Reverse shoulder arthroplasty for type 1 sequelae of a fracture of the proximal humerus.

Aims: The aim of this study was to analyze the results of reverse shoulder arthroplasty (RSA) in patients with type 1 sequelae of a fracture of the proximal humerus in association with rotator cuff deficiency or severe stiffness of the shoulder. Patients and Methods: A total of 38 patients were included: 28 women and ten men. Their mean age at the time of arthroplasty was 73 years (54 to 91). Before the RSA, 18 patients had been treated with open reduction and internal fixation following a fracture. A total of 22 patients had a rotator cuff tear and 11 had severe stiffness of the shoulder with < 0° of external rotation. The mean follow-up was 4.3 years (1.5 to 10). The Constant score and the range of movement of the shoulder were recorded preoperatively and at final follow-up. Preoperatively, radiographs in two planes were performed, as well as CT or arthro-CT scans; radiographs were also performed at final follow-up. Results: The mean Constant score improved from 25 points (5 to 47) preoperatively to 57 points (15 to 81) postoperatively. The mean forward elevation of the shoulder increased from 73° (10° to 130°) preoperatively to 117° (15° to 170°) postoperatively. Previous surgery did not influence the outcome. Patients with rotator cuff tears had lower Constant scores than patients without (p = 0.037). Those with preoperative stiffness of the shoulder had lower postoperative external rotation compared with patients without stiffness (p = 0.046). There was no radiographic evidence of loosening. Three complications occurred, leading to revision surgery in two patients. In all, 17 patients rated their result as very good (45%), another 17 as good (45%), two as satisfactory (5%), and two as unsatisfactory (5%). Discussion: RSA is an effective form of treatment for patients with type 1 sequelae of a fracture of the proximal humerus associated with rotator cuff deficiency or stiffness of the shoulder, with high rates of satisfaction. Rotator cuff tears and stiffness of the shoulder had an adverse effect on the clinical outcome. Cite this article: Bone Joint J 2018;100-B:318-23.

[Structural damage after shoulder dislocation and development of surgical treatment from a historical perspective]. / Struktureller Schaden nach Schulterluxation und operative Therapieentwicklung aus historischer Sicht.

In the nineteenth century there was a high incidence of habitual shoulder instability caused by epileptic seizures and accompanied by therapeutic dilettantism, which led to socioeconomic problems in the working population. In the preradiography era the pathomechanism of shoulder dislocation was only known on the basis of cadaver studies and autopsy findings. The underlying structural disorders of habitual shoulder instability in the Bismarck era were published by Malgaigne, Broca and Hartmann. In1898 the first surgical reconstructive stabilization procedure for habitual shoulder dislocation was performed by Wilhelm Müller in Rostock. At the beginning of the twentieth century Perthes introduced the anatomical reconstruction of the capsulolabral complex, which was copied in the English speaking area by Bankart. Surgical wrong tracks through extra-anatomical procedures, capsulorrhaphy and tendon transfer, were followed by bone block procedures according to Eden-Hybinette and a modification of this procedure by Lange. In the French speaking area Latarjet introduced the transfer of the coracoid process in the middle of the 1950s, which brought the advantage of simultaneous dynamic stabilization to bony augmentation of the glenoidacetabulum .

[Results from the German shoulder- and elbow arthroplasty register (SEPR) : Anatomic or reverse shoulder arthroplasty in B2-glenoids?] / Ergebnisse des deutschen Schulter- und Ellenbogenprothesenregisters (SEPR) : Anatomische oder inverse Prothese bei B2-Glenoid?

