The arthroscopic treatment of anterior shoulder instability with glenoid bone loss shows similar clinical results after Latarjet procedure and iliac crest autograft transfer.

PURPOSE: Recurrent anterior shoulder instability caused by critical bone loss of the glenoid is a challenging condition for shoulder surgeons. The purpose of this prospective multicenter trial was to compare the arthroscopic transfer of the coracoid process (Latarjet procedure) with the arthroscopic reconstruction of the glenoid using iliac crest autografts. METHODS: A prospective multi-center trial was performed in nine orthopaedic centres in Austria, Germany and Switzerland between July 2015 and August 2021. Patients were prospectively enrolled and received either an arthroscopic Latarjet procedure or an arthroscopic iliac crest graft transfer. Standardized follow-up after 6 months and mimimum 24 months included range of motion, Western Ontario stability index (WOSI), Rowe score and subjective shoulder value (SSV). All complications were recorded. RESULTS: 177 patients (group Latarjet procedure: n = 110, group iliac crest graft: n = 67) were included in the study. WOSI (n.s.), SSV (n.s.) and Rowe score (n.s.) showed no difference at final follow-up. 10 complications were seen in group Latarjet procedure and 5 in group iliac crest graft; the frequency of complications did not differ between the two groups (n.s.). CONCLUSION: The arthrosopic Latarjet procedure and arthroscopic iliac crest graft transfer lead to comparable results regarding clinical scores, frequency of recurrent dislocations and complication rates. LEVEL OF EVIDENCE: Level II.

Functional improvements in active elevation, external rotation, and internal rotation after reverse total shoulder arthroplasty with isolated latissimus dorsi transfer: surgical technique and midterm follow-up.

HYPOTHESIS: This study investigated the hypothesis that reverse total shoulder arthroplasty (RSA) in combination with an isolated latissimus dorsi tendon (LDT) transfer in patients with pseudoparalysis of abduction and external rotation (combined loss of active elevation and external rotation [CLEER] syndrome) would demonstrate improved postoperative functional results. METHODS: This study was a retrospective single-surgeon case series of 13 consecutive patients with CLEER who underwent RSA without subscapularis repair and combined with an isolated LDT transfer. We reviewed 10 patients (77%), at a minimum of 2 years, with 3 cases lost to follow-up. Shoulder function was assessed preoperatively and postoperatively using the Constant score and postoperatively using the Oxford Shoulder Score, University of California-Los Angeles score, American Shoulder and Elbow Surgeons score, ADLEIR (activities of daily living [ADLs] requiring active external and internal rotation) score, and ADLIR (ADLs requiring active internal rotation) score. Force in internal rotation (IR) at 0° of abduction, external rotation (ER) at 0° of abduction, and ER at 90° of abduction, as well as IR in the belly-press position, was measured. RESULTS: The mean postoperative follow-up period was 57 months (range, 31-85 months). We observed improvement in the Constant score (from 29.8 ± 6.64 preoperatively to 71.9 ± 10.45 postoperatively, P < .05), as well as abduction force, ER, and forward elevation (P < .05). Postoperatively, the mean American Shoulder and Elbow Surgeons score was 95.1 ± 3.38 and the mean Oxford Shoulder Score was 46.6 ± 1.57. Mean force in IR at 0° of abduction was 5.45 ± 2.42 kg, and mean force in ER at 90° of abduction was 4 ± 1.20 kg. Mean force in ER at 0° of abduction (3.65 ± 1.24 kg) and IR in the belly-press position (4.5 ± 2.84 kg) demonstrated a positive correlation with ADLs. CONCLUSIONS: The results of this study demonstrate that RSA without subscapularis repair, combined with an isolated LDT transfer, provides improved postoperative functional outcomes for patients with CLEER while maintaining sufficiently balanced force in IR and ER to effectively perform ADLs.

Biomechanical comparison of open and arthroscopic Latarjet procedures.

