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Background The present study used a systematic review to analyse the risk of perioperative injections during arthroscopic reconstruction of the rotator cuff of the shoulder. The questions of interest were whether perioperative local injection increases the infection risk and whether the number of postoperative revisions is increased. Material and Methods A systematic review of the U. S. National Library of Medicine/National Institutes of Health (PubMed) database and the Cochrane Library was performed using the PRISMA checklist. The keywords used were “shoulder” and “arthroscopy” and “injection” and “risk”. In the course of the study, work that was not also primarily concerned with the reconstruction of the rotator cuff was excluded. English original articles and case series were included that contained at least some arthroscopic reconstructions of the rotator cuff. The risk of bias was determined using the Newcastle-Ottawa Scale. The content of the articles relevant to the research questions was analysed. Results 48 hits were primarily generated. 9 articles corresponded to the inclusion criteria and were analysed. In the 6 studies with details on the injected substances, cortisone was used in 98 – 100% of the cases. The reported infection and revision rates based on insurance data were higher with injection than without. The risk of bias in the studies analysed here was rather low based on the Newcastle-Ottawa Score. The risk of infection after a cortisone injection before, during or after surgery was increased. Injection was associated with infection in up to 8% of cases with injections within two weeks of surgery. The risk of infection was increased by up to 11 times with injections within 4 weeks after the operation. Likewise, the risk of revision surgery after injection was increased, with the time intervals between injection and surgery sometimes differing between studies. Discussion Local infections and to a lesser extent revision surgery are associated with perioperative injections (with cortisone) within 3 months preoperatively and 4 weeks postoperatively. However, there were only database studies of insurance data with several studies from a few centres. Thus, no causal relationships could be proven. Currently, however, the following can be recommended using a cautious approach: The interval between injection with cortisone before surgery should be at least 2 weeks, better 3 months. No cortisone injections should be applied intraoperatively. Postoperatively, cortisone should not be injected for at least 4 weeks. If, in exceptional cases, deviations from these time limits are required, patients should be informed about an increased risk of complications.

The suprascapular nerve can be compromised as a result of a compression syndrome in different locations. A (proximal) compression within the scapular notch can lead to dorsal shoulder pain and simultaneous weakness of the infraspinatus and supraspinatus muscles. By transection of the lig. transversum this compression syndrome can be treated. By means of a systematic review, the present work analyzes the motor recovery potential after arthroscopic decompression.A systematic review of the U. S. National Library of Medicine/National Institutes of Health (PubMed) database and the Cochrane Library was performed using the PRISMA checklist. The search words used were "suprascapular" and "arthroscopic"; "suprascapular" and "arthroscopy". Based on the evaluated literature, articles in English with at least a partial arthroscopic case series from 4 cases on and a compression syndrome of the suprascapular nerve treated with arthroscopic decompression in the scapular notch were identified. Motor recovery was described by means of EMG, clinical strength and MRI.Primarily 408 hits were generated. Six articles met the inclusion criteria and were further analyzed. The number of arthroscopic cases was between 4 and a maximum of 27. The level of evidence was between III and IV. The majority of the reported clinical results were good. Motor recovery as measured by EMG was observed, recovery of full strength was not achieved in the majority of reported cases (60%), neither was regression of structural (fatty) degeneration of the muscle bellies.Arthroscopic decompression of the suprascapular nerve in the scapular notch provides good clinical results and considerable pain relief. However, in the majority of cases it does not lead to a complete recovery of the strength of the supra- and infraspinatus muscles. Patients should be informed about this. An early decompression after diagnosis in the event of proximal compression within the suprascapular notch combined with beginning EMG or MRI changes appears reasonable. These beginning changes should be further defined. Future studies should develop prognostic criteria for motor recovery. Awareness regarding the diagnosis needs to be improved due to the probably time-dependent irreversibility of resulting muscular weakness.Der N. suprascapularis kann in seinem Verlauf an verschiedenen Stellen komprimiert werden. Ein (proximales) Kompressionssyndrom spezifisch in der Incisura scapulae führt häufig zu dorsalen Schulterschmerzen und zu einer simultanen Kraftabschwächung des Infraspinatus- und Supraspinatusmuskels. Durch Durchtrennung des Lig. transversum kann dieses Kompressionssyndrom behandelt werden. Die vorliegende Arbeit analysiert durch einen systematischen Review das motorische Erholungspotenzial nach arthroskopischer Dekompression.Es wurde eine systematische Durchsicht der Datenbank der U. S. National Library of Medicine/National Institutes of Health (PubMed) und der Cochrane Library unter Anwendung der PRISMA-Checkliste durchgeführt. Als Suchwörter dienten „suprascapular“ und „arthroscopic“; „suprascapular“ und „arthroscopy“. Anhand der evaluierten Literatur wurden Artikel mit zumindest anteiligen arthroskopischen Fallserien ab 4 Fällen bei Kompressionssyndrom mit einer arthroskopischen Dekompression des N. suprascapularis in der Incisura scapulae in englischer Sprache identifiziert. Eine motorische Erholung des Nervs wurde beschrieben anhand von EMG, klinischem Kraftgrad und MRT.Es wurden primär 408 Treffer generiert. Sechs Artikel entsprachen den Einschlusskriterien und wurden weitergehend inhaltlich analysiert. Die arthroskopische Fallzahl lag zwischen 4 und maximal 27. Der Evidenzlevel lag zwischen III und IV. Die berichteten klinischen Ergebnisse waren mehrheitlich gut. Eine motorische Erholung, gemessen mittels EMG, wurde beobachtet, eine Wiedererlangung des vollständigen Kraftgrades in der Mehrzahl der berichteten Fälle nicht (60%), eine Rückbildung von strukturellen (fettigen) Degenerationen der Muskelbäuche ebenso wenig.Die arthroskopische Dekompression des N. suprascapularis in der Incisura scapulae sorgt für klinisch gute Ergebnisse und erhebliche Schmerzerleichterung. Sie führt in der Mehrzahl der Fälle aber nicht zu einer kompletten Erholung des Kraftgrades der Supra- und Infraspinatusmuskulatur. Hierüber sollten Patienten aufgeklärt werden. Eine frühe Dekompression bei klinischer Diagnose bei proximaler Kompression in der Incisura scapulae und leichten Veränderungen im EMG oder MRT erscheint sinnvoll. Diese beginnenden Veränderungen sollten weiter definiert werden. Zukünftige Studien sollten zudem prognostische Kriterien für das Erholungspotenzial des N. suprascapularis entwickeln. Die Awareness hinsichtlich der Diagnose muss wegen der wahrscheinlich zeitabhängigen Irreversibilität der Muskelschwäche erhöht werden.

