Maurice Balke

High complication rate following distal biceps refixation with cortical button.

PurposeThere are several methods for the refixation of the distal biceps tendon which show a variable complication rate. The aim of the present study was to evaluate the clinical outcome and complication rate after distal biceps repair in cortical button technique.MethodsClinical results, complications, strength of elbow flexion and supination and radiological evidence of heterotopic ossification in patients reporting persistent pain were evaluated in 27 male patients after an average of 36.1xa0month following distal biceps tendon repair in cortical button technique.ResultsThe mean Mayo elbow performance score was 95.9 (SD 11.9), the mean disabilities of the arm, shoulder and hand score was 1.9 (SD 4.9) and the mean American shoulder and elbow surgeons (ASES) score was 94.6 (SD 11.6). The mean flexion and supination strength of the involved side relative to the uninvolved side was 91.7xa0% (SD 12.6) and 87.8xa0% (SD 15.9). Nine patients had 14 different complications including four transient lesions of the posterior interosseous nerve, two persistent lesions of the superficial branch of the radial nerve, one symptomatic massive heterotopic ossification and one disengaged cortical button. Three patients had six revisions. Patients with complications had a significantly lower relative supination strength, Mayo elbow performance score, ASES score, pain on VAS (pxa0<xa00.05 each) and satisfaction (pxa0=xa00.005).ConclusionsAs described for other techniques there is a high complication rate of distal biceps tendon repair in cortical button technique which resulted in inferior functional results and satisfaction. Surgeons treating patients with distal biceps tendon rupture should know the specific complications and know how to avoid them.Level of evidenceCase series with no comparison group, Level IV.

Inter- and intraobserver reliability of the Rockwood classification in acute acromioclavicular joint dislocations.

PurposeThe reliability of the Rockwood classification, the gold standard for acute acromioclavicular (AC) joint separations, has not yet been tested. The purpose of this study was to investigate the reliability of visual and measured AC joint lesion grades according to the Rockwood classification.MethodsFour investigators (two shoulder specialists and two second-year residents) examined radiographs (bilateral panoramic stress and axial views) in 58 patients and graded the injury according to the Rockwood classification using the following sequence: (1) visual classification of the AC joint lesion, (2) digital measurement of the coracoclavicular distance (CCD) and the horizontal dislocation (HD) with Osirix Dicom Viewer (Pixmeo, Switzerland), (3) classification of the AC joint lesion according to the measurements and (4) repetition of (1) and (2) after repeated anonymization by an independent physician. Visual and measured Rockwood grades as well as the CCD and HD of every patient were documented, and a CC index was calculated (CCD injured/CCD healthy). All records were then used to evaluate intra- and interobserver reliability.ResultsThe disagreement between visual and measured diagnosis ranged from 6.9 to 27.6xa0%. Interobserver reliability for visual diagnosis was good (0.72–0.74) and excellent (0.85–0.93) for measured Rockwood grades. Intraobserver reliability was good to excellent (0.67–0.93) for visual diagnosis and excellent for measured diagnosis (0.90–0.97). The correlations between measurements of the axial view varied from 0.68 to 0.98 (good to excellent) for interobserver reliability and from 0.90 to 0.97 (excellent) for intraobserver reliability.ConclusionBilateral panoramic stress and axial radiographs are reliable examinations for grading AC joint injuries according to Rockwood’s classification. Clinicians of all experience levels can precisely classify AC joint lesions according to the Rockwood classification. We recommend to grade acute ACG lesions by performing a digital measurement instead of a sole visual diagnosis because of the higher intra- and interobserver reliability.Level of evidenceCase series, Level IV.

