Effectiveness of reverse total shoulder arthroplasty for primary and secondary fracture care: mid-term outcomes in a single-centre experience.

BACKGROUND: The introduction of reverse total shoulder arthroplasty (RSA) as a treatment option in complex proximal humeral fractures, has significantly extended the surgical armamentarium. The aim of this study was to investigate the mid-term outcome following fracture RSA in acute or sequelae, as well as salvage procedures. It was hypothesized that revision RSA (SRSA) leads to similar mid-term results as primary fracture treatment by RSA (PRSA). METHODS: This retrospective study describes the radiological and clinical mid-term outcomes in a standardized single-centre and Inlay design. Patients who underwent RSA in fracture care between 2008 and 2017 were included (minimum follow-up: 2 years, minimum age: 60 years). The assessment tools used for functional findings were range of motion (ROM), Visual Analogue Scale, absolute (CS) plus normative Constant Score, QuickDASH, and Subjective Shoulder Value. All adverse events as well as the radiological results and their clinical correlations were statistically analysed (using p < .05and 95% confidence intervals). RESULTS: Following fracture RSA, 68 patients were included (mean age: 72.5 years, mean follow-up: 46 months). Forty-two underwent primary RSA (PRSA), and 26 underwent revision RSA (SRSA). Adverse advents were observed in 13% (n = 9/68). No statistically significant results were found for the scores of the PRSA and SRSA groups, while the failed osteosynthesis SRSA subgroup obtained statistically significantly negative values for ROM subzones (flexion: p = .020, abduction: p = .020). Decreased instances of tubercle healing were observed for the in PRSA group relative to the SRSA group (p = .006). The absence of bony healing of the tubercles was related to significant negative clinical and subjective outcomes (all scores: p < .05, external rotation: p= .019). Significant postoperative improvements were evaluated in the SRSA group (CS: 23 to 56 at mean, p = .001), the time from index surgery to operative revision revealed no associations in functional findings. CONCLUSIONS: RSA is an effective option in severe shoulder fracture management with predictable results for salvage as well as first-line treatment. Promising mid-term functional results, reasonable implant survival rates, and high patient satisfaction can be achieved. LEVEL OF EVIDENCE: Level III.

Replantation of a circumferentially degloved thumb in an occupational crush injury - A case report and review of the literature.

BACKGROUND: Degloving injuries of the fingers and especially the thumb are highly demanding problems in hand surgery and replantation often is not successful because of severe soft tissue contusion. Only few cases of successfull replantation for hand degloving injuries in thumbs are reported in literature. CASE PRESENTATION: We present the case of a young right hand dominant worker experiencing an occupational accident with a circumferential avulsion of his right thumbs' soft tissue at the level of the metacarpophalangeal (MCP) joint with complete skeletization of his thumb and a deep laceration of the nail bed as he got trapped in a machine.Bony structures and tendons remained intact corresponding Urbaniak class III/Kay class IV injury. Immediate defect coverage by replantation was performed.Additionally, a deep palmar soft tissue defect to his middle finger pulp and a laceration with disruption of his eighth finger nerve on his ring finger was adressed by revision, debridement, direct coaptation of the nerve and occlusive dressing to the middle finger.The patient regained full function and excellent cosmesis without nail deformity but only protective sensibility. He is back to his former sports and occupation. CONCLUSIONS: Though sensitive outcome is poor we recommend primary attempt for defect coverage with replantation following degloving to achieve pliable skin coverage and good cosmesis. Especially in Urbaniak III cases with complete soft tissue degloving lacking fractures or tendon lacerations good functional outcome is possible but we recommend to consent the patient in advance for other reconstructive options and give them realistic exspectations in case of failure.Contrary to popular belief replantation of completely degloved fingers is more than saving nonfunctional parts as motivated patients are able to get back to previous sports and occupation after successful replantation.

Diagnostic parameters in periprosthetic infections: the current state of the literature.

Despite progress in recent years, a definitive diagnosis of PPI is not yet possible. Due to new diagnostic possibilities and the further development of already existing diagnostic tools, a more accurate diagnostic clarification of uncertain cases should be possible. The following article includes an overview of common existing diagnostic tools and instruments, which will likely gain importance in the future.

Reverse shoulder arthroplasty combined with latissimus dorsi transfer: A systemic review.