Intratendinous lesions of the rotator cuff of the shoulder are frequent and may be a distinct clinical entity. Nevertheless, there are only a few publications which deal specifically with this subject. This study analyses the existing literature for the arthroscopic reconstruction of the intratendinous lesion of the supraspinatus tendon, by means of a systematic review, and identifies relevant research questions for future studies.In January 2017, a systematic review of the U. S. National Library of Medicine/National Institutes of Health (PubMed) Database and the Cochrane Library was conducted using the PRISMA checklist. The search words were "supraspinatus" and "interstitial"; "supraspinatus", "tear" and "intratendinous"; "supraspinatus" and "concealed". In the course of the review, articles written in English with at least a partial arthroscopic case series dealing with the reconstruction of the supraspinatus tendon were identified and further analysed.Primarily 70 hits could be generated. Five articles met the inclusion criteria and were analysed in detail. The number of arthroscopic cases ranged between 6 and 33. Level of evidence was IV in all studies. The diagnosis of an intratendinous lesion was made by MR imaging when T2/fat-saturated sequences showed an intratendinous high intensity signal without disruption of the bursal or articular layer. Three different concepts were followed in surgical treatment: opening of the intratendinous lesion from the bursal or articular side or by complete resection of the lesion. The reconstruction was performed with suture anchors in all cases. In the majority of cases, an acromioplasty was also performed. The reported clinical results were mostly good. Healing of the tendon was shown by MR imaging in 81.5 to 100% of cases.After failure of conservative treatment, symptomatic intratendinous lesions of the supraspinatus tendon can be localised intraoperatively and reconstructed after failure of conservative treatment. The expected results are good in the medium term. The evidence level of the studies analysed was low. Future studies should examine the role of alternative conservative and surgical therapies.Intratendinöse Läsionen der Rotatorenmanschette der Schulter treten in relevanter Fallzahl auf und stellen möglichweise eine eigene klinische Entität dar. Dennoch gibt es bislang wenig Fachliteratur, die sich spezifisch hiermit beschäftigt. Die hier vorliegende Arbeit analysiert anhand eines systematischen Reviews die vorhandene Fachliteratur zur arthroskopischen Rekonstruktion der intratendinösen Läsion der Supraspinatussehne und ermittelt relevante Forschungsfragen für zukünftige Studien.Im Januar 2017 wurde eine systematische Durchsicht der Datenbank U. S. National Library of Medicine/National Institutes of Health (PubMed) und der Cochrane Library unter Anwendung der PRISMA-Checkliste durchgeführt. Als Suchwörter dienten „supraspinatus“ und „interstitial“; „supraspinatus“, „tear“ und „intratendinous“; „supraspinatus“ und „concealed“. Anhand der Durchsicht der gefundenen Literatur wurden Artikel mit zumindest anteiligen arthroskopischen Fallserien mit einer Rekonstruktion der Supraspinatussehne in englischer Sprache identifiziert.Es konnten primär 70 Treffer generiert werden. Fünf Artikel entsprachen den Einschlusskriterien und wurden weitergehend inhaltlich analysiert. Die arthroskopische Fallzahl lag zwischen 6 und 33. Die Evidenz betrug ohne Ausnahme Level IV. Die Diagnose wurde kernspintomografisch gestellt, wenn eine intratendinöse Signalanhebung in der Supraspinatussehne in T2-/fettgesättigten Sequenzen ohne Durchbrechung nach bursal oder artikulär zu erkennen war. Drei verschiedene Konzepte wurden in der operativen Behandlung verfolgt: Eröffnung der intratendinösen Läsion von bursal, von artikulär oder Eröffnung durch komplette Resektion des betroffenen Sehnenanteils. Die Rekonstruktion erfolgte jeweils mit Fadenankern. In der Mehrzahl der Fälle wurde zusätzlich eine Akromioplastik durchgeführt. Die berichteten klinischen Ergebnisse waren mehrheitlich gut. Kernspintomografisch gesicherte Einheilungsquoten lagen zwischen 81,5 und 100%.Symptomatische und therapierefraktäre intratendinöse Läsionen der Supraspinatussehne können intraoperativ lokalisiert und rekonstruiert werden. Die zu erwartenden Ergebnisse sind mittelfristig gut. Der Evidenzlevel der analysierten Studien war für das Fachgebiet niedrig. Zukünftige Studien sollten die Rolle alternativer konservativer und operativer Therapieansätze untersuchen.

Background The anterior deltopectoral approach is the standard approach for performing the open Latarjet procedure. Through the use of a more medial and vertical skin incision, the scar can be cosmetically covered by the bra strap in women. We call this incision the bra strap incision. The intention of this study was (1) to elaborate if the bra strap incision is considered beneficial by female patients, (2) to find reproducible landmarks to indicate how the bra strap incision has to be oriented, and (3) to evaluate preliminary clinical results of patients in whom the bra strap incision was used. Methods In 18 patients with a mean follow-up of 21 (range, 12–31) months treated with an open Latarjet procedure through the bra strap incision, the clinical results (scar satisfaction, Constant and Murley score [CMS], and subjective shoulder value [SSV]) were retrospectively analyzed. To assess the typical course of the bra strap, anatomical landmarks were assessed in 100 consecutive female patients as the distance from the bra strap center to (1) the tip of the coracoid process, (2) the superior end of the anterior axillary fold, and (3) the acromioclavicular joint. Results All (18 of 18) patients stated that they would prefer the bra strap incision if the same procedure had to be performed on the opposite shoulder; 16 women were satisfied with the scar. The mean CMS was 83 (range 64–96) points and the mean SSV was 85 (range, 60–100) %. The mean distances from the bra strap center to the acromioclavicular joint, coracoid tip, and axillary fold were 28 (range, 5–60) mm, 15 (range, 2–17) mm, and 30 (range, 2–55) mm. No combination of distance measures and demographic variable revealed a linear relationship. Conclusion This analysis shows that the bra strap incision appears to be highly welcomed by female patients and does not compromise the clinical outcome, when compared to previously published data. However, even though the typical location of the bra strap can be determined, the large variations in the distances make it more preferable to preoperatively mark the incision for optimal placement. Trial registration The study is approved by the Ethical Committee Zurich. (Cantonal Ethical Committee number: ZH-Nr.2017–00891).

