Reconstruction or replacement? A challenging question in surgical treatment of complex humeral head fractures in the elderly.

INTRODUCTION: Surgical treatment of complex humeral head fractures in the elderly is challenging due to osteoporotic bone, comorbidities and reduced compliance. The treatment strategy (reconstruction versus replacement) should allow for a functional aftercare and result in a high patient satisfaction. Major complications leading to surgical revision are crucial and should be avoided. The purpose of this study was to analyse the major complication rate leading to surgical revision and the patient-based outcome in complex humeral head fractures of the elderly population treated either using locking plate fixation (LCP) or reversed total shoulder arthroplasty (rTSA). MATERIALS AND METHODS: All patients older than 65 years surgically treated due to a four-part fracture of the proximal humerus between 2003 and 2015 were enrolled in our retrospective study. Major complications and revision rates were recorded and functional outcome was assessed using the Munich Shoulder Questionnaire (MSQ) allowing for qualitative self-assessment of the Shoulder Pain and Disability Index (SPADI), of the Disability of the Arm, Shoulder and Hand (DASH) score and of the Constant Score. RESULTS: A cohort of 103 patients with a mean age of 73.4 ± 6.2 years suffering from four-part fractures of the humeral head were enrolled. 63 patients were treated using the LCP fixation compared to 40 rTSAs. There were no significant differences in the patient-reported functional outcome. The revision rate was significantly higher in the LCP group (10/63; 15.9%) compared to the rTSA group (1/40; 2.5%). Reasons for revision were avascular head necrosis, cut-out of screws, secondary dislocation of the greater tuberosity and hypersensitivity to metal. CONCLUSIONS: Reversed total shoulder arthroplasty and locking plate fixation are both established surgical procedures for the management of complex proximal humerus fractures in the elderly leading to similar functional results. However the revision rate in the rTSA group was significantly lower. Primary rTSA should, therefore, be favoured in multimorbid elderly patients with an increased complication risk to avoid repeated anaesthesia.

[Lesions of the triceps tendon : Diagnostics, management, treatment]. / Läsionen der Trizepssehne : Diagnostik, Management, Therapie.

The triceps brachii muscle is the main extender of the elbow joint. Triceps tendon rupture or tearing presents a rare injury pattern in general. Distal tendon ruptures occur most commonly in the area of the insertion of the olecranon. Fractures of the radial head are reported as the most common concomitant injury. In many cases, pre-existing degenerative damage predisposes for tendon injury. These include local steroid injections, anabolic steroid abuse, renal insufficiency requiring dialysis, hyperparathyroidism, lupus erythematosus and Marfan's syndrome. However, the most frequent trauma mechanism is a direct fall onto the extended forearm or a blow to the elbow. Beside clinical examination and sonography, magnetic resonance imaging is the diagnostic gold standard. The treatment of triceps tendon injuries includes conservative as well as operative approaches, whereby the indications for surgical treatment must be generously considered depending on the patient's age, functional demands of the patient, involvement of the dominant extremity as well as on the extent of the tendon rupture.

[External fixation for treatment of peripartum pubic symphysis separation : Clinical case and discussion]. / Fixateure externe zur Behandlung der intrapartalen Symphysensprengung : Fallbericht und Diskussion.

A complete peripartum pubic symphysis separation is a rare but severe complication of natural birth. Its incidence is estimated to be 0.03-3 ‰. Minor partial separations with a small width can be treated with a pelvic binder. Separations with major dehiscence should be treated by surgical reduction and fixation. This article presents the case of a 30-year-old woman who suffered a complete rupture of the pubic symphysis during the birth of her second child. Radiographic dehiscence was 39 mm. The operative treatment was carried out using a supra-acetabular external fixator for 12 weeks with a good result.

[Operation preparation in trauma surgery]. / Operationsvorbereitung in der Unfallchirurgie.

The success of a surgical procedure is significantly influenced by several critical factors. The safety of the patient is the primary goal. To this end, the term surgical preparation covers a number of procedures aiming to ensure the safety for the patient and a successful surgical intervention: verifying the indications, planning the intervention, identification of potential harmful factors, risks and countermeasures, patient education and documentation. Trauma surgery poses a particular challenge to preoperative preparation, especially due to urgent surgical interventions. Here, a standardized and evidence-based preoperative evaluation ensures a successful treatment of the patient.

