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.

Arthroscopic Minced Cartilage Repair in the Glenohumeral Joint - Short Term Clinical Outcome in a 33-Year-Old Handyman: A Case Report.

Objective: Clinical outcome data for the novel minced cartilage procedure are sparse. While good results have been shown for the knee joint, this is the first report in the current literature regarding this increasingly important procedure in the glenohumeral joint. Case Description: A 33-year-old handyman with a cartilage defect in the humeral head underwent an all arthroscopic one-stage cartilage repair with the AutoCartTM procedure (Arthrex GmbH, Munich, Germany). A senior specialist examined the patient before surgery, five-, 12-and 24-weeks post-surgery. Outcome parameters (Constant-Murley Score, UCLA Shoulder Score and ASES Score) and radiographic imaging were recorded. Results: At six months, follow-up the outcome parameter showed excellent results, the joint pain decreased to numeric rating scale (NRS) 0. The postoperative magnetic resonance imaging (MRI) revealed a thin cartilage layer in the treated area with sufficient integration to the surrounding tissue. The cartilage in the former defect zone presented a homogeneous signal, which was comparable to the intact cartilage. Conclusion: This case report underlines the growing interest in single-stage arthroscopic minced cartilage procedures and shows promising results in the glenohumeral joint. Yet, larger investigations with long-term follow-up are necessary to provide reliable clinical data to determine if comparable results can be achieved over time.

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.

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.

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.

Promising Mid-Term Outcomes after Humeral Head Preserving Surgery of Posterior Fracture Dislocations of the Proximal Humerus.

BACKGROUND: The aim of this study was to evaluate the clinical outcome after humeral head preserving surgical treatment of posterior fracture dislocations of the proximal humerus. METHODS: Patients with a posterior fracture dislocation of the proximal humerus that were operatively treated in two level-1 trauma centers within a timeframe of 8 years were identified. With a minimum follow-up of 2 years, patients with humeral head preserving surgical treatment were invited for examination. RESULTS: 19/24 fractures (79.2%; mean age 43 years) were examined with a mean follow-up of 4.1 ± 2.1 years. Of these, 12 fractures were categorized as posteriorly dislocated impression type fractures, and 7 fractures as posteriorly dislocated surgical neck fractures. Most impression type fractures were treated by open reduction, allo- or autograft impaction and screw fixation (n = 11), while most surgical neck fractures were treated with locked plating (n = 6). Patients with impression type fractures showed significantly better ASES scores (p = 0.041), Simple Shoulder Test scores (p = 0.003), Rowe scores (p = 0.013) and WOSI scores (p = 0.023), when compared to posteriorly dislocated surgical neck fractures. Range of motion was good to excellent for both groups with no significant difference. CONCLUSIONS: This mid-term follow-up study reports good to very good clinical results for humeral head preserving treatment.

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.

[Injuries of the sternoclavicular joint]. / Verletzungen des Sternoklavikulargelenks.

Injuries of the sternoclavicular joint (SCJ) are rare accounting for 3% of all injuries to the shoulder girdle and are often overlooked. The SCJ is surrounded by tight ligamentous structures, thus substantial energy with corresponding force vectors is needed to cause dislocation. Causative are mostly high-energy traumas. Anterior dislocation is most common but in rare cases potentially life-threatening posterior dislocation occurs, which requires immediate reduction. The established gold standard is 3D reconstruction in contrast-enhanced computed tomography (CT) for depiction of neurovascular structures. Low-grade instability can initially be treated conservatively. For unsuccessful attempts at reduction, high-grade instability and chronic instability various surgical techniques are established. Next to retentive augmentation with suture materials, in acute cases with chronic instability biological tendon augmentation is preferred. In cases of posttraumatic instability arthritis SCJ resection with or without additive biological augmentation can be carried out. Various study groups have shown good to very good midterm outcome.

Fracture-pattern-related therapy concepts in distal humeral fractures.

