[Frozen Shoulder - a short review for the practice].

INTRODUCTION: The Frozen Shoulder is a frequently encountered pathology in clinical practice. This condition often coexists with various comorbidities and is characterized by severe pain and a significantly restricted motion of the affected shoulder. A limited passive external rotation with the arm in adduction, with no signs of any other pathology that could explain the finding, such as shoulder osteoarthritis or an undetected posterior dislocation, is pathognomonic. The course of the disease typically spans over one to two years and is usually self-limiting. In the vast majority of cases, this condition can be managed conservatively. Keywords: shoulder, shoulder stiffness, shoulder pain, conservative therapy.

Operative vs. conservative treatment of AC-Joint Dislocations Rockwood grade ≥ III -An economical and clinical evaluation.

INTRODUCTION: Acromioclavicular joint dislocations (ACD) are one of the most common shoulder injuries. There is no consensus in how to treat higher graded ACD ≥ Rockwood grade III. This study compares operative versus conservative treatment regarding costs and clinical outcome parameters. MATERIALS AND METHODS: This retrospective, consecutive case-control-study includes 14 patients. Seven operatively treated patients were matched, by Rockwood grade, with seven conservatively treated patients. The cost was extracted out of the clinical- and insurance-based cost sheets and furthermore these include the loss of earnings. Clinical examination, demographic data as well as different outcome-questionnaires were recorded. RESULTS: There were no significant differences between operative and conservative treated patients for outcome Questionnaires. Of note, there was a significantly higher incidence of tenderness over the AC-joint (p = 0.0038) postoperatively. As expected, economical evaluation showed various findings in favor of the conservative treatment. The costs for medical services (11012.39vs.1163.81USD; p = 0.0061), days of hospitalization (3.3vs.0days; p < 0.0001); total cost for medical treatment (30262.17 vs. 7833.82 USD; p = 0.0358) were significantly higher in the operative group. CONCLUSION: Even with a limited case number and a retrospective study design almost all clinical results were equal in both groups. Operative therapy of higher graded ACDs (Rockwood > III) compared to conservative is economically inefficient. Under consideration of clinical comparable results, indications for operative treatment should be set very carefully.

Plantar Plating in the Modified Lapidus Procedure: Evaluation of Function and Impairment of the Tibialis Anterior Tendon.

The modified "Lapidus" procedure (MLP) describes the arthrodesis of the first tarsometatarsal joint. We investigate if there are detectable changes of the tendon or the function of the muscle and clinical outcome after MLP. We reviewed 22 feet. All patients underwent magnetic resonance imaging (MRI) at an average of 27 (range, 12-49) months. Clinical outcome was evaluated using the European Foot and Ankle Society score. Strength was measured and complications were assessed. MRI revealed signs of tendinopathy of the tibialis anterior tendon in 13 feet (59%). The mean total European Foot and Ankle Society score at final follow-up was 17 (range, 6-24) points. The mean postoperative Visual Analog Scale score was 1.4 (range, 0-5). Range of motion and force data were not significantly different to the contralateral side. In conclusion, MRI showed signs of tendinopathy in 59%, which does not seem to affect clinical outcome, but has to be considered when choosing the desired implant and placement. MLP leads to high patient satisfaction rates and significant improvement at midterm follow up.

The Metatarsal Cortical Index as an Indicator of Insufficiency Fracture of the Foot.

