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Background There exists a vast number of surgical treatment options for acromioclavicular (AC) joint injuries, and the current literature has yet to determine an equivocally superior treatment. AC joint repair has a long history and dates back to the beginning of the twentieth century. Main body Since then, over 150 different techniques have been described, covering open and closed techniques. Low grade injuries such as Type I-II according to the modified Rockwood classification should be treated conservatively, while high-grade injuries (types IV-VI) may be indicated for operative treatment. However, controversy exists if operative treatment is superior to nonoperative treatment, especially in grade III injuries, as functional impairment due to scapular dyskinesia or chronic pain remains concerning following non-operative treatment. Patients with a stable AC joint without overriding of the clavicle and without significant scapular dysfunction (Type IIIA) may benefit from non-interventional approaches, in contrast to patients with overriding of the clavicle and therapy-resistant scapular dysfunction (Type IIIB). If these patients are considered non-responders to a conservative approach, an anatomic AC joint reconstruction using a hybrid technique should be considered. In chronic AC joint injuries, surgery is indicated after failed nonoperative treatment of 3 to 6 months. Anatomic AC joint reconstruction techniques along with biologic augmentation (e.g. Hybrid techniques, suture fixation) should be considered for chronic high-grade instabilities, accounting for the lack of intrinsic healing and scar-forming potential of the ligamentous tissue in the chronic setting. However, complication and clinical failure rates remain high, which may be a result of technical failures or persistent horizontal and rotational instability. Conclusion Future research should focus on addressing horizontal and rotational instability, to restore native physiological and biomechanical properties of the AC joint.

Purpose Posterolateral rotatory instability (PLRI) of the elbow occurs from an insufficient lateral collateral ligament complex (LCLC). For subacute LCLC injuries, lateral ulnar collateral ligament (LUCL) internal bracing rather than reconstruction may be a viable option. The purpose of the study was to compare the stabilizing effects of LUCL internal bracing to triceps tendon graft reconstruction in simulated PLRI. Methods Sixteen cadaveric elbows were assigned for either LUCL internal bracing ( n  = 8) or reconstruction with triceps tendon graft ( n  = 8). Specimen were mounted and a valgus rotational torque was applied to the ulna to test posterolateral rotatory stability. Posterolateral rotation was measured at 0°, 30°, 60°, 90° and 120° of elbow flexion. Cyclic loading was performed for 1000 cycles at 90° of elbow flexion. Three conditions were compared in each specimen: intact elbow, LUCL and radial collateral ligament (RCL) transected, and then either LUCL internal bracing or reconstruction with triceps tendon graft. Results Transection of the LUCL and RCL significantly increased posterolateral rotation in all degrees of elbow flexion compared to the intact condition ( P  < 0.05). Both LUCL internal bracing and reconstruction restored posterolateral rotatory stability to the native state between 0° and 120° of elbow flexion, with no significant difference in improvement between groups. Similarly, LUCL internal bracing and reconstruction groups showed no significant difference in posterolateral rotation compared to the intact condition during cyclic loading. Conclusions At time zero, both LUCL internal bracing and reconstruction with triceps tendon graft restored posterolateral rotatory stability. As such, this study supports the use of internal bracing as an adjunct to primary ligament repair in subacute PLRI.

