European Society for Surgery of the Shoulder and Elbow (SECEC) rotator cuff tear registry Delphi consensus

Background

The purpose of this study was to establish consensus statements via a Delphi process on the factors that should be included in a registry for those patients undergoing rotator cuff tear treatment.

Methods

A consensus process on the treatment of rotator cuff utilizing a modified Delphi technique was conducted. Fifty-seven surgeons completed these consensus statements and 9 surgeons declined. The participants were members of the European Society for Surgery of the Shoulder and Elbow committees representing 23 European countries. Thirteen questions were generated regarding the diagnosis and follow-up of rotator cuff tears were distributed, with 3 rounds of questionnaires and final voting occurring. Consensus was defined as achieving 80%-89% agreement, whereas strong consensus was defined as 90%-99% agreement, and unanimous consensus was defined by 100% agreement with a proposed statement.

Results

Of the 13 total questions and consensus statements on rotator cuff tears, 1 achieved unanimous consensus, 6 achieved strong consensus, 5 achieved consensus, and 1 did not achieve consensus. The statement that reached unanimous consensus was that the factors in the patient history that should be evaluated and recorded in the setting of suspected/known rotator cuff tear are age, gender, comorbidities, smoking, traumatic etiology, prior treatment including physical therapy/injections, pain, sleep disturbance, sports, occupation, workmen's compensation, hand dominance, and functional limitations. The statement that did not achieve consensus was related to the role of ultrasound in the initial diagnosis of patients with rotator cuff tears.

Conclusion

Nearly all questions reached consensus among 57 European Society for Surgery of the Shoulder and Elbow members representing 23 different European countries. We encourage surgeons to use this minimum set of variables to establish rotator cuff registries and multicenter studies. By adapting and using compatible variables, data can more easily be compared and eventually merged across countries.

Radiologic midterm results of cemented and uncemented glenoid components in primary osteoarthritis of the shoulder: a matched pair analysis

INTRODUCTION

Cemented all-polyethylene glenoid components are considered the gold standard in anatomic shoulder arthroplasty. New designs of cementless metal backed glenoid components showed promising early and midterm results. The aim of this matched-pair analysis was to compare the radiologic results of two cemented glenoid components and a cementless glenoid component in patients with primary osteoarthritis (OA).

METHODS

Sixty shoulders were clinically and radiologically evaluated after a mean follow-up of 59 months. Mean patient age was 70.4 years at surgery. Based on the design of the glenoid component (keel, peg, MB), 3 groups with, respectively, 20 shoulders were formed according to the matching criteria time of follow-up, patient age and gender. RLL and osteolysis in anteroposterior and axillary X-ray images were quantified and combined in a radiologic score (R-Score). Higher scores expressed worse radiologic outcomes. Further radiological parameters such as lateral glenohumeral offset (LGHO) and subluxation index were measured according to Walch. The functional results were documented using the age and gender normalized Constant-Murley score.

RESULTS

Postoperative R-Score was highest in pegged components (peg: 5.7, keel: 2.4, MB: 1.6; p < 0.001) when combining both radiographs and after separate analysis of anteroposterior radiographs. MB glenoids had the lowest R-score in axillary radiographs (peg: 2.2, keel: 1.4, MB: 0.6; MB vs. keel: p = 0.004, MB vs peg: p < 0.001). RLL were more common (p = 0.004) and severe (p = 0.005) in pegged glenoids (RLL incidence: 77.8%, RLL-score: 2.5) than in MB glenoids (RLL incidence: 30%, RLL-score 0.7) and tended (p = 0.084) to have a higher RLL-score than keeled glenoids (RLL incidence: 63.2%, RLL-score:1.4). Both the osteolysis score (keel vs. peg: p < 0.001, MB vs. peg p < 0.001) and the incidence of osteolysis (keel vs. peg: p = 0.008, MB vs peg: p = 0.003) were significant higher in pegged glenoids (peg: osteolysis score: 3.2, osteolysis incidence: 100%; keel: osteolysis score: 1.0, osteolysis incidence: 63.2%, MB: osteolysis score: 0.9, osteolysis incidence: 60%), while the osteolysis score in axillary images was lowest for MB glenoids (peg: 1.2, keel: 0.9, MB: 0.4; peg vs. MB: p = 0.009, keel vs. MB: p = 0.047). Osteolysis in the central axillary zone was least common in MB glenoids (peg: 50%, keel: 47.4%, MB: 15%; peg vs. MB p = 0.035, keel vs. MB p = 0.041). LGHO was highest in MB glenoids (peg: 54.1, keel: 54.5, MB: 57.8; p < 0.001) but did not increase radiographic loosening (r = 0.007; p = 0.958). Preoperative posterior humeral head subluxation seemed to affect incidence of RLL negatively (pre-op posterior decentered 64.3%, pre-op centered 31.9%; p = 0.201) but did not reach statistical significance.

CONCLUSION

Pegged glenoid components had a concerning rate of RLL and osteolysis. MB glenoid components had a better outcome in axillary radiographs concerning RLL and osteolysis. Increased LGHO did not increase radiographic loosening.

LEVEL OF EVIDENCE

Retrospective comperative treatment study Level III.

Is there a correlation between humeral osteoarthritis and glenoid morphology according to Walch?

Aims

The aim of this study was to determine whether there is a correlation between the grade of humeral osteoarthritis (OA) and the severity of glenoid morphology according to Walch. We hypothesized that there would be a correlation.

Methods

Overal, 143 shoulders in 135 patients (73 females, 62 males) undergoing shoulder arthroplasty surgery for primary glenohumeral OA were included consecutively. Mean age was 69.3 years (47 to 85). Humeral head (HH), osteophyte length (OL), and morphology (transverse decentering of the apex, transverse, or coronal asphericity) on radiographs were correlated to the glenoid morphology according to Walch (A1, A2, B1, B2, B3), glenoid retroversion, and humeral subluxation on CT images.

Results

Increased humeral OL correlated with a higher grade of glenoid morphology (A1-A2-B1-B2-B3) according to Walch (r = 0.672; p < 0.0001). It also correlated with glenoid retroversion (r = 0.707; p < 0.0001), and posterior humeral subluxation (r = 0.452; p < 0.0001). A higher humeral OL (odds ratio (OR) 1.17; 95% confidence interval (CI) 1.03 to 1.32; p = 0.013), posterior humeral subluxation (OR 1.11; 95% CI 1.01 to 1.22; p = 0.031), and glenoid retroversion (OR 1.48; 95% CI 1.30 to 1.68; p < 0.001) were independent factors for a higher glenoid morphology. More specifically, a humeral OL of ≥ 13 mm was indicative of eccentric glenoid types B2 and B3 (OR 14.20; 95% CI 5.96 to 33.85). Presence of an aspherical HH in the coronal plane was suggestive of glenoid types B2 and B3 (OR 3.34; 95% CI 1.67 to 6.68).

Conclusion

The criteria of humeral OL and HH morphology are associated with increasing glenoid retroversion, posterior humeral subluxation, and eccentric glenoid wear. Therefore, humeral radiological parameters might hint at the morphology on the glenoid side.

Cite this article: Bone Jt Open 2022;3(6):463–469.

Survival of stemless humeral head replacement in anatomic shoulder arthroplasty: a prospective study

BACKGROUND

The long-term results of shoulder arthroplasty using stemless humeral head components with a mean follow-up period > 10 years were not available until now. The aim of this study was to evaluate the long-term results of shoulder arthroplasty using a stemless humeral head component.

METHODS

Since 2005, we have documented stemless humeral head replacement prospectively. Seventy-five patients with a mean age of 57 years at surgery (40 hemi-shoulder arthroplasties [HSAs] and 35 total shoulder arthroplasties [TSAs], 38 women and 37 men) were clinically and radiologically followed up after a mean period of 126 months (range, 105-157 months). Functional results were documented using the age- and sex-normalized Constant-Murley score (CMS) (ie, relative CMS).

