Das Kapitel gibt Auskunft, wie häufig Verschleißerkrankungen des Schultergelenkes sind und wie oft diese in Deutschland mit einer Schulterendoprothese behandelt werden. In diesem Zusammenhang werden die Grundlagen des DRG-Vergütungssystems erörtert und ihre Anwendungen auf die Primär- und Revisionsendoprothetik am Schultergelenk, auch anhand von Fallbeispielen, dargestellt und diskutiert. Auch wird auf neue Behandlungsmethoden und Individualanfertigungen eingegangen. Ausführlich werden die Implantationszahlen für den Bereich der Primär- und Wechselendoprothetik in Deutschland anhand von Zahlen des Statistischen Bundesamtes dargestellt und Möglichkeiten zur Erfassung über ein Implantatregister diskutiert. Praktische Aspekte der Begutachtung von Patienten mit einliegender Schulterendoprothese werden dargestellt und Bezug auf die unterschiedlichen Rechtsansprüche und die daraus resultierenden Einstufungen genommen.

Structural failures after rotator cuff repair are well known, and despite advances and improved techniques in rotator cuff repair (RCR), retear rates remain high. The aim of this study was to (1) evaluate the midterm clinical and radiological outcomes after revision RCR and to (2) analyze whether preoperative ultrasound can predict outcome of open revision rotator cuff repair. Twenty-five patients who underwent revision RCR in a single institution between 2010 and 2012 were retrospectively reviewed at a minimum follow-up of 2 years. The Constant Score (CS) and the Disabilities of the Arm, Shoulder and Hand score were collected. Ultrasound examination was used both before revision surgery and at follow-up to determine tendon integrity. At the final follow-up, 69.6% patients showed an intact rotator cuff and their CS had improved from 28.3 to 77. 30.4% patients had a persisting rotator cuff defect, and the CS had improved from 24 to 47.7. A preoperative tear size of more than 20 mm from an ultrasound examination could be identified as a factor that would risk structural failure of revision RCR. (1) Clinical outcomes after revision RCR improve in both patients with an intact RC and those with a retear at midterm follow-up. (2) Ultrasound seems to be a useful tool to predict whether reconstruction of recurrent rotator cuff tears is feasible. IV, Case series.

ZusammenfassungAseptische Knieendoprothesenlockerungen sind auch heute noch der häufigste Grund für das Versagen eines Knieimplantates. In diesem Kapitel werden wichtige klinische und radiologische Kriterien und deren Wertigkeit betrachtet. Besonderes Augenmerk werden auf die Pathogenese aseptischer Lockerungen, die Konsensus-Klassifikation für periprothetische Membranen und auf Pathomechanismen der abriebbedingten Osteolysen als Ursache für die sog. Partikelkrankheit gelegt. Risikofaktoren, die die Standzeit einer Endoprothese wesentlich beeinflussen, werden erörtert, differenziert nach patientenbezogenen, individuellen Faktoren, implantatbedingten Ursachen und intraoperativen Einflussfaktoren, einschließlich der chirurgischen Qualität. Zusammenfassend zeigt sich, dass sich die Standzeiten von Knieendoprothesen in den letzten Jahren deutlich verbessert haben und das Gesamtrisiko einer Revision gesunken ist.

Heterotopic ossifications can occur after joint-preserving surgery of the hip and are classified according to Brooker. Main symptoms are pain and a decreasing range of motion. After suitable clinical diagnostics (X-ray, CT-scan) surgical resection of ossifications can lead to freedom from symptoms. Recurrence is effectively prevented by NSAIDs or radiatio.

ZusammenfassungHeterotope Ossifkationen können nach gelenkerhaltenden Operationen am Hüftgelenk auftreten und werden nach Brooker klassifiziert. Leitsymptomatik sind Schmerzen und eine zunehmende Bewegungseinschränkung. Nach entsprechender Diagnostik (Röntgen, CT) kann die operative Ossifikationsentfernung kombiniert mit einer Rezidivprophylaxe (NSAR, alternativ Radiatio) zur Beschwerdefreiheit führen.

Rupturen der Patellarsehne bei liegender KTEP stellen eine seltene aber schwerwiegende Komplikation dar, die in der Regel einer operativen Therapie bedürfen.

