Shoulder pathologies in CrossFit: a magnetic resonance imaging study of 51 cases

BACKGROUND

Recent scientific work shows that the most common injuries in CrossFit© occur in the shoulder joint. This paper aims to provide a review of shoulder pathologies in a young CrossFit© cohort via MRI and clinical examination.

METHODS

A survey was conducted in 13 CrossFit "boxes" in Germany, in which athletes with recurrent shoulder pain could report for a clinical examination and MRI diagnostic. Fifty-one CrossFit athletes with chronic shoulder pain agreed to participate in the study and were then examined physically and by MRI.

RESULTS

Fifty-one active CrossFit athletes aged 21-45 years (mean 33.7 years, 35 male and 16 female) were recruited. The most frequently detected pathologies were partial lesions of the supraspinatus tendon (N.=25; 49%) and labral lesions (N.=11; 21.6%). The findings also identified partial lesions of the subscapularis tendon (N.=9; 17.6%), pulley lesions (N.=9; 17.6%), and partial lesions of the infraspinatus muscle (N.=2; 3.9%).

CONCLUSIONS

These data demonstrate the need for a specific focus on particular shoulder injuries in CrossFit. Knowledge about the type of shoulder pathologies caused by CrossFit training allows for training-specific adaptations with regard to prevention, as well as a more targeted, sport-specific therapy. This study is the first in the literature to present on structural changes in the shoulders of active CrossFit athletes.

Effects on gait kinematics, pedobarography, functional and subjective results after isolated chopart injury

BACKGROUND

This study analysed changes in gait and pedobarography and subjective and functional outcomes after isolated Chopart joint injury.

METHODS

The results of 14 patients were reviewed. Kinematic 3D gait analysis, comparative bilateral electromyography (EMG) and pedobarography were performed.

RESULTS

On the injured side, the 3D gait analysis showed a significantly increased internal rotation and decreased external rotation of the hip and significantly decreased adduction and decreased range of motion (ROM) for the ankle. On the healthy side, the pedobarography revealed a significantly increased mean force in the forefoot, an increased peak maximum force and an increased maximum pressure in the metatarsal. When standing, significantly more weight was placed on the healthy side. The EMG measurements showed no significant differences between the healthy and injured legs.

CONCLUSIONS

After isolated Chopart injuries, significant changes in gait and pedobarography can be seen over the long term.

The Impact of the SARS-COVID-19 Lockdowns on the Subjectively Perceived Performance Level of Amateur Athletes after Returning to the Gyms

Since December 2019, few issues have garnered as much global attention as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-19). The imposed lockdowns in 2020/21, which led to the closure of all gyms, barred people from participating in their favourite sports activities. This study explores athletes' self-evaluations of their performance levels upon return to training facilities post-reopening. Data were collected in May 2021, after the end of the second lockdown, using a national online questionnaire. The study recorded 20 demographic and training-specific parameters to discern the factors influencing self-perceived performance upon resuming gym activities after the 2020/2021 lockdown. A total of 1378 respondents participated in the study. Of the total number of participants, 27.5% (365) reported regaining 100% of their original performance level after reopening their studios, a proportion that comprised 212 males, 150 females, and 3 individuals of unspecified gender. Additionally, 35.7% (474) estimated their performance level to be up to 75%, followed by 30% (398) recording their performance level at 50%, and a minority of 6.8% (90) determining their performance level to be up to 25%. Exercise intensity prior to lockdown, training experience, sex, and concurrent practice of another sport significantly influenced the athletes' self-assessment of their current fitness levels (p > 0.001, p > 0.001, p > 0.001, and 0.006, respectively). We need to understand the factors that shape self-perception, especially in case of another lockdown, in order to provide preventive assistance concerning mental and physical well-being. Positive influences on self-perception include prior athletic experience, intensive training before the lockdown, and continued participation in sports throughout the lockdown. Younger age is also favourable, but this may not necessarily reflect the benefits of youth; rather, it could indicate the current lack of accessible online sports activities for older individuals. Women, however, might have a less favourable perception of their own athletic performance.

Popular Gym Fitness Sport: An Analysis of 1387 Recreational Athletes Regarding Prone to Pain Exercises and the Corresponding Localisations

BACKGROUND

Recreational fitness sports are popular worldwide and rank first among organised sports. This study aims to bridge a knowledge gap by examining which exercises are most prone to causing pain symptoms, as a possible precursor for injury, and analysing the body regions that are most frequently affected.

METHODS

Using an online questionnaire, 20 demographic and training-specific items and 49 sport-specific exercises were recorded. Frequent exercises as well as the incidence and distribution of pain symptoms that the athletes experienced during or in relation to their training were evaluated.

RESULTS

The study assessed common exercises and documented the frequency and distribution of pain symptoms experienced by athletes during or in relation to their training. A total of 1387 respondents were included in this study. Of these, 732 (53.1%) experienced pain during their fitness training, with 333 (24.2%) being female and 397 (22.3%) being male. The method of creating a training plan showed a significant influence (p < 0.001): athletes who devised their own plans reported pain or instability more frequently than those in the comparison groups. Guided exercises on machines resulted in the lowest frequency of pain (11.54%), while exercises with free weights were associated with the highest pain rate among respondents (19.94%). Specifically, exercises such as the back squat, deadlift, bench press, and triceps dips were identified as the exercises most commonly associated with pain. The most frequently reported pain region was the shoulder, followed by the lower back and knees.

CONCLUSION

The findings reveal a significant number of unreported pain symptoms. The disparity between rigorous training volumes and the absence of professional care frequently leads to injuries and pain. It is incumbent upon sports medicine to investigate the root causes of these complaints (pain or instability) to implement preventive measures against potential injuries.

Factors influencing choice of treatment for proximal humeral fractures elaborated in a Delphi consensus process

INTRODUCTION

Hitherto, the decision-making process for treatment of proximal humerus fractures (PHF) remains controversial, with no established or commonly used treatment regimens. Identifying fracture- and patient-related factors that influence treatment decisions is crucial for the development of such treatment algorithms. The objective of this study was to define a Delphi consensus of clinically relevant fracture- and patient-related factors of PHF for clinical application and scientific research.

METHODS

An online survey was conducted among an international panel of preselected experienced shoulder surgeons. An evidence-based list of fracture-related and patient-related factors affecting treatment outcome after PHF was generated and reviewed by the members of the committee through online surveys. The proposed factors were revised for definitions, and suggestions from the first round mentioned in the free text were included as possible factors in the second round of surveys. Consensus was defined as having at least a two-thirds majority agreement.

RESULTS

The Delphi consensus panel consisted of 18 shoulder surgeons who completed 2 rounds of online surveys. There was an agreement of more than two-thirds of the panel for three fracture-related factors affecting treatment decision in the case of PHF: head-split fracture, dislocated tuberosities, and fracture dislocation. Of all patient-related factors, a two-thirds consensus was reached for two factors: age and rotator cuff tear arthropathy.

CONCLUSION

This study successfully conducted a Delphi consensus on factors influencing decision-making in the treatment of proximal humeral fractures. The documented factors will be useful for clinical evaluation and scientific validation in future studies.

The arthroscopic treatment of anterior shoulder instability with glenoid bone loss shows similar clinical results after Latarjet procedure and iliac crest autograft transfer

PURPOSE

Recurrent anterior shoulder instability caused by critical bone loss of the glenoid is a challenging condition for shoulder surgeons. The purpose of this prospective multicenter trial was to compare the arthroscopic transfer of the coracoid process (Latarjet procedure) with the arthroscopic reconstruction of the glenoid using iliac crest autografts.

METHODS

A prospective multi-center trial was performed in nine orthopaedic centres in Austria, Germany and Switzerland between July 2015 and August 2021. Patients were prospectively enrolled and received either an arthroscopic Latarjet procedure or an arthroscopic iliac crest graft transfer. Standardized follow-up after 6 months and mimimum 24 months included range of motion, Western Ontario stability index (WOSI), Rowe score and subjective shoulder value (SSV). All complications were recorded.

RESULTS

177 patients (group Latarjet procedure: n = 110, group iliac crest graft: n = 67) were included in the study. WOSI (n.s.), SSV (n.s.) and Rowe score (n.s.) showed no difference at final follow-up. 10 complications were seen in group Latarjet procedure and 5 in group iliac crest graft; the frequency of complications did not differ between the two groups (n.s.).

CONCLUSION

The arthrosopic Latarjet procedure and arthroscopic iliac crest graft transfer lead to comparable results regarding clinical scores, frequency of recurrent dislocations and complication rates.

LEVEL OF EVIDENCE

Level II.

