Autologous triceps tendon graft for LUCL reconstruction of the elbow: clinical outcome after 7.5 years.

PURPOSE: The objective of this study was to assess mid- to long-term functional outcomes in patients treated for symptomatic posterolateral instability of the elbow (PLRI) using an autologous ipsilateral triceps tendon as graft. METHODS: A total of 196 patients were treated with autologous triceps tendon graft for symptomatic PLRI at single orthopedic institution from 2006 to 2013. The surgical treatment contained arthroscopic instability testing, reconstruction of the lateral ulnar collateral ligament (LUCL) and harvesting autologous ipsilateral triceps tendon as graft. The follow-up outcomes included range of motion (ROM), pain measured on a visual analogue scale (VAS), Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES) and ultrasound to evaluate the integrity of the refixation of the common extensor. RESULTS: A total of 178 patients (female: 73; male: 105) were available for follow-up at a mean of 91 months (range 48-144). No patient reported pain at rest; VAS during activity was 1.8 (range 0-5). The ROM decreased slightly compared to preoperative measurements. Flexion decreased significantly from 135.4 to 131.1, though still within the functional arc of motion. All but 13 patients (8.5%) were clinically stable. However, only two patients received a revision of the LUCL reconstruction due to subjective instability. The mean MEPS in the final follow-up was 91.3 (range 73-100). The mean OES was 46.5 (range 39-48). Three patients reported a pain-free clicking of the elbow. No patient complained about donor site morbidity of the ipsilateral triceps tendon. Ultrasound evaluation showed integrity of the common extensors in all patients. CONCLUSIONS: LUCL reconstruction using the ipsilateral triceps tendon as graft shows good to excellent mid- to long-term results in the treatment of symptomatic posterolateral elbow joint instability with a low re-instability and complication rate.

Clinical and radiological outcomes of a stemless reverse shoulder implant: a two-year follow-up in 56 patients.

BACKGROUND: Since the introduction of stemless anatomic shoulder arthroplasty, many studies have been published on anatomic implants. For reverse stemless implants, however, there are only a few clinical follow-up studies available. The current clinical case series aims to present clinical and radiological outcomes of a new stemless reverse prosthesis system (Lima Shoulder Modular Replacement stemless). METHODS: We prospectively evaluated the outcome of 56 stemless total shoulder arthroplasties in 56 patients with a mean age of 61.2 years (46-76 years) at the time of implantation at a minimum follow-up of 24 months (range 24-41 months). All patients were physically and radiologically examined. Clinical outcomes were evaluated by using the Constant-Murley Score and the Subjective Shoulder Value. RESULTS: The mean Subjective Shoulder Value was 84.27% at the latest follow-up. Significant improvements from preoperative to latest follow-up were documented for Constant-Murley Score (34.9 pts to 74.43 pts, P < .001) and active range of motion (abduction 72° to 130°, flexion 36° to 138°, and external rotation 16°to 28°). There was one complete loosening of the humeral component without reoperation. Radiolucency lines were observed in anteroposterior or axial radiographs at the humeral component in 23% of the cases, most of them in anteroposterior view at the calcar region. Radiolucency line findings did not affect clinical outcomes. Major complications or revisions did not occur so far. CONCLUSION: At short-term follow-up, stemless reverse shoulder systems show comparable clinical and radiological outcomes compared to stemmed reverse implants in the literature.

Revision of a Stemless Anatomic Implant into a Stemless Reverse Implant.

