Background Stemless anatomical shoulder arthroplasty has gained increasing popularity in the management of shoulder osteoarthritis with clinical outcomes comparable to that of conventional stemmed implants. The aim of this study was to evaluate the efficacy and safety of a novel stemless implant at 24 months. Methods Stemless total shoulder arthroplasty was performed in 154 subjects using the new Global ICON™ (Johnson & Johnson MedTech, Warsaw, IN, USA) implant, with prospective follow-up of 24 months. The adjusted Constant Murley score, Oxford Shoulder Score, EQ-5D-5L score and radiographs were examined preoperatively, 3, 12, and 24 months after the implantation. In the follow-up window, data was available for 139 subjects to evaluate success with a primary composite outcome (no radiological evidence of a continuous lucency, adjusted Constant-Murley score >85, no revision & no device-related serious adverse effect). Further data on safety and complications were also gathered. Results Successful clinical 24-month outcomes were observed in 82.7% of subjects. Device survivorship was 98.7% with a total of 2 revisions prior to 2 years. All PROMs scores demonstrated significant improvement from preoperative baseline to 24 months. The mean adjusted Constant Murley score improved from 42.3-103.8 (p<0.001). The Oxford Shoulder Score improved from 20.6-43.1 (p<0.001). The EQ-5D-5L also improved from 0.5-0.8 (p<0.001). No continuous radiolucent lines were noted on radiographic evaluation and there was one device-related serious adverse effect involving bursitis which responded to physical therapy and did not require revision. Conclusion The Global ICON stemless aTSA demonstrates good clinical and radiographic outcomes at short-term follow-up, comparable to that of other stemmed and stemless implants. Its safety and efficacy support its ongoing use and longer-term evaluation.

Background One of complications of the reverse shoulder arthroplasty is acromion fractures, and its therapy is controversial. The aim of the study was to investigate the double-plate osteosynthesis for these fractures. Methods An acromion type III fracture according to classification of Levy was simulated in 16 human shoulder cadavers, and the specimens were randomly divided into two groups . Single-plate osteosynthesis was performed in the first group (locking compression plate) and double-plate osteosynthesis (locking compression plate and one-third tubular locking plate) in the second group. Biomechanical testing included cycling load and load at failure on a material testing machine. During the test, the translation was measured using an optical tracking system. Results The load at failure for the single-plate osteosynthesis was 167 N and for the double-osteosynthesis 233.7 N ( P = 0.328). The average translation was 11.1 mm for the single-plate osteosynthesis and 16.4 mm for the double-plate osteosynthesis ( P = 0.753). The resulting stiffness resulted in 74.7 N/mm for the single-plate osteosynthesis and 327.9 N/mm for the double-plate osteosynthesis ( P = 0.141). Discussion Results of the biomechanical study showed that double-plate osteosynthesis had biomechanical properties similar to those of single-plate osteosynthesis for an acromion type III fracture at time point zero. The missing advantages of double-plate osteosynthesis can be explained by the choice of plate configuration.

The management of the subscapularis tendon in reverse shoulder arthroplasty (RSA) is still discussed controversially. We hypothesized, that (1) patients treated with the subscapularis sparing approach would present with a higher internal rotational strength, while (2) the external rotational motion is not reduced. A prospective, randomized, double blinded clinical trial was conducted. Patients were randomized into two groups: subscapularis sparing approach (group 1) or tenotomy without repair of the subscapularis tendon (group 2). Clinical follow-up examinations were performed at 12 and 24 months. Primary outcome measure was the internal rotational strength at two years measured by a bear-hug test. Secondary outcome measure was the degree of external rotation. The clinical outcome was measured and compared based on the Constant Score (CS), patient satisfaction and Subjective Shoulder Value (SSV). Thirty-four patients with a mean age of 74 years were included, 17 for each group. Indication for surgery was osteoarthritis (6-times), non-reconstructable rotator cuff tear (5-times), and defect arthropathy (23-times). Internal rotational strength was higher in group 1 than in group 2 (bear-hug: 51 Nm vs. 39 Nm). With the contralateral side defining the reference, there was a significant higher loss of for internal rotational strength in group 2 than in group 1 (30 Nm vs. 8.2 Nm; p = 0.006). External rotation did not differ between the groups. The CS improved significantly throughout surgery (p < 0.001). No clinical difference between the groups was observed at 24 months follow-up regarding the CS (p = 0.984). However, subgroup analysis showed better internal rotation preserving the subscapularis. Although technical even more demanding, the subscapularis sparing approach represents advancement in shoulder surgery. By preserving the subscapularis tendon, this technique enhances muscle function with higher internal rotational strength and motion without deficits in external rotation. I.

