Mid-term results of a stemless ceramic on polyethylene shoulder prosthesis - A prospective multicentre study.

INTRODUCTION: Early reports of stemless shoulder arthroplasty have shown promising clinical and radiological outcomes. The purpose of this study was to report on the mid-term results of an implant that utilises a ceramic humeral head. METHODS: A prospective, consecutive, multicentre study of stemless shoulder prosthesis with a minimum of four years of follow-up was conducted between August 2009 and May 2012. The adjusted Constant-Murley Score (CMS), revision rate and presence of radiolucent lines were recorded at intervals. RESULTS: A total of 207 patients were eligible for study inclusion; 62.8% were female and mean age was 64.8 years (range 30-86). Mean follow-up was 70.7 months (range 48-100), 73% underwent TSA and 27% hemiarthroplasty. The mean CMS improvement was 42.6 (p < 0.0001) at 48 months. Radiolucencies were present in 2.7% of humeral zones and 14% of glenoid zones at 48-month follow-up. The revision rate was 6.3% with rotator cuff failure (2.9%) the most common indication. CONCLUSIONS: Mid-term results demonstrate that the studied stemless implant with a ceramic humeral head had clinical and radiological outcomes that are comparable to other reported studies.

Evaluation of a new baseplate in reverse total shoulder arthroplasty - comparison of biomechanical testing of stability with roentgenological follow up criteria.

BACKGROUND AND PURPOSE: To minimize notching problem associated with reversed prostheses, inferior positioning of base plate is recommended. This reduces the risk of notching, but does not eliminate it completely. Both polyethylene/PE-induced osteolysis and implant-to-bone or implant-to-implant contact may still occur, contributing to the risk of screw-breakage and resulting long-term failure. Therefore, the stability and integration of a newly developed base plate without inferior screw and inversion of bearing materials was investigated. PATIENTS AND METHODS: Biomechanical assessment of primary stability of the two types of glenoid baseplate (1- and 2-pegged) was carried out according to ASTM F-2028-02 (American Society for Testing and Materials). Patients with a follow-up period of at least 2 years were clinically (n=78) and for most of them radiologically (n=61) examined. The X-rays were evaluated for loosening and scapular notching. RESULTS: The mean values of micromotions after 100,000 cycles showed no relevant differences between the 2-peg and the 1-peg base plates (47 µm for the 2-peg design and 43 µm for the 1-peg design), i.e. both were below the borderline for secure Osseointegration of 150 µm. Radiologically, no signs of loosening or radiolucent lines/RLL were found for both base plates. The mean incidence of inferior scapular notching was 23.6% (42 mm glenoid sphere: 15.8%). Only grade 1 and grade 2 notching was observed. Additionally as result of absence of PE-induced osteolysis shape, size, borderline and location of notching differed from those observed with conventional reverse total shoulder arthroplasty bearing materials. CONCLUSION: In combination with modified inferior operating technique, the newly designed implant has the potential to reduce the incidence of scapular notching and to avoid both PE-induced osteolysis and metal-screw contact. The new design did not compromise stability of the base plate in any way during the investigation period, as demonstrated both by the data from the biomechanical investigation and also by the radiological follow-up. LEVEL OF EVIDENCE: Level III, case-control study.

[Survival rate and complications of stemmed shoulder prostheses in primary osteoarthritis]. / Standzeiten und Komplikationen der Schaftendoprothesen bei Omarthrose.

Survivorship and survival rate of shoulder prostheses can be affected by a large number of possible complications. An evaluation of the current literature and the prosthesis register, however, shows an overall low revision (1.39 revisions per 100 observation years) and loosening rates (implant-related 10-year survival rate up to 99%), comparable to that of hip and knee endoprostheses. It must be emphasized that cementless stems more often cause problems than cemented components (4.34 compared to 0.77 revisions per 100 observation years) and that secondary rotator cuff rupture (4.6%; functional deficit up to 30%) occurs more frequently than was generally assumed and is often not diagnosed or treated adequately. The infection rate amounts to approximately 1% and according to latest literature the dislocation rate is regressive and is estimated to be approximately 5%.The low complication and revision rates do not justify the replacement of stemmed prostheses by stemless implants and short stem prostheses and the preference given to the new implants is attributed more to the better revision possibilities and easier convertibility into inverse prostheses.

[Traumatic rupture of the pectoralis major tendon--a case report]. / Traumatische Ruptur des Musculus pectoralis major--ein Fallbericht.

