[Anterior shoulder dislocation: revised Dutch Clinical Guideline in practice]. / Primaire anterieure schouderluxatie.

Shoulder dislocations remain the most frequent of joint dislocations, with anterior displacement of the humeral head being the direction of dislocation seen most often (97%). Recently, the Dutch clinical guideline on shoulder dislocations has been revised on the basis of predetermined bottlenecks in clinical practice. In this paper, the guideline is translated to clinical practice by means of two fictional cases, in which the novel recommendations are incorporated. The following topics were systematically assessed based on the best available scientific evidence: primary diagnostics, reduction techniques, painmedication/ sedation surrounding reduction and the need for physiotherapy, stabilization surgery and immobilization. Also, a best practice care pathway is advocated. Since scientific evidence is often inconclusive to provide undebatable therapeutic rules, the committee graded the available evidence and additionally used expert opinion to carefully draft recommendations. The paper concludes with an overview of all the recommendations stated in the updated multidisciplinary guideline.

Total shoulder arthroplasty for primary glenohumeral osteoarthritis: does posterior humeral subluxation persist after correction of the glenoid version at 5 years minimum?

BACKGROUND: Primary glenohumeral osteoarthritis is associated with both excessive posterior humeral subluxation (PHS) and excessive glenoid retroversion in 40% of cases. These morphometric abnormalities are a particular issue because they may be responsible for a deterioration in long-term clinical and radiologic outcomes. The aim of this study was to perform a computed tomographic (CT) analysis of patients who underwent total shoulder arthroplasty (TSA) for primary osteoarthritis (OA) with B2-, B3-, or C-type glenoids in whom an attempt was made to correct for excessive glenoid retroversion and excessive posterior humeral subluxation intraoperatively. MATERIAL: We performed a retrospective, single-center study including 62 TSA patients with a preoperative PHS of the glenohumeral joint (31 men, 31 women, 70 ± 9 years) between January 2000 and January 2014. Glenoids were classified as B2 (32 cases), B3 (13 cases), or C (17 cases). Glenoid retroversion was corrected by anterior asymmetric reaming. Patients were reviewed for clinical and CT scan assessment with a mean follow-up of 8.3 years (minimum 5 years). At final follow-up, the CT images were reconstructed in the scapular plane. A PHS index >65% defined persistence. RESULTS: The revision-free rate was estimated at 93%. Correlation between PHS and retroversion was moderate preoperatively (ρ = 0.58) and strong at final follow-up (ρ = 0.73). Postoperative CT scans on average showed a surgical correction of PHS compared to preoperatively (79% vs. 65% respectively, P < .05) and retroversion (20° vs. 10° respectively, P < .05). At final follow-up, 25 of 62 patients had a persistence in the 2-dimensional (2D) model and 41 of 62 in the corrected 2D model. Persistence of PHS had no influence on clinical outcomes but did demonstrate a significantly higher glenoid loosening rate (20% vs. 59%, P < .05). CONCLUSION: Correlation between PHS and retroversion was moderate preoperatively and strengthened at long-term follow-up. Anterior asymmetric reaming allowed for a surgical improvement of both PHS and retroversion, but it was not sufficient to maintain a correction over time. Glenoid loosening was more frequent in case of PHS persistence but seemingly without clinical relevance.

BRASD trial: biomechanical reposition techniques in anterior shoulder dislocation-a randomized multicenter clinical trial.

