A 3-Dimensional Classification for Degenerative Glenohumeral Arthritis Based on Humeroscapular Alignment

Background

Seminal classifications of degenerative arthritis of the shoulder (DAS) describe either cuff tear arthropathy in the coronal plane or primary osteoarthritis in the cross-sectional plane. None consider a biplanar eccentricity.

Purpose/Hypothesis

The purpose of this study was to investigate humeroscapular alignment (HSA) of patients with DAS in both the anteroposterior (A-P) and superoinferior (S-I) planes on computed tomography (CT) after 3-dimensional (3D) reconstruction and develop a classification based on biplanar HSA in 9 quadrants. It was hypothesized that biplanar eccentricity would occur frequently.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

The authors analyzed 130 CT scans of patients who had undergone shoulder arthroplasty. The glenoid center, trigonum, and inferior angle of the scapula were aligned in a single plane using 3D reconstruction software. Subluxation of the HSA was measured as the distance from the center of rotation of the humeral head to the scapular axis (line from trigonum through glenoid center) and was expressed as a percentage of the radius of the humeral head in both the A-P and the S-I directions. HSA was described in terms of A-P alignment first (posterior/central/anterior), then S-I alignment (superior/central/inferior), for a total of 9 different alignment combinations. Additionally, glenoid erosion was graded 1-3.

Results

Subluxation of the HSA was 74.1% posterior to 23.5% anterior in the A-P direction and 17.2% inferior to 68.6% superior in the S-I direction. A central HSA was calculated as between 20% posterior to 5% anterior (A-P) and 5% inferior to 20% superior (S-I), after a graphical analysis. Posterior subluxation >60% of the radius was labeled as extraposterior, and static acetabularization was labeled as extrasuperior. Overall, 21 patients had central-central, 40 centrosuperior, and 1 centroinferior alignment. Of 60 shoulders with posterior subluxation, alignment was posterocentral in 31, posterosuperior in 25, and posteroinferior in 5. There were 3 patients with anterocentral and 4 anterosuperior subluxation; in addition, 4 cases with extraposterior and 17 with extrasuperior subluxation were identified.

Conclusion

There was a high prevalence of biplanar eccentricity in DAS. The 3D classification system using combined HSA and glenoid erosion can be applied to describe DAS comprehensively.

Distal biceps tendon ruptures occur with the almost extended elbow and supinated forearm - an online video analytic study

Background

Distal biceps tendon ruptures can lead to significant restrictions in affected patients. The mechanisms of injury described in scientific literature are based exclusively on case reports and theoretical models. This study aimed to determine the position of the upper extremities and forces involved in tendon rupture through analyzing video recordings.

Methods

The public YouTube.com database was queried for videos capturing a clear view of a distal biceps tendon rupture. Two orthopedic surgeons independently assessed the videos for the activity that led to the rupture, the arm position at the time of injury and the forces imposed on the elbow joint.

Results

Fifty-six video segments of a distal biceps rupture were included (55 male). In 96.4%, the distal biceps tendon ruptured with the forearm supinated and the elbow isometrically extended (non-dynamic muscle engagement) (71.4%) or slightly flexed (24%). The most common shoulder positions were adduction (85.7%) and neutral position with respect to rotation (92.9%). Most frequently a tensile force was enacted on the elbow (92.9%) and the most common activity observed was deadlifting (71.4%).

Conclusion

Distal biceps tendon ruptures were most commonly observed in weightlifting with a slightly flexed or isometrically extended elbow and forearm supination. These observations may provide useful information for sports specific evidence-based injury prevention, particularly in high performing athletes and individuals engaged in resistance training.

Level of evidence

Observational study.

The Morphology of the Acromioclavicular Joint Does Not Influence the Postoperative Outcome Following Acute Stabilization—A Case Series of 81 Patients

Purpose

To specifically evaluate the influence of the acromioclavicular (AC)-joint morphology on the outcome after arthroscopically assisted coracoclavicular (CC) stabilization surgery with suspensory fixation systems and to investigate whether an additional open AC-joint reduction and AC cerclage improves the clinical outcome for patients with certain morphologic AC-joint subtypes.