The diagnosis of metatarsal stress fractures is challenging. Standard imaging often shows false-negative results. The aim of this study was to create reliable radiologic outcome parameters to predict insufficiency fractures of the metatarsals. We performed an age- and sex-matched case-control study of patients with (n = 18) and without insufficiency fracture (n = 18) of the foot. The metatarsal cortical index (MCI) for each metatarsal was developed to predict an insufficiency fracture. The MCI of each metatarsal was significantly decreased in the insufficiency fracture group compared with the control group (p < .01). The MCI of the fourth ray yielded the highest area under the curve among the analyzed MCI values (area under the curve, 0.79; 95% confidence interval, 0.61-0.90). A cut-off value of 1.62 for the MCI of the fourth ray yielded a sensitivity of 78% and a specificity of 78% to predict insufficiency fracture of the foot (odds ratio, 12.25; 95% confidence interval, 2.54-58.97), and enabled accurate allocation to the insufficiency fracture group versus the control group in 74% of cases. In conclusion, a decreased MCI is associated with metatarsal insufficiency fractures and enables an accurate diagnosis in 3 out of 4 cases. The MCI might aid clinicians in identifying insufficiency fracture, and raise the suspicion of the diagnosis without additional imaging studies.

Structural and Functional Results of Subscapularis and Conjoint Tendon After Latarjet Procedure at 8-Year Average Follow-up.

BACKGROUND: The Latarjet procedure involves initial dissection through a longitudinal split of the subscapularis tendon with only a final partial closure to accommodate the transferred coracoid bone. Furthermore, by transferring the coracoid bone block to the anterior glenoid, the surgeon completely alters the resting and dynamic route of the attached conjoint tendon. The eventual structural and functional integrity of the subscapularis and conjoint tendons is currently unknown. PURPOSE: To examine the structural and functional integrity of the subscapularis and the conjoint tendon after the Latarjet procedure at an 8-year average follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Twenty patients with anterior shoulder instability at a mean age of 30 years (range, 19-50 years) underwent the open Latarjet procedure. Clinical examination at the final follow-up included quantitative isometric measurement of abduction and internal rotation strength compared with the nonoperative side. Patients were assessed via radiograph examination and preoperative computed tomography. Final position and healing of the transferred coracoid bone block were evaluated using standard radiographs. At follow-up, the subscapularis and conjoint tendon were evaluated via magnetic resonance imaging (MRI) with metal artifact reduction techniques and via ultrasound. RESULTS: Nineteen of the 20 shoulders remained stable at the final follow-up; there was 1 redislocation (5%) after 14 months. The mean Rowe score was 83 points (SD, 17.9 points), the mean Constant score was 85 points (SD, 8.1 points), and the Subjective Shoulder Value was 80% (SD, 18%). The mean abduction strength of the operative shoulder was 7.41 ± 2.06 kg compared with 8.33 ± 2.53 kg for the nonoperative side (P = .02). The mean internal rotation strength at 0° for the operative shoulder was 8.82 ± 3.47 kg compared with 9.06 ± 3.01 kg for the nonoperative side (P = .36). The mean internal rotation strength in the belly-press position for the operative shoulder was 8.12 ± 2.89 kg compared with 8.50 ± 3.03 kg (P = .13). Four of 20 shoulders showed mild tendinopathic changes of the subscapularis tendon but no partial or complete tear. One patient exhibited fatty degeneration Goutallier stage 1. Conjoint tendon was in continuity in all 20 shoulders on MRI scans. CONCLUSION: Abduction, but not internal rotation strength, was slightly reduced after the Latarjet procedure at a mean of 8 years of follow-up. The subscapularis tendon was intact based on ultrasound examination, and the conjoint tendon was intact based on MRI scans. Subscapularis muscle girth relative to the supraspinatus muscle remained intact from preoperative measurements based on MRI scans.

How Should We Grade Cervical Disk Degeneration? A Comparison of Two Popular Classification Systems.

