Instabilities and Osteoarthritis of the Sternoclavicular Joint. / Instabilitäten und Arthrose des Sternoklavikulargelenks.

Injury to the sternoclavicular joint (SCG) is very rare, accounting for 3% of shoulder injuries and < 1% of instabilities. Consequently, both the treatment of acute instabilities and their subsequent states (chronic instabilities/SCG arthrosis) are controversial. While treatment has so far been mostly conservative, in recent years there has been a trend towards surgical therapy.Considerable violence, such as that found in traffic accidents or contact sports, can tear the extremely stable ligaments between the medial clavicle and sternum. While anterior dislocation is easier to reduce in most cases, instability remains in up to 50% of cases. In most cases, posterior instability requires rapid reduction, particularly due to the anatomical proximity to important cardio-pulmonary structures. If this succeeds, the rate of persistent instabilities is low. For chronic instability, reconstruction/augmentation of the ligament apparatus with tendon grafts in the "Figure of 8 configuration" has proven to be the standard technique in recent years.

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.

Atrophy patterns in isolated subscapularis lesions.

BACKGROUND: While supraspinatus atrophy can be described according to the system of Zanetti or Thomazeau there is still a lack of characterization of isolated subscapularis muscle atrophy. The aim of this study was to describe patterns of muscle atrophy following repair of isolated subscapularis (SSC) tendon. METHODS: Forty-nine control shoulder MRI scans, without rotator cuff pathology, atrophy or fatty infiltration, were prospectively evaluated and subscapularis diameters as well as cross sectional areas (complete and upper half) were assessed in a standardized oblique sagittal plane. Calculation of the ratio between the upper half of the cross sectional area (CSA) and the total CSA was performed. Eleven MRI scans of patients with subscapularis atrophy following isolated subscapularis tendon tears were analysed and cross sectional area ratio (upper half /total) determined. To guarantee reliable measurement of the CSA and its ratio, bony landmarks were also defined. All parameters were statistically compared for inter-rater reliability, reproducibility and capacity to quantify subscapularis atrophy. RESULTS: The mean age in the control group was 49.7 years (± 15.0). The mean cross sectional area (CSA) was 2367.0 mm2 (± 741.4) for the complete subscapularis muscle and 1048.2 mm2 (± 313.3) for the upper half, giving a mean ratio of 0.446 (± 0.046). In the subscapularis repair group the mean age was 56.7 years (± 9.3). With a mean cross sectional area of 1554.7 mm2 (± 419.9) for the complete and of 422.9 mm2 (± 173.6) for the upper half of the subscapularis muscle, giving a mean CSA ratio of 0.269 (± 0.065) which was seen to be significantly lower than that of the control group (p < 0.05). CONCLUSION: Analysis of typical atrophy patterns of the subscapularis muscle demonstrates that the CSA ratio represents a reliable and reproducible assessment tool in quantifying subscapularis atrophy. We propose the classification of subscapularis atrophy as Stage I (mild atrophy) in case of reduction of the cross sectional area ratio < 0.4, Stage II (moderate atrophy) in case of < 0.35 and Stage III (severe atrophy) if < 0.3.

The V-shaped subscapularis tenotomy for anatomic total shoulder arthroplasty.

PURPOSE: Management of the subscapularis tendon during anatomic total shoulder arthroplasty (TSA) remains controversial. In our unit, subscapularis tenotomy is the preferred technique; however, the potential for tendon gapping and failure is recognised. The purpose of this study is to describe and provide early clinical results of a novel, laterally based V-shaped tenotomy (VT) technique hypothesised to provide greater initial repair strength and resistance to gapping than a transverse tenotomy (TT), with both clinically and radiologically satisfactory post-operative tendon healing and function. METHODS: A retrospective study of patients who underwent primary TSA with VT over a three year period was performed using shoulder and subscapularis-specific outcome scores, radiographs, and ultrasound. A separate cohort of patients who underwent TSA using a subscapularis sparing approach was also reviewed to provide comparative clinical outcomes of a group with TSA and an un-violated subscapularis. RESULTS: Eighteen patients were reviewed at mean 30.4 months (± 11.7). Constant (78.2 ± 12.3), UCLA (8.4 ± 1.5), pain VAS (2.3 ± 2.8), and strength in internal rotation were no different from the comparison group. Likewise, neither were the clinical outcomes of range-of-motion, belly-press, lift-off, and shirt-tuck tests. One patient (5.5%) was found to have a failed subscapularis repair on ultrasound. CONCLUSION: VT during TSA appears to provide healing rates at least equal to those reported for TT, and not dissimilar from those of lesser tuberosity osteotomy. Clinical outcomes are comparable to reported results in the literature for alternative techniques, and not different from those observed here in a comparison cohort with TSA performed without violating the subscapularis tendon. VT therefore potentially offers a more effective and secure tendon repair than a traditional TT, with at least comparable clinical outcomes.

