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Ben H, Kwak JM, Zeng CH, Koh KH, Jeon IH. Anterior radial head subluxation in primary elbow osteoarthritis. INTERNATIONAL ORTHOPAEDICS 2024; 48:809-815. [PMID: 38147072 DOI: 10.1007/s00264-023-06059-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/05/2023] [Indexed: 12/27/2023]
Abstract
PURPOSE To investigate elbows with primary osteoarthritis (OA) for the presence of anterior radial head subluxation. METHODS A total of 71 patients with elbow osteoarthritis and 45 with lateral epicondylitis were initially identified. The baseline characteristics and preoperative elbow X-rays of consecutive patients that had been clinically confirmed with elbow OA or lateral epicondylitis between March 2011 and January 2020 were then retrospectively reviewed. The radiocapitellar ratio (RCR; the ratio of the displacement of the radial head about the diameter of the capitulum) was calculated using lateral views. These RCR values were compared between the OA and lateral epicondylitis cases. RESULT A significant increase was detected in RCR values between patients in elbow OA and the control group (13.2% (± 10.6) vs -1.2% (± 6.8), P<0.001). Based on receiver operating characteristic curves, RCR values had an excellent area under the curve (0.89) for the detection of elbow OA (Youden index, 0.69; sensitivity, 89%; specificity, 80%). Based on the ROC curve, the cutoff value of RCR was 0.04. Patients with RCR ≥ 0.04 had a significantly higher proportion of cases with elbow OA (risk ratio, 31.50 [95% CI, 11.17-88.82]) than those with RCR ˂ 0.04 (P ˂ 0.001). CONCLUSION Radial head subluxation is a radiographic finding associated with elbow OA and RCR ≥ 0.04 could be used as an aetiological factor for elbow OA diagnosis.
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Affiliation(s)
- Hui Ben
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Jae-Man Kwak
- Department of Orthopedic Surgery, Uijeongbu Eulji Medical Center, Eulji University College of Medicine, Uijeongbu-si, Gyeonggi-do, South Korea
| | - Chu Hui Zeng
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kyoung-Hwan Koh
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - In-Ho Jeon
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.
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Liu W, Xiong H, Wang W, Chen S, Li F, Liu J, Yan H, Zhang J, Qian Y, Fan C. Effectiveness and safety of a less-invasive MCL reconstruction technique for contracted or ossified ligaments in patients with elbow stiffness: An open-label, non-randomised, prospective, multicentre trial in China. EClinicalMedicine 2022; 52:101616. [PMID: 36016695 PMCID: PMC9396044 DOI: 10.1016/j.eclinm.2022.101616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/13/2022] [Accepted: 07/25/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The elbow joint is sensitive to trauma from accidents, sports injuries, and surgical trauma. Some patients develop ossification or contracture of the medial collateral ligament (MCL) after elbow trauma. A less invasive reconstruction of the MCL can be performed after resection of diseased MCL. The biomechanical characteristics of this technique have been demonstrated and validated. However, its clinical effectiveness and safety require further confirmation in clinical practice. METHODS This open-label, non-randomised, prospective, multicentre trial included consecutive patients with elbow stiffness from five orthopaedic centres in China. Patients willing to participate in the study, with elbow stiffness caused by traumatic injury, who had reached skeletal maturity, and who had a range of motion of <100° were eligible for inclusion. Patients with immunological or metabolic causes of elbow stiffness, burns, or central nervous system injuries were excluded. In addition, patients who did not require MCL release and reconstruction after intraoperative release of other structures were also excluded. All patients underwent resection of the diseased MCL part in an open arthrolysis. Medial stability of the elbow was reconstructed using a less invasive MCL reconstruction technique that uses fascia and tendon patches. In this study, the primary outcomes, including stability, Mayo Elbow Performance Score (MEPS), Amadio score, were used to comprehensively evaluate