Monteggia fractures and Monteggia-like-lesions: a systematic review

Monteggia injuries are rare, but severe injuries of the elbow including various injury patterns. Treatment of these injuries is still topic of debate and strategies differ widely. In this systematic review on Monteggia injuries in adults, we aimed to clarify the incidence of different injury patterns within Monteggia injuries, investigate the main reasons leading to revision surgery and explore which surgical treatments should be favored to achieve satisfactory clinical results.We initially identified 182 publications and ultimately included 17 retrospective studies comprising 651 cases. All patients were classified using the Bado classification, leading to 30.5% Bado type I fractures, 60.4% type II fractures, 5.1% type III and 3.1% type IV fractures. Mean revision rate was 23%. Ulna non-union (28%) and limited range-of-motion (22%) are the main reasons for revision surgery. Meta-analysis shows a trend toward the use of locking plates for ulna fixation which may lead to less revision surgery and fewer ulna non-unions. Further biomechanical and clinical research is necessary to clarify the role of radial head surgery.

Shoulder complaints and incidence of shoulder pathologies after contralateral major amputation in the mid and long-term

INTRODUCTION

Amputations of the upper extremity are rare but present a life-altering event that is accompanied with considerable restrictions for the affected patients. Even with functional prosthesis, tasks of the amputated limb are usually transferred to the unaffected arm which could result in complaints of the unaffected shoulder in the mid and long term. We therefore aimed to investigate musculoskeletal pain and morphological degenerative changes of the shoulder following a contralateral amputation.

MATERIALS AND METHODS

We included all patients with a major amputation treated at our institution with a minimum of three years since the amputation. All patients received an MRI of both shoulders and were investigated using validated scores for the upper extremity and physical activity (SSV, ASES, DASH, GPAQ, SF-36). Results of the MRIs were investigated for morphological changes by two blinded investigators comparing the side of the amputation and the unharmed upper extremity and results were correlated to the time since amputation and their physical activity.

RESULTS

A total of 20 patients with a mean age of 56 ± 19.9 years (range, 23-82 years) could be included in the study. The mean time since the amputation was 26.3 ± 19 years (range, 3-73 years). On the unharmed upper extremity, the mean SSV was 61.9 ± 24.6, the mean ASES-Score 54.5 ± 20.3, the Constant-score of 63.7 ± 40.4 and a DASH-score of 47.6 ± 23.8. The MRI of the unharmed shoulder showed significant more full-thickness rotator cuff tears and joint effusion compared to the side of the amputation. Significant differences in the degree of a glenohumeral arthritis, AC-joint arthritis, or partial rotator cuff tears could not be found between shoulders.

CONCLUSION

Amputations of the upper extremity are associated with a high disability of the unharmed upper extremity and more full thickness rotator cuff tears compared to the side of the amputation. However, the small number of patients and rotator cuff injuries should be kept in mind when interpreting the data.

LEVEL OF EVIDENCE

IV (retrospective case series).

A salvage procedure: Radial head excision in children and adolescents-short-to-midterm outcomes and overview of the literature

Purpose

Purpose of the study was to report the outcomes after radial head excision in children and adolescents in addition with a review of the current literature.

Methods

We report a series of five children and adolescents, who had undergone a post-traumatic radial head excision. Clinical outcomes were evaluated in terms of elbow/wrist range of motion, stability, deformity and discomforts or restrictions at two follow-up points. Radiographic changes were evaluated.

Results

Patient's age at time of the radial head excision averaged 14.6 (13-16) years. Mean time from the injury to the radial head excision was 3.6 (0-9) years. Follow-up I averaged 4.4 (1-8) years and follow-up II 8.5 (7-10) years. At follow-up I, patients showed an average elbow range of motion of 0-10-120° Ext/Flex and 90-0-80° Pro/Sup. Two patients reported discomfort or pain at the elbow. Four (80%) patients had a symptomatic wrist with pain or crepitation at the distal radio ulnar joint. In three (60%) of them, an ulna plus at the wrist was present. Two patients required ulna shortening and autograft stabilization of the interosseous membrane. At final follow-up, all patients reported full functioning with daily activities. Restrictions were present with sport activities.

Conclusion

Functional results at the elbow joint might be improved and pain syndromes lessen due to the radial head excision. Problems at the wrist are likely secondary to the procedure. A critical analysis of other options should be performed ahead of the procedure and a careless application should be avoided by all means.

Level of evidence

IV.

Factors influencing the outcome after surgical reconstruction of OTA type B and C tibial plateau fractures: how crucial is the restoration of articular congruity?

INTRODUCTION

Only few and inconsistent data about the impact of articular congruity and tolerable residual intraarticular steps and gaps of the joint surface after tibial plateau fractures exist. Therefore, aim of this study was to investigate the correlation between OTA type B and C tibial plateau fracture outcomes and postoperative articular congruity using computed tomography (CT) data.

MATERIALS AND METHODS

Fifty-five patients with a mean age of 45.5 ± 12.5 years and treated for 27 type B and 28 C tibial plateau fractures with pre- and postsurgical CT data were included. Primary outcome measure was the correlation of postoperative intraarticular step and gap sizes, articular comminution area, the postoperative medial proximal tibial angle (MPTA), and the Lysholm and IKDC score. Receiver-operating characteristic (ROC) curves were used to determine threshold values for step and gap heights according to the following outcome scores: IKDC > 70; Lysholm > 80. Secondary outcome measures were the correlation of fracture severity, the number of complications and surgical revisions and the outcome scores, as well as the Tegner activity score before injury and at final follow-up.

RESULTS

After a mean follow-up of 42.4 ± 18.9 months, the mean Lysholm score was 80.7 ± 13.3, and the mean IKDC score was 62.7 ± 17.6. The median Tegner activity score was 5 before the injury and 4 at final follow-up (p < 0.05). The intraarticular step height, gap size, comminution area and MPTA deviation were significantly negatively correlated with the IKDC and Lysholm scores. The cutoff values for step height were 2.6 and 2.9 mm. The gap size threshold was 6.6 mm. In total, an average of 0.5 ± 0.8 (range 0-3) complications occurred, and on average, 0.5 ± 1.1 (range 0-7) surgical revisions had to be performed. The number of complications and surgical revisions also had negative impacts on the outcome. Neither fracture severity nor BMI or patient's age was significantly correlated with the IKDC or Lysholm score.

CONCLUSIONS

Tibial plateau fractures are severe injuries, which lead to a subsequent reduced level of patient activity. Precise reconstruction of the articular surface with regard to intraarticular step and gap size, residual comminution area and joint angle is decisive for the final outcome. Complications and surgical revisions also worsen it.

LEVEL OF EVIDENCE

III.

Rate of progressive healing with a carbon-fiber orthosis in cases of partial union and nonunion after ankle arthrodesis using the Ilizarov external fixator

BACKGROUND

The Ilizarov fixator is a popular device for treating arthrodesis of the ankle joint in complex situations. However, the therapy can fail, with nonunion or partial union that might not be load stable. There is the possibility of follow-up surgery or extended wearing of the fixator. Full weight bearing with a carbon orthosis remains another treatment option, which has not yet been investigated.The aim of the study was to determine the rate of progress that can be obtained with a carbon orthosis in cases of partial union or nonunion after fixator removal.

METHODS

In this retrospective observational study thirty-three patients received a carbon orthosis after fixator removal due to nonunion or partial union. All patients were allowed to walk with the orthosis under full load. The consolidation rate was determined radiologically and compared with the imaging data obtained during the last follow-up. In addition to demographic data, the Foot and Ankle Ability Measure and pain using a numeric rating scale were determined. Nine patients had to be excluded due to insufficient follow-up, and finally n = 24 patients were included in the study.

RESULTS

The average duration of fixator use was 21 weeks (range 15-40 weeks), and the total average follow-up after removal of the fixator was 16 months (range 4- 56). For 14 (58.33%) patients, there was a further increase in consolidation with the orthosis after the fixator was removed.

CONCLUSION

The results show that if there is only partial union or nonunion, further consolidations can be achieved after the application of a carbon orthosis. In a difficult patient population, using an orthosis should therefore be attempted to avoid unnecessary revision operations.

Influence of articular step-off on contact mechanics in fractures of the posterolateral-central tibial plateau - a biomechanical study

BACKGROUND

The posterior quadrants of the tibial plateau are frequently involved in OTA type C tibial plateau fractures. The biomechanical influence of a residual articular step-off of the posterolateral-central (PLC) segment, which is difficult to visualize intraoperatively, remains unclear. Therefore, aim of this study was to investigate the contact area and stress of the tibial plateau in cases of different articular step-offs of the PLC segment.

METHODS

Seven human cadaveric knees were used to simulate articular impressions of the PLC segment with step-offs of 1 mm, 3 mm, and 5 mm. The knees were axially loaded up to 150 N during a total of 25 dynamic cycles of knee flexion up to 90°. Pressure mapping sensors were inserted into the medial and lateral joint compartments beneath the menisci to measure articular contact area and stress.

RESULTS

Between 60° and 90° of knee flexion, increasing PLC segment impressions of the tibial plateau led to increasing contact stress and a significantly reduced contact area. The largest decrease in the contact area was 30 %, with an articular step-off of 5 mm (0.003). An increase in contact stress, especially from a 3-mm step-off, was measured, with a doubling of the mean contact stress at 3-mm and 5-mm step-offs and 90° knee flexion (p = 0.06/0.05).

