Fabian Plachel

Clinical and Functional Outcome of All-Inside Anterior Cruciate Ligament Reconstruction at a Minimum of 2 Years’ Follow-up

PURPOSEnTo evaluate the clinical and functional outcomes for anatomic anterior cruciate ligament (ACL) reconstruction using the all-inside technique with a minimum follow-up of 24 months.nnnMETHODSnPatients undergoing anatomic ACL reconstruction via the all-inside technique between January 2011 and October 2012 were reviewed for inclusion in this study. Functional outcome measures, including the Lysholm score, International Knee Documentation Committee score, visual analog scale score, and Tegner Activity Scale, were used to evaluate outcomes before surgery and at 3, 6, 12, and > 24 months. At final follow-up, anteroposterior knee stability was assessed with KT-2000 (MEDmetric, San Diego, CA) measurements.nnnRESULTSnOf the 92 patients who underwent primary all-inside ACL reconstruction, 79 patients returned to final follow-up with a minimum of 2 years. There were 53 men and 26 women with a mean age of 29 years (range, 18 to 54 years) and a mean follow-up of 29 months (range, 24 to 45 months). The International Knee Documentation Committee score (44.6 v 89.7, P < .0001), Lysholm score (53.4 v 93.1, P < .001), visual analog scale score (5 v 0.1, P < .001), and Tegner activity score (2 v 6, P < .001) showed a significant improvement between baseline and final clinical follow-up. The mean side-to-side KT-2000 difference at final follow-up was 1.7 mm (range; 0 to 6 mm). Overall 10 patients (12.7%) sustained an ACL graft rerupture after a mean of 17.6 months (range, 6.9 to 28.6 months).nnnCONCLUSIONSnThe current data support our first hypothesis that primary anatomic ACL reconstruction using the all-inside technique leads to improved functional outcomes between baseline and clinical follow-up at 24 months. Further, there was no difference in knee stability between the ACL reconstructed- and the contralateral normal knee at 24 months, which confirms our second hypothesis.

Arthroscopic Versus Open Iliac Crest Bone Grafting in Recurrent Anterior Shoulder Instability With Glenoid Bone Loss: A Computed Tomography–Based Quantitative Assessment

PURPOSEnTo assess the iliac crest bone graft (ICBG) position in the en-face view and axial plane comparing arthroscopic with open procedures.nnnMETHODSnA total of 40 consecutive patients with recurrent anterior shoulder instability and glenoid bone loss over 10% treated by 2 independent orthopaedic departments were included. Two independent observers analyzed preoperative and immediate postoperative computed tomography scans of 20 open (group O) and 20 arthroscopic (group A) procedures. Defect and ICBG characteristics of the J-shaped graft in the en-face view and axial plane were manually assessed by multiplanar reconstructed computed tomography scans. Variances in terms of graft positioning were analyzed.nnnRESULTSnNo significant variances in arthroscopic graft positioning were observed. The graft position in the en-face view was comparable in both groups, with the superior extent of the arthroscopic graft (40° ± 9° [inferior extent, 139° ± 16°]) lying significantly higher than the superior extent in group O (50° ± 13°, Pxa0= .005 [inferior extent, 147° ± 21°; Pxa0= .178]). The covered glenoid defect size was above 95% (98% ± 1% in group O vs 95% ± 2% in group A, Pxa0= .001). The arthroscopic graft in the axial plane showed a significantly steeper impaction angle (34.8° ± 7.8° vs 26.9° ± 9.9°, Pxa0= .010), with a significantly increased medial offset compared with group O (6.6 ± 1.7xa0mm vs 5.4 ± 1.3xa0mm, Pxa0= .024). The mediolateral step formation, however, was not significantly different (2.9 ± 1.1xa0mm in group A vs 3.2 ± 0.8xa0mm in group O, Pxa0= .289). The interobserver reliability was very good for all measurements (Rxa0= 0.969; 95% confidence interval, 0.965-0.972).nnnCONCLUSIONSnPositioning of the arthroscopic ICBG in the en-face view and axial plane is comparable to that of the open technique. Good glenoid defect coverage and glenoid concavity reconstruction can be achieved with the arthroscopic technique. The main difference compared with the open procedure is the significantly steeper impaction angle.nnnLEVEL OF EVIDENCEnLevel III, case-control study.