BACKGROUND: Anatomic shoulder arthroplasty in osteoarthritis with biconcave glenoid wear results in decreased functional results and a higher rate of early glenoid loosening. AIM: The aim of the data analysis of the German shoulder arthroplasty register was to clarify whether reverse shoulder arthroplasty can provide better functional results and a lower complication rate than anatomic arthroplasty in osteoarthritis with biconcave glenoid wear. METHODS: The analysis included 1052 completely documented primary implanted arthroplasties with a minimum follow-up of 2 years. In 119 cases, a B2-type glenoid was present. Out of these cases, 86 were treated with an anatomic shoulder arthroplasty, and in 33 cases a reverse shoulder arthroplasty was implanted. The mean follow-up was 47.6 months. RESULTS: The Constant score with its subcategories, as well as the active range of movement improved significantly after anatomic and after reverse shoulder arthroplasty. DISCUSSION: We observed no difference in functional results between both types of arthroplasty; however, reverse arthroplasty showed a significant higher revision rate (21.2%) (3% glenoid loosening, 6% prosthetic instability) than anatomic shoulder arthroplasty (12.8%) (11.6% glenoid loosening, 1.2% prosthetic instability), whereas anatomic shoulder arthroplasty showed a higher rate of glenoid loosening. Functional and radiographic results of both types of arthroplasty are comparable with the results reported in the literature, although our analysis represents results from an implant registry (data pertaining to medical care quality).

[Humeral head replacement in acute proximal humerus fractures]. / Hemiprothese bei proximaler Humerusfraktur.

Complex proximal humerus fractures with an avascular head fragment and unreconstructable fracture types represent indications for humeral head replacement. Special prosthetic designs allow modular anatomical restoration of the centre of rotation and alignment and stable fixation of the tuberosities. These play a key role with respect to the functional outcome and are often prone to complete or partial osteolysis with secondary rotator cuff deficiency. Because the operational procedure is technically demanding, attention must be paid to correct implantation. The functional results which can be expected are reliable with a moderate Constant score of 50 to 60 points and a low pain level. In elderly patients with poor bone quality and an associated increased tuberosity-related complication rate, a primary inverse prosthetic design has to be considered as a reasonable alternative. The overall revision rate is approximately 11 %.

[Strategies in revision shoulder arthroplasty]. / Strategien beim Endoprothesenwechsel der Schulter.

The increasing number of primary shoulder arthroplasty operations is correlated to an increasing revision rate of up to 11.2% for anatomical shoulder arthroplasty and 13.4% for reverse shoulder arthroplasty. To reduce the risk of implant revision the surgeon has to take the possibility of late complications into account for the index operation and to choose a modular implant system. Indications for revision arthroplasty are secondary glenoid wear, aseptic loosening, infections, rotator cuff deficiency, instability, implant malpositioning, mechanical complications and periprosthetic fractures. Due to the high rate of humeral fractures during revision surgery of anatomical stemmed implants (12%) and reverse implants (30%) osteotomy of the humerus is of particular importance. Osteotomy of the humeral shaft with a distal window or transhumeral shaft osteotomy as described by Gohlke can be used. The most demanding step during implantation of the revision implant is the accurate reconstruction of the prosthetic height because the stability, strength of the deltoid muscle and in unfavourable situations the degree of stiffness in the glenohumeral joint all depend on the prosthetic height. The result of anatomical glenoid revision surgery totally depends on the bony defect. Revision glenoid components showed better results compared to glenoid reconstruction using a corticocancellous bone graft but resulted in a higher rate of secondary loosening of the glenoid implant. Cementless glenoid revision implants seem to achieve a higher stability of bony fixation than cemented implants. Due to a better form closure with the reverse humeral implant and a mechanically more favorable loading of the glenoid bone stock, the glenosphere should be implanted with an inferior tilt in revision surgery.

[Instability pattern of acromioclavicular joint dislocations type Rockwood III: relevance of horizontal instability]. / Instabilitätsmuster bei Akromioklavikulargelenkverletzungen vom Typ Rockwood III: Bedeutung der horizontalen Instabilität.