CONCLUSION

From a biomechanical point of view, posterior impressions of the PLC segment greater than a 1-mm step-off should be addressed as anatomically as possible, especially in active patients with the need for higher knee flexion angles.

[Resection arthroplasty and arthrodesis in revision shoulder arthroplasty]

Shoulder arthrodesis and resection arthroplasty can be used as salvage procedures to treat severe complications after shoulder prosthesis failure. for both procedures, the indication and patient selection must be very strict. Shoulder arthrodesis after prosthesis failure can be indicated in young patients in case of chronic neuromuscular dysfunction. Filling the bony defect with either autologous or allogenic material and osteosynthetic primary stability are decisive for a good functional outcome. Aftercare comprises immobilization for 12 weeks and physical load is increased thereafter, depending on the sufficiency of bony consolidation. Resection arthroplasty after shoulder prosthesis failure is mostly reserved for multimorbid patients in case of a chronic infection. Thorough debridement and adequate systemic antibiotic treatment are crucial to achieve bacterial eradication.

Traumatische Rückenmarkverletzungen im Sport – eine Analyse eines spezialisierten Traumazentrums von 22 Jahren

Einführung Aktuell gibt es nur wenige Daten zu traumatischen Wirbelsäulenverletzungen mit neurologischer Beteiligung im Hinblick auf Sportunfälle in Deutschland. Ziel dieser Studie ist es, die Häufigkeit traumatischer Rückenmarksverletzungen, verursacht durch verschiedene Sportunfälle, aus den letzten 22 Jahren darzustellen. 

Methoden Die vorliegende Studie ist eine retrospektive Auswertung traumatischer Rückenmarksverletzungen (tSCI) bei sportlicher Aktivität eines Level-1-Traumazentrums mit Abteilung zur Behandlung von Rückenmarksverletzungen in Deutschland der letzten 22 Jahre.

Die Akten der in den Jahren 1998–2020 behandelten Patient*innen wurden im Hinblick auf die Anamnese untersucht und diejenigen Fälle genauer betrachtet, bei denen es sich ursächlich um Sportaktivitäten handelte. Zusätzlich wurden Art und Schwere der Verletzung sowie die Geschlechtsverteilung erfasst.

Ergebnisse Insgesamt wurden 1630 Patient*innen mit traumatischen Wirbelsäulenverletzungen mit Rückenmarksbeteiligung eingeschlossen. Von diesen 1630 Patient*innen waren n=116 (7,1%) Sportunfälle. Das Alter dieser Subpopulation war mit 41 Jahren signifikant jünger (p=0,05) als die Gesamtgruppe der tSCI mit 50 Jahren. Eine detailliertere Analyse der Sportverletzungen ergab, dass in absteigender Reihenfolge Reit- (n=22), Winter- (n=18), Luft- (n=16), Motor- (n=16) und Radsport (n=15) die häufigsten ursächlichen Faktoren für diese besonders schweren Wirbelsäulenverletzungen waren. Bei der Verteilung der Lokalisation der Wirbelsäulenverletzung in Bezug auf die Art des ausgeübten Sports zeigte sich im Luftsport ein signifikantes Ergebnis, wonach sich die Patient*innen dieser Gruppe hauptsächlich Verletzungen der Lendenwirbelsäule zuzogen (p<0,01). Die Geschlechterverteilung der einzelnen Sportarten zeigt im Pferdesport (männlich < weiblich, p < 0,01), im Luftsport (männlich > weiblich, p = 0,05) und im Radsport (männlich > weiblich, p = 0,07) signifikante Ergebnisse.

Fazit Zusammengefasst ist vor allem Reitsport beim weiblichen Geschlecht in der Kategorie Sportverletzungen am häufigsten ursächlich für traumatische Wirbelsäulenverletzungen, obwohl Frauen insgesamt einen deutlich geringeren Anteil der Patient*innen mit traumatischen Wirbelsäulenverletzungen einnehmen als Männer. Ferner führen Winter- (n=18), Luft- (n=16), Motor- (n=15) und Radsport (n=15) zu häufigen traumatischen Wirbelsäulenverletzungen im Sportsektor. Patient*innen mit traumatischen 

Wirbelsäulenverletzungen mit spinaler Beteiligung bedingt durch Sportunfälle waren signifikant jünger als diejenigen der Gesamtheit aller traumatischer Wirbelsäulenverletzungen.

[Femoral neck stress fracture in a young runner - a rare but severe injury]

A 29-year-old athlete suffered from vague hip pain during the preparation for a marathon competition. During the competition, severe pain forced him to drop out after 29 kilometres. He underwent conventional x-rays immediately, which showed a displaced lateral fracture of the femoral neck. The fracture was immediately treated with a dynamic hip screw. A few days later, the patient was discharged. He returned to sport upon completion of treatment. Vague hip pain after exercise may be an indicator for a rare stress fracture of the femoral neck and should be taken into consideration in athletes. Delayed diagnostic investigation and treatment reduce return-to-sport rates and outcomes.

Instability and results after non-operative treatment of large anterior glenoid rim fractures: is there a correlation between fragment size or displacement and recurrence?

INTRODUCTION

There is little data available on non-operative treatment of anterior glenoid rim fractures (GRF). Nothing is known about fracture size and displacement in comparison to clinical outcomes and instability in a mainly middle-aged patient population. The aim of this study was to demonstrate the results of non-operative treatment in anterior glenoid rim fractures with the special focus on potential instability/recurrence.

METHODS

The inclusion criteria were non-operatively treated anterior GRF of at least ≥ 5 mm width using the age- and gender-matched Constant/Murley score (a.-/g.-CMS) and the Western Ontario Instability Index (WOSI). Radiographic parameters (fracture morphology, displacement, major tuberosity fractures and Hill-Sachs lesion using initial CT and radiographs) and the proportion of the fractured glenoid were detected (2D-CT-circle-method) and osteoarthritis (A.P. and axial radiographs) was classified according to Samilson/Prieto. Proportion of fractured glenoid and medial displacement were correlated with the recurrence rate and the clinical scores.

RESULTS

N = 36 patients could be followed-up after a mean of 4.4 years [12-140 month, average age: 58 (± 13, 33-86) years]. The a.-/g.-CMS was 93 (± 11, 61-100) points, and the WOSI was 81% (± 22%, 35-100%) on average. The mean intraarticular displacement was 4 mm (± 3 mm; 0-14 mm). The 2D-circle-method showed a mean glenoid fracture involvement of 21% (± 11, 10-52%). Two cases of frozen shoulders and one case with biceps pathology were associated with the trauma. Within the followed-up patient group re-instability has occurred in n = 2 patients (6%) within the first two weeks after trauma. Osteoarthritis was found in n = 11 cases. There was no correlation between the scores and the fracture size/displacement [(a.-/g.-CMS vs. displacement: r = - 0.08; p = 0.6; vs. size: r = - 0.29; p = 0.2); (WOSI vs. displacement: r = - 0.14; p = 0.4; vs. size: r = - 0.37; p = 0.06)], but very large (≥ 21%) fractures with displacement ≥ 4 mm showed slightly worse results without significant difference (a.-/g.-CMS p = 0.2; WOSI p = 0.2). The apprehension test was negative in all patients at final follow-up.

CONCLUSION

Non-operative treatment of anterior GRF was associated with overall good results within a mainly middle-aged larger patient group. Re-instability is rare and is not associated with fragment size but can occur in the first weeks after trauma. Size and dislocation of the fracture is not a criterion for the prognosis of potential instability.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Spinal Cord Injury With Tetraplegia in Young Persons After Diving Into Shallow Water: What Has Changed in the Past 10 to 15 Years?

STUDY DESIGN

Retrospective, monocentric, observational study in a tertiary health care center.

OBJECTIVES

To analyze prehospital and clinical findings, complications, neurological improvement and follow-up in a young person cohort with spinal cord injury (SCI) and tetraplegia according to the American Spinal Injury Association (ASIA) Impairment Scale (AIS) A to D after diving into shallow water.

METHODS

Included were all persons younger than 50 years with SCI after head-first diving into shallow water between June 2001 and June 2019. All persons with SCI were divided into complete tetraplegia (AIS A) and incomplete tetraplegia (AIS B, C, and D) to test differences.

RESULTS

A total of 59 males (98.7%) and 1 female with a mean age of 27.7 years suffered an SCI. Alcohol use was documented in 25 cases (41.7%). At the time of admission, 33 people (55%) showed a complete tetraplegia (AIS A) and 27 showed an incomplete tetraplegia with 8 AIS B (13.3%), 15 AIS C (25%), and 4 AIS D (6.7%). At the time of discharge, people with initially complete tetraplegia showed a significant improvement from admission to discharge (P ≤ .004). Persons with incomplete tetraplegia were more likely to improve their neurological status compared with complete tetraplegia patients (P ≤ .001). Especially persons with complete tetraplegia suffered from typical SCI-related problems and complications.