Knöcherne Glenoiddefekte sind häufig, und ihre Genese ist multifaktoriell. Um erhöhte Lockerungsraten der Glenoidkomponente in der Endoprothetik zu verhindern, sind diverse Techniken zur Adressierung des glenoidalen Knochenverlusts verfügbar. Wenn Korrekturfräsung und knöcherne Aufbauten nicht mehr ausreichen, spielen in der heutigen Zeit „patient specific instrumentation“ (PSI) und Individualimplantate eine zentrale Rolle, um diesen Defektsituationen zu begegnen. Nach präziser Planung anhand Computertomographie und dreidimensionaler Rekonstruktion der knöchernen Oberfläche kann eine individuelle Ziellehre für die Implantatpositionierung angefertigt werden. Bei Grenzen der knöchernen Rekonstruktion können speziell angefertigte (Individual‑)Implantate die knöcherne Defektsituation ausgleichen. Häufig kommen Patienten anschließend ohne lange Ruhigstellung des Schultergelenks aus. Die gegenwärtig (gering) verfügbare Literatur beschreibt durchaus gute klinische Ergebnisse, diese beschränken sich jedoch fast ausschließlich auf die inverse Schulterendoprothetik.

Abstract Purpose This study reports the long‐term post‐operative clinical outcomes after arthroscopic posterior bone block augmentation with posterior capsular repair. Methods Eighteen shoulders (13 patients) with unidirectional posterior shoulder instability were treated with an arthroscopic posterior bone block augmentation and posterior capsular repair in 2011 and 2013 in a single specialized orthopaedic clinic. These patients were invited to participate in a clinical and radiological follow‐up examination to receive long‐term results regarding clinical outcomes, instability, and development of osteoarthritis (OA). Results From the initial study group, 13 patients (18 shoulders) could be obtained for a follow‐up examination. The mean follow‐up period was 111 months. At the final follow‐up, two patients (two shoulders) reported recurrent subluxations with a positive apprehension sign. No redislocation was reported. Screw fixation was still in place in seven patients (38.9%). Overall, good clinical outcomes were achieved among Constant–Murley score (77.6 ± 16; p = 0.55), Rowe score (67.5 ± 22.1; p = 0.34), Walch–Duplay score (58.3 ± 28.2) and Western Ontario Shoulder Index (40.4 ± 23.3%; p = 0.96), showing insignificant changes compared with the 2‐year results. Three shoulders developed severe OA (Samilson and Prieto III). No patient required arthroplasty. Conclusion Arthroscopic posterior bone block augmentation with posterior capsular repair represents a salvage procedure that can achieve long‐term shoulder stability with overall moderate clinical results. Patients have to be informed about the probable need for implant removal and the high risk of OA development, especially in the presence of pre‐existing cartilage damage, beforehand. Level of Evidence Level IV.

Glenoid bone defects are frequent and the etiology is multifactorial. To prevent increased loosening rates of the glenoid component in total shoulder arthroplasty (TSA), various techniques are available to address the loss of glenoid bone. When corrective reaming and bone grafting techniques are no longer sufficient, patient-specific instrumentation (PSI) and custom-made implants have become core strategies for managing these defects. Following precise planning based on computed tomography (CT) imaging and three-dimensional reconstruction of the bony surface, an individualized guide can be used to accurately position the implant. When the limits of bone reconstruction have been reached, specially prepared (custom-made) implants can be used to compensate for the bony defect. Patients often require minimal postoperative immobilization of the shoulder joint. The currently limited literature describes favorable clinical outcomes, although these findings are almost exclusively limited to reverse shoulder arthroplasty.

Stemless anatomical shoulder arthroplasty offers numerous potential advantages over stemmed systems. The aim of this prospective study was to evaluate the clinical and radiological 2-year results of a novel metaphyseal anchored stemless shoulder system (Global Icon™ Stemless Shoulder System, DePuy Synthes, Warsaw, IN, USA). Thirty patients with primary osteoarthritis, 14 males and 6 females, were prospectively included in the study. Two-year follow-up data were analyzed for 20 patients. The average age and BMI were 63.4 years and 27.6 kg/m2. The adjusted Constant-Murley Score (aCS), Oxford Shoulder Score (OSS), and EQ-5D-5L were used as primary endpoints to reflect postoperative clinical improvement. Postoperative radiographs in two planes were analyzed for implant loosening and migration. There was an overall clinical improvement 2 years postoperatively. The aCS increased from 58.3 ± 17.7 to 113.7 ± 15.6 points (p < 0.0001). The OSS score improved from 25.5 ± 6.1 to 43.9 ± 6.1 points (p < 0.0001). The EQ-5D-5L value score increased on average from 0.7 ± 0.2 to 0.9 ± 0.1 (p = 0.0004). There was no implant loosening or migration. No revisions were required. In summary, the examined prosthesis system achieved very good clinical and radiographic results 2 years postoperatively without implant failure. Shoulder function and quality of life improved significantly. These results are encouraging for prostheses with bone-preserving designs which rely on peripheral humeral fixation, though more long-term results are needed. Level IV; Case Series; Treatment Study.