Background The extent of fatty infiltration and rotator cuff (RC) atrophy is crucial for the clinical results after rotator cuff repair (RCR). The purpose of this study was to evaluate changes in fatty infiltration and RC atrophy after revision RCR and to correlate them with functional outcome parameters. Methods Patients who underwent arthroscopic revision RCR for symptomatic recurrent full-thickness tear of the supraspinatus tendon between 2008 and 2014 and were retrospectively reviewed with a minimum follow up of 2 years. Magnetic resonance imaging (MRI) was performed pre- and postoperatively to assess 1) tendon integrity after revision RCR according to Sugaya classification, (2) RC atrophy according to Thomazeau classification, and (3) fatty infiltration according to Fuchs MRI classification. Constant score (CS) and the American Shoulder and Elbow Surgeon (ASES) score were used to correlate functional outcome, tendon integrity, and muscle degeneration. Results 19 patients (17 males and 2 females) with a mean age of 57.5 years (range, 34 to 72) were included into the study at a mean follow-up of 50.3 months (range, 24 – 101). At final evaluation, 9 patients (47%) presented with intact RCR and 10 patients (53%) suffered a re-tear after revision repair. No progress of fatty infiltration was observed postoperatively in the group with intact RC, atrophy progressed in only 1 out of 9 patient (11%). Fatty infiltration progressed in 5/10 patients (50%) and RC atrophy increased in 2/10 patients (20%) within the re-tear group. CS (42.7 ± 17.7 preop, 65.2 ± 20.1 postop) and ASES (47.7 ± 17.2 preop, 75.4 ± 23.7 postop) improved significantly from pre- to postoperatively ( p  < 0.001). A positive correlation between fatty infiltration and RC integrity was detected (r = 0.77, p  < 0.01). No correlation between clinical outcome and tendon integrity or RC atrophy was observed. Conclusion Arthroscopic revision RCR leads to reliable functional outcomes even in case of a recurrent RC retear. An intact RCR maintains the preoperative state of fatty infiltration and muscle atrophy but does not lead to muscle regeneration. Level of evidence Level IV; Therapeutic study.

Background: There is limited and inconsistent evidence pertaining to comparative studies examining functional outcomes after acromioclavicular joint (ACJ) stabilization in either the acute or chronic setting for high-grade injuries. Purpose/Hypothesis: The purpose of the study was to compare functional outcomes of patients undergoing arthroscopically assisted ACJ stabilization for isolated acute or chronic type 5 ACJ injuries. It was hypothesized that patients would achieve similar functional outcomes at midterm follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: Consecutive patients who underwent ACJ stabilization using coracoclavicular (CC) suspensory fixation with an additional acromioclavicular (AC) cerclage for isolated acute or chronic type 5 ACJ injuries from January 2015 to August 2021 and had a minimum follow-up of 2 years were identified and their records analyzed. Chronic ACJ injuries were defined as an interval of ≥3 weeks from injury to surgery according to the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine consensus statement and received an additional biological augmentation using a gracilis autograft. Functional outcome measures included the Constant-Murley (CM), American Shoulder and Elbow Surgeons (ASES), and Nottingham Clavicle (NC) scores as well as the visual analog scale (VAS) score for pain, which were compared between groups at the final follow-up. Results: A total of 82 patients (mean age at surgery, 40.3 ± 12.7 years; 54 acute and 28 chronic injuries) with a mean follow-up of 5.5 ± 2.0 years (range, 2.0-9.9 years) were included in the study. At the final follow-up, patients with acute or chronic injuries showed similar CM (acute: 85.3 ± 13.3; chronic: 85.5 ± 12.0; P = .98), ASES (acute: 94.3 ± 10.1; chronic: 93.5 ± 14.4; P = .69), and NC (acute: 85.6 ± 14.2; chronic: 86.8 ± 14.0; P = .68) scores. Furthermore, there was no difference in VAS score for pain (acute: 1.9 ± 1.1; chronic: 2.0 ± 1.6; P = .47) and postoperative subjective satisfaction with the cosmetic appearance of the ACJ (P = .753). Five patients in the acute group and 2 patients in the chronic group experienced failure and underwent revision surgery (acute: 9.3%; chronic: 7.1%; P = .75). Conclusion: Patients who underwent ACJ stabilization using CC suspensory fixation with an additional AC cerclage for isolated type 5 ACJ injuries in the acute setting achieved similar midterm functional outcomes, satisfaction with the cosmetic appearance of the ACJ, and failure rates to those who underwent delayed surgery with additional biological augmentation using a gracilis autograft ≥3 weeks after injury.

