Felix Zeifang

Are there differences between stemless and conventional stemmed shoulder prostheses in the treatment of glenohumeral osteoarthritis

BackgroundConventional stemmed anatomical shoulder prostheses are widely used in the treatment of glenohumeral osteoarthritis. The stemless shoulder prosthesis, in contrast, is a new concept, and fewer outcome studies are available. Therefore, the purpose of the study was to investigate the early functional outcome and postoperative proprioception of a stemless prosthesis in comparison with a standard stemmed anatomic shoulder prosthesis.MethodsTwelve patients (mean age 68.3xa0years [SDu2009±u20095.4]; 5 female, 7 male) with primary glenohumeral osteoarthritis of the shoulder were enrolled, who underwent total shoulder arthroplasty (TSA) with a stemless total shoulder prosthesis, Total Evolution Shoulder System (TESS®; Biomed, France). The control group consisted of twelve (age and gender matched) patients (mean age 67.8xa0years; [SDu2009±u20097.1]; 9 female, 3 male), getting a TSA with a standard anatomic stemmed prosthesis, Aequalis® Shoulder (Tournier, Lyon, France). Patients were examined the day before and six months after surgery. The pre- and postoperative Constant Score (CS) was evaluated and proprioception was measured in a 3D video motion analysis study using an active angle-reproduction (AAR) test.ResultsComparing the postoperative CS, there was no significant difference between the groups treated with the TESS® prosthesis (48.0u2009±u200913.8 points) and the Aequalis® prosthesis (49.3u2009±u20098.6 points; pu2009=u20090.792). There was no significant difference in postoperative proprioception between the TESS® group (7.2° [SDu2009±u20092.8]) and the Aequalis® group(8.7° [SDu2009±u20092.7]; pu2009=u20090.196), either. Comparison of in the results of CS and AAR test pre- and postoperatively showed no significant differences between the groups.DiscussionIn patients with glenohumeral osteoarthritis, treated with TSA, the functional and the proprioceptive outcome is comparable between a stemless and a standard stemmed anatomic shoulder prosthesis at early followup.ConclusionFurther follow-up is necessary regarding the long-term performance of this prosthesis.Trial registrationCurrent Controlled Trials DRKS 00007528. Registered 17 November 2014

Treatment of severe cuff tear arthropathy with the humeral head resurfacing arthroplasty: two-year minimum follow-up

BACKGROUNDnThe aim of the study was to evaluate the outcome of a humeral head resurfacing arthroplasty implanted toward valgus for patients with cuff tear arthropathy (CTA).nnnMATERIALS AND METHODSnWe monitored 24 patients with CTA who underwent resurfacing arthroplasty. Patients were assessed with use of the Constant score and a subjective satisfaction score. The rotator cuff was evaluated preoperatively by magnetic resonance imaging. The Sirveaux classification of glenoid erosion in glenohumeral osteoarthritis with massive rupture of the cuff was used to grade the preoperative status of the glenoid.nnnRESULTSnThe mean absolute Constant score for the entire cohort improved from 21 points (range, 7-44 points) to 63 points (range, 23-89 points) at a mean of 38 months (range, 24-56 months). Patients with an intact or moderately atrophied teres minor muscle (n = 16) showed a significantly better Constant score (P = .011) and greater active external rotation (P = .034) than patients with severe atrophy. Neither the type of glenoid erosion according to Sirveaux nor the inclination angle of the implant has an effect on the clinical or functional outcome.nnnCONCLUSIONSnFor selected patients with CTA, resurfacing arthroplasty of the humeral head provides satisfactory medium-term outcomes. The teres minor muscle is necessary for maintaining or establishing external rotation. In patients with massive limitation of motion and total absence of the subscapularis tendon, the implantation of a humeral surface replacement should be seriously considered.

Ultrasound vs. MRI in the assessment of rotator cuff structure prior to shoulder arthroplasty

BACKGROUND/AIMSnWe compared the accuracy of US to 3 T Tesla MRI for the detection of rotator cuff and long biceps tendon pathologies before joint replacement.nnnMETHODSn45 patients were prospectively included.nnnRESULTSnFor the supraspinatus tendon, the accuracy of US when using MRI as reference was 91.1%. For the infraspinatus tendon, the accuracy with MRI as reference was 84.4%. The subscapularis tendon was consistently assessed by US and MRI in 35/45 patients (accuracy 77.8%). For the long biceps tendon the accuracy was 86.7%.nnnCONCLUSIONnUS detection of rotator cuff and biceps tendon integrity is comparable to MRI and should be preferred in revision cases.