Locking nail versus locking plate for proximal humeral fracture fixation in an elderly population: a prospective randomised controlled trial.

BACKGROUND: Proximal humeral fractures (PHFs) are the third most common fracture in older patients. The purpose of the study was to prospectively evaluate the outcomes of PHF fixation with a locking blade nail (LBN) or locking plate (PHILOS) osteosynthesis in a homogeneous elderly patient population. METHODS: Inclusion criteria were an age > 60 years and the capacity to give informed consent. Patients with isolated tuberosity fractures, previous trauma or surgery, advanced osteoarthritis, fracture dislocation, pathological fractures, open fractures, neurological disorders, full-thickness rotator cuff tears, fracture line at the nail entry point or severely reduced bone quality intra-operatively were excluded. Eighty one patients with PHFs were randomised to treatment using LBN or PHILOS. Outcome measures comprised Constant score, age and gender adjusted Constant score, DASH score, VAS for pain, subjective overall condition of the shoulder (1-6) and active shoulder range-of-motion in flexion and abduction. Plain radiographs were obtained in two planes. All data were collected by an independent observer at 3, 6 and 12 months postoperatively. RESULTS: Thirteen patients were excluded intra-operatively due to rotator cuff tears, fracture morphology or poor bone-quality. Of the remaining 68 patients, 27 in the LBN and 28 in the PHILOS group completed the full follow-up. Mean age at surgery was 75.6 years and the majority of PHFs were three-part fractures (49 patients). Baseline demographics between groups were comparable. All outcome measures improved between assessments (p < 0.001). The LBN group showed improved DASH scores as compared to PHILOS at 12 months (p = 0.042) with fewer incidences of secondary loss of reduction and screw cut-out (p = 0.039). A total of 29 complications (in 23 patients) were recorded, 13 complications (in 12 patients) in the LBN group and 16 complications (in 11 patients) in the PHILOS group (p = 0.941). No significant inter-group difference was observed for any other outcome measures, nor was fracture morphology seen to be associated with clinical outcome or complication rate. CONCLUSIONS: At short-term follow-up, LBN osteosynthesis yielded similar outcomes and complication rates to PHILOS plate fracture fixation in an elderly patient population, though with a significantly lower rate of secondary loss of reduction and screw cut-out. REGISTRATION TRIAL: No. DRKS00015245 at Deutsches Register Klinischer Studien, registered: 22.08.2018, retrospectively registered.

[Distal Humerus Fracture in the Elderly]. / Ellenbogenfraktur im Alter ­ Erhalt oder Ersatz?

Distal humerus fractures show increasing incidence with age. Due to preexisting osteoporosis, the surgeon is regularly confronted with complex comminuted intraarticular fractures. The maintenance of autonomy in daily life and avoidance of permanent care dependency is a dogma in the care of geriatric patients. Accordingly, a stable post-operative situation that allows early functional post-operative treatment is mandatory, especially in the elderly patient. Open reduction and stable internal fixation using double plate osteosynthesis are the current osteosynthetic standard of treatment. Modern precontoured systems with angular stability facilitate stable fixation and reduce surgery time. However, complication rates are high, despite the good functional outcomes in the few available studies which use modern plate systems in a geriatric patient population. Due to the high rate of primary stability, elbow arthroplasty has become an established treatment option for complex distal humerus fractures in elderly patients. Consequently arthroplasty registry data report a growing number of elbow replacements for fracture in recent decades. The standard implant design in the fractures in geriatric patients is the cemented "semi-constrained" total elbow arthroplasty. The disadvantages of total elbow replacement are the lifelong stringent weight restriction patients must adhere to, as well as potential long-term complications associated with arthroplasty, such as aseptic loosening and periprosthetic fractures. Comparative studies with short- and medium-term follow-up show overall comparable functional results for elbow arthroplasty and double plate osteosynthesis, with fewer complications and revisions as well as a shorter duration of surgery within the arthroplasty group. However, long-term outcome studies are necessary to identify potential long-term complications associated with arthroplasty and are pending. Therefore, in reconstruction of fractures of the distal humerus which allow stable fixation and early functional post-operative treatment, open reduction and double plate internal fixation with modern locking plate systems remains the gold standard even for geriatric patients.

Patients' expectations of shoulder instability repair.

