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Background: Arthroscopic treatment of calcifying tendinitis of the shoulder reveals good to excellent results. However, whether the tendon needs to be repaired after removal of the calcific deposit or simply debrided remains unclear. Purpose: To evaluate the structural and clinical results after arthroscopic calcific deposit removal with additional rotator cuff repair or rotator cuff debridement. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 44 patients (46 shoulders) were enrolled in this retrospective cohort study with a mean follow-up of 58.4 months. Patients underwent arthroscopic removal of a calcific deposit and bursectomy after failed nonoperative treatment. A total of 22 patients received additional rotator cuff repair irrespective of the degree of debridement (the repair group), whereas 22 patients received a simple rotator cuff debridement without additional repair (the debridement group). Groups were comparable in sex, age, and size and consistency of the deposits according to the Gärtner and Bosworth classifications. Clinical evaluation was performed by the Constant score, Simple Shoulder Test, American Shoulder and Elbow Surgeons (ASES) score, and numerical rating scales for pain, function, and satisfaction. In 29 patients (14 in the debridement group and 15 in the repair group), additional magnetic resonance imaging at follow-up was performed to evaluate the structural results using the Sugaya classification. Results: All patients were satisfied with the results of surgery; 100% of the repair group and 95.7% of the debridement group reported they would undergo the surgical procedure again. Comparison of the clinical results showed significantly better results in the repair group versus the debridement group for the Constant score (86.2 vs 80.6, respectively; P = .04), the ASES score (98.3 vs 88.9; P = .004), the Simple Shoulder Test (11.6 vs 10; P = .005), and the numerical rating scales for pain (0.1 vs 0.8; P = .007), function (9.6 vs 8.8; P = .008), and satisfaction (9.8 vs 9.1; P = .036). Comparison of the postoperative tendon integrity showed 80% Sugaya grade I in the rotator cuff repair group and 64% Sugaya grade II in the debridement group, with a statistically significant difference in favor of the repair group ( P = .004). Postoperative clinical evaluation revealed no positive O’Brien tests in the repair group, whereas approximately one-third of the debridement group showed a positive O’Brien test during examination. Conclusion: Arthroscopic removal of calcific deposits with rotator cuff debridement or cuff repair showed good to excellent clinical and structural midterm results. However, patients who underwent additional repair of the tendon defect had significantly better clinical results as well as better structural results in terms of tendon integrity.

To evaluate the optimal graft tension angles in a medial patellofemoral ligament (MPFL) reconstruction with selective bundle tensioning in order to restore patellofemoral contact pressure distributions closest to the native state. Twelve human cadaveric knee specimens were mounted with the femur on a custom-made fixation device allowing free range of motion in the knee joint for testing. Using a sensitive pressure film (Tekscan) patellofemoral contact pressure was measured in 15° intervals during a dynamic flexion movement from 0°–90° in the native state, in cut MPFL and after MPFL-reconstruction with a gracilis tendon. The graft was separated in two bundles and was fixed independently on the patella using two knotless anchors. Two groups were made with either the proximal or distal bundle fixed at the femur at a knee flexion angle of 30° and the corresponding other bundle subsequently fixed at the femur at 15°, 45°, 60°, 75° and 90° of knee flexion using extra-cortical fixation and controlled tension of 2N in both groups. The sequence of the flexion angles at the graft fixation was alternated. Pressure measurements were repeated after every fixation of the graft. Cutting the MPFL resulted in significantly reduced patellofemoral contact pressure at all flexion angles. After MPFL reconstruction the patellofemoral contact pressure remained significantly reduced during dynamic knee flexion in all tested double-bundle combinations (p

Background:The best surgical treatment option for symptomatic moderate- to high-grade articular-sided partial-thickness rotator cuff tears (PTRCTs) is still controversial.Purpose/Hypothesis:The purpose of this study was to evaluate patient-reported and clinical outcomes and tendon integrity after arthroscopic debridement or repair for PTRCTs at a minimum of 2 years postoperatively. We hypothesized that the overall outcomes would be positive, showing pain relief, good shoulder function, and high tendon integrity.Study Design:Cohort study; Level of evidence, 3.Methods:We evaluated 30 patients (16 men, 14 women; mean age, 51 years) who underwent arthroscopic treatment for symptomatic PTRCTs (Ellman grades 2 and 3). Debridement was performed in 15 patients, and arthroscopic tendon repair was performed in the remaining 15 patients. Patients completed the Constant score; American Shoulder and Elbow Surgeons (ASES) shoulder score; Western Ontario Rotator Cuff Index; Simple Shoulder Test; and visual analog scale (VAS) for pain, function, and satisfaction. In addition, patients were examined clinically (range of motion, impingement tests, rotator cuff tests, and tests for the long head of the biceps tendon), and morphologic assessment of rotator cuff integrity was performed using direct magnetic resonance arthrography and was classified according to Sugaya.Results:The mean follow-up period was 55 months. The patient-reported outcome measures showed high patient satisfaction, reduction in persistent pain, and good shoulder function. Linear regression analysis showed that the debridement group had significantly better results on the Constant (bias-corrected and accelerated [BCa] 95% CI, 4.20-26.30), ASES (BCa 95% CI, 5.24-39.26), and VAS (pain: BCa 95% CI, 0.13-3.62; function: BCa 95% CI, 1.04-4.84; satisfaction: BCa 95% CI, 0.14-6.28) scores than did the repair group. At follow-up, there was no significant difference between the groups in clinical testing results. Good supraspinatus tendon integrity was seen in most patients: Sugaya classification grade 1 in 13 patients, grade 2 in 11 patients, and grade 3 in 6 patients.Conclusion:Midterm results after arthroscopic debridement and repair for PTRCTs showed high patient satisfaction, good shoulder function, and high tendon integrity for both procedures. Patients who underwent arthroscopic debridement had higher Constant, ASES, and VAS scores compared with patients who underwent tendon repair.

