Postoperative cognitive dysfunction after beach chair positioning compared to supine position in orthopaedic surgery in the elderly.

INTRODUCTION: Postoperative cognitive dysfunction (POCD) occurs in up to 26% of patients older than 60 years 1 week after non-cardiac surgery. Intraoperative beach chair positioning (BCP) is advantageous for some types of shoulder surgery. However, this kind of positioning leads to a downward bound redistribution of blood volume, with possible hypoperfusion of the brain. We hypothesized that patients > 60 years undergoing orthopaedic shoulder surgery in a BCP might experience more POCD than patients operated in the supine position (SP). MATERIAL AND METHODS: A single-centre, prospective observational trial of 114 orthopaedic patients was performed. Study groups were established according to the type of intraoperative positioning. Anaesthesiological management was carried out similarly in both groups, including types of anaesthetics and blood pressure levels. POCD was evaluated using the Trail Making Test, the Letter-Number Span and the Regensburger Word Fluency Test. The frequency of POCD 1 week after surgery was considered primary outcome. RESULTS: Baseline characteristics, including duration of surgery, were comparable in both groups. POCD after 1 week occurred in 10.5% of SP patients and in 21.1% of BCP patients (p = 0.123; hazard ratio 2.0 (CI 95% 0.794-5.038)). After 4 weeks, the incidence of POCD decreased (SP: 8.8% vs. BCP: 5.3%; p = 0.463). 12/18 patients with POCD showed changes in their Word Fluency Tests. Near-infrared spectroscopy (NIRS) values were not lower in patients with POCD compared to those without POCD (54% (50/61) vs. 57% (51/61); p = 0.671). CONCLUSION: POCD at 1 week after surgery tended to occur more often in patients operated in beach chair position compared to patients in supine position without being statistically significant.

It Is Always the Same-A Complication Classification following Angular Stable Plating of Proximal Humeral Fractures.

INTRODUCTION: The aim of this study was to create a novel complication classification for osteosynthesis-related complications following angular stable plating of the proximal humerus subsuming the influence of these complications on clinical outcome in relation to fracture morphology and consequent revision strategies. A total of 1047 proximal humerus fractures with overall 193 osteosynthesis-associated complications (24.5%) were included. The following complication types could be clarified: complication Type 1 is defined by mild varus (<20°) or valgus displacement of the humeral head without resulting in a screw cutout through the humeral head cortex. Type 2a is defined by varus displacement (<20°) of the humeral head associated with screw cutout through the humeral head cortex. Type 2b complication is limited to displacement of the greater tuberosity, lesser tuberosity, or both tuberosities. Complication Type 2c is defined by severe varus dislocation (>20°) of the humeral head with screw cutout at the humeral head cortex. Complication Type 3 describes a displacement of the angular stable plate in the humeral shaft region with associated shaft-sided screw cutout, while the position of the humeral head remains static. Complication Type 4 is characterized by the occurrence of AVN with or without glenoidal affection (4a/b). Clinical outcome according to the constant score was mainly affected by type 2-4, leading to a deteriorated result. Depending on the type of complication, specific revision strategies can be considered. Additionally, more complex fracture patterns fostered the incidence of complications.

Mid-term functional outcome (minimum 24 months, mean 4 years) after locking plate osteosynthesis for displaced fractures of the proximal humerus in 557 cases.

