[The role of hyperlaxity in open stabilisation of post-traumatic shoulder instability]. / Der Einfluss der Hyperlaxität auf die Ergebnisse offener Stabilisierungsoperationen bei posttraumatischen Schulterinstabilitäten.

BACKGROUND: Chronic post-traumatic shoulder instabilities as well as post-traumatic shoulder instabilities in association with joint laxity are accepted reasons for open capsular shift and labral refixation. However, it remains unclear whether hyperlaxity influences clinical outcome and reluxation rates. MATERIAL AND METHOD: A total of 60 patients (48 men and 12 women) with diagnosed post-traumatic anterior glenohumeral instability were included in the study. Average follow-up was 3.6 ± 0.2 years (median 3.1 years, minimum 2 years, maximum 8 years). 37 patients (61 %) had a joint hyperlaxity grade II or more. In 77 % of the cases glenoid osseus defects were observed (< 20 % of the glenoid fossa). RESULTS: Three cases of shoulder dislocations (5 %) recurred after surgery, following a massive trauma during sports activities. One patient was excluded from the study due to other reasons. The average Rowe scores were 88.7 points. No significant differences were observed between patients with and without concomitant hyperlaxity. From 56 patients without postoperative redislocations 55.2 % had a very good, 34 % a good, and 10.3 % a satisfactory result (Rowe score). The relative constant score and force measurement values were significantly lower in hyperlax shoulders. The average loss of external rotation was 3.9 degrees with the arm at the side and 11 degrees with the arm in 90 degrees of abduction. CONCLUSION: Our study shows that hyperlaxity does not lead to a higher redislocation rate following open anatomic refixation of the capsule-labrum complex in combination with a capsular shift.

[Shoulder arthroplasty in rheumatoid arthritis]. / Schulterendoprothetik bei rheumatoider Arthritis.

The long-term survival rate of shoulder arthroplasties is comparable to that of hip arthroplasties, at about 85% after 15 years. The diagnosis of rheumatoid arthritis is the most important predictive factor for the end-result, with a stronger influence than the condition of the rotator cuff or whether a hemiarthroplasty or a total arthroplasty is performed. Unlike the situation in rheumatoid arthritis, in osteoarthritis wear and tear on the glenoid is caused mainly by medial erosion with cranial migration. The functional results are slightly better with total shoulder replacements than with hemiarthroplasties. Arthroplasty in rheumatoid patients is adversely influenced by the poor quality of the rotator cuff, which is either primarily defective or develops secondary insufficiency as a result of the underlying illness. Secondary cranial migration, i.e. secondary rotator cuff failure, occurs in up to half these patients in the long term. It is frequently followed by glenoid loosening after total shoulder arthroplasty. Nevertheless, glenoid loosening is frequently not progressive over long periods and is well tolerated by the majority of patients. Thus, the rate of glenoid revision operations in rheumatoid patients seldom exceeds 5% in mid- and long-term studies. Owing to poor bone quality, glenoid erosion after hemiarthroplasty is more frequent than in patients with osteoarthritis. In contrast to glenoid loosening, glenoid erosion is almost always painful and leads to poor results requiring surgical revision. In shoulder joints that are centred in the coronal plane and in which the rotator cuff is still intact or only moderately worn, with no more than one defective tendon, total arthroplasty should be given preference. The results achieved with humeral head surface replacement are as good as those yielded by conventional hemiarthroplasty; combination with the implantation of a glenoid is technically demanding but leads to even better results. Reverse arthroplasties should be reserved for patients over 70 years of age with complete or almost complete rotator cuff destruction. In younger patients bipolar implants should be used in preference; the functional results attained with these are admittedly limited, but unlike the reverse implants they do not involve the risk of loosening of the metaglenoid.

[Surface replacement shoulder: arthroplasty indications and limits]. / "Resurfacing" des Humeruskopfes : Indikationen und Grenzen.

Surface replacement arthroplasty of the shoulder offers the ability to restore anatomy and biomechanics of the glenohumeral joint, if sufficient humeral bone stock of at least 60% of the humeral head is preserved and no severe deformity is present. The implantation following the individual anatomy helps to avoid complications such as prosthetic malpositioning and periprosthetic fractures. While the use of a glenoid component is technically demanding, revision to a stem prosthesis is relatively easy because of bone stock preservation. Indications for humeral head resurfacing are osteoarthritis (OA), rheumatoid arthritis (RA), avascular necrosis stages 2-4, and stable forms of cuff tear arthropathy (CTA). Published results for OA and RA are comparable to those obtained with modern modular stem prostheses; the use in CTA appears promising under "limited goals criteria."

