Gender-adjusted Constant Score Research Articles

Two-stage shoulder arthroplasty after deep infection of the shoulder caused by arthroplasty, osteosynthesis or other surgical procedures: microbial spectrum, complications and functional outcome after at least 1 year follow-up.

Infection represents probably the most challenging complication in shoulder arthroplasty and all other surgical procedures of the shoulder. A deep infection of the shoulder is often combined with a destruction of the joint and a loss of function. In many cases the arthroplasty is the last resort for these patients to obtain a satisfactory function. The objective of this study was to determine outcome data on microbiota and clinical results of a two-stage shoulder arthroplasty procedure after deep infection of the shoulder. Twenty-six patients with a deep shoulder infection after arthroplasty, osteosynthesis, or rotator-cuff repair were included, while two patients had an empyema without prior surgery. All underwent initial surgical debridement with implantation of an antibiotic-loaded spacer, followed by postoperative systemic antibiotics. The patients obtained definitive shoulder arthroplasty in a second surgery. None of the patients had to undergo more than two surgeries before the arthroplasty. The follow-up analysis including microbiota results, complication rates, and functional outcomes could be determined after at least 1year in 60% of patients (n = 16). The most frequently detected microorganisms were S. epidermidis (31%, n = 10) and Cutibacterium acnes (19%, n = 6). In 28% (n = 9) of cases multi-drug resistant bacteria were detected and in 35% (n = 8) of cases more than one microorganism was found. The overall revision rate was 42%, 11 of 26 patients, in the first 8weeks after arthroplasty. Reasons for revision were joint dislocations in 23% (n = 6), 15% (n = 4) postoperative hematomas, one (4%) re-infection and one (4%) periprosthetic fracture. At follow-up after 19.3 ± 5.5months postoperatively, a mean abduction of 113.4°, anteversion of 122.8° and external rotation of 14° was found, with an average age and gender-adjusted Constant Score of the affected shoulder of 63. The subjects' pain and impairment in normal life measured by a questionnaire with school grades were significantly reduced (p < 0.05) as compared to prior shoulder arthroplasty. The most relevant bacteria in the study cohort were Staphylococcus subspecies and to a lower extent Cutibacterium acnes. A high number of multi-drug resistant and mixed microbiota spectra were detected, defining a need to adapt therapeutic regimen targeting these microbiotas. The two-stage shoulder arthroplasty after a deep infection resulted in excellent infection control with however high early postoperative rates for joint dislocation (23%) and hematomas (15%). At follow-up a stable joint was achieved with a sufficient functional outcome and satisfying outcome for activities of daily living and pain. Trial registration number: DRKS00016927, date of registration: 2019/03/19.

Outcome after operative revision of clavicular nonunions

AbstractBackgroundOver the past decade, the treatment of midshaft clavicular fractures has increasingly shifted from conservative to operative therapy. The overall results seem to be better with surgery, although the problem of nonunion remains. The aim of this study was to report the functional results after operative revision of clavicular nonunions in two German level‑1 trauma centers.MethodsAll patients who underwent surgery for clavicular nonunions during the past 10 years were invited for a structured clinical follow-up examination. The major functional outcome parameter was the age- and gender-adjusted Constant score. Additionally, radiographic fracture union was assessed with the available X‑rays. Complications such as wound site infections were also monitored.ResultsIn total, 31 patients were available for assessment. The mean follow-up rate was 69.7 ± 31.2 months. The mean age of the patients was 52.3 ± 15.2 years. The nonunion was classified as atrophic in 26 cases and hypertrophic in five. A total of 25 (80.6%) patients were treated with angular stable plating combined with autologous bone grafting from the iliac crest. The age- and gender-adjusted Constant score was significantly decreased compared with the noninjured side (82.2 ± 17.1 vs. 95.6 ± 10). Radiographic union was achieved in 30 of the 31 patients (96.8%). Complications with need for surgical revision were recorded for two patients.ConclusionSurgery for clavicular nonunion is a safe and well-established procedure, which leads to radiographic union and good functional results for the majority of cases.