To analyse the current scientific evidence regarding the natural history of the clinical and anatomical progression of rotator cuff tears. A broad systematic review of the literature (PubMed database through January 2014) which was guided, conducted and reported according to PRISMA criteria. This article focuses on the rotator cuff tears. Articles had to meet an inclusion criteria. The methodological quality of each study was individually assessed using a recently developed general assessment tool AMQPP (assessing the methodological quality of published papers). Seven articles dealing with rotator cuff tears were included, one of them was a high-quality study. Three papers assessed the natural history and the natural course of rotator cuff rupture directly. The other studies indirectly assessed the natural history with reports on non-operative and operative therapy trends. All of these articles had been published in four different top medical journals according to 2013 ranking. We found no articles which clearly referred to the role of regression to the mean of rotator cuff tears. The development of symptoms and anatomical deterioration are often directly correlated. Spontaneous recovery to normal levels of function has been successfully achieved, and standardised non-operative treatment programmes are an effective alternative to surgery for many patients. Follow-up is necessary to avoid irreparable stage. However, surgery is still favoured by young active people and highly professional persons who need to get fit in a short period of time. Further research is still necessary. The AMQPP score system is simple and reliable. It works as a quick quality-checking tool which helps researchers to identify the key points in each paper and reach a decision regarding the eligibility of the paper more easily.

The expected duration of incapacity after arthroscopic shoulder surgery is an important factor for therapy planning. The aim of this study was to analyze the duration of sick leave after arthroscopic shoulder surgery in Germany and to identify factors associated with a longer duration of sick leave. We hypothesized that certain patient-related factors may be associated with a longer duration of sick leave. Routine health care data of all patients insured by one German health insurance company who underwent inpatient arthroscopic shoulder surgery between 2010 and 2012 were included in the analysis of the duration of sick leave in this retrospective cohort study (level III evidence). Comparisons were performed for different arthroscopic surgical procedures using the log-rank test. Possible factors that might be associated with a longer duration of incapacity were analyzed. Sick leave was reported in 303 of 660 cases. The median duration of sick leave was 82 days after subacromial decompression and 157 days after rotator cuff repair (p = 0.004). The duration of sick leave was longer in patients older than 50 years (p = 0.044) and in patients with sick leave that started prior to surgery (p

Correct alignment of the rotation of the femoral component and the flexion gap after total knee arthroplasty is difficult in patients with preoperative leg axis deviation. Inaccuracy may result in problems with the patellofemoral joint and instability, in particular. We examined the influence of the preoperative leg axis on the rotation of the femoral component and the symmetry of the flexion gap after total knee arthroplasty using the tibial-cut-first technique. A retrospective study was carried out of 58 consecutive patients who underwent primary LCS total knee arthroplasty using the tibial-cut-first technique in 2008 based on preoperative full-leg radiographs and the final radiographs taken according to Kanekasu’s technique. The patients were divided into three groups (varus–valgus–neutral) according to their preoperative leg axis. Using the tibial-cut-first technique, a mean neutral rotation of the femoral component of 0.5° and a mean symmetrical flexion gap of −0.7° were achieved. Nevertheless, there was a positive correlation of the preoperative leg axis with the rotation of the femoral component. The differences in the rotation of the femoral component and the flexion gap between the three groups were not significant. The only significant difference between the varus and valgus groups was the extent of rotation of the femoral component, with a slightly greater external rotation of 2.7° in the valgus group. This study suggests that it is possible to achieve correct rotational alignment of the femoral component and a symmetrical flexion gap using the tibial-cut-first technique in patients with a preoperatively deviated leg axis. Therapeutic, Level III.

BackgroundSerious injuries due to breakdancing have been presented only as singular case reports to date. So far, there have been no comprehensive studies about injuries in this sport.HypothesisProfessional breakdancing might lead to a higher incidence of injuries than amateur training. Wearing safety equipment is correlated with a decreased incidence of injuries and pain.Study DesignDescriptive epidemiology study.MethodsThe retrospective study surveyed 40 breakdance professionals and 104 amateurs by questionnaire.ResultsThere were 1665 injuries and 206 overuse syndromes found in 380 588 hours of training, leading to a loss of 10 970.6 training days. Professionals reported significantly ( P < .001) more injuries and overuse syndromes with significantly more injuries of the wrist ( P < .001), knee ( P < .001), hip/thigh ( P = .003), ankle/foot ( P = .013), and elbow ( P = .033). No significant differences were found in the time lost per injury and the time lost per overuse syndrome. Pain occurred most frequently in the region of the wrist, spine, shoulder, and ankle. A negative correlation between protective gear and injuries or frequency of pain could not be shown.ConclusionBreakdancing must be considered as a potentially high-risk dancing sport. Even with severe injuries, dancers interrupt training only for limited periods of time.Clinical RelevanceBreakdance injuries and overuse should not be underestimated. Physicians should be aware of the common risks in this highly acrobatic kind of dancing.

Particle-induced osteolysis is a major cause of aseptic loosening after total joint replacement. While the osteolytic cascade initiated by cytokine release from macrophages has been studied extensively, the involvement of T-lymphocytes in this context is controversial and has been addressed by only a few authors. In a former study we detected that the quantity of T-lymphocytes may be influenced by apoptosis in patients with aseptic loosening. In this study we intended to find out more details about the apoptosis-induced shifting of the T-cell number. We focused our interest on the CD4⁺ and CD8 ⁺ T-cells and their relative ratio. Caspase-3 cleaved was evaluated immunohistochemically to detect apoptotic T-cells in capsules and interface membranes from patients with aseptic hip implant loosening and a varying degree of caspase-3 cleaved expression in CD4⁺ and CD8⁺ T-lymphocytes was detected. Moreover, a relationship between the intensity of the apoptotic reactions and the radiological extent of osteolysis was observed. The number of CD4⁺ cells was decreased in the presence of strong apoptotic reactions, respectively extensive osteolysis, while CD8⁺ cells were affected to a much lower degree. Thus, the CD4⁺/CD8 ⁺ ratio changed from 1.0 in cases with only small areas of periprosthetic osteolysis and minimally intense apoptosis to 0.33 in cases with large areas of osteolysis. This may suggest a causal relationship between the apoptosis-induced shift in the CD4⁺/CD8⁺ ratio and the osteolysis respectively aseptic loosening. It is possible that these findings may lead to a new understanding of particle-induced osteolysis. © Ivyspring International Publisher. All rights reserved.