RESULTS

The relative CMS improved significantly (P < .0001) from 56% preoperatively to 90% postoperatively. Its subcategories of pain (8 points preoperatively vs. 12 points postoperatively, P < .0001), activities of daily living (10 points vs. 15 points, P < .0001), range of motion (20 points vs. 29 points, P < .0001), and strength (7 points vs. 11 points, P = .011) improved significantly as well. There was no significant difference in preoperative CMS vs. postoperative CMS, as well as its subcategories, between HSA (44.8 points vs. 67.1 points, P < .0001) and TSA (44.4 points vs. 68.9 points, P = .004). Clinically and radiologically, we observed no loosening of the stemless humeral head component. Stress shielding around the humeral component was not detected. Upward migration of the humeral head was observed in 17.5% of patients (21.6% with HSA and 11.5% with TSA, P = .303). No implant failure was observed on the humeral side. At follow-up, 18.3% of patients had rotator cuff deficiency (13.9% with HSA and 25% with TSA, P = .280). Overall, 9.3% of stemless shoulder arthroplasties were revised to reverse TSAs (5% of HSAs and 14.3% of TSAs, P = .097). TSA showed a trend for a higher revision rate than HSA. Secondary glenoid wear occurred in 64.3% of HSAs, and none of the HSAs were converted to TSAs. We observed an incomplete radiolucent line < 2 mm in 30.4% and glenoid loosening in 11.4% of cemented glenoid components. Kaplan-Meier analysis revealed a 10-year survivorship rate of 96.5% and an estimated 13-year survivorship rate of 90.1% for stemless humeral components.

CONCLUSION

Stemless humeral head replacement showed no loosening and a significant improvement in shoulder function after a mean period of 11 years. The long-term clinical and radiologic results as well as the survivorship of anatomic shoulder arthroplasty using a stemless humeral head implant are comparable to the long-term results of standard stemmed anatomic shoulder arthroplasty.

Prospective midterm results of a new convertible glenoid component in anatomic shoulder arthroplasty: a cohort study

PURPOSE

The purpose of our study was to evaluate the clinical and radiological results of a new anatomic convertible cementless glenoid component.

METHODS

Forty-eight patients with a mean age of 67.3 years were clinically and radiologically followed-up with a mean of 49 months. Indications for glenoid replacement were A2 glenoid wear in 21.7%, B1 glenoid wear in 28.3%, B2 glenoid wear in 28.3%, B3 glenoid wear in 13%, D glenoid wear in 2.2%, and glenoid component loosening in 6.5%.

RESULTS

The Constant-Murley score improved significantly (p < 0.0001) from 50% pre-OP to 103% post-OP. Patients with a B3 glenoid type according to Walch achieved a significant (p = 0.044) lower Constant-Murley Sscore post-OP compared to patients with a B1 glenoid type (88% vs 106%). The mean subluxation index changed significantly (p < 0.0001) from 0.54 pre-OP to 0.46 post-OP. At the metal-back bone interface an incomplete radiolucent line < 1 mm was observed in two cases (4.2%) and an incomplete radiolucent line < 2 mm was observed in another two cases (4.2%). PE dissociation occurred in two cases. No glenoid loosening was observed. The implant related revision rate was 4.2% (2 cases). All components (n = 612.5%) requiring conversion to reverse were converted without any further complications or loosening.

CONCLUSION

Good functional results can be achieved in cases with a B1 and a B2 glenoid after anatomic shoulder arthroplasty using the described metal back glenoid. A conversion from an anatomic to a reverse glenoid component were possible in all cases without any further complications. Conversion of the anatomic glenoid component to a reverse system alleviates revision surgery.

Short-term safety, function, and quality of life in patients treated with Univers Revers prosthesis: a multicenter 2-year follow-up case series

BACKGROUND

The use of reverse total shoulder arthroplasty (RTSA) has dramatically increased in recent years with the advent of new prosthesis designs regularly entering the market. We define the rate of local complications during the first 2 years after RTSA with the Univers Revers prosthesis and describe the changes in radiologic outcomes, as well as function, pain, satisfaction, and quality of life.

METHODS

This multicenter, prospective case series included rotator cuff tear arthropathy patients who underwent RTSA with the Univers Revers. Incidence percentages of complications and pathologic radiographic changes were documented. Mixed-model linear regression was used to examine changes in range of motion, shoulder function (Constant score, Shoulder Pain and Disability Index, Subjective Shoulder Value), and quality of life (EQ-5D-5L [European Quality of Life 5 Dimensions 5 Level] and EQ-VAS [EuroQol Visual Analog Scale]).

RESULTS

Of 187 patients, 59.4% were women, and the mean age was 75.3 years (range, 56-91 years). Twenty-five percent of patients had a postoperative complication; 5 complications were severe (2.7%, 5 of 187), whereby 2 were implant related (1.1%; 95% confidence interval [CI], 0.1%-3.8%). The incidence of scapular notching was 10.6% (95% CI, 6.5%-16%). After 2 years, abduction, flexion, and abduction strength improved by 54° (95% CI, 50°-58°), 57° (95% CI, 53°-60°), and 5 kg (95% CI, 4-5 kg), respectively (P < .001), whereas external rotation at 0° (1°; 95% CI, -1° to 3°) did not improve (P = .4). The Constant score improved by 39 (95% CI, 38-41); Shoulder Pain and Disability Index, by 50 (95% CI, 47-52); and Subjective Shoulder Value, by 43 (95% CI, 41-45) (P < .001). Furthermore, the EQ-5D-5L index value improved by 0.31 (95% CI, 0.30-0.33), and the EQ-VAS score improved by 16 (95% CI, 14-18) (P < .001).

CONCLUSION

Our case series showed a low complication rate with a consistent clinically relevant and statistically significant improvement across most clinical and patient-reported outcomes for the Univers Revers. Long-term safety requires further investigation.

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 .

Classification of humeral head pathomorphology in primary osteoarthritis: a radiographic and in vivo photographic analysis

BACKGROUND

The purpose of this study was to characterize the pathologic changes of the osteoarthritic humeral head.

METHODS

The study included 55 patients with primary osteoarthritis who underwent anatomic shoulder arthroplasty. Several radiologic parameters (radiography, magnetic resonance imaging) were assessed. Humeral head deformity in the transverse plane and humeral cartilage erosion in the coronal plane were chosen for photographic measurements from the resected humeral heads.

RESULTS

In the coronal plane, 82% of patients presented with an aspherical humeral head shape with a significantly longer caudal osteophyte. In the transverse plane, 50% of all patients showed a decentered apex. Patients with an aspherical humeral head shape in the transverse plane showed an aspherical humeral head shape in the coronal plane in 94% and a significantly longer osteophyte than patients with spherical humeral head shape, showing a 3-dimensional deformity of the humeral head during progression of primary osteoarthritis. Patients with an osteophyte length between 7 and 12 mm were associated with a glenoid type B2 in 30% and a decentered apex in the transverse plane in 38%. Patients with a humeral osteophyte longer than 13 mm were significantly more frequently associated with a type B2 glenoid (71%; P < .0001) and a decentered apex in the transverse plane in 52%.

CONCLUSION

It seems that the progression of primary osteoarthritis of the glenohumeral joint is characterized by an increasing 3-dimensional deformity of the humeral head related to the glenoid morphology. We therefore propose an extended Samilson-Prieto classification with type A (spherical) and type B (aspherical) and grade I-IV osteophytes.

Nine-year outcome after anatomic stemless shoulder prosthesis: clinical and radiologic results

BACKGROUND

Several stemless shoulder implants are available on the market, but only a few studies have presented results with sufficient mid- to long-term follow-up. The present study evaluated clinical and radiologic outcomes 9 years after anatomic stemless shoulder replacement.