BACKGROUND: Biomechanical reduction techniques for shoulder dislocations have demonstrated high reduction success rates with a limited pain experience for the patient. We postulated that the combination of biomechanical reduction techniques with the shortest length of stay would also have the lowest pain experience and the highest first reduction success rate. METHODS: A randomized multicenter clinical trial was performed to compare different biomechanical reduction techniques in treating anterior shoulder dislocations without the use of invasive pain relief. Patients who were able to perform adduction of the arm were randomly assigned to Cunningham, the modified Milch, and the scapular manipulation technique. Those who were not able to do so were randomly assigned to modified Milch and the scapular manipulation technique. Primary outcomes were emergency department length of stay and pain experienced during the reduction process, measured by the numeric pain rating scale. Secondary outcomes were reduction time, reduction success, use of analgesics or sedatives, and complications. RESULTS: Three hundred eight patients were included, of whom 134 were in the adduction group. In both groups, no differences in emergency department length of stay and experienced pain were observed between the treatment arms. In the adduction group, the modified Milch technique had the highest first reduction success rates 52% (p = 0.016), within protocol 61% (p = 0.94), and with sedation in the ED 100% ( -). In the no-adduction group, the modified Milch was also the most successful primary reduction technique with 51% success (p = 0.040), within protocol 66% (p = 0.90), and with sedation in the ED 98% (p = 0.93). No complications were recorded in any of the techniques. CONCLUSION: A combination of biomechanical techniques resulted in a similar length of stay in the emergency department and showed similar pain scores with an overall high success rate of reduction. In both groups, the modified Milch had the highest first-reduction success rate. TRIAL REGISTRATION: Netherlands Trial Register NTR5839-1 April 2016. Ethical committee Noord-Holland with the CCMO-number NL54173.094.15.

Surgical Versus Nonsurgical Treatment for Midshaft Clavicle Fractures in Patients Aged 16 Years and Older: A Systematic Review, Meta-analysis, and Comparison of Randomized Controlled Trials and Observational Studies.

BACKGROUND: There is no consensus on the choice of treatment of midshaft clavicle fractures (MCFs). PURPOSE: The aims of this systematic review and meta-analysis were (1) to compare fracture healing disorders and functional outcomes of surgical versus nonsurgical treatment of MCFs and (2) to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies. STUDY DESIGN: Systematic review and meta-analysis. METHODS: The PubMed/MEDLINE, Embase, CENTRAL, and CINAHL databases were searched for both RCTs and observational studies. Using the MINORS instrument, all included studies were assessed on their methodological quality. The primary outcome was a nonunion. Effects of surgical versus nonsurgical treatment were estimated using random-effects meta-analysis models. RESULTS: A total of 20 studies were included, of which 8 were RCTs and 12 were observational studies including 1760 patients. Results were similar across the different study designs. A meta-analysis of 19 studies revealed that nonunions were significantly less common after surgical treatment than after nonsurgical treatment (odds ratio [OR], 0.18 [95% CI, 0.10-0.33]). The risk of malunions did not differ between surgical and nonsurgical treatment (OR, 0.38 [95% CI, 0.12-1.19]). Both the long-term Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley scores favored surgical treatment (DASH: mean difference [MD], -2.04 [95% CI, -3.56 to -0.52]; Constant-Murley: MD, 3.23 [95% CI, 1.52 to 4.95]). No differences were observed regarding revision surgery (OR, 0.85 [95% CI, 0.42-1.73]). Including only high-quality studies, both the number of malunions and days to return to work show significant differences in favor of surgical treatment (malunions: OR, 0.26 [95% CI, 0.07 to 0.92]; return to work: MD, -8.64 [95% CI, -16.22 to -1.05]). CONCLUSION: This meta-analysis of high-quality studies showed that surgical treatment of MCFs results in fewer nonunions, fewer malunions, and an accelerated return to work compared with nonsurgical treatment. A meta-analysis of surgical treatments need not be restricted to randomized trials, provided that the included observational studies are of high quality.

Comparing fracture healing disorders and long-term functional outcome of polytrauma patients and patients with an isolated displaced midshaft clavicle fracture.