The reliable diagnosis of partial-thickness tears of the rotator cuff is still elusive in clinical practise. Therefore, the purpose of the study was to determine the diagnostic accuracy of MR imaging and clinical tests for detecting partial-thickness tears of the rotator cuff as well as the combination of these parameters. 334 consecutive shoulder arthroscopies for rotator cuff pathologies performed during the time period between 2010 and 2012 were analyzed retrospectively for the findings of common clinical signs for rotator cuff lesions and preoperative MR imaging. These were compared with the intraoperative arthroscopic findings as “gold standard”. The reports of the MR imaging were evaluated with regard to the integrity of the rotator cuff. The Ellman Classification was used to define partial-thickness tears of the rotator cuff in accordance with the arthroscopic findings. Descriptive statistics, sensitivity, specificity, positive and negative predictive value were calculated. MR imaging showed 80 partial-thickness and 70 full-thickness tears of the rotator cuff. The arthroscopic examination confirmed 64 partial-thickness tears of which 52 needed debridement or refixation of the rotator cuff. Sensitivity for MR imaging to identify partial-thickness tears was 51.6%, specificity 77.2%, positive predictive value 41.3% and negative predictive value 83.7%. For the Jobe-test, sensitivity was 64.1%, specificity 43.2%, positive predictive value 25.9% and negative predictive value 79.5%. Sensitivity for the Impingement-sign was 76.7%, specificity 46.6%, positive predictive value 30.8% and negative predictive value 86.5%. For the combination of MR imaging, Jobe-test and Impingement-sign sensitivity was 46.9%, specificity 85.4%, positive predictive value 50% and negative predictive value 83.8%. The diagnostic accuracy of MR imaging and clinical tests (Jobe-test and Impingement-sign) alone is limited for detecting partial-thickness tears of the rotator cuff. Additionally, the combination of MR imaging and clinical tests does not improve diagnostic accuracy. Level II, Diagnostic study.

Arthroscopic and open repair of the rotator cuff leads to good clinical and functional results. In order to achieve a successful repair, detailed knowledge of the biomechanics of the intact as well as ruptured rotator cuff and the superior capsule is essential.

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.

Rotator cuff tears are a common cause of shoulder pain that may lead to severe impairment of shoulder function with significant limitation of the quality of life. Furthermore, they are associated with high direct and indirect costs.Conservative therapy and various surgical procedures for rotator cuff repair are all possible treatment options. Therefore, the correct treatment for a symptomatic rotator cuff tear is important.The conservative therapy may be considered as an alternative treatment option for a symptomatic rotator cuff tear in patients with small or incomplete tears with no fatty atrophy or tendon retraction, with only slight pain, and in older patients with few functional demands. Surgical treatment is recommended after failed conservative treatment lasting 3-6 months, with the corresponding psychological strain. Moreover, surgical treatment should be considered as a primary treatment option for a symptomatic rotator cuff tear in young patients with high functional demands, patients with a high level of physical strain in their jobs, large tears, and tears where there is already significant muscle atrophy or tendon retraction.Arthroscopic treatment is considered to be the gold standard because of the better cosmetic results and treatment of concomitant pathological conditions, the lower levels of postoperative pain, the potentially lower risk of shoulder stiffness, and more focused adhesiolysis. However, arthroscopy does not improve clinical results. Because of the current financial situation, however, open rotator cuff repair is still a viable alternative.

Evaluation of the biomechanical performance of repairs of 25 % (Fox/Romeo II) and 50 % (Fox/Romeo III) full-thickness subscapularis tears using a single-suture anchor. Six pairs of human cadaver specimens were used for the testing. Artificial subscapularis tears were created in order to simulate a 25 % (6) and a 50 % (6) full-thickness tear. The reconstructions were made with a double-loaded suture anchor (5.5-mm Bio-Corkscrew with two No. 2 Fiberwire) creating a double-mattress suture repair. Reconstructions were cyclically loaded from 10 to 60 N. The load was increased stepwise up to 100 and 180 N. Cyclic displacement (means + standard dev.) as well as load-to-failure was determined, and mode of failure was recorded. In the reconstructed shoulders at 60 N, a mean cyclic displacement of 3.2 ± 0.7 mm was found in the 25 % tear, 2.6 ± 0.6 mm in the 50 % tear. At 100 N, 5.1 ± 1.2 mm was seen in the 25 % tear and 4.3 ± 0.3 mm in the 50 % tear. At highest load of 180 N, 7.6 ± 2.2 mm was recorded in the 25 % tear, 6.5 ± 0.8 mm was found in the 50 % tear. Ultimate failure load was 486 ± 167 N in the 25 % tear and 455 ± 213 N in the 50 % tear. Statistically significant differences between the tested repairs were seen neither in cyclic displacement nor in ultimate failure loads (p > 0.05). Mode of failure revealed bone fractures and anchor pull-out as major cause in the 25 % group, whereas failure of the suture–tendon interface was the major cause of failure in the 50 % group. Subscapularis repair using a single double-loaded suture anchor revealed similar biomechanical performance in 25 % compared to 50 % full-thickness subscapularis tears. With increased tear size, however, an optimized suture–tendon interface seems to become more relevant in order to decrease failure rate of the repair. A single double-loaded suture anchor provides sufficient biomechanical strength even in Fox/Romeo grade III tears of the subscapularis tendon. However, a modified suture configuration is recommended, especially in grade III tears as the suture–tendon interface is the weakest point of the construct.

The preservation of meniscal structure and function after segmental meniscal loss is of crucial importance to prevent early development of osteoarthritis. Implantation of artificial meniscal implants has been reported as a feasible treatment option. The purpose of this study was to assess the clinical and magnetic resonance imaging (MRI) results 4 years after implantation of a polyurethane scaffold for chronic segmental medial meniscus deficiency following partial medial meniscectomy.Eighteen patients received arthroscopic implantation of an Actifit(®) polyurethane meniscal implant (Orteq Sports Medicine, London, UK) for deficiency of the medial meniscus. Patients were followed at 6, 12, 24, and 48 months. Clinical outcome was assessed using established patient-reported outcome scores (KOOS, KSS, UCLA Activity Scale, VAS for pain). Radiological outcome was quantified by MRI scans after 6, 12, 24, and 48 months evaluating scaffold morphology, tissue integration, and status of the articular cartilage as well as signs of inflammation.Median patient age was 32.5 years (range 17-49 years) with a median meniscal defect size of 44.5 mm (range 35-62 mm). Continuing improvement of the VAS and KSS Knee and Function Scores could be observed after 48 months compared to baseline, whereas improvement of the activity level according to UCLA continued only up to 24 months and decreased from there on. The KOOS Score showed significant improvement in all dimensions. MRI scans showed reappearance of bone bruises in two patients with scaffold extrusion. No significant changes in the articular cartilage could be perceived.Arthroscopic treatment for patients with chronic segmental meniscal loss using a polyurethane meniscal implant can achieve sustainable midterm results regarding pain reduction and knee function.IV.

