Ergebnisse der arthroskopischen subacromialen Dekompression bei Rotatorenmanschettenläsionen und Tendinosis calcarea nach 1 bis 5 Jahren

In der vorliegenden Arbeit wurden 51 Patienten, bei denen eine arthroskopische subacromiale Dekompression durchgeführt wurde, in einem Zeitraum von 1-5 Jahren postoperativ nachuntersucht. Neben dem klinischen und dem sonographischen Befund wurde das subjektive und objektive Befinden anhand spezifischer Scores ermittelt (Constant und Murley Score, UCLA-Rating-Scale, modifizierter SF-36 Score). Die operative Therapie wurde gegebenenfalls durch eine Kalkdepotentfernung oder eine offene oder arthroskopische Naht der Rotatorenmanschette erweitert. Der Constant und Murley Score verbesserte sich postoperativ von 32,5 auf durchschnittlich 76,5 Punkte. Die UCLA-Rating-Scale stieg von 9,8 auf 27,8 Punkte im Durchschnitt. 78,4% der Patienten waren mit dem Ergebnis der Operation zufrieden. Auch im modifizierten SF-36 Score zeigten alle Kategorien Verbesserungen im Vergleich zu vor der Operation. Die Patienten, bei denen eine partielle oder komplette Ruptur der Rotatorenmanschette festgestellt wurde, lag mit 72 Punkten im Constant-Score und 25,8 Punkten in der UCLA-Rating-Scale leicht unter denen des Gesamtkollektives. Nur 65% der Patienten waren mit dem Ergebnis der Operation zufrieden. Lag bei den Patienten ein Kalkdepot vor, wurde ein durchschnittlicher Score nach Constant und Murley von 74,1 Punkten erreicht, in der UCLA-Rating-Scale wurden durchschnittlich 27,4 Punkte erzielt. 75% der Patienten gaben an, zufrieden mit dem Ergebnis der Operation zu sein. Ein signifikanter Unterschied wurde bezüglich der Dominanz des Armes erreicht. Während im Constant-Score nur 73,8 Punkte und in der UCLA-Rating-Scale 26,5 Punkte erreicht wurden, wenn der dominante Arm betroffen war, erzielten die Patienten, deren nicht-dominanter Arm der Erkrankte war, einen durchschnittlichen Constant-Score von 82,8 Punkten und einen UCLA-Score von 31,1 Punkten. Alle Patienten, deren nicht-dominanter Arm operiert wurde, waren mit dem Ergebnis der Operation zufrieden. Dagegen gaben nur 69,4% der Patienten, deren dominanter Arm betroffen war an, ein befriedigendes Ergebnis mit der Operation erreicht zu haben. Bei der sonographischen Untersuchung wurde bei 8 Patienten eine Ausdünnung der Rotatorenmanschette festgestellt. 11 Patienten wiesen sonographische Hinweise auf eine Partialruptur der Rotatorenmanschette auf. Bei 14 Personen im Patientenkollektiv wurde eine oberflächlich unregelmäßige Struktur der Rotatorenmanschette gefunden. Nur bei 23 der Patienten wurde bei der Sonographie eine intakte Rotatorenmanschette ohne pathologischen Befund gefunden. Allerdings konnte vom postoperativen sonographischen Befund nicht auf das Ergebnis der Operation geschlossen werden, da die Patienten mit sonographischen Nachweis einer Partialruptur der Rotatorenmanschette keinen signifikanten Unterschied in ihren Ergebnissen bezüglich des Gesamtkollektives aufwiesen. Unsere Studie zeigt, dass sowohl bei Rotatorenmanschettenläsionen, als auch bei Tendinosis Calcarea befriedigende Ergebnisse mit der arthroskopischen subacromialen Dekompression, die gegebenenfalls mit einer Kalkdepotentferung bzw. mit einer Rotatorenmanschettennaht kombiniert wird, erreicht werden können. Die Dominanz des Armes scheint Einfluss auf das Ergebnis der Operation zu haben und die postoperativen sonographischen Befunde liefern zwar wichtige Informationen für ein mögliches schlechtes Ergebnis, korrelieren jedoch häufig nicht mit dem subjektiven und objektiven Befund des Patienten.Purpose of this study is to evaluate the results of arthroscopic subacromial decompression after 1-5 years. 51 Patients were examined after arthroscopic surgery by clinical examination, clinical scores (Constant and Murley Score, UCLA-Rating-Scale, modified SF-36 Score) and ultrasound. The postoperative CM-Score improved from 32.5 up to 76.5 points, the UCLA Score from 9.8 to 27.8 points. 78.4% of the patients were satisfied with the surgery. The mod. SF-36 Score improved in every category. Patients with a partial- or full-thickness tear of the rotator cuff showed 72 Points in the CM-Score and 25.8 points in the UCLA-Score. Only 65% of the patients were satisfied with the surgery. Patients with a calcific deposit showed postoperatively 74.1 points in the CM-Score and 27.4 points in the UCLA-Score. 75% Patients were satisfied with the surgery. There was a significant difference in the outcome of patients with involved dominant or non-dominant arm. CM-Score and UCLA-Score showed 73.8 and 26.5 points in patients with involved dominant side and 69.4% were satisfied with the surgery. If the non-dominant side was affected they achieved 82.2 and 31.1 points and 100% of them were satisfied. The postoperative ultrasound showed thinning of the rotator cuff in 8 patients, 11 had signs of a partial-rotator cuff tear and 14 Patients had superficial structural changes. Only 23 patients showed no pathologic signs with a normal rotator cuff. But there was no connection between the results of the ultrasound and clinical outcome. Our study showed good results after arthroscopic subacromial decompression eventually combined with removal of calcific deposits or arthroscopic or open rotator cuff repair. Dominance of the affected side seems to be important for the clinical outcome and postoperative ultrasound might be helpful to find a reason for a poor result but often there is no connection between changes in the ultrasound and the postoperative outcome