PURPOSE: To analyze and compare patient expectations of primary and revision shoulder stabilization and to assess the factors associated with patients' expectations. METHODS: Pre-operative patient expectations after shoulder instability repair were prospectively assessed using a self-designed questionnaire. The survey included questions on the expected level and type of return to sports, instability, pain, risk of osteoarthritis, and overall shoulder condition. RESULTS: One-hundred and forty-five patients (99 primary; 46 revision repair) were included. A return to sport at the same level with slight to no restrictions was expected in 95%, a return to high-risk activities in 34%, to moderate in 58%, and to low-risk activities in 9%. No pain [instability] independent of the activity level was expected by 71% [79%] and occasional pain [instability] during contact and overhead activities by 25% [19%]. 61% expected to have no risk of glenohumeral osteoarthritis, 37% a slight, and 2% a significant risk. The overall expectation for the post-operative shoulder was indicated to be normal or nearly normal in 99% of patients. The revision group did not differ from the primary repair group in any variable. High pre-operative sport performance was positively correlated with post-operative sport expectations. The number of dislocations, the duration of instability, and the subjective instability level were negatively correlated with return to sport expectations. CONCLUSION: Patient expectations for primary and revision shoulder instability repair are high. Realistic patient expectations regarding the surgical procedure are necessary to avoid low patient satisfaction, especially in pre-operatively highly active and demanding athletes. The surgeon must not solely base the treatment on the pathology and possible risk factors for failure but should also take the individual expectation of the patient into account. LEVEL OF EVIDENCE: III.

Patient satisfaction with health is substantially improved following ACL reconstruction.

PURPOSE: To prospectively monitor health-related quality of life and return to work after arthroscopic anterior cruciate ligament (ACL) reconstruction in patients with isolated ACL tears. METHODS: Sixty consecutive patients with isolated ACL tears who underwent arthroscopic ACL reconstruction were prospectively monitored using the "Questions on Life Satisfaction Modules" (FLZM) and "Short-Form 12 (SF-12)" quality-of-life outcome measures. The Lysholm score and Tegner activity index were used as functional outcome measures. Additionally, return to work (months) together with level of physical workload was analysed. Outcome measures were assessed the day before surgery and at 6, 12 weeks and 6, 12, and 24 months post-operatively. Quality-of-life outcomes were correlated with functional outcome scores. RESULTS: Satisfaction with health (FLZM) significantly improved within the first 2 years (p < 0.05), and the physical component scale (SF12) showed a significantly higher score after 3, 6, 12 and 24 months as compared with preoperative values (p < 0.05). "General life satisfaction (FLZM)" was initially decreased at 6 weeks (p < 0.05) but increased during the further follow-up period, reaching a score not significantly different from preoperative values. Mean Lysholm score improved from 66 preoperatively to 89 post-operatively (p < 0.05) and the median Tegner activity index improved from four to six points (p < 0.05) at final follow-up. Mean time to return to work was 7 weeks (range 1-34 weeks), and it strongly depended on physical workload. A positive correlation between quality of life and functional outcome (Lysholm score) was observed. CONCLUSION: General life satisfaction is impaired during the early post-operative course, but returns to preoperative values after 2 years. Satisfaction with health reaches higher values after 6, 12 and 24 months post-operatively, and the SF-12 physical component scale was seen to improve during the follow-up period. Improved functional outcomes were observed to correlate with quality-of-life measurements. Thus, patients can preoperatively be informed that they will benefit from ACL reconstruction in terms of an improved knee function and satisfaction with health. Heavy physical workload must be considered as a risk factor for prolonged time lost to return to work. These patients have to be identified and informed about realistic expectations. LEVEL OF EVIDENCE: II.

Does the Arthroscopic Latarjet Procedure Effectively Correct "Off-Track" Hill-Sachs Lesions?

BACKGROUND: The glenoid track concept describes the dynamic interaction of bipolar bone loss in anterior glenohumeral instability. Initial studies have successfully demonstrated this concept's application in clinical populations. In clinical practice, the Latarjet procedure is commonly the preferred treatment in addressing "off-track" Hill-Sachs lesions. The effectiveness of this procedure in restoring such lesions to an "on-track" state, however, has not yet been evaluated or described in the literature. HYPOTHESIS: The Latarjet procedure would transform "off-track" Hill-Sachs lesions to "on-track" lesions. Lesions would remain "on-track" during follow-up, despite glenoid remodeling. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients with "off-track" Hill-Sachs lesions treated with the arthroscopic Latarjet procedure between March 2013 and May 2014 were included. Glenoid track and coracoid graft contact surface area measurements using 3-dimensional computed tomography (3D-CT) were performed preoperatively and at 6-week, 6-month, and at least 12-month (final) follow-up. The mean final follow-up was 23 months. The glenoid diameter, as a percentage of the native glenoid, was also calculated from this imaging. RESULTS: Twenty-six patients met the inclusion criteria. 3D-CT scans were available for all patients preoperatively and postoperatively, with 21 patients (81%) undergoing 6-month follow-up CT and 19 patients (73%) undergoing final follow-up CT. Hill-Sachs lesions remained "on-track" at all follow-up time points. The mean glenoid diameter changed significantly from 84.6% preoperatively to 122.8% at 6 weeks ( P < .001) and from 120.5% at 6 months to 113.9% at final follow-up ( P = .005). This was also reflected in significant remodeling seen in the coracoid graft articular contact area (6 weeks to 6 months, P = .024; 6 months to final follow-up, P = .002). This persisting glenoid arc enlargement at final follow-up avoided "off-track" Hill-Sachs lesions in 6 of 19 patients (32%), which would otherwise have occurred had the coracoid graft remodeled to native glenoid dimensions. CONCLUSION: The Latarjet procedure provides an effective treatment for "off-track" engaging Hill-Sachs lesions, despite an evident glenoid remodeling process. At a mean of 23 months postoperatively, a mean persisting enlargement of the glenoid arc of 14% beyond native dimensions remained, avoiding a recurrent "off-track" lesion in 32% of patients, which would otherwise have occurred with complete remodeling.

