R. W. Fremerey

Outcome after primary and secondary hemiarthroplasty in elderly patients with fractures of the proximal humerus

Thirty-nine consecutive patients with 3- and 4-part proximal humeral fractures and fracture dislocations were treated with hemiarthroplasty. After an average of 42 months (range 5 to 98 months) of follow-up, 17 women and 8 men (average age 64.5 years) were evaluated with the University of California-Los Angeles (UCLA) scale, the Constant-Murley scale, the Hospital for Special Surgery (HSS) scale, and the visual analogue scale. Fair, good, or excellent results were achieved in 80% of the patients on the UCLA and Visual scales, in 72% of the patients on the HSS scale, and in 44% of the patients on the Constant-Murley scale. The highest correlation was between the HSS score and the Visual analogue score. According to the UCLA and Constant-Murley results, the outcome after early (<4 weeks) humeral head replacement was significantly better than after late (> or =4 weeks) humeral head replacement (UCLA score, P=.02; Constant-Murley score, P=.01). After early hemiarthroplasty active forward flexion was significantly better (P=.035). Thus the decision to perform prosthetic humeral head replacement in elderly patients should be made as early as possible after trauma.

Proprioception after rehabilitation and reconstruction in knees with deficiency of the anterior cruciate ligament : a prospective, longitudinal study

We assessed proprioception in the knee using the angle reproduction test in 20 healthy volunteers, ten patients with acute anterior instability and 20 patients with chronic anterior instability after reconstruction of the anterior cruciate ligament (ACL). In addition, the Lysholm-knee score, ligament laxity and patient satisfaction were determined. Acute trauma causes extensive damage to proprioception which is not restored by rehabilitation alone. Three months after operation, there remained a slight decrease in proprioception compared with the preoperative recordings, but six months after reconstruction, restoration of proprioception was seen near full extension and full flexion. In the mid-range position, proprioception was not restored. At follow-up, 3.7 +/- 0.3 years after reconstruction, there was further improvement of proprioception in the mid-range position. There was no difference between open and arthroscopic techniques. The highest correlation was found between proprioception and patient satisfaction. After reconstruction of the ACL reduced proprioception may explain the poor functional outcome in some patients, despite restoration of mechanical stability.

Outcome analysis following open rotator cuff repair. Early effectiveness validated using four different shoulder assessment scales.

Abstract Evaluation of upper extremity function after reconstructive surgery is increasingly important both to predict outcome and for the control of cost-effectiveness. Three validated, self-administered shoulder questionnaires were applied prospectively in 23 otherwise healthy patients with rotator cuff deficiency and correlated to the Constant-Murley Shoulder Score and a visual analogue scale for satisfaction. Seven women and 16 men with combined tears of supraspinatus and infraspinatus (mean age 55.3 ± 10.5 years, r/l: 14/9, follow-up 57.8 ± 15.7 weeks) were gathered prospectively and evaluated pre- and postoperatively with the American Shoulder and Elbow Surgeons (ASES) Shoulder Index, the Simple Shoulder Test (SST) and the Disabilities of the Arm, Shoulder and Hand Module (DASH questionnaire). Additionally, a visual analogue scale for satisfaction was employed. All four scores and the visual analogue scale revealed improvement at a statistically significant level (P < 0.01) after surgery. All questionnaires showed a significant correlation with the Constant-Murley Shoulder Score (ASES: r = 0.871, P < 0.01; DASH: r = –0.758, P < 0.01, SST: r = 0.494, P < 0.05, Pearson’s correlation coefficient). Taken together, all questionnaires were easy to apply, and reliable evaluation of shoulder function was possible with significant correlation to the Constant-Murley Shoulder Score postoperatively. The SST was easy to apply, and compound outcome analysis was possible with the ASES Shoulder Index and DASH questionnaire. The DASH scale was the most complex evaluation instrument. The Constant-Murley Shoulder Score comprises a physical examination, which is advantageous but restricts the application to the office. For postoperative assessment without the patient having to return to the clinic, the ASES Shoulder Index is preferred because of its good correlation to the Constant-Murley Shoulder Score (r = 0.871) and the visual analogue scale for satisfaction (r = 0.762).