[Imaging in evaluating rotator cuff tears]. / Bildgebende Verfahren bei Rotatorenmanschettendefekten der Schulter.

Diagnostic imaging in a patient with shoulder pain should be used only after a comprehensive clinical evaluation of the shoulder. X-ray and ultrasonography are the basic diagnostic tools; computed tomography and magnetic resonance imaging (MRI) should be used only with certain indications. Ultrasonography and MRI have comparable accuracy for identifying and measuring full-thickness rotator cuff tears, but the accuracy for identifying partial-thickness still needs to be improved. MR arthrography has significantly improved sensitivity and specificity for partial-thickness tears of the cuff. Only ultrasound provides a real-time examination tool during shoulder movements. Moreover, dynamic ultrasonography can assess the contraction patterns of the supraspinatus and infraspinatus muscles, which may improve decision making in the treatment of shoulder diseases. In depicting fatty atrophy of the supraspinatus and infraspinatus muscles, MRI remains the reference standard. MRI should not be used as a diagnostic screening tool in patients with chronic shoulder pain because it does not appear to significantly affect treatment or outcome.

[Ultrasound evaluation of the acromioclavicular joint--a correlation of anatomical and sonographical findings]. / Sonometrie des Akromioklavikulargelenkes--Korrelation anatomischer und sonographischer Befunde.

AIM: To compare ultrasound imaging to the anatomy of the acromioclavicular joint. METHODS: 13 cadaveric acromioclavicular joints were examined by ultrasound (11 MHz linear array transducer) to determine the limits of the joint capsule and the width of the joint space. The results were compared to macroscopic sections. RESULTS: Anatomical variations were observed. The joint space of one specimen was completely filled by fibrous tissue, leaving 12 specimens for a complete study. A hypoechoic meniscoid disc was attached to the superior joint capsule, resulting in a convex curvature of the cranial part. The mean sonographic width of the joint space was 3.9 mm +/- 1.7 mm standard deviation (SD). The mean distance of the joint capsule from the articular bone rim of the clavicle, the acromion, and from the middle of the joint space was 1.1 +/- 1.0 mm, 1.3 +/- 0.7 mm, and 2.1 +/- 0.9 mm, respectively. The distance from the joint space to the capsular insertion on the clavicle and on the acromion was 4.4 +/- 1.4 mm and 5.3 +/- 2 mm, respectively. The mean difference between ultrasound and anatomical measurements in the vertical (cranio-caudal) plane was 0.5 +/- 0.5 mm (SD), whereas the mean difference between measurements in the horinzontal (medio-lateral) plane was 1.3 +/- 1.1 mm (SD). CONCLUSION: Due to low cost, safety and wide availability, sonography is suited for the evaluation of the acromioclavicular joint. However, when interpreting the results, errors in measuring, limitations in resolution of the system used, and the anatomy of the acromioclavicular joint and its anatomical variants have to be taken into consideration.

[Ultrasound evaluation of the acromioclavicular joint. A comparison with magnetic resonance imaging]. / Wertigkeit der Ultraschalldiagnostik des Acromioclaviculargelenks. Ein Vergleich mit kernspintomografischen Messungen.

INTRODUCTION: Ultrasound is useful in detecting acromioclavicular pathologies in cases of trauma, inflammations and degenerative changes in sports medicine. Many studies compare joint space and capsular dimensions of symptomatic and asymptomatic patients. However, no study has examined the reproducibility and reliability of these measurements. The aim of this study was to evaluate the reliability of ultrasonographic measurements in assessing the acromioclavicular joint. MATERIALS AND METHODS: 27 acromioclavicular joints of 15 healthy subjects were examined by T1 weighted magnetic resonance imaging (MRI) to determine the normal limits of joint space (a) and joint capsule (b). These measurements were compared to standardised ultrasonographic (11 Mhz) measurements, which were repeated three times. RESULTS: The mean difference between MRI and ultrasound measurements was 1.5 +/- 1.3 mm and 1.3 +/- 1.2 mm for distance a and b, respectively. Reproducibility of ultrasonographic measurements was high with a mean standard deviation of 0.3 +/- 0.2 mm and 0.4 +/- 0.3 mm for distance a and b, respectively. CONCLUSION: Due to low costs, safety and wide availability ultrasonography is suited for the evaluation of the acromiocalvicular joint. However, when interpreting the results measurement errors, limitations in resolution of the system used, and the anatomy of the acromioclavicular joint and its anatomic variants have to be taken into consideration.

[Efficacy of home exercises for symptomatic rotator cuff tears in correlation to the size of the defect]. / Effektivität der Physiotherapie in Eigenregie bei Rotatorenmanschettendefekten.

