[Reliability and validity of the Lever Sign Test in suspected ligament and/or meniscus injuries of the knee: a comparison between an orthopaedist and a physical therapist]. / Reliabilität und Validität des Lever Sign Tests bei Verdacht auf Band- und/oder Meniskus-Verletzung des Knies: ein Vergleich zwischen Orthopäde und Physiotherapeut.

INTRODUCTION: The purpose of this study was to investigate the intertester reliability and validity of the Lever Sign Test. Intertester reliability has received little attention in previous studies. In order to make comparisons with other studies, the intertester reliability and validity of the Lachman and Anterior Drawer Tests were also calculated. PATIENTS/MATERIAL AND METHODS: Patients between 18 and 50 years of age with suspected ligament and/or meniscus injuries were included. Exclusion criteria were suspected malignant, systemic, or central neurologic disease, acute cartilage injury, suspected fracture, or knowledge of the participant's knee findings. Testing was randomized and blinded by an experienced orthopaedic surgeon and a physical therapist. Cohen's kappa was calculated for intertester reliability. Sensitivity and specificity, positive and negative predictive value, and positive and negative likelihood ratio were calculated. MRI findings were used as the gold standard. RESULTS: Thirty-six patients were enrolled in the study, 27 male (75%) and 9 female (25%). The prevalence of anterior cruciate ligament lesions was 44.4%. Cohen's kappa (κ) was κ=0.6 (CI 95% [0.29, 0.91]) for the Lever Sign Test, κ=0.64 (CI 95% [0.35, 0.93]) for the Lachman test, and κ=0.63 (CI 95% [0.3, 0.95]) for the Anterior Drawer Test. The sensitivity of the Lever Sign Test was 0.53 and 0.40 for the orthopaedic surgeon and physical therapist, respectively, specificity was 0.89 and 0.79, the positive predictive value was 0.80 and 0.60, the negative predictive value was 0.70 and 0.62, the positive likelihood ratio was 4.80 and 1.90, respectively, and the negative likelihood ratio was 0.76 and 0.53. CONCLUSION: The estimated intertester reliability of the Lever Sign Test was good. The Lever Sign Test is suitable as a complement to the Lachman Test, which is considered the most valid test in the literature. The weaknesses and ambiguities of the operating mechanism of the Lever Sign Test should not be ignored and should be further explored.

Clavicular hook plate versus dog-bone technique for acute high-grade acromioclavicular joint dislocation: a retrospective cohort study comparing clinical outcome scores, complications, and costs.

INTRODUCTION: Arthroscopically assisted coracoclavicular (CC) ligament fixation techniques have been promoted as providing superior outcomes for the treatment of acute high-grade acromioclavicular joint (ACJ) dislocations. Nevertheless, there is a lack of high-level evidence for clinically relevant benefits. At our institute, orthopaedic surgeons use an arthroscopically assisted coracoclavicular ligament fixation technique (DB), while general trauma surgeons use a clavicular hook plate (cHP) technique. The aim of the study was to compare clinical outcomes, complication rates, and costs between the two groups. MATERIALS AND METHODS: The hospital database was searched for patients treated for acute traumatic high-grade (Rockwood Typ ≥ III) ACJ dislocation using either a cHP or arthroscopically assisted DB technique between 2010 and 2019. Seventy-nine patients could be included (56 patients in the cHP group and 23 in the DB group). QuickDASH scores, subjective shoulder value (SSV) scores, pain scores (numerical pain rating scale 10), and complication rates were retrospectively collected through phone interviews and by screening patient charts as well as surgical reports. Costs per patient were obtained from the hospital's accounting system. RESULTS: Mean follow-up was 54 ± 33.7 and 45 ± 21.7 months in the cHP and DB group, respectively. QuickDASH and SSV scores did not differ, but patients in the cHP group reported significantly lower pain scores (p = 0.033). More patients reported hypertrophic or disturbing scars (p = 0.49) and sensibility disturbances (p = 0.007) in the cHP group. Three patients suffered from a frozen shoulder in the DB group (p = 0.023). CONCLUSION: Patient-reported outcomes are excellent after long-term follow-up for both techniques. There are no clinically relevant differences in clinical outcome scores based on our results and a review of the literature. Both techniques certainly have their benefits regarding secondary outcome measures. LEVEL OF CLINICAL EVIDENCE: Level 3, retrospective cohort study.

A new circle method for measuring humeral torsion on MRI-scans less sensitive to Hill-Sachs lesions.

