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ZusammenfassungDie Ruptur der distalen Bizepssehne tritt am häufigsten bei Männern im mittleren Alter auf (30 bis 50 Jahre). Der typische Mechanismus ist die exzentrische Belastung in strecknaher Ellbogenstellung in Supination, wobei diese Verletzung mit Kraftsport und körperlich belastender Tätigkeit assoziiert ist. Epidemiologische Daten weisen auf eine Zunahme von distalen Bizepsrupturen in den letzten Jahrzehnten hin. Risikofaktoren wie die Verwendung anaboler Steroide, Kraftsport und Nikotinabusus zeigen einen Zusammenhang mit der Verletzung. Bei reduziertem Patientenanspruch oder relevanten Komorbiditäten ist auch unter einer konservativen Behandlung ein gutes funktionelles Ergebnis mit subjektiv guter Patientenzufriedenheit zu erreichen, allerdings unter zu erwartender relevanter Kraftminderung in Flexion (20 %) und Supination (40 %). Durch eine operative Refixation lässt sich das beste funktionelle Resultat erzielen, allerdings einhergehend mit einem nicht unerheblichen Komplikationsrisiko.

Die glenohumerale Instabilitat ist eine der haufigsten Gelenkinstabilitaten des menschlichen Korpers. Haufig sind konservative Masnahmen sowohl fur die sitzende Population als auch fur den Spitzensportler zielfuhrend. Sind trotzdem chirurgische Masnahmen indiziert, kann es zu Komplikationen kommen. In diesem Artikel werden die haufigsten Komplikationen dieser Stabilisierungsoperationen nach Weichteilstabilisierungen und ossaren Augmentationen aufgeteilt und die Vermeidungsstrategien sowie deren pra-, intra- und postoperatives Management beleuchtet.

Purpose The purpose of this study was to perform a Delphi consensus for the treatment of patients with shoulder impingement with intact rotator cuff tendons, comparing North American to European shoulder surgeon preferences. Methods Nineteen surgeons from North America [NAP] and 18 surgeons from Europe [EP] agreed to participate and answered 10 open-ended questions in rounds 1 and 2. The results of the first two rounds were used to develop a Likert style questionnaire for round 3. If agreement at round 3 was 60% for an item, the results were carried forward into round 4. For round 4 the panel members outside consensus >60%, Results There was agreement on the following items: impingement is a clinical diagnosis; a combination of clinical tests should be used; other pain generators must be excluded; radiographs must be part of the work up; MR imaging is helpful; the first line of treatment should always be physiotherapy; a corticosteroid injection is helpful in reducing symptoms; indication for surgery is failure of non-operative treatment for a minimum of 6 months. The NAP were likely to routinely prescribe NSAIDs [NA 89%; EU 35%] and consider steroids for impingement [NA 89%. EU 65%]. Conclusion Consensus was achieved for 16 of the 71 Likert items: impingement is a clinical diagnosis and a combination of clinical tests should be used. The first line of treatment should always be physiotherapy, and a corticosteroid injection can be helpful in reducing symptoms. The indication for surgery is failure of non-operative treatment for a minimum of 6 months. The panel also agreed that SAD is a good choice for shoulder impingement if there is evidence of mechanical impingement with pain not responding to non-surgical measures.

Growth factors such as the use of platelet-rich plasma-containing growth factors, e.g., IL-1 and IL-6 or TNF-alpha, have been extensively studied but their clinical benefits could not be found. However, currently there are upcoming studies on loading growth factors on matrices with promising results in animal models. To date, the easiest and most cost-effective enhancement in rotator cuff repairs is microfracturing of the humeral head to promote bone marrow stimulation.

