Deltoid Muscle Tension Alterations Post Reverse Shoulder Arthroplasty: An Investigation Using Shear Wave Elastography.

INTRODUCTION: This study aimed to evaluate the utility of shear wave elastography (SWE) in assessing changes in deltoid muscle properties following reverse shoulder arthroplasty (RSA). METHODS: Our cohort consisted of 18 patients who underwent RSA due to various conditions, including osteoarthritis, cuff arthropathy, and irreducible proximal humeral fractures. Pre- and postoperative muscle elasticity and stiffness were measured using SWE and were compared with functional outcomes and radiological parameters. RESULTS: Our results showed significant changes in deltoid muscle elasticity after RSA, particularly in the anterior and middle portions. However, these alterations were not correlated with postoperative functional outcomes or specific radiological parameters. The study also underscored the potential of SWE for future applications, including the preoperative assessment of deltoid function, postoperative monitoring, and intraoperative use for optimal component positioning during RSA. CONCLUSION: Further research, involving larger, more homogeneous patient cohorts is needed to confirm these findings and to explore the potential influence of these changes on the biomechanical design of implants and prosthesis positioning in RSA.

The S2e Guideline on Shoulder Stiffness. / Die S2e-Leitlinie Schultersteife.

The clinical picture of "frozen shoulder" is still poorly understood. In order to present the current state of knowledge on aetiology, diagnosis, and treatment, and to provide recommendations for the professional groups involved, a working group was formed by the DGOU and the DVSE to create a German language, evidence-based guideline, which was published in 2022 by the AWMF. The following summarises the development and the most important results.

Surgical stabilization of serial rib fractures is advantageous in patients with relevant traumatic brain injury.

PURPOSE: To evaluate the clinical benefit of surgical stabilization of rib fractures (SSRF) in polytrauma patients with serial rib fractures. METHODS: Retrospective single-center cohort analysis in trauma patients. Serial rib fracture was defined as three consecutive ribs confirmed by chest computer tomography (CT). Study cohort includes 243 patients that were treated conservatively and 34 patients that underwent SSRF. Demographic patient data, trauma mechanism, injury pattern, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) and hospital course were analyzed. Two matched pair analyses stratified for ISS (32 pairs) and GCS (25 pairs) were performed. RESULTS: The majority of patients was male (74%) and aged 55 ± 20 years. Serial rib fractures were associated with more than 6 broken ribs in average (6.3 ± 3.7). Other thoracic bone injury included sternum (18%), scapula (16%) and clavicula (13%). Visceral injury consisted of pneumothorax (51%), lung contusion (33%) and diaphragmatic rupture (2%). Average ISS was 22 ± 7.3. Overall hospital stay was 15.9 and ICU stay 7.4 days. In hospital, mortality was 13%. SSRF did not improve hospital course or postoperative complications in the complete study cohort. However, patients with a significantly reduced GCS (7.6 ± 5.3 vs 11.22 ± 4.8; p = 0.006) benefitted from SSRF. Matched pair analysis stratified for GCS showed shorter ICU stays (9 vs 15 days; p = 0.005) including shorter respirator time (143 vs 305 h; p = 0.003). CONCLUSION: Patients with serial rib fractures and simultaneous moderate or severe traumatic brain injury benefit from surgical stabilization of rib fractures.

CYR61 improves muscle force recreation in a rabbit trauma model.

BACKGROUND: Critically elevated compartment pressures after complicated tibial fractures may result in fibrosis and therefore scarring of muscles with impaired function. Several studies have shown a relationship between angiogenesis and more effective muscle regeneration. Cysteine-rich angiogenic inducer 61 (CYR61) is associated with angiogenesis but it is not clear whether it would restore muscle force, reduce scarring or improve angiogenesis after acute musculoskeletal trauma. OBJECTIVE: We researched whether local application of CYR61 (1) restores muscle force, (2) reduces scar tissue formation, and (3) improves angiogenesis. METHODS: We generated acute soft tissue trauma with temporary ischemia and increased compartment pressure in 22 rabbits and shortened the limbs to simulate surgical fracture debridement. In the test group, a CYR61-coated collagen matrix was applied locally around the osteotomy site. After 10 days of limb shortening, gradual distraction of 0.5 mm per 12 hours was performed to restore the original length. Muscle force was measured before trauma and on every fifth day after trauma. Forty days after trauma we euthanized the animals and histologically determined the percentage of connective and muscle tissue. Immunohistology was performed to analyze angiogenesis. RESULTS: Recovery of preinjury muscle strength was significantly greater in the CYR61 group (2.8 N; 88%) as compared to the control (1.8 N; 53%) with a moderate reduction of connective tissue (9.9% vs. 8.5%). Immunohistochemical staining showed that blood vessel formation increased significantly (trauma vs. control 38.75 ± 27.45 mm2 vs. 24.16 ± 19.81 mm2). CONCLUSIONS: Local application of CYR61 may improve restoration of muscle force and accelerate muscle force recovery by improving angiogenesis and moderately reducing connective tissue.

