Aktuelle Aspekte der Diagnostik und Therapie von Instabilitäten des Schultereckgelenks

Instabilitäten des Schultereck- bzw. Acromioclavicular(AC)gelenks sind häufige Verletzungen des Schultergürtels, die in der Regel durch einen Sturz auf die Schulter verursacht werden und vor allem junge und sportlich aktive Menschen betreffen. Für die Wahl der geeigneten Therapie ist neben Alter und Funktionsanspruch des Patienten vor allem der Grad der Instabilität des Schultereckgelenks ausschlaggebend. Diese wird nach Rockwood anhand des Ausmaßes der vertikalen Instabilität bzw. Translation klassifiziert. Die dynamisch posteriore Translation (DPT) hingegen wird nicht bzw. nur als statisch posteriore Dislokation beim Rockwood Typ IV berücksichtigt. Klinische Studien konnten jedoch zeigen, dass die DPT ein entscheidender Einflussfaktor auf das klinische Outcome bei Instabilitäten des Schultereckgelenks ist. Ziel der vorliegenden Untersuchungen war es, die DPT in modifizierten bilateralen Röntgenaufnahmen nach Alexander zu quantifizieren und mit klinischen und radiologischen Parametern zu korrelieren (Publikation 1), die klinischen und radiologischen Ergebnisse der arthroskopischen Stabilisierung der akuten AC-Gelenkssprengung unter zusätzlicher Verwendung einer acromioclaviculären Cerclage zur Adressierung der DPT zu evaluieren (Publikation 2) und die klinischen und radiologischen Ergebnisse der arthroskopischen Stabilisierung von chronischen Instabilitäten des AC-Gelenks unter Berücksichtigung der vorausgegangenen Therapie zu beurteilen (Publikation 3). Mit der Bestimmung der Überlappungslänge des AC-Gelenks (OLAC) konnte eine Messmethode zur Quantifizierung der DPT in den Alexander-Aufnahmen entwickelt werden, die sowohl mit klinischen als auch radiologischen Parametern korreliert und somit die Bedeutung der horizontalen Translation bei Instabilitäten des AC-Gelenks unterstreicht. Bei der Stabilisierung von akuten AC-Gelenkssprengungen konnte gezeigt werden, dass die coracoclaviculäre Doppel-Button-Technik mit zusätzlicher Verwendung einer acromioclaviculären Cerclage gute klinische Ergebnisse erzielt und die DPT im Vergleich zur bisher angewandten Technik reduziert werden kann. Die operative Rekonstruktion von chronischen Instabilitäten des AC-Gelenks unter Verwendung einer autologen Gracilissehne und synthetischer coracoclaviculärer Augmentation führte sowohl als Revisionseingriff nach gescheiterter initialer AC-Gelenksstabilisierung als auch bei nicht voroperierten Patienten mit chronischer Schultereckgelenkinstabilität zu zufriedenstellenden klinischen und radiologischen Ergebnissen. Zusammengefasst befasst sich die Dissertationsschrift mit aktuellen Aspekten der Diagnostik und Therapie von Instabilitäten des Schultereckgelenks unter besonderer Berücksichtigung der dynamisch horizontalen Translation, welche bisher in der Rockwood Klassifikation nur unzureichend abgebildet ist.Instabilities of the acromioclavicular (AC) joint represent one of the most common injuries of the shoulder girdle, are usually caused by a direct fall on the shoulder and are mainly affecting young patients, who are active in sports. The treatment decision process is influenced by age and functional demands of the patient but mostly by the grade of instability of the AC-joint. AC-joint separations are commonly categorised according to the Rockwood classification system, which is based on the severity of vertical instability. The horizontal component of instability with the dynamic posterior translation (DPT) is neglected in this classification system and only represented in the Rockwood type IV as a static posterior dislocation. However, clinical studies showed that DPT is a crucial factor influencing instabilities of the AC-joint. Aim of the publications included in this thesis was to quantify DPT in modified Alexander views and test for correlation with clinical and radiological parameter (publication 1), to evaluate the clinical and radiological results of the arthroscopic stabilization of acute AC-joint separations using an additional acromioclavicular cerclage addressing the DPT (publication 2) and to evaluate the clinical and radiological outcome of the arthroscopic stabilization of chronic AC-joint instability with respect to the prior treatment (publication 3). With the measurement of the overlapping length of the AC-joint (OLAC) we found a convenient method for quantification of DPT in modified Alexander-views, which correlates with clinical and radiological parameters underlining the importance of horizontal translation in patients with AC-joint instability. The coracoclavicular double-button technique with an additional acromioclavicular cerclage for acute AC-joint separation leads to good clinical results and reduces DPT compared to techniques which were used before. The operative reconstruction of chronic instabilities of the AC-joint using a gracilis tendon autograft with synthetic coracoclavicular augmentation leads to satisfying clinical and radiological results in primary or revision surgical procedures after failed initial AC-joint stabilization. In conclusion, this thesis deals with current aspects of the diagnostic and treatment of instabilities of the AC-joint with emphasis on the DPT, which is up until now insufficiently respected in the Rockwood classification system