Purpose The purpose of this study was to establish consensus statements via a modified Delphi process on revision surgery, rehabilitation and return to play, and clinical follow-up for anterior shoulder instability. Methods A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. Results The primary relative indications for revision surgery include symptomatic apprehension or recurrent instability, additional intra-articular pathologies, and symptomatic hardware failure. In revision cases, the differentiating factors that dictate treatment are the degree of glenohumeral bone loss and rotator cuff function/integrity. The minimum amount of time before allowing athletes to return to play is unknown, but other factors should be considered, including restoration of strength, range of motion and proprioception, and resolved pain and apprehension, as these are prognostic factors of reinjury. Additionally, psychological factors should be considered in the rehabilitation process. Patients should be clinically followed up for a minimum of 12 months or until a return to full, premorbid function/activities. Finally, the following factors should be included in anterior shoulder instability-specific, patient-reported outcome measures: function/limitations impact on activities of daily living, return to sport/activity, instability symptoms, confidence in shoulder, and satisfaction. Conclusion Overall, 92% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were indications and factors affecting decisions for revision surgery, as well as how prior surgeries impact procedure choice. Furthermore, there was unanimous consensus on the role of psychological factors in the return to play, considerations for allowing return to play, as well as prognostic factors. Finally, there was a lack of unanimous consensus on recommended timing and methods for clinical follow-up. Level of Evidence Level V, expert opinion.

Purpose The purpose of this study was to establish consensus statements via a modified Delphi process on the Latarjet procedure, remplissage, and glenoid-bone grafting for anterior shoulder instability. Methods A consensus process on the treatment utilizing a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. Results The technical approaches identified in the statements on the Latarjet procedure and glenoid bone-graft were that a subscapularis split approach should be utilized, and that it is unclear whether a capsular repair is routinely required. Furthermore, despite similar indications, glenoid bone-grafting may be preferred over the Latarjet in patients with bone-loss greater than can be treated with a coracoid graft, and in cases of surgeon preference, failed prior Latarjet or glenoid bone-grafting procedure, and epilepsy. In contrast, the primary indications for a remplissage procedure was either an off-track or engaging Hill-Sachs lesion without severe glenoid bone loss. Additionally, in contrast to the bone-block procedure, complications following remplissage are rare, and loss of shoulder external rotation can be minimized by performing the tenodesis via the safe-zone and not over medializing the fixation. Conclusion Overall, 89% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the prognostic factors that are important to consider in those undergoing a glenoid bone-grafting procedure including age, activity level, Hill-Sachs Lesion, extent of glenoid bone-loss, hyperlaxity, prior surgeries, and arthritic changes. Furthermore, there was unanimous agreement that it is unclear whether a capsular repair is routinely required with a glenoid bone graft, but it may be beneficial in some cases. There was no unanimous agreement on any aspect related to the Latarjet procedure or Remplissage. Level of Evidence Level V: expert opinion.

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.

Previous biomechanical studies used single-pull destructive tests in line with the anchor and are limited by a great variability of bone density of cadaver samples. To overcome these limitations, a more physiological test setting was provided using titanium, bioresorbable, and all-suture anchors.In this controlled laboratory study, 3 anchor constructs were divided into 2 groups: physiological and osteoporotic. Sixty standardized artificial bone specimens (=10 for each anchor in each group) were used for biomechanical testing. The anchors were inserted at a 45° angle as during surgery. Cyclic loading for 1000 cycles followed by ultimate load-to-failure (ULTF) testing was performed. Elongation, ultimate load at failure, and the mode of failure were noted.In the physiological group, the ULTF for the all-suture anchor (mean [standard deviation], 632.9 [96.8 N]) was found to be significantly higher than for the other anchors (titanium, 497.1 [50.5] N, and bioresorbable, 322.4 [3.1 N], P.0001). The titanium anchor showed a significantly higher ULTF than the bioresorbable anchor (P.0001). In the osteoporotic group, the all-suture anchor again showed a higher ULTF compared to the bioresorbable anchor (500.9 [50.6] N vs. 315.1 [11.3] N, P .0001). In the osteoporotic group, cyclic loading revealed a higher elongation after 1000 loading cycles for the bioresorbable (0.40 [0.12] mm) compared to the titanium (0.22 [0.11] mm; P = .01) as well as the all-suture anchor (0.19 [0.15] mm, P = .003).Regarding ULTF, the all-suture anchor outperformed the other anchors in physiological bone, but in osteoporotic bone, significance was reached only compared to the bioresorbable anchor. Although cyclic loading revealed significant differences, these might not be clinically relevant.