Motion patterns in activities of daily living: 3- year longitudinal follow-up after total shoulder arthroplasty using an optical 3D motion analysis system

BackgroundTotal shoulder arthroplasty (TSA) can improve function in osteoarthritic shoulders, but the ability to perform activities of daily living (ADLs) can still remain impaired. Routinely, shoulder surgeons measure range of motion (ROM) using a goniometer. Objective data are limited, however, concerning functional three-dimensional changes in ROM in ADLs after TSA in patients with degenerative glenohumeral osteoarthritis.MethodsThis study included ten consecutive patients, who received TSA for primary glenohumeral osteoarthritis. The patients were examined the day before, 6 months, and 3 years after shoulder replacement as well. We compared them with a control group (n = 10) without any shoulder pathology and measured shoulder movement by 3D motion analysis using a novel 3 D model. The measurement included static maximum values, the ability to perform and the ROM of the ADLs “combing the hair”, “washing the opposite armpit”, “tying an apron”, and “taking a book from a shelf”.ResultsSix months after surgery, almost all TSA patients were able to perform the four ADLs (3 out of 40 tasks could not be performed by the 10 patients); 3 years postoperatively all patients were able to carry out all ADLs (40 out of 40 tasks possible). In performing the ADLs, comparison of the pre- with the 6-month and 3-year postoperative status of the TSA group showed that the subjects did not fully use the available maximum flexion/extension ROM in performing the four ADLs. The ROM used for flexion/extension did not change significantly (preoperatively 135°-0° -34° vs. 3 years postoperatively 131° -0° -53°). For abduction/adduction, ROM improved significantly from 33°-0° -27° preoperatively to 76° -0° -35° postoperatively. Compared to the controls (118°) the TSA group used less ROM for abduction to perform the four ADLs 3 years postoperatively.ConclusionTSA improves the ability to perform ADL and the individual ROM in ADLs in patients with degenerative glenohumeral osteoarthritis over the course of 3xa0years. However, TSA patients do not use their maximum available abduction ROM in performing ADLs. This is not related to limitations in active ROM, but rather may be caused by pathologic motion patterns, impaired proprioception or both.

Dynamic contrast-enhanced ultrasound and elastography assess deltoid muscle integrity after reverse shoulder arthroplasty

BACKGROUNDnThe outcome after reverse shoulder arthroplasty (RSA) depends on the condition of the deltoid muscle, which we assessed with new ultrasound modalities and electromyography (EMG). Contrast-enhanced ultrasound (CEUS) and acoustic radiation force impulse (ARFI) were applied to assess perfusion and elasticity of the deltoid muscle compared with the clinical and functional outcome.nnnMETHODSnThe study recruited 64 patients (mean age, 72.9 years) treated with RSA between 2004 and 2013. The deltoid muscle was examined with EMG and ultrasound imaging. Functional scores such as Constant score and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score were assessed. Among other CEUS parameters, the wash-in perfusion index, time to peak, and rise time were compared between the operated-on and contralateral shoulders as well as between patients with above-average and below-average outcome. The stiffness of the deltoid muscle was analyzed with ARFI.nnnRESULTSnAfter RSA, deltoid perfusion (wash-in perfusion index, Δu2009=u2009-12%u2009±u200922%, Pu2009=u2009.0001) and shoulder function (Constant score, Δu2009=u2009-14u2009±u200924, Pu2009<u2009.0001) were both inferior compared with the contralateral side. This perfusion deficit was associated with a limited range of motion (time to peak and anteversion: ru2009=u2009-0.290, Pu2009=u2009.022). Deltoid perfusion was higher in patients with above-average outcome (rise time, Δu2009=u200933%u2009±u200913%, Pu2009=u2009.038). The operated-on deltoid muscles showed higher stiffness than the contralateral muscles (ARFI, Δu2009=u20090.2u2009±u20090.9 m/s, Pu2009=u2009.0545). EMG excluded functionally relevant axillary nerve injuries in the study population.nnnCONCLUSIONSnCEUS revealed reduced mean perfusion of the deltoid muscle after RSA. Reduced perfusion was associated with limited range of motion and below-average outcome. Functional shoulder impairment after RSA might be predicted by noninvasive CEUS as a surrogate parameter for the integrity of the deltoid muscle.

Foot kinematics in walking on a level surface and on stairs in patients with hallux rigidus before and after cheilectomy.

