Publications by authors named "Markus Scheibel"

130 Publications

[Treatment of subscapularis tendon lesions].

Unfallchirurgie (Heidelb) 2022 Aug 9. Epub 2022 Aug 9.

Klinik für Schulter- und Ellbogenchirurgie, Schulthess Klinik Zürich, Lengghalde 2, 8008, Zürich, Schweiz.

The further development of minimally invasive techniques in recent years, enables adequate intraoperative visualization, mobilization and stable reconstruction even of larger subscapularis tears resulting in good to excellent clinical and structural results. Chronic tears of the subscapularis tendon with high grade muscle atrophy and advanced fatty infiltration can be treated with a muscle tendon transfer (e.g. pectoralis major or latissimus dorsi transfer). If pseudoparalysis and/or signs of anterosuperior decentration of the humeral head or defect arthropathy are present, in most cases a reverse shoulder arthroplasty represents the only surgical option.
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http://dx.doi.org/10.1007/s00113-022-01221-9DOI Listing
August 2022

[Anatomical fracture endoprosthesis-who and how?]

Unfallchirurgie (Heidelb) 2022 Jul 14. Epub 2022 Jul 14.

Schulter- und Ellbogenchirurgie, Schulthess Klinik, Lengghalde 2, 8008, Zürich, Schweiz.

The aim of this review article is to present the indications for an anatomical fracture prosthesis, mostly as a shoulder hemiprosthesis (SHEP) and its value in comparison to other procedures. The healing of the tuberosities in the anatomical position and an intact rotator cuff are particularly important for the successful implantation of a SHEP after proximal humeral fractures. For older patients (> 70 years), the use of reverse shoulder arthroplasty achieves more reliable results and is associated with a lower revision rate. The indications for implantation of a SHEP in non-reconstructible proximal humeral fractures, usually with a head split, should be carefully considered and can be used in cases with well-preserved large tuberosities and in younger patients. Complications of SHEP, such as secondary rotator cuff insufficiency, tuberosity dislocation or resorption and secondary glenoid wear, can be treated using a conversion or a change to reverse shoulder arthroplasty.
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http://dx.doi.org/10.1007/s00113-022-01212-wDOI Listing
July 2022

[Anatomy and diagnostics of subscapularis tendon lesions].

Unfallchirurgie (Heidelb) 2022 Aug 11;125(8):647-658. Epub 2022 Jul 11.

Klinik für Schulter- und Ellbogenchirurgie, Schulthess Klinik Zürich, Lengghalde 2, 8008, Zürich, Schweiz.

Among lesions of the rotator cuff, subscapularis tendon tears are one of the less common injuries and mostly occur in combination with additional lesions of the posterosuperior rotator cuff and the long biceps tendon. If a subscapularis tendon rupture is suspected in the initial clinical testing, the primary diagnostics should include modern cross-sectional magnetic resonance imaging to assess the tendon lesion and to detect concomitant pathologies. Nevertheless, subscapularis tendon lesions are often initially overlooked and first correctly diagnosed during shoulder arthroscopy.
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http://dx.doi.org/10.1007/s00113-022-01207-7DOI Listing
August 2022

Arthroscopically Assisted Stabilization of Chronic Acromioclavicular Joint Instability.

JBJS Essent Surg Tech 2021 Oct-Dec;11(4). Epub 2021 Nov 8.

Department of Shoulder and Elbow Surgery, Schulthess Clinic, Zurich, Switzerland.

This video article demonstrates biological and synthetic acromioclavicular (AC) and coracoclavicular stabilization with use of a hamstring tendon graft and a low-profile TightRope implant (Arthrex). The low-profile TightRope reduces soft-tissue irritation due to knot stacks. The tendon graft is wrapped around the clavicle and the coracoid to avoid weakening of the osseous structures as a result of clavicular and coracoidal tunnel placement.

Description: For this procedure, the patient is placed in the beach chair position. After establishing standard posterior, anteroinferior, and anterolateral (transtendinous) portals, the arthroscopic preparation of the coracoid base is performed. Next, transcoracoidal-transclavicular drilling is performed, and a nitinol suture passing wire is utilized to aid the placement of the TightRope later in the procedure. The graft passage around the clavicle and the coracoid is then set up by placing 2 additional nitinol suture passing wires. Following this, coracoclavicular stabilization is performed with use of the low-profile TightRope device, after which the graft is shuttled around the clavicle and the coracoid with the help of the passing wires. After the acromial drilling, the graft is shuttled laterally transacromially and subcutaneously back to the clavicle, completing the AC cerclage. Finally, the graft ends are sewn together under tension. The deltotrapezial fascia is closed above the graft, incorporating the tendon ends into the suture. Finally, the skin can be closed.

Alternatives: In case of chronic AC joint injuries, many surgical stabilization techniques have been described. On the one hand there are rigid stabilization techniques like the hook-plate or temporary Kirschner wire fixation. On the other hand, there are dynamic stabilization techniques like the modified Weaver-Dunn procedure or solitary synthetic coracoclavicular reconstruction with use of pulley-like devices, with or without additional AC stabilization. As for nonsurgical alternatives, physiotherapy with periscapular stabilization and muscle strengthening may be an option.

Rationale: For the treatment of chronic AC joint instability, many techniques have been described that utilized horizontal and vertical stabilization with a tendon graft combined with a synthetic pulley-like device. Usually, multiple transclavicular and transcoracoidal drill holes are utilized for the graft passage, which could weaken the bone and may result in postoperative fractures of the coracoid and clavicle. Considering this, we present a modified technique that focuses on the optimization of the graft passage. In contrast to other aforementioned techniques, this procedure requires only 1 transcoracoidal-transclavicular tunnel for the TightRope and another transacromial tunnel for the passage of the AC cerclage. By forming a loop of the graft around the coracoid and the clavicle, the graft passage is managed without any additional coracoidal or clavicular drilling.

Expected Outcomes: A dedicated study investigating the specific clinical and radiographic results of our technique will be part of future research. Because the biomechanical principle of reconstruction of our technique is very similar to the technique described by Kraus et al., we refer to their clinical and radiographic results regarding the expected outcome. As shown in the chart in the video, Kraus et al. demonstrated good clinical and radiographic results with their biologic and synthetic AC-stabilization technique at a median follow-up of 24 months. The outcomes measured in that study were the Constant score, Subjective Shoulder Value, AC Joint Instability Score, and Taft score. Patients were divided into 2 groups. Group 1 included patients with failed prior conservative treatment, and group 2 included those with failed prior surgical treatment. Overall, the authors report complete dynamic posterior translation in 1 patient and partial dynamic posterior translation in 5 patients. Although there was no notable enlargement of the TightRope drill hole, the authors of that study found a significant enlargement of the clavicular graft tunnels. However, the enlargement had no clinical relevance.