A considerable number of patients complain about pain after lumbar surgery. The spinal dura mater has been debated as a possible source of this pain. However, there is no information if laminectomy influences the nociceptive sensory innervation of the dura. Therefore, we quantitatively evaluated the density of SP- and CGRP-immunopositive nerve fibers in the dura mater lumbalis in an animal model of laminectomy. Twelve adult Lewis rats underwent laminectomy, in six of them the exposed dura was covered by an autologous fat graft. Further six animals without surgical treatment served as controls. Six weeks after surgery, the animals were perfused and the lumbar dura was processed immunohistochemically for the detection of CGRP- and SP-containing nerve fibers. In controls, the peptidergic nerve fibers were found predominantly in the ventral but rarely in the dorsal dura mater lumbalis. After laminectomy, the density of SP- and CGRP-immunopositive neurons significantly increased in ventral as well as in dorsal parts of the dura. Axonal spines could be observed in some cases at the site of laminectomy. The application of autologous fat grafts failed to inhibit the significant increase in the density of peptidergic afferents. Thus, we have provided the first evidence that laminectomies induce an increase in the density of putative nociceptive SP- and CGRP-immunopositive neurons in the lumbar dura mater ascribable to an axonal sprouting of fine nerve fibers. This effect was not prevented by using autologous fat grafts. It is conceivable that the neuronal outgrowth of nociceptive afferents is a cause of low back pain observed after lumbar surgery.

Objective: It is known that bone mineral density (BMD) and the strength of bone is predicted by body mass. Fat mass is a significant predictor of bone mineral density which correlates with body weight. This suggests that body fat regulates bone metabolism first by means of hormonal factors and second that the effects of muscle and loading are signaling factors in mechanotransduction. Leptin, a peptide hormone produced predominantly by white fat cells, is one of these hormonal factors. The aim of this study was to investigate and measure by micro-CT the different effects of weight-bearing on trabecular bone formation in mice without the stimulation of leptin. Results: Animals with an ad-libitum-diet (Group A) were found to increase body weight significantly at the age of six weeks in comparison with lean mice (Group B). From this point on, the difference increased constantly. At the age of twenty weeks the obese mice were almost twice as heavy as the lean mice. Significant statistical differences are shown between the two groups for body weight and bone mineral density. Examination of trabecular bone (BV/TV, trabecular number (Tb.N.), trabecular thickness (Tb.Th.)) revealed that the only statistically significant difference between the two groups was the Tb.N. for the proximal femur. High weight-bearing insignificantly improved all trabecular bone parameters in the obese mice. Compared with the control-diet Group B, the BV/TV and Tb.N. were slightly higher in the controlled-diet Group A, but not the Tb.Th.. However, correlation was found between Tb.N. and BMD on the one hand and body weight on the other hand. Conclusion: biomechanical loading led to decreased bone mineral density by a decrease in the number of trabeculae. Trabecular thickness was not increased by biomechanical loading in growing mice. Decreased body weight in leptin-deficient mice protects against bone loss. This finding is consistent with the principle of light-weight construction of bone. Differences in cortical and trabecular bone will be examined in later studies. It is not possible to conclude that these results also apply to human beings.

In 40 patients undergoing total hip arthroplasty with the Mayo femoral stem we studied how preoperative digital templating corresponded to the actual intraoperative choice of implant size, position, offset and restoration of leg length.The preoperatively planned sizes of the components showed a high rate of coincidence with the sizes used intraoperatively [Intraclass Correlation Coefficient (ICC) 0.661-0.810]. However, the agreements in offset and CCD correction were poor (ICC 0.476, 0.253). This could be statistically attributed to the change in the distance from the medial margin of the stem to the medial margin of the medial femoral cortex and the height of osteotomy. The agreement in leg length correction was moderate (ICC 0.583), which was attributed to the change in the hip rotation center and the height of osteotomy.Careful preoperative planning was useful for accurate size choice of the Mayo prosthesis. Factors such as the height of osteotomy and the distance from the medial margin of the stem to the medial margin of the medial femoral cortex in relation to the position of the Mayo stem should be taken into account in order to restore ideal offset and leg length.

Small-animal models are useful for the in vivo study of particle-induced osteolysis, the most frequent cause of aseptic loosening after total joint replacement. Microstructural changes associated with particle-induced osteolysis have been extensively explored using two-dimensional (2D) techniques. However, relatively little is known regarding the 3D dynamic microstructure of particle-induced osteolysis. Therefore, we tested micro-computed tomography (micro-CT) as a novel tool for 3D analysis of wear debris-mediated osteolysis in a small-animal model of particle-induced osteolysis. The murine calvarial model based on polyethylene particles was utilized in 14 C57BL/J6 mice randomly divided into two groups. Group 1 received sham surgery, and group 2 was treated with polyethylene particles. We performed 3D micro-CT analysis and histological assessment. Various bone morphometric parameters were assessed. Regression was used to examine the relation between the results achieved by the two methods. Micro-CT analysis provides a fully automated means to quantify bone destruction in a mouse model of particle-induced osteolysis. This method revealed that the osteolytic lesions in calvaria in the experimental group were affected irregularly compared to the rather even distribution of osteolysis in the control group. This is an observation which would have been missed if histomorphometric analysis only had been performed, leading to false assessment of the actual situation. These irregularities seen by micro-CT analysis provide new insight into individual bone changes which might otherwise be overlooked by histological analysis and can be used as baseline information on which future studies can be designed.

