Skiing and snowboarding related deep laceration injuries. A five-season cross-sectional analysis from a level-1 trauma centre in the Swiss Alps.

OBJECTIVES: Lacerations comprise 5.6-33.6% of skiing/snowboarding related injuries. This study aimed to investigate the mechanism of injury and the location of these lacerations and propose preventive measures. METHODS: After our state ethics committee approval, we retrospectively reviewed the medical records and surgical protocols of 46 patients (mean age (±SD) 34.6 (±15.3); 71.4% men) treated for severe skiing/snowboarding lacerations at our level-1 trauma centre between 2016 and 2021. Patients were asked to answer a questionnaire on their skiing experience, equipment used and the circumstances of the accident. RESULTS: Lacerations around the hip, thigh, and knee accounted for 94%. The latter was the most common location (45%). Although 91.3% of patients wore appropriate clothing and full standard protection equipment, it did not offer any extra-resistance against skiing/snowboarding's edges. Skiers were more affected (91.3%) than snowboarders (8.7%). The most common mechanism of injury was inadvertent release of the bindings (52.2%), followed by insufficient ski level for the slope (21.7%) and collisions (17.4%). Long-term trends demonstrated an increasing incidence. CONCLUSION: Identification of body areas at risk and the mechanisms of injury were the most significant findings of this work. These data encourage the development of specific injury prevention programs as the occurrence of these lesions tended to increase over the last few years. To reduce their incidence, we propose skiers to have their bindings regularly adjusted and manufacturers to develop cut-resistant skiwear. LEVEL OF EVIDENCE: IV.

Implication of bone morphology in degenerative rotator cuff lesions: A prospective comparative study between greater tuberosity angle and critical shoulder angle.

BACKGROUND: Degenerative rotator cuff tear is a frequent and multifactorial pathology. The role of bone morphology of the greater tuberosity and lateral acromion has been validated, and can be measured with two plain radiographic markers on true anteroposterior views: the greater tuberosity angle (GTA) and the critical shoulder angle (CSA). However, the interdependence of both markers remains unknown, as well as their relationship with the level of professional and sports activities involving the shoulder. The aim of this prospective comparative study was to describe the correlation between the GTA and CSA in patients with degenerative rotator cuff tears. HYPOTHESIS: GTA and CSA are independent factors from one another and from demographic factors, such as age, dominance, sports, or professional activities. PATIENT AND METHODS: All patients presenting to a shoulder specialized clinic were assigned to two groups. The first consisted of patients with a symptomatic degenerative rotator cuff tear visible on MRI and the control group consisted of patients with any other shoulder complaints and no history or visible imaging of any rotator cuff lesion. RESULTS: There were 51 shoulders in 49 patients in the rotator cuff tear group (RCT) and 53 shoulders in 50 patients in the control group. Patient demographics were similar in both groups. Mean GTA was 72.1°±3.7 (71.0-73.1) in the RCT group and 64.0°±3.3 (63.1-64.9) in the control group (p<0.001). Mean CSA was 36.7°±3.7 (35.7-37.8) in the RCT group, and 32.1°±3.7 (31.1-33.1) in the control group (p<0.001). A summation of GTA and CSA values over 103° increased the odds of having a rotator cuff tear by 97-fold (p<0.001). There was no correlation between GTA and CSA, nor between GTA or CSA and age, sex, tear size, or dominance. Patients with different levels of professional and sports activities did not have significantly different GTA or CSA values. CONCLUSION: GTA and CSA are independent radiologic markers that can reliably predict the presence of a degenerative rotator cuff tear. A sum of both values over 103° increases the odds of having a rotator cuff tear by 97-fold. These markers are not correlated with patient demographic or environmental factors, suggesting that the variability of the native acromion and greater tuberosity morphology may be individual risk factors for rotator cuff tear. LEVEL OF EVIDENCE: II; diagnostic study.

Evaluation of the Circles Measurement and the ABC Classification of Acromioclavicular Joint Injuries.