METHODS

This is a prospective cohort study evaluating the stemless shoulder prosthesis since 2005. Anatomic stemless shoulder replacement using a single prosthesis was performed in 49 shoulders; 17 underwent total shoulder replacement, and 32 underwent hemiarthroplasty. Forty-three patients were clinically and radiologically monitored after a mean of 9 years (range, 90-127 months; follow-up rate, 88%). The indications for shoulder replacement were primary osteoarthritis in 7 shoulders, post-traumatic in 24, instability in 7, cuff tear arthropathy in 2, postinfectious arthritis in 1, and revision arthroplasty in 2.

RESULTS

The Constant-Murley Score improved significantly from 52% to 79% (P < .0001). The active range of motion also increased significantly for flexion from 101° to 118° (P = .022), for abduction from 79° to 105° (P = .02), and for external rotation from 21° to 43° (P < .0001). Radiologic evaluation revealed incomplete radiolucency in 1 patient without clinical significance or further intervention. No revision caused by loosening or countersinking of the humeral implant was observed.

CONCLUSIONS

The 9-year outcome after stemless shoulder replacement is comparable to that of third- and fourth-generation standard shoulder arthroplasty.

[Chronic acromioclavicular joint injury of Rockwood V type with concomitant chronic anterior sternoclavicular instability]

Bipolar dislocation of the clavicle is rare. In the literature, every reported bipolar dislocation of the clavicle is caused by a traumatic injury with loss of function of the affected shoulder. Currently, there is no recommendation to treat. A conservative treatment can be tried first to achieve adequate shoulder function. If this cannot be achieved, surgical treatment will be indicated. In the literature, many options for surgical treatment are described. This article presents a case of a chronic Rockwood V injury with chronic anterior sternoclavicular joint instability. The special feature of this case was the arthroscopically assisted stabilization of the acromioclavicular joint (ACJ) with the ipsilateral semitendinosus tendon graft and the open stabilization of the sternoclavicular joint (SCJ) with the ipsilateral gracilis tendon graft. A lateral fracture of the clavicle in the course of the postoperative treatment was treated with a plate osteosynthesis. At follow-up after six months, the postoperative shoulder function was restored. The ACJ and the SCJ were stable in clinical and radiographic examination. This case report shows the first surgical treatment using two tendon grafts for combined stabilization of the ACJ and SCJ.

Chondral defects of the glenohumeral joint: Long-term outcome after microfracturing of the shoulder

Introduction

An increasing number of young patients are diagnosed with chondral lesions. Minimally invasive surgical techniques are important in order to delay progression of the early stages of osteoarthritis and the need for total joint replacement.

Materials and methods

Patients (n = 32) who had received microfracturing of the shoulder were retrospectively enrolled, of whom 5 had received shoulder replacements after a mean time of 47 months. Of these patients, 23 completed the Disabilities of the Arm, Shoulder and Hand (DASH) and Constant–Murley Scores in addition to an additional subjective questionnaire. Patients were then clinically examined and received x‑ray analysis of the operated shoulder. Data from an additional 4 patients were acquired by telephone interview.

Results

Mean follow-up was 105 months. Of the included patients, 13/27 patients reported no pain, 12/27 patients moderate pain. Of these 12, 6/27 reported pain only at night and 3/27 only during rest. Concerning the outcome of surgery, 19/27 patients were “satisfied” or “very satisfied”. There was a statistically significant increase in internal rotation, but no further differences in the range of motion pre- and postoperatively. Patients without any signs of osteoarthritis before surgery showed statistically significantly better outcomes. There was a statistically significant increase in radiological signs of osteoarthrosis in pre- versus postoperative patients. Patients with bipolar lesions showed statistically significantly poorer Subjective Shoulder Value (SSV) results.

Conclusion

Even though microfracturing does not prevent radiographic progression, microfracture of the glenohumeral joint might be worth considering as part of a treatment regimen for younger patients who may not yet be treated with arthroplasty.

Is the stemless humeral head replacement clinically and radiographically a secure equivalent to standard stem humeral head replacement in the long-term follow-up? A prospective randomized trial

BACKGROUND

Stemless humeral head replacement represents a young generation of shoulder arthroplasty. This study evaluated the differences of this new stemless design compared with the fourth-generation standard stemmed design.

METHODS

Total shoulder arthroplasty was performed in 20 patients with a stemless shoulder prosthesis (group 1) and in 20 patients with a standard stem humeral head replacement (group 2). Twenty-nine patients were examined clinically and radiographically at a minimum follow-up of 2 years and a minimum follow-up of 5 years. Functional results were assessed using the age- and gender-related Constant Score (CS). The radiographic analysis used native x-rays in 3 planes.

RESULTS

The postoperative CS improved significantly in both groups, with no significant difference between the minimum of 2-year and 5-year follow-up. The difference in the CS, its subcategories, and active range of motion between the implant groups was not significant. A significant difference was observed in the radiographic analysis for the zone adjacent to the humeral calcar, with a lower bone mineral density in 41% of group 2 and in 0% in group 1. Radiolucent lines were statistically more frequent in group 2. No statistical differences were observed between the implant groups for the change of the inclination angle, the medial offset, and the lateral offset.

CONCLUSION

Both implants showed consistently good functional and radiologic results without a significant difference and achieved an anatomic reconstruction of the humeral head geometry in the coronal plane.

Glenoid deformity in the coronal plane correlates with humeral head changes in osteoarthritis: a radiographic analysis

BACKGROUND

A variety of measurements can be used to assess radiographic osteoarthritic changes of the shoulder. This study aimed to analyze the correlation between the radiographic humeral-sided Samilson and Prieto classification system and 3 different radiographic classifications describing the changes of the glenoid in the coronal plane.

METHODS

The study material included standardized radiographs of 50 patients with idiopathic osteoarthritis before anatomic shoulder replacement. On the basis of radiographic measurements, the cases were evaluated using the Samilson and Prieto grading system, angle β, inclination type, and critical shoulder angle by 2 independent observers.

RESULTS

Classification measurements showed an excellent agreement between observers. Our results showed that the humeral-sided Samilson and Prieto grading system had a statistically significant good correlation with angle β (observer 1, r = 0.74; observer 2, r = 0.77; P < .05) and a statistically significant excellent correlation with the inclination type of the glenoid (observer 1, r  = 0.86; observer 2, r = 0.8; P < .05). A poor correlation to the critical shoulder angle was observed (r = -0.14, r = 0.03; P > .05).

CONCLUSIONS

The grade of humeral-sided osteoarthritis according to Samilson and Prieto correlates with the glenoid-sided osteoarthritic changes of the glenoid in the coronal plane described by the angle β and by the inclination type of the glenoid. Higher glenoid-sided inclination is associated with higher grade of osteoarthritis in primary shoulder osteoarthritis.

Arthroscopic Stabilization of Chronic Acromioclavicular Joint Dislocations: Triple- Versus Single-Bundle Reconstruction

BACKGROUND

Arthroscopically assisted single-bundle (SB) or double-bundle coracoclavicular (CC) ligament reconstruction using autologous tendon grafts has been reported to provide acromioclavicular (AC) joint (ACJ) stability in chronic instability cases. Recently, additional AC ligament reconstruction to provide triple-bundle (TB) stabilization has been introduced but lacks a comparison of clinical and radiological outcomes.

HYPOTHESIS

Arthroscopically assisted anatomic TB CC and AC reconstruction yields superior clinical and radiological results when compared with nonanatomic SB CC reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Twenty-six patients (mean [±SD] age, 46.9 ± 12.8 years) suffering from chronic high-grade ACJ instability underwent ACJ stabilization using autologous hamstring grafts. Twelve patients underwent combined anatomic TB CC and AC reconstruction using a semitendinosus tendon with clavicular interference screw fixation (TB group), and 14 underwent isolated SB CC reconstruction using the AC GraftRope system with a gracilis tendon (SB group). After a minimum follow-up of 2 years (mean, 29.0 ± 7.4 months), patients were evaluated radiologically and clinically using the Constant, American Shoulder and Elbow Surgeons (ASES), Taft, and Acromioclavicular Joint Instability Score (ACJI) outcome measures.

