Proximal humerus fracture and acromioclavicular joint dislocation.

Proximal humerus fractures and injuries to the acromioclavicular joint are among the most common traumatic diseases of the upper extremity. Fractures of the proximal humerus occur most frequently in older people and are an indicator fracture of osteoporosis. While a large proportion of only slightly displaced fractures can be treated non-operatively, more complex fractures require surgical treatment. The choice of optimal treatment and the decision between joint-preserving surgery by means of osteosynthesis or endoprosthetic treatment is often a difficult decision in which both fracture morphology factors and individual factors should be taken into account. If endoprosthetic treatment is indicated, satisfactory long-term functional and clinical results have been achieved with a reverse shoulder arthroplasty. Injuries to the acromioclavicular joint occur primarily in young, athletic individuals. The common classification according to Rockwood divides the injury into 6 degrees of severity depending on the dislocation. This classification forms the basis for the decision on non-operative or surgical treatment. The indication for surgical treatment for higher-grade injuries is the subject of controversial debate in the latest literature. In chronic injuries, an autologous tendon transplant is also performed. Whereas in the past, treatment was often carried out using a hook plate, which was associated with complications, the gold standard today is minimally invasive treatment using Endobutton systems. This review provides an overview of the two injury patterns and discusses the various treatment options.

Easy and safe: a new surgical fixation technique for acute and chronic anterior instabilities of the sternoclavicular joint: technique and results.

BACKGROUND: Instabilities of the sternoclavicular (SC) joint are a rare injury, accounting for only 3% of all injuries of the shoulder girdle. Although acute posterior dislocations are an emergency and require immediate surgical intervention, anterior instabilities (first and second degree according to Allman) can mostly be treated conservatively. Chronic and highly instable acute anterior instabilities often impose a significant limitation on the lives of affected patients. Currently, there is no established therapeutic algorithm in place. METHODS: This retrospective case series with prospective collection of data was performed at a level I trauma center. Patients treated surgically for anterior SC joint instabilities between January 2013 and December 2019 and with a minimum follow-up of 24 months were included. The injuries comprised 6 acute anterior dislocations treated with tape cerclage in a "figure-of-8" configuration; 12 patients with chronic anterior SC instabilities were treated with autologous tendon grafts. For 1 highly unstable chronic anterior instability, in addition to the tendon graft, synthetic suture material was applied. The clinical evaluation consisted of a physical examination and a standardized questionnaire, which included subjective and objective shoulder scores. RESULTS: Of 24 patients, 19 (79%) with an average age of 32 ± 15 years were available for follow-up. A total of 63% of the patients were male. After a mean follow-up of 57 months, the mean age- and sex-adapted Constant-Murley Shoulder Score of acute anterior luxations amounted to 90 ± 20 points, the Nottingham Clavicle Score to 81 ± 22 points, and the Disability of the Arm, Shoulder and Hand Score to 11 ± 18 points. Chronic anterior instabilities had a mean Constant-Murley Shoulder Score of 90 ± 12 points, Nottingham Clavicle Score of 83 ± 17 points, and Disability of the Arm, Shoulder and Hand Score of 4 ± 5 points. The study shows a complication rate of 10%. Two patients underwent revision surgery. CONCLUSIONS: To conclude, monocortical SC joint fixation in a "figure-of-8" fashion presents a low risk for complication and a low revision rate and can achieve an equally good functional outcome after the treatment of highly unstable acute and chronic anterior SC joint instabilities as other published techniques. Our approach presents less risk to the neurovascular structures of the mediastinum than other published techniques requiring bicortical drilling, therefore making the technique more accessible to hospitals without a cardiothoracic surgical background.

Retrospective analysis of the subscapularis-sparing approach for reverse total shoulder arthroplasty.

PURPOSE: The influence of the subscapularis tendon on reverse total shoulder arthroplasty (RTSA) has been discussed controversially. The aim of the study was to investigate the subscapularis-sparing approach for RTSA and the effect of the intact subscapularis tendon. METHODS: This retrospective comparative study included 93 patients. Among these, 55 underwent the deltopectoral subscapularis-sparing approach, and in 38 cases, the standard deltopectoral approach with subscapularis tenotomy was applied. At the final follow-up, representative shoulder scores were measured, radiographs were taken in two planes, and shoulder sonography was performed. RESULTS: The subscapularis-sparing group showed a significantly higher Constant score (71.8 vs. 65.9 points) and adapted Constant score if the subscapularis tendon was shown to be intact in the postoperative sonography (85.2% vs. 78.6%) (p = 0.005; p = 0.041). Furthermore, these patients had improved abduction (128.2 vs. 116.8, p = 0.009) and external rotation (34.6 vs. 27.1, p = 0.047). However, no significant differences were found for the degree of internal rotation and internal rotation strength. No dislocation or infection was observed. The degree of scapular notching was not significantly different between the two groups (p = 0.082). However, independently from the integrity of the subscapularis the subscapularis-sparing approach showed no difference in clinical and radiographic outcome (Constant score scapularis-sparing 70.0 points vs. tenotomy 66.8 points; p = 0.27). CONCLUSION: The subscapularis-sparing approach RTSA showed improved clinical outcome, abduction, and external rotation, if the subscapularis was shown to be intact at time of follow-up. Both groups showed no difference in internal rotation.

