[Current aspects and new techniques in dislocation of the shoulder joint]

With 12% of all injuries concerning the shoulder, acromioclavicular (AC) joint dislocations are a common injury especially in young and active patients. The Rockwood classification is widely accepted, which differentiates between six types depending on the degree of injury and the vertical dislocation. Because the classification does not adequately address the horizontal instability, its benefits are questionable and there is currently no consensus. For this reason, the classification and the therapy of these injuries are increasingly becoming the subject of scientific investigations. Whereas conservative treatment for type I and II injuries and operative treatment for type IV-VI injuries are widely accepted, there is still no agreement in treating type III lesions. The goal of this review article is to present the current evidence for the diagnostics, different classifications and therapeutic possibilities.

[The cloverleaf plate for osteosythesis of humeral head fractures. Definition of the current position]

In this prospective study we evaluated the functional and radiological results obtained in 62 patients who had been treated for fracture of the humeral head by internal fixation with a cloverleaf plate. They were examined postoperatively, after 14 weeks and after an average follow-up of 75 weeks. Nine patients (14.5%) had dislocated 2-part fractures, 36 had 3-part fractures (58%; additional dislocations of the greater or lesser tubercle), 13 patients (21%) had 4-part fractures and 4 (5.6%) had luxation fractures of the humeral head. Early functional physiotherapy was started on the third day after surgery. The complications observed were: subcutaneous infection (2 cases; 3.2%), haematoma (2 cases; 3.2%), temporal paraesthesia of the axillary nerve (1 case; 1.6%). Only 4 (6.5%) patients suffered from necrosis of the humeral head (partial in 3, total in 1); in 2 cases (3.2%) we switched to a different procedure; in both these patients a humeral head prosthesis was implanted; in both these cases the clinical result was poor because of progressive varus dislocation. To improve mobility we performed arthrolysis in 8 cases (12.9%) and acromioplasty in 10 (16.1%), in addition to removing the plates after fracture consolidation confirmed by X-ray examination. In the present study those of our patients who had been treated with open reduction and internal fixation with a cloverleaf plate achieved average Neer scores of 77+/-13 and average Constant scores of 72.4+/-18, and the rates of complications or revisions were low. "Good" or "very good" results were obtained according to the Constant score in 59% of the treated patients. Even patients with complex 4-part fractures had average Constant scores of 72.7 points ("good"). The accuracy of the refixation of the greater tubercle, sufficiently low fixation of the cloverleaf plate and avoidance of varus position when the humeral head was repositioned were significant parameters influencing the functional outcome in our patients.

Diagnostik und Behandlungsregime der traumatischen dorsalen Schulterluxation

In contrast to anterior dislocations, traumatic dorsal shoulder dislocation is a rare complication of upper extremity injuries. If the diagnosis is overseen and treated incorrectly, severe mobility restrictions might be the consequence for the injured individual. Hence, the aim of this article is to demonstrate the adequate diagnostic and therapeutic management and to critically discuss the literature.

Operative und klinische Erfahrungen mit winkelstabilen Implantaten bei proximalen Humerusfrakturen - Wirklich alles besser?

BACKGROUND

Proximal humeral fractures are common in the elderly as distribution peaks in the 6th and 7th decade. Optimal operative strategy regarding complex proximal humeral fractures is still being discussed controversely. Aim of the study was to evaluate implant associated problems of angle-stable implants in comparison to other established osteosynthetic methods.

METHODS

198 patients with proximal humeral fractures were treated operatively from 2000 to 2004 in our department with a primary angle-stable plate osteosynthesis. 166 patients (98 females and 68 males) were followed up. Retrospectively we characterized the fractures type by using the NEER-classification and assessed the functional results with the CONSTANT-score (CS).

RESULTS

Overall the average score was 73,4+/-20 points (range 22-94 points) compared to the non-affected side (90,8+/-8 points (46-100 points)). Patients with anatomical reduction of the fracture showed significant better results in the CS (p<0,05). Compared with other osteosynthetic methods, the use of angle-stable plate osteosynthesis showed no better functional results in the end. In 10,8% a humeral head necrosis occurred. 36 patients (21,6%) revealed a secondary loss of reduction with dislocation of the locking screws, regardless the angle-stable fixation. In 14 cases operative revision was necessary.

CONCLUSIONS

Using angle-stable implants in the operative treatment of complex proximal humeral fractures good results can be achieved in most cases. Nevertheless, in comparison to alternative operative solutions, the results do not show significant better functional outcome. Important for good functional outcome was an exact anatomical reduction as a material independent variable rather than the decision to use more expensive angle-stable implants. Those, who can fulfil such surgical demands, achieve similar results for the patient, even without using angle-stable implants.

Die winkelstabile Osteosynthese am proximalen Humerus mit der PHILOS-Platte

BACKGROUND

Proximal fracture of the humeral head is the third most frequent fracture in humans. Most (70%) of those affected are over 60 years old. It is hoped that advanced locking medullary screws or plates will reduce the risk of secondary dislocation of screws or fracture segments when the bone of the humeral head is osteoporotic.

