Constanze Nikulka

Structural Integrity and Clinical Function of the Subscapularis Musculotendinous Unit After Arthroscopic and Open Shoulder Stabilization

Background Postoperative subscapularis dysfunction after open shoulder stabilization has recently received increasing attention. The potential advantage of arthroscopic stabilization procedures is that they do not violate the subscapularis musculotendinous unit, which might preserve its structural integrity and clinical function, which would lead to superior clinical results. Hypothesis Arthroscopic shoulder stabilization does not lead to clinical and radiological signs of subscapularis insufficiency. Study Design Cohort study; Level of evidence, 3. Methods Twenty-two patients who underwent arthroscopic (group I, n = 12; average age, 30.9 years; mean follow-up, 37 months) or open (group II, n = 10; average age, 28.8 years; mean follow-up, 35.9 months) shoulder stabilization procedure were followed up clinically (clinical subscapularis tests and signs, Constant Score, Rowe Score, Walch-Duplay Score, Western Ontario Shoulder Instability Index and Melbourne Instability Shoulder Score) and by magnetic resonance imaging (subscapularis tendon integrity, cross-sectional area, defined muscle diameters, and signal intensity analysis [ratio infraspinatus/upper subscapularis and infraspinatus/lower subscapularis]). A third group (group 0) of 12 healthy volunteers served as a control. Results Clinical signs for subscapularis insufficiency were present in 0% of cases in group I and in 70% of cases in group II. There were no statistically significant differences in either group regarding Constant Score, Rowe Score, Walch-Duplay Score, Western Ontario Shoulder Instability Index, and Melbourne Instability Shoulder Score (P > .05). On magnetic resonance image, no subscapularis tendon ruptures were found. The cross-sectional area, the mean vertical diameter, and the mean transverse diameter of the upper and lower subscapularis muscle portion was significantly less in group II than in group 0 (P < .05). The signal intensity analysis revealed the infraspinatus/upper subscapularis ratio was significantly lower in group II than in group I or group 0. The infraspinatus/lower subscapularis ratio did not significantly differ in all 3 groups (P > .05). Conclusion This study confirms previous observations that open shoulder stabilization using a subscapularis tenotomy may lead to atrophy and fatty infiltration of the subscapularis muscle, resulting in postoperative subscapularis dysfunction. As expected, arthroscopic procedures do not significantly compromise clinical subscapularis function and structural integrity. However, no significant differences were observed in the overall outcome.

How long should acute anterior dislocations of the shoulder be immobilized in external rotation

Background Immobilization of the shoulder in external rotation has been shown to reduce the risk of recurrence after traumatic anteroinferior shoulder dislocation. It remains unclear how duration of immobilization affects labral coaptation. Hypothesis Immobilization of the shoulder in 30° of external rotation for 5 weeks allows better coaptation of the anteroinferior labrum than does an immobilization period of 3 weeks. Study Design Cohort study; Level of evidence, 2. Methods Twenty-two patients with traumatic anteroinferior dislocation of the glenohumeral joint were included in this study. Patients were divided into 2 groups. Group 1 consisted of the initial 11 patients (mean age, 37.4 years) immobilized for 3 weeks; group 2 consisted of the subsequent 11 patients (mean age, 29.7 years) immobilized for 5 weeks in 30° of external rotation. With use of magnetic resonance imaging, displacement and separation of the glenoid labrum and anterior joint effusion were assessed in different arm positions (internal rotation, neutral rotation, 30° of external rotation, maximum external rotation) within 3 days, 3 weeks, and 5 weeks after reduction. Results Displacement and separation of the labrum and anterior joint effusion were significantly less, particularly with maximum external rotation compared with neutral and internal rotation, during the acute magnetic resonance imaging evaluation in both groups (P < .05). No statistically significant differences were found in all parameters comparing internal rotation with neutral rotation, 30° of external rotation, and maximum external rotation in both groups after 5 weeks (P > .05). No statistically significant differences were found between both groups comparing the results of the measured variables during the acute, 3-week, and 5-week magnetic resonance imaging examinations (P > .05). Conclusion Immobilization of the shoulder in 30° of external rotation seems to allow a similar coaptation of the glenoid labrum, regardless of duration of immobilization (3 vs 5 weeks). Clinical trials are needed to evaluate the effect of these results on recurrence rates. The optimum position of immobilization in external rotation has yet to be determined.

