Periprosthetic proximal humerus fractures require an individualized treatment approach-results of a multicenter retrospective study.

BACKGROUND: In the last years, there has been increasing use of shoulder arthroplasty. As a result, an increasing incidence of periprosthetic humerus fractures (PPHF) is expected. Therefore, this retrospective, multicenter analysis aimed to collect demographic data from patients with PPHF, their treatment strategies, and associated complications. METHODS: Demographics of patients with PPHF were collected retrospectively from the database of six trauma hospitals between January 2000 and December 2020. All fractures were categorized according to the Wright and Cofield, and Worland classifications. In addition, the type of treatment for PPHF, as well as subsequent complications, were evaluated. RESULTS: A total of 72 patients with a PPHF were identified. The mean age of the 55 female and 17 male patients was 77 years. PPHF occurred a mean of 50 months after primary arthroplasty implantation, almost exclusively as a result of a fall from standing height (n = 67). In-situ implant was a RTSA in 40 patients and a hemiarthroplasty in 32 patients. More than half of the fractures (n = 38) were type B fractures, according to Wright and Cofield. According to Worland, the majority of patients also had a type B fracture (type B1 (n = 22), type B2 (n = 28), type B3 (n = 10)). Associated comorbidities were found in 21 patients. A total of 31 patients were treated non-operatively, 27 with Open Reduction Internal Fixation (ORIF), and 14 with a revision arthroplasty. Nine primary radial nerve palsies were found (pre-operatively), and seven secondarily (post-operatively). Nine patients suffered from non-union (ORIF 4, non operative 4, stem replacement 1). CONCLUSION: The treatment strategy for PPHF is primarily tailored to the individual patient. Decisive factors such as patient's age, fracture type, and primary palsies have to be considered for optimal treatment. In type B1 fractures, there is a recommendation for ORIF because of high non-union rates under non-operative treatment. In contrast, in type B2 fractures, a non-operative approach should be preferred, provided there are no radial nerve lesions. LEVEL OF EVIDENCE: Level IV, epidemiologic study.

Glenohumeral Pathologies following Primary Anterior Traumatic Shoulder Dislocation-Comparison of Magnetic Resonance Arthrography and Arthroscopy.

BACKGROUND: We assessed intraarticular injuries in patients after primary anterior traumatic shoulder dislocation by comparing magnetic resonance arthrography (MRA) results with concomitant arthroscopic findings. METHODS: All patients with primary traumatic shoulder dislocation who underwent arthroscopic surgery between 2001 and 2020 with preoperative MRA were included in this study. MRA was retrospectively compared with arthroscopic findings. Postoperative shoulder function was prospectively assessed using the Disabilities of Arm, Shoulder and Hand score (quick DASH), the Oxford Shoulder Score (OSS), the Subjective Shoulder Value (SSV), as well as the rate of return to sports. RESULTS: A total of 74 patients were included in this study. A Hill-Sachs lesion was consistently found in the corresponding shoulders on MRA and arthroscopy in 35 cases (p = 0.007), a Bankart lesion in 37 shoulders (p = 0.004), and a superior labrum from anterior to posterior (SLAP) lesion in 55 cases (p = 0.581). Of all cases, 32 patients were available for a clinical and functional follow-up evaluation. A positive correlation was found between the level of sport practiced and the Oxford Shoulder Score (redislocation subset) (p = 0.032) and between the age at the time of surgery and the follow-up SSV (p = 0.036). Conversely, a negative correlation was observed between the age at the time of surgery and the Oxford Instability Score (redislocation subset) (p = 0.038). CONCLUSIONS: The results of this study show a good correlation between MRA and arthroscopy. Therefore, MRA is a valid tool for the detection of soft tissue pathologies after primary anterior traumatic shoulder dislocation and can aid in presurgical planning.

Implant-free iliac crest bone graft procedure shows anatomic remodelling without redislocation in recurrent anterior shoulder instability after short-term follow-up.