Important Tips: Utilize a low-profile TightRope device to minimize the risk of suture irritation from knot stacks.The tendon graft should be ≥24 cm in length. If the graft is too short, perform an end-to-end anastomosis of 2 grafts.Utilize an image intensifier to ensure correct drill hole placement and avoid damage to neurovascular structures.The graft passage around the clavicle and the coracoid can be dilated by hand with the use of differently sized drill bits.Incorporate the graft into fascial closure at the end of the procedure.
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http://dx.doi.org/10.2106/JBJS.ST.20.00033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9173557PMC
November 2021

Reverse Shoulder Arthroplasty for Proximal Humerus Head-Split Fractures-A Retrospective Cohort Study.

J Clin Med 2022 May 17;11(10). Epub 2022 May 17.

Center for Musculoskeletal Surgery, Charité-Universitaetsmedizin, 13353 Berlin, Germany.

Head-split fractures are proximal humerus fractures (PHF) that result from fracture lines traversing the articular surface. While head-split fractures are rare, surgical treatment of these complex injuries can be extremely challenging and is associated with high rates of complications. Treatment using primary reverse shoulder arthroplasty (RSA) has been associated with moderate complication rates and reproducible clinical results. The aim of this study was to evaluate clinical and radiographic outcomes, and complication rates of RSA for head-split PHF. Twenty-six patients were evaluated based on Constant Score (CS) and range of motion of both shoulders and Subjective Shoulder Value (SSV). Radiographic analysis evaluated tuberosity healing, prosthetic loosening and scapular notching. Patients achieved good clinical results with a CS of 73.7 points and SSV of 82% after a mean follow-up of 50 months. The relative CS comparing operated versus the unaffected shoulder was 92%. Greater tuberosity healing was achieved in 61%. Patients who suffered a high-energy trauma reached a significantly greater functional outcome. Patients who suffered multifragmentation to the humeral head performed the worst. There were no cases of loosening; scapular notching was visible in two cases. The complication rate was 8%. RSA is an adequate treatment option with for head-split PHF in elderly patients.
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http://dx.doi.org/10.3390/jcm11102835DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9145800PMC
May 2022

Clinical outcomes after refixation of subacute repaired distal biceps tendon ruptures.

JSES Int 2022 May 25;6(3):523-529. Epub 2022 Jan 25.

Center for Musculoskeletal Surgery, Charité - University of Berlin, Berlin, Germany.

Background: The aim of this study was to evaluate the clinical outcome and complication spectrum after delayed repair surgery of distal biceps tendon ruptures, postulating that satisfactory results are possible contrary to previous literature.

Methods: Forty-three of 92 patients with a full workup (= OPT in) undergoing primary distal biceps tendon repair were included in this study. The mean age of participants was 49.5 years (range = 22-66 years). This cohort was divided into two groups: patients undergoing acute repair (<21 days = AR group) and a group with delayed intervention (>21 days = SR group). Beside clinical evaluation, functional scores and detection of heterotopic ossification were documented. Strength of flexion and supination were measured using a BIODEX multipoint system. In addition, thirty-one patients were included only in the evaluation of complications in the absence of consent for clinical examination (= OPT out).

Results: Concerning the OPT-in group, twenty-eight patients (ø age = 48.9 years; 22-63 years) received acute repair after an average of 9.2 ± 3.7 days. On the contrary, 15 patients (ø age = 50.5 years; 32-66 years) were treated with a delay after an average of 31.4 ± 10.4 days. Regarding patient-reported outcome measures, conflicting results emerge (AR/SR: Subjective Elbow Value = 87/80%,  > .05; Mayo score = 96/93 pts,  > .05; the Disabilities of the Arm, Shoulder and Hand score = 6/13 pts,  < .05; and Oxford Elbow Score = 44/39 pts,  < .05). The main complication is the paresthesia of the lateral antebrachial cutaneous nerve, which occurs more in the group of delayed repair (AR: 21.0%, SR 31.8%). Forty-one percentage of patients in the SR group described pain in the elbow with exertion in contrast to 17.3% in the AR group. In terms of elbow strength, no significant difference in the AR or SR group compared with the contralateral side could be observed.

Conclusion: The data suggest that delayed repair of distal biceps ruptures beyond 3 weeks may result in satisfactory clinical outcomes. However, exertional pain and paresthesia of the lateral antebrachial cutaneous nerve may diminish results.
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http://dx.doi.org/10.1016/j.jseint.2021.12.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9091753PMC
May 2022

Dislocation Arthropathy of the Shoulder.

J Clin Med 2022 Apr 4;11(7). Epub 2022 Apr 4.

Department of Shoulder and Elbow Surgery, Schulthess Clinic Zurich, 8008 Zurich, Switzerland.

Glenohumeral osteoarthrosis (OA) may develop after primary, recurrent shoulder dislocation or instability surgery. The incidence is reported from 12 to 62%, depending on different risk factors. The risk of severe OA of the shoulder following dislocation is 10 to 20 times greater than the average population. Risk factors include the patient's age at the first episode of instability or instability surgery, bony lesions, and rotator cuff tears. For mild stages of OA, arthroscopic removal of intraarticular material, arthroscopic debridement, or arthroscopic arthrolysis of an internal rotation contracture might be sufficient. For severe stages, mobilization of the internal rotation contracture and arthroplasty is indicated. With an intact rotator cuff and without a bone graft, results for anatomical shoulder arthroplasty are comparable to those following primary OA. With a bone graft at the glenoidal side, the risk for implant loosening is ten times greater. For the functional outcome, the quality of the rotator cuff is more predictive than the type of the previous surgery or the preoperative external rotation contracture. Reverse shoulder arthroplasty could be justified due to the higher rate of complications and revisions of non-constrained anatomic shoulder arthroplasties reported. Satisfactory clinical and radiological results have been published with mid to long term data now available.
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http://dx.doi.org/10.3390/jcm11072019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8999818PMC
April 2022

Metallic humeral and glenoid lateralized implants in reverse shoulder arthroplasty for cuff tear arthropathy and primary osteoarthritis.

JSES Int 2022 Mar 14;6(2):221-228. Epub 2021 Dec 14.

Department of Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Charité-Universitaetsmedizin Berlin, Berlin, Germany.

Background: Metallic humeral and glenoid lateralized implants have been developed to prevent common problems that can emerge using Grammont's concept (ie, medialization of center of rotation, decreased humeral offset, scapular notching) in reverse shoulder arthroplasty. The purpose of this study was to evaluate the clinical and radiological results of metallic humeral and glenoid lateralized implants for cuff tear arthropathy (CTA) and primary osteoarthritis (OA).

Methods: In this prospective study, patients with CTA or OA who underwent reverse shoulder arthroplasty using augmented base plates for glenoid lateralization and a "curved stem" design for the humeral side were included. The Constant-Murley score and Subjective Shoulder Value were documented at 1- and 2-year follow-ups. Radiographs were reviewed for scapular notching, instability, loosening, osteolysis, ossification, bone resorption, or fractures. Lateralization and distalization shoulder angles were evaluated at the final follow-up.