[Rupture of the distal biceps tendon]. / Rupturen der distalen Bizepssehne.

With an incidence of 3% of all biceps tendon injuries, rupture of the distal biceps tendon is a rare injury but can be associated with significant functional impairment of the elbow. In case of a complete rupture, the diagnosis can be made clinically with a pronounced power deficit, in particular for supination of the forearm. In cases of unclear symptoms magnetic resonance imaging should be included. Regarding the therapeutic approach, there is general consensus in the current literature that surgical treatment with anatomical reconstruction of the tendon footprint is superior to the conservative approach. Various surgical techniques with good biomechanical and clinical results are currently available but no clear superiority of a single technique has so far been demonstrated.

[Patellar fractures]. / Patellafrakturen.

Patellar fractures are a relatively rare entity with an prevalence of 1%. Preoperative computed tomography has gained a significant role as a diagnostic tool for patellar fractures in recent years. It enables an exact assessment of the fracture and helps in the decision making for the correct treatment procedure. Therapeutically, the armamentarium was supplemented by angle stable plate fixation, which potentially enables a better reconstruction of the patella than the conventional tension band fixation. In this context, the results of angle stable plate fixation are promising in terms of functional outcome and lower complication rates. The proven tension band fixation using K­wires or cannulated screws continues to be widespread in clinical practice and retains significance for simple patellar fractures. The use of polyethylene thread material instead of steel wire has shown advantages in biomechanical studies but the clinical application is more restrained.

[Clavicular fractures : Diagnostics, management and treatment]. / Klavikulafrakturen : Diagnostik, Management und Therapie.

Clavicular fractures account for approximately 6% of bony injuries of the shoulder girdle. Patients suffering from this type of injury show 2 peaks (at the 2nd and 8th decades of life) where the majority occur in young active patients during recreational and sports activities. Besides an accurate patient history with a focus on the trauma mechanism, the clinical and radiological investigations are the cornerstones of the diagnostics. Slightly displaced fractures in a pediatric population as well as non-displaced fractures in adults can be treated conservatively. In cases of shortening and/or displacement and high functional demands, operative treatment of clavicular fractures, stable fixation and the possibility of early mobilization and therapy can be achieved; however, the indications for the procedure also depend on other factors. Surgical stabilization can substantially reduce the danger of non-union, which is why it is becoming more important.

[Osteosynthesis of distal fibular fractures with IlluminOss : Video article]. / Osteosynthese einer distalen Fibulafraktur mithilfe von IlluminOss : Videobeitrag.

OBJECTIVE: The aim was minimally invasive osteosynthesis of a distal fibular fracture under the premises of poor soft tissue conditions and existing chronic comorbidities to enable rapid recovery and to reduce soft tissue stress in order to avoid postoperative infections and achieve early weight bearing. INDICATIONS: This involved a distal fibula fracture, classified as 44 B1.1, B1.2, B1.3 according to the working group for osteosynthesis (AO) or a B fracture after Danis and Weber with indications for surgery (cortical disruption and shaft offset > 5 mm), age > 65 years, poor soft tissue conditions and a Charlson score ≥ 1. CONTRAINDICATIONS: Acute or incompletely healed infection in the implantation area, allergy to dental adhesive or implant material, open fractures, multifragmentary and severely dislocated fractures. SURGICAL TECHNIQUE: The surgical technique is demonstrated in detail with the help of a video of the operation and which is available online. A 1-2 cm long incision at the distal pole of the fibula, insertion of an intramedullary wire, reaming of the medullary canal and insertion of the IlluminOss balloon implant, filling the balloon with monomer and curing using visible blue light (436 nm), shortening of the implant, radiological control and wound closure. FOLLOW-UP: Postoperative cooling and elevation of the affected limb, free mobility after postoperative day 1, pain-adjusted full load bearing in VacoPed boot for 6 weeks (depending on pain and swelling). RESULTS: Study currently ongoing, no complications or revisions so far.

