Reverse shoulder arthroplasty for type 1 sequelae of a fracture of the proximal humerus

Aims

The aim of this study was to analyze the results of reverse shoulder arthroplasty (RSA) in patients with type 1 sequelae of a fracture of the proximal humerus in association with rotator cuff deficiency or severe stiffness of the shoulder.

Patients and Methods

A total of 38 patients were included: 28 women and ten men. Their mean age at the time of arthroplasty was 73 years (54 to 91). Before the RSA, 18 patients had been treated with open reduction and internal fixation following a fracture. A total of 22 patients had a rotator cuff tear and 11 had severe stiffness of the shoulder with < 0° of external rotation. The mean follow-up was 4.3 years (1.5 to 10). The Constant score and the range of movement of the shoulder were recorded preoperatively and at final follow-up. Preoperatively, radiographs in two planes were performed, as well as CT or arthro-CT scans; radiographs were also performed at final follow-up.

Results

The mean Constant score improved from 25 points (5 to 47) preoperatively to 57 points (15 to 81) postoperatively. The mean forward elevation of the shoulder increased from 73° (10° to 130°) preoperatively to 117° (15° to 170°) postoperatively. Previous surgery did not influence the outcome. Patients with rotator cuff tears had lower Constant scores than patients without (p = 0.037). Those with preoperative stiffness of the shoulder had lower postoperative external rotation compared with patients without stiffness (p = 0.046). There was no radiographic evidence of loosening. Three complications occurred, leading to revision surgery in two patients. In all, 17 patients rated their result as very good (45%), another 17 as good (45%), two as satisfactory (5%), and two as unsatisfactory (5%).

Discussion

RSA is an effective form of treatment for patients with type 1 sequelae of a fracture of the proximal humerus associated with rotator cuff deficiency or stiffness of the shoulder, with high rates of satisfaction. Rotator cuff tears and stiffness of the shoulder had an adverse effect on the clinical outcome. Cite this article: Bone Joint J 2018;100-B:318–23.

[Structural damage after shoulder dislocation and development of surgical treatment from a historical perspective]

In the nineteenth century there was a high incidence of habitual shoulder instability caused by epileptic seizures and accompanied by therapeutic dilettantism, which led to socioeconomic problems in the working population. In the preradiography era the pathomechanism of shoulder dislocation was only known on the basis of cadaver studies and autopsy findings. The underlying structural disorders of habitual shoulder instability in the Bismarck era were published by Malgaigne, Broca and Hartmann. In1898 the first surgical reconstructive stabilization procedure for habitual shoulder dislocation was performed by Wilhelm Müller in Rostock. At the beginning of the twentieth century Perthes introduced the anatomical reconstruction of the capsulolabral complex, which was copied in the English speaking area by Bankart. Surgical wrong tracks through extra-anatomical procedures, capsulorrhaphy and tendon transfer, were followed by bone block procedures according to Eden-Hybinette and a modification of this procedure by Lange. In the French speaking area Latarjet introduced the transfer of the coracoid process in the middle of the 1950s, which brought the advantage of simultaneous dynamic stabilization to bony augmentation of the glenoidacetabulum .

[Instability pattern of acromioclavicular joint dislocations type Rockwood III: relevance of horizontal instability]

BACKGROUND

There is no evidence-based treatment algorithm established for acromioclavicular joint (AC joint) dislocation classified as type Rockwood III injury. Recent meta-analyses revealed no advantage of surgical treatment compared to the non-operative approach. Both surgical and non-surgical approaches have been reported with inconsistent results. Therefore, the hypothesis of the current study was that patients classified as having Rockwood grade III injury may have different degrees of horizontal AC joint instability.

MATERIAL AND METHODS

A total of 18 consecutive patients who had sustained a dislocation of the AC joint classified as Rockwood III were evaluated radiologically to quantify the horizontal instability of the AC joint. The specific radiological investigation included lateral stress x-rays (Alexander view) und axial stress x-rays with the affected arm in a horizontal adduction position.

RESULTS

The dynamic horizontal instability of the AC joint was found to be independent of the vertical dislocation measured in the Rockwood classification.

CONCLUSION

For further treatment studies Rockwood III injuries should be distinguished in patients presenting with or without a substantial horizontal AC joint instability.

[Nerve compression syndrome of the shoulder : Arthroscopic decompression procedures]

Several nerve compression syndromes have been described in the literature involving compression of the axillary nerve in the quadrangular space and most importantly compression of the suprascapular nerve in the suprascapular as well as the spinoglenoid notch. This article describes the arthroscopic techniques of nerve decompression around the shoulder.

[Update on shoulder surgery 2010: current treatment strategies for traumatic lesions of the shoulder]

The article summarizes the basic literature findings and innovations in the treatment of traumatic shoulder lesions published during the last 3 years. It covers trends in acromioclavicular joint dislocation, traumatic shoulder instability, rotator cuff tears as well as fractures of the humeral head. In particular prospective clinical studies with a high level of evidence are cited, which concern about the outcome of surgical and non-surgical treatment methods and the optimal point for treatment. The aim of this review is therefore to provide direct implications for the clinical treatment algorithm of such lesions.

