Christoph Bartl

Subscapularis Function and Structural Integrity After Arthroscopic Repair of Isolated Subscapularis Tears

Background: Results of arthroscopic repair of isolated subscapularis tendon tears have not been widely studied. A detailed evaluation of subscapularis function with subscapularis strength quantification has not been performed to date. Purpose: To evaluate postoperative subscapularis muscle function and to assess the clinical outcome and structural tendon integrity with postoperative magnetic resonance imaging after arthroscopic repair of isolated subscapularis tears. Study Design: Case series; Level of evidence, 4. Methods: In a prospective study, isolated subscapularis tendon tears in 21 patients were treated with an all-arthroscopic repair. The average age of the study population was 43 years. The mean interval between trauma and surgery was 5.8 months. In 19 patients, a traumatic event caused the onset of symptoms. Subscapularis muscle function was assessed with specific clinical tests and the Constant scoring system. Postoperative subscapularis strength was evaluated with a custom-made electronic force measurement plate. All patients underwent postoperative magnetic resonance imaging to assess structural integrity of the repair. Results: The average duration of follow-up was 27 months. The Constant score increased from 50 points preoperatively to 82 points postoperatively (P < .01). Most positive preoperative lift-off and belly-press tests were reversed by surgery, with a rate of 5 (24%) persistent positive tests after surgery. In operated shoulders, subscapularis strength in the belly-press (65 vs 87 N; P < .05) and the lift-off position (44 vs 68 N; P < .05) was significantly reduced compared with the contralateral shoulder. Magnetic resonance imaging revealed an intact repair in 20 patients. Atrophy of the upper subscapularis muscle portion was present in about one-fourth of the patients and in all patients with a positive postoperative belly-press test. Conclusion: Arthroscopic repair of isolated subscapularis tendon tears achieves substantial improvement of shoulder function and a low rerupture rate. Despite excellent clinical results, a significant postoperative subscapularis strength deficit compared with the contralateral shoulder persists that can be quantified with use of the force measurement plate. Atrophy of the upper subscapularis muscle is present in 25% of the patients in the postoperative course.

Open Repair of Isolated Traumatic Subscapularis Tendon Tears

Background: Diagnosis, operative treatment, and outcome assessment of isolated traumatic subscapularis tendon tears have not been widely studied. Purpose: To report the clinical outcome, value of clinical tests, predictive outcome factors, and return to sports in the management of isolated traumatic subscapularis tendon tears. Study Design: Case series; level of evidence, 4. Methods: Thirty consecutive patients with a confirmed isolated subscapularis tear, except for associated biceps tendon injury or humeral avulsion of the glenohumeral ligaments (HAGL) lesions, found at arthroscopy were included in the study. The average age of the study population was 43.1 years. In all 30 patients, a traumatic event caused the onset of symptoms. The mean delay between trauma and surgery was 4 months. All patients underwent open tendon reconstruction with a suture anchor technique via a deltopectoral approach. Clinical assessment was done using the Constant score and specific subscapularis tests. Postoperative tendon integrity was assessed with ultrasound and magnetic resonance imaging. Sports activity, including competition level, sports discipline, and postoperative return to sports, was evaluated. Results: The average duration of follow-up was 46 months (range, 25-72 months). Seven patients had a full-thickness tear of the upper third of the tendon, 11 patients a full-thickness tear of the upper two-thirds of the tendon, and 12 patients had a complete subscapularis tendon tear. The Constant score increased from 51.3 preoperatively to 82.2 postoperatively (P < .01). Twenty-seven patients rated their postoperative result as excellent or good. Most positive preoperative lift-off and belly-press tests were reversed by surgery, with a rate of 6 (20%) persistent positive tests after surgery. Positive postoperative subscapularis tests were more likely related to a higher preoperative degree of fatty subscapularis muscle infiltration (P < .05). Ultrasound and magnetic resonance imaging revealed a structural intact repair at follow-up in 28 shoulders (93%). Seventy-five percent of athletes returned to their previous competition level. Conclusion: Early repair of isolated traumatic subscapularis tendon tears and associated biceps tendon lesions or HAGL lesions achieves good functional outcomes with a low rerupture rate and allows return to sports activity. Delay of surgery and higher degrees of preoperative fatty infiltration of the subscapularis muscle impair postoperative subscapularis function.