BACKGROUND: There is no evidence-based treatment algorithm established for acromioclavicular joint (AC joint) dislocation classified as type Rockwood III injury. Recent meta-analyses revealed no advantage of surgical treatment compared to the non-operative approach. Both surgical and non-surgical approaches have been reported with inconsistent results. Therefore, the hypothesis of the current study was that patients classified as having Rockwood grade III injury may have different degrees of horizontal AC joint instability. MATERIAL AND METHODS: A total of 18 consecutive patients who had sustained a dislocation of the AC joint classified as Rockwood III were evaluated radiologically to quantify the horizontal instability of the AC joint. The specific radiological investigation included lateral stress x-rays (Alexander view) und axial stress x-rays with the affected arm in a horizontal adduction position. RESULTS: The dynamic horizontal instability of the AC joint was found to be independent of the vertical dislocation measured in the Rockwood classification. CONCLUSION: For further treatment studies Rockwood III injuries should be distinguished in patients presenting with or without a substantial horizontal AC joint instability.

[Latissimus dorsi transfer--comparison of results after primary and revision surgery: a retrospective matched-pair analysis]. / Zeigt der Latissimus-dorsi-Transfer als Revisionsoperationvergleichbare Ergebnisse zum Primäreingriff? Eine retrospektive Matched-Pair-Analyse

AIM: Latissimus dorsi transfer (LdT) has been proposed for the treatment of irreparable rotator cuff tears of the infra- and supraspinatus. The purpose of this retrospective study was to evaluate the results of latissimus dorsi transfer in revision surgery in comparison to primary surgery. METHOD: Between 1998 and 2005 a group of 124 patients has been treated with a latissimus dorsi transfer. From this group 34 patients (Group 1 = revision LdT n = 17, Group 2 = primary LdT n = 17)were examined in a retrospective matched-pair study after an average follow-up of 20 months (Group 1) and 28 months (Group 2) by clinical examination and X-ray. Functional results were assessed with use of the age- and gender-matched Constant Score (CS). RESULTS: The age- and gender-matched Constant Score increased significantly in both groups from preoperatively 51% in Group 1 and 57% in Group 2 up to a postoperative score of 73% in Group 1 and 84% in Group 2 (p = 0.001/p = 0.007). By comparison of the 2 groups there is a significantly higher postoperative age- and gender-matched Constant Score for Group 2 (p = 0.03). Active ROM showed postoperatively no significant difference (Abd/Flex p = 0.8). The Hornblower sign is significantly more frequently positive in Group 1(p < 0.001). The comparison of arthroscopically and open previous surgery for the subgroups of revision latissimus dorsi transfer shows a trend for an increased postoperative age- and gender-matched Constant Score in the arthroscopic group (82%/69% p = 0.06) with a preoperative CS of 50%/52% (p = 0.9). There is no significant difference in the incidence of postoperative complications. CONCLUSION: Considering the correct indication for latissimus dorsi transfer there is no difference for reduction of pain and active ROM between primary and revision surgery. But the revision cases show a significantly lower age- and gender-matched Constant Score and a higher incidence of a positive Hornblower sign. A higher risk of postoperative complications for the revision group could not be found. In summary, the latissimus dorsi transfer was of significant benefit for both groups and we can also recommend this technique for revision surgery.

Osteochondral autologous transplantation for the treatment of full-thickness cartilage defects of the shoulder: results at nine years.

We describe the outcome at a mean follow-up of 8.75 years (7.6 to 9.8) of seven patients who had undergone osteochondral autologous transplantation for full-thickness cartilage defects of the shoulder between 1998 and 2000. These patients have been described previously at a mean of 32.6 months when eight were included. One patient has been lost to follow-up. The outcome was assessed by the Constant shoulder score and the Lysholm knee score to assess any donor-site morbidity. Standard radiographs and MR scores were obtained and compared with the pre-operative findings and the results from the previous review. No patient required any further surgery on the shoulder. The mean Constant score improved significantly until the final follow-up (p = 0.018). The Lysholm score remained excellent throughout. There was a significant progression of osteoarthritic changes from the initial surgery to the first and final follow-up but this did not appear to be related to the size of the defect, the number of cylinders required or the Constant score (p = 0.016). MRI showed that all except one patient had a congruent joint surface at the defect with full bony integration of all osteochondral cylinders. The results have remained satisfactory over a longer period with very good objective and subjective findings.