Osteochondral autologous transplantation for the treatment of full-thickness cartilage defects of the shoulder

We describe the outcome at a mean follow-up of 8.75 years (7.6 to 9.8) of seven patients who had undergone osteochondral autologous transplantation for full-thickness cartilage defects of the shoulder between 1998 and 2000. These patients have been described previously at a mean of 32.6 months when eight were included. One patient has been lost to follow-up. The outcome was assessed by the Constant shoulder score and the Lysholm knee score to assess any donor-site morbidity. Standard radiographs and MR scores were obtained and compared with the pre-operative findings and the results from the previous review.

No patient required any further surgery on the shoulder. The mean Constant score improved significantly until the final follow-up (p = 0.018). The Lysholm score remained excellent throughout. There was a significant progression of osteoarthritic changes from the initial surgery to the first and final follow-up but this did not appear to be related to the size of the defect, the number of cylinders required or the Constant score (p = 0.016). MRI showed that all except one patient had a congruent joint surface at the defect with full bony integration of all osteochondral cylinders.

The results have remained satisfactory over a longer period with very good objective and subjective findings.

[Arthrodesis of the shoulder. A new and soft-tissue-sparing technique with a deep locking plate in the supraspinatus fossa]

Arthrodesis of the glenohumeral joint is a difficult intervention that involves a relatively high probability of complications. A stable internal fixation and secure consolidation is required. The operation needs to achieve several conditions: thorough denudation of the cartilage and partial decortication of the subchondral bone; good congruence of the corresponding surfaces; compression of the gap by tension screws and lasting stability. For increased primary stability a neutralizing plate is generally used as well as a compression screw. Up to now, the plate has usually been applied starting from the scapular spine and extending across the acromial corner to the humeral shaft. A wide exposure is needed for this procedure; the plate is difficult to shape during the operation and often causes some discomfort because it protrudes at the acromial corner. We present an alternative position of the plate in the supraspinatus fossa, where we have sited a 4.5 mm LCP locking plate (Synthes). The implant is inserted under the acromion, does not cause any discomfort at the acromial corner, and is far easier to shape. When it is used in association with a transarticular compressive screw, the technique results in a very stable situation, which allows physiotherapy from the first day after surgery onward.

Magnetresonanztomographische Untersuchung des Musculus subscapularis nach offener vorderer Schulterstabilisierung

PURPOSE

Analysis of the magnetic resonance imaging of the subscapularis musculotendinous unit (SSC) after primary and revision open shoulder stabilization and their correlation with the clinical function.

MATERIALS AND METHODS

In a retrospective cohort study, 13 patients (mean age of group A: 36.5 years) after primary and 12 (mean age of group B: 34.2 years) after revision open stabilization underwent postoperative MRI of the shoulder. The digital data was analyzed with respect to the vertical und transverse diameters (V[slashed circle], T[slashed circle]) in a defined image slice. A signal intensity analysis was performed (infraspinatus/subscapularis signal-to-noise ratio = ISP/SSC SNR). The clinical examination included the SSC tests and signs and the Constant and Rowe score. Twelve healthy volunteers (group C) served as the control.

RESULTS

From group C to group B, the mean V[slashed circle] of the SSC decreased significantly (p < 0.05) as did the mean T[slashed circle] of the cranial part of the SSC muscle (= crSSC) (p < 0.05). The mean T[slashed circle] of the caudal part of the SSC muscle (= caSSC) did not differ significantly between all groups (p > 0.05). The ISP-SSC SNR was significantly lower (p < 0.05) in the crSSC of groups A und B than in group C. In the caSSC, the SNR increased in groups A and B. In 53.8 % of group A and 92.3 % of group B, clinical signs of SSC insufficiency were found. There was no significant difference between the Constant and the Rowe score in both groups (p > 0.05). Complete tendon ruptures were not observed in any case.

CONCLUSIONS

MRI enables semi-quantitative analysis of the postoperative changes of the subscapularis muscle. The decrease of the ISP/SSC SNR points to a fatty degeneration in the crSSC. The results provide indications of the causes of the clinical dysfunction of the subscapularis musculotendinous unit after open shoulder stabilization.

Three-dimensional glenoid deformity in patients with osteoarthritis: a radiographic analysis

BACKGROUND

In osteoarthritis of the shoulder, the tilt of the glenoid surface undergoes an eccentric deformation not only in the anteroposterior but also in the superoinferior direction. The goals of this study were to analyze glenoid version in the coronal plane and to clarify the relationship between retroversion and inferior inclination of the glenoid.

METHODS

Standardized radiographs of 100 consecutive patients with primary osteoarthritis of the shoulder and 100 otherwise healthy patients with shoulder pain (the control group) were included in this study and were analyzed by two independent observers.

RESULTS

We defined four different types of inclination deformity of the glenoid. In a type-0 glenoid, a line at the base of the coracoid process and a line at the glenoid rim run parallel. Both lines intersect below the inferior glenoid rim in a type-1 glenoid. In a type-2 glenoid, the line at the base of the coracoid process and the glenoid line intersect between the inferior glenoid rim and the center of the glenoid. In a type-3 glenoid, the lines intersect above the base of the coracoid process. A significant difference (p < 0.0001) in the distribution of glenoid types between the two patient groups was observed. Forty-seven patients with osteoarthritis showed combined posterior and inferior glenoid wear. We found no correlation between the type of inclination and the type of glenoid morphology. The interobserver reliability of our observations was very high.

CONCLUSIONS

In osteoarthritis, eccentric inferior glenoid wear is frequent and independent from retroversion deformity of the glenoid. Normalization of glenoid version in both transverse and coronal planes may reduce eccentric loading of the prosthetic glenoid, which has been associated with loosening.