A 49-year-old male athlete sustained a complete rupture of the pectoralis major muscle while bench pressing. The inferior and the superior border of the clavicular lamina and the sternal lamina were fixed with mattress sutures. After that transosseous reinsertion via drill holes (no suture anchors). The lateral rim of both tendons was fixed with Mason-Allen sutures. Final adaption of the distal tendon stump above the reinserted tendon (doubling). Postoperative immobilisation for 3 weeks in Gilchrists sling was followed by active-assistive step-by-step mobilisation. A speedy rehabilitation was planned after 6 weeks, but at this time the patient was doing strength training, swimming, pull-ups and press-ups at his own responsibility. Normal mobility and previous sports activity were achieved in spite of the early and extremely high stress. We assume that the very strong and secure reinsertion technique with 4 mattress sutures, Mason-Allen sutures and doubling of the tendon close to the foot print region may be the reason for the good result in spite of the massive and early loading.

[Medium-term results of anatomic straight-shaft IMAGE implantation in primary hip joint endoprosthetics--a prospective study]. / Mittelfristige Ergebnisse nach Implantation des anatomisch geformten Geradschafts IMAGE im Rahmen der primären Hüftendoprothetik--eine prospektive Studie.

AIM: The IMAGE prosthesis was developed with the objective of proximal load induction to avoid stress shielding and proximal bone resorption. In this study patients were followed clinically and radiologically with a special emphasis on osteointegration of the shaft in the proximal and distal regions. In addition, the reconstruction of the bony geometry of the proximal humerus was investigated. METHOD: 95 consecutive patients (mean age: 61.1 years) with an IMAGE shaft were followed up prospectively over five years after primary hip arthroplasty. Radiologically, the osteointegration was appraised on the basis of the parameters cortical bone hypertrophy, radiolucent lines, shaft sintering and the position of the rotational centre. The clinical parameters assessed were the Harris hip score (HSS) and the WOMAC score. RESULTS: In Dorr C configuration no distal cortical bone hypertrophy was visible, in contrast to 19% in types A and B. By means of this criterion in 81% of the cases, a metaphyseal anchoring can be assumed. In 20% of the cases proximal and in 11.1% distal radiolucent lines were found. In only 3.3 % of the patients were the radiolucent lines due to unwanted distal osteointegration. In most cases the reasons were PE wear and metallosis. In 18.8% a distal anchoring was visible. Sintering (in total 18 prostheses) was greatest in Dorr C configuration and high-grade osteoporosis. The difference in offset reconstruction was 4.23 mm on average. In reconstruction of the rotational centre the variability was between 2.0 and 6.9 mm. 94.13 points were attained in the HHS and 10.13 points in the WOMAC score. Specific complications related to the implantation were not observed. CONCLUSIONS: Proximal stress transmission can be supported and the danger of stress shielding can be reduced by means of an appropriate design of a prosthetic stem. Distal corticoid hypertrophy was found in only 19% of the patients with the prosthesis model investigated as compared to 60% having prostheses with distal femoral anchoring. The medium-term clinical results are excellent, so that the shaft appears suitable for primary as well as secondary osteoarthritis of the hip joint.

[Manifestation of generalized osteoarthritis in a genealogically investigated population]. / Manifestation der generalisierten Osteoarthrose in einer genealogisch überprüften Patientengruppe.

BACKGROUND: The definition of generalized osteoarthritis in the literature is just as controversial as the discussion about correlations between GOA and Heberden's nodes (HN). Therefore, both questions were investigated in patients with proven heredity in a genealogical study of 931 family members. MATERIAL AND METHODS: In 106 patients with HN and 109 control subjects, 70 joints and spinal segments were investigated with respect to characteristic functional parameters. In addition, 44 joints and spinal segments were investigated radiologically. RESULTS: GOA affects both the small and large joints as well as the spine. This phenomenon is the more pronounced the more finger joints are affected by Heberden's and Bouchard's nodes. CONCLUSIONS: GOA affects the entire musculoskeletal system. The varying manifestation in individual joints and spinal segments is probably attributable to multifactorial local and systemic factors. In an earlier study, a genetic disposition with a maximum HA prevalence of 30% was identified in the study population. Since HA is considered a genetic marker for GOA, it can be assumed that the same is true of GOA prevalence.

[Establishing the differential indication for anatomical and reversed shoulder endoprostheses in rheumatoid arthritis]. / Zur Differenzialindikation anatomischer und inverser Schulterendoprothesen bei chronischer Polyarthritis.