METHODS

From January 2002 to August 2005, 225 displaced humeral head fractures in 223 patients aged on average 66+/-15 years were treated with a new locking proximal humeral plate.

RESULTS

In 176 patients in whom follow-up was possible, the average Constant Score after 9 months was 70+/-19 points (raw data), or 81+/-22% in the normalized score. No significant difference was detected between the younger group up to 65 years of age (73% points) and those over 65 years of age (80% points). Axial deviations by more than 30 degrees were noted in 11 (5%), and of 159 displaced tubercles, malreduction by more than 5 mm was noted in 14 (9%). Two infections and two haematomas had to be treated so far. Primary screw perforations were seen in 24 (11%) cases as well as further implant dislocations in 3 (1,7%). Plate dislocations out of the shaft existed in 4 (2,4%) and 14 collapses of the humeral head with secondary screw perforations were recorded. All other complications arose out of technical faults, such as 24 screw perforations (11%) into the glenohumeral joint and 3 (1.7%) cases of secondary implant dislocation from the humeral head and 5 (3%) from the shaft, and 14 (8%) sinterings with glenohumeral screw perforation. So far, in addition to 1 case of pseudarthrosis with a broken plate, 5 (3%) cases of total and 9 (5%) of partial avascular humeral head necrosis have been observed.

CONCLUSION

The new implant provides superior stability in the fixation of humeral head fragments and has proved its worth in everyday clinical practice when additional indirect fixation of the tubercle is needed, as it frequently is in elderly patients.

[Effects of functional electric stimulation on shoulder subluxation and upper limb motor function recovery of patients with hemiplegia resulting from stroke]

OBJECTIVE

To observe the effects of functional electric stimulation (FES) on shoulder subluxation and motor function recovery of the upper extremities of patients with hemiplegia resulting from stroke.

METHODS

Forty-eight hemiplegic patients were randomly divided into two groups for treatment with FES and shoulder pads, respectively. The recovery of the patient's shoulder subluxation and movement function of upper extremities were evaluated 6 weeks after treatment and the effects of two therapies were compared.

RESULTS

The shoulder subluxation and movement function of the upper extremities were improved after treatment with both therapies (P<0.01, and FES showed better effect (P<0.01).

CONCLUSIONS

FES can improve shoulder subluxation and motor function of the upper extremities affected by hemiplegia resulting from stroke.

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.

Arthroscopic findings in atraumatic shoulder instability

PURPOSE

The goal of this study was to evaluate the intra-articular pathology in patients with atraumatic shoulder instability who did not respond to conservative treatment.

TYPE OF STUDY

Prospective case series.

METHODS

Of 226 patients treated for shoulder instability over a 2-year-period, 43 patients (average age, 27.5 years; 26 men and 17 women) were classified as having atraumatic instability. None had responded to physiotherapy. The intra-articular pathology was documented during diagnostic arthroscopy before the definitive surgical procedure.

RESULTS

Three types of lesions of the capsulolabral complex were defined: incomplete labral lesions, pathologic elongation of the capsule or "non-Bankart lesions" (type I), classic Bankart lesions (type II), and complex lesions of the labrum and capsule (type III). Type I was found in 19 patients (44.2%); type II lesions were seen in 13 (30.2%); and type III in 11 (25.6%) patients. Hill-Sachs lesions were found in 26 shoulders (60.5%). Chondral lesions of the glenoid were seen in 10 shoulders (23%); SLAP lesions in 5 (11.7%); and partial, articular-side defects of the supraspinatus tendon in 3 (6.9%) patients.

CONCLUSIONS

Atraumatic onset of shoulder instability does not imply the absence of intra-articular lesions, at least in patients not showing a response to physiotherapy. Arthroscopy is helpful to diagnose the definite intra-articular pathology.

LEVEL OF EVIDENCE

Level IV.

[The arthroscopic SLAP refixation]

Lesions of the superior glenoid labrum and the insertion of the biceps tendon are a common cause for shoulder pain in patients performing overhead sports. The therapeutic management depends on the type of lesion, and should be carried out using an arthroscopic procedure. While type I SLAP lesions should be treated conservatively or with simple debridement, SLAP II, IV, and V lesions, with a detachment of the labrumanchor- complex, should be refixed with suture anchors. Only in cases of type III lesions with a bucket handle-like lesion of the labrum, but stable insertion of the biceps tendon, a simple debridement can be performed. From the biomechanical point of view, large type III lesions should also be reconstructed. To improve the arthroscopic view for preparation of the glenoid neck, an intraarticular loop ("Imhoff-suspension sling") can prevent the posterosuperior labrum from falling into the joint. The arthroscopic SLAP refixation is a technically highly demanding procedure which provides good clinical results for the patient.

[MR imaging of variants of the superior labral-bicipital complex and SLAP lesions]

In the detection of SLAP (superior labral anterior to posterior) lesions of the shoulder MR arthrography shows a significantly higher sensitivity compared with conventional MR techniques and therefore, represents the method of choice in diagnostic imaging of the superior labral-bicipital complex. On the basis of morphological criteria it mostly allows distinction of traumatic lesions and anatomic variants of the superior labrum and the biceps anchor as well as classification of detected SLAP lesions (types 1-4 according to Snyder). However, the differentiation of a SLAP type 2 lesion and a sublabral recess can be very difficult, even if all distinction criteria are considered.

