Clinical outcomes in latissimus dorsi transfer single- versus double-incision technique.

BACKGROUND/HYPOTHESIS: In patients with irreparable postero-superior rotator cuff lesions, a latissimus dorsi transfer (LDT) is performed. For this surgery, different techniques are used. In this study, we aim to compare the patient's functional outcome after treatment with modified L'Episcopo "single-incision" and modified Gerber "double-incision" technique for LDT. METHODS: 44 patients with irreparable postero-superior rotator cuff ruptures, refractory to physiotherapeutic treatment were included. 21 patients were treated using a modified L'Episcopo "single-incision", 23 patients with modified Gerber "double-incision" surgical approach. All patients had full-thickness tears of at least two complete tendons, and all had fully functioning deltoid and subscapularis muscles. Preoperatively, there were statistically significant differences between the two groups in all preoperative CMS sub-parameters except "power" and "pain". In the postoperative follow-up, a functional assessment using "Constant-Murley Score" (CMS) and "Age- and gender-related CMS" was conducted. STUDY DESIGN: Retrospective-comparative trial. RESULTS: There were no statistically significant differences between age, sex and time of follow-up between the two study groups (p > 0.05). The mean age was 59.2(± 6.3) years, and the mean follow-up time was 45.4(± 9.3) months for both groups taken together. Mean CMS improved for both groups together from 24.2 ± 8.2 points prior to surgery, to 62.8 ± 17.4 points after a mean follow-up time of 45.4 ± 9.3 months post surgery. The patients treated with "single-incision" surgery (n = 21) gained significantly (p < 0.001) more in CMS and all CMS-sub-scoring parameters except power and pain, compared to the patients treated with "double-incision" technique (n = 23). CONCLUSION: This survey shows appealing post-operative functional outcome in patients with irreparable postero-superior rotator cuff lesions treated with two different techniques for LDT. We believe that the presentation of these methods and their results might encourage shoulder surgeons to implement these techniques. Especially the "single-incision" LDT surgery might be a more accustomed technique for many shoulder surgeons well trained in the deltopectoral approach.

The female geriatric proximal humeral fracture: protagonist for straight antegrade nailing?

INTRODUCTION: Straight antegrade humeral nailing (SAHN) has become a standard technique for the surgical fixation of proximal humeral fractures, which predominantly affect elderly females. The nail's proximal anchoring point has been demonstrated to be critical to ensure reliable fixation in osteoporotic bone and to prevent iatrogenic damage to the superior rotator cuff bony insertion. Anatomical variations of the proximal humerus, however, may preclude satisfactory anchoring of the nail's proximal end and may bare the risk of rotator cuff violation, even though the nail is inserted as recommended. The aim of this study was to evaluate the anatomical suitability of proximal humeri of geriatric females aged 75 years and older for SAHN. Specifically, we sought to assess the proportion of humeri not anatomically amenable to SAHN for proximal humeral fracture. MATERIALS AND METHODS: A total of 303 proximal humeri of 241 females aged 75 years and older (mean age 84.5 ± 5.0 years; range 75-102 years) were analyzed for this study. Multiplanar two-dimensional reformations (true ap, true lateral, and axial) were reconstructed from shoulder computed tomography (CT) data sets. The straight antegrade nail's ideal entry point, "critical point" (CP), and critical distance (CD; distance between ideal entry point and CP) were determined. The rate of proximal humeri not anatomically suitable for SAHN (critical type) was assessed regarding proximal reaming diameters of currently available straight antegrade humeral nails. RESULTS: Overall, 35.6% (108/303) of all proximal humeri were found to be "critical types" (CD <8 mm) as to the recommended minimal proximal reaming diameter of 10 mm of straight antegrade nails currently in use. Moreover, 43.2% (131/303) of the humeri were considered "critical types" with regard to the alternatively used larger proximal reaming diameter of 11.5 mm. Mean CD was 9.0 ± 1.7 mm (range 3.5-13.5 mm) and did not correlate with age (r = -0.04, P = 0.54). No significant differences in CD and rate of "critical types" were found between left and right humeri as well as between females aged between 75 and 84 years (n = 151) and females aged 85 and older (n = 152). CONCLUSIONS: More than a third of proximal humeri of geriatric females are "critical types" as to SAHN and may, therefore, be at risk for procedure-related complications, such as rotator cuff violation, fixation failure, and potential malreduction. In view of this finding, we recommend to routinely analyze multiplanar CT reformations of the uninjured contralateral side prior to surgery to improve selection of patients for SAHN and to minimize foreseeable complications. For "critical type" humeri, an alternative surgical procedure should be considered.

