Stefan Rahm

Latissimus Dorsi Tendon Transfer for Treatment of Irreparable Posterosuperior Rotator Cuff Tears Long-Term Results at a Minimum Follow-up of Ten Years

BACKGROUND Transfer of the latissimus dorsi tendon to the greater tuberosity of the humerus for treatment of an irreparable rotator cuff tear has been reported to yield good-to-excellent short to intermediate-term results in well-selected patients. The purpose of this study was to evaluate the long-term outcome of such transfers for irreparable posterosuperior rotator cuff tears to determine the durability of the results and to identify risk factors for an unfavorable outcome. METHODS Fifty-seven shoulders in fifty-five patients (seventeen women and thirty-eight men with a mean age of fifty-six years) were managed with latissimus dorsi tendon transfer. Final follow-up was performed at a mean of 147 months. Outcome measures included the Constant score and the Subjective Shoulder Value (SSV). Osteoarthritis, the acromiohumeral distance, and the so-called critical shoulder angle were assessed on standardized radiographs. RESULTS Forty-six shoulders in forty-four patients were available at the time of final follow-up. The mean SSV increased from 29% preoperatively to 70% at the time of final follow-up, the relative Constant score improved from 56% to 80%, and the pain score improved from 7 to 13 points (p < 0.0001 for all). Mean flexion increased from 118° to 132°, abduction increased from 112° to 123°, and external rotation increased from 18° to 33°. Mean abduction strength increased from 1.2 to 2.0 kg (p = 0.001). There was a slight but significant increase in osteoarthritic changes. Inferior results occurred in shoulders with insufficiency of the subscapularis muscle and fatty infiltration of the teres minor muscle. Superior functional results were observed in shoulders with a small postoperative critical shoulder angle. CONCLUSIONS Latissimus dorsi tendon transfer offered an effective treatment for irreparable posterosuperior rotator cuff tears, with substantial and durable improvements in shoulder function and pain relief. Shoulders with fatty infiltration of the teres minor muscle and insufficiency of the subscapularis muscle tended to have inferior results, as did those with a large critical shoulder angle. LEVEL OF EVIDENCE Therapeutic level IV. See Instructions for Authors for a complete description of levels of evidence.

Long-term Restoration of Anterior Shoulder Stability: A Retrospective Analysis of Arthroscopic Bankart Repair Versus Open Latarjet Procedure.

BACKGROUND Various operative techniques are used for treating recurrent anterior shoulder instability, and good mid-term results have been reported. The purpose of this study was to compare shoulder stability after treatment with the 2 commonly performed procedures, the arthroscopic Bankart soft-tissue repair and the open coracoid transfer according to Latarjet. METHODS A comparative, retrospective case-cohort analysis of 360 patients (364 shoulders) who had primary repair for recurrent anterior shoulder instability between 1998 and 2007 was performed. The minimum duration of follow-up was 6 years. Reoperations, overt recurrent instability (defined as recurrent dislocation or subluxation), apprehension, the subjective shoulder value (SSV), sports participation, and overall satisfaction were recorded. RESULTS An open Latarjet procedure was performed in 93 shoulders, and an arthroscopic Bankart repair was done in 271 shoulders. Instability or apprehension persisted or recurred after 11% (10) of the 93 Latarjet procedures and after 41.7% (113) of the 271 arthroscopic Bankart procedures. Overt instability recurred after 3% of the Latarjet procedures and after 28.4% (77) of the Bankart procedures. In the Latarjet group, 3.2% of the patients were not satisfied with their result compared with 13.2% in the Bankart group (p = 0.007). Kaplan-Meier analysis of survivorship, with apprehension (p < 0.001), redislocation (p = 0.01), and operative revision (p < 0.001) as the end points, documented the substantial superiority of the Latarjet procedure and the decreasing effectiveness of the arthroscopic Bankart repair over time. Twenty percent of the first recurrences after arthroscopic Bankart occurred no earlier than 91 months postoperatively, as opposed to the rare recurrences after osseous reconstruction, which occurred in the early postoperative period, with only rare late failures. CONCLUSIONS In this retrospective cohort study, the arthroscopic Bankart procedure was inferior to the open Latarjet procedure for repair of recurrent anterior shoulder dislocation. The difference between the 2 procedures with respect to the quality of outcomes significantly increased with follow-up time. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Operative treatment of chronic irreparable Achilles tendon ruptures with large flexor hallucis longus tendon transfers.

