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Background: Additional stabilization of the “comma sign” in anterosuperior rotator cuff repair has been proposed to provide biomechanical benefits regarding stability of the repair. Purpose: This in vitro investigation aimed to investigate the influence of a comma sign–directed reconstruction technique for anterosuperior rotator cuff tears on the primary stability of the subscapularis tendon repair. Study Design: Controlled laboratory study. Methods: A total of 18 fresh-frozen cadaveric shoulders were used in this study. Anterosuperior rotator cuff tears (complete full-thickness tear of the supraspinatus and subscapularis tendons) were created, and supraspinatus repair was performed with a standard suture bridge technique. The subscapularis was repaired with either a (1) single-row or (2) comma sign technique. A high-resolution 3D camera system was used to analyze 3-mm and 5-mm gap formation at the subscapularis tendon-bone interface upon incremental cyclic loading. Moreover, the ultimate failure load of the repair was recorded. A Mann-Whitney test was used to assess significant differences between the 2 groups. Results: The comma sign repair withstood significantly more loading cycles than the single-row repair until 3-mm and 5-mm gap formation occurred ( P≤ .047). The ultimate failure load did not reveal any significant differences when the 2 techniques were compared ( P = .596). Conclusion: The results of this study show that additional stabilization of the comma sign enhanced the primary stability of subscapularis tendon repair in anterosuperior rotator cuff tears. Although this stabilization did not seem to influence the ultimate failure load, it effectively decreased the micromotion at the tendon-bone interface during cyclic loading. Clinical Relevance: The proposed technique for stabilization of the comma sign has shown superior biomechanical properties in comparison with a single-row repair and might thus improve tendon healing. Further clinical research will be necessary to determine its influence on the functional outcome.

We describe a reproducible, step-by-step arthroscopic technique for anchorless transosseous rotator cuff repair using an X-box configuration with the Arthrotunneler device. The technique uses 2 bone tunnels and 4 high-strength sutures and is suitable for medium to large tears of the supra- and infraspinatus that would alternatively need a double-row repair with 4 anchors. Biomechanically, results appear to be similar as for anchored transosseous equivalent techniques. Enhanced biological healing and lower material costs are the possible benefits of this appealing arthroscopic approach that mimics the previous gold standard.

When revising failed double-row and suture-bridge rotator cuff repairs medial failures represent a potential feature. In the presence of a compromised healing environment, patch augmentation becomes a logical adjunct from a mechanical and biological point of view. A reproducible step-by-step revision technique is described that reinforces the weak central cuff area with an absorbable synthetic scaffold.

BACKGROUND: Shoulder arthroplasty (SA) complications require standardization of definitions and are not limited to events leading to revision operations. We aimed to define an international consensus core set of clinically relevant unfavorable events of SA to be documented in clinical routine practice and studies.METHODS: A Delphi exercise was implemented with an international panel of experienced shoulder surgeons selected by nomination through professional societies. On the basis of a systematic review of terms and definitions and previous experience in establishing an arthroscopic rotator cuff repair core set, an organized list of SA events was developed and reviewed by panel members. After each survey, all comments and suggestions were considered to revise the proposed core set including local event groups, along with definitions, specifications, and timing of occurrence. Consensus was reached with at least two-thirds agreement.RESULTS: Two online surveys were required to reach consensus within a panel involving 96 surgeons. Between 88% and 100% agreement was achieved separately for local event groups including 3 intraoperative (device, osteochondral, and soft tissue) and 9 postoperative event groups. Experts agreed on a documentation period that ranged from 3 to 24 months after SA for 4 event groups (peripheral neurologic, vascular, surgical-site infection, and superficial soft tissue) and that was lifelong until implant revision for other groups (device, osteochondral, shoulder instability, pain, late hematogenous infection, and deep soft tissue).CONCLUSION: A structured core set of local unfavorable events of SA was developed by international consensus to support the standardization of SA safety reporting. Clinical application and scientific evaluation are needed.