this technique. Outcomes were assessed at 6 weeks, 6 months, and 1 year postoperatively and annually thereafter. This study reports the results of one arm of the trial that has been registered with the Chinese Clinical Trial Registry (chictr.org.cn), ChiCTR-INC-16010019. FINDINGS Between January 1, 2017 and March 1, 2020, 104 eligible patients were enrolled. The mean follow-up time was 43·47 (95% CI, 41·45 - 45·49) months. Among all 104 patients, 100 (96%) patients who underwent MCL reconstruction retained medial stability at the last follow-up. All outcomes from the last follow-up were used for comparison with the preoperative outcomes. No differences in preoperative and postoperative stability scores were observed (P = 0·7820). Extension, flexion, pronation, and supination of the injured elbow improved significantly (P < 0·0001, P < 0·0001, P < 0·0001, P < 0·0001). The mean range of motion (ROM) and forearm rotational range of motion (FRR) increased by 71·25° (152%) (P < 0·0001) and 30·83° (25%) (P < 0·0001), respectively. Additionally, the Mayo Elbow Performance Score (MEPS) and muscle strength had increased after evaluation at follow-ups (P < 0·0001, P < 0·0001). Drastic pain relief and nerve symptom reduction were observed, as evaluated using VAS scores and Amadio scores, respectively (P < 0·0001, P < 0·0001). Seventeen (16%) patients experienced a recurrence of elbow stiffness of varying severity, but only two patients had poor or fair results. Several common and non-severe complications, including infection in one (1%) patient, new nerve symptoms in seven (7%) patients, new pain in one (1%) patient, fracture in one (1%) patient, and valgus instability in four (4%) patients, were observed and properly treated in this study. INTERPRETATION The less invasive MCL reconstruction technique using fascia and tendon patches is an effective method for restoring medial stability in patients with elbow stiffness after complete arthrolysis with certain safety. The technique shows prospects for elbow MCL reconstruction in clinical practice. FUNDING The study was supported by the National Key Research and Development Program of China (No. 2021YFC2400805), National Natural Science Foundation of China (No. 81830076), Young Elite Scientist Sponsorship Program by Cast (No. YESS20200153), Shanghai Sailing Program (No. 20YF1436000), Shanghai Municipal Science and Technology Commission Foundation (No.19ZR1439200), Municipal Hospital Newly-developing Cutting-edge Technologies Joint Research Program of Shanghai Shenkang Hospital Development Centre (No. SHDC12018130).
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Affiliation(s)
- Wenjun Liu
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, PR China
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital South Campus, Shanghai Fengxian District Central Hospital, Shanghai, PR China
| | - Hao Xiong
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, PR China
- Shanghai Engineering Research Centre for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, PR China
| | - Wei Wang
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, PR China
- Shanghai Engineering Research Centre for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, PR China
| | - Shuai Chen
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, PR China
- Shanghai Engineering Research Centre for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, PR China
| | - Fengfeng Li
- Department of Orthopaedics, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, PR China
| | - Junjian Liu
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, PR China
| | - Hede Yan
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, PR China
| | - Jingwei Zhang
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital South Campus, Shanghai Fengxian District Central Hospital, Shanghai, PR China
- Corresponding authors.
| | - Yun Qian
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, PR China
- Shanghai Engineering Research Centre for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, PR China
- Corresponding authors.
| | - Cunyi Fan
- Department of Orthopaedics, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, PR China
- Shanghai Engineering Research Centre for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, PR China
- Corresponding authors.