[Biomechanical tests for type II SLAP lesions of the shoulder joint before and after arthroscopic repair]

Superior labral anterior-to-posterior (SLAP) lesions can cause shoulder pain partly by causing glenohumeral instability. The purpose of this study was to examine the effect of a simulated type II SLAP lesion and subsequent repair on glenohumeral translation of the vented shoulder. In eight cadaver joints, a robotic/UFS testing system was used to measure joint translation by applying an anterior, posterior, or inferior load of 50 N to each shoulder. The "apprehension tests" for anterior and posterior instability were simulated by applying an anterior load of 50 N with an external rotation torque of 3 Nm or a posterior load of 50 N with an internal rotation torque of 3 Nm. Each loading condition was applied at 30 degrees and 60 degrees of glenohumeral abduction with a constant joint compressive load (44 N) to the intact, simulated SLAP lesion, and repaired shoulder. Repair of the type II SLAP was then performed by placing a Suretac through the labrum both anterior and posterior to the biceps anchor and testing was repeated. ANOVA was used to compare translation of the intact joint, the joint after the type II SLAP lesion had been simulated, and after repair. At 30 degrees of abduction, anterior translation of the intact vented shoulder joint from anterior loading was 18.7+/-8.5 mm and increased to 26.2+/-6.5 mm after simulation of the type II SLAP lesion ( p< or =0.05). The arthroscopic repair did not restore anterior translation (23.9+/-8.6 mm) to the same degree as the intact joint ( p> or =0.05). At 60 degrees of abduction, anterior translation of 16.6+/-9.6mm in the intact joint was not significantly increased at 19.4+/-10.1 after simulation of the type II SLAP lesion ( p=0.0527). AP loading also resulted in inferior translation. At 30 degrees of abduction it was 3.8+/-4.0 mm in the intact joint and increased to 8.5+/-5.4 mm after the type II SLAP lesion ( p< or =0.05. After repair the inferior translation decreased significantly to 6.7+/-5.3 mm ( p< or =0.05). Although inferior translations were less at 60 degrees of abduction, results were similar to those at 30 degrees after repair. There were no significant increases in translation after SI/AP combined external rotation torque or posterior-anterior combined internal rotation torque loading. In this study the repair of a type II SLAP lesion only partially restored translations to the same degree as an intact vented shoulder joint. Therefore, improved repair techniques or an anteroinferior capsulolabral procedure in addition to the type II SLAP lesion repair might be needed to restore normal joint function.

[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.

[SLAP-lesions of the shoulder]

The advent of shoulder arthroscopy, as well as our improved understanding of shoulder anatomy and biomechanics, has led to the identification of previously undiagnosed lesions involving the superior labrum and biceps tendon anchor. Although the history and physical examinations as well as improved imaging modalities (i. e. magnetic resonance arthrography) are extremely important in understanding the pathology, the definitive diagnosis of SLAP lesions ("superior labrum anterior and posterior") is accomplished through diagnostic arthroscopy. Treatment of these lesions is directed according to the type of SLAP lesion. In general, type I and III SLAP lesions are debrided, whereas type II and many type IV lesions are repaired. The purpose of this article is to review the anatomy, classification, diagnosis and current treatment recommendations.

[Biomechanical investigations for the development of a SLAP-II-lesion]

The superior labral-biceps-tendon-complex forms an anatomical and functional unit and combines static and dynamic elements of shoulder stability. At present, only theoretical hypotheses exist on the etiology of the microtraumatic SLAP-II-lesion. To gain further insight into this, an instrument was developed to simulate throwing motions such as the late-cocking/early acceleration phase as well as deceleration/follow-through. Sixteen freshly frozen shoulder specimens were tested, varying the loads on the biceps tendon (25 N, 50 N, 100 N) and the compression of the humeral head against the glenoid (25 N, 50 N, 80 N). Each shoulder had to run through a certain number of cycles during the particular phase of throwing. The tests were stopped after a SLAP-II-lesion was observed, or after a limit of 15,000 cycles. Every 1,000 cycles the results of the tests were checked arthroscopically. A SLAP-II-lesion developed in only 10% of the specimens during the acceleration/ late cocking phase whereas in the deceleration/ follow-through phase 83% developed such a lesion. According to our results, the deceleration/follow-through of the throwing motion seems to be responsible for creating microtraumatic SLAP-II-lesions. One reason is the loss of the centering function of the long head of the biceps tendon during total internal rotation, another is the increased posterosuperior translation of the humeral head in this position, which leads to a non-physiological contact, creating lesions in this area due to the large sheering forces.

[Results of repair of SLAP lesion]

The surgical repair of SLAP lesions has become increasingly more common as the techniques and instrumentation have improved. However, there are few studies examining the results of repair of SLAP lesions. The goals of this paper are to summarize the recommended treatment for SLAP lesions and to report upon the studies available to date which report the results of SLAP repair.

