Peter Ogon

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.

Biceps Tenoscopy in Arthroscopic Treatment of Primary Synovial Chondromatosis of the Shoulder

Primary synovial chondromatosis (PSC) of the shoulder is a rare condition and usually necessitates operative therapy. Arthroscopic partial synovectomy with removal of loose osteochondromas may be regarded as the current surgical treatment of choice. However, involvement of the biceps tendon sheath (BTS) occurs in almost half of the patients and required additional open surgery in all previously reported cases. We successfully performed tenoscopy of the BTS and long head of the biceps tendon during arthroscopic treatment of PSC in a 26-year-old male competitive wrestler. Biceps tenoscopy enabled minimally invasive partial (teno)synovectomy and removal of all osteochondromas within the BTS. The symptoms of PSC fully subsided within 2 postoperative weeks. There were no functional restrictions at the 3-month follow-up examination. These preliminary results support the feasibility, safety, and efficacy of biceps tenoscopy as a complement in arthroscopic treatment of PSC of the shoulder, dispensing with the need for additional open surgery. The spectrum of indications for biceps tenoscopy has still to be defined. Conceivable indications are proposed. This first report of a diagnostic and interventional biceps tenoscopy entails a detailed step-by-step description of the surgical technique.

Tenoscopic Suprapectoral Biceps Tenodesis

Existing arthroscopic techniques of proximal biceps tenodesis may be complicated by difficulty of tendon identification, restoration of length-tension relation, cosmetic deformity, persistent biceps pain, and shoulder stiffness requiring surgical revision in a relevant proportion of cases. In this context, biceps tenoscopy, an emerging discipline of shoulder endoscopy, offers major benefits. Tenoscopy comprises endoscopic treatment of tendons and tendon sheaths. The presented technique of tenoscopic suprapectoral biceps tenodesis (TSBT) substantially facilitates tendon identification and reduces invasiveness by avoidance of unnecessary surgical involvement of the deltoid space and bursa. TSBT enables effective treatment of the biceps tendon and surrounding tissues (biceps tendon sheath, tenosynovium, transverse humeral ligament) being consistently involved in proximal biceps pathologies. The physiological length-tension relation of the musculotendinous unit is reliably maintained. Technically, the procedure of tenodesis is simplified and accelerated by redundancy of tendon exteriorization. The aforementioned benefits of TSBT may lead to superior clinical and cosmetic outcomes and lower incidences of persistent proximal biceps pain and postoperative shoulder stiffness compared with conventional techniques of arthroscopic biceps tenodesis.

Preoperative planning of calcium deposit removal in calcifying tendinitis of the rotator cuff - possible contribution of computed tomography, ultrasound and conventional X-Ray

BackgroundThe purpose of the present study was to investigate the accuracy of Ultrasound (US), conventional X-Ray (CX) and Computed Tomography (CT) to estimate the total count, localization, morphology and consistency of Calcium deposits (CDs) in the rotator cuff.MethodsUS, CX and CT imaging was performed pre-operatively in 151 patients who underwent arthroscopic removal of CDs in the rotator cuff. In all procedures: (1) total CD counts were determined, (2) the CDs appearance in each image modality was correlated to the intraoperative consistency and (3) CDs were localized in their relation to the acromion using US, CX and CT.ResultsUsing US158 CDs, using CT 188 CDs and using CX 164 CDs were identified. Reliable localization of the CDs was possible with all used diagnostic modalities. CT revealed 49% of the CDs to be septated, out of which 85% were uni- and 15% multiseptated. CX was not suitable for prediction of CDs consistency. US reliably predicted viscous-solid CDs consistency only when presenting with full sound extinction (PPV 84.6%) . CT had high positive and negative predictive values for detection of liquid-soft (PPV 92.9%) and viscous-solid (PPV 87.8%) CDs.ConclusionUS and CX are sufficient for preoperative planning of CD removal with regards to localization and prediction of consistency if the deposits present with full sound extinction. This is the case in the majority of the patients. However, in patients with missing sound extinction CT can be recommended if CDs consistency of the deposits should be determined. Satellite deposits or septations are regularly present, which is of importance if complete CD removal is aspired.

