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

Background: Shoulder magnetic resonance imaging (MRI) is commonly performed in patients with frozen shoulder (FS). However, the necessity of MRI and its diagnostic value is questionable. Therefore, the purpose of the present study was to clarify whether routine MRI could identify additional shoulder pathologies not previously suspected in the clinical examination and if any change in the treatment plan based on these additional MRI findings in FS patients was observed. Materials and methods: The medical records of all patients who presented in our outpatient clinic with a diagnosis of FS from January 2017 to December 2018 were retrospectively reviewed. Patient demographics, the number of patients who received a shoulder MRI, changes in the diagnosis or identification of structural shoulder pathologies following MRI examination (if performed), as well as any alternation in the initially suggested treatment plan were recorded. Results: A total of 609 patients (male: 241, female: 368) diagnosed with an FS and an average age of 52 ± 10 (range: 18 to 81) years were identified. In 403 of the 609 patients (66%), a shoulder MRI was performed. An additional structural shoulder pathology was identified in 89 of 403 (22%) patients following the shoulder MRI, mostly rotator cuff tears (partial: 46/403 [11.4%], full-thickness: 30/403 [7.4%], rerupture following reconstruction: 10/403 [2.5%]) and labrum tears (3/403 [0.7%]). At minimum 2-year follow-up, 11 of 403 (2.7%) patients were treated surgically for the additional pathology identified on the MRI scan consisting of an arthroscopic rotator cuff reconstruction in 10 patients and a labrum refixation in one patient. Five of the 609 (0.8%) patients were treated for refractory FS by arthroscopic capsulotomy. Conclusions: Although additional pathologies were identified in 22% of the patients, a change in treatment plan due to the MRI findings was only observed in 2.7% (37 MRIs needed to identify 1 patient with FS requiring surgery for the additional MRI findings). Therefore, routine use of shoulder MRI scans in patients with FS but without suspicion of an additional pathology may not be indicated.

Background: The diagnosis of adhesive capsulitis (AC) of the shoulder might be challenging, as it is a diagnosis of exclusion and mainly based on the clinical examination. The purpose of the present study was to investigate the validity and reliability of 4 commonly reported radiological parameters suggesting a superior humeral head migration on anteroposterior (a/p) shoulder radiograph in identifying patients with AC. Methods: The a/p shoulder radiographs of 100 patients with AC and 100 control subjects were retrospectively reviewed. A disruption of the normal scapulohumeral arch (≥2 mm), the acromiohumeral interval (AHI), the inferior glenohumeral distance (IGHD), and the upward migration index (UMI) were measured. Results: A disruption of the scapulohumeral arch was observed in 80% in the AC and 20% in the control group. The mean AHI was 9.3 ± 1.3 mm and 11.0 ± 1.7 mm (P

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

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

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

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

Abstract Purpose Patella baja after total knee arthroplasty (TKA) is a common problem that is usually treated via proximal transfer of the tibial tubercle. As the long‐term outcomes of this procedure are unclarified, this study aimed to investigate the changes in clinical function and radiographic patellar height during five years of follow‐up. Methods Sixty patients with patella baja after TKA who underwent proximalisation of the tibial tubercle were followed up for a mean of 71 months (range 21–153 months). The pre‐ and postoperative range of motion (ROM) and clinical scores (Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)) were compared. The radiographic patellar height was measured with the Caton‐Deschamps index (CDI), Blackburne‐Peel ratio (BP), and modified Insall‐Salvati index (MIS). Results Proximalisation of the tibial tubercle resulted in a significant improvement in the ROM from 80° to 88°. The KSS and WOMAC did not improve or even worsened after the intervention. The radiographic patellar height immediately after tibial tubercle transfer was not better than prior to the intervention (CDI 0.72 vs. 0.63, p = 0.72; BP 0.66 vs. 0.61, p = 0.72; MIS 1.59 vs. 1.55, p = 1.00) and further decreased significantly so that the mean final values were worse than the values in the native joint (CDI 0.59 vs. 0.78, p = 0.001; BP 0.58 vs. 0.74, p = 0.001; MIS 1.39 vs. 1.81, p

Introduction In the field of arthroscopic rotator cuff repair (ARCR), reporting standards of published studies differ dramatically, notably concerning adverse events (AEs). In addition, prognostic studies are overall methodologically poor, based on small data sets and explore only limited numbers of influencing factors. We aim to develop prognostic models for individual ARCR patients, primarily for the patient-reported assessment of shoulder function (Oxford Shoulder Score (OSS)) and the occurrence of shoulder stiffness 6 months after surgery. We also aim to evaluate the use of a consensus core event set (CES) for AEs and validate a severity classification for these events, considering the patient’s perspective.Methods and analysis A cohort of 970 primary ARCR patients will be prospectively documented from several Swiss and German orthopaedic clinics up to 24 months postoperatively. Patient clinical examinations at 6 and 12 months will include shoulder range of motion and strength (Constant Score). Tendon repair integrity status will be assessed by ultrasound at 12 months. Patient-reported questionnaires at 6, 12 and 24 months will determine functional scores (subjective shoulder value, OSS), anxiety and depression scores, working status, sports activities, and quality of life (European Quality of Life 5 Dimensions 5 Level questionnaire). AEs will be documented according to a CES. Prognostic models will be developed using an internationally supported regression methodology. Multiple prognostic factors, including patient baseline demographics, psychological, socioeconomic and clinical factors, rotator cuff integrity, concomitant local findings, and (post)operative management factors, will be investigated.Ethics and dissemination This project contributes to the development of personalised risk predictions for supporting the surgical decision process in ARCR. The consensus CES may become an international reference for the reporting of complications in clinical studies and registries. Ethical approval was obtained on 1 April 2020 from the lead ethics committee (EKNZ, Basel, Switzerland; ID: 2019-02076). All participants will provide informed written consent before enrolment in the study.Trial registration number NCT04321005.Protocol version Version 2 (13 December 2019).

Younger patients in particular may require biceps tenodesis following tenotomy to avoid the development of a biceps “Popeye deformity.” It is, however, difficult to predict whether a tenodesis is cosmetically necessary, since this deformity develops to a very variable degree, as the biceps muscle will retract in the postoperative course to an unknown amount with active contraction. Through the intraoperative electrical stimulation of the musculocutaneous nerve, the maximal contraction of the muscle can intraoperatively be provoked and thus the amount of Popeye deformity becomes apparent. We conclude that this method could be useful for intraoperative decision making if biceps tenodesis is needed and helps to avoid this surgical step and its associated risks, which otherwise often is performed unnecessarily, just in case.

Abstract 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).

Abstract Despite numerous available treatment strategies, the management of complex proximal humeral fractures remains demanding. Impaired bone quality and considerable comorbidities pose special challenges in the growing aging population. Complications after operative treatment are frequent, in particular loss of reduction with varus malalignment and subsequent screw cutout. Locking plate fixation has become a standard in stabilizing these fractures, but surgical revision rates of up to 25% stagnate at high levels. Therefore, it seems of utmost importance to select the right treatment for the right patient. This article provides an overview of available classification systems, indications for operative treatment, important pathoanatomic principles, and latest surgical strategies in locking plate fixation. The importance of correct reduction of the medial cortices, the use of calcar screws, augmentation with bone cement, double-plate fixation, and auxiliary intramedullary bone graft stabilization are discussed in detail.