Bisphosphonates in Medical Practice

Bisphosphonates in medical practice : , Bisphosphonates in medical practice : , کتابخانه دیجیتال جندی شاپور اهواز

Open reduction and internal fixation versus casting for highly comminuted and intra-articular fractures of the distal radius (ORCHID): protocol for a randomized clinical multi-center trial

AbstractBackgroundFractures of the distal radius represent the most common fracture in elderly patients, and often indicate the onset of symptomatic osteoporosis. A variety of treatment options is available, including closed reduction and plaster casting, K-wire-stabilization, external fixation and open reduction and internal fixation (ORIF) with volar locked plating. The latter is widely promoted by clinicians and hardware manufacturers. Closed reduction and cast stabilization for six weeks is a simple, convenient, and ubiquitously available intervention. In contrast, ORIF requires hospitalization, but allows for functional rehabilitation.Given the lack of randomized controlled trials, it remains unclear whether ORIF leads to better functional outcomes one year after injury than closed reduction and casting.Methods/DesignORCHID (Open reduction and internal fixation versus casting for highly comminuted intra-articular fractures of the distal radius) is a pragmatic, randomized, multi-center, clinical trial with two parallel treatment arms. It is planned to include 504 patients in 15 participating centers throughout Germany over a three-year period. Patients are allocated by a central web-based randomization tool.The primary objective is to determine differences in the Short Form 36 (SF-36) Physical Component Score (PCS) between volar locked plating and closed reduction and casting of intraarticular, comminuted distal radius fractures in patients > 65 years of age one year after the fracture. Secondary outcomes include differences in other SF-36 dimensions, the EuroQol-5D questionnaire, the Disability of the Arm, Shoulder, and Hand (DASH) instrument. Also, the range of motion in the affected wrist, activities of daily living, complications (including secondary ORIF and revision surgery), as well as serious adverse events will be assessed. Data obtained during the trial will be used for later health-economic evaluations. The trial architecture involves a central statistical unit, an independent monitoring institute, and a data safety monitoring board. Following approval by the institutional review boards of all participating centers, conduct and reporting will strictly adhere to national and international rules, regulations, and recommendations (e.g., Good Clinical Practice, data safety laws, and EQUATOR/CONSORT proposals)DiscussionTo our knowledge, ORCHID is the first multicenter RCT designed to assess quality of life and functional outcomes following operative treatment compared to conservative treatment of complex, intra-articular fractures of the distal radius in elderly patients. The results are expected to influence future treatment recommendations and policies on an international level.Trial registrationISRCTN: ISRCTN76120052 Registration date: 31.07.2008; Randomization of first patient: 15.09.2008

The treatment of displaced intra-articular distal radius fractures in elderly patients.

BACKGROUND From 2000 to 2012, the annual incidence of inpatient treatment for distal radius fracture in Germany rose from 65 to 86 per 100 000 persons. It is unclear whether open reduction and volar angle-stable plate osteosynthesis (ORIF), a currently advocated treatment, yields a better functional outcome or quality of life than closed reposition and casting. METHODS In the ORCHID multi-center trial, 185 patients aged 65 and older with an AO type C distal radial fracture were randomly assigned to ORIF or closed reposition and casting. Their health-related quality of life and hand/arm function were assessed 3 and 12 months afterward with the Short Form 36 (SF-36) questionnaire and the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. The radiological findings, range of movement of the wrist, and EuroQol-5D (EQ-5D) scores were documented as well. RESULTS Among the 149 patients in the intention-to-treat-analysis, there was no significant difference in SF-36 scores between the two treatment groups at one year (mean difference, 3.3 points in favor of ORIF; 95% confidence interval, -0.2 +6.8 points; p = 0.058). The DASH scores showed moderately strong, but clinically unimportant effects in favor of ORIF, and there was no difference in EQ-5D scores. ORIF led to better radiological results and wrist mobility at 3 months, with comparable results at 12 months. 37 of the patients initially allotted to nonsurgical treatment underwent secondary surgery due to significant loss of reduction. CONCLUSION The findings with respect to mobility, functionality, and quality of life at 12 months provide marginal and inconsistent evidence for the superiority of volar angle-stable plate osteosynthesis over closed reduction and casting in the treatment of intra-articular distal radius fractures. Primary nonsurgical management is also effective in suitable patients.

