[Periprosthetic humeral fractures: from osteosynthesis to prosthetic replacement]. / Periprothetische Humerusfraktur ­ von der Plattenosteosynthese bis zum Prothesenwechsel.

OBJECTIVE: Stabilization of the humeral shaft and the restoration of shoulder function dependent on the osseous integrity of the prosthetic stem component. INDICATIONS: In cases of a stable prosthesis stem, an isolated plate osteosynthesis is possible. Prosthesis stem replacement is indicated in cases of a loose stem. With sufficient bone stock of the proximal humeral segment, a change to a shorter humeral shaft component with subsequent plate fixation of the fracture is possible. If the bone stock is poor, conversion to a long revision stem is necessary. CONTRAINDICATIONS: Inoperability of the patient due to serious comorbidities. Advanced age and low demands on shoulder function are relative contraindications for complex prosthesis replacements. SURGICAL TECHNIQUE: Plate osteosynthesis can be done through an anterior or posterior approach, stem replacement only from anterior deltopectoral approach. When changing humeral shaft components, the loose shaft and all cement residues are removed, the fracture is reduced and, if possible, a shorter shaft is implanted with subsequent plate osteosynthesis of the fracture. When changing to a long revision stem, additional osteosynthesis with cerclages wires is usually sufficient. In case of poor bone stock, an additive autologous or allogenic bone grafting can be performed. An instable anatomical prosthesis with poor shoulder function may require conversion to an inverse prosthesis. POSTOPERATIVE MANAGEMENT: In cases of an isolated plate osteosynthesis with an otherwise stable prosthesis, immediate active rehabilitation of the upper limb is advocated. When a prosthesis replacement and conversion to an inverse prosthesis is performed the shoulder is immobilized in 30° abduction for 6 weeks. Passive and after 3 weeks active-assistive shoulder movement up to 90° abduction and flexion is allowed. RESULTS: In 40 patients with a periprosthetic humeral fracture, an isolated plate osteosynthesis was performed in 30 cases and a prosthesis replacement in 10 cases. Complications included 3 infections and 3 temporary radial nerve palsies. Revisions due to pseudarthrosis were necessary in 2 cases.

[Instability after operative and conservative treatment of isolated Mason type II fractures]. / Instabilität nach operativer und konservativer Versorgung von isolierten Mason-II-Frakturen.

BACKGROUND: Radial head fractures are the most frequent fractures of the elbow joint in adults. For Mason type II fractures without concomitant injuries favorable results have been shown with operative and conservative management. There is insufficient evidence concerning elbow joint stability after conservative treatment compared to open reduction and internal fixation (ORIF). MATERIALS AND METHODS: All patients with isolated Mason type II (two part fracture displaced >2 mm and <5 mm) radial head fractures between 1 January 2003 and 1 April 2013 were retrospectively reviewed. Exclusion criteria were age <18 years, associated fractures of the ipsilateral extremity or elbow luxation. A total of 50 patients (mean age 44.2 years, range 19-71 years) who received either ORIF (n = 31) or conservative treatment (n = 19) were included. The mean follow-up was 43.2 months (range 9-61 months). Patients were evaluated using the Disability of the Arm, Shoulder and Hand (DASH) score, Mayo Elbow Performance score (MEPS), and Oxford Elbow score (OES). Joint stability (varus and valgus stress) was assessed under fluoroscopy and a distinction was made between slight instability (angulation <10°), moderate instability (angulation ≥10°) and gross instability (elbow dislocation). RESULTS: Residual fracture displacement (conservative: 2.7 mm, ORIF: 1.4 mm, p < 0.042) and varus/valgus joint stability (3% ORIF vs. 26% conservative, p = 0.031) showed significant differences. The stability as tested by a radiological dynamic procedure showed an instability after ORIF in 3% of the joints compared to 26% after conservative treatment; however, this did not influence the short to mid-term clinical outcome: No significant differences were found in the DASH score (conservative 33 points, ORIF 36 points), MEPS (conservative 76 points, ORIF 78 points) and OES (conservative 41 points, ORIF 43 points). DISCUSSION: Both conservative management and operative treatment had a good functional outcome. Operative treatment showed a positive tendency concerning radiological and functional outcome without statistical significance.

[Bony Bankart lesions and glenoid defects : From refixation techniques to bony augmentation]. / Knöcherne Bankart-Läsion und Glenoiddefekte : Von Techniken der Refixierung bis zur knöchernen Augmentation.