Background: Cheese-wiring, the suture that cuts through the meniscus, is a well-known issue in meniscal repair. So far, contributing factors are neither fully understood nor sufficiently studied. Hypothesis/Purpose: To investigate whether the construct stiffness of repair sutures and devices correlates with suture cut-through (cheese-wiring) during load-to-failure testing. Study Design: Controlled laboratory study. Methods: In 131 porcine menisci, longitudinal bucket-handle tears were repaired using either inside-out sutures (n = 66; No. 0 Ultrabraid, 2-0 Orthocord, 2-0 FiberWire, and 2-0 Ethibond) or all-inside devices (n = 65; FastFix360, Omnispan, and Meniscal Cinch). After cyclic loading, load-to-failure testing was performed. The mode of failure and construct stiffness were recorded. A receiver operating characteristic curve analysis was performed to define the optimal stiffness threshold for predicting meniscal repair failure by cheese-wiring. The 2-tailed t test and analysis of variance were used to test significance. Results: Loss of suture fixation was the most common mode of failure in all specimens (58%), except for the Omnispan, which failed most commonly because of anchor pull-through. The Omnispan demonstrated the highest construct stiffness (30.8 ± 3.5 N/mm), whereas the Meniscal Cinch (18.0 ± 8.8 N/mm) and Ethibond (19.4 ± 7.8 N/mm) demonstrated the lowest construct stiffness. The Omnispan showed significantly higher stiffness compared with the Meniscal Cinch ( P < .001) and Ethibond ( P = .02), whereas the stiffness of the Meniscal Cinch was significantly lower compared with that of the FiberWire ( P = .01), Ultrabraid ( P = .04), and FastFix360 ( P = .03). While meniscal repair with a high construct stiffness more often failed by cheese-wiring, meniscal repair with a lower stiffness failed by loss of suture fixation, knot slippage, or anchor pull-through. Meniscal repair with a stiffness >26.5 N/mm had a 3.6 times higher risk of failure due to cheese-wiring during load-to-failure testing (95% CI, 1.4-8.2; P < .0001). Conclusion: Meniscal repair using inside-out sutures and all-inside devices with a higher construct stiffness (>26.5 N/mm) was more likely to fail through suture cut-through (cheese-wiring) than that with a lower stiffness (≤26.5 N/mm). Clinical Relevance: This is the first study investigating the impact of construct stiffness on meniscal repair failure by suture cut-through (cheese-wiring).

I Tab. 1 ist in der zweiten Zeile, dritte Spalte ein Fehler aufgetreten. In der Beach-Chair-Lagerungsposition besteht der Vorteil „Einfache Primardiagnostik bei stabiler Skapula“. Der Nachteil ist die „Hypertension und verminderte Gehirnperfusion“. In der letzten Zeile in der Seitenlagenposition …

The growth in the relevance of the circular economy is confirmed today by the presence of numerous concurrent initiatives at a global level in terms of both policy level and labelling initiatives. Despite the presence of these initiatives, there is still no international agreement on systems to measure this effort. The ISO/TC 323 initiative aims precisely to develop responses to this challenge over the next three years. This article presents the main features of this initiative, in particular WG3 at a global level and the parallel UNI/CT 057 initiative.

Suprapectoral tenodesis is a frequently used technique for treating pathologies of the long head of the biceps brachii (LHBB) tendon. However, so far, no Gold Standard treatment exist. Hence, the arthroscopic LassoLoop360 (LL360) technique is introduced aiming to provide secure fixation and improved biomechanical properties. It was hypothesized, that the LL360 technique would show superior biomechanical response to cyclic loading and ultimate load-to-failure testing compared to the commonly used simple Lasso Loop (SLL). Twenty-two porcine superficial flexor digitorum tendons were prepared using a No. 2 suture according to either the SLL or the LL360 technique. Displacement after cyclic loading (1.000 cycles) between 5 and 30 N, ultimate load-to-failure (ULTF), mode of failure as well as the construct stiffness were tested. Significantly less displacement was found in the LL360 group (SLL 2.25 ± 0.51 mm; LL360 1.67 ± 0.37 mm; p = 0.01). Ultimate Load to Failure was significantly higher in the LL360 (168.6 ± 29.6 N) as compared to the SLL (124.1 ± 25.8 N, p = 0.02). The LL360 also revealed a significant higher stiffness compared to the SLL (SLL 13.1 ± 0.9 N/mm vs. LL360 19.1 ± 1.0 N/mm, p

