Sandwich Technique for Large Osteochondral Lesions of the Knee.

OBJECTIVE: To evaluate whether a sandwich technique procedure for large osteochondral lesions (OCL) of the medial femur condyle reduces clinical symptoms and improves activity level as well as to assess repair tissue integration on MRI over 2 years. DESIGN: Twenty-one patients (median age: 29 years, 18-44 years) who received matrix-associated autologous chondrocyte transplantation (MACT) combined with cancellous bone grafting at the medial femur condyle in a 1-step procedure were prospectively included. Patients were evaluated before surgery (baseline) as well as 3, 6, 12, and 24 months postoperatively, including clinical evaluation, Lysholm score, Tegner Activity Rating Scale, and MRI with Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score and a modified Whole-Organ Magnetic Resonance Imaging Score (WORMS). RESULTS: Seventeen patients were available for the 24-month (final) follow-up (4 dropouts). Lysholm significantly improved from 48 preoperatively stepwise to 95 at final follow-up (P < 0.05). Tegner improvement from 2.5 at baseline to 4.0 at final follow-up was not significant (P = 1.0). MOCART score improved significantly and stepwise from 65 at 3 months to 90 at 24 months (P < 0.05). Total WORMS improved from 14.5 at surgery to 7.0 after 24 months (P < 0.05). Body mass index and defect size at surgery correlated with total WORMS at final follow-up (P < 0.05) but did not correlate with clinical scores or defect filling. CONCLUSION: MACT combined with cancellous bone grafting at the medial femoral condyle reduces symptoms continuously over 2 years. A 1-step procedure may reduce perioperative morbidity. However, despite improvements, patients' activity levels remain low, even 2 years after surgery.

[Clinical results after refixation of proximal hamstring tendon ruptures comparing different anchor systems]. / Klinische Ergebnisse nach Refixation proximaler Hamstring-Sehnen-Rupturen unter Berücksichtigung verschiedener Ankersysteme.

BACKGROUND: Injuries to the hamstring muscles and tendon complex are among the most frequent muscular injuries with proximal hamstring tendon avulsion being a particularly severe form. The surgical treatment of these injuries is superior to conservative management with respect to patient satisfaction, recovery of muscle strength and function as well as return to sport rates. It is therefore the method of choice. OBJECTIVE: Presentation and comparison of the surgical results after treatment with titanium, polyether ether ketone (PEEK) and all suture anchors. MATERIAL AND METHODS: A systematic search was carried out in the PubMed medical database and the results are summarized. RESULTS: All systems exhibit comparable biomechanical properties regarding elongation and ultimate failure load. Tendon repair with these anchors results in good to excellent clinical outcomes and shows high return to sport and low complication rates. Patient satisfaction after hamstring tendon repair is reported to be over 90% and return to sport rate is 80-100%. The muscle strength recovers to 80-90% in comparison to the contralateral side. CONCLUSION: All available anchors systems provide good to excellent clinical outcomes and an explicit advantage for one anchor system could so far not be shown.

[Irreparable rotator cuff tear-reverse shoulder arthroplasty and alternative procedures]. / Irreparable Rotatorenmanschettenruptur ­ inverse Prothese und Alternativverfahren.

Irreparable rotator cuff tears represent a significant everyday clinical challenge. A high degree of tendon retraction and muscle degeneration means that a direct reconstruction is impossible. Patients often suffer from pain and pseudoparalysis. In older patients this can reliably be resolved by the implantation of a semiconstrained inverse shoulder prosthesis; however, for younger patients joint-preserving techniques should be employed. Furthermore, for frail older patients who may not be suitable for a joint replacement operation, alternative treatment strategies are required. Management options include physiotherapy and pain relieving or reconstructive operations. Minimally invasive arthroscopic treatment approaches can lead to pain relief and slight functional improvements in selected patients; however, to restore the active movement of the joint a partial cuff repair, augmentation with a graft or replacement with muscle transfer is necessary. This article presents the various treatment options and the results reported in the literature. Through this a treatment algorithm is suggested in order to facilitate management decisions.

