Surgical treatment of fracture sequelae of the proximal humerus according to a pathology-based modification of the Boileau classification results in improved clinical outcome after shoulder arthroplasty

BACKGROUND

Fracture sequelae of the proximal humerus were classified by Boileau into four types. Since there are pathomorphological differences and specific characteristics within the four types, we have developed a subclassification. For elderly patients, shoulder arthroplasty is mostly recommended. Based on the available literature and clinical trial results, a subclassification could be created that suggests a specific therapy for each subgroup. The aim of this study was to evaluate the endoprosthetic therapy according to the proposed subclassification and to provide an overview of the clinical and radiological results after endoprosthetic treatment of proximal humerus fracture sequelae.

METHODS

Patients with fracture sequelae of the proximal humerus who underwent arthroplasty according to the suggestion of the subclassification were included. Minimum time to follow-up was twelve months. General condition and several specific shoulder scores as the Constant-Murley Score (CS) were recorded at the follow-up examination. Complication and revision rates were analyzed.

RESULTS

In total, 59 patients (72.6 ± 10.0 years, 47 females, 12 males) were included. Mean follow-up time was 31.3 ± 17.0 months. Reverse shoulder arthroplasty was performed in 49 patients and anatomic shoulder arthroplasty was performed in ten patients. The CS increased by 47.3 points from preoperative (15.0) to postoperative (62.3). Good or very good clinical results were seen in 61% of the patients. Complications were observed in twelve (20%) patients and revision surgery was performed in nine (15%) patients.

CONCLUSION

Due to of the variety of fracture sequelae of the proximal humerus, a modification of the Boileau classification seems necessary. This study shows that endoprosthetic treatment for fracture sequelae can significantly improve the shoulder function in elderly patients. Good clinical results can be achieved with a comparatively low revision rate following the treatment suggestions of the proposed subclassification of the Boileau classification.

LEVEL OF EVIDENCE IV

Case series.

Correct positioning of the calcar screw leads to superior results in proximal humerus fractures treated with carbon-fibre-reinforced polyetheretherketone plate osteosynthesis with polyaxial locking screws

BACKGROUND

Plate osteosynthesis with implants made of carbon-fibre-reinforced polyetheretherketone (CFR-PEEK) has recently been introduced for the treatment of fractures of the proximal humerus (PHFs). The advantages of the CFR-PEEK plate are considered to be its radiolucency, its favourable modulus of elasticity, and the polyaxial placement of the screws with high variability of the angle. The primary aim of this study is to investigate the influence of calcar screw positioning on the complication and revision rates after CFR-PEEK plating of PHFs. The secondary aim is to assess its influence on functional outcome.

MATERIAL AND METHODS

Patients were identified retrospectively. Minimum follow-up was 12 months. The cohort was divided into two groups depending on the distance of the calcar screw to the calcar (group I: < 12 mm, group II: ≥ 12 mm). The range of motion (ROM), Subjective Shoulder Value Score (SSV) and Constant-Murley Score (CS) were analysed at follow-up examination. Subjective complaints, complications (e.g. humeral head necrosis, varus dislocation) and the revision rate were evaluated.

RESULTS

51 patients (33 female, 18 male) with an average age of 68.6 years were included after a period of 26.6 months (group I: 32 patients, group II: 19 patients). Apart from the gender distribution, no significant differences were seen in the patient characteristics. The outcome scores showed significantly better clinical results in group I: SSV 83.4 vs 71.2, p = 0.007; CS 79.1 vs 67.8, p = 0.013. Complications were seen less frequently in group I (18.8 % vs 47.4 %, p = 0.030).

CONCLUSION

This study shows that the positioning of the calcar screw is relevant for CFR-PEEK plate osteosynthesis in PHFs with a good reduction of the fracture. Optimal positioning of the calcar screw close to the calcar (< 12 mm) is associated with a lower rate of complications, resulting in significantly superior functional outcomes.

LEVEL OF EVIDENCE

III, retrospective cohort study.

[The shoulder and elbow register of the DVSE-trend monitoring or early warning system? : A literature-based analysis]

The endoprosthesis register (SEPR) of the D‑A-CH Association for Shoulder and Elbow Surgery e. V. (DVSE) collects data on the implantation of shoulder and elbow endoprostheses. The question arises as to whether the data is only used to monitor trends in arthroplasty, or whether it can also be used as an early warning system for risks and possible complications. The existing literature on the SEPR was analyzed and compared with other national endoprosthesis registries. The SEPR of the DVSE enables the collection and analysis of epidemiological data on primary implantation, follow-up and revision in shoulder and elbow endoprosthetics. It is an instrument of quality control and contributes to ensuring the greatest possible patient safety. It is used for the early detection of risks and potential requirements associated with shoulder and elbow arthroplasty.

Functional results and unfavorable events after treatment of proximal humerus fractures using a new locking plate system

BACKGROUND

Proximal humerus fractures are often treated with a fixed-angle titanium plate osteosynthesis. Recently, plates made of alternative materials such as carbon fibre-reinforced polyetheretherketone (CFR-PEEK) have been introduced. This study presents the postoperative results of patients treated with a CFR-PEEK plate.