AIM: Although the outcome of surgical treatment of rotator cuff tears is well documented in the literature, less is known about the efficacy of home exercises for symptomatic rotator cuff tears in correlation to the size of the defect. METHODS: A series of 30 patients (38 shoulders) with rotator cuff tears seen by ultrasonography were included in this prospective study. Rotator cuff tears were divided into partial defects (group A), full thickness tears of the supraspinatus tendon (group B), and massive rotator cuff defects (group C). Treatment consisted of a home program of stretching and strengthening exercises that were performed by the patients daily for a period of 12 weeks and controlled by a physician every 2 weeks. Range of motion, a modified constant score, and impingement signs at initial examination and after 12 weeks were compared. RESULTS: All groups experienced improvement in range of motion. The Constant scores improved significantly (p < 0.05) in all groups (A: 13.0 [+/- 7.9 SD], B: 13.2 [+/- 11.4 SD], and C: 17.5 [+/- 6.6 SD]). Impingement signs showed a downward trend in all groups. DISCUSSION: The results of this study show that patients with rotator cuff defects do benefit from simple home exercises independent from the size of the defect.

[Ultrasound diagnosis of the rotator cuff]. / Sonographie der Rotatorenmanschette.

Shoulder sonography is a well-established and standardized method to evaluate the status of the rotator cuff, the long head of the biceps, and the subacromial and subdeltoid bursae. Using high-frequency linear probes, the sensitivity in detecting total tears sized 0.5 cm and greater is > 90% and in detecting partial thickness tears of at least one-third of the cuff substance > 75% when using the dual-criteria standard. Ultrasound achieves comparable or better results than native magnetic resonance tomography at far less cost. False results can be excluded in the majority of cases by strict adherence to a dual-criteria model. The ability to display the joint's soft tissue structures in real time is unique up to now. The limits of sonography are (1) in the estimation of tear size in global tears as retraction of tendon stumps under the acromion cannot be visualized and (2) in the evaluation of status of rotator cuff muscles since volumetric information about atrophy can be gained by ultrasonography, but a differentiation between simple atrophy and fatty degeneration is not possible.

[Ultrasound diagnosis of the acromioclavicular joint]. / Sonographie des Akromioklavikulargelenks.

Although standardized sonographic techniques are available, the diagnostic capabilities of sonography in diseases and injuries of the acromioclavicular [AC] joint are not yet widely used. Nevertheless, standardized sonographic techniques are available for examining injuries and diseases of the AC joint. Analogous to X-ray techniques, the bony relations of the clavicle and the acromion can be displayed. Joint effusions and marginal alterations of the subchondral bone plate can be imaged. However, there is no reliable method to display the articular disc and the coracoclavicular ligaments. There is no reproducible method for displaying the articular disk. Tears of the deltoid and trapezius muscles and their common fascia are easily detectable in high-grade injuries of the AC joint. The differentiation between acjoint injuries, i.e. Rockwood II/Rockwood IV, is facilitated, which aids in therapeutic decision making. In combination with conventional X-ray examination, sonography of the AC joint can be used at low cost and is easy to learn.

[Principles of shoulder prosthesis implantation]. / Prinzipien der Schulterendoprothetik.

Patients with an intact rotator cuff and a humeral head that is centered in the glenoid fossa will benefit from both: a hemiarthroplasty and a total shoulder arthroplasty. However, the functional outcome following total shoulder arthroplasty is superior to that of hemiarthroplasty. Superior migration or mal-positioning of the humeral head in the anterior or posterior direction are generally associated with a maximum active flexion of 90 degrees and a high rate of loosening of the glenoid component. Total shoulder arthroplasty leads to superior results in patients with osteoarthritis and mal-positioning of the humeral head in the posterior direction. However, if the head can not be centralized in the glenoid fossa a significant risk of glenoid loosening remains. A superior functional outcome of total shoulder arthroplasty in patients with rheumatoid arthritis can be observed. On the other hand inferior bone quality and a rotator cuff might lead to loosening of the glenoid component. Radiographic signs of glenoid loosening are frequently observed. However, these hardly require operative revisions. If a glenoid component can not be inserted, a bipolar or inverse prosthesis might be considered an alternative.

[Management of old neglected posttraumatic acromioclavicular joint instability and arthrosis]. / Die Behandlung veralteter, posttraumatischer Akromioklavikulargelenk-instabilitäten und -arthrosen.