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Background: It has been suggested that platelet-rich plasma (PRP) improves healing after arthroscopic rotator cuff repair. The current literature provides ample but inconsistent data on this topic. Purpose: To systematically review the current in vivo evidence for the use of platelet concentrates (PRP) in the arthroscopic treatment of rotator cuff tears to assess effectiveness, safety, and cost-effectiveness. Study Design: Meta-analysis and cost-effectiveness analysis. Methods: Published evidence from controlled, human trials of rotator cuff repair augmented with platelet concentrates was systematically gathered, and data on retear rates were extracted. Mathematical and clinical heterogeneity was evaluated, and fixed-effect meta-analysis was performed to calculate the risk ratio (RR) of retears and the number needed to treat (NNT). Subgroup analyses were made for small/medium tears (n = 404) and large/massive tears (n = 374). Cost-effectiveness was assessed using data from this meta-analysis and using cost data from the literature, including extensive sensitivity analyses, to calculate the incremental cost-effectiveness ratio (ICER). Results: Thirteen studies published between 2010 and 2014 were identified for analysis. The RR for retear for all patients was 0.87 (95% CI, 0.67-1.12; P = .286). For small- and medium-sized tears (Conclusion: In large tears, even with double-row repair, the beneficial effects of PRP alone are insufficient to compensate the progressed tissue damage. The study data suggest that PRP may promote healing of small- and medium-sized tears to reduce retear rates. However, despite the substantial biological effect, at current cost, the use of PRP is not cost-effective in arthroscopic repair of small- and medium-sized tears.

Background: The arthroscopic Latarjet procedure combines the benefits of arthroscopic surgery with the low rate of recurrent instability associated with the Latarjet procedure. Only short-term outcomes after arthroscopic Latarjet procedure have been reported. Purpose: To evaluate the rate of recurrent instability and patient outcomes a minimum of 5 years after stabilization performed with the arthroscopic Latarjet procedure. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent the arthroscopic Latarjet procedure before June 2008 completed a questionnaire to determine whether they had experienced a dislocation, subluxation, or further surgery. The patients also completed the Western Ontario Shoulder Instability Index (WOSI). Results: A total of 62 of 87 patients (64/89 shoulders) were contacted for follow-up. Mean follow-up time was 76.4 months (range, 61.2-100.7 months). No patients had reported a dislocation since their surgery. One patient reported having subluxations since the surgery. Thus, 1 patient (1.59%) had recurrent instability after the procedure. The mean ± standard deviation aggregate WOSI score was 90.6% ± 9.4%. Mean WOSI domain scores were as follows: Physical Symptoms, 90.1% ± 8.7%; Sports/Recreation/Work, 90.3% ± 12.9%; Lifestyle, 93.7% ± 9.8%; and Emotions, 88.7% ± 17.3%. Conclusion: The rate of recurrent instability after arthroscopic Latarjet procedure is low in this series of patients with a minimum 5-year follow-up. Patient outcomes as measured by the WOSI are good.

Zusammenfassung Bei posterioren Schulterschmerzen sollte an eine Pathologie im Bereich des N. suprascapularis gedacht werden. Der Nerv kann in seinem Verlauf an der Incisura scapulae eingeklemmt werden oder durch eine Ruptur der Rotatorenmanschette von seinem anatomischen Verlauf abweichen und unter Zug geraten. Dies kann ein Grund fur persistierende Schmerzen auch nach erfolgreicher Rotatorenmanschettennaht sein. Diagnostisch ist die klinische und neurologische Untersuchung wegweisend, wahrend die diagnostische, radiologisch kontrollierte Testinfiltration (Sonographie oder Durchleuchtung) den aktuellen Goldstandard darstellt. Die arthroskopische Dekompression an der Incisura scapulae ist eine sichere und zuverlassige Methode, den Nerv zu befreien. Verschiedene Studien zeigen eine Verbesserung der Muskelfunktion und fuhren zu einer Schmerzreduktion.