METHODS

Patients with proximal humerus fractures treated with a CFR-PEEK plate (PEEKPower™ Humeral Fracture Plate (HFP)) were included. In follow-up examination, age and gender adjusted Constant-Murley Score (ACS), Subjective Shoulder Value (SSV), Quick Disabilities of the Arm, Shoulder and Hand Score (QDASH) and pain score (Visual Analog Scale (VAS)) were analyzed. General condition at follow-up was measured by European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L). Range of motion was recorded. In addition, radiographs at follow-up, unfavorable events and revision rate were analyzed.

RESULTS

In total, 98 patients (66.0 ± 13.2 years, 74 females, 24 males) were reexamined. Mean follow-up was 27.6 ± 13.2 months. There were 15 2-part, 28 3-part and 55 4-part fractures. The functional scores showed good results: SSV 83.3 ± 15.6%, QDASH 13.1 ± 17.0 and ACS 80.4 ± 16.0. A 4-part-fracture, head split component, nonanatomic head shaft reposition and preoperative radiological signs of osteoarthritis were significant negative predictors for poorer clinical scores. Unfavourable events were observed in 27 patients (27.6%). Revision surgery was performed in 8 (8.2%) patients. Risk factors for an unfavourable event were female gender, age of 50 years and older, diabetes, affected dominant hand, 4-part fracture, head split and preoperative radiological signs of osteoarthritis.

CONCLUSION

There are several advantages of the CFR-PEEK plate (PEEKPower™ Humeral Fracture Plate (HFP)) such as the polyaxial screw placement and higher stability of locking screws. In summary, the CFR-PEEK plate osteosynthesis is a good alternative with comparable clinical results and some biomechanical advantages. Proximal humerus fractures show good clinical results after treatment with a CFR-PEEK plate. The revision rate and the risk of unfavorable events are not increased compared to conventional titanium plate osteosynthesis.

LEVEL OF EVIDENCE

IV.

[Fracture analysis, indication for endoprosthesis and implant selection in proximal humeral fractures]

Proximal humeral fractures (PHF) are the third most common fracture in humans and the incidence is increasing. There are basically three treatment strategies: conservative, joint-preserving reconstructive or joint-replacing procedures. In addition to fracture morphology, patient-specific and surgeon-specific factors are particularly important when deciding on treatment. The experience and training of the surgeon also play a decisive role. In the case of joint-preserving treatment, the risk of osteosynthesis failure and of sequelae of the fracture must always be assessed. If conservative or reconstructive treatment methods are not promising, the joint-replacing procedure is the treatment of choice. The anatomical fracture prosthesis is only indicated, if at all, for young patients with a destroyed humeral head with a preserved rotator cuff and large fragments of the tuberosities. In advanced age, the implantation of a reverse endoprosthesis is increasingly used for dislocated, multifragmentary PHF. In both procedures, the anatomical healing of the tuberosities has a significant impact on the functional outcome.

GIRD syndrome in male handball and volleyball players: Is the decrease of total range of motion the turning point to pathology?

BACKGROUND

Adaptations in glenohumeral range of motion may affect overhead athletes and lead to shoulder pathologies.

OBJECTIVE

The purpose of this study was to evaluate glenohumeral internal rotation deficit (GIRD) and postero-superior impingement among male handball and volleyball players and the relationship between these pathologies and training level (amateur vs. professional), position (attack vs. no attack), experience (> 5 years vs. < 5 years) and sports.

METHODS

Sixty-seven handball players and 67 volleyball players with a mean age of 25 [± 5] years were included. The range of motion including external and internal rotation in 90∘ abduction of the dominant and non-dominant shoulder was measured of each examined athlete. Visual analogue scale, disabilities of the shoulder and hand score, constant score and subjective shoulder value were recorded. The athletes were examined for postero-superior impingement and abduction force was measured with an isokinetic dynamometer.

RESULTS

Internal rotation was significantly lower and external rotation was significantly greater in the dominant arm for both sports. 72% presented with GIRD. GIRD was more prevalent in athletes active for > 5 years (odds ratio (OR) 3), in those training > 3 times per week (OR 1.4) and in handball players (OR 2.7). 24% presented with postero-superior impingement. Players active for > 5 years (OR 1.22), professionals (OR 1.14), volleyball players (OR 1.19), offensive players (OR 2.2) and athletes with GIRD > 10∘ (OR 1.5) showed a higher prevalence of postero-superior impingement.

CONCLUSION

GIRD is a common phenomenon in handball and volleyball players. Offensive players are frequently suffering from postero-superior impingement. GIRD > 10∘ leads in nearly 75% of the athletes to a decrease of total range of motion and a high rate of postero-superior impingement. Thus, a decreased range of motion seems to be the turning point from adaptation to pathology. Therefore, regular controls of range of motion and countermeasures by means of stretching the posterior shoulder joint should be integrated in the training content.

Treatment of avascular necrosis of the humeral head - Postoperative results and a proposed modification of the classification

BACKGROUND

Avascular necrosis of the humeral head after proximal humeral fracture i.e. type 1 fracture sequelae (FS) according to the Boileau classification is a rare, often painful condition and treatment still remains a challenge. This study evaluates the treatment of FS type 1 with anatomic and reverse shoulder arthroplasty and a new subclassification is proposed.

