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Background Insufficient tuberosity healing is the most common reason for poor outcome after treatment of proximal humerus fractures (PHFs) using hemiarthroplasty (HA). In these cases, revision to reverse total shoulder arthroplasty (RTSA) can improve function and reduce pain in the short term, however, long-term results remain scarce. Aim of this study was to evaluate the clinical and radiological mid- to long-term results in patients with a revision RTSA after failed HA for PHF. Methods In this retrospective study all patients that received a revision to RTSA after failed fracture HA between 2006 and 2018 were included. A total of 49 shoulders in 48 patients (38 female, 10 male; mean age 82 ± 9 years) were identified in our database. A total of 20 patients (17 female, 3 male; mean age was 79 ± 9 years) were available for follow-up examination after a mean time period of approximately eight years (3–14 years) after revision surgery. At final follow-up, patients were assessed using a subjective shoulder value (SSV), range of motion (ROM), visual analogue score (VAS), the Constant Score (CS) and the 12-Item Short Form Survey (SF-12). Results At final follow-up, mean CS was 55 ± 19 (19–91), VAS averaged 3 ± 3 (0–8) and mean SSV was 61 ± 18% (18–90%). Mean SF-12 was 44 (28–57) with a mean physical component summary (PCS) of 38 (21–56) and a mean mental component summary (MCS) of 51 (29–67). On average active forward flexion (FF) was 104° (10–170°), active abduction (ABD) was 101° (50–170°), active external rotation (ER) was 19° (10–30°) and active internal rotation (IR) of the lumbosacral transition was reached. Three patients presented with a periprosthetic humeral fracture after RTSA implantation and underwent a reoperation (15%) during follow-up period. Conclusions Revision RTSA results in promising clinical results in patients after initial failed HA after PHF. A complication and reoperation rate of 15% is tolerable in consideration of satisfactory functional and psychological outcome. Trial registration Retrospectively registered.

Background Treatment of enterococcal periprosthetic joint infections (PJI) is challenging due to non-standardized management strategies and lack of biofilm-active antibiotics. The optimal surgical and antimicrobial therapy are unknown. Therefore, we evaluated characteristics and outcome of enterococcal PJI. Methods Consecutive patients with enterococcal PJI from two specialized orthopedic institutions were retrospectively analyzed. Both institutions are following the same diagnostic and treatment concepts. The probability of relapse-free survival was estimated using Kaplan-Meier survival curves and compared by log-rank test. Treatment success was defined by absence of relapse or persistence of PJI due to enterococci or death related to enterococcal PJI. Clinical success was defined by the infection-free status, no subsequent surgical intervention for persistent or perioperative infection after re-implantation and no PJI-related death within 3 months. Results Included were 75 enterococcal PJI episodes, involving 41 hip, 30 knee, 2 elbow and 2 shoulder prostheses. PJI occurred postoperatively in 61 episodes (81%), hematogenously in 13 (17%) and by contiguous spread in one. E. faecalis grew in 64 episodes, E. faecium in 10 and E. casseliflavus in one episode(s). Additional microorganism(s) were isolated in 38 patients (51%). Enterococci were susceptible to vancomycin in 73 of 75 isolates (97%), to daptomycin in all 75 isolates, and to fosfomycin in 21 of 22 isolates (96%). The outcome data was available for 66 patients (88%). The treatment success after 3 years was 83.7% (95% confidence interval [CI]; 76.1–96.7%) and the clinical success was 67.5% (95% CI; 57.3–80.8%). In 11 patients (17%), a new PJI episode caused by a different pathogen occurred. All failures occurred within 3 years after surgery. Conclusion About half of enterococcal PJI were polymicrobial infections. The treatment success was high (84%). All treatment failures occurred within the first 3 years after revision surgery. Interestingly, 17% of patients experienced a new PJI caused by another pathogen at a later stage. Trial registration The study was retrospectively registered with the public clinical trial identification NCT0253022 at https://www.clinicaltrials.gov on 15 July 2015.