Background:All-inside arthroscopic meniscal repairs are favored by most clinicians because of their lower complication rate and decreased morbidity compared with inside-out techniques. Until now, only 1000 cycles have been used for biomechanical testing.Hypothesis:All-inside meniscal repairs will show inferior biomechanical response to cyclic loading (up to 100,000 cycles) and load-to-failure testing compared with inside-out suture controls.Study Design:Controlled laboratory study.Methods:Bucket-handle tears in 72 porcine menisci were repaired using the Omnispan and Fast-Fix 360 (all-inside devices) and Orthocord 2-0 and Ultrabraid 2-0 sutures (matched controls). Initial displacement, displacement after cyclic loading (100, 500, 1000, 2000, 5000, 10,000, and 100,000 cycles) between 5 and 20 N, ultimate load to failure, and mode of failure were recorded, as well as stiffness.Results:Initial displacement and displacement after cyclic loading were not different between the groups. The Omnispan repair demonstrated the highest load-to-failure force (mean ± SD, 151.3 ± 21.5 N) and was significantly stronger than all the other constructs (Orthocord 2-0, 105.5 ± 20.4 N; Ultrabraid 2-0, 93.4 ± 22.5 N; Fast-Fix 360, 76.6 ± 14.2 N) ( P < .0001 for all). The Orthocord vertical inside-out mattress repair was significantly stronger than the Fast-Fix 360 repair ( P = .003). The Omnispan (30.8 ± 3.5 N/mm) showed significantly higher stiffness compared with the Ultrabraid 2-0 (22.9 ± 6.9 N/mm, P < .0001) and Fast-Fix 360 (23.7 ± 3.9 N/mm, P = .001). The predominant mode of failure was suture failure.Conclusion:All-inside meniscal devices show comparable biomechanical properties compared with inside-out suture repair in cyclic loading, even after 100,000 cycles.Clinical Relevance:Eight to 10 weeks of rehabilitation might not pose a problem for all repairs in this worst-case scenario.

Meniscal repair devices have been extensively tested during the past decades as reported in the literature. Reviewing the different meniscal repair devices and sutures with their respective biomechanical properties. For this meta-analysis, we conducted a systematic online search using PubMed, EMBASE, CCTR, and CINAHL using the search terms Meniscus OR Meniscal AND Biomechanics AND Repair). Load-to-failure (LtF), stiffness, and cyclic outcome measures were extracted independently and in duplicate. The systematic search revealed 841 manuscripts in total. After exclusion of duplicates and irrelevant publications, 41 studies remained for final analysis. The studies were published in English and German from 1995 to 2013. Due to differing cyclic force protocols, cyclic outcomes had to be excluded. Overall, sutures had a higher LtF [suture: 87.7 ± 0.3 N (weighted mean ± standard error), device: 56.3 ± 0.1 N] and stiffness (suture: 8.9 ± 0.04 N/mm, device: 8.6 ± 0.04 N/mm) than devices, both p

Shoulder dislocation and subsequent anterior instability is a common problem in young athletes. The arthroscopic Bankart repair was originally described by Morgan et al. in 1987. The procedure has benefited from many technical advancements over the past 25 years and currently remains the most commonly utilized procedure in the treatment of anterior glenohumeral instability without glenoid bone loss. Capsulolabral repair alone may not be sufficient for treatment of patients with poor capsular tissue quality and significant bony defects. In the presence of chronic anterior glenoid bony defects, a bony reconstruction should be considered. The treatment of anterior shoulder instability with transfer of the coracoid and attached conjoint tendon such as the Latarjet procedure has provided reliable results. The arthroscopic Latarjet procedure was described in 2007 by the senior author, who has now performed the procedure over 450 times. The initial surgical technique has evolved considerably since its introduction, and this article presents a comprehensive update on this demanding but well-defined procedure. This article reviews technical tips to help the surgeon perform the surgery more smoothly, navigate through challenging situations, and avoid potential complications. Level of evidence V.