BackgroundWalking down stairs is a clinically relevant daily activity for older persons. The aim of this pilot study was to investigate the impact of cheilectomy on walking on level ground and on stairs.Methods3D motion analysis of foot kinematics was performed in eight patients with hallux rigidus and 11 healthy control participants with a 12-camera system, using the Heidelberg foot measurement method before and one year after surgery. The clinical results were documented using the AOFAS Scale.ResultsThe range of motion of the first metatarsophalangeal joint did not improve after the operation under any gait condition. Preoperatively, hallux dorsi-/plantarflexion in level walking was 11.9° lower in patients than in controls (pu2009=u20090.006), postoperatively 14.5° lower (pu2009=u20090.004). Comparing walking conditions in patients, hallux dorsi-/plantarflexion was significantly higher in level walking than in climbing stairs (difference up stairs – level: -8.1°, pu2009=u20090.018).The AOFAS Scale improved significantly from 56.9u2009±u200919.9 points (meanu2009±u2009SD), preoperatively, to 75.9u2009±u200913.9 points, postoperatively (pu2009=u20090.027).ConclusionsCheilectomy is appropriate for reducing symptoms of hallux rigidus. However, neither a positive influence on the range of motion in walking on level ground and on stairs nor a functional improvement was observed in this group of patients.Trial registrationNCT01804491

3D motion capture using the HUX model for monitoring functional changes with arthroplasty in patients with degenerative osteoarthritis.

BACKGROUNDnAlthough shoulder hemiarthroplasty (SHA) can improve function in osteoarthritic shoulders, the ability to perform activities of daily living (ADL) may remain impaired. Shoulder surgeons routinely measure parameters such as range of motion, pain, satisfaction and strength. A common subjective assessment of ADL is part of the Constant Score (CS). However, there is limited objective evidence on whether or not shoulder hemiarthroplasty can restore normal range of motion (ROM) in ADL.nnnMETHODSnThe study included eight consecutive patients (n=8; seven women, one man), who underwent SHA for glenohumeral osteoarthritis. The patients were examined the day before, as well as 6 months and 3 years after shoulder replacement. They were compared with a control group with no shoulder pathology, and shoulder movement was measured with 3D motion analysis using the Heidelberg Upper Extremity (HUX) model. Measurements included static maximum values and four ADL.nnnRESULTSnComparing the preoperative to the 3-year postoperative static maximum values, there were significant improvements for abduction from 50.5° (SD ± 3 2.4°) to 72.4° (SD ± 38.2°; p=0.031), for adduction from 6.2° (SD ± 7.7°) to 66.7° (SD ± 18.0°; p=0.008), for external rotation from 15.1° (SD ± 27.9°) to 50.9° (SD ± 27.3°; p=0.031), and for internal rotation from -0.6° (SD ± 3.9°) to 35.8° (SD ± 28.2°; p=0.031). There was a trend of improvement for flexion from 105.8° (SD ± 45.7°) to 161.9° (SD ± 78.2°; p=0.094) and for extension from 20.6° (SD ± 17.0°) to 28.0° (SD ± 12.5°; p=0.313). The comparison of the 3-year postoperative ROM between the SHA group and controls showed significant differences in abduction; 3-year postoperative SHA ROM 72.4° (SD ± 38.2°) vs. 113.5° (SD ± 29.7°) among controls (p=0.029). There were no significant differences compared to the control group in adduction, flexion/extension and rotation 3 years after SHA surgery. In performing the ADL, the pre- to the 6-month and 3-year postoperative status of the SHA group resulted in a significant increase in ROM in all planes (p<0.05). Comparing the preoperative to the 3-year postoperative ROM used in ADL, there was an improvement in the flexion/extension plane, showing an improvement trend from preoperative 85°-0°-25° to postoperative 127°-0°-38° (p=0.063). In comparison, controls used a significantly greater ROM during ADL with mean flexion/extension of 139°-0°-63° (p=0.028). For the abduction/adduction plane, ROM improved significantly from preoperative 25°-0°-19° to postoperative 78°-0°-60° (p=0.031). In comparison to controls with abduction/adduction of 118°-0°-37° 3 years postoperative, the SHA group also used significantly less ROM in the abduction/adduction plane (p=0.028).nnnCONCLUSIONnWhile SHA improves ROM in ADL in patients with degenerative glenohumeral osteoarthritis, it does not restore the full ROM available for performing ADL compared to controls. 3D motion analysis with the HUX model is an appropriate measurement system to detect surgery-related changes in shoulder arthroplasty.