To evaluate the current status of scientific research on the natural history of frozen shoulder as published in the literature. This systematic review was carried out on PubMed data and was guided by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Articles had to meet inclusion criteria. The quality of the papers was assessed using a newly developed tool, AMQPP (Assessing the Methodological Quality of Published Papers). The AMQPP score was correlated with the level of evidence rating according to the Oxford Centre for Evidence-Based Medicine. Suitable papers were divided into groups according to the shoulder condition on which they reported. This article focuses on the frozen shoulder. Seven articles on frozen shoulder met the inclusion criteria. One article was considered to have level 1 of evidence. Three articles had level 3 and the remaining 3 had level 4. Three papers assessed the natural history and the natural course of different forms of stiff shoulder. The others indirectly assessed the natural history by evaluating therapy trends. None of the articles clearly referred to the role of regression to the mean of frozen shoulder specifically. Spontaneous recovery to normal levels of function is possible and standardised non-operative treatment programmes are an effective alternative to surgery in most cases. However, patients with high risk factors such as diabetes mellitus, and those who suffer chronic symptoms or bilaterally affected, would benefit from early surgery. We also concluded that AMQPP score is simple and straight forward. It works as a quick quality-checking tool which helps researchers to identify the key points in each paper and reach a decision regarding the eligibility of the paper more easily. The AMQPP score is still open for further development.

Background: It has been postulated that use of a larger femoral head could reduce the risk of dislocation after total hip arthroplasty, but only limited clinical data have been presented as proof of this hypothesis. Methods: From 1969 to 1999, 21,047 primary total hip arthroplasties with varying femoral head sizes were performed at one institution. Patients routinely were followed at defined intervals and were specifically queried about dislocation. The operative approach was anterolateral in 9155 arthroplasties, posterolateral in 3646, and transtrochanteric in 8246. The femoral head diameter was 22 mm in 8691 of the procedures, 28 mm in 8797, and 32 mm in 3559. Results: One or more dislocations occurred in 868 of the 21,047 hips. The cumulative risk of first-time dislocation was 2.2% at one year, 3.0% at five years, 3.8% at ten years, and 6.0% at twenty years. The cumulative ten-year rate of dislocation was 3.1% following anterolateral approaches, 3.4% following transtrochanteric approaches, and 6.9% following posterolateral approaches. The cumulative ten-year rate of dislocation was 3.8% for 22-mm-diameter femoral heads, 3.0% for 28-mm heads, and 2.4% for 32-mm heads in hips treated with an anterolateral approach; 3.5% for 22-mm heads, 3.5% for 28-mm heads, and 2.8% for 32-mm heads in hips treated with a transtrochanteric approach; and 12.1% for 22-mm heads, 6.9% for 28-mm heads, and 3.8% for 32-mm heads in hips treated with a posterolateral approach. Multivariate analysis showed the relative risk of dislocation to be 1.7 for 22-mm compared with 32-mm heads and 1.3 for 28-mm compared with 32-mm heads. Conclusions: In total hip arthroplasty, a larger femoral head diameter was associated with a lower long-term cumulative risk of dislocation. The femoral head diameter had an effect in association with all operative approaches, but the effect was greatest in association with the posterolateral approach. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

The most common cause of implant failure in joint replacement is aseptic loosening due to particle-induced osteolysis. Bisphosphonates have been shown to be effective against particle-induced osteolysis when administered daily. We investigated the effect of a single subcutaneous dose of a more potent third generation bisphosphonate on particle-induced osteolysis. We utilized the murine calvaria osteolysis model in C57BL/J6 mice. Bone resorption was measured as resorption within the midline suture using Giemsa staining. Twenty-eight mice were used, seven per group. Seven animals were treated with a single dose of zoledronic acid (ZA) directly after surgery and seven animals were treated four days postoperatively. For statistical analysis one-way ANOVA and a Student's t-test were used. Bone resorption was 0.26+/-0.09 mm(2) in animals with particle implantation, 0.14+/-0.05 mm(2) in animals with particle implantation and ZA treatment directly after surgery (p = 0.0047), and 0.15+/-0.05 mm(2) in animals with particle implantation and ZA treatment on the fourth postoperative day (p = 0.006). In conclusion, particle-induced bone resorption was markedly decreased by a single s.c. dose of a third generation bisphosphonate. This important new finding holds great promise, because single dose treatment of particle-induced osteolysis may reduce side effects compared to repeated application of bisphosphonates.

Bearing surface wear and periprosthetic osteolysis due to wear particles are among the most common reasons for joint replacement failure. A murine calvarial model of wear particle-induced osteolysis has been used to identify different biologic factors associated with this problem and to test nonsurgical methods of modulating the host response to particulate debris. This model has utilized titanium particles, however, in clinical practice the most common source of particulate debris is polyethylene particles from bearing surface wear. We now report a calvarial model of wear particle-induced osteolysis based on commercially available polyethylene particles. We found that compared to sham surgery osteoclast recruitment and bone resorption can be induced by introduction of the titanium particles or polyethylene particles. However, bone resorption was significantly higher with polyethylene particles compared to titanium particles (p=0.02). We consider the polyethylene based murine calvarial model of wear particle-induced osteolysis a reliable and clinically relevant tool to understand the host factors and potential pharmacologic interventions that can influence wear debris generated osteolysis. This model might serve as an extension of the well-established titanium based bone resorption model.

Background: A widely variable prevalence of dislocation after total hip arthroplasty has been reported, partly because of varying durations of follow-up for this specific end-point. The effect of demographic factors on the long-term risk of dislocation as a function of time after total hip arthroplasty is not well understood. The purpose of the present study was to determine the risk of dislocation as a function of time after Charnley total hip arthroplasty and to investigate the demographic factors that influence the cumulative risk of dislocation. Methods: Six thousand six hundred and twenty-three consecutive primary Charnley total hip arthroplasties were performed in 5459 patients at one institution between 1969 and 1984. The patients included 2869 female patients and 2590 male patients with a mean age of sixty-three years. All procedures were performed with a 22-mm femoral head, and all femoral and acetabular components were fixed with cement. The patients were followed at routine intervals and were specifically queried about dislocation. The cumulative risk of dislocation was calculated with use of the Kaplan-Meier method. Results: Three hundred and twenty hips (4.8%) dislocated. The cumulative risk of a first-time dislocation was 1% at one month and 1.9% at one year and then rose at a constant rate of approximately 1% every five years to 7% at twenty-five years for patients who were alive and had not had a revision by that time. Multivariate analysis revealed that the relative risk of dislocation for female patients (as compared with male patients) was 2.1 and that the relative risk for patients who were seventy years old or more (as compared with those who were less than seventy years old) was 1.3. Three underlying diagnoses—osteonecrosis of the femoral head, acute fracture or nonunion of the proximal part of the femur, and inflammatory arthritis—were associated with a significantly greater risk of dislocation than osteoarthritis was. Conclusions: The cumulative long-term risk of dislocation after total hip arthroplasty is considerably greater than has been reported in short-term studies. The incidence of dislocation is highest in the first year after arthroplasty and then continues at a relatively constant rate for the life of the arthroplasty. Patients at highest risk are female patients and those with a diagnosis of osteonecrosis of the femoral head or an acute fracture or nonunion of the proximal part of the femur. Level of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