Single versus double row suture anchor fixation for greater tuberosity fractures - a biomechanical study.

BACKGROUND: Fractures of the humeral greater tuberosity (GT) are a frequent injury progressively treated with arthroscopic suture anchor repair. Yet, no biomechanical study has been performed comparing fixation strength of arthroscopic single- (SR) vs. double row (DR) fixation. METHODS: Standardized fractures of the greater tuberosity were created in 12 fresh frozen proximal humeri. After random assignation to the SR or DR group the fixed humeri were tested applying cyclic loading to the supraspinatus and infraspinatus tendon. Load to failure and fragment displacement were assessed by means of an electrodynamic material testing machine using an optical tracking system. RESULTS: Load to failure values were higher in the DR group (649 N; ±176) than in the SR group (490 N; ±145) however without statistical significance (p = .12). In greater tuberosity displacement of 3-5 mm surgical treatment is recommended. The fixing constructs in this study did not reach displacement landmarks of 3 or 5 mm before construct failure as shown in previous studies. Thus the applied traction force (N) at 1 mm displacement was analyzed. In the SR group the load at 1 mm displacement was 277 N; ±46 compared to 260 N; ±62 in the DR group (p = .65). CONCLUSION: The results suggest that both techniques are viable options for refixation of greater tuberosity fractures. LEVEL OF EVIDENCE: Laboratory study.

How Satisfied Are Patients with Arthroscopic Bankart Repair? A 2-Year Follow-up on Quality-of-Life Outcome.

PURPOSE: To report general life and health satisfaction after arthroscopic Bankart repair in patients with post-traumatic recurrent anterior glenohumeral instability and to investigate postoperative time lost to return to work at 2-year follow-up. METHODS: Between 2011 and 2013 patients treated with arthroscopic Bankart repair in the beach chair position for acute shoulder instability were included in this study. Questions on Life Satisfaction Modules (FLZM) and the Short Form 12 (SF-12) were used as quality-of-life outcome scales. Oxford Instability Score (OIS), Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), and self-reported American Shoulder and Elbow Surgeons (ASES) shoulder index were used as functional outcome scales. Return to work (months) was monitored and analyzed depending on physical workload. Data were assessed the day before surgery and prospectively monitored until 24 months postoperatively. Quality-of-life outcome was correlated with functional shoulder outcome and compared with normative age-adjusted data. Paired t-test, Wilcoxon test, Mann-Whitney U-Test, and Spearman's correlation coefficient were used for statistical analysis. RESULTS: Fifty-three patients were prospectively included. The mean age at surgery was 29.4 years. Satisfaction with general life and satisfaction with health (FLZM) as well as physical component scale (SF-12) improved significantly to values above normative data within 6 to 12 months after surgery (each P < .001). OIS, QuickDASH, and ASES improved significantly from baseline until 24 months after surgery (each P < .001). For ASES, improvement above minimal clinically important difference was shown. There was a positive correlation between quality of life and functional outcome scores (P < .05; rho, 0.3-0.4). Mean time to return to work was 2 months (range, 0-10; standard deviation, 1.9), with significantly longer time intervals observed in patients with heavy physical workload (3.1 months; range, 0 to 10; standard deviation, 2.4; P = .002). CONCLUSIONS: Following arthroscopic Bankart repair, quality of life was impaired during early course after surgery and increased significantly above preoperative levels within 6 to 12 months after the procedure. A steady state of excellent quality-of-life and functional outcomes was noted after 12 months of follow-up. Quality-of-life outcome scales correlated significantly with the functional outcome. Heavy physical workload must be considered as a risk factor for prolonged time lost to return to work. LEVEL OF EVIDENCE: Level III, prospective noncomparative therapeutic case series.

