Neural and cortisol responses to acute psychosocial stress in work-related burnout: The Regensburg Burnout Project.

BACKGROUND: While several attempts have been made to elucidate the pathophysiology of burnout, neural stress responses have not yet been investigated. Therefore, the aim of this study was to examine salivary cortisol and - for the first time - neural responses to acute psychosocial stress within a strictly specified sample consisting of individuals suffering from burnout (BO group) and a healthy comparison group (HC group). METHODS: After a multi-stage recruitment procedure based on burnout symptomatology and pathogenesis, 55 individuals suffering from burnout (25 women) and 61 individuals serving as HC group (31 women) out of an initial sample of 1022 volunteers were exposed to acute psychosocial stress during functional magnetic resonance imaging (fMRI) applying ScanSTRESS. RESULTS: No differences were found between the BO and the HC group with respect to cortisol and mean neural stress responses. However, an exploratory comparison of neural stress responses of the first and second run of ScanSTRESS (exposure-time effect) revealed group-specific response patterns in one cluster peaking in the left dorsal anterior cingulate cortex (dACC). While the neural activation of the HC group was higher in the first compared to the second run of ScanSTRESS (i.e., decreasing activation), this pattern was reversed in the BO group (i.e., increasing activation). CONCLUSIONS: Our analysis mainly did not provide evidence for altered acute cortisol and mean neural stress responses in burnout. However, the BO group was characterized by a limited capacity to show decreasing activation over stress exposure-time and exhibited instead increasing activation. Importantly, this group difference manifested in the left dACC which is both involved in neural stress processing and affected in individuals suffering from burnout. Given the present results, it seems promising to further examining temporal dynamics of neural stress responses in (sub-) clinical conditions such as burnout.

Neural responses to acute stress predict chronic stress perception in daily life over 13 months.

The importance of amygdala, hippocampus, and medial prefrontal cortex (mPFC) for the integration of neural, endocrine, and affective stress processing was shown in healthy participants and patients with stress-related disorders. The present manuscript which reports on one study-arm of the LawSTRESS project, aimed at investigating the predictive value of acute stress responses in these regions for biopsychological consequences of chronic stress in daily life. The LawSTRESS project examined law students either in preparation for their first state examination (stress group [SG]) or in the mid-phase of their study program (control group [CG]) over 13 months. Ambulatory assessments comprising perceived stress measurements and the cortisol awakening response (CAR) were administered on six sampling points (t1 = - 1 year, t2 = - 3 months, t3 = - 1 week, t4 = exam, t5 = + 1 week, t6 = + 1 month). In a subsample of 124 participants (SG: 61; CG: 63), ScanSTRESS was applied at baseline. In the SG but not in the CG, amygdala, hippocampus, and (post-hoc analyzed) right mPFC activation changes during ScanSTRESS were significantly associated with the trajectory of perceived stress but not with the CAR. Consistent with our finding in the total LawSTRESS sample, a significant increase in perceived stress and a blunted CAR over time could be detected in the SG only. Our findings suggest that more pronounced activation decreases of amygdala, hippocampus, and mPFC in response to acute psychosocial stress at baseline were related to a more pronounced increase of stress in daily life over the following year.

Investigation of cross-sectional and longitudinal associations between work-related burnout and hair cortisol: The Regensburg Burnout Project.