Reverse shoulder arthroplasty after failed pectoralis major tendon transfer with a minimum follow-up of 5 years. A case series

BACKGROUNDnTreatment strategies after failed pectoralis major tendon transfer (PMTT) are scarce in literature and no information is available for patients treated with reverse shoulder arthroplasty (RSA) for failed PMTT.nnnMETHODSnWe performed a retrospective outcome study of all patients who underwent revision with RSA after failed PMTT at our institution. From 1999 to 2009 we included 8 patients (8 shoulders). The minimum follow-up was 5 years with a mean follow-up time of 97 months (range, 64-134). Clinical and radiological evaluation comprised range of motion, Constant Murley score (CMS), Simple Shoulder Test (SST) as well as standard X-rays in 2 planes. Pain was measured using VAS pain scale. The patients were asked to rate their satisfaction at final follow-up.nnnRESULTSnAll outcome measures improved significantly post-surgical compared to pre-surgical, including the CMS (17.8-62.8), SST (1.8-7.3) and VAS (7.1-1). Active abduction and anterior flexion improved significantly (pxa0<xa0.001) from 65.6° to 125° and from 62.5° to 136.3°, respectively. There were 2 complications. One patient sustained transient musculocutaneous nerve palsy that resolved completely after 5 months and one patient sustained postoperative hematoma and had to be revised 4 days after surgery. 4 (50%) patients rated their results as excellent and 4 (50%) rated them as good.nnnCONCLUSIONSnRSA is a good option for treating patients after failed pectoralis major tendon transfer. After a minimum follow-up of 5 years, functional outcome is good and patient satisfaction is high.nnnLEVEL OF EVIDENCEnLevel IV, Case series, Treatment study.

The Effect of Scapula Tilt and Best-Fit Circle Placement When Measuring Glenoid Bone Loss in Shoulder Instability Patients

PURPOSEnTo analyze the effect of lack of standardization on the reliability of current measurement techniques for glenoid bone loss in clinical practice.nnnMETHODSnTen consecutive patients with anterior glenoid bone loss due to recurrent anterior shoulder instability and available computed tomographic (CT) scans of the affected shoulder were included in this study. One hundred seventy 3-dimensional en-face view images of the 10 glenoids with up to 20° degrees of tilt in the anterior, posterior, superior, and inferior direction were rendered. Three independent observers first identified the en-face view images and subsequently performed measurements of the defect surface and diameter as well as the glenoid surface and diameter on all 170 images. Measurements were completed based on the conventional best-fit circle technique using the edge of the visible glenoid bone as reference and additionally based on the so-called spoon technique, which places the best-fit circle on the edge of the visible glenoid concavity.nnnRESULTSnThe overall agreement regarding en-face view image selection between the observers was 30% (K-alphaxa0= 0.10, 95% confidence interval 0.02-0.22). Tilt of the en-face view in any direction resulted in significant alterations of all 4 measurement parameters as well as the relative defect area and diameter (P < .05). The conventional and the spoon techniques rendered significantly different results regarding all 4 measurement parameters as well as the relative defect area (P < .05).nnnCONCLUSIONnImpreciseness of scapula positioning for creation of an en-face view of the glenoid as well as varying best-fit circle placement significantly alter glenoid defect size measurement results.nnnCLINICAL RELEVANCEnBecause the glenoid defect size plays an important role in the choice of treatment for anterior shoulder instability, measurement techniques need to be as precise as possible.

Humeral bone grafting in stemless shoulder arthroplasty

Stemless shoulder arthroplasty with metaphyseal fixation of the humeral component is increasingly used in the treatment of primary or secondary osteoarthritis, achieving significant pain relief and improving both range of motion and patient satisfaction [1, 4, 6]. The majoradvantagesof the stemlesshumeral design are preservation of humeral bone stock, anatomical reconstruction regardless of humeral malalignment, fewer stem-related complications, and ease of revision [2]. Hawi et al. recently showed good long-term clinical and radiological outcomes with a revision rate of approximately 7% without humeral implantrelated complications [6]. Currently, poor bone quality, including osteoporosis or metaphyseal cystic changes, is described to be a contraindication for stemless shoulder prostheses [5]. Thus, it is generally recommended to switch to a stemmed prosthesis to provide bone ingrowth and primary stability. The purpose of the following technique is to embrace the advantages of the stemless design when treating severe primary or secondary osteoarthritis, even in the presence of a large humeral bone defect, using the Eclipse prosthesis (Arthrex, Naples, FL, USA) combined with a humeral autograft (. Fig. 1a–d). Technical note

The “triple dislocation fracture”: anterior shoulder dislocation with concomitant fracture of the glenoid rim, greater tuberosity and coracoid process—a series of six cases