INTRODUCTION: Despite being originally developed for the evaluation of lumbar disk degeneration, the Pfirrmann classification has emerged as the most popular classification system for cervical disk degeneration. However, with the Suzuki classification, a new classification system that is specifically tailored for the evaluation of cervical disk disease was introduced. In this study, we aim to evaluate differences in inter- and intraobserver reliability of both classifications in a head-to-head comparison. METHODS: In total, we have evaluated 120 cervical disks within 40 patients via magnetic resonance imaging according to the Pfirrmann and Suzuki classification. The degree of disk degeneration was evaluated by two independent musculoskeletal radiologists. After 6 months, the classification was reassessed to evaluate the intraobserver reliability. The inter- and intraobserver reliabilities were then calculated using Cohen's kappa. RESULTS: The inter- and intraobserver reliability provided a significant agreement between all ratings in Pfirrmann as well as the Suzuki classification (p>0.001). The interobserver reliability was determined to be fair in both the Suzuki classification (κ=0.290) and the Pfirrmann classification (κ=0.265). The intraobserver reliability was substantial in the Suzuki classification (κ=0.798), while it was almost perfect in the Pfirrmann classification (κ=0.858). CONCLUSIONS: Although not designed for the evaluation of cervical disk degeneration, the Pfirrmann classification yielded equal inter- and higher intraobserver reliability. Both classification systems are viable options for the grading of cervical disk degeneration. While the Pfirrmann classification has the advantage of being better established, the Suzuki classification may be clinically superior due to a better representation of cervical disk degeneration and the consideration of disk bulging for the classification of cervical disk degeneration.

Non-Adherence to Pain Medication Increases Risk of Postoperative Frozen Shoulder.

BACKGROUND: Postoperative frozen shoulder (FS) or adhesive capsulitis is a relatively frequent complication (5-20%), even after simple arthroscopic shoulder surgeries. The pathophysiology is still unclear, but psychological factors may play a pivotal role. From clinical experience, we hypothesized that patients, who are reluctant to take medications, particularly "pain-killers," have an increased incidence of postoperative FS. METHODS: We identified twenty patients who underwent limited arthroscopic operations of the shoulder and developed postoperative FS. Twenty patients with matching type of surgery, age, and gender served as control group (n = 20). All patients were at least one year postoperative and asymptomatic at the time of examination. Demographic data, the patient's adherence to self-medication (including self-medicating scale, SMS), development the Quality of life (QoL), and depression scale (PHQ-4-questionnaire) were assessed. RESULTS: Patients with FS had a 2-fold longer rehabilitation and 3-fold longer work inability compared to the patients without FS (P < 0.009 and P < 0.003, respectively). Subjective shoulder value SSV (P = 0.075) and post-operative improvement of QoL (P = 0.292) did not differ among the groups. There was a trend-but not significant-toward less coherence to self-medication in the FS-group (26.50 vs. 29.50; P = 0.094). Patients with postoperative FS significantly more often stated not to have "taken pain-killers as prescribed" (P = 0.003). CONCLUSIONS: Patients reporting unwillingness to take the prescribed pain medications had a significantly higher incidence of postoperative FS. It remains unclear whether the increased risk of developing FS is due to reduced postoperative analgesia or a critical attitude toward taking medication. However, patients who are reluctant to take painkillers should strongly be encouraged to take medications as prescribed.

Characterization of Deposits in Calcific Tendinitis of the Shoulder: Deposits Are Composed of Large Aggregates of Highly Crystalline, Rod-Like Crystals.

BACKGROUND: In the current literature, deposits in calcific tendinitis are described as amorphous masses of hydroxyapatite with a size in the range of 5 to 20 µm. Theoretically, these are too big to be phagocytized by macrophages and induce an inflammatory reaction. PURPOSE: To better characterize the deposits seen in calcific tendinitis. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Included in the study were 6 patients with a history of at least 1 year of shoulder pain (range, 1-14 years). Shoulder arthroscopy was performed under general anesthesia, and calcium deposits from the supraspinatus tendon and biopsies from the adjacent subacromial bursa were taken. Samples were analyzed by light microscopy and immunostained for macrophages. Scanning electron microscopy and energy-dispersive x-ray (EDX) analysis were used to assess the morphology and chemical composition of the calcific deposits. RESULTS: Light microscopy showed round and bulky calcium deposits partially surrounded by activated CD68-positive macrophages within inflammatory tissue. Some hemosiderin positive mononuclear cells, indicative for (micro-) hemorrhage, were seen. Scanning electron microscopy revealed that the large calcific deposits (1-20 µm) were composed of rod-like structures. These highly crystalline rods had a size of approximately 100 nm in length and 20 nm in width. Chemical composition by EDX analysis showed that crystals were composed of mainly calcium, oxygen, and phosphorus, equaling the chemical composition of hydroxyapatite. CONCLUSION: Deposits in calcific tendinitis of the rotator cuff are not amorphous but composed of highly crystalline structures. Fragmentation of these aggregates and subsequent release of the needle-like nanocrystals might initiate the strong inflammatory reaction often seen in patients with calcifying tendinitis of the rotator cuff.