BACKGROUND: Burnout is characterized by feelings of exhaustion, depersonalization as well as reduced personal accomplishment and is linked to various negative health effects. Previous studies on biological correlates of burnout have focused on the hypothalamic-pituitary-adrenal (HPA) axis. However, especially studies on hair cortisol concentrations (HCC) were often based on cross-sectional data and yielded inconsistent results, probably due to the heterogeneity of the selected samples. Accordingly, the aim of the present study was to investigate cross-sectional as well as longitudinal associations between burnout and HCC within a sample consisting of a strictly specified group of individuals suffering from burnout (BO group) and a healthy comparison group (HC group). METHODS: After a multi-stage recruitment procedure based on burnout symptoms and pathogenesis, eligible subjects (out of an initial sample of 1022 volunteers) were assigned either to a BO (n = 55) or HC group (n = 59), as described in detail in Bärtl et al. (2022). Burnout symptoms as well as HCC (1 cm hair samples) were measured repeatedly at two sampling time points t1 (n = 114) and t2 (n = 100) with an interval of M = 7.20 months (SD = 1.16) between assessments. RESULTS: In the total study sample, no cross-sectional associations between burnout and HCC were found either at t1 or at t2. When the analysis was restricted to the BO group, HCC was positively related to burnout symptomatology at t1 but not t2. In the longitudinal analysis, burnout symptoms at t1 were significant negative predictors of HCC at t2. However, the change in HCC from t1 to t2 was not associated with the change in burnout symptoms. CONCLUSIONS: In the present study, we investigated the association between HCC and burnout in a strictly defined sample of subjects suffering from burnout and healthy controls. Our findings mainly do not support our hypotheses. At least, the positive association between HCC and burnout symptoms only within the BO group supports the idea that HPA axis alterations in burnout might only become apparent once a certain threshold of burnout symptomatology has been exceeded, while the longitudinal data provide some empirical evidence for the potential long-term development of hypocortisolism in burnout. However, respective results remain relatively inconclusive.

Comparing two psychosocial stress paradigms for imaging environments - ScanSTRESS and fNIRS-TSST: Correlation structures between stress responses.

The present post-hoc analysis of two independent studies conducted in different laboratories aimed at comparing reactions of stress activation systems in response to two different psychosocial stress induction paradigms. Both paradigms are based on the Trier Social Stress Test (TSST) and suited for neuroimaging environments. In an in-depth analysis, data from 67 participants (36 men, 31 women) from a functional magnetic resonance imaging study implementing ScanSTRESS were compared with data from a functional near-infrared spectroscopy (fNIRS) study implementing the so-called 'fNIRS-TSST' including 45 participants (8 men, 37 women). We tested the equivalence of correlation patterns between the stress response measures cortisol, heart rate, affect, and neural responses in the two samples. Moreover, direct comparisons of affective and neural responses were made. Similar correlation structures were identified for all stress activation systems, except for neural contrasts of paradigm conditions (stress vs. control) showing significant differences in association with cortisol, heart rate, and affective variables between the two samples. Furthermore, both stress paradigms elicited comparable affective and cortical stress responses. Apart from methodological differences (e.g., procedure, timing of the paradigms) the present analysis suggests that both paradigms are capable of inducing moderate acute psychosocial stress to a comparable extent with regard to affective and cortical stress responses. Moreover, similar association structures between different stress response systems were found in both studies. Thus, depending on the study objective and the respective advantages of each imaging approach, both paradigms have demonstrated their usefulness for future studies.

Higher allostatic load in work-related burnout: The Regensburg Burnout Project.

BACKGROUND: Burnout and chronic work stress have been linked to various negative health outcomes. While the mechanisms underlying this interplay are still unclear, the allostatic load (AL) model was suggested to demonstrate a possible biological pathway. However, previous studies provided divergent results regarding the association between burnout and AL, probably also due to the heterogeneity of selected samples. Therefore, the aim of the present study was to examine differences in AL between a conceptually strictly specified group of individuals suffering from burnout (BO group) and a healthy comparison group (HC group). METHODS: After a multi-stage recruitment procedure with strict inclusion criteria based on burnout symptomatology and pathogenesis, the BO group (n = 56) was compared to the HC group (n = 65) regarding an index of AL. The AL-index included 14 parameters: high-sensitivity c-reactive protein (hsCRP), tumor necrosis factor-alpha (TNF-α), interleukin 6 (IL-6), fibrinogen, d-dimer, plasminogen activator inhibitor 1 (PAI-1), glycosylated hemoglobin (HbA1c), high-density lipoprotein (HDL) cholesterol, total cholesterol to HDL cholesterol ratio (TC/HDL), dehydroepiandrosterone-sulphate (DHEA-S), systolic blood pressure (SBP), diastolic blood pressure (DBP), waist-hip ratio (WHR), and body fat percentage. RESULTS: The BO group showed significantly higher AL-scores in comparison to the HC group. This effect remained significant after adjusting for sex, age, and smoking status. Additionally, burnout symptoms (assessed with the Maslach Burnout Inventory; MBI), MBI-subscales emotional exhaustion and depersonalization as well as chronic work stress (assessed with the effort-reward imbalance questionnaire) were significantly associated with higher AL-scores. CONCLUSIONS: Consistent with our hypothesis, we detected higher AL-scores in the BO compared to the HC group, indicating a greater cumulative physiological burden in individuals suffering from burnout. Given the high heterogeneity in individuals experiencing burnout symptoms, future studies may focus on well-specified subgroups, when examining the association between burnout and psychophysiological dysregulations.