CONCLUSIONS

People with SCI and tetraplegia at the time admission show neurological improvement in 50% of the cases with an overall better outcome in persons with incomplete tetraplegia. The surgical treatment of SCI within 24 hours seems to be associated with a better neurological outcome and a lower level of tetraplegia. The incidence of SCI caused by diving into shallow water remains stable without a significant change, especially in high-risk groups. More education and prevention programs are necessary to avoid these injuries.

Sonication in the diagnosis of fracture-related infections (FRI)-a retrospective study on 230 retrieved implants

BACKGROUND

In fracture-related infections (FRI), both the diagnosis of the infection and the identification of the causative pathogen are crucial to optimize treatment outcomes. Sonication has been successfully used for periprosthetic joint infections (PJI); however, its role in FRI remains unknown. Our aim was to determine the diagnostic accuracy (sensitivity, specificity) of sonicate fluid culture (SFC). The primary objective was to compare SFC with peri-implant tissue culture (PTC) overall and among subgroups using the consensus definition by Metsemakers et al. The secondary objective was to determine the yield of SFC in possible fracture-related infections (PFRI).

METHODS

From March 2017 to May 2019, 230 cases of retrieved implants were retrospectively reviewed. To perform sonication, explants were placed in sterile polypropylene jars intraoperatively. After treatment in an ultrasonic bath (Bandelin, Berlin, Germany), sonicate fluid was incubated into blood culture bottles, and conventional culturing was eventually performed. Sensitivity and specificity were determined using two-by-two contingency tables. McNemar's test was used to compare proportions among paired samples while Fisher's exact test was used for comparison between categorical variables.

RESULTS

Of the 230 cases, 107 were identified as FRI, whereas 123 were aseptic revision cases (ARC). Of the latter, 105 were labeled as PFRI. Sensitivity of SFC was higher in comparison with PTC, although this did not reach statistical significance (90.7% vs. 84.1%; p = .065). The specificity of SFC was significantly lower than that of PTC (73.2% vs. 88.6%; p = .003). In PFRI, SFC yielded significantly more positive results than PTC (33/105 vs. 14/105; p = .003). Overall, 142 pathogens were identified by SFC, whereas 131 pathogens were found by PTC.

CONCLUSIONS

We found that sonication of fracture fixation devices may be a useful adjunct in FRI, especially in "low-grade" infections lacking confirmatory clinical criteria. Standardized diagnostic protocols are warranted in order to further optimize the diagnostic accuracy.

Accuracy of radiographic measurement techniques for the Taylor spatial frame mounting parameters

Aim

The correction accuracy of the Taylor Spatial Frame (TSF) fixator depends considerably on the precise determination of the mounting parameters (MP). Incorrect parameters result in secondary deformities that require subsequent corrections. Different techniques have been described to improve the precision of MP measurement, although exact calculation is reportedly impossible radiologically. The aim of this study was to investigate the accuracy of intraoperative and postoperative radiographic measurement methods compared to direct MP measurement from TSF bone mounting.

Methods

A tibial Sawbone® model was established with different origins and reference ring positions. First, reference MPs for each origin were measured directly on the frame and bone using a calibrated, digital vernier calliper. In total 150 MPs measured with three different radiographic measurement techniques were compared to the reference MPs: digital radiographic measurements were performed using soft-copy PACS images without (method A) and with (method B) calibration and calibrated image intensifier images (method C).

Results

MPs measured from a non-calibrated X-ray image (method A) showed the highest variance compared to the reference MPs. A greater distance between the origin and the reference ring corresponded to less accurate MP measurements with method A. However, the MPs measured from calibrated X-ray images (method B) and calibrated image intensifier images (method C) were intercomparable (p = 0.226) and showed only minor differences compared to the reference values but significant differences to method A (p < 0,001).

Conclusion

The results demonstrate that MPs can be accurately measured with radiographic techniques when using calibration markers and a software calibration tool, thus minimizing the source of error and improving the quality of correction.

Immobilization in External Rotation and Abduction Versus Arthroscopic Stabilization After First-Time Anterior Shoulder Dislocation: A Multicenter Randomized Controlled Trial

BACKGROUND

Treatment of first-time shoulder dislocation (FSD) is a topic of debate. After high rates of recurrent instability after nonoperative management were reported in the literature, primary repair of FSD significantly increased. At the same time, new concepts were proposed that had promising results for immobilization in external rotation (ER) and abduction (ABD).

PURPOSE

The aim of this study was to evaluate the recurrence rates (primary outcome) and clinical outcomes (secondary outcome parameters) of immobilization in ER+ABD versus arthroscopic primary stabilization after FSD.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

In a multicenter randomized controlled trial, patients with FSD were randomized to either treatment with immobilization in 60° of ER plus 30° of ABD (group 1) or surgical treatment with arthroscopic Bankart repair (group 2). Clinical evaluation was performed 1, 3, and 6 weeks as well as 6, 12, and 24 months postoperatively or after reduction, including range of motion, instability testing, subjective shoulder value, Constant-Murley score, Rowe score, and Western Ontario Shoulder Instability Index. Recurrent instability events were prospectively recorded.

RESULTS

Between 2011 and 2017, a total of 112 patients were included in this study. Of these, 60 patients were allocated to group 1 and 52 to group 2. At the 24-month follow-up, 91 patients (81.3%) were available for clinical examination. The recurrence rate was 19.1% in group 1 and 2.3% in group 2 (P = .016). No significant differences were found between groups regarding clinical shoulder scores (P > .05). Due to noncompliance with the immobilization treatment protocol, 4 patients (6.7%) were excluded.

CONCLUSION

Immobilization in ER+ABD versus primary arthroscopic shoulder stabilization for the treatment of FSD showed no differences in clinical shoulder scores. However, recurrent instability was significantly higher after nonoperative treatment.

Long-term follow up of extensor tendon ruptures of the knee using electromyography and three-dimensional gait analysis

BACKGROUND

The aim of this study was to analyze the long-term outcomes of extensor tendon ruptures of the knee using exact measuring tools.

METHODS

The results of patients treated for extensor tendon rupture with a minimum follow up of 10 years were reviewed. Electromyography (EMG) and three-dimensional (3D) gait analyses were performed and compared with the healthy side of each patient and with the gait patterns of 20 healthy controls. Functional outcome scores were assessed using the Lysholm score and Knee Injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

After a mean of 13.4 ± 3 years, 23 patients were available for follow up. The mean Lysholm score was 86.6, and the KOOS averaged 78.1. Gait analysis showed no major kinematic differences between these patients compared with healthy controls. In the squat test, the mean peak amplitude of the rectus femoris muscle was significantly smaller on the injured side than on the healthy side (140.21 ± 66.13 μV vs. 168.25 ± 91.77 μV; P = 0.01). The mean peaks of the vastus lateralis and medialis EMG signals were also lower on the injured side (P = 0.63; P = 0.08). Correspondingly, the thigh girth at 20 cm and 10 cm above the knee was significantly lower on the injured side. One patient had re-rupture after patella tendon repair.

CONCLUSION

At long-term follow up the patients reached good clinical outcomes and exhibited mainly physiological gait patterns after rupture of knee extensor tendons. However, the thigh muscles showed hypotrophy and a significantly smaller EMG signal amplitude during a high-intensity task on the formerly injured side.

Secondary purulent infections of the elbow joint: a retrospective, single-center study

Background

Septic arthritis of the elbow joint is a rare condition. Limited data is available on infections of the elbow joint following trauma or prior surgery on this joint. The aim of this study was to describe the etiology, comorbidities, bacterial spectrum and therapy of secondary purulent elbow infections.

Methods

Patients treated in our hospital were selected through retrospective chart review between 2006 and 2015. We included all patients with an empyema of the elbow after a trauma or surgical intervention on this joint. 30 patients between 26 and 82 years (mean: 52.47) were included.

Results

Seven patients (23.3%) were female, 23 (76.7%) male. 22 patients (73.3%) had a history of trauma, eight (26.7%) had prior elective surgeries on their elbow. Between one and 25 surgeries (mean: 5.77) were necessary for treatment. In nine patients, debridement and synovectomy were sufficient, eight patients (26.7%) received resection of the elbow joint. One patient was treated with a chronic fistula. In 18 patients (60%), cultures of aspiration/intraoperative swabs were positive for Staphylococcus aureus, four of these were methicillin-resistant. Four patients (13.3%) had positive cultures for Staphylococcus epidermidis, in five patients (16.7%) no bacteria could be cultured.

Conclusions

Secondary infections of the elbow joint are a rare disease with potentially severe courses, requiring aggressive surgical treatment and possibly severely impacting elbow function. Staphylococcus aureus was the most common bacteria in secondary infections and should be addressed by empiric antibiotic treatment when no suspicion for other participating organisms is present.