Around one third of humeral fractures and 2-6% of all fractures occur to the distal part of the humerus. There is a bimodal distribution differentiating between young male patients with high-energy and elderly female patients with low-energy trauma related to osteoporosis. The AO classification and Dubberley subclassification are used in daily routine. Most fractures are diagnosed on radiographs. For further evaluation, three-dimensional computed tomography is recommended, especially for comminuted or complex fractures. Owing to the long immobilization and resultant poor functional outcome, conservative treatment is followed for inoperable patients. The operative approach and osteosynthesis depend on the fracture pattern. In A1 avulsion fractures, open reduction and screw fixation are recommended. In A2/A3 fractures, a triceps-sparing approach following a 90° double-plate construction (radial dorsal/ulnar lateral) with locking plates is favored. Partial articular B1/B2 fractures are exposed via a medial or lateral approach using unilateral locking plates to stabilize the medial/lateral column. Coronal shear fractures (B3) are classified after Dubberley and are treated via an extended Kocher approach and headless compression screws in anteroposterior direction. If there is a further posterior comminution or a lateral column fragment, stabilization is needed for the lateral/medial column with a precontoured locking plate. In solely articular fracture patterns, a dorsal approach with either a 90° or 180° double-plate construction is advised. If a reconstruction is not possible owing to fracture complexity or bone quality, total elbow arthroplasty is a viable option. However, lifelong limitation in weight-bearing up to 5 kg, limited longevity, and the potential for complicated revision surgery should be considered.

Concomitant glenohumeral pathologies associated with acute and chronic grade III and grade V acromioclavicular joint injuries.

PURPOSE: The purpose of this study was to identify the risk of concomitant glenohumeral pathologies with acromioclavicular joint injuries grade III and V. METHODS: Patients who underwent arthroscopically-assisted stabilization of acromioclavicular joint injuries grade III or grade V between 01/2007 and 12/2015 were identified in the patient databases of two surgical centres. Gender, age at index surgery, grade of acromioclavicular joint injury (Rockwood III or Rockwood V), and duration between injury and index surgery (classified as acute or chronic) were of interest. Concomitant glenohumeral pathologies were noted and their treatment was classified as debridement or reconstructive procedure. RESULTS: A total of 376 patients (336 male, 40 female) were included. Mean age at time of arthroscopic acromioclavicular joint reconstruction surgery was 42.1 ± 14.0 years. Overall, 201 patients (53%) had one or more concomitant glenohumeral pathologies. Lesions of the biceps tendon complex and rotator cuff were the most common. Forty-five patients (12.0%) had concomitant glenohumeral pathologies that required an additional repair. The remaining 156 patients (41.5%) received a debridement of their concomitant pathologies. Rockwood grade V compared to Rockwood grade III (p = 0.013; odds ratio 1.7), and chronic compared to acute injury were significantly associated with having a concomitant glenohumeral pathology (p = 0.019; odds ratio 1.7). The probability of having a concomitant glenohumeral pathology was also significantly associated with increasing age (p < 0.0001). CONCLUSIONS: Concomitant glenohumeral pathologies were observed in 53% of surgically treated patients with an acute or chronic acromioclavicular joint injury of either grade III or V. Twenty-two percent of these patients with concomitant glenohumeral pathologies received an additional dedicated repair procedure. Although a significant difference in occurrence of concomitant glenohumeral pathologies was seen between Rockwood grades III and V, and between acute and chronic lesions, increasing age was identified as the most dominant predictor. LEVEL OF EVIDENCE: Level IV, case series.

Failure and revision rates of proximal humeral fracture treatment with the use of a standardized treatment algorithm at a level-1 trauma center.

BACKGROUND: The aims of this study were to evaluate treatment failure and revision rates of proximal humeral fracture (PHF) treatment with a standardized treatment algorithm within the reality of a level-1 trauma center and to identify predictors of subsequent surgery. MATERIALS AND METHODS: The medical database of a level-1 trauma center was screened for all primary treatments of PHFs between January 2009 and June 2012. Medical records and imaging were analyzed to identify the fracture morphology, pre-existing diseases, revision surgeries and treatment failures (conversion to another treatment). The patients were asked about subsequent surgeries by phone. A functional outcome questionnaire was mailed to participating patients. RESULTS: Follow-up data were available for 423 of 521 patients (312 females, 111 males). The mean age at the time of primary treatment was 68.3 years; mean follow-up was 24.6 ± 12.3 months. The overall rate of mandatory re-operations was 15.6%, including a failure rate of 8.3%; another 7.6% of patients had additional arthroscopic surgeries. Treatment with anatomic hemi-prostheses was associated with the highest re-operation rates, and lowest outcomes. Involvement of the medial calcar region, complex fracture morphologies, cigarette smoking and alcohol-abuse were predictors for subsequent surgery. Patients without subsequent surgery had significantly higher functional outcome scores than patients with additional surgery. CONCLUSIONS: With the use of a standardized treatment algorithm no treatment modality was at significantly higher risk for having additional surgery. Complex fracture types, involvement of the medial calcar, cigarette-smoking and alcohol-abuse were associated with subsequent surgeries. LEVEL OF EVIDENCE: Level IV case series.