Background: Transfer of the flexor hallucis longus (FHL) tendon aims to restore function and relieve pain in chronic Achilles tendon (AT) disease. The goal of the present study was to investigate the clinical and radiographic outcomes of FHL transfer to the AT and to compare the transtendinous technique to the transosseous technique. We hypothesized that the type of technique would have a notable impact on outcome. Methods: Forty patients (42 ankles) were retrospectively reviewed and divided into group 1 (transtendinous technique, 22 patients/24 ankles) and group 2 (transosseous technique, 18 patients/18 ankles). Outcome parameters included the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Victorian Institute of Sports Assessment-Achilles (VISA-A) score, Foot Function Index (FFI), and Short Form-36 (SF-36) scores. Magnetic resonance imaging of the lower leg was performed preoperatively to assess muscle quality and fatty infiltration. Postoperatively, isokinetic plantar flexion strength was assessed using a Con-Trex dynamometer. Results: In group 1 (follow-up, 73 months; age, 52 years), the AOFAS score improved from 66 points to 89 points (P < .001) with average values for the VISA-A of 76 points, FFI-D pain 15%, and FFI-D function 22%. In group 2 (follow-up, 35 months; age, 56 years), the AOFAS score increased from 59 points to 85 points (P < .001) with mean values for the VISA-A 76 points, FFI-D pain 25%, and FFI-D function 24%. At follow-up, the average SF-36 score in group 1 was 66% and in group 2 was 77%. Isokinetic testing at 30 deg/s in group 1 revealed notable weakness in the operated ankle averaging 54.7 N·m (75% of normal), and in group 2 the average was 58.2 N·m (77% of normal). No statistically significant differences were found between the groups. Conclusion: The hypothesis was disproved. Both techniques for FHL transfer to AT, intratendinous and transosseous, provided good to excellent clinical and functional outcome in the treatment of irreparable AT disease. Level of Evidence: Level III, retrospective comparative series.

Inferior Results of Salvage Arthrodesis After Failed Ankle Replacement Compared to Primary Arthrodesis

Background: Up to now, there has been no evidence that salvage arthrodesis would perform inferior when compared with primary ankle arthrodesis. The purpose of this study was to compare their clinical and radiographic results. Methods: A retrospective analysis was performed using 2 validated scores and assessment of radiographic union by comparing 23 patients who underwent salvage ankle arthrodesis (group SA = salvage arthrodesis) after failed total ankle replacement with 23 matched patients who received primary ankle arthrodesis (group PA = primary arthrodesis). The mean follow-up period was 38 (range 16-92) months in group SA and 56 (23-94) months in group PA. Results: Complete union was achieved in 17 patients (74%) after a mean time of 50 (13- 114) weeks in group SA and in 16 patients (70%) after a mean time of 23 (10-115) weeks in group PA. The SF-36 score averaged 48 points (7-80) in SA and 66 points (14-94; P = .006) in group PA. In group SA the mean FFI was 57% (22-82) for pain and 71% (44-98) for function. In group PA significantly better results for pain with 34% (0-88; P = .002) and function with 48% (1-92; P = .002) were found. Conclusion: Salvage arthrodesis led to impaired life quality and reduced function combined with significantly higher pain when compared with primary ankle arthrodesis. These findings can be used to counsel our patients preoperatively. Level of Evidence: Level III, retrospective case series.

Standard axillary radiographs of the shoulder may mimic posterior subluxation of the lateral end of the clavicle.

Objectives: On standard axillary radiographs of normal shoulders, the clavicle may appear subluxated posteriorly. This subluxation might be viewed as an indication for surgical stabilization in acromioclavicular (AC) injury. The purpose of this study was to assess the reliability of identification of anteroposterior displacements of the AC joint on standard axillary radiographs of the human shoulder. Methods: We performed 170 radiographs of the AC joint in 10 cadaveric shoulders using various projection angles. The distance from the anterior margin of the acromion to the distal clavicle was measured to identify an “optimal” view to image the true anteroposterior alignment of normal AC joints. Results: On the standard axillary view of intact shoulders, we found an average posterior translation of 1.7 mm (range, −3 to 7; SD, 2.8) and of 0.9 mm (range, −5 to 5; SD, 2.8) in an “optimal view,” tilted 15 degees dorsal and 15 degees lateral. Conclusions: The standard axillary radiograph has a very high sensitivity but poor accuracy in identifying a posterior clavicular translation in the AC joint. We could not identify a reliable modification of the axillary radiographic projection to improve the accuracy. Therefore, an apparent posterior subluxation of the clavicle identified on an axillary radiograph is more likely a false positive finding than an identification of a true pathology.