Sonication of retrieved implants improves sensitivity in the diagnosis of periprosthetic joint infection

BACKGROUND

Sonication is a valuable tool in the diagnosis of periprosthetic joint infections (PJI). However, conditions and definition criteria for PJI vary among studies. The aim of this study was to determine the diagnostic performance (i.e., specificity, sensitivity) of sonicate fluid culture (SFC) against periprosthetic tissue culture (PTC), when using European Bone and Joint Infection Society (EBJIS) criteria.

METHODS

From March 2017 to April 2018, 257 implants were submitted for sonication. PJI was defined according to the EBJIS criteria as well as according to the International Consensus Meeting criteria of 2018 (ICM 2018). Only cases with at least one corresponding tissue sample were included. Samples were cultured using traditional microbiological plating techniques. Sensitivity and specificity were determined using two-by-two contingency tables. McNemar's test was used to compare proportions among paired samples. Subgroup analysis was performed dividing the cohort according to the site of PJI, previous antibiotic treatment, and time of manifestation. Prevalence of pathogens was determined for all patients as well as for specific subgroups.

RESULTS

Among the 257 cases, 145 and 112 were defined as PJI and aseptic failure, respectively. When using the EBJIS criteria, the sensitivity of SFC and PTC was 69.0 and 62.8%, respectively (p = .04). Meanwhile, the specificity was 90.2 and 92.9%, respectively (p = .65). When adopting ICM 2018 criteria, the sensitivity of SFC and PTC was 87.5 and 84.4% (p = .63) respectively, while the specificity was 85.1 and 92.5% (p = .05), respectively. The most commonly identified pathogens were coagulase-negative staphylococci (26% overall), while 31% of PJI were culture-negative and 9% polymicrobial.

CONCLUSIONS

SFC exhibited significantly greater sensitivity versus PTC when using the EBJIS criteria. Nevertheless, the diagnosis of PJI remains a difficult challenge and different diagnostic tools are necessary to optimize the outcome.

Necrotizing fasciitis and the midterm outcomes after survival

Background and Aims:

Radical surgical intervention is necessary to save patients’ lives in cases of necrotizing fasciitis. This leads to persistent disabilities and most likely to a deteriorated quality of life. The purpose of this study was to evaluate the midterm outcomes after survival of necrotizing fasciitis.

Materials and Methods:

A retrospective analysis of 69 patients, treated for necrotizing fasciitis between 2003 and 2012. The patients were identified using the International Classification of Diseases (10th Revision) code M 72.6. Of the 50 survivors, 22 patients completed the Short Form 36 and Short Musculoskeletal Function Assessment questionnaires as a postal survey. The follow-up averaged 59 months (range: 6–128 months).

Results:

The average age at the time of necrotizing fasciitis was 60.0 years. The body mass index average was 29.7. The patients had a significantly decreased physical component summary score of 33.3 compared to a normative group (p < 0.001) (Short Form 36). They further showed a significantly decreased dysfunction and bother indices (Short Musculoskeletal Function Assessment) (p < 0.001). An increased age (⩾70 years) was associated with an inferior role emotional (p = 0.048) and physical functioning (p = 0.011) as well as social functioning (p = 0.038) (Short Form 36). The majority of patients (16, 72.7%) complained of pain at the final follow-up and 50% of patients required an assistive device on a regular basis.

Conclusion:

Patients who survived necrotizing fasciitis suffer from functional impairment and changed body appearance. Assistive devices or pain medication are often required, and the patients present with significantly decreased physical, social, and emotional functioning at the midterm follow-up. The patient’s age is a critical factor regarding functional or mental outcome parameters. Further research on the post-hospital course and long-term multidisciplinary care is required to improve the outcomes of these patients.

Semitendinosus autograft augmentation after bilateral patellar tendon re-rupture: a case report and technique note

BACKGROUND

Acute bilateral patellar tendon rupture is a rare occurrence, especially in young patients in the absence of comorbidities. We describe a case of bilateral patellar tendon re-rupture in a young patient without predisposing factors. Further, we explain a technique for autograft augmented patellar tendon repair with bidirectional fixation using an ipsilateral semitendinosus graft in transosseous patellar and tibia bone tunnels.

CASE PRESENTATION

We present the case of a 40-year-old healthy worker with bilateral acute on chronic patellar tendon rupture maintained following initial trauma and Krackow repair 2 years ago. He underwent bilateral reconstruction using semitendinosus autograft. At 1 year postoperatively, he has maintained the full range of motion and strength without re-rupture.

CONCLUSION

This is the first case describing a new fixation technique after bilateral patellar tendon re-rupture. The use of semitendinosus autograft for reconstruction of the patellar tendon after re-rupture is a viable and effective option.

[Periprosthetic humeral fractures: from osteosynthesis to prosthetic replacement]

OBJECTIVE

Stabilization of the humeral shaft and the restoration of shoulder function dependent on the osseous integrity of the prosthetic stem component.

INDICATIONS

In cases of a stable prosthesis stem, an isolated plate osteosynthesis is possible. Prosthesis stem replacement is indicated in cases of a loose stem. With sufficient bone stock of the proximal humeral segment, a change to a shorter humeral shaft component with subsequent plate fixation of the fracture is possible. If the bone stock is poor, conversion to a long revision stem is necessary.

CONTRAINDICATIONS

Inoperability of the patient due to serious comorbidities. Advanced age and low demands on shoulder function are relative contraindications for complex prosthesis replacements.

SURGICAL TECHNIQUE

Plate osteosynthesis can be done through an anterior or posterior approach, stem replacement only from anterior deltopectoral approach. When changing humeral shaft components, the loose shaft and all cement residues are removed, the fracture is reduced and, if possible, a shorter shaft is implanted with subsequent plate osteosynthesis of the fracture. When changing to a long revision stem, additional osteosynthesis with cerclages wires is usually sufficient. In case of poor bone stock, an additive autologous or allogenic bone grafting can be performed. An instable anatomical prosthesis with poor shoulder function may require conversion to an inverse prosthesis.

POSTOPERATIVE MANAGEMENT

In cases of an isolated plate osteosynthesis with an otherwise stable prosthesis, immediate active rehabilitation of the upper limb is advocated. When a prosthesis replacement and conversion to an inverse prosthesis is performed the shoulder is immobilized in 30° abduction for 6 weeks. Passive and after 3 weeks active-assistive shoulder movement up to 90° abduction and flexion is allowed.

RESULTS

In 40 patients with a periprosthetic humeral fracture, an isolated plate osteosynthesis was performed in 30 cases and a prosthesis replacement in 10 cases. Complications included 3 infections and 3 temporary radial nerve palsies. Revisions due to pseudarthrosis were necessary in 2 cases.

Differences between primary and secondary definitive osteosynthesis for fractures of the lower leg with concomitant acute compartment syndrome

PURPOSE

To analyze the differences in outcomes between primary and secondary definitive osteosynthesis for fractures of the lower leg with concomitant acute compartment syndrome (ACS).

METHODS

From our trauma database, we identified a total of 107 patients with 126 fractures of AO/OTA type 41-44 and 120 ACS from January 01, 2001 to December 31, 2015 who were treated with primary or secondary definitive osteosynthesis after concomitant fasciotomy.

RESULTS

Seventy-one patients with 77 fractures of AO/OTA classification type 41-44 suffering ACS received primary definitive osteosynthesis at the time of compartmental incision (POCI) and were compared to 36 patients with 49 fractures of AO/OTA type 41-44 and ACS, who received secondary definitive osteosynthesis after compartmental incision and soft tissue coverage (SOCI). Patients with POCI had a significantly shorter length of hospital stay with significantly fewer necessary surgeries to achieve definitive fracture treatment and soft tissue closure than SOCI patients (p ≤ 0.001). The overall rate of infections in both groups was 13%, without any difference between POCI and SOCI.

CONCLUSIONS

POCI for AO/OTA fractures type 41-44 with ACS is a safe and effective procedure without increasing the infection rate compared to a gradual treatment (SOCI). However, the possible selection bias due to the retrospective study design needs to be considered.

[Basic principles of fracture healing]

BACKGROUND

In contrast to other tissues, bone has the remarkable ability to heal without scarring. After union of the fracture, the remodeled bone ideally does not differ from the original bone, especially in terms of biomechanical properties. The healing of a fracture resembles the embryonic development of bone. Depending on the biomechanical properties of the fracture, bone heals directly or indirectly, which refers to the formation of cartilage as a step before new bone appears. Currently, treatment of the patient is often limited to anatomical reduction and optimization of the fracture environment with respect to biomechanics.

PROSPECTS

Future treatment strategies, however, could include systemic medication that could be especially beneficial for patients at risk of complications in fracture healing. The aim of this review is to provide an overview on the process of fracture healing and to depict possibilities for current and future treatment strategies.

Bilateral Proximal Humerus Fracture - a Rare Combination with a High Complication Rate after Surgery

INTRODUCTION

Bilateral acute proximal humerus fractures are rare. There are no data available about these bilateral injuries. The aim of the study was to analyse bilateral proximal humerus fractures retrospectively in terms of incidence, complications and revisions.

