Kaywan Izadpanah

Prognostic factors in nonoperative therapy for chronic symptomatic calcific tendinitis of the shoulder

OBJECTIVE To define prognostic factors in chronically symptomatic patients with calcific tendinitis of the shoulder. METHODS We evaluated 420 patients (488 shoulders) in the context of a prospective cohort study. Epidemiologic data were assessed. The radiographic and sonographic appearance of the calcific deposits was classified. The mean period of nonoperative therapy was 4.4 years (range 0.5-13.7 years). After referral to our institution, standardized nonoperative therapy was continued for a minimum of 3 months. Failure of nonoperative therapy was defined as the persistence of symptomatic calcific tendinitis of the shoulder after a minimum of 6 months. Prognostic factors (determined at P < 0.05 by chi-square test) were analyzed by logistic regression. RESULTS Of the 420 patients, 269 (64%) were women, 151 (36%) were men. The mean age of the patients was 51.3 years (range 28-84 years). Occurrence of calcific tendinitis of the shoulder was unilateral in 84% and bilateral in 16%. Gärtner type I calcific deposits were found in 37%, type II in 32%, and type III in 31%. Failure of nonoperative therapy was observed in 114 patients (27%). Negative prognostic factors were bilateral occurrence of calcific tendinitis of the shoulder, localization to the anterior portion of the acromion, medial (subacromial) extension, and high volume of the calcific deposit. Positive prognostic factors were a Gärtner type III deposit and a lack of sonographic sound extinction of the calcific deposit. CONCLUSION Our findings demonstrate the existence of prognostic factors in the nonoperative treatment of chronic symptomatic calcific tendinitis of the shoulder. Guidelines for optimal treatment can be implemented according to these factors to avoid a long-term symptomatic disease course.

Proximal Humeral Fracture Treatment in Adults

Most proximal humeral fractures affect elderly patients and can be treated nonoperatively with good functional outcomes.The treatment of displaced three and four-part fractures remains controversial and depends on a variety of underlying factors related to the patient (e.g., comorbidity, functional demand), the fracture (e.g., osteoporosis), and the surgeon (e.g., experience).Throughout the literature, open reduction and locking plate osteosynthesis is associated with considerable complication rates, particularly in the presence of osteoporosis.Low local bone mineral density, humeral head ischemia, residual varus displacement, insufficient restoration of the medial column, and nonanatomic reduction promote failure of fixation and impair functional outcome.The outcome of hemiarthroplasty is closely related to tuberosity healing in an anatomic position to enable the restoration of rotator cuff function. Reverse shoulder arthroplasty may provide satisfactory shoulder function in geriatric patients with preexisting rotator cuff dysfunction or after the failure of first-line treatment.

Computer Navigation in Balloon Kyphoplasty Reduces the Intraoperative Radiation Exposure

Study Design. Comparison of the dose area product (DAP), the radiation time and the operation time during computer navigated and conventional balloon kyphoplasty procedures. Objective. To compare the patients radiation exposure and operation time in a balloon kyphoplasty procedure with and without using a navigation system for the placement of working needles. Summary of Background Data. Minimal invasive spine surgery is associated with high radiation exposure for both the patient and the surgeon. The use of computer navigation has led to a reduced radiation exposure in experimental trials. To our knowledge, there is no clinical data determining the influence of computer navigation on radiation exposure and operation time in a balloon kyphoplasty procedure. Methods. Twenty-nine patients with 30 osteoporotic vertebra fractures were treated with a computer-navigated kyphoplasty. The placement of the working needles in thoracic spine fractures was performed after acquiring an intraoperative three-dimensional data set. Fractures of the lumbar spine were treated using fluoroscopic three-dimensional navigation. During each procedure the operation time, the overall radiation time, and the DAP were documented. The data of the navigated operations were compared to a control group of consisting of 30 conventional balloon kyphoplasty procedures. Results. In the conventional kyphoplasty group the average operation times for thoracic spine (ts) and lumbar spine (ls) were 61 and 57 minutes, respectively. The average radiation times were 175 and 165 seconds. The DAP applied to the patient was 1972 and 2105 cGy cm2. The average operation times in the navigated group were 67 minutes in the ts and 62 minutes in the ls. The average radiation time was reduced significantly in the navigated group (99 seconds ts and 74 seconds ls). The DAP applied to the patient was also significantly lower (1245 cGy cm2 (ts) and 1318 cGy cm2 (ls)). Conclusion. The use of computer navigation systems in balloon kyphoplasty procedures reduces the radiation exposure of patients and surgeons significantly. The increased technical effort did not lead to a significant longer operation time. Hence, the use of computer navigation systems in balloon kyphoplasty procedures is recommended.