Results: There were 23 patients with CTA and 19 patients with OA (27 women; mean age, 76 years; range, 59-85) available for examination at 2 years. Both groups increased significantly in all outcome measures compared with baseline ( < .01). Although patients with OA generally had lower baseline scores, the outcome scores were similar and did not show any statistically significant differences. The mean Constant-Murley score and Subjective Shoulder Value at the final follow-up were 78 points (standard deviation [SD] 10) and 84% (SD 11) for patients with CTA, respectively, and corresponding values were 80 points (SD 16) and 92% (SD 12) for the OA group. No scapular notching was observed. The mean value of the lateralization shoulder angle was 81.5° (SD 9.7) and for the distalization shoulder angle was 54.8° (SD 9.4). Neither scapular spine fractures nor instability was observed in this patient cohort.

Conclusion: Metallic humeral and glenoid lateralization achieves excellent clinical results in terms of shoulder function, pain relief, muscle strength, and patient-reported subjective assessment without instability or radiographic signs of scapular notching. Patients with primary OA showed an overall trend toward better clinical improvement than patients with CTA.
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http://dx.doi.org/10.1016/j.jseint.2021.10.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8888182PMC
March 2022

Subacromial Bursa: A Neglected Tissue Is Gaining More and More Attention in Clinical and Experimental Research.

Cells 2022 02 14;11(4). Epub 2022 Feb 14.

Julius Wolff Institute, Berlin Institute of Health at Charité-Universitaetsmedizin Berlin, 13353 Berlin, Germany.

The subacromial bursa has long been demolded as friction-reducing tissue, which is often linked to shoulder pain and, therefore, partially removed during shoulder surgery. Currently, the discovery of the stem cell potential of resident bursa-derived cells shed a new light on the subacromial bursa. In the meanwhile, this neglected tissue is gaining more attention as to how it can augment the regenerative properties of adjacent tissues such as rotator cuff tendons. Specifically, the tight fibrovascular network, a high growth factor content, and the large progenitor potential of bursa-derived cells could complement the deficits that a nearby rotator cuff injury might experience due to the fact of its low endogenous regeneration potential. This review deals with the question of whether bursal inflammation is only a pain generator or could also be an initiator of healing. Furthermore, several experimental models highlight potential therapeutic targets to overcome bursal inflammation and, thus, pain. More evidence is needed to fully elucidate a direct interplay between subacromial bursa and rotator cuff tendons. Increasing attention to tendon repair will help to guide future research and answer open questions such that novel treatment strategies could harvest the subacromial bursa's potential to support healing of nearby rotator cuff injuries.
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http://dx.doi.org/10.3390/cells11040663DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8870132PMC
February 2022

Surgical treatment of a symptomatic os acromiale by arthroscopy-assisted double-button fixation: a case report.

Arch Orthop Trauma Surg 2022 Jan 21. Epub 2022 Jan 21.

Department of Shoulder and Elbow Surgery, Schulthess Clinic, Zurich, Switzerland.

Case: We present the case of a symptomatic os acromiale in a 51-year-old female patient. Arthroscopy-assisted treatment was performed using a double-button fixation system and additional suture cerclage. The patient presented with complete radiographic bone union, pain relief, improved range of motion and did not require hardware removal at the 12-month follow-up.

Conclusion: The achievement of persistent consolidation between the two fragmented bone surfaces, without further need for hardware removal and improved clinical outcome, suggests that our minimally invasive technique is appropriate for this specific indication. To our knowledge, this technique has not been described in the literature yet.
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http://dx.doi.org/10.1007/s00402-022-04341-4DOI Listing
January 2022

Two-Stage Exchange Arthroplasty for Periprosthetic Shoulder Infection Is Associated with High Rate of Failure to Reimplant and Mortality.

J Clin Med 2021 Nov 6;10(21). Epub 2021 Nov 6.

Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlind, Charitéplatz 1, 10117 Berlin, Germany.

Background: Patients with a periprosthetic joint infection (PJI) of the shoulder, who fail to undergo reimplantation in an attempted two-stage exchange seem to be neglected in the current literature. The aim of this study was to assess the clinical course of patients after the first stage in the process of an attempted two-stage exchange for shoulder PJI.

Methods: After a retrospective review of our institutional database between 2008 and 2018, 49 patients, who were treated with an intended two-stage exchange for shoulder PJI, were identified. Patients' demographics, laboratory and health status parameters, along with records of clinical outcome were collected. The primary outcome measurements analyzed were infection eradication, successful reimplantation, and patient survival.

Results: Reimplantation was completed in only 35 (71%) of 49 cases and eradication of infection was achieved in 85.7% of patients with successful reimplantation after a mean follow-up duration of 5.1 years (1.1 to 10.2 years). Reasons for failure to reimplant were premature death in 36%, high general morbidity in 29%, satisfaction with the current status in 21%, or severe infection with poor bone and soft tissues in 14% of the patients. Of the 14 cases without reimplantation, eradication rate of infection was 57% after a mean follow-up of 5 years (2.6 to 11 years). The overall mortality rate of the entire cohort was 25% at the latest follow-up and 10% within ninety days after implant removal. Patients who deceased or did not undergo reimplantation during the follow-up were significantly older and had a significantly higher Charlson comorbidity index (CCI).

Conclusions: While the two-stage exchange arthroplasty can lead to high rates of infection eradication, a considerable subset of patients never undergoes the second stage for a variety of reasons. Shoulder PJI and its treatment are associated with a high risk of mortality, especially in patients with older age and higher CCI.
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http://dx.doi.org/10.3390/jcm10215186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8584704PMC
November 2021

Mid- to long-term results of postoperative immobilization in internal vs. external rotation after arthroscopic anterior shoulder stabilization.

JSES Int 2021 Nov 3;5(6):960-966. Epub 2021 Sep 3.

Center for Musculoskeletal Surgery, Department for Shoulder and Elbow Surgery, Charité-Universitaetsmedizin Berlin, Berlin, Germany.

Background: There is still a disagreement on the postoperative rehabilitation concerning position of immobilization of the shoulder after arthroscopic anterior shoulder stabilization and its influence on the clinical outcome. The aim of this study was to evaluate the clinical results and the recurrence rate after arthroscopic anteroinferior shoulder stabilization and postoperative immobilization in internal rotation vs. external rotation.

Methods: Twenty-five patients (22 male and 3 female, mean age 28.5 years) were included in this prospective nonrandomized cohort study. In group I (11 male, 2 female, mean age 28 years), the postoperative functional immobilization was carried out in internal rotation of 60°, and in group II (11 male, 1 female, mean age 30 years), 15° of external rotation of the arm for 4 weeks in both groups. The clinical follow-up was performed at 2, 4, and 6 weeks as well as at 3, 6, and 12 months postoperatively including assessment of range of motion and functional shoulder scores (Subjective Shoulder Value, Constant score, Rowe score, Walch Duplay score, Melbourne Instability Shoulder Score). Furthermore, shoulder instability was evaluated using the apprehension, relocation, and surprise tests. Mid-term follow-up data were additionally assessed after a minimum of 4 years.