Objectives: The literature on humeral torsion angles (retrotorsion) reveals great inconsistencies between methodology and values. Decreased retrotorsion was suspected to correlate with instability, but evidence is contradictory. The measurement according to the gold standard method of Bernageau and Godefroy (B&G) can be challenging especially in the presence of Hill-Sachs-lesions. Therefore, we have developed and evaluated a new measurement method for the humeral torsion angle on MRI-scans. Materials and Methods: Three investigators have measured 67 patients (35 with shoulder instability, 32 healthy) on axial MRIs with 603 measurements used for reliability calculation. The new Circle-method determines the retrotorsion by overlaying two circles on the transversal section of the humeral head. The first circle is adjusted congruent with the margin of the humeral head, whereas the second circle is adjusted to the greater tubercle. The line bisecting the centres of these circles is defined as the humeral head axis. This method was compared to B&G. Results: The mean retrotorsion angle of all patients was 25°± 25° (mean ± SD) with B&G, and 24° ± 27° with the Circle-method. Neither method revealed a significant difference between stable and unstable shoulders (p = 0.47). Of the 35 patients with unstable shoulders 21 (60%) presented Hill-Sachs lesions. No significant differences between patients with or without Hill-Sachs lesions (Circle-method: p = 0.61; B&G: p = 0.67). The reliability parameters for both methods were similar. Conclusions: The new Circle-method is as precise as the method of B&G. It may yield more consistent values in cases with substantial Hill-Sachs-lesions. Our data do not suggest retrotorsion as a predictor of instability.

Shoulder arthroplasty for proximal humeral fracture treatment: a retrospective functional outcome analysis.

PURPOSE: Following proximal humeral fractures hemiarthroplasty (HA) or reversed total shoulder arthroplasty (rTSA) are performed if osteosynthesis or conservative treatment is not possible. HA has been reported to result in decreased functional outcomes compared with rTSA. Secondary shoulder arthroplasty, performed after a different initial treatment, has also been associated with inferior outcomes. METHODS: Patients recieving a shoulder arthroplasty related to a proximal humeral fracture from 2010 to 2019 were included. A retrospective analysis of functional outcomes was performed using QuickDASH and subjective shoulder value (SSV). RESULTS: The mean [standard deviation (SD)] follow-up time among the 82 included patients was 48 (28) months. The mean age was 70 (10) years. The mean age for HA was significantly different from rTSA [57 (9) and 72 (21) years; p < .001]. The mean QuickDASH score for primary arthroplasty was 11 (2) versus 12 (16) for secondary arthroplasty (p = .313). The mean SSV for primary arthroplasty was 84 (22) versus 82 (17) for secondary arthroplasty (p = .578). The mean QuickDASH score for HA was 24 (36) versus 9 (15) for rTSA (p = .346). The mean SSV for HA was 70 (34) versus 86 (17) for rTSA (p = .578). CONCLUSION: Functional outcomes after fracture-related shoulder arthroplasty were excellent in an older population, even when performed secondarily after failed primary osteosynthesis or conservative treatment. No significant differences in shoulder function were identified between rTSA and HA, likely due to restrictive indications for HA.

Proximal humeral fracture-dislocation: Outcome analysis in osteosynthesis and arthroplasties.

PURPOSE: Proximal humeral fracture-dislocations (PHFD) are challenging to treat. In older patients, usually arthroplasty is performed. In younger patients, osteosynthesis is chosen. This study presents functional outcomes of these different treatment modalities. METHODS: All patients operated for PHFD from 2010 until 2017 were included. Osteosynthesis was performed in younger patients and if reconstruction was possible. Either an open deltopectoral approach or a minimal invasive plate osteosynthesis (MIPO) was performed. Hemiarthroplasty (HA) was done if reconstruction of the tubercles was possible, age was below 63 years and no signs of osteoarthritis were present. In all other cases, a reverse total shoulder arthroplasty (rTSA) was done. The primary endpoint was functional outcome assessed with the QuickDASH Score (QDS). Secondary outcomes were subjective shoulder value (SSV), complications, revisions, and conversion into arthroplasty. RESULTS: The mean follow-up of 40 patients was 56 ± 24 months. The mean QDS was 4.5 (0.6-9.1) and the mean SSV was 90 (80-98.6). Of these, 33 patients (mean age: 50) had an osteosynthesis, 25 were treated with MIPO. Only 18% were converted into an arthroplasty after a mean of 22 months. Among them, 7 patients received a primary arthroplasty (mean age: 68), no revisions were recorded. Subgroup analysis showed functional outcome deficits in avascular necrosis (AVN) compared to no AVN (p = 0.021), revision surgery compared to no revision (p = 0.040) and in HA compared to rTSA (p = 0.007). CONCLUSION: Both osteosynthesis and primary arthroplasty after PHFD can lead to good or even excellent functional outcome. Revision rates in osteosynthesis are high. Revision procedures or secondary conversion into arthroplasty after failed osteosynthesis decrease outcome scores significantly.