Tumor grafts derived from sarcoma patients retain tumor morphology, viability, and invasion potential and indicate disease outcomes in the chick chorioallantoic membrane model

The chick chorioallantoic membrane (CAM) assay was used to evaluate whether xenotransplanted sarcomas retain the histological characteristics and functional behavior of the original tumors. Metabolically active tumor tissue, identified by dynamic-contrast MRI, from 28 patients with a bone or soft-tissue tumors was applied to the CAM. Angiogenesis and graft and host behaviors were evaluated. The essential features and immunohistochemical characteristics of the original tumors were maintained, illustrating the diversity of sarcomas. Graft viability was inversely related to patient survival, but longer follow-up and more patients are needed to relate tumor graft behavior to natural history. We conclude that the CAM assay is a potential prognostic and predictive preclinical xenograft model for tumors that are difficult to culture in vitro, such as sarcomas; therefore, the use of the CAM assay may facilitate personalized medicine.

The laser-pointer assisted angle reproduction test for evaluation of proprioceptive shoulder function in patients with instability.

IntroductionOver the last decade, proprioceptive function gained increasing attention in joint disorders such as instability of the shoulder. Common tests for evaluation of proprioception are limited by their complexity and high technical demands. Thus, they are hardly applicable during daily routine. Our hypothesis was that the simplified “laser-pointer assisted angle reproduction test” (LP-ART) presented here allows for clinically feasible assessment of proprioceptive shoulder function.MethodsActive angle reproduction capability as an aspect of sensorimotor function was evaluated with the new method in patients with shoulder instability (nxa0=xa024) and healthy controls (nxa0=xa024). 15 patients had traumatic, 9 non-traumatic anterior instability (6 bilateral), 17 were treated surgically, 13 non-operatively. Tests were performed in flexion and abduction in different angles (55°, 90°, 125°) in randomized order.ResultsAngle reproduction capability was worst below shoulder level (55°) in all groups. Best results were achieved at shoulder level (90°). Healthy controls showed overall better results than patients with instability. Patients after surgical stabilization had better results in 55° and 90° abduction compared to instability patients before surgery.ConclusionsThe new LP-ART presented here is a technically simple, yet effective instrument for evaluation of the proprioceptive function of the shoulder. In contrast to former test setups it is feasible in daily routine. Compared to healthy controls, patients with unstable shoulder joints show significant proprioceptive disorders that can be quantified by the LP-ART.

Excellent results of lesser tuberosity transfer in acute locked posterior shoulder dislocation

PurposeThe aim of the present study was to evaluate the clinical and radiological results of lesser tuberosity transfer in acute locked posterior shoulder dislocation with a humeral head defect between 25 and 45xa0%.MethodsClinical and radiological results of seven patients with locked posterior shoulder dislocation with a humeral head defect between 25 and 45xa0% which were managed with a modification of the McLaughlin procedure within 14xa0days after injury were evaluated retrospectively after a mean follow-up of 41xa0months.ResultsAll shoulders remained stable. The results were good in one and excellent in six patients with a median absolute Constant score of 92 (range 80–98). Mean active pain-free abduction was 171.4° (SD 6.4), mean flexion was 175.7° (SD 4.9), and mean external rotation was 54.3° (SD 17.6). Internal rotation was restricted in all patients. There were no radiological signs of osteoarthritis.ConclusionsLesser tuberosity transfer shows excellent clinical and radiographic mid-term results in acute cases of locked posterior shoulder dislocation with a reverse Hill-Sachs lesion between 25 and 45xa0%.Level of evidenceCase series with no comparison group, Level IV.

Management of shoulder instability: the current state of treatment among German orthopaedic surgeons