PURPOSE: To biomechanically compare the effectiveness of the standard open and arthroscopic techniques of the Latarjet procedure to address a critical anterior glenoid defect in combination with a capsular insufficiency. METHODS: Translation testing of 12 human cadaveric shoulder specimens was performed in a robot-assisted setup under 3 different conditions: (1) intact/vented shoulder joint, (2) combined anterior glenoid bone and capsular defect, and (3) open and arthroscopic Latarjet procedures. Testing was performed for each condition in 2 test positions: 60° of glenohumeral abduction with neutral rotation (ABD position) and 60° of abduction and external rotation (ABER position). Each position was tested with a passive humerus load of 30 N in the anterior, inferior, and anteroinferior directions. Translational movement of the humeral head was evaluated with and without the application of a 10-N load to the conjoint tendon (CJT). RESULTS: In the ABD position, translations after the open Latarjet procedure significantly differed from the arthroscopic technique in the anterior and anteroinferior directions when testing was performed with loading of the CJTs (CJT loading). Without CJT loading, the open Latarjet technique showed significantly lower translations in the anterior, inferior (P = .004), and anteroinferior (P = .001) testing directions in the ABD position. In the ABER position, the arthroscopic procedure showed no significant difference compared with the standard open procedure. CONCLUSIONS: We found a superior stabilization effect of the open Latarjet technique in the ABD position. The difference is ascribed to the anterior capsular repair, which was performed within the open technique and omitted during the arthroscopic procedure. CLINICAL RELEVANCE: The reduction of translation in a pure abduction position of the arm is more effectively performed with a conventional open Latarjet technique that includes a capsular repair. In combined ABER position, there was no difference found between the open and arthroscopic Latarjet techniques.

Results of Arthroscopic Revision Rotator Cuff Repair for Failed Open or Arthroscopic Repair: A Prospective Multicenter Study on 100 Cases.

BACKGROUND: Retears after rotator cuff repair (RCR) have been associated with poor clinical results. Meaningful data regarding the role of arthroscopic revision RCR are sparse thus far. PURPOSE/HYPOTHESIS: To investigate results after arthroscopic revision RCR. We hypothesized that (1) arthroscopic revision RCR would lead to improved outcomes, (2) the clinical results would be dependent on tendon integrity and (3) tear pattern, tendon involvement, and repair technique would influence clinical and structural results. STUDY DESIGN: Case series; Level of evidence 4. METHODS: During a 40-month period, 100 patients who underwent arthroscopic revision RCR were prospectively enrolled in this multicenter study. Outcomes were evaluated preoperatively, at 6 months (6M), and at 24 months (24M) using the Constant score (CS), the Oxford Shoulder Score (OSS), and the Subjective Shoulder Value (SSV). Tendon integrity at 2 years was analyzed using magnetic resonance imaging. A total of 13 patients (13%) were lost to follow-up, and 14 patients (14%) had a symptomatic retear before the 24M follow-up. RESULTS: All clinical scores improved significantly during the study period (CS: preoperative, 44 ± 16; 6M, 58 ± 22; 24M, 69 ± 19 points; OSS: preoperative, 27 ± 8; 6M, 36 ± 11; 24M, 40 ± 9 points; SSV: preoperative, 43% ± 18%; 6M, 66% ± 24%; 24M, 75% ± 22%) (P < .01). At 2 years, a retear rate of 51.8% (43/83) and a surgical revision rate of 12.6% (11/87) were observed. Mean full-thickness tear size decreased from 5.00 ± 1.61 cm2 to 3.25 ± 1.92 cm2 (P = .041). Although the Sugaya score improved from 4.5 ± 0.9 to 3.7 ± 1.4 (P = .043), tendon integrity did not correlate with better outcome scores. Previous open RCR, involvement of the subscapularis, chondral lesions of Outerbridge grade ≥2, and medial cuff failure were correlated with poorer SSV scores at 2 years (P≤ .047). Patients with traumatic retears had better CS and OSS scores at 2 years (P≤ .039). CONCLUSION: Although arthroscopic revision RCR improved shoulder function, retears were frequent but usually smaller. Patients with retears, however, did not necessarily have poorer shoulder function. Patient satisfaction at 2 years was lower when primary open RCR was performed, when a subscapularis tear or osteoarthritis was present, and when the rotator cuff retear was located at the musculotendinous junction. Patients with traumatic retears showed better functional improvement after revision.

Arthroscopic reconstruction of chronic AC joint dislocations by transposition of the coracoacromial ligament augmented by the Tight Rope device: a technical note.