Transfer of the tendon of latissimus dorsi for the treatment of massive tears of the rotator cuff: a new single-incision technique

We describe 14 patients who underwent transfer of latissimus dorsi using a new technique through a single-incision. Their mean age was 61 years (47 to 76) and the mean follow-up was 32 months (19 to 42). The mean Constant score improved from 46.5 to 74.6 points. The mean active flexion increased from 119 degrees to 170 degrees , mean abduction from 118 degrees to 169 degrees and mean external rotation from 19 degrees to 33 degrees . The Hornblower sign remained positive in three patients (23%) as did the external rotation lag sign also in three patients (23%). No patient had a positive drop-arm sign at follow-up. No significant difference was noted between the mean pre- and postoperative acromiohumeral distance as seen on radiographs. An increased grade of osteoarthritis was found in three patients (23%). Electromyographic analysis showed activity of the transferred muscle in all patients.

Intra-articular volume assessment in glenohumeral instability

It is commonly claimed that instability of the shoulder is associated with an enlarged joint volume. The purpose of our study was to assess the intra-articular volume in acute and chronic glenohumeral dislocation. Sixty-seven patients were examined by intra-articular infusion of saline solution. Three groups could be formed. Group 1 (n = 51) consisted of patients with first time traumatic dislocation, group 2 (n = 8) of cases with recurrent post-traumatic dislocation. The patients of group 3 (n = 8) suffered from impingement syndrome and served as the control group. The joint volume was correlated to the body surface area (BSA). We found a strong correlation between height, sex and intra-articular joint volume. There was no statistically significant difference in joint volume correlated to BSA between the three groups. There is no statistically significant difference in joint volume correlated to BSA in patients with traumatic anterior instability, chronic instability and individuals without glenohumeral instability.

[Traumatic anterior shoulder dislocation]

The purpose of this paper is to outline the present state of treatment for traumatic anterior shoulder dislocation. Pathoanatomic changes as well as intrinsic and extrinsic prognostic factors are discussed. Based on these, treatment options for first time traumatic dislocations and chronic posttraumatic instability are recommended.

Aktuelle klinische Untersuchung der Schulter

Successful treatment of any pathologic condition of the shoulder requires an accurate diagnosis. Physical examination represents an integral part in the assessment of shoulder disorders. Pain, loss of strength, decreased range of motion and instability are the most common symptoms that can be caused by a great variety of different shoulder pathologies. Therefore, a sophisticated clinical approach is essential. A standardized evaluation including different diagnostic tests and clinical signs improves diagnostic accuracy by specifically examining one component of the shoulder complex. In most cases a careful physical examination will establish or suggest a diagnosis and special investigative techniques such as imaging procedures can be applied more selectively for confirmation or further evaluation of the pathological entity.

Schulterendoprothetik

Shoulder arthroplasty covers an extensive indication spectrum of degenerative, inflammatory to infectious, tumorous, instability-associated and neurogenic disease to acute trauma and posttraumatic joint destruction. Each of these indications requires its own regime and an appropriate implant. Osteoarthritis is the most frequent indication, and will be used as an example for surgical management, bringing the manufacturer-nonspecific general guidelines, joint mechanics and surgical technology into agreement. The fundamentals of the technique of implantation refer to the anatomical adaptability of the third generation of shoulder prostheses, which permits an accurate reconstruction of glenohumeralen joint centring. This article also describes far-reaching principles, which are generally applicable to all indications for shoulder arthroplasty.

Osteochondral autologous transplantation for the treatment of full-thickness articular cartilage defects of the shoulder

We performed eight osteochondral autologous transplantations from the knee joint to the shoulder. All patients (six men, two women; mean age 43.1 years) were documented prospectively. In each patient the stage of the osteochondral lesion was Outerbridge grade IV with a mean size of the affected area of 150 mm2. All patients were assessed by using the Constant score for the shoulder and the Lysholm score for the knee. Standard radiographs, magnetic resonance imaging and second-look arthroscopy were used to assess the presence of glenohumeral osteoarthritis and the integrity of the grafts. After a mean of 32.6 months (8 to 47), the mean Constant score increased significantly. Magnetic resonance imaging revealed good osseointegration of the osteochondral plugs and congruent articular cartilage at the transplantation site in all but one patient. Second-look arthroscopy performed in two cases revealed a macroscopically good integration of the autograft with an intact articular surface. Osteochondral autologous transplantation in the shoulder appears to offer good clinical results for treating full-thickness osteochondral lesions of the glenohumeral joint. However, our study suggests that the development of osteoarthritis and the progression of pre-existing osteoarthritic changes cannot be altered by this technique.

Schulterinstabilit�ten

Shoulder instability includes different degrees of instability from painful hyperlaxity to subluxation to dislocation. Different classifications of shoulder instability have been created in order to facilitate decision making for treatment. None of these, however, has gained acceptance. Subject to the indications, shoulder instability can be treated conservatively or surgically after repositioning the acute dislocation. A survey of arthroscopic and open stabilization procedures and their results are given in relation to the indications.

[Diagnosis and treatment of anterior and posterior shoulder dislocation. II. Treatment]

In Part I the anatomy, biomechanics, different pathologic changes, and diagnostic tools for anterior and posterior instability were discussed. In this second part, treatment of an acute dislocation is introduced. Furthermore different surgical procedures and their indications are discussed. Algorithms for treatment of first-time dislocation, chronic anterior instability, and posterior instability are presented.

