Joint-preserving surgical treatment options for irreparable posterosuperior rotator cuff tear : Partial repair, superior capsular reconstruction, latissimus dorsi, lower trapezius, or a balloon?

Treatment of irreparable rotator cuff tears in young active patients is challenging. A variety of therapeutic options are available. Only a few joint-preserving treatment options show reliable improvements over a long-term follow-up period. However, the treatment outcomes of joint preservation procedures are not comparable to those of RTSA, as patients are typically younger and have higher expectations. It is remarkable that most of the joint-preserving therapeutic options for irreparable rotator cuff ruptures lack long-term treatment results. This article highlights the indications, technical aspects, and treatment outcomes of the most commonly performed joint-preserving surgeries for irreparable rotator cuff rupture. = Die Behandlung der irreparablen posterosuperioren Rotatorenmanschettenruptur bei jungen, aktiven Patienten stellt eine Herausforderung dar. Es bestehen verschiedene Therapieoptionen. Nur vereinzelte gelenkserhaltende Therapieoptionen zeigen über einen langen Nachkontrollzeitraum verlässliche Verbesserungen der Schulterfunktion und Patientenzufriedenheit. Die Behandlungsergebnisse der gelenkserhaltenden Operationen sind jedoch nicht mit jenen der RTSA vergleichbar, da die Patienten typischerweise jünger sind und höhere Ansprüche haben. Bemerkenswert ist, dass zu den meisten gelenkerhaltenden Eingriffen bei irreparablen Rotatorenmanschettenrupturen Langzeittherapieergebnisse fehlen. In dieser Übersichtsarbeit werden die am häufigsten vorgenommenen gelenkerhaltenden Eingriffe hinsichtlich Indikationen, technischer Aspekte und Behandlungsresultaten beleuchtet

Compliance with wearing a thoracolumbar orthosis in nonoperative treatment of osteoporotic vertebral fractures: A prospective sensor-controlled study

BACKGROUND CONTEXT Hyperextension orthoses (HOs) for non-operative treatment of osteoporotic vertebral fractures (OVFs) are widely prescribed. However, the compliance, how much an HO is worn after it has been prescribed, is widely unknown. PURPOSE This study was performed to assess the wearing time of HOs for OVFs in a prospective blinded, sensor-controlled manner. STUDY DESIGN / SETTING A prospective, single blinded observational study was performed. PATIENT SAMPLE This study prospectively included 18 patients who were treated non-operatively with an HO for OVFs. OUTCOME MEASURES The true wearing time was measured using a hidden temperature-based sensor. The patients were invited to return for regular follow-up every 2 weeks for 6 weeks, at which time clinical evaluation (including a visual analog scale for pain and the Oswestry disability questionnaire) and radiographs of the spine were performed. METHODS Full compliance was defined as a wearing time of 15 hours per day. Correlation between compliance and demographic differences, patient reported outcomes and radiographic changes of the vertebral structures were calculated. RESULTS The mean HO wearing time was 5.5±3.3 hours (37%±22% compliance). Female patients used the HO significantly longer per day than did male patients (6.5±3.2 vs 2.9±2.0 hours, p=.039). Age and body mass index had no influence on wearing behavior. CONCLUSIONS Overall, compliance with wearing HOs is poor and shows great variability with significant gender-dependency but not associated with BMI, age, or pain-level. Further studies are required to confirm our results that the wearing time does not have an influence on kyphotic progression of the osteoporotic fractured segment, nor on clinical outcome at short term. LEVEL OF EVIDENCE I

Die Bedeutung von computerunterstützter Operationstechnik und Planung der Glenoidpositionierung bei anatomischer Schultertotalprothese

Die Behandlung der Omarthrose durch die Implantation einer anatomischen Schultertotalprothese führt bei korrekter Indikation zu verlässlichen, sehr guten und langanhaltenden Behandlungsergebnissen. Bei zunehmender posteriorer glenoidaler Abnutzung kommt es zur Zunahme von Komplikationen und Revisionen, welche die Schulterfunktion negativ beeinflussen. Durch die Anwendung von präoperativer dreidimensionaler (3D-)Planung und intraoperativer Guidance-Technologien wird versucht, die Behandlung der anatomischen Schultertotalprothese bei B2-, B3- und C‑Glenoiden verlässlicher zu machen. In diesem Übersichtsartikel soll der Stellenwert der computerassistierten Technologien bei Implantation einer anatomischen Schulterprothese beleuchtet werden

Long-term recurrence rate in anterior shoulder instability after Bankart repair based on the on- and off-track concept