Background Supracondylar osteotomies are a frequently and successfully used technique in the treatment of coronal plane deformities and unicompartmental osteoarthritis of the knee. While lateral open wedge techniques are common for valgus deformities, the data about medial open wedge techniques for varus deformities is sparse. The aim of this study was to compare the biomechanical properties of medial and lateral open wedge osteotomies using a locking Tomofix® plate (DePuy Synthes, Oberdorf, Switzerland). Our hypothesis was that there would be no difference regarding biomechanical outcome parameters between these two groups. Methods Medial and lateral open wedge osteotomies were performed in composite bone model as routine. Each experimental group contained 6 constructs. Standardized osteotomy gaps of ten millimeters were performed and Tomofix® plates were fixed to third generation composite bones. The constructs were subsequently mounted into a servohydraulic testing machine. Axial and torsional loadings were applied as described in previous experimental studies. All specimens were subject to a load to failure mode with the mechanism of failure being noted. Findings Both experimental groups showed comparable biomechanical properties under axial and torsional loadings. Mean high force axial stiffness was 3772 N/mm for lateral and 4185 N/mm for the medial construct. Significant differences were noted for torsional stiffness under low- (0 N) and mid-force (150 N) loadings (P = 0.002; P = 0.009), favoring the medial open wedge constructs. Interpretation Medial open wedge osteotomy yields comparable biomechanical stability to the lateral open wedge procedure on the distal femur in a composite bone model.

The anterior stability of reverse total shoulder arthroplasty is affected by multiple factors. However, the effect of glenosphere inclination on stability has rarely been investigated, which is what this study aims to look into. Reverse shoulder arthroplasty was performed on 15 cadaveric human shoulders. The anterior dislocation forces and range of motion in internal rotation in the glenohumeral joint (primary measured parameters) were tested in a shoulder simulator in different arm positions and implant configurations, as well as with a custom-made 10° inferiorly inclined glenosphere. The inclination and retroversion of the baseplate as well as the distance between the glenoid and coracoid tip in two planes (secondary measured parameters) were evaluated on CT scans. In biomechanical testing, the custom-made inclined glenosphere showed no significant influence on anterior stability other than glenoid lateralisation over all arm positions as well as the neck-shaft angle in two arm positions. The 6 mm lateralised glenosphere reduced internal rotation at 30° and 60° of glenohumeral abduction. In 30° of glenohumeral abduction, joint stability was increased using the 155° epiphysis compared with the 145° epiphysis. The mean inclination was 16.1°. The inclination was positively, and the distance between the glenoid and coracoid tip in the anterior-to-posterior direction was negatively correlated with anterior dislocation forces. The custom-made inferiorly inclined glenosphere did not influence anterior stability, but baseplate inclination itself had a significant effect on stability.

Verletzungen der lateralen Klavikula und des Akromioklavikulargelenks (ACG) sind häufige, alltagsrelevante Ereignisse, die insbesondere aktive Erwachsene im Alter von 20 bis 40 Jahren betreffen. Für die Einteilung von ACG-Verletzungen ist die Rockwood-Klassifikation etabliert. Laterale Klavikulafrakturen werden nach Neer resp. Jäger und Breitner klassifiziert. Eine neuere Einteilung ist die Klassifikation nach Cho. Je nach vorliegendem Verletzungsmuster und insbesondere vorliegender Instabilität finden sowohl konservative als auch operative Versorgungsstrategien Anwendung. Dieser Beitrag gibt einen Überblick über einzelne Versorgungskonzepte.

Injurie to the lateral clavicle and acromioclavicular joint (ACJ) are frequent events which are relevant to everyday life and particularly affect active adults at the age of 20-40 years. The Rockwood classification has been established for the classification of ACJ injuries. Lateral clavicle fractures are classified according to the Neer classification or the Jäger and Breitner classification. A newly established classification is the Cho classification. Depending on the injury pattern and in particular the presence of instability, various conservative and surgical care strategies are used. This article provides an overview of the various treatment concepts.

