Bart Berghs

Arthroscopic rotator cuff repair with double-row fixation.

BACKGROUND The treatment of rotator cuff tears has evolved from open surgical repairs to complete arthroscopic repairs over the past two decades. In this study, we reviewed the results of arthroscopic rotator cuff repairs with the so-called double-row, or footprint, reconstruction technique. METHODS Between 1998 and 2002, 264 patients underwent an arthroscopic rotator cuff repair with double-row fixation. The average age at the time of the operation was fifty-nine years. Two hundred and thirty-eight patients (242 shoulders) were available for follow-up; 210 were evaluated with a full clinical examination and thirty-two, with a questionnaire only. Preoperative and postoperative examinations consisted of determination of a Constant score and a visual analogue score for pain as well as a full physical examination of the shoulder. Ultrasonography was done at a minimum of twelve months postoperatively to assess the integrity of the cuff. RESULTS The average score for pain improved from 7.4 points (range, 3 to 10 points) preoperatively to 0.7 point (range, 0 to 3 points) postoperatively. The subjective outcome was excellent or good in 220 (90.9%) of the 242 shoulders. The average increase in the Constant score after the operation was 25.4 points (range, 0 to 57 points). Ultrasonography demonstrated an intact rotator cuff in 83% (174) of the shoulders overall, 47% (fifteen) of the thirty-two with a repair of a massive tear, 78% (thirty-two) of the forty-one with a repair of a large tear, 93% (113) of the 121 with a repair of a medium tear, and 88% (fourteen) of the sixteen with a repair of a small tear. Strength and active elevation increased significantly more in the group with an intact repair at the time of follow-up than in the group with a failed repair; however, there was no difference in the pain scores. CONCLUSIONS Arthroscopic rotator cuff repair with double-row fixation can achieve a high percentage of excellent subjective and objective results. Integrity of the repair can be expected in the majority of shoulders treated for a large, medium, or small tear, and the strength and range of motion provided by an intact repair are significantly better than those following a failed repair. LEVEL OF EVIDENCE Therapeutic Level IV.

One-stage revision for patients with a chronically infected reverse total shoulder replacement

We retrospectively reviewed 11 consecutive patients with an infected reverse shoulder prosthesis. Patients were assessed clinically and radiologically, and standard laboratory tests were carried out. Peroperative samples showed Propionbacterium acnes in seven, coagulase-negative Staphylococcus in five, methicillin-resistant staphylococcus aureus in one and Escherichia coli in one. Two multibacterial and nine monobacterial infections were seen. Post-operatively, patients were treated with intravenous cefazolin for at least three days and in all antibiotic therapy was given for at least three months. Severe pain (3 of 11) or severe limitation of function (3 of 11) are not necessarily seen. A fistula was present in eight, but function was not affected. All but one patient were considered free of infection after one-stage revision at a median follow-up of 24 months, and without antibiotic treatment for a minimum of six months. One patient had a persistent infection despite a second staged revision, but is now free of infection with a spacer. Complications included posterior dislocation in one, haematoma in one and a clavicular fracture in one. At the most recent follow-up the median post-operative Constant-Murley score was 55, 6% adjusted for age, gender and dominance. A one-stage revision arthroplasty reduces the cost and duration of treatment. It is reliable in eradicating infection and good functional outcomes can be achieved.

Glenohumeral relationship in the transverse plane of the body

Reconstruction of a normal glenohumeral relationship is desirable for a successful arthroplasty. Double-contrast computed tomography was performed on 49 healthy shoulders in young volunteers. For creation of a uniform spatial reference system, the subjects were positioned in a thoracobrachial orthosis with the arm adducted in the coronal plane and the forearm flexed in the sagittal plane, and they were examined in dorsal recumbency. The classical anatomic angles were measured, and the anatomic axes were determined and quantified as angles to the coronal plane. When the axis of the glenoid was correlated to the axis of the humeral head, a mean of 8.5 degrees divergence in a clear Gaussian distribution was found. This contrasts with the variability of the version of the humeral head and of the glenoid and offers a useful guideline in difficult prosthetic surgery of the shoulder in which normal anatomic landmarks are lost because of arthritic or traumatic deformity.