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

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

BACKGROUND: How the shape of the glenoid defect being reconstructed influences stability in reversed shoulder arthroplasty has never been evaluated. The purpose of this study was to compare the reconstruction of two different shaped defects in reversed shoulder arthroplasty. METHODS: Two groups (ten Sawbone scapulae each) of oblique- and rectangular-shaped glenoid defects were tested biomechanically. On the anterior half of the glenoid, bony defects (rectangular and oblique shaped) were prepared and reconstructed subsequently with a graft and reversed shoulder arthroplasty. As a control group, Sawbones without glenoid deficiency were used. In addition, these tests were reproduced in cadavers. FINDINGS: In Sawbones, no significant difference in initial stability was found between the two groups (p>0.05). Additionally, in the cadaver tests no significant difference was found between the groups with different defects (p>0.05). During the preparation, macroscopic loosening of the oblique bone grafts was found in three cases after the performance of the reversed shoulder arthroplasty due to the lack of medial support. The localization of the highest micromotion were measured primarily between the scapula bone and the graft compared to the measured micromotions between glenoid implant and the graft. INTERPRETATION: If the oblique-shaped bone graft was secured under the baseplate, the rectangular defect preparation did not show a significantly higher primary stability. However, the advantage of medial support in rectangular defects leads to more stability while placing the bone graft and baseplate during the surgical technique and should therefore be considered a preferable option.

[Chronic bony instability of the elbow joint]. / Chronische knöcherne Instabilitäten des Ellenbogengelenkes.

The high stability of the elbow joint is provided by the congruent articular surfaces in combination with soft tissue stabilizers. The main osseous contributor of elbow stability is the coronoid, which is therefore referred to as a primary stabilizer. The radial head as a secondary stabilizer together with the medial collateral ligament assures valgus stability and together with the coronoid it assures posterolateral stability. Insufficiency of the osseous stabilizers may lead to difficulties in the treatment of chronic dislocation and complex instability. Thereby reconstruction of the osseous constraints of the elbow joint is not performed in isolation from addressing insufficient soft-tissue stabilizers. Bony stabilizers and reconstructional procedures are discussed in this review.

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

AIMS: Our aim was to investigate the outcomes of patients with a displaced fracture of the glenoid fossa who are treated conservatively. There is little information in the literature about the treatment of these rare injuries non-operatively. PATIENTS AND METHODS: We reviewed 24 patients with a mean age of 52 years (19 to 81) at a mean of 5.6 years (11 months to 18 years) after the injury. RESULTS: At final follow-up, the mean Constant and Murley score was 79 points (18 to 98); the mean Western Ontario Shoulder Instability Index score (WOSI) was 77% (12 to 100) and the mean Rowe score was 93 points (50 to 100). Fractures with little intra-articular displacement (≤ 3 mm) had an uneventful outcome. Those with intra-articular displacement of ≤ 3 mm had a significant better mean Constant and Murley score than those with displacement of ≥ 5 mm and/or a fracture gap of ≥ 5 mm. Poor clinical results such as nonunion and post-traumatic osteoarthritis were associated with displaced or angulated glenoid fragments and significant intra-articular displacement. CONCLUSION: Glenoid fossa fractures with displacement of ≥ 5 mm should be treated surgically if the patient's condition allows. Displacement and angulation can lead to nonunion and a poor outcome if the degree of displacement results in a persistent fracture gap in the glenoid fossa or if the angulation of fragments leads to malunion. Cite this article: Bone Joint J 2016;98-B:1074-9.

[Winged scapula in lyme borreliosis]. / Scapula alata nach Borreliose-Infektion.

Here we present the case of a young patient with one-sided winged scapula and lyme borreliosis. This disease can be very delimitating in daily life. If non-operative treatment fails, dynamic or static stabilization of the scapula can be a therapeutic option.

Heterotopic ossification of the shoulder joint following spinal cord injury: an analysis of 21 cases after single-dose radiation therapy.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: Heterotopic ossification (HO) affecting the hips is a common complaint of patients suffering traumatic spinal cord injury. However, the incidence of HO of the shoulder is considerably rare. In this context, we report on our results of 13 patients with a total of 21 cases of shoulder HO and single-dose radiation therapy. SETTING: Department of Spinal Cord Injury and Department of General and Trauma Surgery, BG-University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Germany. METHODS: The study group consists of 12 male and 1 female patient with a mean age of 55.5 years (range from 24 to 81 years; s.d.=14.5). Primary outcome measures were defined as the number of HO relapses and the number of side or adverse effects in relation to the radiation therapy. RESULTS: At the time of latest follow-up during hospitalization, the mean shoulder flexion was 92.1° while mean abduction was 94.5°. The average external rotation was 26.4°. No HO recurrence occurred and none of the patients suffered any adverse effects related to radiation therapy. CONCLUSIONS: In conclusion, single-dose radiation therapy in the treatment of shoulder HO due to spinal cord injury is an effective and reliable method, although the risk of secondary side effects related to the radiation therapy remain unknown.