Long-term Results After Arthroscopic Repair of Isolated Subscapularis Tears.

BACKGROUND: Although some reports have presented short- to midterm results after arthroscopic repair of isolated subscapularis (SSC) tendon tears, long-term evaluation is still lacking. HYPOTHESIS: Long-term results after arthroscopic repair of isolated SSC tears are comparable with the functional and radiological short- to midterm outcomes described in the literature. STUDY DESIGN: Case series, Level of evidence, 4. METHODS: This study assessed 17 patients (5 females and 12 males; mean age, 45.6 years) with isolated SSC tears (Fox and Romeo classification types 2-4) who underwent all-arthroscopic suture anchor repair. The mean interval from symptom onset to the time of surgery was 5.3 months in 16 patients (94.1%). One patient (5.9%) was symptomatic for a prolonged period (104 months) before surgery. All patients were assessed with a clinical examination preoperatively. SSC function was investigated using specific clinical tests and common scoring systems, including Constant, American Shoulder and Elbow Surgeons (ASES), Disabilities of the Arm, Shoulder and Hand (DASH), and Simple Shoulder Test (SST) scores. At follow-up, muscular strength was evaluated using an electronic force-measuring plate. Structural integrity of the repair was assessed using magnetic resonance imaging (MRI). RESULTS: At a mean follow-up of 98.4 ± 19.9 months, the mean Constant score improved from 47.8 preoperatively to 74.2 postoperatively ( P = .001). Higher Constant ( P = .010) and ASES ( P = .001) scores were significantly associated with a shorter time from symptom onset to surgery. The size of the SSC lesion did not correlate with any clinical score outcome ( P = .476, .449, .985, and .823 for Constant, ASES, DASH, and SST scores, respectively). Three patients (17.6%) had persistent positive clinical test results (belly-press/lift-off). Compared with the uninjured contralateral side, SSC strength was significantly reduced in the belly-press position ( P = .031), although active internal ( P = .085) and external ( P = .093) rotation was not affected. In 1 patient, a rerupture was detected by MRI. Six patients had cranial SSC atrophy. Overall, 88.2% of patients were "very satisfied" or "satisfied" with their results. CONCLUSION: Arthroscopic repair of isolated SSC tears results in significant clinical improvements and enduring tendon integrity, although SSC strength remains reduced in the long term. Early surgical treatment seems to be a relevant factor allowing good shoulder function.

Arthroscopic Repair of Subscapularis Tendon Tears.

The subscapularis is the largest and strongest muscle of the rotator cuff, and it plays an essential role in global shoulder function. Beyond its primary function as an internal rotator, the subscapularis also acts to pull the humeral head posteriorly on the glenoid and is an important dynamic and static anterior stabilizer of the glenohumeral joint. In comparison with tears of the tendons of the rest of the rotator cuff, isolated tears of the subscapularis have a tendency for both early retraction and fatty infiltration. Consequently, full-thickness tears of the subscapularis tendon generally require surgical management. Arthroscopic suture-anchor repair allows anatomic reconstruction of the anterior aspect of the rotator cuff, with all of the benefits of arthroscopic surgery. The principal steps of this procedure include (1) verifying the subscapularis tear and identifying any concomitant lesions during diagnostic arthroscopy, (2) exposing the subscapularis tendon, (3) releasing tendon adhesions and so enabling anatomic reduction, (4) placing suture anchors at the anatomic subscapularis footprint on the lesser tuberosity and anatomically repairing the subscapularis tendon to its anatomic insertion, and (5) performing biceps tenodesis or tenotomy, if indicated. Postoperatively, patients with an isolated subscapularis tear are managed with immobilization in a sling for 6 weeks, while those with combined anterosuperior rotator cuff tears are managed with an abduction pillow. Arthroscopic subscapularis reconstruction provides a good structural repair, substantially restores shoulder mobility and strength, reduces pain, and results in high levels of patient satisfaction and return of shoulder function as measured by functional outcome scores.

Results of Arthroscopic Bankart Repair for Anterior-Inferior Shoulder Instability at 13-Year Follow-up.

