Comparing major joint injuries, interventions and late sequelae in elite male handball players with an age-matched control group.

INTRODUCTION: Handball is a contact sport which involves throwing and jumping, exposing players to serious physical stress. There is a high risk of injuries leading to possible long-term sequelae. The aim of this study was to assess the incidence of musculoskeletal injuries in elite male handball players compared with an age-matched control group. PATIENTS AND METHODS: Former elite handball players, who had played on the Swiss national team between 1980 and 1985, answered a questionnaire about injuries, surgical interventions and their current health status. A total of 34 athletes were compared with 58 age-matched volunteers, who only engaged in recreational sports or no sports at all. RESULTS: The mean age of the athletes was 58.4 years (range 52-68 years) and did not differ significantly from the mean age of the control group of 58.7 years (range 53-69 years). In the control group, 70 % engaged in recreational sports. There was no statistical difference regarding the life-long incidence of shoulder injuries and surgical interventions, sequelae or persistent shoulder pain. Athletes had more interventions after elbow injuries (0.09 vs. 0, p = 0.047), but the difference with respect to chronic pain or late sequelae was not statistically significant. For knee injuries, there were no significant differences regarding the incidence of injuries or interventions, the prevalence of secondary consequences or persistent pain. Concerning the foot and ankle, there was a significantly higher incidence of injuries (0.5 vs. 0.03, p < 0.001) and interventions (0.5 vs. 0.09, p < 0.001) in athletes, but no statistical difference regarding sequelae or persistent pain. Overall quality of life had identical ratings in both groups (athletes mean 85.9 %, controls mean 85.8 %). DISCUSSION: Top handball players did not sustain more shoulder or knee injuries than the age-matched control group. The elbow was more at risk in these top athletes, but long-term consequences appeared to be less severe. The most distinctive difference was seen in foot and ankle injuries. CONCLUSIONS: A career as an elite handball player had no adverse effect on the overall quality of life of elite handball players 25 to 30 years after retiring from professional sports.

Evidence-based algorithm to treat patients with proximal humerus fractures-a prospective study with early clinical and overall performance results.

BACKGROUND: On the basis of patients' demands, bone quality, and fracture type, we developed an evidence-based treatment algorithm for proximal humerus fractures (PHF) that includes all treatment modalities from open reduction and internal fixation, hemiprosthesis, to reverse total shoulder arthroplasty. This study was done to assess its feasibility and early clinical outcome. MATERIALS AND METHODS: Patients with isolated PHF in 2014 and 2015 were included in this prospective study. The quality of life (EQ-5D) and the level of autonomy before injury were recorded. The fractures were classified and local bone quality was measured. When possible, patients were treated according to the algorithm. Radiographic and clinical follow-up-Constant score, subjective shoulder value, and EQ-5D-took place after 3 months and 1 year. The rate of unplanned surgery was analyzed. RESULTS: A total of 192 patients (mean age 66 years; 58 male, 134 female) were included. Of these, 160 (83%) were treated according to the algorithm. In total, 132 patients were treated conservatively, 36 with open reduction and internal fixation and 24 with reverse total shoulder arthroplasty or hemiarthroplasty. Generally, the mean EQ-5D before trauma and 1 year after treatment was equal to 0.88 to 0.9 points. After 1 year, the overall mean relative Constant score was 95% and mean subjective shoulder value 84%. Unplanned surgery was necessary in 21 patients. CONCLUSION: This comprehensive algorithm is designed as a noncompulsory treatment guideline for PHF, which prioritize the patient's demands and biology. The high adherence proves that it is a helpful tool for decision making. Furthermore, this algorithm leads to very satisfying overall results with low complication and revision rates.

Early Arthroscopic Repair of Acute Traumatic Massive Rotator Cuff Tears Leads to Reliable Reversal of Pseudoparesis: Clinical and Radiographic Outcome.