[Air Entrapment Caused by Valve Mechanisms in Chronic Wounds, a Benign Phenomenon? A Series of Three Cases]. / Air Entrapment durch einen Ventilmechanismus bei chronischen Wunden, ein harmloses Phänomen? Eine Beschreibung von 3 Fällen.

BACKGROUND: Benign subcutaneous emphysema caused by a valve mechanism and subsequent air entrapment is rare. Less invasive treatment can be performed, but acute life-threatening infectious diseases should be ruled out before treatment; these include gas gangrene or other infections caused by gas producing bacteria. PATIENTS AND METHODS: We retrospectively report on three patients with chronic wounds who developed benign subcutaneous extremity emphysema caused by valve mechanisms with subsequent air entrapment. Patient 1 had a chronic wound at his stump after a lower leg amputation years ago. Due to weight loading and unloading of the lower leg prosthesis while walking, air was sucked in and triggered subcutaneous emphysema. Patient 2 had a persistent fistula at his lateral thigh due to a chronic osteomyelitis and Girdlestone hip. Caused by the up-and-down movements of the femur during walking air was entrapped and led to emphysema. Patient 3 had a drain in his knee for development of a chronic fistula because of a persistent infection of his knee prosthesis. In extension of the knee, the drain was clamped in and air was entrapped during knee flexion and then seeped into the surrounding subcutaneous tissue. No signs of infection in the blood samples were present in two of the patients. None of the patients had fever and no gas producing bacteria were identified in the microbiological cultures. Only multisensitive Staphylococcus aureus was present in the wounds of patients 1 and 2. RESULTS: Two patients were treated surgically. One patient was treated by fasciotomy plus debridement and irrigation of the wound. A second patient was treated by debridement of the Girdlestone hip, air evacuation and insertion of a drain. No sign of infection - such as necrosis or gangreneous tissue - was seen during these operations. In patient 3, the drain was removed in flexion of the knee and air was removed from the subcutaneous tissue through a separate, sterile needle punction. CONCLUSION: There have been few published reports on benign subcutaneous emphysema caused by a valve mechanism. No standardised treatments exist, as it is initially difficult to distinguish this condition from an acute life-threatening infection. If a patient has a chronic wound at the location of the endoprosthesis or stump prosthesis after amputation, the possibility of benign air entrapment should be routinely considered.

Influence of different peg length in glenoid bone loss: A biomechanical analysis regarding primary stability of the glenoid baseplate in reverse shoulder arthroplasty.

BACKGROUND: There is no biomechanical basis to determine the influence of different length of the central peg of the baseplate anchored within the native scapula in glenoid defect reconstruction in cases of degenerative or posttraumatic glenoid bone loss in reversed shoulder arthroplasty. OBJECTIVE: The purpose of this study was to analyse the stability of different peg lengths used in glenoid bone loss in reversed shoulder arthroplasty. METHODS: Different lengths of metaglene pegs with different depths of peg anchorage performed with or without metaglene screws in sawbone foam blocks were loaded in vertical and horizontal directions for differentiating load capacities. Simulated physiological loadings were then applied to the peg implants to determine the limits of loading in each depth of anchorage. RESULTS: The loading capacity of the implant was reduced as less of the peg was anchored. The vertically loaded implants showed a significantly higher stability, in contrast to those loaded horizontally at a corresponding peg length and depth of anchorage (p < 0.05). The tests revealed that the metaglene screws are more essential for primary stability than is the peg particularly in the vertically directed loadings (2/3 anchored: peg contributed to 28% of the stability, 1/3 anchorage: peg contributed to 12%). Under the second test conditions, the lowest depth of peg anchorage (1/3) resulted in 322 Newtons [N] in the long peg with a vertical loading direction, and in 130 N in the long peg with a horizontal loading direction (p < 0.05). CONCLUSION: The pegs should be anchored as deeply as possible into the native scapula bone stock. The metaglene screws play a major role in the initial stability, in contrast to the peg, and they become more important when the depth of the peg anchorage is reduced. If possible, four metaglene screws should be used in cases of uncontained bone loss to guarantee the highest stability.

[Surgical treatment of 3- and 4-part fractures of the humeral head using a polyaxial-locking plate: results and patient satisfaction]. / Die polyaxial-winkelstabile Platte in der Versorgung von 3- und 4-Fragment-Frakturen des Humeruskopfs: objektive Ergebnisse und Patientenzufriedenheit.