Rotator Cuff Preservation in Arthroscopic Treatment of Calcific Tendinitis

PURPOSE We sought to evaluate (1) clinical and radiologic results after arthroscopic calcific deposit (CD) removal and (2) the relevance of remnant calcifications (RCs). METHODS The study included 102 patients undergoing arthroscopic CD removal, preserving integrity of the rotator cuff. Postoperatively, we divided patients into 2 groups according to the extent of CD removal achieved. Group 1 consisted of patients with complete CD removal. Group 2 included patients showing minor RCs. Ninety-three patients (99 shoulders) completed follow-up. The mean patient age was 50.6 years (31 to 68 years), and the mean follow-up period was 37.3 months (24 to 83 months). We obtained anteroposterior (AP) and outlet radiographs before surgery, postoperatively, and at follow-up. We used the absolute and age- and sex-related Constant scores (CSabs, CSrel) as outcome measures. We compared both groups statistically (Mann-Whitney U test; P < .05). RESULTS Complete CD removal was achieved in 82 of 99 (82.8%) shoulders (group 1). Postoperatively, minor RCs were found in 17 of 99 (17.2%) shoulders (group 2), an average of 58.6% (± 26.2) of the mean preoperative size. All RCs showed complete (14 of 17) or virtually complete (3 of 17) resolution at follow-up. Overall mean CSabs and CSrel were 88.8 points (± 10.4) and 99.0% (± 3.7), respectively. Mean values of CSabs and CSrel in group 1 (89.5 points ± 9.5 and 99.1% ± 3.7, respectively) and group 2 (86.1 points ± 12.9 and 98.7% ± 4.2, respectively) did not differ. CONCLUSIONS Arthroscopic CD removal, preserving integrity of the rotator cuff yielded good to excellent results in 90% of patients and avoided iatrogenic tendon defects in all patients. Minor RCs did not impair clinical outcome and spontaneously resolved at follow-up. LEVEL OF EVIDENCE Level IV, therapeutic case series.

In Vivo Analysis of Coracoclavicular Ligament Kinematics During Shoulder Abduction

Background: Anatomic reconstruction of the coracoclavicular ligaments for the treatment of acromioclavicular joint separations provides superior biomechanical stability compared with other procedures. Clavicular and coracoidal footprints of the conoid ligament (CL) and the trapezoid ligament (TL) are well described. So far, little is known about their kinematics and the changes of the coracoclavicular distance during shoulder abduction. Hypothesis: The coracoclavicular distance along the coracoclavicular ligaments changes significantly with shoulder abduction and weightbearing. Study Design: Descriptive laboratory study. Methods: With use of an open magnetic resonance imaging scanner, the shoulders of 13 healthy volunteers were examined in supine and sitting positions. Three-dimensional magnetic resonance images of the shoulders were obtained in 30° increments of abduction (0°-120°). A manual segmentation of the scapula, the clavicle, and the coracoclavicular ligaments was performed. The insertion points of the coracoclavicular ligaments were identified, and automated measures along the ligamentous course were carried out. Results: During transfer from the lying to sitting position, the coracoclavicular distance showed significant lengthening of 3 mm along the center of the CL, which significantly increased another 3 mm during shoulder abduction to a total lengthening of 6 mm. In the supine position, the coracoclavicular distance along the TL did not elongate significantly. In the sitting position, the distance along the medial portion of the TL shortened significantly, whereas the distance along the center portion did not elongate significantly during shoulder abduction. Conclusion: The distances between the coracoclavicular insertion points depend on both patient and shoulder positioning. To prevent overconstraining of the graft, the CL should be fixated during 90° to 120° of shoulder abduction in a sitting position. Isometric reconstruction of the TL can be achieved if precise fixation of the graft at the centers of the conoidal and clavicular footprints is performed.