[Diagnosis and therapy of chronic patellofemoral instability]. / Diagnostik und Therapie der chronischen patellofemoralen Instabilität.

The chronic patellofemoral instability is a multifactorial disease, which is mostly congenital. Luxation of the patella is mainly atraumatic. Sole conservative treatment is often unsuccessful. Surgical treatment is needed in most cases and requires consideration of all pathologic changes of the patella-stabilizing anatomic structures. Rupture of the medial patellofemoral ligament is almost pathognomonic. In addition, the frontal mechanical axis, rotation of femur and tibia, the trochlear shape, the distance from the tibial tuberosity to the trochlear sulcus and the patellar height play an important role. Often, in addition to soft tissue reconstruction, the bony alignment needs to be corrected. Consideration of risk factors in both adult and adolescent patients is needed to avoid recurrent instability.

No healing improvement after rotator cuff reconstruction augmented with an autologous periosteal flap.

PURPOSE: To show descriptive clinical and magnetic resonance (MR) imaging results after an additional periosteal flap augmentation in mini-open rotator cuff reconstruction and to evaluate potential healing improvement at long-term follow-up. METHODS: Twenty-three patients with degenerative rotator cuff tears were followed after receiving a mini-open single-row repair with a subtendinous periosteal flap augmentation. Data were collected preoperatively, after 12 months and after 11 years. Clinical examination, simple shoulder test (SST), Constant-Murley Score (CS), ultrasonography examination and 3T MR imaging were performed. RESULTS: Out of 23 patients, 20 were available for short-term and 19 for final follow-up at a median of 11.5 years (range 10.4-13.0). Questions answered with "yes" in SST improved from baseline 5.0 (range 1.0-8.0) to short 10.5 (range 8.0-12.0) and final follow-up 12.0 (range 7.0-12.0). CS improved from 53.5 (range 25.0-66.0) to 80.8 (range 75.9-89.3) and finally to 79.8 points (range 42.3-95.4). Improvement was highly significant (p < 0.05). Severe retears were found in 9/19 patients. Ossifications along the refixed tendon were noticed in 8/19 cases. Ossifications did not correlate with clinical outcome. At final follow-up, patients with retears seemed likely to have lower strength values in CS (mean ± SD) than patients without retears (7.3 ± 4.1 vs. 12.8 ± 5.3; p < 0.05). CONCLUSION: No positive effect on improving healing response in rotator cuff refixation with a periosteal flap augmentation could be found. Retear rate is comparable to that of conventional rotator cuff refixation in the published literature. Ossifications along the tendon, without negatively affecting the clinical outcome, were seen. This invasive technique cannot be advised and should not be used anymore. LEVEL OF EVIDENCE: IV.

[Patellar tendon ruptures : Internal bracing and augmentation technique]. / Patellarsehnenruptur : Internal Bracing und Augmentationstechnik.

OBJECTIVE: To report a surgical technique for the treatment of patellar tendon ruptures augmented with an internal brace suture tape. INDICATIONS: Acute patellar tendon ruptures, fractures of the distal patellar pole, chronic insufficiency of the patellar tendon or revision surgery for failed repairs. CONTRAINDICATIONS: Severe damage to the surrounding soft tissue. Local infection. Life-threatening conditions. SURGICAL TECHNIQUE: Direct longitudinal anterior approach to the patellar tendon. Two parallel transosseous bone tunnels are drilled in the patella and tibial tuberosity with a 2.4 mm drill bit. Two separate FiberTapes® (Arthrex, Naples, FL; USA) are shuttled through the proximal and distal bone tunnels around the tendon in "X" and "O" type configuration. Patellar height is reestablished under fluoroscopic control and both FiberTapes are tied down. Both tendon ends are debrided and readapted with absorbable sutures. POSTOPERATIVE MANAGEMENT: Passive motion exercise to 90° of flexion from day 1. Partial load to 20 kg of body weight with knee in locked full extension brace during first 2 weeks. Isometric exercises from week 3. Passive flexion to 110° from week 4 (adapted to pain). Free active range of motion and weight bearing from week 7. RESULTS: In more than 10 years of clinical application, positive results were continuously found in acute as well as chronic patellar tendon ruptures. These results are consistent with those in the current literature.