Plate Fixation for Irreducible Proximal Humeral Fractures in Children and Adolescents-A Single-Center Case Series of Six Patients.

BACKGROUND: Recommended treatment for severely displaced proximal humeral fractures in children is the closed reduction and percutaneous fixation by K-wires or intramedullary nailing. METHODS: From January 2016 to January 2017 6, 21 children/adolescents (range 8 to 16 years) with proximal humeral fractures were treated surgically for severe displacement. In these six patients, several attempts of closed reduction were unsuccessful, and an open reduction was performed. The humeral head was fixed with a 3.5 mm T-plate without affecting the growth plate. Plate removal was performed at a mean interval of 132 days after initial surgery. Two years after initial surgery, the clinical outcome was assessed by the Constant-Murley score and QuickDASH score (including sport/music and work) and the shoulder joint was evaluated with a standardized sonographic examination for the rotator cuff and the conjoint tendon. RESULTS: In all six patients, dorsal displacement of the fracture was irreducible due to the interposition of tendinous or osseous structures. Intraoperatively, the interposed structures were the long biceps tendon in two, periosteal tissue in two, a bony fragment in one, and the long biceps tendon together with the conjoint tendon in one case. At mean follow-up of 26 months (range 22 months to 29 months), patients showed very good clinical results with an excellent mean Constant-Murley score of 97.5 (range 91 to 100) and mean QuickDASH score (including sport/music and work) of 5.5 (range 0-20.8). An X-ray follow-up 6 weeks after surgery demonstrated early consolidation and correct alignment in all patients. A sonographic evaluation at 2 years post injury showed that the biceps and the conjoined tendon were intact in all patients. CONCLUSIONS: If a proximal humeral fracture is not reducible by closed means, a tissue entrapment (most likely biceps tendon) should be considered. Treatment with an open reduction and plate fixation yields very good clinical and radiological results and preserves interposed structures as the biceps and conjoint tendon.

Swiss-wide multicentre evaluation and prediction of core outcomes in arthroscopic rotator cuff repair: protocol for the ARCR_Pred cohort study.

INTRODUCTION: In the field of arthroscopic rotator cuff repair (ARCR), reporting standards of published studies differ dramatically, notably concerning adverse events (AEs). In addition, prognostic studies are overall methodologically poor, based on small data sets and explore only limited numbers of influencing factors. We aim to develop prognostic models for individual ARCR patients, primarily for the patient-reported assessment of shoulder function (Oxford Shoulder Score (OSS)) and the occurrence of shoulder stiffness 6 months after surgery. We also aim to evaluate the use of a consensus core event set (CES) for AEs and validate a severity classification for these events, considering the patient's perspective. METHODS AND ANALYSIS: A cohort of 970 primary ARCR patients will be prospectively documented from several Swiss and German orthopaedic clinics up to 24 months postoperatively. Patient clinical examinations at 6 and 12 months will include shoulder range of motion and strength (Constant Score). Tendon repair integrity status will be assessed by ultrasound at 12 months. Patient-reported questionnaires at 6, 12 and 24 months will determine functional scores (subjective shoulder value, OSS), anxiety and depression scores, working status, sports activities, and quality of life (European Quality of Life 5 Dimensions 5 Level questionnaire). AEs will be documented according to a CES. Prognostic models will be developed using an internationally supported regression methodology. Multiple prognostic factors, including patient baseline demographics, psychological, socioeconomic and clinical factors, rotator cuff integrity, concomitant local findings, and (post)operative management factors, will be investigated. ETHICS AND DISSEMINATION: This project contributes to the development of personalised risk predictions for supporting the surgical decision process in ARCR. The consensus CES may become an international reference for the reporting of complications in clinical studies and registries. Ethical approval was obtained on 1 April 2020 from the lead ethics committee (EKNZ, Basel, Switzerland; ID: 2019-02076). All participants will provide informed written consent before enrolment in the study. TRIAL REGISTRATION NUMBER: NCT04321005. PROTOCOL VERSION: Version 2 (13 December 2019).