Tuberosity refixation improves functional outcome following primary reverse shoulder arthroplasty in proximal humeral fracture.

INTRODUCTION: The purpose of this prospective study was to examine clinical results of tuberosity refixation in RSA for the treatment of displaced PHF in elderly patients. We hypothesized that tuberosity refixation would increase clinical outcome. METHODS: In this prospective study, 50 patients were included after receive a primary RSA for complex proximal humeral fracture between March 2013 and December 2015 for follow-up after three, 12 and 24 months. A functional and radiological assessment was performed on the patients. RESULTS: At final follow-up after a mean period of 25.1 months, data were available for 30 women and 6 men (74% of the included overall study collective) with a mean age of 77 years (range 55-93 years) at time of surgery. The tuberosities were refixated in 74% (n = 37) and in 26% (n = 13) resected. RSA with tuberosity refixation resulted in better clinical shoulder function compared to RSA with non-refixated tuberosities. The data show an external rotation with a significant difference (24.9° vs. 14°, p < 0.05) in favor of participants with refixation. The raw CMS was statistically significant (71.3 vs. 56.3, p < 0.05) after refixation, and SSV was significant improved (82.7% vs. 68%, p < 0.05) in the same group. Among 3 of 50 patients a total of 3 complications occurred with a total of 6% surgical revision. CONCLUSIONS: In this prospective study, tuberosity refixation as part of fracture treatment using RSA results in better external rotation, subjective assessment of shoulder recovery (measured by SSV and by raw CMS) in elderly patients, compared with tuberosity excision. LEVEL OF EVIDENCE: II, Prospective comparative study.

Implant-dependent behavior of tunnel widening and clavicular button migration after arthroscopic-assisted treatment of acromioclavicular joint instabilities.

INTRODUCTION: Despite ongoing discussions for the previous few decades, there is still no consensus regarding the optimal surgical technique for acromioclavicular joint instabilities. The purpose of this study was to determine the impact of various implant materials following arthroscopically assisted stabilization of acromioclavicular joint instabilities on tunnel widening and implant migration. We hypothesized an implant-dependent behavior for tunnel widening and implant migration with differences when comparing acute and chronic acromioclavicular joint instabilities. METHODS: This study compared 105 patients with acromioclavicular joint instabilities that were managed operatively with coracoclavicular double button constructs. Two of the groups containing acute cases were treated with either a double button construct with a wire (TR) or a tape (D) as a central pillar. The two groups with chronic cases were either treated with a wire (T+) or tape D+ as a central pillar and additional hamstring tendon augmentation (+). One central transclavicular-transcoracoidal drill channel was made in the acute cases, while additional medial and lateral drill channels to augment the central pillar with the hamstring tendon were made. The central drill channel in all cases and the medial/lateral drill channels in chronic cases were subsequently radiologically analyzed immediately postoperatively and at follow-up. Following this, additional radiological analysis of the implant migration of the clavicular button took place. RESULTS: All groups showed significant tunnel widening of the central drill channel at follow-up (p ≤ 0.001). The TR+ technique demonstrated significant widening in both the medial (p ≤ 0.001) and lateral (p ≤ 0.001) drill channels. The D and D+ group displayed significant higher rates of clavicular button migration to a cortical and intraosseous level (p ≤ 0.002). CONCLUSION: Tunnel widening and implant migration following arthroscopically assisted management of acromioclavicular joint instabilities are dependent on the chosen implant. The stable tape showed a significantly increased degree of tunnel widening with respect to the central drill channel in comparison with the wire. In contrast, a higher degree of load capacity of the tape ultimately favors a protected intraosseous graft healing for chronic cases, which leads to less tunnel widening of the medial and lateral drill channel. Finally, the D/D+ implant groups showed higher rates of implant migration due to lower contact surface area of the implant at the upper clavicular cortex.

Superior clinical results for early arthroscopic treatment of grade IIIb and V acromioclavicular joint instability compared to delayed operative treatment.