A stress MRI of the shoulder for evaluation of ligamentous stabilizers in acute and chronic acromioclavicular joint instabilities

To show the feasibility of a stress magnetic resonance imaging (MRI) as a new method for simultaneous evaluation of the morphology and the functional integrity of the acromioclavicular joint (ACJ) ligamentous stabilizers.

Frakturen des Humeruskopfes

Fractures of the proximal humerus are commonly seen especially in the elderly population. High-energy trauma in young people can be distinguished from low-energy trauma in the elderly resulting from falls of a low height which are typically characterized by osteoporosis. A precise analysis of fractures is essential for a good understanding of the fracture and an individual therapy for which the LEGO-Codman classification provided by Hertel is recommended. Nonsurgical therapy is commonly performed and widely accepted not only for simple fractures. For osteosynthesis angular stable implants became the gold standard but are frequently associated with a high rate of complications some of which can be lowered by an improved surgical technique. Even today varus dislocated fractures are challenging, especially in combination with destruction of the medial column. In those cases where stable osteosynthesis can no longer be achieved arthroplasty is indicated. The clinical results of anatomic fracture arthroplasty are strongly related with correct ingrowth of the tuberosities. Reverse fracture arthroplasty may be considered but indications should be interpreted with caution and preferably used in patients older than 75 years.

Grenzen der Rekonstruktion – Prothesen

Fractures of the proximal humerus are common, particularly seen in elderly, female patients. Using open reduction and internal fixation good clinical results can be achieved in general. But even today not every problem has been solved in the treatment of proximal humeral fractures. Varus displaced fractures are particularly challenging, especially when the medial column is destroyed. Anatomical reduction of the humeral head and medial bone contact are crucial for a good surgical outcome. Otherwise a secondary varus collapse and/or an implant failure are predictable. Further challenges are the intra-articular fracture patterns, as well as fractures with an initial ischemic humeral head. The indications for prosthetic replacement are always present if an initially stable internal fixation could not be achieved. The reverse fracture prostheses represent an increasingly common treatment option; however, the indication should be reserved for the elderly over 75 years.

Brain parenchymal TNF-α and IL-1β induction in experimental pneumococcal meningitis

Triggers of brain inflammation in pneumococcal meningitis are unknown. TNF-α and IL-1β were upregulated (real time PCR and in situ hybridization) in neurons and astrocytes time-dependently and maximally in the hippocampus during murine pneumococcal meningitis. Upregulation of TNF-α and IL-1β mRNA in the brain parenchyma was independent of cerebrospinal fluid leukocytosis, pneumococcal pneumolysin and H2O2, but it was potently induced by pneumococcal cell wall (PCW) fragments. Brain TNF-α mRNA was downregulated by a matrix metalloproteinases inhibitor. PCW fragments were located in the brain parenchyma. In conclusion, PCW fragments and matrix metalloproteinases trigger cytokine induction in the brain parenchyma during pneumococcal meningitis.

[Limitations of reconstruction - prostheses].

Fractures of the proximal humerus are common, particularly seen in elderly, female patients. Using open reduction and internal fixation good clinical results can be achieved in general. But even today not every problem has been solved in the treatment of proximal humeral fractures. Varus displaced fractures are particularly challenging, especially when the medial column is destroyed. Anatomical reduction of the humeral head and medial bone contact are crucial for a good surgical outcome. Otherwise a secondary varus collapse and/or an implant failure are predictable. Further challenges are the intra-articular fracture patterns, as well as fractures with an initial ischemic humeral head. The indications for prosthetic replacement are always present if an initially stable internal fixation could not be achieved. The reverse fracture prostheses represent an increasingly common treatment option; however, the indication should be reserved for the elderly over 75 years.