IntroductionThe aim of this study was to evaluate the current state of treatment in traumatic anterior shoulder dislocation in Germany and to detect changes over the last 12xa0years.MethodsSeven hundred ninety-six trauma and/or orthopaedic departments were found in the German hospital directory 2012. The websites of each department were searched for the email address of the responsible shoulder surgeon (if applicable) or the head of the department. Seven hundred forty-six email addresses were found, and emails with the request to participate in an online survey were sent in January 2013. Six hundred seventy-five emails probably reached the correct addressee. Seventy-one emails were rejected, and no contact could be made. One-hundred ninety-one (28xa0%) participated in the study. The data were compared to similar data from a survey on shoulder dislocation performed in the same department and published in 2001.ResultsAfter the first-time traumatic shoulder dislocation in patients aged younger than 30xa0years participating in sports, 14xa0% of the participants would prefer conservative treatment, 83xa0% arthroscopic, and 3xa0% open surgery. When surgery was indicated, arthroscopic Bankart repair was the treatment of choice for 93xa0% of the participants. In 2001, 27xa0% had indicated conservative treatment after the first-time shoulder dislocation in active patients younger than 30xa0years. When surgery was indicated, 66xa0% had performed arthroscopic and 34xa0% open stabilization. For the standard arthroscopic Bankart repair without concomitant injuries, 41xa0% of the participants use two and 54xa0% three suture anchors. Knotless anchors were preferred by 72xa0%. In the case of glenoid bone loss greater than 25xa0%, only 46xa0% perform a procedure for glenoid bone augmentation. Fifteen percent of the participants always recommended immobilization in external rotation after traumatic first-time shoulder dislocation.ConclusionsThe majority of participants recommend arthroscopic Bankart repair with two or three suture anchors in young persons with the first-time dislocations. Compared to 2001 less recommend conservative treatment, complex “open” surgical procedures are no longer used. The knowledge that a Bankart procedure likely fails in significant glenoid bone loss is not implemented in the clinical practice. Thus, there is a need to educate surgeons on this topic.

Soft tissue injury of the shoulder after single non-dislocating trauma: prevalence and spectrum of intraoperative findings during shoulder arthroscopy and treatment results

Background and purposeThe purpose of our study was to present the spectrum and prevalence of intraarticular lesions in patients with shoulder pain after a single non-dislocating shoulder trauma and to evaluate the clinical results according to pathology and workers’ compensation status.MethodsSixty consecutive patients (61 shoulders) with shoulder pain following a single non-dislocating shoulder trauma had shoulder arthroscopy. The indication for surgery was either persistent pain for 3xa0months or longer after trauma and/or an intraarticular lesion on MRI. Patients with history of shoulder complaints, previous shoulder surgery, a complete rotator cuff tear or a fracture of the shoulder girdle were excluded. Intraarticular findings during shoulder arthroscopy were retrospectively analyzed. After a minimum follow-up of 1xa0year patients were contacted by telephone interview and ASES score, Simple Shoulder Test, Subjective Shoulder Value and residual pain were assessed for the entire population and for patients with and without workers’ compensation.ResultsThe most common intraarticular findings were SLAP (44.3xa0%) and Pulley (19.7xa0%) lesions followed by lesions of the anterior or posterior labrum (14.8xa0%). The mean age of the 13 women and 47 men was 41.9xa0years (SD 10.9). Patients with workers’ compensation had significantly lower scores than patients without and had a significantly lower return to work rate than patients without.InterpretationIn patients with persistent shoulder pain after sprain or contusion arthroscopy revealed a broad spectrum of intraarticular findings. Patients with workers’ compensation claims had worse results than those without.Level of evidenceCase series (Level IV).

Low inter- and intraobserver variability allows for reliable tunnel measurement in ACL reconstruction using the quadrant method.