Arthroscopic iliac crest bone grafting in recurrent anterior shoulder instability: minimum 5-year clinical and radiologic follow-up

Purpose: To investigate the clinical and radiologic mid- to long-term results of arthroscopic iliac crest bone-grafting for anatomic glenoid reconstruction in patients with recurrent anterior shoulder instability. Methods: Seventeen patients were evaluated after a minimum follow-up of 5 years. Clinical [range of motion, subscapularis tests, apprehension sign, Subjective Shoulder Value (SSV), Constant Score (CS), Rowe Score (RS), Walch Duplay Score (WD), Western Ontario Shoulder Instability Index (WOSI)], and radiologic [X-ray (true a.p., Bernageau and axillary views) and computed tomography (CT)] outcome parameters were assessed. Results: Fourteen patients [mean age 31.1 (range 18–50) years] were available after a follow-up period of 78.7 (range 60–110) months. The SSV averaged 87 (range 65–100) %, CS 94 (range 83–100) points, RS 89 (range 30–100) points, WD 87 (range 25–100) points, and WOSI 70 (range 47–87) %. The apprehension sign was positive in two patients (14%). One patient required an arthroscopic capsular plication due to a persisting feeling of instability, while the second patient experienced recurrent dislocations after a trauma, but refused revision surgery. CT imaging showed a signifcant increase of the glenoid index from preoperative 0.8±0.04 (range 0.7–0.8) to 1.0±0.11 (range 0.8–1.2) at the fnal follow-up (p<0.01). Conclusion: Arthroscopic reconstruction of anteroinferior glenoid defects using an autologous iliac crest bone-grafting tech nique yields satisfying clinical and radiologic results after a mid- to long-term follow-up period. Postoperative re-dislocation was experienced in one (7.1%) of the patients due to a trauma and an anatomic reconstruction of the pear-shaped glenoid confguration was observed. Level of evidence IV

High rate of unexpected positive cultures in presumed aseptic revision of stiff shoulders after proximal humerus osteosynthesis

Background: The aim of this study was to investigate the prevalence of positive microbiology samples after osteosynthesis of proximal humerus fractures at the time of revision surgery and evaluate clinical characteristics of patients with positive culture results. Methods: All patients, who underwent revision surgery after locked platting, medullary nailing or screw osteosynthesis of proximal humeral fractures between April 2013 and July 2018 were retrospectively evaluated. Patients with acute postoperative infections, those with apparent clinical signs of infection and those with ≤1 tissue or only sonication sample obtained at the time of implant removal were excluded. Positive culture results of revision surgery and its correlation with postoperative shoulder stiffness was analyzed in patients with an interval of ≥6 months between the index osteosynthesis and revision surgery. Results: Intraoperatively obtained cultures were positive in 31 patients (50%). Cutibacterium acnes was the most commonly isolated microorganism, observed in 21 patients (67.7%), followed by coagulase negative staphylococci in 12 patients (38.7%). There were significantly more stiff patients in the culture positive group compared to the culture-negative group (19/21, 91% vs. 15/26, 58%, p = 0.02). Furthermore, 11 of 12 (91.7%) patients with growth of the same microorganism in at least two samples had a stiff shoulder compared to 23 of 35 (65.7%) patients with only one positive culture or negative culture results (p = 0.14). Conclusion: Infection must always be considered as a possibility in the setting of revision surgery after proximal humerus osteosynthesis, especially in patients with postoperative stiffness

The role of serum C-reactive protein in the diagnosis of periprosthetic shoulder infection