Cerebrospinal fluid proteome shows disrupted neuronal development in multiple sclerosis.

Despite intensive research, the aetiology of multiple sclerosis (MS) remains unknown. Cerebrospinal fluid proteomics has the potential to reveal mechanisms of MS pathogenesis, but analyses must account for disease heterogeneity. We previously reported explorative multivariate analysis by hierarchical clustering of proteomics data of MS patients and controls, which resulted in two groups of individuals. Grouping reflected increased levels of intrathecal inflammatory response proteins and decreased levels of proteins involved in neural development in one group relative to the other group. MS patients and controls were present in both groups. Here we reanalysed these data and we also reanalysed data from an independent cohort of patients diagnosed with clinically isolated syndrome (CIS), who have symptoms of MS without evidence of dissemination in space and/or time. Some, but not all, CIS patients had intrathecal inflammation. The analyses reported here identified a common protein signature of MS/CIS that was not linked to elevated intrathecal inflammation. The signature included low levels of complement proteins, semaphorin-7A, reelin, neural cell adhesion molecules, inter-alpha-trypsin inhibitor heavy chain H2, transforming growth factor beta 1, follistatin-related protein 1, malate dehydrogenase 1 cytoplasmic, plasma retinol-binding protein, biotinidase, and transferrin, all known to play roles in neural development. Low levels of these proteins suggest that MS/CIS patients suffer from abnormally low oxidative capacity that results in disrupted neural development from an early stage of the disease.

Scarf osteotomy for hallux valgus deformity: Radiological outcome, metatarsal length and early complications in 118 feet.

BACKGROUND: Scarf osteotomy has been widely used to restore axial orientation of the first ray in the treatment of hallux valgus deformity. The aim of the study was to present our radiological outcomes of bunion reconstruction, identify surgical complications in early follow-up, and assess to what extent a shortening of the first metatarsal is present after surgery as a possible cause of postoperative metatarsalgia. METHODS: We enrolled 106 patients (118 feet) and assessed patients' pre- and postoperative measurements of hallux valgus and intermetatarsal angles on weightbearing X-ray images. Three different methods of measuring metatarsal length were compared and early postoperative complications noted. RESULTS: Hallux valgus angle decreased significantly by an average of 18.7 degrees and the intermetatarsal angle by 7.8 degrees. Using three methods of measuring metatarsal length, all showed significant shortening of the first metatarsal. Mean relative lengthening of the second metatarsal averaged 0.45mm. The Coughlin method showed the highest interrater reliability (ICC=0.96). CONCLUSIONS: Significant reduction of the hallux valgus angle and intermetatarsal angle was demonstrated with a low complication rate. There was significant shortening of the first metatarsal. The Coughlin method clearly demonstrated an excellent interrater reliability. LEVEL OF EVIDENCE: Level IV.

Long-Term Clinical and Radiological Results After Hook Plate Osteosynthesis of Lateral Clavicle Fractures.

