Frank Gohlke

Correlation of power Doppler sonography with vascularity of the synovial tissue of the knee joint in patients with osteoarthritis and rheumatoid arthritis.

OBJECTIVEnTo examine the significance of power Doppler sonography (PDS) in the diagnosis of synovial hypertrophy of the knee joint by verifying and comparing the PDS findings with histopathologic findings of synovial membrane vascularity.nnnMETHODSnThe knee joints of 23 patients who were undergoing arthroplasty of the knee joint because of osteoarthritis or rheumatoid arthritis were examined with ultrasound before arthroplasty. The vascularity of the synovial membrane was classified semiquantitatively using PDS. A sample of synovial tissue was obtained during the arthroplasty, and the vascularity of the synovial tissue was evaluated by immunohistochemistry (factor VIII) and was graded qualitatively by a pathologist who was unaware of the PDS findings. The visual qualitative grading by the examiner was controlled by analyzing PDS images and histologic samples using a digital image evaluation system.nnnRESULTSnThe correlation between the qualitative PDS results and the qualitative grading of the vascularity by the pathologist was 0.89 by Spearmans rho (P < 0.01). The Pearson correlation coefficient between the digital analysis of the PDS images and the digital analysis of the tissue sections was 0.81 (P < 0.01). Digital image analysis and qualitative grading by the examiner had a correlation of 0.89 by Spearmans p (P < 0.01) for the PDS images. The correlation between the qualitative estimation of vascularity by the pathologist and the digital image analysis was 0.88 by Spearmans rho (P < 0.01).nnnCONCLUSIONnIn the present study, PDS proved to be a reliable diagnostic method for qualitative grading of the vascularity of the synovial tissue. In clinical practice, PDS allows further differentiation of the hypertrophic synovium.

The pattern of the collagen fiber bundles of the capsule of the glenohumeral joint

The macroscopic anatomy and the architecture of the collagen fiber bundles were studied in the joint capsules of 43 cadaver shoulders. All the specimens were transilluminoted by polarized light after preparation by Spalteholz technique. Areas of high-fiber density and complex structure were examined histologically. The macroscopically recognizable ligaments are composed of collagen fiber bundles in several layers of differing thickness and orientation. A simple pattern of radial and circular fibers is found only in the relatively thin posterior capsule. A complex pattern of cross-linking was visible in the superior capsule, and a system of fiber bundles spirally crossing each other was present in the anterior/inferior capsule. The examination under polarized light revealed a continuous transition between the ligamentous reinforcements at the anterior inferior capsule, which radiated obliquely from the glenoid rim and varied greatly in form and orientation. The complicated structure of the joint capsule would suggest that the capsular cylinder has to be regarded as a functional entity and that the current biomechanical concepts must be modified if we want to understand its stabilizing effect. The structural features of the superior capsule present new insight about the pathogenesis of rotator cuff tearing, which can develop as a result of shearing stress between the capsular and tendinous layers.

The Stabilizing Sling for the Long Head of the Biceps Tendon in the Rotator Cuff Interval A Histoanatomic Study

A histoanatomic study of the rotator cuff interval was done in 13 cadaveric specimens to investigate the relation of its ligamentous structures to the long head of the biceps tendon, with a special focus on revealing a stabilizing function. After macroscopic evaluation, the lateral half of the rotator cuff interval capsule was cut into three sections: medial, middle, and lateral. These sections were embedded in methacrylate, and then serial sections were made and stained for polarized light microscopy. The superior glenohumeral ligament was seen to form a fold having the macroscopic appearance of a U-shaped anterior suspension sling for the long head of the biceps tendon. Microscopic evaluation revealed an important role of the fasciculus obliquus in the roof of this sling. Fibers of the supraspinatus tendon join the posterosuperior part of the sling. The subscapularis tendon is not involved in this suspensory mechanism. As a result of these observations, we determined that the superior glenohumeral ligament and the fasciculus obliquus are the most important ligamentous reinforcements of a stabilizing sling for the long head of the biceps tendon in the rotator cuff interval. Their histologic appearance indicates they function to protect the long head of the biceps against anterior shearing stress. A lesion of this sling might lead to anterior instability of the biceps tendon.