Dual-room twin-CT scanner in multiple trauma care: first results after implementation in a level one trauma centre.

PURPOSE: The trauma centre of the Wuerzburg University Hospital has integrated a pioneering dual-room twin-CT scanner in a multiple trauma pathway. For concurrent treatment of two trauma patients, two carbon CT examination and intervention tables are positioned head to head with one sliding CT-Gantry in the middle. The focus of this study is the process of trauma care with the time to CT (tCT) and the time to operation (tOR) as quality indicator. METHODS: All patients with suspected multiple trauma, who required emergency surgery and who were initially diagnosed by the CT trauma protocol between 05/2018 and 12/2018 were included. Data relating to time spans (tCT and tOR), severity of injury and outcome was obtained. RESULTS: 110 of the 589 screened trauma patients had surgery immediately after finishing primary assessment in the ER. The ISS was 17 (9-34) (median and interquartile range, IQR). tCT was 15 (11-19) minutes (median and IQR) and tOR was 96.5 (75-119) minutes (median and IQR). In the first 30 days, seven patients died (6.4%) including two within the first 24 h (2%). There were two ICU days (1-6) (median and IQR) and one (0-1) (median and IQR) ventilator day. CONCLUSION: The twin-CT technology is a fascinating tool to organize high-quality trauma care for two multiple trauma patients simultaneously.

[Do COVID-19 restrictions lead to a decrease in severely injured patients at a level 1 trauma center in Germany?] / Führt eine COVID-19-bedingte Ausgangsbeschränkung zu einer Reduktion schwer verletzter Patienten an einem überregionalen Traumazentrum?

BACKGROUND: Intensive care and ventilator capacities are essential for treatment of COVID-19 patients. Severely injured patients are often in continuous need of intensive care and ventilator treatment. The question arises, whether restrictions related to COVID-19 have led to a decrease in severely injured patients and thus to an increase in intensive care unit (ICU) capacity. MATERIAL AND METHODS: A retrospective analysis of all seriously injured patients with an injury severity score (ISS) ≥16 was performed between 17 March and 30 April 2020 at a level 1 trauma center in Germany. The mechanism of injury and the ISS were recorded. Further data were collected as to whether it was a work-related accident, a documented suicide attempt and if surgery was necessary in the first 24 h after arrival in hospital. Data from 2018 and 2019 served as a control group. RESULTS: There was no substantial difference in the total number of seriously injured patients (2018 n = 30, 2019 n = 23, 2020 n = 27). Furthermore, there was no relevant difference in the number of patients needing intensive care or ventilator treatment when leaving the shock room. The number of patients needing an operative intervention within the first 24 h after arriving at hospital was slightly higher in 2020. The mean ISS was at a constant level during all 3 years. In 2020 there was no polytraumatized motorbike rider, who did not have a work-related accident (2018 n = 5, 2019 n = 4, 2020 n = 0). A noticeable increase in work-related accidents was observed (2018: 10%, 2019: 26.1%, 2020 44.4%). DISCUSSION: Restrictions related to COVID-19 did not lead to a reduction in seriously injured patients needing ICU care. Due to the monocentric data analysis there is room for misinterpretation. In general, intensive care and operating capacities should be managed with adequate consideration for seriously injured patients even in times of crisis, such as the COVID-19 pandemic. Confirmation through the German Trauma Register is pending.

[Outcome after plate stabilization of symphyseal diastasis]. / Ergebnisse nach Plattenstabilisierung der Symphysensprengung.