We present a new arthroscopic technique for chronic AC joint dislocations with coracoacromial ligament transposition and augmentation by the Tight Rope device (Arthrex, Naples, USA). First the glenohumeral joint is visualised to repair concomitant lesions, such as SLAP lesions, if needed. Once the rotator interval is opened and the coracoid is identified, the arthroscope is moved to an additional anterolateral portal. A 1.5 cm incision is made 2 cm medial to the AC joint. After drilling a 4 mm hole with a cannulated drill through the clavicle and coracoid a Tight Rope is inserted, the clavicule is reduced and stabilized with the implant. The arthroscope is moved to the subacromial space and a partial bursectomy is performed to visualise the CA ligament and lateral clavicle. The CA ligament is armed with a strong braided suture using a Lasso stitch and dissected from the undersurface of the acromion. It is then reattached to the distal part of the clavicle by transosseous suture fixation after abrasion of its undersurface. Although this combined arthroscopic procedure of AC joint augmentation with a Tight Rope combined with a ligament transposition is technically demanding, it is a safe method to reconstruct the coracoclavicular ligaments and achieve a sufficient reduction of the clavicle without the need of further implant removal or autologous tendon transplantation.

Arthroscopic release of the superior transverse ligament and SLAP refixation in a case of suprascapular nerve entrapment.

We report a case of suprascapular nerve entrapment at the suprascapular notch combined with a type II SLAP lesion resulting in supraspinatus and infraspinatus muscle weakness and shoulder pain in a 27-year-old female professional handball player. The magnetic resonance imaging scan showed significant atrophy of the supraspinatus and infraspinatus muscles. Electromyography revealed an isolated proximal lesion of the suprascapular nerve. The patient was treated by an arthroscopic release of the superior transverse ligament and repair of the type II SLAP lesion. Follow-up evaluations were performed 6 weeks, 3 months, and 6 months postoperatively. The Constant score improved from 51 to 84 points. Electromyography studies 3 and 6 months after surgery showed significant improvement with normal reinnervation of the supraspinatus and infraspinatus muscles. To our knowledge, this is the first report of proximal suprascapular nerve entrapment with coincidence of a SLAP lesion that was treated arthroscopically. On the basis of this case, we found that arthroscopic release of the superior transverse ligament is an effective procedure for decompression of the suprascapular nerve. Although it is a technically demanding procedure, the arthroscopic approach has the advantage of detecting concomitant lesions such as SLAP lesions.

The effects of valgus medial opening wedge high tibial osteotomy on articular cartilage pressure of the knee: a biomechanical study.

PURPOSE: The objective of this study was to quantify the effect of different loading axes and of a valgus opening wedge high tibial osteotomy (HTO) on tibiofemoral cartilage pressure. METHODS: Six human knee specimens were tested with a load of 1000N in extension in a materials testing machine using a specially designed fixture. Pressure in the medial and lateral joint compartment was recorded using pressure-sensitive films. Different loading alignments (varus, straight, and valgus) were simulated. A medial opening wedge HTO was performed adjusting the loading axis to slight valgus. The first measurement was performed with intact medial collateral ligament (MCL). Then the MCL was dissected gradually and the cartilage pressure again analyzed. RESULTS: There was a significant correlation of the load distribution with the position of the loading axis. The medial compartment was predominantly loaded in the varus setting. The more lateral the loading line intersected the knee, the more pressure was redistributed laterally. The opening wedge HTO without the MCL release resulted in a significant increase of the pressure medially (P = .002). Only after a complete release of the MCL was a significant decrease of pressure medially observed after opening wedge HTO (P = .003). CONCLUSIONS: The position of the loading axis in the frontal plane has a strong effect on the tibiofemoral cartilage pressure distribution of the knee. The medial compartment is predominantly loaded in a varus knee; a neutral mechanical axis slightly loads the lateral more than the medial compartment. In valgus alignment, the main load runs through the lateral compartment. CLINICAL RELEVANCE: A medial opening wedge HTO maintains high medial compartment pressure despite the fact that the loading axis has been shifted into valgus. Only after complete release of the distal fibers of the MCL does the opening wedge HTO produce a decompression of the medial joint compartment.

Arthroscopic Technique for Stabilization of Chronic Acromioclavicular Joint Instability With Coracoclavicular and Acromioclavicular Ligament Reconstruction Using a Gracilis Tendon Graft.