Daily life stress and the cortisol awakening response over a 13-months stress period - Findings from the LawSTRESS project.

The LawSTRESS project is a controlled prospective-longitudinal study on psychological, endocrine, central nervous and genetic predictors of responses to long-lasting academic stress in a homogenous cohort. In this first project report, we focused on the association between daily life stress and the cortisol awakening response (CAR). The CAR, a distinct cortisol rise in the first 30-45 min after morning awakening, is a well-established marker of cortisol regulation in psychoneuroendocrinology. Law students from Bavarian universities (total n = 452) have been studied over a 13-months period at six sampling points starting 12 months prior exam. The stress group (SG) consisted of students experiencing a long-lasting and significant stress period, namely the preparation for the first state examination for law students. Law students assigned to the control group (CG) were studied over an equally long period without particular and sustained stress exposure. To investigate stress related alterations in the CAR, we examined a subsample of the LawSTRESS project consisting of 204 students with 97 participants from the SG (69.1% female, mean age = 22.84 ± 1.82) and 107 from the CG (78.5% female, mean age = 20.95 ± 1.93). At each sampling point, saliva samples for cortisol assessment were collected immediately upon awakening and 30 as well as 45 min later. Perceived stress in daily life was measured by repeated ambulatory assessments (about 100 queries over six sampling points). The time course of perceived stress levels in the two groups differed significantly, with the SG showing an increase in perceived stress until the exam and a decrease thereafter. Stress levels in the CG were relatively stable. The CAR was not significantly different between groups at baseline. However, a blunted CAR in the SG compared to the baseline measure and to the CG developed over the measurement timepoints and reached significance during the exam. Remarkably, this effect was neither associated with the increase in perceived stress nor with anxiety and depression symptoms, test anxiety and chronic stress at baseline. The present study successfully assessed multidimensional stress trajectories over 13 months and it documented the significant burden, law students preparing for the first state examination are exposed to. This period was related to a blunted CAR with presumed physiological consequences (e.g., on energy metabolism and immune function). Mean psychological stress levels as well as the CAR returned to baseline levels after the exam, suggesting a fast recovery in the majority of the participants.

Dissociation of behavioral and neural responses to provocation during reactive aggression in healthy adults with high versus low externalization.

The externalizing spectrum describes a range of heterogeneous personality traits and behavioral patterns, primarily characterized by antisocial behavior, disinhibition, and substance (mis)use. In psychopathology, abnormalities in neural threat, reward responses and the impulse-control system may be responsible for these externalizing symptoms. Within the non-clinical range, mechanisms remain still unclear. In this fMRI-study, 61 healthy participants (31 men) from the higher versus lower range of the non-clinical variation in externalization (31 participants with high externalization) as assessed by the subscales disinhibition and meanness of the Triarchic-Psychopathy-Measure (TriPM) performed a monetary modified Taylor-Aggression-Paradigm (mTAP). This paradigm consisted of a mock competitive-reaction-time-task played against a fictional opponent with preprogrammed win- and lose-trials. In lose-trials, participants were provoked by subtraction of an amount of money between 0 and 90 cents. As a manipulation check, provocation induced a significant rise in behavioral aggression levels linked with an increased activation in the anterior cingulate cortex (ACC). High externalization predicted reduced ACC responses to provocation. However, high externalizing participants did not behave more aggressively than the low externalization group. Additionally, the high externalizing group showed a significantly lower positive affect while no group differences emerged for negative affect. In conclusion, high externalization in the non-clinical range was related to neural alterations in regions involved in affective decision-making as well as to changes in affect but did not lead to higher behavioral aggression levels in response to the mTAP. This is in line with previous findings suggesting that aberrations at multiple levels are essential for developing externalizing disorders.

