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Background: To successfully treat a periprosthetic infection, successful bacteria eradication and successful wound closure are mandatory. Despite adequate surgical débridement in the deep, persistence of wound drainage and subsequent persistence of periprosthetic infection may occur, especially in patients with compromised soft tissue conditions. This study presents a transcutaneous compression suture technique with iodine gauze that was used in patients with persistent wound secretion in therapy-resistant periprosthetic shoulder infections in order to achieve successful infection control and wound healing. Methods: All patients with persistent periprosthetic or implant-associated shoulder joint infections despite correct previous surgical and antibiotic therapy attempts were included in the study. In all patients, in addition to repeat deep surgical débridement, a transcutaneous “iodine-gauze-compression-suture” was performed with postoperative antibiotic therapy. The primary endpoint was infection control; the secondary endpoint was wound healing rate; and the third endpoint was complication rate after index surgery. Results: Ten consecutive patients with a mean age of 74 (±7.6) years and a mean follow-up of 14 (±2) months were included. All ten patients showed infection control and successful wound healing, with no need for further revision surgery. In 8 out of 10 patients, the wound healing was fast and completely uncomplicated. Two out of 10 patients showed delayed wound healing with fibrin coatings for 3 and 4 weeks, respectively. No additional intervention was necessary in both patients. Conclusions: Transcutaneous iodine gauze compression sutures were used to achieve successful infection control without additional revision surgery in 10 out of 10 patients who previously underwent surgery with failed infection control. This wound closure technique is a reliable adjunctive therapy method in the treatment of implant-associated infections of the shoulder in patients with fragile wound conditions.

Background: Eccentric biconcave (B2) glenoid erosion in primary glenohumeral arthritis is common. There are serious concerns regarding the longevity of fixation of cemented glenoids if anatomic total shoulder arthroplasties (aTSAs) are used in B2 glenoid. The purpose of this study is to analyze the mid- to long-term results of aTSA with B2 glenoids. Methods: This is a retrospective study of a single center experience. Thirty patients (32 shoulders) at an average of 9.2 years (range, 5.0-16.6, ±3.2) after primary TSA were evaluated. Clinical and radiographic outcomes were analyzed. Results: The mean preoperative intermediate glenoid version was −14° ± 7° (range, −2° to −29°) and the mean humeral subluxation according to the plane of the scapula was 67% ± 9% (range, 49%-87%). There was a significant improvement for all the postoperative clinical outcome parameters including the mean absolute and relative Constant Score, subjective shoulder value, active elevation, external rotation, abduction, internal rotation, pain scores, and strength (P

Background: There is little consensus on the best treatment after failed conservative management of recurrent posterior shoulder instability. The purpose of this study was to analyze our clinical and radiological mid-term to long-term results of an open, posterior bone block procedure for the treatment of recurrent posterior shoulder instability. Methods: From 1999 to 2015, 14 patients were included in the study and available for clinical and radiographic follow-up (FU). FU included a standardized physical examination, assessment of the Constant-Murley-Score, subjective shoulder value, American Shoulder and Elbow Surgeons score, and Western Ontario Shoulder Instability Index. Conventional radiographs and a computed tomography (CT)–scan were performed preoperatively and at latest FU. Glenohumeral arthropathy was classified as per Samilson and Prieto. The CT scans were used to evaluate the structure of the graft (resorption, union), graft positioning, glenoid version, centering of the humeral head, and glenoid erosion and morphology. Results: The median age at the time of surgery was 26 years (range 16-41 years) and the median FU period was 9 years (range 4-20 years). The rate of reported dynamic postoperative subluxation and instability was 46% (n = 6) and the rate of dynamic posterior instability during clinical testing at FU was 31% (n = 4). The tested instability rate in the traumatic group was 14% (n = 1) compared to the atraumatic group with 50% (n = 3) during clinical FU. The mean Constant-Murley-Score increased from preoperatively (77 ± 11 points) to postoperatively (83 ± 14 points, P = .158). The last FU showed an American Shoulder and Elbow Surgeons score of 85 ± 12; the Western Ontario Shoulder Instability Index score was 715 ± 475 points. The mean subjective shoulder value increased from 58% ± 19 preoperatively to 73% ± 17 at final FU (P = .005). Degenerative changes increased by at least one grade in 67% of the patients. Mean preoperative glenoid retroversion (CT) was 7.5° ± 6°. The position of the graft was optimal in 86% (n = 12). In 62% of the cases, a major resorption of the graft (Zhu grade II) was observed. Conclusion: The rate of tested recurrent instability at last FU was as high as 31% (n = 4, atraumatic [n = 3] vs. traumatic [n = 1]) after a median FU of 9 years. Given the moderate improvement of clinical outcome scores, shoulder stability and the increase of degenerative joint changes by at least one grade (Samilson/Prieto) in 67% of patients, a posterior bone block procedure is not a uniformly satisfying treatment option for recurrent posterior shoulder subluxation, especially in cases of atraumatic posterior instability.