[Postoperatively recurring instability of the shoulder--a fault analysis in 46 cases]

AIM

The successful operative stabilization of the shoulder joint is a demanding surgical procedure. The causality of shoulder instability is complex with in some cases multiple lesions in different anatomical structures. The surgeon has to understand the complexity of factors causing instability in order to be therapeutically successful. The aim of the study was to document the intraoperative pathology in revision instability surgery.

METHOD

46 patients with recurrent postoperative instability were included (8 female, 38 male, follow-up > 12 months). After diagnostic arthroscopy an open revision surgery was performed in all cases.

RESULTS

In 19 cases (40%) an insufficient surgical procedure was performed (inadequate capsular shift with worn out labral tissue). Selection of an incorrect surgical technique was the reason for revision in 12 patients (25%). Anamnestically 5 patients reported a re-injury, whereas objectively only one patient described an adequate trauma. The most frequent finding was an open rotator interval (persisting Foramen Weitbrecht), which was seen in 22 cases (46%).

CONCLUSION

A stable range of motion of the shoulder is achieved by a variety of different factors, which leads in most instances to a combination of pathological changes in case of a dislocated shoulder. To understand the contributing factors of an instable shoulder joint is a necessity to carry out a successful surgical procedure.

Radiale Stoßwellentherapie der Tendinosis calcarea der Rotatorenmanschette - Eine prospektive Studie

AIM

The aim of the study is to evaluate the influence of radial shock wave therapy (RSWT) on the course of calcifying tendinitis of the rotator cuff.

MATERIAL AND METHODS

35 patients with a mean age of 47.5 years suffering from calcifying tendinitis stage Gaertner 2 with a mean size of 16.6 mm in typical location (true-ap view) for a mean of 28 months were treated by low-energy RSWT three times. The acromio-humeral distance averaged 10.4 mm measured at the true-ap view. All patients were clinically and radiologically followed-up at 4 weeks, 3, 6 and 12 months after the last treatment.

RESULTS

The Constant score improved significantly (p < 0.0001) during the first 4 weeks after RSWT from a mean of 68.5 to a mean of 80.5 points and remained approximatively constant at 3, 6 and 12 months follow-up. After 4 weeks 25.7% of the patients had no pain, 54.3% reported about pain relief. In the course of the follow-up a significant improvement of pain was observed: up to 80.8% painless and 19.2% pain relief 12 months after RSWT. Radiologically 4 weeks after RSWT the X-ray examination showed in 17.6% no calcific deposit, in 20.5% a disintegration and in 61.5% no changes of the calcific deposit. At further follow-up we found a complete resorption of the calcific deposit in 75% up to 12 months after RSWT and 25% had no change in calcific deposit. Overall three patients (8.5%) had to undergo surgical treatment 3-7 months after RSWT.

CONCLUSION

The low-energy RSWT leads within the first 4 weeks to a significant pain relief and an improvement of shoulder function. In consideration of the long history, the size and the spontaneous resorption rate of the calcific deposit, an inductive effect of RSWT on the resorption of the calcific deposit can be assumed.

Die Rekonstruktion von gro�en Rotatorenmanschettenrupturen

Tendon retraction and fatty degeneration is a major problem in repair of massive rotator cuff tears. Especially in the transosseous refixation technique, a tension-free refixation cannot be obtained in all cases. The purpose of this prospective study was to evaluate the postoperative results using a new tension-free reinsertion technique with a Corkscrew suture anchor system. Thirty patients (25 males, 5 females) with complete one and two tendon tears underwent open rotator cuff repair (rupture of one tendon: n=14, 47%). The torn tendons were mobilized and reinserted medially to reduce tension. Medialization was achieved by inserting tendon near the osteochondral border in a bony trough. The number of implanted suture anchors ranged from 2 to 6 (mean: 3.56). The mean age was 56 years (39-68 years) with a follow-up of 24 months (17-33 months). In one patient physical and sonographic examination showed a complete and in two patients a partial rerupture. A temporarily frozen shoulder occurred in two cases. No infection or rejection response was seen. In no case was revision surgery necessary. No displacement or loosening of the Corkscrew anchors was noticed. The constant score improved from 45 points preoperatively to 85 points at the time of follow-up (mean). The Corkscrew suture anchor system in combination with the new suture technique offers the possibility of a stable reinsertion even in reduced calcified bone structure. This facilitates good conditions for stable fibroblastic healing. Our midterm results show good osseous union combined with a low rerupture rate.

[Superior labrum-biceps anchor complex]

The focus in overhead sport injuries of the shoulder has been directed on lesions of the superior labrum-biceps complex during the last few years. This is due to improved imaging modalities as well as a better understanding of the anatomy and biomechanics. Arthroscopy is capable of diagnosing and treating these lesions. The anatomy, biomechanics, and operative treatment strategies and techniques are described in detail. The superior labrum anterior-posterior (SLAP) lesion is found in young active overhead athletes. Based on their classification and concomitant lesions, the unstable SLAP lesions (types II and IV) have to be repaired in order to restore stability to the superior labrum-biceps complex for stabilizing the glenohumeral joint. According to our own results and after review of the current literature, SLAP repair yields good results in overhead athletes enabling them to return to pain-free participation in their sport.