INTRODUCTION: With the help of a J-shaped bicortical iliac crest bone graft, the morphology of the glenoid can be augmented without having to use screws to achieve glenohumeral stability. The aim of this retrospective clinical study was to evaluate the clinical stability and function of the shoulder joint as well as the radiological remodelling process and arthropathic outcomes following the J-bone graft technique. MATERIALS AND METHODS: 34 patients with recurrent shoulder dislocations and bony glenoid defects were treated with the J-bone graft technique between 2010 and 2018 at our level-I trauma centre. 15 patients (18 shoulders) could be recruited for the study. Pain levels, ASES, UCLA, SST, DASH, Rowe and WOSI Scores were collected using questionnaires. In 13 patients (16 shoulders) the Constant Score, ROM, CT with 3D reconstruction of the glenoid to assess the graft remodelling and X-rays were performed additionally. RESULTS: None of the patients suffered subluxations or recurrent dislocations during the follow-up period. The overall complication rate was 11%. The evaluation using objective and subjective shoulder function scores yielded good-to-excellent results. Radiological assessment at follow-up showed a low rate of moderate-to-severe arthritis (12%) and a high rate of shoulders without any signs of arthritic degeneration (53%). The CT scans all revealed an almost complete restoration of the glenoid with none of the grafts being resorbed. A rise in the average glenoid circumference and glenoid area could be demonstrated between preoperative measurements (81.6 and 82.4%, respectively) and follow-up measurements (104 and 102.5%, respectively). CONCLUSION: The results of this study show a successful stabilisation of the shoulder joint and a low complication rate following the J-bone graft technique. Remodelling of the bone graft could be demonstrated, which in turn led to an almost perfect glenoid surface area of 100%.

Complication rate after operative treatment of three- and four-part fractures of the proximal humerus: locking plate osteosynthesis versus proximal humeral nail.

PURPOSE: There is still disagreement regarding the optimal surgical treatment of three- and four-part fractures of the proximal humerus. The aim of this monocentric, retrospective study was to compare the complication rate of internal fixation with a locking plate versus proximal humeral nailing after a one-year follow-up. METHODS: From 2005 to 2016, 292 patients suffered a fracture of the proximal humerus and were treated surgically at our level-I trauma center. According to the inclusion criteria, 50 patients were included in this study: 19 of these (11 three-part fractures and 8 four-part fractures) were treated with a proximal humeral nail (HN) and 31 (12 three-part fractures and 19 four-part fractures) with a locking plate (LP) osteosynthesis. Classification was performed according to the Hertel classification. At a 1-year follow-up, the complication rate of the two treatment methods was compared. RESULTS: Twenty patients (40%) suffered at least one complication. Of these, six patients (12%) were treated with a HN and 14 (28%) with a LP (p = 0.39). The most frequent complication was screw perforation (22%), followed by non-union (16%). Humeral head necrosis (10%) occurred only in the LP cohort. One wound infection occurred in a patient treated with a HN. Four-part fractures were treated more frequently with a LP. However, the difference was non-significant in this sample (p = 0.186). CONCLUSIONS: The results of our study provide some evidence that in terms of complication rate, both treatment options are comparable for internal fixation of three- and four-part fractures of the proximal humerus. The type of fracture seems to be decisive for the choice of implant.

Structural and molecular characteristics of axons in the long head of the biceps tendon.

The innervation of the long head of the biceps tendon (LHBT) is not sufficiently documented. This is a drawback since pathologies of the LHBT are a major source of shoulder pain. Thus, the study aimed to characterize structurally and molecularly nervous elements of the LHBT. The proximal part of 11 LHBTs was harvested intraoperatively. There were 8 female and 3 male specimens. Age ranged from 66 to 86 years. For structural analyses, nervous elements were viewed in the transmission electron microscope. For molecular characterization, we used general neuronal markers including antibodies against neurofilament and protein gene product 9.5 (PGP9.5) as well as specific neuronal markers including antibodies against myelin basic protein (MBP), calcitonin gene-related product (CGRP), substance P (SP), tyrosine hydroxylase (TH), and growth-associated protein 43 (GAP43). Anti-neurofilament and anti-PGP9.5 visualized the overall innervation. Anti-MBP visualized myelination, anti-CGRP and anti-SP nociceptive fibers, anti-TH sympathetic nerve fibers, and anti-GAP43 nerve fibers during development and regeneration. Immunolabeled sections were analyzed in the confocal laser scanning microscope. We show that the LHBT contains unmyelinated as well as myelinated nerve fibers which group in nerve fascicles and follow blood vessels. Manny myelinated and unmyelinated axons exhibit molecular features of nociceptive nerve fibers. Another subpopulation of unmyelinated axons exhibits molecular characteristics of sympathetic nerve fibers. Unmyelinated sympathetic fibers and unmyelinated nociceptive fibers express proteins that are found during development and regeneration. Present findings support the hypothesis that ingrowth of nociceptive fibers are the source of chronic tendon pain.