Background: The need for coracoclavicular (CC) stabilization in the fixation of fractures with CC instability (Neer type IIB and V) was biomechanically demonstrated by higher construct strength than isolated locking plate osteosynthesis. It was the purpose of this study to prove noninferiority of the new cow-hitch suture repair technique compared with the well-established suture tape double-button fixation with regard to overall fixation strength and cyclic loading properties. Methods: Twelve human cadaver shoulders (7 right and 5 left) were matched for sex and age (mean age: 75 ± 5 years). An oblique parasagittal fracture line 20 mm medial to the acromioclavicular joint line was created, and the CC ligaments were dissected. Six shoulders were reconstructed by a double FiberTape fixation with two suture buttons (group DB), and the remaining six shoulders by a cow-hitch suture repair using a double FiberWire with only coracoid button fixation (group CH). Both reconstruction techniques were tested in a servo-hydraulic material testing machine for cyclic displacement (mm), stiffness (N/mm), and maximum load-to-failure (N) after 500 cycles at 3 mm/s and inferosuperior load between 15 and 70 N. Superior fragment displacement in space was recorded using a MicroScribe digitizer. Results: There were no statistically significant differences regarding cyclic displacement (group DB: 0.7 mm; group CH: 1.3 mm; P = .36), stiffness (group DB: 177 N/mm; group CH: 116 N/mm; P = .17), maximum load-to-failure (group DB: 560 N; group CH: 492 N; P = .59), and superior displacement in space of the medial fragment (group DB: 3.2 mm; group CH: 1.6 mm; P = .48). Conclusion: Fixation of unstable distal clavicle fractures using a double FiberWire cow-hitch suture repair with isolated coracoid button fixation for stand-alone CC stabilization resulted in similar biomechanical properties to a double-suture button fixation with FiberTapes while avoiding prominent clavicular implants.

Background: The treatment of complex proximal humerus fractures with hemiarthroplasty is associated with a high failure rate due to secondary displacement of the tuberosities. It was the aim of this in-vitro study to compare the mechanical stability of tuberosity reattachment obtained with the so-called “Cow-Hitch” (CH) cerclage compared with conventional tuberosity reattachment. Methods: A 4-part proximal humerus fracture was created in 10 fresh-frozen, human cadaveric shoulders. The greater and lesser tuberosity were reattached to the hemiarthroplasty stem with in total 4 CH Cerclages in the Cow-Hitch group. The conventional technique—recommended for the tested implant—was used in the control group using 6 sutures. A total of 5000 loading cycles with forces of 350N were applied, while motion (in mm) of the tuberosities was recorded in 3 directions (anteroposterior = AP, mediolateral = ML, inferosuperior = IS) with a telecentric camera. Results: After 5000 loading cycles, the CH group showed less fragment displacement (AP: 2.3 ± 2.3 mm, ML: 1.8 ± 0.9 mm, IS: 1.3 ± 0.5 mm) than the conventional group (AP: 9.8 ± 12.3 mm, ML: 5.5 ± 5.6 mm, IS: 4.5 ± 4.7 mm). The differences were not statistically significant (AP: P = .241; ML: P = .159; IS: P = .216). The lesser tuberosity fragment displacement in the CH group after 5000 cycles was less in the AP (2.3 ± 3.3 vs. 4.0 ± 2.8, P = .359) and IS (1.9 ± 1.2 vs. 3.1 ± 1.8; P = .189) directions but higher in the ML direction (7.2 ± 5.7 vs 6.3 ± 3.6, P = .963). Conclusions: In-vitro, “Cow-Hitch” cerclage results in mean greater tuberosity displacements of 2 mm and reliably prevents displacements greater than 5 mm. In contrast, the conventional fixation technique yields unreliable, variable stability with low to complete displacement upon cyclical loading.