Results: Twenty patients (19 male and 1 female) with an average age of 28 years were followed up for 62 (53-72) months after arthroscopic stabilization. The comparison of both groups showed almost equal results regarding the range of motion without any significant differences ( > .05). The evaluation of the shoulder function scores also showed no significant differences with an average Subjective Shoulder Value of 95% vs. 91%, Constant score of 89 vs. 88 points, Rowe score of 96 vs. 94 points, Walch Duplay score of 86 vs. 89 points, Melbourne Instability Shoulder Score of 96 points, and Western Ontario Shoulder Instability Index of 88% vs. 84% ( > .05). There was no recurrent dislocation in both groups.

Conclusion: The type of immobilization after arthroscopic shoulder stabilization does not influence the clinical results after a mid- to long-term follow-up.
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http://dx.doi.org/10.1016/j.jseint.2021.07.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8568811PMC
November 2021

Histological and molecular features of the subacromial bursa of rotator cuff tears compared to non-tendon defects: a pilot study.

BMC Musculoskelet Disord 2021 Oct 14;22(1):877. Epub 2021 Oct 14.

Julius Wolff Institute, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, 13353, Berlin, Germany.

Background: The role of the subacromial bursa in the development or healing of shoulder pathologies is unclear. Due to this limited knowledge, we aimed to understand specific reactions of the subacromial bursa according to rotator cuff (RC) pathologies compared to non-tendon defects of the shoulder. We hypothesized that the tissue composition and inflammatory status of the bursa are likely to vary between shoulder pathologies depending on the presence and the extent of RC lesion.

Method: Bursa samples from patients with either 1) shoulder instability with intact RC (healthy bursa, control), 2) osteochondral pathology with intact RC, 3) partial supraspinatus (SSP) tendon tear, or 4) full-thickness SSP tear were investigated histologically and on gene expression level.

Result: Bursae from SSP tears differed from non-tendon pathologies by exhibiting increased chondral metaplasia and TGFβ1 expression. MMP1 was not expressed in healthy bursa controls, but strongly increased with full-thickness SSP tears. Additionally, the expression of the inflammatory mediators IL1β, IL6, and COX2 increased with the extent of SSP tear as shown by correlation analysis. In contrast, increased angiogenesis and nerve fibers as well as significantly upregulated IL6 and COX2 expression were features of bursae from patients with osteochondral pathology. Using immunohistochemistry, CD45+ leukocytes were observed in all examined groups, which were identified in particular as CD68+ monocytes/macrophages.

Conclusion: In summary, besides the strong increase in MMP1 expression with SSP tear, molecular changes were minor between the investigated groups. However, expression of pro-inflammatory cytokines correlated with the severity of the SSP tear. Most pronounced tissue alterations occurred for the osteochondral pathology and full-thickness SSP tear group, which demonstrates that the bursal reaction is not exclusively dependent on the occurrence of an SSP tear rather than longstanding degenerative changes. The present bursa characterization contributes to the understanding of specific tissue alterations related to RC tears or non-tendon shoulder pathologies. This pilot study provides the basis for future studies elucidating the role of the subacromial bursa in the development or healing of shoulder pathologies.
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http://dx.doi.org/10.1186/s12891-021-04752-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8518155PMC
October 2021

Lateralized vs. classic Grammont-style reverse shoulder arthroplasty for cuff deficiency Hamada stage 1-3: does the design make a difference?

J Shoulder Elbow Surg 2022 Feb 25;31(2):341-351. Epub 2021 Aug 25.

Shoulder and Elbow Surgery, Schulthess Clinic, Zurich, Switzerland; Charité-Universitaetsmedizin Berlin, Berlin, Germany. Electronic address:

Background: Reverse shoulder arthroplasty (RSA) with a lateralized design is thought to improve outcomes. Our aim was to compare RSA with the classic Grammont prosthesis against a prosthesis with 135° inclination and a lateralized glenosphere for cuff-deficient shoulders.

Methods: Patients with irreparable massive posterosuperior rotator cuff tear Hamada grade 1-3 underwent RSA and were documented prospectively up to 24 months postsurgery. Comparative RSA groups were "lateralized" (L), with 135° humeral inclination and 36+4-mm lateralized glenosphere (n = 44), and "Grammont" (G), with 155° humeral inclination and 36+2-mm eccentric glenosphere (n = 23). Range of motion including the Apley scratch test, abduction strength, Constant-Murley score (CS), and Shoulder Pain and Disability Index (SPADI) were assessed. Anteroposterior and axial radiographs were evaluated at 24 months, and additional measurements of scapular neck and glenoid anatomy, baseplate and glenosphere position, center of rotation, humeral offset, and lateralization and distalization shoulder angles were made. Linear regression and mixed models adjusted for sex differences and preoperative values were applied.

Results: Overall CS and SPADI outcomes were not significantly different between groups (P ≥ .654). For group L, external rotation remained stable up to the 2-year follow-up and was higher than for group G (P = .012 ); a greater proportion of group L patients could reach the lumbar vertebra 3 (L3) (70% vs. 48% in group G) (P = .26). Group G had a higher inferior glenosphere overhang (P = .020) and center of rotation (COR) medialization (P < .001), whereas group L had higher humeral offset (P < .001) and lateralization shoulder angle (P < .001) with a trend toward higher baseplate positioning (P = .045). The rate of scapular notching was 2.9 times higher for group G than group L (P = .001).

Conclusion: RSA with 135° humeral inclination and a lateralized glenosphere shows similar outcome scores as the classic Grammont design but enables better preservation of external rotation and reduces the rate of scapular notching compared with the classic Grammont design in Hamada 1-3 patients with irreparable posterosuperior tears.
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http://dx.doi.org/10.1016/j.jse.2021.07.022DOI Listing
February 2022

Minced Cartilage Procedure for One-Stage Arthroscopic Repair of Chondral Defects at the Glenohumeral Joint.

Arthrosc Tech 2021 Jul 20;10(7):e1677-e1684. Epub 2021 Jun 20.

Schulthess Clinic, Zurich, Switzerland.

Chondral defects of the glenohumeral joint are common but still remain a diagnostic and management challenge. Whereas arthroplasty is a reasonable treatment option in the elderly and low-demand population, joint preservation should be aimed for the remaining patients. For larger defects the current gold standard of treatment is autologous chondrocyte implantation. However, disadvantages such as high cost, the restriction in availability of specialized laboratories, and the 2-stage surgical design need to be accounted for if choosing this option. Showing first good clinical results for the knee joint, minced cartilage implantation is moreover a cost-effective procedure bringing autologous cartilage chips harvested from the defect walls and bringing them into the area of damage in a single-step open or arthroscopic approach. We describe an arthroscopic strategy of this technique to treat chondral defects at the glenohumeral joint.
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http://dx.doi.org/10.1016/j.eats.2021.03.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8322290PMC
July 2021

Prediction of Shoulder Stiffness After Arthroscopic Rotator Cuff Repair.

Am J Sports Med 2021 09 26;49(11):3030-3039. Epub 2021 Jul 26.

Shoulder and Elbow Surgery, Schulthess Clinic, Zurich, Switzerland.