METHODS

All bilateral proximal humerus fractures were evaluated retrospectively using the institution's database, with the focus on cause of the injury, fracture severity and the clinical course compared to published information on monolateral proximal humerus fractures. Bilateral posterior dislocation fractures were excluded, because these fractures are a separate entity.

RESULTS

Between 2005 and 2016, n = 17 patients were primarily treated within our hospital for an acute proximal humerus fracture on both sides (n = 12 female, n = 5 male, average age: 68 years; overall 34 proximal humerus fractures). The general trauma mechanism was a fall on both arms (82% [18% polytrauma]). There were 65% displaced 3-/4-part proximal humerus fractures. Angle-stable plate osteosynthesis was performed predominantly (64%), followed by fracture prosthesis (18%; tension wiring: 3%; non-operatively: 15%). Overall, n = 10 patients (59%) or n = 18 (53%) proximal humerus fractures developed a complication, primarily with loss of reduction or implant loosening (44%). In n = 14 (78%) of the complications further operations were necessary. Alcohol abuse was increasingly found in 29% of the cases within the bilateral patient cohort compared to patients with monolateral fractures.

CONCLUSION

Bilateral proximal humerus fractures are mainly associated with comminuted displaced fractures and a higher complication rate in comparison to monolateral fractures after surgical treatment.

Bone grafting in oblique versus prepared rectangular uncontained glenoid defects in reversed shoulder arthroplasty. A biomechanical comparison

BACKGROUND

How the shape of the glenoid defect being reconstructed influences stability in reversed shoulder arthroplasty has never been evaluated. The purpose of this study was to compare the reconstruction of two different shaped defects in reversed shoulder arthroplasty.

METHODS

Two groups (ten Sawbone scapulae each) of oblique- and rectangular-shaped glenoid defects were tested biomechanically. On the anterior half of the glenoid, bony defects (rectangular and oblique shaped) were prepared and reconstructed subsequently with a graft and reversed shoulder arthroplasty. As a control group, Sawbones without glenoid deficiency were used. In addition, these tests were reproduced in cadavers.

FINDINGS

In Sawbones, no significant difference in initial stability was found between the two groups (p>0.05). Additionally, in the cadaver tests no significant difference was found between the groups with different defects (p>0.05). During the preparation, macroscopic loosening of the oblique bone grafts was found in three cases after the performance of the reversed shoulder arthroplasty due to the lack of medial support. The localization of the highest micromotion were measured primarily between the scapula bone and the graft compared to the measured micromotions between glenoid implant and the graft.

INTERPRETATION

If the oblique-shaped bone graft was secured under the baseplate, the rectangular defect preparation did not show a significantly higher primary stability. However, the advantage of medial support in rectangular defects leads to more stability while placing the bone graft and baseplate during the surgical technique and should therefore be considered a preferable option.

[Bony Bankart lesions and glenoid defects : From refixation techniques to bony augmentation]

Rim defects of the anterior glenoid cavity are a main reason for residual shoulder instability after traumatic dislocation of the shoulder. These defects can be the result of a glenoid rim fracture or chronic glenoid erosion after repeated shoulder dislocations. Treatment concepts for these entities are entirely different. While in the acute fracture situation glenoid rim fractures can be treated operatively or non-operatively, augmentation of the anterior glenoid for stabilization of the shoulder should be considered if the defect exceeds 15-25% of the anterior glenoid. The purpose of this article is to summarize the diagnostics and indications for treatment of glenoid rim fractures. Radiological assessment and options for augmentation are reviewed for both acute fractures as well as chronic instability following an anterior glenoid rim defect.

Biomechanical analysis of anterior bone graft augmentation with reversed shoulder arthroplasty in large combined glenoid defects compared with total bony joint line reconstruction (modified bony-increased-offset reversed shoulder arthroplasty)

BACKGROUND

The aim of this biomechanical study was to compare 2 surgical techniques for the reconstruction of large, combined, uncontained glenoid defects with reversed shoulder arthroplasty (RSA).

METHODS

Three groups of scapulae with RSA were tested by the application of a physiological combination of compressive/shear loads in Sawbones (Pacific Research Laboratories, Inc., Vashon Island, WA, USA) and cadavers. Two of the groups (both Sawbones and cadaveric specimens) consisted of anterior combined defects (14 mm in depth), and the third group served as a control group (only Sawbones specimens). The first group with an anterior combined defect was reconstructed with anterior bone grafts to contain the defect and cancellous bone to fill the central defect before RSA with partial bony joint line reconstruction (p-BJR). In the second group with an anterior combined defect, the dorsal rim was reamed and the joint line was reconstructed with a bone disc fully covering the peg. This total BJR (t-BJR) corresponds to the technique of bony-increased-offset-RSA (BIO-RSA).

RESULTS

At 150 µm of displacement, the loadings in the inferior-superior (IS) direction were significantly more stable than those in the anterior-to-posterior (AP) direction within both reconstructed defect groups (P ≤ .002). In contrast, no significant differences were found between the partial BJR and t-BJR group in either direction (Sawbones: AP: P = .29; IS: P = .44; cadavers: AP: P = .67; IS: P = .99). The control group revealed significantly higher values in all loadings of the IS direction and significantly higher loadings at 40 µm and 150 µm in the AP direction.

CONCLUSION

Both techniques could be applied for such complex defects provided that there is sufficient medial bone stock for a t-BJR. Significantly greater stability was found in the IS direction than in the AP direction within each group, which could be explained by the longer screw anchoring within the superior and inferior columns. Both defect groups were less stable than the group of intact glenoids.

Arthroscopic Lateral Border Resection in Medialized Scapula Neck Fractures

Scapula neck fractures are rare injuries, leaving several treatment options. Standardized markers for operative treatment are a decreased glenopolar angle ≤22°, lateral border offset (LBO) of the glenoid ≥20 mm, angular deformity ≥45°, or LBO ≥15 mm plus angular deformity ≥35°. If operative treatment is not performed before union, the fracture heals malaligned with possible mechanical complications due to a medialized glenoid and the protruding lateral border. Common operative treatment comprises a corrective osteotomy for the anatomic correction of the malunited fracture, leaving intra-articular pathologies like adhesive capsular stiffness unaddressed. Our presented arthroscopic technique for the treatment of sequelae of scapula neck fractures combines a 270° capsulotomy with arthroscopic resection of a protruding lateral border. With use of this technique, excellent shoulder function can be restored with a minimally invasive procedure. Therefore, arthroscopic treatment could be favorable in selected cases of malunited scapula neck fractures.

Results of non-operative treatment of fractures of the glenoid fossa

AIMS

Our aim was to investigate the outcomes of patients with a displaced fracture of the glenoid fossa who are treated conservatively. There is little information in the literature about the treatment of these rare injuries non-operatively.

PATIENTS AND METHODS

We reviewed 24 patients with a mean age of 52 years (19 to 81) at a mean of 5.6 years (11 months to 18 years) after the injury.

RESULTS

At final follow-up, the mean Constant and Murley score was 79 points (18 to 98); the mean Western Ontario Shoulder Instability Index score (WOSI) was 77% (12 to 100) and the mean Rowe score was 93 points (50 to 100). Fractures with little intra-articular displacement (≤ 3 mm) had an uneventful outcome. Those with intra-articular displacement of ≤ 3 mm had a significant better mean Constant and Murley score than those with displacement of ≥ 5 mm and/or a fracture gap of ≥ 5 mm. Poor clinical results such as nonunion and post-traumatic osteoarthritis were associated with displaced or angulated glenoid fragments and significant intra-articular displacement.

CONCLUSION

Glenoid fossa fractures with displacement of ≥ 5 mm should be treated surgically if the patient's condition allows. Displacement and angulation can lead to nonunion and a poor outcome if the degree of displacement results in a persistent fracture gap in the glenoid fossa or if the angulation of fragments leads to malunion. Cite this article: Bone Joint J 2016;98-B:1074-9.

Treatment of Chronic Acromioclavicular Joint Dislocation in a Paraplegic Patient with the Weaver-Dunn Procedure and a Hook-Plate

In case of patients with spinal cord injury and concomitant acromioclavicular (AC) joint-dislocation the treatment is challenging, as in this special patient group the function of the shoulder joint is critical because patients depend on the upper limb for mobilization and wheelchair-locomotion. Therefore the goal of this study was to examine, if the treatment of chronic AC-joint dislocation using the Weaver-Dunn procedure augmented with a hook-plate in patients with a spinal cord injury makes early postoperative wheelchair mobilization and the wheelchair transfer with full weight-bearing possible. In this case the Weaver-Dunn procedure with an additive hook-plate was performed in a 34-year-old male patient with a complete paraplegia and a posttraumatic chronic AC-joint dislocation. The patient was allowed to perform his wheelchair transfers with full weight bearing on the first post-operative day. The removal of the hook-plate was performed four months after implantation. At the time of follow-up the patient could use his operated shoulder with full range of motion without restrictions in his activities of daily living or his wheel-chair transfers.