Degenerative isolated cartilage defects of the patellofemoral joint are associated with more severe symptoms compared to trauma-related defects: results of the German Cartilage Registry (KnorpelRegister DGOU).

PURPOSE: The purpose of this study was to utilize data from the German Cartilage Registry (KnorpelRegister DGOU) to examine the hypothesis that degenerative cartilage defects of the patellofemoral joint are associated with more severe clinical symptoms compared to trauma-related defects. METHODS: All patients with isolated focal cartilage defects of the patellofemoral joint registered in the German Cartilage Registry until May 2017 were included in the study. Patients with previous surgery of the ipsilateral knee were excluded. Baseline data including etiology (traumatic, degenerative), size, location and ICRS grade of the cartilage defects as well as the duration of symptoms were analyzed. Clinical symptoms were evaluated by means of the numeric analog scale (NAS) for pain and the Knee injury and Osteoarthritis Outcome Score (KOOS). Group comparisons were performed using the Mann-Whitney-U test along with the Chi-squared test and Fisher's exact test. A bivariate correlation analysis and a multivariable linear regression analysis were performed to investigate the association between the defect characteristics and the clinical scores. RESULTS: A total of 423 patients (203 traumatic and 220 degenerative defects) were included. Isolated degenerative cartilage defects were found to have significantly more trochlear locations (28% vs. 18%; p = 0.006), significantly less ICRS grade 4 lesions (50% vs. 73%; p = 0.002) and a significantly smaller defect size [median 300 (IQR 105-400) vs. 300 (200-400) mm2] when compared to those from traumatic etiology. Traumatic defects showed significantly better KOOS-ADL [77 (60-90) vs. 69 (56-82); p = 0.005], KOOS-pain [69 (56-81) vs. 61 (47-75); p = 0.001] and NAS [2 (1-5) vs. 4 (1-6); p = 0.005] scores compared to degenerative defects. The correlation analysis revealed only weak correlations between the quantitative defect characteristics and clinical scores. CONCLUSIONS: Degenerative isolated cartilage defects in the patellofemoral joint are associated with more severe clinical symptoms in comparison to trauma-related defects. Additionally, they show a larger variance regarding their location with more trochlear defects. LEVEL OF EVIDENCE: III.

[Anterolateral stabilization using the modified Lemaire technique for ACL deficiency]. / Anterolaterale Stabilisierung mittels modifizierter Lemaire-Plastik bei insuffizientem vorderem Kreuzband.

OBJECTIVE: Treatment of persistent anterolateral knee instability. INDICATIONS: Subjective/objective (rotational) instability of the knee after anatomic anterior cruciate ligament (ACL) reconstruction. ACL re-rupture including special demands (e.g., high-performance athletes, hyperlaxity) RELATIVE CONTRAINDICATIONS: Osteoarthritis, additional instability of the knee, which should be treated independently; non-anatomic ACL reconstruction with persisting instability should be treated first with anatomic ACL reconstruction. ABSOLUTE CONTRAINDICATIONS: General contraindications for surgery (e. g. septic arthritis), acute irritation of the affected knee. SURGICAL TECHNIQUE: Supine position. Incision along the proximal lateral femoral epicondyle. Marking of the needed width and length of the iliotibial band (ITB) graft. Passing the ITB graft underneath the lateral collateral ligament. Find and mark the isometric point for fixation next to the lateral femoral epicondyle. Fixation of the ITB graft. Layered wound closure. POSTOPERATIVE MANAGEMENT: Knee brace for at least 6 weeks. Range of motion (RoM): from postoperative day 1: flexion-extension 90-0-0°; first 2 weeks after surgery: partial weight bearing (20 kg). RESULTS: An anterolateral extra-articular reconstruction may reduce a persistent anterolateral rotatory instability as well as the re-rupture rate following ACL reconstruction with good patient-reported short-term outcomes. Based on current (biomechanical) data, anterolateral tenodesis seems to be superior to a reconstruction of the anterolateral ligament. If a tenodesis is performed, the graft should be fixed in an isometric position, with neutral rotation of the knee and low graft tension to avoid extraphysiologic load within the lateral compartment. Indications for such a procedure may include a high-grade pivot shift or revision ACL reconstruction as well as a persistent anterolateral rotatory instability following anatomic ACL reconstruction.