Introduction: There is a paucity of literature regarding serum C-reactive protein (CRP) in the evaluation of a shoulder periprosthetic joint infection (PJI). The purpose of the current study was to establish cutoff values for diagnosing shoulder PJI and evaluate the influence of the type of infecting microorganism and the classification subgroups according to last proposed International Consensus Meeting (ICM) criteria on the CRP level. Materials and methods: A retrospective analysis of all 136 patients, who underwent septic or aseptic revision shoulder arthroplasty in our institution between January 2010 and December 2019, was performed. Shoulder PJI was defined according to the last proposed definition criteria of the ICM. Serum CRP levels were compared between infected and non-infected cases, between infection subgroups, as well as between different species of infecting microorganisms. A receiver-operating characteristic (ROC) analysis was performed to display sensitivity and specificity of serum CRP level for shoulder PJI. Results: A total of 52 patients (38%) were classified as infected, 18 meeting the criteria for definitive infection, 26 for probable infection and 8 for possible infection. According to the ROC curve, an optimized serum CRP threshold of 7.2 mg/l had a sensitivity of 69% and specificity of 74% (area under curve = 0.72). Patients with definitive infection group demonstrated significantly higher median serum CRP levels (24.3 mg/l), when compared to probable, possible infection groups and PJI unlikely group (8 mg/l, 8.3 mg/l, 3.6 mg/l, respectively, p < 0.05). The most common isolated microorganism was Cutibacterium acnes in 25 patients (48%) followed by coagulase-negative staphylococci (CNS) in 20 patients (39%). Patients with a PJI caused by high-virulent microorganisms had a significantly higher median serum CRP level compared to patients with PJI caused by low-virulent microorganisms (48 mg/l vs. 11.3 mg/l, p = 0.04). Conclusions: Serum CRP showed a low sensitivity and specificity for the diagnosis of shoulder PJI, even applying cutoffs optimized by receiver-operating curve analysis. Low-virulent microorganisms and patients with probable and possible infections are associated with lower CRP levels compared to patients with definitive infection and infections caused by high-virulent microorganisms

All-Suture Anchor vs. Knotless Suture Anchor for the Treatment of Anterior Shoulder Instability—A Prospective Cohort Study

All-suture or soft-anchors (SA) represent a new generation of suture anchor technology with a completely suture-based system. This study’s objective was to assess Juggerknot® SA, for arthroscopic Bankart repair in recurrent shoulder instability (RSI), and to compare it to a commonly performed knotless anchor (KA) technique (Pushlock®). In a prospective cohort study, 30 consecutive patients scheduled for reconstruction of the capsulolabral complex without substantial glenoid bone loss were included and operated on using the SA technique. A historical control group was operated on using the KA technique for the same indication. Clinical examinations were performed preoperatively and 12 and 24 months postoperatively. RSI and WOSI at 24 months were the co-primary endpoints, evaluated with logistic and linear regression. A total of 5 out of 30 (16.7%) patients suffered from RSI in the SA group, one out of 31 (3.2%) in the KA group (adjusted odds ratio = 10.12, 95% CI: 0.89–115.35), and 13.3% in the SA group and 3.2% in the KAgroup had a revision. The median WOSI in the SA group was lower than in the KA group (81% vs. 95%) (adjusted regression coefficient = 10.12, 95% CI: 0.89–115.35). Arthroscopic capsulolabral repair for RSI using either the SA or KA technique led to satisfying clinical outcomes. However, there is a tendency for higher RSI and lower WOSI following the SA technique

Arthroscopically assisted stabilization of chronic bidirectional acromioclavicular joint instability using a low-profile implant and a free tendon graft