[Air Entrapment Caused by Valve Mechanisms in Chronic Wounds, a Benign Phenomenon? A Series of Three Cases]

BACKGROUND

Benign subcutaneous emphysema caused by a valve mechanism and subsequent air entrapment is rare. Less invasive treatment can be performed, but acute life-threatening infectious diseases should be ruled out before treatment; these include gas gangrene or other infections caused by gas producing bacteria.

PATIENTS AND METHODS

We retrospectively report on three patients with chronic wounds who developed benign subcutaneous extremity emphysema caused by valve mechanisms with subsequent air entrapment. Patient 1 had a chronic wound at his stump after a lower leg amputation years ago. Due to weight loading and unloading of the lower leg prosthesis while walking, air was sucked in and triggered subcutaneous emphysema. Patient 2 had a persistent fistula at his lateral thigh due to a chronic osteomyelitis and Girdlestone hip. Caused by the up-and-down movements of the femur during walking air was entrapped and led to emphysema. Patient 3 had a drain in his knee for development of a chronic fistula because of a persistent infection of his knee prosthesis. In extension of the knee, the drain was clamped in and air was entrapped during knee flexion and then seeped into the surrounding subcutaneous tissue. No signs of infection in the blood samples were present in two of the patients. None of the patients had fever and no gas producing bacteria were identified in the microbiological cultures. Only multisensitive Staphylococcus aureus was present in the wounds of patients 1 and 2.

RESULTS

Two patients were treated surgically. One patient was treated by fasciotomy plus debridement and irrigation of the wound. A second patient was treated by debridement of the Girdlestone hip, air evacuation and insertion of a drain. No sign of infection - such as necrosis or gangreneous tissue - was seen during these operations. In patient 3, the drain was removed in flexion of the knee and air was removed from the subcutaneous tissue through a separate, sterile needle punction.

CONCLUSION

There have been few published reports on benign subcutaneous emphysema caused by a valve mechanism. No standardised treatments exist, as it is initially difficult to distinguish this condition from an acute life-threatening infection. If a patient has a chronic wound at the location of the endoprosthesis or stump prosthesis after amputation, the possibility of benign air entrapment should be routinely considered.

Isolated pediatric radial head and neck fractures. A rare injury. Analysis and follow up of 19 patients

PURPOSE

Isolated pediatric radial head and neck fractures are rare. In recent literature, their incidence is estimated to be around 1% of all fractures. High rates of complications are reported. Beside non-operative treatment, head fractures are treated with k-wires, mini-screws or polypins, whereas neck fractures are treated more and more with elastic stable intramedullary nailing (ESIN). Purpose of the study was to evaluate the operative management, complications and clinical outcomes of these injuries.

METHODS

Retrospective analysis between 2002 and 2014. 19 children with isolated radial head and neck fractures were treated in our institution. Age averaged 11 years (range 6-16). Operative treatment with elastic stable intramedullary nailing (ESIN) was performed in 13 patients, in one patient with an additional k-wire; two screw, two k-wire and one polypin fixation was performed in the others. One child was treated non-operatively.

RESULTS

Follow up averaged 19 months (2-89). Initial complications occurred in nine children such as fracture dislocation (1), nonunion (1), malunion (1), elbow ankylosis (1), infection (1), crossunion (2), intraarticular screw penetration (1) and radial nerve irritation (1). ESIN lead a complication rate of 36%, mini-screw fixation and k-wire fixation showed a complication rate of 100%. All children (100%) with an open reduction maneuver and 36% children with closed or percutaneous reduction developed a complication. Secondary surgeries included ESIN removal and k-wire fixation (1), open arthrolysis (1), debridement (1), removal of crossunion (1), radial head removal plus arthrolysis (3) and screw removal (1). Subsequently 74% (14) children showed a free or <20° limited range of motion on final follow up. Implant removal was performed after an average of 8 weeks (5-12). Three patients were transferred to our surgical department after a complication following initial treatment. Excluding these, an overall complication rate of 37.5% was noted.

CONCLUSIONS

Radial head injuries in children are rare. In this population, neck fractures occur more frequently. If conservative treatment is not possible, ESIN seems to be a simple and protective procedure for neck fractures; polypins or screws can be used for complicated radial head fractures. Complications occur frequently after open reduction. If closed reduction and internal fixation is possible, range of motion can be completely restored.

Influence of surgical approach on component positioning in primary total hip arthroplasty

Background

Minimal invasive surgery (MIS) has gained growing popularity in total hip arthroplasty (THA) but concerns exist regarding component malpositioning. The aim of the present study was to evaluate femoral and acetabular component positioning in primary cementless THA comparing a lateral to a MIS anterolateral approach.

Methods

We evaluated 6 week postoperative radiographs of 52 hips with a minimal invasive anterolateral approach compared to 54 hips with a standard lateral approach. All hips had received the same type of implant for primary cementless unilateral THA and had a healthy hip contralaterally.

Results

Hip offset was equally restored comparing both approaches. No influence of the approach was observed with regard to reconstruction of acetabular offset, femoral offset, vertical placement of the center of rotation, stem alignment and leg length discrepancy. However, with the MIS approach, a significantly higher percentage of cups (38.5 %) was malpositioned compared to the standard approach (16.7 %) (p = 0.022).

Conclusions

The MIS anterolateral approach allows for comparable reconstruction of stem position, offset and center of rotation compared to the lateral approach. However, surgeons must be aware of a higher risk of cup malpositioning for inclination and anteversion using the MIS anterolateral approach.

[Surgical treatment of 3- and 4-part fractures of the humeral head using a polyaxial-locking plate: results and patient satisfaction]

INTRODUCTION

In recent years, new angle-stable plate implants with polyaxial screw direction were developed with the aim of an improved treatment of displaced 3- and 4-part fractures of the proximal humerus. There are only a few studies available about polyaxial implants in the treatment of 3- and 4-part proximal humerus fractures. Therefore, the aim of this study was to evaluate clinical results and complications of open reduction and internal fixation of displaced 3- and 4-part fractures using a polyaxial plate.

PATIENTS AND METHODS

Within 51 months, 105 patients with a displaced 3- or 4-part fracture of the proximal humerus were treated with a polyaxial locking plate. The complications were evaluated and the Constant & Murley score was assessed and correlated with patient satisfaction ("very satisfied" to "not satisfied"). Additionally, the results were compared with those of monoaxial plates from the literature. Furthermore, the operative experience of the surgeons at the time of surgery was correlated with the objective results of the patients.

RESULTS

65 patients (average age: 71.3 ± 11.4 years; average follow-up: 19,6 ± 9,8 month [10-44 month]) with a displaced 3- or 4-part fracture were re-examined retrospectively (female: n = 54; male: n = 11). Overall, there were 27 3-part fractures and 38 4-part fractures. The Constant and Murley Score was on average 62.1 ± 16.5 points and the complication rate was 26 %. The most frequent complication was screw perforation through the humeral head. Patient satisfaction with clinical outcome was high within the whole study group. 40 % of the patients were "very satisfied" with their shoulder function, 29 % were "satisfied" ("fair": 12 %, "not satisfied": 19 %). Additionally, the operative experience of the surgeons influenced the final clinical result.

CONCLUSION

In comparison to the literature we could not delineate better clinical outcomes or lower complication rates with polyaxial implants compared to monoaxial plates in 3- and 4-part fractures. Nevertheless, the majority of patients were satisfied with the clinical result in the context of age-related shoulder function. In addition, a close correlation could be detected between the degree of satisfaction and the objectively measured shoulder function. A high level of operative experience is required to avoid typical complications and to achieve a good clinical result.

[Trampoline-related injuries in children: an increasing problem]

INTRODUCTION

The sales of recreational trampolines have increased during the past few years. Severe injuries are associated in part with trampoline sport in the domestic setting. Therefore, this study was conducted to confirm the hypothesis of an increase in trampoline-related injuries in conjunction with the increasing sales of recreational trampolines and to find out what kind of injuries are most frequent in this context.

METHODS

Between 01/1999 and 09/2013 all trampoline-related injuries of children (0-16 years of age) were assessed retrospectively. Only those cases were evaluated which described with certainty a trampoline-associated trauma. The fractures were considered separately and assigned to specific localisations. Additionally, accidents at home were differentiated from institutional accidents.

RESULTS

Within the past 13 years and 9 months trampoline-related injuries were seen in 195 infants. Fractures were present in 83 cases (42 %). The average age was 10 ± 3.4 years (range: 2-16 years). Within first half of the observed time period (7½ years; 01/1999 to 06/2006) 73 cases were detected with a significantly increasing number of injuries up to 122 cases between 07/2006 and 09/2013 (7 years, 3 months), which corresponds to an increase of 67 % (p = 0,028). The vast majority of these injuries happened in the domestic setting (90 %, n = 175), whereas only 10 % (n = 20) of the traumas occurred in public institutions. In 102 children (52 %) the lower extremity was affected and in 51 patients (26 %) the upper extremity was involved (head/spine/pelvis: n = 42, 22 %). The upper extremity was primarily affected by fractures and dislocations (n = 38, 76 %). At the upper extremity there were more injuries requiring surgery in contrast to the lower extremity (n = 11) or cervical spine (n = 1).