RESULTS

The mean Constant score increased significantly in both groups, from 71.6 preoperatively to 88.8 postoperatively in the TB group and from 67.8 to 82.6 in the SB group (P ≤ .009). No intergroup difference was found regarding the final Constant or ASES scores. Regarding the ACJ-specific scores, the final outcomes were significantly different: 10.9 (TB group) versus 9.0 (SB group) for the mean Taft score (P = .018) and 84.7 versus 58.4, respectively, for the mean ACJI score (P = .0001). No significant radiological difference was found regarding the mean CC distance (10.7 mm [TB group] vs 13.1 mm [SB group]). The TB group showed superior horizontal ACJ stability (P = .011), which was associated with a better clinical outcome according to the ACJI and Taft scores. In the SB group, the rate of ACJ instability recurrence was higher (21% vs 8% [TB group]).

CONCLUSION

Combined arthroscopically assisted anatomic TB CC and AC ligament reconstruction using an autologous semitendinosus tendon graft provides superior clinical and radiological results compared with isolated nonanatomic SB CC ligament reconstruction using the AC GraftRope system. In particular, the TB technique can better restore horizontal ACJ stability, which is associated with superior ACJ-specific outcome scores.

How to discriminate between acute traumatic and chronic degenerative rotator cuff lesions: an analysis of specific criteria on radiography and magnetic resonance imaging

BACKGROUND

Discrimination between acute traumatic and chronic degenerative rotator cuff lesions (RCLs) is an important aid to decision making in therapeutic management. To date, no clinical signs or radiologic findings that enable confident differentiation between these distinct etiologic entities have been identified. The purpose of this investigation was to perform a systematic analysis of known radiographic and magnetic resonance imaging (MRI) features of RCLs and of further, not yet accurately described parameters. The hypothesis was that there are specific radiologic features that allow reliable discrimination between traumatic and nontraumatic RCLs.

METHODS

Fifty consecutive patients with RCLs confirmed by MRI were enrolled in this study. Group A was made up of 25 patients with a history of trauma within the previous 6 weeks and no pre-existing shoulder pain, whereas group B comprised 25 patients with shoulder pain for not more than 12 months and no history of relevant trauma. Radiographs and magnetic resonance images were analyzed in a standardized protocol.

RESULTS

No radiographic features were found to differ significantly between the 2 groups. On MRI, edema in the injured muscle was more common in group A (37.5% vs 4%, P = .04). A characteristic feature in traumatic RCLs was a wavelike appearance (kinking) of the central tendon (64% vs 32%, P = .03). In group B, more muscular atrophy was found (29.2% vs 60%, P = .02). Thinning and retraction did not differ between the groups.

CONCLUSION

MRI, but not radiography, can be used to help discriminate between traumatic and nontraumatic RCLs. Although no absolute distinguishing feature was found, edema, kinking, and muscular atrophy are positive criteria for differentiation.

Midterm results of stemless shoulder arthroplasty: a prospective study

BACKGROUND

This study evaluated the functional and radiologic results of shoulder arthroplasty using a single type of stemless humeral head implant with a minimum follow-up of 5 years.

METHODS

Stemless shoulder arthroplasties in 78 patients at a mean age of 58 years were prospectively evaluated at a mean clinical and radiologic follow-up of 72 months. Functional results were documented using the age- and sex-adjusted Constant score with standardized radiographic examination.

RESULTS

The Constant score improved significantly from 38.1% to 75.3% (P < .0001). Active range of motion improved significantly for flexion (from 114° to 141°), abduction (from 74° to 130°), and external rotation (from 25° to 44°; P < .0001). Bone mineral density was reduced in 34.9% of the older population, without an influence on shoulder function (Constant score without lowering of bone density; 73%; Constant score with lowering of bone density 80%; P = .404). The overall complication rate was 12.8%, with an overall revision rate of 9%. None of the stemless implants were revised for loosening.

CONCLUSION

The functional and radiologic results of the stemless shoulder arthroplasty are comparable to the third and fourth generation of standard stem arthroplasty.

[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.

Balance ability and postural stability among patients with painful shoulder disorders and healthy controls

Background

In therapeutic settings, patients with shoulder pain often exhibit deficient coordinative abilities in their trunk and lower extremities. The aim of the study was to investigate 1) if there is a connection between shoulder pain and deficits in balance ability and postural stability, 2) if pain intensity is related to balance ability and postural stability, and 3) if there is a connection between body mass index (BMI) and balance ability and postural stability.

Methods

In this case–control study, patients (n = 40) with pathological shoulder pain (> 4 months) were matched with a healthy controls (n = 40) and were compared with regard to their balance ability and postural stability. Outcome parameters were postural stability, balance ability and symmetry index which were measured using the S3-Check system. In addition, the influence of shoulder pain intensity and BMI on the outcome parameters was analysed.

Results

Patients with shoulder pain showed significantly worse results in measurements of postural stability right/left (p < 0.01) and front/back (p < 0.01) as well as balance ability right/left (p = 0.01) and front/back (p < 0.01) compared to healthy controls. There were no significant group differences with regard to symmetry index. However, there was a significant (p < 0.01) symmetry shift towards the affected side within the shoulder pain group. There was no correlation between pain intensity and measurements of balance ability or postural stability. Likewise, no correlation between BMI and deficiencies in balance ability and postural stability was established.

Conclusions

Patients with pathological shoulder pain (> 4 months) have deficiencies in balance ability and postural stability; however the underlying mechanisms for this remain unclear. Neither pain intensity nor BMI influenced the outcome parameters. Patients with shoulder pain shift their weight to the affected side. Further research is needed to determine if balance training can improve rehabilitation results in patients with shoulder pathologies.

Results of arthroscopic partial repair of large retracted rotator cuff tears

PURPOSE

To evaluate the midterm results of partial rotator cuff repair using the Constant score and the acromiohumeral radiographic measurement.

METHODS

Thirty-eight patients with a mean age of 65 years and a large retracted rotator cuff tear (at least 2 tendons) were included in the study. Patients underwent clinical examination, standard radiography, and isometric strength testing at a mean follow-up of 47 months. The rotator cuff tears were classified as posterosuperior, anterosuperior, or global tears (≥3 tendons), and an arthroscopic partial repair was performed.

RESULTS

The mean Constant score significantly increased from 56 points before surgery to 71 points after surgery (P = .041); the mean age- and sex-adjusted Constant score significantly improved from 63% to 90% at a mean follow-up of 47 months after arthroscopic partial rotator cuff repair (P = .003); and the subcategories pain and activity significantly improved (P = .001, P = .014, respectively). The active range of motion improved from 133° of flexion and 111° of abduction before surgery to 163° of forward flexion and 156° of abduction after surgery (P < .001). However, the active range of external rotation decreased from 44° before surgery to 36° after surgery. Further, there was a trend toward a decrease in the mean acromiohumeral distance from 7.0 mm before surgery to 5.6 mm after surgery. The abduction strength did not significantly improve after surgery (4.2 kg before surgery and 4.8 kg after surgery; P = .116).

CONCLUSIONS

An arthroscopic partial repair of the rotator cuff is an effective tool to improve the Constant score by restoring active forward flexion and abduction and through pain relief. Further, we found that a pathologically decreased acromiohumeral distance cannot be reversed by a partial rotator cuff repair.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

The acromial index is not predictive for failed rotator cuff repair

BACKGROUND

The main objective of this study was to evaluate the association between the acromial index (AI) and the incidence of recurrent tears of the rotator cuff (RC) in a cohort of patients with full thickness tears who underwent arthroscopic primary repair.