Molecular Pattern and Density of Axons in the Long Head of the Biceps Tendon and the Superior Labrum.

The type II superior labrum anterior to posterior (SLAP) repair is a viable option in young and demanding patients, although a prolonged period of pain after surgery is described in the literature. The reason for this fact remains unknown. Thus, the purpose of this study was to investigate the molecular pattern of the biceps tendon anchor, where the sutures for repair are placed. The long head of the biceps tendon (LHBT), including the superior labrum, was dissected in the setting of reverse total shoulder arthroplasty. Immunohistochemical staining was performed using neurofilament (NF) and protein gene product (PGP) 9.5 as general markers for axons and calcitonin gene-related peptide (CGRP) and substance P for nociceptive transmission. A quantitative assessment was performed according to the two regions of interest (ROIs), i.e., the anterosuperior (ROI I) and the posterosuperior labrum (ROI II). Eleven LHBTs with a mean age of 73 years (range: 66-87 years) were harvested intraoperatively. Six LHBTs were gained in osteoarthrosis and five in fractures. We found an inhomogeneous distribution of axons in the anterosuperior and posterosuperior parts of the labrum in all the specimens irrespective of the age, gender, and baseline situation. There was a significantly higher number (p < 0.01) as well as density (p < 0.001) of NF-positive axons in ROI I compared to ROI II. Nociceptive fibers were always found along the NF-positive axons. Thus, our results indicate that the biceps tendon anchor itself is a highly innervated region comprising different nerve qualities. The anterosuperior labrum contains a higher absolute number and density of axons compared to the posterosuperior parts. Furthermore, we were able to prove the presence of nociceptive fibers in the superior labrum. The results obtained in this study could contribute to the variability of pain after SLAP repair.

How to visualize the innervation pattern in tendons: A methodical guide.

BACKGROUND: Tendon pathologies are common and several data suggests that the peripheral nervous system is involved in this disorder. Immunohistochemistry (IHC) is one of the pillars to characterize nervous structures and their implication in the pathogenesis of chronic tendon pain. Most commonly, formalin-fixed, paraffin-embedded (FFPE) tendons are used for immunohistochemical characterization of the innervation. However, FFPE specimens exhibit major disadvantages: First, antigens (proteins) are masked and antigen retrieval is necessary to restore antigenicity. Second, FFPE specimens involve immunolabeling with enzyme-conjugated antibodies but this approach has limitations when multiple antigens are of interest simultaneously. Consequently, there is a demand in the orthopedic community for an alternative immunohistochemical approach to visualize tendon innervations. RESULTS: Here, we present a guide how to visualize tendon innervation. This guide couples paraformaldehyde fixation, cryo-embedding, immunofluorescence, and confocal laser scanning microscopy. We demonstrate the utility of our approach in the long head of the biceps tendon. For nerve fiber characterization, we used different neuronal markers including antibodies against neurofilament, protein gene product 9.5, calcitonin gene related peptide, and substance P. We show that it is possible to collect high quality, multicolor images of the innervation pattern of tendons. To map immunolabeled structures and the anatomical structures of the tendon fluorescence images and bright field images were merged. CONCLUSION: For the orthopedic community our approach might be a convenient research tool to simultaneously utilize multiple neuronal markers on the same tissue section and to define with greater accuracy the heterogeneity of tendon innervation.