CONCLUSION

The underlying data show a significant increase of trampoline-related injuries within the past years. The upper extremity is the second most affected after the lower extremity, but is more associated with fractures in contrast to other localisations and had to be operated on the most. Because of the increase of recreational trampolines within past years an increase of trampoline-associated injuries has to be expected in the future. The security guidelines should be followed exactly and the infants should be under supervision.

Evaluation of immobilization in external rotation after primary traumatic anterior shoulder dislocation: 5-year results

BACKGROUND

It is still not clear which method is the most efficient for treating primary traumatic anterior shoulder dislocation. Immobilization in external rotation has become increasingly discussed within the last 10 years. The aim of this study was to evaluate the rate of recurrence and clinical outcome of the immobilization in external rotation after primary traumatic anterior dislocation within a midterm period of 5 years. Additionally, a summary of literature is given according to the present knowledge of this issue.

METHODS

From May 2004 to May 2006, 28 patients with primary traumatic anterior shoulder dislocations were included in a prospective MRI-controlled study. After a follow-up of 5 years, the recurrence rate and clinical outcomes of the patients were evaluated using clinical scores (Constant and Murley score, Western Ontario Shoulder Instability Index, Rowe score).

RESULTS

After 5 years, 26 patients (93 %; males, n = 25; female, n = 1; mean age, 29.3 years) were interviewed concerning re-dislocations. In the meantime, four patients (15 %) experienced a re-dislocation (ø 12.2 months) after the end of the immobilization. Overall, 21 patients (75 %) were included in a clinical follow-up (CM score: ø 92.8 points; Western Ontario Shoulder Instability Index: ø 87 %; Rowe score (in 17 patients): ø 94.2 points). Upon clinical examination, unidirectional anterior instability was found in one patient, which corresponds to an overall instability rate of 19 % within the examined patient population including the re-dislocations.

CONCLUSIONS

Immobilization in external rotation shows satisfactory results after 5 years in regard to recurrence and instability rates and clinical outcomes. The data show that with immobilization in external rotation, re-dislocations occur within the first 2 years.

[A new reduction technique for posterior locked shoulder dislocation. Case report and technique description]

The case of a 61-year-old male with posterior dislocation of the right shoulder joint is presented and a new technique for closed reduction of posterior locked shoulder dislocation is described. The technique involves four steps: in step 1 a constant traction is applied on the injured arm, in step 2 the arm is internally rotated and in steps 3 and 4 the second arm of the physician is used as a lever arm to lateralize and ventralize the shoulder. Lateralization and ventralization of the humeral head are essential to engage the humeral head and to pass it around the glenoid during reduction. Steps 3 and 4 are performed simultaneously. In the presented case the patient suffered a traumatic shoulder dislocation with a rim fracture of the glenoid. After reduction the shoulder was stable and conservative treatment was performed. A 2 year follow-up examination revealed a pain-free and stable shoulder with free range of motion and an Oxford instability score of 48 points. The described reduction technique for posterior locked shoulder dislocation is a simple and gentle technique, which can be performed easily by one person.Presentation of a reduction technique for locked posterior shoulder dislocation. Constant traction and internal rotation is performed for engaging the locked humeral head. After disengaging the humeral head the reduction is performed by using the arm of the physician as a lever arm.

Combining of small fragment screws and large fragment plates for open reduction and internal fixation of periprosthetic humeral fractures

Operative treatment of periprosthetic humeral fractures in elderly patients with osteoporotic bone requires a stable fixations technique. The combination of 3.5 cortical screws with washers in a 4.5 Arbeitsgemeinschaft für Osteosynthesefragen, Limited-contact dynamic compression plate or Locking plate, allows a stable periprosthetic fixation with the small 3.5 screws and 4.5 screws above and below the prosthesis, respectively. This combination is a cost-effective technique to treat periprosthetic humeral fractures.

Thoracic vertebral body fracture after total hip replacement in diffuse idiopathic skeletal hyperostosis

This article describes the critical clinical sequelae of a patient with diffuse idiopathic skeletal hyperostosis who sustained an acute iatrogenic thoracic vertebral body fracture with subsequent spinal cord injury after a total hip replacement, with a final lethal course.A 57-year-old woman was referred to the authors' institution after undergoing a total hip replacement in the supine position for secondary osteoarthritis. Postoperatively, the patient had symptoms of an incomplete paraplegia. Computed tomography scan and magnetic resonance imaging revealed diffuse idiopathic skeletal hyperostosis and an acute unstable fracture of T11 with spinal contusion. A posterior spinal fusion of T10-L1 with laminectomy of T11 was performed immediately on admission. Postoperatively, no improvement of the neurological deficit was observed. After developing multiorgan failure while in intensive care, the patient died 2 months after the total hip replacement.The morphological and functional symptoms of diffuse idiopathic skeletal hyperostosis with the typical ossification of the longitudinal ligaments and the associated loss of bending forces of the spine were detected postoperatively. This severe case demonstrates that the surgeon must be alert to possible complications due to intraoperative maneuvers in patients with stiffened spinal disorders undergoing total hip replacement.

Clinical outcome and complications using a polyaxial locking plate in the treatment of displaced proximal humerus fractures. A reliable system?

INTRODUCTION

The surgical treatment of displaced proximal humeral fractures (ORIF) is a perpetual challenge to the surgeon. For this reason, the principle of polyaxiality was developed to provide an improved primary stability of the fracture through better anchorage of the screws, especially in osteoporotic bone. The aim of this study was to present clinical results with the polyaxial locking plate in the operative treatment of proximal humerus fractures in order to determine whether the technique of polyaxiality leads to better functional outcome and lower complication rates in comparison to monoaxial plates in the literature.

PATIENTS AND METHODS

Seventy-three patients with displaced proximal humeral fractures were treated surgically with the polyaxial locking Suture Plate™ (Arthrex(®)) between 03/2007 and 06/2009. Fifty-two of the patients (mean age, 69.9 ± 12.1) were included in a radiographical and clinical examination using the Constant score (CS) and the Disabilities of the Arm, Shoulder and Hand score (DASH).

RESULTS

The follow-up examinations were on average 13.9 ± 4.5 months (10-27 months) after surgical treatment. The mean CS of the patients was 66.0 ± 13.7 points, the age- and gender-related CS was 90.9% ± 20.0% and the mean DASH score was 23.8 ± 19.8 points for the injured side. The patients with a nearly anatomical reduction of their fracture (n = 13) reached a significantly higher CS (75.1 ± 8.5; p = 0.004) and DASH-score (13.6 ± 11.6; p = 0.043) and none of these patients had a complication. The complications were identified in 12 (23.1%) cases, 5 of which involved loss of reduction. All of these 5 cases were lacking of initial medial column support and 4 of which were type C2.3 AO-Classification.

CONCLUSION

The data show that the combination of angular stability with the possibility of variable polyaxial screw direction is a good concept for reduction and fixation of displaced proximal humeral fractures, but anatomical reduction and medial support remain important preconditions for a good outcome. However, a significantly lower rate of complications or better clinical outcome than that reported in the literature could not be found.

Improved wire stiffness with modified connection bolts in Ilizarov external frames: a biomechanical study

Frame stability in Ilizarov external fixators is mainly dependent on the tension of the transosseous wires, which are clamped to the ring by connection bolts. It was the purpose of this biomechanical study to investigate the holding capacity of a modified bolt design featuring a ruffled wire-bolt interface (TrueLok™) and its influence on wire stiffness in comparison with that of classic bolts featuring a smooth, unruffled wire-bolt interface. Six different ring and bolt configurations were tested using a simplified model consisting of a single ring and wire. The holding capacity at two different tightening torques (10 and 14 Nm) of classic cannulated bolts (CB) and slotted bolts (SB) was determined on Ilizarov and Taylor Spatial Frame (TSF™) rings, whereas the modified TrueLok™ CBs and SBs were used with the TrueLok™ rings. The wire stiffness was calculated via a regression analysis of the load-displacement graphs. The modified TrueLok™ bolts demonstrated significantly better slippage resistance than the classic bolts in all configurations and wire stiffness was significantly higher in the TrueLok™ frame set-ups. After maximum loading, all of the wires showed plastic deformation, including constant wire deflection and dent marks at the clamped wire ends. In conclusion, the decrease in wire stiffness can be explained mainly as a result of wire slippage, but plastic deformation and material yielding also contribute. The relatively simple modification made by roughening the wire-bolt interface results in improved holding capacity and wire stiffness. A frame that contains these modified TrueLok™ bolts should provide improved mechanical stiffness.