BACKGROUND: Arthroscopy-assisted cortical fixation devices have been increasingly used in the operative management of both acute and chronic cases of acromioclavicular joint instability (ACJI). It has been hypothesized that delayed surgical management leads to inferior clinical and radiologic outcomes compared to acute treatment. The purpose of this study is to compare clinical and radiologic outcomes, scapula dyskinesia, and failure or revision rates of arthroscopically treated acute and chronic ACJI. METHODS: This retrospective study of prospectively collected data included all surgically treated patients with grade IIIb and V chronic ACJI between 2013 and 2017, matched 1:1 to a group of acute grade IIIb and V ACJI patients treated during the same time period. Chronic ACJI was defined as delayed surgical treatment >21 days after injury. Chronic cases received an additional hamstring autograft next to the suture pulley systems. Follow-up was obtained at an average of 3.2 years (range: 1.4-6.2). Clinical outcome scores included the Constant-Murley Score (CMS), Taft Score (TF), Nottingham Clavicle Score (NCS), ACJI Score, Sick Scapula Score (SSS), Subjective Shoulder Value (SSV), Subjective Shoulder Test (SST), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, and the visual analog scale pain score. Radiologic follow-up was obtained pre- and postoperatively and at final follow-up. The 2-year results were compared to the results of a 1:1 matched-pair group comprising patients who were treated with an acute ACJI during the same period. RESULTS: Thirty-three (80.5%) of 41 chronic ACJI cases were available for follow-up and were compared with 33 matched-pair cases of acute ACJI (of 41). The clinical scores were significantly better in the acute cohort for the CMS (92 ± 8 vs. 88 ± 8, P = .030), ASES (91 ± 13 vs. 85 ± 13, P = .002), SSS (1.4 ± 1.6 vs. 3.4 ± 2.5, P = .0004), NCS (86 ± 13 vs. 81 ± 13, P = .049), TF (9.9 ± 1.9 vs. 9.0 ± 2.1, P = .030), and ACJI (83 ± 13 vs. 75 ± 1, P = .003). In contrast to the chronic cohort, the acute cohort illustrated a significant loss of reduction at follow-up (P = .020). CONCLUSION: Based on the results of this study, early arthroscopy-assisted operative treatment of grade IIIb and V ACJIs seems superior to delayed surgical intervention of grade IIIb and V ACJIs. Furthermore, an additional autograft loop leads to less loss of reduction compared with suture pulley/suspensory loop fixation standalones.

Arthroscopically assisted single tunnel reconstruction for acute high-grade acromioclavicular joint dislocation with an additional acromioclavicular joint cerclage.

PURPOSE: Purpose of this study was to demonstrate that a single tunnel reconstruction of high-grade acromioclavicular (AC) joint instabilities with implants of the second generation is sufficient for stabilisation, especially in combination with an AC cerclage. METHODS: Patients with an acute AC-joint dislocation type Rockwood III-B and V were included. Besides clinical follow-up examination, radiographs were analysed. The functional outcome measures were Constant Score (CS), Taft score (TS), ACJI score and patient's satisfaction. Horizontal instability was evaluated by clinical examination and radiological with an Alexander view. RESULTS: Thirty-five patients with a mean follow-up of 29 months were included. Ninety-seven per cent were satisfied with their result, with an average Subjective Shoulder Value of 90%. The CS averaged at 90 ± 10 points, TS at 11 ± 1 points and ACJI at 78 ± 18 points. Radiologically, 3 of 29 patients (10%) showed a persisting horizontal instability. The coracoclavicular (CC) distance improved from 22 preoperative to 10 mm postoperative, which was comparable to the contralateral side (10 mm, p = 0.103). At follow-up the CC distance increased to 13 mm (p = 0.0001). CONCLUSION: AC-joint stabilisation with a single tunnel reconstruction using a second-generation implant results in good to excellent clinical results with high patient satisfaction. The additional AC augmentation improves stability in horizontal instable AC-joints and is recommended in all high-grade AC joint stabilisations. Nonetheless, reduction was slightly lost over time due to an elongation or suture failure of the coraco-clavicular fixation. LEVEL OF EVIDENCE: IV.

Minimum 2-year results of the second-generation CFR-PEEK locking plate on the proximal humeral fracture.

PURPOSE: The aim of this study was to analyse and compare the 24-month range of motion results of patients treated with CFR-PEEK2 versus conventional titanium plate osteosyntheses (TAL-P). We hypothesized similar clinical outcomes but a better range of motion in the CFR-PEEK2 group than the TAL-P group in the 2-year follow-up. METHODS: This retrospective study analysing prospectively collected data included all patients that presented with a PHF and were treated with CFR-PEEK2 between November 2016 and April 2018. Follow-up was performed after a minimum of 24 months, evaluating the functional degree of movement functional scores, including the Subjective Shoulder Value (SSV) as well as an age- and sex-adapted Constant-Murley score (CMS). The 2-year results were compared to the results of a matched pair group comprising patients that were treated with TAL-P during the same period. RESULTS: Of the 35 patients included (mean age: 61.2 [18-78] years), 30 (86%) patients completed the 24-month follow-up in the CFR-PEEK2-group. After 24 months, the mean CMS was 89.9 points (pt) (44.5-100 pt) and the mean SSV was 86.7% (35-100%). Compared to the matched-pair TAL-P cohort, the 24-month follow-up showed similar results (CMS: 88.6 pt. (40.5-100 pt.) [p = 0.9]; SSV: 76% (30-100%) [p = 0.05]). However, significantly better degrees of forward flexion and internal rotation as well as a better range of motion in abduction was recorded in patients treated with CFR-PEEK2 plates than TAL-P. CONCLUSION: At the 24-month follow-up, patients who received treatment with CFR-PEEK2 compared to those that received TAL-P showed enhanced range of motion whilst having similar clinical scores.

