Hydrodilatation with corticosteroids is the most effective conservative management for frozen shoulder.

PURPOSE: The purpose of this overview is to summarise the findings of meta-analyses of randomised controlled trials that compare conservative treatment options for frozen shoulder. METHODS: The authors conducted an electronic literature search for meta-analyses published using PubMed, Web of Science and the Cochrane Library. Two researchers independently applied selection criteria and assessed quality of meta-analyses using A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2). Short-, medium- and long-term outcomes were synthesised narratively. RESULTS: A total of 319 studies were identified, of which 8 meta-analyses were eligible for inclusion. All included meta-analyses were judged to be low or critically low quality according to AMSTAR-2, however, their data synthesis and interpretation was considered valid. Physiotherapy, intra-articular and subacromial corticosteroid injection (CSI), and arthrographic distension/hydrodilatation with corticosteroid were reported with sufficient evidence. Intra-articular CSI and arthrographic distension/hydrodilatation with corticosteroid provide advantages over placebo in short-term pain relief, range of motion (ROM) and shoulder function, with improvements in ROM continuing into the medium and long term. Arthrographic distension/hydrodilatation with corticosteroid provides medium-term and long-term improvements in ROM over intra-articular CSI and physiotherapy. Proprioceptive neuromuscular facilitation provides advantages over conventional physiotherapy for pain improvement and external rotation in the short term. CONCLUSIONS: Arthrographic distension/hydrodilatation with corticosteroid provides superior pain relief in the short term and improvement in range of motion across all time frames for frozen shoulder when compared to CSI or physiotherapy. LEVEL OF EVIDENCE: Level IV.

Achilles tendon allograft for an irreparable massive rotator cuff tear with bony deficiency of the greater tuberosity.

Management of combined bony and tendinous deficiency of the posterosuperior rotator cuff represents a challenge in young patients. In this case report, a 44-year-old woman that presented an osteonecrosis of the greater tuberosity had a pseudoparalytic shoulder. She beneficiated from a fresh-frozen Achilles tendon allograft with calcaneal bone, which was used to reconstruct the rotator cuff and the concomitant bony defect. At 12-month follow-up, the patient was pain free and had complete range of motion, normal strength, a SANE score of 95 and radiographically the allograft was healed. An Achilles tendon allograft may therefore be a viable surgical option to reconstruct a combine posterosuperior rotator cuff tear and greater tuberosity bone defect. Level of evidence IV.

Clinical and epidemiological differences between implant-associated and implant-free orthopaedic infections.

PURPOSE: Although there have been many publications regarding the risk factors for implant-associated orthopaedic infections, none have investigated how clinical presentations and epidemiology may differ between infections with and without osteosynthetic material. METHODS: We pooled clinical data from several databases of adult patients with orthopaedic infections hospitalized at Geneva University Hospitals from January 2004 to December 2014. RESULTS: Among 2740 episodes of orthopaedic infections, 76% were implant-free osteoarticular or soft tissue infections. Among the 665 (24% of the total episodes) infections that involved osteosynthetic material, 319 (49%) were total joint arthroplasties, 143 single plates, and 50 single nails. The remainders were mixed implant infections, pins, wires, screws, cerclages or spondylodeses. The implant-associated, compared to the implant-free, infections were significantly more frequently associated with female sex, older age, bacteraemia and skin commensal infections, e.g. coagulase-negative staphylococci, corynebacteria or propionibacteria. In contrast, implant-associated infections were significantly less frequently associated with immune suppression, abscess formation, infections due to Staphylococcus aureus or streptococci, polymicrobial pathogens and foot infections. The serum CRP levels at admission were similar (median 82 vs. 75 mg/L). CONCLUSIONS: Compared to implant-free infections, implant-associated orthopaedic infections are more likely monomicrobial, bacteraemic and due to skin commensals. They involve more often female and older patients, but are less often associated with immune suppression, abscess formation and foot infections.

Reducing a Shoulder Dislocation Without Sweating. The Davos Technique and its Results. Evaluation of a Nontraumatic, Safe, and Simple Technique for Reducing Anterior Shoulder Dislocations.