PURPOSE: It was the aim of this study to analyze the clinical and radiographic outcome after early arthroscopic repair regardless of the age of patients. METHODS: Patients with massive traumatic cuff tear and clinical pseudoparesis for forward elevation treated by subsequent early arthroscopic repair from 2011 until 2014 were included in this retrospective study. Exclusion criteria were Goutallier grade ≥3 fatty infiltration and prior shoulder problems or surgery. Magnetic resonance imaging (MRI), radiographs, and functional assessments were performed preoperatively and at follow-up. RESULTS: A total of 21 patients (male/female 15/6; age range: 30-83) were included. Preoperative MRI showed complete 2 tendon tears in 7 patients, 3 tendon tears in 13 patients and all tendons ruptured in one patient. All patients had full passive range of motion and the mean active elevation was 35.7° (range: 0°-60°). Nine patients also had a pseudoparesis for external rotation (mean: 10°, range: -30° to 40°). The mean delay until surgery was 33 days (range: 13-60). At follow-up (mean: 39 months, range: 24-60) all patients showed reversal of pseudoparesis, mean elevation of 165.2° (range: 110°-180°) and mean external rotation of 49.3° (range: -20° to 80°). The mean Constant score was 82 points (range: 56-95), and the mean subjective shoulder value was 93% (range: 50-100). The overall retear rate was 20% (n = 4). Fatty infiltration increased at least 1 grade in patients who had a retear and in 56% of patients (n = 9) without retear. Age was not a predictor for retear. CONCLUSIONS: This study shows that early arthroscopic repair of traumatic massive RCT with pseudoparesis may lead to successful results regardless of patients' age. A complete restoration of the function can be expected even in patients with retear. The retear rate is low and the increase of fatty infiltration minimal. LEVEL OF EVIDENCE: Level IV, case series.

Osteosynthesis of type III acromial fractures with locking compression plate, lateral clavicular plate, and reconstruction plate: a biomechanical analysis of load to failure and strain distribution.

BACKGROUND: Acromial stress fractures following reverse shoulder arthroplasty have been increasingly studied because of potential functional impairment caused by this complication. The purpose of this study was to evaluate and compare different plating techniques for a type III acromial fracture (also referred to as "scapular spine fracture") in a biomechanical setting with special regard to primary stability and modes of failure. METHODS: Type III acromial fractures were simulated on 19 Sawbones scapulae and plated with either a lateral clavicular plate (LatCP), a locking compression plate (LCP), or a reconstruction plate (RecoP). We performed testing on 5 scapulae for each plate according to a staircase protocol (100 cycles each step): 50 N and 100 N, then increasing 100 N each step up to 800 N or until failure. The last series of mechanical tests included 3-dimensional micro-motion analysis. RESULTS: The average force needed to cause failure of the osteosynthesis construct was 376 N for the LatCP, 506 N for the LCP, and 360 N for the RecoP. The difference between the LCP and RecoP was significant (P = .047). The average displacements of the acromion were 12.1 mm, 13.4 mm, and 11.7 mm, respectively. The spring constant was not significantly different between the plates. The LatCP showed increased strain medially, whereas the strain on the RecoP was spread more laterally. The LCP presented a balanced strain distribution, spread evenly over the fracture line. CONCLUSIONS: In a biomechanical setting, the LCP showed superiority over the LatCP and RecoP as stabilization hardware for type III acromial fractures.

Presence of IL-17 in synovial fluid identifies a potential inflammatory osteoarthritic phenotype.

PURPOSE: Osteoarthritis (OA) is a common and heterogeneous arthritic disorder. Patients suffer pain and their joints are characterized by articular cartilage loss and osteophyte formation. Risk factors for OA include age and obesity with inflammation identified as a key mediator of disease pathogenesis. Interleukin-17A (IL-17) is a pro-inflammatory cytokine that has been implicated in inflammatory diseases such as rheumatoid arthritis. IL-17 can upregulate expression of inflammatory cytokines and adipocytokines. The aim of this study was to evaluate IL-17 levels in the synovial fluid of patients with end-stage knee and hip OA in relation to inflammation- and pain-related cytokines and adipocytokines in synovial fluid and serum, and clinical and radiographic disease parameters. METHODS: This is a cross-sectional study of 152 patients undergoing total hip and knee arthroplasty for OA. IL-17, IL-6, leptin, adiponectin, visfatin, resistin, C-C Motif Chemokine Ligand 2 (CCL2), C-C Motif Chemokine Ligand 7 (CCL7) and nerve growth factor (NGF) protein levels were measured in synovial fluid and serum using enzyme-linked immunosorbent assay (ELISA). Baseline characteristics included age, sex, body mass index, co-morbidities, pain and function, and radiographic analyses (OA features, K&L grade, minimal joint space width). RESULTS: 14 patients (9.2%) had detectable IL-17 in synovial fluid. These patients had significantly higher median concentrations of IL-6, leptin, resistin, CCL7 and NGF. Osteophytes, sclerosis and minimum joint space width were significantly reduced in patients with detectable IL-17 in synovial fluid. No differences were found in pain, function and comorbidities. IL-17 concentrations in synovial fluid and serum were moderately correlated (r = 0.482). CONCLUSION: The presence of IL-17 in the synovial fluid therefore identifies a substantial subset of primary end-stage OA patients with distinct biological and clinical features. Stratification of patients on the basis of IL-17 may identify those responsive to therapeutic targeting.