[Arthroscopic-assisted management of intra-articular scapular fractures in a rugby player]. / Arthroskopisch assistierte Versorgung einer intraartikulären Skapulafraktur bei einem Rugbyspieler.

Scapular fractures are a rare injury entity accounting for 0,4-1 % of all fractures and 3-5 % of fractures involving the shoulder girdle. This study focuses on a 29-year-old male patient who sustained an intraarticular scapular fracture during a "Rugby Bundesliga" match after direct impact with another player. The clinical and radiological examinations showed a dislocated multifragmentary transverse scapular fracture involving the superior border, the medial border and the glenoid (Euler and Rüedi D2b/AO 14 F1.3e). The patient was subjected to arthroscopic surgery and underwent early postoperative functional rehabilitation without weight-bearing and with a limited range of motion of 90° abduction/anteversion. In the first match of the second half of the season (5 months post-operatively), the patient was available to play, and in the clinical follow-up 6 months post-operatively, he was pain-free with excellent clinical results (CS 100 pt, SSV 98 %, OSS 12 pt, ASES 100 pt). No pain or restrictions in the range of motion were reported. In conclusion, the arthroscopic-assisted management of intra-articular scapular fractures is a safe and effective choice of treatment in young and active patients.

Prospective clinical results of an additive ligament bracing for stabilizing simple and complex elbow instabilities.

INTRODUCTION: Ligament bracing augments ligament repair using a non-absorbable suture tape. Although biomechanically an increase in primary stability has been proven, there is a lack of clinical evidence. Purpose of this study was to evaluate clinical results of patients treated with ligament bracing due to primary elbow instability, including an analysis of complications. Furthermore, clinical results for patients treated with and without early functional mobilization were compared. MATERIALS AND METHODS: This prospective case-series evaluated clinical and functional results from patients treated with ligament bracing due to primary elbow instability. Clinical outcome measures were range of motion (ROM) as well as objective and subjective elbow scores [Mayo Elbow Performance Score (MEPS); Disabilities of Arm, Shoulder and Hand Score (DASH score)]. Stability was evaluated sonographically by humero-radial gapping under varus stress. RESULTS: This study involved 34 patients treated with ligament bracing. After a mean follow-up of 12.9 months ROM was 112° ± 29, MEPS 88 ± 13 points, DASH 91 ± 11 points, and 84% were satisfied with their result. Lateral joint gapping was 2.4 mm. No significant difference was observed regarding a postoperative mobilization with and without limitations. Most common complication after ligament bracing was elbow stiffness including heterotopic ossifications in four patients (12%). CONCLUSION: Operatively treated elbow instability with additional ligament bracing results in good clinical outcomes with high patient satisfaction and recovery of elbow stability. The high primary stability of the ligament bracing allows early functional mobilization without bracing, which facilitates postoperative rehabilitation. Elbow stiffness with heterotopic ossification seems to be a potential complication. Furthermore, the optimal tensioning of the ligament bracing remains challenging, including the risk of an over tensioning. LEVEL OF EVIDENCE: III.

Biomechanical Comparison of Two Fixation Techniques for Lateral Ulnar Collateral Ligament Repair With Ligament Bracing.

PURPOSE: Ligament bracing is a technique of suture reinforcement that can be used to augment lateral ulnar collateral ligament repair in the treatment of posterolateral rotatory instability of the elbow, thereby improving early stability of the repair. However, multiple failures of the ulnar anchor during implantation have been documented. We hypothesized that the use of a cortical button for ulnar fixation of the ligament brace would be biomechanically comparable to a suture anchor construct. METHODS: Sixteen elbows were tested with a materials testing machine. The intact, dissected, and repaired lateral collateral ligament complex was tested with a cyclic varus rotational torque of 0.5-3.5 Nm in 120°, 90°, 60°, and 30° elbow flexion. For the repair, the specimens were randomized into 2 groups: ulnar fixation of the ligament bracing using a suture anchor and ulnar fixation of the ligament bracing using a cortical button. The number of implant failures was documented. A load-to-failure protocol was conducted in 90° elbow flexion. RESULTS: Load to failure was comparable and was found to be 20.7 Nm in the suture anchor group and 21.8 Nm in the cortical button group. Laxity after ligament bracing did not differ significantly between suture anchor and cortical button fixation. Compared with the native ligament, the laxity was significantly reduced after ligament bracing. The failure mode was slippage of the suture tape through the humeral anchor in all cases. Additionally, the capitellum was damaged in 9 of 16 cases. CONCLUSIONS: A cortical button for ulnar fixation of the ligament bracing was comparable with a suture anchor fixation with regard to biomechanical properties such as laxity and load to failure. CLINICAL RELEVANCE: A cortical button fixation is less prone to failure of insertion. This would improve the implantation technique, while clinical results are expected to be comparable.