[Acute injury of the posterior cruciate ligament with femoral avulsion : Arthroscopic ligament repair and bracing]. / Akute Verletzung des hinteren Kreuzbandes mit femoraler Avulsion : Banderhaltende arthroskopische Refixation und Bracing.

OBJECTIVE: The aim of arthroscopic bracing of the posterior cruciate ligament (PCL) is to restore anatomic and biomechanic function in acute PCL tears. Therefore, primary augmentation of the PCL by using a stable suturing system is used. INDICATIONS: Acute tears of the PCL, femoral avulsions, isolated or combined in cases of multiligament injuries (knee dislocations of Schenk types II-IV). CONTRAINDICATIONS: Chronic instabilities of the PCL, infection of the knee joint. SURGICAL TECHNIQUE: Arthroscopic preparation of the femoral PCL footprint. Suturing of the PCL stump with non-resorbable sutures. Placement of the femoral and tibial tunnel with a specific arthroscopic PCL guide. Femoral fixation of the bracing system and the PCL augmenting sutures extracortical via a button or intraarticular with a suture anchor. Tibial fixation via a button has to be performed in a minimum of 80° of flexion and under permanent anterior drawer tension. POSTOPERATIVE MANAGEMENT: Brace in full extension with posterior support 24 h/day, range of motion (ROM) restricted up to 90° of flexion and limited weight bearing with 20 kg for the first 6 weeks postoperatively. After 6 weeks, weight bearing and ROM can be increased and a solid frame brace with posterior support is recommended for the next 6 weeks.

T2-relaxation time of cartilage repair tissue is associated with bone remodeling after spongiosa-augmented matrix-associated autologous chondrocyte implantation.

OBJECTIVE: To investigate whether T2 relaxation time measurements of cartilage repair tissue and structural changes of the knee joint are associated with subchondral bone architecture after spongiosa-augmented matrix-associated autologous chondrocyte implantation (MACI). DESIGN: Both knees of 25 patients (25.5 ± 7.8y; 10 women) were examined preoperatively and 2.7 years after unilateral spongiosa-augmented MACI with 3T magnetic resonance (MR) imaging. Cartilage composition was assessed using T2 relaxation time measurements, subchondral trabecular bone microstructure was quantified using a 3D phase-cycled balanced steady state free-precision sequence. Structural knee joint changes were assessed using the modified Whole-Organ Magnetic Resonance Imaging Score (WORMS). The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was used for the postoperative description of the area that underwent MACI. Correlations were assessed using Spearman's rank correlation coefficients. RESULTS: Hypertrophy of the cartilage repair tissue was found in 2 of 25 patients, both after a MACI procedure at the patella, 21 patients showed congruent filling. In subchondral bone of the cartilage repair compartment, apparent trabecular thickness was significantly higher in compartments with elevated cartilage T2 (n = 17; 0.37 ± 0.05 mm) compared to those showing no difference in cartilage T2 compared to the same compartment in the contralateral knee (n = 8; 0.27 ± 0.05 mm; P = 0.042). Significant correlations were found between the overall progression of WORMS and the ipsilateral vs contralateral ratio of average trabecular thickness (r = 0.48, P = 0.031) and bone fraction (r = 0.57, P = 0.007). CONCLUSIONS: After spongiosa-augmented MACI, T2 values of cartilage repair tissue and structural knee joint changes correlated with the quality of the underlying trabecular bone.