Theoretically, micromotion might occur even in stable cement-implant interface conditions. It was hypothesized that smoothing of the matte surfaces of femoral components because of abrasion or corrosion phenomena is a possible consequence of micromotion. Two new and 11 femoral components that were retrieved after 2 to 15 years of stable cement-implant interface conditions were inspected, investigated with light microscopy, and evaluated with surface roughness measurement by a profilometer. No surface changes were observed such as abrasion or corrosion phenomena except at the tip and the collar of the femoral components. The surface roughness was Ra = 1.0 and 1.1 micro m in the new femoral components and Ra (mean) = 0.96 micro m (range; 0.8-1.5 micro m) in the retrieved components. There was no correlation between time in situ and surface roughness as confirmed by regression analysis. These data suggest that significant micromotion was not present at the studied interface.

Background: Some patients have a dislocation for the first time many years after a total hip arthroplasty, but little is known about the risk factors and outcomes associated with late dislocation. The purposes of this study were (1) to determine the prevalence of late dislocation after total hip arthroplasty, (2) to characterize demographic and other factors associated with such late dislocations, and (3) to report the outcomes of such late dislocations. Methods: Between 1969 and 1995, 19,680 primary total hip arthroplasties were performed in 15,964 patients at our institution. According to a prospective surveillance protocol, the patients were followed routinely at regular intervals and were specifically queried at each time-point about whether (and, if so, when) the hip had dislocated. First dislocations that occurred five years or more after the operation were defined as late dislocations. Results: Five hundred and thirteen (2.6%) of the 19,680 hips dislocated. Of the 513 hips, 165 (0.8% of the entire cohort; 32% of the dislocated hips) first dislocated five or more years after the primary arthroplasty. The median time until the occurrence of these late dislocations was 11.3 years (range, five to 24.9 years) after the operation. Late dislocation was more frequent than early dislocation in women (p = 0.03), and late dislocation was associated with a younger age at the time of the primary total hip arthroplasty (median, sixty-three years) than was early dislocation (median, sixty-seven years) (p = 0.02). Clinical factors associated with late dislocation included previous subluxations without dislocation in twenty patients, a substantial episode of trauma in eleven patients, and onset of marked cognitive or motor neurologic impairment in eleven patients. Radiographically, the late dislocation occurred in association with polyethylene wear of >2 mm in eighteen hips, with implant loosening with migration or a change in position in eight, and with initial malposition of the acetabular implant (anteversion of 30d or abduction of >55d) in thirty. Late dislocation recurred in ninety (55%) of the 165 hips and was treated with a reoperation in fifty-five hips (33% of the hips with late dislocation; 61% of the hips with recurrent dislocation). Conclusions: Late dislocation is more common than was previously thought. Several separate processes, some distinct from those associated with early dislocation, can lead to late dislocation. Late dislocation can occur in association with a long-standing problem with the prosthesis that manifests late (such as malposition of the implant or recurrent subluxation), it can occur in association with a new problem (such as neurologic decline, an episode of trauma, or polyethylene wear), or it can occur in association with any combination of these factors. The likelihood of the first late dislocation recurring is high.

This autopsy study analyzed the migration of polyethylene wear debris adjacent to uncemented femoral components with circumferential porous coating. Five femoral specimens retrieved at autopsy from 3 patients were investigated. Two stems were 40% porous coated, 2 were 80% porous coated, and 1 was 100% porous coated. The implants' time in situ ranged from 53 to 132 months (average, 94.8 months). All patients were followed clinically and radiographically until death. Radiographically, 3 of the stems were bone ingrown with proximal bone loss, 1 stem was mainly fibrous encapsulated, and 1 stem was completely fibrous encapsulated. Histologic examination of bone adjacent to the middle and distal sections of the femoral implant revealed no polyethylene wear debris or granulation tissue in any of the specimens. In 2 bone-ingrown cases, a small number of polyethylene particles and small areas of granulation tissue were present at the proximal level. This granulation tissue, however, did not cause major osteolysis. The findings in this study imply that circumferential porous coating of cementless femoral components could prevent distal migration of polyethylene wear debris along the bone-implant interface in both bone-ingrown and fibrous-encapsulated femoral implants.

A 62-year-old female patient showed radiographic signs of severe linear wear of the acetabular component six years after cementless total hip arthroplasty. This suggested wear-through of the acetabular liner with secondary wear of the titanium shell. At revision surgery wear-through of both the inlay and the acetabular shell were confirmed. Despite meticulous debridement serum titanium levels remained elevated for more than 12 months. Wear-through of a polyethylene acetabular liner with secondary wear of the titanium shell can lead to increased titanium serum levels. Titanium serum levels can remain highly elevated despite revision surgery.