Methods

Patients with an acute acromioclavicular joint injury, who underwent arthroscopically assisted CC stabilization with suspensory fixation systems with or without concomitant AC cerclage between January 2009 and June 2017 were identified and included in this retrospective cohort analysis. AC-joint morphology was assessed on preoperative radiographs and categorized as “flat” or “non-flat” (“oblique”/“curved”) subtypes. After a minimum of 2 years of follow-up, postoperative Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES), and visual analog scale (VAS) scores for pain were collected. A subgroup analysis of clinical outcomes depending on the surgical technique and morphological subtype of the AC joint was performed.

Results

Eighty-one patients (95% male, mean age 35 ± 12 years) could be included at a mean follow-up of 57 ± 14 months. Radiographic assessment of AC-joint morphology showed 24 (30%) cases of flat type, 38 (47%) cases of curved type, and 19 (23%) cases of oblique morphology. Postoperatively, no clinically significant difference could be detected after the treatment of AC joint injury via CC stabilization with or without concomitant AC cerclage (VAS_rest: P = .067; VAS_max: P = .144, ASES: P = .548; SANE: P = .045). No clinically significant differences were found between the surgical techniques for the flat morphologic subtype (VAS_rest: P = .820; VAS_max: P = .251; SANE: P = .104; ASES: P = .343) or the non-flat subtype (VAS_res: P = .021; VAS_max: P = .488; SANE: P = .243, ASES: P = .843).

Conclusions

In arthroscopically assisted AC stabilization surgery with suspensory fixation systems for acute AC-joint injury, the AC-joint morphology did not influence the postoperative outcome, independent of the surgical technique. No clinical benefit of performing an additional horizontal stabilization could be detected in our collective at mid-term follow-up.

Level of Evidence

Level IV, therapeutic case series.

Subacromial Decompression in Patients With Shoulder Impingement With an Intact Rotator Cuff: An Expert Consensus Statement Using the Modified Delphi Technique Comparing North American to European Shoulder Surgeons

PURPOSE

To perform a Delphi consensus for the treatment of patients with shoulder impingement with intact rotator cuff tendons, comparing North American with European shoulder surgeon preferences.

METHODS

Nineteen surgeons from North America (North American panel [NAP]) and 18 surgeons from Europe (European panel [EP]) agreed to participate and answered 10 open-ended questions in rounds 1 and 2. The results of the first 2 rounds were used to develop a Likert-style questionnaire for round 3. If agreement at round 3 was ≤60% for an item, the results were carried forward into round 4. For round 4, the panel members outside consensus (>60%, <80%) were contacted and asked to review their response. The level of agreement and consensus was defined as 80%.

RESULTS

There was agreement on the following items: impingement is a clinical diagnosis; a combination of clinical tests should be used; other pain generators must be excluded; radiographs must be part of the workup; magnetic resonance imaging is helpful; the first line of treatment should always be physiotherapy; a corticosteroid injection is helpful in reducing symptoms; indication for surgery is failure of nonoperative treatment for a minimum of 6 months. The NAP was likely to routinely prescribe nonsteroidal anti-inflammatory drugs (NAP 89%; EP 35%) and consider steroids for impingement (NAP 89%; EP 65%).

CONCLUSIONS

Consensus was achieved for 16 of the 71 Likert items: impingement is a clinical diagnosis and a combination of clinical tests should be used. The first line of treatment should always be physiotherapy, and a corticosteroid injection can be helpful in reducing symptoms. The indication for surgery is failure of no-operative treatment for a minimum of 6 months. The panel also agreed that subacromial decompression is a good choice for shoulder impingement if there is evidence of mechanical impingement with pain not responding to nonsurgical measures.

LEVEL OF EVIDENCE

Level V, expert opinion.