Externalizing behavior in healthy young adults is associated with lower cortisol responses to acute stress and altered neural activation in the dorsal striatum.

The externalizing spectrum is characterized by disinhibition, impulsivity, antisocial-aggressive behavior as well as substance (mis)use. Studies in forensic samples and mentally impaired children suggested that higher rates of externalization are linked to lower cortisol stress responses and altered affect-related neural activation. In this fMRI-study, we investigated whether externalizing behavior in healthy participants is likewise associated with altered cortisol responses and neural activity to stress. Following a quasi-experimental approach, we tested healthy participants (N = 61, 31 males) from the higher versus lower range of the non-clinical variation in externalization (31 participants with high externalization) as assessed by the subscales disinhibition and meanness of the Triarchic-Psychopathy-Measure. All participants were exposed to ScanSTRESS, a standardized psychosocial stress paradigm for scanner environments. In both groups, ScanSTRESS induced a significant rise in cortisol levels with the high externalization group showing significantly lower cortisol responses to stress than the low externalization group. This was mainly driven by males. Further, individual increases in cortisol predicted neural response differences between externalization groups, indicating more activation in the dorsal striatum in low externalization. This was primarily driven by females. In contrast, post-hoc analysis showed that hypothalamic-pituitary-adrenal axis hyporeactivity in males was associated with prefrontal and hippocampal activation. Our data substantiate that individuals from the general population high on externalization, show reduced cortisol stress responses. Furthermore, dorsal striatum activity as part of the mesolimbic system, known to be sensitive to environmental adversity, seems to play a role in externalization-specific cortisol stress responses. Beyond that, a modulating influence of gender was disclosed.

Sex-specific interaction between cortisol and striato-limbic responses to psychosocial stress.

Although women and men differ in psychological and endocrine stress responses as well as in the prevalence rates of stress-related disorders, knowledge on sex differences regarding stress regulation in the brain is scarce. Therefore, we performed an in-depth analysis of data from 67 healthy participants (31 women, taking oral contraceptives), who were exposed to the ScanSTRESS paradigm in a functional magnetic resonance imaging study. Changes in cortisol, affect, heart rate and neural activation in response to psychosocial stress were examined in women and men as well as potential sex-specific interactions between stress response domains. Stress exposure led to significant cortisol increases, with men exhibiting higher levels than women. Depending on sex, cortisol elevations were differently associated with stress-related responses in striato-limbic structures: higher increases were associated with activations in men but with deactivations in women. Regarding affect or heart rate responses, no sex differences emerged. Although women and men differ in their overall stress reactivity, our findings do not support the idea of distinct neural networks as the base of this difference. Instead, we found differential stress reactions for women and men in identical structures. We propose considering quantitative predictors such as sex-specific cortisol increases when exploring neural response differences of women and men.

Increasing Deactivation of Limbic Structures Over Psychosocial Stress Exposure Time.

BACKGROUND: Understanding the interplay between central nervous system and hypothalamic-pituitary-adrenal axis responses to stress in humans is assumed to be essential to contribute to the central question of stress research, namely how stress can increase disease risk. Therefore, the present study used a neuroimaging stress paradigm to investigate the interplay of 3 stress response domains. Furthermore, we asked if the brain's stress response changes over exposure time. METHODS: In a functional magnetic resonance imaging study, changes in brain activation, cortisol levels, affect, and heart rate in response to an improved ScanSTRESS protocol were assessed in 67 young, healthy participants (31 females). RESULTS: Stress exposure led to significant increases in cortisol levels, heart rate, and negative affect ratings as well as to activations and deactivations in (pre)limbic regions. When cortisol increase was used as a covariate, stronger responses in the hippocampus, amygdala, medial prefrontal cortex, and cingulate gyrus were observed. Responses within the same regions predicted negative affect ratings. Remarkably, an increasing deactivation over the two ScanSTRESS runs was found, again, in the same structures. A reanalysis of an independent sample confirmed this finding. CONCLUSIONS: For the first time, reactions in a cluster of (pre)limbic structures was consistently found to be associated with changes in cortisol and negative affect. The same neural structures showed increasing deactivations over stress exposure time. We speculate that investigating possible associations between exposure-time effects in neural stress responses and stress-related interindividual differences (e.g., chronic stress) might be a promising new avenue in stress research.