[Patellar sleeve fractures : Bracing and augmentation technique with suture tape]. / Patella-Sleeve-Fraktur : Bracing- und Augmentationstechnik mit einem Fadentape.

OBJECTIVE: Transosseous augmentation of patellar sleeve fractures (PSF) with suture tape in young athletes. INDICATIONS: Acute avulsions of the proximal or distal patellar pol with clinical relevant deficit of knee extension. CONTRAINDICATIONS: Local infections, severe soft tissue damage (relative contraindication), fractures of the patella or tibial tuberosity. SURGICAL TECHNIQUE: Direct longitudinal anterior approach to the patella. Debridement of the proximal patellar tendon insertion. Anatomic reduction of any osteochondral fragments. Transosseous augmentation of the tendon with FiberTapes® (Arthrex, Naples, FL, USA). POSTOPERATIVE MANAGEMENT: Passive motion exercise to 30° of flexion from day 1; increase to 60° from week 3; 90° from week 5. Partial load-bearing of 20 kg with knee in locked full extension brace during first 2 weeks. Isometric exercises from week 3. Free active ROM and full weight bearing from week 7. RESULTS: If diagnosis and treatment is early and sufficient augmentation of the tendon and periosteum is provided, good to excellent functional outcome can be expected.

Retrograde fixation of the lesser trochanter in the adolescent: new surgical technique and clinical results of two cases.

INTRODUCTION: Avulsions of the lesser femoral trochanter are rare injuries in the adolescent population. An acute avulsion causes severe functional impairment with compromised hip flexion. Recent literature reports the superiority of surgical treatment for apophyseal avulsion fractures of the pelvis in adolescents. Unfortunately, there are no guidelines for an evidence-based treatment of lesser trochanter avulsions established. We present the cases of two adolescent athletes treated operatively. MATERIALS AND METHODS: Two adolescent males, 12 and 16 years old, suffered an avulsion of the lesser trochanter during soccer. They reported immobilizing groin pain with subjective impairment in daily activities and inability to perform sports. Surgical treatment with a new retrograde technique by applying an adapted mini-open anterior approach was performed. Intraoperatively, both cases showed an intact musculo-tendinous unit attached to the avulsed fragment. RESULTS: Both patients showed excellent postoperative results and were satisfied with the clinical outcome. In the postoperative follow-up an adequate consolidation of the lesser trochanter was visible. No complications were postoperatively reported at final follow-up. CONCLUSIONS: The retrograde fixation technique has led to an excellent outcome without complications in two adolescents with acute lesser trochanter apophyseal avulsions. Further clinical use may support the value of this new surgical technique.

Arthroscopic transtibial pullout repair for posterior meniscus root tears.