Combination of microfracture and periostal-flap for the treatment of focal full thickness articular cartilage lesions of the shoulder: a prospective study

Focal full-thickness articular cartilage lesions of the shoulder are less common than those of the lower extremity but are often symptomatic and may progress to degenerative osteoarthritis. This prospective study evaluated our clinical results for cartilage repair in five patients with chondral defects localized at the humeral head using a combination of microfracture and periostal flap, all by deltoidopectoral approach. Mean follow-up was 25.8 months (range 24-31) and consisted of a clinical examination, Constant score examination, radiography, and magnetic resonance imaging; three patients underwent a second-look arthroscopy an average of 8 months following cartilage repair. We found the Constant score significantly improved over the preoperative level, from 43.4% to 81.8%. Pain was reduced significantly to 18.6 points. Radiography and magnetic resonance imaging showed progression of the osteoarthritis in two patients. Second-look arthroscopy revealed a significantly reduced cartilage lesion. This is the first report of a combination of microfracture and a periostal flap for repair of focal full-thickness cartilage lesions at the shoulder. Short-term follow-up clinical results were satisfactory. It is essential to address the underlying pathology. Results must be reconfirmed in a long-term study.

[Intraarticular pathology of atraumatic shoulder dislocations. An arthroscopic study]

AIM OF THE STUDY

According to the literature, atraumatic shoulder dislocations occur without or only minor trauma,self-reduction and no or little pain. Little is known about intraarticular pathology in this entity. It was the purpose of our study to evaluate such findings.

METHODS

During a 2-year period,226 patients had surgery for shoulder dislocation.28 patients met the criteria for atraumatic dislocation as above (group A). Patients with bony pathology or recurrent microtrauma were excluded. All had been treated with a rehabilitation program without success.28 consecutive patients with surgery after posttraumatic dislocation served as a control group (group B). At the beginning of the surgery,arthroscopy was performed in all patients and the intraarticular findings were recorded. For the capsulo-labral pathology,we determined 3 types: type I had capsular elongation or scarring and included so called "non-Bankart-lesions"; type II had classic "Bankart"-lesions and type III more complex capsulo-labral lesions like e.g. "ALSPA"-lesions.

RESULTS

The mean age in group A was 27.6 y and 26.2 y in group B.12 patients in group A and 5 in group B were female. The average no.of dislocations was 10 (1-30) or 9 (1-28), respectively. In group A we saw type I lesions in 11 patients (39.3%), type II lesions in 9 (32.1%) and type III lesions in 8 (28.6%) patients. In group B we found type I lesions in 8 (28.6%), type II lesions in 4 (14.3%) and type III lesions in 16 (57.1%) patients.Hill-Sachs lesions were found in 22 (78.6%) and 23 (82.1%) of the patients, respectively.Also, we saw chondral glenoid damage, cuff lesions and SLAP-lesions in both groups.

CONCLUSION

The above mentioned criteria for atraumatic shoulder dislocation do not exclude intraarticular pathology comparable to posttraumatic cases, at least for patients, who do not respond to a conservative treatment. Besides the etiology, the given pathology must be considered for therapy.

[Shoulder arthroplasty - Clinical results in 171 patients]

AIM

Review and critical evaluation of 181 shoulder arthroplasties performed on 171 patients between December 1992 and January 1997.

METHOD

We performed 118 hemiarthroplasties and 63 total shoulder replacements in 171 patients with an average age of 56.5 years. The patients were examined clinically and radiologically before surgery and followed-up for an average of two years. The Constant score was used for postoperative functional assessment.

RESULTS

46 % of the patients were very satisfied and 31 % were satisfied with the outcome. We found a significant pain reduction and an improvement of active joint function. The average Constant score was 34.9 preoperatively and 65.2 postoperatively. Overall, we found the best results after joint replacement in patients treated for avascular necrosis or fracture sequelae of the humeral head. A revision surgery had to be performed in 16 patients (8.8 %).

CONCLUSION

The results of this study are encouraging and underline the growing importance of shoulder arthroplasty. The preoperative limited range of motion, previous surgeries, and the status of the rotator cuff are preoperative indicators for a favourable postoperative outcome. Preoperative planning, anatomical reconstruction, and an optimal rehabilitation programme are the keys for successful shoulder arthroplasty.

[Isolated traumatic rupture of the subscapular muscle tendon as an adolescent injury]

INTRODUCTION

Until now no case of a traumatic tear of the subascapularis muscle in children was described in the German speaking literature. Using the example of 2 cases of a 12 and 14 year boys youth history, clinic, diagnostics and therapy will be presented.

METHODS

The accident happened in extension and external rotation of the arm without dislocation. Beside the complete tear of the SCP-tendon in one case an accompanying expanded humeral flake fracture at the minor tuberosity was found. Under protection of the epiphysis line the refixation was performed using suture anchors.

RESULTS

The post-operative control after 12 months showed a complete tendon healing, no arthritis or delayed bony ingrowth with return to full activity.

CONCLUSION

Isolated traumatic SCP-tears can be occur also in young patients. As major consequence, it is necessary to perform a thorough clinical examination with additional apparative diagnostics (Sonography, MRI). This way, this rare but important lesion can be detected early and lead to adequate surgery without any delay.