Reliable Clinical and Sonographic Outcomes of Subpectoral Biceps Tenodesis Using an All-Suture Anchor Onlay Technique

PURPOSE

To evaluate the clinical outcomes and structural integrity of primary subpectoral biceps tenodesis using an all-suture anchor onlay technique for long head of the biceps (LHB) tendon pathology.

METHODS

We conducted a retrospective case series with prospectively collected data of patients who underwent primary, isolated subpectoral biceps tenodesis with a single all-suture anchor onlay fixation between March 2017 and March 2019. Outcomes were recorded at a minimum follow-up of 12 months based on assessments of the American Shoulder and Elbow Surgeons (ASES) score, LHB score, and elbow flexion strength and supination strength measurements. The integrity of the tenodesis construct was evaluated using ultrasound.

RESULTS

Thirty-four patients were available for clinical and ultrasound examination at a mean follow-up of 18 ± 5 months. The mean ASES score significantly improved from 51.0 ± 14.2 points preoperatively to 89.8 ± 10.5 points postoperatively (P < .001). The minimal clinically important difference for the ASES score was 8.7 points, which was exceeded by 31 patients (91.2%). The mean postoperative LHB score was 92.2 ± 8.3 points. Regarding subcategories, an average of 47.2 ± 6.3 points was reached for "pain/cramps"; 26.4 ± 6.1 points, "cosmesis"; and 18.6 ± 2.6 points, "elbow flexion strength." Both elbow flexion strength and supination strength were similar compared with the nonoperated side (P = .169 and P = .210, respectively). In 32 patients, ultrasound examination showed an intact tenodesis construct, whereas 2 patients (5.9%) sustained failure of the all-suture anchor fixation requiring revision.

CONCLUSIONS

Primary subpectoral biceps tenodesis using an all-suture anchor onlay technique for pathology of the LHB tendon provides reliable clinical results and a relatively low failure rate (5.9%).

LEVEL OF EVIDENCE

Level IV, case series.

Low rate of substantial loss of reduction immediately after hardware removal following acromioclavicular joint stabilization using a suspensory fixation system

PURPOSE

To evaluate immediate loss of reduction in patients undergoing hardware removal after arthroscopically assisted acromioclavicular (AC) joint stabilization using a high-tensile suture tape suspensory fixation system and to identify risk factors associated with immediate loss of reduction.

MATERIALS AND METHODS

Twenty-two consecutive patients with a mean age of 36.4 ± 12.6 years (19-56), who underwent hardware removal 18.2 ± 15.0 months following arthroscopically assisted stabilization surgery using a suspensory fixation system for AC joint injury between 01/2012 and 01/2021 were enrolled in this retrospective monocentric study. The coracoclavicular distance (CCD) as well as the clavicular dislocation/acromial thickness (D/A) ratio were measured on anterior-posterior radiographs prior to hardware removal and immediately postoperatively by two independent raters. Loss of reduction, defined as 10% increase in the CCD, was deemed substantial if the CCD increased 6 mm compared to preoperatively. Constitutional and surgical characteristics were assessed in a subgroup analysis to detect risk factors associated with loss of reduction.

RESULTS

Postoperatively, the CCD significantly increased from 12.6 ± 3.7 mm (4.8-19.0) to 14.5 ± 3.3 mm (8.7-20.6 mm) (p < 0.001) while the D/A ratio increased from 0.4 ± 0.3 (- 0.4-0.9) to 0.6 ± 0.3 (1.1-0.1) (p = 0.034) compared to preoperatively. In 10 cases (45%), loss of reduction was identified, while a substantial loss of reduction (> 6 mm) was only observed in one patient (4.5%). A shorter time interval between index stabilization surgery and hardware removal significantly corresponded to immediate loss of reduction (11.0 ± 5.6 vs. 30.0 ± 20.8 months; p = 0.007), as hardware removal within one year following index stabilization was significantly associated with immediate loss of reduction (p = 0.027; relative risk 3.4; odds ratio 11.67).