Purpose Although there are various new scaffold-based techniques for cartilage regeneration it remains unclear up to which defect size they can be used. The present study reports of a cell-free collagen type I gel matrix for the treatment of large cartilage defects of the knee after a two-year follow-up. Methods Twenty-eight patients with a mean cartilage defect size of 3.71±1.93 cm² were treated with a cell-free collagen type I gel matrix (CaReS-1S®, Arthro Kinetics AG, Krems/ Donau, Austria) via a mini-arthrotomy. Clinical outcome was assessed preoperatively and six weeks as well as six, 12 and 24 months after surgery using various clinical outcome scores (IKDC, Tegner, KOOS, VAS). Cartilage regeneration was evaluated via MRI using the MOCART score. Results Seventeen male and 11 female patients with a mean age of 34.6 years were included in this study. Significant pain reduction (VAS) could be noted after six weeks already. Patient activity (IKDC, Tegner) could be significantly improved from 12 months on and nearly reached reported pre-operative values. All subject categories of the KOOS except for symptom (swelling) showed significant improvements throughout the study. Constant significant improvements of the mean MOCART score were observed from 12 months on. MR images did not yield any signs of infection or synovitis. After 24 months a complete defect filling could be noted in 24 out of 28 cases with a mainly smooth surface, complete integration of the border zone and homogenous structure of the repaired tissue. Conclusion Cell-free collagen type I matrices appear to be a safe and suitable treatment option even for large cartilage defects of the knee. Results of this study were comparable to the better-established findings for small cartilage defects. Midand long-term results will be needed to see if clinical and MR-tomographic outcome can be maintained beyond 24 months.

Rotator cuff repair leads to good clinical results even in the long term. However, despite the clinical results, a high structural failure rate is seen especially in chronic and massive rotator cuff tears.

This chapter will cover several aspects of extra-articular shoulder endoscopy, including regional anatomy, indications and several surgical techniques

Trotz der hervorragenden klinischen Resultate findet sich sowohl nach offener als auch nach arthroskopischer Rekonstruktion von Rupturen der Rotatorenmanschette insbesondere in chronischen grosen Rupturen eine hohe Rate an Rerupturen. Um die biomechanischen Voraussetzungen fur die Heilung der Sehne an den Knochen zu optimieren, wurden das Konzept der Doppelreihenrekonstruktion sowie der „Transosseous-equivalent-Rotatorenmanschettenrekonstruktion“ eingefuhrt. Diese Techniken waren zunachst nicht nur in der Lage, die biomechanischen Eigenschaften im Vergleich zur Einreihenrekonstruktion mit einfachen Nahttechniken zu verbessern, sondern es konnte damit auch eine anatomischere Wiederherstellung des flachigeren Sehnenansatzes erreicht werden, was theoretisch zu einer gunstigeren Heilung fuhren sollte. Insbesondere im Vergleich zu Einreihenrekonstruktionen unter Verwendung von Fadenankern mit multiplen Faden und modifizierten Nahttechniken konnte die Verwendung der Doppelreihenrekonstruktionen weder eine signifikante Verbesserung der klinischen Ergebnisse, noch eine Reduktion der Rerupturrate erreichen. Da die Sehnen-Faden-Verbindung das schwachste Glied in der Kette darstellt, ist biomechanisch nicht die Menge an Ankern entscheidend, die verwendet werden, sondern die Anzahl an Faden, welche die Sehne penetrieren und die verwendete Nahttechnik. Der entscheidende Faktor bezuglich der Sehnenheilung scheint jedoch die Biologie und die damit verbundene Sehnenqualitat zu sein, denn trotz vieler Technikinnovationen und einer dramatischen Anzahl an Publikationen bezuglich dieses Themengebiets konnten uber die letzten Jahre weder die klinischen Ergebnisse verbessert werden, noch konnte die Rerupturrate entscheidend gesenkt werden.

High initial fixation strength, mechanical stability and biological healing of the tendon-to-bone interface are the main goals after rotator cuff repair surgery. Advances in the understanding of rotator cuff biology and biomechanics as well as improvements in surgical techniques have led to the development of new strategies that may allow a tendon-to-bone interface healing process, rather than the formation of a fibrovascular scar tissue. Although single-row repair remains the most cost-effective technique to address a rotator cuff tear, some biological intervention has been recently introduced to improve tissue healing and clinical outcome of rotator cuff repair. Animal models are critical to ensure safety and efficacy of new treatment strategies; however, although rat shoulders as well as sheep and goats are considered the most appropriate models for studying rotator cuff pathology, no one of them can fully reproduce the human condition. Emerging therapies involve growth factors, stem cells and tissue engineering. Experimental application of growth factors and platelet-rich plasma demonstrated promising results, but has not yet been transferred into standardized clinical practice. Although preclinical animal studies showed promising results on the efficacy of enhanced biological approaches, application of these techniques in human rotator cuff repairs is still very limited. Randomized controlled clinical trials and post-marketing surveillance are needed to clearly prove the clinical efficacy and define proper indications for the use of combined biological approaches. The following review article outlines the state of the art of rotator cuff repair and the use of growth factors, scaffolds and stem cells therapy, providing future directions to improve tendon healing after rotator cuff repair. Level of evidence Expert opinion, Level V.

Purpose Objective evaluation of the optimal graft tension angle to fully restore patellofemoral contact pressure in reconstruction of the medial patellofemoral ligament (MPFL) in comparison to the native knee. Methods Twelve cadaveric knee specimens were fixed in a custom-made fixation device. A sensitive pressure film (Tekscan) was fixed in the patellofemoral joint, and patellofemoral contact pressure was assessed during a dynamic flexion movement from 0° to 90°. The MPFL was cut and measurements were repeated. Reconstruction of the MPFL was performed with the gracilis tendon subsequently fixed in the femur at 15°, 30°, 45°, 60°, 75°, and 90° of knee flexion under controlled tension (2 N). The sequence of the flexion angles was alternated. Pressure measurements were repeated after every fixation of the graft. Results No significant differences were seen in the overall patellofemoral contact pressure compared to the native knee ( P > .05). However, medial patellofemoral pressure showed a significant increased patellofemoral contact pressure after MPFL reconstruction at a knee flexion angle during graft fixation of 15° ( P = .027), 45° ( P = .050, P = .044), and 75° ( P = .039). Moreover, proximal/distal patellofemoral contact pressure revealed a significantly reduced contact pressure at 15° ( P = .003), 30° ( P = .009), 45° ( P = .025), 75° ( P = .021), and 90° ( P = .022) of flexion distal after MPFL reconstruction compared with the intact knee. Lateral patellofemoral contact pressure was significantly reduced in all performed reconstructions ( P Conclusions The flexion angle during graft fixation for MPFL reconstruction did not have a significant impact on the overall patellofemoral contact pressure. However, selective medial, proximal, distal, and lateral patellofemoral contact pressure was significantly altered for all reconstructions. Fixation of the MPFL graft at 60° of flexion was able to most closely restore patellofemoral contact pressure compared with the intact knee. Clinical Relevance Based on the findings of the present study, fixation of the graft in anatomic reconstruction of the MPFL should be considered in 60° of flexion under low tension (2 N) to most closely restore patellofemoral contact pressure compared with the native knee.