INTRODUCTION: Stemless anatomic implants are the growing standard for solving osteoarthritis of the shoulder. If there are secondary rotator cuff insufficiency and the need to revise the implant into a reverse total shoulder, there is usually the option to revise it into a stemmed implant with losing the benefits of stemless implants. There are only a few stemless reverse implants available on the market. Usually, they are recommended as primary implants, but not for revision surgery. Case Report. A 61-year-old male with an indwelling anatomic stemless TESS (Total Evolutive Shoulder System, Zimmer Biomet, Warsaw, USA) implant presented in our clinic with growing pain and loss of range of motion. The TESS was implanted in 2007 as a hemishoulder arthroplasty. The X-ray was showing a stable implanted corolla with clearly growing protrusion of the glenoid. Because of the clinical presentation and the ultrasound investigation that showed only remnants of the supraspinatus and infraspinatus left, we decided that it is necessary to revise the stable implant in a reverse total shoulder arthroplasty. As the TESS was not designed to be convertible, it was clear that it has to be explanted. Due to the young age of the patient, we proposed an "off-label" change to a stemless reverse implant, e.g., the LIMA SMR stemless reverse prosthesis. A revision was possible without much bone loss, so the stemless reverse implant could be used. The clinical and radiological 2-year follow-up showed a good result. CONCLUSION: Stemless implants are well known for anatomic implants, rarely for reverse implants, and seldom used for revision into reverse stemless. This case report shows that it is possible to revise a stemless anatomic implant with a stemless reverse, as long as the rules for implantation are applicable.

Hidden instability in posttraumatic stiff elbows.

BACKGROUND: Hidden instability could be one of the reasons for reoccurring stiffness after arthrolysis in posttraumatic elbows. Associated instability in stiff posttraumatic elbows is clinically hard to detect. Surgical treatment for instability and stiffness in the same surgical setting is challenging and has not been evaluated as of yet. HYPOTHESIS: The primary hypothesis assumes (1) the existence of a posttraumatic "stiff and unstable elbow" and (2) that coexisting instability can be detected by arthroscopic instability testing. The secondary objective was to report the midterm results after arthrolysis and ligament stabilization in the stiff and unstable elbow. METHODS: From 2005 to 2015, 55 patients received arthroscopic arthrolysis of the elbow due to posttraumatic elbow stiffness at our institution. The arthroscopic instability was categorized into three grades with a switching stick: grade I (= stable), grade II (mild instability) and grade III (grossly instable). In cases of persisting instability (grade II-III), a ligament stabilization procedure was performed and all patients were followed up clinically at a minimum of 12 months. Besides ROM and clinical joint stability, PROs (patient reported outcomes) were assessed with the PREE-score (patient-rated elbow evaluation) and the Oxford-Elbow-score (OES). Furthermore, the MEPS (Mayo-elbow-performance-score) was assessed. RESULTS: Out of 55 cases presenting for arthrolysis, coexisting elbow instability was detected during arthroscopic instability testing in 22 cases (40%). All 22 patients received additional ligament stabilization. At final follow-up 62.7 ± 35.7 months postoperatively, 20 patients (12 men; 8 women) with a mean age of 42 ± 16.8 were available. PREE, OES and MEPS were 19.8 ± 25.3, 37.5 ± 9.8 and 80 ± 14.5, respectively. ROM improved significantly from 95° ± 29° to 110° ± 24° postoperatively (p = 0.045). Five patients required revision arthrolysis within the follow-up period (20%). One patient demonstrated persisting instability (5%). CONCLUSION: Intraoperative instability diagnostics during arthroscopic arthrolysis helps detect persisting posttraumatic instability and may provide a solid indication for a concurrent ligament stabilization procedure. This study is the first to present the postoperative results after arthrolysis with stabilization of the posttraumatic, stiff and unstable elbow. However, the results are heterogenic with 25% requiring revision arthrolysis. Therefore, the stiff but unstable elbow remains a complex clinical presentation in need of further investigations. LEVEL OF EVIDENCE: IV.

A bottom-up approach to assess verbal therapeutic techniques. Development of the Psychodynamic Interventions List (PIL).