Reversed arthroscopic subacromial decompression for symptomatic irreparable rotator cuff tears: mid-term follow-up results in 34 shoulders.

BACKGROUND In the elderly, there is no guideline for the treatment of irreparable rotator cuff lesions. The results of open or arthroscopic repair are variable. We hypothesized that the use of a reversed arthroscopic subacromial decompression (RASD) would yield comparable results. MATERIAL AND METHODS Between January 2004 and December 2006, thirty-eight patients underwent a RASD for irreparable cuff tears in 39 shoulders. The surgical procedure consisted of a tenotomy of the long head of the biceps tendon, a debridement of the torn rotator cuff and a tuberoplasty, without violation of the coracoacromial arch and the acromion. RESULTS Thirty-three patients (age 69.9 +/- 7.3 years) were available for clinical and radiological evaluation of 34 shoulders (male/female ratio: 11/22), at a mean follow-up of 38 months (range: 21 months-52 months). Two of 33 patients had required revision surgery, and were excluded from further statistical analysis. In the remaining 31 patients (32 shoulders), the modified Constant-Murley score (CMS) improved from 34.9% +/- 11.6 to 84.0% +/- 11.6 (p < 0.0001). The preoperative mobility did not correlate with the final result. Preoperative pain was found to correlate negatively to the modified CMS at follow-up (p= 0.0038). Although the acromiohumeral height decreased with 2.58 mm +/- 1.68 and the severity of glenohumeral osteoarthritis increased with one grade (Samilson-Prieto classification), there was no correlation with the functional outcome. CONCLUSION We conclude that for irreparable rotator cuff tears in the elderly, excellent mid-term results can be achieved with a RASD.

Posterior shoulder instability: current concepts review

PurposePosterior shoulder instability has been difficult to diagnose and even more challenging to manage. However, it is being diagnosed and treated more frequently, particularly after sports injuries. The purpose of this article is to review literature concerning the management of these pathologies.MethodsA literature review was carried out in the main medical databases to evaluate the several studies concerning the open and arthroscopic treatment of posterior shoulder instability.ResultsBecause of better awareness of the pathology, better technical investigations, and a better understanding of shoulder biomechanics, more and more mechanical factors that can cause posterior instability have been described. Structural abnormalities can be divided into bony abnormalities and soft-tissue abnormalities. Each group can also be divided into abnormalities caused by trauma (macro- or microtrauma) or congenital. These abnormalities can be treated with non-anatomic and anatomic stability procedures. During the last decades, the latter have been described more frequently, most of them arthroscopically.ConclusionFor surgical treatment to be successful, the instability must be attributable to mechanical factors that can be modified by surgery. Because of better knowledge of the pathology, a more specific surgery can be performed. This lesion-specific surgery has improved clinical results compared to non-anatomic stability procedures, particularly when that surgery has been performed arthroscopically.

Quantified measurement of subacromial impingement.

We modified the Hawkins impingement maneuver in order to develop a quantifiable and reproducible impingement test. The involved anatomic structures were examined with magnetic resonance imaging of 3 cadaveric shoulders. The reproducibility of the clinical sign was assessed with an interobserver and intraobserver reliability test, with calculation of the intraclass correlation coefficient (ICC). The quantified Hawkins maneuver appears to be a reproducible clinical test (median interobserver ICC, 0.9331; median intraobserver ICC, 0.9748) and creates bony contact between the greater tuberosity and the anterolateral acromion. This test enables the clinician to quantify the subacromial space.