Additional coracoclavicular augmentation reduces revision rates in the treatment of lateral clavicle fractures as compared to angle-stable plate osteosynthesis alone.

INTRODUCTION: There is no uniform approach to the management of lateral clavicle fractures. Recent studies have investigated additive coracoclavicular (CC) augmentation as a treatment option; however, it is unclear whether it is superior to conventional locking plate osteosynthesis. METHODS: We carried out a retrospective analysis of 40 patients with lateral clavicle fracture (Neer type IIb) who were treated between 2014 and 2017 with either a hybrid locking plate osteosynthesis/additive arthroscopy-assisted CC augmentation (HP) procedure or a locking plate osteosynthesis only (PO) approach to determine which strategy was more effective. At follow-up, subjective shoulder value, age- and sex-adjusted Constant-Murley score, Taft (TF) score, American Shoulder and Elbow score, Nottingham clavicle score, and Visual Analogue Scale score were compared between patient groups. A radiologic evaluation was also conducted. RESULTS: A total of 14/17 patients (83%; 9 male/5 female, mean age: 43 ± 15 years) were followed up in the PO group. The mean follow-up time was 29 ± 12.4 months. In the HP group, 17/23 patients (74%; 9 male/8 female, mean age: 43 ± 17 years) were followed up, with a mean follow-up time of 18 ± 7.1 months. There were no significant differences in clinical parameters between the HP and PO groups; notably, the shoulder girdle-specific TF score was comparable in the 2 groups (HP: 11.3 ± 1.1 points and PO: 10.9 ± 0.9 points). In the HP group, additional pathologies were identified and arthroscopically treated in 35% of cases. Radiologic examination revealed a significant difference between pre- and postoperative CC distance in the HP group (P = 0.001). CONCLUSION: Additive CC augmentation in combination with locking plate osteosynthesis seems to improve the vertical stability and reduces the revision rate in patients with a lateral clavicle fracture. Furthermore, an arthroscopy-assisted procedure allows for an intraoperative detection and single-step treatment of accompanying intraarticular pathologies.

Anterior Locking Plate Osteosynthesis of Patellar Factures - Analysis of Complications and Functional Outcome. / Die winkelstabile Plattenosteosynthese der Patellafraktur ­ Komplikationsanalyse und funktionelles Ergebnis.

BACKGROUND: Tension band wiring is the standard procedure for patellar fractures, but is associated with a high rate of implant related complications and implant failure. Tension band wiring may fail, especially with multifragmentary and comminuted fractures. Plate fixation of complex patellar fractures seems to be superior to wiring, both clinically and biomechanically. The aim of this study was to evaluate complications after locking plate fixation in patellar fractures two years after surgery and to access the functional outcome. MATERIAL AND METHODS: As part of a prospective case series, all patients who had received locking plate fixation of a patellar fracture between April 2013 and May 2018 were clinically examined two years postoperatively and potential complications were evaluated. RESULTS: A total of 38 patients aged 19 - 87 years were included. Complications occurred in a total of five patients (13%), including one reactive prepatellar bursitis, one chronic infection and loss of reduction due to a dislocated pole fragment in three cases. The average active range of motion of the affected knee joint two years postoperatively was 133°. The Tegner activity scale score reached 3 points, the Lysholm score 95 points and the Kujala score 95 points. CONCLUSION: With an overall relatively low complication rate and good clinical outcome, dislocated distal pole fragments are a common complication after plate fixation of patellar fractures. If preoperative diagnostic testing shows a pole fragment, a modified hook-plate can be used, with the possibility of fixing the pole fragment.

Latest Trends in the Current Treatment of Proximal Humeral Fractures - an Analysis of 1162 Cases at a Level-1 Trauma Centre with a Special Focus on Shoulder Surgery. / Aktuelle Entwicklungen der Versorgungsrealität proximaler Humerusfrakturen ­ eine Auswertung von 1162 Fällen an einem Level-1-Traumazentrum mit schulterchirurgischem Schwerpunkt.