[Physical activity after shoulder arthroplasty]

A hemi- or total shoulder arthroplasty was performed in 171 patients between 1992 and 1997. We examined 118 patients under the age of 70 regarding their level of physical activity. For a pre- and postoperative comparison we divided the patients in two groups. Group one included all patients with osteoarthritis, rheumatoid arthritis, instability associated arthritis, avascular necrosis and other arthropathies. Group two included acute fractures and fracture sequelae. The postoperative outcome was functionally assessed by using the Constant score. There was an average Constant score of 60,9 for group one and 67,1 for group two. Both groups showed a domination of activities with motion patterns unspecific for the shoulder. There were more patients in group two reporting activities which depend on a good or very good shoulder function. There is no general estimation for the ability to be active in sports after shoulder arthroplasty. An individual assessment of the shoulder function is essential. Important criterias beside motivation and age are the status of the rotator cuff and the soft tissue balancing. The correct indication for shoulder arthroplasty as well as the preoperative planning and the postoperative rehabilitation program are essential for a good functional outcome and the key for physical activity after shoulder arthroplasty.

[Proximal humeral head fractures--Future development of shoulderimplants]

In 1951 a shoulder prosthesis was developed for the treatment of complex humeral head fractures by Neer. The Neer-II-Prosthesis, which was developed further in 1973 represents the basis of modern shoulder implants. The unsatisfactory postoperative functional results for primary humeral head replacement required the development of new adaptable implants for the treatment of complex humeral fractures, which allow the reconstruction of humeral length, the reconstruction of center of rotation and humeral offset, the anatomic positioning, the reconstruction of retrotorsion and the secure refixation of the tuberosities. The development of third and fourth generation of humeral head prosthesis achieves a three-dimensional adaptability for the conditions of posttraumatic arthritis. Primary and secondary humeral head replacement in humeral head fractures as well as revision of prosthetic replacement are complex and technical demanding operations with high and different requirements on implants having to be realised on further development.

[Current concepts in treatment of rotator cuff tears]

The expectation of a functional shoulder joint, even in advanced age, the growing experience and success in shoulder surgery have brought the operative treatment another step further. The goal of any advanced knowledge should be a proper treatment of the patients and the pathology. Complex rotator cuff tears can be repaired by means of muscle transfer and partial reconstruction. In cases of irreparable rotator cuff tear arthropathy prosthetic replacement of the gleno-humeral joint can be performed. In this article a review on the different techniques and indications for rotator cuff repair is given.

[Arthroscopic treatment of shoulder instability]

Arthroscopic treatment of glenohumeral instability has become more common over the last years. Compared with open reconstruction which still is the gold standard in the treatment of glenohumeral instability the arthroscopic techniques show several advantages but also disadvantages that must be proved for every single case. Careful patient selection with regard of prognostic preoperative and intraoperative factors is substantial for successful treatment. When indicated using clinical, radiological and arthroscopic findings the results of arthroscopic stabilization could be improved over the last years and failure rates could be decreased.

[The macroscopic aspect of rotator cuff tears in traumatic and nontraumatic rupture cases]

The decision whether a rotator cuff tear has a traumatic or degenerative origin still causes some controversy. Especially in medical expert appraisals the etiology of the rotator cuff tear plays an important role referring to insurance services for the patient. The purpose of this paper is to compare the intraoperative pathomorphologic shape of the cuff tear in traumatic and degenerative cases. This study reports of 56 patients with rotator cuff tears which were divided in primarily acute, subacute traumatic and degenerative study groups referring to their history of present illness. We considered the location of the tear, the shape and the size. Furthermore the grade of retraction of the supraspinatus tendon, its quality and the shape of the long head of biceps were examined. The results showed that in general the shape of the tear gives only in some cases significant information whether the etiology is traumatic or not. The isolated rupture of the subscapularis muscle and the hematoma at the edge of the tendon is significant for the trauma. In comparison with the degenerative study group the tenosynovitis and the dislocation of the long head of biceps is in our study significant for traumatic tears.

[Recommendations for diagnosis and expert assessment of traumatic rotator cuff lesions]

Traumatic rotator cuff lesions are a very rare condition. However, this article represents a comprehensive survey according to current knowledge on anatomy, biomechanics, and pathogenesis of rotator cuff pathology. Because of the relatively high prevalence of degenerative changes with increasing age, including partial and complete rotator cuff tears, it may be difficult to demonstrate the causality of an acute traumatic rotator cuff tear. Therefore, a catalogue of potential adequate and inadequate trauma mechanisms is proposed. Emphasis is also placed on posttraumatic diagnostic steps following persistent rotator cuff deficient shoulder function (e.g., ultrasound, MRI). From a legal aspect (e.g., private accident insurance, workers compensation claim), different minor and major criteria are defined, which could help experts to judge the causality of posttraumatic rotator cuff deficiency. These criteria mainly refer to distinct details concerning patients' history, trauma mechanism, primary clinical appearance, and diagnostic findings.

[Rotator cuff tears: diagnosis and therapy]

Since the life span of our society is increasing and the expectation of high functional demands is growing more and more older people take part in sports activities emphasises the necessity of early diagnosis of rotator cuff lesions and their correct treatment. The goal of any diagnostic means should be a proper treatment of rotator cuff lesions according to the detected pathology. New arthroscopic techniques to surgically reconstruct rotator cuff tears have brought the operative repair techniques another step further. In cases of large and complex cuff tears the surgeon can individually select an adequate reconstruction procedure which includes anatomical-, partial-, tendon-transfer and muscle-transfer repairs. In cases of irreparable tears with cuff-tear arthropathy and consecutive superior migration of the humeral head hemiarthroplasty or the inverse deltoid prosthesis have to be considered. Based on clinical, radiological and arthroscopic findings we developed algorithms that will lead to the best suited procedure for a given lesion.