[Revision of failed fracture hemiarthroplasties to reverse total shoulder prosthesis through the transhumeral approach : method incorporating a pectoralis-major-pedicled bone window].

ZusammenfassungOperationszielSchmerzfreiheit, Wiederherstellung von Funktion und aktivem Bewegungsumfang.IndikationenFehlgeschlagene posttraumatische Schulterprothesen mit insuffizienter Rotatorenmanschette, Pseudoparalyse, chronischer Instabilität, schwerer Einsteifung.KontraindikationenFortgeschrittene Glenoiddestruktion.Schwere Läsionen des Musculus deltoideus (> 50%) und komplette Paresen des Nervus axillaris.Floride Infektionen.OperationstechnikDeltoideopektoraler Zugang.Exposition des fehlgeschlagenen Implantats und Entfernung unter Fensterung des Humerus. Periartikuläre Arthrolyse unter Schonung neurovaskulärer Strukturen.Präparation des Glenoids, zementfreie Fixation der Glenoidbasisplatte (Metaglène) und Aufbringen der Glenosphäre.Fensterung des Humerusschafts, Entfernung von Knochenzement, Vorlage von Draht- und Fadencerclagen und zementierte Implantation der Humeruskomponente (langstielig) in 10–30° Retroversion zum Unterarm.Anatomiegerechte Rekonstruktion der Weichteile unter Erhalt der Außenrotatoren (Refixation dislozierter Tuberkula, ggf. Transposition des Musculus latissimus dorsi und Musculus teres major nach LEpiscopo).WeiterbehandlungFür 6 Wochen postoperativ Thoraxabduktionskissen und passive oder aktiv-assistierte Beübung unter Einbeziehung einer motorisierten Übungsschiene (Ormed, Freiburg).ErgebnisseVon 2000 bis 2005 wurden insgesamt 84 Schulterprothesenrevisionen unter Verwendung der Grammont-Prothese durchgeführt, davon 34 Wechsel fehlgeschlagener Frakturhemiprothesen (fünf Männer, 29 Frauen) über ein humerales Knochenfenster. 25 Patienten wurden bis zu 59 Monate postoperativ prospektiv erfasst, zusätzlich wurden neun Patienten telefonisch/schriftlich befragt (n = 34, durchschnittliches Lebensalter 68 Jahre [59–82 Jahre], durchschnittlicher Nachuntersuchungszeitraum 31,5 Monate [12–59 Monate]).Der alters- und geschlechtsadaptierte Constant-Score betrug präoperativ 17,5% und verbesserte sich postoperativ auf 63%. Die Bewegungsumfänge für die aktive Elevation und Innenrotation konnten deutlich verbessert werden (Elevation präoperativ durchschnittlich 48°, postoperativ 125°). In allen Fällen verbesserte sich die Schmerzsituation.Die Funktion korrelierte mit dem Ausmaß der Weichteilschädigung. 14 Patienten waren sehr zufrieden mit dem Operationsergebnis, 16 zufrieden und vier unzufrieden. Insgesamt fanden sich acht Komplikationen.AbstractObjectiveAlleviation of pain, restoration of function and active range of motion.IndicationsFailed posttraumatic shoulder prostheses with insufficient rotator cuff, pseudoparalysis, chronic instability, severe ankylosis.ContraindicationsAdvanced glenoid destruction.Severe lesions of the deltoid muscle (> 50%) and axillary nerve palsy.Florid infections.Surgical TechniqueDeltopectoral approach.Exposure of the failed implant and explantation by fenestration of the humerus. Periarticular release with preservation of neurovascular structures.Exposure of the glenoid, cementless fixation of the glenoid base plate (metaglène) and application of the glenoid ball (glenosphere).Fenestration of the humeral shaft, removal of bone cement, placement of wire and suture loops, and cemented implantation of the humeral component (long revision stem) in 10–30° retroversion related to the long axis of the forearm.Anatomic reconstruction of the soft tissues with preservation of the external rotators (reattachment of dislocated tubercles and, if necessary, transposition of latissimus dorsi and teres major as described by LEpiscopo).Postoperative ManagementFor 6 weeks postoperatively, abduction brace and passive or active-assisted exercises including continuous passive motion (Ormed, Freiburg, Germany).ResultsFrom 2000 to 2005, a total of 84 shoulder replacement revisions were performed with the reverse prosthesis, of which 34 were revisions of failed fracture hemiarthroplasties (five men, 29 women) through a bone window in the humerus. 25 patients were followed prospectively for up to 59 months postoperatively; an additional nine patients were interviewed by telephone or in writing (n = 34, average age 68 years [59–82 years], average follow-up 31.5 months [12–59 months]).The preoperative age- and gender-related Constant Score was 17.5% and improved to 63% postoperatively. Range of motion for active elevation and internal rotation was substantially improved (average elevation preoperatively 48°, postoperatively 125°). Pain was relieved in every patient. Function correlated to the extent of soft-tissue damage.14 patients were very satisfied with the surgical outcome, 16 were satisfied and four dissatisfied. There were eight complications in total.