BACKGROUND: The best surgical management of displaced proximal humeral fractures remains a matter of considerable debate. This study presents mid-term functional outcome (median 4 years) after locking plate osteosynthesis for displaced proximal humeral fractures. METHODS: Between February 2002 and December 2014 1031 patients with 1047 displaced proximal humeral fractures were treated by open reduction and locking plate fixation with the same implant and received consecutive prospective follow up at least 24 months after surgical treatment. Clinical follow-up consisted of Constant Murley score (CS), Disabilities of the Arm, Shoulder and Hand score (DASH), and Short Form 36 questionnaire (SF-36). Complete follow-up could be performed in 557 (53.2%) cases, with a mean follow-up of 4.0 ± 2.7 years. RESULTS: Of 557 patients (67% women; mean age at time of osteosynthesis: 68.3 ± 15.5 years) absolute CS of all patients 4 ± 2.7 years after surgery was 68.4 ± 20.3 points. Normalized CS according to Katolik was 80.4 ± 23.8 points, and CS in percentage to the contralateral side (%CS) was 87.2 ± 27.9%. DASH score was at 23.8 ± 20.8 points. Osteosynthesis related complications (secondary displacement, screw cutout, avascular necrosis (n = 117 patients) were associated with lower functional scores (mean CS was 54.5 ± 19.0 p.; nCS 64.5 ± 22.9 p.;%CS 71.2 ± 25.0%; DASH score 31.9 ± 22.4 p.). The SF 36 was 66.5 points in the case cohort and a vitality mean of 69.4 points. Patients with a complication showed lower results (SF 36 56.7; vitality mean 64.9 points). CONCLUSIONS: Overall, patients following locking plate osteosynthesis of displaced proximal humeral fractures showed good to moderate outcomes four years after surgery. Mid-term functional outcomes correlate significantly with those at 1 year postoperatively. Furthermore, there is a significant negative correlation of midterm functional outcome with the occurrence of complications. LEVEL OF EVIDENCE: Level III, prospective nonconsecutive patients.

The Accuracy of Distal Clavicle Fracture Classifications-Do We Need an Amendment to Imaging Modalities or Fracture Typing?

Background: Despite its fair-to-moderate reliability, the "modified Neer classification" is widely accepted and used. The purpose of this study was to reevaluate its applicability. Methods: Of n = 59 patients with distal clavicle fractures, fractures were classified on standard radiographs. Afterwards, an MRI examination was performed, and fractures reclassified. The primary outcome parameter was quantifying the rate of misclassification. The secondary outcome parameters were the evaluation of the ligamentous injury constellations. Results: In all cases, the fracture course and ligamental integrity could be assigned to the fracture type. Correction of the classification was necessary in n = 5 (8.5%) cases. In n = 3 (5%) cases, a correction was necessary from Neer I to Craig IIc and thus from conservative to operative treatment. Mean coracoclavicular distance (CCD) in Neer I was 10.2 ± 2.1 mm versus 14.2 ± 3.9 mm in Craig IIc (p = 0.02). The mean fracture angle in Neer I was 25.1 ± 3.3° versus 36.8 ± 4.4° in Craig IIc (p = 0.02). Conclusion: Cross-sectional imaging resulted in higher precision. Nevertheless, recommendations remain for standard radiographs. The CCD and fracture angle should be considered. An angle of >30° can be assumed as a parameter of instability. A previously undescribed fracture type does not seem to exist. The modified Neer classification is an appropriate and complete fracture classification.

One-year follow-up-case report of secondary tension pneumothorax in a COVID-19 pneumonia patient.

PURPOSE: The Coronavirus Disease 2019 (COVID-19) may result not only in acute symptoms such as severe pneumonia, but also in persisting symptoms after months. Here we present a 1 year follow-up of a patient with a secondary tension pneumothorax due to COVID-19 pneumonia. CASE PRESENTATION: In May 2020, a 47-year-old male was admitted to the emergency department with fever, dry cough, and sore throat as well as acute chest pain and shortness of breath. Sputum testing (polymerase chain reaction, PCR) and computed tomography (CT) confirmed infection with the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2). Eleven days after discharge, the patient returned to the emergency department with pronounced dyspnoea after coughing. CT showed a right-sided tension pneumothorax, which was relieved by a chest drain (Buelau) via mini open thoracotomy. For a period of 3 months following resolution of the pneumothorax the patient complained of fatigue with mild joint pain and dyspnoea. After 1 year, the patient did not suffer from any persisting symptoms. The pulmonary function and blood parameters were normal, with the exception of slightly increased levels of D-Dimer. The CT scan revealed only discrete ground glass opacities (GGO) and subpleural linear opacities. CONCLUSION: Tension pneumothorax is a rare, severe complication of a SARS-CoV-2 infection but may resolve after treatment without negative long-term sequelae. LEVEL OF EVIDENCE: V.

Supraspinatus Tenotomy in Reverse Shoulder Arthroplasty for Fractures: A Comparative Cohort Study.