BACKGROUND Since its first proposal, the concept of on- and off-track lesions in anterior shoulder instability has gained clinical relevance as a tool to predict the failure rate of arthroscopic Bankart repair. Current literature only reports either short-term follow-up or long-term results of small sample sizes. The aim of this study was to provide a long-term evaluation of recurrent instability following arthroscopic Bankart repair in a large cohort using the on-track vs. off-track concept as a predictor for failure. METHODS We retrospectively analyzed 271 patients who underwent primary arthroscopic Bankart repair for anterior shoulder instability between 1998 and 2007. All patients with a minimum follow-up of 78 months and a preoperative computed tomographic (CT) or magnetic resonance imaging (MRI) scan were included into the study. Preoperative CT and/or MRI scans were used to determine the glenoid track and width of Hill-Sachs lesion. Recurrence of instability was defined as presence of instability symptoms (dislocation, subluxation, and/or apprehension) or revision surgery (stabilization procedure) and was assessed as the primary outcome parameter. RESULTS The glenoid track of 163 shoulders was assessed (female n = 51, male n = 112) with a mean follow-up of 124 months (99.4-145.6, standard deviation = 2.5) and a mean age of 24 years (20-34.). An off-track Hill-Sachs lesion was found in 77 cases (47%), and in 86 cases (53 %) it was on-track. The rate of recurrent instability in the off-track group was 74% (n = 57) compared with 27% (n = 23) in the on-track group (P < .001). The overall rate of revision surgery due to instability was 29% (n = 48) after a mean time of 50.9 months (±42.8) following Bankart repair. The rate of revision surgery in the off-track group was 48% (n = 37) after a mean of 53.5 months (±42.0) vs. 13% (n = 11) after 42.3 months (±46.3) in the on-track group (P < .001). CONCLUSION This study shows that the on- and off-track concept helps to distinguish patients for whom an isolated arthroscopic Bankart repair yields long-term benefits. Because of the high rate of recurrent instability in the off-track group, an off-track lesion should be treated surgically in such a way that the off-track lesion is converted into an on-track lesion

Transcutaneous compression suture with iodine gauze for wound closure in revision surgery for therapy-resistant periprosthetic shoulder infections

BACKGROUND To successfully treat a periprosthetic infection, successful bacteria eradication and successful wound closure are mandatory. Despite adequate surgical débridement in the deep, persistence of wound drainage and subsequent persistence of periprosthetic infection may occur, especially in patients with compromised soft tissue conditions. This study presents a transcutaneous compression suture technique with iodine gauze that was used in patients with persistent wound secretion in therapy-resistant periprosthetic shoulder infections in order to achieve successful infection control and wound healing. METHODS All patients with persistent periprosthetic or implant-associated shoulder joint infections despite correct previous surgical and antibiotic therapy attempts were included in the study. In all patients, in addition to repeat deep surgical débridement, a transcutaneous "iodine-gauze-compression-suture" was performed with postoperative antibiotic therapy. The primary endpoint was infection control; the secondary endpoint was wound healing rate; and the third endpoint was complication rate after index surgery. RESULTS Ten consecutive patients with a mean age of 74 (±7.6) years and a mean follow-up of 14 (±2) months were included. All ten patients showed infection control and successful wound healing, with no need for further revision surgery. In 8 out of 10 patients, the wound healing was fast and completely uncomplicated. Two out of 10 patients showed delayed wound healing with fibrin coatings for 3 and 4 weeks, respectively. No additional intervention was necessary in both patients. CONCLUSIONS Transcutaneous iodine gauze compression sutures were used to achieve successful infection control without additional revision surgery in 10 out of 10 patients who previously underwent surgery with failed infection control. This wound closure technique is a reliable adjunctive therapy method in the treatment of implant-associated infections of the shoulder in patients with fragile wound conditions

Fixationssysteme und Techniken zur arthroskopischen Rotatorenmanschettenrekonstruktion : Evidenz im Jahr 2021