Hidden degloving rotator cuff tears secondary to glenohumeral dislocation

A rare form of rotator cuff tear (RCT) is observed secondary to glenohumeral dislocation, followed by immediate repositioning, as well as formation of scar tissue between tendons and tuberosities. Radiographic diagnosis of such "degloving" tears is problematic because they are obscured by scar tissue. We aimed to describe characteristics of degloving tears and report outcomes following their arthroscopic repair. Among 67 patients who underwent arthroscopic repair of RCTs secondary to shoulder dislocation, we identified 8 patients (12%) (7 anterior dislocations and 1 posterior dislocation), aged 54.5 years (range, 38-61 years), with typical characteristics of degloving tears. Preoperative imaging revealed massive 2- or 3-tendon tears in all patients (6 with a ruptured or dislocated long head of the biceps), evaluated preoperatively and at greater than 2 years, using the absolute and age- and gender-adjusted Constant scores, Subjective Shoulder Value, and Simple Shoulder Test score. The absolute Constant score improved from 27 (range, 17-54) to 89 (range, 62-95). The age- and gender-adjusted Constant score improved from 31 (range, 24-57) to 97 (range, 83-100). The Simple Shoulder Test score improved from 2 (range, 0-4) to 12 (range, 9-12), while the Subjective Shoulder Value improved from 18 (range, 10-30) to 90 (range, 60-100). All patients were very satisfied (63%) or satisfied (37%). We have described a particular form of RCT secondary to glenohumeral dislocation, resulting in degloving of the rotator cuff, followed by repositioning of tendons. The formation of scar tissue can obscure tendon tears on ultrasound, in which case further imaging is recommended to ascertain the diagnosis and avoid therapeutic delays.

Short and midterm results of reverse shoulder arthroplasty according to the preoperative etiology

Reverse shoulder arthroplasty (RSA) has shown promising results for cuff tear arthropathy but the indication has been extended to fracture sequelae and revision shoulder arthroplasty with different preconditions. Further, the clinical relevance of inferior scapular notching for different etiologies is uncertain. Our hypothesis was that preoperative etiology as well as the occurrence of scapular notching would significantly influence the clinical outcome. We reviewed 76 reverse shoulder arthroplasties for cuff tear arthropathy (45 patients), fracture sequelae (10 patients) and revision arthroplasty (21 patients) retrospectively. The follow-up consisted of 71 patients and the mean follow-up period was 23months (±14months). All patients were evaluated postoperatively using the Constant score adjusted for age and gender and the simple shoulder test. A radiological investigation was performed preoperatively and at the time of the final follow-up including the evaluation of scapular notching according to Sirveaux. For further evaluation of scapular notching, patients were separated into three groups according to the inferior glenosphere overlap: negative or no inferior overlap -6-0mm), mild overlap (1-4mm) and pronounced overlap (5-9mm). After a mean follow-up of 23months the average age- and gender-adjusted Constant score (CS) was 77.8% (±26%). According to the etiology, patients with cuff tear arthropathy (CTA) showed a higher CS of 83% compared with patients with fracture sequelae (CS 73%) and compared with patients who had undergone RSA as a revision for failed shoulder arthroplasty (CS 69%). The difference was significant comparing the cuff tear arthropathy patients with the revision surgery patients (p=0.035). Within the group of fracture sequelae, patients with type three sequelae according to the Boileau classification (surgical neck nonunion) had a significantly worse outcome compared with the type four fracture sequelae patients (severe tuberosity dislocation) (CS 57 vs. 87%, p=0.01). The overall complication rate was 27% with 8% infections and 9% dislocations. Revision surgery was necessary in 11.5% with removal or replacement of the implants in 8%. Inferior scapular notching was detected in 43% of the patients. These patients had an inferior CS (70±18%) compared with patients without scapular notching (84±25%, p=0.015). The incidence of scapular notching was significantly reduced with an increasing inferior overlap of the glenosphere. In conclusion, we found the preoperative etiology to influence the clinical results after RSA with superior results given for cuff tear arthropathy and inferior results for revision arthroplasty and fracture sequelae type three. Further, we found a correlation between scapular notching and the clinical outcome. The inferior scapular notching was significantly reduced by an increased inferior glenosphere overlap. Level IV, case series, treatment study.