Wechsel fehlgeschlagener Frakturprothesen auf inverse Revisionsimplantate über den transhumeralen Zugang

ZusammenfassungOperationszielSchmerzfreiheit, Wiederherstellung von Funktion und aktivem Bewegungsumfang.IndikationenFehlgeschlagene posttraumatische Schulterprothesen mit insuffizienter Rotatorenmanschette, Pseudoparalyse, chronischer Instabilität, schwerer Einsteifung.KontraindikationenFortgeschrittene Glenoiddestruktion.Schwere Läsionen des Musculus deltoideus (> 50%) und komplette Paresen des Nervus axillaris.Floride Infektionen.OperationstechnikDeltoideopektoraler Zugang.Exposition des fehlgeschlagenen Implantats und Entfernung unter Fensterung des Humerus. Periartikuläre Arthrolyse unter Schonung neurovaskulärer Strukturen.Präparation des Glenoids, zementfreie Fixation der Glenoidbasisplatte (Metaglène) und Aufbringen der Glenosphäre.Fensterung des Humerusschafts, Entfernung von Knochenzement, Vorlage von Draht- und Fadencerclagen und zementierte Implantation der Humeruskomponente (langstielig) in 10–30° Retroversion zum Unterarm.Anatomiegerechte Rekonstruktion der Weichteile unter Erhalt der Außenrotatoren (Refixation dislozierter Tuberkula, ggf. Transposition des Musculus latissimus dorsi und Musculus teres major nach LEpiscopo).WeiterbehandlungFür 6 Wochen postoperativ Thoraxabduktionskissen und passive oder aktiv-assistierte Beübung unter Einbeziehung einer motorisierten Übungsschiene (Ormed, Freiburg).ErgebnisseVon 2000 bis 2005 wurden insgesamt 84 Schulterprothesenrevisionen unter Verwendung der Grammont-Prothese durchgeführt, davon 34 Wechsel fehlgeschlagener Frakturhemiprothesen (fünf Männer, 29 Frauen) über ein humerales Knochenfenster. 25 Patienten wurden bis zu 59 Monate postoperativ prospektiv erfasst, zusätzlich wurden neun Patienten telefonisch/schriftlich befragt (n = 34, durchschnittliches Lebensalter 68 Jahre [59–82 Jahre], durchschnittlicher Nachuntersuchungszeitraum 31,5 Monate [12–59 Monate]).Der alters- und geschlechtsadaptierte Constant-Score betrug präoperativ 17,5% und verbesserte sich postoperativ auf 63%. Die Bewegungsumfänge für die aktive Elevation und Innenrotation konnten deutlich verbessert werden (Elevation präoperativ durchschnittlich 48°, postoperativ 125°). In allen Fällen verbesserte sich die Schmerzsituation.Die Funktion korrelierte mit dem Ausmaß der Weichteilschädigung. 14 Patienten waren sehr zufrieden mit dem Operationsergebnis, 16 zufrieden und vier unzufrieden. Insgesamt fanden sich acht Komplikationen.AbstractObjectiveAlleviation of pain, restoration of function and active range of motion.IndicationsFailed posttraumatic shoulder prostheses with insufficient rotator cuff, pseudoparalysis, chronic instability, severe ankylosis.ContraindicationsAdvanced glenoid destruction.Severe lesions of the deltoid muscle (> 50%) and axillary nerve palsy.Florid infections.Surgical TechniqueDeltopectoral approach.Exposure of the failed implant and explantation by fenestration of the humerus. Periarticular release with preservation of neurovascular structures.Exposure of the glenoid, cementless fixation of the glenoid base plate (metaglène) and application of the glenoid ball (glenosphere).Fenestration of the humeral shaft, removal of bone cement, placement of wire and suture loops, and cemented implantation of the humeral component (long revision stem) in 10–30° retroversion related to the long axis of the forearm.Anatomic reconstruction of the soft tissues with preservation of the external rotators (reattachment of dislocated tubercles and, if necessary, transposition of latissimus dorsi and teres major as described by LEpiscopo).Postoperative ManagementFor 6 weeks postoperatively, abduction brace and passive or active-assisted exercises including continuous passive motion (Ormed, Freiburg, Germany).ResultsFrom 2000 to 2005, a total of 84 shoulder replacement revisions were performed with the reverse prosthesis, of which 34 were revisions of failed fracture hemiarthroplasties (five men, 29 women) through a bone window in the humerus. 25 patients were followed prospectively for up to 59 months postoperatively; an additional nine patients were interviewed by telephone or in writing (n = 34, average age 68 years [59–82 years], average follow-up 31.5 months [12–59 months]).The preoperative age- and gender-related Constant Score was 17.5% and improved to 63% postoperatively. Range of motion for active elevation and internal rotation was substantially improved (average elevation preoperatively 48°, postoperatively 125°). Pain was relieved in every patient. Function correlated to the extent of soft-tissue damage.14 patients were very satisfied with the surgical outcome, 16 were satisfied and four dissatisfied. There were eight complications in total.