OBJECTIVE: Anatomic repair of the torn meniscal root using transosseous sutures through the proximal tibia. INDICATIONS: Nontraumatic meniscal root tears without severe degenerative changes (Kellgren-Lawrence grade ≤ 2), good quality meniscal tissue, traumatic root tears with or without concomitant anterior cruciate ligament tears or multiligament injuries. CONTRAINDICATIONS: Uncorrected varus or valgus malalignment (>3°), osteoarthritis Kellgren-Lawrence grades III and IV, and diffuse articular cartilage changes International Cartilage Regeneration and Joint Preservation Society (ICRS) grades III and IV of the effected compartment, noncompliance. SURGICAL TECHNIQUE: Root tear confirmed by probing; location for the planned root refixation on the tibial plateau is identified. A tibial socket or full transtibial tunnel created with an aiming drill guide. Using a self-retrieving suture passing device or a curved suture passer, the torn meniscus root sutured with no. 0 non-absorbable braided suture. Meniscal sutures passed through the tibial tunnel and the meniscus root reduced into the socket or tunnel by tensioning the free ends of the sutures, followed by fixation on the tibial cortex. FOLLOW-UP: Toe touch weight-bearing for 6 weeks, restricted range of motion (0-60° of flexion) for 6 weeks, no axial loading at flexion angles >90° until 6 months postoperatively. RESULTS: For medial root tears, pullout repair significantly improves functional outcome scores and seems to prevent the progression of osteoarthritis in the short-term. Complete healing observed in only 60% of patients. Negative prognostic factors: varus malalignment > 5°, cartilage degeneration Outerbridge grade III and IV, and older age. Outcomes after lateral root repair are encouraging with apparent prevention of progression of osteoarthritis.

[Fixation of bony avulsions of the posterior cruciate ligament by a suture-bridge™ technique]. / Refixation tibialer knöcherner Avulsionsverletzungen des hinteren Kreuzbandes in Fadenankertechnik.

OBJECTIVE: Anatomical reduction of bony avulsions of the posterior cruciate ligament (PCL) by a suture-bridge™ (Arthrex, Naples, FL, USA) technique to restore posterior knee stability. INDICATIONS: Acute bony tibial avulsions of the PCL and multifragmentary fractures. CONTRAINDICATIONS: Chronic condition of avulsion fractures or posterior instability, advanced knee osteoarthritis, high-grade soft tissue injury, infection. SURGICAL TECHNIQUE: Prone position, minimally invasive posterior medial approach, exposure and reduction of the bony fragment, positioning of the proximal suture-anchor (interfragment), suturing the PCL and knotting to achieve repositioning of the anterior part of the fragment, tighten both ends of the tape by two suture anchors distally to the PCL insertion to fix the posterior part of the fragment. POSTOPERATIVE MANAGEMENT: Knee extension brace with posterior tibial support for 6 weeks, 20 kg partial weight-bearing and restricted flexion up to 90° for 6 weeks, physiotherapy in prone position from the first postoperative day. Full weight bearing after x­ray and clinical control after 6 weeks. RESULTS: Since 2016, 6 cases of a bony avulsion of the PCL treated with this technique (mean age 38 years; range 17-60 years). Postoperative x­ray at 6 weeks showed no fragment dislocation and complete bone healing. Irritation due to the anchor material was not observed up to 6 months postoperatively. No wound healing problems, infections, thrombosis or arthrofibrosis observed. No revisions. According to a recent review comparing the open with an arthroscopic fracture treatment the arthroscopic treatment may lead to a slightly higher subjective and objective outcome. Interestingly, the rate of arthrofibrosis was slightly elevated in the arthroscopic group. Seven of 18 included studies describe a suture fixation in case of a comminuted fracture. Especially in these cases a suture-bridge ™ fixation seems to be reasonable.

Erratum to: Anatomic stabilization of chronic lateral instability of the ankle : Gold technique.

Erratum to: Oper Orthop Traumatol 2017 https://doi.org/10.1007/s00064-017-0513-9 The article was wrongly published under the article type "Review". Please note that the article is an "Original Paper".The publisher apologizes to the authors and ….

Surgical repair of acute pectoralis major muscle ruptures.