Ultrasound of the coracoacromial ligament in asymptomatic volunteers and patients with shoulder impingement.

BACKGROUND: The coracoacromial ligament is part of the coracoacromial arch, which is considered to be involved in shoulder impingement. PURPOSE: To compare the coracoacromial ligament on ultrasound in asymptomatic volunteers and in patients with subacromial shoulder impingement. MATERIAL AND METHODS: Twenty-nine asymptomatic volunteers (mean age, 35.5 years) and 29 patients (mean age, 49.9 years) with shoulder impingement, diagnosed by experienced shoulder surgeons, were prospectively included. Two radiologists obtained and analyzed ultrasound images of the coracoacromial ligament in the longitudinal axis. RESULTS: The ligament thickness was 1.4 ± 0.2 mm at its midportion, 1.8 ± 0.4 mm at the coracoid, and 2.1 ± 0.6 mm at the acromion in asymptomatic volunteers compared with 1.3 ± 0.2 mm, 1.9 ± 0.5 mm, and 1.9 ± 0.5 mm in impingement patients for observer 1. The ligament length was 30.6 ± 2.4 mm in asymptomatic volunteers compared with 30.4 ± 3.6 mm in impingement patients for observer 1. An anteriorly convex shape of the superficial contour of the coracoacromial ligament was significantly more frequent in impingement patients compared with asymptomatic volunteers for both observers (observer 1: 10% (3/29) versus 45% (13/29), P value <0.01; observer 2: 10% (3/29) versus 38% (11/29), P value <0.03). The comparison of the remaining parameters of the coracoacromial ligament, such as the thickness, length, echogenicity, and fibrillation did not reveal significant differences between volunteers and patients. CONCLUSION: While thickness or length of the coracoacromial ligament were similar in volunteers and patients with shoulder impingement, an anteriorly convex shape of the superficial contour of the coracoacromial ligament was significantly more frequent in impingement patients compared with asymptomatic volunteers.

Unacceptable failure of hemiarthroplasty combined with biological glenoid resurfacing in the treatment of glenohumeral arthritis in the young.

BACKGROUND: Treatment of glenohumeral osteoarthritis in young patients is challenging. Total shoulder arthroplasty reliably addresses pain and dysfunction but compromises glenoid bone stock. Various efforts have been made to avoid a prosthetic glenoid component or to prevent glenoid erosion after hemiarthroplasty. Capsular interposition, meniscal allograft, and more recently, GraftJacket (Wright Medical Technology Inc, Arlington, TN, USA), a human dermal collagen allograft, have been proposed for interposition arthroplasty in young patients with glenohumeral osteoarthritis. METHODS: From 2009 to 2010, GraftJacket was used for glenoid resurfacing combined with humeral resurfacing or a stemmed hemiarthroplasty in 6 patients with a mean age of 47 years (34-57 years). Before GraftJacket was available, 5 patients were treated with a meniscal allograft and 6 with capsular interposition arthroplasty. RESULTS: At a mean of 16 months (9-22 months) after the GraftJacket was implanted, 5 of the 6 patients were revised to a total shoulder arthroplasty or a reverse total shoulder arthroplasty. The sixth patient was dissatisfied but declined further surgery. The mean relative, preoperative Constant score decreased from 35% (range, 13%-61%) to 31% (range, 15%-43%) at revision or latest follow-up. Of the 5 patients with meniscal allograft, 3 underwent revision at a mean of 22 months (range, 12-40 months), and 4 of the 6 patients with capsular interposition were revised at a mean of 34 months (range, 23-45 months). The mean relative Constant scores preoperatively and at revision or latest follow-up were 44% (range, 19%-68%) and 58% (range, 9%-96%) for the meniscal allograft patients and 47% (range, 38%-62%) and 63% (range, 32%-92%) for the capsular interposition cases. CONCLUSION: In our hands, 3 different types of biological resurfacings combined with humeral hemiarthroplasty have an unacceptable early failure rate.