We present an arthroscopic technique for stabilization of chronic acromioclavicular (AC) joint instability using a transclavicular-transcoracoidal button technique, combined with a coracoclavicular and AC ligament reconstruction using the gracilis tendon. This arthroscopic technique achieves an anatomic reduction of the clavicle without further implant removal. It ensures vertical and horizontal stabilization of the AC joint. Using a horizontal drill hole through the clavicle and looping the gracilis tendon graft around the coracoid avoids weakening of the coracoid with the risk of fracture.

Subacromial spacer implantation for massive rotator cuff tears: Clinical outcome of arthroscopically treated patients.

BACKGROUND: Massive rotator cuff tears (MRCT) can be treated arthroscopically by partial reconstruction, tenotomy/tenodesis of the long head of the biceps, and debridement. A new treatment option is the additional implantation of a biodegradable spacer (InSpace Balloon®; ISB) into the subacromial space, which reduces subacromial shear forces to keep the humeral head centered in the glenoid. The aim of this study is to investigate the clinical outcome of patients with MRCT who were treated arthroscopically with or without an additional ISB. METHODS: The clinical outcome of patients treated with conventional arthroscopic techniques (n = 11, group A, partial repair, biceps tenotomy, and debridement) and that of patients treated with a supplementary ISB (n = 12, group B) was retrospectively analyzed. Preoperatively and postoperatively, shoulder function was assessed with the Constant and American Shoulder and Elbow Surgeons (ASES) scores. At follow-up after a mean of 22 months, patients filled out a questionnaire about their subjective satisfaction. RESULTS: Preoperative shoulder function was lower in patients treated with an ISB (ASES score: group A, 59.1; group B, 31.5; Constant score: group A, 60.7; group B, 36.8). At follow-up, both groups had improved shoulder function (Constant score: group A, 60.7-77.6; p < 0.001; group B, 36.8-69.5; p < 0.001; ASES score: group A, 59.1-88.6; p < 0.001; group B, 31.5-85.7; p < 0.001). Patients in both groups were subjectively satisfied with their outcome. CONCLUSION: The ISB is a feasible treatment option for MRCT, providing subjective pain relief and improved shoulder function. Further studies with larger patient collectives and longer follow-up are needed to confirm whether it is a safe and cost-effective treatment.

Biomechanical testing of distal femur osteotomy plate fixation techniques: the role of simulated physiological loading.

BACKGROUND: Implants for fracture and/or osteotomy fixation are often tested according to basic mechanical test models such as open gap tests or 4-point-bending tests. These may be suitable to test and compare different implants for safety and clinical approval, but are not always representative of the post-operative situation, which is decisive when it comes to bone healing. In the current study the Knee Expert Group of the Association for the Study of Internal Fixation has compared the available open gap test results of the latest version of the TomoFix Medial Distal Femoral Plate and the antecedent plate design, with the test results of a more physiological and life-like test model. In the open gap test model the antecedent plate design was found to have superior stiffness and fatigue strength. METHODS: In the current study simulated postoperative conditions for medial closing wedge supracondylar osteotomies were used. The constructs were subjected to cyclical axial and torsional loading and were subsequently tested to failure. RESULTS: The more life-like tests in this study showed that the latest version was either more or equally stable and stiff than the antecedent version of the plate, in all of the tests. It is argued that the difference in results between the two loading models is due to differences in test design. CONCLUSIONS: These test results stress the importance of not only using standard open gap and 4-point-bending tests, but also to use as life-like as possible test conditions for any form of biomechanical testing of new implants.

Influence of glenosphere design and material on clinical outcomes of reverse total shoulder arthroplasty.