Background: Although short- to mid-term clinical data of patients undergoing arthroscopic capsulolabral revision repair (ACRR) for recurrent anterior shoulder instability are promising, evidence pertaining to long-term functional, sports- and work-related outcomes is scarce. Purpose/Hypothesis: The purpose was to provide prospectively collected long-term functional outcomes, sports activity, and work ability of patients undergoing ACRR for recurrent anterior shoulder instability. It was hypothesized that patients would maintain significant functional improvement, along with sufficient sports activity and work ability, at a minimum follow-up of 20 years. Study Design: Case Series; Level of Evidence 4. Methods: Patients who underwent ACRR between September 1998 and August 2003 and had a minimum follow-up of 20 years were analyzed. Functional outcome measures included the Rowe and Constant-Murley (CM) scores, as well as the visual analog scale (VAS) for pain, which were collected preoperatively, at short-term follow-up (a minimum of 2 years), and at a minimum final follow-up of 20 years. The Single Assessment Numeric Evaluation and Simple Shoulder Test (SST) scores were only collected at the final follow-up. Return to sports and work—including sports and work level and discipline—were evaluated using a custom sports and work ability assessment tool. Results: A total of 29 patients (mean age at surgery, 28.6 ± 9.8 years) were included in the study, with a mean follow-up of 21.1 ± 1.5 years (range, 20-24 years). The rate of recurrent instability was 27.6% (n = 8), while 10.3% (n = 3) underwent revision surgery. In those without recurrent instability, the Rowe and CM scores showed significant improvements at both the minimum 2-year and minimum 20-year follow-ups, compared with preoperatively (P < .001, respectively). Neither the CM (87.9 ± 8 vs 83.4 ± 11; P = .055) nor the Rowe (86.7 ± 18.7 vs 86.9 ± 15.8; P = .958) score differed significantly between the minimum 2-year and 20-year follow-ups. At the minimum 20-year follow-up, the VAS pain score was 0.6 ± 1.6 at rest, was 1.1 ± 1.4 during exercise, and the SST (%) was 89.3 ± 13.5. The amount of activity (P = .022) and the subjective shoulder mobility (P = .021) significantly declined from the minimum 2-year to the 20-year follow-up. Conclusion: Patients undergoing ACRR for recurrent anterior shoulder instability had a recurrent instability rate of 27.6% at a minimum 20-year follow-up. Those patients without recurrence maintained significant improvements in functional outcomes and achieved a favorable postoperative sport activity and work ability.

Background The purpose of this study was to perform a derotational osteotomy at the distal femur, as is done in cases of patellofemoral instability, and demonstrate the predictability of three-dimensional (3D) changes on axes in a cadaveric model by the use of a new mathematical approach. Methods Ten human cadaveric femurs, with increased antetorsion, underwent a visually observed derotational osteotomy at the distal femur by 20°, as is commonly done in clinics. For surgery, a single cut osteotomy with a defined cutting angle was calculated and given using a simple 3D-printed cutting guide per specimen, based on a newly-created trigonometrical model. To simulate post-operative straight frontal alignment in a normal range, a goal for the mechanical lateral distal femur angle (mLDFA) was set to 87.0° for five specimens (87-goal group) and 90.0° for five specimens (90-goal group). Specimens underwent pre- and post-operative radiographic analysis with CT scan for torsion and frontal plane x-ray for alignment measurements of mLDFA and anatomical mechanical angle (AMA). Results Performed derotation showed a mean of 19.69° ±1.08°SD (95% CI: 18.91° to 20.47°). Regarding frontal alignment, a mean mLDFA of 86.9° ±0.66°SD (87-goal-group) and 90.42° ±0.25° SD (90-goal group), was observed ( p  = 0.008). Overall, the mean difference between intended mLDFA-goal and post-operatively achieved mLDFA was 0.14° ±0.56° SD (95% CI: -0.26° to 0.54°). Conclusion A preoperative calculated angle for single cut derotational osteotomy at the distal femur leads to a clinically precise post-operative result on torsion and frontal alignment when using this approach.