Arthroplasty compared to internal fixation by locking plate osteosynthesis in comminuted fractures of the distal humerus.

PURPOSE: The purpose of this study was to evaluate and compare the results after double locking plate osteosynthesis (ORIF) and total elbow arthroplasty (TEA) in AO type C fractures of the distal humerus. METHODS: This retrospective study includes clinical results of 29 patients (9xTEA, 20xORIF) with a mean age of 62 years. The male to female ratio was 8:21. Range of motion, MEPS, DASH and complications were evaluated. Patients older than 60 years (n = 19) were filtered and compared statistically. RESULTS: After a mean follow-up of 25 months the ORIF-group reached an extension-flexion of 99°±23° and the TEA-group of 111°±13°. The ORIF-group vs. the TEA-group had a mean MEPS of 85±17 vs. 94±11 and DASH of 34±24 vs. 24±12. In patients older than 60 years extension-flexion was 97°±23° after ORIF and 110°±14 after TEA (p = 0.237). The ORIF-group vs. the TEA-group had a mean MEPS of 82±21 vs. 94±11 (p = 0.078) and DASH of 45±18 vs. 26±11 (p = 0.023). The ORIF-group had a 4.4 times higher risk for major complications. CONCLUSION: TEA and ORIF lead to comparable functional results, but major complications are more common after ORIF. Despite this, ORIF remains the gold standard for younger and older patients because of the lifelong loading limitation after TEA, unknown implant survival and problematic revision surgery. For patients older than 60 years a primary TEA can be recommended in exceptional cases, if the loading limitation is acceptable for the individual or the fracture is not reconstructable.

Arthroscopy after locked plating of proximal humeral fractures: implant removal, capsular release, and intra-articular findings.

PURPOSE: The purpose of this study was to determine the outcomes of arthroscopy after proximal humeral plating and the occurrence of concomitant pathology and avascular necrosis. METHODS: Forty-five patients (28 women; median age, 58.5 years [range, 30 to 82 years]) underwent arthroscopies of 46 shoulders because of unsatisfactory results after locked plating of proximal humeral fractures. They were prospectively followed up for 3, 12, and 24 months postoperatively. Relevant intra-articular lesions were documented. The patients were assigned to 1 of the following groups: (1) articular screw perforation, (2) subacromial plate impingement, or (3) post-traumatic/postoperative shoulder stiffness. Shoulder range of motion and function as measured with the age- and gender-adjusted Constant-Murley score, as well as the Simple Shoulder Test, were compared among the groups. RESULTS: Concomitant lesions of the articular cartilage, long head of the biceps tendon, tuberosities, and rotator cuff were found in 34 patients (75%). Two-thirds of patients (n = 31) had a partial or complete 270° capsular release. Of the patients, 84% (n = 38) underwent 3 and 12 months' follow-up and 82% (n = 37) underwent 24 months' follow-up. The active range of abduction (P = .029), flexion (P = .048), and internal rotation (P = .0005) had improved significantly at 24 months' follow-up compared with the preoperative status. The mean adjusted Constant-Murley score of patients with post-traumatic shoulder stiffness (n = 15, 64.2% ± 7.9%) and articular screw perforation (n = 19, 73.3% ± 8.4%) was significantly lower (P = .0089 and P = .042, respectively) than that of patients with subacromial plate impingement (n = 12, 93.4% ± 4.3%). CONCLUSIONS: High rates of relevant articular pathologies and the necessity of capsular release in a majority of patients with unsatisfactory results after locked plating of proximal humeral fractures make arthroscopy a valuable revision tool with promising results in cases of high plate positioning, screw perforation, and postoperative/post-traumatic shoulder stiffness. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Has the arthroscopically assisted reduction of acute AC joint separations with the double tight-rope technique advantages over the clavicular hook plate fixation?