BACKGROUND: Although clavicle fractures are a common injury in polytrauma patients, the functional outcome of displaced midshaft clavicle fractures (DMCFs) in this population is unknown. Our hypothesis was that there would be no differences in fracture healing disorders or functional outcome in polytrauma patients with a DMCF compared with patients with an isolated DMCF, regardless of the treatment modality. METHODS: A retrospective cohort study of patients (treated at our level I trauma center) with a DMCF was performed and a follow-up questionnaire was administered. Polytrauma patients, defined as an Injury Severity Score ≥16, and those with an isolated clavicle fracture were compared. Fracture healing disorders (nonunion and delayed union) and delayed fixation rates were determined. Functional outcome was assessed by the Quick Disability of the Arm, Shoulder, and Hand questionnaire. RESULTS: A total of 152 patients were analyzed, 71 polytrauma patients and 81 patients with an isolated DMCF. Questionnaire response of 121 patients (80%) was available (mean, 53 months; standard deviation, 22 months). No differences were found between polytrauma patients and those with an isolated DMCF with regard to nonunion (7% vs. 5%, respectively), delayed union (4% vs. 4%), and delayed fixation rate (13% vs. 13%). Polytrauma patients had an overall worse functional outcome, regardless of initial nonoperative treatment or delayed operative fixation. CONCLUSION: Polytrauma patients had a similar nonunion and delayed fixation rate but had an overall worse functional outcome compared with patients with an isolated DMCF. For polytrauma patients, a wait and see approach can be advocated without the risk of decreased upper extremity function after delayed fixation.

Systematic review of complications after intramedullary fixation for displaced midshaft clavicle fractures.

BACKGROUND: The number of displaced midshaft clavicle fractures treated surgically is increasing, and open reduction and intramedullary fixation is an emerging surgical treatment option. The study quality and scientific levels of published evidence in which possible complications of this treatment are presented vary greatly. METHODS: We performed systematic computer-based searches of EMBASE and PubMed/MEDLINE. Studies included for review reported complications after intramedullary fixation alone or in comparison to either treatment with plate fixation and/or nonoperative treatment. The Level of Evidence rating and Quality Assessment Tool were used to assess the methodological quality of the studies. Included studies were ranked according to their levels of evidence. RESULTS: Six articles were eligible for inclusion and final quality assessment; 3 studies were graded the highest level of evidence. Major complications like bone-healing problems and deep infections requiring implant removal were reported at a rate no higher than 7%. Reported rates for minor complications, such as wound infection and implant irritation that could be resolved without further surgery, were as high as 31%. CONCLUSION: The noted rates for major complications requiring additional surgery were low, but implant-related problems that require additional surgery might present with high prevalence. Owing to routine implant removal, treatment with intramedullary fixation often requires an additional surgical procedure.

Association between acromial index and outcomes following arthroscopic repair of full-thickness rotator cuff tears.

BACKGROUND: The purposes of this study were to evaluate the association between the acromial index and full-thickness rotator cuffs and to determine if the size of the acromial index was associated with outcomes in a cohort of patients who had had arthroscopic repair of full-thickness rotator cuff tears. METHODS: The acromial index was calculated for three groups by individual researchers: 115 patients (120 shoulders) who had arthroscopically repaired full-thickness rotator cuff tears without osteoarthritis (Group I); sixty-four patients (sixty-eight shoulders) who had intact rotator cuffs with osteoarthritis (Group II); and twenty-one patients (twenty-one shoulders) who had intact rotator cuffs, without osteoarthritis, and were managed for other pathology (Group III). The acromial index is the distance between the glenoid plane and the lateral border of the acromion divided by the distance between the glenoid plane and the lateral aspect of the humeral head. Ninety-two patients (ninety-three shoulders) from Group I met inclusion criteria for subjective follow-up. Minimum two-year subjective data were obtained on 86% (seventy-nine patients [eighty shoulders]) of these ninety-two patients to determine the association of the acromial index on surgical outcomes. Surgical factors were also analyzed. Significance was set at p < 0.05. RESULTS: The acromial index demonstrated high intraobserver agreement (kappa, 0.960; 95% confidence interval, 0.940 to 0.984) and high interobserver agreement (kappa, 0.960; 95% confidence interval, 0.922 to 0.979). The mean acromial index (and standard deviation) was 0.687 ± 0.08 for Group I, 0.685 ± 0.11 for Group II, and 0.694 ± 0.07 for Group III. No significant differences were found. At an average duration of follow-up of 3.0 years (range, 2.0 to 5.4 years), the mean American Shoulder and Elbow Surgeons scores improved from 59 to 93 points (p = 0.001) in the seventy-nine patients from Group I who had minimum two-year duration of subjective follow-up. The mean postoperative scores were 10.4 points (range, 0 to 54.5 points) for the Quick Disabilities of the Arm, Shoulder and Hand Outcome Measure and 9.2 points (on a scale of 1 to 10 points) for patient satisfaction. When the patients with a large acromial index (>0.682) were compared with those with a small acromial index (≤ 0.682), the patients in the former group had a greater likelihood of having a tear involving two or more rotator cuff tendons (p = 0.017), required more anchors to achieve repair (p = 0.007), had slightly lower patient satisfaction scores (mean, 8.9 compared with 9.5 points; p = 0.055) and Short Form-12 Physical Component Summary scores (mean, 49.1 compared with 55.2 points; p = 0.04), and had higher Quick Disabilities of the Arm, Shoulder and Hand scores (mean, 12.9 compared with 7.4 points; p = 0.042). CONCLUSIONS: An association between the size of the acromial index and that of full-thickness rotator cuff tears was not confirmed; however, a larger acromial index was associated with an increased number of tendons torn and anchors used for repair. In addition, patients with a larger acromial index had more disability as recorded by the Quick Disabilities of the Arm, Shoulder and Hand Outcome Measure and poorer physical health as measured by the Short Form-12 Physical Component Summary score.

