Ulrich J. Spiegl

Clinical and structural outcomes after arthroscopic single-row versus double-row rotator cuff repair: a systematic review and meta-analysis of level I randomized clinical trials

BACKGROUND The purpose of this study was to perform a systematic review and meta-analysis of all available level I randomized controlled trials comparing single-row with double-row repair to statistically compare clinical outcomes and imaging-diagnosed re-tear rates. METHODS A literature search was undertaken to identify all level I randomized controlled trials comparing structural or clinical outcomes after single-row versus double-row rotator cuff repair. Clinical outcomes measures included in the meta-analysis were the American Shoulder and Elbow Surgeons, University of California-Los Angeles, and Constant scores; structural outcomes included imaging-confirmed re-tears. Meta-analyses compared raw mean differences in outcomes measures and relative risk ratios for imaging-diagnosed re-tears after single-row or double-row repairs by a random-effects model. RESULTS The literature search identified a total of 7 studies that were included in the meta-analysis. There were no significant differences in preoperative to postoperative change in American Shoulder and Elbow Surgeons, University of California-Los Angeles, or Constant scores between the single-row and double-row groups (P = .440, .116, and .156, respectively). The overall re-tear rate was 25.9% (68/263) in the single-row group and 14.2% (37/261) in the double-row group. There was a statistically significant increased risk of sustaining an imaging-proven re-tear of any type in the single-row group (relative risk, 1.76 [95% confidence interval, 1.25-2.48]; P = .001), with partial-thickness re-tears accounting for the majority of this difference (relative risk, 1.99 [95% confidence interval, 1.40-3.82]; P = .039). CONCLUSION Single-row repairs resulted in significantly higher re-tear rates compared with double-row repairs, especially with regard to partial-thickness re-tears. However, there were no detectable differences in improvement in outcomes scores between single-row and double-row repairs.

Biomechanical Consequences of Coracoclavicular Reconstruction Techniques on Clavicle Strength

Objectives: Lateral clavicle fractures have been reported following coracoclavicular (CC) ligament reconstruction with bone tunnels through the clavicle. Several techniques for CC reconstruction with different drill-hole measurements have been described. Our objective was to evaluate clavicle weakening related to tunnel diameters for common CC-reconstruction techniques. Methods: Testing was performed on 2 groups of 18 matched pair clavicles, which were randomly distributed between groups. There were no significant differences between the groups regarding bone mess density (BMD), clavicle width, age, and gender. One clavicle from each pair was prepared according to one of two reconstruction techniques; the contralateral clavicle was left intact. Both techniques placed 2 tunnels through the medial clavicle, 30 mm and 45 mm from the lateral border. Group 1 (mean age: 53, range: 44-63; mean BMD: 0.48, range: 0.39-0.59) was prepared with 2.4 mm tunnels and augmentation devices. Group 2 (mean age: 56, range: 45-63; mean BMD: 0.47, range 0.35-0.61) was prepared with 6.0 mm tunnels with hamstring grafts and tenodesis screws. A 3-point bending load was applied to the distal clavicles at 15 mm/min until failure. Ultimate failure load and anterior-posterior width 45 mm medial from the lateral border were recorded for each specimen. Strength reduction was determined as the percent reduction in ultimate failure load between paired intact and surgically prepared clavicles. Relative tunnel size was determined as the quotient of tunnel diameter and clavicle width. An independent observer performed all clavicle width measurements. Non-parametric statistics were used (MWU, Kendall’s Tau). Results: The 6.0 mm technique significantly reduced clavicle strength relative to intact (p = 0.02) and caused significantly more strength reduction than the 2.4 mm technique (p = 0.02) (Figure). The 2.4 mm technique was not significantly different from intact. All but one fractures occurred at the medial tunnel. Clavicle width at the medial hole varied highly (mean: 18.1 mm, range: 12.3 - 27.1 mm). There was a significant approximately linear correlation between clavicle width and strength reduction (p = 0.04, tau = -0.36) and between relative tunnel size and strength reduction (p < 0.01, tau = 0.51). Therefore, clavicle strength reductions of 30% and 50% relative to the intact state can be expected with relative tunnel diameters of 34.5% and 49.8% of the clavicle width, respectively. The intra-observer correlation coefficient of the width measurement was excellent (0.99; 95% CI: 0.98 - 0.99). Conclusion: Coracoclavicular ligamentous reconstruction with 6.0 mm tunnels, graft, and tenodesis screws caused significantly greater decreases in the strength of the clavicle when compared to 2.4 mm tunnels with augementation devices and undrilled controls. Additionally, strength reductions correlated highly with the ratio of tunnel width relative to overall clavicle width. This information can help optimize techniques for reconstructing unstable distal clavicles and can influence the intraoperative decision-making process based on the individual clavicle width.