[Periprosthetic humeral fractures: Strategies and techniques for osteosynthesis]. / Periprothetische Humerusfraktur: Strategien und Techniken der Osteosynthese.

The prevalence of periprosthetic humeral fractures (PHF) is currently low and accounts for 0.6-2.4%. Due to an increase in the rate of primary implantations a quantitative increase of PHF is to be expected in the near future. The majority of PHF occur intraoperatively during implantation with an increased risk for cementless stems and when performing total arthroplasty. Additional risk factors are in particular female gender and the severity of comorbidities. In contrast, postoperative PHF mostly due to low-energy falls, have a prevalence between 0.6% and 0.9% and are significantly less common. The prognosis and functional outcome following revision by open reduction internal fixation (ORIF) essentially depend on a thorough assessment of the indications for revision surgery, the operative treatment and the pretraumatic functional condition of the affected shoulder. In the armamentarium of periprosthetic ORIF of the humerus cerclage systems and locking implants as well as a combination of both play a central role. In comminuted fractures with extensive defect zones, severely thinned cortex or extensive osteolysis a biological augmentation of the ORIF should be considered. In this context when the indications are correctly interpreted, especially in the case of a stable anchored stem, various groups have reported that a high bony union rate can be achieved. As the treatment of PHF is complex it should be performed in dedicated centers in order to adequately address potential comorbidities, especially in the elderly population.

[Classification of periprosthetic shoulder fractures]. / Klassifikation periprothetischer Schulterfrakturen.

The key targets in the treatment of periprosthetic humeral fractures (PHF) are the preservation of bone, successful bony consolidation and provision of a stable anchoring of the prosthesis with the major goal of restoring the shoulder-arm function. A substantial problem of periprosthetic shoulder fractures is the fact that treatment is determined not only by the fracture itself but also by the implanted prosthesis and its function. Consequently, the exact preoperative shoulder function and, in the case of an implanted anatomical prosthesis, the status and function of the rotator cuff need to be assessed in order to clarify the possibility of a secondarily occurring malfunction. Of equal importance in this context is the type of implanted prosthesis. The existing classification systems of Wright and Cofield, Campbell et al., Groh et al. and Worland et al. have several drawbacks from a shoulder surgeon's point of view, such as a missing reference to the great variability of the available prostheses and the lack of an evaluation of rotator cuff function. The presented 6­stage classification for the evaluation of periprosthetic fractures of the shoulder can be considered just as simple or complex to understand as the classification of the working group for osteosynthesis problems (AO, Arbeitsgemeinschaft für Osteosynthesefragen), depending on the viewpoint. From our point of view the classification presented here encompasses the essential points of the existing classification systems and also covers the otherwise missing points, which should be considered in the assessment of such periprosthetic fractures. The classification presented here should provide helpful assistance in the daily routine to find the most convenient form of therapy.

[Periprosthetic humeral fractures: Strategies and techniques of revision arthroplasty]. / Periprothetische Humerusfraktur: Strategien und Techniken der Revisionsendoprothetik.

The primary aims when performing revision arthroplasty of periprosthetic humeral fractures (PHF) are preservation of bone stock, achieving fracture healing and preserving a stable prosthesis with the focus on regaining the preoperative shoulder-arm function. The indications for revision arthroplasty are given in PHF in combination with loosening of the stem. In addition, further factors must be independently clarified in the case of an anatomical arthroplasty. In this context secondary glenoid erosion as well as rotator cuff insufficiency are potential factors for an extended revision procedure. For the performance of revision surgery modular revision sets including long stems, revision glenoid and metaglene components as well as plate and cerclage systems are obligatory besides the explantation instrumentation. Despite a loosened prosthesis, a transhumeral removal of the stem along with a subpectoral fenestration are often required. Length as well as bracing of revision stems need to bridge the fracture by at least twice the humeral diameter. Moreover, in many cases a combined procedure using an additional distal open reduction and internal fixation (ORIF) plus cable cerclages as well as biological augmentation might be needed. Assuming an adequate preparation, the experienced surgeon is able to achieve a high fracture union rate along with an acceptable or even good shoulder function and to avoid further complications.