Ruptures of the patellar tendon after total knee arthroplasty represent a rare but severe complication, which in general requires surgical therapy.To implement a classification and correspondent therapy algorithm in consideration of the current literature for the treatment of patellar tendon ruptures after TKA.A review of the recent literature and the author's experience are summarized in a classification and correspondent therapy algorithm for the treatment of patellar tendon ruptures after TKA.Ruptures of the patella tendon can be classified as avulsions (Type I), acute (Type II) and chronic ruptures (Type III). Avulsions are often of iatrogenic nature and can be sufficiently treated by transosseous refixation prior to implantation of the revision TKA. Acute ruptures of the patellar tendon can originate from trauma or intraoperative injury. The rupture can be restored by primary suture in combination with a wire cerclage in the case of good tendon quality and the absence of patient comorbidities (Type IIA). In the case of poor tendon quality or existing comorbidities (Type IIB) additional augmentation of the ruptured tendon, utilizing the autologous semitendinosus/gracilis tendon, is recommended. Chronic ruptures revealing a good patellar bone stock (Type IIIA) can be treated by a combination of a semitendinosus augmentation and a turndown quadriceps tendon flap. In the case of a poor patellar bone stock (Type IIIB) transpatellar fixation of the semitendinosus tendon is virtually impossible, so that an allograft augmentation or the use of a soft tissue muscle flap (i. e. the gastrocnemius flap) has to be considered. A failed complex reconstruction with or without infection (Type IIIC) is an invidious surgical task and needs to be addressed by the utilization of a muscle flap, an allograft or a patellectomy with or without arthrodesis.

BACKGROUND:Vitamin D and calcium deficiency has a higher incidence in the orthopedic-trauma surgery patient population than generally supposed. In the long term this can result in osteomalacia, a form of altered bone mineralization in adults, in which the cartilaginous, non-calcified osteoid does not mature to hard bone.AIM:The current value of vitamin D and its importance for bones and other body cells are demonstrated.RESULTS:The causes of vitamin D deficiency are insufficient sunlight exposure, a lack of vitamin D3 and calcium, malabsorption, and rare alterations of VDR signaling and phosphate metabolism. The main symptoms are bone pain, fatigue fractures, muscular cramps, muscle pain, and gait disorders, with an increased incidence of falls in the elderly. Osteopathies induced by pharmaceuticals, tumors, rheumatism or osteoporosis have to be considered as the main differential diagnoses.CONCLUSIONS:In addition to the recording of symptoms and medical imaging, the diagnosis of osteomalacia should be ensured by laboratory parameters. Adequate treatment consists of the high-dose intake of vitamin D3 and the replacement of phosphate if deficient. Vitamin D is one of the important hormone-like vitamins and is required in all human cells. Deficiency of vitamin D has far-reaching consequences not only for bone, but also for other organ systems.

The minimally invasive direct anterior approach for total hip arthroplasty (THA) was first published in 1985. Since then the technique has been further improved and the indications have been extended. The approach utilizes the muscle gap between the tensor fasciae latae muscle on the lateral side and the sartorius muscle on the medial side. This muscle gap allows a direct and quick approach to the hip joint with good muscle preservation. During preparation of the femur the tensor fasciae latae muscle is at risk of being damaged. The lateral cutaneous nerve of the thigh (NCFL) and its branches are also in danger of being damaged during skin incision and dissection of the subcutaneous tissue. In this article the technique, risks and current clinical results of THA using the minimally invasive direct anterior approach are described. The results from the literature, as well as own results are compared to the traditional transgluteal lateral Bauer approach and discussed. Reviewing the literature, special attention has been given to the incidence of NCFL lesions, damage of the tensor fasciae latae muscle and positioning of the cup. Especially for the latter, the general view is hindered in the minimally invasive technique.

Técnica quirúrgica Abordaje deltopectoral. Exposición del implante aflojado, retirada mediante fenestración en el húmero. Liberación periarticular con preservación de estructuras neurovasculares. Exposición de la glenoides, fijación no cementada de la placa base (metaglena) y colocación de la bola glenoidea (glenoesfera). Fenestración de la diáfisis humeral, extracción del cemento, colocación de cerclajes de sutura y alámbricos, y cementación del componente humeral (vástago de revisión largo) con un ángulo de retroversión de 10-30o tomando como referencia el eje longitudinal del antebrazo. Reconstrucción anatómica de las partes blandas con preservación de los rotadores externos (reinserción de las tuberosidades desplazadas, y en caso de ser necesario, transposición del latissimus dorsi y teres major según la técnica de L’Episcopo). Manejo postoperatorio Férula de abducción y ejercicios pasivos y activosasistidos incluyendo movilidad pasiva continua (Ormed, Friburgo, Alemania) durante 6 semanas tras la intervención.