The influence of variations of the coracoacromial arch on the development of rotator cuff tears

In order to define the geometry of the coracoacromial arch in both its bony and soft parts and to bring it into relationship with rotator cuff tears, 54 cadaver shoulders (from subjects aged 47–90 years) were dissected And X-rayed (anteroposterior projection and supraspinatus outlet view). Partial rotator cuff tears were assessed additionally by transillumination and polarized microscopy. After transfixation of the coracoacromial arch with a polyurethane mould, sections were made along the coracoacromial ligament. The morphology of the acromion was described following the classification of Bigliani et al. [5]. Amongst other parameters, measurements were taken between the long axis of the scapula, the spina, and the acromion. In 19 of 22 cases, a traction osteophyte was associated with rotator cuff tears. In incomplete tears, spurs were completely encased within the ligament and did not impair the subacromial space. The number of rotator cuff tears was significantly increased in shoulders with “curved” acromia, flat acromial slope, and increased angle between the scapular plane and the spina (intact, mean 58°; tears, mean 47°). The morphology of the subacromial space was secondarily determined by this angle. In contrast to Bigliani et al. we were unable to find a “hooked” acromion. These results indicate that the combination of a flat and curved acromion or a position of the acromioclavicular joint above the cranial pole of the glenoid must be regarded as considerable risks for the development of rotator cuff tears. The concept of anterior acromioplasty is supported by our results.

Balance Sheets of Knee and Functional Scores 5 Years After Total Knee Arthroplasty for Osteoarthritis A Source for Patient Information

To improve patient information on the results of total knee arthroplasty (TKA) for osteoarthritis, 253 primary TKAs of a prospective study with a mean follow-up of 5.3 years were analyzed. The increase or decrease of the individual variables of the Knee Society knee and function score and the percentage of operated knees in which these variables increased were determined. Improvement in pain rating had the largest increase of all variables, contributing 60% to the knee score increase. Pain improved in 95% of the knees. Alignment improved in about 90% of knees and accounted for 25% of knee score increase. Improvement in level walking contributed more to increase of function score than better stair-climbing abilities. Level walking improved in 80% of knees and stair climbing in 55%. Pain is the most rewarding indication for TKA, followed by deformity and poor walking ability. Key words: total knee arthroplasty, knee score, functional score, patient information.