The aim of this study was to evaluate return to sports after arthroscopic Bankart stabilization. This is a retrospective study including all athletes aged

Background The objective of this study was to systematically review and quantitatively synthesize the data on recurrence rates after shoulder immobilization in internal versus external rotation in first-time, traumatic shoulder dislocations. Materials and methods We performed a systematic search of the keywords “(((external rotation) OR internal rotation) AND immobilization) AND shoulder” in the online databases PubMed, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Library. Random-effects models were used to calculate the cumulatively pooled risk ratios (RRs) of recurrent shoulder dislocations. All analyses were also stratified by age. Results We included 5 studies with a total of 471 patients (230 internal rotation and 241 external rotation) published between 2001 and 2011 in English. The pooled random-effects RR for recurrence of shoulder dislocations at all ages was 0.74 (95% confidence interval [CI], 0.44-1.27; P = .278). The RR was 0.70 (95% CI, 0.38 to 1.29; P = .250) for patients aged 30 years or younger and 0.78 (95% CI, 0.32 to 1.88; P = .579) for those aged older than 30 years. Conclusion The current best evidence does not support a relative effectiveness of immobilization in external rotation compared with internal rotation to avoid recurrent shoulder dislocations in patients with traumatic anterior shoulder dislocations.

Background:Supraspinatus tears are common in pitchers. However, the effect of these tears on glenohumeral (GH) mechanics is incompletely understood.Purpose/Hypothesis:To describe the effect of supraspinatus tears and repairs on GH kinematics during an abbreviated throwing motion using the intact shoulder girdle. The hypothesis was that supraspinatus tears would lead to an increase of GH translation in the coronal plane and supraspinatus repairs would restore GH kinematics.Study Design:Controlled laboratory study.Methods:Six shoulders from 3 fresh-frozen cadavers were tested in a novel 7 degrees of freedom robotic testing system. Torsos were mounted and the wrist was pinned to an actuator mounted on an upper frame. After the deltoid was removed, the shoulders were studied during an abbreviated throwing motion (ATM) from maximum external rotation to the midcoronal plane to establish a baseline. The ATM was repeated after creation of a 1-cm supraspinatus tear, after creation of a 3-cm supraspinatus tear, and after repair with a transosseous equivalent (TOE) technique. Retroreflective bone markers and high-speed infrared cameras were used to measure GH kinematics and calculate the center of rotation of the GH joint (CORGH) instantaneously.Results:The 1- and 3-cm supraspinatus tears did not significantly alter GH translation. The TOE repair shifted the CORGHposteriorly, as evidenced by a significant decrease in the overall GH translation in all 3 planes ( P = .003, .019, and .026, for x-y, y-z, and x-z planes, respectively).Conclusion:In contrast to a TOE repair of the supraspinatus tendon, isolated supraspinatus tears did not perturb GH kinematics in this cadaveric model of the throwing shoulder.Clinical Relevance:In throwing athletes, treatment of rotator cuff tears should be addressed with caution to avoid an unintended alteration in GH kinematics due to overtightening of the tendon.

Background Uniaxial biomechanical testing of sutures and devices remains the gold standard as in-vivo testing is currently not feasible. The purpose of this study was thus to biomechanically test non-absorbable Ethibond 2-0. Methods In nine porcine menisci, a bucket-handle tear was created and a repair was performed in a vertical inside-out technique using a 2-0 Ethibond suture. The menisci were clamped to a mechanical testing system and gap formation was recorded using a high-resolution digital camera. Vertical displacement, load-to-failure were measured and stiffness was calculated. Results The initial displacement was 5.89±1.42mm with increasing displacement between 1 and 500 cycles. The increase between cycle 300 and 500 was 0.22mm and was lower than between cycle 1 to 300 (p=0.21) whereas the increase between cycle 100 and 300 was not significantly different from 1 to 100 (p=0.41). The suture failed at 60.5±7.9N. The stiffness was 19.4±7.8N/mm. Discussion In conclusion, the Ethibond TM 2-0 vertical repair yields satisfactory biomechanical results compared to other sutures.