Can reverse shoulder arthroplasty in post-traumatic revision surgery restore the ability to perform activities of daily living?

BACKGROUNDnFailed shoulder arthroplasty and failed internal fixation in fractures of the proximal humerus can benefit from implantation of a reverse total shoulder arthroplasty (RSA). While there is some evidence that RSA can improve function regarding range of motion (ROM), pain, satisfaction, and strength, there is sparse data how this translates into activities of daily living (ADLs). A marker-based 3D video motion analysis system has recently been designed that can measure changes of ROM in dynamic movements in every plane. The hypothesis was that a gain of maximum ROM also translates into the ability to perform ADLs and into a significant increase of ROM in ADLs.nnnMATERIALS AND METHODSnSix consecutive patients (5 women, 1 man; 2× failed arthroplasty, 4× failed open reduction and internal fixation) who received RSA were examined the day before and 1 year after shoulder replacement. A 3D motion analysis system using a novel upper extremity model measured active maximum values and ROM in four ADLs.nnnRESULTSnComparing the pre- to the 1-year postoperative status, RSA resulted in a significant increase in mean maximum values for active flexion (humerus to thorax) of 37° (S.D. ±23°), from 50 to 87° [P=0.005], and for active abduction averaging of 17° (S.D. ±13°), from 52 to 69° [P=0.027]. The extension decreased significantly by about 8° (S.D. ±16°), from a mean of 39 to 31° [P=0.009]. For active adduction and internal and external rotation, there were trends for improvements, but no significant changes. Only three additional tasks of the ADL (out of 13/24 preoperatively) could be performed after revision surgery. Comparing the preoperative to the postoperative ROM in the ADLs in flexion/extension, ROM improved significantly in one (tying an apron) of four ADLs. There were no significant changes in the abduction/adduction and internal/external rotation in any ADLs.nnnCONCLUSIONnRSA in revision cases significantly improved maximum active flexion and abduction, but decreased extension in this series. However, the patients were only able to use this greater ROM to their benefit in one of four ADLs.

Cementless humeral head resurfacing for degenerative glenohumeral osteoarthritis fails at a high rate

PurposenThe aim of the study was to examine clinical and radiographic results of a cementless humeral surface and to evaluate prognostic parameters for implant failure.nnnMethodsn34 shoulders were examined preoperatively and after a mean 2.7 years. Radiographic parameters, Constant scores (CS) and complications were recorded.nnnResultsnThe mean CS improved from 27 to 51 points. Eight patients (24%) had an implant revision for secondary glenoid erosion. In the revision group was an increase of the LGHO of 8.4%.nnnConclusionsnThe study shows a high revision-rate (24%). Predictor for an implant failure was an operative changing of the LGHO.

A predominant Th1 polarization is present in synovial fluid of end-stage osteoarthritic knee joints - analysis of peripheral blood, synovial fluid & synovial membrane

Thorough understanding of the complex pathophysiology of osteoarthritis (OA) is necessary in order to open new avenues for treatment. The aim of this study was to characterize the CD4+ T cell population and evaluate their activation and polarization status in OA joints. Fifty‐five patients with end‐stage knee OA (Kellgren–Lawrence grades III–IV) who underwent surgery for total knee arthroplasty (TKA) were enrolled into this study. Matched samples of synovial membrane (SM), synovial fluid (SF) and peripheral blood (PB) were analysed for CD3+CD4+CD8– T cell subsets [T helper type 1 (Th1), Th2, Th17, regulatory T cells] and activation status (CD25, CD69, CD45RO, CD45RA, CD62L) by flow cytometry. Subset‐specific cytokines were analysed by cytometric bead array (CBA). SM and SF samples showed a distinct infiltration pattern of CD4+ T cells. In comparison to PB, a higher amount of joint‐derived T cells was polarized into CD3+CD4+CD8– T cell subsets, with the most significant increase for proinflammatory Th1 cells in SF. CBA analysis revealed significantly increased immunomodulating cytokines [interferon (IFN)‐γ, interleukin (IL)‐2 and IL‐10] in SF compared to PB. Whereas in PB only a small proportion of CD4+ T cells were activated, the majority of joint‐derived CD4+ T cells can be characterized as activated effector memory cells (CD69+CD45RO+CD62L–). End‐stage OA knees are characterized by an increased CD4+ T cell polarization towards activated Th1 cells and cytokine secretion compared to PB. This local inflammation may contribute to disease aggravation and eventually perpetuate the disease process.