BACKGROUND: In addition to joint destruction, there is often also a loss of rotator cuff function in rheumatism patients. Thus, joint replacement alone using an anatomical prosthesis is unable to achieve satisfactory results. A half-linked inverse prosthesis, on the other hand, achieves improved function even in the presence of non-functioning rotator cuffs. PATIENTS AND METHODS: Of 157 shoulder prostheses that were followed up, 21 had been implanted in patients with rheumatoid arthritis. An anatomical endoprosthesis was implanted in 15 cases and an inversed endoprosthesis in six cases (average age 55.5/66.6 years). RESULTS: The Constant score improved from 23 to 65 points for the anatomical prosthesis and from 15 to 67 points for the inversed endoprosthesis. An analogous improvement was also noted for mobility, strength and pain relief. CONCLUSION: The results of anatomical prostheses depend substantially on the extent of damage to the rotator cuff. Implantation of a semi-constrained inversed prosthesis provides a solution for severely damaged joints since it has a fixed centre of rotation. One prerequisite of success, however, is a sufficient bone stock in the glenoid region. The indication for bipolar prostheses, in contrast, is particularly strong when implantation of an inverse prosthesis is no longer possible.

[Differential indication of anatomic and reversed shoulder prostheses in fracture sequelae]. / Differenzialindikation anatomischer und inverser Schulterendoprothesen in der sekundären Frakturprothetik.

AIM: Results of shoulder replacement in fracture sequelae are not satisfying. This is due to an insufficient function of the rotator cuff, mostly because of a secondary necrosis of the tubercles. The aim of this study was to investigate if the differentiated use of anatomic and reversed prostheses in dependence of the preoperative anatomic situation is able to optimise the results. METHOD: The aim of this study was a comparison of 55 patients with secondary trauma prostheses in fracture sequelae. In 36 cases (especially fracture sequelae types 1 and 2 according to Boileau), anatomic head prostheses (Affinis, FU 24 months) and in 19 cases (especially fracture sequelae types 3 and 4 according to Boileau), inversed prostheses (Delta III, FU 18.3 months) were implanted. RESULTS: The Constant score of the patients with fracture sequelae types 1 and 2 according to Boileau and Walch improved from 19 to 68 on average (anatomic prosthesis), and for types 3 and 4 from 9 to 47.5 (inversed prosthesis). For these special indications, fracture sequelae types 3 and 4 show remarkably better results than those with an anatomic head prosthesis mentioned in literature. The preoperative score of the collective of patients we examined was 10 points less than the one in comparable publications. The postoperative improvement is therefore clearly more significant. CONCLUSION: The differentiated indication of anatomic and reversed shoulder prostheses in fracture sequelae leads to a noticeable improvement of the postoperative results. In slight malformations (fracture sequelae types 1 and 2) the anatomic prosthesis is the better choice. For severe deformations (fracture sequelae types 3 and 4) however, the implantation of a reversed prosthesis is the more convincing intervention. Moreover, the differentiated indication allows for a better prediction of the expected result.

[Reconstruction of the rotational centre of the humeral head depending on the prosthetic design]. / Rekonstruktion des Humeruskopfdrehpunktes in Abhängigkeit vom Prothesendesign.

AIM: The displacement of the rotation centre of the humeral head in relation to the axis of the shaft varies strongly between individuals. The Affinis shoulder endoprosthesis has a double excentric adjustment possibility that permits us to adapt the head to the medial and dorsal offset. So far, such examinations have taken place exclusively on anatomic preparations. This raises the question of whether the need for such a prosthetic system can be derived from the anatomic variation of the pivot points. METHOD: In 49 patients with an implanted Affinis shoulder prostheses, we calculated the individual rotation centres of the head from the position of the relocatable prosthetic cone and the excentric position of the head. In addition, we used the Constant score to record the clinical function. RESULTS: In the examined case material, we needed the entire setting range of 12 mm mediolateral and 6 mm dorsoventral of the prosthesis, as it presented a great variation of the rotational centres of the head. The majority of the head centres were displaced in a posterior-lateral direction. The examination showed that none of the found anatomic head centres could have been reconstructed exactly with a conventional prosthesis. Prostheses with a single excentricity would allow correct adjustment in only 9 cases, as the adjustable rotational centres of the head are situated in an orbit, which limits the setting possibilities. In 20 of the 49 patients humeral head prosthesis were implanted in cases of primary osteoarthritis. The Constant score of this group improved from 18 points preoperatively to 76 points after 24.1 months in the mean. CONCLUSION: The high variation of the head centres indicates the necessity of a freely adjustable system, such as in a double excentric bearing. This is a way that permits an optimal reconstruction of the anatomic conditions. Therefore all technical chances for bony balancing should be used to adapt the prosthesis to the bone and not the bone to the prosthesis.