Sexual dimorphism in the anatomy of the ulnar collateral thumb ligament.

BACKGROUND: Treatment of ruptured ulnar collateral thumb metacarpophalangeal (MCP) joint ligaments (UCL) necessitate a profound anatomic knowledge for optimal surgical repair in order to preserve range of motion and ensure postoperative joint stability. Therefore, knowledge of the angle between the UCL and the longitudinal axis of the first metacarpal bone could be useful. METHODS: In this study 46 ulnar collateral thumb MCP joint ligaments in 15 male and 15 female embalmed anatomic specimens were dissected and the angles between the longitudinal axis of the first metacarpal bone and the proper (PUCL) as well as the accessory ulnar collateral thumb MCP ligament (AUCL) were measured. RESULTS: In male specimens the angle for the PUCL measured on average 133.5° (±2.35°) and 122.75° (±3.8°) for the AUCL. A significantly different angle was measured for female specimens which showed on average 137.88° (±3.51°) for the PUCL and 128.65° (±4.14°) for the AUCL. CONCLUSIONS: Optimal surgical repair or reconstruction of torn ulnar collateral thumb MCP joint ligaments should aim for an angle of approximately 135° in PUCL and 126° in AUCL in relation to the longitudinal axis of the metacarpal bone. Differences in men and women should be considered if possible. LEVEL OF EVIDENCE: IV (anatomic study).

Epidemiology, treatment and outcome after compartment syndrome of the thigh in 69 cases - Experiences from a level I trauma centre.

BACKGROUND: Compartment syndrome of the thigh (CST) is a rare condition, and its delayed diagnosis and therapy may lead to devastating adverse effects. Thus, the aim of this study was to present the amassed clinical experiences, regarding diagnosis and treatment of CST at a level I trauma centre. MATERIALS AND METHODS: The database was reviewed for all patients with a manifest CST treated surgically between 1995 and 2014. RESULTS: 69 patients (61 males and 8 females) met the inclusion criteria, with a mean age of 42.9 years (range: 11-87 years). Forty-four patients (64%) presented with an isolated CST. There was a significant association between complication rates and high impact vs. blunt trauma (12/32, 38% vs. 0/20, 0%; p = 0.0022; Fisher's exact test). The number of surgeries in patients with a concomitant femur fracture was significantly increased (in mean: 2.8 vs. 4.9 surgical interventions; p < 0.001; U test). CONCLUSION: Patients after high impact trauma showed the highest complication rate. Concomitant femur fractures were associated with an increased number of surgical interventions. The synopsis of trauma mechanism, clinical presentation, age, anticoagulation status and clinical experience of the trauma surgeon seem to be the best tools to correctly diagnose CST.

Neurofilament distribution in the superior labrum and the long head of the biceps tendon.

BACKGROUND: The postoperative course after arthroscopic superior labrum anterior to posterior (SLAP) repair using suture anchors is accompanied by a prolonged period of pain, which might be caused by constriction of nerve fibres. The purpose was to histologically investigate the distribution of neurofilament in the superior labrum and the long head of the biceps tendon (LHBT), i.e. the location of type II SLAP lesions. METHODS: Ten LHBTs including the superior labrum were dissected from fresh human specimen and immunohistochemically stained against neurofilament (NF). All slides were scanned at high resolution and converted into tagged image file format, and regions of interest (ROIs) were defined as follows: ROI I-superior labrum anterior to the LHBT origin, ROI II-mid-portion of the superior labrum at the origin of the LHBT, ROI III-superior labrum posterior to the LHBT origin and ROI IV-the most proximal part of the LHBT before its attachment to the superior labrum. The entire images were automatically segmented according to the defined ROIs and measured using a programmed algorithm specifically created for this purpose. The NF-positive cells were counted, and their total size and the area of other tissue were measured separately for the different ROIs. RESULTS: Distribution of NF-positive cells in absolute numbers revealed a clear but insignificantly higher amount in favour of ROI I, representing the superior labrum anterior to the LHBT origin. Setting ROI I at 100%, a significant difference could be seen compared to ROI III, representing the superior labrum posterior to the LHBT origin (ROI I vs. ROI III with a p value < 0.05). CONCLUSIONS: Summarizing, the density of neurofilament is inhomogeneously distributed throughout the superior labrum with the highest number of neurofilament in the anterior superior labrum. Thus, suture placement in type II SLAP repair could play an important role for the postoperative pain-related outcome.