[Epidemiology, treatment and results of proximal humeral fractures: experience of a district hospital in a sports- and tourism area]

AIM OF THE STUDY

The epidemiology, therapy and results of proximal humeral fractures in a touristic area were investigated and our concept for treatment presented.

METHODS

Between 1.1.1999 and 30.04.2000 adult patients with proximal humeral fractures were included, the fractures classified (Codman/Neer and AO) and results determined after an average of 9 months.

RESULTS

62 adults were treated. 59 (95 %) had an accident during leisure time, mainly skiing accidents (52 %). 7 patients (11 %) had an associated luxation of the shoulder. 51 (82 %) were treated conservatively, 11 (18 %) operatively with a T-plate. The conservatively treated had to wear a Gilchrist-cast for an average of 29 (operatively 13) days, started passive movement after 20 (operatively 9) days, and active movement after 44 (operatively 45) days. The 32 employed (52 %) were not able to work for 46 days on average. Overall, 52 patients (84 %) were totally or mostly satisfied with the result. 5 among the 13 patients (38.5 %) with 3- or 4-part-fractures, and 4 among the 11 operated patients (36.4 %) were not satisfied with the result.

CONCLUSIONS

Proximal humeral fractures are common skiing injuries, they need a long and intensive treatment and are economically expensive. The Codman/Neer and AO-classifications are equal. The results for simple, mainly conservatively treated fractures (Codman/Neer 1, 2A, 2-part) are good. Complex, mainly operatively treated fractures (Codman/Neer 3- and 4-part) have a much poorer prognosis. Diagnostically the computed tomography with 3-D-reconstruction is recommended for a better representation of the fracture and a safer choice of the therapeutical strategy.

[Complex fractures of the humeral head: which long-term results can be expected?]

BACKGROUND

Although improved techniques of internal fixation and prosthetic replacement were introduced successfully in the field of operative fracture care, treatment of complex fractures of the proximal humerus also involving the humeral head remains to be a challenge to the trauma surgeon. We therefore investigated clinical and radiological long-term results after humeral head preserving procedures.

METHODS

41 patients with a three or four part fracture of the humeral head were evaluated on average 6.6 years (min. 4.4 y; max. 9.0 y) after the trauma. The evaluation was based on the Constant- and HSS score clinically and on the Neer score radiologically. Nine patients were treated conservatively (group A), 13 patients had primarily an operative treatment (group B) and another 19 were operated upon after failure of conservative means. 24 of the patients were female and 17 male, with an average age of 52 years (min. 14.4 y; max. 71.2 y). According to Neers 's fracture classification of humeral head fractures we saw 14 type IV, 25 times a combination of type IV and V and in another 2 cases a type VI fracture.

RESULTS

In group A (conservative) the Constant score showed on average 82.0 points for the injured and 95.3 points for the contralateral shoulder, the HSS score revealed 73.6 points and Neer's x-ray score 5.6 points. Group B (operated) showed also good results on average according to a Constant score of 72.1 points (fractured humerus) compared with 98.1 points of the contralateral shoulder. HSS score was 64.7 points. The radiological results reached 4.0 points. Group C (conservatively failed, secondary operation) achieved 68.2 points for the injured side and 95.8 points for the contralateral side according to Constant and 59.5 points according to HSS score. The x-ray evaluation showed 5.3 points. Fracture type did not influence the outcome in any of the groups. There was no humeral head necrosis in group A, one in group B (2.4 %) and four in group C (9.8 %).

CONCLUSION

These data show that regarding to clinical and radiological long-term results also complex fractures of the humeral head should be treated by head preserving procedures.

Arthroscopic repair of anterosuperior (supraspinatus/subscapularis) rotator cuff tears: a prospective cohort with 2- to 4-year follow-up. Classification of biceps subluxation/instability

PURPOSE

The purpose of this study was to evaluate the outcome of patients who underwent arthroscopic repair of anterosuperior rotator cuff tears. The null hypothesis, that there was no difference between preoperative scores and postoperative scores, was tested statistically.

TYPE OF STUDY

A cohort study.

METHODS

The preoperative and postoperative status of patients with anterosuperior rotator cuff tears was analyzed using the Constant score, American Shoulder and Elbow Society Index (ASES Index), a visual analog pain scale (VAS), a single question of percent function compared with the opposite unaffected extremity, and a single question reflecting satisfaction, "would you undergo the surgery and the postoperative rehabilitation to achieve the result you have today." There were also 2 groups compared: 1 that had a "tac" used for repair of the subscapularis tendon, and the other that used a "tie" technique for subscapularis repair. All supraspinatus tendon tears were complete and were repaired using a soft-tissue fixation device.

RESULTS

There was a statistically significant difference for all outcome measures except for the objective Constant score of the tie group, P =.58. Follow-up was 2 to 4 years. There were no differences based on sex or type of fixation device used for repair of the subscapularis tendon. There were no reruptures, clinically.

CONCLUSIONS

The arthroscopic repair of anterosuperior rotator cuff tears provides reliable expectation for improvement in function, decreases in pain, decreases in clinical findings of biceps subluxation and inflammation, improvement in shoulder scores, and the improvement of clinical findings of subscapularis insufficiency.