The effects of arm elevation on the 3-dimensional acromiohumeral distance: a biplane fluoroscopy study with normative data.

HYPOTHESIS AND BACKGROUND: Narrowing of the subacromial space has been implicated in several shoulder pathologies. However, the location of the minimum distance points during clinical testing has not been defined. We sought to measure the in vivo minimum distance and location of the minimum distance points on the acromion and proximal humerus during arm elevation. METHODS: Eight healthy male subjects (mean age, 30 years) underwent a dynamic in vivo biplane fluoroscopy assessment of scaption and forward elevation. For each frame, the 3-dimensional position and orientation of the humerus and scapula were determined, and the acromiohumeral distance (AHD) was measured as the shortest distance between the acromion and proximal humerus. RESULTS: The minimum AHD was 2.6 ± 0.8 mm during scaption and 1.8 ± 1.2 mm during forward flexion at elevation angles of 83° ± 13° and 97° ± 23°, respectively. The minimum distance point was located on the articular surface of the humeral head from the neutral arm position until 34° ± 8° for scaption and 36° ± 6° for forward flexion. Upon further elevation, the minimum distance point was located within the footprint of the supraspinatus muscle until 72° ± 12° for scaption and 65° ± 8° for forward flexion. At greater elevation angles, the minimum distance points were between the acromion and the proximal humeral shaft, distal from the greater tuberosity. CONCLUSIONS: The shortest AHD was at approximately 90° of arm elevation. The AHD was no longer measured intra-articularly or within the supraspinatus footprint above approximately 70° of arm elevation.

Surgical anatomy of the shoulder.

The glenohumeral articulation is a versatile joint that requires a complex integration of bony ligamentous, musculotendinous, and neurovascular structures for proper function. Injuries resulting from dysfunction are common and potentially debilitating. Many of these injuries can be managed nonsurgically; however, if surgical treatment is indicated, a thorough knowledge of the anatomy of the shoulder girdle is critical. It is important for the surgeon to be aware of commonly used arthroscopic and surgical approaches to the glenohumeral joint along with anatomic structures at risk with each surgical approach and methods of avoiding injury.

Systematic review of the complications of plate fixation of clavicle fractures.