Damage control surgery - experiences from a level I trauma center.

BACKGROUND: There is still no evidence in literature for damage control orthopaedics (DCO), early total care (ETC) or using external fixation solely in fractures of the long bones in multi-system-trauma. The aim of this study was to determine parameters influencing the choice of treatment in clinical routine (DCO, ETC, or EF) in femoral or tibial shaft fractures in combination with multi-system-trauma, severe soft tissue damage or both. METHODS: Data of 236 patients with 280 fractures of long bones of the lower extremities treated at a level I trauma center were analysed. Clinical parameters on arrival (age, sex [m/f], ISS, fracture site [femur/tibia], soft tissue damage [closed or open fractures according to the Gustilo-Anderson classification], pulmonary injury [yes/no]) were collected and analysed whether they influence the choice of upcoming treatment (DCO/ETC/EF). RESULTS: Our findings showed that high ISS and severe soft tissue damage (grade III) significantly correlated with DCO. High ISS, old age, female sex and fracture site (tibia) correlated with EF. This group of sole use of external fixation had highest rate of complications, 69% were associated with at least one complication. CONCLUSION: Severely injured patients are treated significantly more often with DCO or EF. The presence of higher ISS (≥16) and of type III open fractures increased the use of DCO. However, ISS, fracture-site, patient's age, type III open fractures or sex (female) increased the use of EF compared to ETC.

Acromioclavicular joint dislocation treated with Bosworth screw and additional K-wiring: results after 7.8 years - still an adequate procedure?

BACKGROUND: The acromioclavicular (AC) joint dislocation is a major reason for shoulder instability. Different concepts of treatment and surgical methods are described in the literature. Thus, the purpose of this study was to present our data of long-term follow-up of patients having undergone treatment of acromioclavicular (AC) joint dislocation using the Bosworth Screw with additional K-wiring. METHODS: This study was conducted as a retrospective single centre data analysis. All patients treated operatively for AC joint dislocation with a Bosworth screw and additional K-wire fixation at our Department were asked to participate in this study. RESULTS: The study population consisted of 22 patients, 20 male and 2 female, with a mean age of 40 years ±15.6 years. Three grade-II lesions, 13 grade-III lesions, four grade-IV lesions and two grade-V lesions according to the Rockwood classification were found. The overall mean clinical outcome at the latest follow up was: Constant 95, DASH 6.4, ASES 94.6, SST 99.02, UCLA 33.1, ACJI 91.82 and VAS 0.29 - representing a good-to-excellent long-term outcome in all patients after at least 2 years follow-up (range; 2 - 19 years). Overall, 19 patients (86%) reported to be very satisfied with the achieved result, 15 patients (68%) reported to be able to participate in every sports activity and 16 patients (73%) reported to be able to perform their daily work without limitations. Overall, complications occurred in three patients (14%). Only one patient remained unsatisfied with the achieved result. CONCLUSION: Summarizing, our reported results showed that surgical fixation of acute AC joint dislocation with a Bosworth screw and additional K-wire fixation leads to good-to-excellent functional outcome and highly satisfactory results in the majority of patients. Despite its complications, in accordance with our results, Bosworth screw fixation with additional K-wiring in AC joint dislocation represents an adequate surgical procedure. LEVEL OF EVIDENCE: Level IV, retrospective study.

The influence of sex and trauma impact on the rupture site of the ulnar collateral ligament of the thumb.