[Magnetic resonance analysis of the subscapularis muscle after open anterior shoulder stabilization]. / Magnetresonanztomographische Untersuchung des Musculus subscapularis nach offener vorderer Schulterstabilisierung.

PURPOSE: Analysis of the magnetic resonance imaging of the subscapularis musculotendinous unit (SSC) after primary and revision open shoulder stabilization and their correlation with the clinical function. MATERIALS AND METHODS: In a retrospective cohort study, 13 patients (mean age of group A: 36.5 years) after primary and 12 (mean age of group B: 34.2 years) after revision open stabilization underwent postoperative MRI of the shoulder. The digital data was analyzed with respect to the vertical und transverse diameters (V[slashed circle], T[slashed circle]) in a defined image slice. A signal intensity analysis was performed (infraspinatus/subscapularis signal-to-noise ratio = ISP/SSC SNR). The clinical examination included the SSC tests and signs and the Constant and Rowe score. Twelve healthy volunteers (group C) served as the control. RESULTS: From group C to group B, the mean V[slashed circle] of the SSC decreased significantly (p < 0.05) as did the mean T[slashed circle] of the cranial part of the SSC muscle (= crSSC) (p < 0.05). The mean T[slashed circle] of the caudal part of the SSC muscle (= caSSC) did not differ significantly between all groups (p > 0.05). The ISP-SSC SNR was significantly lower (p < 0.05) in the crSSC of groups A und B than in group C. In the caSSC, the SNR increased in groups A and B. In 53.8 % of group A and 92.3 % of group B, clinical signs of SSC insufficiency were found. There was no significant difference between the Constant and the Rowe score in both groups (p > 0.05). Complete tendon ruptures were not observed in any case. CONCLUSIONS: MRI enables semi-quantitative analysis of the postoperative changes of the subscapularis muscle. The decrease of the ISP/SSC SNR points to a fatty degeneration in the crSSC. The results provide indications of the causes of the clinical dysfunction of the subscapularis musculotendinous unit after open shoulder stabilization.

Three-dimensional glenoid deformity in patients with osteoarthritis: a radiographic analysis.

BACKGROUND: In osteoarthritis of the shoulder, the tilt of the glenoid surface undergoes an eccentric deformation not only in the anteroposterior but also in the superoinferior direction. The goals of this study were to analyze glenoid version in the coronal plane and to clarify the relationship between retroversion and inferior inclination of the glenoid. METHODS: Standardized radiographs of 100 consecutive patients with primary osteoarthritis of the shoulder and 100 otherwise healthy patients with shoulder pain (the control group) were included in this study and were analyzed by two independent observers. RESULTS: We defined four different types of inclination deformity of the glenoid. In a type-0 glenoid, a line at the base of the coracoid process and a line at the glenoid rim run parallel. Both lines intersect below the inferior glenoid rim in a type-1 glenoid. In a type-2 glenoid, the line at the base of the coracoid process and the glenoid line intersect between the inferior glenoid rim and the center of the glenoid. In a type-3 glenoid, the lines intersect above the base of the coracoid process. A significant difference (p < 0.0001) in the distribution of glenoid types between the two patient groups was observed. Forty-seven patients with osteoarthritis showed combined posterior and inferior glenoid wear. We found no correlation between the type of inclination and the type of glenoid morphology. The interobserver reliability of our observations was very high. CONCLUSIONS: In osteoarthritis, eccentric inferior glenoid wear is frequent and independent from retroversion deformity of the glenoid. Normalization of glenoid version in both transverse and coronal planes may reduce eccentric loading of the prosthetic glenoid, which has been associated with loosening.

Transfer of the tendon of latissimus dorsi for the treatment of massive tears of the rotator cuff: a new single-incision technique.