BACKGROUND: Separation of the pubic symphysis with corresponding diastasis can be stabilized by symphyseal plating. OBJECTIVE: Which pelvic injuries are stabilized with symphyseal plating and what is their outcome? MATERIAL AND METHODS: A retrospective evaluation of 64 patients who underwent symphyseal plating over a period of 24 months was conducted. RESULTS: Of the patients 56 were male and 8 female with a mean age of 44 years (SD ± 17 years). The main cause of the pelvic injuries were traffic accidents. The distribution according to the AO fracture classification was 14â€¯× B1, 10â€¯× B2, 5â€¯× B3, 23â€¯× C1, 9â€¯× C2 and 3â€¯× C3 injuries. The distribution according to the Young and Burgess classification showed 9â€¯× APC I, 18â€¯× APC II, 13â€¯× APC III, 9â€¯× LC I, 3â€¯× LC II, 2â€¯× LC III and 10â€¯× VS injuries. The mean Injury Severity Score (ISS) was 32 (SD ± 17) and the mean inpatient stay was 29 days (SD ± 16 days; positive correlation p ≤ 0.001). Radiological implant loosening occurred in 52 patients. 14 patients required treatment for severe complications. The leading reason for revision surgery was implant failure (n = 8). CONCLUSION: These observations suggest that radiological signs of implant loosening are commonly observed but rarely the reason for revision surgery. Complete implant failures, however; occur mainly within the first postoperative weeks and require early revision. A timely clarification by additional X-ray imaging should be carried out if this is suspected.

Anatomically shaped locking plates for radial head and olecranon fracture fixation in Monteggia-like lesions.

BACKGROUND: Monteggia-like lesions are rare injuries. We retrospectively reviewed 40 consecutive patients with Monteggia-like lesions treated at a level I trauma center from 2009 to 2016. Clinical results were evaluated with a focus on the use of modern locking plates. OBJECTIVE AND METHODS: Twenty-eight patients had Bado type II fractures, 11 had Bado type I, and 1 had Bado type III. All patients were treated by plate fixation of the ulna with a locking compression plate or double mini-plates. Fixation or replacement was performed for radial head fractures. We characterized all fractures and recorded the range of motion (ROM); 100-point visual analog scale (VAS) scores for pain and function; Disabilities of the Arm, Shoulder and Hand (DASH) score; and Mayo Elbow Performance Score (MEPS). A follow-up rate of 78% was reached at an average of 36 months (range, 12-95 months). RESULTS: Stable fixation without recurrent instability was accomplished. The average ROM for flexion reached 130∘ with an extension deficit of 13∘. The sum of supination and pronation was 136∘. The VAS scores for pain and function were 20 and 75, respectively. The average MEPS and DASH scores were 84 and 28, respectively. Bado type I fractures had better outcomes for all variables, especially forearm rotation (p< 0.05). The complication rate was 22.5% and revision rate was 17.5%. CONCLUSION: This fracture repair technique can safely achieve good and excellent outcomes in most cases and is partly superior to previously published techniques. However, Bado type II fractures still have a risk of poor results.

Increased Mortality Among Critically Injured Motorcyclists Over 65 Years of Age.

BACKGROUND: Motorcycle accidents account for a large fraction of the patients with polytrauma treated in German hospitals. Clinical experience indicates that an in- creasing number of older motorcyclists are having accidents. We studied whether such individuals are subject to higher mortality and longer hospital stays. METHODS: We retrospectively evaluated data from the Traumaregister DGU® (TR- DGU) concerning all patients (n = 13 850) who were registered in the TR-DGU as having sustained trauma in a motorcycle accident from 2002 to 2015 and who had an Injury Severity Score (ISS) greater than 8. The patients were divided into four age groups for further study. RESULTS: Despite a nearly identical severity of anatomical injury according to the ISS, persons sustaining trauma in motorcycle accidents who were over 65 years of age (n = 892) needed longer and more intensive treatment than their younger counter- parts. They were invasively ventilated for a longer time (+ 1.2 days), kept for a longer time on the intensive care unit (+ 1.7 days), and stayed in the hospital three days longer. These older persons injured in motorcycle accidents had a disproportionate mortality in comparison to other polytrauma patients and a significantly elevated mor- tality in comparison to their younger counterparts-15.8%, compared to 7.2% among patients aged 45 to 64. Older trauma patients are more likely than younger ones to develop lethal complications in the later course of their hospitalization, while younger trauma patients who die generally do so as a direct result of the traumatic injury. CONCLUSION: Patients over age 65 who sustain trauma in motorcycle accidents have a higher mortality, a longer duration of ventilation, and longer stays in the intensive care unit and in the hospital overall than their younger counterparts. These patients present a special challenge to the treating medical team.

Posttraumatic elbow agility and reduction of muscle force after intra-articular distal fractures of the humerus in adults.

