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PubMed1997

[MRI arthrography--improved diagnosis of shoulder joint instability].

In a prospective study, we examined 34 patients with shoulder instabilities and 5 patients with unclear chronic shoulder pain (4 females, 35 males; 18-56 years of age, median 28 years) by CT arthrography and MRT arthrography from August 1994 through December 1995. No complications were seen when gadolinium-DPTA was applied intra-articularly. Twenty-three patients were followed up by operation and/or arthroscopy; 20 patients underwent a modified, open Bankart operation. In this paper, we present a new classification for damage of the anterior capsule and labrum. MRT arthrography showed better results in judging the anterior labrum and in determining the degree of damage to the labrum (sensitivity, specificity and accuracy 100%) in comparison with CT arthrography (sensitivity 90%, specificity 100%, accuracy 91%). Furthermore, MRT arthrography gave clearer results than CT arthrography regarding SLAP and cartilage lesions. Thus, MRT arthrography has proved to be a very exact method for diagnosing shoulder instabilities and is superior to CT arthrography in diagnostic accuracy.

Adolescent↗
PubMed1997

[Open Bankart repair using suture anchors in posttraumatic shoulder instability: 2 to 5-year results].

The aim of this study was to evaluate the results after open Bankart repair using suture anchors in patients with recurrent posttraumatic anterior shoulder instability. Some 32 patients were prospectively observed for a mean of 40 months (24-60) after stabilization. The mean age at the time of operation was 29.7 years. All patients were postoperatively immobilized in a sling for 3 weeks. According to the criteria of Rowe, 29 patients (90.6%) had good or excellent results. Two patients (6.3%) developed recurrent instability 6-24 months postoperatively; 93.7% were not or only slights limited in sports activities. Bankart repair is an excellent treatment for recurrent posttraumatic anterior shoulder instability. The use of suture anchors is an appropriate way of reattaching the capsuloligamentous complex to the glenoid to restore stability to an unstable joint.

Adult↗
PubMed2000

[Mid-term outcome of postoperative infections of the shoulder].

Between 1 January 1986 and 31 December 1997, in the traumatology department of Nuremberg hospital, a total of 46 patients with postoperative infections of the shoulder were treated. The primary surgical procedure was carried out for various reasons. The diagnosis of infection was found on clinical parameters such as pain, redness, and swelling, in combination with laboratory parameters and diagnostic aspiration of joint fluid. The period between operation and infection ranged between 4 days and 9 months. The main question was whether a local infection or an infection of the glenohumeral joint, called empyema, was involved. Some cases required diagnostic aspiration. Macroscopic inspection of the fluid was helpful, as was cell counting and analysis of fluid pH [14]. The fluid was given to a gram preparation. In case of infection of the joint, diagnostic arthroscopy was performed with a saline lavage (10-15 l). Local synovectomy was carried out when local synovitis was found. Similar to the therapy of the knee, antibiotic collagen (Sulmycin-Implant) (no PMMA chains as former) was applied. We compared patients who were operated as usual, i.e., by great incision and open wound-drain (group 1, 21 patients), with patients who were operated arthroscopically assisted (group 2, 25 patients). We saw an earlier reconvalescence in the second group. Of the 46 patients, 25 were followed-up for an average of 4 years. The results were rated according to the Constant score. The mean total score of 25 patients was 61 points (range 43-78 points). Positive intra-articular bacterial culture was an important prognostic factor; inspite of an arthroscopical procedure, results were not as good as without joint infection. Generally, the arthroscopic procedure with application of the Sulmycin Implant leads to better results than the open procedure with application of PMMA chains.

Arthroscopy↗
PubMed2004

[Postoperative imaging of the shoulder].

Correct interpretation of imaging findings in the postoperative shoulder is impaired by surgical distortion of normal anatomy and possible artifacts. Advanced postoperative imaging of the shoulder in addition to the selection of the best suited modality necessitates familiarity with the surgical procedure that has been performed and its consecutive morphological changes. This article reviews the most common arthroscopic and open techniques used for treatment of shoulder instability, lesions of the superior labral-bicipital complex, primary impingement, and rotator cuff tears, their typical postoperative imaging findings, as well as the diagnostic performance of cross sectional imaging techniques in the detection of recurrent lesions and complications.