BACKGROUND: The management of proximal humeral fracture (PHF) is not only complex but ever changing. Published epidemiological data are often dated and do not factor in demographic changes or the latest developments in implant material and surgical techniques. AIMS: The primary aim of this study was to evaluate changes in the epidemiology and actual treatment of PHF at a level-1 trauma centre, with a special focus on shoulder surgery. HYPOTHESES: 1. Between 2009 to 2012 and 2014 to 2017, an increase in complex PHF entities can be observed. 2. In correlation with fracture complexity, an increasing number of comorbidities, especially osteoporosis, can be observed. METHODS: Between 2014 and 2017, a total of 589 patients (73% female; mean age: 68.96 ± 14.9 years) with 593 PHFs were treated. Patient records and imaging (XRs and CTs) of all patients were analysed. Fractures with ad latus displacement of a maximum of 0,5 cm and/or humeral head angulation of less than 20° were classified as non-displaced. Patients with displaced fractures were included in the analysis of the therapeutic algorithm. These results were compared to those of a cohort 2009 to 2012 (566 patients, 569 PHFs), which used the same inclusion criteria. RESULTS: The two cohorts showed comparable patient numbers, as well as gender and age distributions. Between 2009 to 2012 and 2014 to 2017, a decrease in 2-part fractures (13.9 to 8.6%) and a simultaneous increase in 4-part fractures (20.4 to 30%), and thus fracture complexity was observed. Further decreases were observed in conservative therapy (27.8 to 20.6%), nail osteosynthesis (10.7 to 2.7%) and anatomic shoulder arthroplasty (5,4 to 1%). Furthermore, there was an increase in the use of locking plate osteosynthesis (43.2 to 56.7%) and reverse shoulder arthroplasty (9 to 18.4%). The general trend shows an increase in surgical therapy between the years (72.2 to 79.4%), as well as an increase in osteoporosis incidence (13 to 20.6%). The greatest numbers of comorbidities were found in 3- and 4-part fractures. CONCLUSION: There is an increase in both the complexity of fractures and the number of surgically treated fractures between 2009 and 2012. Furthermore, an increase in osteoporosis numbers can be observed. New implants (PEEK, fenestrated screws for cement augmentation) and new surgical techniques (double plating osteosynthesis) were used as a result of increasing fracture complexity. Moreover, reverse total shoulder arthroplasty was used more commonly.

Double plating - surgical technique and good clinical results in complex and highly unstable proximal humeral fractures.

INTRODUCTION: A stable fixation of highly unstable proximal humerus fractures remains challenging and complication rates, especially secondary varus dislocation, remains high. Different techniques of double plate osteosynthesis have been suggested for the treatment of complex proximal humeral fractures as they are well established for other fractures. The aim of this study was to evaluate an operative technique using an angular stable lateral plate supported by a one-third tubular plate positioned anteriorly at the lesser tuberosity for unstable proximal humeral fractures. PATIENTS AND METHODS: Retrospectively, patients treated with a double plate osteosynthesis were included between January 2014 and December 2017. Out of 31, 25 patients (80.6%) with an average age of 53.1 years ± 12.5 were available for follow-up. 60% of the patients were male. The clinical evaluation consisted of a physical examination and standardised questionnaire including subjective and objective shoulder scores like the Constant-Murley Shoulder Score, Simple Shoulder Score, and Subjective Shoulder Value. RESULTS: After a mean follow-up of 30.9 months (range, 12-76 months) eighteen patients (72%) had either excellent or good results regarding the Constant-Murley Shoulder Score with a mean value of 77 points ± 17. Average Simple Shoulder Score was 76% ± 0.2 and Subjective Shoulder Value 72% ± 0.2%. Mean NSA at time of follow-up 135° ± 13°. Nine patients had an implant-removal, five in combination with arthrolysis after a mean of 7.2 months. Three patients underwent surgery for secondary arthroplasty. The study shows a complication rate of 16%. No revision-surgery because of secondary varus dislocation was reported. DISCUSSION: Arthroplasty is the less favourable treatment for a younger, active cohort of patients with highly unstable proximal humeral fractures as results are not as good and options for revision are limited. Double plate osteosynthesis can be used in addition to calcar screws, bone graft augmentation, cement augmentation and additional free screws for more multidirectional stability and shows good clinical results despite a higher rate of avascular necrosis and high primary stability with comparable complication-rates to single plate osteosynthesis. It seems to be a valid alternative to primary fracture arthroplasty and can prevent secondary varus displacement.

Suture tape augmentation of the lateral ulnar collateral ligament increases load to failure in simulated posterolateral rotatory instability.