STUDY DESIGN Retrospective case report. PURPOSE This case demonstrates that paraplegia can develop due to chylous leakage into the spinal canal without obvious retroperitoneal or intrathoracic involvement. BACKGROUND INFORMATION This clinical presentation of chylous leakage has not been reported previously. RESULTS A 61-year-old female with osteoporosis suffered a pathologic fracture of the vertebral bodies T12 and L1 and developed partial paraplegia two weeks later. Imaging showed expansive pooling of intraspinal fluid without intrathoracic or retroperitoneal involvement. A blood-tinged fluid was aspirated from dorsal. Repeated surgery by a posterior approach with drainage of the fluid did not improve the patient's condition, so she was finally transferred to our hospital. Under the suspected diagnosis of lymphatic leakage a scintiscan with 123I-iodinephenylpentadekanacid-marked cream verified the presumption of a lymph fistula at the level of T12/L1, originating from the thoracic duct. By permanent draining of the posterior fistula without suction and strict intravenous alimentation the fluid production decreased continuously and finally ceased completely. Simultaneously, the neurologic state improved gradually without returning to normal completely. CONCLUSIONS This case demonstrates that paraplegia can develop due to chylous leakage into the spinal canal without obvious retroperitoneal or intrathoracic involvement. This differential diagnosis should be kept in mind when treating patients with abundant fluid drainage into or from the spinal canal.

We report on a female patient who underwent an arthroscopy of the right knee and was given a continuous femoral nerve block catheter. The postoperative course was initially unremarkable, but when postoperative mobilisation was commenced, 18 hours after removal of the catheter, the patient noticed paralysis and hypaesthesia. Examination confirmed the diagnosis of femoral nerve dysfunction. Colour duplex sonography of the femoral artery and computed tomography of the lumbar spine and pelvis yielded no pathological findings. Overnight the neurological deficits decreased without therapy and were finally no longer detectable. We speculate that during the administration of the local anaesthetic a depot formed, localised in the medial femoral intermuscular septa, which was leaked after first mobilisation. To our knowledge no similar case has been published up to now. We conclude that patients who are treated with a nerve block should be informed and physician should be aware that delayed neurological deficits are possible.

Background Periprosthetic osteolysis is a major cause of aseptic loosening in joint arthroplasty. This study investigates the impact of CT (calcitonin) deficiency and CT substitution under in-vivo circumstances on particle-induced osteolysis in Calca -/- mice. Methods We used the murine calvarial osteolysis model based on ultra-high molecular weight polyethylene (UHMWPE) particles in 10 C57BL/6J wild-type (WT) mice and twenty Calca -/- mice. The mice were divided into six groups: WT without UHMWPE particles (Group 1), WT with UHMWPE particles (Group 2), Calca -/- mice without UHMWPE particles (Group 3), Calca -/- mice with UHMWPE particles (Group 4), Calca -/- mice without UHMWPE particles and calcitonin substitution (Group 5), and Calca -/- mice with UHMWPE particle implantation and calcitonin substitution (Group 6). Analytes were extracted from serum and urine. Bone resorption was measured by bone histomorphometry. The number of osteoclasts was determined by counting the tartrate-resistant acid phosphatase (TRACP) + cells. Results Bone resorption was significantly increased in Calca -/- mice compared with their corresponding WT. The eroded surface in Calca -/- mice with particle implantation was reduced by 20.6% after CT substitution. Osteoclast numbers were significantly increased in Calca -/- mice after particle implantation. Serum OPG (osteoprotegerin) increased significantly after CT substitution. Conclusions As anticipated, Calca -/- mice show extensive osteolysis compared with wild-type mice, and CT substitution reduces particle-induced osteolysis.

Particle-induced osteolysis is a major cause of aseptic loosening after total joint replacement. The purpose of the current study was to evaluate the DNA damage repair capacity of macrophages in patients with aseptic hip loosening by determination of ERCC1. Moreover, we wanted to elucidate if the potency of the DNA-repair mechanisms correlates with the survival of joint implants. For this purpose we compared the immunohistochemical ERCC1 expression in capsules and interface membranes of patients with loosening of a hip replacement in the first 10 years after implantation with those in patients with late loosening. In analogy with ERCC1 studies on cancer in humans we calculated the semi-quantitative H-score by multiplying the staining intensity with the proportion score of positive stained macrophages. The level of ERCC1 reaction in the specimens taken from patients with early aseptic loosening (mean H-score 0.57) was clearly lower in comparison with those from patients undergoing exchange hip arthroplasty later than 10 years after surgery (mean H-score 2.24). We determined an H-score for ERCC1 expression of 1 as a cutoff point giving a sensitivity and specificity of 100% for identification of early aseptic loosening after less than 10 years. In summary, lower levels of ERCC1 were found in patients with early aseptic loosening compared to patients with aseptic loosening later than 10 years.

Plain radiography, bone scintigraphy, digital subtraction arthrography and various other techniques can be used to evaluate loosening of hip replacements. These methods are associated with radiation exposure and some of them have an increased morbidity. Furthermore, in some cases the results are not conclusive.The osteoclast biomarkers tartrate-resistant acid phosphatase 5b (TRAP 5b) and C-terminal telopeptides of type I collagen (CTX) in serum taken from 12 patients with aseptic loosening were measured. Serum samples from 24 other patients, 12 with an intact arthroplasty and 12 without any kind of joint replacement, served as control groups.The serum level of CTX was increased in comparison to the control groups, but the differences were not significant. In contrast, the increase in TRAP 5b in patients with aseptic loosening was highly significant (P0.001). A TRAP 5b value of 3.365 U/L was determined as a cut-off value, giving a sensitivity of 83.3% and specificity of 91.7% to differentiate the patients with aseptic loosening from those with an intact arthroplasty. Measurement of serum TRAP 5b may be a clinically relevant assay for monitoring patients after arthroplasty.

The treatment of acetabular bone defects presents a great challenge in revision total hip arthroplasty (THA). The purpose of this study was to evaluate the clinical and radiological outcome of revision THA using jumbo cups for acetabular reconstruction after applying the bone-grafting technique. We studied 17 patients with acetabular defects ranging from Type 2A to Type 3A according to Paprosky's classification. According to the AAOS-score twelve patients were classified as Type II and five patients as Type III. Uncemented press-fit cups with an outer diameter larger than 64 mm were used in all cases. Fifteen patients received morselized bone allografts. In eight patients an additional screw fixation was necessary. The mean follow-up period was 82 months (range 33-149). The mean Harris Hip Score was preoperatively 62 and at the time of the last follow-up examination 83 points (p = 0.007). Two acetabular components failed, one due to aseptic loosening and another one due to septic loosening. There was a trend of displacement of the femoral head centre towards the infero-lateral position after using jumbo cups that approached statistical significance (p = 0.065). Closure of acetabular defects of Types 2A to 3A according to Paprosky's classification and type II to III according to the AAOS-score respectively can be satisfactorily accomplished using jumbo cups after applying the bone-grafting technique.