We describe 14 patients who underwent transfer of latissimus dorsi using a new technique through a single-incision. Their mean age was 61 years (47 to 76) and the mean follow-up was 32 months (19 to 42). The mean Constant score improved from 46.5 to 74.6 points. The mean active flexion increased from 119 degrees to 170 degrees , mean abduction from 118 degrees to 169 degrees and mean external rotation from 19 degrees to 33 degrees . The Hornblower sign remained positive in three patients (23%) as did the external rotation lag sign also in three patients (23%). No patient had a positive drop-arm sign at follow-up. No significant difference was noted between the mean pre- and postoperative acromiohumeral distance as seen on radiographs. An increased grade of osteoarthritis was found in three patients (23%). Electromyographic analysis showed activity of the transferred muscle in all patients.

Intra-articular volume assessment in glenohumeral instability.

It is commonly claimed that instability of the shoulder is associated with an enlarged joint volume. The purpose of our study was to assess the intra-articular volume in acute and chronic glenohumeral dislocation. Sixty-seven patients were examined by intra-articular infusion of saline solution. Three groups could be formed. Group 1 (n = 51) consisted of patients with first time traumatic dislocation, group 2 (n = 8) of cases with recurrent post-traumatic dislocation. The patients of group 3 (n = 8) suffered from impingement syndrome and served as the control group. The joint volume was correlated to the body surface area (BSA). We found a strong correlation between height, sex and intra-articular joint volume. There was no statistically significant difference in joint volume correlated to BSA between the three groups. There is no statistically significant difference in joint volume correlated to BSA in patients with traumatic anterior instability, chronic instability and individuals without glenohumeral instability.

[Traumatic anterior shoulder dislocation]. / Traumatische vordere Schulterluxation.

The purpose of this paper is to outline the present state of treatment for traumatic anterior shoulder dislocation. Pathoanatomic changes as well as intrinsic and extrinsic prognostic factors are discussed. Based on these, treatment options for first time traumatic dislocations and chronic posttraumatic instability are recommended.

[Shoulder Arthroplasty. Surgical management]. / Schulterendoprothetik. Operatives Management.

Shoulder arthroplasty covers an extensive indication spectrum of degenerative, inflammatory to infectious, tumorous, instability-associated and neurogenic disease to acute trauma and posttraumatic joint destruction. Each of these indications requires its own regime and an appropriate implant. Osteoarthritis is the most frequent indication, and will be used as an example for surgical management, bringing the manufacturer-nonspecific general guidelines, joint mechanics and surgical technology into agreement. The fundamentals of the technique of implantation refer to the anatomical adaptability of the third generation of shoulder prostheses, which permits an accurate reconstruction of glenohumeralen joint centring. This article also describes far-reaching principles, which are generally applicable to all indications for shoulder arthroplasty.

Osteochondral autologous transplantation for the treatment of full-thickness articular cartilage defects of the shoulder.

We performed eight osteochondral autologous transplantations from the knee joint to the shoulder. All patients (six men, two women; mean age 43.1 years) were documented prospectively. In each patient the stage of the osteochondral lesion was Outerbridge grade IV with a mean size of the affected area of 150 mm2. All patients were assessed by using the Constant score for the shoulder and the Lysholm score for the knee. Standard radiographs, magnetic resonance imaging and second-look arthroscopy were used to assess the presence of glenohumeral osteoarthritis and the integrity of the grafts. After a mean of 32.6 months (8 to 47), the mean Constant score increased significantly. Magnetic resonance imaging revealed good osseointegration of the osteochondral plugs and congruent articular cartilage at the transplantation site in all but one patient. Second-look arthroscopy performed in two cases revealed a macroscopically good integration of the autograft with an intact articular surface. Osteochondral autologous transplantation in the shoulder appears to offer good clinical results for treating full-thickness osteochondral lesions of the glenohumeral joint. However, our study suggests that the development of osteoarthritis and the progression of pre-existing osteoarthritic changes cannot be altered by this technique.

[Shoulder instability. Classification and treatment]. / Schulterinstabilitäten. Klassifikation und Behandlung.