CONCLUSIONS

Substantial loss of reduction after hardware removal of a high-tensile suture tape suspensory fixation system was rare, indicating that the postoperative result of AC stabilization is not categorically at risk when performing this procedure. Even though radiological assessment of the patients showed a statistically significant immediate superior clavicular displacement after this rarely required procedure, with an increased incidence in the first year following stabilization, this may not negatively influence the results of ACJ stabilization in a clinically relevant way.

LEVEL OF EVIDENCE

IV.

Minimum 10-Year Clinical Outcomes After Arthroscopic 270° Labral Repair in Traumatic Shoulder Instability Involving Anterior, Inferior, and Posterior Labral Injury

BACKGROUND

Current literature reports highly satisfactory short- and midterm clinical outcomes in patients with arthroscopic 270° labral tear repairs. However, data remain limited on long-term clinical outcomes and complication and redislocation rates in patients with traumatic shoulder instability involving anterior, inferior, and posterior labral injury.

PURPOSE

To investigate, at a minimum follow-up of 10 years, the clinical outcomes, complications, and recurrent instability in patients with 270° labral tears involving the anterior, inferior, and posterior labrum treated with arthroscopic stabilization using suture anchors.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective outcomes study was completed for all patients with a minimum 10-year follow-up who underwent arthroscopic 270° labral tear repairs with suture anchors by a single surgeon. Outcome measures included pre- and postoperative Rowe score, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test, visual analog scale for pain, and Single Assessment Numeric Evaluation (SANE). Western Ontario Shoulder Instability Index (WOSI) scores were collected postoperatively. Complication data were collected, including continued instability, subluxation or dislocation events, and revision surgery. Failure was defined as any cause of revision surgery.

RESULTS

In total, 21 patients (mean ± SD age, 27.1 ± 9.6 years) with 270° labral repairs were contacted at a minimum 10-year follow-up. All outcome measures showed statistically significant improvements as compared with those preoperatively: Rowe (53.9 ± 11.4 to 88.7 ± 8.9; P = .005), ASES (72.9 ± 18.4 to 91.8 ± 10.8; P = .004), Simple Shoulder Test (8.7 ± 2.4 to 11.2 ± 1.0; P = .013), visual analog scale (2.5 ± 2.6 to 0.5 ± 1.1; P = .037), and SANE (24.0 ± 15.2 to 91.5 ± 8.3; P = .043). The mean postoperative WOSI score at minimum follow-up was 256.3 ± 220.6. Three patients had postoperative complications, including a traumatic subluxation, continued instability, and a traumatic dislocation, 2 of which required revision surgery (14.2% failure rate).

CONCLUSION

Arthroscopic repairs of 270° labral tears involving the anterior, inferior, and posterior labrum have highly satisfactory clinical outcomes at 10 years, with complication and redislocation rates similar to those reported at 2 years. This suggests that repairs of extensile labral tears are effective in restoring and maintaining mechanical stability of the glenohumeral joint in the long term.

Excellent clinical and radiological outcome following locking compression plate fixation of displaced medial clavicle fractures

BACKGROUND

Treatment of medial clavicle fractures is still controversially discussed in the community of upper extremity surgeons. An increasing number of symptomatic non-unions following conservative treatment of displaced fractures led to the development of various surgical approaches. Aim of this study was to evaluate the clinical and radiological outcome following operative treatment of displaced medial end clavicle fractures.

METHODS

Patients who presented with a displaced fracture of the medial clavicle between September 2012 and December 2019 were retrospectively enrolled in this study. All patients were operatively treated with open reduction and internal fixation (ORIF) using an anatomically precontoured locking compression plate (LCP) originally designed for the lateral clavicle (Synthes®, Umkirch, Germany). Functional outcome was recorded using the American Shoulder and Elbow Surgeons (ASES) Score, the Munich Shoulder Questionnaire (MSQ), Shoulder Pain and Disability Index (SPADI) and Constant Score.