Scapulothoracic Bursitis and Snapping Scapula Syndrome A Critical Review of Current Evidence

Background: Symptomatic scapulothoracic disorders, such as painful scapular crepitus and/or bursitis, are uncommon; however, they can produce significant pain and disability in many patients. Purpose: To review the current knowledge pertaining to snapping scapula syndrome and to identify areas of further research that may be helpful to improve clinical outcomes and patient satisfaction. Study Design: Systematic review. Methods: We performed a preliminary search of the PubMed and Embase databases using the search terms “snapping scapula,” “scapulothoracic bursitis,” “partial scapulectomy,” and “superomedial angle resection” in September 2013. All nonreview articles related to the topic of snapping scapula syndrome were included. Results: The search identified a total of 167 unique articles, 81 of which were relevant to the topic of snapping scapula syndrome. There were 36 case series of fewer than 10 patients, 16 technique papers, 11 imaging studies, 9 anatomic studies, and 9 level IV outcomes studies. The level of evidence obtained from this literature search was inadequate to perform a formal systematic review or meta-analysis. Therefore, a critical review of current evidence is presented. Conclusion: Snapping scapula syndrome, a likely underdiagnosed condition, can produce significant shoulder dysfunction in many patients. Because the precise origin is typically unknown, specific treatments that are effective for some patients may not be effective for others. Nevertheless, bursectomy with or without partial scapulectomy is currently the most effective primary method of treatment in patients who fail nonoperative therapy. However, many patients experience continued shoulder disability even after surgical intervention. Future studies should focus on identifying the modifiable factors associated with poor outcomes after operative and nonoperative management for snapping scapula syndrome in an effort to improve clinical outcomes and patient satisfaction.

Symptomatic internal impingement of the shoulder in overhead athletes.

The term “internal impingement” describes the normal physiological contact that occurs between the posterosuperior glenoid and the greater tuberosity in positions of hyperabduction and external rotation. This physiological contact can become symptomatic when repeated overhead motion results in partial articular-sided posterosuperior rotator cuff tears and lesions of the posterosuperior glenoid labrum. The precise pathophysiology involved with the development of symptomatic internal impingement has been debated extensively over the past few decades. However, current literature suggests that symptomatic internal impingement may result from a combination of multiple factors involving repetitive overhead activity, physiological remodeling of the throwing shoulder, posterior capsule contracture, and scapular dyskinesis, among other factors. These can all lead to scapulohumeral hyperangulation and associated pathologic findings. The purpose of this article is to review the relevant anatomy, pathophysiology, diagnosis, and management of symptomatic internal impingement through a critical review of current evidence.

O-arm®-based spinal navigation and intraoperative 3D-imaging: first experiences

Since the first use of instrument-tracking techniques in the early 1990s, image-guided technologies became a leading topic in all branches of spine surgery. Today, navigation is a widely available tool in spine surgery and has become a part of clinical routine in many centers for a large variety of indications. Spinal navigation may not only contribute to more precision during surgery, but it may also reduce radiation exposure and fluoroscopy time, with advantages not only for the patient but also for the operating room personnel. Different registration algorithms have been developed differing in terms of the type of image data used by the navigation system (preoperatively acquired computed tomography [CT] images, intraoperatively acquired fluoroscopy images) and the way virtual and physical reality is matched. There is a tendency toward a higher accuracy for 3D fluoroscopy-based registration algorithms. The O-arm® represents a new flat-panel technology with the source and detector moving in a 360° arc around the patient. In combination with the Stealth® station system, navigation may start immediately after automated registration with already referenced instruments. After instrumentation, an additional scan may confirm intraoperatively the correct positioning of the instrumentation. The first experiences with the system are described in this paper.