Arthroscopic capsular release for refractory shoulder stiffness: A critical analysis of effectiveness in specific etiologies

The purpose of this study is to report and compare the outcome of arthroscopic capsular release in patients with shoulder stiffness with post-traumatic, postsurgical, and idiopathic etiologies. We hypothesize that patients with idiopathic or post-traumatic stiffness have better outcomes after arthroscopic capsular release than those with shoulder stiffness with a postsurgical etiology. A retrospective review of 115 patients who underwent arthroscopic capsular release for refractory shoulder stiffness was performed. There were 60 men and 55 women with a mean age of 49 years (range, 27 to 81 years). The patients were divided into 3 groups according to the etiology of stiffness: post-traumatic (26 patients), postsurgical (48 patients), and idiopathic (41 patients). Arthroscopic capsular release was performed in all patients after a mean of 9 months of physical therapy (range, 6 to 13 months). At a mean follow-up of 46 months (range, 25 to 89 months), the overall subjective shoulder value in all groups improved from 29% to 73% and the age- and gender-adjusted Constant score improved from 35% to 86%. The mean pain score decreased from 7.5 to 1, and mean active forward flexion, external rotation, and internal rotation increased from 97 degrees , 14 degrees , and the L5 vertebral level, respectively, to 135 degrees , 38 degrees , and the T11 vertebral level, respectively (P < .0001). There was no significant difference between the outcomes of idiopathic and post-traumatic stiffness (P = .7). However, the Constant score and subjective shoulder value were significantly lower in the postsurgical group compared with the idiopathic and post-traumatic groups (P = .0001 and P = .006, respectively). Arthroscopic capsular release is an effective treatment for refractory shoulder stiffness. Patients with idiopathic and post-traumatic shoulder stiffness have better outcomes than patients with postsurgical stiffness.

Open screw fixation of large anterior glenoid rim fractures: mid- and long-term results in 29 patients

The aim of this retrospective study was to analyse the clinical, functional and radiographic outcomes of patients sustaining traumatic anterior dislocations of the shoulder in combination with large anterior glenoid rim fractures, treated by open reduction and internal screw fixation (ORIF). Twenty-nine patients with a mean follow-up of 6.5 years (2.5-12 years) were evaluated clinically using the Constant and DASH scores, radiographs in two planes and isokinetic muscle strength measurement (Biodex 3 PRO). Mean age was 41.6 years (17-68 years). There was no case of postoperative re-dislocation. Eight out of 29 patients (27.5%) underwent revision surgery to remove the screws. The mean age- and gender-adjusted Constant score was 93.3% (range 64-102%), and the mean DASH score was 10.1 points (range 0-71 points). On radiological examination, 6 patients had signs of osteoarthritis: Samilson type I (n = 3) and II (n = 3). Significant differences for maximal strength in external rotation and muscular endurance compared to the unaffected side were found (P < 0.035). Twenty-seven patients (93%) were satisfied or very satisfied with the result after surgery. ORIF seems to be a good treatment option in cases of large glenoid rim fractures to avoid re-dislocation in the mid-term. Prospective randomised studies are necessary to compare these findings with those after non-operative or arthroscopic treatment of these injuries.

