Mid- to long-term clinical and radiological outcome after conservative treatment of acute, first-time posterior shoulder dislocations

Hintergrund Ein erstmaliges nach hinten gerichtetes Luxationsereignis der Schulter kann zu Defekten an gelenkbeteiligten Strukturen führen. Eine konservative, nicht chirurgische Therapie einer solchen Verletzung ist möglich. Deren Erfolg hängt jedoch maßgeblich von bestimmten Patientencharakteristika und dem Ausmaß der strukturellen Schäden ab. Klinische und radiologische Referenzwerte existieren bisher nicht in der Literatur. Methodik Im Rahmen einer retrospektiven, multizentrischen Studie wurden insgesamt 28 Patientinnen und Patienten (29 Schultern) mit initial konservativem Therapieansatz und vorhandener posttraumatischer Schnittbildgebung nach einem durchschnittlichen Nachbeobachtungszeitraum von 8,3 ± 2,7 Jahren nachuntersucht. Die betroffene Schulter wurde klinisch und radiologisch analysiert und schulterspezifische Scores wurden erhoben. Strukturelle knöcherne Schäden wurden vermessen. Die Patientenkohorte wurde entsprechend dem Erfolg bzw. Misserfolg der initial konservativen Therapie in Subgruppen unterteilt. Korrelationen mit Parametern für den Misserfolg des konservativen Therapieansatzes wurden berechnet. Ergebnisse 69% der in die Studie eingeschlossenen Patientinnen und Patienten konnten erfolgreich konservativ therapiert werden. Während des Nachbeobachtungszeitraumes wurde bei sechs Schultern (21%) eine erneute Luxation verzeichnet. Aufgrund persistierender Beschwerden im betroffenen Gelenk mussten insgesamt 9 Schultern (31%) im Verlauf sekundär operativ versorgt werden. Die Analyse der strukturellen Defekte zeigte bei Betrachtung von Lage und Größe (Gamma-Winkel) der verletzungsverursachten Impressionsfraktur am Oberarmkopf bei Patientinnen und Patienten, die im Verlauf operativ versorgt werden mussten, eine größere Ausdehnung als in der erfolgreich konservativ therapierten Subgruppe (97,8 ± 7,2°, vs. 93,3 ± 9,7°, p=0,09), jedoch ohne statistische Signifikanz zu erreichen. Bei beiden Patientensubgruppen, bei denen die initial konservative Therapie nicht erfolgreich war, zeigte sich ein angepasster Gamma-Winkel > 90°. Eine vermehrte posttraumatische posteriore Dezentrierung des Gelenkes konnte in der Reluxation-Subgruppe - verglichen mit der Patientengruppe ohne Reluxationen - beobachtet werden (61,9 ± 12,5% vs. 50,6 ± 6,4%, p=0,05). Das Ausmaß der posttraumatischen Dezentrierung korrelierte innerhalb der erfolgreich konservativ therapierten Patientenkohorte mit einer schlechteren follow-up Beurteilung der Schulter mittels WOSI Score (p=0,02) und einer ausgeprägteren follow-up posterioren Dezentrierung (p=0,007). Des Weiteren wurde innerhalb dieser Subgruppe ein signifikanter Zusammenhang zwischen höherem Alter zum Zeitpunkt des Auftretens der Verletzung und besseren klinischen Scores im Verlauf (SSV: p=0,02; ROWE: p=0,035 und WOSI: p=0,045) beobachtet. Schlussfolgerung Eine erstmalige hintere Schulterluxation kann mit guten klinischen Ergebnissen im mittel- und langfristigen Verlauf konservativ therapiert werden. Prädiktoren für einen erfolgreichen konservativen Therapieansatz sind ein mittleres bis hohes Alter zum Zeitpunkt des erstmaligen Luxationsereignisses, ein posttraumatisch glenohumeral zentriertes Schultergelenk und ein kleiner Gamma-Winkel der Impressionsfraktur.A first-time posterior shoulder dislocation can lead to structural defects at joint building structures. A conservative, non-surgical treatment is possible. However, its success depends on certain patients’ characteristics and the extent of structural defects. Clinical and radiological reference values have not yet been defined. Methods In the context of a multi-centric retrospective study, 29 shoulders in 28 patients with an initial conservative treatment approach and posttraumatic cross-sectional imaging were examined after a mean follow-up of 8.3 ± 2.7 years. The affected shoulder was clinically and radiologically analysed and shoulder specific outcome scores were obtained. Structural bone defect characteristics were measured and objectified. Patients were split into subgroups based on the success of the initial conservative therapy. Associations with parameter indicating failure of treatment were calculated. Results A success rate of 69% amongst all patients with a conservative therapy approach was seen at mid- to long-term follow up. During follow-up a redislocation was noted in 6 shoulders (21%). Due to persistent symptoms, 9 shoulders (31%) had to undergo secondary surgery. Analysis of measured structural defects with regards to size and localization (gamma-angle) of the injury caused impression fracture at the humeral head revealed increased values in patients who needed secondary surgery during follow-up period compared to successfully conservatively treated patients (97.8 ± 7.2° vs. 93.3 ± 9.7°, p=0.09), without reaching statistical significance. Both subgroups labeled as failure of conservative therapy showed an adapted gamma angle > 90°. A higher posterior glenohumeral subluxation was noted in the redislocation subgroup - compared to the noredislocation group (61.9 ± 12.5% vs. 50.6 ± 6.4%, p=0.05). The extent of posttraumatic posterior glenohumeral subluxation correlated with a worse follow-up assessment of the affected shoulder via WOSI (p=0.02) and follow-up posterior glenohumeral decentering (p=0.007) within the successfully conservatively treated patient subgroup. Furthermore, a significant correlation between an older age at the time of initial dislocation as well as better clinical scores (SSV: p=0.02; ROWE: p=0.035 and WOSI: p=0.045) was seen within this subgroup. Conclusion A first-time posterior shoulder dislocation can be treated conservatively with good outcome after mid- and long-term follow-up. Predictors of a successful conservative therapy are a middle to old age at the time of initial dislocation, a centered joint after injury and a small gamma angle of the impression fracture

