Martin Jaeger

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.

Stabilization of the long head of the biceps tendon in the context of early repair of traumatic subscapularis tendon tears.

BACKGROUND Tears of the subscapularis tendon commonly are associated with instability of the long head of the biceps tendon. Standard surgical treatment includes tenodesis or tenotomy of the biceps tendon. However, chronic discomfort from spasms and cosmetic disadvantages have been reported following both procedures, while the potential for functional impairments remains controversial. We investigated the outcome of stabilization of the long head of the biceps tendon in the context of early repair of traumatic tears of the subscapularis tendon. METHODS We performed stabilization of an unstable, structurally intact long head of the biceps tendon in twenty-one patients in the acute phase after a traumatic tear of the subscapularis tendon. The average period from the injury to the surgery was 6.2 weeks. Open tendon stabilization and subscapularis reconstruction were performed with transosseous sutures. The follow-up consisted of clinical examination (with determination of the absolute, age and gender-related, and individual relative Constant scores; clinical evaluation of the long head of the biceps; and subjective determination of shoulder function) and dynamic ultrasound examination. RESULTS The average follow-up period was 28.4 months. The mean absolute Constant score increased from 26.3 points preoperatively to 79.3 points postoperatively (p < 0.01). The mean age and gender-related Constant score improved from 28.0% to 87.0% (p < 0.01). Seven patients showed clinical symptoms consistent with mild biceps tendinopathy. Using dynamic ultrasound examination, we found two cases of recurrent instability (medial subluxation) of the long head of the biceps tendon. Secondary rupture of the long head of the biceps tendon occurred in one patient, twenty-six months after the surgery. CONCLUSIONS The functional outcomes of stabilization of the long head of the biceps tendon in the context of early repair of a traumatic tear of the subscapularis tendon were comparable with the results of tenodesis or tenotomy reported in previous studies. The cosmetic results were superior, and chronic discomfort from spasms was not observed. Stabilization of the tendon of the long head of the biceps can be recommended as a treatment option for selected patients and should be discussed as an alternative to tenodesis or tenotomy, particularly in a young patient.

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.

Flexible fixation and fracture healing: do locked plating 'internal fixators' resemble external fixators?

External and internal fixators use bone screws that are locked to a plate or bar to prevent periosteal compression and associated impairment of blood supply. Both osteosynthesis techniques rely on secondary bone healing with callus formation with the exception of compression plating of simple, noncomminuted fractures. External fixation uses external bars for stabilization, whereas internal fixation is realized by subcutaneous placement of locking plates. Both of these “biologic” osteosynthesis methods allow a minimally invasive approach and do not compromise fracture hematoma and periosteal blood supply. Despite these similarities, differences between the two fixation methods prevail. Locked plating “internal fixators” allow a combination of biomechanical principles such as buttressing and dynamic compression. Periarticular locking plates are anatomically contoured to facilitate fixation of articular fractures. They allow for subchondral stabilization using small-diameter angular stable screws as well as buttressing of the joint and the metaphyseal component of a fracture. Biomechanically, they can be far stiffer than external fixators, because subcutaneous plates are located much closer to the bone surface than external fixator bars. External fixators have the advantage of being less expensive, highly flexible, and technically less demanding. They remain an integral part of orthopaedic surgery for emergent stabilization, for pediatric fractures, for definitive osteosynthesis in certain indications such as distal radius fractures, and for callus distraction.

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.

Focussed classification of scapula fractures: failure of the lateral scapula suspension system.

INTRODUCTION Following an increase in the incidence of scapular fractures and interest in the outcome of their treatment, a basic classification system was developed for ease of use in the emergency setting. It has been expanded to a comprehensive system to allow for more in-depth classification of scapular fractures for clinical research and surgical decision making. It focusses on three specific regions of the scapula: the scapular body, the glenoid fossa and the lateral scapular suspension system (LSSS). This article presents a classification of the LSSS involvement to better characterise the injuries of this region and to emphasise its relevance to evaluation of the position of the scapula, hence the glenoid fossa, and so the centre of rotation of the shoulder joint. METHODS An iterative consensus and evaluation process comprising an international group of seven experienced shoulder specialist and orthopaedic trauma surgeons was used to specify and evaluate the failure of the LSSS associated with scapula fractures. This was supported by a series of agreement studies. The system considered lack of involvement (S0), incomplete (S1) and complete (S2) failure of the LSSS. The last evaluation was conducted on a consecutive collection of 120 scapula fractures documented by three-dimensional computed tomography (3D CT) reconstruction videos. RESULTS Surgeons agreed on the involvement/failure of the LSSS in 47% of the 120 cases with an overall Kappa of 0.54. The sample most likely included 70 S0, 29 S1 and 21 S2 cases, where surgeons showed median classification accuracies of 93%, 71% and 80% for these categories, respectively. While two surgeons showed some uncertainty about their classification, the remaining surgeons only failed to identify LSSS failure in <20% of the cases. Kappa coefficients of reliability for classification of incomplete and complete LSSS involvement according to subcategories were 0.85 and 0.82, respectively. CONCLUSION While LSSS involvement can be reliably identified, its characterisation regarding complexity is problematic even with 3D CT images. The proposed LSSS system is considered clinically relevant and sufficient to further assess its role in treatment-decision processes and outcome prognosis.

Fractures of the humerus head

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.