The Role of Arthroscopy in the Management of Glenohumeral Osteoarthritis: A Markov Decision Model

PURPOSE The purposes of this study were (1) to construct a theoretical Markov decision model to compare the total remaining quality-adjusted life-years following either arthroscopic management (AM) or total shoulder arthroplasty (TSA) for the treatment of glenohumeral osteoarthritis and (2) to determine the possible effects of age on the preferred treatment strategy. METHODS A Markov decision model was constructed to compare AM and TSA in patients with glenohumeral osteoarthritis. The rates of surgical complications, revision surgery, and death were derived from the literature and analyzed. The principal outcome measure was the mean total remaining quality-adjusted life-years after each treatment strategy. Sensitivity analyses were performed for age at the initial procedure, utilities, and transition probabilities. RESULTS This theoretical decision model showed that AM was the preferred strategy for patients younger than 47 years, TSA was the preferred strategy for patients older than 66 years, and both treatment strategies were reasonable for patients aged between 47 and 66 years. The model was highly sensitive to age at the index surgery, utilities of wellness states, survivorship, and the probability of failure after either AM or TSA. CONCLUSIONS According to this theoretical decision model, AM was the preferred treatment strategy for patients younger than 47 years, primary TSA was the preferred treatment strategy for patients older than 66 years, and both treatment options were reasonable for patients aged between 47 and 66 years. LEVEL OF EVIDENCE Level II, economic and decision analysis.

Evaluation of a treatment algorithm for acute traumatic osseous Bankart lesions resulting from first time dislocation of the shoulder with a two year follow-up

BackgroundStudies dealing with acute osseous Bankart lesions and corresponding treatment strategies are rare. The purpose of this study is to analyze the results after applying our treatment algorithm for acute glenoid rim fractures caused by first time traumatic anterior shoulder dislocations.Methods25 patients were included in this retrospective case series. All patients sustained a first time shoulder dislocation caused by ski or snowboard accidents. An osseous Bankart lesion was detected in all shoulders. Operative therapy was performed in patients with osseous defects of 5% or more, otherwise conservative therapy was initiated. Primary study outcome parameter was the Rowe score. Additionally, the outer rotation deficit and operative complications were analysed.Results12 patients showed a defect size of less than 5% and were treated conservatively. The average lesion size was 2%. For these patients, the Rowe score was excellent in 58%, good in 25%, and moderate in 17% of patients. Three patients (25%) complained about a feeling of instability. 13 patients had a lesion size of more than 5%, average 15%, and were treated operatively. The Rowe score for this group was excellent in 54%, good in 31%, and moderate results in 15% of patients. One patient (8%) complained about a feeling of instability, without recurrent dislocations. There were no statistically significant differences between both study groups (ROWE score: p = 0.98).ConclusionsApplying our treatment algorithm for acute osseous Bankart lesions consisting of a conservative strategy for small defect sizes and a surgical approach for medium-sized and large defects leads to encouraging mid-term results and a low rate of recurrent instability in active patients.

Association between scapula bony morphology and snapping scapula syndrome.

HYPOTHESIS AND BACKGROUND Scapular incongruity has been described as a contributing factor to the development of snapping scapula syndrome (SSS). The purpose of this retrospective case-control study was to determine the association between scapula bony morphology on magnetic resonance imaging (MRI) and the diagnosis of SSS. METHODS Bony morphologies of the scapula were evaluated on MRI scans of 26 patients with SSS and 19 patients with non-SSS pathologies. The medial scapula corpus angle (MSCA) was measured on axial MRI sequences. Scapulae were categorized as straight, S shaped, or concave. Two independent observers performed the measurements. Interobserver and intraobserver agreements of MSCA measurements were determined with intraclass correlation coefficients. RESULTS Axial scapula bony morphology identified 28 scapulae of the straight type, 14 S-shaped scapulae, and 5 concave scapulae. All 5 concave scapulae had confirmed SSS. Measurement of the MSCA showed excellent interobserver agreement of 0.80 (95% confidence interval [CI], 0.67 to 0.89) and intraobserver agreement of 0.70 (95% CI, 0.52 to 0.82). There were significant differences in the mean MSCAs between shoulders with SSS (14.4° ± 19.3°) and non-SSS shoulders (-3.3° ± 15.3°, P = .001). The odds ratio was 8.4 (95% CI, 2.2 to 31.8) for positive MSCA and SSS. The scapulothoracic distance was significantly decreased in the SSS group (14.9 ± 5.8 mm) compared with the non-SSS patients (24.0 ± 6.7 mm, P < .001). DISCUSSION AND CONCLUSION Anterior angulation of the medial scapula in the axial plane was associated with SSS. Patients with a concave-shaped scapula and a positive MSCA have a 12-fold increased risk of SSS. The MSCA may prove helpful in determining the location and amount of scapular resection needed for patients with SSS.