The relation of the coracoclavicular ligament insertion to the acromioclavicular joint: a cadaver study of relevance to lateral clavicle resection.

Resection of the lateral end of the clavicle is a common procedure for arthrosis of the acromioclavicular joint (AC-joint). However, no anatomical data on the distance between the insertions of the coracoclavicular ligaments and the AC-joint have been reported. In 36 cadaver shoulders (18 male), we studied the relation between the AC-joint and the insertions of the joint capsule, trapezoid and conoid ligaments. The distance from the AC-joint to the medial end of its capsule was, on average, 0.7 cm (0.4-0.9) cm in women and 0.8 (0.4-1.2) cm in men. In women, the trapezoid ligament began, on average, at 0.9 (0.4-1.6) cm and ended at 2.4 (2.0-2.8) cm and in men, it began at 1.1 (0.8-1.6) cm and ended at 2.9 (2.1-3.8) cm medial to the AC joint. The corresponding figures for the conoid ligament were 2.6 (2.0-3.7) cm and 4.7 (3.9-6.2) cm. A resection of 1 cm of the lateral clavicle detaches 8%, a resection of 2 cm 60% and a resection of 2.5 cm 90% of the trapezoid ligament. We recommend a maximum resection of 1 cm of the lateral clavicle because a resection of 2 cm or more may cause postoperative AC-joint instability and related pain.

The effect of suture materials and techniques on the outcome of repair of the rotator cuff: A PROSPECTIVE, RANDOMISED STUDY

In a prospective, randomised study on the repair of tears of the rotator cuff we compared the clinical results of two suture techniques for which different suture materials were used. We prospectively randomised 100 patients with tears of the rotator cuff into two groups. Group 1 had transosseous repair with No. 3 Ethibond using modified Mason-Allen sutures and group 2 had transosseous repair with 1.0 mm polydioxanone cord using modified Kessler sutures. After 24 to 30 months the patients were evaluated clinically using the Constant score and by ultrasonography. Of the 100 patients, 92 completed the study. No significant statistical difference was seen between the two groups: Constant score, 91% vs 92%; rate of further tear, 18% vs 22%; and revision, 4% vs 4%. In cases of further tear the outcome in group 2 did not differ from that for the intact repairs (91% vs 91%), but in group 1 it was significantly worse (94% vs 77%, p = 0.005). Overall, seven patients had complications which required revision surgery, in four for pain (two in each group) and in three for infection (two in group 1 and one in group 2).

2D SPLASH: a new method to determine the fatty infiltration of the rotator cuff muscles

The objective of this paper is to quantify the fatty degeneration (infiltration) of rotator cuff muscles with a new spectroscopic FLASH (SPLASH) sequence. Before planned surgery (reconstruction or muscle transfer), 20 patients (13 men, 7 women; 35–75 years) with different stages of rotator cuff disease underwent an MR examination in a 1.5-T unit. The protocol consists of imaging sequences and a newly implemented SPLASH, which allows an exact quantification of the fat/water ratio with a high spatial resolution in an arbitrarily shaped region of interest (ROI). The percentages of fat in the rotator cuff muscles were determined. To determine statistically significant differences between the different stages of rotator cuff tear, a Kruskal-Wallis H test was used. Fatty infiltration of the supraspinatus muscle was correlated with cross-sectional area (CSA) measures (Bravais-Pearson). We found significant differences between different stages of rotator cuff disease, the fatty infiltration and the volume loss (determined by the occupation ratio) of the supraspinatus muscle. With the increasing extent of rotator cuff disease, fatty infiltration increases significantly, as does the volume loss of the supraspinatus muscle. Comparing fatty infiltration and the occupation ratio individually, there was only a moderate inverse correlation between fatty infiltration and the occupation ratio, with considerable variation of data. Fatty infiltration of the infraspinatus muscle occurred when the infraspinatus tendon was involved to a lesser extent. The SPLASH sequence allows exact quantification of fatty infiltration in an arbitrarily shaped ROI. The extent of atrophy and fatty infiltration correlates with the size of the tear. Atrophy and fatty infiltration correlate only moderately and should be evaluated separately.