Secondary latissimus dorsi transfer after failed reverse total shoulder arthroplasty.

BACKGROUND: Combined single-stage reverse total shoulder arthroplasty (RTSA) plus latissimus dorsi transfer (LDT) has been reported to be a reliable treatment for pseudoparalysis of elevation and external rotation caused by irreparable rotator cuff tears. Secondary LDT in patients with pseudoparalysis of external rotation after previous RTSA has not yet been studied. METHODS: Ten patients were treated with LDT at a mean of 27 months (range, 4-134 months) after RTSA. Standard LDT was performed in 4 patients and a LDT plus teres major transfer according to L'Episcopo in 6 patients. All patients had preoperative and postoperative clinical evaluation, including the assessment of the Constant score and the subjective shoulder value. RESULTS: RTSA increased the preoperative mean relative Constant score from 26% (range, 11%-67%) to 51% (range, 20%-100%; P = .05). At a mean of 49 months (range, 23-67 months) after additional LDT, the relative Constant score further increased to 58% (range, 34%-100%; P = .141), remaining significantly superior to the score before RTSA (P = .021). The mean subjective shoulder value was 15% (range, 0%-30%) before and 44% (range, 20%-70%) after RTSA (P = .273) and was 56% (range, 20%-90%) after LDT (P = .686), a significant overall improvement of the state of the shoulder compared with before RTSA (P = .042). Mean active flexion increased from 36° (range, 0°-130°) to 86° (range, 10°-140°) after RTSA (P = .024) and to 109° (range,70°-140°) after LDT (P = 0.017 compared with pre-LDT; P = .011 compared with pre-RTSA). Mean active external rotation decreased from 0° (range, -80° to 50)° to -18° (range, -50°to 10)° after RTSA (P = .079) and was improved to 2° (-40° to 40)° after LDT (P = .24 compared with pre-LDT; P=.865 compared with pre RTSA). CONCLUSION: Secondary LDT significantly improves active mobility in patients with residual dysfunction after RTSA.

Is the lateral extension of the acromion related to the outcome of shoulder injections?

OBJECTIVE: To assess patients' outcomes after subacromial or glenohumeral injections based on the degree of lateral extension of the acromion. METHODS: 307 patients were prospectively included after therapeutic fluoroscopy-guided subacromial (n = 148) or glenohumeral (n = 159) injections with anaesthetic and long-acting corticosteroids. Pre- and post-injection outcomes at 1 week and 1 month were obtained using the 11-point numerical rating scale (NRS) for pain. Lateral extension of the acromion was quantified and categorized by the critical shoulder angle (CSA) and the acromion index (AI) on anteroposterior conventional radiographs. RESULTS: Patients' outcomes at 1 week and 1 month were significantly improved (p < 0.001) compared to baseline for subacromial and glenohumeral injection patients. Patients with a CSA <35° showed significantly higher pain reduction 1 month after subacromial injection compared to patients with a CSA >35° (4.2 ± 2.6 vs. 3.2 ± 3.0, p = 0.04). A significant difference in the 1-month NRS change in pain scores is noted for smaller AIs after subacromial injection (4.3 ± 2.8 vs. 2.6 ± 2.9; p = 0.01). No significant association was noted between clinical outcome and the lateral extension of the acromion after glenohumeral joint injections. CONCLUSIONS: A short lateral extension of the acromion was associated with better clinical outcomes in subacromial injection patients but not in glenohumeral injection patients. KEY POINTS: • Patients' outcomes at 1 month improved significantly compared to baseline for subacromial injections. • Patients' outcomes at 1 month improved significantly compared to baseline for glenohumeral injections. • Short acromial lateralization was associated with better clinical outcome after subacromial injection. • The acromial lateralization was not associated with clinical outcome after glenohumeral injection.