The influence of the subscapularis tendon on reverse total shoulder arthroplasty (RTSA) has been discussed controversially. The aim of the study was to investigate the subscapularis-sparing approach for RTSA and the effect of the intact subscapularis tendon. This retrospective comparative study included 93 patients. Among these, 55 underwent the deltopectoral subscapularis-sparing approach, and in 38 cases, the standard deltopectoral approach with subscapularis tenotomy was applied. At the final follow-up, representative shoulder scores were measured, radiographs were taken in two planes, and shoulder sonography was performed. The subscapularis-sparing group showed a significantly higher Constant score (71.8 vs. 65.9 points) and adapted Constant score if the subscapularis tendon was shown to be intact in the postoperative sonography (85.2

Objective: Clinical outcome data for the novel minced cartilage procedure are sparse. While good results have been shown for the knee joint, this is the first report in the current literature regarding this increasingly important procedure in the glenohumeral joint. Case Description: A 33-year-old handyman with a cartilage defect in the humeral head underwent an all arthroscopic one-stage cartilage repair with the AutoCartTM procedure (Arthrex GmbH, Munich, Germany). A senior specialist examined the patient before surgery, five-, 12-and 24-weeks post-surgery. Outcome parameters (Constant-Murley Score, UCLA Shoulder Score and ASES Score) and radiographic imaging were recorded. Results: At six months, follow-up the outcome parameter showed excellent results, the joint pain decreased to numeric rating scale (NRS) 0. The postoperative magnetic resonance imaging (MRI) revealed a thin cartilage layer in the treated area with sufficient integration to the surrounding tissue. The cartilage in the former defect zone presented a homogeneous signal, which was comparable to the intact cartilage. Conclusion: This case report underlines the growing interest in single-stage arthroscopic minced cartilage procedures and shows promising results in the glenohumeral joint. Yet, larger investigations with long-term follow-up are necessary to provide reliable clinical data to determine if comparable results can be achieved over time.

Purpose: Torn anterior cruciate ligaments in children are rare injuries. The incidence of concomitant avulsion fracture in the skeletally immature patient is high. Reports of arthroscopic reconstruction in the literature are sparse.Case Presentation: We present the case of a femoral avulsion fracture of the anterior cruciate ligament in a seven-year-old girl. The patient underwent arthroscopic refixation with DynacordTM Suture and Suture Button. At a follow-up of 8 weeks, the patient had free range of motion and a stable knee, with a negative Lachman-and Pivot-Shift-test in particular.Conclusion: Refixation of femoral avulsion fracture can lead to good results. Open physes and size of the knee should be taken into account. Anatomic reconstruction is compulsory to receive bone on bone healing.

Purpose Ligament bracing is a technique of suture reinforcement that can be used to augment lateral ulnar collateral ligament repair in the treatment of posterolateral rotatory instability of the elbow, thereby improving early stability of the repair. However, multiple failures of the ulnar anchor during implantation have been documented. We hypothesized that the use of a cortical button for ulnar fixation of the ligament brace would be biomechanically comparable to a suture anchor construct. Methods Sixteen elbows were tested with a materials testing machine. The intact, dissected, and repaired lateral collateral ligament complex was tested with a cyclic varus rotational torque of 0.5e3.5 Nm in 120 degrees, 90 degrees, 60 degrees, and 30 degrees elbow flexion. For the repair, the specimens were randomized into 2 groups: ulnar fixation of the ligament bracing using a suture anchor and ulnar fixation of the ligament bracing using a cortical button. The number of implant failures was documented. A load-to-failure protocol was conducted in 90 degrees elbow flexion. Results Load to failure was comparable and was found to be 20.7 Nm in the suture anchor group and 21.8 Nm in the cortical button group. Laxity after ligament bracing did not differ significantly between suture anchor and cortical button fixation. Compared with the native ligament, the laxity was significantly reduced after ligament bracing. The failure mode was slippage of the suture tape through the humeral anchor in all cases. Additionally, the capitellum was damaged in 9 of 16 cases. Conclusions A cortical button for ulnar fixation of the ligament bracing was comparable with a suture anchor fixation with regard to biomechanical properties such as laxity and load to failure. Clinical relevance A cortical button fixation is less prone to failure of insertion. This would improve the implantation technique, while clinical results are expected to be comparable. (J Hand Surg Am. 2022;47(10):1016.e1-e8. Copyright (c) 2022 by the American Society for Surgery of the Hand. All rights reserved.)

Traumatic posterior shoulder joint instability can be associated with a bony defect in the area of the posterior glenoid. For bony defects larger than 11% of the glenoid surface, a 10-fold increased rate of recurrent dislocation after soft-tissue posterior shoulder stabilization alone was observed. This defect size should therefore be classified as critical or in need of care in terms of bony augmentation. The available studies on posterior bone block augmentation primarily involve arthroscopic techniques with screw fixation. With anatomical placement of the bone block in the sense of complementary coverage of the bone defect, the surgical technique shows mostly good results regarding restoration of shoulder stability. However, there were frequent problems due to the implant material that had been introduced, which often had to be removed after remodeling or partial resorption of the bone graft. Inconsistent and sometimes insufficient results were reported when the technique was extended to other indication areas (soft tissue insufficiency, functional instability) and when the bone graft was placed extra-anatomically. Furthermore, existing glenoid dysplasia, incipient omarthrosis, and decentering of the humeral head negatively influenced the results. A strict indication and an implant-free technical implementation are therefore recommended.