BACKGROUND: The number of displaced midshaft clavicle fractures treated surgically is increasing and plate fixation is often the treatment modality of choice. The study quality and scientific levels of evidence at which possible complications of this treatment are presented vary greatly in literature. PURPOSES: The purpose of this systematic review is to assess the prevalence of complications concerning plate fixation of dislocated midshaft clavicle fractures. METHODS: A computer-based search was carried out using EMBASE and PUBMED/MEDLINE. Studies included for review reported complications after plate fixation alone or in comparison to either treatment with intramedullary pin fixation and/or nonoperative treatment. Two quality assessment tools were used to assess the methodological quality of the studies. Included studies were ranked according to their levels of evidence. RESULTS: After study selection and reading of the full texts, 11 studies were eligible for final quality assessment. Nonunion and malunion rates were less than 10% in all analysed studies but one. The vast majority of complications seem to be implant related, with irritation or failure of the plate being consistently reported on in almost every study, on average ranging from 9 to 64%. CONCLUSION: The quantity of relevant high evidence studies is low. With low nonunion and malunion rates, plate fixation can be a safe treatment option for acute dislocated midshaft clavicle fractures, but complications related to the implant material requiring a second operation are frequent. Future prospective trials are needed to analyse the influence of various plate types and plate position on implant-related complications.

Molecular analysis of the 2011 HPAI H5N2 outbreak in ostriches, South Africa.

The third outbreak of highly pathogenic avian influenza (HPAI) H5N2 in less than seven years affected ostriches of South Africa's Western Cape during 2011. Twenty farms tested PCR positive for the presence of HPAI H5N2 between March and November 2011. Three HPAI H5N2 (AI2114, AI2214, AI2512) and 1 H1N2 (AI2887) viruses were isolated during this period, but H6N2 and H1N2 infections of ostriches were also confirmed by PCR. HPAI H5N2 isolate AI2114 produced an intravenous pathogenicity index (IVPI) score of 1.37 in chickens whereas isolate AI2214 produced an IVPI score of 0.8. The former virus had an additional, predicted N-linked glycosylation site at position 88 of the hemagglutinin protein as well as an E627K mutation in the PB2 protein that was lacking from AI2214. Four variations at HA0 were detected in the PCR-positive cases. Phylogenetically, the branching order of outbreak strains indicated a lack of reassortment between outbreak strains that implied a single outbreak source and a wild duck origin for the progenitor outbreak strain. The 2011 outbreak strains had no genetic relationships to the previous 2004 and 2006 HPAI H5N2 outbreak viruses. Molecular clock analysis based on the N2 neuraminidase genes estimated a recent common ancestor for the outbreak tentatively dated at September 2010. Deep sequencing results of 16 clinical PCR-positive samples yielded data in the range of 573 to 12,590 base pairs (bp), with an average of 4468 bp of total genomic sequence recovered per sample. This data was used to confirm the lack ofreassortment and to assign samples into one of two epidemiologic groups to support epidemiologic tracing of the spread of the outbreak. One farm (no. 142), thought to have played a major epidemiologic role in the outbreak, was confirmed by deep sequencing to contain a mix of both epidemiologic virus groups.

Phylogenetic analysis of low-pathogenicity avian influenza H6N2 viruses from chicken outbreaks (2001-2005) suggest that they are reassortants of historic ostrich low-pathogenicity avian influenza H9N2 and H6N8 viruses.

Low-pathogenicity (LPAI) and high-pathogenicity (HPAI) avian influenza viruses are periodically isolated from South African ostriches, but during 2002 the first recorded outbreak of LPAI (H6N2) in South African chickens occurred on commercial farms in the Camperdown area of KwaZulu/Natal (KZN) Province. Sequence analysis of all eight genes were performed and phylogenetic analysis was done based on the hemagglutinin and neuraminidasc sequences. Results from phylogenetic analyses indicated that the H6N2 chicken viruses most likely arose from a reassortment between two South African LPAI ostrich isolates: an H9N2 virus isolated in 1995 and an H6N8 virus isolated in 1998. Two cocirculating sublineages of H6N2 viruses were detected, both sharing a recent common ancestor. One of these sublineages was restricted to the KZN province. The neuraminidase gene contained a 22-amino acid deletion in the NA-stalk region, which is associated with adaptation to growth in chickens, whereas the other group, although lacking the NA-stalk deletion, spread to commercial farms in other provinces. The persistence of particular H6N2 types in some regions for at least 2 yr supports reports from Asia and southern California suggesting that H6N2 viruses can form stable lineages in chickens. It is probable that the ostrich H6N8 and H9N2 progenitors of the chicken H6N2 viruses were introduced to ostriches by wild birds. Ostriches, in which AI infections are often subclinical, may serve as mixing vessels for LPAI strains that occasionally spill over into other poultry.