Arthrography↗
PubMed2004

[New developments for the surgical treatment of shoulder problems].

Tremendous advancement has been made in the surgical treatment of the shoulder within the last years. Arthroscopic techniques for treatment of rotator cuff lesions, instability problems and biceps tendon lesions are today established because of significant improvement of instruments, suture materials and anchor techniques. The 4th generation of shoulder prosthesis systems guarantee today anatomical and biomechanical advantages with significant functional improvement for the patient.

Arthroplasty, Replacement↗
PubMed2004

[Shoulder instability].

Shoulder instability is a common clinical feature leading to recurrent pain and limited range of motion within the glenohumeral joint. Instability can be due a single traumatic event, general joint laxity or repeated episodes of microtrauma. Differentiation between traumatic and atraumatic forms of shoulder instability requires careful history and a systemic clinical examination. Shoulder laxity has to be differentiated from true instability followed by the clinical assessment of direction and degree of glenohumeral translation. Conventional radiography and CT are used for the diagnosis of bony lesions. MR imaging and MR arthrography help in the detection of soft tissue affection, especially of the glenoid labrum and the capsuloligamentous complex. The most common lesion involving the labrum is the anterior labral tear, associated with capsuloperiostal stripping (Bankart lesion). A number of variants of the Bankart lesion have been described, such as ALPSA, SLAP or HAGL lesions. The purpose of this review is to highlight different forms of shoulder instability and its associated radiological findings with a focus on MR imaging.

Arthrography↗
PubMed1996

[Diagnostic imaging of instability of the shoulder joint].

The diagnosis of glenohumeral instability is based on the patient's history and physical examination. The main objective in using imaging techniques is to define the type and extent of the underlying pathology for therapeutic planning. Plain radiography is the initial step in the diagnostic procedure but can miss typical lesions of the glenohumeral joint structures. CT arthrography and MR imaging offer great sensitivity and accuracy for the detection of traumatic abnormalities of the labral-capsular complex, fractures of the glenoid rim and Hill-Sachs lesions. The advantages and pitfalls of both imaging techniques are discussed.

Chronic Disease↗
PubMed1996

[Ultrasound diagnosis of the shoulder].

Sonography of the shoulder joint is a well-established technique in the hands of the experienced examiner, when using a standardized protocol. It has proved invaluable in assessing pathological soft tissue changes, especially after trauma. The static evaluation of anatomy and dynamic assessment of function are especially helpful in both preoperative staging and postoperative follow-up. The normal anatomy, examination techniques, including our own variations, and pathological conditions are discussed. The findings and various classifications of impingement syndrome, rotator cuff injuries, biceps tendon lesions and inflammatory changes are examined. Review of the major articles in the literature shows excellent correlation with our results, the overall sensitivity in the case of rotator cuff lesions being over 90%. A well-performed ultrasound examination in most cases obviates the need for the more invasive arthroscopy and the more cumbersome and expensive MRI examinations.

Adolescent↗
PubMed2002

[Ultrasound diagnosis in shoulder trauma].

In cases of injuries to the shoulder region, ultrasonography is an ideal supplement to clinical and radiologic examination, including dynamic functional evaluation. The advantages of the method in children and adults are mainly the reduction of conventional radiographs and thus a minimum exposure to radiation. Despite the growing experience of clinicians and the development of high-resolution sonographic technology, primary conventional radiology cannot be dispensed with. Moreover, sonographic examination is rather time-consuming. Evaluation of the subacromial space and the glenohumeral joint itself is impossible in adults, and diagnosis of lesions to the labrum and the articular capsule requires a great deal of experience on the part of the clinician. Ultrasonography has gained increasing importance in the evaluation and follow-up of shoulder trauma in adults and children.

Adult↗
PubMed2003

[Open versus arthroscopic shoulder stabilization. An analysis of the treatment costs].