Computed tomography-based prediction of the straight antegrade humeral nail's entry point and exposure of "critical types": truth or fiction?

BACKGROUND: Straight antegrade intramedullary nailing of proximal humerus fractures has shown promising clinical results. However, up to 36% of all humeri seem to be "critical types" in terms of the potential violation of the supraspinatus (SSP) tendon footprint by the nail's insertion zone. The aims of this study were to evaluate if a computed tomography (CT) scan could reliably predict the nail's entry point on the humeral head and if it would be possible to preoperatively estimate the individual risk of iatrogenic violation of the SSP tendon footprint by evaluating the uninjured contralateral humerus. METHODS: Twenty matched pairs of human cadaveric shoulders underwent CT scans, and the entry point for an antegrade nail as well as measurements regarding critical distances between the entry point and the rotator cuff were determined. Next, gross anatomic measurements of the same data were performed and compared. Furthermore, specimens were reviewed for critical types. RESULTS: Overall, 42.5% of all specimens were found to be critical types. The CT measurements exhibited excellent intra-rater and inter-rater reliability (intraclass correlation coefficients >0.90). Similarly, excellent agreement between the CT scan and gross anatomic measurements in contralateral shoulders (intraclass correlation coefficients >0.88) was found. CONCLUSION: Assessing the uninjured contralateral side, CT can reliably predict the entry point in antegrade humeral nailing and preoperatively identify critical types of humeral heads at risk of iatrogenic implantation damage to the SSP tendon footprint. This study may help surgeons in the decision-making processon which surgical technique should be used without putting the patient at risk for iatrogenic, implant-related damage to the rotator cuff.

Allergic Reaction to Polyether Ether Ketone Following Cross-Reactivity to Epoxy Resin.

Polyether ether ketone (PEEK) is a thermoplastic polymer frequently used in engineering but also in medical devices. Only 1 case of allergic reaction to PEEK used as an implanted medical device has been reported so far; however, the route of sensitization remained unclear. Here we report on a 62-year-old male patient with a preknown, severe type IV allergy to epoxy resin. He reported strong pain in his shoulder after implantation of a PEEK-containing device after a rotator cuff injury. For testing, the device was implanted in a small pouch subcutaneously on the abdomen. The patient reported massive pain starting 8 hours after the implantation, strictly limited to the procedural area and showing perifocal erythema. A possible explanation of the sensitization mode is the source material for PEEK and epoxy resin, as both are mainly based on bisphenols. An allergic reaction to PEEK with preknown epoxy resin sensitization has not been reported so far. As epoxy resins are a frequent cause of occupational contact dermatitis and PEEK is widely used for medical and nonmedical devices, we believe that this is of great clinical relevance.

The relevance of neutral arm positioning for true ap-view X-ray to provide true projection of the humeral head shaft angle.

INTRODUCTION: Textbooks commonly recommend using the true anterior-posterior (ap)-view with the patient's arm in a sling and therefore in internal rotation (IR) for radiologic diagnostic assessment of the proximal humerus after trauma. However, IR or external rotation (ER) may affect the projection of the head shaft angle (HSA) and therefore bias the diagnostic conclusion significantly. We hypothesized that neutral rotation (NR) of the arm is mandatory for true ap-view to provide true projection of the HSA. MATERIALS AND METHODS: A simplified geometrical model of the proximal humerus was used to examine the influence of different arm positions and angulations of the central ray in relation to the projection of the HSA. RESULTS: Both ER and IR misleadingly suggested an increased valgus angle. Simulating the true ap-view with the central ray in cranio-caudal direction, IR changed the projection of the HSA substantially. CONCLUSION: In conclusion, standard fixation of the patient's arm in a shoulder sling in IR for true ap-view may result in an oblique projection, potentially leading to incorrect surgical implications. To prevent misdiagnosed valgus or varus angulation, NR of the arm should be obeyed when performing true ap-view X-ray. We, therefore, highly recommend to overcome the traditionally arm position, ensuring the true amount of dislocation to assure correct surgical implications and comparable follow-up examinations.