Recovery of subscapularis and shoulder function following arthroscopic treatment of isolated anterior and combined anterosuperior rotator cuff lesions.

BACKGROUND: The purpose of the study was to evaluate the recovery of the subscapularis and shoulder function dependent on the type of lesion and type of surgical treatment, when compared to the non-affected contralateral shoulder. We hypothesized that regardless of type of lesion and performed surgical intervention, a significant muscle insufficiency as compared to the healthy contralateral side will remain. PATIENTS AND METHODS: Sixty-eight patients (14 females and 54 males) with an anterior or anterosuperior cuff lesion at an average age of 55.7 ± 11.7 years (range 20-80 years) were prospectively evaluated up to 24 months. Intraoperatively, the lesions were classified according to current systems and treated by debridement or reconstruction. Pre- and postoperatively, the Constant Score (CS) as well as the belly-press angle (BPA) and back-to-hand distance (BHD) on the affected and on the contralateral shoulder was noted. RESULTS: 29.4% had an isolated subscapularis lesion whereas 69.1% had concomitant supraspinatus pathology. In 17 patients an arthroscopic debridement and in 51 patients an arthroscopic repair were performed. Postoperatively, all patients revealed a significant improvement of the CS, BPA and BHD (p < 0.05) independent of the type of lesion or the surgical intervention. However, reconstruction of the subscapularis tendon resulted in significant differences of CS, BPA and BHD (p < 0.05) compared to the contralateral shoulder. CONCLUSION: Reconstruction of subscapularis lesions cannot provide full subscapularis function since a residual subscapularis insufficiency remains, other than in patients with small partial tears treated with debridement alone.

The treatment of displaced intra-articular distal radius fractures in elderly patients.

BACKGROUND: From 2000 to 2012, the annual incidence of inpatient treatment for distal radius fracture in Germany rose from 65 to 86 per 100 000 persons. It is unclear whether open reduction and volar angle-stable plate osteosynthesis (ORIF), a currently advocated treatment, yields a better functional outcome or quality of life than closed reposition and casting. METHODS: In the ORCHID multi-center trial, 185 patients aged 65 and older with an AO type C distal radial fracture were randomly assigned to ORIF or closed reposition and casting. Their health-related quality of life and hand/arm function were assessed 3 and 12 months afterward with the Short Form 36 (SF-36) questionnaire and the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. The radiological findings, range of movement of the wrist, and EuroQol-5D (EQ-5D) scores were documented as well. RESULTS: Among the 149 patients in the intention-to-treat-analysis, there was no significant difference in SF-36 scores between the two treatment groups at one year (mean difference, 3.3 points in favor of ORIF; 95% confidence interval, -0.2 +6.8 points; p = 0.058). The DASH scores showed moderately strong, but clinically unimportant effects in favor of ORIF, and there was no difference in EQ-5D scores. ORIF led to better radiological results and wrist mobility at 3 months, with comparable results at 12 months. 37 of the patients initially allotted to nonsurgical treatment underwent secondary surgery due to significant loss of reduction. CONCLUSION: The findings with respect to mobility, functionality, and quality of life at 12 months provide marginal and inconsistent evidence for the superiority of volar angle-stable plate osteosynthesis over closed reduction and casting in the treatment of intra-articular distal radius fractures. Primary nonsurgical management is also effective in suitable patients.

Treatment of bone marrow edema syndrome with intravenous ibandronate.