Background Two-stage exchange arthroplasty is still the preferred treatment choice for chronic PJI. However, the results remain unpredictable. We analyzed the treatment success of patients with an infected hip prosthesis, who were treated according to a standardized algorithm with a multidisciplinary team approach and evaluated with a strict definition of failure. Methods In this single-center prospective cohort study, all hip PJI episodes from March 2013 to May 2015 were included. Treatment failure was assessed according to the Delphi-based consensus definition. The Kaplan-Meier survival method was used to estimate the probability of infection-free survival. Patients were dichotomized into two groups depending on the number of previous septic revisions, duration of prosthesis-free interval, positive culture with difficult-to-treat microorganisms, microbiology at explantation, and microbiology at reimplantation. Results Eighty-four patients with hip PJI were the subject of this study. The most common isolated microorganisms were coagulase-negative staphylococci (CNS) followed by Staphylococcus aureus and Propionibacterium . Almost half of the study cohort (46%) had at least one previous septic revision before admission. The Kaplan-Meier estimated infection-free survival after 3 years was 89.3% (95% CI, 80% to 94%) with 30 patients at risk. The mean follow-up was 33.1 months (range, 24–48 months) with successful treatment of PJI. There were no statistical differences in infect eradication rate among the dichotomized groups. Conclusions High infect eradication rates were achieved in a challenging cohort using a standardized two-stage exchange supported by a multidisciplinary approach.

IntroductionAlthough age is considered to be the major risk factor of primary glenohumeral osteoarthritis (GOA), younger population may suffer from degenerative changes of the shoulder joint without evidence of any leading cause. The purpose of this study was to investigate the risk profile in young patients suffering from presumably primary GOA.MethodsA consecutive group of 47 patients undergoing primary shoulder arthroplasty for early-onset GOA below the age of 60 years at time of surgery was retrospectively identified and prospectively evaluated. Patients with identifiable cause for GOA (secondary GOA) were excluded. The resulting 32 patients (mean age 52 ± 7 years; 17 male, 15 female) with primary GOA were matched by age (± 3 years) and gender to 32 healthy controls (mean age 53 ± 7 years; 17 male, 15 female). Demographic data and patient-related risk factors were assessed and compared among both groups to identify extrinsic risk factors for primary GOA. Patients were further subdivided into a group with concentric GOA (group A) and a group with eccentric GOA (group B) to perform a subgroup analysis.ResultsPatients had a significantly higher BMI (p = 0.017), were more likely to be smokers (p < 0.001) and to have systematic diseases such as hypertension (p = 0.007) and polyarthritis (p < 0.001) and a higher Shoulder Activity Level (SAL) (p < 0.001) when compared to healthy controls. Furthermore, group B had a significantly higher SAL not only compared to healthy controls but also to group A, including activities such as combat sport (p = 0.048) and weightlifting (p = 0.01).ConclusionsSeveral patient-specific risk factors are associated with primary GOA in the young population, as well as highly shoulder demanding activities in the development of eccentric GOA. Consequently, a subset of young patients with eccentric primary GOA could in reality be secondary due to a muscular imbalance between internal and external rotators caused by improper weight training.Level of evidenceIII, Case–Control study

Osteoarthritis (OA), traditionally viewed as a mechanical wear-and-tear condition, is increasingly recognized as an inflammatory disorder with autoimmune features. Despite its high global prevalence, disease-modifying treatments remain limited. Therapeutic plasma exchange (TPE) offers a novel, mechanistically targeted approach by removing systemic inflammatory mediators, pathogenic autoantibodies, and degradative enzymes such as matrix metalloproteinases. By modulating cytokines like interleukin-1 beta (IL-1β), tumor necrosis factor-alpha (TNF-α), and interleukin-6 (IL-6) and depleting cartilage-directed autoantibodies, TPE may disrupt the inflammatory and immune cascades driving joint degradation. This editorial explores TPE as a potential adjunct therapy in OA, particularly for patients with inflammatory or metabolic phenotypes. While complications such as hypotension, vascular access issues, and transient immunosuppression must be considered, the safety profile of TPE is well-established in other autoimmune conditions. Future clinical trials are urgently needed to validate efficacy, optimize protocols, and identify ideal patient subgroups. If successful, TPE could represent a paradigm shift from symptomatic relief toward disease modification in OA, with the potential to improve long-term outcomes and quality of life.