BACKGROUND: Acromioclavicular joint (ACJ) injuries are common. Despite this, it remains unclear how best to assess, classify, and manage these cases. A simple, reliable, valid, and accurate radiographic parameter to measure ACJ displacement would allow improved consistency of diagnosis and subsequent treatment pathways. PURPOSE: To evaluate "the circles measurement" and associated "ABC classification" as a tool for assessing ACJ displacement and injury classification. STUDY DESIGN: Descriptive laboratory study. METHODS: The circles measurement is taken from a lateral Alexander radiograph of the shoulder. The measurement is the center-to-center distance between 2 circles drawn to define the lateral extent of the clavicle and the anteromedial extent of the acromion; it is independent of the displacement plane, judging total ACJ displacement in any direction rather than trying to quantify vertical and/or horizontal displacement. When utilized clinically, the circles measurement is a single measurement calculated as the difference between values recorded for the injured and uninjured sides. Validation of the circles measurement was performed using lateral Alexander radiographs (including ±20° projection error in all planes) and computed tomography of standardized ACJ injury simulations. We assessed inter- and intrarater reliability, convergent validity, and discriminant validity of the circles measurement and subsequently generated a classification of ACJ injury based on displacement. RESULTS: Reliability and validity of the circles measurement was excellent throughout. Interrater reliability (ICC [intraclass correlation coefficient] [2,1], 95% CI; n = 78; 4 observers) was 0.976 (0.964-0.985). Intrarater reliability (ICC [2,1]; 95% CI; n = 78; 2 measures) was 0.998 (0.996-0.998). Convergent validity (Pearson correlation coefficient, r) was 0.970 for ideal radiographs and 0.889 with ±20° projection error in all planes. Discriminant validity, with 1-way analysis of variance, showed a P value of <.0001 and effect size (η2) of 0.960, with the ability to distinguish between the previously defined stable (Rockwood IIIA) and unstable (Rockwood IIIB) injuries. The results permitted objective, statistically sound parameters for the proposed ABC classification system. CONCLUSION: The circles measurement is a simple, reliable, valid, accurate, and resilient parameter for assessing ACJ displacement and can be used in conjunction with the proposed ABC classification to define ACJ injuries more accurately and objectively than previously described. CLINICAL RELEVANCE: This novel parameter has the potential to standardize the initial assessment and possibly the subsequent clinical management of ACJ injuries, in addition to providing a standardized measure for future research.

BiPOD arthroscopically assisted bidirectional stabilisation technique for high-grade acromioclavicular joint injury: two-year clinical and radiological outcomes.

PURPOSE: The purpose of this study was to evaluate the intermediate-term clinical and radiological outcomes for acute, unstable acromioclavicular joint (ACJ) injuries treated with the arthroscopically assisted BiPOD stabilisation technique. METHODS: Twenty-three patients who sustained acute, unstable ACJ injuries were included in this prospective study. We recorded demographics, injury classification, time to surgery, clinical scores, radiological outcomes and complications; each patient completed a minimum of 2 years post-operative observation. RESULTS: Mean follow-up was 26 months (range, 24-34). Clinical outcomes scores demonstrated good 2-year results: relative Constant score, 97.9/100; ACJ Index, 89.4/100; Subjective Shoulder Value, 92.4/100 and Taft = 11.1/12. Final C-C distance showed a mean of 0.7 mm (SD ± 1.8 mm) at 2 years. Complication rate was 9%. CONCLUSION: The BiPOD technique shows excellent, reliable intermediate-term results with a favourable complication rate compared to existing techniques; it provides a comprehensive surgical option for the stabilisation of acute ACJ injuries restoring both vertical and horizontal stability.

A biomechanical study comparing the mean load to failure of two different osteosynthesis techniques for step-cut olecranon osteotomy.