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Jordan DB, Kharlamov A, Schimoler PJ, DeMeo PJ, Miller MC. Valgus fatigue and nonlinear damage accretion of the anterior bundle of the elbow medial collateral ligament (AMCL). J Biomech 2022; 137:111094. [PMID: 35489236 DOI: 10.1016/j.jbiomech.2022.111094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 11/29/2022]
Abstract
Failure by fatigue is one mechanism by which ligaments can rupture, with the accumulation of damage gradually degrading the ligament strength. Baseball pitchers who perform repeated high-level throwing continuously subject the medial ligament complex of the elbow to extreme levels of loading, which can lead to fatigue and eventual rupture. This study sought to investigate this behavior and quantify the fatigue properties of the anterior bundle of the medial collateral ligament (AMCL) with respect to valgus elbow torque. Eleven pairs of cadaveric elbow specimens were used for this study. One side of each pair was tested in vertical elongation at four flexion angles and then tested to failure at 90° of flexion. The contralateral specimens were tested in valgus fatigue at 90° of flexion using a specialized apparatus with application of known moments based on the elongation failure load. The average tensile failure load for the AMCL was 595.3 ± 201.9 N. During cycling, the average increase in the maximum valgus rotation angle was 4.77° ± 2.82°. The average maximum stretch of the AMCL middle band increased from 1.066 ± 0.017 to 1.076 ± 0.018 near the time of fatigue failure. The average cycles to failure for specimens tested at 90% and 80% of the estimated failure torque were 3211 ± 4721.33 and 25063 ± 30487.58, respectively. The nonlinear non-dimensional fatigue life and damage accretion results work in conjunction to predict the fatigue properties for a valgus elbow motion of arbitrary torque magnitude at 90° of elbow flexion.
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Affiliation(s)
| | | | - Patrick J Schimoler
- University of Pittsburgh, United States; Allegheny General Hospital, Pittsburgh, PA, United States
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Liu W, Xiong H, Chen S, Zhang J, Wang W, Qian Y, Fan C. Biomechanical Evaluation of a Low-Invasive Elbow Medial Collateral Ligament Reconstruction Technique With Fascia and Tendon Patches. Front Bioeng Biotechnol 2022; 10:831545. [PMID: 35392401 PMCID: PMC8980741 DOI: 10.3389/fbioe.2022.831545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/18/2022] [Indexed: 11/21/2022] Open
Abstract
Background: Injury to the medial collateral ligament (MCL) of the elbow has become increasingly common in sports, and the elbow is prone to contracture and ossification in trauma. Effective reconstruction of the MCL with reduction of irritation to the elbow has rarely been reported. This study introduces a minimally invasive elbow MCL reconstruction technique and evaluates the valgus stability. Methods: Eight fresh-frozen elbow specimens underwent reconstruction of the anterior bundle of the MCL (AMCL) first with the flexor carpi ulnaris fascia patches, followed by reconstruction of the posterior bundle of the MCL (PMCL) with the triceps tendon patches. The valgus angles of each specimen were examined in three stages as follows: intact MCL, reconstruction of the AMCL alone, and reconstruction of the MCL (including AMCL and PMCL). Finally, specimens were loaded to failure, and failure modes were recorded. Results: AMCL reconstruction alone had similar valgus stability at all testing angles (p = 0.080, 30° flexion; p = 0.064, 60° flexion; p = 0.151, 90° flexion; p = 0.283, 120° flexion) compared with the intact MCL, as did MCL reconstruction (p = 0.951, 30° flexion; p = 0.739, 60° flexion; p = 0.841, 90° flexion; p = 0.538, 120° flexion). More importantly, a significant difference existed between the MCL reconstruction and the AMCL reconstruction alone at 30° flexion (p = 0.043) and 60° flexion (p = 0.013) but not at the 90° flexion (p = 0.369) and 120° flexion (p = 0.879). The mean maximum failure torque of MCL reconstruction was 24.02 Nm at 90° elbow flexion. Conclusion: Both AMCL reconstruction alone and MCL reconstruction provided valgus stability comparable with the native MCL, and importantly, MCL reconstruction provided more valgus stability than AMCL reconstruction alone at 30° flexion and 60° flexion of the elbow. Therefore, the new MCL reconstruction technique might be a useful guide for the treatment of elbow MCL injuries or deficiencies.