RESULTS

Overall 18 patients with a mean age of 54.5 ± 23.5 years suffering from a displaced fracture of the medial clavicle were identified. The mean follow-up was 40.9 ± 26.2 months. The mean ASES accounted for 88.3 ± 20.8 points, the mean MSQ was 83.1 ± 21.7 points, the mean SPADI was 85.6 ± 22.5 and a mean normative age- and sex-specific Constant Score of 77.5 ± 19.1 points resulted. No minor or major complications were observed. Radiologic fracture consolidation was achieved in all patients after a mean of 6.4 months.

CONCLUSION

Surgical treatment of displaced medial clavicle fractures using an anatomically precontoured locking plate originally designed for the lateral clavicle led to very good to excellent clinical and functional results.

TRIAL REGISTRATION

No: DRKS00024813 , retrospectively registered 19.03.2021 ( www.drks.de ).

[Acute rupture of the pectoralis major muscle at the musculotendinous junction : Case report of a rare injury and literature review]

Die Pectoralis-major-Ruptur (PMR) ist eine seltene Verletzung, die v. a. beim Kraftsport aufritt. Vorgestellt wird der Fall eines 31-jährigen Profibasketballspielers, der sich beim Bankdrücken eine Komplettruptur am muskulotendinösen Übergang des M. pectoralis major (PM) zugezogen hatte. Drei Wochen nach dem erlittenen Trauma erfolgte bei persistierenden Schmerzen und Kraftdefizit die Refixation des PM. Drei Monate postoperativ konnte der Patient bei vollem Bewegungsumfang schmerzfrei in den Basketballsport zurückkehren. Die Verletzungsentität wird vor dem Hintergrund der aktuellen Literatur diskutiert und das operative Vorgehen im Detail dargestellt.

Epicondylopathia humeri radialis

BACKGROUND

Lateral epicondylitis is a common orthopaedic condition often massively restricting the quality of life of the affected patients. There are a wide variety of treatment options - with varying levels of evidence.

METHOD

The following statements and recommendations are based on the current German S2k guideline Epicondylopathia radialis humeri (AWMF registry number: 033 - 2019). All major German specialist societies participated in this guideline, which is based on a systematic review of the literature and a structured consensus-building process.

OUTCOMES

Lateral epicondylitis should be diagnosed clinically and can be confirmed by imaging modalities. The Guidelines Commission issues recommendations on clinical and radiological diagnostic workup. The clinical condition results from the accumulated effect of mechanical overload, neurologic irritation and metabolic changes. Differentiating between acute and chronic disorder is helpful. Prognosis of non-surgical regimens is favourable in most cases. Most cases spontaneously resolve within 12 months. In case of unsuccessful attempted non-surgical management for at least six months, surgery may be considered as an alternative, if there is a corresponding structural morphology and clinical manifestation. At present, it is not possible to recommend a specific surgical procedure.

CONCLUSION

This paper provides a summary of the guideline with extracts of the recommendations and statements of its authors regarding the pathogenesis, prevention, diagnostic workup as well as non-surgical and surgical management.

[Irreparable rotator cuff tear-reverse shoulder arthroplasty and alternative procedures]

Irreparable rotator cuff tears represent a significant everyday clinical challenge. A high degree of tendon retraction and muscle degeneration means that a direct reconstruction is impossible. Patients often suffer from pain and pseudoparalysis. In older patients this can reliably be resolved by the implantation of a semiconstrained inverse shoulder prosthesis; however, for younger patients joint-preserving techniques should be employed. Furthermore, for frail older patients who may not be suitable for a joint replacement operation, alternative treatment strategies are required. Management options include physiotherapy and pain relieving or reconstructive operations. Minimally invasive arthroscopic treatment approaches can lead to pain relief and slight functional improvements in selected patients; however, to restore the active movement of the joint a partial cuff repair, augmentation with a graft or replacement with muscle transfer is necessary. This article presents the various treatment options and the results reported in the literature. Through this a treatment algorithm is suggested in order to facilitate management decisions.

All-suture anchor and unicortical button show comparable biomechanical properties for onlay subpectoral biceps tenodesis

Hypothesis

The purpose of this study was to biomechanically evaluate onlay subpectoral long head of the biceps (LHB) tenodesis with all-suture anchors and unicortical buttons in cadaveric specimens.