BACKGROUND: Anterior shoulder dislocation is a well-known injury for people working in emergency departments (EDs). Throughout the years, the focus has been shifted onto more gentle reduction techniques with less risk of iatrogenic injury, fracture displacement, and less pain for the patient. We present the results of one such technique, the Davos reduction maneuver, also known as the Boss-Holzach-Matter technique, as well as its advantages, disadvantages, and a few practical tips. DISCUSSION: We evaluated, retrospectively, 100 patients presenting with an anteroinferior shoulder dislocation, who were treated in the ED of the university hospital of Geneva, Switzerland, in a time period of 18 months. In every case, the Davos technique was used for shoulder reduction. The detailed technique is described. Successful reduction was achieved in 86 patients. There were no neurological complications. Greater tuberosity fracture malreduction was noted in one case. Eighteen patients received no analgesia. Our results were comparable or superior to other reduction techniques. CONCLUSION: We concluded that the Davos technique is an easy, nontraumatic, very well-tolerated, and most of all, safe way to reduce a shoulder. It is complication free and easy to apply, giving reproducible and comparable or superior results to other reduction techniques. At the same time, it is well tolerated by a compliant patient, which makes it an ideal first-time reduction technique for anterior shoulder dislocations.

Comparison of fixation properties between coil-type and screw-type anchors for rotator cuff repair: A virtual pullout testing using 3-dimensional finite element method.

BACKGROUND: Pullout of inserted anchor constitutes one of the pathomechanisms of re-tearing after rotator cuff repair. The purpose of the present study was to investigate the fixation properties of suture anchors using 3-dimensional finite element method. METHODS: The computer models of three types of anchors (TwinFix Ti, HEALICOIL PK and HEALICOIL RG) were inserted into the isotropic cube model that simulated cancellous bone. In the virtual pullout testing, a tensile load (500 N) along the long axis of the inserted anchor was applied to the site of suture thread attachment to simulate a traction force. The distribution of von Mises equivalent stress, the failure patterns of elements inside the cube and the anchor displacement were compared among the three anchors. RESULTS: In TwinFix Ti, the highest stress concentration was seen around the anchor threads close to the surface of the cube, which caused element failure at this site. On the other hand, both HEALICOIL PK and HEALICOIL RG demonstrated a high stress concentration as well as element failure around the anchor tip. Comparing the anchor displacement, HEALICOIL RG showed the smallest displacement among the three anchors. The tensile loads that required a 0.1-mm displacement for TwinFix Ti, HEALICOIL PK and HEALICOIL RG were 400 N, 370 N, and greater than 500 N, respectively. CONCLUSIONS: The bony structures close to the footprint surface may be damaged during surgery due to preparation for the bony bed as well as the insertion of anchors. Thus, we assumed that HEALICOIL RG represented the best initial fixation properties among the three anchors tested. Virtual pullout testing using 3-dimensional finite element method could reveal the detailed biomechanical characteristics of each suture anchor, which would be important for shoulder surgeons to improve the clinical outcomes of rotator cuff repair.

Increased risk of joint failure in hip prostheses infected with Staphylococcus aureus treated with debridement, antibiotics and implant retention compared to Streptococcus.

PURPOSE: The debridement, antibiotic and implant retention (DAIR) procedure is an option for patients with prosthetic hip joint infections for whom arthroplasty removal is problematic. Unfortunately, some of the guidelines proposed for deciding on DAIR management of arthroplasty infections fail to take into consideration the role of the infecting pathogen. While Staphylococcus aureus and streptococci are major contributors to infected hip arthroplasties, their respective contributions to treatment success or failure rates with the DAIR procedure have not been thoroughly analysed from a microbiological perspective. METHODS: This retrospective study included all patients who were hospitalised in Geneva University Hospitals between 1996 and 2012 and were initially treated with DAIR for prosthetic hip joint monomicrobial infection due to S. aureus or Streptococcus spp. The outcome of DAIR treatment was evaluated after a minimal follow-up of two years. A literature search was also performed to retrieve data from additional DAIR-treated cases in other institutions. RESULTS: In our institution, 38 DAIR-treated patients with hip arthroplasty monomicrobial infections underwent at least one surgical debridement (median two, range one to five), exchange of mobile parts and concomitant targeted antibiotic therapy for several weeks or months. A literature search identified outcome data in other institutions from 52 additional DAIR-treated cases according to our study criteria. After merging our own data with those retrieved from other reports, we found a failure rate of 21 % instead of 24 % for S. aureus-infected, DAIR-treated patients, but no failure in 14 streptococcal-infected patients. In the pooled data, the failure rate linked with S. aureus infections was significantly higher than that with Streptococcus ssp. (19/90 vs 0/14 episodes; Fisher's exact test, P = 0.07). CONCLUSIONS: DAIR-treated patients with prosthetic hip joint infections due to S. aureus tended to have worse outcomes than those infected with Streptococcus spp. The specific influence of the infecting pathogen should be considered in future guidelines and recommendations.