BACKGROUND: In this pilot study, we investigated the therapeutic efficacy of intravenous Ibandronate compared to pain medication on the outcome of bone marrow edemas (BME) of the knee and talus. PATIENTS AND METHODS: Fifteen patients with a painful BME of the knee and 15 patients with a BME of the ankle, confirmed on MRI, were enrolled and treated with three ambulatory infusions of each 6 mg Ibandronate (group 1). A control group (group 2) of 10 patients with a BME of the knee and 10 patients with a BME of the talus was treated with pain medication and partial weight bearing. Patients were evaluated clinically at baseline and at 1, 3, 6 and 12 months after therapy start with a visual analog pain-scale (VAS) and specific joint scores (Larson knee- and Mazur ankle-score). BMEs were assessed with MRI at baseline and after 6 months in both groups. RESULTS: In the knee group, the mean VAS pain score decreased from 8.5 at baseline to 1.2 at 12 months (p < 0.0001) in patients treated with Ibandronate and, respectively, from 8.1 to 4.0 in the control group (p < 0.001). In the ankle group, the mean VAS pain score decreased from 8.2 at baseline to 0.9 at 12 months (p < 0.0001) in patients treated with Ibandronate and, respectively, from 7.9 to 3.9 in the control group (p < 0.001). The mean Mazur ankle score increased from 51 to 91 points (p < 0.001) in group 1, and from 52 to 72 points in group 2 (p < 0.01). The mean Larson knee score increased from 54 to 89 points (p < 0.001) at 12 months in group 1, and from 51 to 70 points in group 2 (p < 0.01). For both joints, we observed a significant clinical improvement in the Ibandronate treatment group and in the control group, but functional results were significantly more improved in the Ibandronate treatment group. Only the Ibandronate treatment group showed a significant BME regression at the 6 months MRI follow-up. CONCLUSIONS: Intravenous Ibandronate therapy showed significantly better clinical results and BME regression rates on MR-imaging compared to analgesic medication in combination with partial weight bearing in the treatment of BME of the knee and talus and shortens the natural course of the disease.

Long-term outcome and structural integrity following open repair of massive rotator cuff tears.

BACKGROUND: Surgical repair of massive rotator cuff tears is associated with less favorable clinical results and a higher retear rate than repair of smaller tears, which is attributed to irreversible degenerative changes of the musculotendinous unit. MATERIALS AND METHODS: During the study period, 25 consecutive patients with a massive rotator cuff tear were enrolled in the study and the tears were repaired with an open suture anchor repair technique. Preoperative and postoperative clinical assessments were performed with the Constant score, the simple shoulder test (SST) and a pain visual analog scale (VAS). At the final follow-up, rotator cuff strength measurement was evaluated and assessment of tendon integrity, fatty degeneration and muscle atrophy was done using a standardized magnetic resonance imaging protocol. RESULTS: The mean follow-up period was 70 months. The mean constant score improved significantly from 42.3 to 73.1 points at the final follow-up. Both the SST and the pain VAS improved significantly from 5.3 to 10.2 points and from 6.3 to 2.1, respectively. The overall retear rate was 44% after 6 years. Patients with an intact repair had better shoulder scores and rotator cuff strength than those with a failed repair, and also the retear group showed a significant clinical improvement (each P<0.05). Rotator cuff strength in all testing positions was significantly reduced for the operated compared to the contralateral shoulder. Muscle atrophy and fatty infiltration of the rotator cuff muscles did not recover in intact repairs, whereas both parameters progressed in retorn cuffs. CONCLUSIONS: Open repair of massive rotator tears achieved high patient satisfaction and a good clinical outcome at the long-term follow-up despite a high retear rate. Also, shoulders with retorn cuffs were significantly improved by the procedure. Muscle atrophy and fatty muscle degeneration could not be reversed after repair and rotator cuff strength still did not equal that of the contralateral shoulder after 6 years. LEVEL OF EVIDENCE: Level IV.

Combined tears of the subscapularis and supraspinatus tendon: clinical outcome, rotator cuff strength and structural integrity following open repair.