PURPOSE AND HYPOTHESIS: Although sex- and gender-specific analyses have been gaining more attention during the last years they have rarely been performed in orthopaedic literature. The primary purpose of this study was to investigate whether for injuries of the UCL the specific location of the rupture is influenced by sex. A secondary study question addressed the sex-independent effect of trauma intensity on the rupture site of the UCL. METHODS: This study is a retrospective analysis of all patients with either a proximal or distal bony avulsion or with a mid-substance tear or ligament avulsion of the UCL treated surgically between 1992 and 2015 at two level-I trauma centres. Trauma mechanisms leading to the UCL injury were classified into the following categories: (1) blunt trauma (i.e., strains), (2) low-velocity injuries (e.g., fall from standing height, assaults), and (3) high-velocity injuries (e.g., sports injuries, motor vehicle accidents). After reviewing the surgical records, patients were divided into three groups, depending upon the ligament rupture site: (1) mid-substance tears, (2) proximal ligament or bony avulsions and (3) distal ligament or bony avulsions. Dependencies between the specific rupture site and the explanatory variables (sex, age, and trauma intensity) were evaluated using χ2 test and logistic regression analysis. RESULTS: In total, 1582 patients (1094 males, 488 females) met the inclusion criteria. Mean age was 41 years (range: 9-90 years). Taking into account the effects of sex on trauma intensity (p<0.001) and of trauma intensity on rupture site (p<0.001), mid-substance tears occurred more frequently in women, whereas men were more prone to distal ligament or bony avulsions (p<0.001). In other words, sex and rupture site correlated due to the effects of sex on trauma intensity and of trauma intensity on rupture site, but taking into account those effects there still was a significant effect of sex on rupture site. CONCLUSIONS: The results of this study demonstrate that with regression analysis both sex and trauma intensity allow to predict rupture site in UCL injuries.

Matrix Production Affects MRI Outcomes After Matrix-Associated Autologous Chondrocyte Transplantation in the Knee.

BACKGROUND: Matrix-associated autologous chondrocyte transplantation (MACT) has been an effective therapy for large, full-thickness cartilage lesions for years. However, little is known about how graft maturation is affected by characteristics of transplanted chondrocytes. PURPOSE: To investigate the influence of gene expression of chondrocytes at the time of transplantation on MRI outcomes up to 2 years after MACT. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study included 25 patients with 27 symptomatic traumatic defects of articular cartilage, who had undergone MACT in the knee. Postoperative MRI examinations were conducted at 3, 6, 12, and 24 months after surgery. Biochemical graft maturation was assessed by measuring T2 relaxation time values of the transplant and healthy native cartilage areas. The MOCART (magnetic resonance observation of cartilage repair tissue) score was used to evaluate the morphological quality of regeneration tissue. Gene expression (collagen type I, collagen type II, aggrecan, versican, and interleukin-1ß) was determined by real-time polymerase chain reaction (PCR) in transplant residuals at the time point of transplantation and was correlated with MRI outcomes using Spearman's rank correlation coefficient. A Friedman test with post hoc analysis (Wilcoxon signed rank test) conducted with a Bonferroni correction was applied to compare scores at different time points. RESULTS: T2 relaxation time of regeneration tissue improved from a mean ± SD of 74.6 ± 20.1 milliseconds at 3 months to 47.9 ±13.3 milliseconds at 24 months ( P < .003). These values were similar to the T2 relaxation times of the native surrounding cartilage (50.9 ± 15 ms). The calculated T2 index (ratio of regeneration tissue to native cartilage) improved from 1.63 ± 0.76 at 3 months to 1.0 ± 0.4 at 24 months ( P < .011). The MOCART score increased from 51.6 ± 15 points to 72.4 ± 12.2 points ( P < .001). Improvement of the T2 index over time significantly correlated with aggrecan, COL1A1, COL2A1, and versican expression ( rs = 0.9, P < .001; rs = 0.674, P < .012; rs = 0.553, P < .05; and rs = 0.575, P < .04, respectively). No correlation was found for IL-1ß. CONCLUSION: These data demonstrate that matrix production in transplanted chondrocytes affects maturation of MACT grafts in MRI 2 years after surgery.

Progression of function and pain relief as indicators for returning to sports after arthroscopic isolated type II SLAP repair-a prospective study.