Background: Seminal classifications of degenerative arthritis of the shoulder (DAS) describe either cuff tear arthropathy in the coronal plane or primary osteoarthritis in the cross-sectional plane. None consider a biplanar eccentricity. Purpose/Hypothesis: The purpose of this study was to investigate humeroscapular alignment (HSA) of patients with DAS in both the anteroposterior (A-P) and superoinferior (S-I) planes on computed tomography (CT) after 3-dimensional (3D) reconstruction and develop a classification based on biplanar HSA in 9 quadrants. It was hypothesized that biplanar eccentricity would occur frequently. Study Design: Cross-sectional study; Level of evidence, 3. Methods: The authors analyzed 130 CT scans of patients who had undergone shoulder arthroplasty. The glenoid center, trigonum, and inferior angle of the scapula were aligned in a single plane using 3D reconstruction software. Subluxation of the HSA was measured as the distance from the center of rotation of the humeral head to the scapular axis (line from trigonum through glenoid center) and was expressed as a percentage of the radius of the humeral head in both the A-P and the S-I directions. HSA was described in terms of A-P alignment first (posterior/central/anterior), then S-I alignment (superior/central/inferior), for a total of 9 different alignment combinations. Additionally, glenoid erosion was graded 1-3. Results: Subluxation of the HSA was 74.1% posterior to 23.5% anterior in the A-P direction and 17.2% inferior to 68.6% superior in the S-I direction. A central HSA was calculated as between 20% posterior to 5% anterior (A-P) and 5% inferior to 20% superior (S-I), after a graphical analysis. Posterior subluxation >60% of the radius was labeled as extraposterior, and static acetabularization was labeled as extrasuperior. Overall, 21 patients had central-central, 40 centrosuperior, and 1 centroinferior alignment. Of 60 shoulders with posterior subluxation, alignment was posterocentral in 31, posterosuperior in 25, and posteroinferior in 5. There were 3 patients with anterocentral and 4 anterosuperior subluxation; in addition, 4 cases with extraposterior and 17 with extrasuperior subluxation were identified. Conclusion: There was a high prevalence of biplanar eccentricity in DAS. The 3D classification system using combined HSA and glenoid erosion can be applied to describe DAS comprehensively.

Objectives: The purpose of this study was to evaluate the clinical and functional outcomes following arthroscopic Bankart repair for the treatment of anterior shoulder instability at long-term follow-up. It was hypothesized that arthroscopic Bankart repair would lead to an excellent clinical and functional outcome with a low rate of instability recurrence. Methods: Patients who underwent arthroscopic Bankart repair between October 1996 and April 2002 at a single institution were included. Patient-reported outcome measures (American Shoulder and Elbow Surgeons [ASES] Score, Constant-Murley Score [CMS], Visual Analog Scale for pain [VAS-P] and instability [VAS-I] at rest and during activity, satisfaction with the postoperative result [1-10 scale]), sporting ability as well as the rate of redislocation and reinstability (in patients without redislocations) were evaluated after a minimum follow-up of 20 years. Results: In total, 71 patients (78.9% male) were included in this study at a median follow-up of 23 (interquartile range 22-25) years. At the time of surgery, patients were 28.3 ± SD 8.6 years old. Arthroscopic Bankart repair was performed in 19.1% of patients following primary anterior shoulder dislocation and in 80.9% of patients for recurrent anterior shoulder instability. Shoulder function was good to excellent at follow-up (ASES Score: 95.0 [83.0-98.0], CMS: 81.1 ± 15.5). The median pain and instability levels were low both at rest (VAS-P: 1.0 [0-1.0], VAS-I: 0 [0-1.0] and during activity (VAS-P: 1.0 [0-2.0], VAS-I: 2.0 [1.0-4.0]). Overall satisfaction with the postoperative result was high (9.0 [8.0-10]). Postoperative redislocations occurred in 15.4% of patients. Subjective residual instability was reported in 18.2% of the patients that did not suffer a shoulder redislocation, resulting in an overall rate of any instability of 30.8%. Postoperative sporting ability improved in 46.8%, declined in 12.9% and remained unchanged in 40.3% of patients. Conclusions: Twenty years postoperatively, arthroscopic Bankart repair was associated with good to excellent shoulder function, low pain levels and high patient satisfaction. About 1 in 3 patients, however, suffered from shoulder instability of whom approximately half reported a redislocation postoperatively.