Purpose Purpose of this study was to evaluate the mid- to long-term outcome after conservatively treated first-time posterior shoulder dislocations and to determine structural defects associated with failure. Methods In this multi-centric retrospective study, 29 shoulders in 28 patients with first-time acute posterior shoulder dislocation (Type A1 or A2 according to the ABC classification) and available cross-sectional imaging were included. Outcome scores as well as radiological and magnetic resonance imaging were obtained at a mean follow-up of 8.3 ± 2.7 years (minimum: 5 years). The association of structural defects with redislocation, need for secondary surgery, and inferior clinical outcomes were analysed. Results Redislocation occurred in six (21%) shoulders and nine shoulders (31%) underwent secondary surgery due to persistent symptoms. The posttraumatic posterior glenohumeral subluxation was higher in the redislocation group compared to the no redislocation group; however, statistical significance was not reached (61.9 ± 12.5% vs. 50.6 ± 6.4%). Furthermore, a higher adapted gamma angle was observed in the failed conservative treatment group versus the conservative treatment group, similarly without statistically significant difference (97.8° ± 7.2°, vs. 93.3° ± 9.7°). The adapted gamma angle was higher than 90° in all patients of failed conservative therapy and the redislocation group. An older age at the time of dislocation showed a significant correlation with better clinical outcomes (SSV: r  = 0.543, p  = 0.02; ROWE: r  = 0.418, p  = 0.035 and WOSI: r  = 0.478, p  = 0.045). Posterior glenohumeral subluxation after trauma correlated with a worse WOSI ( r  = − 0.59,  p  = 0.02) and follow-up posterior glenohumeral decentring ( r  = 0.68, p  = 0.007). The gamma angle ( r  = 0.396, p  = 0.039) and depth of the reverse Hill–Sachs lesion ( r  = 0.437, p  = 0.023) correlated significantly with the grade of osteoarthritis at follow-up. Conclusion Conservative treatment is a viable option in patients with an acute traumatic posterior shoulder dislocation with good outcome after mid- and long-term follow-up especially in patients with centred joint, low gamma angle, and middle or old age. Level of evidence IV.

Background: For high-grade dislocation of the acromioclavicular (AC) joint, surgical treatment is widely recommended. This study aimed to evaluate the clinical and radiological outcomes after arthroscopic-assisted stabilization of acute high-grade AC joint dislocations using a low-profile suture button (LPSB) combined with percutaneous AC cerclage fixation. A secondary objective was to quantify clavicular tunnel widening (cTW) and explore its correlation with clinical and radiological outcomes. Methods: This retrospective study included 45 patients with acute Rockwood type V injuries treated with the LPSB technique and additional AC cerclage. Clinical outcomes were the Constant Score (CS), Subjective Shoulder Value (SSV), Taft Score (TF), AC Joint Instability Score (ACJI), and VAS for pain upon palpation. Radiological assessment included coracoclavicular (CC) distance and percentage deviations compared to the contralateral side, reclassified according to Rockwood, dynamic posterior translation (DPT), cTW measurements, and assessment of ossifications and AC joint osteoarthritis. Results: After 35.3 months, significant improvements were observed in CC distance and percentage deviation. A total of 27.3% were reclassified as Rockwood type III and 2.3% as type V. Initial overreduction persisted in 18.2%. DPT was observed in 34.1% of cases. The mean CS was 89.64, the SSV was 91.1, and the VAS was 0.8. cTW occurred only below the superior button and increased significantly over time, showing a negative correlation with the SSV but no correlation with any radiological outcome parameter. No implant-related revision surgery was reported. Conclusions: Arthroscopic-assisted stabilization of acute high-grade AC joint dislocations using the LPSB technique with AC cerclage fixation provides excellent clinical outcomes and high patient satisfaction, with minimal implant-related complications and no need for revision surgery due to implant issues. Although cTW occurs, its clinical impact appears limited within this procedure.

Background Pathologies of the long head of the biceps (LHB) tendon are frequently seen as concomitant pathologies during arthroscopic surgery for rotator cuff injuries or the labroligamentous complex of the shoulder. Currently, there are two treatment options: Tenotomy is quick and easy to perform with low complications rates, but has limited functional results, especially in demanding patients; tenodesis of the tendon has shown beneficial cosmetic and functional results, but usually requires an implant for tendon-to-bone attachment and, therefore, carries the risk of implant-related complications. The implant-free loop tenodesis (LT) procedure was developed to combine the advantages of both treatment modalities and has shown promising functional and cosmetic results in a prospective pilot study. This study aims to establish the implant-free LT procedure versus arthroscopic anchor tenodesis (AAT) for the treatment of LHB pathologies during shoulder arthroscopy in terms of structural and functional outcome. Methods A national multi-center, two-arm, parallel-group, randomized, controlled, non-inferiority trial will be conducted. Patients are eligible for trial participation if they are at least 18 years of age and present to one of the five enrolling centers with LHB tendon-associated complaints and MRI-confirmed LHB tendinopathy, instability due to SLAP or pulley lesions, or partial rupture. Patients with current or previous shoulder injury that would interfere with post-treatment rehabilitation or study assessment will be excluded from study participation. Participating patients will be randomized 1:1 to receive either LT or AAT and will be followed up for 24 months after surgery. The primary endpoint will be the functional and cosmetic outcome as assessed by the biceps-specific LHB score at 12 months after surgery. Secondary outcomes include assessment of surgery-related complications, overall shoulder and arm function, and structural outcome as evaluated by ultrasound and an additional MRI scan at the final study visit. Discussion The study will evaluate whether the implant-free loop tenodesis procedure is non-inferior to arthroscopic implant-based tenodesis in terms of functional and cosmetic results at 12 months post-treatment. Trial registration Trial was prospectively registered at the German Clinical Trials Register (DRKS) on 12 th June 2024, Registration-ID DRKS00034361, https://drks.de/search/de/trial/DRKS00034361 .