BACKGROUND: The aim of this study was to evaluate the functional and radiographic outcome in patients with reverse total shoulder arthroplasty (RSA) for displaced proximal humeral fractures (PHF) with or without tenotomy of the supraspinatus tendon. METHODS: Between June 2011 and June 2018, 159 patients (age >65 years) with a displaced proximal humeral fracture underwent reverse total shoulder arthroplasty (Grammont design) in a single-center study and were longitudinally followed up. In all cases, the tuberosities were attached to the prosthesis in a standardized procedure. Functional outcome, range of motion as well as tuberosity integration, resorption and displacement were assessed at final follow-up. Outcomes were compared between patients that underwent RSA in combination with tenotomy of the supraspinatus (ST) and patients that underwent RSA without supraspinatus tenotomy (NT). RESULTS: At a mean follow up of 22.2 ± 16.4 months 76 patients (mean age 77.1 ± 7.2 years, 83% women) could be evaluated (follow-up rate 47.8%). There were no statistically significant differences between the ST (n = 29) and NT groups (n = 47) in tuberosity integration, resorption 20°: 65.5% vs. 14.9%, p < 0.05) and active abduction (>120°: 89.7% vs. 21.3%, p < 0.05). Tuberosity integration (ST and NT together: n = 34) showed better functional results than resorption or displacement (p < 0.05). CONCLUSIONS: Tenotomy of the supraspinatus tendon in RSA for displaced PHF leads to similar radiographic results regarding tuberosity integration, resorption and displacement but better functional outcome with regard to range of motion. LEVEL OF EVIDENCE: III.

Screw-Tip Augmented Locked Plating Versus Primary Reverse Total Shoulder Arthroplasty in Displaced Proximal Humeral Fractures: A Retrospective Comparative Cohort Study With a Mean Follow-Up of 39 Months.

INTRODUCTION: This study compared the clinical and radiologic outcomes of screw-tip augmented locking plate osteosynthesis (STA) vs primary reverse total shoulder arthroplasty (RSA) in elderly patients with displaced proximal humeral fractures. METHODS: 60 patients (age >65 years) with a displaced proximal humeral fracture underwent open reduction and internal fixation with locking plate and fluoroscopy controlled screw-tip augmentation. Sixty matched individuals (age, gender, fracture pattern, and mean follow-up) treated by RSA for fractures were identified from the institutional database and outcomes as well as occurring complications and need for revision surgery were compared. RESULTS: At 39 months' follow-up, 25 patients in the STA group (mean age 74.5 ± 12 years, 76.7% woman) showed a mean Constant Score (CS) of 68 ± 18.8 points. Mean %CS compared to the contralateral side was 81.6 ± 19.8%. Of 60 matched individuals in the RSA group, 22 patients (mean age 78.9 ± 8.2 years, 76.7% woman) showed a mean CS of 60.6 ± 21.2 points (P = .33), and the mean %CS compared to the contralateral side was 81.6 (74.7 ± 18.6)% (P = .14). The overall complication rate in STA group was 32% (secondary varus or valgus displacement >10°, n = 4, avascular necrosis, n = 4). In RSA group, the overall complication rate was 4.5% (P = <.05). We observed one early onset infection. Revision surgery with removal of the prosthesis and PMMA spacer implantation for two-stage revision was necessary. The follow-up rate was 41.7 vs 36.7%. CONCLUSIONS: Screw-tip augmented locked plating and reverse total shoulder arthroplasty result in comparable satisfying functional outcome 3 years following a displaced proximal humeral fracture in elderly patients. However, we noted a higher complication and revision rate in the STA group. In contrast, primary reversed shoulder arthroplasty resulted in a lower rate of complications and revisions, which may be beneficial in elderly patients.

Influence of chemotherapy and endocrine treatment on fractures in postmenopausal women with breast cancer - a retrospective cohort study.

Due to a significant increase in the overall survival of women with breast cancer (BC), preventing the long-term consequences of BC treatments is of the utmost importance. Treatments such as aromatase inhibitors (AI), chemotherapy (CHT), and tamoxifen (TAM) may lead to accelerated bone loss and increased fracture risk. The aim of this retrospective cohort study was to evaluate the treatment-induced fracture risk in a large cohort of postmenopausal women with or without BC. It included 4,115 women with BC and 4,115 healthy women from the Disease Analyzer database (IQVIA). Women with breast cancer were matched 1:1 to women without BC with regard to age, index year, and physician. Within 5 years of the index date, 25.3% of women with BC and 14.6% of healthy women sustained fractures. In this study, aromatase inhibitor therapy was significantly associated with a higher incidence of fractures compared to healthy women who had not undergone such therapy (HR: 3.36, p<0.001). In conclusion, postmenopausal women with BC who receive AI treatment exhibited an increased incidence of fractures when compared to the healthy cohort, while treatment with TAM or CHT showed no such association.