&lt;jats:title&gt;Abstract&lt;/jats:title&gt;&lt;jats:sec&gt; &lt;jats:title&gt;Background&lt;/jats:title&gt; &lt;jats:p&gt;Economic burden and personnel shortages lead to a reduction in the time spent on surgical training of young resident physicians. This underlines the importance of courses for learning and optimizing surgical skills. Particularly for orthopaedic trauma surgery, training on fractured cadaveric specimens has proven highly useful. The present study investigates a method to induce realistic fracture patterns in fresh frozen elbow specimens, leaving the skin and soft tissue envelope intact.&lt;/jats:p&gt; &lt;/jats:sec&gt;&lt;jats:sec&gt; &lt;jats:title&gt;Methods&lt;/jats:title&gt; &lt;jats:p&gt;For fracture simulation, 10 human cadaveric specimens with intact soft tissue envelopes were placed in 90° flexion in a custom-made high-impact test bench and compressed by an impactor. The fractures were subsequently classified using conventional x‑rays.&lt;/jats:p&gt; &lt;/jats:sec&gt;&lt;jats:sec&gt; &lt;jats:title&gt;Results&lt;/jats:title&gt; &lt;jats:p&gt;Of the 10 specimens, 6 could be classified as distal humerus fractures and 4 as olecranon fractures. The fractures of the distal humerus were mainly type C according to &lt;jats:italic&gt;Arbeitsgemeinschaft Osteosynthesefragen&lt;/jats:italic&gt; (AO) criteria, the olecranon fractures were mainly type IIB according to the Mayo classification. Subsequently, all 10 specimens would have been appropriate for use in musculoskeletal trauma courses.&lt;/jats:p&gt; &lt;/jats:sec&gt;&lt;jats:sec&gt; &lt;jats:title&gt;Conclusion&lt;/jats:title&gt; &lt;jats:p&gt;With the given setup it was possible to induce realistic fracture patterns in fresh frozen cadaveric specimens. The advantage of the presented technique lies in the preservation of soft tissue. With their intact soft tissue envelopes, these pre-fractured preparations could be used in courses to precisely train resident physicians directly on human cadaver preparations. Further research should focus on finding reliable predictors to improve the precision of fracture induction in specimens.&lt;/jats:p&gt; &lt;/jats:sec&gt

Patient-specific risk profile associated with early-onset primary osteoarthritis of the shoulder: is it really primary?

Introduction Although age is considered to be the major risk factor of primary glenohumeral osteoarthritis (GOA), younger population may suffer from degenerative changes of the shoulder joint without evidence of any leading cause. The purpose of this study was to investigate the risk profile in young patients suffering from presumably primary GOA. Methods A consecutive group of 47 patients undergoing primary shoulder arthroplasty for early-onset GOA below the age of 60 years at time of surgery was retrospectively identified and prospectively evaluated. Patients with identifiable cause for GOA (secondary GOA) were excluded. The resulting 32 patients (mean age 52 +/- 7 years; 17 male, 15 female) with primary GOA were matched by age (+/- 3 years) and gender to 32 healthy controls (mean age 53 +/- 7 years; 17 male, 15 female). Demographic data and patient-related risk factors were assessed and compared among both groups to identify extrinsic risk factors for primary GOA. Patients were further subdivided into a group with concentric GOA (group A) and a group with eccentric GOA (group B) to perform a subgroup analysis. Results Patients had a significantly higher BMI (p = 0.017), were more likely to be smokers (p < 0.001) and to have systematic diseases such as hypertension (p = 0.007) and polyarthritis (p < 0.001) and a higher Shoulder Activity Level (SAL) (p < 0.001) when compared to healthy controls. Furthermore, group B had a significantly higher SAL not only compared to healthy controls but also to group A, including activities such as combat sport (p = 0.048) and weightlifting (p = 0.01). Conclusions Several patient-specific risk factors are associated with primary GOA in the young population, as well as highly shoulder demanding activities in the development of eccentric GOA. Consequently, a subset of young patients with eccentric primary GOA could in reality be secondary due to a muscular imbalance between internal and external rotators caused by improper weight training

Patient-specific risk profile associated with early-onset primary osteoarthritis of the shoulder: is it really primary?