METHODS

This single-center, retrospective, comparative study, included all consecutive patients with a proximal humeral FS type 1 treated surgically in a four-year period. All patients were classified according to the proposed 3 different subtypes. Constant score (CS), Quick DASH score, subjective shoulder value (SSV) as well as revision and complication rate were analyzed. In the preoperative radiographs the acromio-humeral interval (AHI) and greater tuberosity resorption were examined.

RESULTS

Of 27 with a FS type 1, 17 patients (63%) with a mean age of 64 ± 11 years were available for follow-up at 24 ± 10 months. 7 patients were treated with anatomic and 10 with reverse shoulder arthroplasty. CS improved significantly from 16 ± 7 points to 61 ± 19 points (p < 0.0001). At final follow-up the mean Quick DASH Score was 21 ± 21 and the mean SSV was 73 ± 21 points. The mean preoperative AHI was 9 ± 3 mm, however, 8 cases presented an AHI < 7 mm. 4 cases had complete greater tuberosity resorption. The complication and revision rate was 19%; implant survival was 88%.

CONCLUSION

By using the adequate surgical technique good clinical short-term results with a relatively low complication rate can be achieved in FS type 1. The Boileau classification should be extended for fracture sequelae type 1 and the general recommendation for treatment with hemiarthroplasty or total shoulder arthroplasty has to be relativized. Special attention should be paid to a decreased AHI and/or resorption of the greater tuberosity as indirect signs for dysfunction of the rotator cuff. To facilitate the choice of the adequate prosthetic treatment method the suggested subclassification system should be applied.

Locked fracture dislocations of the proximal humerus: postoperative results and a proposed modification of the classification

Background

Locked dislocations of the glenohumeral joint are disabling and often painful conditions and the treatment is challenging. This study evaluates the functional outcome and the different prosthetic treatment options for chronic locked dislocations of the glenohumeral joint and a subclassification is proposed.

Methods

In this single-center retrospective case series, all patients with a chronic locked dislocation treated surgically during a four-year period were analyzed. Constant score (CS), Quick Disabilities of Shoulder and Hand Score (DASH), patient satisfaction (subjective shoulder value (SSV)), revision rate and glenoid notching were analyzed.

Results

26 patients presented a chronic locked dislocation of the glenohumeral joint. 16 patients (62%) with a mean age of 75 [61–83] years were available for follow-up at 24 ± 18 months. CS improved significantly from 10 ± 6 points to 58 ± 21 points (p < 0.0001). At the final follow-up, the mean DASH was 27 ± 23 and the mean SSV was 58 ± 23 points. The complication rate was 19% and the revision rate was 6%; implant survival was 94%. Scapular notching occurred in 2 (13%) cases (all grade 1).

Conclusion

With good preoperative planning and by using the adequate surgical technique, good clinical short-term results with a low revision rate can be achieved. The authors suggest extending the Boileau classification for fracture sequelae type 2 and recommend using a modified classification to facilitate the choice of treatment as the suggested classification system includes locked posterior and anterior dislocations with and without glenoid bone loss.

Level of evidence:

IV.

Higher primary stability of tuberosity fixation in reverse fracture arthroplasty with 135° than with 155° humeral inclination

BACKGROUND

Proximal humeral fractures in elderly patients are frequently treated with reverse total shoulder arthroplasty, and tuberosity healing improves clinical outcome and patient satisfaction. So far reverse prostheses with different humeral inclination (HI) angles have been used. However, it has not been investigated yet if the HI angle affects the primary stability of the tuberosity fixation in primary reverse total shoulder arthroplasty for proximal humeral fractures in a biomechanical setting.

METHODS

A 4-part fracture was created in 7-paired human cadaver proximal humeri after preceding power analysis. After randomization in a pairwise fashion, reverse prostheses with either 135° (n = 7) or 155° (n = 7) were implanted. The tuberosities were reduced anatomically to the metaphysis of the prostheses and were fixed with 3 suture cerclages in a standardized technique. Tightening was performed with a cerclage tension device with 50 Newton meter (N m). Before biomechanical testing, the initial vertical and horizontal gap formation was measured. The humeri were placed in a custom-made test setup enabling internal and external rotation. Cyclic loading with a gradually increasing load magnitude was applied with a material testing machine starting with 20 N m and increasing by 5 N m after each 100th cycle until failure (>15° rotation of the tuberosities). Any motion of the tuberosities was measured with a 3-dimensional camera system.

RESULTS

Overall, the 155° group reached an average of 1460 ± 270 cycles and the 135° group of 1900 ± 271 cycles (P = .048). In contrast to the 135° group, in the 155° group, a mean initial vertical (0.3 ± 0.7 mm) and horizontal (2.7 ± 3.3 mm) gap formation could be observed before cyclic loading. After 1100 cycles, the 155° group showed increased rotation of both lesser and greater tuberosities in all 3 axes around the humeral shaft compared with the 135° group.

CONCLUSION

Primary stability of the reattached tuberosities is significantly increased, whereas rotational movements are decreased in prostheses with an anatomic HI of 135° compared with a 155° HI according to the original Grammont design. In addition, a 135° HI allows an exact anatomic reposition of the tuberosities, whereas this was not possible for the 155° design. However, transferability and clinical relevance of these biomechanical results have to be verified with clinical studies.