PURPOSE: Simple elbow dislocations are accompanied with lateral ulnar collateral ligament ruptures. For persisting instability, surgery is indicated to prevent chronic posterolateral rotatory instability. After lateral collateral ligament (LCL) complex repair the repair is protected by temporary immobilization, limited range of motion and hinged bracing. Internal bracing is an operative alternative augmenting the LCL repair using non-absorbable suture tapes. However, the stability of LCL repair with and without additional augmentation remains unclear. The hypothesis was that LCL repair with additional suture tape augmentation would improve load to failure. Secondary goal of this study was to evaluate different humeral fixation techniques. A humeral fixation using separate anchors for the LCL repair and the augmentation was not expected to provide superior stability compared to using only one single anchor. METHODS: Twenty-one elbows were tested. A cyclic varus rotational torque of 0.5-3.5 Nm was applied in 90°, 60°, 30°, and 120° elbow flexion to the intact, torn, and repaired LCLs. The specimens were randomized into three groups: repair alone (group I), repair with additional internal bracing using two anchors (group II), repair using one humeral anchor (group III). A load-to-failure protocol was conducted. RESULTS: Load to failure was significantly higher in groups II (26.6 Nm; P = 0.017) and III (23.18 Nm; P = 0.038) than in group I (12.13 Nm). No significant difference was observed between group II and III. All specimens lost reduction after LCL dissection by a mean of 4.48° ± 4.99° (range 0.66-15.82). The mean reduction gain after repair was 7.21° ± 4.97° (2.70-21.23; mean over reduction, 2.73°). The laxity was comparable between the intact and repaired LCLs (n.s.), except for varus movements at 30° in group II (P = 0.035) and 30° (P = 0.001) and 120° in group III (P = 0.008) with significantly less laxity. Inserting the ulnar suture anchor showed failure in the thread in 10 cases. CONCLUSION: LCL repair with additional internal bracing yielded higher load to failure than repair alone. Repair with additional internal bracing for the humeral side using one anchor was sufficient. A higher primary stability would facilitate postoperative management and allow immediate functional treatment. Reducing the number of humeral anchors would save costs.

Injury patterns following simple elbow dislocation: radiological analysis implies existence of a pure valgus dislocation mechanism.

INTRODUCTION: The aim of the present study was to analyze the injury pattern and thus the dislocation mechanism after simple elbow dislocation using radiographs and magnetic resonance imaging (MRI) data sets. MATERIALS AND METHODS: The MRI data sets of 64 patients with a mean age of 44 years (18-77 years) were analyzed retrospectively. The inclusion criteria for the study were (1) radiograph with confirmed simple elbow dislocation, (2) low-energy trauma, (3) MRI of the affected elbow ≤ 3 weeks after trauma. The dislocation direction was determined using radiographs. The integrity of the lateral collateral ligament complex (LCLC), common extensor origin (CEO), anterior capsule (AC), medial collateral ligament (MCL), and common flexor origin (CFO) as well as the joint congruity were assessed based on MRI. RESULTS: 34 patients (53%) had a posterolateral, 26 patients (41%) a posterior, and 4 patients (6%) a posteromedial dislocation. LCLC and AC were affected in 64 out of 64 patients (100%). MCL was affected in 58 patients (91%). CEO were affected in 25 patients (39%) and the CFO in 20 patients (31%). In 11 patients (17%) the injury pattern was more pronounced medially than laterally (MCL, CFO, LCLC), with 2 of these patients exhibiting only a partial LCLC tear. All cases with joint incongruency (n = 12, 19%) showed CEO and/or CFO involvement. CONCLUSIONS: Simple elbow dislocation leads to a very heterogeneous spectrum of soft tissue injury pattern. A small proportion of patients showed medially pronounced injury patterns. These findings strongly indicate existence of a "reversed Horii circle" with an underlying valgus mechanism (medial force induction) originating and continuing from medial to anterior.

Anatomic factors influencing the anterior stability of reverse total shoulder arthroplasty.

BACKGROUND: Several factors affect the stability of the reverse shoulder arthroplasty. The influence of bony anatomy on anterior stability remains unclear. This study aimed to identify the correlations between bony anatomy and anterior dislocation forces. METHODS: The differences in anterior dislocation force in reverse total shoulder arthroplasty reported in a previous biomechanical study were used to analyze the anatomic factors influencing anterior stability. The critical shoulder angle, glenocoracoid distance in 2 planes, and glenoid inclination were measured in the tested specimens using 3-dimensional computed tomographic scans and radiographs. Anatomic parameters were then correlated with the anterior dislocation forces. RESULTS: The critical shoulder angle had no correlation with anterior stability. The glenocoracoid distance in anteroposterior direction showed a negative correlation with the stability of a reverse shoulder arthroplasty with a 9-mm lateralized glenosphere and 155° humeral inclination in 30° and 60° glenohumeral abduction with the arm in 30° external rotation (r = -0.662, P = .004; r = -0.794, P = .011) and 30° glenohumeral abduction with neutral rotation (r = -0.614, P = .009). Using the same hardware configuration, the anterior stability had a negative correlation with the glenocoracoid distance in the mediolateral direction in 30° of glenohumeral abduction with the arm in 0° and 30° of external rotation (r = -0.542, P = .025; r = -0.497, P = .042). CONCLUSION: The distance between the coracoid tip and glenoid in 2 planes had a significant negative correlation with the anterior stability of the reverse shoulder arthroplasty with a lateralized glenosphere and 155° humeral inclination. The findings suggest that only glenoid lateralization is influenced by the bony anatomy.