Background: Olecranon osteotomies are frequently used to expose distal humeral intraarticular fractures. The step-cut olecranon osteotomy (SCOOT) is an augmented version of the oblique olecranon osteotomy, which has recently been evaluated biomechanically with tension band wiring (TBW) fixation. However, complications with TBW are common. In this study, we, therefore, compared the mean load to failure of TBW with compression screws for SCOOT fixation. We hypothesized a higher load to failure for the compression screw group. Methods: We performed a SCOOT on 36 Sawbones. Eighteen were fixed with TBW, and another 18 with two compression screws. The humeroulnar joint was simulated using an established test setup, which allows the application of triceps traction force through a tendon model to the ulna, while the humeroulnar joint is in a fixed position. Eight models of each fixation group were tested at 20°, and eight at 70° of flexion by isometrical loading until failure, which was defined as either a complete fracture or gap formation of more than 2 mm at the osteotomy site. Results: At 20° of flexion, mean load to failure was similar between the TBW group (1360 ± 238 N) and the compression screw group (1401 ± 261 N) (P = .88). Also, at 70° of flexion, the mean load to failure was similar between the TBW group (1398 ± 215 N) and the compression screw group (1614 ± 427 N) (P = .28). Conclusions: SCOOTs fixed with TBW and compression screws showed similar loads to failure. A SCOOT fixed with compression screws might be a valuable alternative for surgeons when treating intraarticular distal humeral fractures. However, future in vivo studies are necessary to confirm our results in a clinical setting.

A biomechanical confirmation of the relationship between critical shoulder angle (CSA) and articular joint loading.

BACKGROUND: The critical shoulder angle (CSA) has been shown to be correlated with shoulder disease states. The biomechanical hypothesis to explain this correlation is that the CSA changes the shear and compressive forces on the shoulder. The objective of this study is to test this hypothesis by use of a validated computational shoulder model. Specifically, this study assesses the impact on glenohumeral biomechanics of modifying the CSA. METHODS: An inverse dynamics 3-dimensional musculoskeletal model of the shoulder was used to quantify muscle forces and glenohumeral joint forces. The CSA was changed by altering the attachment point of the middle deltoid into a normal CSA (33°), a reduced CSA of 28°, and an increased CSA of 38°. Subject-specific kinematics of slow and fast speed abduction in the scapular plane and slow and fast forward flexion measured by a 3-dimensional motion capture system were used to quantify joint reaction shear and compressive forces. RESULTS: Increasing the CSA results in increased superior-inferior forces (shearing forces; integrated over the range of motion; P < .05). Reducing CSA results in increased lateromedial (compressive) forces for both the maximum and integrated sum of the forces over the whole motion (P < .01). DISCUSSION/CONCLUSION: Changes in the CSA modify glenohumeral joint biomechanics with increasing CSA producing higher shear forces that could contribute to rotator cuff overuse, whereas reducing the CSA results in higher compressive forces that contribute to joint wear.

Technique Tip: Platysma-flap Approach to the Clavicle.

The surgical treatment of a displaced fracture of the clavicular shaft generally consists in an open reduction and plate fixation. The most common complications of the classic direct "transplatysma" approach are hardware related. These consist of simple hardware irritations requiring secondary plate removal but also feared wound healing problems ranging from dehiscence to superficial and deep wound infections. In the present article, we describe the so-called "platysma-flap" approach in which the platysma muscle is entirely preserved and distally raised as a flap. This modified exposure allows to cover the osteosynthesis with a viable, well perfused soft tissue envelope and is a safe alternative to the standard "transplatysma" approach.

Impact of vertical and horizontal malrotation on measurements of anteroposterior radiographs of the scapula: need for standardized images in modern omometry.

BACKGROUND: An increasing number of parameters measured on anteroposterior radiographs are used for the evaluation of the bony geometry of the scapula. Inhomogeneous acquisition of images is common because of the lack of standardization in radiographic positioning. Images with malrotation around the horizontal axis of the scapula are particularly frequent. We hypothesized that malrotated images would result in large variations in measured radiographic parameters and that image standardization using qualitative and semiquantitative "omometric" criteria would decrease these variations in measurements. "Omometry" is a newly introduced umbrella term that contains all standardized measurements on plain radiographs of the shoulder, analogous to the term "coxometry," which is widely used for the radiographic assessment of the osseous pelvis and hip. METHODS: In this experimental, cadaveric radiographic study, 7 dry-bone human scapula cadaveric specimens from anonymous donors were used to obtain 210 radiographs. We incrementally rotated (steps of 3°) every scapula around its horizontal and vertical axis, with a total range of 42° per each axis. Then, we measured 5 radiographic parameters on every image and observed their change with malrotation. Furthermore, we introduced 4 omometric criteria defining an appropriate (presence of ≥3 criteria) radiographic image to improve standardization of scapular image acquisition. RESULTS: Overall, measured values remained stable within a narrow range of ±9° of malrotation. Beyond this range, values of all parameters significantly deviated (>±2°) from the initial value. Measurements on appropriate images were significantly less prone to deviation. Within the appropriate images, those with 4 criteria showed a higher specificity than those with 3 criteria. CONCLUSION: There is significant variation in values of measured radiographic parameters on anteroposterior radiographs of the scapula with substantially malrotated images. With the use of the 4 newly introduced semiquantitative and qualitative omometric criteria, which define an appropriate image, reliability of the measured parameters can be significantly improved.