Tensioning device increases biomechanical stability of tuberosity fixation technique with cerclage sutures in reverse shoulder arthroplasty for fracture

BACKGROUND

Complex proximal humeral fractures in elderly patients are increasingly treated with primary reverse total shoulder arthroplasty. Many surgeons use cerclage sutures for tuberosity fixation in reverse total shoulder arthroplasty for proximal humeral fractures. In this study, we hypothesized that sutures fixated with a tensioning device would achieve higher initial fixation stability of the tuberosities compared with manually knotted cerclage sutures in a biomechanical model.

METHODS

A 4-part fracture was created in 7-paired human cadaver proximal humeri. The tuberosities were reduced anatomically and fixed with 3 cerclage sutures in a standardized technique. Tightening was performed either manually (n = 7) or with a cerclage tensioning device with 50 Newton meter (N m) (n = 7). The humeri were placed in a custom-made test setup enabling internal and external rotation. Cyclic loading with gradually increasing load was applied with a material testing machine starting with 20 N m and increasing by 5 N m after each 100th cycle until failure (>15° rotation of the tuberosities). Motion of the tuberosities was measured with a 3-dimensional camera system.

RESULTS

Overall, the knot group reached 1040 ± 152 cycles, and the device group reached 1820 ± 719 cycles (P = .035). Major fragment motion was detected in the humeral shaft axis and in the distal divergence of the tuberosities. After 900 cycles, the knot group showed increased rotation of both lesser and greater tuberosities in all 3 axes around the humeral shaft compared with the device group.

CONCLUSION

Biomechanical stability of the reattached tuberosities is significantly increased, and rotational movement of the tuberosities is decreased after tightening of the applied cerclage sutures with a tensioning device compared with manual knotting. However, transferability of these promising biomechanical results and their clinical relevance have to be verified with clinical studies.

Proximal humeral fracture morphology in patients with advanced osteoarthritis: An observational study in a surgically treated cohort

BACKGROUND

Several factors affect proximal humeral fracture (PHF) morphology. In the presence of glenohumeral osteoarthritis (GOA), the joint kinematics is alternated which might influence fracture configuration. The purpose of this study was to identify fracture patterns in patients with advanced osteoarthritis to facilitate recognition and treatment.

METHODS

In this retrospective analysis, and computed tomography (CT) scans of all patients undergoing surgical treatment for a PHF during a 5-year period were analyzed. Fracture pattern according to the AO Foundation/Orthopaedic Trauma Association (AO-OTA) classification and the presence of GOA were evaluated. In addition, critical shoulder angle (CSA), glenoid configuration, and glenoid inclination (GI) were measured.

RESULTS

Of the 713 patients, 574 met the inclusion criteria. A total of 166 patients showed radiological signs of GOA (28.9%). Advanced GOA (stage 2 or 3) was identified in 23 patients (4.0%). In this group, the mean age was 77 ± 10 years, mean CSA was 28.8 ± 4.2°, and the mean GI was 19.0 ± 7.8°. All fractures were extra-articular metaphyseal fractures (5 A2, 11 A3, 7 B1.1). Patients with advanced GOA had more than threefold risk (risk ratio 3.2; confidence interval 95% 2.80-3.74; p < 0.0001) for sustaining a metaphyseal fracture. In patients with GOA grade 1 compared to patients with no radiographic signs of GOA, this could not be observed.

CONCLUSION

Patients experiencing PHF with radiological signs of advanced GOA have a higher risk of sustaining a metaphyseal fracture compared to individuals with the absence of or mild GOA. To date, no classification system for PHFs takes preexisting osteoarthritis into account, although it might indicate a different treatment and therefore the recognition is crucial.

Proximal humeral fracture morphology in patients with advanced cuff tear arthropathy: an observational study in a surgically treated cohort

BACKGROUND

In the presence of cuff tear arthropathy (CTA), joint kinematics is alternated and fracture configuration might be different. The purpose of this study was to identify fracture patterns in patients with advanced CTA to facilitate recognition and treatment.

METHODS

Radiographs and computed tomography scans of all patients undergoing surgical treatment for a proximal humeral fracture (PHF) in our institution during a 5-year period were retrospectively analyzed. Fracture pattern according to the AO-OTA and Resch classification and the presence of CTA were evaluated. Glenoid configuration according to Walch, fatty atrophy of the supraspinatus muscle and the centrum-collum-diaphyseal (CCD) angle were analyzed.

RESULTS

A total of 574 out of 713 patients were included. Twenty-three patients (4%) with a mean age of 82 ± 8 years showed advanced CTA with acetabularization of the acromion (≥ stage 3 according to Hamada/Fukuda). There were exclusively valgus fractures with a mean CCD angle of 158° ± 18°. Patients with CTA ≥ grade 3 had a nearly twofold greater risk (risk ratio: 1.8; confidence interval (CI): 95% 1.6-1.9; p < 0.0001) of sustaining a valgus fracture compared to patients without or with CTA < grade 3. The risk for a tuberosity fracture was nearly twofold greater in patients without or with mild CTA (risk ratio: 1.68; confidence interval (CI): 95% 1.17-2.40; p = 0.0046) compared to those with advanced CTA.

CONCLUSION

In advanced CTA, a predominantly valgus fracture pattern can be observed. In addition, fractures of the greater tuberosity were significantly less frequent and were rarely displaced. Up to date, no classification system for PHF has been developed in the setting of CTA although it might indicate a different treatment, and therefore, recognition is crucial. However, when present, this changes the fracture pattern and ability to treat the fracture as the rotator cuff can no longer be utilized as a means of reducing the fragments.