[Current status and perspectives of shoulder replacement]

Basis of the modern shoulder implants is the Neer II-system, a non constrained total shoulder prosthesis with conforming radii of curvature and improved protection against dislocation. The second generation of shoulder prosthesis is based on the geometric shaft design of the Neer II prosthesis and offers not only a variety of modular head- and shaft-sizes but also through different radii a physiologic rotation-translation-mechanism. The third generation of humeral head prosthesis carries the concept of an anatomic reconstruction one step further and enables the surgeon to adjust the inclination and the eccentric offset of the humeral head to restore the centre of rotation. The latest development in shoulder arthroplasty are humeral head prosthesis with a fully variable 3-dimensional modularity to independently adjust the prosthetic head position regardless of the individual shaft geometry. This achieves a 3-dimensional adaptability of the prosthetic head about the stem axis in the coronary and in the sagittal plane. Besides of the humeral shaft prosthesis an alternative concept of shoulder joint replacement is established - the replacement of the humeral head articular surface. A hemispheric surface prosthesis - cup arthroplasty - is cemented onto the residual humeral head, which eliminates the obligatory humeral head resection and the reaming of the medullary canal. Bipolar shoulder prosthesis are humeral shaft prosthesis with a bi-rotational head system. Their indication is limited to pre-existing lesions of the rotator cuff and/or the glenoid surface. The inverse total shoulder prosthesis reverses the articular surface morphology of the humeral head and the glenoid. The hemispheric glenoid component serves as the centre of rotation for the concave epiphyseal proximal humerus component. This implant is especially used in cases of massive rotator cuff deficiencies. The role of shoulder prosthesis in treating acute humeral head fractures needs special consideration. A fracture prosthesis has to restore the exact length of the humerus, the centre of rotation, and the anatomical retroversion. Positioning of the tubercula and their adequate osteosynthesis is most critical and fundamental to ensure a correct healing process. A failed consolidation of the tubercula does not lead to a satisfying result. The shoulder joint replacement can be sufficiently fixated in cemented, cementless or hybrid techniques. Today several component design variations of cemented glenoid implants exist. Their main distinction is the fixation system which can be divided into two main groups - the keel - and the peg-shaped glenoid components. The peg-shaped anchorage system shall guarantee a greater stability against shear-forces. Cementless glenoid components consist of a polyethylene inlay and a surface treated metal-back with an integrated fixation system. These fixation systems are object of intensive biomechanical research and range from conventional screw fixation to specialised cone systems and self-cutting cage-screw-systems. The critical area of cementless glenoid components is the transition zone of the PE-inlay and the metal-back because of high force development. The question of implanting a hemi- or total shoulder prosthesis is answered by the morphologic changes of the glenoid articular surface, which includes the size of the subchondral defect and the underlying etiology of the shoulder joint disease, and the age of the patient. Preoperative planning must consist of an adequate radiologic work-up - X-ray, CT or MRI - to accurately assess the glenoid morphology. G. Walch categorised the different glenoid lesions and developed a very important classification of possible glenoid deformations. To compare and evaluate the operative results one must consider the different shoulder prosthesis and the discrepancies between a hemi- and a total shoulder prosthetic replacement. Looking at the loosening and survival rate of the implant the results are

Evolution of lesions of the labrum-ligament complex in posttraumatic anterior shoulder instability: a prospective study

The aim of this study was to evaluate the evolution of intraarticular disease in posttraumatic shoulder instability. Ninety-one patients with posttraumatic shoulder instability were examined arthroscopically. The intraarticular disease was recorded on a special documentation sheet (containing 67 descriptive items). The patients were divided into 5 subgroups: first-time dislocation (n = 9); first or second recurrence (n = 12); 3 to 5 recurrences (n = 23); 6 or more recurrences (n = 32); and chronic subluxations (n = 15). All data were examined statistically. Each lesion was correlated with stage of evolution, age, and number of recurrences. The most frequent lesions were regrouped into "lesion families." The initial and most constant lesion was the periosteal disinsertion of the anteroinferior labrum (single lesion). The labral detachment was succeeded in a second stage by the disinsertion of the glenohumeral ligament complex (double lesion). With additional recurrences, stress mechanisms altered the detached structures through tissue damage (triple lesion). The fourth stage saw the extension of the degenerative process, which led to failure at the insertion site and destruction of the labrum-ligament complex (quadruple lesion). This study reveals that recurrences progressively damage stabilizing structures. A pathophysiological classification into 4 stages is proposed, however, that would permit a precise therapeutic strategy for arthroscopic shoulder stabilization.

[Treatment strategy in first traumatic anterior dislocation of the shoulder. Plea for a multi-stage concept of preventive initial management]