OBJECTIVE: Knowing which specific verbal techniques "good" therapists use in their daily work is important for training and evaluation purposes. In order to systematize what is being practiced in the field, our aim was to empirically identify verbal techniques applied in psychodynamic sessions and to differentiate them according to their basic semantic features using a bottom-up, qualitative approach. METHOD: Mixed-Method-Design: In a comprehensive qualitative study, types of techniques were identified at the level of utterances based on transcribed psychodynamic therapy sessions using Qualitative Content Analysis (4211 utterances). The definitions of the identified categories were successively refined and modified until saturation was achieved. In a subsequent quantitative study, inter-rater reliability was assessed both at the level of utterances (n = 8717) and at the session level (n = 38). The convergent validity of the categories was investigated by analyzing associations with the Interpretive and Supportive Technique Scale (ISTS). RESULTS: The inductive approach resulted in a classification system with 37 categories (Psychodynamic Interventions List, PIL). According to their semantic content, the categories can be allocated to three dimensions: form (24 categories), thematic content (9) and temporal focus (4). Most categories showed good or excellent inter-rater reliability and expected associations with the ISTS were predominantly confirmed. The rare use of the residual category "Other" suggests that the identified categories might comprehensively describe the breadth of applied techniques. CONCLUSIONS: The atheoretical orientation and the clear focus on overt linguistic features should enable the PIL to be used without intensive training or prior theoretical knowledge. The PIL can be used to investigate the links between verbal techniques derived from practice and micro-outcomes (at the session level) as well as the overall therapeutic outcomes. This approach might enable us to determine to what extent the outcome of therapy is due to unintended or non-theoretically relevant techniques.

Suprapectoral biceps tenodesis using a suture plate: clinical results after 2 years.

PURPOSE: Several techniques for performing a tenodesis of the long head of biceps (LHB) are described. Only few outcome studies are published. This note describes a unicortical fixation via a suture plate-comparable to a distal biceps refixation-performed arthroscopically or mini-open via standard suprapectoral approach. The aim of this study is to show the clinical outcome after 6, 12, and 24 months. MATERIALS AND METHODS: A consecutive series of 50 (35 male, 15 female) patients at the mean age of 49 years (range 23-75) who underwent tenodesis of the LHB were followed for 2 years. All patients were operated by a single surgeon (CS). The clinical evaluation included Constant score, Scheibel LHB score and VAS. Structural integrity of the tenodesis was checked by ultrasound control. Integrity of the tenodesis was evaluated indirectly by detecting the LHB-tendon up to the ultrasound-reflex of the button. No tendon at the button-reflex was considered as failure of the tenodesis. An independent examiner who was not the operating surgeon performed all evaluations. (MG evaluated the patients operated by CS). RESULTS: Mean follow-up was 29.5 (range 22-32) months. The mean pre-operative Constant Murley score (CMS) was 67.4 points (range 45-78) and increased to 84.7 points (range 51-99) after 2 years. LHB Score was 90.8 after 24 months. We identified 2 failed biceps fixations (4%). Pain relief was achieved in most patients within the first 12 weeks. After 2 years, the mean biceps flexion strength averaged 84% of the healthy arm. CONCLUSIONS: Tenodesis of the LHB with a unicortical suture plate is a safe fixation technique with good-to-excellent clinical results after a minimum follow-up of 2 years. Long-term follow-up is needed.

Psychodynamic therapy from the perspective of self-organization. a concept of change and a methodological approach for empirical examination.

UNLABELLED: Observations from therapeutic practice and a series of empirical findings, for example, those on discontinuous change in psychotherapeutic processes, suggest modelling the therapeutic process as a self-organizing system with stable and critical instable phases and abrupt transitions. Here, a concept of psychotherapeutic change is presented that applies self-organization theory to psychodynamic principles. The authors explain the observations and considerations that form the basis of the concept and present some connections with existing findings and concepts. On the basis of this model, they generated two hypotheses regarding the co-occurrence of instability and discontinuous change and the degree of synchrony between the therapist and patient. A study design to test these hypotheses was developed and applied to a single case (psychodynamic therapy). After each session, patient and therapist rated their interaction. A measure of instability was calculated across the resulting time series. Sequences of destabilization were observed. On the basis of points of extreme instability, the process was divided into phases. Local instability maxima were accompanied by significant discontinuous change. Destabilization was highly synchronous in therapist and patient ratings. The authors discussed the concept and the methodological procedure. The approach enables the operationalization of crises and to empirically assess the significance of critical phases and developments within the therapeutic relationship. KEY PRACTITIONER MESSAGE: We present a concept of change that applies self-organization theory to psychodynamic therapy. We empirically tested the hypotheses formulated in the concept based on an extract of 125 long-term psychodynamic therapy sessions. We continuously monitored the therapeutic interaction and calculated a measure of the instability of the assessments. We identified several sequences of stable and unstable episodes. Episodes of high instability were accompanied by discontinuous change. On the basis of these episodes of high instability, we divided the process into four phases. Mean values of variables differed across these phases. Destabilization proved to be highly synchronous in therapist and patient ratings. The approach allows to empirically assess critical phases and developments within the therapeutic relationship.