UNLABELLED: Resection arthroplasty of the AC joint was performed in 42 cases of osteoarthrosis and residual instability of traumatic origin including 26 shoulders with horizontal instability of more than half of the width of the clavicula and lesions of the deltotrapezoid fascial complex (Rockwood type II: 7; type III: 9; type IV: 17; type V: 9). 23 cases were treated with a sole Weaver-Dunn procedure. 26 cases with horizontal instability and lesions of the deltotrapezoid fascia (Rockwood IV and V type) were treated in 7 cases with the standard Weaver-Dunn procedure and in 19 cases with a modified Weaver-Dunn procedure in combination with a coracoclavicular (3 x 1) and acromio-clavicular (1 x 1) 1 mm PDS string augmentation and double breasting fascioplasty of the deltotrapezoid complex. RESULTS: Successful results (in Patte-Score) after a minimum follow-up of 2 years (mean: 32 months) were reached in 88.4% of cases with only Weaver/Dunn procedure with a significant difference of good and excellent results in the horizontally stable group (93.8%) versus the horizontally unstable group (57.2%). In the group with horizontal instability and Weaver-Dunn procedure and complex additional stabilization with fascioplasty and PDS augmentation, 89.5% excellent and good results were found. CONCLUSION: Cases with horizontal instability (type Rockwood IV and V) seem to be over-represented among patients with failed conservative treatment. Resection arthroplasty with ligament transposition after Weaver/Dunn gives excellent results in posttraumatic osteoarthrosis with mainly vertical and moderate horizontal instability. In cases with advanced horizontal instability after Rockwood IV and V injuries, almost equal results can be reached by an additional coracoclavicular and acriomioclavicular PDS augmentation with deltotapezoid fascioplasty.

[Biomechanics of injury of the cervical spine]. / Beschleunigungsverletzung der Halswirbelsäule.

Whiplash injuries of the cervical spine are of special medical and socio-economic importance. Biomechanical studies of the injury have proven, that a hypertranslation of the capito-cervical region takes place first, leading to ligamentous hyperdistension and ruptures, when exceeding elastic deformation, thus possibly resulting in mechanical disturbance and rotatory malpositioning. Diagnosis of so called "functional disorders" bears difficulties concerning objective tests for structural lesions. This demands the definition of diagnostic parameters and clinical signs, which also consider vegetative phenomena. This paper aims at a systematic clinical and radiological check. Adequate therapeutic means have to be concordant to prognosis. Therefore functional parameters should already determine differential diagnosis. This is based on technical feasibilities and needs future scientific efforts.

Treatment of old neglected dislocations of the AC-joint with residual instability and/or secondary osteoarthrosis.

Resection arthroplasty of the AC joint was performed in 42 cases of osteoarthrosis and residual instability of traumatic origin including 26 shoulders with horizontal instability of more than half of the width of the clacicula and lesions of the deltotrapezoid fascial complex (Rockwood type II: 7; type III: 9; type IV: 17; type V: 9). 23 cases were treated with a sole Weaver-Dunn procedure. 26 cases with horizontal instability and lesions of the deltotrapezoid fascia (Rockwood IV and V type) were treated in 7 cases with the standard Weaver-Dunn procedure and in 19 cases with a modified Weaver-Dunn procedure in combination with a coracoclavicular (3 × 1) and acromio-clavicular (1 × 1) 1 mm PDS string augmentation and double breasting fascioplasty of the deltotrapezoid complex. RESULTS: Successful results (in Patte-Score) after a minimum follow-up of 2 years (mean: 32 months) were reached in 88,4 % of cases with only Weaver/Dunn procedure with a significant difference of good and excellent results in the horizontally stable group (93.8 %) versus the horizontally unstable group (57.2 %). In the group with horizontal instability and Weaver-Dunn procedure and complex additional stabilization with fascioplasty and PDS augmentation, 89,5 % excellent and good results were found. CONCLUSION: Cases with horizontal instability (type Rockwood IV and V) seem to be overrepresented among patients with failed conservative treatment. Resection arthroplasty with ligament transposition after Weaver/Dunn gives excellent results in posttraumatic osteoarthrosis with mainly vertical and moderate horizontal instability. In cases with advanced horizontal instability after Rockwood IV and V injuries, almost equal results can be reached by an additional coracoclavicular and acriomioclavicular PDS augmentation with deltotapezoid fascioplasty.

[Results of surgical therapy of ruptures of the rotator cuff of the shoulder]. / Ergebnisse der operativen Therapie von Rupturen der Rotatorenmanschette der Schulter.