OBJECTIVES: To assess both clinical and radiological long-term outcomes after hook plate osteosynthesis for Neer type II lateral clavicle fractures. DESIGN: Retrospective case series. SETTING: Level-1 trauma center. PATIENTS/PARTICIPANTS: Patients who underwent open reduction internal fixation with a hook plate for displaced fractures of the lateral third of the clavicle (Neer type II) at a single trauma hospital were identified. INTERVENTION: Lateral clavicle open reduction internal fixation with a hook plate. MAIN OUTCOME MEASURES: At the first of 2 long-term follow-up appointments, bilateral magnetic resonance imaging (MRI) scans and strength measurements were performed, Constant-Murley score, subjective shoulder value (SSV), and Oxford shoulder score (OSS) of both shoulders were obtained. At the second follow-up, specific acromioclavicular (AC) score, SSV, and OSS were obtained. RESULTS: Twenty-one patients (mean age, 29.5 ± 9.7 years) could be included who were available for at least 1 of 2 follow-ups after 7.4 years (±2.3) and 13.9 years (±2.2). Bony union was achieved in all patients (100%) at an average of 3.4 months (±1.4). The hook plate was removed at an average of 5.5 months (±3.3) after initial surgery in all patients. No significant side-to-side differences were found in OSS, Constant-Murley score, SSV, and specific AC score and for strength testing and MRI scans. CONCLUSIONS: Long-term outcome after hook plate fixation of Neer type II lateral clavicle fractures demonstrated good clinical results and shoulder strength without higher radiographic rates of AC joint osteoarthritis, subacromial impingement, or rotator cuff lesions. That may be related to a standardized early plate removal after bony fracture union. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Cervical disc degeneration reduces distance between vertebral artery and surgical landmarks.

PURPOSE: Anterior cervical decompression surgery exposes the vertebral artery to the risk of injury. This risk can increase if the natural course of the vertebral artery is altered. Therefore, this study evaluated if the distance between surgical landmarks and the vertebral artery decrease with the progression of cervical disc degeneration. METHODS: This study analyzed 40 patients with cervical magnetic resonance imaging. We evaluated the distance between the uncinate process and the vertebral artery in axial-plane T2 weighted sequences of the cervical levels C3-C6. The cervical disc degeneration was graded according to the Pfirrmann- and Suzuki classification. The decrease of the distance was evaluated using a one-way ANOVA. RESULTS: The distance between the uncinate process and the vertebral artery decreased with increasing disc degeneration (p ≤ 0.015). ROC analysis provided an acceptable area under the curve in both classifications for the detection of a vertebral artery to the uncinate process distance of zero. The presence of Pfirrmann grade V had a positive predictive value of 69% for the presence of contact between the uncinate process and the vertebral artery. CONCLUSION: High-grade cervical disc degeneration according to the Pfirrmann- and the Suzuki classification decrease the distance between the uncinate process and the vertebral artery. High-grade disc degeneration therefore should raise the awareness of the surgeon for the loss of the distance between surgical landmarks and the vertebral artery. However, screening for high-grade disc degeneration alone cannot substitute the thorough evaluation of the anatomical course of the vertebral artery before surgery.

Nonoperative Treatment of Anterior Glenoid Rim Fractures After First-Time Traumatic Anterior Shoulder Dislocation: A Study with 9-Year Follow-up.