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Affiliation(s)
- Wenjun Liu
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital South Campus, Shanghai, China
| | - Hao Xiong
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Shuai Chen
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
| | - Jingwei Zhang
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital South Campus, Shanghai, China
| | - Wei Wang
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
- *Correspondence: Wei Wang, ; Yun Qian, ; Cunyi Fan,
| | - Yun Qian
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
- *Correspondence: Wei Wang, ; Yun Qian, ; Cunyi Fan,
| | - Cunyi Fan
- Department of Orthopedics, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Shanghai Engineering Research Center for Orthopaedic Material Innovation and Tissue Regeneration, Shanghai, China
- *Correspondence: Wei Wang, ; Yun Qian, ; Cunyi Fan,
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Numaguchi K, Momma D, Matsui Y, Oohinata J, Yamaguchi T, Inoue N, Kondo E, Iwasaki N. Changes in elbow joint contact area in symptomatic valgus instability of the elbow in baseball players. Sci Rep 2021; 11:19782. [PMID: 34611207 PMCID: PMC8492740 DOI: 10.1038/s41598-021-99193-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 09/20/2021] [Indexed: 11/14/2022] Open
Abstract
The aim of this study was to evaluate the joint contact area of the dominant side and that of the non-dominant side without valgus instability in symptomatic pitchers. Ten symptomatic elbow medial ulnar collateral ligament (UCL) deficient baseball pitchers participated in this study. Computed tomography (CT) data from the dominant and non-dominant elbows were obtained with and without elbow valgus stress. The CT imaging data of each elbow joint were reconstructed using a 3D reconstruction software package, and the radiocapitellar and ulnohumeral joint contact areas were calculated. The center of the contact area and the translation from the position without stress to the position with valgus stress were also calculated. With elbow valgus stress, the contact area changed, and the center of the radiocapitellar joint contact area translated significantly more laterally in the dominant elbow than in the non-dominant elbow (p = 0.0361). In addition, the center of the ulnohumeral joint contact area translated significantly more posteriorly in the dominant elbow than in the non-dominant elbow (p = 0.0413). These changes in contact areas could be the reason for cartilage injury at the posterior trochlea in pitchers with UCL deficiency.
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Affiliation(s)
- Kyosuke Numaguchi
- Faculty of Medicine and Graduate School of Medicine, Department of Orthopaedic Surgery, Hokkaido University, Sapporo, Japan
| | - Daisuke Momma
- Center for Sports Medicine, Hokkaido University Hospital, Kita 14, Nishi 5, Sapporo, Hokkaido, 060-8638, Japan.
| | - Yuki Matsui
- Faculty of Medicine and Graduate School of Medicine, Department of Orthopaedic Surgery, Hokkaido University, Sapporo, Japan
| | | | | | - Nozomu Inoue
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, USA
| | - Eiji Kondo
- Center for Sports Medicine, Hokkaido University Hospital, Kita 14, Nishi 5, Sapporo, Hokkaido, 060-8638, Japan
| | - Norimasa Iwasaki
- Faculty of Medicine and Graduate School of Medicine, Department of Orthopaedic Surgery, Hokkaido University, Sapporo, Japan
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Study of intraarticular pressures in the elbow joints. J Biomech 2019; 97:109378. [DOI: 10.1016/j.jbiomech.2019.109378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 09/24/2019] [Accepted: 09/26/2019] [Indexed: 11/18/2022]
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Bellato E, Fitzsimmons JS, Kim Y, Bachman DR, Berglund LJ, Hooke AW, O'Driscoll SW. Articular Contact Area and Pressure in Posteromedial Rotatory Instability of the Elbow. J Bone Joint Surg Am 2018; 100:e34. [PMID: 29557868 DOI: 10.2106/jbjs.16.01321] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Joint incongruity in posteromedial rotatory instability (PMRI) has been theorized to determine early articular degenerative changes. Our hypothesis was that the articular contact area and contact pressure differ significantly between an intact elbow and an elbow affected by PMRI. METHODS Seven cadaveric elbows were tested under gravity varus stress using a custom-made machine designed to simulate muscle loads and allow passive elbow flexion (0° to 90°). The mean contact area and contact pressure data were collected and processed using the Tekscan sensor and software. After