Arthroskopische Rotatorenmanschettenrekonstruktionen wurden initial mit einer einreihigen („single row“) Technik beschrieben. Im Rahmen technischer Weiterentwicklungen der arthroskopischen Chirurgie wurden diverse Techniken zur zweireihigen („double row“), transossären und transossär-äquivalenten Sehnenfixation entwickelt, nicht zuletzt durch eine zunehmende Verbreitung knotenloser Anker. Die klinischen Ergebnisse zeigen keine relevanten Unterschiede zwischen den jeweiligen Techniken. Biomechanisch sind zweireihige Rekonstruktionen jedoch durch Vergrößerung der Kontaktfläche an der Insertionsstelle und der erreichten Stabilität überlegen, insbesondere mit medial geknoteten Fäden, welche in eine laterale Reihe als sog. Suture-Bridge abgespannt werden. Klassischerweise wurden Schraubanker aus Metall für eine arthroskopische Sehnenfixierung verwendet. Im Laufe der letzten Jahre wurde das Anker-Portfolio jedoch durch moderne bioresorbierbare und nichtresorbierbare (PEEK) Schraub- und Einschlaganker sowie auch um reine Fadenanker (All-suture) erweitert. Ein allgemeingültiger Goldstandard für die Ankerverwendung existiert bis dato nicht, wobei die meisten gängigen Anker – zumindest bei guter Knochenqualität – Arthroskopische Rotatorenmanschettenrekonstruktionen wurden initial mit einer einreihigen („single row“) Technik beschrieben. Im Rahmen technischer Weiterentwicklungen der arthroskopischen Chirurgie wurden diverse Techniken zur zweireihigen („double row“), transossären und transossär-äquivalenten Sehnenfixation entwickelt, nicht zuletzt durch eine zunehmende Verbreitung knotenloser Anker. Die klinischen Ergebnisse zeigen keine relevanten Unterschiede zwischen den jeweiligen Techniken. Biomechanisch sind zweireihige Rekonstruktionen jedoch durch Vergrößerung der Kontaktfläche an der Insertionsstelle und der erreichten Stabilität überlegen, insbesondere mit medial geknoteten Fäden, welche in eine laterale Reihe als sog. Suture-Bridge abgespannt werden. Klassischerweise wurden Schraubanker aus Metall für eine arthroskopische Sehnenfixierung verwendet. Im Laufe der letzten Jahre wurde das Anker-Portfolio jedoch durch moderne bioresorbierbare und nichtresorbierbare (PEEK) Schraub- und Einschlaganker sowie auch um reine Fadenanker (All-suture) erweitert. Ein allgemeingültiger Goldstandard für die Ankerverwendung existiert bis dato nicht, wobei die meisten gängigen Anker – zumindest bei guter Knochenqualität – ausreichende Stabilität gewährleisten. Beim Nahtmaterial kam es ebenso zu relevanten Weiterentwicklungen, sodass dem Versagen der Nähte heutzutage weniger Bedeutung zukommt. Das Aufkommen von bandartigem Nahtmaterial (Tapes) konnte in diversen biomechanischen Studien seine Überlegenheit nachweisen, jedoch ist bei geknoteten Techniken mit Tapes aufgrund des womöglich negativen Einflusses durch größere Knoten Vorsicht geboten. Nicht zuletzt ist die mediale Stichposition möglichst nahe des Rotatorenkabels von großer Bedeutung, da der häufigste Versagensmechanismus einer Rotatorenmanschettenrekonstruktion mit modernem Naht- und Ankermaterial weiterhin ein Hindurchschneiden der Fäden durch das vorgeschädigte Sehnengewebe ist. = Arthroscopic rotator cuff repair was originally described with a single row technique. With technical advances in arthroscopic surgery various techniques for a double row, transosseous and transosseous-equivalent (TOE) tendon fixation were developed, especially with increasing use of knotless suture anchors. The clinical results show significantly different results with respect to the technique applied; however, biomechanical data could demonstrate improved footprint coverage and mechanical strength of double row reconstruction techniques. Techniques with a combination of medial row mattress sutures and a knotless lateral row in a suture bridge technique (modified TOE) are superior to fully knotless double row repair. Metal screw-in anchors were originally used in the first decade of arthroscopic rotator cuff repair; however, the portfolio has been substantially expanded over the recent years as resorbable and non-resorbable push-in and screw-in anchors as well as all-suture anchors have been introduced. No generally valid gold standard for anchor usage exists to date but most available anchors offer sufficient biomechanical strength, at least in good bone quality. Substantial improvements could also be achieved in the field of suture material available for rotator cuff repair, which is no longer the weak point of the construct in terms of suture breakage. The development of tape-type sutures could demonstrate biomechanical superiority in several studies; however, caution is advised for knotted techniques with the use of tapes due to possible negative effects of the bigger knot size. As the most frequent failure mode in arthroscopic rotator cuff repair remains suture material cutting through the damaged tendon, it should be highlighted that a stitch position just medial to the rotator cable provides the strongest suture hold

Effectiveness of proximal tibial tubercle transfer in patients with patella baja after total knee arthroplasty

PURPOSE Patella baja after total knee arthroplasty (TKA) is a common problem that is usually treated via proximal transfer of the tibial tubercle. As the long-term outcomes of this procedure are unclarified, this study aimed to investigate the changes in clinical function and radiographic patellar height during five years of follow-up. METHODS Sixty patients with patella baja after TKA who underwent proximalisation of the tibial tubercle were followed up for a mean of 71 months (range 21-153 months). The pre- and postoperative range of motion (ROM) and clinical scores (Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)) were compared. The radiographic patellar height was measured with the Caton-Deschamps index (CDI), Blackburne-Peel ratio (BP), and modified Insall-Salvati index (MIS). RESULTS Proximalisation of the tibial tubercle resulted in a significant improvement in the ROM from 80° to 88°. The KSS and WOMAC did not improve or even worsened after the intervention. The radiographic patellar height immediately after tibial tubercle transfer was not better than prior to the intervention (CDI 0.72 vs. 0.63, p = 0.72; BP 0.66 vs. 0.61, p = 0.72; MIS 1.59 vs. 1.55, p = 1.00) and further decreased significantly so that the mean final values were worse than the values in the native joint (CDI 0.59 vs. 0.78, p = 0.001; BP 0.58 vs. 0.74, p = 0.001; MIS 1.39 vs. 1.81, p < 0.001). CONCLUSION Proximalisation of the tibial tubercle in patients with patella baja after TKA does neither lead to significant improvements in the clinical outcome nor in the radiographic patellar height during long-term follow-up. LEVEL OF EVIDENCE III