Background: The objective of this study was to conduct a meta-analysis and cost-effectiveness analysis of the effect of glenoid design on radiolucency, loosening, and revision after total shoulder arthroplasty. Methods: We conducted a systematic review of PubMed, MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and CINAHL with use of a search for the terms arthroplasty AND shoulder AND (peg OR keel). Data on study design and on the end points of radiolucency, loosening, and revision were extracted independently and in duplicate. Random-effect models were used to calculate the pooled risk ratio and risk difference. The risk difference was used to estimate the number needed to treat (the number of individuals who would have to receive a pegged component to avoid one loosening or revision). Results: Eight studies with a total of 1460 patients (mean age, sixty-seven years) were included. The mean study quality was 1.75 points (95% confidence interval [CI], 1.26 to 2.24) on the 3-point modified Jadad scale. There was no significant difference in the risk of any radiolucency (risk ratio, 0.42; 95% CI, 0.12 to 1.42) or in the risk of severe radiolucency (risk ratio, 0.65; 95% CI, 0.23 to 1.82) between pegged and keeled components. The pooled risk ratio for revision was 0.27 (95% CI, 0.08 to 0.88) in favor of pegged components (p = 0.028). At a cost-effectiveness threshold of $50,000 per quality-adjusted life year, pegged components can be between $2325 and $40,920 more expensive than keeled components and still be cost-effective. Conclusions: Our study produced evidence that pegged glenoid components were associated with a lower revision risk compared with keeled components. However, the difference was rather small and will therefore be most meaningful to high-volume shoulder arthroplasty centers. Because of the similarity between primary and secondary costs, pegged glenoid designs were more cost-effective than keeled glenoid designs. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hypothesis: In this study, we aim to test whether scapular winging results in a significant change in glenohumeral translation in the initial phase of the throwing motion. Methods: Six shoulders underwent an abbreviated throwing motion (ATM) from late cocking to the end of acceleration by use of a validated robotic system. The intact specimens were tested to establish a baseline. The position of the scapula was then affected to simulate scapular winging by placing a cylindrical wedge under the inferior angle of the scapula, and the ATM was performed again. For both conditions, the average glenohumeral translations and scapular rotations were plotted over time to calculate the area under the curve, as a representative of the overall glenohumeral translations and scapular rotations observed during the ATM. Results: Throughout the motion, the winged scapulae showed, on average, 7.7 � more upward rotation, 1.6 � more internal rotation, and 5.3 � more anterior tipping as compared with the baseline. The scapular position relative to the hanging arm was significantly different between the baseline and scapular winging conditions in all arm positions, except for maximal external rotation and the neutral position. Comparing the area under the curve at baseline and with scapular winging indicated that scapular winging significantly increased anterior translation of the glenohumeral joint whereas translation in the superior/inferior and medial/lateral directions did not result in a change in translation. Discussion: These results may suggest a more important role of abnormalities in scapular position in predisposing throwing athletes to shoulder injuries of the anterior capsulolabral structures and consecutive glenohumeral instability. Level of evidence: Basic Science Study, Biomechanics. 2013 Journal of Shoulder and Elbow Surgery Board of Trustees.

BACKGROUNDThe purpose of this biomechanical study was to determine the effect of shortened clavicle malunion on the center of rotation of the glenohumeral (GH) joint, and the capacity of repair to restore baseline kinematics.METHODSSix shoulders underwent automated abduction (ABD) and abbreviated throwing motion (ATM) using a 7-DoF automated upper extremity testing system in combination with an infrared motion capture system to measure the center of rotation of the GH joint. ATM was defined as pure lateral abduction and late cocking phase to the end of acceleration. Torsos with intact clavicle underwent testing to establish baseline kinematics. Then, the clavicles were subjected to midshaft fracture followed by kinematics testing. The fractured clavicles underwent repairs first by clavicle length restoration with plate fixation, and then by wiring of fragments with a 2-cm overlap to simulate shortened malunion. Kinematic testing was conducted after each repair technique. Center of rotation of the GH joint was plotted across all axes to outline 3D motion trajectory and area under the curve.RESULTSThroughout ABD, malunion resulted in increased posterior and superior translation compared to baseline. Plate fixation restored posterior and superior translations at lower abduction angles but resulted in excess anterior and inferior translation at overhead angles. Throughout ATM, all conditions were significantly anterior and superior to baseline. Translation with malunion was situated anterior to the fractured and ORIF conditions at lower angles of external rotation. Plate fixation did not restore baseline anteroposterior or superoinferior translation at any angle measured.CONCLUSIONSThis study illustrates the complex interplay of the clavicle and the GH joint. While abnormal clavicle alignment alters shoulder motion, restoration of clavicle length does not necessarily restore GH kinematics to baseline. Rehabilitation of the injured shoulder must address the osseous injury and the dynamic forces of the shoulder girdle.