Crisis-repair sequences - considerations on the classification and assessment of breaches in the therapeutic relationship.

BACKGROUND: Recent research indicates that temporary deteriorations of variables monitored continuously in the course of the therapeutic relationship are important characteristics of psychotherapeutic change. These so-called rupture-repair episodes were assessed by different authors using different mathematical methods. METHODS: The study deals with the criteria for identifying rupture-repair episodes that have been established in previous studies. It proposes modifications of these criteria which prospectively could make it possible to identify rupture-repair episodes more precisely and consistently. The authors developed an alternative criterion. This criterion is able to include crisis patterns which had not been considered before, as well as to characterize the length of the crises. As a sample application, the different criteria were applied to continuously measured assessments of the therapeutic interaction in psychodynamic therapy courses (ten shorter processes and one long-term therapy). RESULTS: The analysis revealed that the number of the identified rupture-repair episodes differed depending on the criterion that was used. Considerably more crises were identified with the newly developed criterion. The authors developed a classification of crisis patterns. They distinguished five patterns of crises and their resolution in therapy processes and ascertained the frequency of distribution. The most frequent pattern was the simple V-shape. The second most common pattern was a decline over more than one session with a sudden repair. The longest downward trend comprised a period of six sessions. CONCLUSIONS: The findings of the study give insight into basic mechanisms of change within the therapeutic relationship. A phenomenological discussion of how a crisis is defined is useful to create a methodological approach to the operationalization of crises, to differentiate specific characteristics and to specifically link these characteristics to the outcome in future studies. The methodological deliberations might be applyable to different research areas where the analysis of fluctuations in a variable of interest over time is relevant.

Instability and discontinuous change in the experience of therapeutic interaction: an extended single-case study of psychodynamic therapy processes.

The authors developed a concept that applies self-organization theory to psychodynamic principles. According to this concept, episodes of temporary destabilization represent a precondition for abrupt changes within the therapeutic process. The authors examined six courses of therapy (patients diagnosed with depression and personality disorder). After each therapy session, patients rated their experience of the therapeutic interaction. A measure of instability was used to identify episodes of destabilization with respect to patients' interaction experience throughout the process. Episodes of pronounced destabilization occurred in the four courses of therapy that showed better therapy outcomes. These episodes were characterized by temporary strong deteriorations in interaction experience (negative peaks). Three of the four courses showed subsequent discontinuous improvements to a higher level of interaction. Results indicate that the systematic inclusion of a measure of instability is worthwhile in investigations of discontinuous changes. This method allows the theoretical assumptions of the psychodynamic approach to be tested.

[Abrupt transient deteriorations in the experienced interaction and their relationship to the experience of other important persons--operationalisation of transference aspects in therapeutic processes]. / Abrupte vorubergehende verschlechterungen der therapeutischen Interaktion und deren Bezug zum Erleben anderer Bezugspersonen--Eine Methode zur Operationalisierung von Ubertragungsaspekten im Therapieprozess.

OBJECTIVES: Abrupt transient deterioration in the experienced therapeutic interaction is regarded as a sign of the emergence of negative transference aspects. How can these sessions be characterized in terms of similarity to the experience of other important relationships and in relation to the process? METHODS: The interaction-experience in six therapy courses was measured continuously (Intrex). Abrupt deterioration was statistically determined. The correlation between the experienced therapeutic interaction and nontherapeutic interaction patterns was determined. RESULTS: The transference aspects measured were instable over time. There were significant correlations with the experience of previous and current significant others, and parental interaction. The strongest correlations existed nearly consistently to the interaction with the most important person during the best times. CONCLUSION: The method allows measuring change and transference aspects in an economic way. After validation, it could be used for clinical diagnostics. Sessions thus selected could be analyzed more precisely with other procedures.