METHODS

A prognostic study of a prospective case series of 103 patients with full thickness RC tears was undertaken. The average age was 59.5 years (39-74) and follow-up was 30.81 months (12-72). True anterior-posterior X-rays were obtained during the pre-operative evaluation. Pre and post-operative magnetic resonance imaging (MRI) were recorded.

RESULTS

Eighteen cases with recurrent tears (17.4%) were seen on post-operative MRI. The average AI for patients with recurrent tears was 0.711 ± 0.065 and for patients without recurrent tears 0.710 ± 0.064 (p < 0.05). A positive association between age and recurrent tears of the RC was noted (average ages: recurrent tears group 63 ± 5.9 years; group without recurrent tears 58.8 ± 7.5 years) (r = -0.216; p = 0.029). We did not find an association between size of the primary tear and recurrent tears (r = -0.075; p < 0.05) or between degrees of retraction of the primary and recurrent tears of the cuff (r = -0.073; p < 0.05). We observed that 38.9% of the recurrent tears cases presented with more than one tendon affected before the arthroscopy. At follow-up, none of these recurrent tears showed more than one tendon affected on MRI evaluation.

CONCLUSION

In this study, we found that the AI radiological measurement is not a predictor for recurrent tears of the RC after primary arthroscopic repair.

Midterm results of a total shoulder prosthesis fixed with a cementless glenoid component

BACKGROUND

The aim of this study was to evaluate the midterm results and complications of a total shoulder arthroplasty implanted with a metal-backed, bone-ingrowth glenoid component.

MATERIALS AND METHODS

In total, 62 patients (65 shoulders) diagnosed with primary osteoarthritis were treated with total shoulder arthroplasty with a cementless glenoid component. The mean age was 66 years (range, 54-85 years). Fifty-three patients were evaluated after a mean of 64 months (range, 26-85 months). Functional results were documented by use of the age- and sex-adjusted Constant score. Radiolucent line (RLL) assessment of the glenoid component was performed by use of true anteroposterior and axillary views.

RESULTS

The Constant score improved significantly from 49% preoperatively to 89.8% postoperatively (P < .0001). Active range of motion improved significantly for flexion (from 118° to 146°), abduction (from 87° to 133°), and external rotation (from 21° to 44°) (P < .0001). In 3 cases (5.7%), RLLs of 1 mm or less were present, and 1 case (1.8%) had an RLL of 2 mm or less in 1 zone. Glenoid component loosening occurred in 5 cases (9.4%) because of breakage of the cage screw. Four of these patients presented preoperatively with a type B1 glenoid and one patient with type A2. Two of the patients who underwent revision also had a complete tear of the rotator cuff. The revision rate was 11.3% (6 patients) after a mean of 68 months.

CONCLUSION

After midterm follow-up, clinical outcomes of patients operated on with a cementless, metal-backed glenoid implant improved significantly. However, an unacceptable rate of complications and revisions was found. Glenoid loosening predominantly occurred in patients with preoperative eccentric glenoid morphology and was also related to cranial migration of the proximal humerus during the follow-up period.

Are there advantages of the combined latissimus-dorsi transfer according to L'Episcopo compared to the isolated latissimus-dorsi transfer according to Herzberg after a mean follow-up of 6 years? A matched-pair analysis

HYPOTHESIS

The aim of the study was to evaluate differences of clinical results between the latissimus-dorsi transfer combined with teres-major transfer (G1) and the isolated latissimus-dorsi transfer (G2) for the treatment of massive irreparable postero-superior rotator cuff tears.

METHODS

We performed the combined latissimus-dorsi/teres-major transfer in 17 patients at a mean age of 57 years. Furthermore, 17 patients at a mean age of 61 years were treated using the isolated latissimus-dorsi transfer. Both groups were followed-up clinically, radiologically, and with surface electromyography using the same study protocol.

RESULTS

The Constant score (CS) improved significantly from 48.3 points pre-op to 69.5 points post-op after a follow-up of 58 months in G1. The active range of motion improved in G1 sig. for flexion (124° pre-op, 166.5° post-op) and for abduction (117° pre-op, 163° post-op). The CS improved significantly from 45.1 points pre-op to 74.2 points post-op after a follow-up of 51 months in G2. The flexion and abduction increased significantly from 133.3° pre-op to 176° post-op, resp. from 113.3° pre-op to 173° post-op. The comparison of both surgical techniques showed a significant better active flexion and abduction for G2.

CONCLUSION

Both techniques achieved good functional results but the isolated latissimus-dorsi transfer produced a better active abduction and flexion, whereas the combined latissmus-dorsi/teres-major transfer achieved an increase in abduction strength. In contrast to the combined latissimus-dorsi/teres-major transfer, a progression of cuff tear arthropathy was not observed with the isolated latissimus-dorsi transfer.

Do anatomic variants of the acromion shape in the frontal plane influence pain and function in calcifying tendinitis of the shoulder?

PURPOSE

To evaluate the relationship of a large acromion index and calcifying tendinitis of the supraspinatus tendon at the shoulder.

MATERIALS AND METHODS

Between 2002 and 2008, 109 consecutive patients with isolated calcifying tendinitis of the supraspinatus tendon were prospectively analysed by clinical investigation and standardized radiographs. Deposit size and appearance were measured and classified according to Bosworth and Gartner. The acromion index (AI) was calculated based on measurements on true anteroposterior radiographs. Pain record on VAS scale, active and passive range of motion and the constant score (CS) were recorded.

RESULTS

The mean age of the patients was 48.2 ± 8.0 (n = 46 male 48.6 ± 7.3; n = 63 female 47.9 ± 8.6; P > 0.05). Pain and function were not significantly correlated with deposit size or classification. The acromion index (mean 0.64 ± 0.08) was not significantly correlated with the affected or dominant side, gender, deposit size or classification or any functional parameter like pain and the CS or its subgroups.

CONCLUSION

The theoretical concept of a high acromion index resulting in an increased resulting upward force against the subacromial space, which influences pain and function in calcifying tendinitis of the shoulder, was not supported.

Is there an association between SLAP lesions and biceps pulley lesions?

PURPOSE

The purpose of this study was to evaluate the prevalence of SLAP and biceps reflection pulley lesions. The hypothesis was that these lesions do not occur concomitantly and they have a different etiology.

METHODS

We prospectively analyzed 3,395 shoulder arthroscopies that were independently performed by 2 surgeons between 2004 and 2008 regarding the prevalence of SLAP and biceps pulley lesions. Intraoperative findings were correlated with patient history and clinical examination. Exclusion criteria were type I SLAP lesions, full-thickness rotator cuff tears, and a history of shoulder dislocation.

RESULTS

This study included 182 patients with SLAP lesions (prevalence, 5.4%; 138 men; mean age, 47 years) and 87 patients with pulley lesions (prevalence, 2.6%; 63 men; mean age, 49 years). Isolated SLAP lesions were present in 157 cases, and isolated pulley lesions in 62 cases. The concomitant presence of a SLAP lesion and pulley lesion was significantly rare (10%, P = .003). In 55 (35%; 42 men [76%]; mean age, 43 years) of the cases with isolated SLAP lesions and 40 (65%; 27 men [68%]; mean age, 49 years) with isolated pulley lesions, there was a significant association with history of trauma (P < .01). Most SLAP lesions (32 [58%], P = .174 [not significant]) and most pulley lesions (28 [70%], P < .01) resulted from falling on the outstretched arm with external arm rotation in SLAP lesions and internal rotation in pulley lesions (P > .05).