Hintergrund Valgisierende Orthesen stellen eine kostengunstige Alternative in der Behandlung der medialen Gonarthrose dar. Sie helfen zum einen in der praoperativen Diagnostik als Entscheidungshilfe, ob ein Patient aller Voraussicht nach von einer valgisierenden Osteotomie des Tibiakopfes profitiert. Daruber hinaus ist ein direkter klinischer Nutzen in Form einer Schmerzlinderung und Besserung der Kniegelenkfunktion in einigen Arbeiten gezeigt worden.

Hintergrund Die monokondylare Kniegelenkprothese stellt eine gute Alternative zur Umstellungsosteotomie und zur bikondylaren Knieprothese in der Behandlung der medialen Gonarthrose dar. Mit der korrekten Indikation sind die zu erwartenden Ergebnisse von Umstellungsosteotomie und unikondylarer Prothese vergleichbar.

To evaluate knee laxity after anatomic ACL reconstruction with additional suture repair of a medial meniscus tear. Kinematics of the intact knee were determined in 12 human cadaver specimens in response to a 134-N anterior tibial load (aTT) and a combined rotatory load of 10 Nm valgus and 4 Nm internal tibial rotation (aTTPS) using a robotic/universal force moment sensor testing system. Subsequently, the ACL was resected following the creation of a standardized tear of the medial meniscus, a standard meniscus repair and an ACL reconstruction using an anatomic single-bundle (6) or an anatomic double-bundle technique (6). Knee kinematics were determined following every sub-step. Significant increase of aTT in the ACL-deficient knee was found (p ≤ 0.001) with a further increase in the ACL-deficient knee with additional medial meniscal rupture (p ≤ 0.001). ACL reconstructions significantly decreased aTT compared with the ACL and meniscus-ruptured knee. No significant differences were seen between the intact knee and the ACL-reconstructed knee with additional meniscal repair (p

Die Lasionen der proximalen Bizepssehne konnen den Bizepsanker, den intraartikularen Anteil der Sehne sowie den Pulley-Apparat betreffen. Eine genaue Differenzierung anhand der klinischen Untersuchung und Anamnese ist oftmals schwierig, da die klinischen Tests zur Evaluation einer Bizepspathologie zwar sensitiv, jedoch nicht spezifisch sind. Die Kombination verschiedener spezifischer Tests kann diese jedoch verbessern. Bildgebende Verfahren wie die Sonographie oder die Kernspintomographie bzw. die Magnetresonanz (MR)-Arthrographie geben wichtige Informationen bezuglich begleitender Pathologien. Daruber hinaus eignet sich insbesondere die MR-Arthrographie zur Erfassung einer Bizepssehnenpathologie hoher Sensitivitat.

The present article summarizes the different osteotomy techniques for an extension of standard surgical approaches to the knee joint in selected patients. The aim is to achieve satisfactory exposure and reduce potential postoperative complications compared to alternative techniques, such as the V-Y plasty or the quadriceps snip procedures. Osteotomy of the tibial tubercle is a reasonable extension of the anteromedial or the anterolateral surgical approach in selected patients undergoing revision total knee replacement. This osteotomy will provide excellent surgical exposure of the knee without the risk of avulsion of the patellar tendon and will preserve the blood supply of the patella and the surrounding soft tissue. Moreover, functional clinical outcome will be improved by minimizing damage to the extensor mechanism. Osteotomy of the lateral femoral condyle gives excellent exposure of the posterolateral aspect of the knee joint which might be necessary in some patients with fractures of the posterolateral tibial plateau as well as patients undergoing open allograft transplantation of the lateral meniscus. An alternative option for an extended exposure to the posterolateral knee joint is accomplished by osteotomy or partial resection of the fibular head which is also described as having good clinical results and a low complication rate.

Chronic patellar tendinosis (jumper's knee) is a common problem among athletes. Conservative treatment is successful in most of the cases including, among others, the use of nonsteroidal anti-inflammatory drugs, local cryotherapy, eccentric muscle training, limitation of sports activity, and local infiltration. In approximately 10% of conservatively treated patients, conservative treatment fails and surgery is required. Different open and arthroscopic surgical techniques have been described in the literature. The presented all-arthroscopic surgical technique for the treatment of chronic patellar tendinosis includes debridement of soft tissue at the lower patellar pole and resection of the bony lower patellar pole. It leads to excellent clinical results comparable to described open treatment and provides the benefits of a minimally invasive and safe procedure with a faster recovery and return to sporting activities after surgery. An additional bony resection in case of a prominent lower patellar pole does not lead to a significant extension of the operation time and may avoid a relapse or treatment failure in selective cases. Therefore, arthroscopic treatment such as the presented technique may be the preferred method for surgical treatment of chronic patellar tendinosis.

The present article summarizes the development of a simple, objective, and non-invasive measurement device for tibiofemoral rotation to assess static rotational knee laxity. The device is based on the dial test with the patient lying prone and the knee flexed to 30°. From measurements of 30 healthy participants, the device achieved high inter- and intra-observer reliability and showed a high correlation of the measured results with the contralateral knees of the participants. Measurements of the device were also performed in a human cadaver study and revealed highly correlated results when compared to the simultaneous measurements of a knee navigation system, which was used as an invasive standard method to assess tibial rotation. In human cadaver specimens, it was shown that a simulated tear of the posterolateral bundle as well as a complete ACL tear led to a significant increase in isolated tibiofemoral rotation compared to the intact ACL. A retrospective case series investigated the clinical results as well as knee laxity measurements after ACL surgery in vivo. Rotational, as well as anteroposterior (AP), knee laxity was objectively assessed in 52 patients at a mean postoperative follow-up of 27 months by comparing the measured results with the results of the contralateral unaffected knee in each patient. The clinical results were comparable to the results reported in the literature. Moreover, rotational laxity was successfully restored after ACL reconstruction, whereas AP laxity showed significant differences compared to the contralateral knees although they were defined as clinically successful according to the IKDC classification. A non-invasive and objective knee rotational measurement device has been developed, which offers good potential for objective quality control in knee ligament injuries and their treatment. Review article, Level IV.