The purpose of this paper is to outline the treatment protocol for the first time traumatic anterior shoulder dislocator, with options including conservative, arthroscopic and open surgical treatment. Regarding the subclassification of the first time traumatic anterior dislocater, it is imparitive to differentiate between the unidirectional dislocator with and without hyperlaxity. This subclassification takes into account the structural quality of the stabilizing ligamentous structures of the glenohumeral capsule. The patient with hyperelastic ligaments exhibit elastic deformation of the glenohumeral ligaments at the time of dislocation and thus, sustain less interstitial structural damage to the ligament. Therefore, these patients benefit from non-operative treatment. There are extrinsic and intrinsic factors which determine the outcome of the primary traumatic anterior shoulder dislocation. Extrinsic factors are those that are not related to changes in the shoulder morphology. The most important extrinsic factor is the age of the patient at the time of injury. The younger the patient at the time of injury the greater the risk of recurrence. As a rule, those patients 25 years of age or less, at the time of initial injury are less likely to spontaneously stabilize without surgical intervention, than they are to develop recurrence. Secondly, the type and level of sport participation is related to recurrence. Although the severity of the trauma can not be quantified, it certainly has an influence on recurrence. Immobilization remains controversial. A rehabilitation program is more likely to be successful in atraumatic instability. Patient compliance is important regardless of the type of treatment selected. Intrinsic factors include injury to the various anatomic structures about the shoulder, occurring at the time of primary anterior shoulder dislocation. A deep Hill Sachs lesion is more likely to result in recurrence secondary to both the impaction of the bone, as well as, the reduction of the area of articular surface. A displaced bony Bankart is a highly unstable situation secondary to the loss of the butress to retain the humeral head. In contrast to a Hill Sachs lesion or a bony Bankart, a concomittent fracture of the greater tuberosity is unlikely to result in recurrent dislocation. Isolated laberal detachment is not related to recurrence, but a complete disruption of the laberal ligament complex is highly correlated with recurrence. A rare subluxation erecta, as a special form of traumatic inferior instability, has a high recurrence rate. With increasing age there is a higher risk of concomittent rotator cuff tear. In most situations surgical repair of the rotator cuff tear results in resolution of the instability. The essential issue in determining the treatment protocol is to define concomittent hyperlaxity in the injured shoulder. Concomittent hyperlaxity precludes initial surgical treatment. The orthopedic surgeon treating the patient at the time of injury needs to design a concise treatment protocol for the patient based on the assessment of the extrinsic and intrinsic factors. An unreducable shoulder dislocation or associated vascular injury requires emergent intervention. Absolute indications for surgical treatment include: persistent dislocation, bony Bankart, a grossly displaced greater tuberosity fracture, and rupture of the subscapularis tendon. Surgical stabilization of primary anterior traumatic dislocation is indicated if the following strict criteria are met: adequate trauma, no self reduction, unidirectional instability without hyperlaxity, Hill Sachs lesion, age below 26 years, high level of sport activity and the special situation of luxatio erecta. Post primary stabilization is indicated for persistent subluxation, subjective instability or demonstrated pathologic instability tests. Rotator cuff tears due to traumatic dislocation in the elderly population require surgical repair.

[Current status of shoulder arthroscopy]

Arthroscopic and open shoulder surgery have to be combined for a successful surgical therapy of the shoulder joint. A surgeon performing open surgery only or just treating by arthroscopic measurements can not cover the full spectrum of modern shoulder surgery. Isolated diagnostic arthroscopy is rarely indicated. Far more common, diagnostic arthroscopy is combined with an operative procedure both to confirm preoperative assessment of pathology and to uncover associated lesions. The results of arthroscopic stabilisation of chronic anterior posttraumatic dislocations fail to compare with high success rates of open procedures. Better patient selection will probably be the key to improving results. In case of acute traumatic first time dislocation in young highly sportive athletes the arthroscopic repair of the isolated Bankart-Perthes lesion offers the attractive advantage of anatomic reconstruction with minimal soft tissue dissection. Further indications for arthroscopic measurements of pathologies of the glenohumeral joint are synovectomy in rheumatoid arthritis, capsulotomy of shrunk capsule in frozen shoulder and tenodesis for lesions of the long head of the biceps. The arthroscopic subacromial decompression according to Ellman is the most often and successful performed procedure at the shoulder joint and has overcome the classic Neer open acromioplasty. For smaller tears of the supraspinatus tendon the arthroscopic acromioplasty can be combined with an all arthroscopic suture repair or with an mini-open repair. Larger tears of the rotator cuff are still the domain for open reconstructive procedures. In case of associated or isolated AC-joint arthritis an arthroscopic Mumford procedure can be performed. For chronic calcific tendinitis isolated arthroscopic excision of the calcium deposit is of great value. Additionally, acromioplasty is needed for true mechanical obstruction of the subacromial space.

Determination of subacromial space width and inferior acromial mineralization by 3D CT. Preliminary data from patients with unilateral supraspinatus outlet syndrome

A reduction of the subacromial space and an increased subacromial pressure have been considered to play an important role in the pathogenesis of rotator cuff lesions. The objective of the current study was to develop a CT based method for measuring the acromiohumeral distance and inferior acromial mineralization. In seven patients with unilateral rupture of the rotator cuff and two with impingement syndrome, transverse CT images were obtained at a section thickness of 1 mm with muscular relaxation in a standardized position. The bones were then reconstructed three-dimensionally, and the minimal vertical distance between the acromion and the humerus was determined in three secondary frontal images on both sides. The distribution of mineralization within the inferior surface of the acromion was assessed using CT osteoabsorptiometry. Although the Constant score was significantly reduced in the diseased shoulders, the width of the subacromial space was not routinely lower than on the contralateral side. In seven cases the maximal inferior acromial mineralization was identical in both shoulders, and in two cases it was lower on the affected side. These preliminary data suggest that with muscular relaxation no narrowing of the subacromial space can be detected in secondary frontal CT images, and that a potential increase of subacromial pressure is not high enough to cause a measurable increase in inferior acromial bone density. The method presented makes it possible to investigate the pathogenesis of the supraspinatus outlet syndrome in vivo with greater precision than has so far been possible with conventional radiography.