Investigations in generalized osteoarthritis. Part 2: special histological features in generalized osteoarthritis (histological investigations in Heberden's nodes using a histological score).

OBJECTIVE: In accordance with the literature, our previous epidemiological, clinical and genetical investigations have confirmed a correlation between generalized osteoarthritis (GOA) and Heberden's nodes. Heberden's nodes can be considered as genetic markers for the existence of a generalized osteoarthritic predisposition. The present study's concern was to establish whether there are special histological features in this disease. METHODS: Layered sections of 218 distal finger joints from 56 deceased persons were investigated using a histological-histochemical score modified by Mankin. RESULTS: In Heberden's nodes, we found all the typical degradative sequences of the osteoarthritic process but also some specific modifications. The osteoarthritis (OA) starts with a subchondral ossification and manifests a reactive tidemark flaking. At this time, the surface of the cartilage is not yet destroyed. Later on, there is progression of general degradation. Significant differentiation from the control group is possible using a histological score. CONCLUSIONS: In patients with Heberden's nodes, the OA starts with the subchondral ossification. Heberden's nodes are the specific manifestation of GOA in the distal finger joints. Further studies are therefore required to assess whether the same pathogenetic mechanism can be seen in OA of the large joints in GOA.

Investigations in generalized osteoarthritis. Part 1: genetic study of Heberden's nodes.

OBJECTIVE: Until the current molecular genetic investigations, all available data concerning the genetic predisposition to Heberden's nodes are based on a single investigation by Stecher in the 1940s. There is controversy in the literature about the correlation between Heberden's nodes and generalized osteoarthritis (GOA). Our own epidemiological and clinical investigations support this correlation. Therefore, the question arises as to whether the remarkable inheritance described by Stecher is correct and whether Heberden's nodes can indeed be used as a genetic marker for GOA. METHODS: From our clinical trial on 106 patients with Heberden's arthritis, we could identify 88 families from index cases. Altogether, we included 931 family members over a maximum of four generations. First of all, the genealogical trees of the families were established. Subsequently, we examined the patients' hands in respect of Heberden's nodes and completed the genealogical trees during home visits. RESULTS: In the 88 families analyzed, 152 patients with manifest Heberden's arthritis were listed (26 males, 126 females). The genealogical analysis of 156 descendants (74 males, 82 females) of 93 patients with Heberden's nodes suggests autosomal dominant inheritance. In view of the age-related manifestation and age pattern of the descendants, we postulate a heterozygous manifestation for women (dominant gene action) and only a homozygous manifestation for men (recessive gene action). CONCLUSIONS: The genealogic analysis does not contrast with the quite remarkable inheritance described by Stecher but rather supports the hypothesis that manifestation is dominant in females and recessive in males. From our point of view, this heredity does not contradict latest genetic assays which show the possibility of genetic defects causing the hereditary osteoarthritis (OA).

[Latissimus dorsi transfer in case of irreparable rotator cuff tear--a comparative analysis of primary and failed rotator cuff surgery, in dependence of deficiency grade and additional lesions]. / Latissimus-dorsi-Plastik zur Versorgung irreparabler Rotatorenmanschettenmassendefekte--Eine vergleichende Analyse nach primärer und sekundärer Rekonstruktion in Abhängigkeit vom Ausmass des Rotatorendefektes und zusätzlicher Läsionen.