Mesenchymal Stromal Cell-Based Therapy-An Alternative to Arthroplasty for the Treatment of Osteoarthritis? A State of the Art Review of Clinical Trials

Osteoarthritis (OA) is the most common degenerative joint disorder worldwide and to date no regenerative treatment has been established in clinical practice. This review evaluates the current literature on the clinical translation of mesenchymal stromal cell (MSC)-based therapy in OA management with a focus on safety, outcomes and procedural specifics. PubMed, Cochrane Library and clinicaltrials.gov were searched for clinical studies using MSCs for OA treatment. 290 articles were initially identified and 42 articles of interest, including a total of 1325 patients, remained for further examination. Most of the included studies used adipose tissue-derived MSCs or bone-marrow-derived MSCs to treat patients suffering from knee OA. MSC-based therapy for knee OA appears to be safe and presumably effective in selected parameters. Yet, a direct comparison between studies was difficult due to a pronounced variance regarding methodology, assessed outcomes and evidence levels. Intensive scientific engagement is needed to identify the most effective source and dosage of MSCs for OA treatment in the future. Consent on outcome measures has to be reached and eventually patient sub-populations need to be identified that will profit most from MSC-based treatment for OA

Delphi survey on conventional conservative treatment of functional posterior shoulder instability

<jats:title>Abstract</jats:title><jats:sec><jats:title>Background</jats:title><jats:p>Posterior shoulder instability is caused by structural or functional defects. While the former are mostly treated surgically, physiotherapy is considered the treatment of choice in functional shoulder instability. However, it often has limited success unless very specific and intensive training programs are applied by trained experts. Currently, there is no consensus on the treatment of functional posterior shoulder instability.</jats:p></jats:sec><jats:sec><jats:title>Objective</jats:title><jats:p>To improve treatment of this pathology, a standardized treatment recommendation is required to serve as a guideline for physiotherapy. The aim of this study was to establish expert consensus for treatment recommendations for functional posterior shoulder instability.</jats:p></jats:sec><jats:sec><jats:title>Design</jats:title><jats:p>The Delphi survey technique was employed.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>A standardized training program for treatment of functional posterior shoulder instability was developed by a local expert committee. Two rounds of an online Delphi survey were then conducted. The panel of the Delphi survey comprised nine leading scientific experts in the field of functional shoulder instability who treat patients with shoulder-related problems conservatively and operatively.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>The response rate was 100% and there were no dropouts. The final program consists of three groups of exercises with increasing difficulty. The exercises are mostly easy to perform and focus on the scapula-retracting muscles and the muscles responsible for external rotation of the shoulder. The treatment program should be executed under the supervision of a therapist at the beginning and later may be performed by the patients themselves.</jats:p></jats:sec><jats:sec><jats:title>Conclusion</jats:title><jats:p>Consensus on a new exercise guideline dedicated to the treatment of functional posterior shoulder instability was achieved. This guideline should not only help to treat this challenging pathology but also provide a starting point for further scientific research and ongoing improvement.</jats:p></jats:sec&gt

Delphi-Verfahren zur konventionellen konservativen Therapie der funktionellen hinteren Schultergelenkinstabilität