In this study the total costs of clinical open and arthroscopic anterior shoulder stabilization were evaluated, analyzed and compared. From 1988 to 1998 147 patients underwent open (Bankart) or arthroscopic (ASK) anterior shoulder stabilization. We randomized two groups of 30 patients for each method (Bankart: 25 male, 5 female, 29 years of age; ASK: 25 male, 5 female, 26 years of age) and evaluated the costs of their clinical treatment. The total cost was significantly ( p<0.05, Mann-Whitney U-Test) higher for the open (5639 euro) than for the arthroscopic (4601 euro) therapy. There was a significant difference between the groups for the average cost of surgery (Bankart: 2741 euro; ASK: 2315 euro, p<0.05) and the average postoperative treatment cost (Bankart: 2202 euro; ASK: 1630 euro, p<0.05) whereas the average preoperative treatment cost was not significantly different (Bankart: 669 euro, ASK: 657 euro). The staff costs for the surgical procedure (Bankart: 1800 euro (32%), ASK: 1319 euro (29%)) and the postoperative staff costs of the nurses (Bankart: 1271 euro (23%), ASK: 997 euro (22%)) represented the greatest parts of the total costs. The average duration of the clinical treatment was 15.8 days for the open- and 12,4 days for the arthroscopic group.

Adult↗
PubMed2003

[Anatomy of the superior labrum complex of the shoulder].

The outstanding progress achieved in MRI and arthroscopic techniques has forced orthopedic surgeons to consider the anatomy of the shoulder joint in detail. The superior labrum complex shows a broad range of variations, which is the reason for some difficulties regarding diagnostic conclusions as well as therapeutic considerations. In particular, the differentiation between the normal and pathological adherence of the labrum is a serious clinical problem. The glenoid labrum consists of circularly arranged collagenous fibers attached to the osseous margin of the glenoid by a fibrocartilaginous transitional zone. The cranial part of the labrum is more compact than the caudal one. It is also connected to the joint capsule and the integrated ligaments. Most of the fibers of the long head of the biceps tendon insert at the supraglenoid tubercle, only some of them continue in the fibrous ring. So-called SLAP lesions have to be differentiated from variations. In up to 18% of the patients normal clefts can be seen, e. g., sublabral holes, and in less than 6% other rare variations, e. g., the so-called Buford complex.

Arthroscopy↗
PubMed2003

[Anatomy of the glenoid labrum].

Most instabilities or pain syndromes are associated with injuries or morphologic changes in the glenoid labrum complex or long head of the biceps tendon origin. The first anatomic descriptions go back to Fick in 1910 and since then many authors have described the anatomy of these structures. It was Snyder who introduced the term SLAP lesions, classifying superior, anterior, posterior labrum changes into four grades. It is still unclear whether all of the described and arthroscopically observed changes are due to a post-traumatic, acquired lesion or whether anatomic variations can be present as well. In order to elucidate this problem, 36 cadaver shoulder joints were inspected macroscopically and sectioned for microscopic evaluation. Here the glenoid could be divided into an superior and an anterior- superior area demonstrating a wide variety of morphologic labral glenoid changes, while the dorsal and inferior sectors of the glenoid showed a relatively uniform anatomy of a firm labrum-glenoid bond. Four types of biceps tendon attachments could be identified similar to the description given by Vangsness. In addition, a variety of anterior-superior changes could be found. The sublabral hole as described by Esch in the clinical setting was found to be a physiologic variant. Precise knowledge of the anatomic morphology of the normal glenoid in its variations seems to be necessary to understand variants and allow for distinguishing between physiologic anatomic variants and pathoanatomic changes in imaging and the clinical setting.

Aged↗
PubMed2003

[MR imaging of variants of the superior labral-bicipital complex and SLAP lesions].

In the detection of SLAP (superior labral anterior to posterior) lesions of the shoulder MR arthrography shows a significantly higher sensitivity compared with conventional MR techniques and therefore, represents the method of choice in diagnostic imaging of the superior labral-bicipital complex. On the basis of morphological criteria it mostly allows distinction of traumatic lesions and anatomic variants of the superior labrum and the biceps anchor as well as classification of detected SLAP lesions (types 1-4 according to Snyder). However, the differentiation of a SLAP type 2 lesion and a sublabral recess can be very difficult, even if all distinction criteria are considered.