Primary traumatic anterior shoulder dislocations can be associated with displaced anterior glenoid rim fractures. Nonoperative treatment of such fractures has been shown to have excellent results in a small cohort of patients; as such, we have been treating these fractures nonoperatively, regardless of fragment size and degree of displacement, provided that post-reduction computed tomography scans revealed an anteroposteriorly centered humeral head. The aim of this study was to analyze the medium- to long-term results of nonoperative treatment of displaced anterior glenoid rim fractures, assessing in particular the residual instability and development of osteoarthritis. METHODS: In a 2-center study, 30 patients with a mean age of 48 years (range, 29 to 67 years) were evaluated clinically with use of the Subjective Shoulder Value, Constant score, American Shoulder and Elbow Surgeons score, and Western Ontario Shoulder Instability index, as well as radiographically with use of radiographs and computed tomography scans at a mean follow-up of 9 years (range, 5 to 14 years). RESULTS: Fracture-healing was documented in all patients. Seven patients (23%) had post-fracture onset of osteoarthritis (5 with Samilson grade I and 2 with Samilson grade IV). Of these, 1 patient had recurrent instability that was successfully treated with hemiarthroplasty 9 years after the index injury (relative Constant score, 101%), and was excluded from further analysis. No other patient had a recurrent redislocation, subluxation, or positive apprehension. The other 6 patients with new-onset radiographic osteoarthritis were pain-free (mean Constant score pain scale, 15 points) with good shoulder function (relative Constant score, 84% to 108%). A total of 26 patients (90%) rated their functional outcome as good or very good, and 3 patients (10%) rated it as fair. The mean relative Constant score was 97% (range, 61% to 108%), the mean American Shoulder and Elbow Surgeons score was 92 points (range, 56 to 100 points), and the mean Western Ontario Shoulder Instability index score was 126 points (range, 0 to 660 points). All patients returned to full-time work. CONCLUSIONS: Nonoperative treatment of anterior glenoid rim fractures following primary traumatic anterior shoulder dislocation results in excellent clinical outcomes with a very low rate of residual instability and, thus, treatment failure. Asymptomatic radiographic osteoarthritis occurred in roughly 1 of 4 patients. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A cadaveric study of the three different palpation-guided techniques for glenohumeral joint injections.

BACKGROUND: It is not known whether an anterior, posterior or superior approach using the Neviaser portal is more accurate for glenohumeral joint injections. The aim of this study was to evaluate the accuracy of the palpation-guided technique and compare the three different approaches. METHODS: Palpation-guided glenohumeral joint injections were performed in 48 shoulders (24 cadavers) by two operators. Each shoulder was injected by three different approaches with a different coloured latex solution. The three approaches included the anterior, posterior and superior methods. The accuracy and location of unsuccessful injections were assessed through dissection of the shoulders. RESULTS: Posterior injections were the most successful with an accuracy rate of 89.6%, followed by anterior injections (75%) and superior injections (54.2%). Both posterior (p = 0.0001) and anterior injections (p = 0.03) were statistically significantly more accurate than superior injections. The most common failure mode was an intratendinous or intramuscular injection, which occurred most frequently with a superior approach. CONCLUSIONS: Use of a superior approach through the Neviaser portal for the palpation-guided technique for glenohumeral joint injections showed a statistically significant inferior accuracy when compared to both the posterior and anterior approaches and is therefore not recommended. Posterior approached injections were the most accurate.

Risk factors for secondary displacement in conservatively treated proximal humeral fractures.

AIMS: Conservative treatment of moderately displaced proximal humeral head fractures yields good clinical results, but secondary fragment displacement may occur. Identification of those fractures at risk of displacement may influence initial decision-making. METHODS: A total of 163 shoulders in 162 patients with conservatively treated isolated proximal humeral fractures were included. The fractures occurred between January 2015 and May 2018. The mean age of the patients was 69 years (26 to 100) and the mean follow-up was 144 days (42 to 779). The fractures were classified according to Neer. Scores for osteoporosis (Tingart, Deltoid Tuberosity Index (DTI)) and osteoarthritis (OA) of the glenohumeral joint were assessed. Translation of the head on follow-up radiographs of more than 10 mm was defined as displacement. Eccentric head index (EHI) describes the offset of the humeral head centre in relation to the diaphyseal axis. The ratio was estimated on anteroposterior (AP) and Neer views. Medial hinge was considered intact if the medial cortex proximal and distal to the fracture was in line on AP view. RESULTS: Secondary fracture displacement occurred in 41 patients (25.2%). Clinical risk factors were alcohol abuse (odds ratio (OR) 6.8; 95% confidence interval (CI) 1.3 to 36; p = 0.025) and previously diagnosed osteoporosis (OR 4.6; 95% CI 0.6 to 34; p = 0.136). Age (OR 1.1; 95% CI 1.0 to 1.1; p = 0.003) and sex (OR 0.9; 95% CI 0.3 to 2.8; p = 0.867) were not independent factors. Radiological risk factors were OA grade 3 (OR 16.4; 95% CI 0.25 to 37.6; p = 0.107) and osteoporosis with the DTI (OR 10; 95% CI 0.8 to 250; p = 0.031) being more predictive than the Tingart score (OR 2.3; 95% CI 0.8 to 4.7; p = 0.041). A high EHI (AP/Neer > 0.4, OR 18.9; 95% CI 2.1 to 30.9/3.0; 95% CI 1.1 to 8.0; p = 0.002/p = 0.033) and a disrupted medial hinge (OR 3.7; 95% CI 1.1 to 12.6; p = 0.039) increased the risk of secondary displacement significantly. Neer classification had no influence. CONCLUSION: During conservative treatment, a quarter of patients showed secondary fracture displacement of at least 10 mm. Patients with alcohol abuse, severe OA, and osteoporosis are at risk. Newly defined EHI and disrupted medial hinge are relevant predictors for secondary displacement. Cite this article: Bone Joint J 2020;102-B(7):881-889.