High tuberosity healing rate associated with better functional outcome following primary reverse shoulder arthroplasty for proximal humeral fractures with a 135° prosthesis

Background

Reverse shoulder arthroplasty (RSA) is a common treatment for proximal humeral fractures. (PHF) in the elderly. This study evaluates the functional outcome and the influence of. tuberosity healing (TH) following RSA with 135° humeral inclination and a neutral glenosphere without lateralization for PHFs.

Methods

In this retrospective case series, all patients with an acute PHF treated with primary RSA with 135° humeral inclination and a standard glenosphere without lateralization during a four-year period were followed up. Constant score (CS), patient satisfaction (subjective shoulder value (SSV)), TH and glenoid notching were analyzed.

Results

38 patients with a mean age of 77 ± 8 years were available for follow-up at 34 ± 5 months. The mean adjusted CS was 61 ± 9 points. TH of the greater tuberosity (GT) was 82% and resulted in significantly improved abduction (117° vs. 81°; P < 0.001), forward flexion (139° vs. 99°; p < 0.001), external rotation (28° vs. 10°; p = 0.002), CS (65 vs. 41 points; p < 0.001) and patient satisfaction (SSV 79% vs. 48%; p < 0.001). TH of the LT was 87% without affecting internal rotation or overall outcome. The complication- and revision rate was 5%; implant survival was 100%. Scapular notching occurred in 3 (8%) cases (all grade 1).

Conclusion

RSA with 135° humeral inclination and a standard glenosphere for PHF leads to good functional outcome in combination with a high rate of TH and a low rate of scapular notching. The short-term revision rate is low and the results are predictable and continuous. TH is associated with improved ROM, patient satisfaction and functional outcome.

Latissimus dorsi transfer for massive posterosuperior rotator cuff tears: what affects the postoperative outcome?

BACKGROUND

The management of irreparable posterosuperior rotator cuff tears (IPSRCTs) in young active individuals is still a challenge. The aim of this study was to evaluate the influence of sex, surgical technique, previous surgical procedures, tear genesis, and presence of a preoperative external rotation lag sign on the functional outcome after latissimus dorsi transfer (LDT) for IPSRCTs.

METHODS

Retrospectively, all patients with IPSRCTs treated with LDT during a 10-year period were followed up. Preoperative evaluation included the visual analog scale (VAS) score, range of motion, and the Constant score (CS). Postoperatively, the VAS score, range of motion, CS, American Shoulder and Elbow Surgeons score, and Subjective Shoulder Value were recorded. Preoperative and postoperative radiologic evaluation was performed using the Hamada-Fukuda classification and the acromiohumeral interval.

RESULTS

In total, 67 of 79 patients (85%), with a mean age of 63 years, were available for follow-up at 54 ± 28 months. The CS improved from 24 ± 6 points preoperatively to 68 ± 17 points at follow-up (P < .001). Active flexion increased from 83° ± 47° to 144° ± 35°; abduction, from 69° ± 33° to 134° ± 42°; and external rotation, from 24° ± 18° to 35° ± 21°. Postoperatively, the Subjective Shoulder Value was 69% ± 19% and the American Shoulder and Elbow Surgeons score was 76 ± 21. The VAS score decreased from 6.3 ± 1.1 to 1.8 ± 2 (P < .001). Abduction strength increased from 0.4 ± 0.4 kg to 3.6 ± 2.2 kg (P < .001). The acromiohumeral interval decreased from 7.9 ± 2.6 mm to 5.1 ± 2.2 mm, and arthropathy worsened from Hamada-Fukuda stage 1.4 to stage 2.1. The rate of conversion to a reverse prosthesis was 6%.

CONCLUSION

LDT represents a reliable and reproducible treatment option with good clinical midterm results after surgical treatment. Sex, genesis, preoperative presence of an external rotation lag sign, and previous surgical procedures do not affect the overall clinical outcome.

Relative effectiveness of insects versus hummingbirds as pollinators of Rubiaceae plants across elevation in Dominica, Caribbean

Most angiosperms rely on animal pollination for reproduction, but the dependence on specific pollinator groups varies greatly between species and localities. Notably, such dependence may be influenced by both floral traits and environmental conditions. Despite its importance, their joint contribution has rarely been studied at the assemblage level. At two elevations on the Caribbean island of Dominica, we measured the floral traits and the relative contributions of insects versus hummingbirds as pollinators of plants in the Rubiaceae family. Pollinator importance was measured as visitation rate (VR) and single visit pollen deposition (SVD), which were combined to assess overall pollinator effectiveness (PE). In the wet and cool Dominican highland, we found that hummingbirds were relatively more frequent and effective pollinators than insects, whereas insects and hummingbirds were equally frequent and effective pollinators at the warmer and less rainy midelevation. Furthermore, floral traits correlated independently of environment with the relative importance of pollinators, hummingbirds being more important in plant species having flowers with long and wide corollas producing higher volumes of dilute nectar. Our findings show that both environmental conditions and floral traits influence whether insects or hummingbirds are the most important pollinators of plants in the Rubiaceae family, highlighting the complexity of plant-pollinator systems.