Instabilitaten sind eine haufige Ursache von Schulterbeschwerden bei jungen sportlichen Patienten und stellen den behandelnden Arzt oft vor eine diagnostische Herausforderung. Im Vergleich zur wesentlich ofter auftretenden ventralen Instabilitat wird die dorsale Schulterinstabilitat wenig beachtet. Sie wird daher vielfach ubersehen oder falsch behandelt.

Die arthroskopische Rotatorenmanschettennaht (RMN) befindet sich auf dem Siegeszug zum „Goldstandard“ in der operativen Behandlung der Rotatorenmanschette (RM). In unserer Klinik, in der wir bereits seit dem Jahr 2000 alle RMN ausschlieslich arthroskopisch durchfuhren, haben wir immer wieder Falle mit unbefriedigendem Verlauf gesehen, als deren Ursache meist eine (partielle) Reruptur diagnostiziert wurde. Das ist der Grund, weswegen wir – bei aller Begeisterung fur die Arthroskopie – hier die Frage aufwerfen mochten: Was tun, wenn die Manschette nicht heilt?

Etwa 5% der Patienten in der Schulterpraxis berichten uber ratselhafte Schulterbeschwerden, die ohne ausere Ursache oder nach einem Bagatellereignis aufgetreten sind. Die zunehmend massiven Schmerzen qualen die Betroffenen vor allem auch nachts. Erst spater fallt den Patienten auf, dass sie ihre Schulter nicht mehr gut bewegen konnen und ihnen viele alltagliche Verrichtungen wie das Schliesen des Bustenhalters oder das Ziehen des Parktickets und auch die Korperpflege zunehmend Muhe bereiten — das Krankheitsbild der Frozen Shoulder ist voll entwickelt.

Disabled shoulders of throwing athletes typically present with extended undersurface partial tears of the rotator cuff, which include the posterior supraspinatus and the anterior infraspinatus tendon to a variable extent. We propose a modified transtendon repair technique to adequately treat this subset of patients. The repair includes two double-loaded anchors, at the anterior and the posterior end of the tear, respectively. With the help of an angulated penetrator we create a medial and a lateral band of sutures on top of the cuff, producing a broad contact in the tendon-to-bone interface. All the 9 so far operated patients were young men, 7 of them base-ball pitchers, and 5 active in competitive sports. The Constant Score rose from 72 points preoperatively to 99 points at 12 months follow-up. Three of the still active pitchers were able to return to their previous level in sports after one year. The improved footprint contact of our novel repair construct should allow for better healing and, therefore, a higher chance of return to competition.

Arthroscopic rotator cuff reconstruction (ARCR) is a challenging operative procedure in the treatment of symptomatic cuff tears. The literature does not consistently report on surgical complications after this procedure.

The proximal humerus is a well-known site of predilection for the solitary osteochondroma-the most common benign bone tumor. Subscapularis tears were underreported in the pre-arthroscopic era. Literature about rotator cuff impairment caused by osteochondromas is almost non-existent. We will present the case of a young man, who had a complete non-traumatic subscapularis tear, where the tendon had been peeled off the lesser tuberosity by an osteochondroma. Diagnostic features such as MRI and arthroscopy are emphasized. The patient was successfully treated by open resection of the tumor and reattachment of the tendon with suture anchors.

The standard technique for repairing partial-thickness tears of the supraspinatus tendon includes completion of the lesion to a full-thickness tear. Partial articular-side supraspinatus tendon avulsions (PASTA) form a subgroup deserving special consideration. We present a transtendon suture technique that is able to preserve the intact tendon fibers and to achieve firm attachment of the tendon to the humeral footprint using 1 double-loaded bone anchor. The surgical technique is described in detail, and pitfalls and complications are noted. The clinical results of the first 22 consecutive patients are reported, showing an increase in the UCLA score from 17.1 to 31.2 points and a patient satisfaction rate of 91%.