Background: Derotational osteotomy of the distal femur allows the anatomic treatment of patellofemoral maltracking due to increased femoral antetorsion. However, such rotational osteotomy procedures have a high potential of intended/unintended changes of frontal alignment. Purpose/Hypothesis: The purpose of this study was to perform derotational osteotomy of the distal femur and to demonstrate the utility of a novel trigonometric approach to address 3-dimensional (3D) changes on 2-dimensional imaging (axial computed tomography [CT] and frontal-plane radiography). The hypothesis was that 1-step single-cut osteotomy can simultaneously correct torsion and frontal alignment based on preoperatively calculated cutting angles. Study Design: Controlled laboratory study. Methods: Eight human cadaveric whole legs (4 lower limb torsos) underwent derotational osteotomy of the distal femur of 20°. A straight leg axis, determined as a mechanical femorotibial angle (mFTA) of 0°, was chosen as a goal for postoperative frontal alignment. The inclination of the cutting angle from the lateral view was calculated individually for each cadaveric leg and was represented by a simple 3D-printed cutting guide for surgery. Specimens underwent CT for the measurement of torsion, while the frontal leg axis was determined on an upright radiograph preoperatively and postoperatively. Preoperative and postoperative angles were compared with the mathematical prediction model. Results: The preoperative mFTA ranged from –3.9° (valgus) to +3.4° (varus) (mean, –0.2° ± 2.6°). A postoperative mean mFTA of 0.37° ± 0.69° (95% CI, –0.22° to 0.95°) was achieved (P = .01). Derotation showed a mean of 19.1° ± 2.1° (95% CI, 17.3°-20.8°). The oblique cutting plane for the correction of valgus legs showed a mean of 5.9° ± 6.8° and, for the correction of varus legs, a mean of –10.0° ± 4.5° projected on the perpendicular plane to the virtual anatomic shaft axis from the sagittal view. Conclusion: Single-cut distal femoral osteotomy can be performed to simultaneously address rotational as well as frontal alignment using a preoperatively defined oblique cut, as determined by the presented reproducible calculation model. Clinical Relevance: This study adds important knowledge to the technique of derotational osteotomy. This approach provides an individual, oblique single cut for the correction of torsion and frontal axis within a clinically insignificant margin. Simplified tables for calculation and a surgical reference make this model reproducible and safe.

Background: Despite growing evidence on the role of the posterior ulnar collateral ligament (pUCL) in elbow stability, current ligament bracing techniques are mainly focused on the anterior ulnar collateral ligament (aUCL). A dual-bracing technique combines the repair of the pUCL and aUCL with a suture augmentation of both bundles. Purpose: To biomechanically assess a dual-bracing approach addressing aUCL and pUCL for humeral-sided complete UCL lesions to restore medial elbow laxity without overconstraining. Study Design: Controlled laboratory study. Methods: A total of 21 unpaired human elbows (11 right, 10 left; 57.19 ± 11.7 years) were randomized into 3 groups to compare dual bracing with aUCL suture augmentation and aUCL graft reconstruction. Laxity testing was performed with 25 N applied 12 cm distal to the elbow joint for 30 seconds at randomized flexion angles (0°, 30°, 60°, 90°, and 120°) for the native condition and then for each surgical technique. A calibrated motion capture system was used for assessment, allowing the 3-dimensional displacement during the complete valgus stress cycle between the optical trackers to be quantified as joint gap and laxity. The repaired constructs were then cyclically tested through a materials testing machine starting with 20 N for 200 cycles at a rate of 0.5 Hz. The load was increased stepwise by 10 N for 200 cycles until displacement reached 5.0 mm or complete failure occurred. Results: Dual bracing and aUCL bracing resulted in significantly (P = .045) less joint gapping at 120° of flexion compared with aUCL reconstruction. No significant differences in valgus laxity were found among the surgical techniques. Within each technique, there were no significant differences between the native and the postoperative state in valgus laxity and joint gapping. No significant differences between the techniques were observed in cycles to failure and failure load. Conclusion: Dual bracing restored native valgus joint laxity and medial joint gapping without overconstraining and provided similar primary stability regarding failure outcomes as established techniques. Furthermore, it was able to restore joint gapping in 120° of flexion significantly better than aUCL reconstruction. Clinical Relevance: This study provides biomechanical data on the dual-bracing approach that may help surgeons to consider this new method of addressing acute humeral UCL lesions.