Background: Postoperative shoulder stiffness (POSS) is a prevalent adverse event after arthroscopic rotator cuff repair (ARCR) that is associated with major limitations in everyday activities and prolonged rehabilitation.

Purpose/hypothesis: The purpose was to develop a predictive model for determining the risk of POSS within 6 months after primary ARCR. We hypothesized that sufficient discrimination ability of such a model could be achieved using a local institutional database.

Study Design: Case-control study; Level of evidence, 3.

Methods: Consecutive primary ARCRs documented in a local clinical registry between 2013 and 2017 were included, and patients who experienced POSS before the final clinical 6-month follow-up were identified. A total of 29 prognostic factor candidates were considered, including patient-related factors (n = 7), disease-related factors (n = 9), rotator cuff integrity factors (n = 6), and operative details (n = 7). We used imputed data for the primary analysis, and a sensitivity analysis was conducted using complete case data. Logistic regression was applied to develop a model based on clinical relevance and statistical criteria. To avoid overfitting in the multivariable model, highly correlated predictors were not included together in any model. A final prognostic model with a maximum of 8 prognostic factors was considered. The model's predictive accuracy was assessed by the area under the receiver operating characteristic curve (AUC). Internal validation was performed using bootstrapping.

Results: Of 1330 ARCR cases (N = 1330 patients), 112 (8.4%) patients had POSS. Our final model had a moderate predictive ability with an AUC of 0.67. The predicted risks of POSS ranged from 2.3% to 38.9% and were significantly higher in women; patients with partial tears, low baseline passive shoulder abduction, and lack of tendon degeneration; and when no acromioplasty was performed.

Conclusion: A prognostic model for POSS was developed for patients with ARCR, offering a personalized risk evaluation to support the future decision process for surgery and rehabilitation.
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http://dx.doi.org/10.1177/03635465211028980DOI Listing
September 2021

Nonoperative and Operative Soft-Tissue, Cartilage, and Bony Regeneration and Orthopaedic Biologics of the Shoulder: An Orthoregeneration Network (ON) Foundation Review.

Arthroscopy 2021 10 20;37(10):3200-3218. Epub 2021 Jul 20.

Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A.. Electronic address:

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electro-magnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the shoulder including the rotator cuff tendons, glenohumeral articular cartilage, glenoid labrum, the joint capsule, and bone. Promising and established treatment modalities include hyaluronic acid (HA); platelet-rich plasma (PRP) and platelet rich concentrates (PRC); bone marrow aspirate (BMA) comprising mesenchymal stromal cells (MSCs alternatively termed medicinal signaling cells and frequently, misleadingly labelled "mesenchymal stem cells"); MSC harvested from adipose, umbilical, or placental sources; factors including vascular endothelial growth factors (VEGF), basic fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), transforming growth factor-beta (TGFβ), bone morphogenic protein (BMP), and matrix metalloproteinases (MMPs); prolotherapy; pulsed electromagnetic field therapy; microfracture and other marrow-stimulation techniques; biologic resurfacing using acellular dermal allografts, allograft Achilles tendons, allograft lateral menisci, fascia lata autografts, and porcine xenografts; osteochondral autograft or allograft); and autologous chondrocyte implantation (ACI). Studies involving hyaluronic acid, platelet rich plasma, and medicinal signaling cells of various origin tissues have shown mixed results to-date as isolated treatments and as surgical adjuncts. Despite varied results thus far, there is great potential for improved efficacy with refinement of current techniques and translation of burgeoning preclinical work. LEVEL OF EVIDENCE: Level V, expert opinion.
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http://dx.doi.org/10.1016/j.arthro.2021.06.033DOI Listing
October 2021

Arthroscopic Knotless-Anchor Rotator Cuff Repair.

JBJS Essent Surg Tech 2020 Jul-Sep;10(3). Epub 2020 Sep 18.

Schulthess Klinik, Zurich, Switzerland.

The most common type of rotator cuff lesion is a tear of the supraspinatus tendon, with arthroscopic rotator cuff repair representing an established treatment option. Several double-row techniques have been described to achieve complete coverage of the rotator cuff footprint. Among these is the bridging, double-row, transosseous-equivalent rotator cuff repair, which has become one of the most popular techniques for its maximized contact area and initial fixation strength. However, medial cuff failure is a common complication following this procedure. To reduce medial strangulation and overall surgical time, all-knotless anchor repair has been introduced as an alternative technique. The arthroscopic knotless, bridging, double-row, transosseous-equivalent technique is performed with the patient in the beach-chair position via lateral operative and viewing portals. A medial row of suture anchors is placed in the usual fashion. The tendon is then perforated twice per anchor with use of a suture-passer device, after which the suture limbs are bridged over the tendon and fixed in a lateral row of anchors. Excellent functional outcomes as well as satisfaction in >90% of patients have been reported with the supraspinatus knotted double-row, bridging, transosseous-equivalent repair. No significant differences have been reported for clinical results and tendon integrity on magnetic resonance imaging when comparing knot-tying and knotless double-row transosseous-equivalent rotator cuff repair; however, the rate of medial cuff failure was lower among knotless procedures. The major steps of the procedure, which are demonstrated in this video article, include (1) diagnostic arthroscopy; (2) supraspinatus tear visualization and debridement; (3) decortication of the footprint on the greater tuberosity; (4) placement of the medial row of anchors loaded with nonabsorbable suture tape; (5) separate suture passage of each limb, perforating the tendon with use of a suture passer; (6) fixation of the tape in the lateral row of anchors, creating a bridging configuration; and (7) anterolateral acromioplasty with use of an arthroscopic burr. Complications are rare following this procedure. As postoperative rehabilitation is essential for tendon healing, the operative arm should be placed in an abduction brace for 6 weeks, with only passive mobilization.
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http://dx.doi.org/10.2106/JBJS.ST.19.00021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8154396PMC
September 2020

Swiss-wide multicentre evaluation and prediction of core outcomes in arthroscopic rotator cuff repair: protocol for the ARCR_Pred cohort study.

BMJ Open 2021 04 22;11(4):e045702. Epub 2021 Apr 22.

Orthopaedic Surgery and Traumatology, University Hospital Basel, Basel, Switzerland.

Introduction: In the field of arthroscopic rotator cuff repair (ARCR), reporting standards of published studies differ dramatically, notably concerning adverse events (AEs). In addition, prognostic studies are overall methodologically poor, based on small data sets and explore only limited numbers of influencing factors. We aim to develop prognostic models for individual ARCR patients, primarily for the patient-reported assessment of shoulder function (Oxford Shoulder Score (OSS)) and the occurrence of shoulder stiffness 6 months after surgery. We also aim to evaluate the use of a consensus core event set (CES) for AEs and validate a severity classification for these events, considering the patient's perspective.