Concept for Minimally Invasive Hook Plate Stabilisation of the Acromioclavicular Joint.

AIMS: Despite the availability of various operative procedures, hook plates are still one of the main implants used for the treatment of acromioclavicular (AC) joint dislocation. The aim of this report is to present a novel minimally invasive operation technique for AC hook plate fixation. The functional outcomes of patients operated upon with this technique are presented. PATIENTS AND METHODS: A retrospective analysis was performed for 5 patients who were operated upon with minimally invasive hook plate fixation. The QuickDASH score (QDS) and subjective shoulder value (SSV) were used to express functional outcomes, and the numeric rating scale (NRS) was used to evaluate pain. RESULTS: The mean (SD) follow-up was 30±7 months. Patients were hospitalized for a mean of 3±1 days and operated upon for a mean of 54±7 minutes. Functional outcomes measured with the QDS showed a median (IQR) of 2.3 (0 - 6.8) and a median SSV relative to the healthy side of 95% (89 - 100). The median NRS was 0 (0 - 0). CONCLUSION: Minimally invasive hook plate fixation for acromioclavicular joint dislocation led to excellent functional outcome scores without complications in a small case series of 5 patients.

Seven-year course of asymptomatic acromioclavicular osteoarthritis diagnosed by MRI.

BACKGROUND: Asymptomatic acromioclavicular osteoarthritis (AC-OA) is a frequent finding in shoulder magnetic resonance imaging (MRI). Its natural course is unknown. Therefore, the question arises whether a resection should be performed simultaneously with shoulder surgery for another reason to prevent future pain and reoperation. The purpose of this study was to investigate the mid-term course of asymptomatic AC-OA. METHODS: Overall, 114 asymptomatic AC-OA diagnosed on MRI were followed for 7 years between 2011 and 2018. At baseline, MRI signal enhancement in the clavicle and acromion, OA grade, physical demand as well as the parameters (1) Constant Score Visual Analogue Scale, (2) pain on AC-joint compression, and (3) cross-body adduction test were measured. All patients were followed up after 7 years by interview, and in case of symptoms by clinical examination. The endpoint "deterioration" was reached if 2 of the 3 parameters turned worse. RESULTS: Asymptomatic AC-OA remained asymptomatic in 83% of cases, 7% turned better, 10% turned worse. Physical demand and osteoarthritis grade increased the risk of deterioration, whereas MRI signal enhancement in the clavicle or acromion had no influence on outcome. During follow-up, the frequency of pain on AC-joint compression increased from 11% to 16% (P = .24), the frequency of a positive cross-body adduction test increased from 6% to 20% (P = .017), and the mean Constant Score Visual Analogue Scale increased from 10 to 13 points (P < .001) indicating less pain. CONCLUSIONS: Asymptomatic AC-OA remained asymptomatic in 90% over 7 years. A simultaneous resection of an asymptomatic AC-OA during shoulder surgery for another reason is not indicated in every patient.

Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome.

BACKGROUND: Locking plates for open reduction-internal fixation (ORIF) of proximal humeral fractures are widely used. We observed an unusually high number of patients with complications referred to our institution. It was the purpose of this study to report these complications, as well as their treatment and outcome. MATERIALS AND METHODS: From 2003 to 2010, all patients treated for complications after ORIF with locking plates for proximal humeral fractures were prospectively collected and retrospectively analyzed. Patients were followed up clinically and radiographically. RESULTS: In total, 121 patients (67 women and 54 men; mean age, 59 years) were referred after primary locking plate ORIF; 80% had a 3- or 4-part fracture. A mean of 3 complications occurred per patient, including malreduction, primary screw cutout, malunion, nonunion, avascular necrosis, and infection. Secondary screw cutout was found in 57% of patients, causing glenoid destruction in 33% of patients. A mean of 1.5 revision surgeries were needed. Hemiarthroplasty, total shoulder arthroplasty, and reverse shoulder arthroplasty improved the mean Constant score (24 to 55 points, P < .05; 29 to 54 points, P = .3; and 25 to 48 points, P < .05, respectively) after a mean of 24 months. In 6 patients, glenoid implantation was no longer possible because of the destruction by perforated head screws. CONCLUSION: In this negatively selected series, complications resulted in secondary arthroplasties in over 50% of the patients. Shoulder function, though improved, remained substantially restricted even after revision surgery. Glenoid destruction by locking screws was the most devastating and previously almost unseen complication, which limited the options of treatment.

Proximal anterior cruciate ligament tears: the healing response technique versus conservative treatment.