Is routine magnetic resonance imaging necessary in patients with clinically diagnosed frozen shoulder? Utility of magnetic resonance imaging in frozen shoulder

BACKGROUND Shoulder magnetic resonance imaging (MRI) is commonly performed in patients with frozen shoulder (FS). However, the necessity of MRI and its diagnostic value is questionable. Therefore, the purpose of the present study was to clarify whether routine MRI could identify additional shoulder pathologies not previously suspected in the clinical examination and if any change in the treatment plan based on these additional MRI findings in FS patients was observed. MATERIALS AND METHODS The medical records of all patients who presented in our outpatient clinic with a diagnosis of FS from January 2017 to December 2018 were retrospectively reviewed. Patient demographics, the number of patients who received a shoulder MRI, changes in the diagnosis or identification of structural shoulder pathologies following MRI examination (if performed), as well as any alternation in the initially suggested treatment plan were recorded. RESULTS A total of 609 patients (male: 241, female: 368) diagnosed with an FS and an average age of 52 ± 10 (range: 18 to 81) years were identified. In 403 of the 609 patients (66%), a shoulder MRI was performed. An additional structural shoulder pathology was identified in 89 of 403 (22%) patients following the shoulder MRI, mostly rotator cuff tears (partial: 46/403 [11.4%], full-thickness: 30/403 [7.4%], rerupture following reconstruction: 10/403 [2.5%]) and labrum tears (3/403 [0.7%]). At minimum 2-year follow-up, 11 of 403 (2.7%) patients were treated surgically for the additional pathology identified on the MRI scan consisting of an arthroscopic rotator cuff reconstruction in 10 patients and a labrum refixation in one patient. Five of the 609 (0.8%) patients were treated for refractory FS by arthroscopic capsulotomy. CONCLUSIONS Although additional pathologies were identified in 22% of the patients, a change in treatment plan due to the MRI findings was only observed in 2.7% (37 MRIs needed to identify 1 patient with FS requiring surgery for the additional MRI findings). Therefore, routine use of shoulder MRI scans in patients with FS but without suspicion of an additional pathology may not be indicated

Effect of Abduction Brace Wearing Compliance on the Results of Arthroscopic Rotator Cuff Repair

Background: The benefit of protective bracing after rotator cuff reconstruction has been debated for many years, although immobilization compliance has never been assessed objectively to date. In a previous study, compliance with the wearing of an abduction brace was measured for the first time with use of temperature-sensitive sensors. The purpose of the present follow-up study was to assess the effect of immobilization compliance on tendon-healing after rotator cuff repair. Methods: The clinical and radiographic outcomes for 46 consecutive patients with objectively assessed abduction brace wearing compliance after arthroscopic repair of a superior rotator cuff tear were prospectively analyzed. Rotator cuff integrity was examined with ultrasound. Clinical outcomes were assessed with the relative Constant-Murley score (RCS), the Subjective Shoulder Value (SSV), and pain and patient satisfaction ratings. Receiver operating characteristic (ROC) curves were used to determine the optimal cutoff value of abduction brace compliance for discriminating between shoulders that will and will not have a retear and the association of compliance with the failure of rotator cuff repair. Results: After a mean duration of follow-up of 20 ± 9 months, the odds ratio for having a rotator cuff repair failure was 13-fold higher for patients with a compliance rate of <60% (p = 0.037). The retear rate was 3% (1 of 35 patients) in the high-compliance cohort (≥60% compliance) and 27% (3 of 11) in the low-compliance cohort (<60% compliance) (p = 0.037). No differences in RCS, SSV, pain, or postoperative patient satisfaction were observed between patients with ≥60% compliance and those with <60% compliance. Conclusions: Patients with a compliance rate of <60% had a 13-fold increase in the risk of rotator cuff retear. The 2 patients with the lowest compliance rates (11% and 22%) both had retears. Due to the small sample size, no final conclusions can be drawn regarding the influence of immobilization compliance on tendon-healing after rotator cuff repair. These findings justify a prospective trial with a larger cohort to confirm or disprove the value of compliance with abduction bracing. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence