Fatty degeneration of the deltoid muscle associated with displaced proximal humerus fractures.

INTRODUCTION: The use of reverse shoulder arthroplasty (RSA) has increased dramatically over the last two decades, with many surgeons now indicating RSA for the acute management of displaced proximal humerus fractures (PHF) in the elderly. RSA relies on adequate deltoid muscle function to obtain a good outcome, yet no literature to date exists which discusses preoperative assessment of deltoid structure prior to RSA. The purpose of this study was to assess for preoperative fatty deltoid-degeneration in patients with displaced PHF. MATERIALS AND METHODS: We reviewed the axial CT scans of 100 consecutive patients with a displaced PHF. Fatty degeneration within each of the three deltoid-heads was graded at three levels, according to Goutallier and colleagues. Fractures were classified according to Neer. RESULTS: Seventy-nine percent of the patients were female, 75% showed 3 or 4 parts fractures. The average cross-sectional area of the posterior deltoid was greatest-representing 37%, 40% and 42% of total area at each level, respectively. Severe fatty degeneration (Stages 3 and 4) was observed in the posterior deltoid only (26%). Absence of fatty degeneration (Stage 0) was observed in < 25% of cases. The Inter-Observer-Reliability for the continuous variables proved to be high. CONCLUSION: Preoperative deltoid fatty degeneration is common in displaced PHF in the elderly. Because CT is commonly obtained to assess fracture morphology and for preoperative planning purposes, it is an ideal tool to assess the deltoid additionally. Future studies are warranted to determine whether preoperative fatty infiltration of the deltoid correlates with mid and long term functional outcomes when RSA is used acutely to manage a PHF. LEVEL OF EVIDENCE: Level IV-consecutive case series.

Arthroscopic Debridement for Irreparable Rotator Cuff Tears.

BACKGROUND: Arthroscopic debridement represents a salvage procedure for irreparable rotator cuff tears. It is important to accurately diagnose the patient for irreparable rotator cuff tears. The diagnosis and the therapeutic options must be explained to the patient. It is mandatory that the patient understands the primary goal of the arthroscopic debridement being reduction of pain, not improving strength or function. METHODS: The procedure consists of 7 distinct steps to debride the soft tissues and alleviate pain. RESULTS: Even though there is a lack of evidence that this procedure is superior to other therapeutic options, it has shown good results in patients with the main complaint of pain. CONCLUSION: The results reported in some studies should, however, be interpreted with caution, taking into consideration the substantial structural damage in irreparable defects.

[Posttraumatic nonunions and malunions of the proximal humerus. Possibilities and limitations of corrective osteotomy]. / Posttraumatische Fehlstellungen und Pseudarthrosen des proximalen Humerus. Möglichkeiten und Grenzen der Korrekturosteotomie.

BACKGROUND: According to the future demographic trends the incidence of proximal humeral fractures and subsequent posttraumatic malunions and nonunions of the proximal humerus are expected to substantially increase. OBJECTIVES: This article reviews the indications, techniques and outcomes of corrective osteotomy for the treatment of posttraumatic nounions and malunions of the proximal humerus. METHODS: A selective literature search was performed and personal surgical experiences are reported. RESULTS: Malunions of the proximal humerus can occur after both surgical and conservative management of fractures. Due to the complex anatomy of the proximal humerus, malunions have to be systematically assessed regarding epiphyseal and metaphyseal malpositioning. Furthermore, the objective anatomical disorder has to be completely correlated with the subjective patient complaints. The associated soft tissue structures, such as the glenohumeral joint capsule and ligaments, long head of the biceps tendon, rotator cuff and muscles inserting in the metaphysis, can independently cause discomfort to the patient and need to be meticulously identified as such. CONCLUSION: A variety of corrective surgical strategies are available, which are indicated depending on the location and extent of the malunion. The depicted single-cut osteotomy technique represents an elegant therapeutic option for multidimensional deformities of the proximal humerus. Nonunions of the proximal humerus can usually be successfully managed with autologous cancellous bone grafting and locking plate osteosynthesis.

[First degree open, proximal and distal fractures of the lower arm with scapholunate ligament rupture. Case report of severe extremity trauma]. / Erstgradig offene, proximale und distale Unterarmfraktur mit skapholunärer Bandruptur. Kasuistik eines schweren Extremitätentraumas.

The combination of proximal and distal radius and ulna fractures with scapholunate ligament injury is extremely rare and this type of injury may potentially only be possible in osteoporotic bone. In this case report this rare injury is discussed, a possible therapy regime is presented and a typical postoperative complication is shown.

FTY720 application following isolated warm liver ischemia improves long-term survival and organ protection in a mouse model.

BACKGROUND: Ischemia-reperfusion-Injury (I/RI) is a common complication in transplant-, liver-, and heart surgery. The I/RI is mediated and aggravated by different types of leukocytes such as lymphocytes, monocytes, and neutrophil granulocytes, with consecutive enlargement of the expression of adhesion molecules. This study shows an organ-protective effect of an intraoperative FTY720 administration following warm liver ischemia (Pringle's maneuver). METHODS: Male c57BL6/J mice (n = 46, body weight [BW] 25 to 30 g) were used. Either FTY720 (1 mg/kg BW), steroids (5 mg/kg BW), or physiological saline solution was administered intraperitoneally. Liver-ischemia was applied for 30 minutes with subsequent follow-up for 48 hours. At termination, all surviving animals were sacrificed. The impact of the drugs administered on long-term survival, time of death, and development of blood T-lymphocyte concentration was determined. Follow-up of T-lymphocyte concentration in peripheral blood was examined throughout FACS-analysis. RESULTS: Following 30 minutes of ischemia, FTY720, but not steroid or vehicle treatment, showed a significant protective effect on long-term survival. FACS-analysis showed significant T-lymphocyte depletion in peripheral blood following FTY720 but not steroids or vehicle treatment. CONCLUSION: The improved long-term survival following FTY720 application shown in this study might be due to a protective effect of FTY720 in prevention of I/RI. This might be mediated by the T-lymphocyte depletion shown in the FACS-analysis.

FTY720 for treatment of ischemia-reperfusion injury following complete renal ischemia; impact on long-term survival and T-lymphocyte tissue infiltration.

BACKGROUND: Organ dysfunction due to ischemia-reperfusion (I/R) injury is a common problem in transplant, liver, trauma, and heart surgery. I/R injury is mediated by upregulated expression of endothelial cell surface adhesion molecules and subsequent adhesion and activation of circulating leukocytes. The purpose of this study was to evaluate the effect of an intraoperative administration of FTY720 in an animal model with controlled bilateral warm kidney ischemia compared to steroids or placebo application. METHODS: Male C57BL6/J mice (n = 72, weight 25 to 30 g) were exposed to 30 minutes of bilateral kidney ischemia and followed by a 48 hour observation period. FTY720 (1 mg/kg body weight [BW]), steroids (5 mg/kg BW), or saline solution were administered. In addition, a sham-operated control group was included. At the termination of the experiments, all surviving animals were humanely killed. The impact of the various drugs on overall animal survival, timing of death, peripheral T-cell count, and T-lymphocyte infiltration in the kidneys was determined. RESULTS: Following bilateral kidney I/R injury, FTY720 was associated with a significant improved animal survival (85.7%) compared with steroids (50%) or controls (42.4%). FACS analysis showed significant T-lymphocyte depletion in peripheral blood in the FTY720 but not in the other groups. T-lymphocyte tissue concentration in liver and kidney tissue did not show statistically significant differences following FTY720, steroid, or saline treatment. CONCLUSION: FTY720, when administered intraoperatively, improved survival significantly in mice submitted to bilateral kidney ischemia but did not have any significant impact on the parenchymal T-lymphocyte infiltration in the ischemic organ.

FTY720 for treatment of ischemia-reperfusion injury following complete renal ischemia in C57/BL6 mice.

BACKGROUND: Organ dysfunction followed by single-organ or even multiorgan failure due to ischemia-reperfusion injury (I/RI) is a common problem in liver and heart transplantation. Various approaches had been attempted to prevent this I/RI. One is the administration of FTY720, a synthetic structural analogue of sphingosine, which induces T-lymphocyte homing with consecutive lymphopenia. The purpose of this study was to evaluate the effect of intraoperative FTY720 administration following controlled bilateral kidney ischemia in comparison to steroid or placebo application. METHODS: Male c57BL6/J mice (n = 115; body weight 25 to 30 g) received either FTY720 (1 mg/kg body weight) or steroids or saline solution. Ischemia was applied for 30 or 60 minutes with subsequent follow-up for 48 hours. At termination all surviving animals were sacrificed. RESULTS: Following 30 minutes of ischemia, FTY720, but neither steroid nor vehicle treatment showed significant protective effects on long-term survival after controlled bilateral warm kidney ischemia. Fluorescein-activated cell sorting (FACS) analysis showed a significant T-lymphocyte depletion in peripheral blood after FTY720 treatment, which was not observed after steroid or vehicle treatment. CONCLUSION: The improved long-term survival shown in this study might be due to a protective effect of FTY720 to prevent I/RI, which may be mediated by the lymphocyte depletion shown in the FACS analysis.