Shoulder instability includes different degrees of instability from painful hyperlaxity to subluxation to dislocation. Different classifications of shoulder instability have been created in order to facilitate decision making for treatment. None of these, however, has gained acceptance. Subject to the indications, shoulder instability can be treated conservatively or surgically after repositioning the acute dislocation. A survey of arthroscopic and open stabilization procedures and their results are given in relation to the indications.

[Radial shock wave therapy in calcifying tendinitis of the rotator cuff--a prospective study]. / Radiale Stosswellentherapie der Tendinosis calcarea der Rotatorenmanschette--Eine prospektive Studie.

AIM: The aim of the study is to evaluate the influence of radial shock wave therapy (RSWT) on the course of calcifying tendinitis of the rotator cuff. MATERIAL AND METHODS: 35 patients with a mean age of 47.5 years suffering from calcifying tendinitis stage Gaertner 2 with a mean size of 16.6 mm in typical location (true-ap view) for a mean of 28 months were treated by low-energy RSWT three times. The acromio-humeral distance averaged 10.4 mm measured at the true-ap view. All patients were clinically and radiologically followed-up at 4 weeks, 3, 6 and 12 months after the last treatment. RESULTS: The Constant score improved significantly (p < 0.0001) during the first 4 weeks after RSWT from a mean of 68.5 to a mean of 80.5 points and remained approximatively constant at 3, 6 and 12 months follow-up. After 4 weeks 25.7% of the patients had no pain, 54.3% reported about pain relief. In the course of the follow-up a significant improvement of pain was observed: up to 80.8% painless and 19.2% pain relief 12 months after RSWT. Radiologically 4 weeks after RSWT the X-ray examination showed in 17.6% no calcific deposit, in 20.5% a disintegration and in 61.5% no changes of the calcific deposit. At further follow-up we found a complete resorption of the calcific deposit in 75% up to 12 months after RSWT and 25% had no change in calcific deposit. Overall three patients (8.5%) had to undergo surgical treatment 3-7 months after RSWT. CONCLUSION: The low-energy RSWT leads within the first 4 weeks to a significant pain relief and an improvement of shoulder function. In consideration of the long history, the size and the spontaneous resorption rate of the calcific deposit, an inductive effect of RSWT on the resorption of the calcific deposit can be assumed.

[Superior labrum-biceps anchor complex]. / Oberer Labrum-Bizepsanker- KomplexPathologie, Diagnostik und Therapie.

The focus in overhead sport injuries of the shoulder has been directed on lesions of the superior labrum-biceps complex during the last few years. This is due to improved imaging modalities as well as a better understanding of the anatomy and biomechanics. Arthroscopy is capable of diagnosing and treating these lesions. The anatomy, biomechanics, and operative treatment strategies and techniques are described in detail. The superior labrum anterior-posterior (SLAP) lesion is found in young active overhead athletes. Based on their classification and concomitant lesions, the unstable SLAP lesions (types II and IV) have to be repaired in order to restore stability to the superior labrum-biceps complex for stabilizing the glenohumeral joint. According to our own results and after review of the current literature, SLAP repair yields good results in overhead athletes enabling them to return to pain-free participation in their sport.

[Proximal humeral head fractures--Future development of shoulderimplants]. / Proximale Oberarmfrakturen - Zukünftige Entwicklung in der Endoprothetik -

In 1951 a shoulder prosthesis was developed for the treatment of complex humeral head fractures by Neer. The Neer-II-Prosthesis, which was developed further in 1973 represents the basis of modern shoulder implants. The unsatisfactory postoperative functional results for primary humeral head replacement required the development of new adaptable implants for the treatment of complex humeral fractures, which allow the reconstruction of humeral length, the reconstruction of center of rotation and humeral offset, the anatomic positioning, the reconstruction of retrotorsion and the secure refixation of the tuberosities. The development of third and fourth generation of humeral head prosthesis achieves a three-dimensional adaptability for the conditions of posttraumatic arthritis. Primary and secondary humeral head replacement in humeral head fractures as well as revision of prosthetic replacement are complex and technical demanding operations with high and different requirements on implants having to be realised on further development.