Introduction Confronted with a failed rotator cuff (RC) repair or a massive tear with compromised tissue quality patch augmentation becomes a logical adjunct from a mechanical and biological point of view. We hypothesize that augmentation of the repair with a novel bioabsorbable scaffold might improve healing rates with few complications and reasonable added costs. Methods A consecutive series of 54 patients was prospectively included since 3/14. The case series includes 38 revision cases (typically medial failures) and 16 primary repairs in massive tears. The operation is technically demanding but reproducible and includes 12 steps (video). The cuff is repaired with a standard suture bridge construct using 1–2 medial and 2 lateral anchors; no additional anchors are needed for patch augmentation. The proposed scaffold (BioFiber, Tornier) consists of biosynthetic fibers woven into a lattice structure and fully absorbing in the Krebs cycle over 18 months. Results Until now 14 patients have completed 24 mo FU including constant score (CS), subjective shoulder value (SSV) and a native MRI. The CS rose from 46 to 85 points, the SSV from 43 to 89%. MR scans showed an intact repair in 12 cases, typically Sugaya type III (intact but thinnend cuff). 2 retears were observed (14%). In this series of 54, one shoulder was revised for infection, one shoulder received a reversed prosthesis and two more were sucessfully revised because of a symptomatic gap formation at the posterior edge of the patch. Reversal of pseudoparesis in massive tears was achieved in 10 cases. The added costs of patch augmention were about 600 Euros, added operation time after the learnig curve less than 30. Patch integration has been observed at repeat arthroscopy. Conclusion We report a learnable technique for patch augmentation in the revision setting and for massive RC tears. Implant costs are reasonable; the material has been succesfully used in abdominal wall hernias and cosmetic breast surgery. The scaffold is made from fully absorbable synthetic fibres degrading without known toxicity and containing no DNA residues. It has good mechanical and biological properties. The preliminary results suggest an improved outcome and higher healing rates in these critical situations.

Posterior shoulder instability is rare, appears in varying clinical patterns and can be the main symptom in patients with instability in more than one direction. The purpose was to analyze and categorize our patients and to report on the results of operative treatment by arthroscopy. A consecutive series of 32 shoulders in 31 patients from a 7-year period was chosen for retrospective clinical evaluation with VAS for pain, Rowe Score, Constant Score and Simple Shoulder Test. Follow-up rate was 100 %, the mean FU period was 28 months (range 13–58). Allocation based on clinical and intraoperative criteria resulted in the 4 groups A to D characterized by an increasing traumatic impact. Patients received a posterior Bankart repair with bone anchors in 21 or capsular plication to the intact labrum in 11 cases. The clinical outcome scores were generally good and all showed a trend towards better results from A to D, but without significance. Pain on VAS pre- and postoperatively showed a significant (p

The case of a 22-year-old man with synovial chondromatosis (SC) of the shoulder joint is described. A literature review confirmed that SC of the glenohumeral joint is very rare and that the etiology of the disease is still unknown. The diagnosis is often delayed, and the preferred form of management remains controversial. We consider magnetic resonance imaging (MRI) a valuable tool in detecting SC at an early phase and estimating the intrasynovial extent of the disease. Shoulder arthroscopy today represents an elegant treatment option for removing the chondromas and performing a partial synovectomy. It might, however, be insufficent in cases of involvement of the bicipital tendon sheath and other recesses of the joint.