The literature data on patellar height following unicompartmental knee arthroplasty (UKA) are scarce.A total of 41 knee joints in 37 patients after UKA were prospectively evaluated for patellar height by using the Insall-Salvati and modified Insall-Salvati ratio. Patellar height was measured preoperatively, postoperatively, at 6, 12 weeks, and, at 1 year postoperatively. Patients were categorized according to age, gender, operated side, and rehabilitation program.Regarding all the patients, the Insall-Salvati ratio demonstrated a significant decrease only for the time period "postoperatively-1 year postoperatively", whereas the modified Insall-Salvati ratio showed a significant decrease only for the period "preoperatively-postoperatively". The Insall-Salvati ratio showed a significant decrease in the patellar height of men and left knees, whereas the modified Insall-Salvati ratio revealed a significant decrease in patients older than 65 years and those who followed a specific rehabilitation program.The decrease in the patellar height after UKA occurs within the first postoperative year. Women, right knees, patients younger than 65 years and those who do not follow a specific rehabilitation program are less prone to decrease in the patellar height; ratio-specific differences are evident for each subgroup.Diagnostic study, Level III.

The goal of the present study was to evaluate static anteroposterior and rotational knee laxity after ACL reconstructions with two noninvasive measurement devices by comparing the measured results of the operated with the contralateral healthy knees of the patients.Fifty-two consecutive patients were reviewed after isolated single-bundle transtibial ACL reconstruction using a BPTB graft. At a mean follow-up of 27 months, sagittal AP laxity was tested using a noninvasive knee measurement system (Genourob) with an applied pressure of 67 N, 89 N and 134 N. Rotational laxity was measured using a noninvasive rotational knee laxity device (Rotameter) with an applied torque of 5, 8 and 10 Nm. The results were compared with the measurements of the patients' healthy contralateral knees. Tegner, Lysholm and IKDC score were used in order to evaluate the clinical outcome.Pivot shift was negative (33) or glide (16) in 49 patients with 12 of 16 (75%) patients having also a pivot glide on the healthy contralateral side; Lachman tests were negative in 50 cases. Subjective assessment of the IKDC score was classified according to category A in 44 patients, B in 5 patients and C in 3 patients. Mean Lysholm score was 94.5 ± 9.5, median Tegner score was 7 (3-9) preoperative and 6 (3-9) at follow-up (n.s.). Anteroposterior knee laxity measurements revealed mean side-to-side differences of 0.6-1.3 mm (P0.0001). Rotational laxity measurements revealed no statistical significant differences between the operated and the contralateral knee (n.s.). The measured differences in the entire rotational range varied from 0.2° to 1° depending on the applied torque. In those 3 patients with a positive pivot shift, differences in the entire rotational range of 4.5° at 5 N, 4.6° at 8 N and 4.1° at 10 N were found.Static knee laxity was quantified after ACL surgery using the introduced noninvasive measurement systems by comparing the measured results of the operated with the contralateral healthy knees. Significant differences were found in AP laxity although they were defined as clinically successful according to the IKDC classification. No significant differences were found in rotational knee laxity measurements. Therefore, the used noninvasive masurement devices might offer a high potential for objective quality control in knee ligament injuries and their treatment.Retrospective case series, Level IV.

Achieving an adequate restoration of the muscle-tendon-bone unit and the anatomical footprint is essential for a successful outcome in open and arthroscopic rotator cuff repair. The described suture grasping technique using triple-loaded suture anchors might combine high initial fixation strength with good footprint coverage. It describes two mattress' stitches medial at the articular margin of the tendon. Additionally, a third mattress stitch is performed laterally to increase footprint contact and avoid dog-ear deformity. The triple-mattress repair is easy to perform and might be a good alternative in either arthroscopic or open rotator cuff repair.

Muscle injuries are common in sports. They are usually caused by either acute (mostly eccentric mechanisms) or chronic overloading with a lack of muscle coordination. They present in clinical practice as bruises and muscle sprains. Due to the rigours of a modern society and the high economic cost of time off work, an effective treatment needs to be employed. The key to an optimised therapy rests in the appropriate timing between immobilisation and mobilisation. The interval to muscle repair might be shortened by certain adjuvant therapies. In doing so, it is important that no physiological phases of wound healing are overlooked. Muscle healing can be accelerated by externally induced higher metabolic turnover. Surgical therapy is sometimes necessary in selected cases and in serious injuries.

Ruptures of the biceps tendon account for a high percentage of tendon ruptures. The aetiology of proximal ruptures of the long head of the biceps tendon is often degenerative and they are frequently associated with lesions of the rotator cuff. The clinical findings are often not specific and long lasting. Distal ruptures of the biceps tendon mostly occur during eccentric contraction of the biceps muscle.Clinical tests, the associated haematoma and a distalisation or proximalisation of the muscle belly in combination with ultrasound or MRI to rule out combined diseases lead to the diagnosis. The possible options include conservative and operative treatment. Tenotomy and tenodesis lead to comparable results in the literature. Therefore, conservative treatment is mostly recommended in proximal ruptures. Operative treatment is preferred in distal ruptures of the biceps tendon in order to achieve an anatomical reconstruction of the muscle function. Chronic ruptures of the distal biceps tendon can be successfully treated with free autografts or allografts.

Oral and intra-articular injections of cortisone will lead to significant improvement and comparable results in the treatment of adhesive capsulitis of the shoulder.In a prospective randomized evaluation, 40 patients with idiopathic adhesive capsulitis of the shoulder were treated with an oral corticoid treatment regimen or 3 intra-articular injections of corticosteroids. Follow-up was after 4, 8, and 12 weeks, and 6 and 12 months. For the clinical evaluation, the Constant-Murley (CM) score, the Simple Shoulder Test (SST) and visual analog scales (VAS) for pain, function, and satisfaction were used.In the patients treated with oral glucocorticoids, significant improvements were found for the CM score (P.0001), SST (P=.035), VAS (P.0001), and range of motion (P.05) at the 4-week follow-up. The patients treated with an intra-articular glucocorticoid injection series also significantly improved in the CM score (P.0001), SST (P.0001), the VAS (P.0001), and range of motion (P.05) after 4 weeks. These results were confirmed at all other follow-up visits. Superior results were found for intra-articular injections in range of motion, CM score, SST, and patient satisfaction (P.05). Differences in the VAS for pain and function were not significant (P.05).The use of cortisone in the treatment of idiopathic shoulder adhesive capsulitis leads to fast pain relief and improves range of motion. Intra-articular injections of glucocorticoids showed superior results in objective shoulder scores, range of motion, and patient satisfaction compared with a short course of oral corticosteroids.

