3T-magnetic resonance-throwing motion analysis. MATERIALS AND METHODS: This prospective study was performed on a 3T-MRI scanner. A T2-weighted-3D sequence in three specific positions of throwing motion of the dominant shoulder was performed under isometric 5 N loading conditions or without loading, respectively. Measurements were performed in high (140°) abduction/external rotation, medium (110°) abduction/external rotation and low (45°) adduction-flexion/internal rotation. Multiplanar rotational reconstructions along the LHB in the bicipital groove allowed for the localization of the LHB including the degree of motion in the three most proximal slices. RESULTS: 12 healthy volunteers (age 22­34 years) were enrolled. Adduction led to an anterior deviation of the LHB within the bicipital groove. Loading conditions in medium (110°) elevation/external rotation furthermore led to a significant anterior deviation of the LHB. Conclusion Our findings support the thesis that pulley lesions result from movements of the LHB especially in extreme positions during throwing/overhead activities. Load application in the medium (110°) elevation/external rotation position might enable a better evaluation of patients with dedicated pulley lesions. These results need further evaluation in larger study cohorts and in patients with dedicated rotator cuff lesions, which will be the focus of ongoing studies.

[The painful patellofemoral joint. Biomechanics, diagnosis and therapy]. / Das schmerzhafte Patellofemoralgelenk : Biomechanik, Diagnostik und Therapie.

New knowledge about the pathophysiology and biomechanics of the patellofemoral joint (PFJ) has led to a better understanding and new treatment options. To recognise the main pathology is the most important and difficult part. This article describes the basic principles of biomechanics (static, passive and active factors) and their influence on the PFJ. Patients are classified into three groups (pain, instability and arthritis). This is achieved by a clinical evaluation and standard X-rays. The instability group is analysed additionally with MRI. The aim of this evaluation is to analyse the biomechanical cause of the instability. Based on a pathophysiological concept a new therapeutic algorithm is introduced.

[Job satisfaction of radiologists in Germany - status quo]. / Berufszufriedenheit von Radiologen in Deutschland - aktueller Stand.

PURPOSE: The aim of this study was to identify and evaluate the work-related satisfaction of radiologists and its influencing factors in Germany. MATERIALS AND METHODS: For this purpose an invitational letter for an online opinion survey was sent to all member physicians of the Deutsche Roentgengesellschaft in 2008. 1200 questionnaires were completed (response rate 21 %) and evaluated statistically. RESULTS: 81.7 % of radiologists declared themselves as being "very" or "rather satisfied". The level of satisfaction was largely independent of age, gender, status, salary or family status. It increased over the last 5 years for 37.5 % of participants and decreased for 24.8 %. Nevertheless, 72 % of respondents indicated that they would not choose to specialize in radiology again. The main reason given was the workload. 65.6 % deemed it to be "considerably" or "rather too high". Concomitantly, more than 70 % of respondents indicated that the workload had increased "a lot" or "rather". Further reasons for not wanting to select the radiological profession again were "unfavorable working hours" and "unsatisfactory career perspectives". CONCLUSION: The job satisfaction of radiologists in Germany is generally very high in spite of the perception of an extensive and frequently increasing workload. The high workload was the dominant factor against a renewed selection of the field of radiology. These data have to be interpreted in light of the current lack of residents and trained radiologists in Germany to counteract the trend toward emigration.

[May eccentric training be effective in the conservative treatment of chronic supraspinatus tendinopathies? A review of the current literature]. / Kann exzentrisches Training in der konservativen Therapie von chronischen Supraspinatus-Tendinopathien effektiv sein? Eine Übersicht zur aktuellen Literatur.

Eccentric training (ET) has been shown to be an effective conservative treatment option for chronic patellar and Achilles tendinopathies. As part of the four-muscle-tendon-complex of the rotator cuff, the supraspinatus is involved most commonly in shoulder disorders. Histopathologic alterations of the supraspinatus tendon are comparable to findings in lower extremity tendinopathies. Hence, the question arises whether the concept of eccentric training can be successfully transferred to the upper extremity. Yet, no randomised controlled trials have been published to support this theory. This problem emerges from the fact that the supraspinatus is part of a complex functional unit. Consequently, surrounding soft tissues are frequently concomitantly affected. The inherent etiology and genesis of pathologic alterations in the supraspinatus tendon and its influence on shoulder disorders is not clear to date. However, the apparent success of ET in managing tendinopathies of the lower extremity urges further scientific work for developing evidence-based guidelines for the conservative treatment of tendinopathies in the shoulder region. Taking into account this lack of data as well as the anatomical and functional constraints, the aim of this work is to review the current state of the literature.

Clinical and structural evaluation of arthroscopic double-row suture-bridge rotator cuff repair: early results of a novel technique.

PURPOSE: Assessment of repair integrity and clinical outcome after arthroscopic repair of rotator cuff tears in double-row suture-bridge technique with the use of a new knotless suture-anchor system. METHODS: The first treated 25 patients with arthroscopic rotator cuff repair in the suture-bridge technique using a novel knotless anchor and chain-link suture system were evaluated. Patients with isolated full-thickness supraspinatus tears were selected. They were followed clinically with functional scores (Constant score, ASES index), visual analog scale (VAS), and instrumentally with Isobex digital strength analyzer preoperatively, at 6 and 14 months postoperatively. The repair integrity was evaluated with MRI at an average of 14 months postoperatively. RESULTS: Significant improvement of pain, strength, range of motion, and functional scores occurred (P < 0.05). There was a re-tear rate of 20%. The subjective parameters (VAS and ASES Index) showed non-significant (n.s.) differences between the re-tear and intact repair groups, whereas the objective parameters (Constant score, muscle power and active ROM) showed significant differences between both groups (P < 0.05). CONCLUSION: The functional outcome has improved significantly with this new knotless anchor-chain system and was more superior in shoulders with intact repair, whereas the resulted repair integrity was not better than other types of double-row repair techniques mentioned in the recent literature. However, this early report of the novel technique may show limited power for comparison due to the relatively small sample size.