Outcomes and Tendon Integrity After Arthroscopic Treatment for Articular-Sided Partial-Thickness Tears of the Supraspinatus Tendon: Results at Minimum 2-Year Follow-Up

Background: The best surgical treatment option for symptomatic moderate- to high-grade articular-sided partial-thickness rotator cuff tears (PTRCTs) is still controversial. Purpose/Hypothesis: The purpose of this study was to evaluate patient-reported and clinical outcomes and tendon integrity after arthroscopic debridement or repair for PTRCTs at a minimum of 2 years postoperatively. We hypothesized that the overall outcomes would be positive, showing pain relief, good shoulder function, and high tendon integrity. Study Design: Cohort study; Level of evidence, 3. Methods: We evaluated 30 patients (16 men, 14 women; mean age, 51 years) who underwent arthroscopic treatment for symptomatic PTRCTs (Ellman grades 2 and 3). Debridement was performed in 15 patients, and arthroscopic tendon repair was performed in the remaining 15 patients. Patients completed the Constant score; American Shoulder and Elbow Surgeons (ASES) shoulder score; Western Ontario Rotator Cuff Index; Simple Shoulder Test; and visual analog scale (VAS) for pain, function, and satisfaction. In addition, patients were examined clinically (range of motion, impingement tests, rotator cuff tests, and tests for the long head of the biceps tendon), and morphologic assessment of rotator cuff integrity was performed using direct magnetic resonance arthrography and was classified according to Sugaya. Results: The mean follow-up period was 55 months. The patient-reported outcome measures showed high patient satisfaction, reduction in persistent pain, and good shoulder function. Linear regression analysis showed that the debridement group had significantly better results on the Constant (bias-corrected and accelerated [BCa] 95% CI, 4.20-26.30), ASES (BCa 95% CI, 5.24-39.26), and VAS (pain: BCa 95% CI, 0.13-3.62; function: BCa 95% CI, 1.04-4.84; satisfaction: BCa 95% CI, 0.14-6.28) scores than did the repair group. At follow-up, there was no significant difference between the groups in clinical testing results. Good supraspinatus tendon integrity was seen in most patients: Sugaya classification grade 1 in 13 patients, grade 2 in 11 patients, and grade 3 in 6 patients. Conclusion: Midterm results after arthroscopic debridement and repair for PTRCTs showed high patient satisfaction, good shoulder function, and high tendon integrity for both procedures. Patients who underwent arthroscopic debridement had higher Constant, ASES, and VAS scores compared with patients who underwent tendon repair