Glenohumeral joint lavage does not affect clinical outcomes in open reduction and internal fixation of displaced intracapsular proximal humeral fractures: a prospective, randomized, double-blinded trial.

BACKGROUND: This prospective, randomized, and double-blinded trial evaluates the effect of intraoperative glenohumeral joint lavage in open reduction and internal fixation of displaced intracapsular proximal humeral fractures. METHODS: Between January 2016 and April 2018, 86 patients (mean age: 65.2 ± 16.3 years) with a displaced intracapsular proximal humeral fracture were treated by open reduction and internal fixation using locking plates. Patients were randomized to either locked plating followed by intraoperatively performed glenohumeral joint lavage (group L, n = 36) or locked plating without the lavage (group NL, n = 36). Functional outcome assessment included range of shoulder motion, strength, and the Constant score, obtained 6 weeks, 3 months, 6 months, and 12 months postoperatively. A total of 62 shoulders could be reviewed for final investigation (86% follow-up). RESULTS: One year after open reduction and internal fixation, the mean Constant score was 70 ± 14 (group L, n = 31) compared with 73 ± 14 (group NL, n = 31, P = .272). The mean forward flexion and abduction in group L was 134 ± 33 and 128 ± 33 as compared with 139 ± 32 and 135 ± 32 in group NL, respectively (P = .538, P = .427). The mean external rotation was 40 ± 16 (group L) compared with 44 ± 16 (group NL) (P = .210). The overall complication rate was 9.6% and did not differ significantly between the groups (P = .321). In group L, there were 2 cases of avascular necrosis (6.5%) and 1 case of secondary displacement (3.2%). In group NL, 1 case of avascular necrosis (3.2%) and 1 case of secondary displacement were noted (3.2%, P = .742). CONCLUSION: The results of this study do not demonstrate a need for glenohumeral joint lavage in open reduction and internal fixation of displaced intracapsular proximal humeral fractures with regard to shoulder function at 1-year follow-up.

Operative treatment of 2-part surgical neck type fractures of the proximal humerus in the elderly: Cement augmented locking plate PHILOS™ vs. proximal humerus nail multiloc®.

INTRODUCTION: The purpose of this prospective randomized controlled clinical trial was to compare locked plating with intramedullary nailing in the treatment of displaced 2-part surgical neck type proximal humeral fractures in elderly patients. PATIENTS AND METHODS: Patients ≥60 years of age with a displaced 2-part surgical neck type fracture of the proximal humerus were surgically treated and randomized for either augmented locking plate fixation Group LP or multiplanar intramedullary nailing Group IN. The primary outcome parameter was the Disabilities of the Shoulder, Arm and Hand (DASH) Score after 24 months. Secondary outcome parameters were the age- and gender adjusted Constant Murley Score (CS), the American Shoulder and Elbow Score (ASES), the Oxford Shoulder Score (OSS) and the Short Form 36 (SF-36) after 6 weeks, 3 months, 6 months, 12 and 24 months. Further parameters included the quality of fracture reduction as well as complications and revision surgeries. 60 patients with a mean age of 75±9.8 were included and longitudinally followed over 24 months (follow-up rate: 83.3%). RESULTS: The mean DASH-Scores at 24 months was 32.6 ± 9.7 points in Group LP versus 37.8 ± 8.3 points in Group IN (p = 0.04). The mean Constant Murley Score at 24 months follow-up was 76.2 ± 7.7 points in Group LP compared to 72 ± 9.1 points in Group IN (p = 0.08). The ASES at 24 months follow-up was 75.1 ± 9 points in Group LP versus to 73.5 ± 8.9 in Group IN (p = 0.51). The OSS at 24 months was 43.7 ± 8.1 in Group LP compared to 38.2 ± 10 in Group IN (p = 0.03). The SF-36 at 24 months was 74.7 ± 12.5 in Group LP versus to 70.9 ± 12.8 in Group IN (p = 0.29). Screw cutting out was observed in n = 2 (6,7%) cases of Group LP, and in none of Group IN (p = 0.49). Revision surgery was necessary in n = 2 (6.7%) cases of Group LP and in two cases of Group IN (6.7%, p = 1). CONCLUSION: Functional outcomes are similar at 2-years follow-up in locked plating with screw tip augmentation compared to intramedullary nailing. Both implants reached low complication- and revision rates for two-part surgical neck types fractures of the proximal humerus in patients ≥60 years, if anatomic fracture reduction and accurate implant position was obtained.