BACKGROUND: Anterosuperior rotator cuff tears involving the subscapularis and supraspinatus tendons are less common than other tears of the rotator cuff. The purpose of this study was to report the clinical outcome, rotator cuff strength and structural integrity of open repair of combined anterosuperior rotator cuff tears. PATIENTS AND METHODS: Forty-eight patients at an average age of 58 years underwent open repair of a combined supraspinatus and subscapularis tendon tear. The follow-up evaluation included clinical scores, rotator cuff strength testing with a custom-made force measurement plate (FMP) and postoperative MRI to evaluate repair integrity and muscle cross-sectional area. RESULTS: After a mean follow-up of 49 months the average Constant score improved from 43 points preoperatively to 79 points postoperatively. The SST and the pain VAS were significantly improved by the procedure (each <0.05). The combined tear group with partial subscapularis tears (G1) did not achieve significantly better score results than the combined tear group with a full-thickness subscapularis tear (G2) (p > 0.05). Strength for all rotator cuff components was reduced significantly (p < 0.05) compared with the contralateral shoulder in both groups. MRI revealed a retear-rate of 4% for the subscapularis and a retear-rate of 19% for the supraspinatus. Postoperative muscle cross-sectional area of all rotator cuff muscles did not differ significantly between G1 and G2 (p > 0.05). CONCLUSION: Open repair of combined anterosuperior rotator cuff tears achieved good postoperative results despite a residual rotator cuff strength deficit. Combined supraspinatus-/full-thickness subscapularis tears achieved equal clinical and radiographic results compared with supraspinatus-/partial-thickness subscapularis tears.

Arthroscopic Capsulolabral Revision Repair for Recurrent Anterior Shoulder Instability.

INTRODUCTION: Arthroscopic capsulolabral reconstruction via the anteroinferior 5:30 portal allows secure placement of the suture anchors in the lower half of the glenoid and adequate retensioning of the inferior glenohumeral ligament. STEP 1 EXAMINATION UNDER ANESTHESIA: With the patient under anesthesia, and prior to surgical intervention, assess the direction of glenohumeral instability and the presence of joint hyperlaxity to confirm the repair strategy preoperatively and to determine if additional procedures such as rotator interval closure or inferior capsular plications are needed. STEP 2 ARTHROSCOPIC EVALUATION AND PORTAL PLACEMENT: Underestimating the anteroinferior bone loss is one of the most common failures of arthroscopic capsulolabral revision repairs. STEP 3 MOBILIZATION OF CAPSULOLABRAL COMPLEX: Mobilize the capsulolabral complex down to the 6:00 position with a bent rasp to create a bleeding surface for biological healing. STEP 4 ANCHOR PLACEMENT: Place anchors at 5:30, 4:30, and 3:00, with additional anchors in the inferior half of the glenoid if more capsular material has to be shifted. STEP 5 CAPSULOLABRAL SHIFT AND KNOT TYING: A sufficient capsular shift of the anterior band of the inferior glenohumeral ligament at the lowest fixation point (5:30 anchor) is a key step of the procedure. STEP 6 ADDITIONAL TISSUE RECONSTRUCTION: Consider performing a rotator interval closure in patients with joint hyperlaxity or if a residual "drive through" sign with inferior instability remains after retensioning of the capsulolabral structures. STEP 7 REHABILITATION: Start with passive exercises and increase to active-assisted and active exercises. RESULTS: In our study of fifty-six patients treated with arthroscopic capsulolabral revision repair for recurrent anterior shoulder instability, arthroscopic evaluation at the revision repair showed glenoid bone loss measuring up to 10% of the inferior glenoid width due to compression fracture of the glenoid rim in almost 50% of the cases and glenoid bone loss measuring 10% to 20% in about 20% of the cases. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Open reduction and internal fixation versus casting for highly comminuted and intra-articular fractures of the distal radius (ORCHID): protocol for a randomized clinical multi-center trial.