Pectoralis major inverse plasty for functional reconstruction in patients with anterolateral deltoid deficiency

After establishing anatomical feasibility, functional reconstruction to replace the anterolateral part of the deltoid was performed in 20 consecutive patients with irreversible deltoid paralysis using the sternoclavicular portion of the pectoralis major muscle. The indication for reconstruction was deltoid deficiency combined with massive rotator cuff tear in 11 patients, brachial plexus palsy in seven, and an isolated axillary nerve lesion in two. All patients were followed clinically and radiologically for a mean of 70 months (24 to 125). The mean gender-adjusted Constant score increased from 28% (15% to 54%) to 51% (19% to 83%). Forward elevation improved by a mean of 37 degrees , abduction by 30 degrees and external rotation by 9 degrees . The pectoralis inverse plasty may be used as a salvage procedure in irreversible deltoid deficiency, providing subjectively satisfying results. Active forward elevation and abduction can be significantly improved.

Arthroscopic Debridement of Massive Irreparable Rotator Cuff Tears

The purpose of this study was to evaluate clinical and radiologic results of arthroscopic debridement of massive irreparable rotator cuff tears. Thirty-one patients (mean age, 70.6 years) were retrospectively reviewed for a mean of 47 months (range, 24 to 69 months) after arthroscopic debridement of an irreparable rotator cuff tear. Operative treatment included biceps tenotomy in 24 cases (77.4%). No acromioplasty was performed to maintain the coracoacromial arch. Clinical outcome was assessed by use of the American Shoulder and Elbow Surgeons (ASES) and Constant scores, as well as measurement of abduction strength and elbow flexion strength compared with the contralateral side at final follow-up. Preoperative and follow-up radiographs were evaluated for acromiohumeral distance and grade of osteoarthritis according to the Samilson-Prieto classification. The mean ASES score was significantly improved from 24.0 to 69.8 points at follow-up. Scores for pain were reduced from 7.8 to 2.9 points on a visual analog scale ranging from 0 to 10 points. The age- and gender-adjusted Constant score was 72.2%. Radiologic analysis showed progression of osteoarthritis in 10 cases (32.3%); this had no influence on the ASES score. Acromiohumeral distance decreased from 8.3 to 7.0 mm. Biceps strength was 6.1 kg on the operated side and 6.3 kg on the contralateral side. Abduction strength was significantly lower on the operated side at 2.6 kg versus 3.7 kg on the contralateral side. No complication related to the procedure was reported. For elderly patients with low functional demands, arthroscopic debridement in combination with biceps tenotomy is a safe procedure and leads to significant functional improvement without loss of biceps strength. Progression of osteoarthritic changes cannot be prevented, but no influence on the clinical result could be shown. Level IV, therapeutic case series.

Arthroscopic prevalence of pulley lesions in 1007 consecutive patients

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.

CLINICAL AND STRUCTURAL RESULTS OF OPEN REPAIR OF AN ISOLATED ONE-TENDON TEAR OF THE ROTATOR CUFF

Background: The clinical outcomes of open rotator cuff repair are well established, but the structural results and their effect on clinical outcome are poorly known. We assessed the structural changes in the musculotendinous units after open rotator cuff repair and correlated these findings with the clinical outcome to establish a benchmark for future series. Methods: Thirty-two consecutive standardized open repairs of a single tendon tear of the rotator cuff were analyzed in twenty-one men and eleven women with an average age of 59.0 years. The supraspinatus tendon was involved in twenty-two patients and the subscapularis tendon, in ten. The clinical outcome, including the Constant score, was assessed prospectively for all patients at an average of thirty-eight months postoperatively. The structural outcome was assessed on standardized magnetic resonance imaging scans. Results: The mean overall subjective shoulder value was 82.8% of the value for a normal shoulder. On the average, the age and gender-adjusted Constant score increased from 63.9% preoperatively to 94.5% postoperatively (p < 0.0001); the score for pain, from 6.8 points to 13.2 points (p < 0.0001); and the score for activities of daily living, from 11.2 points to 17.9 points (p < 0.0001). The overall rerupture rate was 13% (four of the thirty-two shoulders). All reruptures were distinctly smaller than the original tear. Muscular atrophy or fatty infiltration did not significantly decrease after the tendon repair. In fact, fatty infiltration in the supraspinatus (p < 0.0053) and infraspinatus (p < 0.003) muscles increased significantly. Conclusions: Direct open repair of a complete, isolated tear of one tendon of the rotator cuff resulted in significant subjective and objective improvement and very high patient satisfaction. Successful direct repair was not associated with a decrease in preoperative muscular atrophy and was associated with increased fatty infiltration of the muscle. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Clinical and Structural Results of Open Repair of an Isolated One-Tendon Tear of the Rotator Cuff