Innervation of the acromioclavicular joint by the suprascapular nerve.

BACKGROUND: The suprascapular nerve is largely responsible for the majority of the sensory innervation of the acromioclavicular joint. In this anatomical study, we describe, in detail, the anatomy of the sensory innervation of the acromioclavicular joint by the branches of the suprascapular nerve. METHODS: Twenty-seven shoulders from 17 cadaveric specimens were carefully dissected to identify the course of the suprascapular nerve, with the main focus being on the sensory innervation of the acromioclavicular joint. Nine specific measurements of the acromioclavicular joint sensory nerves were made of each shoulder in relation to distinct anatomical landmarks to determine the mean location and course of these nerves. RESULTS: In all 27 shoulders (100%), a sensory branch to the acromioclavicular joint with a proximal origin from the suprascapular nerve could be depicted ("first sensory branch"). The mean length of this branch was 4.3 cm (range: 3.3-5.3 cm). In 14 shoulders (52%), a further sensory branch of the suprascapular nerve innervating the posterior acromioclavicular joint capsule could be identified ("second sensory branch"). DISCUSSION: A detailed anatomical description of the sensory innervation of the acromioclavicular joint from suprascapular nerve branches was performed, which can potentially aid in the development of more focused anesthetic blockades and acromioclavicular joint denervation procedures.

Guided growth with tension band plate or definitive epiphysiodesis for treatment of limb length discrepancy?

BACKGROUND: It is not exactly known whether guided growth or definitive epiphysiodesis techniques are superior in treating limb length discrepancy (LLD). The purpose of the present study was therefore to find out if definitive epiphysiodesis is associated with more powerful LLD correction than tension band plate epiphysiodesis. METHODS: Pediatric patients with LLD treated either with tension band plating as a guided growth technique (temporary epiphysiodesis) or a percutaneous drilling technique (definitive epiphysiodesis) around the knee and a minimum follow-up of 12 months were included in this retrospective study. Radiographic measurements were performed by two independent reviewers. The reduction in side difference between preoperative radiographs and last follow-up was calculated and compared between surgical techniques. RESULTS: Thirty-eight patients (mean age 13.6 years) were included, 17 treated with temporary and 21 with definitive epiphysiodesis. Average follow-up was at 578 days. The reduction of the LLD in 12 months was 5.7 mm in patients treated with temporary epiphysiodesis and 8.4 mm with definitive epiphysiodesis, respectively (p = 0.22). In both groups, LLD could be statistically significantly reduced after 12 and 24 months. Definitive epiphysiodesis had a lower revision rate (4.8% vs. 17.6%). Intra- and interobserver reliability of the measurements was excellent. CONCLUSIONS: As in earlier studies supposed, temporary epiphysiodesis with tension band plating seems to correct LLD less powerful compared to definitive percutaneous epiphysiodesis. However, in the present study, the differences of LLD correction were not statistically significant. We do not recommend the use of tension band plates for LLD correction due to inferior correction with higher complication and revision rate.