Dynamic in vitro analysis of tractile forces of the anterior cruciate ligament (ACL) transplant using patellar and semitendinosus muscle tendon: a cadaver study.

PURPOSE: The presented biomechanical study focused on the in vitro analysis of tractile forces working on the anterior cruciate ligament (ACL) and the ACL transplants, respectively, using a semitendinosus and/or patellar tendon during a passive flexion-extension movement (150-0°). MATERIAL AND METHODS: Overall, 15 fresh frozen human knee joint pairs were examined. At first during arthroscopy, the tibial insertion of the ACL was drilled using a special hollow drill. Thereby, a bone cylinder was exposed at which a dynamometer was attached to enable for direct registration of tractile forces on the ACL via the connection between ACL-dynamometer and computer. The ACL transplant was fixed at the femur using a so-called endo-button, whereas the dynamometer was attached to the tibial end of the ACL transplant. The dynamic part of the examination was performed using the knee kinemator device developed by Plitz and Wirth et al. using different preload. RESULTS: The curves of the tractile forces of the ACL were qualitatively homogeneous with only low force values in the middle flexion position, whereas during maximum flexion and extension the forces increased reaching a maximum in the 0° position. Also, in testing the ACL transplants a force decrease between 0 and 50° flexion was recognized with even greater forces resulting at the 150° position depending on the anterior position of the femoral drill channel for implanting the ACL transplant. The amount of pre-loading showed no influence on the form of the tractile force curve. However, by enhancing the preload to 70 N, the maximal force in the ACL transplant increased significantly. CONCLUSION: The tractile forces assessed within the ACL during passive flexion movements between 10 and 90° were not greater than the forces measured in the ACL transplants. Thus, the clinical consequence is that in the early postoperative phase passive mobilization might be performed in this motion range without putting the ACL transplant at risk for damage.

[Bent titanium elastic nail in clavicular non-union. Case report and review of the literature]. / Verbogener elastischer Titannagel bei Klavikulapseudarthrose. Fallbericht mit Literaturübersicht.

Fractures of the clavicle can often be treated conservatively. For severely dislocated but simple fractures in which conservative treatment often fails, intramedullary nailing with titanium elastic nails (TEN) shows similar results to stable plate osteosynthesis. We present the case of a 28-year-old female patient who had been treated with TEN osteosynthesis 4 years previously but clavicular non-union developed. Due to a new traumatic incident, the implanted intramedullary titanium nail was bent and migrated into the manubrium sterni. We were able to remove the wire and stable plate osteosynthesis was carried out. Bending and migration of titanium wires used in clavicular fractures are relatively rare complications and patients must be informed accordingly. These complications can be avoided by removal of the wire 3-12 months after implantation when the fracture has healed.

[Traumatic elbow dislocations in bouldering]. / Ellenbogenluxationsverletzungen beim Trendsport Bouldern.

Bouldering is a new trend sport which has become popular in recent years. From April 2011 to June 2012 a total of 5 patients with elbow dislocations from bouldering were admitted to our level 1 trauma center. The injuries varied from simple elbow dislocations to complex fracture dislocations. Elbow dislocations occurred during falling backwards when patients tried to protect themselves by retroversion of both arms. In all cases the falling height was less than 4 meters. The bouldering injury pattern, the diagnostic and therapeutic management as well as the rehabilitation program are described in detail in this article. To the best of our knowledge this is the first report on the special danger of bouldering for complex elbow injuries.

Functional results following titanium elastic-stable intramedullary nailing (ESIN) of mid-shaft clavicle fractures.