BACKGROUND: Anterior-inferior shoulder instability is a common injury in young patients, particularly those practicing overhead-throwing sports. Long-term results after open procedures are well studied and evaluated. However, the long-term results after arthroscopic repair and risk factors of recurrence require further assessment. HYPOTHESIS: Arthroscopic Bankart repair results are comparable with those of open repair as described in the literature. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 180 shoulders with anterior-inferior shoulder instability were stabilized arthroscopically, met the inclusion criteria and the patients were able to be contacted at a minimum of 10-year follow-up. Of these patients, 143 agreed to participate in the study. Assessment was performed clinically in 104 patients using the American Shoulder and Elbow Surgeons score, Constant score, American Academy of Orthopaedic Surgeons score, Rowe score, and the Dawson 12-item questionnaire. The Samilson-Prieto score was used to assess degenerative arthropathy in radiographs available for 100 shoulders. Additionally, 15 patients participated through a specific questionnaire and 24 patients through a telephone survey. RESULTS: The overall redislocation rate was 18.18%. Redislocation rates for the different types of fixation devices were as follows: FASTak/Bio-FASTak, 15.1% (17/112); SureTac, 26.3% (5/19); and Panalok, 33.3% (4/12). Concomitant superior labral anterior-posterior repair had no effect on clinical outcome. Redislocation rate was significantly affected by the patient's age and duration of postoperative rehabilitation. Redislocation rate tended to be higher if there had been more than 1 dislocation preoperatively ( P = .098). Severe dislocation arthropathy was observed in 12% of patients, and degenerative changes were significantly correlated with the number of preoperative dislocations, patient age, and number of anchors. The patient satisfaction rate was 92.3%, and return to the preinjury sport level was possible in 49.5%. CONCLUSION: Clinical outcome at a mean follow-up of 13 years after arthroscopic repair of anterior-inferior shoulder instability is comparable with the reported results of open Bankart repair in the literature and allows management of concomitant lesions arthroscopically. Modifiable risk factors of postoperative redislocation and arthropathy must be considered. Stabilization after the first-time dislocation achieves better clinical and radiological outcomes than after multiple dislocations.

A multicenter study to evaluate subscapularis muscle function using 5:30 o'clock portal for antero-inferior shoulder stabilization.

INTRODUCTION: The purpose of this study was to compare the outcome after arthroscopic antero-inferior shoulder stabilization with and without using a 5:30 o'clock portal. MATERIALS AND METHODS: Sixty-two patients [age (mean ± SD), 28.05 ± 8.25 years] with a mean follow-up of 15.23 ± 5.02 months were included in this study. Thirty-one patients underwent arthroscopic antero-inferior shoulder stabilization using the 5:30 o'clock portal in center A (group I) and were compared to 31 matched patients managed with the 3 o'clock portal in center B (group II). Physical examination, standard shoulder scores, ultrasound assessment and subscapularis strength measurement were used to evaluate postoperative shoulder function. RESULTS: Good to excellent results were seen in both groups. No significant differences were seen when comparing ASES, Constant and Rowe Score of both groups. Patients of group II achieved a significant higher score in the SST than patients of group I. (p < 0.05) Patients of group I had a significantly lesser loss of passive external rotation in 0° and 90° of abduction. (p = 0.04; p = 0.056) Ultrasound evaluation and strength measurement showed no significant differences in subscapularis muscle integrity or function neither between the involved and uninvolved shoulder nor between both groups. CONCLUSION: Arthroscopic anterior-inferior shoulder stabilization results in excellent clinical results. When considering portal placement, the deep trans-subscapularis portal allows a more precise suture anchor placement at the inferior glenoid rim and capsular shift with a significant improved external rotation but does not negatively affect the subscapularis function in terms of internal rotation strength or structural integrity. LEVEL OF EVIDENCE: III.

Can young and active patients participate in sports after osteochondral autologous transfer combined with valgus high tibial osteotomy?

PURPOSE: To evaluate sporting activity following osteochondral autologous transfer (OAT) combined with valgus high tibial osteotomy (HTO) in young and active patients with focal osteochondral defects of the medial femoral condyle and concomitant varus malalignment. METHODS: Thirty patients with focal osteochondral defects of the medial femoral condyle and varus malalignment >2° were enrolled. All patients were active in sports on a regular base prior to surgery (lifetime), but were unable to perform sports at the time of surgery. Sporting activity 1 year preoperatively and at final follow-up was compared using a previously published sports questionnaire, which assesses sports level, number of sports disciplines, sports frequency, sports duration and the participation in 32 common sports disciplines. Additionally, the Tegner activity scale and the Activity Rating Scale were used. RESULTS: After a mean follow-up of 6.9 years (2.5-9.8; SD 2.4), 76.7 % of patients were participating in sports on a regular basis (Fig. 2). Compared to 1 year preoperatively, there was no difference (n.s.) with regard to sports, the number of sports disciplines, sports frequency and sports duration (Fig. 4). The median Tegner activity scale measured preoperatively 5.0 (2.0-7.0) and post-operatively 5.0 (4.0-7.0) points (Fig. 3), and the ARS changed from 5.7 to 5.3 points (n.s.). The different types of sports disciplines were comparable between 1 year preoperatively and at follow-up. CONCLUSION: A high return to sports rate and an activity level comparable to the state at 1 year preoperatively can be expected in young and active patients after combined OAT and valgus HTO. This seems to be relevant in clinical practice when planning, indicating and performing these complex procedures. LEVEL OF EVIDENCE: IV.