OBJECTIVE: Surgical repair of a partial or complete tear of the pectoralis major muscle to restore internal rotation, adduction, and anteversion. INDICATIONS: Acute avulsion, acute tear of the tendinous insertion, acute tear of the musculotendinous region (<6 weeks after trauma). Relative indication: chronic retracted tear (>6 weeks). CONTRAINDICATIONS: Muscular tears, local infection, other general contraindications. SURGICAL TECHNIQUE: Open repair using suture anchors or flip buttons. POSTOPERATIVE MANAGEMENT: Week 1-3: early passive-assisted functional physical therapy. Week 3-6: early active-assisted functional physical therapy. Week 7-9: active assisted free range of motion (ROM). From week 9: free ROM. From week 12: exercise with resistance, careful strengthening. RESULTS: Between 2005 and 2017, 20 men with an acute or subacute tear of the pectoralis major muscle underwent surgery. Mean age 36 years (range 28-55 years). No previous antibiotic treatment or steroid abuse/treatment reported. Reasons for rupture were weight lifting (bench-press, n = 10), skiing and snowboard accidents (n = 3), fitness training (n = 3), soccer (n = 1), martial arts (n = 1), a canyoning accident (n = 1), and a simple fall (n = 1). Follow-up examinations were performed 6 weeks and 3 months postoperative. No infections or wound healing disorders; no revisions necessary. Normal muscle function via open refixation of the tendon stump. No re-rupture observed. Free ROM observed 3 months after surgery.

[Paresis of the brachial plexus after anterior shoulder luxation : Traumatic damage or compression due to hematoma?] / Parese des Plexus brachialis nach vorderer Schulterluxation : Traumatische Schädigung oder hämatombedingte Kompression?

After traumatic anterior shoulder dislocation and self-reduction, the patient initially showed an inconspicuous clinical course. At the time of presentation in the emergency room the upper limb neurological status was reported to be normal. After discharge, paresis of the brachial plexus of the left arm occurred within 8 h. A subsequently performed computed tomography (CT) scan revealed a hematoma close to the brachial plexus, which was treated by surgical decompression and resulted in symptom relief. This case report describes a rare but significant complication after anterior shoulder dislocation, which should not be underestimated in the setting of a surgical emergency admission.

[Osteoarthritis of the shoulder: pathogenesis, diagnostics and conservative treatment options]. / Omarthrose: Pathogenese, Diagnostik und konservative Therapieoptionen.

PATHOGENESIS: Osteoarthritis of the shoulder is characterized by a progressive degenerative process, which is based on chronic inflammation with intra-articular release of different cytokines and proteolytic enzymes. The main predisposing factors are a history of trauma or surgery, as well as chronic overuse or instability of the glenohumeral joint. Affected patients especially suffer from impaired joint function and pain, which are often associated with cognitive and psychosocial restrictions. DIAGNOSTICS: Possible co-pathologies have to be evaluated carefully both clinically and radiologically as they must be taken into account in the therapeutic procedure. If arthroplasty of the shoulder is planned, a pre-operative CT scan is mandatory in order to evaluate the bone stock of the glenoid, which has a decisive influence on the choice of implant. TREATMENT: Conservative treatment options are oral pain medication, physical therapy, and intra-articular injections, whereby, in comparison to corticosteroids, hyaluronic acid seems to be advantageous especially with respect to the duration of a positive clinical effect.

[Modern treatment strategies for the long head of the biceps tendon]. / Moderne Behandlungsstrategien der langen Bizepssehne.

The long head of the biceps and the biceps pulley sling are prone to acute or degenerative injury. As they both were identified as major pain generators, adequate diagnosis and treatment is vital for successful treatment of shoulder pain. Although the basic principles to address either pathology have not changed over the last decades, new trends have evolved to simplify surgical options. SLAP (superior labral tear from anterior to posterior) repair is seen more restrictive and is mostly performed in young individuals, whereas tenotomy or tenodesis are more often used in patients over 30. The long head of the biceps and pulley lesions are treated with either tenotomy or tenodesis. Surgical techniques for tenodesis are especially less invasive using current implants. Tenodesis is performed either intraarticular, supra- or subpectoral with tenodesis screws or suture anchors. Soft tissue tenodesis has become unpopular over the last decade. Surgical treatment of the long head of the biceps pathologies allows highly satisfying results if the indication is chosen thoroughly.