BACKGROUND: One of the currently used surgical techniques in isolated type II SLAP lesions is arthroscopic SLAP repair. Postoperatively, patients tend to suffer from a prolonged period of pain and are restricted in their sports activities for at least 6 months. The aim of this study was to prospectively evaluate the clinical outcome as well as the postoperative course of pain after arthroscopic type II SLAP repair. METHODS: Outcome measures were assessed using the Individual Relative Constant Score (CSindiv), the American Shoulder and Elbow Surgeons (ASES) Score, the Visual Analogue Scale (VAS), and the Short Form 36 (SF-36). Data were collected preoperatively, as well as at 3, 6, 12 and >24 months postoperatively. RESULTS: Eleven patients with an average age of 31.8 years (range: 22.8-49.8 years) underwent arthroscopic repair of isolated type II SLAP lesions. Mean follow-up time was 41.9 months (range: 36.1-48.4 months). 6 months after surgery, there was a statistically significant improvement of function according to the CSindiv (p = 0.004), the ASES Score (p = 0.006), and the SF-36 subscale "physical functioning" (p = 0.014) and a statistically significant decrease of pain according to the VAS (p = 0.007) and the SF-36 subscale "bodily pain" (p = 0.022) compared to preoperative levels. CONCLUSIONS: Arthroscopic repair of isolated type II SLAP lesions with suture anchors leads to a satisfactory functional outcome and return to pre-injury sports levels, with delayed, but significant pain relief observed 6 months after surgery. Thus, a return to sports should not be allowed earlier than 6 months after surgery, when patients have reached pain-free function and recovered strength. TRIAL REGISTRATION: Researchregistry1761 (UIN).

Displaced Neer Type IIB distal-third clavicle fractures-Long-term clinical outcome after plate fixation and additional screw augmentation for coracoclavicular instability.

BACKGROUND: Unstable Neer Type IIB fractures require meticulous surgical treatment. Thus, the aim of this study was to present long-term outcomes after plate fixation and minimally invasive coracoclavicular (CC) stabilization using screw fixation. METHODS: A consecutive series of patients with unstable Neer Type IIB displaced clavicle fractures, treated by open reduction and internal fixation (ORIF) with a plate and additional screw fixation for coracoclavicular ligament instability, was reviewed in order to determine long-term clinical and radiological outcome. RESULTS: Seven patients, six males and one female, with a mean age of 37 ± 8 years (median: 36 years; range, 28-51 years), were evaluated. At latest follow-up, after a mean of 67 months (range, 11-117 months), patients presented with the following mean scores: DASH: 0.57, ASES: 98.81, UCLA: 34.29, VAS: 0.43, Simple Shoulder Test: 11.57. However, two complications were observed: one case of implant loosening and one non-union. There were no differences observed between the CC distances comparing postoperative X-rays to those in final follow-up. In 25% of our patients early postoperative complications occurred. In all patients reoperation was necessary to remove the implanted screw. CONCLUSION: The results of the present study indicate that the treatment of Neer Type IIB lateral clavicle fractures with ORIF using a plate and additional CC screw fixation, leads to satisfying clinical and radiological outcomes in the long-term. However, considering an early postoperative complication rate of 25% and a 100% rate of secondary surgery due to removal of the CC screw does not seem to justify this technique anymore.

Displaced juvenile Tillaux fractures : Surgical treatment and outcome.

BACKGROUND: Approximately 15 % of all juvenile injuries of the long bones involve the epiphyseal growth plate, and 2.9 % of these are juvenile Tillaux fractures. The Tillaux fracture is of great importance because it involves a major weight-bearing articular surface. Treatment protocols in the literature are not uniform for this kind of fracture, and numerous case reports can be found describing various treatment methods. The aim of this study was to present the clinical outcome at long-term follow-up after treatment of displaced Tillaux fractures. METHODS: In all, 168 children and adolescent patients with physeal injuries of the distal tibia were treated from 2003 to 2012. Seven patients were identified as having Tillaux fractures requiring surgical treatment and therefore were included in our study and evaluated retrospectively. RESULTS: Seven patients with Tillaux fractures underwent surgical reconstruction by open or closed reduction. Excellent results were achieved in 90 % of the patients, with a mean Foot and Ankle Score at the last follow-up of 98.71. CONCLUSION: Anatomical reduction is required for every displaced epiphyseal fracture via open reduction and internal fixation, especially in cases with ≥2 mm fragment displacement. Plaster cast immobilization and non-weight-bearing mobilization for at least 4 weeks might be a good way of ensuring optimal surgical results and preventing complications.