BACKGROUND: The aim of this multicentre retrospective study was to compare reverse total shoulder arthroplasty clinical outcomes with glenospheres of different diameters, designs and materials. METHODS: Between 2003 and 2008, 133 patients were divided into three groups: 60 (45%) with 36-mm standard CoCrMo (group A), 21 (16%) with 36-mm eccentric cobalt-chromium-molybdenum (CoCrMo) (group B) and 52 (39%) with 44-mm cross-linked ultra-high molecular weight polyethylene (X-UHMWPE) (group C) glenospheres. Mean (SD) follow-up was 38.7 (17.4) months. Clinical evaluation included Constant score and range of motion. Radiographic analysis included radiolucent lines, instability, loosening and assessment of scapular notching. RESULTS: Mean Constant score significantly increased for all groups (Wilcoxon test, p < 0.001). Group C allowed a higher and stable increase in range of motion. After 12 months and 24 months, groups C and B showed less pain than group A (Mann-Whitney U-test, p < 0.05). Group C had significantly lower scapular notching than group B (Mann-Whitney U-test, p = 0.001) and A (Mann-Whitney U-test, p = 0.009) at 12 months, 24 months and 36 months. Groups A and C presented 5 (8.3%) and 4 (7.6%) early complications, respectively. CONCLUSIONS: The present study reported good results for all groups, although groups C and A presented better clinical outcomes, significantly lower notching and instability. A 44-mm X-UHMWPE glenosphere allowed a faster and more stable functional recovery, despite poorest pre-operative conditions. Additional long-term studies are needed to evaluate survivorship.

Improvements in surgical technique of valgus high tibial osteotomy.

We present four technical modifications of high tibial osteotomy which improve its safety and reproducibility. (a) Open wedge correction: opening wedge osteotomy from the medial side avoids lateral muscle detachment, dissection of the peroneal nerve, proximal fibula osteotomy, and leg shortening; only one osteotomy needs to be performed and the correction can be adapted intraoperatively. (b) Biplanar osteotomy: in addition to the transverse osteotomy of the posterior tibia a second ascending osteotomy in the coronary plane underneath the tibial tuberosity is performed. This provides improved rotational stability of the osteotomy and creates an anterior buttress against sagittal tilting of the osteotomy planes. (c) Incomplete osteotomy with plastic deformation of the tibia: 10 mm of lateral bone stock is left intact. The osteotomy is opened gradually over several minutes by sequential impaction of flat chisels or by use of a special spreading tool. Manifest fractures of the lateral cortex with resulting instability are avoided. Rapid bone healing is promoted. (d) Rigid fixation: stable osteosynthesis allows for early mobilization and avoids losses-of-correction. We use a medial plate-fixator which can be applied percutanously. In 112 patients operated on using this modified technique no pseudarthosis or loss-of-correction was observed.

Large osteochondral defects of the femoral condyle: press-fit transplantation of the posterior femoral condyle (MEGA-OATS).

BACKGROUND AND AIMS: Large osteochondral defects in the weight-bearing zone of the knee remain a challenging therapeutic problem. Surgical options include drilling, microfracturing, and transplantation of osteochondral plugs but are often insufficient for the treatment of large defects of the femoral condyle. PATIENTS AND METHODS: Large osteochondral defects of the femoral condyle (mean defect size 7.2 cm(2) range 3-20) were treated by transplantation of the autologous posterior femoral condyle. Between 1984 and 2000, 29 patients were operated on: in 22 the medial, in 6 the lateral femoral condyle, and in one the trochlear groove was grafted. Thirteen patients underwent simultaneous high tibial valgus osteotomy. In the first series (1984-1999) the graft was temporarily fixed with a screw ( n=12), but from 1999 we used a newly developed press-fit technique ( n=17) avoiding screw fixation of the graft. The operative technique comprising graft harvest, defect preparation, transplantation, and fixation is described. Patients were clinically evaluated using the Lysholm score, and magnetic resonance imaging with intravenous contrast was performed 6 and 12 weeks after surgery (mean follow-up 17.7 months (range 3-46). RESULTS: Pain and swelling were reduced in 26 patients. Three patients of the first series reported persistent problems and were subjectively not satisfied. The mean Lysholm score rose from preoperatively 52 to 77 points after 3 months, 74 after 6, 88 after 12, and 95 after 18. Magnetic resonance imaging showed good graft viability in all cases. We saw one arthrofibrosis after 6 months but noted no problems related to the loss of the missing posterior condyle. CONCLUSION: Large osteochondral defects of the femoral condyle can be treated by transplantation of the autologous posterior femoral condyle. The use of only one osteochondral piece renders better approximation of the femoral cartilage curvature and thus joint congruence than in mosaic plasty. However, whether loss of the posterior condyle has a long-term negative impact on the knee joint remains to be elucidated.