BACKGROUND: Treatment of distal intra-articular humerus fractures is still a technical challenge. Until now, little is known about the regain of strength and elbow agility after surgical treatment of these fractures. Due to small collectives there is only limited data. OBJECTIVE: Investigation of regained strength and elbow agility in patients with intra-articular distal humerus fractures. METHODS: A total of 28 patients were treated with distal intra-articular humerus fractures followed up for an average period of 62.3 months. The following parameters were examined: Arthrosis, heterotopic ossification, functional outcome (MEPS, DASH score, LES) and isometric strength of the elbow in extension and flexion was tested in 30∘, 60∘ and 90∘ in a custom-made positioning device. RESULTS: There was a high complication rate with 32%. At the 60th month post injury, range of motion (ROM) of the elbow was 114∘ with a reduction of 32∘ compared to the contralateral uninjured side (p< 0.001). The highest reduction was seen in extension with an average loss of 16∘ (p< 0.001). Loss of motion correlated with the fracture severity regarding the AO-classification (r= 0.54, p< 0.01). The average regained muscle force was 81.5% in flexion and 92% in extension in comparison to the contralateral healthy side. Patients over 60 years had less range of motion and inferior results in the DASH score compared to younger patients. CONCLUSIONS: Functional impairment in terms of reduced ROM and muscle force is a common complication after distal intra-articular humerus fracture. Patients over 60 years have a higher deficit of motion in the injured elbow joint and an inferior clinical outcome. Superiority of modern angle-stable implants could yet not be shown.

Comparing the MRI-based Goutallier Classification to an experimental quantitative MR spectroscopic fat measurement of the supraspinatus muscle.

BACKGROUND: The Goutallier Classification is a semi quantitative classification system to determine the amount of fatty degeneration in rotator cuff muscles. Although initially proposed for axial computer tomography scans it is currently applied to magnet-resonance-imaging-scans. The role for its clinical use is controversial, as the reliability of the classification has been shown to be inconsistent. The purpose of this study was to compare the semi quantitative MRI-based Goutallier Classification applied by 5 different raters to experimental MR spectroscopic quantitative fat measurement in order to determine the correlation between this classification system and the true extent of fatty degeneration shown by spectroscopy. METHODS: MRI-scans of 42 patients with rotator cuff tears were examined by 5 shoulder surgeons and were graduated according to the MRI-based Goutallier Classification proposed by Fuchs et al. Additionally the fat/water ratio was measured with MR spectroscopy using the experimental SPLASH technique. The semi quantitative grading according to the Goutallier Classification was statistically correlated with the quantitative measured fat/water ratio using Spearman's rank correlation. RESULTS: Statistical analysis of the data revealed only fair correlation of the Goutallier Classification system and the quantitative fat/water ratio with R = 0.35 (p < 0.05). By dichotomizing the scale the correlation was 0.72. The interobserver and intraobserver reliabilities were substantial with R = 0.62 and R = 0.74 (p < 0.01). CONCLUSION: The correlation between the semi quantitative MRI based Goutallier Classification system and MR spectroscopic fat measurement is weak. As an adequate estimation of fatty degeneration based on standard MRI may not be possible, quantitative methods need to be considered in order to increase diagnostic safety and thus provide patients with ideal care in regard to the amount of fatty degeneration. Spectroscopic MR measurement may increase the accuracy of the Goutallier classification and thus improve the prediction of clinical results after rotator cuff repair. However, these techniques are currently only available in an experimental setting.

Significant pain reduction and improved functional outcome after surgery for displaced midshaft clavicular fractures.

PURPOSE: Displaced midshaft clavicular fractures can be treated conservatively as well as operatively by titan elastic nail (TEN) or plate fixation. This survey was performed to evaluate the clinical results of each treatment method and elaborate advantages or possible complications of each modality. METHODS: Between 2008 and 2013, 102 patients were prospectively included in our study-37 patients for conservative treatment with a rucksack bandage for 4 to 6 weeks, 41 patients for plate osteosynthesis, and 24 for intramedullary stabilization with TEN. Disabilities of the Arm, Shoulder and Hand (DASH), Constant Murley Score (CMS), and visual analog scale (VAS) for pain and function as well as time of invalidity were recorded over a 1-year period. RESULTS: The clinical data collected reveals that all three different therapies lead to good or excellent clinical results after 1 year. However, one can observe advantages of operative treatment in comparison to conservative therapy in some characteristics. CONCLUSION: Our data shows that there are several indications where operative treatment has advantages compared to conservative treatment. In special fracture types (Robinson 2B1), TEN gives the best results. Plate fixation is extraordinarily sufficient in pain reduction within the first 5 weeks and indicated in more-part fractures (Robinson 2B2). Nevertheless, conservative treatment is always a good and promising way to treat clavicular fractures, so that individual indications and thorough patient informative talks are inevitable.