CONCLUSIONS

The concomitant presence of biceps tendon-associated lesions in the form of SLAP and pulley lesions is significantly rare. A history of falling on the abducted and externally rotated arm was typical in patients with SLAP lesions, whereas a fall on the arm with internal rotation was often noted in patients with pulley lesions.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Open repair of isolated traumatic subscapularis tendon tears

BACKGROUND

Diagnosis, operative treatment, and outcome assessment of isolated traumatic subscapularis tendon tears have not been widely studied.

PURPOSE

To report the clinical outcome, value of clinical tests, predictive outcome factors, and return to sports in the management of isolated traumatic subscapularis tendon tears.

STUDY DESIGN

Case series; level of evidence, 4.

METHODS

Thirty consecutive patients with a confirmed isolated subscapularis tear, except for associated biceps tendon injury or humeral avulsion of the glenohumeral ligaments (HAGL) lesions, found at arthroscopy were included in the study. The average age of the study population was 43.1 years. In all 30 patients, a traumatic event caused the onset of symptoms. The mean delay between trauma and surgery was 4 months. All patients underwent open tendon reconstruction with a suture anchor technique via a deltopectoral approach. Clinical assessment was done using the Constant score and specific subscapularis tests. Postoperative tendon integrity was assessed with ultrasound and magnetic resonance imaging. Sports activity, including competition level, sports discipline, and postoperative return to sports, was evaluated.

RESULTS

The average duration of follow-up was 46 months (range, 25-72 months). Seven patients had a full-thickness tear of the upper third of the tendon, 11 patients a full-thickness tear of the upper two-thirds of the tendon, and 12 patients had a complete subscapularis tendon tear. The Constant score increased from 51.3 preoperatively to 82.2 postoperatively (P < .01). Twenty-seven patients rated their postoperative result as excellent or good. Most positive preoperative lift-off and belly-press tests were reversed by surgery, with a rate of 6 (20%) persistent positive tests after surgery. Positive postoperative subscapularis tests were more likely related to a higher preoperative degree of fatty subscapularis muscle infiltration (P < .05). Ultrasound and magnetic resonance imaging revealed a structural intact repair at follow-up in 28 shoulders (93%). Seventy-five percent of athletes returned to their previous competition level.

CONCLUSION

Early repair of isolated traumatic subscapularis tendon tears and associated biceps tendon lesions or HAGL lesions achieves good functional outcomes with a low re-rupture rate and allows return to sports activity. Delay of surgery and higher degrees of preoperative fatty infiltration of the subscapularis muscle impair postoperative subscapularis function.

Influence of SLAP lesions on chondral lesions of the glenohumeral joint

From 2004 to 2008 we evaluated 431 SLAP lesions during 3,395 shoulder arthroscopies and compared two groups of patients, one with SLAP lesion as group I and one without SLAP lesions as group II. Exclusion of type I SLAP lesions, rotator cuff tears and history of dislocation of the shoulder in both groups left 182 cases in group I, and additionally, exclusion of all-type SLAP lesions left 251 patients in group II. In group I, SLAP lesion-associated chondral lesions were present in 20% at the humerus (4% group II, p = 0.005), 18% at the glenoid (5% in group II, p = 0.05) and 14% glenohumeral (3% group II, p = 0.04). We observed a pattern of typical localization of SLAP-associated chondral lesions at the humerus underneath the biceps tendon (78%) and at the anterior half of the glenoid (63%) in group I in contrast to the central region of the humerus (82%) and the central region at the glenoid (55%) in group II. The association of SLAP and chondral lesions was not influenced by the presence of trauma or age of the patients. SLAP lesions seem to be a risk factor for subsequent early onset of osteoarthritis either caused by a bicipital chondral print or glenohumeral instability or a combination of both.

How much are radiological parameters related to clinical symptoms and function in osteoarthritis of the shoulder?

Loss of joint space, formation of osteophytes and deformation are common features of osteoarthritis. Little information exists about the radiological features of arthrosis in relation to clinical findings and the radiological appearance in degenerative shoulder joint disease especially with regard to decision making about the timing of joint replacement. We retrospectively examined 120 standardised X-rays of patients with advanced osteoarthritis of the shoulder. Exclusion criteria included rotator cuff tear, severe glenoid erosion or protrusion. Measurements of joint space width at three levels in each plane (anteroposterior and axillary view), humeral head diameter and size of humeral osteophytes were made by two independent examiners. Osteoarthritis was graded according to Samilson and Prieto. Seventy-five of these patients had a complete record from the clinical investigation (pain record on VAS scale, active and passive range of motion) and the constant score (CS). Mean joint space width in the central anteroposterior level was 1.46 mm +/- 1.08 and in the central axillary 0.98 mm +/- 1.02. Increasing age was positively correlated with joint space narrowing at all measured levels. The joint space width was not correlated with the Samilson grade or the size of osteophytes. The joint space width was neither correlated with pain nor active or passive ROM. Pain was correlated with active and passive flexion and abduction but not for internal or external rotation. The size of the osteophytes was negatively correlated (active and passive) with flexion, abduction and external and internal rotation. The study illustrates that joint space narrowing and development of osteophytes are reliable but independent parameters of primary shoulder arthrosis and should be recorded separately. The size of the caudal humeral osteophyte is a predictive factor for function and should be taken into account for clinical decision making. The primary clinical feature, pain, as the main indication for surgery is not related to radiological parameters.

How long should acute anterior dislocations of the shoulder be immobilized in external rotation?

BACKGROUND

Immobilization of the shoulder in external rotation has been shown to reduce the risk of recurrence after traumatic anteroinferior shoulder dislocation. It remains unclear how duration of immobilization affects labral coaptation.

HYPOTHESIS

Immobilization of the shoulder in 30 degrees of external rotation for 5 weeks allows better coaptation of the anteroinferior labrum than does an immobilization period of 3 weeks.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Twenty-two patients with traumatic anteroinferior dislocation of the glenohumeral joint were included in this study. Patients were divided into 2 groups. Group 1 consisted of the initial 11 patients (mean age, 37.4 years) immobilized for 3 weeks; group 2 consisted of the subsequent 11 patients (mean age, 29.7 years) immobilized for 5 weeks in 30 degrees of external rotation. With use of magnetic resonance imaging, displacement and separation of the glenoid labrum and anterior joint effusion were assessed in different arm positions (internal rotation, neutral rotation, 30 degrees of external rotation, maximum external rotation) within 3 days, 3 weeks, and 5 weeks after reduction.

RESULTS

Displacement and separation of the labrum and anterior joint effusion were significantly less, particularly with maximum external rotation compared with neutral and internal rotation, during the acute magnetic resonance imaging evaluation in both groups (P < .05). No statistically significant differences were found in all parameters comparing internal rotation with neutral rotation, 30 degrees of external rotation, and maximum external rotation in both groups after 5 weeks (P > .05). No statistically significant differences were found between both groups comparing the results of the measured variables during the acute, 3-week, and 5-week magnetic resonance imaging examinations (P > .05).

CONCLUSION

Immobilization of the shoulder in 30 degrees of external rotation seems to allow a similar coaptation of the glenoid labrum, regardless of duration of immobilization (3 vs 5 weeks). Clinical trials are needed to evaluate the effect of these results on recurrence rates. The optimum position of immobilization in external rotation has yet to be determined.