New quantitative radiographic parameters for vertical and horizontal instability in acromioclavicular joint dislocations.

PURPOSE: The aim of this study was to identify the most accurate and reliable quantitative radiographic parameters for assessing vertical and horizontal instability in different Rockwood grades of acromioclavicular joint (ACJ) separations. Furthermore, the effect of projectional variation on these parameters was investigated in obtaining lateral Alexander view radiographs. METHODS: A Sawbone model of a scapula with clavicle was mounted on a holding device, and acromioclavicular dislocations as per the Rockwood classification system were simulated with the addition of horizontal posterior displacement. Projectional variations for each injury type were performed by tilting/rotating the Sawbone construct in the coronal, sagittal or axial plane. Radiographic imaging in the form of an anterior-posterior Zanca view and a lateral Alexander view were taken for each injury type and each projectional variation. Five newly defined radiographic parameters for assessing horizontal and vertical displacement as well as commonly used coracoclavicular distance view were measured. Reliability, validity and the effect of projectional variation were investigated for these radiographic measurements. RESULTS: All radiographic parameters showed excellent intra- and interobserver reliability. The validity was excellent for the acromial centre line to dorsal clavicle (AC-DC) in vertical displacement and for the glenoid centre line to posterior clavicle (GC-PC) in horizontal displacement, whilst the remaining measurements showed moderate validity. For AC-DC and GC-PC, convergent validity expressed strong correlation to the effective distance and discriminant validity demonstrated its ability to differentiate between various grades of ACJ dislocations. The effect of projectional variation increased with the degree of deviation and was maximal (3 mm) for AC-DC in 20° anteverted malpositioning and for GC-PC in 20° retroverted malpositioning. CONCLUSIONS: AC-DC and the GC-PC are two novel quantitative radiographic parameters of vertical and horizontal instability in ACJ dislocations that demonstrate excellent reliability and validity with reasonable inertness to malpositioning. The use of AC-DC for assessing vertical displacement and GC-PC for assessing horizontal displacement in a single Alexander view is recommended to guide the appropriate management of ACJ dislocations. A better appreciation of the degree of horizontal instability, especially in lower Rockwood grades (II, III) of ACJ dislocations, may improve management of these controversial injuries.

Triceps-sparing extra-articular step-cut olecranon osteotomy for distal humeral fractures: an anatomic study.

BACKGROUND: This anatomic study investigated the distal humeral articular surface exposure achievable through a triceps-sparing oblique extra-articular osteotomy of the olecranon with a step-cut modification compared with the anconeus flap transolecranon apex distal chevron osteotomy. In addition, the bone contact surface areas of the osteotomized surfaces after transolecranon and extra-articular osteotomies were compared. METHODS: Seven pairs of fresh adult cadaveric elbow joints were examined. Each of the right elbows underwent triceps-sparing extra-articular step-cut olecranon osteotomy (SCOOT) with an anconeus flap, and the left elbows underwent the anconeus flap transolecranon apex distal chevron osteotomies (CO). The articular surface exposed by each of the osteotomy techniques was then digitally analyzed using a 3-dimensional measurement system. The bone contact surface area of the osteotomized surfaces was also assessed. RESULTS: The percentage of total joint exposed by the SCOOT group was less than the CO group (SCOOT: 64% ± 3% vs. CO: 73% ± 3%; P = .002). There was significantly greater bone contact surface area of the osteotomized surfaces in the SCOOT group compared with the CO group (SCOOT: 1172 ± 251 mm2 vs. CO: 457 ± 133 mm2; P = .002). CONCLUSION: The triceps SCOOT procedure with an anconeus flap provides excellent distal humeral articular surface exposure with the added benefit of a substantially increased (2.6-times) bone contact surface area of the osteotomized surfaces.