Adipokines correlate with pain in lower limb osteoarthritis: different associations in hip and knee.

PURPOSE: Our aim was to investigate whether serum and synovial-fluid (SF) concentrations of interleukin-6 (IL-6), leptin, adiponectin, resistin or visfatin are associated with joint pain in hip and knee in end-stage osteoarthritis (OA). METHODS: A cross-sectional study assessing patients with hip and knee OA undergoing total joint arthroplasty between January and December 2010 was conducted at a large university hospital. Serum and SF cytokine and adipokine concentrations were determined in samples obtained on the day of surgery. The main outcome was pain severity measured pre-operatively using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and visual analogue scale (VAS) pain scores. RESULTS: A total of 206 patients were involved (112 with hip and 94 with knee OA). Median age was 72 years [interquartile range (IQR) 66-79], 59% were women. All adipokine levels were significantly higher in the SF of hip joints than in that of knee joints, except for leptin, which tended to be higher in the knee. In both hip and knee OA, median serum concentrations of leptin, adiponectin, resistin and visfatin exceeded those in SF, whereas for IL-6, median concentrations were much higher in SF than in serum. In hip OA, worse pain was significantly associated with high SF concentrations of IL-6, visfatin and leptin; in knee OA, it was associated with high SF leptin and low SF adiponectin concentrations and a low adiponectin-leptin ratio. CONCLUSION: Our findings support a connection between intra-articular concentrations of several adipokines and severity of preoperative OA pain. However, the specific adipokines differed by joints: in hip OA, pain was associated with IL-6 and visfatin and in knee OA with adiponectin; leptin played a role in both hip and knee OA.

Aseptic loosening rate of the humeral stem in the Coonrad-Morrey total elbow arthroplasty. Does size matter?

BACKGROUND: Aseptic implant loosening is one of the most common complications leading to revision surgery in total elbow arthroplasty. Different humeral stem lengths are available with varying designs. In general, the decision of which stem length to use depends on the surgical diagnosis or simply the surgeon preference. Often, the longer stem is used for post-traumatic or revision cases while for rheumatoid patients the shorter stem is preferred. There are no data in the literature to favor one humeral stem size over the other according to the diagnosis. METHODS: We analyzed the total elbow joint database of the Coonrad-Morrey design at our institution for aseptic loosening leading to revision and compared the revision rate and the survival of the 4- and 6-inch humeral stems. RESULTS: Overall, revision for aseptic humeral loosening is infrequent and occurred in only 16 of 711 total elbow arthroplasties during a mean follow-up of 88 months. There was no significant difference in the revision rate between the 2 stem lengths (1.9% for the 4-inch stems and 2.6% for the 6-inch stem). CONCLUSION: Revision rate was correlated to the surgical diagnosis and was significantly higher for post-traumatic patients than for rheumatoid patients (5.1% vs 0.66%, P < .001). Of interest, and possibly not surprising, the mean time to revision was shorter for the 4-inch stems than it was for the 6-inch stems (37 vs 95 months, P = .034).

Humeral head reconstruction for Hill-Sachs defects: a biomechanical comparison of 2 fixation techniques for bone grafting.

PURPOSE: The purpose of this biomechanical study was to compare anterograde with retrograde screw fixation for allograft reconstruction of Hill-Sachs defects. METHODS: In 8 pairs of fresh-frozen humeral heads, a 40% Hill-Sachs defect was created. The resultant wedge-shaped osteochondral fragment was used as allograft. For each technique, two 3.75-mm screws were used for fixation. To test the strength of fixation, a custom tool was used that would apply load to the graft. By use of a materials testing machine, a staircase cyclic loading protocol was performed (500 cycles at 10, 20, 30, and 40 N) and then load to failure. Graft displacement was measured by an optical tracking system. RESULTS: For the 2 techniques, graft displacement increased with increasing load and increasing number of cycles up to a mean of 0.9 ± 0.42 mm for anterograde fixation and 1.1 ± 0.79 mm for retrograde fixation. This increase was significant within each technique across all 4 loading levels (P < .05). However, there were no significant differences in graft displacement between the 2 techniques at any loading level or number of cycles (P = .16 to P = .96). In addition, the load to failure between the anterograde and retrograde techniques (98.5 N and 95.6 N, respectively) was not significantly different (P = .706). CONCLUSIONS: The initial fixation and failure strength of anterograde and retrograde graft fixation techniques for substantial Hill-Sachs defects do not significantly differ in a biomechanical cadaveric model. CLINICAL RELEVANCE: This biomechanical study supports that in an engaging Hill-Sachs defect, both anterograde and retrograde screw fixation techniques can be used for fixation of humeral head allografts.