BACKGROUND: Fractures of the distal radius represent the most common fracture in elderly patients, and often indicate the onset of symptomatic osteoporosis. A variety of treatment options is available, including closed reduction and plaster casting, K-wire-stabilization, external fixation and open reduction and internal fixation (ORIF) with volar locked plating. The latter is widely promoted by clinicians and hardware manufacturers. Closed reduction and cast stabilization for six weeks is a simple, convenient, and ubiquitously available intervention. In contrast, ORIF requires hospitalization, but allows for functional rehabilitation.Given the lack of randomized controlled trials, it remains unclear whether ORIF leads to better functional outcomes one year after injury than closed reduction and casting. METHODS/DESIGN: ORCHID (Open reduction and internal fixation versus casting for highly comminuted intra-articular fractures of the distal radius) is a pragmatic, randomized, multi-center, clinical trial with two parallel treatment arms. It is planned to include 504 patients in 15 participating centers throughout Germany over a three-year period. Patients are allocated by a central web-based randomization tool.The primary objective is to determine differences in the Short Form 36 (SF-36) Physical Component Score (PCS) between volar locked plating and closed reduction and casting of intraarticular, comminuted distal radius fractures in patients > 65 years of age one year after the fracture. Secondary outcomes include differences in other SF-36 dimensions, the EuroQol-5D questionnaire, the Disability of the Arm, Shoulder, and Hand (DASH) instrument. Also, the range of motion in the affected wrist, activities of daily living, complications (including secondary ORIF and revision surgery), as well as serious adverse events will be assessed. Data obtained during the trial will be used for later health-economic evaluations. The trial architecture involves a central statistical unit, an independent monitoring institute, and a data safety monitoring board. Following approval by the institutional review boards of all participating centers, conduct and reporting will strictly adhere to national and international rules, regulations, and recommendations (e.g., Good Clinical Practice, data safety laws, and EQUATOR/CONSORT proposals). DISCUSSION: To our knowledge, ORCHID is the first multicenter RCT designed to assess quality of life and functional outcomes following operative treatment compared to conservative treatment of complex, intra-articular fractures of the distal radius in elderly patients. The results are expected to influence future treatment recommendations and policies on an international level. TRIAL REGISTRATION: ISRCTN: ISRCTN76120052 Registration date: 31.07.2008; Randomization of first patient: 15.09.2008.

Subscapularis function and structural integrity after arthroscopic repair of isolated subscapularis tears.

BACKGROUND: Results of arthroscopic repair of isolated subscapularis tendon tears have not been widely studied. A detailed evaluation of subscapularis function with subscapularis strength quantification has not been performed to date. PURPOSE: To evaluate postoperative subscapularis muscle function and to assess the clinical outcome and structural tendon integrity with postoperative magnetic resonance imaging after arthroscopic repair of isolated subscapularis tears. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In a prospective study, isolated subscapularis tendon tears in 21 patients were treated with an all-arthroscopic repair. The average age of the study population was 43 years. The mean interval between trauma and surgery was 5.8 months. In 19 patients, a traumatic event caused the onset of symptoms. Subscapularis muscle function was assessed with specific clinical tests and the Constant scoring system. Postoperative subscapularis strength was evaluated with a custom-made electronic force measurement plate. All patients underwent postoperative magnetic resonance imaging to assess structural integrity of the repair. RESULTS: The average duration of follow-up was 27 months. The Constant score increased from 50 points preoperatively to 82 points postoperatively (P < .01). Most positive preoperative lift-off and belly-press tests were reversed by surgery, with a rate of 5 (24%) persistent positive tests after surgery. In operated shoulders, subscapularis strength in the belly-press (65 vs 87 N; P < .05) and the lift-off position (44 vs 68 N; P < .05) was significantly reduced compared with the contralateral shoulder. Magnetic resonance imaging revealed an intact repair in 20 patients. Atrophy of the upper subscapularis muscle portion was present in about one-fourth of the patients and in all patients with a positive postoperative belly-press test. CONCLUSION: Arthroscopic repair of isolated subscapularis tendon tears achieves substantial improvement of shoulder function and a low rerupture rate. Despite excellent clinical results, a significant postoperative subscapularis strength deficit compared with the contralateral shoulder persists that can be quantified with use of the force measurement plate. Atrophy of the upper subscapularis muscle is present in 25% of the patients in the postoperative course.