Secondary tension pneumothorax in a COVID-19 pneumonia patient: a case report.

PURPOSE: Especially in elderly and multimorbid patients, Coronavirus Disease 2019 (COVID-19) may result in severe pneumonia and secondary complications. Recent studies showed pneumothorax in rare cases, but tension pneumothorax has only been reported once. CASE PRESENTATION: A 47-year-old male was admitted to the emergency department with fever, dry cough and sore throat for the last 14 days as well as acute stenocardia and shortage of breath. Sputum testing (polymerase chain reaction, PCR) confirmed SARS-CoV-2 infection. Initial computed tomography (CT) showed bipulmonary groundglass opacities and consolidations with peripheral distribution. Hospitalization with supportive therapy (azithromycin) as well as non-invasive oxygenation led to a stabilization of the patient. After 5 days, sputum testing was negative and IgA/IgG antibody titres were positive for SARS-CoV-2. The patient was discharged after 7 days. On the 11th day, the patient realized pronounced dyspnoea after coughing and presented to the emergency department again. CT showed a right-sided tension pneumothorax, which was relieved by a chest drain (Buelau) via mini open thoracotomy. Negative pressure therapy resulted in regression of the pneumothorax and the patient was discharged after 9 days of treatment. CONCLUSION: Treating physicians should be aware that COVID-19 patients might develop severe secondary pulmonary complications such as acute tension pneumothorax. LEVEL OF EVIDENCE: V.

Screw-tip augmentation versus standard locked plating of displaced proximal humeral fractures: a retrospective comparative cohort study.

BACKGROUND: This study compared the clinical and radiologic outcomes of screw tip-augmented locking plate osteosynthesis vs. standard locked plating in elderly patients with displaced proximal humeral fractures. METHODS: Of the 94 patients older than 65 years with displaced proximal humeral fractures, 55 underwent fixation with a locking plate only whereas 39 underwent fixation using a locking plate with fluoroscopy-controlled polymethyl methacrylate augmentation of screw tips. RESULTS: At 2 years' follow-up, the locking plate-only group showed a mean Constant score (CS) of 62.6 ± 17.4 points, mean CS as a percentage of the uninjured side of 78.2% ± 18.9%, and mean age- and sex-adjusted CS of 72.4 ± 20.5 points. Among the 39 patients who underwent locked plating with polymethyl methacrylate augmentation of screw tips, the mean CS was 63.7 ± 18.5 points (P = .28), the mean CS as a percentage of the uninjured side was 79.5% ± 20.4% (P = .36), and the mean age- and sex-adjusted CS was 76.8 ± 26.2 points (P = .11). The mean Disabilities of the Arm, Shoulder and Hand score was 26.4 ± 21.3 in the locking plate-only group compared with 23.6 ± 19.2 in the group with screw tip-augmented locking plate osteosynthesis (P = .41). The overall complication rate was 16.3% in the locking plate-only group compared with 12.8% in the group with screw tip-augmented osteosynthesis (P = .86); loss of fixation occurred in 10.9% vs. 5.1% (P = .74). The follow-up rate was 81%. CONCLUSIONS: Loss of fixation was less frequent when augmentation of screw tips was performed; however, at the 2-year follow-up, the clinical and radiologic outcomes were not significantly different compared with standard locked plating without augmentation.

Open reduction and internal fixation of displaced proximal humeral fractures. Does the surgeon's experience have an impact on outcomes?