Im Rahmen einer biomechanischen Studie an Schweineschultern wurde an verschiedenen Rekonstruktionen der Rotatorenmanschette die Elongation unter zyklischer Belastung mittels Radiostereometrieanalyse (RSA) in 3 Ebenen (dorsoventral, kraniokaudal, mediolateral) bestimmt. Die Infraspinatussehne und der Humeruskopf wurden dafur mit Tantalumkugeln markiert und in einem speziellen Kalibrierungskafig platziert, in dem die RSA-Messungen mittels 2 mobilen Rontgenapparaten, welche in 2 Ebenen simultan auslosen, erfolgten. Die markierten Sehnen wurden zunachst fur 50 Zyklen mit 20 N belastet. Danach erfolgten die Ablosung der Sehnen nach Standardschema und die Refixation mittels verschiedener „single-row“ und „double-row“ -Rekonstruktionen. Die rekonstruierten Sehnen wurden mit 40, 60, 80 und 100 N fur jeweils 50 Zyklen belastet. Die ermittelte Elongation der RSA wurde mit der gemessenen Elongation mittels Video-Extensometer, welches fur die kraniokaudale Ebene als Referenzmethode diente, verglichen. Die zyklische Belastung der intakten Sehnen zeigte mit der RSA-Messung eine durchschnittliche Dislokation von 0,06±0,08 mm in der x-Ebene, 0,16±0,18 mm in der y-Ebene und 0,19±0,28 mm in der z-Ebene. Hochsignifikante Unterschiede wurden in der kraniokaudalen Ebene zwischen den getesteten Fixierungen bei 40, 60, 80 und 100 N gefunden (p 0,05). Die Messung der Elongation mittels RSA in der kraniokaudalen Ebene zeigte im Vergleich mit den Messungen des Video-Extensometers eine hohe Korrelation im Korrelationskoeffizient nach Pearson (r=0,87). Die Radiostereometrieanalyse ist eine exzellente Methode zur Messung der Elongation unter zyklischer Belastung von Rotatorenmanschettenrekonstruktionen. Im Vergleich zum Video-Extensometer erfolgt die Messung in 3 Ebenen, was eine zusatzliche Aussage bezuglich der Auswirkungen der Scherkrafte auf die getestete Fixierung ermoglicht.

The purpose of the present study was the prospective evaluation of the results of fluoroscopic-guided intra-articular cortisone injection series in the treatment of adhesive capsulitis of the shoulder. Twenty-five patients (9 m, 16 w) with a mean age of 49 ± 8 years and stage II frozen shoulder syndrome according to the Reeves classification were treated with an intra-articular cortisone injection series (3 injections at 0, 4, 12, weeks). Clinical examination, ASES score and SF 36 score were performed at 0, 4, 8, 12 weeks, 6 and 12 months. In the results, significant improvements were seen in flexion (99 ± 30°-119 ± 31°, P < .0001), abduction (72 ± 24-99 ± 34°, P < .0001), external rotation (14 ± 16°-28 ± 21°, P < .0001) and internal rotation already at first follow-up after 4 weeks of treatment. The results were confirmed at any other follow-up. ASES score improved from 28 ± 13 to 45 ± 18 after 4 weeks (P < .0001), 59 ± 21 after 8 weeks (P < .0001), 63 ± 25 at 3 months (P < .0001), 64 ± 28 (P < .0001) at 6 months and 73 ± 27 (P < .0001) points at final follow-up after 1 year. Evaluation of the SF-36 Score showed significant improvements in almost all categories (physical and mental) after 4 weeks of treatment (P < .05). In conclusion, a fluoroscopic-guided intra-articular injection series of cortisone is an effective treatment option in frozen shoulder syndrome leading to a fast pain reduction and increased range motion.

Zusammenfassung Die chronische Tendinose der Patellarsehne entsteht durch intrinsische und extrinsische Faktoren, welche zu einer Uberlastung des Extensormechanismus fuhren. Neben der Sportart und der Sportfrequenz ist moglicherweise ein prominenter unterer Patellarpol ein weiterer pradisponierender Faktor. Die operative Behandlung der chronischen Tendinose der Patellarsehne (Jumper's Knee) sollte mit einer rein arthroskopischen Therapie erfolgen, welche die Vorteile einer minimal-invasiven Technik mit schneller Rehabilitation und geringer Komplikationsrate mit exzellenten klinischen Ergebnissen, die mit den in der Literatur beschriebenen Resultaten der offenen operativen Behandlung vergleichbar sind, kombiniert.

Generally, outcome after surgical repair of complete Achilles tendon rupture is good. However, some patients have ongoing problems with dorsiflexion of the ankle joint. We report on eight patients, who did not achieve heel contact because of reduced ankle dorsiflexion 5 months after surgical repair of complete Achilles tendon rupture. All patients received at least three cycles of injections with 200-300 units of Botulinum toxin A (BOTOX) into the gastrocnemius and soleus muscle. Weakening of the triceps surae by Botulinum toxin allowed patients to perform the required exercises and to tolerate casting at night. Thus, all patients were able to tolerate plantigrade foot position 9 months after beginning of Botulinum toxin treatment. At final follow-up after 2 years, pain had significantly improved, and a mean dorsiflexion of 21 degrees was reached. In conclusion, treatment of the calf muscles with BOTOX is a safe and effective method to improve restricted dorsiflexion in patients after Achilles tendon repair.