IntroductionCorrect anatomic tunnel positions are essential in anterior cruciate ligament (ACL) reconstruction. To establish recommendations for tunnel positioning based on anatomical findings and to compare tunnel positions with clinical results, different radiological measurement methods as the quadrant method exist. Comparing the data of different observers requires the validation of the reliability of measurement methods. The purpose of this study therefore was to determine the reliability of the quadrant method to measure tunnel positions in ACL reconstruction. The hypothesis was, that the quadrant method shows a low inter- and intraobserver variability.Materials and methodsIn a test/retest scenario 20 knee surgeons were asked to determine defined tunnel positions in five lateral radiographs applying the quadrant method. Rotation, angle deviation, height and depth of the quadrant as well as absolute and relative tunnel positions of each observation were measured along referenced scales. Mean sizes and angle deviations of the quadrants, tunnel positions and deviations between the test/retest positions were calculated as well as standard deviations and range.ResultsInterobserver variability analyses, to plan as well as to determine tunnel positions in ACL reconstruction, showed a mean variability (SD) ofxa0<1xa0mm, with ranges of 2.5xa0mm for planning and 3.7xa0mm for determination of tunnel positions using the quadrant method. Intraobserver analysis showed mean variability with deviations ofxa0<1xa0mm and maximum standard deviations of 0.7xa0mm and ranges of up to 2.3xa0mm.ConclusionsWe confirmed the hypothesis that the quadrant method has a low inter- and intraobserver variability. Based on the presented validation data, the quadrant method can be recommended as reliable method to radiographically describe insertion areas of the ACL as well as to determine tunnel positions in ACL reconstruction intra and postoperatively.

Variability of landmark acquisition affects tunnel calculation in image-free ACL navigation

PurposeThe purpose of this study was to determine the inter- and intraobserver variability of intraarticular landmark identification for tunnel position calculation in image-free anterior cruciate ligament (ACL) navigation.MethodsIn a test/retest scenario, thirteen experienced ACL surgeons (>50 reconstructions year) experienced in image-free ACL navigation were asked to identify the landmarks required for image-free ACL navigation in the same cadaver knee. Landmark positions were registered using a fluoroscopic ACL navigation system. Positions were determined using validated radiological measurement methods. For variability analysis, mean positions, deviations between the test/retest positions, standard deviations (SD) and range were calculated.ResultsInterobserver analysis showed a mean variability (SD) for the tibial landmark positions of 3.0xa0mm with deviations of up to 24.3xa0mm (range). Mean femoral landmark variability was 2.9xa0mm (SD) with deviations of up to 11.3xa0mm (range). Intraobserver analysis showed a tibial reproducibility of 2.2xa0mm (SD 2.0xa0mm; range 10.9xa0mm) and a femoral of 1.9xa0mm (SD 1.9xa0mm; range 10.4xa0mm).ConclusionThe data of the presented study suggest that a considerable inter- and intraobserver variability in intraarticular landmark identification exists. Reasonable ranges were found that have to be considered as a potential risk for miscalculation of tunnel positions in image-free ACL reconstruction.Clinical relevanceLandmark acquisition affects tunnel calculation in image-free ACL.Level of evidenceIV.

Variability of tunnel positioning in ACL reconstruction

AbstractIntroductionSince tunnel positioning isn one of the key factors in anterior cruciate ligament (ACL) reconstruction and the variability of tunnel positioning in ACL reconstruction has so far never been analyzed, the objective of this study was to determine the inter- and intra-observer variability of tibial and femoral tunnel positioning in ACL reconstruction.Materials and methodsIn an operating room setup, 13 surgeons were asked to identify the tunnel positions in one and the same ACL-deficient cadaver knee. Using a fluoroscopic based ACL navigation system, tunnel positions were digitally measured in a test/re-test scenario. For variability analysis mean positions, standard deviations and range were calculated as well as differences between test/re-test positions.ResultsThe intraobserver analysis showed a tibial variability of 3.3xa0mm (SD 2.1, range 7.5xa0mm) and a femoral variability of 2.0xa0mm (SD 1.6xa0mm, range 6.8xa0mm). The interobserver variability of the tibial tunnel positions was 3.2xa0mm (SD) with a range of 18.3xa0mm and a femoral variability of 3.7xa0mm (SD) with a range of 13.2xa0mm.ConclusionsThis study demonstrates that a reasonable inter- and intra-observer variability in ACL tunnel positioning exists even among experienced surgeons. Although deviations of 2–3xa0mm may seem to be acceptable at first sight, a range of up to 18.3xa0mm indicates that outliers exist, which can cause graft failure. More reliable reconstruction techniques should be developed to reduce the variability in tunnel positioning.