Classification of glenohumeral joint instability

Shoulder instabilities have been classified according to the etiology, the direction of instability, or on combinations thereof. The current authors describe a classification system, which distinguishes between static instabilities, dynamic instabilities, and voluntary dislocation. Static instabilities are defined by the absence of classic symptoms of instability and are associated with rotator cuff or degenerative joint disease. The diagnosis is radiologic, not clinical. Dynamic instabilities are initiated by a trauma and may be associated with capsulolabral lesions, defined glenoid rim lesions, or with hyperlaxity. They may be unidirectional or multidirectional. Voluntary dislocation is classified separately because dislocations do not occur inadvertently but under voluntary control of the patient.

The often overlooked posterior dislocation of the shoulder

Unlike most shoulder dislocations, the posterior dislocation is truly a diagnostic challenge to the treating physician because it may be missed more often than it is recognized. In fact, more than 60% of posterior dislocations are misdiagnosed initially by the treating orthopedic surgeon, and the correct diagnosis is often delayed for months or years. A history of seizures, electroshock, or a fall onto a flexed, adducted arm should alert the physician to the possibility of posterior dislocation. A careful physical examination with comparison to the unaffected arm must be performed with particular attention given to subtle posterior fullness and anterior flatness of the shoulder, along with a lack of external rotation and abduction. A radiographic trauma series made in the scapular plane must always be obtained in cases of shoulder trauma to rule out posterior dislocation. A computed tomographic scan may also be necessary. The correct diagnosis of this injury will facilitate proper orthopedic evaluation and treatment and will reduce the incidence of missed posterior shoulder dislocation and its associated morbidity.

[Damage to the glenoid labrum and expert assessment]

AIM

Development of criteria for the medical-legal interpretation of different patterns of labral lesions according to the labrum pathology and mechanism of injury.

METHODS

A metaanalysis of the literature concerning injuries and diseases of the shoulder involving the glenoid labrum was performed.

RESULTS

Lesions of the superior, anterior and posterior labrum are rare and of different severity. Arthroscopically they are divided into distinct types. They develop either spontaneously together with intraarticular diseases, due to chronic fatigue or by injury. In this field the stability of the shoulder joint and the tension of the long head of the biceps tendon play an important role. There is no correlation between the type of lesion and mechanism of injury. With respect to medical-legal interpretation, the currently used classification of labral lesions is not very helpful or is even confusing. We therefore propose a new classification according to the meniscus pathology which shows a striking similarity to labral pathology. There are two types of labral lesions: Type one shows degenerative defects, which may be influenced by mechanical loading; type two follows from shoulder instability.

CONCLUSIONS

Medical-legal interpretation of labral lesions should follow the same principles that were shown to be useful in knee joint instability and meniscal tears. Only traumatic luxations of the shoulder joint may lead to labral tears without any other alterations.

Arthroscopic lavage compared with nonoperative treatment for traumatic primary anterior shoulder dislocation: a 2-year follow-up of a prospective randomized study

A prospective randomized study was performed on 30 consecutive patients with traumatic primary anterior shoulder dislocation to compare treatment results of arthroscopic lavage with results of conventional nonoperative treatment. The patients were between 18 and 30 years of age and had no history of shoulder problems. At the 2-year follow-up, 3 (20%) of 15 patients in the lavage group had a redislocated shoulder compared with 9 (60%) of 15 patients in the nonoperative group (P = .03). Two of the patients in the lavage group compared with 6 of the patients in the control group had been operated on or were scheduled for stabilizing surgery. Functional outcome according to the Constant and Rowe shoulder scores did not reveal any significant difference (P = .07) between the groups. However, by the Rowe classification 2 of 15 patients in the lavage group had poor results versus 8 of 15 in the control group, indicating an advantage for the lavage treatment. The study showed that arthroscopic lavage reduced the risk for recurrent dislocation when compared with nonoperative treatment.

Posterior shoulder dislocation associated with fracture of the humeral anatomic neck: treatment guidelines and long-term outcome

OBJECTIVE

We describe here 10 cases of posterior shoulder dislocation associated with fracture of the humeral anatomic neck.

METHODS

Patients were treated according to our uniform treatment guidelines, in which only the dislocated humeral head (closed, if possible) was reduced, without any concomitant repositioning or internal fixation for fractures.

RESULTS

Reduction resulted in an acceptable repositioning of the fractured fragments in all but one case. Anatomic neck fractures were impacted by applying longitudinal pressure for stabilization. Although early physiotherapy was initiated, redisplacement of the bone fragments did not occur. Of nine patients who were followed for more than 2 years, complete recovery of function was achieved in all but two patients. The completely detached humeral head became avascular necrotic accompanied by subchondral collapse in one case, and in the other case the displaced lesser tuberosity caused a decreased range of movement.

CONCLUSION

We recommend initially treating such patients by either open or closed reduction of the dislocated humeral head and impaction of the fracture, with neither repositioning nor internal fixation of any of the fractured fragments. A completely detached humeral head or bone fragments displaced more than 10 mm after reduction of the dislocated humeral head contraindicate the use of this method.