[Use of NSAIDs in traumatology]. / Du bon usage des AINS en traumatologie.

In traumatology, non-steroidal anti-inflammatory drugs (NSAIDs) are widely used, due to their efficacy in controlling pain and safety profile. Nonetheless, experimental and retrospective studies about the use of NSAIDs in traumatology raise the question about a possible negative influence on bone remodeling through inhibition of prostaglandin synthesis. The results from these studies must be interpreted with caution, as bone repair can be influenced by several parameters. When used in the case of sprains or tendinitis, unwanted side effects of NSAIDs seem to be limited; on the other hand, benefits in terms of antalgic effect are less clear. We have conducted a review of the literature aimed to suggest practical solutions for the use of NSAIDs in traumatology.

[Pit falls in the emergency walk-in clinic: lower limb (2)]. / Pièges en orthopédie ambulatoire: le membre inférieur (2).

The lower limb is the seat of many traumatic lesions especially the foot and ankle. To misdiagnose these injuries leads to pain, instability, early arthritis and poor results. Clinical examination is very important and also standard X rays. New imaging techniques such as MRI will help to delineate some difficult to see lesions such as Lisfranc's fracture-dislocations, osteochondral lesions or occult hip fractures.

[Pit falls in the emergency walk in clinic: upper limb]. / Pièges en orthopédie ambulatoire: le membre supérieur.

Trauma to the upper extremity presents difficulties in diagnosis because of the complexity of the anatomy and of the structures involved. These injuries are common, representing more that 45% of all injuries coming to a walk-in emergency center. Commonly missed or misdiagnosed injuries are listed below with clinical examples. Posterior dislocation of the shoulder or perilunar dislocations of the carpus are still commonly missed today in spite of ample information in all medically oriented media. This series of articles is tended to warn emergency room practitioners of the these traps for the unwary.

'Frozen shoulder' is ill-defined. How can it be described better?

Frozen shoulder, a common and debilitating shoulder complaint, has been the subject of uncertainty within the scientific literature and clinical practice.We performed an electronic PubMed search on all (1559) articles mentioning 'frozen shoulder' or 'adhesive capsulitis' to understand and qualify the range of naming, classification and natural history of the disease. We identified and reviewed six key thought leadership papers published in the past 10 years and all (24) systematic reviews published on frozen shoulder or adhesive capsulitis in the past five years.This revealed that, while key thought leaders such as the ISAKOS Upper Extremity Council are unequivocal that 'adhesive capsulitis' is an inappropriate term, the long-term and short-term trends showed the literature (63% of systematic reviews assessed) preferred 'adhesive capsulitis'.The literature was divided as to whether or not to classify the complaint as primary only (9 of 24) or primary and secondary (9 of 24); six did not touch on classification.Furthermore, despite a systematic review in 2016 showing no evidence to support a three-phase self-limiting progression of frozen shoulder, 11 of 12 (92%) systematic reviews that mentioned phasing described a three-phase progression. Eight (33%) described it as 'self-limiting', three (13%) described it as self-limiting in 'nearly all' or 'most' cases, and six (25%) stated that it was not self-limiting; seven (29%) did not touch on disease resolution.We call for a data and patient-oriented approach to the classification and description of the natural history of the disease, and recommend authors and clinicians (1) use the term 'frozen shoulder' over 'adhesive capsulitis', (2) use an updated definition of the disease which recognizes the often severe pain suffered, and (3) avoid the confusing and potentially harmful repetition of the natural history of the disease as a three-phase, self-limiting condition. Cite this article: EFORT Open Rev 2020;5:273-279.DOI: 10.1302/2058-5241.5.190032.

Morbidity associated with isolated iliac wing fractures.