Cartilage, Articular↗
PubMed2003

[Biomechanical investigations for the development of a SLAP-II-lesion].

The superior labral-biceps-tendon-complex forms an anatomical and functional unit and combines static and dynamic elements of shoulder stability. At present, only theoretical hypotheses exist on the etiology of the microtraumatic SLAP-II-lesion. To gain further insight into this, an instrument was developed to simulate throwing motions such as the late-cocking/early acceleration phase as well as deceleration/follow-through. Sixteen freshly frozen shoulder specimens were tested, varying the loads on the biceps tendon (25 N, 50 N, 100 N) and the compression of the humeral head against the glenoid (25 N, 50 N, 80 N). Each shoulder had to run through a certain number of cycles during the particular phase of throwing. The tests were stopped after a SLAP-II-lesion was observed, or after a limit of 15,000 cycles. Every 1,000 cycles the results of the tests were checked arthroscopically. A SLAP-II-lesion developed in only 10% of the specimens during the acceleration/ late cocking phase whereas in the deceleration/ follow-through phase 83% developed such a lesion. According to our results, the deceleration/follow-through of the throwing motion seems to be responsible for creating microtraumatic SLAP-II-lesions. One reason is the loss of the centering function of the long head of the biceps tendon during total internal rotation, another is the increased posterosuperior translation of the humeral head in this position, which leads to a non-physiological contact, creating lesions in this area due to the large sheering forces.

Acceleration↗
PubMed2003

[Superior labrum-biceps anchor complex].

The focus in overhead sport injuries of the shoulder has been directed on lesions of the superior labrum-biceps complex during the last few years. This is due to improved imaging modalities as well as a better understanding of the anatomy and biomechanics. Arthroscopy is capable of diagnosing and treating these lesions. The anatomy, biomechanics, and operative treatment strategies and techniques are described in detail. The superior labrum anterior-posterior (SLAP) lesion is found in young active overhead athletes. Based on their classification and concomitant lesions, the unstable SLAP lesions (types II and IV) have to be repaired in order to restore stability to the superior labrum-biceps complex for stabilizing the glenohumeral joint. According to our own results and after review of the current literature, SLAP repair yields good results in overhead athletes enabling them to return to pain-free participation in their sport.

Adult↗
PubMed2003

[SLAP lesions as a cause of posterior instability].

SLAP lesions disrupt the perilabral architecture, but so far there have been no reports about posterior instability due to SLAP lesions. In a prospective study of 30 patients with recurrent posterior instability, we found SLAP lesions as a reason for instability in three cases. The purpose of this study is to point out that SLAP lesions can be a cause of posterior instability. Thirty patients with clinical posterior shoulder instability underwent diagnostic arthroscopy before operative stabilization procedures, three of whom (three males, aged 29-51 years) showed a SLAP lesion (once case each of types II, III, and IV) as a cause of posterior instability. All three patients had a history of a fall on the outstretched arm. All patients underwent arthroscopic refixation of the labrum. After arthroscopic refixation of the SLAP lesions, two patients were completely stable (SLAP II and III), whereas one patient (SLAP IV) reported microinstability during overhead activity but complete stability during activity of daily living. The same patient complained about moderate pain in extreme external-flexion rotation with slightly reduced range of motion in external-flexion position. All other patients were free of pain and showed free range of motion. Our results demonstrate that SLAP lesions can be a cause for posterior shoulder instability. In our cases, posterior shoulder instability caused by SLAP lesions was successfully treated by arthroscopic refixation of the torn biceps anchor. When treating posterior shoulder instability, SLAP lesions should be taken into account.

Adult↗
PubMed2003

[Follow-up treatment with physiotherapy after arthroscopic reconstruction in SLAP lesions].

An appropriate physiotherapeutic treatment program complements an optimal operative result. In the instance of SLAP lesions, a differentiated therapy is only possible on consultation with the surgeon. A detailed treatment design allows optimal guidance of the patient to his or her personal goal. Important treatment elements include the optimization of the ability of the humerus head to centralize and the proprioception of the shoulder joint, as well as reinstatement of strength and endurance, especially of the rotator cuff.

Aftercare↗