Can low-profile double-plate osteosynthesis for olecranon fractures reduce implant removal? A retrospective multicenter study.

BACKGROUND: Because of poor soft-tissue coverage at the proximal ulna and prominent posteriorly positioned implants, hardware removal remains the most common reason for revision surgery of olecranon fractures that were operatively treated using plate osteosynthesis. We hypothesized that low-profile double-plate osteosynthesis would reduce the number of soft tissue-related hardware removals compared with single posterior plating whereas the functional results would be comparable. METHODS: This study retrospectively included patients who were treated with low-profile double-plate osteosynthesis or a posterior 2.7-/3.5-mm locking compression plate (LCP) for isolated olecranon fractures from 3 study centers. In addition to the implant removal rate, functional outcome measures (range of motion; Mayo Elbow Performance Score; Disabilities of the Arm, Shoulder and Hand score) were statistically compared. RESULTS: The study included 79 patients, with a mean follow-up period of 36 months (range, 24-77 months). Of these patients, 37 were treated with low-profile double-plate osteosynthesis and 42, with a 2.7-/3.5-mm LCP. The mean age was 57 years (range, 18-93 years). Range of motion after treatment with low-profile double-plate osteosynthesis and a 2.7-/3.5-mm LCP measured 129° (range, 80°-155°) and 139° (range, 100°-155°), respectively. The Mayo Elbow Performance Scores were 95 (range, 65-100) and 99 (range, 85-100), respectively (P = .028), and the Disabilities of the Arm, Shoulder and Hand scores were 5.0 (range, 0-49) and 4.6 (range, 0-28), respectively (P = .673). Hardware was removed in 32% and 50% of patients after treatment with double-plate osteosynthesis and a 2.7-/3.5-mm LCP, respectively (P = .11). Hardware removal owing to soft-tissue irritation was noted in 27% of patients after double-plate osteosynthesis and 38% after LCP treatment (P = .30). DISCUSSION: Low-profile double-plate osteosynthesis for treating olecranon fractures resulted in good clinical outcomes. However, the rate of hardware removal was not significantly reduced, and the functional results were comparable to those of common single-posterior plate osteosynthesis.

Clinical evaluation of double-plate osteosynthesis for olecranon fractures: A retrospective case-control study.

INTRODUCTION: Single, dorsal plating is a commonly used technique for treating olecranon fractures. Double-plate osteosynthesis is an alternative treatment. Aim of this study was to present the surgical technique using this novel double-plate implant for olecranon fractures and review clinical results, complication rates and revision surgeries. Results were compared to single, dorsal plating. HYPOTHESIS: Does double-plate osteosynthesis for olecranon fractures improve material's tolerance with respect to osteosynthesis by single dorsal plating? PATIENTS AND METHODS: Between February 2011 and March 2015, we retrospectively evaluated 47 patients who were included in this study: 25 were treated with a low-profile double-plate osteosynthesis and 22 with an anatomically pre-shaped 3.5mm locking compression plate (LCP). The 2 groups were the result of a change of implants in our department in 2013. Patient satisfaction, range of motion, patient related outcome scores (Mayo Elbow Performance Score [MEPS], Disabilities of Arm, Shoulder and Hand Score [DASH]), complications and revision surgeries were evaluated. Results between both implant types were statistically compared using the Mann-Whitney U test. RESULTS: After a mean follow-up of 41 months (range: 25-61), the low-profile double-plate group showed a range of motion of 127°, MEPS of 94 and DASH of 6. The 3.5mm LCP group was found to have a range of motion of 130°, MEPS of 96 and DASH of 8. No clinical difference was found between groups. A total of 9 revision surgeries after double-plate osteosynthesis were recorded including seven implant removals and two intraarticular screws. One loosening of a screw without revision surgery was reported. The 3.5mm LCP group had 9 revision surgeries including eight implant removals and one intraarticular screw. DISCUSSION: Low-profile double-plate osteosynthesis is a safe and effective alternative treatment of olecranon fractures. Subjective and objective clinical outcome measures revealed a low complication rate and excellent results. Still, implant removal due to soft tissue irritation remains an issue. These findings were comparable to common dorsal plate osteosynthesis. LEVEL OF EVIDENCE: III, retrospective case-control study.