INTRODUCTION: To evaluate outcomes following open reduction and internal fixation of displaced proximal humeral fractures with regards to the surgeon's experience. MATERIAL AND METHODS: Patients were included undergoing ORIF by use of locking plates for displaced two-part surgical neck type proximal humeral fractures. Reduction and functional outcomes were compared between procedures that were conducted by trauma surgeons [TS], senior (>2 years after board certified) trauma surgeons [STS] and trauma surgeons performing ≥50 shoulder surgeries per year [SS]. Quality of reduction was measured on postoperative x-rays. Functional outcomes were assessed by gender- and age-related Constant Score (nCS). Secondary outcome measures were complication and revision rates. RESULTS: Between 2002-2014 (12.5 years) n = 278 two-part surgical neck type humeral fractures (AO 11-A2, 11-A3) were included. Open reduction and internal fixation was performed with the following educational levels: [TS](n = 68, 25.7%), [STS](n = 110, 41.5%) and [SS](n = 77, 29.1%). Functional outcome (nCS) increased with each higher level of experience and was significantly superior in [SS] (93.3) vs. [TS] (79.6; p = 0.01) vs. [STS] (83.0; p = 0.05). [SS] (7.8%) had significantly less complications compared with [TS] (11.3%; p = 0.003) and [STS](11.7%; p = 0.01) moreover significantly less revision rates (3.9%) vs. [TS](8.2%) and [STS](7.4%) (p<0.001). Primary revision was necessary in 13 cases (4.7%) due to malreduction of the fracture. CONCLUSION: Quality of reduction and functional outcomes following open reduction and internal fixation of displaced two-part surgical neck fractures are related to the surgeon's experience. In addition, complications and revision rates are less frequent if surgery is conducted by a trauma surgeon performing ≥50 shoulder surgeries per year.

Correction to: Medical speciality, medication or skills: key factors of prehospital joint reduction. A prospective, multicenter cohort study.

The original version of this article unfortunately contained a mistake.

Medical speciality, medication or skills: key factors of prehospital joint reduction. A prospective, multicenter cohort study.

PURPOSE: Joint dislocations occur frequently in prehospital settings. The medical specialities of emergency physicians are heterogeneous. Decision making and the success rates of reduction attempt can vary greatly. The aim of this prospective multicentre study was to identify the factors most crucial for achieving successful prehospital reduction. METHODS: Study was conducted from 05/2012-05/2015 investigating cases of shoulder, patella and ankle joint dislocations in 16 emergency physician rescue stations. Parameters included: affected joint, type and use of medication, incidence and circumstances of reduction or reduction attempt and medical specialty as well as subjective skill status. RESULTS: In total 118 patients could be included. Mean age was 40.1 ± 21.3 years. Medical specialties were: n = 61 (51.7%) anaesthesiologists (A), n = 41 (34.5%) surgeons (S), and n = 16 (13.5%) internal medicine/others (I/O). Reduction attempt was performed in n = 97 (82.2%). With taking into account the complexity of the reduction (S) had significantly the highest success rates followed by (A) and (I/O). Regarding the applied medication there was neither a significant correlation between pain (p = 0.161) nor success of reduction (p = 0.09). A higher number of attempts does not improve the success rate (p ≤ 0.001), the pain level was no predictor for success of reduction attempt (p = 0.88). CONCLUSION: A successful reduction is determined by the trias of affected joint, skill level and medical specialty of the physician. In each case this trias should be considered by the physician in charge and he must evaluate limitations and circumstances.

Concomitant glenohumeral injuries in Neer type II distal clavicle fractures.

BACKGROUND: To identify the prevalence of concomitant glenohumeral injuries in surgically treated Neer type II distal clavicle fractures and relate its clinical importance. METHODS: Between 11/2011 and 11/2015 41 patients, suffering from a displaced and unstable distal clavicle fracture were included. 20 patients (group 1) received surgical treatment by means of plate osteosynthesis in combination with an arthroscopically assisted coraco-clavicular ligament augmentation. In group 2 (n = 21 patients) the fracture was treated by hooked plating solely, and diagnostic arthroscopy was conducted during hardware retrieval after the fracture had healed. All arthroscopies were performed in a standardized fashion, images were blinded retrospectively, and evaluated by two independent investigators. RESULTS: In total, concomitant glenohumeral pathologies were found in 26.8% of cases (41 patients, mean age 43.6 ± 16.6 years). In Group 1 (n = 20, arthroscopically assisted fracture treatment) the prevalence was 25%, in Group 2 (n = 21, diagnostic arthroscopy during implant removal) 28.5% (p = 0.75). Concomitant glenohumeral injuries included Labrum- and SLAP-tears, partial and full thickness rotator cuff tears as well as lesions to the biceps pulley system. Concomitant injuries were addressed in 2 patients of group 1 (10%, 2× labrum repair) and in 3 patients of group 2 (14.3%, of Group 2 (2× arthroscopic cuff repair of full thickness tear, 1× subpectoral biceps tenodesis in an type IV SLAP lesion, p = 0.68). CONCLUSION: The present study could clarify the acute and for the first time mid-term implication and clinical relevance of concomitant glenohumeral injuries. They have been observed in averaged 27% of Neer type II distal clavicle fractures at these two times. However, the findings of this study show that not all concomitant lesions remain symptomatic. While lesions are still present after fracture healing, it's treatment may be depicted upon symptoms at the time of implant removal. In turn, early diagnosis and treatment of concomitant injuries seems reasonable, as untreated injuries can remain symptomatic for more than 6 months after the fracture and recovery may be delayed.