INTRODUCTION: In recent years, new angle-stable plate implants with polyaxial screw direction were developed with the aim of an improved treatment of displaced 3- and 4-part fractures of the proximal humerus. There are only a few studies available about polyaxial implants in the treatment of 3- and 4-part proximal humerus fractures. Therefore, the aim of this study was to evaluate clinical results and complications of open reduction and internal fixation of displaced 3- and 4-part fractures using a polyaxial plate. PATIENTS AND METHODS: Within 51 months, 105 patients with a displaced 3- or 4-part fracture of the proximal humerus were treated with a polyaxial locking plate. The complications were evaluated and the Constant & Murley score was assessed and correlated with patient satisfaction ("very satisfied" to "not satisfied"). Additionally, the results were compared with those of monoaxial plates from the literature. Furthermore, the operative experience of the surgeons at the time of surgery was correlated with the objective results of the patients. RESULTS: 65 patients (average age: 71.3 ± 11.4 years; average follow-up: 19,6 ± 9,8 month [10-44 month]) with a displaced 3- or 4-part fracture were re-examined retrospectively (female: n = 54; male: n = 11). Overall, there were 27 3-part fractures and 38 4-part fractures. The Constant and Murley Score was on average 62.1 ± 16.5 points and the complication rate was 26 %. The most frequent complication was screw perforation through the humeral head. Patient satisfaction with clinical outcome was high within the whole study group. 40 % of the patients were "very satisfied" with their shoulder function, 29 % were "satisfied" ("fair": 12 %, "not satisfied": 19 %). Additionally, the operative experience of the surgeons influenced the final clinical result. CONCLUSION: In comparison to the literature we could not delineate better clinical outcomes or lower complication rates with polyaxial implants compared to monoaxial plates in 3- and 4-part fractures. Nevertheless, the majority of patients were satisfied with the clinical result in the context of age-related shoulder function. In addition, a close correlation could be detected between the degree of satisfaction and the objectively measured shoulder function. A high level of operative experience is required to avoid typical complications and to achieve a good clinical result.

[Trampoline-related injuries in children: an increasing problem]. / Trampolinassoziierte Verletzungen im Kindesalter. Ein zunehmendes Problem.

INTRODUCTION: The sales of recreational trampolines have increased during the past few years. Severe injuries are associated in part with trampoline sport in the domestic setting. Therefore, this study was conducted to confirm the hypothesis of an increase in trampoline-related injuries in conjunction with the increasing sales of recreational trampolines and to find out what kind of injuries are most frequent in this context. METHODS: Between 01/1999 and 09/2013 all trampoline-related injuries of children (0-16 years of age) were assessed retrospectively. Only those cases were evaluated which described with certainty a trampoline-associated trauma. The fractures were considered separately and assigned to specific localisations. Additionally, accidents at home were differentiated from institutional accidents. RESULTS: Within the past 13 years and 9 months trampoline-related injuries were seen in 195 infants. Fractures were present in 83 cases (42 %). The average age was 10 ±â€Š3.4 years (range: 2-16 years). Within first half of the observed time period (7½ years; 01/1999 to 06/2006) 73 cases were detected with a significantly increasing number of injuries up to 122 cases between 07/2006 and 09/2013 (7 years, 3 months), which corresponds to an increase of 67 % (p = 0,028). The vast majority of these injuries happened in the domestic setting (90 %, n = 175), whereas only 10 % (n = 20) of the traumas occurred in public institutions. In 102 children (52 %) the lower extremity was affected and in 51 patients (26 %) the upper extremity was involved (head/spine/pelvis: n = 42, 22 %). The upper extremity was primarily affected by fractures and dislocations (n = 38, 76 %). At the upper extremity there were more injuries requiring surgery in contrast to the lower extremity (n = 11) or cervical spine (n = 1). CONCLUSION: The underlying data show a significant increase of trampoline-related injuries within the past years. The upper extremity is the second most affected after the lower extremity, but is more associated with fractures in contrast to other localisations and had to be operated on the most. Because of the increase of recreational trampolines within past years an increase of trampoline-associated injuries has to be expected in the future. The security guidelines should be followed exactly and the infants should be under supervision.