PurposeSeveral studies describe risk factors for primary periprosthetic joint infection (PJI) and general treatment outcome factors like microbe spectrum or patient-specific risk factors. However, these general and patient dependent findings cannot solely explain all cases of infection persistence after a prior septic revision. This study analyzes possible specific and patient independent reasons for failure after revisions for PJI in knee and hip arthroplasty.MethodsIn a prospective analysis all patients were included that were treated: (1) at our department, (2) with a two-stage exchange, (3) between 2013 and 2017, (4) due to an infection persistence after a previous revision for PJI. Possible reasons for infection persistence were identified using a checklist algorithm, based on international guidelines.Results70 patients with infection persistence could be included (44 knee joints, 26 hip joints). The average age was 71 years, the CCI (Charlson Comorbidity Index) 2.8 and the ASA (American Society of Anesthesiologists) score 2.7. In 85% at least one possible reason for patient independent infection persistence could be identified analyzing the previous infection therapy: (1) 50% inadequate therapy concept (n = 35), (2) 33% inadequate surgical debridement (n = 23), (3) 30% inadequate antimicrobial therapy (n = 21), (4) 13% missed external bacterial primary focus (n = 9). After the individual failure analysis, all 70 patients were treated with a two-stage exchange in our department and in 94.9% infection freedom could be achieved (34.3 ± 10.9 months follow-up).ConclusionsIn the majority of failed revisions with subsequent infection persistence at least one possible patient independent failure cause could be identified. The entire previous therapy should be critically reviewed following failing revisions to optimize the outcome of septic revisions. By using a checklist algorithm, high rates of infection freedom were achieved.

Background The importance of several scapulothoracic muscles, including trapezius and serratus anterior, in maintaining physiological scapula kinematics has been highlighted in the past. However, the relationship between the scapula and the latissimus dorsi muscle remains unclear. Our clinical surgical observation is that the latissimus dorsi does not directly attach but rather runs superficial to the inferior angle of the scapula. Based on this observation, we hypothesise that the latissimus dorsi creates a dynamic track on which the scapula glides under the muscle belly during elevation of the arm, creating the latissimus-scapula overlap (LSO). Methods All consecutive patients who had a whole-body computed tomography scan (CT) in case of polytrauma evaluation between 2018 and 2021, with complete depiction of the scapula and latissimus dorsi muscle, were analysed. 150 shoulders in 90 patients with arms up were matched according to their age (within five years), gender, and affected side with 150 shoulders in 88 patients with arms down. Patients with pathologies of the upper extremities or thorax that potentially could alter LSO measurements were excluded. LSO was calculated as a ratio of the measured area of the latissimus dorsi projection on the scapula and the total scapula area. Results The mean age of the 178 patients (48 females; 13 males) was 60 years. The arms-up group showed a significantly higher LSO than the arms-down group (19.9 ± 6.3% vs. 2.7 ± 2.2%; p  < 0.0001). In the arms-up group, approximately one fifth of the scapula was overlapped inferiorly by the muscle belly of the latissimus dorsi, contrary to the almost non-existing LSO in the arms-down group. Conclusion With arms up, humans show a significantly higher LSO in comparison to arms down indicating that the latissimus dorsi indeed creates a dynamic track on which the scapula is forced to travel during abduction of the arm. This finding of increased LSO during the elevation of the arm warrants further consideration of the role of the latissimus dorsi in scapula kinematics and potentially scapular dyskinesis. Level of evidence Level two diagnostic study.