INTRODUCTION:The management of acute acromioclavicular joint (ACJ-) injuries especially of type III is still controversial.METHODS:In this retrospective study the results of early ACJ reconstructions immediately after trauma (group early repair, ER) were compared with the results of delayed reconstructions in patients who first got conservative treatment and failed after some time (group delayed repair, DR). Overall, 49 patients were analysed clinically and radiographically with a mean follow-up of 53 months (range 20-92). In group ER twenty-nine patients were treated with a modified Phemister technique according to Mayr including a PDS coracoclavicular sling and temporary K- wire fixation. In group DR twenty patients were treated with a modified Weaver-Dunn-procedure with additionally transposition of the coracoacromial ligament and AC-joint resection.RESULTS:A comparison of the overall results revealed a statistically significant better outcome in the early repair group, regarding the Constant Score, the degree of acromioclavicularjoint-reduction, numbers of complications and patient;s satisfaction.CONCLUSION:Our results point out that early reconstruction of ACJ-injuries in type III-V avoids the inferior clinical results of delayed reconstructions using a modified Weaver-Dunn-procedure.

This study retrospectively analyzed 1007 diagnostic shoulder arthroscopies. The study included 72 patients with an arthroscopically verified pulley lesion as the main pathologic finding. Epidemiologic data and arthroscopic findings were evaluated in all patients, and 53 were clinically examined with the Constant score after a minimum follow-up of 2 years. We observed an incidence of 7.1% for pulley lesions. An isolated rupture of the superior glenohumeral ligament (SGHL) was seen in 53 patients (73.6%) and a combined partial articular-side tear of the rotator cuff adjacent to rotator interval in 19 (26.4%). Thirty-one patients (43%) had a history of trauma, whereas 41 (57%) had none. Overall, the mean postoperative Constant score adjusted for age and gender was 80.1% (range, 47%-135%). Patients with a SGHL lesion only (85.7%) exhibited a significant (P = .047) higher age- and gender-adjusted Constant score compared with patients with a combined partial surface tendon tear (73.1%). Our epidemiologic data accentuate the need for careful evaluation of the superolateral aspect of rotator interval to avoid underdiagnosis of pulley lesions at shoulder arthroscopy. Our findings provide evidence that the clinical outcome of isolated SGHL lesions is better compared with combined partial articular-side rotator cuff tear. With respect to the progressive pathologic process of pulley lesions, we recommend an early surgical treatment.

BACKGROUND:Pseudarthroses of the clavicle after fractures of the medial third often present with local pain, compromised shoulder function, or neurovascular symptoms. Reconstruction of normal clavicular anatomy and solid fusion is a prerequisite for good clinical outcome after surgical treatment. In this study, 24 patients with clavicular pseudarthrosis were treated with the anatomical precontoured Meves plate. In 11 patients, additional bone grafting was done.METHOD:Nineteen patients could be reexamined with a mean follow-up of 74.5 months. In all of them, solid fusion was achieved.RESULTS:The Constant score improved from 70.4 points preoperatively up to 82.5 points postoperatively (89.3% age-related). Sixteen patients were satisfied or very satisfied with the operative result.CONCLUSION:In our patients, secure healing of clavicular nonunion was achieved with the anatomical precontoured Meves plate, with good or excellent clinical outcomes.