Methods And Analysis: A cohort of 970 primary ARCR patients will be prospectively documented from several Swiss and German orthopaedic clinics up to 24 months postoperatively. Patient clinical examinations at 6 and 12 months will include shoulder range of motion and strength (Constant Score). Tendon repair integrity status will be assessed by ultrasound at 12 months. Patient-reported questionnaires at 6, 12 and 24 months will determine functional scores (subjective shoulder value, OSS), anxiety and depression scores, working status, sports activities, and quality of life (European Quality of Life 5 Dimensions 5 Level questionnaire). AEs will be documented according to a CES. Prognostic models will be developed using an internationally supported regression methodology. Multiple prognostic factors, including patient baseline demographics, psychological, socioeconomic and clinical factors, rotator cuff integrity, concomitant local findings, and (post)operative management factors, will be investigated.

Ethics And Dissemination: This project contributes to the development of personalised risk predictions for supporting the surgical decision process in ARCR. The consensus CES may become an international reference for the reporting of complications in clinical studies and registries. Ethical approval was obtained on 1 April 2020 from the lead ethics committee (EKNZ, Basel, Switzerland; ID: 2019-02076). All participants will provide informed written consent before enrolment in the study.

Trial Registration Number: NCT04321005.

Protocol Version: Version 2 (13 December 2019).
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http://dx.doi.org/10.1136/bmjopen-2020-045702DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8070866PMC
April 2021

Impact of Sports Activity on Medium-Term Clinical and Radiological Outcome after Reverse Shoulder Arthroplasty in Cuff Deficient Arthropathy; An Institutional Register-Based Analysis.

J Clin Med 2021 Feb 18;10(4). Epub 2021 Feb 18.

Department Shoulder and Elbow Surgery, Schulthess Clinic, 8008 Zurich, Switzerland.

There is a lack of consensus on what physicians can recommend and what patients can expect concerning sports activity after reverse shoulder arthroplasty (RSA). The purpose of this retrospective register-based observational study was to investigate the association between participation in sports or physical activity involving the upper extremity and 5-year clinical and radiological outcomes for primary RSA patients. We screened the institutional arthroplasty registry for patients reporting the type and level of sports postoperatively after primary, unilateral RSA due to rotator cuff deficiency. One hundred thirty-eight patients with clinical and radiological outcomes documented at a minimum 5-year follow-up were divided into three groups comprising those who participated regularly in: sports mainly involving the upper extremity (sports upper extremities, SUE, = 49), sports mainly involving the lower extremities (sports lower extremities, SLE, = 21), and those who did not participate in sports at all (no sports, NS, = 68). The participants had a mean age of 72 years (standard deviation (SD) 8) and were overall predominantly female patients (62%). Primary clinical outcomes included the Constant Score (CS) and Shoulder Pain and Disability Index (SPADI). Secondary radiographs were analyzed for radiolucent lines (RLL), signs of glenoid or humeral prosthesis loosening, bone resorption, bone formation, and scapular notching. A total number of 8 senior surgeons were involved in treatment of patients, and two types of prosthesis were used. The SUE group had non-significantly higher mean scores for CS (75 points) and SPADI (88 points) compared to SLE (71 and 78 points, respectively) and NS patients (66 and 78 points, respectively) ( ≥ 0.286). The incidence of RLL around the humeral diaphysis was higher in NS compared to SUE patients (32% versus 12%, respectively) ( = 0.025); all other radiological parameters were similar between the groups. There were no cases of loosening in the SUE group that led to revision surgery. Patients engaging in sports activities involving the upper extremity show similarly good functional scores 5 years post-RSA as the other groups, without additional signs of implant loosening as a result of increased shoulder use.
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http://dx.doi.org/10.3390/jcm10040828DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7922026PMC
February 2021

Immobilization in External Rotation and Abduction Versus Arthroscopic Stabilization After First-Time Anterior Shoulder Dislocation: A Multicenter Randomized Controlled Trial.

Am J Sports Med 2021 03 17;49(4):857-865. Epub 2021 Feb 17.

Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Charité Universitaetsmedizin Berlin, Berlin, Germany.

Background: Treatment of first-time shoulder dislocation (FSD) is a topic of debate. After high rates of recurrent instability after nonoperative management were reported in the literature, primary repair of FSD significantly increased. At the same time, new concepts were proposed that had promising results for immobilization in external rotation (ER) and abduction (ABD).

Purpose: The aim of this study was to evaluate the recurrence rates (primary outcome) and clinical outcomes (secondary outcome parameters) of immobilization in ER+ABD versus arthroscopic primary stabilization after FSD.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: In a multicenter randomized controlled trial, patients with FSD were randomized to either treatment with immobilization in 60° of ER plus 30° of ABD (group 1) or surgical treatment with arthroscopic Bankart repair (group 2). Clinical evaluation was performed 1, 3, and 6 weeks as well as 6, 12, and 24 months postoperatively or after reduction, including range of motion, instability testing, subjective shoulder value, Constant-Murley score, Rowe score, and Western Ontario Shoulder Instability Index. Recurrent instability events were prospectively recorded.

Results: Between 2011 and 2017, a total of 112 patients were included in this study. Of these, 60 patients were allocated to group 1 and 52 to group 2. At the 24-month follow-up, 91 patients (81.3%) were available for clinical examination. The recurrence rate was 19.1% in group 1 and 2.3% in group 2 ( = .016). No significant differences were found between groups regarding clinical shoulder scores ( > .05). Due to noncompliance with the immobilization treatment protocol, 4 patients (6.7%) were excluded.

Conclusion: Immobilization in ER+ABD versus primary arthroscopic shoulder stabilization for the treatment of FSD showed no differences in clinical shoulder scores. However, recurrent instability was significantly higher after nonoperative treatment.
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http://dx.doi.org/10.1177/0363546520987823DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7961655PMC
March 2021

Evaluation and Management of Glenohumeral Instability With Associated Bone Loss: An Expert Consensus Statement Using the Modified Delphi Technique.

Arthroscopy 2021 06 13;37(6):1719-1728. Epub 2021 Jan 13.

Rush University Medical Center, Chicago, Illinois, U.S.A.

Purpose: To establish an international expert consensus, using the modified Delphi technique, on the evaluation and management of glenohumeral instability with associated bone loss.

Methods: A working group of 6 individuals generated a list of statements related to history and physical examination, imaging and specialized diagnostic tests, bone loss quantification and classification, treatment outcomes and complications, and rehabilitation for the management of glenohumeral instability associated with bone loss to form the basis of an initial survey for rating by a group of experts. The expert group (composed of 22 high-volume glenohumeral instability experts) was surveyed on 3 occasions to establish a consensus on the statements. Items with over 70% agreement and less than 10% disagreement achieved consensus.

Results: After a total of 3 rounds, 31 statements achieved consensus. Eighty-six percent of the experts agreed that a history of multiple dislocations and failed soft-tissue surgery should raise suspicion about the possibility of an associated bone deficit. Ninety-five percent of the experts agreed that 3-dimensional (3D) computed tomography (CT) is the most accurate diagnostic method to evaluate and quantify bone loss. Eighty-six percent of the experts agreed that any of the available methods to measure glenoid bone deficiency is adequate; however, 91% of the experts thought that an en face view of the glenoid using 3D CT provides the most accurate method. Ninety-five percent of the experts agreed that Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Ninety percent of the experts agreed that in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed and any of the available options is valid. There was no consensus among experts on how Hill-Sachs injuries should be managed or on how postoperative rehabilitation should be carried out.