Tendon-bone contact pressure and biomechanical evaluation of a modified suture-bridge technique for rotator cuff repair.

The aim of the study was to evaluate the time-zero mechanical and footprint properties of a suture-bridge technique for rotator cuff repair in an animal model. Thirty fresh-frozen sheep shoulders were randomly assigned among three investigation groups: (1) cyclic loading, (2) load-to-failure testing, and (3) tendon-bone interface contact pressure measurement. Shoulders were cyclically loaded from 10 to 180 N and displacement to gap formation of 5- and 10-mm at the repair site. Cycles to failure were determined. Additionally, the ultimate tensile strength and stiffness were verified along with the mode of failure. The average contact pressure and pressure pattern were investigated using a pressure-sensitive film system. All of the specimens resisted against 3,000 cycles and none of them reached a gap formation of 10 mm. The number of cycles to 5-mm gap formation was 2,884.5 + or - 96.8 cycles. The ultimate tensile strength was 565.8 + or - 17.8 N and stiffness was 173.7 + or - 9.9 N/mm. The entire specimen presented a unique mode of failure as it is well known in using high strength sutures by pulling them through the tendon. We observed a mean contact pressure of 1.19 + or - 0.03 MPa, applied on the footprint area. The fundamental results of our study support the use of a suture-bridge technique for optimising the conditions of the healing biology of a reconstructed rotator cuff tendon. Nevertheless, an individual estimation has to be done if using the suture-bridge technique clinically. Further investigation is necessary to evaluate the cell biological healing process in order to achieve further sufficient advancements in rotator cuff repair.

[Who is using outpatient psychotherapy in Germany?]. / Wer nimmt in Deutschland ambulante Psychotherapie in Anspruch?

Facing the current political controversies concerning health care, the present study examines the question who is using outpatient psychotherapy in Germany. Using data drawn from a nationally representative survey of 5120 Germans 7% stated they had used oupatient psychotherapy in the former 6 years or being actually in outpatient psychotherapy. Comparisions of socio-economic variables between persons with and without use of outpatient psychotherapy showed, contrary to expectations, that psychotherapy is not utilised by so called "YARVIS" (young, attractive, rich, verbal, intelligent, successful) patients.

[Personality assessment with the NEO-Five-Factor Inventory: the 30-Item-Short-Version (NEO-FFI-30)]. / Persönlichkeitsdiagnostik mit dem NEO-Fünf-Faktoren-Inventar: Die 30-Item-Kurzversion (NEO-FFI-30).

Over these past years, German researchers have shown much interest for Costa and McCrae's five factor model as well as for their instrument: the NEO-Five-Factor Inventory . Nevertheless, results from a recent survey study using the German version of the NEO-FFI on a representative population sample (n = 1908) have reported problems to replicate the factor structure of the instrument. Insufficient psychometric indices of single items led to partly unsatisfactory scale values. A logical consequence of this was the development of a short version of the instrument with better psychometric properties. This article reports item and scale values of the NEO-FFI-30 for the German population sample. The five scales reach good internal consistency and are highly correlated with the original NEO-FFI scales. Furthermore, the influence of sociodemographic variables and correlations with the Giessentest appear to be very similar for both the original instrument and the short version. Moreover, the factor structure was replicated in an independent sample of 2508 adults. Results confirm the reliability, and factor and construct validity of this economic instrument without any significant loss in information.

Ambivalence over Emotional Expressiveness: psychometric evaluation of the AEQ-G18 in a representative German survey.