Arthroscopic Treatment of Calcific Tendinitis of the Shoulder: Letter to the Editor

Dear Editor: The recently published article ‘‘Calcifying Tendinitis of the Shoulder: Midterm Results After Arthroscopic Treatment’’ by Balke et al contains methodological and content-related issues requiring more detailed reflection and discussion. Also, in consideration of available knowledge about pathogenesis, prognosis, and results of arthroscopic treatment, some of the results and suggested conclusions need to be put into perspective. The authors present a retrospective study including 62 patients (70 shoulders) who underwent arthroscopic removal of calcific deposits. Surgeries were performed from 2000 to 2007. The number of involved surgeons remains unclear. They incised the rotator cuff over the deposit and removed it with a full radius resector and curettes. This technique inevitably involves substantial damage to the rotator cuff tendon, particularly when aiming for complete deposit removal. The authors do not further specify whether and how they controlled the extent of resection. This implies a considerable performance bias (type II error), which even increases with the number of involved surgeons. An aim of the study was to assess the development of rotator cuff tears. In this respect, ultrasound examinations of 48 shoulders were performed after a mean follow-up of 6 years (range, 2-13 years), corresponding to a follow-up rate of 69%. Presence of a partial rotator cuff tear was assumed when sonography showed fluid within the tendon or thinning of the tendon of more than 50%. Since the described technique of calcific deposit removal causes damage to the rotator cuff tendon, it appears more than likely that such lesions were falsely rated as degenerative rotator cuff tears at follow-up. This methodological problem could have been adequately addressed by comparison with ultrasound examinations obtained in the early postoperative phase shortly after remission of postoperative artifacts. Additional subacromial decompression was performed in 44 of 70 shoulders (63%) with type II and III acromion shapes according to Bigliani, which showed fraying of the coracoacromial ligament or erosions of the undersurface of the acromion. The subitem pain of the Constant score was significantly better in the decompression group (11.4 points compared with 12.9 points; P = .048). The authors concluded that subacromial decompression reduces postoperative pain. This conclusion needs to be questioned for several reasons. Most importantly, evaluation of the value of additional acromioplasty in arthroscopic treatment of calcifying tendinitis requires a prospective, randomized, controlled study design. Seil et al incised the rotator cuff over the deposit and then expressed the calcific deposit with blunt instruments. Subacromial decompression was indicated if signs of mechanical irritation were apparent on the undersurface of the acromion or if the calcific deposit could not be completely removed without creating major damage to the tendon. This was only the case in 6 of 58 (10.3%) patients. The mean Constant score was 90.9 points at 24-month follow-up. Others also reported excellent clinical outcomes in approximately 90% of their cases regardless of additional subacromial decompression. Calcific deposits with medial localization related to the acromion are more likely to require surgery because of chronic symptomatic nonoutlet impingement. All this supports the estimation that subacromial decompression does not represent a causative treatment of symptomatic rotator cuff calcifications. Balke et al do not adequately question that the reported clinical outcome (mean Constant score, 76.2 points) was considerably inferior compared with that found in the literature. The operative technique might have been a possible cause, as sharp excision of a calcific deposit inevitably results in a rotator cuff lesion. This is particularly true for large, solid deposits. However, the authors neither specified sizes nor consistencies of the surgically addressed deposits. At follow-up, relevant partial rotator cuff tears were sonographically detected in 11 of 48 (23%) of the operated shoulders and in only 3 of 48 (6%) of the contralateral shoulders. On the contrary, Seil et al found no relevant partial rotator cuff tears after blunt calcific deposit removal. It is a considerable drawback that the relevance of residual calcifications has been discounted. The wide range of followup (2-13 years) involves a potential selection bias (type I error) because some of the residual calcifications might have resolved in the interim while others might have not. The study should have reported on surgical complications.

Arthroscopic Removal of Chronic Symptomatic Calcifications of the Supraspinatus Tendon Without Acromioplasty Analysis of Postoperative Recovery and Outcome Factors