Pectoralis major transfer for the treatment of irreparable anterosuperior rotator cuff tears

The purpose of this study was to evaluate the outcome of subcoracoid pectoralis major transfer for the treatment of irreparable anterosuperior rotator cuff tears. This type of tear involves complete rupture of the subscapularis in combination with either the supraspinatus alone or the supraspinatus and infraspinatus. These ruptures are characterised by a poor quality of the rotator cuff that does not allow for a direct tendon-to-bone reconstruction. Between 2000 and 2006, 15 patients were treated using a deltopectoral approach and transfer of the clavicular part of the pectoralis major to the lesser tuberosity and to the anterior part of the greater tuberosity. After an average follow-up (follow-up rate 100%) of 37 months the average functional rating using the Constant and Murley score (CS) increased from 51.73 +/- 16.18 to 68.17 +/- 8.84 points (p = 0.005). The mean subcategories of the Constant score for pain (p = 0.005), activities of daily living (p = 0.008) but not for range of motion (p = 0.9), significantly improved. At follow-up 13 patients (87%) were available for magnetic resonance imaging (MRI) of the shoulder. Nine patients (70%) had an intact transferred pectoralis major muscle, two (15%) had one that was thin but intact and two patients a rupture (one complete). Two patients had postoperative haematoma and one patient developed cuff tear arthropathy. The good results confirm that pectoralis major transfer is a reliable treatment option for irreparable anterosuperior rotator cuff injuries with significant improvement in pain and function.

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.

A new arthroscopic classification of articular-sided supraspinatus footprint lesions: a prospective comparison with Snyder's and Ellman's classification

The aim of this study was to find a descriptive rationale to quantify articular-sided supraspinatus tendon tears in the transverse and coronal planes, leading to a 2-dimensional description of the tear pattern. Fifty-six consecutive patients with articular-sided, symptomatic supraspinatus tendon tears diagnosed clinically and by magnetic resonance imaging underwent standardized diagnostic arthroscopy. Intra-articular findings of the rotator cuff were classified according to Ellman and Snyder. In addition, the longitudinal tear was assessed according to the length of the peeled-off bony footprint in the coronal plane. The sagittal tear extension was defined as a tear of the lateral reflection pulley on the medial border of the supraspinatus tendon and/or a tear in the area of the crescent zone. Statistically, we found a high correlation (r = 0.920, P < .0001) between the classifications of Ellman and Snyder, and we found only a slight correlation between the classifications of Snyder and Ellman with this new classification. Neither the classification of Snyder nor that of Ellman reproduced the extension of the partial-thickness rotator cuff tear in the transverse and coronal planes related to its etiologic pathomorphology.

Arthroscopic rotator cuff repair in overhead-throwing athletes

BACKGROUND

When overhead-throwing athletes suffer from a rotator cuff tear, their ability to perform sporting activities is significantly impaired.

HYPOTHESIS

Arthroscopic rotator cuff repair allows amateur overhead-throwing athletes to return to their preoperative level of overhead-throwing sports.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Twenty-one overhead-throwing athletes (14 male and 7 female; average age, 58.9 years, range, 46-69 years) were reviewed for clinical outcome with the Constant Score and structural integrity of the repair on magnetic resonance imaging. The average follow-up was 25.7 months (24-29 months). Athletes were asked to retrospectively assess their sporting activity for pain, strength, endurance, and range of motion before onset of symptoms, preoperatively and at follow-up. They also were asked to evaluate their overall performance as a percentage of their original performance (0% to 100%). Retear rates and Constant Scores were compared with those of 32 patients who were not overhead-throwing athletes and who were operated on during the same time span.

RESULTS

Patients significantly improved their Constant Score from 54.9 to 84.2 (P < .001). Sporting activity was not significantly influenced by repair integrity; the retear rate was 23.8% (5/21). There was no significant difference for retear rate (25%; 8/32) or clinical outcome (Constant Score 84.5, P = .993) compared with patients who were not involved in overhead-throwing sports or any sports. All patients returned to their overhead-throwing sport an average of 6.3 months (3-12 months) after the surgery. Participation (2.1 per week) and duration (2.3 hours) of overhead-throwing activity postoperatively were not significantly lower than before the patient was injured (2.2 per week, P = .290; and 2.4 hours, P = .285). Patients estimated their overall activity level to be 91.9% of their original, noninjured condition, which was significantly improved from the preoperative condition of 34.8% (P < .001).

CONCLUSION

Arthroscopic rotator cuff repair led to good clinical results in this group of overhead-throwing athletes. Patients were able to return to overhead-throwing sports, most of them at the same preoperative level.

A new SLAP test: the supine flexion resistance test

PURPOSE

This study describes a new test to detect SLAP lesions. The sensitivity, specificity, and positive and negative predictive values with respect to the diagnosis of a SLAP lesion were determined in comparison to Speed's test and the O'Brien test.

METHODS

One hundred fifty patients presenting for arthroscopic surgery with persisting pain or functional disability of the shoulder underwent a complete shoulder examination. All patients underwent Speed's test, the O'Brien test, and the new supine flexion resistance test. The clinical results of the tests were correlated with the presence of a SLAP lesion by direct arthroscopic visualization.

RESULTS

The supine flexion resistance test had a sensitivity of 80% and a specificity of 69%, whereas Speed's test and the O'Brien test had sensitivities of 60% and 94%, respectively, and specificities of 38% and 28%, respectively. Regarding isolated SLAP lesions, the supine flexion resistance test was highly sensitive, with a sensitivity of 92% (58% for Speed's test and 75% for the O'Brien test). For isolated tears of the supraspinatus, the specificity of the supine flexion resistance test was 75% (14% for Speed's test and 17% for the O'Brien test).

CONCLUSIONS

Compared with the O'Brien test and Speed's test, the supine flexion resistance test proves to be more specific, with a specificity of 69% for the whole study population (28% for the O'Brien test and 38% for Speed's test) and with a specificity of 75% for the group of patients with isolated supraspinatus lesions (17% for the O'Brien test and 14% for Speed's test). The new test is a useful and effective test for detecting type II SLAP lesions. The high specificity enables the elimination of false-positive results of other clinical tests that are more sensitive but not specific.

LEVEL OF EVIDENCE

Level II, development of diagnostic criteria with consecutive patients and universally applied gold standard.

Magnetic resonance imaging of arthroscopic supraspinatus tendon repair

BACKGROUND

While a number of studies have documented the very good clinical results of arthroscopic rotator cuff repair, very few authors have specifically assessed cuff integrity, supraspinatus atrophy, and fatty infiltration and their influence on the clinical outcome.

METHODS

We evaluated fifty-three consecutive patients (average age, 60.9 years) who had undergone arthroscopic repair of an isolated supraspinatus tendon tear. After an average duration of follow-up of 26.4 months, all patients were evaluated clinically with use of the Constant score and underwent standardized magnetic resonance imaging at our institution. The preoperative and postoperative magnetic resonance images were evaluated by two independent observers who were blinded to the clinical outcome of the patient. Evaluation criteria were cuff integrity; atrophy of the supraspinatus; and fatty infiltration of the supraspinatus, infraspinatus, and subscapularis. These findings were correlated to the clinical outcome.

RESULTS

Regardless of the tendon integrity, every parameter of the Constant score was significantly improved after the repair. The overall average Constant score was improved from 53.5 to 83.4 points (p < 0.001). The retear rate in our series was 25% (thirteen of fifty-three). Patients who had a retear had significantly less abduction strength (p = 0.043) and a significantly lower total Constant score (p = 0.012) than those who had an intact repair. A higher degree of preoperative supraspinatus atrophy and Stage-2 fatty infiltration of the supraspinatus were positive predictors of a retear. Also, an older age was an important predictor of a retear (p = 0.011). Progression of structural changes in the rotator cuff was halted when the repair remained intact, but there was no significant reversal of fatty infiltration or muscle atrophy. When the repairs failed, there was significant progression of fatty infiltration and atrophy of the supraspinatus.

CONCLUSIONS

The clinical and structural results of arthroscopic repairs of isolated supraspinatus tears are equal to those reported following open repair. Fatty infiltration and muscle atrophy cannot be reversed by successful arthroscopic repair. Higher degrees of muscular atrophy and fatty infiltration preoperatively are associated with recurrence of the tear as well as progression of fatty infiltration and muscular atrophy and an inferior clinical result.