BACKGROUNDnA combined fracture of the glenoid rim, greater tuberosity, and coracoid process after anterior shoulder dislocation is a rare event. Only 1 patient has been reported in the literature.nnnMETHODSnAll patients with a first-time traumatic anterior shoulder dislocation in a level A trauma center were retrospectively reviewed. Among the 2068 patients treated between 1998 and 2013, we identified 6 patients (0.3%; 1 female, 5 male) with triple dislocation fracture (anterior shoulder dislocation with concomitant fracture of the glenoid rim, greater tuberosity, and coracoid process). All patients underwent surgery and had computed tomography scans before surgery and the first postoperative day. Mean follow-up time was 59 months. Clinical and radiographic evaluation, Constant-Murley Score, Simple Shoulder Test, and Subjective Shoulder Value were performed at the final follow-up.nnnRESULTSnSurgery was determined individually according to the radiologic findings, patients age, and personal demands. Glenoid reconstruction was performed in all 6 patients, greater tuberosity refixation in 4 patients, and coracoid process refixation in 3. Two patients needed revision surgery due to loss of reduction. At the final follow-up, mean abduction was 133°, mean anterior flexion was 138°; the mean Constant-Murley Score was 72 points; the mean Simple Shoulder Test was 9 points; and the mean Subjective Shoulder Value was 72%. No recurrent instability occurred.nnnCONCLUSIONSnA triple dislocation fracture, especially coracoid process fractures, can easily be overlooked in radiographs. Computed tomography scans are strongly recommended in patients with a first-time traumatic shoulder dislocation. Because recurrent joint instability and secondary arthropathy are serious complications after anterior shoulder dislocation, surgery should be considered and provides satisfying to excellent results.

Anterosuperiore Rotatorenmanschettenläsion beim jungen Patienten

ZusammenfassungEinleitungDie anterosuperiore Rotatorenmanschettenläsion (ASRML) bezeichnet die kombinierte Verletzung der Subskapularis- und der Supraspinatussehne, welche i.xa0d.xa0R. mit einer Pathologie am Rotatorenintervall assoziiert ist. Das Vollbild der ASRML reicht von der höhergradigen Pulley-Läsion über die transmurale Ruptur der Supraspinatussehne kombiniert mit einer partiellen Läsion der Subskapularissehne (z.u2009B. „hidden lesion“) bis hin zur anterosuperioren Massenruptur.DiagnostikDie Diagnose der ASRML basiert primär auf einer gezielten Anamnese, weshalb zu Beginn zwischen einem akuten Trauma und einer degenerativen Ursache zu unterscheiden bzw. der individuelle Anspruch zu erfragen ist. Eine strukturierte klinische Untersuchung mit isolierter und ganzheitlicher Evaluierung der entsprechenden Rotatorenmanschette ist wesentlicher Bestandteil der Diagnostik. Als Goldstandard der radiologischen Bildgebung gilt die Magnetresonanztomographie, wenngleich v.xa0a. partielle kraniale Läsionen der Subskapularissehne (z.u2009B. Pulley-Läsion) häufig als falsch-negativ interpretiert werden.TherapieDie Therapie der ASRML ist multifaktoriell bedingt und muss nach Zusammenschau der funktionellen Ansprüche und diagnostischen Befunde individuell entschieden werden. Die arthroskopische Versorgung gilt als Mittel der Wahl. Insbesondere beim jungen und aktiven Patienten ist die anatomische Rekonstruktion der Rotatorenmanschette vorzuziehen. Als Salvage-Operation konnten mittels Muskeltransfer bzw. Implantation einer inversen Endoprothese zufriedenstellende langfristige Ergebnisse erzielt werden.AbstractIntroductionThe anterosuperior rotator cuff lesion (ASRCL) denotes the concomitant injury of the subscapularis and supraspinatus tendons, which is usually associated with axa0pathology on the rotator interval. The full-scale of the ASRCL ranges from the higher-grade lesion of the biceps pulley through the transmural tear of the supraspinatus tendon combined with axa0partial lesion of the subscapular tendon (e.u2009g. hidden lesion) to the massive anterosuperior rotator cuff tear.DiagnosisThe diagnosis of ASRCL is primarily based on anamnestic history, making it necessary to differentiate between an acute trauma and axa0degenerative cause and to determine the individual’s physical use and demand. Axa0structured clinical examination with isolated and complete evaluation of the respective rotator cuff is an essential component of the diagnosis. Magnetic resonance imaging is considered the gold standard of radiological imaging, although partial cranial lesions of the subscapular tendon (e.u2009g. lesion of the biceps pulley) are often misdiagnosed.TherapyThe therapy of ASRCL is multifactorial and must be decided on an individual basis after determination of all the functional requirements and diagnostic findings. Arthroscopic surgery is considered the treatment of choice. Anatomical reconstruction of the rotator cuff is especially preferred in young and active patients. Satisfactory long-term results have been achieved by means of muscle transfer or reverse shoulder prosthesis used as axa0salvage operation.