Clinical outcome of reverse total shoulder arthroplasty combined with latissimus dorsi transfer for the treatment of chronic combined pseudoparesis of elevation and external rotation of the shoulder.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) allows correction of pseudoparesis of elevation caused by irreparable rotator cuff tear but does not address loss of active external rotation. Latissimus dorsi transfer (LDT) is an established procedure for correction of pseudoparesis of external rotation. METHODS: Forty-one shoulders of 40 consecutive patients, who were a mean age of 70 years old (range 47-85 years), underwent RTSA combined with LDT for irreparable rotator cuff failure with severe shoulder dysfunction. RESULTS: Nine orthopedic complications occurred in 7 of the 41 shoulders. Four shoulders were lost to follow-up, and 5 were excluded from the functional analysis. The mean follow-up of the eligible 32 shoulders with the prosthesis still in place was 53 months (range, 24-105 months). The age-related Constant score increased significantly from a preoperative mean of 45% (range, 16%-80%) to 89% (range, 25%-100%). The mean subjective shoulder value increased from 33% (range, 0%-70%) to 75% (range, 30%-100%). Active external rotation significantly improved from a mean of 4° (range, -30° to 40°) to 27° (range, -10° to 70°). A preoperative external rotation lag sign could be corrected in 25 of the 32 shoulders. For the 16 shoulders with at least 5 years of follow-up, the Constant scores were 47% (range, 16%-80%) preoperatively, 92% (range, 51%-100%) at 2 years, and 94% (range, 57%-100%) at the latest follow-up, and the respective subjective shoulder values were 32% (range, 0%-70%), 73% (range, 30%-100%), and 80% (range, 60%-100%). CONCLUSION: If treated with RTSA combined with LDT, patients with pseudoparesis of elevation and pseudoparesis of external rotation can expect an excellent clinical outcome for a period beyond 5 years, provided that complications that require removal of the prosthesis can be prevented.

Suture anchor fixation of bony Bankart fractures: comparison of single-point with double-point "suture bridge" technique.

BACKGROUND: As an alternative to the standard single-point suture-anchor technique, a suture-bridge technique has been described for the treatment of bony Bankart fractures. There is, however, little evidence supporting one technique over the other. Purpose/ HYPOTHESIS: To compare the failure strength, fixation stability, and loading mechanics of the 2 techniques for the fixation of bony Bankart fractures. We hypothesized that use of the double-point suture-bridge technique would result in superior strength and fixation stability because of the increased compression and contact area between the bony fragment and glenoid fracture site. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 16 shoulders (8 pairs) were tested with an intact glenoid, after creation of a 15% bony Bankart fracture, and after fragment fixation using a single-point or suture-bridge technique. Paired specimens were randomly assigned to each technique. Cyclic progressive loading was applied via a materials testing machine to the glenoid concentrically and eccentrically according to a staircase protocol. Failure strength, fragment displacement, glenoid strain load transfer, and contact area were quantified. RESULTS: No significant differences in failure strength were found between the single-point and suture-bridge techniques (mean strength, 74 ± 28 N vs 77 ± 56 N, respectively; P = .91). Additionally, no significant differences were found for glenoid load transfer (P ≥ .318) and glenohumeral joint contact (P = .357) between the 2 techniques. Centralized loading, however, produced significant differences in fragment displacement at 5, 150, and 200 N (P ≤ .045), with the single-point technique permitting greater fragment displacement in all cases (0.06-0.28 mm). Similarly, eccentric loading caused significantly greater fragment displacement with the single-point technique at ≥25 N compared with the suture-bridge technique (mean range, 0.38-0.63 mm vs 0.14-0.19 mm, respectively; .009 ≤ P ≤ .048). CONCLUSION: Single-point and suture-bridge techniques for the fixation of bony Bankart fragments have equivalent failure strengths and load transfers. The suture-bridge technique does provide statistically greater initial fracture fragment stability; however, the clinical implications of this are presently unknown. CLINICAL RELEVANCE: This study will aid in the selection of the optimal repair technique for bony Bankart fractures by providing important insights into the quality of initial fixation and ultimate strength.