This study was performed to review and compare the outcome of a consecutive series of 96 rotator cuff repairs performed with an open versus arthroscopic technique. The arthroscopic repairs include the beginning of the learning curve.Case series.In a 24-month period from 1999 to 2001, 95 patients underwent a cuff repair with bony reattachment by 1 surgeon; 4 patients had surgery on both shoulders. We present subjective outcome data from 96 of 99 operated shoulders by the use of a visual analog scale (VAS), the Simple Shoulder Test (SST), and the question of overall patient satisfaction. Thirty shoulders undergoing surgery before February 2000 had open cuff repair (12 classic open, 18 mini-open) and 66 shoulders undergoing surgery after February 2000 had an arthroscopic cuff repair with suture anchors. All but 3 shoulders had the supraspinatus/infraspinatus tendon refixed, 32% had a subscapularis reattachment, and 21% an additional SLAP repair.Groups A (30 shoulders, open repair) and B (66 shoulders, arthroscopic repair) were comparable concerning tear size, cause of the tear, professional shoulder strain, and preoperative pain intensity. At follow-up evaluation (15-40 months after surgery), group B had significantly better pain relief on the VAS (P.05), more yes answers in the SST (9.7 vs. 8.7, not significant), and a higher patient satisfaction rate of 92.4% versus 80% (not significant). From the 12 questions of the SST, all but 1 showed a higher percentage of yes answers in group B; for 3 questions concerning mobility the difference was significant (P.07). There was no correlation between tear size and outcome in the SST.Arthroscopic cuff repair yielded equal or better results than open repair, even at the beginning of the learning curve. Patients with an arthroscopic repair had a significantly better decrease in pain and a better functional result concerning mobility. Arthroscopic repair is successful for large and small tears. Biomechanically, large tears might even benefit more than small ones.Level IV.

Analysis of 100 consecutive femoral fractures admitted to our institution revealed an incidence of about 1 fracture per 2,000 children per year. Epidemiologic data may help to promote prevention. Initial treatment was performed by many doctors, thus rendering guidelines to safe and cost-effective management indispensable. In the last decade, growing concern to reduce hospital stays and costs led to new approaches that replaced traction as a therapeutic principle. Today, we consider immediate spica casting a good option for the group 0-5 years old, whereas in the age group 5-12 years old elastic stable intramedullary nailing (ESIN) produces reliably good results. Minor complications were common and could be avoided partially, but they did not affect the good final outcome.

In the Basel study (BS) (1960-73) on cardiovascular and peripheral arterial diseases, a mortality follow-up was completed for the period 1965-80. Of the 4,224 men at risk for these diseases, 531 died. The causes of death were established from the death certificates and classified into 8 groups. For each case 2 age- and sex-matched controls were selected and compared with the corresponding cases with regard to the various variables obtained at the three examinations (1960, 1965, 1971). This report dealth with cancer mortality, plasma lipids, plasma vitamins, alcohol and cigarette consumption, and intake of milk and citrus fruits. The results were all obtained at the second follow-up examination (BS III, 1971-73). Cancer of the lung, stomach, large bowel, and all other sites were treated separately. The average follow-up from BS III until death varied from 3.7 years (other sites) to 4.9 years (cancer of the lung). Of 129 cancer deaths, the highest incidence was found for cancer of the lung (38) followed by stomach (19) and large bowel, (15) and the remainder (57) was for other sites. Plasma lipids did not differ significantly among cases and controls. However, the lowest values were observed in colorectal cancer and gastric carcinoma (mean cholesterol, 213 mg/dl). beta-Carotene was significantly lower in cancer cases of the lung than in controls (14.8 micrograms/dl vs. 23.7; P less than .05). It was also low in gastric cancer cases (13.0 micrograms/dl). Vitamin A was below average only in cases with gastric cancer (difference due to the small number not significant). Vitamin C was consistently lower in cancer cases than in controls. The lowest value was found for cancer of the stomach and corresponded to a below-average consumption of citrus fruits. Vitamin E was low in cancer of the colon. Plasma lipids correlated strongly with vitamin E (tau = 0.5) and to a lesser extent with vitamin A (tau = 0.25). beta-Carotene correlated poorly with beta-lipoproteins (low-density and very low-density lipoproteins) but significantly with total cholesterol. Smoking was inversely related, as was alcohol consumption, to the beta-carotene level. From these results, the conclusion was that vitamins influence carcinogenesis in humans.