Medial injuries of the clavicle: more prevalent than expected? A big data analysis of incidence, age, and gender distribution based on nationwide routine data.

PURPOSE: Although shoulder-girdle injuries occur frequently, injuries of the medial part remain widely unexplored. This study overviews these rare injuries with a focus on incidence, age, and sex distribution in Germany. METHODS: The data are based on diagnoses according to ICD-10 in all German hospitals provided by the German Federal Statistical Office. ICD-10 codes S42.01 (medial clavicle fracture, MCF) and S43.2 (sternoclavicular joint dislocation, SCJD) were evaluated in detail between 2012 and 2014. RESULTS: We identified 14,264 cases with medial clavicle injuries (MCIs). MCFs occurred more often (11.6% of all clavicle-related shoulder-girdle injuries vs. 0.6% for SCJD). Mean ages of MCI were significantly different between males (43.7 years) and females (57.1 years) (p < 0.01). Age demonstrated a bimodal distribution with peaks at 20 and 50 years, which were predominantly associated with males. Females showed more injuries at age beyond 70 years. This applies to both SCJD and MCF. The incidence rate of these shoulder-girdle injuries was 47.0 per 100,000 person-years, for MCIs overall 5.9 (4.1 for men, 1.8 for women). This indicates disparity with a significant predominance of male patients over females as for all shoulder-girdle injuries (p < 0.01). Among children (< 16 years old), the incidence rate showed no significant difference in gender ratio. CONCLUSION: MCIs appear more frequently than estimated so far and are distinguished from other clavicle fractures in that they occur more at higher age and peaking around 50 years. Further work on possible prevention strategies should focus on the most frequently affected groups of men around 20 and 50 years old.

Shoulder girdle injuries involving the medial clavicle differ from lateral clavicle injuries with a focus on concomitant injuries and management strategies: A retrospective study based on nationwide routine data.

INTRODUCTION: Although shoulder girdle injuries are frequent, those of the medial part are widely unexplored. Our aim is to improve the knowledge of this rare injury and its management in Germany by big data analysis. METHODS: The data are based on ICD-10 codes of all German hospitals as provided by the German Federal Statistical Office. Based on the ICD-10 codes S42.01 (medial clavicle fracture, MCF) and S43.2 (sternoclavicular joint dislocation, SCJD), anonymized patient data from 2012 to 2014 were evaluated retrospectively for epidemiologic issues. We analyzed especially the concomitant injuries and therapy strategies. RESULTS: A total of 114,003 cases with a clavicle involving shoulder girdle injury were identified with 12.5% of medial clavicle injuries (MCI). These were accompanied by concomitant injuries, most of which were thoracic and craniocerebral injuries as well as injuries at the shoulder/upper arm. A significant difference between MCF and SCJD concerning concomitant injuries only appears for head injuries (p = 0.003). If MCI is the main diagnosis, soft tissue injuries typically occur as secondary diagnoses. The MCI are significantly more often associated with concomitant injuries (p < 0.001) for almost each anatomic region compared with lateral clavicle injuries (LCI). The main differences were found for thoracic and upper extremity injuries. Different treatment strategies were used, most frequently plate osteosynthesis in more than 50% of MCF cases. Surgery on SCJD was performed with K-wires, tension flange or absorbable materials, fewer by plate osteosynthesis. CONCLUSIONS: We proved that MCI are rare injuries, which might be why they are treated by inhomogeneous treatment strategies. No standard procedure has yet been established. MCI can occur in cases of severely injured patients, often associated with severe thoracic or other concomitant injuries. Therefore, MCI appear to be more complex than LCI. Further studies are required regarding the development of standard treatment strategy and representative clinical studies.

Injuries of the Medial Clavicle: A Cohort Analysis in a Level-I-Trauma-Center. Concomitant Injuries. Management. Classification.

Introduction: Although shoulder girdle injuries are frequent, those of the medial clavicle are widely unexplored. An applied classification is less used just as a standard management. Methods: A retrospective analysis of medial clavicle injuries (MCI) during a 5-year-term in a Level-1-Trauma-Center. We analyzed amongst others concomitant injuries, therapy strategies and the classification following the AO standards. Results: 19 (2.5%) out of 759 clavicula injuries were medial ones (11 A, 6 B and 2 C-Type fractures) thereunder 27,8% were displaced and thus operatively treated Locked plate osteosynthesis was employed in unstable fractures and a reconstruction of the ligaments at the sternoclavicular joint (SCJ) in case of their disruption. 84,2% of the patients sustained relevant concomitant injuries. Numerous midshaft fractures were miscoded as medial fracture, which limited the study population. Conclusions: MCI resulted from high impact mechanisms of injury, often with relevant dislocation and concomitant injuries. Concerning medial injury's complexity, treatment should occur in specialized hospitals. Unstable fractures and injuries of the SCJ ligaments should be considered for operative treatment. Midshaft fractures should be clearly distinguished from the medial ones in ICD-10-coding. Further studies are required also regarding a subtyping of the AO classification for medial clavicle fractures including ligamental injuries.

Injuries of the Sternoclavicular Joint - An Innovative Approach in the Management of a Rare Injury: Tight Rope Fixation of the Costo-Clavicular Ligament.