Allogenic bone grafting for augmentation in two-part proximal humeral fracture fixation in a high-risk patient population.

INTRODUCTION: The surgical fixation of unstable, varus displaced two-part fractures of the proximal humerus remains challenging. MATERIALS AND METHODS: In a case series of 10 non-compliant, high-risk patients (median age 63 years; range 52-78), a cancellous allograft was used to augment plate fixation of the fractures. RESULTS: After a median follow-up of 28.5 months, all but one fracture were healed, with the bony allografts incorporated without any systemic or local complications. No significant loss of reduction or evidence of avascular necrosis of the humeral head was seen. The median Constant-Murley Score was 72.0 (range 45-86). Median pain on a visual analog scale was 1 (range 0-7). Median values for the range of motion were flexion: 155° (range 90-170), abduction: 168° (range 95-180) and external rotation: 43° (range: 30-50). Compared to the uninjured contralateral side, flexion was impaired by 13 %, abduction by 14 %, and external rotation by 15 %. Median abduction power was 64 % of the uninjured side. The median varus displacement was 51° (range 45-59) preoperatively, 4° (range -5 to 19) intraoperatively, and 13° (range 1-18) at the time of the final follow-up, relating to an improvement of 38° compared to the preoperative status. CONCLUSIONS: The augmentation of proximal humeral fracture fixation using a cancellous allograft might be a viable and reliable alternative to prevent early varus failure and to, moreover, lead to bony union in a non-compliant or high-risk patient population.

Functional and clinical outcome of total shoulder arthroplasty with oversized glenoid.

BACKGROUND: The Epoca-Reconstruction-(Reco)®-Glenoid has been developed to treat patients with cuff-tear-arthropathy. The glenoid component of this system has a hemispheric shape that canopies the humeral head. This design is believed to provide a stable fulcrum and restore normal deltoid function. The purpose of this study was to analyse strengths and disadvantages of the Epoca-Reco®-Glenoid in cuff-tear-arthropathy patients. Changes in functional outcome using Constant-Murley-Scoring(CMS), CMS sub-scoring parameters and radiological outcome were analysed. For this purpose, a classification for radiologic lucency was proposed. Diverging results, influencing factors and alternative treatment options have been discussed to analyse weaknesses and enhance future development of this arthroplastic model. MATERIALS AND METHODS: 23 patients aged 68 ± 8.4 years with irreparable cuff-tear-arthropathy refractory to physiotherapeutic treatment were treated with Reco-Glenoid Total-Shoulder-Arthroplasty (TSA). Pre-operative standardized evaluations included history, physical examination, radiographs, computer tomography and clinical scorings. The post-operative controls included physical examination with CMS, video documentation and radiological evaluation. RESULTS: After a median follow-up time of 38 ± 18 months, the CMS had been significantly improved (p < 0.001) from (17.4 ± 5.8) to (43.2 ± 19.2) points. Significant improvement in pain, activities of daily life, range of motion (p < 0.001) and power (p = 0.006) was achieved. Significantly, inferior results in functional outcome and higher lucency rates were observed in female patients and in patients treated with small glenoid components. The follow-up rate was 100 %. CONCLUSION: The semi-constraint reconstruction glenoid prosthesis model in cuff-tear-arthropathy patients significantly improves shoulder function, however, it yields controversial results, with satisfactory results in male and poor results in female patients. Revision rate of the female cohort and loosening of the glenoid component in this short-term follow-up is of concern. Further investigations taking BMD, osteopenic conditions and influence of surface area in smaller individuals into consideration are recommended, to determine whether this is the underlying cause of the inferior results in females.

A randomized study of the effectiveness of suprascapular nerve block in patient satisfaction and outcome after arthroscopic subacromial decompression.