Anteroposterior pelvic radiographs are routinely used to monitor cup orientation in total hip arthroplasty (THA). Analysis of planar radiographs leads to a certain degree of measurement error for the cup anteversion (AV). With the current study, we wanted to clarify whether planar radiography can be used for accurate evaluation of the THA position. The postoperative orientation of pelvic implants in 42 patients was analyzed according to five documented mathematical algorithms using planar radiographs. Postoperative computed tomography (CT) pelvis scans were available for all patients. A CT-based navigation system was used to determine AV. The comparison showed that all five formulas presented substantial variations for the AV angle. Of these, Widmer’s algorithm presented the smallest difference compared to the CT. Misinterpretation of postoperative planar radiographs is a common problem in THA. Planar radiographs are too imprecise for exact evaluation of the correct cup AV after THA. CT-based analysis may be necessary if exact values are required.

An analysis of plain radiographs, digital subtraction arthrography, and radionuclide arthrography was performed in 25 revision hip arthroplasties to evaluate the efficacy and usefulness of these methods in the diagnosis of loosening. The findings by each method were compared with intraoperative assessment of the status of components and expressed in terms of sensitivity, specificity, and predictive accuracy. Overall accuracy for the acetabular component by plain radiographs was 80%; by digital subtraction arthrography, 88%; by radionuclide arthrography, 68%. Overall accuracy for the femoral component by plain radiographs was 92%; by digital subtraction arthrography, 84%; radionuclide arthrography, 76%. We consider subtraction arthrography and radionuclide arthrography to be adjuvant diagnostic tools which may be indicated in individual cases of suspected implant loosening of total hip arthroplasty. The routine use of these two methods is not warranted when compared to plain radiographs. In 25 Fällen von Revisionsoperationen von Hüftgelenksersatz wurden Röntgenbilder, digitale Subtraktionsarthrographien und Radionuklidarthrographien analysiert, um die Effizienz dieser Methoden hinsichtlich der Diagnose von Implantatlockerungen festzustellen. Die Ergebnisse der drei genannten radiologischen Untersuchungsmethoden wurden mit der intraoperativ festgestellten Implantatstabilität verglichen. Es wurde die Sensitivität, Spezifität und die Vorhersagegenauigkeit für alle drei Methoden bestimmt. Die Vorhersagegenauigkeit für die acetabulären Komponenten betrug 80% für Röntgenbilder, 88% für digitale Subtraktionsarthrographien und 68% für Radionuklidarthrographien. Die Vorhersagegenauigkeit für die femoralen Komponenten betrug 92% für Röntgenbilder, 84% für digitale Subtraktionsarthrographien und 76% für Radionuklidarthrographien.Wir sehen in der Subtraktionsarthrographie und der Radionuklidarthrographie adjuvante diagnostische Mittel, welche im Einzelfall bei fraglich gelockerten Implantaten indiziert sind. Als Routinemassnahme scheinen diese beiden Methoden im Vergleich zu einfachen Röntgenbildern aber nicht indiziert zu sein.

Background: The hip joint is a common location for metastatic disease. Actual as well as impending fractures at this site are frequently due to mechanical instability after tumor invasion and are usually treated surgically with hip arthroplasty. The objective of this study was to analyze survival and influences on survival after hip arthroplasty for metastatic hip disease. Methods: Two hundred and ninety-nine patients who had undergone a total of 306 hemiarthroplasty or total hip arthroplasty procedures for treatment of a pathologic or an impending pathologic hip fracture between 1969 and 1996 at our institution were included in this study. Data that had been acquired prospectively within the total joint registry of our institution were reviewed retrospectively. Results: The median duration of survival after the arthroplasty was 8.6 months. The duration of survival was significantly associated with the site of the fracture, location of the primary tumor, and time from the diagnosis of the primary tumor to the surgery for the fracture (p ≤ 0.05). The time from the diagnosis to the arthroplasty was a significant independent predictor of survival. Conclusions: Patients undergoing hip arthroplasty for metastatic disease have a limited life expectancy, with only 40% (120) of the 299 patients in our series still alive at one year after the surgery. By identifying prognostic factors regarding life expectancy, this study provides surgeons and oncologists with information with which to weigh risks and benefits of hip arthroplasty for individual patients preoperatively. Level of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

An aggressive destruction pattern resulting in joint deformation has not been described in skeletal cystic angiomatosis (SCA) so far. We present the case of a 6-year-old boy with such findings strongly resembling Gorham’s disease (massive osteolysis). Since the prognosis of the latter entity tends to be less favorable than in SCA, particularly SCA without extraskeletal involvement, careful differentiation of both disorders appears to be important.

Background Aseptic loosening is one of the greatest problems in hip replacement surgery. The rotation center of the hip is believed to influence the longevity of fixation. The aim of this study was to compare the influence of cemented and cementless cup fixation techniques on the position of the center of rotation because cemented cup fixation requires the removal of more bone for solid fixation than the cementless technique. Methods We retrospectively compared pre- and post-operative positions of the hip rotation center in 25 and 68 patients who underwent artificial hip replacements in our department in 2007 using cemented or cementless cup fixation, respectively, with digital radiographic image analysis. Results The mean horizontal and vertical distances between the rotation center and the acetabular teardrop were compared in radiographic images taken pre- and post-operatively. The mean horizontal difference was −2.63 mm (range: -11.00 mm to 10.46 mm, standard deviation 4.23 mm) for patients who underwent cementless fixation, and −2.84 mm (range: -10.87 to 5.30 mm, standard deviation 4.59 mm) for patients who underwent cemented fixation. The mean vertical difference was 0.60 mm (range: -20.15 mm to 10.00 mm, standard deviation 3.93 mm) and 0.41 mm (range: -9.26 mm to 6.54 mm, standard deviation 3.58 mm) for the cementless and cemented fixation groups, respectively. The two fixation techniques had no significant difference on the position of the hip rotation center in the 93 patients in this study. Conclusions The hip rotation center was similarly restored using either the cemented or cementless fixation techniques in this patient cohort, indicating that the fixation technique itself does not interfere with the position of the center of rotation. To completely answer this question further studies with more patients are needed.