Die Außenrotationsruhigstellung nach primärtraumatischer Schulterluxation

ZusammenfassungDie orthetische Immobilisation des reponierten Glenohumeralgelenks nach Erstluxation erfolgt historisch bedingt zumeist in Innenrotationsstellung des Arms. Abhängig von verschiedenen in- und extrinsischen Prognosefaktoren resultieren darunter teils unbefriedigend hohe Reluxationsraten von bis zu 96%, insbesondere bei jungen Patienten mit hohem funktionellem Anspruch. In verschiedenen Grundlagenarbeiten wurde eine verbesserte Reposition und anatomische Position des abgelösten anteroinferioren Kapsel-Labrum-Komplexes in Außenrotation nachgewiesen.Erste vorliegende klinische Untersuchungen scheinen den Nutzen der Immobilisationsposition zu belegen. Nach Außenrotationsruhigstellung wurden signifikant geringere Reluxationsraten und eine anatomiegetreuere Position der abgelösten passiven Stabilisatoren im Vergleich zur herkömmlichen Immobilisation in Innenrotation nachgewiesen. Dennoch ist die Anzahl verfügbarer Daten derzeit noch limitiert. Insbesondere in Bezug auf die exakte Immobilisationsposition des Humeruskopfes, den Einfluss des Hämarthros und der spezifischen Kapsel-Labrum-Läsion auf das radiologische und klinische Resultat sind weitere prospektive Studien mit entsprechenden Nachuntersuchungszeiträumen wünschenswert, um den exakten Stellenwert dieses Therapiekonzepts evaluieren zu können.AbstractImmobilization of the shoulder following dislocation and reduction is traditionally carried out using internal rotation braces. However, high recurrence rates of up to 96% may result depending on several concomitant intrinsic and extrinsic prognostic factors, such as age and level of physical activity. Recently, different cadaveric and radiologic studies have suggested an improved tissue apposition of the affected labroligamentous structures in a better anatomic position during external rotation of the humeral head. Recent clinical outcome studies have supported the hypothetical benefit of this immobilization technique. Significantly lower recurrent dislocation rates and a better anatomic positioning of the affected structures were observed after immobilization in external rotation compared to immobilization in internal rotation.However, the number of available studies in this respect is still limited. Further prospective evidence is therefore desirable to evaluate the contribution of exact positioning of the immobilization, influence of hemarthros and specific capsulolabral lesions to the long-term clinical and radiological outcome of this new concept of immobilization.Immobilization of the shoulder following dislocation and reduction is traditionally carried out using internal rotation braces. However, high recurrence rates of up to 96% may result depending on several concomitant intrinsic and extrinsic prognostic factors, such as age and level of physical activity. Recently, different cadaveric and radiologic studies have suggested an improved tissue apposition of the affected labroligamentous structures in a better anatomic position during external rotation of the humeral head. Recent clinical outcome studies have supported the hypothetical benefit of this immobilization technique. Significantly lower recurrent dislocation rates and a better anatomic positioning of the affected structures were observed after immobilization in external rotation compared to immobilization in internal rotation.However, the number of available studies in this respect is still limited. Further prospective evidence is therefore desirable to evaluate the contribution of exact positioning of the immobilization, influence of hemarthros and specific capsulolabral lesions to the long-term clinical and radiological outcome of this new concept of immobilization.

Immobilization by external rotation after primary traumatic shoulder dislocation

ZusammenfassungDie orthetische Immobilisation des reponierten Glenohumeralgelenks nach Erstluxation erfolgt historisch bedingt zumeist in Innenrotationsstellung des Arms. Abhängig von verschiedenen in- und extrinsischen Prognosefaktoren resultieren darunter teils unbefriedigend hohe Reluxationsraten von bis zu 96%, insbesondere bei jungen Patienten mit hohem funktionellem Anspruch. In verschiedenen Grundlagenarbeiten wurde eine verbesserte Reposition und anatomische Position des abgelösten anteroinferioren Kapsel-Labrum-Komplexes in Außenrotation nachgewiesen.Erste vorliegende klinische Untersuchungen scheinen den Nutzen der Immobilisationsposition zu belegen. Nach Außenrotationsruhigstellung wurden signifikant geringere Reluxationsraten und eine anatomiegetreuere Position der abgelösten passiven Stabilisatoren im Vergleich zur herkömmlichen Immobilisation in Innenrotation nachgewiesen. Dennoch ist die Anzahl verfügbarer Daten derzeit noch limitiert. Insbesondere in Bezug auf die exakte Immobilisationsposition des Humeruskopfes, den Einfluss des Hämarthros und der spezifischen Kapsel-Labrum-Läsion auf das radiologische und klinische Resultat sind weitere prospektive Studien mit entsprechenden Nachuntersuchungszeiträumen wünschenswert, um den exakten Stellenwert dieses Therapiekonzepts evaluieren zu können.AbstractImmobilization of the shoulder following dislocation and reduction is traditionally carried out using internal rotation braces. However, high recurrence rates of up to 96% may result depending on several concomitant intrinsic and extrinsic prognostic factors, such as age and level of physical activity. Recently, different cadaveric and radiologic studies have suggested an improved tissue apposition of the affected labroligamentous structures in a better anatomic position during external rotation of the humeral head. Recent clinical outcome studies have supported the hypothetical benefit of this immobilization technique. Significantly lower recurrent dislocation rates and a better anatomic positioning of the affected structures were observed after immobilization in external rotation compared to immobilization in internal rotation.However, the number of available studies in this respect is still limited. Further prospective evidence is therefore desirable to evaluate the contribution of exact positioning of the immobilization, influence of hemarthros and specific capsulolabral lesions to the long-term clinical and radiological outcome of this new concept of immobilization.Immobilization of the shoulder following dislocation and reduction is traditionally carried out using internal rotation braces. However, high recurrence rates of up to 96% may result depending on several concomitant intrinsic and extrinsic prognostic factors, such as age and level of physical activity. Recently, different cadaveric and radiologic studies have suggested an improved tissue apposition of the affected labroligamentous structures in a better anatomic position during external rotation of the humeral head. Recent clinical outcome studies have supported the hypothetical benefit of this immobilization technique. Significantly lower recurrent dislocation rates and a better anatomic positioning of the affected structures were observed after immobilization in external rotation compared to immobilization in internal rotation.However, the number of available studies in this respect is still limited. Further prospective evidence is therefore desirable to evaluate the contribution of exact positioning of the immobilization, influence of hemarthros and specific capsulolabral lesions to the long-term clinical and radiological outcome of this new concept of immobilization.