Incidence, characteristics, and long-term follow-up of sternoclavicular injuries: An epidemiologic analysis of 92 cases.

BACKGROUND: The majority of published studies concerning sternoclavicular injuries are case series or systematic reviews. Prospective studies on the subject are hindered by the low incidence of these lesions. The aims of the present study were to provide an overview of this rare entity compared with those described in the literature and to present the long-term clinical outcome. METHODS: We performed a retrospective data analysis of all sternoclavicular injuries treated at a single Level I trauma center from 1992 to 2011. Long-term clinical outcome was assessed using the ASES [American Shoulder and Elbow Surgeons], SST [Simple Shoulder Test], UCLA [University of California-Los Angeles] Shoulder Scale, and VAS [Visual Analog Scale] at latest follow-up. RESULTS: We detected an overall incidence of 0.9% of sternoclavicular injuries related to all shoulder-girdle lesions. Ninety-two patients (52 males and 40 females) with a mean (SD) age of 39.2 (19.5) years (median, 41 years; range, 4-92 years) were included in this study. The main trauma mechanism was fall. Classification was performed according to Allman, the time point of treatment after initial trauma, and the direction of the dislocation. Nine patients of the 15 Grade III lesions were treated conservatively by closed reduction and immobilization, while four patients were treated surgically by open reduction and internal fixation. Forty-nine percent of the patients were available for long-term follow-up at a median of 11.3 years (range, 5.3-22.6 years) with a mean ASES score of 96.21, SST score of 11.69, UCLA score of 31.89, and VAS score of 0.47. CONCLUSION: We found an overall incidence of 0.9% of sternoclavicular joint injuries related to all shoulder-girdle lesions and of 1.1% related to all dislocations, which is slightly lower compared with those described in the literature. Furthermore, we observed a high number of physeal sternoclavicular injuries with a percentage of 16% and overall good-to-excellent results at long-term follow-up. LEVEL OF EVIDENCE: Epidemiologic study, level IV.

Risk factors for humeral head necrosis and non-union after plating in proximal humeral fractures.

AIM: The aim of this study was to evaluate risk factors for the development of humeral head necrosis and non-union after proximal humeral fractures-in particular, general risk factors that exist independent of fracture type. MATERIALS AND METHODS: This study included patients (n=154) treated for proximal humeral fracture by means of open reduction and internal fixation (ORIF) using the Philos plate at a single level I trauma centre between January 2005 and December 2013. Follow-up monitoring included radiographic examination before hospital discharge, and again at 6 weeks, 12 weeks, and 6 months after surgery. At a minimum follow-up time of 6 months, radiographs taken in the anteroposterior and axial projection were evaluated in regard to the development of humeral head necrosis, non-union, and secondary screw cut out. RESULTS: A total of 154 patients (61 males, 93 females) were available for radiological checkup. Mean age was 55.8 years (range: 19-91 years). There were statistically significant correlations between the development of avascular necrosis (AVN) and fracture type, non-union and smoking, and screw cut out - as well as overall complication rate - and age. The time to surgery did not influence the risk for AVN or non-union, independent of fracture type. In this study population, the risk of developing non-union after ORIF was 3.9-fold higher in heavy smokers (i.e., >20 cigarettes per day). The risk for screw cut out was 4.1-fold higher in patients over 60 years of age, and the overall risk for complications was 3.3-fold higher. CONCLUSION: The older the patient, the more carefully one must consider the decision between conservative and operative treatments. If surgical treatment is performed, screw length should be selected depending on the patient's age. Heavy smokers must be informed preoperatively of the increased risk for bony non-union after ORIF.