Level of physical activity in elderly patients after hemiarthroplasty for three- and four-part fractures of the proximal humerus

Abstract We report on 13 physically active patients who performed sports activities at a weekend or recreational level when they suffered a severe proximal humerus fracture or fracture dislocation. All patients were treated using the NEER II hemiarthroplasty, 9 patients within 4 weeks after trauma and 4 patients 2, 5, 10 and 15 months after trauma. At an average follow-up of 50 (range 6–98) months, all patients were evaluated, both by clinical review and radiographs. Patients obtained 69.0 points using the HSS score (Hospital for Special Surgery) for evaluation. Subjectively, 85% of the patients evaluated the result as ‘good’ or ‘excellent’ on a visual analogue scale for satisfaction. There was no radiographic evidence of implant loosening. At an average period of 33 (range 16–52) weeks 10 patients started with their physical activities again without a change in their participation level.

One- versus two-incision technique for anterior cruciate ligament reconstruction with patellar tendon graft Results on early rehabilitation and stability

Abstract Anterior cruciate ligament (ACL) reconstruction with patellar tendon graft has become a standard procedure. The graft can be inserted either using two tunnels and a lateral femoral incision or with a femoral half-tunnel drilled from the joint, thus avoiding the lateral incision. Advantages have been claimed for the single-incision technique in the early rehabilitation period. Forty patients with ACL deficiency were included in a prospective randomized trial comparing the single- and two-incision technique with a follow-up period of 12 months. Preoperative data did not show any significant difference between the two groups. At early follow-up no differences were observed with respect to complications or the progress of rehabilitation. Evaluation at 12 months postoperatively using the IKDC form revealed good to excellent results in 70% of patients. ACL reconstruction reduced anterior translation of the knee significantly at the 6-month and 12-month follow-up with a slight increase of MMD values at 12 months in both groups. The arthroscopic single-incision technique did not differ from the mini-open technique in terms of postoperative pain medication, incidence of effusion, postoperative range-of-motion or any rehabilitation parameters. Stability was comparable in both groups at all time periods. We conclude that an arthroscopic single-incision technique has no advantage over a mini-open two-incision technique for ACL reconstruction with patellar tendon graft in terms of subjective or objective parameters.

The coracoacromial ligament: anatomical and biomechanical properties with respect to age and rotator cuff disease.

The coracoacromial ligament (CAL) plays an important role in the pathoetiology of the subacromial impingement syndrome especially in those patients who do not have bony abnormalities. A total of 40 shoulders were dissected to determine the anatomical and biomechanical properties of the CAL in shoulders with either intact rotator cuffs or rotator cuff disease, taken from cadavers of persons who were of various ages at death. The specimens from cadavers with rotator cuff degeneration had a shorter lateral and medial band of the CAL than those of the specimens taken from shoulders with intact rotator cuffs. The cross-sectional area of the lateral band was also enlarged in older specimens with rotator cuff degeneration. Analysis of the structural properties showed a higher load to failure and a higher stiffness in the younger than in older specimens. In material properties, there was a higher failure stress in specimens with normal rotator cuffs than in the specimens with rotator cuff disease but only in older specimens. The decreased material properties in older specimens with rotator cuff disease may be caused by the previously reported histological differences with tissue disorganization and a lack of parallel bundle orientation associated with rotator cuff disease.