The purpose of this study was to evaluate the reliability of a new developed device to measure tibial rotation, the Rotameter. Thirty healthy subjects (15 males, 15 females, 24 years) were examined with the Rotameter measurement device. External and internal rotation was performed at an applied torque of 5, 10 and 15 Nm by two independent examiners in order to test the inter-observer reliability. The patients were measured again after a mean of 31 +/- 43 days by the same examiners to test the intra-observer reliability. Statistical analysis was performed using the intra-class correlation coefficient. The Pearson Correlation coefficient was used to compare the measurements of the left with the right side of the participants. In the measurements, a high inter- and intra-observer reliability was found at 5, 10 and 15 Nm of applied torque for the external rotation, internal rotation and the rotational range (internal + external rotation). Comparison of the left and the right knee of the same participant also revealed high correlations in the Pearson correlation coefficient at all applied torques. In conclusion, the Rotameter testing device for the measurement of tibial rotation showed a high inter-observer and intra-observer reliability. It is easy to perform and might be used in a wide field as a non-invasive instrument to objectively determine rotational stability and to investigate the restoration of the rotational stability after surgical procedures.

Summary Open-wedge high tibial osteotomy (HTO) is becoming increasingly popular for the treatment of varus gonarthrosis in the active patient. Various implants can be used that differ with regard to fixation stability, design and osteotomy technique. Some risk factors are associated with a poor clinical outcome, such as a fracture of the opposite cortex and an imprecise osteotomy. In this clinical study, serial Radiostereometric Analysis (RSA) and long lower limb weight-bearing radiographs were used to (1) quantify micromotion between fixated tibial segments and (2) the amount of revarisation over time. It was found that a high primary stability offered by a long and rigid internal fixator is associated with favorable clinical results.

The purpose of the present study is the evaluation of a possible influence of the preoperative deposit stage, the postoperative deposit elimination and failed preoperative extracorporeal shockwave therapy on the surgical outcome of arthroscopic treatment of tendinosis calcarea. From 1997 to 2004, 65 patients underwent arthroscopic resection of calcific deposits of the shoulder after failed conservative treatment. Patients with rotator cuff tears, major cartilage damage, or previous surgery were excluded. Out of 50 patients 45 (17 men, 28 women) that could be contacted with a mean age of 49 +/- 8 years could be followed-up with a mean of 36 months (14-89) after surgery. A total of 24 patients (53.3%) underwent preoperative extracorporeal shock-wave therapy (ESWT). For the clinical evaluation the Constant and Murley Score, the Simple Shoulder Test, the Western Ontario Rotator Cuff Index (WORC) and visual analog scales for pain, function and satisfaction were used. For the radiological evaluation, the classifications according to Gaertner and Bosworth were used. Statistical analysis was done with the Wilcoxon test, the Mann-Whitney test and ANOVA. The Constant and Murley Score improved significantly from preoperative 63.5 +/- 11.4 to postoperative 93.9 +/- 9.9 points (P.0001) at follow-up, the Simple Shoulder Test from 1.7 +/- 2 to 9.9 +/- 2.8 points (P.0001), the WORC score from 1,591.2 +/- 337.4 to 345.4 +/- 392 points (P.0001). The visual analog scales for pain, function and patient satisfaction also significantly improved (P.0001). Preoperative radiological evaluation according to the Gaertner classification revealed 37 type I deposits, 6 type II and 2 type III deposits; postoperative no calcific deposits were seen in 37 patients, 6 type I and 2 type III deposits. According to the Bosworth classification 13 type I, 19 type II and 13 type III deposits were seen preoperatively. Postoperative X-rays showed 6 type I and 1 type II and III deposits. There was no significant correlation of the clinical results with the pre- or postoperative findings. The 24 patients who underwent ESWT before surgery did not show significantly better results than patients without ESWT. In conclusion, arthroscopic removal of calcific deposits of the shoulder shows good clinical results for pain reduction, shoulder function and patient satisfaction. The type of calcific deposit and the preoperative treatment of the shoulder with ESWT did not have any significant impact on the postoperative results.

The described surgical technique with the arthroscopic resection of the lower patellar pole for the treatment of chronic patellar tendinosis leads to excellent clinical results. It combines the advantages of a minimal-invasive method with fast rehabilitation and return to sporting activities with comparable results to described open procedures.

Background Double-row repair is suggested to have superior biomechanical properties in rotator cuff reconstruction compared with single-row repair. However, double-row rotator cuff repair is frequently compared with simple suture repair and not with modified suture configurations. Hypothesis Single-row rotator cuff repairs with modified suture configurations have similar failure loads and gap formations as double-row reconstructions. Study Design Controlled laboratory study. Methods We created 1 × 2-cm defects in 48 porcine infraspinatus tendons. Reconstructions were then performed with 4 single-row repairs and 2 double-row repairs. The single-row repairs included transosseous simple sutures; double-loaded corkscrew anchors in either a double mattress or modified Mason-Allen suture repair; and the Magnum Knotless Fixation Implant with an inclined mattress. Double-row repairs were either with Bio-Corkscrew FT using modified Mason-Allen stitches or a combination of Bio-Corkscrew FT and PushLock anchors using the SutureBridge Technique. During cyclic load (10 N to 60-200 N), gap formation was measured, and finally, ultimate load to failure and type of failure were recorded. Results Double-row double-corkscrew anchor fixation had the highest ultimate tensile strength (398 ± 98 N) compared to simple sutures (105 ± 21 N; P < .0001), single-row corkscrews using a modified Mason-Allen stitch (256 ± 73 N; P = .003) or double mattress repair (290 ± 56 N; P = .043), the Magnum Implant (163 ± 13 N; P < .0001), and double-row repair with PushLock and Bio-Corkscrew FT anchors (163 ± 59 N; P < .0001). Single-row double mattress repair was superior to transosseous sutures ( P < .0001), the Magnum Implant ( P = .009), and double-row repair with PushLock and Bio-Corkscrew FT anchors ( P = .009). Lowest gap formation was found for double-row double-corkscrew repair (3.1 ± 0.1 mm) compared to simple sutures (8.7 ± 0.2 mm; P < .0001), the Magnum Implant (6.2 ± 2.2 mm; P = .002), double-row repair with PushLock and Bio-Corkscrew FT anchors (5.9 ± 0.9 mm; P = .008), and corkscrews with modified Mason-Allen sutures (6.4 ± 1.3 mm; P = .001). Conclusion Double-row double-corkscrew anchor rotator cuff repair offered the highest failure load and smallest gap formation and provided the most secure fixation of all tested configurations. Double-loaded suture anchors using modified suture configurations achieved superior results in failure load and gap formation compared to simple suture repair and showed similar loads and gap formation with double-row repair using PushLock and Bio-Corkscrew FT anchors. Clinical Relevance Single-row repair with modified suture configurations may lead to results comparable to several double-row fixations. If double-row repair is used, modified stitches might further minimize gap formation and increase failure load.