Advances in biology and mechanics of rotator cuff repair

High initial fixation strength, mechanical stability and biological healing of the tendon-to-bone interface are the main goals after rotator cuff repair surgery. Advances in the understanding of rotator cuff biology and biomechanics as well as improvements in surgical techniques have led to the development of new strategies that may allow a tendon-to-bone interface healing process, rather than the formation of a fibrovascular scar tissue. Although single-row repair remains the most cost-effective technique to address a rotator cuff tear, some biological intervention has been recently introduced to improve tissue healing and clinical outcome of rotator cuff repair. Animal models are critical to ensure safety and efficacy of new treatment strategies; however, although rat shoulders as well as sheep and goats are considered the most appropriate models for studying rotator cuff pathology, no one of them can fully reproduce the human condition. Emerging therapies involve growth factors, stem cells and tissue engineering. Experimental application of growth factors and platelet-rich plasma demonstrated promising results, but has not yet been transferred into standardized clinical practice. Although preclinical animal studies showed promising results on the efficacy of enhanced biological approaches, application of these techniques in human rotator cuff repairs is still very limited. Randomized controlled clinical trials and post-marketing surveillance are needed to clearly prove the clinical efficacy and define proper indications for the use of combined biological approaches. The following review article outlines the state of the art of rotator cuff repair and the use of growth factors, scaffolds and stem cells therapy, providing future directions to improve tendon healing after rotator cuff repair.LEVEL OF EVIDENCE: Expert opinion, Level V

Management of Irreparable Posterosuperior Rotator Cuff Tears—A Current Concepts Review and Proposed Treatment Algorithm by the AGA Shoulder Committee

Posterosuperior rotator cuff tears range among the most common causes of shoulder complaints. While non-operative treatment is typically reserved for the elderly patient with low functional demands, surgical treatment is considered the gold standard for active patients. More precisely, an anatomic rotator cuff repair (RCR) is considered the most desirable treatment option and should be generally attempted during surgery. If an anatomic RCR is impossible, the adequate choice of treatment for irreparable rotator cuff tears remains a matter of debate among shoulder surgeons. Following a critical review of the contemporary literature, the authors suggest the following evidence- and experience-based treatment recommendation. In the non-functional, osteoarthritic shoulder, treatment strategies in the management of irreparable posterosuperior RCT include debridement-based procedures and reverse total shoulder arthroplasty as the treatment of choice. Joint-preserving procedures aimed at restoring glenohumeral biomechanics and function should be reserved for the non-osteoarthritic shoulder. Prior to these procedures, however, patients should be counseled about deteriorating results over time. Recent innovations such as the superior capsule reconstruction and the implantation of a subacromial spacer show promising short-term results, yet future studies with long-term follow-up are required to derive stronger recommendations

High degree of consensus achieved regarding diagnosis and treatment of acromioclavicular joint instability among ESA-ESSKA members

Purpose To develop a consensus on diagnosis and treatment of acromioclavicular joint instability. Methods A consensus process following the modified Delphi technique was conducted. Panel members were selected among the European Shoulder Associates of ESSKA. Five rounds were performed between October 2018 and November 2019. The first round consisted of gathering questions which were then divided into blocks referring to imaging, classifications, surgical approach for acute and chronic cases, conservative treatment. Subsequent rounds consisted of condensation by means of an online questionnaire. Consensus was achieved when >= 66.7% of the participants agreed on one answer. Descriptive statistic was used to summarize the data. Results A consensus was reached on the following topics. Imaging: a true anteroposterior or a bilateral Zanca view are sufficient for diagnosis. 93% of the panel agreed on clinical override testing during body cross test to identify horizontal instability. The Rockwood classification, as modified by the ISAKOS statement, was deemed valid. The separation line between acute and chronic cases was set at 3 weeks. The panel agreed on arthroscopically assisted anatomic reconstruction using a suspensory device (86.2%), with no need of a biological augmentation (82.8%) in acute injuries, whereas biological reconstruction of coracoclavicular and acromioclavicular ligaments with tendon graft was suggested in chronic cases. Conservative approach and postoperative care were found similar Conclusion A consensus was found on the main topics of controversy in the management of acromioclavicular joint dislocation. Each step of the diagnostic treatment algorithm was fully investigated and clarified