[Arthroscopic treatment of posterior shoulder instability]

OBJECTIVE

Reconstruction of the posterior stabilizing structures of the glenohumeral joint in arthroscopic technique.

INDICATIONS

Posterior shoulder instability and/or chronic subluxations with lesions of the posterior labrum and capsuloligamentous structures.

CONTRAINDICATIONS

Voluntary instability or posterior instability due to pathologic muscle patterning, posterior instability with glenoid fracture, large bone defects of the humeral head (20% of the inferior posterior glenoid) or locked posterior dislocations, dysplasia of the glenoid with pathologic retroversion > 25 degrees .

SURGICAL TECHNIQUE

Mobilization of the pathologic and extraanatomically healed labroligamentous complex, decortication of the glenoid rim, repositioning and refixation of the labroligamentous complex at the glenoid rim using suture anchors.

POSTOPERATIVE MANAGEMENT

Abduction splint at 15 degrees for 3 weeks. Functional therapy with passive mobilization that avoids forced internal rotation. Muscle strengthening only after free range of motion has been achieved. Return to sports that put strain on the shoulder after 6 months.

RESULTS

Eleven patients with a mean age of 31 years were prospectively documented and followed for a mean of 33 months postoperatively. One patient suffered from a traumatic recurrence and one patient experienced recurrent subluxations. The overall mean Rowe score was 95 out of 100 points.

Clinical outcome and tendon integrity of arthroscopic versus mini-open supraspinatus tendon repair: a magnetic resonance imaging-controlled matched-pair analysis

PURPOSE

Arthroscopic rotator cuff repair produces equally good clinical results compared with open or mini-open repair. However, there are concerns about whether the same repair integrity can be achieved. The purpose of our study was to compare clinical and structural results of arthroscopic and mini-open rotator cuff repair.

METHODS

Nineteen patients who had arthroscopic rotator cuff repair (mean follow-up, 25.0 months) were matched for age, gender, and duration of symptoms with nineteen patients who had mini-open repair (mean follow-up, 17.6 months). We compared preoperative and follow-up Constant scores, as well as early range of motion after 6 weeks and 3 months. All patients were examined with the same magnetic resonance imaging system at follow-up to evaluate cuff integrity.

RESULTS

There was no difference in clinical and structural outcome. The overall Constant score improved from 53.8 to 83.9 in the arthroscopic group and from 53.5 to 83.7 in the mini-open group. Early range of motion did not differ significantly at 6 weeks or 3 months postoperatively. The number of retears was 6 (31.6%) in the arthroscopic group and 7 (36.8%) in the mini-open group. This difference was not statistically significant (P = .7358). Although smaller retears had no influence on the clinical result, more retracted retears correlated with lower abduction strength regardless of the repair method.

CONCLUSIONS

In isolated supraspinatus tears arthroscopic rotator cuff repair produces excellent clinical results and equivalent tendon integrity compared with mini-open repair.

LEVEL OF EVIDENCE

Level III, retrospective therapeutic comparative study.

Recentering the humeral head for glenoid deficiency in total shoulder arthroplasty

Substantial posterior glenoid wear causing static posterior subluxation of the humeral head in patients with primary osteoarthritis has been described. Persistent humeral head subluxation after total shoulder arthroplasty can result in early polyethylene wear and glenoid component loosening. In our prospective cohort study, we hypothesized that in patients with posterior glenoid wear from osteoarthritis, static posterior decentering of the humeral head could be recentered during total shoulder arthroplasty by surgical correction of glenoid alignment in the transverse plane with soft tissue balancing. We performed total shoulder arthroplasties in 77 patients with primary osteoarthritis and a mean age of 67.6 years. The mean clinical and radiographic followup was 2 years (range, 1-7 years). Patients with preoperative posteriorly decentered humeral heads did not have posterior decentering develop postoperatively. Twenty patients (83.3%) had centered humeral heads and four patients (16.6%) had anterior decentering. Midterm results of total shoulder arthroplasties in shoulders with humeral head decentering caused by glenoid deficiency in the transverse plane showed correction of the decentering by lowering the high side or by bone grafting with soft tissue balancing can be well maintained.

Influence of tendon healing after arthroscopic rotator cuff repair on clinical outcome using single-row Mason-Allen suture technique: a prospective, MRI controlled study

The reported functional results of rotator cuff repair performed arthroscopically have been good. Only little is known about the cuff integrity after arthroscopic repair and how it influences the outcome. The aim of the study is to set a baseline of what rate of healing response respectively re-tears to expect and how cuff integrity alters the outcome. Fifty-three consecutive patients with an isolated supraspinatus tendon tear were arthroscopically operated and their tendons repaired. All pre- and postoperative data were prospectively collected. At a minimum follow-up after 24 months (average 26.4 months), the integrity of the cuff was evaluated by an open magnetic resonance imaging and the patients' function and satisfaction were documented and graded to the sex- and age-related Constant-score also using a dynamometer for strength testing. The re-tear rate was 24.5% with 13 non-healed tendons. The Constant-score of all patients improved significantly. The scores of the patients with a re-tear were significantly lower than those of the patient with an intact cuff. That was due to a less good performance in strength testing. The other categories of the Constant-score did not show any differences. The age of the patients with a re-tear was significantly higher. With the exception of age, we did not find any negative prognostic factor for a re-tear, and with the exception of re-tear no other factor influenced the Constant-score. Arthroscopic supraspinatus tendon repair yields a re-tear rate of 25% which is comparable with the results of open or mini/open repair. Cuff integrity influences postoperative strength and Constant-score. Patients older than 65 years show a higher re-tear rate. Therapeutic Level IV is the level of evidence.

Postoperative subscapularis muscle insufficiency after primary and revision open shoulder stabilization

BACKGROUND

Postoperative subscapularis muscle insufficiency after open shoulder stabilization procedures represents an unrecognized condition.

HYPOTHESIS

Primary and revision open shoulder stabilization using the inverted L-shaped tenotomy approach impairs subscapularis muscle recovery and affects final clinical outcome.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Twenty-five patients who underwent primary (group 1: n = 13; mean age, 36.5 years; follow-up, 48 months) or revision (group 2: n = 12; mean age, 34.2 years; follow-up, 52 months) open shoulder stabilization procedures were followed up clinically (clinical subscapularis tests and signs, Constant score, and Rowe score) and by magnetic resonance imaging (tendon integrity, defined muscle diameters, and signal intensity analysis [ratio infraspinatus/upper subscapularis muscle and infraspinatus/lower subscapularis muscle]). A third group (group 0) of 12 healthy volunteers served as a control.

RESULTS

Clinical signs for subscapularis muscle insufficiency were present in 53.8% of cases in group 1 and 91.6% of cases in group 2. There were no significant differences between groups with regard to Constant and Rowe scores (P > .05). On magnetic resonance imaging, no complete tendon ruptures were found. The mean vertical diameter of the subscapularis muscle and the mean transverse diameter of the upper subscapularis muscle portion were significantly greater in group 0 than in group 1 and greater in group 1 than in group 2 (P < .05). The mean transverse diameter of the lower subscapularis muscle was comparable in all groups (P > .05). The signal intensity analysis revealed the infraspinatus/upper subscapularis muscle ratio was greater in group 0 than in group 1 and greater in group 1 than in group 2 (P < .05). The infraspinatus/lower subscapularis muscle ratio was lower in group 0 than in groups 1 and 2 (P < .05).

CONCLUSION

Open shoulder stabilization using an inverted L-shaped tenotomy approach may lead to atrophy and fatty infiltration, particularly of the upper part of the subscapularis muscle, resulting in postoperative subscapularis muscle insufficiency. Revision procedures using the same approach may further compromise clinical subscapularis muscle function and structure. The lower portion of the subscapularis muscle seems to have a compensating effect that may, in addition to a meticulous capsulolabral reconstruction, account for the uncompromised overall clinical outcome.

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.