Biomechanical evaluation of internal fixation techniques for unstable meso-type os acromiale

BACKGROUND Several internal fixation surgical techniques have been described for the treatment of symptomatic os acromiale. The purpose of this study was to compare the biomechanical characteristics of different internal fixation techniques for the operative treatment of unstable meso-type os acromiale in a cadaveric model. METHODS Testing was performed on 12 matched pairs of cadaveric acromia with simulated meso-type os acromiale. Twelve specimens were prepared with 2 cannulated 4.0-mm screws only (SO group), inserted in the anterior-posterior direction. Contralateral specimens were repaired with screws and a tension band (TB group). An inferiorly directed load to the anterior acromion was applied at a rate of 60 mm/min until failure. Ultimate failure load, stiffness, and fracture pattern were recorded and analyzed. RESULTS Ultimate failure load was significantly higher for the TB group (mean, 336 N ± 126 N; range, 166-623 N; P = .01) than for the SO group (mean, 242 N ± 57 N; range, 186-365 N). In contrast, no significant difference in stiffness was found between the SO group (mean, 22.1 N/mm ± 4.7 N/mm; range, 13.0-33.3 N/mm; P = .94)) and the TB group (mean, 22.2 N/mm ± 2.9 N/mm; range, 18.2-26.6 N/mm). CONCLUSION Surgical repair of simulated unstable meso-type os acromiale by a combination of cannulated screws with a tension band leads to significantly higher repair strength at time zero in a cadaveric model compared with cannulated screws alone.

Biomechanical Comparison of Arthroscopic Single- and Double-Point Repair Techniques for Acute Bony Bankart Lesions

Objectives: Single-point and double-point arthroscopic reconstruction techniques for acute osseous Bankart lesions have been described in the literature. We hypothesized that the double-point fixation technique (bony Bankart bridge) would provide superior fracture reduction and stability at time zero compared to the single-point technique in a cadaveric bony Bankart model. Methods: Testing was performed on 14 matched glenoid pairs with simulated bony Bankart fractures; the defect width was 25% of the glenoid diameter and the fracture was perpendicular to the 3 o’clock position. Additionally, a labral avulsion was created and extended from the 6 to the 12 o’clock position. All labral avulsions were then repaired above and below the bony Bankart with suture anchors. Half of the bony Bankart fractures were repaired with a double-point technique, while the contralateral glenoid was repaired with a single-point technique (Fig 1). Following the repairs, distance between the intra-articular surfaces of the fragment and glenoid were measured for an unloaded condition and with 10 N of tension applied to the fragment, to quantify fracture displacement. To determine the biomechanical stability of the repairs, specimens were secured in a tensile testing machine and aligned so that the load vector was 30° medial to the superior-inferior plane. The repair constructs were preconditioned with sinusoidal cyclic loading between 5 N to 25 N for 10 cycles and then pulled to failure at a rate of 5 mm/min. Load (N) at 1 mm and 2 mm of fracture displacement were determined. Non-parametric statistics were used (MWU). Results: The bony Bankart defect length measured more than half of the maximum antero-posterior diameter of the inferior glenoid in all specimens. Loads at 1 mm and 2 mm of fracture displacement, and fracture reduction are reported in Table 1. The double-point technique required significantly higher forces to achieve fracture displacements of 1 mm (mean: 60.6 N, range: 39.0 N to 93.3 N; p = 0.001) and 2 mm (mean: 94.4 N, range: 43.4 N to 151.2 N; p = 0.004) (Fig 1) than the single-point technique (1 mm displacement mean: 30.2 N, range: 14.0 N to 54.1 N; 2 mm displacement mean: 63.7, range: 26.6 to 118.8). Fracture displacement was significant lower after double-point repair for both the unloaded condition (mean: 1.1 mm, range: 0.3 to 2.4 mm; p = 0.005) (Fig 1) and in response to a 10 N anterior force applied to the defect (mean: 1.6 mm, range: 0.5 to 2.7 mm; p = 0.001) compared to single-point repair (unloaded mean: 2.1 mm, range: 1.3 to 3.4 mm; loaded mean: 3.4, range: 1.9 to 4.7 mm). Conclusion: The double-point fixation technique (bony Bankart bridge) for clinically relevant sized, acute osseous Bankart lesions resulted in lower fracture displacement and superior stability at time zero in comparison to the single-point technique and was the preferred biomechanical technique in this model of bony Bankart fractures. This information may influence the surgical technique used to treat large osseous Bankart fractures and the postoperative rehabilitation protocols implemented when such repair techniques are used.