Operative treatment of 2-part surgical neck fractures of the proximal humerus (AO 11-A3) in the elderly: Cement augmented locking plate Philos™ vs. proximal humerus nail MultiLoc®.

BACKGROUND: Proximal humeral fractures are with an incidence of 4-5 % the third most common fractures in the elderly. In 20 % of humeral fractures there is an indication for surgical treatment according to the modified Neer-Criteria. A secondary varus dislocation of the head fragment and cutting-out are the most common complications of angle stable locking plates in AO11-A3 fractures of the elderly. One possibility to increase the stability of the screw-bone-interface is the cement augmentation of the screw tips. A second is the use of a multiplanar angle stablentramedullary nail that might provide better biomechanical properties after fixation of 2-part-fractures. A comparison of these two treatment options augmented locking plate versus multiplanar angle stable locking nail in 2-part surgical neck fractures of the proximal humerus has not been carried out up to now. METHODS/DESIGN: Forty patients (female/male, ≥60 years or female postmenopausal) with a 2-part-fracture of the proximal humerus (AO type 11-A3) will be randomized to either to augmented plate fixation group (PhilosAugment) or to multiplanar intramedullary nail group (MultiLoc). Outcome parameters are Disabilities of the Shoulder, Arm and Hand-Score (DASH) Constant Score (CS), American Shoulder and Elbow Score (ASES), Oxford Shoulder Score (OSS), Range of motion (ROM) and Short Form 36 (SF-36) after 3 weeks, 6 weeks, 3 months, 6 months, 12 and 24 months. DISCUSSION: Because of the lack of clinical studies that compare cement augmented locking plates with multiplanar humeral nail systems after 2-part surgical neck fractures of the proximal humerus, the decision of surgical method currently depends only on surgeons preference. Because only a randomized clinical trial (RCT) can sufficiently answer the question if one treatment option provides advantages compared to the other method we are planning to perform a RCT. TRIAL REGISTRATION: Clinical Trial ( NCT02609906 ), November 18, 2015, registered retrospectively.

Complications of locked plating for proximal humeral fractures-are we getting any better?

BACKGROUND: Complication rates reported after locking plate fixation of proximal humeral fractures still range up to 40%. Whether modifications of surgical techniques, use of primary shoulder arthroplasty, or a fracture-specific management resulted in decreased complication rates during recent years remains unclear. Therefore, the aim of this long-term observation study was to analyze the incidence of complications and revision surgery after locked plating. METHODS: Between February 2002 and December 2013, 788 patients (aged 67.4 ± 17.3 years) with displaced proximal humeral fractures were treated with locking plate, primary hemiarthroplasty (HA), or reverse shoulder arthroplasty (RSA). Standardized follow-up included radiographs at 1 day, 6 weeks, and 3, 6, and 12 months. Complications and unplanned revision surgery were prospectively recorded over the complete follow-up. RESULTS: Of 788 patients, 646 (82%) were treated with locking plate, 82 (10.4%) with HA, and 60 (7.6%) with RSA. Mean follow-up was 14.8 ± 3.8 months. The mean complication rate associated with locked plating was 12.8%, and revision surgery was necessary in 11.6%. Within the last 5 years, the loss of fixation rate markedly decreased from 14.3% to 4.8%; simultaneously, an increased use of RSA was observed. CONCLUSION: The overall complication rate of locking plate osteosynthesis for proximal humeral fractures has been decreasing considerably within the last years. Among others, this might be due to an increased use of primary RSA for complex fracture types. In addition to a precise surgical technique, choosing the adequate treatment for each individual fracture to avoid complications and revision surgery is of utmost importance.