AIM: Latissimus dorsi transfer is a difficult operation with a long rehabilitation. We investigated if it is worth the effort. METHOD: We used this technique in 22 patients with an inoperable rotator cuff tear (15 patients had a primary surgery, 7 patients were operated after failed prior rotator cuff repair). Additional lesions were also considered in the analysis. The average follow up was 9 months. The results were divided in 4 groups: severe indication, primary reconstruction, 3-tendon rupture, secondary reconstruction. RESULTS: The best results were achieved by the group "severe indication" (raising in the Constant score from 38 to 79 points). The group with primary surgery (increasing from 43 to 67 points) had better results than the group with failed prior reconstruction (increasing from 33 to 62 points). In case of additional rupture of the subscapularis tendon (45 to 58 points) or insufficiency of the deltoid muscle (33 to 45 points) the results are not satisfactory. The postoperative pain relief was felt as the predominant improvement. CONCLUSION: The latissimus dorsi transfer is a valuable and safely reproducible procedure. Depending on the preoperative grade of deficiency it is possible to achieve a shoulder function of 60-90 % in comparison to the healthy shoulder. Despite the difficult operation technique and the long rehabilitation phase, the LDP is worth the effort on patients with irreparable rotator cuff tears. It is not the right procedure in cases of defect arthropathy--in these cases inverted shoulder prosthesis should be used.

[Examination of Heberden arthrosis with a histological-histochemical score]. / Untersuchungen zur Heberden-Arthrose mittels eines histologisch-histochemischen Scores.

QUESTIONS: In case of Heberden's nodes the osteoarthritis starts with a so called tidemark flaking as a reaction to a subchondral ossification. The question was, if a differentiation in relation to a control group by an objective score is possible. METHODS: 218 finger joints from 56 cadavers were investigated morphologically (score). RESULTS: The osteoarthritis starts with a subchondral ossification. At this time the surface of the cartilage is not destroyed yet. Reactive tidemark flaking is the beginning of the general degradation. In relation to a control group a significant differentiation by a histological score is possible. CONCLUSIONS: In case of Heberden's nodes the osteoarthritis starts with the subchondral ossification. Because Heberden's nodes are the specific manifestation of the Generalized Osteoarthritis on the distal finger joints, further studies have to assess, if the same pathogenetic mechanism can be seen in osteoarthritis of the large joints.

[Correlation between degenerative changes of the thoracic spine and the finger joints--a roentgenological study in generalized osteoarthrosis]. / Zur Beziehung zwischen den degenerativen Veränderungen an der Halswirbelsäule und den Fingergelenken--eine röntgenologische Untersuchung bei der Generalisierten Osteoarthrose.

PURPOSE: Different studies in patients with rheumatoid arthritis demonstrated a correlation between degenerative changes of the cervical spine and peripheral joints. The aim of study therefore was to assess the relations of degenerative changes of the cervical spine and peripheral joints. METHODS: 106 patients suffering on Generalized Osteoarthritis were examined by standard radiography of the hands and cervical spine. All images were evaluated according to Kellgren grades. The mean values of the cervical spine and finger joints were compared in three calculations, for this purpose the finger joints were "segmental", "functional" and randomized arranged. RESULTS AND CONCLUSIONS: Concerning quality and quantity the highest correlation was observed in the group of the so-called "segmental-arrangement". Therefore a association between the cervical spine and the finger joints seems possible relating to manifestation, pattern and graduation of degenerative processes. At this stage there is no statement possible about the direction of the correlation.

[Functional compensation of complete axillary paralysis. A case report]. / Funktionelle Kompensation einer kompletten Axillarisparese. Ein Fallbericht.

Two patients with complete paralysis of the axillary nerve are reported on. One case is well documented. In both cases there was very good functional adaptation, resulting from hypertrophy of the rotator cuff so that there was only a slight or no loss of movement. The rotator cuff should therefore be exercised at an early stage when there is isolated axillary nerve damage. The function of the supraspinous muscle is also discussed.

Essay in the classification of morning and evening types of activity in the light of the daily course of autonomically influenced body functions.

The present study is an attempt for an objective classification of types of activity by determining the daily periodicity of autonomically influenced body functions. On the basis of a questionnaire, the 23 probands of the test group were classified into morning types (7), evening types (11) and indifferent types (5). Then, for a period of 12h from 07(00) to 18(00), 17 different autonomically influenced parameters were recorded and their mean daily courses calculated separately for the probands of the morning and of the evening type. A comparison of the synchronous values showed that the greatest differences occur between the types at 10(00) and 17(00). At these times of the day, a multidimensional variance and discrimination analysis was carried out which resulted in a very good discrimination of the probands at 10(00) and in a satisfactory one at 17(00). At the same time, an evaluation of the individual parameters recorded was carried out according to their informative value. The most important parameters proved to be the vibration threshold, the R wave height, T wave height, peak time of the pupillogram and d.c. resistance of the skin. On the basis of these results, the classification of 10 probands of an independent test group was effected by a discrimination analysis. In 7 cases this resulted in an agreement with the classification according to the questionnaire.