Background: Posterior shoulder instability is caused by structural or functional defects. While the former are mostly treated surgically, physiotherapy is considered the treatment of choice in functional shoulder instability. However, it often has limited success unless very specific and intensive training programs are applied by trained experts. Currently, there is no consensus on the treatment of functional posterior shoulder instability. Objective: To improve treatment of this pathology, a standardized treatment recommendation is required to serve as a guideline for physiotherapy. The aim of this study was to establish expert consensus for treatment recommendations for functional posterior shoulder instability. Design: The Delphi survey technique was employed. Methods: A standardized training program for treatment of functional posterior shoulder instability was developed by a local expert committee. Two rounds of an online Delphi survey were then conducted. The panel of the Delphi survey comprised nine leading scientific experts in the field of functional shoulder instability who treat patients with shoulder-related problems conservatively and operatively. Results: The response rate was 100% and there were no dropouts. The final program consists of three groups of exercises with increasing difficulty. The exercises are mostly easy to perform and focus on the scapula-retracting muscles and the muscles responsible for external rotation of the shoulder. The treatment program should be executed under the supervision of a therapist at the beginning and later may be performed by the patients themselves. Conclusion: Consensus on a new exercise guideline dedicated to the treatment of functional posterior shoulder instability was achieved. This guideline should not only help to treat this challenging pathology but also provide a starting point for further scientific research and ongoing improvement.Hintergrund: Die hintere Schulterinstabilität kann durch strukturelle Schäden oder ein funktionelles Defizit bedingt sein. Während Erstere vorwiegend chirurgisch angegangen werden, gilt bei funktionellen Defiziten Physiotherapie als Mittel der Wahl. Jedoch hat diese oft nur begrenzten Erfolg, sofern nicht überaus spezifische und intensive Trainingspläne von gut ausgebildeten Trainern angewendet werden. Aktuell besteht kein Konsens hinsichtlich der Behandlung der funktionellen hinteren Schulterinstabilität. Ziel: Um die Behandlung dieser speziellen Erkrankung zukünftig zu verbessern, bedarf es eines standardisierten Behandlungsplans als Leitlinie für die Physiotherapie. Ziel dieser Studie war die Etablierung eines Expertenkonsenses zur Behandlungsempfehlung für die funktionelle hintere Schultergelenkinstabilität. Design: Es wurde die Delphi-Methode angewendet. Methoden: Ein standardisierter Trainingsplan für diese Indikation wurde von einem Expertenteam erarbeitet. Dieser Trainingsplan durchlief 2 Runden in einem Online-Delphi-Verfahren. Teilnehmer des Delphi-Verfahrens waren 9 führende Experten auf dem Gebiet der konservativen und operativen Therapie der funktionellen hinteren Schultergelenkinstabilität. Ergebnisse: Die Antwortrate in dem Delphi-Verfahren betrug 100 %, es gab keine Abbrecher. Der finale Trainingsplan untergliedert sich in 3 Gruppen von Übungen mit jeweils schrittweise ansteigender Komplexität. Die Übungen sind größtenteils leicht durchzuführen und richten sich auf die schulterblattretrahierende Muskulatur und die Außenrotatoren des Schultergelenks. Das Programm sollte zu Beginn noch unter therapeutischer Kontrolle durchgeführt werden, um eine exakte Durchführung zu gewährleisten. In späteren Stadien erfolgt es dann eigenständig durch die Patienten. Schlussfolgerung: Ein Konsens hinsichtlich eines neuen Trainingsplans als Richtlinie speziell für die Behandlung der hinteren funktionellen Schulterinstabilität wurde erreicht. Dieser Trainingsplan soll dabei helfen, diese anspruchsvolle Erkrankung zu behandeln und außerdem den Startpunkt für weiterführende wissenschaftliche Untersuchungen bilden

Middle trapezius transfer for treatment of irreparable supraspinatus tendon tears- anatomical feasibility study

Purpose!#!The purpose of this study was to investigate the anatomical feasibility of a middle trapezius transfer below the acromion for treatment of irreparable supraspinatus tendon tears.!##!Methods!#!This study involved 20 human cadaveric shoulders in 10 full-body specimens. One shoulder in each specimen was dissected and assessed for muscle and tendon extent, force vectors, and distance to the neurovascular structures. The opposite shoulder was used to evaluate the surgical feasibility of the middle trapezius transfer via limited skin incisions along with an assessment of range of motion and risk of neurovascular injury following transfer.!##!Results!#!The harvested acromial insertion of the middle trapezius tendon showed an average muscle length of 11.7 ± 3.0 cm, tendon length of 2.7 ± 0.9 cm, footprint length of 4.3 ± 0.7 cm and footprint width of 1.4 ± 0.5 cm. The average angle between the non-transferred middle trapezius transfer and the supraspinatus was 33 ± 10° in the transversal plane and 34 ± 14° in the coronal plane. The mean distance from the acromion to the neurovascular bundle was 6.3 ± 1.3 cm (minimum: 4.0 cm). During surgical simulation there was sufficient excursion of the MTT without limitation of range of motion in a retracted scapular position but not in a protracted position. No injuries to the neurovascular structures were noted.!##!Conclusion!#!Transfer of the acromial portion of the middle trapezius for replacement of an irreparable supraspinatus seems to be feasible in terms of size, vector, excursion, mobility and safety. However, some concern regarding sufficiency of transfer excursion remains as scapula protraction can increase the pathway length of the transfer.!##!Level of evidence!#!Basic Science Study/Anatomical Study