Methods

After evaluation of bone mineral density, 18 fresh-frozen, unpaired human cadaveric shoulders were randomly assigned to 2 groups: One group received an onlay subpectoral LHB tenodesis with 1 all-suture anchor, whereas the other group received a tenodesis with 1 unicortical button. The specimens were mounted in a servo-hydraulic material testing system. Tendons were initially loaded from 5 N to 100 N for 5000 cycles at 1 Hz. Displacement of the repair constructs was observed with optical tracking. After cyclic loading, each specimen was loaded to failure at a rate of 1 mm/s.

Results

The mean displacement after cyclic loading was 6.77 ± 3.15 mm in the all-suture anchor group and 8.41 ± 3.17 mm in the unicortical button group (P = not significant). The mean load to failure was 278.05 ± 38.77 N for all-suture anchor repairs and 291.36 ± 49.69 N for unicortical button repairs (P = not significant). The most common mode of failure in both groups was LHB tendon tearing. There were no significant differences between the 2 groups regarding specimen age (58.33 ± 4.37 years vs. 58.78 ± 5.33 years) and bone mineral density (0.50 ± 0.17 g/cm² vs. 0.44 ± 0.19 g/cm²).

Conclusion

All-suture anchors and unicortical buttons are biomechanically equivalent in displacement and load-to-failure testing for LHB tenodesis. All-suture anchors can be considered a validated alternative for onlay subpectoral LHB tenodesis.

[Rupture of the distal biceps tendon]

With an incidence of 3% of all biceps tendon injuries, rupture of the distal biceps tendon is a rare injury but can be associated with significant functional impairment of the elbow. In case of a complete rupture, the diagnosis can be made clinically with a pronounced power deficit, in particular for supination of the forearm. In cases of unclear symptoms magnetic resonance imaging should be included. Regarding the therapeutic approach, there is general consensus in the current literature that surgical treatment with anatomical reconstruction of the tendon footprint is superior to the conservative approach. Various surgical techniques with good biomechanical and clinical results are currently available but no clear superiority of a single technique has so far been demonstrated.

[Primary (idiopathic) shoulder stiffness : Definition, disease progression, epidemiology and etiology]

Shoulder stiffness is characterized by restriction of the active and passive movement of the glenohumeral joint. The stiffness is ultimately caused by fibrosis and the resulting contracture of the glenohumeral joint capsule and its ligaments; however, the term stiff shoulder is only a descriptive umbrella term that must be further defined as the course of the disease and the recommended treatment are decisively influenced by the cause of the shoulder stiffness. Primary shoulder stiffness, also known as idiopathic shoulder stiffness or "frozen shoulder", must be distinguished from various forms of secondary shoulder stiffness and often occurs in three stages, which can all last for several months to years: the initial "freezing phase", followed by a "frozen phase" and finally a "thawing phase". Although primary shoulder stiffness is a frequent pathological alteration with an prevalence of 2-5% in the general population, the exact etiology remains largely unknown; however, there is consensus throughout the literature that certain systemic pathologies, such as diabetes mellitus are associated with a higher incidence of primary shoulder stiffness.

Biomechanical Comparison of Onlay Distal Biceps Tendon Repair: All-Suture Anchors Versus Titanium Suture Anchors

BACKGROUND

A rupture of the distal biceps tendon is the most common tendon rupture of the elbow and has received increased attention in the past few years. Newly developed all-suture anchors have the potential to minimize surgical trauma and the risk of adverse events because of the use of flexible drills and smaller drill diameters.

PURPOSE/HYPOTHESIS

The purpose was to biomechanically compare all-suture anchors and titanium suture anchors for distal biceps tendon repair in cadaveric specimens. The hypothesis was that all-suture anchors would show no differences in load to failure or displacement under cyclic loading compared with titanium suture anchors.

STUDY DESIGN

Controlled laboratory study.