Reverse shoulder arthroplasty (RSA) combined with latissimus dorsi transfer (LDT) is described for patients with cuff arthropathy and a combined loss of abduction and external rotation. The purpose of this systemic review was to present clinical and radiological outcomes following RSA combined with LDT. A comprehensive literature review was performed to identify studies reporting clinical and radiological results of RSA combined with LDT. Seven articles that describe the treatment of 116 patients were selected. Functional scores, range of motion, radiological outcome, complications, rehabilitation regime, surgical technique, patient demographics and indication were analyzed and discussed. All studies reported significant improvement in functional scores and abduction and external rotation. Complications occurred in 26% of patients. Although high-level studies are lacking, this systemic review shows that RSA combined with LDT is a reliable surgical method with which to treat patients with loss of active abduction and loss of external rotation. The available data are insufficient to draw conclusions regarding the long-term outcomes of this procedure. LEVEL OF EVIDENCE: IV.

Long-term outcome following upper extremity replantation after major traumatic amputation.

BACKGROUND: Amputations in general and amputations of upper extremities, in particular, have a major impact on patients' lives. There are only a few long-term follow-up reports of patients after macro-replantation. We present our findings in contrast with the existing literature. METHODS: Sixteen patients with traumatic macro-amputation of an upper extremity were eligible for inclusion in this study. Altogether, the patients underwent replantation in 3 institutions between 1983 and 2011. RESULTS: Twelve male and four female patients with an average age at injury of 40.6 years (range, 14-61 years) were included in this study. The mean follow-up period was 13.5 years (range, 4.4-32.6 years; SD, 5.7 years). The mean disabilities of the arm, shoulder and hand (DASH) outcome measure was 41 (range, 5.2-94.8; SD, 18.2), functional independence measurement (FIM) was 125 (range, 120-126; SD, 1.8). Chen I representing very good function was accounted in six, Chen II representing good function in eight, Chen III (fair) in one and Chen IV (bad function) in one patient. CONCLUSIONS: We found that while the majority of the included patients exhibited good or very good function of the extremity, none of the replanted appendages regained normal levels of functionality. In addition, all participants were very satisfied with their outcomes. Positive long-term results with high rates of subjective satisfaction are possible after replantation of upper extremities.

[Minimally invasive treatment of intra-articular calcaneal fractures with the 2­point distractor]. / Minimal-invasive Versorgung intraartikulärer Fersenbeinfrakturen mit dem 2­Punkt-Distraktor.

OBJECTIVE: Open treatment of calcaneus fractures often has an increased risk of wound healing. Minimally invasive treatment with small incisions reduces complications. INDICATIONS: Calcaneal fractures with malalignment/comminution >1-2 mm; broadening, varus alignment of the calcaneal length axis or shortening; emergency surgery for open fractures or compartment syndrome. CONTRAINDICATIONS: Local or general contraindications. SURGICAL TECHNIQUE: Standardised positioning; restoration of length/axis with 2­point distractor under fluoroscopic control. Fragment reduction via small incisions. Fixation with 7.3 mm cannulated screws and 4.0 mm sustentaculum screws. POSTOPERATIVE MANAGEMENT: Cast-free and no weight bearing for 6 weeks; then weight bearing in a heel off-loading shoe for another 6 weeks with physiotherapy; if needed postoperative cast until soft tissue consolidation. RESULTS: Of 212 calcaneal fractures, 182 were treated with this technique. Wound healing complication rate was 2.7%; 4.7% of patients required secondary arthrodesis of the subtalar joint.

[Pre-requisites, observations and benefits of the DGU trauma registry in Austria]. / Voraussetzungen, Erfahrungen und Nutzen des Traumaregisters der DGU in Österreich.

The trauma registry of the DGU was founded in 1992 with the objective of collecting data on severely injured patients. The purpose of this registry, in which Austrian trauma units have taken part since 1998, is to answer questions related to the field of trauma management. Using the example of the Linz Trauma Center (UKH Linz), which has actively participated since 2012, the authors would like to share their experiences of collecting data in order to motivate other departments to participate in the trauma registry. We would like to make suggestions regarding implementation methods for high-quality data acquisition.However, the availability of essential human resources must be guaranteed, since the recording of data from severely injured patients sometimes takes 60-90 min. Additionally, an automatic data acquisition method is currently unavailable for technical reasons.

[Early functional treatment of intra-articular fractures of the proximal interphalangeal joint of the finger using a modified traction device]. / Die frühfunktionelle Therapie intraartikulärer Mittelgliedbasisfrakturen mit der modifizierten Traktionsschiene.