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

BACKGROUND: It is still not clear which method is the most efficient for treating primary traumatic anterior shoulder dislocation. Immobilization in external rotation has become increasingly discussed within the last 10 years. The aim of this study was to evaluate the rate of recurrence and clinical outcome of the immobilization in external rotation after primary traumatic anterior dislocation within a midterm period of 5 years. Additionally, a summary of literature is given according to the present knowledge of this issue. METHODS: From May 2004 to May 2006, 28 patients with primary traumatic anterior shoulder dislocations were included in a prospective MRI-controlled study. After a follow-up of 5 years, the recurrence rate and clinical outcomes of the patients were evaluated using clinical scores (Constant and Murley score, Western Ontario Shoulder Instability Index, Rowe score). RESULTS: After 5 years, 26 patients (93 %; males, n = 25; female, n = 1; mean age, 29.3 years) were interviewed concerning re-dislocations. In the meantime, four patients (15 %) experienced a re-dislocation (ø 12.2 months) after the end of the immobilization. Overall, 21 patients (75 %) were included in a clinical follow-up (CM score: ø 92.8 points; Western Ontario Shoulder Instability Index: ø 87 %; Rowe score (in 17 patients): ø 94.2 points). Upon clinical examination, unidirectional anterior instability was found in one patient, which corresponds to an overall instability rate of 19 % within the examined patient population including the re-dislocations. CONCLUSIONS: Immobilization in external rotation shows satisfactory results after 5 years in regard to recurrence and instability rates and clinical outcomes. The data show that with immobilization in external rotation, re-dislocations occur within the first 2 years.

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

INTRODUCTION: The surgical treatment of displaced proximal humeral fractures (ORIF) is a perpetual challenge to the surgeon. For this reason, the principle of polyaxiality was developed to provide an improved primary stability of the fracture through better anchorage of the screws, especially in osteoporotic bone. The aim of this study was to present clinical results with the polyaxial locking plate in the operative treatment of proximal humerus fractures in order to determine whether the technique of polyaxiality leads to better functional outcome and lower complication rates in comparison to monoaxial plates in the literature. PATIENTS AND METHODS: Seventy-three patients with displaced proximal humeral fractures were treated surgically with the polyaxial locking Suture Plate™ (Arthrex(®)) between 03/2007 and 06/2009. Fifty-two of the patients (mean age, 69.9 ± 12.1) were included in a radiographical and clinical examination using the Constant score (CS) and the Disabilities of the Arm, Shoulder and Hand score (DASH). RESULTS: The follow-up examinations were on average 13.9 ± 4.5 months (10-27 months) after surgical treatment. The mean CS of the patients was 66.0 ± 13.7 points, the age- and gender-related CS was 90.9% ± 20.0% and the mean DASH score was 23.8 ± 19.8 points for the injured side. The patients with a nearly anatomical reduction of their fracture (n = 13) reached a significantly higher CS (75.1 ± 8.5; p = 0.004) and DASH-score (13.6 ± 11.6; p = 0.043) and none of these patients had a complication. The complications were identified in 12 (23.1%) cases, 5 of which involved loss of reduction. All of these 5 cases were lacking of initial medial column support and 4 of which were type C2.3 AO-Classification. CONCLUSION: The data show that the combination of angular stability with the possibility of variable polyaxial screw direction is a good concept for reduction and fixation of displaced proximal humeral fractures, but anatomical reduction and medial support remain important preconditions for a good outcome. However, a significantly lower rate of complications or better clinical outcome than that reported in the literature could not be found.

[A new reduction technique for posterior locked shoulder dislocation. Case report and technique description]. / Eine neue Repositionstechnik für die verhakte hintere Schulterluxation. Fallbericht und Beschreibung der Repositionstechnik.

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

[Tuberculous rice body synovitis of the shoulder joint]. / Tuberkulöse Reiskornsynovitis des Schultergelenks.

The clinical presentation of synovitis with rice bodies is found in a few systemic diseases as accompanying manifestations within joints or joint-associated bursa. A 79-year old patient was examined, who had complained of pain and swelling in the left shoulder for a long time. Sonography identified multiple spindle-shaped joint bodies within the joint effusion. MRI showed a large amount of so-called rice bodies with joint effusion in the shoulder and a massive destruction of the rotator cuff of the left shoulder. The histological examination showed a tuberculosis-specific inflammatory response with giant cells and epithelioid granulomas and molecular biological detection of Mycobacterium tuberculosis. Within a few months after surgical removal of the rice bodies from the joint space and the bursa a relapse occurred with repeated synovial effusion followed by a renewed surgical removal of the joint bodies. We describe the rare case of a patient with unilateral musculoskeletal manifestation of tuberculosis presented as synovitis of the left shoulder and the adjacent bursa with rice bodies and accelerated growth trend without coexisting active tuberculosis or tuberculosis in the previous history. Furthermore, a brief summary of the literature is given.