[Arthroscopic fracture treatment of the shoulder joint]

In recent years, the understanding of shoulder fractures has changed due to the progress of arthroscopy. In addition to the cosmetic result, the access morbidity, particularly the integrity of the subscapularis muscle in glenoid and scapular fractures, must be mentioned as an advantage of a minimally invasive approach. Furthermore, necessary secondary interventions, e. g. hook plate removal, can be prevented or minimized by modern implants and arthroscopic techniques.However, the available data and publications are almost exclusively limited to technical notes or small case series, so statements about faster recreation or potential reduction of infection risk cannot be made. Whether addressing concomitant injuries has an effect on the clinical and functional outcome is also unclear at the present time.

Are there any prognostic prediction parameters (PPPs) in the treatment of the massive rotator cuff tear with latissimus dorsi transfer? Latissimus dorsi transfer in massive rotator cuff tears

PURPOSE OF THE STUDY

Especially in such complex salvage procedures as latissimus dorsi transfer for irreparable rotator cuff tears there is a need for valid prognostic prediction parameters. Parameters such as osteoarthritis, acromiohumeral distance, subscapularis, or teres minor insufficiency are controversial. The aim of this study is to present our data and to evaluate the literature regarding such parameters.

METHODS

Fifty-seven patients with a follow-up of 3 years (range, 18-72 months, n = 57) were selected for this study. Average age of patients at the time of surgery was 64.9 years. Patients were evaluated using the age and gender adjusted scoring system according to Constant and Murley score (CS). Standard radiography was attempted containing a true-ap, outlet, and axillary view. The acromio-humeral distance was measured in the true ap view. The grade of glenohumeral osteoarthritis and cuff tear arthropathy was detected using the classification of Hamada et al. Differences in CS were compared for each of the PPP.

RESULTS

Mean Constant score increased significantly (p < 0.0001) 3 years postoperatively from initially 22.7 points to 66.0 points (adjusted CS 80.3%). We found a major difference in the Constant score in patients with or without previous surgery (80.4% vs, 65.2%).

CONCLUSION

Latissimus dorsi transfer is an excellent option in the treatment of irreparable postero-superior tears of the rotator cuff in well-selected patients. The literature remains ambiguous with regard to valid prognostic predictive parameters for complex salvage procedures, owing to the consistent use of small study samples. Thus, there is an overwhelming need for a multicenter study.

[Is the patient age a negative predictive factor in the reconstruction of SLAP lesions?]

BACKGROUND

The treatment strategy of SLAP (superior labrum anterior posterior) lesions is generally a matter of controversy, particularly in patients over 40 years of age. Various factors, such as the increasing number of associated injuries in older age, play a role in the decision-making process. There currently is no empirical evidence for the greater efficacy of treatment planning for SLAP repair as compared to tenodesis/tenotomy. The aim of this study was to analyse, as part of a cohort comparison, the results after SLAP repair in patients under and over 40 years of age.

METHODS

We followed 45 patients after surgical treatment of a SLAP lesion, with a mean follow-up of 60 months (5 years), clinically using the Constant score (CS), the Rowe score, and the "subjective shoulder value" (SSV). Of these, 18 patients in group 1 (age at surgery<40 years, mean age at surgery 29 years, range: 21-39 years) and 27 patients in group 2 (age≥40 years at surgery, mean age at surgery 50 years, range: 40-60 years).

RESULTS

A mean CS of 89% (min 16%-max 105%) resulted. The Rowe score averaged 90 points (min. 35 points-max 100 points), while the SSV averaged 90% (min 20%-max 100%). In comparing the two groups, neither displayed a significant difference in the CS (p=0.198) (group 1: min 58%-max 105%, median 92%, group 2: min 16%-max 105%, median 89%) nor in the Rowe score (p=0.5) (group 1: min 55-max 100 points, median 85 points, group 2: min 35-max 100 points, median 92.5 points). The SSV also showed no significant difference in level (p=0.068) between the two groups (group 1: min 60%-max 100%, median 95%, group 2: min 20%-max 100%, median 90%), although the SSV in group 1 had a better correlation with the CS than in group 2.

DISCUSSION

The patient's age seems to have less influence on the outcome after reconstruction of SLAP than previously thought. Even at age≥40 years results show that the reconstruction results of the complex SLAP are comparable with the known literature data, and that it is good clinical practice. Impact on the long-term outcome seems to be particularly dependent on the number and severity of associated injuries, not the patient's age.

[Sport injuries and overuse damage of the elbow]

Sports injuries of the elbow joint can be acute or can arise due to chronic overuse. Such overstress syndromes are common in overhead, throwing and racket sports activities. The present article introduces diagnostic algorithms developed from knowledge gained through motion analysis, clinical examination and further imaging. The diagnosis of the overtaxing syndromes mainly depends on these findings. Basically most of the disorders in the elbow joint can be treated conservatively. If this is not the case or if the conservative treatment does not succeed, arthroscopic techniques, ligament reconstruction or nerve decompression are the major alternatives. The prognosis for regaining elbow function and returning to the previous level of performance is generally good. The resulting therapy recommendations are summarised on the basis of the current highest grades of evidence.