OBJECTIVE: The present study evaluates a questionnaire on ambivalence over emotional expressiveness, the AEQ-G18 [1], [2], with regard to its statistical parameters, the influence of socio-demographic variables, and its interrelationship with depression and quality of life. METHODS: A representative German sample (1009 participants from East Germany and 1034 participants from West Germany) completed the AEQ-G18 [1], [2], the depression screener DEP-2 [3], the Profile of Mood States POMS [4], the revised Beck Depression Inventory BDI [5], the short form of the Patient Health Questionnaire PHQ-9 [6] and the SF-36 health survey questionnaire [7]. RESULTS: Our study was only partially able to confirm the two factors effect ambivalence and competence ambivalence postulated by Traue et al. [1], [2]. Women scored somewhat higher on the scale effect ambivalence. Participants with a higher educational background exhibited less emotional ambivalence. Emotional ambivalence correlated positively with depression and reduced psychological state of health (depression, fatigue, and anger), whereas it correlated negatively with health-related quality of life and positive attitude (vigor). In addition to the scales of the AEQ-G18, we developed a short form, the AEQ-G10, and provide normative data for the AEQ-G18 and the AEQ-G10. CONCLUSION: This study presents normative data for two variations of a clinically relevant, valid, and time-efficient diagnostic instrument used for the evaluation of ambivalence over emotional expressiveness, the AEQ-G18 and its short form, the AEQ-G10.

[Standardization of the German short version of "profile of mood states" (POMS) in a representative sample--short communication]. / Normierung der deutschen Kurzform des Fragebogens "Profile of Mood States" (POMS) anhand einer repräsentativen Bevölkerungsstichprobe--Kurzbericht.

The questionnaire "Profile of Mood States (POMS)" is recommended as a measure of mood states in patients and non-clinical samples. On the basis of a representative sample (2043 subjects) reference values for the four scales (DEPRESSION/ANXIETY, FATIGUE, VIGOR, ANGER) of the German short version of the "Profile of Mood States" (POMS--35 items, 7 point scale, instruction "How you have been feeling during the past 24 hours?") are presented. The scale ANGER was independent from variables gender, age, education and current residence. In contrast to the other three scales these differentiations were necessary and detailed reference values are reported.

Two-question depression-screeners - the solution to all problems?

UNLABELLED: Depression constitutes a considerable issue in medicine and it is anticipated that the amount of people suffering from affective disorders will increase significantly. It would be useful to have a simple, fast screening procedure which would help detect depression. In four recently published articles a two-question depression-screener is recommended. METHOD: Sensitivity, specificity, likelihood ratios, negative and positive predictive values were compared. RESULTS: For four different clinical samples and one sample that was representative of the German population the prevalence for depression ranged from 6.9 % to 18.1 %. Sensitivity and specificity reached values from 72.6 % to 96.6 % and from 56.9 % to 90.0 % respectively. All negative predictive values were high (< 97 %) opposed to positive predictive values (17.8 % to 38.5 %). CONCLUSION: Overall, it seems that the two-question screenings are well suited for the exclusion of a major depression. It is possible that regular screening could further lower the percentage of undiagnosed cases.

[Development of a short version of the Insecurity Questionnaire (U-Bogen-24) by Ullrich & Ullrich de Muynck]. / Die Entwicklung einer Kurzversion (U-Bogen-24) des Unsicherheitsfragebogens von Ullrich und Ulirich de Muynck.

The psychometric properties of a newly developed short version of the "Unsicherheitsfragebogen" (Insecurity Questionnaire) by Ullrich & Ullrich de Muynck are examined using data drawn from a nationally representative survey of 652 former East and 1283 former West Germans. In addition, the questionnaire was tested on a clinical sample of 318 psychotherapy inpatients. The study demonstrates good test-theoretical features regarding parameters of items and subscales. In the population sample woman score higher on subscales fear of criticism and incapacity in saying NO and lower on scale being able to demand. Female psychotherapy patients score higher on scale fear of criticism and lower on scale being able to demand than male psychotherapy patients. When comparing psychotherapy patients to the population sample with respect to gender, male and female psychotherapy patients score higher on scales fear of criticism, fear of contact and incapacity in saying NO and lower on scale being able to demand. Scale means as reference values for the population sample as well as for the psychotherapy patients are reported.