METHODS

Sixteen unpaired, fresh-frozen human cadaveric elbows were randomized to 2 groups, which underwent onlay distal biceps tendon repair with 2 anchors. Bone mineral density at the radial tuberosity was evaluated in each specimen. In the first group, distal biceps tendon repair was performed using all-suture anchors. In the second group, titanium suture anchors were applied. After cyclic loading for 3000 cycles, the repair constructs were loaded to failure. The peak load to failure as well as repair construct stiffness and mode of failure were determined.

RESULTS

The mean (±SD) peak load was 293.53 ± 122.15 N for all-suture anchors and 280.02 ± 69.34 N for titanium suture anchors (P = .834); mean stiffness was 19.78 ± 2.95 N/mm and 19.30 ± 4.98 N/mm, respectively (P = .834). The mode of failure was anchor pullout for all specimens during load to failure. At the proximal position, all-suture anchors showed a displacement of 1.53 ± 0.80 mm, and titanium suture anchors showed a displacement of 0.81 ± 0.50 mm (P = .021) under cyclic loading. At the distal position, a displacement of 1.86 ± 1.04 mm for all-suture anchors and 1.53 ± 1.15 mm for titanium suture anchors was measured (P = .345). A positive correlation between bone mineral density and load to failure was observed (r = 0.605; P = .013).

CONCLUSION

All-suture anchors were biomechanically equivalent at time zero to titanium suture anchors for onlay distal biceps tendon repair. While the proximally placed all-suture anchors demonstrated greater displacement than titanium suture anchors, the comparable displacement at the distal position as well as the similar load and mechanism of failure make this difference unlikely to be clinically significant.

CLINICAL RELEVANCE

All-suture anchors performed similarly to titanium suture anchors for onlay distal biceps tendon repair at time zero and represent a reasonable alternative.

Surgical revision of radial head fractures: a multicenter retrospective analysis of 466 cases

BACKGROUND

Radial head fractures lead to persisting disability in a considerable number of cases. This study aimed to investigate their most common revision causes and procedures.

METHODS

This multicenter retrospective study reviewed the cases of 466 adult patients who had undergone surgical revision after operative or nonoperative treatment of a radial head fracture. The initial diagnosis was a Mason type I fracture in 13.0%, Mason type II fracture in 14.6%, Mason type III fracture in 22.8%, Mason type IV fracture in 20.9%, terrible-triad injury in 12.8%, Monteggia-like lesion in 13.1%, and Essex-Lopresti lesion in 2.0%. Initial treatment was nonoperative in 30.2%, open reduction and internal fixation (ORIF) in 44.9%, radial head arthroplasty in 16.6%, radial head resection in 3.7%, sole treatment of concomitant injuries in 2.6%, and fragment excision in 2.0%. Up to 3 revision causes and procedures were recorded per case.

RESULTS

The most common complications were stiffness (67.4%), instability (36.5%), painful osteoarthritis (29.2%), ORIF related (14.8%), nonunion or necrosis (9.2%), radial head arthroplasty related (7.5%), ulnar neuropathy (6.0%), and infection (2.6%). Revision procedures frequently included arthrolysis (42.1%), arthroplasty (24.9%), implant removal (23.6%), ligament repair or reconstruction (23.0%), débridement (14.2%), repeated ORIF (8.2%), and/or radial head resection (7.7%). Mason type I or II fractures were primarily revised because of stiffness and painful osteoarthritis. Complications after Mason type III fractures were predominantly ORIF related. Fracture-dislocations showed a wide range of complications, with instability and stiffness comprising the most common causes of revision.

CONCLUSIONS

The complications of radial head fractures are characteristic to their classification. Knowledge of these findings might guide surgeons in treating these injuries and may help counsel patients accordingly.