Background: Shoulder surgery results in several months of rehabilitation, which is often underestimated by patients preoperatively. Currently, there is little written about this process of recovery. Information on this would help patients to anticipate the trajectory of their recovery. This would also provide a reference point allowing surgeons to compare a patient's progress in their recovery. The purpose of our study was to analyze and document the expected rate of recovery for the most common shoulder operations. Methods: A retrospective analysis of all patients who underwent total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RTSA), arthroscopic rotator cuff repair (ARCR), and arthroscopic biceps tenodesis (BT) using prospectively collected data from the Surgical Outcomes System registry was performed. All patients included had a complete 2-year follow-up data set. The pain score (visual analog scale) was measured preoperatively at 2, 6, and 12 weeks and 6, 12, and 24 months. The American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) score were recorded preoperatively and after 6, 12, and 24 months. The speed of recovery, defined as the percentage of total improvement, for each procedure was assessed as the primary outcome parameter at all time points. Results: All shoulder interventions resulted in significant improvement of the pain, SANE, and ASES scores 2 years after shoulder surgery. The speed of recovery of all 3 scores was highest after TSA at all measured time points and slowest after ARCR and BT. Measured by the pain score, 90% and 82% of the total improvement after TSA and RTSA was completed after 6 weeks compared to 58% and 59% after ARCR and BT, respectively. Six months postoperatively the ASES recovery rate was significantly higher after arthroplasty (TSA 96% and RTSA 85%) compared to ARCR and BT (76% and 77%, respectively). The SANE score recovery rate was between 82% and 92% (TSA 92%, RTSA 89%, ARCR 87%, BT 82%) 6 months after surgery. After 1 year all patient groups reached 89% or more of the total improvement in all scores, except for the pain after ARCR (89%). Conclusion: The improvement in pain is fastest after TSA and slowest after ARCR and BT. After TSA and RTSA, >80% of the total pain reduction is achieved 6 weeks postoperatively, whereas after ARCR and BT, >80% of the pain reduction is achieved only 6 months postoperatively. At 12 months postoperatively, the differences in recovery curves were not significant.

Background: The treatment of complex proximal humerus fractures in the elderly with reverse total shoulder arthroplasty is an established treatment option. Healing of the greater tuberosity (GT) is associated with better outcomes. It was the aim of this cadaver study to compare the stability of GT refixation obtained with the so-called “cow hitch” cerclage fixation with that of the recommended standard suture cerclage technique. Methods: A 4-part proximal humerus fracture was created in 10 fresh-frozen, human cadaveric shoulders. A CT was performed preoperatively to ensure the comparability of bone density and fracture patterns. In the experimental group the GT was reattached to the stem of the reverse total shoulder arthroplasty with the “cow hitch” suture cerclage (CH) technique, the conventional (CON) technique recommended for the tested implant was used in the control group. Humeri were tested with a uniaxial material testing machine. In total, 5000 loading cycles with forces from 250 to 350N were applied while motion (in mm) of the tuberosities was recorded with a telecentric camera. Results: After 5000 loading cycles, the CH group showed a significantly smaller displacement of the bone fragment (0.74 ± 0.31 mm) than the CON group [2.29 ± 1.08 mm (P < .05)]. After the first three cycles the mean displacement was 0.14 mm (±0.12) in the CH and 1.42 mm (±0.21) in the CON (P < .0001) groups. Conclusions: GT reattachment with the “cow hitch” suture cerclage showed a significantly more stable fixation compared with the currently for the used prosthetic system recommended suture cerclage technique in an in vitro 4-part proximal humeral fracture model.