Definition of Osteoporosis

The word “osteoporosis” literally means porous bone, indicating that the bone density is low and the bones are thin. But bone does not fracture due to thinness alone. In the early 1990s, a consensus meeting of the World Health Organization (WHO) defined osteoporosis as:

Risk Factors for Osteoporosis and Fractures

Until recently, the diagnosis of osteoporosis was made only when the patient presented with painful fractures. Today, with a greater consciousness of health and healthy living, we realise that recognition and avoidance of risk factors can prevent many chronic illnesses. A 50-year-old postmenopausal woman who goes to her physician for a yearly “check-up” expects to have her blood pressure taken, her cholesterol measured and a mammography performed – that is good medical practice. Likewise, she should ask for a bone mineral density measurement to investigate her risk for developing osteoporosis (Fig. 21.1). Results of studies even suggest that low bone mass density is a better predictor of fracture risk than increased cholesterol is of having a heart attack and high blood pressure of having a stroke (Fig. 21.2). We are now aware of many genetic and acquired factors which are responsible for and/or contribute to the development of osteoporoses. Furthermore, a low bone mineral density is associated with a lower risk of breast cancer: stimulating effects of oestrogen on both trabecular bone and mammary cells may be responsible for this correlation. Another study has shown that bone density changes might be related to the progression of atherosclerosis, or vice versa, in haemodialysis patients.

Management of Osteoporotic Fractures

The main goal of osteoporosis treatment is to prevent fragility fractures. Often, a low-trauma fracture of an elderly patient is the first manifestation of osteoporosis, which was an asymptomatic disease until the fracture event. Low-trauma fractures require orthopaedic trauma management including conservative management with casting or splinting, as well as surgical management with osteosynthesis or joint replacement. In elderly patients with reduced bone mass, surgical stabilisation should allow for early weight-bearing in fractures of the lower extremity, the spine and pelvic ring and for early physiotherapy in fractures of the upper extremity. For these fractures with markedly reduced bone loss, special implants are needed to provide stable fracture fixation to allow bone healing. Early fracture management, rapid mobilisation and active physiotherapy following fracture stabilisation are important to preserve joint function, to prevent joint contractures, to provide muscle strengthening for walking security and to prevent complications due to immobilisation.

Structure and Architecture of Bone

The human skeleton has 204–214 individual bones; it weighs about 10 kg and accounts for about 15 % of the body weight. A rough breakdown differentiates the skeleton of the trunk (trunk or axial skeleton) from the skeleton of the extremities (peripheral skeleton). The skeleton includes the following bones:

Osteoporosis in Children and Adolescents

During growth, the shape, architecture and strength of the bones are modulated by three major processes: growth, modelling and remodelling. Modelling is of particular interest as it appears that bone is much more capable of responding to external loads during growth than at any other time. Remodelling also occurs during growth, but is limited, and does not participate in active growth, i.e. to accrue bone. Information on the pattern of bone mineral deposition is illustrated in Figs. 40.1 and 40.2, which show the plots and velocity curves of total body bone mineral content during growth. The authors of these longitudinal studies of boys and girls have also shown that, on average, 26 % of adult total bone mineral was accrued during the 2 years around peak bone mineral content velocity, at average ages of 12.5 years for girls and 14.1 years for boys. Furthermore, it is of interest that true bone density does not increase with size or age, and reported increases in BMD with age are a reflection of growth and an increase in size rather than an increase in bone mineral per unit volume. The crucial importance of food in childhood to achieve optimal physical and cognitive development has long been acknowledged as has the recognition that the promotion of children’s health will help to reduce diet-related risks of many adult diseases, including degenerative and cardiovascular disorders, diabetes type two, cancers, obesity and osteoporosis. Consequently, nutrition guidelines for children from 2 to 11 years have just been published: the Position of the American Dietetic Association.