Complete dislocation of the acromioclavicular joint: operative versus conservative treatment

The preferred treatment for complete acromioclavicular separation is still controversial. The purpose of this study was to compare conservative and operative treatment on the basis of a long follow- up period, including subjective and objective clinical assessments as well as radiological evaluation. Forty-two patients with complete acromioclavicular dislocation treated operatively and 38 patients treated conservatively were examined at a mean follow-up of 6.3 years (SD=2.5). Assessment included the UCLA and the Constant-Murley scores as well as evaluation of pain, function and satisfaction. Shoulder strength was measured objectively using a cable tensiometer in four planes. The operative technique was suturing of the torn ligaments and stabilization of the acromioclavicular joint using resorbable coracoclavicular PDS banding. In conservative treatment, early physiotherapy accepting the deformity was performed in most patients. Clinical results according to the UCLA and Constant-Murley Scores as well as evaluation of pain, function and strength were similar in both groups. Three months postoperatively, the conservatively treated patients had less pain, a better range of motion and a significantly earlier return to work. Post-traumatic osteoarthritis developed only in those patients whose acromioclavicular joint healed in partial dislocation. The persisting deformity, which must be expected in conservative treatment, did not affect the patient’s outcome regarding pain or function and especially not regarding shoulder strength. With respect to the time for recovery, conservative treatment is superior to operative management. Therefore, most patients can be treated conservatively, even those patients who are heavy overhead workers or overhead athletes.

Posttraumatische Verlängerungsosteotomie der verkürzten Klavikula

ZusammenfassungOperationsziel Wiederherstellung der anatomischen Klavikulalänge zur Beseitigung schmerzhafter Funktionsstörungen des Schultergürtels. Indikationen In Verkürzung verheilte Klavikulafraktur mit schmerzhaften Funktionsstörungen des Schultergürtels körperlich aktiver Patienten. Kontraindikationen Asymptomatische posttraumatische Verkürzung der Klavikula.Schwere Osteoporose.Infiziertes Wundgebiet. Operationstechnik Hautschnitt im Verlauf der Spaltlinien senkrecht zur Klavikula. Osteotomie im ehemaligen Frakturbereich und Anfrischen der Knochenenden. Interposition eines autogenen, kortikospongiösen Spans vom ipsilateralen Beckenkamm entsprechend der vorher ermittelten Längendifferenz. Stabilisierung mit einer 3,5-mm-LC-DC-Platte. Weiterbehandlung Gilchrist-Verband. Ab 1. postoperativen Tag geführte Bewegungen, isometrische Muskelübungen. Aktive Bewegungsübungen 6 Wochen postoperativ. Volle Überkopfaktivität und muskuläre Rehabilitation gegen Widerstand nach Einheilung des Knochenspans (10–12 Wochen postoperativ). Röntgenkontrollen nach 6 und 12 Wochen. Ergebnisse Zwischen Juni 1991 und November 1999 wurden sechs Patienten operiert (männlich/weiblich = 4:2, 29±12 Jahre). Der durchschnittliche Nachuntersuchungszeitraum betrug 3,9±3,2 Jahre (0,4–9 Jahre). Fünf von sechs Patienten erzielten ein sehr gutes Ergebnis. Die Patienten erreichten im Mittel 95±8,4 Punkte im Constant-Murley-Score (maximal 100 Punkte) und 32,5±3,8 Punkte im UCLA-Score (Maximal 35 Punkte).AbstractObjective Restoration of clavicular length by osteotomy, interposition of an iliac crest autograft, and plate fixation to correct glenohumeral and scapulothoracic dysfunction. Indications Posttraumatic shortening of clavicle, accompanied by pain and impairment of glenohumeral function, particularly in overhead manual labor or sporting activities. Contraindications Asymptomatic shortening without functional or neurovascular impairment.Severe osteoporosis.Infection. Surgical Technique Sagittal approach along Langers lines. Osteotomy at fracture site and debridement. Lengthening of clavicle according to preoperative planning and interposition of an iiac crest autograft. Stabilization with 3.5-mm LC-DC plate and screws. Results Between June 1991 and November 1999, six patients (male/female = 4:2, 29±12 years) wich symptomatic shortening of the clavicle were treated by a lengthening osteotomy. The mean follow-up was 3.9±3.2 years (range 0.4–9 years). Based on the Constant-Murley score and the UCLA score, all patients but one had an excellent result. The scores averaged 95±8.4 points (Constant-Murley, maximum 100 points) and 32.5±3.8 points (UCLA, maximum 35 points).