The healing response technique (HRT) is a nonreconstructive method to promote healing in proximal anterior cruciate ligament (ACL) tears. The study reviews clinical and radiological long-term results. Thirty patients (average age 31 years) were treated according to the protocol described by Steadman et al. For comparison, an age- and gender-matched control group of conservatively treated patients (CST; n = 127) was selected. At follow-up (mean: 4 years), all patients were evaluated using Kneelax-3-arthrometer, magnetic resonance imaging (MRI), and by clinical examination. Two HRT patients were lost to follow-up and 10 (36%) patients needed definitive ACL reconstruction. The rate of secondary ACL reconstruction in the initial CST group was 56% (71 of 127). Nineteen of the conservatively treated patients were selected according to above-mentioned criteria. The average Lysholm score in the HRT group was 91 (CST group = 90), and the Orthopaedische Arbeitsgemeinschaft Knie score was 93 (CST group = 92). Tegner score decreased from 6.8 before injury to 5.7 at the time of follow-up (CST group: 6.0 to 5.1). Kneelax-3-arthrometer showed a significant higher anterior knee laxity compared with the noninjured side in both groups. MRI showed improvement of the ACL in both groups. HRT in adult patients is associated with a high revision rate of 36% secondary ACL reconstruction, comparable with primary conservative treatment (p = 0.056). For the remaining patients (64%), HRT did not result in better outcomes than conservative treatment.

Magnetic resonance histologic correlation in rotator cuff tendons.

PURPOSE: To relate histologic changes in rotator cuff tendons to the appearance on T1-weighted as well as fat-suppressed T2-weighted and proton density-weighted magnetic resonance imaging (MRI) sequences. MATERIALS AND METHODS: T1-weighted, fat-suppressed T2-weighted and fat-suppressed proton density-weighted sequences of 18 cadaveric shoulders were acquired. The supraspinatus, infraspinatus, and subscapularis tendons were evaluated histologically. Twenty-six abnormalities were found in 23 of 37 tendons. In addition, histologically normal tendon parts (n = 32), including three segments with normal histology but abnormal MR signal, considered to represent magic angle effects, were defined. All regions of interest (ROIs) were evaluated by two musculoskeletal radiologists independently and blinded to histology. RESULTS: In the 26 areas with anatomically intact tendons but abnormal histological findings mucoid degeneration (n = 13), chondroid metaplasia (n = 11), fatty infiltration (n = 1), and foreign-body granuloma (n = 1) after tendon suture were found. Compared to normal tendon, mucoid degeneration was hyperintense on T2-weighted fat-suppressed (P = 0.007) and on proton density-weighted fat-suppressed images (P = 0.006). Chondroid metaplasia was hyperintense compared to normal tendon in all sequences (P < 0.05). Mucoid degeneration was hypointense compared to chondroid metaplasia on T2-weighted fat-suppressed images (P = 0.038) and hypointense compared to magic angle artifacts on T1-weighted images (P = 0.046). CONCLUSION: Chondroid metaplasia of rotator cuff tendons appears to be more common than expected. Both mucoid degeneration and chondroid metaplasia may explain increased tendon signal on MR images of the rotator cuff.

Degeneration of the long biceps tendon: comparison of MRI with gross anatomy and histology.

OBJECTIVE: The objective of our study was to relate alterations in biceps tendon diameter and signal on MR images to gross anatomy and histology. MATERIALS AND METHODS: T1-weighted, T2-weighted fat-saturated, and proton density-weighted fat-saturated spin-echo sequences were acquired in 15 cadaveric shoulders. Biceps tendon diameter (normal, flattened, thickened, and partially or completely torn) and signal intensity (compared with bone, fat, muscle, and joint fluid) were graded by two readers independently and in a blinded fashion. The distance of tendon abnormalities from the attachment at the glenoid were noted in millimeters. MRI findings were related to gross anatomic and histologic findings. RESULTS: On the basis of gross anatomy, there were six normal, five flattened, two thickened, and two partially torn tendons. Reader 1 graded nine diameter changes correctly, missed two, and incorrectly graded four. The corresponding values for reader 2 were seven, one, and five, respectively, with kappa = 0.75. Histology showed mucoid degeneration (n = 13), lipoid degeneration (n = 7), and fatty infiltration (n = 6). At least one type of abnormality was found in each single tendon. Mucoid degeneration was hyperintense compared with fatty infiltration on T2-weighted fat-saturated images and hyperintense compared with magic-angle artifacts on proton density-weighted fat-saturated images. MRI-based localization of degeneration agreed well with histologic findings. CONCLUSION: Diameter changes are specific but not sensitive in diagnosing tendinopathy of the biceps tendon. Increased tendon signal is most typical for mucoid degeneration but should be used with care as a sign of tendon degeneration.