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.

[Computerized tomography measurement of anteroposterior humeral dislocation. Proposing a method. Application to centered osteoarthritis]

PURPOSE OF THE STUDY

The authors proposed a CT method to measure the humeral head subluxation in sagittal plane. They used this method to analysed the sagittal position of the humeral head, in primary gleno humeral osteoarthritis without humeral head elevation.

MATERIAL AND METHODS

The control group was composed of 50 shoulder computed tomography in small rotator cuff tear confined to the supraspinatus muscle (Bernageau stade I on the arthrography). We evalued computer tomographic findings in 104 cases of primary gleno humeral osteoarthritis without humeral head elevation. The results were expressed in rate of subluxation.

RESULTS

This method can be used to measure sagittal subluxation of the humeral head in scapulo humeral pathology. In 35 per cent of cases, gleno humeral osteoarthritis without humeral head elevation, the posterior subluxation (rate of subluxation > 55 per cent) can explain the arthritic evolution. If total shoulder arthroplasty is performed, persistent posterior subluxation may result in premature posterior wear of the glenoïd component, or, in premature loosening of the glenoïd component.

CONCLUSION

The method used for sagittal subluxation of the humeral head measurement is precise. This study, emphasizes the pronostic interest and the therapeutic consequences of this measurement in gleno humeral osteoarthritis without humeral head elevation.

The treatment of displaced supracondylar fractures of the humerus in children. A comparison of three methods

This retrospective study compares the long-term results of the treatment of 135 children with displaced extension-type supracondylar fractures of the humerus using 3 different methods. Closed reduction and percutaneous fixation was superior with excellent and good results in 87% and had the lowest incidence of poor results (8%). Open reduction and wire fixation, and closed reduction with a plaster cast gave excellent and good results in 74% and 60% respectively. Closed reduction and wire fixation is recommended as the treatment for grades II and III supracondylar fractures.

[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.

Arthroscopic Bankart suture repair for traumatic anterior shoulder instability: analysis of the causes of a recurrence

Eighty-two patients with traumatic anterior shoulder instability were treated with an arthroscopic transglenoid multiple suture technique (Caspari's method) and followed-up for more than 2 years. A retrospective analysis of the clinical outcome was performed to determine the factors related to poor results. The mean age at operation was 21 years (range, 13 to 50 years) and the mean follow-up period was 40 months (range, 24 to 70 months). According to the status of the ligament-labrum complex and the glenoid bone defect, the Bankart lesions were classified into five types arthroscopically. There were 21 shoulders of type 1, 33 shoulders of type 2, 22 shoulders of type 3, and 6 shoulders of type 5. Twenty-four of the patients played contact sports before the operation. The clinical outcome was assessed by Rowe's criteria (1978). To analyze the factors related to a poor outcome, a multivariate analysis was done to assess the influence of 12 clinical factors (age at operation, age at first dislocation, sex, dominant side, disease duration, number of dislocations, sporting activity before operation, inferior joint laxity, thickness of the ligament-labrum complex, type of Bankart lesion, number of sutures, and method of suture fixation). Fifty-five of 82 patients had an excellent outcome, 14 had a good result, and 13 had a poor result. According to postoperative instability, redislocation was seen in 13 patients (16%), resubluxation in 2 patients (2%), with a recurrence rate of 18%. The mean limitation of external rotation at 90 degrees abduction was 6.0 degrees (range, 0 degrees to 30 degrees), and there was a 10 degrees loss of external rotation in 10 patients. The factors significantly related to recurrence were a type 3 Bankart lesion, playing contact sports preoperatively, a thin ligament-labrum complex, and repair with less than four sutures. In conclusion, a 18% rate of recurrence is not acceptable. To obtain a better clinical outcome, very careful selection of patients for this technique is necessary. Our analysis of the factors related to a poor outcome may help to decide what the proper indications are for this technique.

[Indications and results of shoulder prosthetics in complex proximal humerus fractures]

Complex fractures of the proximal humerus are uncommon injuries and a therapeutic challenge to the orthopaedic surgeon. Successful treatment requires proper evaluation of the patient and analysis of standardized high-quality radiographs. The trauma series of radiographs (including true anteroposterior and lateral views in the scapular plane, and axillary view) is essential for accurate fracture assessment. Generally, joint-preserving reconstructive techniques are emphasized, aiming at restoration of the anatomy of the proximal humerus. In young individuals with excellent quality of the bone fragments, careful techniques of reduction and fixation, avoiding additional surgical devascularization, should be performed, even in case of possible impairment of the vascular supply to the humeral head. In elderly individuals with osteoporotic bone and limited compliance throughout aftercare, humeral head replacement may be indicated less restrictively. In the latter group hemiarthoplasty generally can be expected to result in painfree shoulders. However, recovery of function and range of motion are much less predictable.