Imaging-guided subacromial therapeutic injections: prospective study comparing abnormalities on conventional radiography with patient outcomes.

OBJECTIVE: The purpose of this study was to compare abnormalities detected on conventional shoulder radiography with improvement in pain and shoulder function after subacromial injections. SUBJECTS AND METHODS: We conducted a prospective outcomes study including 98 consecutive patients after fluoroscopy-guided subacromial injections who returned outcome questionnaires and who underwent routine shoulder radiography. Numeric pain rating scale (NRS) data were collected before and, along with patient global impression of change (PGIC) data, at 1 week and 1 month after injection. Outcome differences were assessed using the Student t test and Mann-Whitney U test. Logistic regression analysis was done, including radiographic variables compared with the outcome improvement. The odds ratios with 95% CIs were identified for the significant predictors. RESULTS: A significant difference in overall improvement was found depending on the posterior acromial slope. Patients with a slope of more than 36° had significantly lower NRS and PGIC scores at 1 week and 1 month (p < 0.025) compared with those with a slope of 36° or less, with 86.4% of patients with a slope of more than 36° reporting significant improvement at 1 month. This was the only variable linked with improvement in the logistic regression analysis, with an odds ratio of 2.16 (95% CI, 1.11-4.22). Patients with calcific tendinitis had significantly lower NRS scores at both 1 week and 1 month (p = 0.03 and 0.05, respectively) and PGIC scores at 1 week (p = 0.05). CONCLUSION: A posterior acromial slope of more than 36° and the presence of calcific tendinitis on conventional shoulder radiography are associated with better outcomes. Patients with a slope of more than 36° showed the best improvement.

Do synovial leptin levels correlate with pain in end stage arthritis?

PURPOSE: We evaluated whether synovial fluid (SF) leptin concentrations correlate with pain severity in patients with hip or knee endstage osteoarthritis (OA) and whether they mediate the association between increased joint pain and (1) female gender and (2) obesity. METHODS: We conducted a cross-sectional study including patients with primary hip and knee OA undergoing joint replacement between January and December 2010. SF leptin concentrations obtained on the day of surgery were assessed. Main outcome was pain severity measured pre-operatively using WOMAC and VAS pain scales. RESULTS: A total of 219 patients were included, 123 hip and 96 knee arthroplasties. Mean age was 72 years, 59% were women. Mean SF leptin levels were 22.9 (±25.6) ng/ml in women and 5.4 (±5.9) ng/ml in men. Levels >19.6 ng/ml (highest quartile) were significantly associated with increased pain on both WOMAC (mean difference -9.6, 95% CI -15.1 to -4.0) and VAS scale (mean difference 0.8, 95% CI 0.2-1.3). Associations remained unchanged after adjusting for age, co-morbidities, contra-lateral arthritic joint, OA site, and disability. The associations observed between increased pain and female gender or obesity were substantially reduced after adjusting for SF leptin. CONCLUSION: Joint pain is associated with SF leptin concentrations. Increased pre-operative pain observed in women and obese may be related to high intra-articular leptin levels.

Posttraumatic elbow arthritis in the young adult: evaluation and management.

Degenerative joint disease following trauma to the elbow is difficult to manage in any patient. However, this condition becomes substantially more challenging in the young, active population. Increased activity demands and limited functional capacity of total elbow arthroplasty mean that joint arthroplasty should be regarded as a salvage procedure. The primary goal of treatment is to restore a pain-free or minimally painful functional joint while preserving future surgical options. This requires accurate assessment of the primary patient complaint, be it terminal pain and stiffness or pain along the entire arc of motion. Patients who report stiffness and pain at terminal motion may benefit from arthroscopic or open osteocapsular débridement. Those with advanced degenerative changes and pain throughout the entire arc of motion may require joint resurfacing with interposition arthroplasty, partial joint arthroplasty, or total joint arthroplasty.