Background: Little knowledge exists on postoperative recovery of pain and shoulder function following arthroscopic removal of calcific deposits of the supraspinatus tendon (ACDSSP). Certain factors may influence outcome, including acromial morphology. Purpose: To examine postoperative recovery following ACDSSP without acromioplasty and to analyze influential outcome factors. Study Design: Case series; Level of evidence, 4. Methods: This prospective study evaluated 82 patients (105 shoulders) after ACDSSP without acromioplasty. Time periods for postoperative recovery of pain and subjective shoulder function were recorded. The absolute and normalized Constant scores (CSabs and CSnorm, respectively), Oxford Shoulder Score (OSS), DASH score (DS), and subjective shoulder value (SSV) were measured after a mean follow-up of 33.9 months. Analyzed outcome factors included localization of the calcific deposit (CD), acromial morphology, radiographic extent of CD removal, type of nonoperative treatment, and preoperative duration of symptoms. Results: Mean duration of postoperative pain was 2.2 weeks. Recovery of subjective shoulder function required 11.1 weeks on average. Mean ± standard deviation follow-up values were 91.1 ± 8.3 for CSabs, 104.2% ± 8.2% for CSnorm, 13.1 ± 2.6 for OSS, 1.81 ± 4.59 for DS, and 93.8% ± 10.7% for SSV. Abduction was significantly (P = .008) lower in patients with type III (170° ± 17.5°) compared with type I (174° ± 20.7°) and type II (179° ± 4.5°) acromions. Also, abduction was significantly (P = .001) lower in patients with long-standing symptoms (>72 months). Minor calcific remnants were found in 19 of 105 shoulders (18.1%), but affected neither postoperative recovery nor outcome. Conclusion: ACDSSP without acromioplasty yielded favorable outcomes and effected fast remission of pain regardless of acromial morphology. However, recovery of subjective shoulder function required almost 3 months on average. Minimal restriction of abduction occurred in patients with hook-shaped acromions and long-standing preoperative symptoms. The present data do not support routine performance of acromioplasty.

Examination of concomitant glenohumeral pathologies in patients treated arthroscopically for calcific tendinitis of the shoulder and implications for routine diagnostic joint exploration

BackgroundGlenohumeral exploration is routinely performed during arthroscopic removal of rotator cuff calcifications in patients with calcific tendinitis of the shoulder (CTS). However, evidence on the prevalence of intraarticular co-pathologies is lacking and the benefit of glenohumeral exploration remains elusive. The aim of the present study was to assess and quantify intraoperative pathologies during arthroscopic removal of rotator cuff calcifications in order to determine whether standardized diagnostic glenohumeral exploration appears justified in CTS patients.MethodsOne hundred forty five patients undergoing arthroscopic removal of calcific depots (CD) that failed conservative treatment were included in a retrospective cohort study. Radiographic parameters including number/localization of calcifications and acromial types, intraoperative arthroscopic findings such as configuration of glenohumeral ligaments, articular cartilage injuries, and characteristics of calcifications and sonographic parameters (characteristics/localization of calcification) were recorded.ResultsOne hundred forty five patients were analyzed. All CDs were removed by elimination with a blunt hook probe via “squeeze-and-stir-technique” assessed postoperatively via conventional X-rays. Neither subacromial decompression nor refixation of the rotator cuff were performed in any patient. Prevalence of glenohumeral co-pathologies, such as partial tears of the proximal biceps tendon (2.1%), superior labral tears from anterior to posterior (SLAP) lesions (1.4%), and/or partial rotator cuff tears (0.7%) was low. Most frequently, glenohumeral articular cartilage was either entirely intact (ICRS grade 0 (humeral head/glenoid): 46%/48%) or showed very mild degenerative changes (ICRS grade 1: 30%/26%). Two patients (1.3%) required intraarticular surgical treatment due to a SLAP lesion type III (n = 1) and an intraarticular rupture of CD (n = 1).ConclusionsRoutine diagnostic glenohumeral exploration does not appear beneficial in arthroscopic treatment of CTS due to the low prevalence of intraarticular pathologies which most frequently do not require surgical treatment. Exploration of the glenohumeral joint in arthroscopic removal of CD should only be performed in case of founded suspicion of relevant concomitant intraarticular pathologies.

Planung und Vorbereitung bei Frakturen und degenerativen Erkrankungen im Bereich des Schultergürtels

Fur die erfolgreiche Durchfuhrung eines operativen Eingriffs ist eine genaue und vollstandige praoperative Planung unerlasslich. Im folgenden Artikel wird diese Planung im Bereich des Schultergurtels erortert. Dabei werden besonders die Humeruskopffraktur, die Luxation des Schultereckgelenks, die Klavikulafraktur, die Skapulafraktur mit besonderer Berucksichtigung der Glenoidfrakturen sowie die Omarthrose besprochen. Der Planungsalgorithmus umfasst die Diagnostik der Verletzung respektive Erkrankung, die sich anhand von Klassifikationen entsprechend kategorisieren lasst und zur Therapieentscheidung fuhrt. Im Rahmen einer operativen Behandlung sind Operationszeitpunkt, Lagerung des Patienten, Operationszugang und die Implantatwahl sorgfaltig zu wahlen. Dieses ist mit allen an der Versorgung des Patienten beteiligten Berufsgruppen vor der Operation abzusprechen, um einen optimalen Behandlungsablauf zu gewahrleisten.