Conclusions: The essential statements on which the experts reached consensus included the following: A history of multiple dislocations and failed soft-tissue surgery should make surgeons consider the possibility of an associated bone deficit. Three-dimensional CT is the most accurate diagnostic method to evaluate and quantify bone loss. Although any of the available methods to measure glenoid bone deficiency is adequate, an en face view of the glenoid using 3D CT provides the most accurate method. Hill-Sachs lesions are poorly quantified and classified by current imaging systems. Finally, in cases with a glenoid bone deficit greater than 20%, glenoid bone graft reconstruction should be performed.

Level Of Evidence: Level V, consensus statement.
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http://dx.doi.org/10.1016/j.arthro.2020.12.237DOI Listing
June 2021

Glenoid Component Loosening in Anatomic Total Shoulder Arthroplasty: Association between Radiological Predictors and Clinical Parameters-An Observational Study.

J Clin Med 2021 Jan 11;10(2). Epub 2021 Jan 11.

Shoulder and Elbow Surgery, Schulthess Clinic, 8008 Zurich, Switzerland.

The mechanisms of glenoid component loosening in anatomic total shoulder arthroplasty (aTSA) are still unclear, and it remains undetermined which specific radiographic features are associated with clinical outcomes. Patients with primary osteoarthritis who underwent aTSA with a stemless implant and a pegged glenoid between January 2011 and December 2016 were extracted from a local registry. Anteroposterior radiographs were evaluated at six, 12, 24 months, and five years post-TSA for lateral humeral offset (LHO), joint gap (JG), acromiohumeral distance (AHD), and radiolucency (modified Franklin score); 147 patients were included. Mixed-model linear regression was used. Both constant score (CS) and subjective shoulder value (SSV) markedly decreased at five years follow-up compared to one year ( < 0.001 for both). AHD, LHO, and JG all showed a consistent and statistically significant decline over time, with the joint gap decreasing by half. Consistently, smaller JG and AHD were correlated with lower SSV ( = 0.03 and = 0.07, respectively). Massive loosening was associated with a 14.5 points lower SSV ( < 0.01). Finally, narrowing of the JG was significantly correlated with increased radiolucency ( < 0.001) and tended toward worse SSV ( = 0.06). In summary, radiographic parameters displaying medialization and cranialization after aTSA with a cemented pegged glenoid are useful predictors of impaired shoulder function.
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http://dx.doi.org/10.3390/jcm10020234DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7826694PMC
January 2021

Fracture-Specific and Conventional Stem Designs in Reverse Shoulder Arthroplasty for Acute Proximal Humerus Fractures-A Retrospective, Observational Study.

J Clin Med 2021 Jan 6;10(2). Epub 2021 Jan 6.

Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Charité-Universitaetsmedizin Berlin, 13353 Berlin, Germany.

Tuberosity healing and stem design can be outcome-dependent parameters in hemiarthroplasty for proximal humerus fractures (PHF). The relevance of fracture-specific stem design in reverse shoulder arthroplasty (RSA) is still a matter of debate. This retrospective study evaluates tuberosity healing and function for fracture specific stems (A) compared to conventional stems (B) in RSA for complex PHF in 26 patients (w = 21, mean age 73.5 years). Clinically, range of motion (ROM), Constant-Murley-Score (CS), Subjective Shoulder Value (SSV), and external rotation lag signs (ERLS) were evaluated. Healing of greater tuberosity (GT) and lesser tuberosity (LT), scapular notching, and loosening were examined radiologically. There were no statistical significant differences with regards to CS (A: 73 ± 11; B: 77 ± 9 points), SSV (A: 78% ± 11%; B: 84% ± 11%), external rotation (A: 18° ± 20°; B: 24° ± 19°), or internal rotation (A: 5.7 ± 2.2; B: 6.7 ± 2.8 CS-points) ( > 0.05). Mean forward flexion was superior for group A ( = 0.036). Consolidation of GT (82%) and LT (73%) was similar in both groups. Anatomical healing was slightly higher in group B ( > 0.05). Scapular notching was found in 27% (A) and 55% (B) ( > 0.05). RSA for PHF provides good to excellent clinical results. The quantitative and qualitative union rate for both cohorts was similar, indicating that fracture stems with open metaphyseal designs to allow for bone ingrowth do not improve tuberosity healing. ERLS correlates with a worse function in CS and ROM in all planes.
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http://dx.doi.org/10.3390/jcm10020175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7825286PMC
January 2021

The ligamentous injury pattern in acute acromioclavicular dislocations and its impact on clinical and radiographic parameters.

J Shoulder Elbow Surg 2021 Apr 30;30(4):795-805. Epub 2020 Nov 30.

Department for Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Charité-Universitaetsmedizin Berlin, Berlin, Germany; Department of Orthopedics and Orthopaedic Surgery, University Medicine Greifswald, Greifswald, Germany.

Background: Acromioclavicular (AC) joint dislocations are classified according to the Rockwood (RW) classification, which is based on radiographic findings. Several authors have suggested magnetic resonance imaging (MRI) for visualization of the capsuloligamentous structures stabilizing the AC joint. The aim of this study was to describe the ligamentous injury pattern in acute AC joint dislocations by MRI and investigate associations with clinical and radiographic parameters.

Methods: This prospective study included 45 consecutive patients (5 women and 40 men; mean age, 33.6 years [range, 19-65 years]) with an acute AC joint separation (RW type I in 5, RW type II in 8, RW type III in 18, and RW type V in 14). All patients underwent physical examination of both shoulders, and clinical scores (Subjective Shoulder Value, Constant score, Taft score, and Acromioclavicular Joint Instability Score) were used to evaluate the AC joint clinically as well as radiographically. Post-traumatic radiography included bilateral anteroposterior stress views and bilateral Alexander views to evaluate vertical instability and dynamic posterior translation. MRI was performed for assessment of the AC and coracoclavicular (CC) ligaments and the delto-trapezoidal fascia.

Results: Radiographic and MRI classifications were concordant in 23 of 45 patients (51%), whereas 22 injuries (49%) were misjudged; of these, 6 (13%) were reclassified to a more severe type and 16 (36%), to a less severe type. The integrity of the CC ligaments was found to have a clinical impact on vertical as well as horizontal translation determined by radiographs and on clinical parameters. Among patients with an MRI-confirmed complete disruption of the CC ligaments, 68% showed a radiographic CC difference > 30% and 75% showed complete dynamic posterior translation. Inferior clinical parameters were noted in these patients as compared with patients with intact CC ligaments or partial disruption of the CC ligaments (Constant score of 67 points vs. 49 points [P < .05] and Acromioclavicular Joint Instability Score of 51 points vs. 23 points [P < .05]). The inter-rater and intra-rater reliability for assessment of the ligamentous injury pattern by MRI was fair to substantial (r = 0.37-0.66).