How many radiographs are needed to detect angular stable head screw cut outs of the proximal humerus - A cadaver study

INTRODUCTION Cut out of locking head screws is the most common complication of locking plates in fracture fixation of the proximal humerus with potentially disastrous consequences. Aim of the study was to find the single best and combination of radiographic projections to reliably detect screw cut outs. MATERIALS AND METHODS The locking plate was fixed to six cadaveric proximal humeri. Six different radiographs were performed: anteriorposterior in internal (apIR), in neutral (ap0) and in 30° external rotation (apER); axial in 30° (ax30) and 60° (ax60) abduction and an outlet view. Each head screw (n=9) was sequentially exchanged to perforate the humeral head with the tip and all radiographs were repeated for each cut out. Randomized image reading by two blinded examiners for cut out was done for single projection and combinations. RESULTS Interrater agreement was 0.72-0.93. Best single projection was ax30 (sensitivity 76%) and the worst was the outlet view (sens. 17%). Standard combination of apIR/outlet reached a sens. of 54%. The best combination of two was: apER/ax30 (90% sens.), of three: apIR/apER/ax30 (96% sens.) and of four: apIR/ap0/apER/ax30 (100% sens.). CONCLUSION Standard radiographs (ap/outlet), especially in internal rotation, may miss nearly half of screw cut outs. Single best radiographic projection was an axial view with 30° abduction. To account for all cut outs and correct screw position a combination of four projections was needed. These simple and feasible intraoperative and postoperative radiographs help to detect screw perforations of the locking plate reliably. LEVEL OF EVIDENCE I (Study of Diagnostic Test).

Deltoid muscle shape analysis with magnetic resonance imaging in patients with chronic rotator cuff tears

BackgroundIt seems appropriate to assume, that for a full and strong global shoulder function a normally innervated and active deltoid muscle is indispensable. We set out to analyse the size and shape of the deltoid muscle on MR-arthrographies, and analyse its influence on shoulder function and its adaption (i.e. atrophy) for reduced shoulder function.MethodsThe fatty infiltration (Goutallier stages), atrophy (tangent sign) and selective myotendinous retraction of the rotator cuff, as well as the thickness and the area of seven anatomically defined segments of the deltoid muscle were measured on MR-arthrographies and correlated with shoulder function (i.e. active abduction). Included were 116 patients, suffering of a rotator cuff tear with shoulder mobility ranging from pseudoparalysis to free mobility. Kolmogorov-Smirnov test was used to determine the distribution of the data before either Spearman or Pearson correlation and a multiple regression was applied to reveal the correlations.ResultsOur developed method for measuring deltoid area and thickness showed to be reproducible with excellent interobserver correlations (r = 0.814–0.982).The analysis of influencing factors on active abduction revealed a weak influence of the amount of SSP tendon (r = −0.25; p < 0.01) and muscle retraction (r = −0.27; p < 0.01) as well as the stage of fatty muscle infiltration (GFDI: r = −0.36; p < 0.01). Unexpectedly however, we were unable to detect a relation of the deltoid muscle shape with the degree of active glenohumeral abduction. Furthermore, long-standing rotator cuff tears did not appear to influence the deltoid shape, i.e. did not lead to muscle atrophy.ConclusionsOur data support that in chronic rotator cuff tears, there seems to be no disadvantage to exhausting conservative treatment and to delay implantation of reverse total shoulder arthroplasty, as the shape of deltoid muscle seems only to be influenced by natural aging, but to be independent of reduced shoulder motion.

Fluoroscopic, magnetic resonance imaging, and electrophysiologic assessment of shoulders with massive tears of the rotator cuff