Magnetic resonance imaging analysis of the subscapularis muscle after arthroscopic and open shoulder stabilization

To evaluate the subscapularis muscle (SSC) after arthroscopic and open shoulder stabilization, three groups [after arthroscopic (A), after open shoulder stabilization (B), healthy volunteers (0)] underwent magnetic resonance imaging. Magnetic resonance parameters were compared with clinical SSC tests and shoulder scores. From Group 0 to B, the diameters of the SSC decreased, and the fatty degeneration of the upper SSC increased (P<.05) from Group 0 and A to B according to clinical findings. The functional shoulder scores did not differ (P>.05). Magnetic resonance analysis provides reasons of postoperative SSC dysfunction.

Die Außenrotationsruhigstellung nach primärtraumatischer Schulterluxation@@@Immobilization by external rotation after primary traumatic shoulder dislocation

ZusammenfassungDie orthetische Immobilisation des reponierten Glenohumeralgelenks nach Erstluxation erfolgt historisch bedingt zumeist in Innenrotationsstellung des Arms. Abhängig von verschiedenen in- und extrinsischen Prognosefaktoren resultieren darunter teils unbefriedigend hohe Reluxationsraten von bis zu 96%, insbesondere bei jungen Patienten mit hohem funktionellem Anspruch. In verschiedenen Grundlagenarbeiten wurde eine verbesserte Reposition und anatomische Position des abgelösten anteroinferioren Kapsel-Labrum-Komplexes in Außenrotation nachgewiesen.Erste vorliegende klinische Untersuchungen scheinen den Nutzen der Immobilisationsposition zu belegen. Nach Außenrotationsruhigstellung wurden signifikant geringere Reluxationsraten und eine anatomiegetreuere Position der abgelösten passiven Stabilisatoren im Vergleich zur herkömmlichen Immobilisation in Innenrotation nachgewiesen. Dennoch ist die Anzahl verfügbarer Daten derzeit noch limitiert. Insbesondere in Bezug auf die exakte Immobilisationsposition des Humeruskopfes, den Einfluss des Hämarthros und der spezifischen Kapsel-Labrum-Läsion auf das radiologische und klinische Resultat sind weitere prospektive Studien mit entsprechenden Nachuntersuchungszeiträumen wünschenswert, um den exakten Stellenwert dieses Therapiekonzepts evaluieren zu können.AbstractImmobilization of the shoulder following dislocation and reduction is traditionally carried out using internal rotation braces. However, high recurrence rates of up to 96% may result depending on several concomitant intrinsic and extrinsic prognostic factors, such as age and level of physical activity. Recently, different cadaveric and radiologic studies have suggested an improved tissue apposition of the affected labroligamentous structures in a better anatomic position during external rotation of the humeral head. Recent clinical outcome studies have supported the hypothetical benefit of this immobilization technique. Significantly lower recurrent dislocation rates and a better anatomic positioning of the affected structures were observed after immobilization in external rotation compared to immobilization in internal rotation.However, the number of available studies in this respect is still limited. Further prospective evidence is therefore desirable to evaluate the contribution of exact positioning of the immobilization, influence of hemarthros and specific capsulolabral lesions to the long-term clinical and radiological outcome of this new concept of immobilization.Immobilization of the shoulder following dislocation and reduction is traditionally carried out using internal rotation braces. However, high recurrence rates of up to 96% may result depending on several concomitant intrinsic and extrinsic prognostic factors, such as age and level of physical activity. Recently, different cadaveric and radiologic studies have suggested an improved tissue apposition of the affected labroligamentous structures in a better anatomic position during external rotation of the humeral head. Recent clinical outcome studies have supported the hypothetical benefit of this immobilization technique. Significantly lower recurrent dislocation rates and a better anatomic positioning of the affected structures were observed after immobilization in external rotation compared to immobilization in internal rotation.However, the number of available studies in this respect is still limited. Further prospective evidence is therefore desirable to evaluate the contribution of exact positioning of the immobilization, influence of hemarthros and specific capsulolabral lesions to the long-term clinical and radiological outcome of this new concept of immobilization.