INTRODUCTION: Treatment of intra-articular fractures of the middle phalanx is both difficult and controversial. We report our experience of using a modified dynamic traction device (mTD) utilizing only one pin in the head of the middle phalanx and thus facilitating further open reconstructive surgery at the proximal interphalangeal joint (PIP). The pin does not necessarily have to be inserted in the movement axis of the joint. AIM OF THE STUDY: The aim of the study was to a) determine the effectiveness of the mTD, particularly in comparison with other distraction systems used in the treatment of middle phalanx fractures as described in the literature, and b) compare the results of patients treated using an mTD only with the results of those treated with an mTD in combination with additional open reconstructive surgery. PATIENTS AND METHODS: 26 patients with a mean age of 37 years were treated for intra-articular fractures of the base of the middle phalanx using an mTD in the period between 2007 and 2011. 13 of these patients also underwent additional open reconstructive surgery. 18 of the 26 patients (69%) were reevaluated after 33 months (range 9-44 months); 10 of these had undergone additional open reconstructive surgery. Follow-up of 14 of the patients included their completion of a structured questionnaire and calculation of their DASH scores as well as radiological and clinical examinations. 4 patients completed the questionnaire and had their DASH score calculated. Measurement of range of motion was performed by the treating general practitioner. Patient records were analysed with a particular focus on complications and duration of therapy. RESULTS: The mTD was used for an average of 34 days (range 8-53 days) and overall treatment took an average of 74 days (range 66-154 days). 4 pin tract infections were reported. The mean DASH score was 6.4. The mean range of motion in the PIP joint was 70° (range 30-110°). The range of motion of the PIP and DIP joints (61º) was significantly poorer in patients with additional surgery than that (82º) in patients with sole mTD treatment. Treatment with the mTD gave results similar to those obtained with other distraction devices with good subjective evaluation by the patients. CONCLUSION: Dynamic traction with the help of the modified traction devices is suitable for treating intra-articular fractures of the proximal interphalangeal joint, as demonstrated by a comparison with the literature. Patients who underwent additional open surgery showed less favorable results. The present method has the advantage that only one wire needs to be inserted subcapitaly at a distance from the fracture in the middle finger and this facilitates further surgical interventions.

Delayed diagnosed posterior interosseous nerve palsy due to intramuscular myxoma.

We present a case of posterior interosseous nerve palsy after bowel surgery associated with intramuscular myxoma of the supinator muscle. The initial symptoms of swelling of the forearm made it difficult to distinguish the condition from extravasations after intravenous cannulation. The diagnosis was finally established with nerve conduction studies and MRI 3 months after symptom onset. The patient underwent surgery for removal of the tumour and decompression of the posterior interosseous nerve. The histological examination identified the tumour as intramuscular myxoma and the patient made a full recovery with no recurrence of the lesion until present. Every swelling on the forearm causing neurological disorders is tumour suspected and should be examined clinically as well as electrophysically and radiographically. Early surgery and nerve decompression should follow immediately after the diagnosis. In case of intramuscular myxoma, good recovery of function after surgery with low recurrence risk may be expected.

[Therapy relevant imaging in modern surgical treatment of arthrosis of the shoulder: interesting facts for orthopedic surgeons]. / Therapierelevante Bildgebung in der modernen Arthrosebehandlung am Beispiel des Schultergelenks: Wissenswertes für den Orthopäden.

CLINICAL/METHODICAL ISSUE: Imaging for shoulder surgery varies a lot nowadays. Advantages and disadvantages of possible imaging methods according to the pathology and treatment options are described. STANDARD RADIOLOGICAL METHODS: Digital projection radiography in 3 planes, ultrasonography, MRI, CT scanning and scintigrams. METHODICAL INNOVATIONS: Special axial view to visualize the glenoid situation, as well as 3-D CT scanning for larger defects and classification. PERFORMANCE: Imaging of the glenoid situation, the version and erosion in axial view x-ray is mandatory to plan and control glenoid replacement. ACHIEVEMENTS: Useful application of imaging methods for the daily routine of orthopedic surgeons. PRACTICAL RECOMMENDATIONS: Digital 3 plane x-ray imaging in arthroplasty surgery is the minimum requirement. For rotator cuff lesions ultrasonography is good. In order to gain information on fatty infiltration of rotator muscles MRI is needed as well as for intra-articular lesions. For bony defects CT and reconstruction 3-D are recommended.