[Recurrent instability and instability arthropathy]

Capsulolabral reconstruction (Bankart repair) is recommended as the first line treatment in young and functionally demanding active patients with anteroinferior shoulder instability, due to the high tendency to recurrent dislocation. This has become established both for arthroscopic and open primary shoulder stabilization with good clinical outcome; nevertheless, recurrence of dislocation is reported in up to 25% of patients. Risk factors for failed surgery are patient (e.g. young age, male gender and contact sports) and surgery (e.g. primarily underestimated glenoid bone loss, Hill-Sachs lesion, non-treatment of bipolar defects or malpositioned anchors) related. In the management of recurrent instability, it is necessary to carry out a thorough clinical investigation in addition to extended diagnostics with X‑ray and computed tomography. A second Bankart repair is only indicated in patients with low demands and without any glenoid bone loss. In the majority of patients, bony augmentation of the glenoid is necessary and realized by coracoid or iliac crest bone block transfer. The Latarjet procedure is biomechanically advantageous due to the additional sling effect of the conjoined tendons and both techniques show good clinical outcomes and a low recurrence rate. Furthermore, engaging Hill-Sachs lesions also require additional treatment. Remplissage of the infraspinatus muscle, iliac crest bone block transfer and partial joint replacement are viable options. A final consensus for treatment of Hill-Sachs lesions has yet to be defined. Dislocation arthropathy is an underestimated complication as a result of frequent recurrent dislocations. After development of dislocation arthropathy, patients reported a painful restriction of range of motion rather than instability. Arthroscopic arthrolysis and comprehensive arthroscopic management (CAM procedure) are possible joint-preserving treatment options.

Proximal radius fracture morphology following axial force impact: a biomechanical evaluation of fracture patterns

Background

The most common location for articular fractures of the radial head is often reported to be the anterior lateral aspect of the radial head with the arm in neutral position. However, these findings mainly base on clinical observations rather than precise biomechanical measurements. The purpose of this study was to evaluate the formation of proximal radius fractures, the association between axial forces and fracture morphology, energy to failure and bone stiffness in a biomechanical in-vitro setup.

Methods

18 fresh-frozen cadaveric radii performed axial load compression with 10 mm/min loading until bone failure. Energy to failure and bone stiffness were recorded. Proximal radial head fracture morphology and affection of the anterolateral quadrant were optically analyzed.

Results

All radii survived a compression load of 500 N. The mean compressive forces that lead to failure were 2,56 kN (range 1,30 – 7,32). The mean stiffness was 3,5 kN/mm (range 2,0 – 4,9). 11 radial neck fractures and 7 radial neck and radial head multifragment fractures were documented. The anterolateral quadrant was involved in 78% of tested radii.

Conclusion

The anterolateral quadrant of the radial head (in neutral position of the forearm) is confirmed to be the most common location for articular radial head fractures in a biomechanical setting. In case of a fall on the outstretched arm radial neck fractures should be securely ruled out due to prior occurrence to radial neck and head fractures.

Fractures of the proximal ulna: current concepts in surgical management

Fractures of the proximal ulna range from simple olecranon fractures to complex Monteggia fractures or Monteggia-like lesions involving damage to stabilizing key structures of the elbow (i.e. coronoid process, radial head, collateral ligament complex).

In complex fracture patterns a computerized tomography scan is essential to properly assess the injury severity.

Exact preoperative planning for the surgical approach is vital to adequately address all fracture parts (base coronoid fragments first).

The management of olecranon fractures primarily comprises tension-band wiring in simple fractures as a valid treatment option, but modern plate techniques, especially in comminuted or osteoporotic fracture types, can reduce implant failure and potential implant-related soft tissue irritation.

For Monteggia injuries, the accurate anatomical restoration of ulnar alignment and dimensions is crucial to adjust the radiocapitellar joint.

Caution is advised if the anteromedial facet (anatomical insertion of the medial collateral ligament) of the coronoid process is affected, to avoid posteromedial instability.

Radial head reconstruction or replacement is essential in Monteggia-like lesions to restore normal elbow function.

The postoperative rehabilitation programme should involve active elbow motion exercises without limitations as early as possible following surgery to avoid joint stiffness.

Cite this article: EFORT Open Rev 2019;4:1-9. DOI: 10.1302/2058-5241.4.180022.