Background Although techniques and options for suitable graft substitutes for anterior cruciate ligament surgery continue to improve, failures occur because of many reasons. Errors in surgical techniques seem to be important reasons. Hypothesis Inappropriate positioning of the tunnels may be the most important reason for these failures. Anatomical anterior cruciate ligament revision reconstruction, using autografts, may yield acceptable outcomes. Study Design Case series; Level of evidence, 4. Methods This retrospective study involved 148 anterior cruciate ligament revision reconstructions performed in our hospital using autografts. One hundred and seven patients were followed up at a mean of 72.9 ± 20.6 months. Clinical evaluation was performed using the Lysholm score, the Tegner rating system, the International Knee Documentation Committee evaluation form, and the KT-1000 arthrometer. Radiographs were evaluated for signs of osteoarthritis according to the Jaeger and Wirth classification. Results Inappropriate positioning of the tunnels was the most important reason (63.5%) for anterior cruciate ligament reconstruction failure. The average Lysholm score improved significantly at the follow-up (88.5±12.4 vs 51.5±24.9; P < .001). Moreover, the average Tegner activity score improved significantly compared with the activity score before revision surgery (6.3±1.8 vs 2.8±1.8; P < .001). The International Knee Documentation Committee score was A in 17 cases, B in 45, C in 37, and D in 8. Radiographic evaluation revealed that 33 patients had degenerative findings of grade I, 35 of grade li, 16 of grade III, and 2 of grade IV. Conclusion Anatomical anterior cruciate ligament revision reconstruction provides satisfactory midterm results as far as stability and function of the knee are concerned. In spite of these favorable subjective and objective results, the radiological evaluation revealed a significant progression of osteoarthritis.

The aim of this prospective study is to evaluate the clinical results of arthroscopic resection of the lower patellar pole in patients with patellar tendinosis.Twenty patients underwent an arthroscopic resection of the lower patellar pole between 2002 and 2004. All of them were evaluated at 6 weeks and 3, 6, 12, and 24 months after surgery using the Tegner activity level, the Lysholm score, the Kujala score, a modified jumper's knee classification according to Blazina, and visual analog scales for pain, function, and satisfaction. Clinical evaluation was performed 2 years after surgery. In addition, magnetic resonance imaging was performed preoperatively and at a 2-year follow-up.By 6 weeks postoperatively and at every other follow-up visit, significant improvements were seen in the Lysholm score (P = .001), the Kujala score (P = .001) and the visual analog scales. The Tegner score improved significantly by 3 months postsurgery (P = .01). Two years after surgery, the Tegner score improved from 4.4 +/- 2.9 to 7.95 +/- 1.6 (P.0001); the Lysholm score from 57.1 +/- 17.1 to 97.3 +/- 4.4 (P.0001); and Kujala score from 53.7 +/- 14.7 to 95.4 +/- 7.8 (P.0001). The jumper's knee classification showed excellent (stage 0) or good (stage I) results in 18 of 20 patients. At follow-up, all but one magnetic resonance image showed hypodens areals in the proximal aspect of the patellar tendon, and small osteophytes were seen in some cases at the resection area. These findings did not seem to have any influence on the results.The arthroscopic resection of the lower patellar pole as a minimal invasive method to treat jumper's knee provides satisfactory clinical results in knee function and pain reduction with fast recovery and return to sport activities.Level IV, therapeutic case series.

reconstructive surgery, 3D CT reconstructions and the possibility to make animations that can mimic the effect of the location of the Hill–Sachs lesion. It was also the time where the indication for stabilizing surgery was at least six dislocations and that open procedures had a low failure rate but also in some cases with a significant reduction in external rotation. Other open procedures like Bristow–Latarjet were known to have low recurrence rate but showed the same risk of reducing the ability to fully externally rotate the arm overhead, which is a disadvantage for the active overhead athlete. In the 1990s arthroscopic repair became more and more popular possibly due to the fact that the pathology could be assessed more precisely and because the repair aimed at being more anatomic, but at the very end of the last century, the drawback was initially associated with a recurrence rate of over 30 %. Today, we know that the number of recurrences not only increases the risk of osteoarthritis but also makes simple arthroscopic Bankart repair less effective. During the past 15 years, we have been moving from a discussion between open Bankart and arthroscopic When we were young residents, we were taught that a Hill–Sachs lesion of the humeral head was a normal finding in glenohumeral instability and that it had no clinical significance. This was before MR technology, arthroscopic

Calcific tendonitis is a common cause of shoulder pain which mainly affects patients within the age of 30–60 years. Women are more frequently affected. Patients suffer from typical impingement pain which may highly impair shoulder function as well as quality of life. Additional ultrasound and radiological evaluation of the affected shoulder can secure the diagnosis. Moreover, the size and the shape of the calcific deposit as well as the localization can be determined.

In the present chapter, the surgical technique for open meniscal allograft transplantation is described. Preoperative planning and postoperative protocol are also described.

Tears of the superior labrum involving the biceps anchor are a common entity, especially in athletes, and may highly impair shoulder function. If conservative treatment fails, successful arthroscopic repair of symptomatic SLAP lesions has been described in the literature particularly for young athletes. However, the results in throwing athletes are less successful with a significant amount of patients who will not regain their pre-injury level of performance. The clinical results of SLAP repairs in middle-aged and older patients are mixed, with worse results and higher revision rates as compared to younger patients. In this population, tenotomy or tenodesis of the biceps tendon is a viable alternative to SLAP repairs in order to improve clinical outcomes. The present article introduces a treatment algorithm for SLAP lesions based upon the recent literature as well as the authors' clinical experience. The type of lesion, age of patient, concomitant lesions, and functional requirements, as well as sport activity level of the patient, need to be considered. Moreover, normal variations and degenerative changes in the SLAP complex have to be distinguished from "true" SLAP lesions in order to improve results and avoid overtreatment. The suggestion for a treatment algorithm includes: type I: conservative treatment or arthroscopic debridement, type II: SLAP repair or biceps tenotomy/tenodesis, type III: resection of the instable bucket-handle tear, type IV: SLAP repair (biceps tenotomy/tenodesis if >50 % of biceps tendon is affected), type V: Bankart repair and SLAP repair, type VI: resection of the flap and SLAP repair, and type VII: refixation of the anterosuperior labrum and SLAP repair.