INTRODUCTION While plate fixation remains the gold standard for surgical treatment for displaced mid-shaft clavicle fractures (DMCF), intramedullary fixation has emerged as a promising alternative. However, due to its more demanding technique and depending on the fracture's nature, an open reduction can be necessary. Aim of this study was to compare the outcome of open reduction versus closed reduction of DMCF using ESIN. PATIENTS AND METHODS Titanium Elastic Nail (TEN) were used to treat 40 patients undergoing minimally invasive ESIN between December 2006 and July 2009. A total of 19 patients were treated with a closed reduction and 21 patients required open reduction. RESULTS Open reduction increases operative time and fluoroscopy time significantly versus closed reduction (open 80.8 ± 35.9 min; closed 30.5 ± 8.5 min). No significant differences were found regarding strength measurement (75.7 ± 22.0 N in the closed group and 74.2 ± 26.0 N in the open group), DASH score (5.1 ± 6.5 closed group vs. 5.8 ± 7.3 open group) and Constant score (87.4 ± 9 points closed group vs. 85.3 ± 7.2 points open group). No major complications were observed. CONCLUSION There was no significant difference comparing patients who were treated with an open versus a closed technique. If appropriately indicated we believe that using ESIN is an adequate and successful operative technique for DMCF. There were no significant differences in shoulder function after either procedure.

Improvements of complex post-traumatic stress disorder symptoms during a multimodal psychodynamic inpatient rehabilitation treatment - results of an observational single-centre pilot study.

Background: Complex post-traumatic stress disorder (CPTSD) describes chronic disturbances in self-organization (i.e. affect dysregulation; negative self-concept; severe difficulties in relationships) which are frequently observed in survivors of prolonged, repeated or multiple traumatic stressors. So far, evidence of psychodynamic treatment approaches for CPTSD is scarce.Methods: In this single-centre observational pilot study, symptom change during a 6-week psychodynamic inpatient treatment in a multimodal psychosomatic rehabilitation centre was evaluated using repeated measures analyses of variance (ANOVAs). Patients completed questionnaires on PTSD and CPTSD symptoms (ITQ), anxiety, depression and somatization (BSI-18), functional impairment (WHODAS) and epistemic trust, mistrust and credulity (ETMCQ) before (T1) and at the end of treatment (T2). A hierarchical linear regression analysis was calculated to identify factors associated with improved CPTSD symptoms.Results: A total of n = 50 patients with CPTSD were included in the study, of whom n = 40 (80%) completed treatment. Patients reported a significant reduction of CPTSD symptoms during treatment with a large effect size (-3.9 points; p < .001; η2 = .36), as well as a significant reduction of psychological distress (p < .001; η2 = .55) and functional impairment (p < .001; η2 = .59). At the end of treatment, 41.0% of patients no longer fulfilled the diagnostic criteria for CPTSD. Changes in epistemic stance included improved epistemic trust (ß = -.34, p = .026) and decreased epistemic credulity (ß = .37, p = .017), which together with lower age (ß = .43, p = .012) and lower depression levels at baseline (ß = .35, p = .054) were significantly associated with baseline adjusted mean change of CPTSD symptoms during therapy and explained 48% of its variance.Discussion: In our study, patients reported a significant reduction of CPTSD symptoms and comorbid symptoms during a multimodal psychodynamic inpatient rehabilitation treatment. Improved epistemic trust may facilitate the establishment of a trusting therapeutic relationship, thus fostering an environment of openness for knowledge transfer (i.e. social learning) and the exploration of diverse viewpoints and perspectives in the therapeutic process.

Complex post-traumatic stress disorder (CPTSD) is a condition often found in individuals who have experienced severe trauma, such as childhood abuse or torture.A study involving 50 patients with CPTSD showed significant improvements in symptoms and overall quality of life after undergoing a 6-week integrative multimodal psychodynamic inpatient rehabilitation treatment.The study also highlighted that improvement in epistemic trust could be a potential mechanism of change contributing to the positive therapeutic outcomes.

Footprint reconstruction in a rotator cuff tear associated cyst of the greater tuberosity: augmented anchorage.

Tears of the rotator cuff (RC) complicated by bone cysts at the footprint might represent a challenge for the shoulder surgeon. This might be additionally aggravated in elderly patients with inferior bone quality due to osteopenia or osteoporosis. In this report we present a technique for open repair of RC tears by augmenting the cystic lesion at the greater tuberosity using bone void filler in combination with a double row anchor reconstruction technique. Despite disadvantageous position and size of the cyst, using this technique the footprint can be restored by obtaining an anatomical position of the supraspinatus tendon. The application range of this technique is not limited to defined bony defects and presents a promising novel surgical approach. Level of evidence V.