Anterosuperiore Rotatorenmanschettenläsion beim jungen Patienten Anterosuperior rotator cuff defects in young patients

ZusammenfassungEinleitungDie anterosuperiore Rotatorenmanschettenläsion (ASRML) bezeichnet die kombinierte Verletzung der Subskapularis- und der Supraspinatussehne, welche i.xa0d.xa0R. mit einer Pathologie am Rotatorenintervall assoziiert ist. Das Vollbild der ASRML reicht von der höhergradigen Pulley-Läsion über die transmurale Ruptur der Supraspinatussehne kombiniert mit einer partiellen Läsion der Subskapularissehne (z.u2009B. „hidden lesion“) bis hin zur anterosuperioren Massenruptur.DiagnostikDie Diagnose der ASRML basiert primär auf einer gezielten Anamnese, weshalb zu Beginn zwischen einem akuten Trauma und einer degenerativen Ursache zu unterscheiden bzw. der individuelle Anspruch zu erfragen ist. Eine strukturierte klinische Untersuchung mit isolierter und ganzheitlicher Evaluierung der entsprechenden Rotatorenmanschette ist wesentlicher Bestandteil der Diagnostik. Als Goldstandard der radiologischen Bildgebung gilt die Magnetresonanztomographie, wenngleich v.xa0a. partielle kraniale Läsionen der Subskapularissehne (z.u2009B. Pulley-Läsion) häufig als falsch-negativ interpretiert werden.TherapieDie Therapie der ASRML ist multifaktoriell bedingt und muss nach Zusammenschau der funktionellen Ansprüche und diagnostischen Befunde individuell entschieden werden. Die arthroskopische Versorgung gilt als Mittel der Wahl. Insbesondere beim jungen und aktiven Patienten ist die anatomische Rekonstruktion der Rotatorenmanschette vorzuziehen. Als Salvage-Operation konnten mittels Muskeltransfer bzw. Implantation einer inversen Endoprothese zufriedenstellende langfristige Ergebnisse erzielt werden.AbstractIntroductionThe anterosuperior rotator cuff lesion (ASRCL) denotes the concomitant injury of the subscapularis and supraspinatus tendons, which is usually associated with axa0pathology on the rotator interval. The full-scale of the ASRCL ranges from the higher-grade lesion of the biceps pulley through the transmural tear of the supraspinatus tendon combined with axa0partial lesion of the subscapular tendon (e.u2009g. hidden lesion) to the massive anterosuperior rotator cuff tear.DiagnosisThe diagnosis of ASRCL is primarily based on anamnestic history, making it necessary to differentiate between an acute trauma and axa0degenerative cause and to determine the individual’s physical use and demand. Axa0structured clinical examination with isolated and complete evaluation of the respective rotator cuff is an essential component of the diagnosis. Magnetic resonance imaging is considered the gold standard of radiological imaging, although partial cranial lesions of the subscapular tendon (e.u2009g. lesion of the biceps pulley) are often misdiagnosed.TherapyThe therapy of ASRCL is multifactorial and must be decided on an individual basis after determination of all the functional requirements and diagnostic findings. Arthroscopic surgery is considered the treatment of choice. Anatomical reconstruction of the rotator cuff is especially preferred in young and active patients. Satisfactory long-term results have been achieved by means of muscle transfer or reverse shoulder prosthesis used as axa0salvage operation.

Arthroskopische Doppelreihenrekonstruktion hochgradiger Rupturen der Subskapularissehne