OBJECTIVE: This retrospective study was designed to evaluate mid-term results of patients after surgical treatment of rotator-cuff-tears by means of clinical and ultrasonographical examination with special regard to factors influencing the prognosis. METHOD: 126 patients were examined clinically and ultrasonographically at a mean postoperative period of 37 months after surgery for rotator cuff lesions. A conservative therapy failed to be successful for at least 3 months before. All patients received an open decompression of the subacromial space, 68.6% of the patients received an additional reconstruction of the rotator cuff. The results were evaluated by use of the Constant-Score. The ultrasonographical examination was performed according to the technique described by Hedtmann. RESULTS: 69% of the patients showed good and excellent results. The mean Constant-Score was 81.4% of the age- and sex-related normal values. Patients with lesions extending more than 3 cm did significantly worse than those with smaller ruptures (Constant-Score: 74.2% vs. 90.6%). An involvement of the subscapularis-tendon was related with bad results. A rerupture was seen ultrasonographically in 17.3% of the patients. CONCLUSION: Regarding strict criteria of evaluation almost 70% of our patients not responding to conservative treatment achieved good and excellent results after surgery. Smaller lesions and tears solely involving the supraspinatus-tendon were associated with a better prognosis. Ultrasonography allows a reliable examination of the rotator-cuff-anatomy postoperatively performed, too.

[Ultrasonography of the shoulder in subacromial syndromes with disorders and injuries of the rotator cuff]. / Schultersonographie bei Subakromialsyndromen mit Erkrankungen und Verletzungen der Rotatorenmanschette.

Shoulder sonography was performed prospectively in 4172 patients with 4588 shoulders affected with pathology of the subacromial space, among them 1227 operated cases with 425 rotator cuff tears (292 total tears and 133 partial tears). A two-criterion model with formal as well as echogenic and dynamic criteria was used for the diagnosis of cuff tears. The overall sensitivity in diagnosing rotator cuff tears was 95.3% (97.3% in total tears and 91.0% in partial tears). False-negative results were found overall in 1.6% of cases. Overall accuracy for all defects was 94.9%. Involvement of the supraspinatus tendon was found in 95.8%, of the infraspinatus in 39.3% and of the subscapularis in 10.1%. In 33.6% of cases, involvement of the long head of biceps was found. It was clearly correlated with the size of the tears: 25.9% in isolated supraspinatus tears and 68.8% in three-tendon tears of subscapularis, supraspinatus and infraspinatus. Differentiation between fresh, traumatic tears and degenerative tears is possible by means of measuring retraction, determining the length of the distal cuff stump and by formal criteria of the stump configuration as well as by bursal criteria. Differentiation of old tears of suspected traumatic origin from those with degenerative causes is impossible.

[The so-called post-discotomy syndrome--failure of intervertebral disk surgery?]. / Das sog. Postdiskotomiesyndrom--Fehlschläge der Bandscheibenoperation?

The Post-discectomy-Syndrome (PDS) is a clinical entity with various components from individual disposition, sequelae of the underlying disc degeneration and of the operation, as well. These include local back pain, persisting (poly-)radicular pain and facet irritation with pseudoradicular irradiation due to segmental instability, epidural scarring and local arachnoiditis. Diagnosis has to focus on separation from failed-back-surgery-syndromes (FBSS) with single components like insufficient discal or bony decompression or segmental instability. Arachnoiditis seems to be the least modifiable factor and should be excluded if fusion or revision of the spinal canal is planned. A 100 point-score for grading of PDS is presented.

[Chemonucleolysis using chymopapain and collagenase. 3-year results of a prospective randomized study]. / Chemonukleolyse mit Chymopapain und Kollagenase. 3-Jahres-Ergebnisse einer prospektiv-randomisierten Studie.

100 patients were prospectively and randomized treated by chemonucleolysis either by collagenase (n = 50/400 ABC-U/disc) or by chymopapain (n = 50/4000 I.U.). The success rate after 1 year was 70% for collagenase and 78% after chymopapain, and 72%/80% after 3 years, respectively. Successful results increased significantly during the first year after treatment and remained stable after that point. After chymopapain, one case of successfully treated anaphylaxis (2%) occurred. After collagenase, 3 cases of secondary sequestrations were observed in cases with primarily closed discograms with intact dorsal longitudinal ligament.

[Experimental studies of change in the center of rotation of the moveable segment after intervertebral disk removal]. / Experimentelle Untersuchungen zur Drehpunktveränderung des Bewegungssegmentes nach Bandscheibenausräumung.

The in vitro effect of nucleus pulposus removal from human lumbar FSU's was investigated in a special test apparatus. Instability was determined by ROM, loss of disc height and displacement of the center of rotation. Disc height showed a decrease of 3.2 mm under axial load (700N). ROM increased up to 70%. The center of rotation demonstrated a distinct displacement in extension and lateral bending.