BACKGROUND It was the purpose of this paper to analyze structural, functional, and electrophysiologic variables that may determine preserved overhead function for patients with massive rotator cuff tears. METHODS Nineteen patients (20 shoulders) were prospectively included in either the pseudoparalytic (n = 9) or the non-pseudoparalytic group (n = 11). Fatty infiltration was graded according to Goutallier, and anterior (subscapularis) and posterior (infraspinatus and teres minor) tear extension was graded 0 (no involvement) to 4 (full tear) on magnetic resonance imaging. Glenohumeral and scapulothoracic rhythm was assessed by fluoroscopic motion analysis, and electromyographic evaluation of the deltoid muscle was performed. RESULTS We found no significant difference of fatty infiltration of the supraspinatus (3.9 vs 3.6), infraspinatus (3.9 vs 3.8), and teres minor (1.7 vs 0.6) or of the posterior tear extension (2.6 vs 2.0) between pseudoparalytic and non-pseudoparalytic shoulders. Global tear extension in the parasagittal plane (205° vs 163°) and subscapularis involvement (2.6 vs 1.2), however, showed significant differences between the two groups, and no patient with a full-thickness supraspinatus and infraspinatus tear with extension into the inferior half of the subscapularis was able to lift the arm to 90°. Fluoroscopic assessment revealed almost total loss of active glenohumeral abduction in the pseudoparalytic group. CONCLUSION Despite global tear extension, the single most important predictor for preserved shoulder function is the integrity of the inferior subscapularis insertion. Furthermore, electromyographic evaluation identifies a well-differentiated deltoid innervation as beneficial for a well-preserved shoulder function, but it does not protect from pseudoparalysis.

Reverse total shoulder arthroplasty for massive, irreparable rotator cuff tears before the age of 60 years: long-term results

Background: There has been serious concern regarding the longevity and durability of outcomes of reverse total shoulder arthroplasty (RTSA) in younger patients. It was the purpose of this study to analyze long-term outcomes and complications of RTSA for irreparable rotator cuff tears in patients younger than 60 years. Methods: Twenty patients (23 shoulders) with a mean age of 57 years (range, 47 to 59 years) were evaluated at a mean of 11.7 years (range, 8 to 19 years) after RTSA. Fifteen shoulders (65%) had undergone previous non-arthroplasty surgery. Longitudinal clinical and radiographic outcomes were assessed. Results: At the time of final follow-up, the mean absolute and relative preoperative Constant score (CS) (and standard deviation) had improved from 24 ± 9 to 59 ± 19 points (p < 0.001) and from 29% ± 11% to 69% ± 21% (p < 0.001), respectively. The mean Subjective Shoulder Value (SSV) had increased from 20% ± 13% to 71% ± 27% (p < 0.001). There were also significant improvements in the mean active anterior elevation (from 64° to 117°), active abduction (from 58° to 111°), pain scores, and strength (all p ⩽ 0.001). Clinical outcomes did not significantly deteriorate beyond 10 years and the functional results of patients with previous surgical procedures were not significantly inferior to the results of those with primary RTSA. The grade of, and number of patients with, radiographically apparent notching increased over time; the mean relative CS was lower in patients in whom the notching was grade 2 or higher (57%) than it was in those with no or grade-1 notching (81%; p = 0.006). Nine (39%) had ≥1 complication, with 2 failed RTSAs (9%). Conclusions: RTSA in patients younger than 60 years leads to substantial subjective and functional improvement without clinical deterioration beyond 10 years. It is associated with a substantial complication rate, and complications compromise ultimate subjective and objective outcomes. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Radiodense ligament markers for radiographic evaluation of anterior cruciate ligament reconstruction

INTRODUCTION Early clinical and radiographic diagnosis of failed or loosened anterior cruciate ligament (ACL) reconstructions can be challenging. The aim of the present study is to retrospectively evaluate the use of radiologically visible markers in the ACL graft, serving as a potential diagnostic tool in ACL graft rupture and insufficiency. METHODS Twenty patients were included in the study. ACL reconstruction was performed with use of a hamstring autograft in hybrid fixation technique. The graft was marked with two radiodense suture knots, one at the tibial and femoral tunnel openings. Radiographs were performed postoperatively, after 6 weeks and 12 months. Four distances between markers and landmarks were measured in anteroposterior and three in lateral radiographic views and the positional change between the timepoints of measurement was calculated. RESULTS Measurements of the marker distances on radiographs showed an excellent interobserver reliability (κ=0.97). In two measured distal anteroposterior distances statistically significant changes could be detected between 6 weeks and 12 months postoperatively in one patient with MRI-documented ACL rerupture and in five patients with ACL elongation defined as anteroposterior-translation with side-to-side difference of ≥3 mm measured with a Rolimeter device. On lateral radiographs, marker distances were highly variable and did not correlate with clinical ACL elongation. CONCLUSION The application of radiodense ACL graft markers is a straight-forward, non-expensive and potentially useful diagnostic tool to identify the position of the transplant and for diagnosis of graft elongation or failure. However, the method is sensitive to the radiological projection, which should be further studied and optimized.