Scintigraphic evaluation of rhBMP-2-biocoated implants reveals no ectopic bone formation

The main objectives of the study described below were of two-fold nature: (1) to examine if rhBMP-2-biocoated implants in a pig model could lead to ectopic bone formation and (2) if quantitative and/or qualitative differences could be found between adhesively and covalently bonded BMP II using the scintigraphic method. In order to examine these central questions, 26 Göttingen minipigs were allocated to three groups with a control group (n=7) and two study groups (n=9 each) receiving one of three implant types: (a) chromosulfuric acid treated titanium surface as control, (b) non-covalently bonded BMP-2, and (c) covalently bonded and immobilized rhBMP-2. Each animal received four barbell-shaped implants, one in the proximal and distal metaphysis of each femur. The scintigraphic analyses were conducted after four, eight, and 12 weeks postoperatively. The visual (qualitative) analysis failed to show ectopic bone formation in any of the three groups. The statistical analysis of the relative values for bone formation yielded no significant differences between the groups, although the limitation in the applied methods do not enable one to draw conclusions regarding the histomophometric results.

[Biochemical analysis of the synovial fluid of the shoulder joint in patients with and without rotator cuff tears]

AIM

The biochemical changes associated with rotator cuff tearing are still unclear. The aim of this study is to assess whether concentrations of matrix metalloproteinase in the synovial fluid are specifically altered in shoulders with torn rotator cuff tendons.

PATIENTS AND METHOD

Synovial fluid was extracted via arthroscopy in 21 patients with complete rotator cuff tears (RCTs). The control group was composed of 21 patients without complete tears. The catabolic cartilage metabolism markers MMP-1 (collagenase), MMP-3 (stromelysin1) and MMP-13 (collagenase3) were quantified by an ELISA test and these results were then statistically analysed using SAS.

RESULTS

The mean concentration of the 21 samples with rotator cuff tears shows a higher concentration of MMP 3 (2601.73 ng/mL vs. 1775.67 ng/mL) and MMP 13 (2.69 ng/mL vs. 2.35 ng/mL) as well as a significantly higher concentration of MMP 1 (p=0.0047) in the control group.

CONCLUSIONS

A significant variation in the concentration of catabolic cartilage enzymes in the synovial fluid in patients with and without rotator cuff tears could not be found. Nonetheless, there is a bias for the MMP-3 and MMP-13 values, which makes a conductive influence in the aetiology of osteoarthritis probable.

[Shoulder injuries in overhead athletes: utility of MR arthrography]

INTRODUCTION

The goal of this work was to assess the accuracy of the MR-Arthrografie in the evaluation of over head athletes injuries in comparison with athroscopy.

MATERIAL AND METHODS

In 29 patients (middle age: 30 years, 21 male, 8 female, age 16 - 53 years) with persistent pain after conservative therapy an Arthro-MRI with intraarticular application of gadolinum was performed prior to arthroscopic surgery. The MRI was retrospectivly analysed of three examiners independently from one another. The result were compared to the results of the Arthroscopy. Interrater Reliability was calculated by using of Cohens Kappa.

RESULTS

The MR-Arthrography could demonstrate 8 of 9 (88.9 %) partial tears of he rotator cuff. All SLAP (Superiores Labrum from Anterior to Posterior) Lesions as well as all bankart type Lesions were recognized through the MR-Arthrography. However, dependent upon the experience of the examiner in a span between 33.3 % (fellow radiologist) and 93.3 % (consultant radiologist). We found a high agreement between consultant radiologist and shoulder surgeon with Kappa of 0.79 for rotator cuff tear-, 0.86 for Bankart- and 0.82 for SLAP-Läsionen.

[Delayed repair of traumatic shoulder girdle muscle tears]

Muscle ruptures effecting the shoulder girdle represent a comparatively rare event. Especially after delayed diagnostics, the operative result is only heavily predictable. Due to few case reports, there are no experiences to guide us. This case report describes the delayed surgical treatment of two cases of traumatic shoulder girdle muscle tears. These results encourage, that also after a long time period operative treatment can lead to a good result.

[Isolated traumatic rupture of the subscapular muscle tendon as an adolescent injury]

INTRODUCTION

Until now no case of a traumatic tear of the subascapularis muscle in children was described in the German speaking literature. Using the example of 2 cases of a 12 and 14 year boys youth history, clinic, diagnostics and therapy will be presented.

METHODS

The accident happened in extension and external rotation of the arm without dislocation. Beside the complete tear of the SCP-tendon in one case an accompanying expanded humeral flake fracture at the minor tuberosity was found. Under protection of the epiphysis line the refixation was performed using suture anchors.

RESULTS

The post-operative control after 12 months showed a complete tendon healing, no arthritis or delayed bony ingrowth with return to full activity.

CONCLUSION

Isolated traumatic SCP-tears can be occur also in young patients. As major consequence, it is necessary to perform a thorough clinical examination with additional apparative diagnostics (Sonography, MRI). This way, this rare but important lesion can be detected early and lead to adequate surgery without any delay.

Transdermal fentanyl in postoperative pain

BACKGROUND AND OBJECTIVES

The aim of this study was to determine the safety and effectiveness of a transdermal fentanyl delivery system for the relief of pain following abdominal surgery.