Patient expectations of primary and revision anterior cruciate ligament reconstruction.

PURPOSE: Unrealistic patient expectations have been shown to negatively influence patient-reported outcomes in orthopaedic surgery. Knowledge about patient expectations is important to associate preoperative expectations with the reasonable outcome of a specific procedure. The purpose of this study was to prospectively analyse and to compare patient expectations of primary and revision anterior cruciate ligament reconstruction (ACLR) and to assess the factors associated with patient expectations. METHODS: Preoperative expectations of 181 consecutive patients undergoing ACLR were assessed prospectively using a 5-item questionnaire. Primary ACLR (P-ACLR) was performed in 133 patients (73%), whereas 48 patients (27%) underwent revision ACLR (R-ACLR). The questionnaire assessed the expectation of the overall condition of the knee joint, return to sports, instability, pain, and risk of osteoarthritis. RESULTS: All patients expected a normal (38%) or nearly normal (62%) condition of the knee joint. Return to sports at the same level was expected by 91%. With regard to instability (pain), no instability (pain) independent of the activity level was expected by 77% (58%). No or only a slightly increased risk of the development of osteoarthritis was expected by 98%. The R-ACLR group showed a significantly lower expectation of the overall condition (p = 0.001), return to sports (p < 0.001), and pain (p = 0.002). No statistically significant difference was found between female and male patients (n.s.). In the P-ACLR group, patients with a history of previous knee surgery showed inferior expectations of return to sports (p = 0.015) and risk of osteoarthritis (p = 0.011). Age, number of previous knee surgeries, and pre-injury sports level significantly influenced patient expectations. CONCLUSIONS: Overall, patient expectations of ACL reconstruction are high. Patients undergoing revision ACL reconstruction have lower but still demanding expectations. Younger patients, patients without a history of knee surgery, and highly active patients have higher expectations. Explicit patient information about realistic goals of ACL reconstruction seems to be necessary in order to prevent postoperative dissatisfaction despite a successful operation in the surgeons' point of view. LEVEL OF EVIDENCE: Prospective case series, Level IV.

Sporting Activity After Arthroscopic Bankart Repair for Chronic Glenohumeral Instability.

PURPOSE: The purpose of this study was to collect detailed data on postoperative sporting activity after arthroscopic Bankart repair for chronic shoulder instability. METHODS: Of 113 patients who underwent arthroscopic Bankart repair between February 2008 and August 2010, 81 met the inclusion criteria and were surveyed by a specially designed postal sport-specific questionnaire. Of these 81 patients, 66 (82%) were available for evaluation. RESULTS: All previously active patients performed some activity at follow-up. Of 9 patients (56%) who had been inactive, 5 took up new activities postoperatively. Forty-four patients (66%) stated that surgery had (strongly) improved their sporting proficiency. Seventeen patients (26%) reported no impact, and 5 patients (8%) reported a further deterioration compared with preoperatively. The improvement in sporting proficiency was negatively correlated with the preoperative risk level (ρ = 0.42, P < .001), preoperative performance level (ρ = 0.31, P = .012), and preoperative Tegner scale (ρ = 0.36, P = .003), as well as hours of sporting activity per week (ρ = 0.25, P = .042), whereas age showed a positive correlation (ρ = 0.28, P = .023). There was no change in duration, frequency, number of disciplines, Tegner activity scale, risk category, or performance level. CONCLUSIONS: Arthroscopic Bankart repair provides a high rate of return to activity among patients treated for chronic shoulder instability. A number of previously inactive patients returned to activity postoperatively. However, one-third of patients reported no benefit from surgery in terms of sporting activity. The improvement in sporting proficiency was highly dependent on the demands on the shoulder in sports, as well as the age of the patient. Overall, there was no significant increase in duration, frequency, number of disciplines, Tegner activity scale, or performance level between preoperative and follow-up evaluation and no increased return to high-risk activities. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Arthroscopic Suture Anchor Fixation of Bony Bankart Lesions: Clinical Outcome, Magnetic Resonance Imaging Results, and Return to Sports.