OBJECTIVE:Alleviation of pain, restoration of function and active range of motion.INDICATIONS:Failed posttraumatic shoulder prostheses with insufficient rotator cuff, pseudoparalysis, chronic instability, severe ankylosis.CONTRAINDICATIONS:Advanced glenoid destruction. Severe lesions of the deltoid muscle (> 50%) and axillary nerve palsy. Florid infections.SURGICAL TECHNIQUE:Deltopectoral approach. Exposure of the failed implant and explantation by fenestration of the humerus. Periarticular release with preservation of neurovascular structures. Exposure of the glenoid, cementless fixation of the glenoid base plate (metaglène) and application of the glenoid ball (glenosphere). Fenestration of the humeral shaft, removal of bone cement, placement of wire and suture loops, and cemented implantation of the humeral component (long revision stem) in 10-30 degrees retroversion related to the long axis of the forearm. Anatomic reconstruction of the soft tissues with preservation of the external rotators (reattachment of dislocated tubercles and, if necessary, transposition of latissimus dorsi and teres major as described by L'Episcopo).POSTOPERATIVE MANAGEMENT:For 6 weeks postoperatively, abduction brace and passive or active-assisted exercises including continuous passive motion (Ormed, Freiburg, Germany).RESULTS:From 2000 to 2005, a total of 84 shoulder replacement revisions were performed with the reverse prosthesis, of which 34 were revisions of failed fracture hemiarthroplasties (five men, 29 women) through a bone window in the humerus. 25 patients were followed prospectively for up to 59 months postoperatively; an additional nine patients were interviewed by telephone or in writing (n=34, average age 68 years [59-82 years], average follow-up 31.5 months [12-59 months]). The preoperative age- and gender-related Constant Score was 17.5% and improved to 63% postoperatively. Range of motion for active elevation and internal rotation was substantially improved (average elevation preoperatively 48 degrees , postoperatively 125 degrees ). Pain was relieved in every patient. Function correlated to the extent of soft-tissue damage. 14 patients were very satisfied with the surgical outcome, 16 were satisfied and four dissatisfied. There were eight complications in total.

Tumor necrosis factor alpha (TNFalpha) plays a fundamental role in the pathogenesis of wear particle-induced periprosthetic osteolysis. However, particle-induced mechanisms that control TNFalpha gene expression are not yet well characterized. LITAF [lipopolysaccharide (LPS)-induced TNFalpha factor] is a novel transcription factor that regulates expression of the TNFalpha gene, but nothing is known about its role in wear particle-induced osteolysis. We evaluated the effect of titanium aluminum vanadium (TiAlV) and polyethylene particles on mRNA expression of LITAF. A human monocytic leukemia cell line (THP-1) was used in this in vitro study. THP-1 monocytes were differentiated to macrophage-like cells and exposed to LPS-detoxified polyethylene particles and prosthesis-derived TiAlV particles. Supernatant was used for TNFalpha protein measurement and total RNA was extracted from cells. LITAF was analyzed at the mRNA level using semiquantitative RT-PCR. Both polyethylene and TiAlV particles induced significant upregulation of LITAF mRNA that was followed by a significant TNFalpha response. These effects were dependent on the particle dose. Low particle concentrations exhibited no significant effect on expression of TNFalpha and LITAF mRNA. In comparison to exposure to polyethylene and TiAlV particles, LPS stimulation exhibited similar upregulation of LITAF mRNA, but led to an overwhelming TNFalpha response. Our findings provide evidence that LITAF is implicated in the pathogenesis of wear particle-induced osteolysis.

Infections of the shoulder joint are rare but nevertheless carry a high risk of complications. Successful therapy is mostly operative and should be planned according to the causes, stage, and expansion of the infection and the expected spectrum of bacteria. Moreover, the patient's general condition and previous illnesses must be considered. Patients with rheumatoid arthritis and immunotherapy are especially at risk for complications and require special attention. Shoulder infections and periprosthetic infections can be treated with arthroscopy, with open debridement, or, in the case of periprosthetic infections, with one- or two-stage exchange procedures. In cases of noncontrollable infections, resection arthroplasty or arthrodesis can be performed as a last resort. Results and possible complications are described herein, including those based on our own results.

Success rates relating to relief from pain and improved function following open reconstruction of the rotator cuff have been documented in many studies. At least for small to medium-size tears the question currently arises of whether an arthroscopic repair would not also give good treatment results. At present, however, the results of arthroscopic repair are not yet comparable to those yielded by the open techniques, at least in terms of recurrent defects especially in the case of massive tears (affecting more than two tendons). Open surgical repair is currently still recommended for all patients who require maximal postoperative function and strength and for elderly patients. Open repairs have a lower rate of re-rupture than arthroscopic repairs, but arthroscopic repair offers the benefits of lower morbidity. The decision on which technique is indicated should be made by an experienced surgeon with special training in this area and with due consideration for newer aspects in diagnostic imaging techniques, so as to avoid unsatisfactory results. In certain cases of irreparable cuff tears affecting two tendons and with fatty infiltration of the muscle and substantial loss of function muscle transfer can be considered in active patients; this can offer some functional improvement in the medium to long term, but do not lead to full restoration of function.