METHODS

In a nonblinded, noncrossover, placebo-controlled study, 40 ASA I and II patients of both sexes, 18-69 years of age, who were scheduled for abdominal surgery under general anesthesia, were randomly divided into two groups of 20 patients each. Patients in group I received a transdermal patch containing 0.16 mg/cm2 of fentanyl, which was applied to the skin over the subclavian area 60 minutes before the induction of anesthesia. For body weight less than 60 kg, a 30 cm2 patch was applied, and for weight greater than 60 kg, a 40 cm2 patch was used. A second group of 20 patients received placebo patches of identical size. Approximately 20 to 30 minutes before the expected end of surgery, 60 mg ketorolac was administered intramuscularly. Patients were observed for 36 hours after placement of the patch. If patients reported their pain at rest as 5 or greater at rest on a 0-10 visual analog scale, they were given 30-mg increments of ketorolac 5 to 7 hours apart. If this regimen did not relieve their pain, they received 1,300 mg acetaminophen between two ketorolac doses. If despite this, they still had pain 30 minutes afterward, intravenous morphine was given, and the patients were excluded from further study. The patch was removed in four patients in the fentanyl group and seven in the placebo group for various reasons, which included, inadequate pain relief requiring additional analgesia postoperatively and more than 1 microgram/kg of sufentanil given intraoperatively or immediately prior to the end of surgery. During the 36-hour observation period, 30 doses of 30 mg ketorolac and 14 doses of 1.3 g acetaminophen were given to 13 patients in the placebo group and 18 doses of ketorolac and 8 doses of acetaminophen were administered to 16 in the fentanyl group.

RESULTS

The differences in postoperative analgesic requirements were significant. Plasma fentanyl concentrations at 12 and 24 hours after the application of the fentanyl patch were 0.98 +/- 0.14 ng/mL and 1.22 +/- 0.17 ng/mL, respectively. At 8, 16, 24, and 36 hours after application of the patch, the pain relief, assessed by a VAS at rest and with movement, was similar in the two groups. In the fentanyl and control groups, 12 and 5 patients, respectively, experienced nausea, and 2 and 3 patients, respectively, vomited.

CONCLUSIONS

Similar postoperative analgesia was achieved with less parenteral analgesics in patients who received transdermal fentanyl preoperatively than in control patients. Fentanyl, 50-75 micrograms/h, administered in a transdermal delivery system, did not depress respiratory rate or hemoglobin oxygen saturation. Although the exact role of continuously administered opioids in managing acute postoperative pain has yet to be clearly defined, it is concluded that if properly used, this new transdermal device can be effective in providing a background of analgesia, which may assist in the management of acute postoperative pain as well as some chronic pain states.

Successful use of epidural blood patch for postdural puncture headache following lumbar sympathetic block

BACKGROUND AND OBJECTIVES

A 21-year-old man was scheduled for a diagnostic lumbar sympathetic block for reflex sympathetic dystrophy of the right lower extremity.

METHODS

The patient experienced paresthesias with possible puncture of a dural sleeve during needle placement under fluoroscopy. After discharge, the patient developed a positional headache, which increased in intensity over 48 hours. An epidural blood patch was subsequently performed.

RESULTS

The patient obtained complete relief from the headache.

CONCLUSION

Postdural puncture headache resulting from leakage of cerebrospinal fluid through a punctured dural sleeve may be successfully treated with an epidural blood patch should more conservative treatments fail.

Migraine headache following stellate ganglion block for reflex sympathetic dystrophy

The alteration of extracranial blood flow in conjunction with clinical signs of autonomic nervous system dysfunction have led to various explanations concerning the pathophysiology of migraine headache. Reflex sympathetic dystrophy, a painful disorder of the sympathetic nervous system, can be treated by blocking the sympathetic nerves located in the stellate ganglion, resulting in vasodilation, ptosis, miosis, and anhydrosis. In theory, these changes could trigger a migraine headache attack secondary to autonomic dysfunction reflecting an imbalance between sympathetic and parasympathetic nervous systems. This may be especially true in a patient with a previous history of meningitis that may have resulted in a disorder of cerebrovascular regulation. We report a 56-year-old man with no previous history of migraine who developed migraine with aura after a stellate ganglion block. These episodic headaches occurred with decreasing frequency and severity for over 6 months, with eventual complete resolution. This interesting phenomenon has not been reported in the English literature and may help to better understand the pathophysiology of migraine.

Cardiopulmonary complications during laparoscopy: two case reports

Laparoscopic surgery is growing in popularity. As a result, laparoscopic procedures are being done on a broader and older patient population. These patients may have underlying cardiopulmonary disease that predisposes them to complications not seen in younger patients. Anesthesiologists should be aware of this possibility and of the problems inherent to the pneumoperitoneum necessary for laparoscopy. We present two cases involving elderly patients to illustrate cardiopulmonary complications that can occur during establishment or maintenance of the increased intra-abdominal pressures required for laparoscopic surgery. The first case describes a patient who developed bradycardia and asystole during insufflation for a laparoscopic hernia repair. The second case involves severe hypercarbia and a pneumothorax due to massive subcutaneous emphysema that developed during a laparoscopic colon resection.

Subdural injection of a local anesthetic with steroids: complication of epidural anesthesia

We describe the unintentional injection of a small amount of local anesthetic with steroids into the subdural space during an attempted lumbar epidural injection for low back pain. When small volumes of local anesthetic are injected into the subdural space, a patchy and unilateral block of greater magnitude than expected will result. When larger volumes of local anesthetic are injected, a massive motor and sensory block can occur due to the small confines of this space. Accidental subdural injection must be recognized early and treated appropriately to avoid serious complications, especially in an outpatient setting.