testing the intact specimen (intact elbow), a PMRI injury was simulated (PMRI elbow) and the specimen was tested again. RESULTS The PMRI elbows were characterized by initial joint subluxation and significantly elevated articular contact pressure. Both worsened, corresponding with a reduction in contact area, as the elbow was flexed from 0° until the joint subluxation and incongruity spontaneously reduced (at a mean [and standard error] of 60° ± 5° of flexion), at which point the mean contact pressure decreased from 870 ± 50 kPa (pre-reduction) to 440 ± 40 kPa (post-reduction) (p < 0.001) and the mean contact area increased from 80 ± 8 mm to 150 ± 58 mm (p < 0.001). This reduction of the subluxation was also followed by a shift of the contact area from the coronoid fracture edge toward the lower portion of the coronoid. At the flexion angle at which the PMRI elbows reduced, both the contact area and the contact pressure of the intact elbows differed significantly from those of the PMRI elbows, both before and after the elbow reduction (p < 0.001). CONCLUSIONS The reduction in contact area and increased contact pressures due to joint subluxation and incongruity could explain the progressive arthritis seen in some elbows affected by PMRI. CLINICAL RELEVANCE This biomechanical study suggests that the early degenerative changes associated with PMRI reported in the literature could be subsequent to joint incongruity and an increase in contact pressure between the coronoid fracture surface and the trochlea.
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Affiliation(s)
- Enrico Bellato
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Orthopedics and Traumatology, University of Turin Medical School, Turin, Italy
| | | | - Youngbok Kim
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Orthopedic Surgery, Haeundae Paik Hospital, Inje University, Busan, South Korea
| | - Daniel R Bachman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Abstract
Elbow pain is a frequent presenting symptom in athletes, particularly athletes who throw. The elbow can be injured as a result of acute trauma, such as a direct blow or a fall onto an outstretched hand or from chronic microtrauma. In particular, valgus extension overload during the throwing motion can precipitate a cascade of chronic injuries that can be debilitating for both casual and high-performance athletes. Prompt imaging evaluation facilitates accurate diagnosis and appropriate targeted interventions.
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Affiliation(s)
- Matthew D Bucknor
- From the Department of Radiology and Biomedical Imaging, University of California-San Francisco, 185 Berry St, Lobby 6, Suite 350, San Francisco, CA 94158
| | - Kathryn J Stevens
- From the Department of Radiology and Biomedical Imaging, University of California-San Francisco, 185 Berry St, Lobby 6, Suite 350, San Francisco, CA 94158
| | - Lynne S Steinbach
- From the Department of Radiology and Biomedical Imaging, University of California-San Francisco, 185 Berry St, Lobby 6, Suite 350, San Francisco, CA 94158
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Abstract
Radial head fractures are the most common fractures around the elbow. Because they are often accompanied by ligamentous injuries, we recommend considering them to be osteoligamentous injuries rather than simple fractures, even in undisplaced or minimally displaced fractures. Surgeons should always suspect and actively exclude concomitant ligament tears. The incidence of these associated injuries increases with greater severity of the radial head fracture. However, the standard Mason classification system does not adequately address this problem, and all attempts to establish a new classification system that provides concise treatment algorithms have failed. This article discusses the current treatment options and the current controversies in nonsurgical therapy, open reduction and internal fixation (ORIF) and radial head replacement.
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Affiliation(s)
- Klaus Josef Burkhart
- Department for Shoulder Surgery, Rhön-Clinic, Bad Neustadt, Salzburger Leite 1, 97616 Bad Neustadt/Saale, Germany.
| | - Kilian Wegmann
- Department for Trauma, Hand and Elbow Surgery, University of Cologne, Kerpener Straße 62, 50937 Köln, Germany
| | - Lars P Müller
- Department for Trauma, Hand and Elbow Surgery, University of Cologne, Kerpener Straße 62, 50937 Köln, Germany
| | - Frank E Gohlke
- Department for Shoulder Surgery, Rhön-Clinic, Bad Neustadt, Salzburger Leite 1, 97616 Bad Neustadt/Saale, Germany
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