Conclusion: The integrity of the CC and AC ligaments found on MRI has an impact on clinical and radiographic parameters.
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http://dx.doi.org/10.1016/j.jse.2020.10.026DOI Listing
April 2021

The Schulthess local Shoulder Arthroplasty Registry (SAR): cohort profile.

BMJ Open 2020 11 26;10(11):e040591. Epub 2020 Nov 26.

Research, Teaching and Development, Schulthess Klinik, Zurich, Switzerland

Purpose: Clinical registries are essential for evaluation of surgical outcomes. The Schulthess Shoulder Arthroplasty Registry (SAR) was established in 2006 to evaluate safety, function, quality-of-life and patient satisfaction in patients undergoing shoulder arthroplasty.

Participants: Adult patients undergoing anatomic or reverse shoulder joint replacement at the Schulthess Klinik, a high-volume, leading orthopaedic surgery centre in Zürich, Switzerland.

Findings To Date: Between March 2006 and December 2019, the registry covered 98% of eligible operations. Overall, 2332 patients were enrolled with a total of 2796 operations and 11 147 person-years of follow-up. Mean age at baseline was 71 (range: 20-95), 65% were women. Most common indication was rotator cuff tears with osteoarthritis (42%) and the mean preoperative Constant Score was 31 (±15). The most frequent arthroplasty type was reverse, increasing from 61% in 2006-2010 to 86% in 2015-2019. Functional recovery peaked at 12-month postoperatively and did not show a clinically relevant deterioration during the first ten follow-up years. Since its establishment, the registry was used to address multiple pertinent clinical and methodological questions. Primary focus was on comparing different implant configurations (eg, glenosphere diameter) and surgical techniques (eg, latissimus dorsi transfer) to maximise functional recovery. Additionally, the cohort contributed to the determination of the clinical relevance and validity of radiological monitoring of cortical bone resorption and scapular notching. Finally, SAR data helped to demonstrate that returning to sports was among key patient expectations after reverse shoulder arthroplasty.

Future Plans: As first patients are approaching the 15 years follow-up landmark, the registry will continue providing essential data on long-term functional outcomes, implant stability, revision rates and aetiologies as well as patient satisfaction and quality-of-life. In addition to research and quality-control, the cohort data will be brought back to the patients by bolstering real-time clinical decision support.
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http://dx.doi.org/10.1136/bmjopen-2020-040591DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7692837PMC
November 2020

Simultaneous Posterior Shoulder Dislocation and Acromioclavicular Joint Separation: Single-Stage Arthroscopic Treatment of Combined Injuries: A Case Report.

JBJS Case Connect 2020 Apr-Jun;10(2):e0467

1Department of Shoulder and Elbow Surgery, Schulthess Clinic, Zurich, Switzerland 2Department of Shoulder and Elbow Surgery, Charité-Universitaetsmedizin Berlin, Berlin, Germany.

Case: We report on a patient who received arthroscopic treatment after a unique traumatic combined injury comprising a posterior shoulder dislocation with posterior labrum damage, a reverse Hill-Sachs lesion, and a concomitant Rockwood type-V acromioclavicular joint dislocation.

Conclusion: Arthroscopy was applied to address all pathologies in a single-stage procedure. The outcome of reduced operating and patient recovery time suggests that our intervention is ideal for this specific indication.
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http://dx.doi.org/10.2106/JBJS.CC.19.00467DOI Listing
February 2021

[Ruptures of the Distal Biceps and Triceps Tendon].

Z Orthop Unfall 2020 Dec 9;158(6):663-682. Epub 2020 Jul 9.

Ruptures of the distal biceps and triceps tendon are rare. Most frequently these injuries occur in men, athletes and patients with physically demanding work activities. This review article describes aetiology and pathogenesis as well as diagnostics, treatment options, the expected outcome and provides insights in our own approach.
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http://dx.doi.org/10.1055/a-0999-8250DOI Listing
December 2020

Correction to: Screw fixation in stemless shoulder arthroplasty for the treatment of primary osteoarthritis leads to less osteolysis when compared to impaction fixation.

BMC Musculoskelet Disord 2020 06 6;21(1):355. Epub 2020 Jun 6.

Department of Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Charité-Universitaetsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.

An amendment to this paper has been published and can be accessed via the original article.
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http://dx.doi.org/10.1186/s12891-020-03360-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7276062PMC
June 2020

The Biomechanical Effect of Bone Grafting and Bone Graft Remodeling in Patients With Anterior Shoulder Instability.

Am J Sports Med 2020 07 21;48(8):1857-1864. Epub 2020 May 21.

Department of Shoulder and Elbow Surgery, Center for Musculoskeletal Surgery, Charité-Universitaetsmedizin Berlin, Berlin, Germany.

Background: Individual constitutional differences in glenoid shape and bone remodeling require a patient-specific and longitudinal approach to evaluate the biomechanical effects of glenoid bone grafting in patients with anterior shoulder instability.

Purpose: To quantify the longitudinal, in vivo, biomechanical effects of bone grafting, bone graft remodeling, and glenoid shape in patients with anterior shoulder instability by means of patient-specific finite element models.

Study Design: Descriptive laboratory study.

Methods: In total, 25 shoulders of 24 patients with anterior shoulder instability and anterior glenoid bone loss underwent an arthroscopic iliac crest bone graft transfer (ICBGT) procedure with either autologous or allogenic bone. Patient-specific finite element simulations based on preoperative, postoperative, and follow-up computed tomography scans were used to quantify the bone-mediated stability ratio (SR) and the distance to dislocation. Additionally, the relationship between glenoid morphological parameters and the SR was assessed.

Results: The ICBGT procedure significantly increased the SR and distance to dislocation in the 2-, 3-, and 4-oclock directions immediately after the surgical intervention ( < .01) in both the autograft and the allograft groups. Although the SR and distance to dislocation decreased subsequently, autografts showed long-term effects on SR and dislocation distance in the 3-o'clock direction ( < .01) and on SR in the 4-o'clock direction ( < .01). Allografts showed no significant effect on SR and dislocation distance in long-term follow-up ( > .05). Overall, glenoid retroversion as well as cavity depth predicted stability in all 4 dislocation directions, with glenoid cavity depth showing the highest correlation coefficients ( = 0.71, 0.8, 0.73, and 0.7 for 2-, 3-, 4-, and 5-o'clock, respectively).

Conclusion: The autologous ICBGT procedure biomechanically improved anterior shoulder stability in long-term follow-up, whereas the use of allografts did not show any bone-mediated biomechanical effect at follow-up due to resorption. Furthermore, in addition to measurements of defect extent, the glenoid depth and version seem to be useful parameters to determine the biomechanical effect and need for glenoid bone grafting in patients with shoulder instability.

Clinical Relevance: This study proposes the use of autologous bone grafts for a successful long-term stabilization effect. Additionally, this study proposes additional glenoid morphological measures to predict shoulder stability.
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http://dx.doi.org/10.1177/0363546520919958DOI Listing
July 2020
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