[Classification and therapy of the unstable shoulder]

Instability of the shoulder can be classified as uni- or multidirectional with or without general hyperlaxity. Instability of a shoulder without hyperlaxity is often caused by a single traumatic event for the unidirectional instability and by two or several different events for the rarer multidirectional instability. The diagnosis of unidirectional instability is made with a positive apprehension test. For multidirectional instabilities, the anterior and posterior apprehension tests are positive. The treatment consists of surgical repair of the labrum-capsule complex for both the uni- and the multidirectional instabilities without hyperlaxity. For shoulders with a concomitant hyperlaxity, uni- or multidirectional instability is often caused by only minor trauma. Hyperlaxity itself is not a disease but represents a risk factor of instability. The typical feature of hyperlaxity is the positive "sulcus sign". Unidirectional instability with hyperlaxity is characterised by a positive apprehension test combined with a positive sulcus sign. Multidirectionally unstable shoulders with hyperlaxity have a positive anterior and posterior apprehension test as well as a positive sulcus sign. The unidirectional instability with hyperlaxity is best treated surgically whereas conservative treatment is recommended for the multidirectional instability with hyperlaxity. The voluntary instability without loss of control of position of the shoulder is not a real instability and has an excellent prognosis without treatment.

[The first dislocation of the shoulder]

The classical anterior-inferior dislocation of the shoulder is diagnosed easily by clinical examination and x-ray. The additional lesions like impression fracture at the humerus, avulsion of the anterior rim of the glenoid, lesions of the rotator cuff or neurologic deficits are more difficult to realise. In young patients the redislocation rate is rather high. Indication for surgery is still on debate. Modern diagnostic tools will help to determine additional lesions. More problems are incountered in presence of a posterior dislocation. Those are often overlooked.

[Osteosynthesis of proximal humerus fractures]

Only 5% of adult fractures are fractures of the proximal humerus. In 80% of these fractures one can expect a good result, because they are generally nondisplaced, stable and allow early mobilization. However, the other 20% of these fractures present not only problems with reduction and adequate fixation but also the risk of humeral head necrosis and painful shoulder ankylosis. The operative treatment of displaced fractures of the proximal humerus has changed during the last few years. Minimal osteosynthesis takes into consideration the great extend and the biological aspects of these fractures and provides sufficient stability for early functional therapy. The Neer-classification has proved very useful for both, the indication for and the choice of an operative procedure.

The evaluation and treatment of the injured acromioclavicular joint in athletes

Injuries to the acromioclavicular joint are among the most commonly occurring problems in the athletic patient population. However, these injuries are often confused with other problems associated with the shoulder complex. This confusion was noted by Hippocrates (460-377 BC), who realized that acromioclavicular dislocation often was misdiagnosed as a glenohumeral injury. Galen (129-199 AD) experienced an acromioclavicular dislocation and could not tolerate the tight bandaging recommended at the time and thus became one of the earliest noncompliant patients. The understanding of acromioclavicular injuries and their management has evolved rapidly during the last 2 decades. This review will clarify the current concepts in the management and treatment of acromioclavicular injuries in the athlete.

Arthroscopic repair of glenolabral injuries with an absorbable fixation device

In view of potential problems with metallic implants around the shoulder a bioabsorbable tact has been used in arthroscopic repair of labral lesions in the shoulder joint. We report on a consecutive series of 70 patients (71 shoulders) who had arthroscopic stabilization of Bankart lesions, SLAP lesions, and other labral detachments with the Suretac device. Minimum follow-up time was 12 months (range 12 to 27 months). Clinical outcome was assessed with the Constant score. The recurrence of dislocation or subluxation in the 42 unstable shoulders was 12% (5 of 42), and in 78% (33 of 42) the Constant score was rated good or excellent. The recurrence of dislocation in true anteroinferior dislocators was 3.2% (1 of 31). A total of 82.3% (14 of 17) of patients with SLAP repairs were rated good or excellent, and 53% (9 of 17) returned to their preinjury level of sporting activities. Eight (67%) of 12 patients with labral detachments other than Bankart and SLAP lesions were rated good or excellent, and 64% (7 of 11) returned fully to sports.

[MRI arthrography--improved diagnosis of shoulder joint instability]

In a prospective study, we examined 34 patients with shoulder instabilities and 5 patients with unclear chronic shoulder pain (4 females, 35 males; 18-56 years of age, median 28 years) by CT arthrography and MRT arthrography from August 1994 through December 1995. No complications were seen when gadolinium-DPTA was applied intra-articularly. Twenty-three patients were followed up by operation and/or arthroscopy; 20 patients underwent a modified, open Bankart operation. In this paper, we present a new classification for damage of the anterior capsule and labrum. MRT arthrography showed better results in judging the anterior labrum and in determining the degree of damage to the labrum (sensitivity, specificity and accuracy 100%) in comparison with CT arthrography (sensitivity 90%, specificity 100%, accuracy 91%). Furthermore, MRT arthrography gave clearer results than CT arthrography regarding SLAP and cartilage lesions. Thus, MRT arthrography has proved to be a very exact method for diagnosing shoulder instabilities and is superior to CT arthrography in diagnostic accuracy.