BACKGROUND: Iliac wing fractures have received little attention in the literature. Commonly occurring after a direct blow, they are rotationally and vertically stable. However, one must be aware of their potential for major morbidity including soft tissue, abdominal organ, and vascular lesions. This study examines the incidence, radiographic findings, soft tissue injuries, and complications associated with isolated iliac wing fractures. METHODS: Retrospective review between 2003 and 2006 of a consecutive series of 450 polytraumatized patients treated in a level-1 University trauma center. Hospital charts and radiographs were reviewed and all patients with an isolated iliac wing fracture were requested to return for a clinical and radiologic examination. RESULTS: One hundred twenty patients had major pelvic trauma. Only 10 sustained a fracture limited to the iliac wing, all after high-energy trauma. Nine of 10 patients sustained a total of 36 additional injuries involving head, thorax, spine, abdomen, urologic, and orthopedic systems. Only two patients underwent internal fixation of their fracture, one because of the fracture compressing the bowel and the other because of a very large rotated iliac wing fragment. Two patients with open fractures were treated with irrigation and débridement and no internal fixation. CONCLUSIONS: An isolated iliac wing fracture not compromising the stability of the pelvic ring may be interpreted as a benign injury. However, serious and potentially life-threatening associated injuries may be present requiring emergency abdominal, vascular, or neurologic surgery. A thorough search for such injuries is critical. Most iliac wing fractures can be managed nonoperatively.

Vancomycin-induced DRESS syndrome in a female patient.

BACKGROUND: DRESS syndrome (drug rash with eosinophilia and systemic symptoms) is a hypersensitivity reaction with skin rashes, eosinophilia, fever, lymph node enlargement and internal organ involvement. CASE REPORT: A 60-year-old diabetic woman was hospitalized at the University Hospitals of Geneva for mid-leg amputation due to peripheral arterial occlusive disease. No drug allergy was reported. Because of a wound infection by methicillin-resistant Staphylococcus aureus, treatment with vancomycin (2 g/day) in continuous perfusion was initiated. Approximately 2 weeks later, she developed a toxidermia with fever, a progressive maculopapular skin rash, eosinophilia and acute renal insufficiency. The skin biopsy revealed a necrosis with lymphocytic and eosinophilic infiltrations, supporting the suspicion of DRESS syndrome. A cure was achieved by the withdrawal of vancomycin and the administration of methylprednisolone (1 g/day), antihistaminics and topical mometasone, without the introduction of other antibiotics. CONCLUSION: Vancomycin can be a cause of DRESS syndrome. A high index of suspicion is warranted in order not to miss this potentially lethal disease.

Supraspinatus Intramuscular Calcified Hematoma or Necrosis Associated with Tendon Tear.

Introduction. Rotator cuff intramuscular calcification is a rare condition usually caused by heterotopic ossification and myositis ossificans. Case Presentation. We describe a patient with voluminous calcified mass entrapped in supraspinatus muscle associated with corresponding tendon tear. Histological examination corresponded to a calcified hematoma or necrosis. Patient was surgically managed with open excision of the calcified hematoma and rotator cuff arthroscopic repair. At 6 months, supraspinatus muscle was healed, and functional outcome was good. Discussion and Conclusion. We hypothesized that supraspinatus intramuscular calcified hematoma was responsible for mechanical stress on the tendon. This association has never been described.

Is there a significant seasonality in the occurrence of osteoarticular infections?

Clinical experience suggests fluctuation in the occurrence of osteoarticular infections. We performed a single-centre study during 2004-2012, dividing each year into the four seasons according to the Gregorian calendar. A total of 455 episodes of osteoarticular infections were retrieved. There were 91 prosthetic joint infections (45 of haematogenous origin) and 159 cases of septic arthritis. The median period between early symptoms and diagnosis of infection was 27 days. The overall number of infections per season, cumulated over the 8-year study period, was 119 in spring, 129 in summer, 95 in fall, and 112 in winter, which did not reflect any significant seasonal fluctuation. None of the different subgroups of infections, namely arthroplasties (p for trend = 0.755), haematogenous arthroplasty infections (p = 0.493), gram-negative episodes or arthritis (p = 0.290), showed any season-related fluctuation. We conclude that osteoarticular infections, including haematogenous prosthetic joint infections, do not show any significant seasonality.

Arterial supply of the glenoid: an anatomic study.

Surgery is performed on the glenoid for a variety of pathologic conditions, and an adequate blood supply is required to achieve good healing of soft tissue and bone. The objective of this investigation was to study the arterial supply of the glenoid in 24 fresh human cadaveric specimens. The vascular supply originates from branches of the anterior and posterior circumflex arteries and the suprascapular artery and branches directly from the infraspinatus and teres minor muscles. The antero-superior portion of the glenoid is poorly vascularized, with a specific area that is completely devoid of blood supply. In addition, circumferentially around the glenoid rim, there is an area of approximately 5 mm from the edge that is completely devoid of vascularity. Adequate bone and soft-tissue healing in the glenoid, particularly in its anterosuperior portion, after fracture repair, osteotomy, total shoulder arthroplasty, and capsular procedures may be compromised by the demonstrated hypovascularity.