Optimization of human papillomavirus type 16 (HPV-16) L1 expression in plants: comparison of the suitability of different HPV-16 L1 gene variants and different cell-compartment localization.

Virus-like particle-based vaccines for high-risk human papillomaviruses (HPVs) appear to have great promise; however, cell culture-derived vaccines will probably be very expensive. The optimization of expression of different codon-optimized versions of the HPV-16 L1 capsid protein gene in plants has been explored by means of transient expression from a novel suite of Agrobacterium tumefaciens binary expression vectors, which allow targeting of recombinant protein to the cytoplasm, endoplasmic reticulum (ER) or chloroplasts. A gene resynthesized to reflect human codon usage expresses better than the native gene, which expresses better than a plant-optimized gene. Moreover, chloroplast localization allows significantly higher levels of accumulation of L1 protein than does cytoplasmic localization, whilst ER retention was least successful. High levels of L1 (>17% total soluble protein) could be produced via transient expression: the protein assembled into higher-order structures visible by electron microscopy, and a concentrated extract was highly immunogenic in mice after subcutaneous injection and elicited high-titre neutralizing antibodies. Transgenic tobacco plants expressing a human codon-optimized gene linked to a chloroplast-targeting signal expressed L1 at levels up to 11% of the total soluble protein. These are the highest levels of HPV L1 expression reported for plants: these results, and the excellent immunogenicity of the product, significantly improve the prospects of making a conventional HPV vaccine by this means.

Ecology and epidemiology of avian influenza in ostriches.

Avian influenza is important because of its potential devastating effect on poultry health and trade. The ostrich industry of South Africa has not escaped the consequences of control and export restrictions resulting from notifiable virus infections. Ostrich farmers first observed a syndrome of green urine in the early and mid 1980s. An H7N1 subtype, causing high mortality in young ostriches but with a low pathogenicity index for chickens, was first isolated in 1991. The first highly pathogenic subtype affecting ratites was reported during the 2000 epidemic of H7N1 in Italy. Low pathogenic subtypes were isolated in South Africa from 1991 to 2004, with one HPAI isolated in 2004. International research work on ostriches with both H5 and H7 subtypes, in both low and high pathogenic pathotypes, found the severity of clinical disease was not directly correlated to the pathotype. The ecology and epidemiology of infections in ostriches is not well understood. Surveys suggest local migratory water birds may play an important role. They have direct contact with ostrich flocks through the free-range production systems. Seasonal occurrence is seen, with the wet colder months more favourable for virus survival and detection. Management, population density, immune status and age are other important determinants of the severity of disease. Surveillance and monitoring must be implemented to understand the ecology and epidemiology, which extends to the validation and standardisation of diagnostic and serological methods for ostriches. Serious consideration should be given to vaccination, education and the use of separate production zones as part of a control programme.

Identification of three novel mycoplasma species from ostriches in South Africa.

Mycoplasmas have been implicated in certain clinical syndromes in ostriches and are associated with upper respiratory tract infections. As these infections result in production losses, they are of considerable economic importance to the South African ostrich industry. Although poultry mycoplasmas have been shown to infect ostriches, the existence of unique ostrich-specific mycoplasmas has been suggested. In this study, mycoplasmas were isolated from ostriches in the Klein Karoo, Central Karoo and Garden Route areas of the Western and Northern Cape Provinces of South Africa and identified using 16S rRNA gene sequencing. These sequences indicated that ostriches in these areas carry three unique mycoplasmas and were not infected with chicken mycoplasmas. Phylogenetic analysis of the 16S rRNA sequences of the three isolated ostrich mycoplasmas showed them to be quite divergent and to fall into two distinct phylogenetic groupings. Unique sequences within the 16S rRNA gene of the ostrich mycoplasmas were subsequently used for the development of specific primers for the detection and diagnosis of mycoplasma infections in ostriches. Chickens kept in close proximity to infected ostriches were not infected with these ostrich mycoplasmas.