ZusammenfassungOperationszielWiederherstellung der Sehnenintegrität mit dem Ziel der glenohumeralen Zentrierung des Humeruskopfs und dadurch Verbesserung sowohl des Schmerzzustands als auch der Funktionalität der betroffenen Schulter.IndikationenIsolierte oder kombinierte Läsionen der Subskapularissehne (SSC) mit einer vertikalen Rupturgröße von über zwei Drittel der humeralen Insertion ohne signifikante Weichteildegeneration und Dezentrierung des Humeruskopfs.KontraindikationenChronische Verletzung der SSC mit hochgradiger Atrophie bzw. fettiger Infiltration der Muskulatur und statischer glenohumeraler Dezentrierung.OperationstechnikIm Rahmen der arthroskopischen Versorgung erfolgt im ersten Schritt eine 270°-Tenolyse der SSC mit anschließender Insertion und Verknotung der medialen Fadenankerreihe und Abspannen der Fäden nach lateral im Sinne einer transossär-äquivalenten Doppelreihenrekonstruktion.WeiterbehandlungAnlage einer Schultergelenkorthese mit ca.xa020°-Abduktions- und Innenrotationslagerung 24u202fh nach Operation. Diese wird für insgesamt 6xa0Wochen getragen. Regelmäßige Physiotherapie mit funktioneller Behandlung progredienter Intensität. Überkopfsportarten nach 6xa0Monaten.ErgebnisseIn biomechanischen Arbeiten zeigt sich die Doppelreihenrekonstruktion der Versorgung mittels Einzelreihen- oder transossärer Nahttechnik überlegen. Erste klinische Untersuchungen bestätigen diesen Trend, wenngleich mittel- bis langfristige Ergebnisse noch abzuwarten sind.AbstractObjectiveReconstruction of tendon integrity to maintain glenohumeral joint centration and hence to restore shoulder functional range of motion and to reduce pain.IndicationsIsolated or combined full-thickness subscapularis tendon tears (≥upper two-thirds of the tendon) without both substantial soft tissue degeneration and cranialization of the humeral head.ContraindicationsChronic tears of the subscapularis tendon with higher grade muscle atrophy, fatty infiltration, and static decentration of the humeral head.Surgical techniqueAfter arthroscopic three-sided subscapularis tendon release, two double-loaded suture anchors are placed medially to the humeral footprint. Next to the suture passage, the suture limbs are tied and secured laterally with up to two knotless anchors creating axa0transosseous-equivalent repair.Postoperative managementThe affected arm is placed in axa0shoulder brace with 20° of abduction and slight internal rotation for 6xa0weeks postoperatively. Rehabilitation protocol including progressive physical therapy from axa0maximum protection phase to axa0minimum protection phase is required. Overhead activities are permitted after 6xa0months.ResultsWhile previous studies have demonstrated superior biomechanical properties and clinical results after double-row compared to single-row and transosseous fixation techniques, further mid- to long-term clinical investigations are needed to confirm these findings.OBJECTIVEnReconstruction of tendon integrity to maintain glenohumeral joint centration and hence to restore shoulder functional range of motion and to reduce pain.nnnINDICATIONSnIsolated or combined full-thickness subscapularis tendon tears (≥upper two-thirds of the tendon) without both substantial soft tissue degeneration and cranialization of the humeral head.nnnCONTRAINDICATIONSnChronic tears of the subscapularis tendon with higher grade muscle atrophy, fatty infiltration, and static decentration of the humeral head.nnnSURGICAL TECHNIQUEnAfter arthroscopic three-sided subscapularis tendon release, two double-loaded suture anchors are placed medially to the humeral footprint. Next to the suture passage, the suture limbs are tied and secured laterally with up to two knotless anchors creating axa0transosseous-equivalent repair.nnnPOSTOPERATIVE MANAGEMENTnThe affected arm is placed in axa0shoulder brace with 20° of abduction and slight internal rotation for 6xa0weeks postoperatively. Rehabilitation protocol including progressive physical therapy from axa0maximum protection phase to axa0minimum protection phase is required. Overhead activities are permitted after 6xa0months.nnnRESULTSnWhile previous studies have demonstrated superior biomechanical properties and clinical results after double-row compared to single-row and transosseous fixation techniques, further mid- to long-term clinical investigations are needed to confirm these findings.

Superiore Kapselrekonstruktion: Indikation und klinische Resultate

ZusammenfassungDie optimale Therapie der irreparablen bzw. partiell reparablen Rotatorenmanschettenruptur wird weiterhin kontrovers diskutiert. In Abhängigkeit von patienten- und pathologiespezifischen Faktoren bestehen sowohl konservative, als auch verschiedene operative Behandlungsoptionen. Das Verfahren der superioren Kapselrekonstruktion („superior capsular reconstruction“, SCR) mit Verwendung eines Auto- oder Allografts stellt hierbei einen relativ neuen Therapieansatz dar, dessen Indikationsgebiet bislang noch nicht abschließend geklärt ist. In diesem Artikel soll ein Überblick über die aktuelle Datenlage, die Indikationsstellung und erste klinische und strukturellen Ergebnisse der SCR gegeben werden.AbstractThe treatment of irreparable or partial reparable rotator cuff tendon tears is still discussed controversially. Depending on patient- and pathology-specific factors, conservative as well as different surgical treatment options exist. Superior capsular reconstruction (SCR) using an autograft or allograft represents axa0relatively novel surgical technique. However, the ideal indication for this procedure is still under debate. This review article provides an overview about the current literature concerning indications and early clinical and structural results of SCR.