Arthroscopic Bankart procedure: two- to five-year followup with clinical correlation to severity of glenoid labral lesion

We report our results using the arthroscopic Bankart technique described by Morgan (transglenoid suture) on 60 consecutive patients with anterior instability. All had detachment of the glenoid labrum at surgery. Forty-seven patients were available for final followup, which ranged from 2 to 5 years. Of these patients, 18 had experienced recurrent dislocation and 3 had experienced episodes of subluxation after surgery, for an overall failure rate of 42%. Partway into the study, we began to correlate severity of glenoid labral lesion with outcome. We classified the labral lesion in 37 patients using stringent criteria at the time of surgery. Followup among these patients averaged 37 months. Of 22 cases of simple detachment of the labrum with no other significant lesion (Type II labrum), there was one failure (4.5%). Of the 15 cases with significant or complete degeneration of the glenoid labrum-inferior glenohumeral ligament complex (Types IV or V labra), 13 failed (87%). Of the patients without recurrent instability, loss of external rotation averaged 1.5 degrees, strength was 5+/5+ in abduction and external rotation. Average postoperative function was 94% of preinjury levels subjectively, and most patients were able to return to previous activities, including throwing and other overhead sports. Our findings indicate that rates of redislocation after this arthroscopic Bankart procedure correlate directly with the degree of glenoid labrum-inferior glenohumeral ligament complex lesion.

Trauma-instability-voluntarism classification for glenohumeral instability

Classification of glenohumeral instability is confusing. We think that the existence of trauma, directions of instability, voluntarism, and other factors make classification difficult. The purpose of this article is to create a new classification. One hundred eighty-nine patients with glenohumeral instability involving 207 joints (mean patient age 21.5 years) were subjects of this investigation. Our new classification, which is composed of three main factors (level of trauma, direction of instability, and voluntarism) and some subfactors, simplified it quite well. Abbreviations also make it easier to indicate each joint's condition. About half the subjects had no trauma or mild trauma. Two thirds of the joints with more than one dislocation or subluxation showed instability in other directions in addition to the direction of dislocation or subluxation. This classification is very useful to compare pathogenesis and results of treatment in patients with glenohumeral instability.

[Differential therapy of traumatically-induced persistent posterior shoulder dislocation. Review of the literature]

Three-hundred and twenty-nine cases of posterior dislocation of the shoulder documented in 300 articles published in the international literature are reviewed. They included 130 cases in which the duration of the dislocation was longer than 6 weeks and the dislocation could be classified as persistent primary dislocation. This group is the second largest group following that with acute primary dislocation. The mechanism of injury may be direct or indirect force: trauma, convulsions or electrocution are usually responsible for this type of dislocation, which often persists for longer than 6 weeks. Anatomically, 97.5% of dislocations are classified as subacromial. Posterior dislocation of the shoulder is commonly misdiagnosed on plain antero-posterior radiographs, and in over 50% of cases the diagnosis was missed on first examination. The typical signs of primary traumatic posterior dislocation of the shoulder are described. Management of persistent traumatic posterior dislocation of the shoulder depends on the size of the anterior Hill-Sachs lesion, the precipitating mechanism and the duration of dislocation. The results of 109 surgically and 24 conservatively treated dislocations of this type that have been published in the international literature are reviewed. Closed reduction is indicated in carefully selected cases with an anterior Hill-Sachs lesion under 15% of the size of humeral head (measured in the axillary view) that has been dislocation for less than 2 months. In most due to convulsions there was a distinct anterior Hill-Sachs lesion, which led to recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

[Instability of the shoulder joint in the athlete]

In all shoulder instabilities it is very important to classify the type of instability precisely in order to choose the right form of therapy and predict the results. The acronyms TUBS, which means traumatic instability, unidirectional, Bankart lesion, and good response to surgery, and AMBRI, which means atraumatic aetiology, multidirectional, and good for rehabilitation, represent the complete range of possible instabilities. We discuss the subtypes in the differentiation of various instabilities and the different causes and pathologies for instability, the clinical and radiological tests possible, and the different surgical treatment options, as well as the results in the literature. A modification of the Bankart procedure and the arthroscopic Caspari capsulorrhaphy procedure for traumatic instabilities are described. The capsular T-shift by Neer and Foster is explained as a surgical treatment for multidirectional instability.

Locked posterior dislocation of the shoulder: treatment using rotational osteotomy of the humerus

This study reports the use of rotational osteotomy in 10 patients with locked posterior dislocation of the shoulder. The average interval between injury and diagnosis was 155 days (range, 21-400 days). Patients were aged 40-78 years old, with an average age of 53 years. Articular impaction fracture of the humeral head involved 20-40% of the articular surface as determined by CT analysis. There were no postoperative complications except a transient axillary nerve palsy. Patients were started on immediate passive motion followed by an active program at 2-3 weeks. Using the Rowe/Zarins scale, six patients had good-excellent results, two fair results, and two poor results. The poor results were seen in cases where articular cartilage damage was advanced. Rotational osteotomy is an effective procedure at restoring glenohumeral congruity and early functional activity in the patient with locked posterior shoulder dislocation given the following criteria: (a) healthy articular cartilage, (b) a humeral head defect involving less than 40% of the articular surface, and (c) a patient who is able to participate in an active rehabilitation program.