Biomechanical comparison of the Locking Compression superior anterior clavicle plate with seven and ten hole reconstruction plates in midshaft clavicle fracture stabilisation.

PURPOSE: The purpose of this study was to characterise the biomechanical properties of the seven hole superior anterior clavicle LCP (locking compression plate) and to compare these with the properties of commonly applied implants used for the stabilisation of clavicular midshaft fractures such as the locking 7- and ten hole reconstruction plate. METHODS: Twenty-four synthetic clavicles were used. A transverse midshaft fracture was induced. The clavicles were fixed with angle stable clavicle LCPs, seven hole and ten hole reconstruction plates (n = 8 each). Twenty cycles of axial compression and torsion were performed for each sample, which was followed by 1,000 cycles of three point bending and ultimately bending to failure. Axial, torsional and cantilever bending stiffness were calculated from the data recorded. RESULTS: The clavicle LCP showed the highest overall stiffness compared to the seven and ten hole reconstruction plate. Significantly higher stiffness values were found for axial compression and external rotation. In the load-to-failure tests, the ten hole reconstruction plate especially showed early signs of plastic deformation, which might account for early plate insufficiency so frequently observed clinically. CONCLUSION: The results indicate that the clavicle LCP, as compared to the reconstruction plates, leads to superior biomechanical stability in the treatment of midshaft clavicle fractures.

Cysteine-rich matricellular protein improves callus regenerate in a rabbit trauma model.

PURPOSE: Open fractures with severe soft-tissue trauma are predisposed to poor bone healing. The vital coupling between osteo- and angiogenesis is disturbed. Cysteine-rich protein 61 (CYR61) is an angiogenic inducer promoting vascularisation. However, little is known about the effect of CYR61 on the callus regenerate after acute musculoskeletal trauma. Therefore, our aim was to determine whether local administration of CYR61: (1) has an influence on callus formation and remodelling, (2) increases bone volume and (3) partially restores callus stability. METHODS: A musculoskeletal trauma was created in 20 rabbits. To simulate fracture-site debridement, the limb was shortened. In the test group, a CYR61-coated collagen matrix was locally applied around the osteotomy. After ten days, gradual distraction was commenced (0.5 mm/12 h) to restore the original length. New bone formation was evaluated histomorphometrically, radiographically and biomechanically. RESULTS: Osseus consolidation occured in all animals. Average maximum callus diameter was higher in the test group [1.39 mm; standard deviation (SD) = 0.078 vs 1.26 mm (SD = 0.14); p = 0.096]. In addition, bone volume was higher (p = 0.11) in the test group, with a mean value of 49.73 % (SD = 13.68) compared with 37.6 % (SD = 5.91). Torsional strength was significantly higher (p = 0.005) in the test group [105.43 % (SD = 31.68 %) vs. 52.57 % (SD = 24.39)]. Instead, stiffness of the newly reconstructed callus decreased (64.21 % (SD = 11.52) vs. 71.30 % (SD = 32.25) (p = 0.81)). CONCLUSIONS: CYR61 positively influences callus regenerate after acute trauma, not only histologically and radiographically but also biomechanically, most probably by a CYR61-associated pathway.

Stem cell- and growth factor-based regenerative therapies for avascular necrosis of the femoral head.

Avascular necrosis (AVN) of the femoral head is a debilitating disease of multifactorial genesis, predominately affects young patients, and often leads to the development of secondary osteoarthritis. The evolving field of regenerative medicine offers promising treatment strategies using cells, biomaterial scaffolds, and bioactive factors, which might improve clinical outcome. Early stages of AVN with preserved structural integrity of the subchondral plate are accessible to retrograde surgical procedures, such as core decompression to reduce the intraosseous pressure and to induce bone remodeling. The additive application of concentrated bone marrow aspirates, ex vivo expanded mesenchymal stem cells, and osteogenic or angiogenic growth factors (or both) holds great potential to improve bone regeneration. In contrast, advanced stages of AVN with collapsed subchondral bone require an osteochondral reconstruction to preserve the physiological joint function. Analogously to strategies for osteochondral reconstruction in the knee, anterograde surgical techniques, such as osteochondral transplantation (mosaicplasty), matrix-based autologous chondrocyte implantation, or the use of acellular scaffolds alone, might preserve joint function and reduce the need for hip replacement. This review summarizes recent experimental accomplishments and initial clinical findings in the field of regenerative medicine which apply cells, growth factors, and matrices to address the clinical problem of AVN.