Clinical and radiological outcomes of the Ivory arthroplasty for trapeziometacarpal joint osteoarthritis with a minimum of 5 years of follow-up: a prospective single-centre cohort study

We present the results of a 5 year prospective follow-up study on the functional outcome after total replacement of the trapeziometacarpal joint with the Ivory prosthesis (Memometal, Stryker Corporate, Kalamazoo, Michigan, USA) in 22 patients. The female to male ratio was 21:1 and the mean age was 66 (range 54–78) years. The mean follow-up period was 67 (range 60–77) months after operation. Patient satisfaction was high. The mobility of the operated thumb was restored to a range of motion comparable to the contralateral thumb. Key pinch and grip strength improved by 13% and 31%, respectively. Overall function, according to Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, improved by 59%. Pain decreased by 85% according to the numerical rating scale. Radiological evaluation revealed no loosening of the implant after 5 years except in one patient who required revision due to polythene wear with secondary joint instability. Another patient had asymptomatic polythene wear that required no revision but remains in follow-up. The 5 year overall survival of the prosthesis was 95%. These medium-term results suggest that the Ivory arthroplasty is a reliable option for treating advanced trapeziometacarpal arthritis, because it appears to give a very good functional outcome and has the potential for long-term survival rates.

The wrist hyperflexion and abduction of the thumb (WHAT) test: a more specific and sensitive test to diagnose de Quervain tenosynovitis than the Eichhoff’s Test

De Quervain’s disease has different clinical features. Different tests have been described in the past, the most popular test being the Eichhoff’s test, often wrongly named as the Finkelstein’s test. Over the years, a misinterpretation has occurred between these two tests, the latter being confused with the first. To compare the Eichhoff’s test with a new test, the wrist hyperflexion and abduction of the thumb test, we set up a prospective study over a period of three years for a cohort of 100 patients (88 women, 12 men) presenting spontaneous pain over the radial side of the styloid of the radius (de Quervain tendinopathy). The purpose of the study was to compare the accuracy of the Eichhoff’s test and wrist hyperflexion and abduction of the thumb test to diagnose correctly de Quervain’s disease by comparing clinical findings using those tests with the results on ultrasound. The wrist hyperflexion and abduction of the thumb test revealed greater sensitivity (0.99) and an improved specificity (0.29) together with a slightly better positive predictive value (0.95) and an improved negative predictive value (0.67). Moreover, the study showed us that the wrist hyperflexion and abduction of the thumb test is very valuable in diagnosing dynamic instability after successful decompression of the first extensor compartment. Our results support that the wrist hyperflexion and abduction of the thumb test is a more precise tool for the diagnosis of de Quervain’s disease than the Eichhoff’s test and thus could be adopted to guide clinical diagnosis in the early stages of de Quervain’s tendinopathy.

Epidermoid cyst of the phalanx of the finger caused by nail biting

Abstract Intraosseous epidermoid inclusion cysts of the phalanx of the finger are rare, and are regarded as reactive or post-traumatic pseudotumours. We describe a case of an epidermoid cyst in the distal phalanx of the fifth finger caused by chronic nail biting, which was successfully excised.

De Quervain Tenosynovitis Following Trapeziometacarpal Ball-and-Socket Joint Replacement.

Background One of the surgical treatment options for trapeziometacarpal (TMC) joint arthritis is a prosthetic ball-and-socket replacement. One of the complications in the postoperative setting is de Quervain tendinopathy. Purposes Although this complication has been reported following a resection athroplasty, we questioned whether lengthening of the thumb following the Ivory (Memometal, Stryker Corporate, Kalamazoo, MI, USA) ball-and-socket arthroplasty could be a causal factor. Methods In a prospective study regarding the overall outcome of the Ivory prosthesis, we analyzed 96 cases (83 patients; 69 female, 12 male, 8 bilateral) of primary implanted Ivory prosthesis and the incidence of de Quervain disease during the first year following surgery. We found a particularly high incidence (17%) of de Quervain tendinopathy the first year following this ball-and-socket arthroplasty. We measured the lengthening of the thumb radiographically in the group presenting de Quervain and the asymptomatic group and compared this measure between the two groups. Results We did not find any measurable or statistically significant difference between the groups regarding lengthening. Discussion These findings suggest that lengthening of the thumb following ball-and-socket arthroplasty is not a causal factor in the development of de Quervain tendinopathy within one year after surgery.