Background:. The benefit of protective bracing after rotator cuff reconstruction has been debated for many years, although immobilization compliance has never been assessed objectively to date. In a previous study, compliance with the wearing of an abduction brace was measured for the first time with use of temperature-sensitive sensors. The purpose of the present follow-up study was to assess the effect of immobilization compliance on tendon-healing after rotator cuff repair. Methods:. The clinical and radiographic outcomes for 46 consecutive patients with objectively assessed abduction brace wearing compliance after arthroscopic repair of a superior rotator cuff tear were prospectively analyzed. Rotator cuff integrity was examined with ultrasound. Clinical outcomes were assessed with the relative Constant-Murley score (RCS), the Subjective Shoulder Value (SSV), and pain and patient satisfaction ratings. Receiver operating characteristic (ROC) curves were used to determine the optimal cutoff value of abduction brace compliance for discriminating between shoulders that will and will not have a retear and the association of compliance with the failure of rotator cuff repair. Results:. After a mean duration of follow-up of 20 ± 9 months, the odds ratio for having a rotator cuff repair failure was 13-fold higher for patients with a compliance rate of

Background:. Primary traumatic anterior shoulder dislocations can be associated with displaced anterior glenoid rim fractures. Nonoperative treatment of such fractures has been shown to have excellent results in a small cohort of patients; as such, we have been treating these fractures nonoperatively, regardless of fragment size and degree of displacement, provided that post-reduction computed tomography scans revealed an anteroposteriorly centered humeral head. The aim of this study was to analyze the medium- to long-term results of nonoperative treatment of displaced anterior glenoid rim fractures, assessing in particular the residual instability and development of osteoarthritis. Methods:. In a 2-center study, 30 patients with a mean age of 48 years (range, 29 to 67 years) were evaluated clinically with use of the Subjective Shoulder Value, Constant score, American Shoulder and Elbow Surgeons score, and Western Ontario Shoulder Instability index, as well as radiographically with use of radiographs and computed tomography scans at a mean follow-up of 9 years (range, 5 to 14 years). Results:. Fracture-healing was documented in all patients. Seven patients (23%) had post-fracture onset of osteoarthritis (5 with Samilson grade I and 2 with Samilson grade IV). Of these, 1 patient had recurrent instability that was successfully treated with hemiarthroplasty 9 years after the index injury (relative Constant score, 101%), and was excluded from further analysis. No other patient had a recurrent redislocation, subluxation, or positive apprehension. The other 6 patients with new-onset radiographic osteoarthritis were pain-free (mean Constant score pain scale, 15 points) with good shoulder function (relative Constant score, 84% to 108%). A total of 26 patients (90%) rated their functional outcome as good or very good, and 3 patients (10%) rated it as fair. The mean relative Constant score was 97% (range, 61% to 108%), the mean American Shoulder and Elbow Surgeons score was 92 points (range, 56 to 100 points), and the mean Western Ontario Shoulder Instability index score was 126 points (range, 0 to 660 points). All patients returned to full-time work. Conclusions:. Nonoperative treatment of anterior glenoid rim fractures following primary traumatic anterior shoulder dislocation results in excellent clinical outcomes with a very low rate of residual instability and, thus, treatment failure. Asymptomatic radiographic osteoarthritis occurred in roughly 1 of 4 patients. Level of Evidence:. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.