PURPOSE: The purpose of this study was to compare the results after arthroscopically assisted double TightRope(®)-(TR) reduction with results after clavicular hook plate (HP) fixation in acute high-grade acromioclavicular (AC) joint separations. METHODS: Between 2004 and 2010, 69 consecutive patients with acute AC joint separations type Rockwood III and V were subjected to surgical reconstruction. 56 patients (81 %) were available for evaluation. Thereof, 30 (median age: 39 years; n = 12 acute Rockwood III and n = 18 Rockwood V injuries) were treated by a clavicular HP and 26 (median age: 39 years; n = 10 acute Rockwood III and n = 16 Rockwood V injuries) using the double TR technique. Group HP was evaluated at a median of 48 (7-77) months after surgery and the TR group 17 (7-29) months after stabilization. Visual Analogue Scale (VAS) for Pain, Simple Shoulder Test (SST), Constant Score (CS) and Taft Score (TS) were assessed. Sonographic measurements were performed to evaluate recurrent instability. RESULTS: Clinical examination demonstrated comparable results without significant differences. In the groups HP and TR, the VAS was median 0.8 (range, 0.0-7.5) and 0.4 (range, 0.0-5.7), the SST reached median 11 (range, 0-12 points) and 12 points (range, 8-12 points). The CS was median 92.4 % (range, 21.5-105.4 %) and 94.0 % (range, 54.6-105.3 %) and the TS median 10 (range, 3-12 points) and 10 points (range, 5-12 points). Sonographic measurements showed a mean coracoclavicular (CC) distance of 25.3 ± 4.5 (HP) and 25.5 ± 4.3 mm (TR) (n.s.). In both groups, CC distance of the operated side was significantly higher compared to the uninjured side. The complication rate was 13 % in group HP and 12 % in group TR. CONCLUSIONS: In acute high-grade AC joint instabilities, both techniques lead to mostly good and excellent clinical results, although comparable partial recurrent vertical instability could be observed. Diagnosis and therapy of concomitant glenohumeral injuries and no obligatory implant removal are advantages of the arthroscopic procedure.

Arthroscopically assisted stabilization of chronic AC-joint instabilities in GraftRope™ technique with an additive horizontal tendon augmentation.

PURPOSE: A chronic symptomatic acromioclavicular joint (ACJ) instability is a possible consequence of an acute ACJ separation. Besides vertical instability a horizontal component of the instability is common in high-grade ACJ separation and clinically relevant; especially, in chronic cases. A new technique of horizontal biologic ACJ augmentation with a transacromial gracilis tendon loop as an addition to the arthroscopically assisted stabilization with the GraftRope™ device is described and first clinical and sonographical results are shown. HYPOTHESIS: The results after arthroscopically assisted single bundle reconstruction of the coracoclavicular (CC) ligaments with an additional horizontal tendon augmentation are comparable to the results of other stabilizing techniques in chronic ACJ instabilities. METHODS: A consecutive series of 20 patients with chronic symptomatic ACJ instability was stabilized with this new technique. 16 patients were followed-up clinically and sonographically. Patient satisfaction, visual analogue scale (VAS), simple shoulder test (SST), Constant score (CS) and Taft score (TS) were assessed. Bilateral sonographic measurements were performed to evaluate recurrent instabilities. Complications and concomitant glenohumeral injuries were analyzed. RESULTS: Sixteen patients (n = 2 female, n = 14 male, median age 40 (21-61) years, follow-up rate 84 %) were evaluated median 13 months (range 4-27 months) after indexed operation. 11 patients had a chronic ACJ instability after Rockwood type III, and 5 patients after Rockwood type V lesion. 6 patients suffered a recurrent symptomatic instability after operative treatment. 10 patients of the group were primary stabilized with the new technique. 15 of 16 patients were satisfied with the result of the operation at the follow-up examination. The VAS was median 4.6 of 10 points (range 1.1-7.4 points). The SST reached 9 points (range 5-12 points). The adjusted CS was median 84 % (range 46-93 %) and TS median 9 points (range 5-12 points). The sonographic measurements showed a significant difference in the CC distance between the unaffected and the affected side (21.7 vs. 24.8 mm, p = 0.009). The acromioclavicular distance was median 11 mm (range 7-17 mm) after resection of the lateral clavicle. Concomitant glenohumeral injuries were arthroscopically detected in seven patients. Postoperative complications occurred in one patient (wound infection). In one case, the clavicular washer was removed due to local paresthesia after healing of the graft. CONCLUSIONS: The arthroscopically assisted stabilization of chronic ACJ instabilities with the GraftRope™ device and an additive horizontal tendon augmentation technique leads to good short-term results with a supplementary horizontal stabilization.