Background: The costoclavicular ligament (CCL) provides the most tight stability within the sternoclavicular joint (SCJ), followed by the most cited sternoclavicular ligaments (SCL). Their disruption may cause severe instability of the SCJ. Different treatment options, such as the use of plates, wires or autologous tendons are associated with mainly limited functional outcome. Could a stabilization of CCL next to an anatomic fixation of the SCL provide sufficient reconstruction of the SCJ? Methods: A 58-year-old male showed severe anterior and painful instability of the SCJ following a fall on his shoulder 8 weeks ago. The SCJ had been reconstructed in an open procedure with stabilization of the CCL employing 2 tight ropes and anatomical suture of the SCL. Follow-up was carried out 78 weeks after operation. Results: The reduction of the SCJ was successful. X-ray proved the anatomic position of the SCJ. Pain was decreased in between the first 6 weeks. The patient showed uneventful follow-up and returned to work 6 months after the procedureas a hard working farmer. Conclusions: Innovative stabilization of the CCL with tight ropes additional to a suture of the SCL may enable anatomic reconstruction of the SCJ considering cosmetic and functional results.

Predictive Value of EuroSCORE II in Patients Undergoing Left Ventricular Assist Device Therapy.

Background Left ventricular assist devices (LVADs) are nowadays a widespread option for the effective treatment of heart failure. We hypothesized that the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) might be a superior tool in clinical decision making compared with other established score systems. Methods In this retrospective, single-center analysis, between 2008 and 2014, 40 consecutive patients were followed for up to 36 months after LVAD (Thoratec HeartMate II) implantation. Postoperative survival was correlated to the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) levels, Destination Therapy Risk Score (DTRS), HeartMate II Risk Score (HMRS), and EuroSCORE II. Results Overall, a positive outcome (survival, transplantation, or weaning) was reached in 87.5% (30 days), 70% (1 year), and 60% (2 and 3 years) of cases. Patients were categorized as high, medium, and low risk by use of the different scores. Within the created subgroups, the following 1-year positive outcomes were achieved-INTERMACS: high risk 58% versus low risk 68%; EuroSCORE II: high risk 17% versus low risk 89%; DTRS: high risk 44% versus low risk 75%; and HMRS: high risk 60% versus low risk 100%. After 1 year, the EuroSCORE II classification's area under the receiver operating characteristic curve (AUC) was superior (AUC = 0.78) and Fisher exact test revealed a significant predictive value for this classification (p = 0.0037) but not for INTERMACS levels, DTRS, or HMRS classifications. Conclusion These results support the assumption that EuroSCORE II risk classification may be useful to predict survival in LVAD patients. In our observation, it proved to be superior to INTERMACS, DTRS, and HMRS after 1 year.

Special Treatment and Wound Care of the Driveline Exit Site after Left Ventricular Assist Device Implantation.

OBJECTIVE: Despite good results following implantation of left ventricular assist devices (LVADs), infections of the driveline and device pocket remain a major problem for patients on long-term support. We present the data from heart failure patients treated with a Thoratec HeartMate-II LVAD (Thoratec Corporation, Pleasanton, California, United States). METHODS: From January 2008 to April 2011, in our institution, 40 heart failure patients (NYHA IV) were supported with a HeartMate-II LVAD. The driveline maintenance of 17 patients consisted of the use of Octenidine for the wound dressing, whereas merbromin was additionally used for local irrigation in 31 patients. The data concerning driveline infections were analyzed retrospectively. RESULTS: In our study, 95% of the entire cohort was free from infections of the system. Two patients in the conventional group (11.8%) developed a driveline infection at a mean of 130.5 days during 3,416 patient-days (0.21 infection/patient-years). In the Merbromid group (Co. New FaDem SRL Farmaceutici & Chimici, Giugliano, Campania, Italy), all patients were free from any driveline infections during the observation period. In a log-rank comparison, the difference reached statistical significance (p = 0.043). CONCLUSION: During our observation period, fewer infections were noted with merbromin treatment. A multicenter setting in a larger cohort should be performed to confirm these findings, although a (double-) blinded setting might be difficult to achieve.

Selective reduction of afterload in right heart assist therapy: a mock loop study†.

OBJECTIVES: The treatment of right ventricular failure is closely linked to effects on pulmonary vascular resistance and thus the right ventricular (RV) afterload. Medical therapy includes afterload-decreasing drugs such as nitric oxide and prostacycline. However, current devices for mechanical unloading of the right ventricle aim at a decrease in preload increasing the pulmonary volume loading. In our concept study, we tested a minimally invasive right ventricular assist device (MIRVAD) that specifically reduces the afterload. METHODS: The MIRVAD is supposed to be a foldable device for temporary transvascular placement in the pulmonary artery. We incorporated a MIRVAD prototype into a mock circulatory loop that can reproduce haemodynamic interaction between the pump and the physiological system. Pulmonary hypertension (PH), right heart failure (RHF) and MIRVAD-assisted cases were simulated. The key haemodynamic parameters for RV unloading were recorded. RESULTS: Mock loop simulation attested to a sufficient right ventricular unloading by serial application of a miniaturized impeller pump in the pulmonary artery. The afterload, represented by the pulmonary arterial root pressure, was recovered to the healthy range (32.62-10.93 mmHg) for the simulated PH case. In the simulated RHF case, the impaired pulmonary perfusion increased from 43.4 to 88.8% of the healthy level and the total ventricular work reduced from 0.381 to 0.197 J at a pump speed of 3500 rpm. At pump speeds higher than 3500 rpm, the pulmonary valve remains constantly open and the right ventricular configuration changes into a simple perfused hollow body. CONCLUSIONS: The feasibility of RV unloading by a selective decrease in RV afterload was proved in principle. By alternation of the pump speed, gradual reloading in sense of a myocardial training may be achieved. The results will be validated by future animal trials where the relationship between the level of support and pulmonary vascular pressure can be investigated in vivo. Further device design concerning foldable impeller leaflets will be carried out. At a final stage, the crimped version is supposed to reach a size below 1 cm to facilitate minimally invasive insertion.