PURPOSE: The purpose of this study was to evaluate the outcome, return to sporting activity, and postoperative articular cartilage and bony morphology of shoulders that underwent arthroscopic suture anchor repair of bony Bankart lesions. METHODS: The inclusion criteria for this retrospective study were anterior glenoid rim fractures after traumatic shoulder instability that were treated with arthroscopic suture anchor repair. Patients were surveyed by a questionnaire including sport-specific outcome, Rowe score, Western Ontario Shoulder Instability Index, and Oxford Instability Score. Three-tesla magnetic resonance imaging could be performed in 30 patients to assess osseous integration, glenoid reconstruction, and signs of osteoarthritis. RESULTS: From November 1999 to April 2010, 81 patients underwent an anterior bony Bankart repair in our department (50 arthroscopic suture anchor repairs, 5 arthroscopic screw fixations, and 26 open repairs). The 55 arthroscopic repairs comprised a consecutive cohort of patients treated by a single surgeon. Of the 50 patients in the suture anchor group, 45 (90%) were available for evaluation. At 82 ± 31 months postoperatively, the mean Rowe score was 85.9 ± 20.5 points, the mean Western Ontario Shoulder Instability Index score was 89.4% ± 14.7%, and the mean Oxford Instability Score was 13.6 ± 5.4 points. Compared with the contralateral shoulder, all scores showed a significantly reduced outcome (P < .001, P < .001, and P < .001, respectively). A redislocation occurred in 3 patients (6.6%). Regarding satisfaction, 35 patients (78%) were very satisfied, 9 (20%) were satisfied, and 1 was partly satisfied. Overall, 95% of patients returned to any sporting activity after surgery. The number of sports disciplines (P < .001), duration (P = .005), level (P = .02), and risk category (P = .013) showed a significant reduction compared with the pretrauma condition. However, only 19% of patients reported that shoulder complaints were the reason for the reduction in activity. Nonunion occurred in 16.6%, with a higher frequency in patients with chronic lesions (P = .031). Anatomic reduction was achieved in 72%, the medial step-off in patients with nonanatomic reduction averaged 1.8 ± 0.9 mm, and the remaining glenoid defect size averaged 6.8% ± 7.3%. Full-thickness cartilage defects of the anterior glenoid were detected in 70% of patients. CONCLUSIONS: Arthroscopic suture anchor repair may enable an anatomic reduction of bony Bankart lesions with no or only minimal articular steps and provides successful midterm outcomes concerning clinical scores, recurrence, and patient satisfaction. The return to activity is limited for various, mostly non-shoulder-related causes. Chronic lesions may have an inferior healing potential; therefore early surgical stabilization of acute Bankart fragments is suggested to avoid possible nonunion. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Prevalence of and Risk Factors for Dislocation Arthropathy: Radiological Long-term Outcome of Arthroscopic Bankart Repair in 100 Shoulders at an Average 13-Year Follow-up.

BACKGROUND: Glenohumeral osteoarthritis is a well-documented, long-term complication of open stabilization procedures. However, there is a lack of knowledge about long-term radiographic outcome after arthroscopic Bankart procedures. HYPOTHESIS: Glenohumeral osteoarthritis will develop less frequently in arthroscopic Bankart repair compared with open repairs reported in the literature. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The inclusion criteria for this study were (1) all-arthroscopic Bankart repair for a (2) symptomatic anteroinferior shoulder instability and (3) a minimum follow-up of 10 years. True anteroposterior and lateral radiographs were obtained to evaluate the prevalence and grade of osteoarthritis according to the Samilson classification. Patients were assessed by the Constant score and examined for passive external rotation deficits. RESULTS: Of 165 shoulders that fulfilled the inclusion criteria, 100 were available for evaluation. The median Constant score at an average±SD 156.2±18.5 months after Bankart repair was 94 (range, 46-100). Twenty-one shoulders (21%) sustained a recurrent dislocation. Overall, 31% of shoulders showed no evidence of glenohumeral osteoarthritis; 41% showed mild, 16% moderate, and 12% severe degenerative changes. Osteoarthritis did not correlate with Constant score results (P=.427). The grade of osteoarthritis was significantly associated with the number of preoperative dislocations (P=.016), age at initial dislocation (P=.005) and at surgery (P=.002), and the number of anchors used (P=.001), whereas time from initial dislocation to surgery (P=.854) and external rotation deficit at 0° and 90° of abduction (P=.104 and .348, respectively) showed no significant correlation. Recurrent dislocation did not affect the presence or grade of osteoarthritis (P=.796 and .665, respectively). CONCLUSION: At an average 13 years after arthroscopic Bankart repair, osteoarthritic changes are a common finding and, overall, are comparable with reports in the literature regarding open procedures as well as nonoperative treatment. The extent of trauma sustained during preoperative dislocations and the age of the patient seem to be more relevant for long-term dislocation arthropathy than the kind of treatment. Accordingly, the study hypothesis must be rejected. Avoiding preoperative dislocations is more important for the prevention of osteoarthritis than short-term treatment. The number of anchors used was found to be a predictor for long-term development of osteoarthritis.