The clinical outcomes of open rotator cuff repair are well established, but the structural results and their effect on clinical outcome are poorly known. We assessed the structural changes in the musculotendinous units after open rotator cuff repair and correlated these findings with the clinical outcome to establish a benchmark for future series. Thirty-two consecutive standardized open repairs of a single tendon tear of the rotator cuff were analyzed in twenty-one men and eleven women with an average age of 59.0 years. The supraspinatus tendon was involved in twenty-two patients and the subscapularis tendon, in ten. The clinical outcome, including the Constant score, was assessed prospectively for all patients at an average of thirty-eight months postoperatively. The structural outcome was assessed on standardized magnetic resonance imaging scans. The mean overall subjective shoulder value was 82.8% of the value for a normal shoulder. On the average, the age and gender-adjusted Constant score increased from 63.9% preoperatively to 94.5% postoperatively (p < 0.0001); the score for pain, from 6.8 points to 13.2 points (p < 0.0001); and the score for activities of daily living, from 11.2 points to 17.9 points (p < 0.0001). The overall rerupture rate was 13% (four of the thirty-two shoulders). All reruptures were distinctly smaller than the original tear. Muscular atrophy or fatty infiltration did not significantly decrease after the tendon repair. In fact, fatty infiltration in the supraspinatus (p < 0.0053) and infraspinatus (p < 0.003) muscles increased significantly. Direct open repair of a complete, isolated tear of one tendon of the rotator cuff resulted in significant subjective and objective improvement and very high patient satisfaction. Successful direct repair was not associated with a decrease in preoperative muscular atrophy and was associated with increased fatty infiltration of the muscle.

The results of repair of massive tears of the rotator cuff.

Massive tears of the tendons of the rotator cuff cause atrophy and fatty degeneration of the rotator cuff muscles and painful loss of function of the shoulder. Repair of massive rotator cuff tears is often followed by retears of the tendons, additional muscular degeneration, and a poor clinical outcome. The purposes of this study were to determine whether a new method of repair of rotator cuff tendons can yield a lower retear rate and a better clinical outcome than previously reported methods, to assess the muscular changes following repair of massive tears of the musculotendinous units, and to correlate findings on magnetic resonance imaging with the clinical results. Twenty-nine massive rotator cuff tears involving complete detachment of at least two tendons were repaired operatively with use of a new laboratory-tested technique in a prospective study. At least two years (average, thirty-seven months; range, twenty-four to sixty-one months) postoperatively, twenty-seven patients were evaluated clinically and with magnetic resonance imaging to determine the clinical outcome, the integrity of the repair, and the condition of the rotator cuff muscles. The age and gender-adjusted Constant score improved from an average of 49 percent preoperatively to an average of 85 percent postoperatively, corresponding to a subjective shoulder value of 78 percent of that of a normal shoulder. Pain-free flexion improved from an average of 92 degrees to an average of 142 degrees, and abduction improved from an average of 82 degrees to an average of 137 degrees. Pain decreased and performance of activities of daily living improved significantly (p < 0.05). The seventeen patients who had a structurally successful repair all had an excellent clinical outcome. Muscle atrophy could not be reversed except in successfully repaired supraspinatus musculotendinous units. Fatty degeneration increased in all muscles. The method of repair of massive rotator cuff tears that was used in this study yielded a comparatively low retear rate and good-to-excellent clinical results; however, the repair did not result in substantial reversal of muscular atrophy and fatty degeneration. Retears occurred more often in patients who had had a shorter interval between the onset of the symptoms and the operation (p < 0.05). Patients who had a retear had improvement of the shoulder compared with the preoperative state, but they had less improvement than did those who had a successful repair.