Introduction!#!Although age is considered to be the major risk factor of primary glenohumeral osteoarthritis (GOA), younger population may suffer from degenerative changes of the shoulder joint without evidence of any leading cause. The purpose of this study was to investigate the risk profile in young patients suffering from presumably primary GOA.!##!Methods!#!A consecutive group of 47 patients undergoing primary shoulder arthroplasty for early-onset GOA below the age of 60 years at time of surgery was retrospectively identified and prospectively evaluated. Patients with identifiable cause for GOA (secondary GOA) were excluded. The resulting 32 patients (mean age 52 ± 7 years; 17 male, 15 female) with primary GOA were matched by age (± 3 years) and gender to 32 healthy controls (mean age 53 ± 7 years; 17 male, 15 female). Demographic data and patient-related risk factors were assessed and compared among both groups to identify extrinsic risk factors for primary GOA. Patients were further subdivided into a group with concentric GOA (group A) and a group with eccentric GOA (group B) to perform a subgroup analysis.!##!Results!#!Patients had a significantly higher BMI (p = 0.017), were more likely to be smokers (p &amp;lt; 0.001) and to have systematic diseases such as hypertension (p = 0.007) and polyarthritis (p &amp;lt; 0.001) and a higher Shoulder Activity Level (SAL) (p &amp;lt; 0.001) when compared to healthy controls. Furthermore, group B had a significantly higher SAL not only compared to healthy controls but also to group A, including activities such as combat sport (p = 0.048) and weightlifting (p = 0.01).!##!Conclusions!#!Several patient-specific risk factors are associated with primary GOA in the young population, as well as highly shoulder demanding activities in the development of eccentric GOA. Consequently, a subset of young patients with eccentric primary GOA could in reality be secondary due to a muscular imbalance between internal and external rotators caused by improper weight training.!##!Level of evidence!#!III, Case-Control study

Full-wedge metallic reconstruction of glenoid bone deficiency in reverse shoulder arthroplasty

&lt;jats:title&gt;Abstract&lt;/jats:title&gt;&lt;jats:sec&gt; &lt;jats:title&gt;Background&lt;/jats:title&gt; &lt;jats:p&gt;Medial epicondylitis is a common orthopedic condition that typically results from overuse or previous microtrauma of the flexor-pronator mass. Repetitive eccentric loading of the muscles leads to subsequent degeneration of the flexor tendons.&lt;/jats:p&gt; &lt;/jats:sec&gt;&lt;jats:sec&gt; &lt;jats:title&gt;Diagnosis&lt;/jats:title&gt; &lt;jats:p&gt;Patients present with a painful elbow. In the case of concomitant elbow pathologies, including ulnar neuritis and ulnar collateral ligament injury, there should be a detailed examination. Generally, the diagnosis is based on the clinical examination. T2-weighted magnetic resonance imaging can be useful for chronic courses, over 6 months.&lt;/jats:p&gt; &lt;/jats:sec&gt;&lt;jats:sec&gt; &lt;jats:title&gt;Treatment&lt;/jats:title&gt; &lt;jats:p&gt;Nonsurgical management is the mainstay of treatment. Hence, surgical treatment may be indicated for patients with persistent symptoms after conservative treatment. In the case of a surgical treatment, arthroscopy can be useful to capture concomitant elbow pathologies.&lt;/jats:p&gt; &lt;/jats:sec&gt

Immobilization in external rotation and abduction versus arthroscopic stabilization after first-time anterior shoulder dislocation: a multicenter randomized controlled trial

Background: Treatment of first-time shoulder dislocation (FSD) is a topic of debate. After high rates of recurrent instability after nonoperative management were reported in the literature, primary repair of FSD significantly increased. At the same time, new concepts were proposed that had promising results for immobilization in external rotation (ER) and abduction (ABD). Purpose: The aim of this study was to evaluate the recurrence rates (primary outcome) and clinical outcomes (secondary outcome parameters) of immobilization in ER+ABD versus arthroscopic primary stabilization after FSD. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: In a multicenter randomized controlled trial, patients with FSD were randomized to either treatment with immobilization in 60° of ER plus 30° of ABD (group 1) or surgical treatment with arthroscopic Bankart repair (group 2). Clinical evaluation was performed 1, 3, and 6 weeks as well as 6, 12, and 24 months postoperatively or after reduction, including range of motion, instability testing, subjective shoulder value, Constant-Murley score, Rowe score, and Western Ontario Shoulder Instability Index. Recurrent instability events were prospectively recorded. Results: Between 2011 and 2017, a total of 112 patients were included in this study. Of these, 60 patients were allocated to group 1 and 52 to group 2. At the 24-month follow-up, 91 patients (81.3%) were available for clinical examination. The recurrence rate was 19.1% in group 1 and 2.3% in group 2 (P = .016). No significant differences were found between groups regarding clinical shoulder scores (P > .05). Due to noncompliance with the immobilization treatment protocol, 4 patients (6.7%) were excluded. Conclusion: Immobilization in ER+ABD versus primary arthroscopic shoulder stabilization for the treatment of FSD showed no differences in clinical shoulder scores. However, recurrent instability was significantly higher after nonoperative treatment