PURPOSE: The purpose of this study was to evaluate the efficiency of the suprascapular nerve (SSN) block in pain reduction after arthroscopic subacromial decompression operations and its influence on patient satisfaction. Furthermore, we wanted to evaluate whether better perioperative pain management could positively influence postoperative shoulder function. METHODS: In this prospective, randomized, double-blinded clinical trial, 3 groups of patients--each with 15 participants--were treated with SSN block (10 mL of 1% ropivacaine), placebo, or a subacromial infiltration of local anesthesia (20 mL of 1% ropivacaine). Preoperative and postoperative pain was evaluated with a visual analog scale. Functional outcome was measured by the Constant-Murley score, and patient satisfaction was measured anecdotally by interview 2 days, 2 weeks, and 6 weeks after surgery. RESULTS: The SSN group reported significantly lower levels of postoperative pain, required significantly less analgesia, had better range of motion, and had higher levels of postoperative satisfaction in comparison to the subacromial infiltration group and placebo group. CONCLUSIONS: Patients treated with SSN blocks had less pain overall, which led to a decreased need for analgesics in comparison to the subacromial infiltration and placebo groups. Furthermore, patients in the SSN-blocked group achieved better postoperative ROM and were significantly more satisfied after surgery.

Normal glenoid rim anatomy and the reliability of shoulder instability measurements based on intrasite correlation.

PURPOSE: To evaluate the glenoid shape and to evaluate if the contralateral glenoid can be used as size reference. METHODS: Two independent investigators prospectively analysed shoulder computer-tomographies of 90 patients. The glenoids were positioned in a true "en face" view and evaluated for size and shape. The intraindividual correlation of these parameters between left and right side were assessed. RESULTS: In the 90 computer tomographically evaluated shoulder pairs a significant intraindividual correlation of size and shape was seen (P < 0.001). The intraindividual difference in glenoid surface area averaged 1.8% of the total glenoid surface. The shape of the inferior hemisphere correlated 100%. We found all the inferior glenoids to be circular. CONCLUSION: Our study clearly shows that the inferior glenoid in healthy individuals has the shape of a circle. The high side-to-side correlation of the glenoid surface area can be applied when measuring bony defects by evaluation of the contralateral side.

Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures-a randomized, controlled, clinical trial.

OBJECTIVE: To compare elastic stable intramedullary nailing (ESIN) with nonoperative treatment of fully displaced midshaft clavicular fractures in adults. DESIGN: The study was a randomized, controlled, clinical trial. SETTING: Level 1 trauma center. PATIENTS AND METHODS: Sixty patients between 18 and 65 years of age participated and completed the study. They were randomized to either operative or nonoperative treatment with a 2-year follow-up. INTERVENTION: Thirty patients were treated with a simple shoulder sling and 30 patients with ESIN within 3 days after trauma. MAIN OUTCOME MEASUREMENT: Complications after operative and nonoperative treatments, Disabilities of the Arm, Shoulder and Hand (DASH) score and Constant Shoulder Score for outcome measurement, and clavicular shortening. RESULTS: Fracture union was achieved in all patients in the operative group, whereas nonunion was observed in 3 of 30 patients of the nonoperative group. Two symptomatic malunions required corrective osteotomy in the nonoperative group. Medial nail protrusion occurred in 7 cases in the operative group. Implant failure with revision surgery was necessary in 2 patients after an additional adequate trauma. DASH scores were lower in the operative group throughout the first 6 months and 2 years after trauma, with a significant difference during the first 18 weeks. Constant scores were significantly higher after 6 months and 2 years after intramedullary stabilization. Patients in the operative group showed a significant improvement of posttraumatic clavicular shortening; they were also more satisfied with cosmetic appearance and overall outcome. CONCLUSIONS: ESIN of displaced midshaft clavicular fractures resulted in a lower rate of nonunion and delayed union, a faster return to daily activities, and a better functional outcome. Clavicular shortening was significantly lower, and overall satisfaction was higher in the operative group.

Distal forearm fracture in the adult: is ORIF of the radius and closed reduction of the ulna a treatment option in distal forearm fracture?

INTRODUCTION: Distal forearm fractures in younger adults are rare injuries resulting from high energy trauma. Treatment options vary from cast fixation, external fixator, percutaneus pinning and open reduction and internal fixation. METHOD: We retrospectively reviewed 13 patients aged 18-59 from 1996 to 2005 with a distal unstable forearm fracture. All were treated with open reduction and internal fixation of the radius. The ulna was stabilized either by an open reduction and internal fixation or by a closed reduction with or without pin fixation and cast fixation in all cases. At follow-up, we evaluated the radiologic results in terms of forearm fracture retention and functional outcome according to the wrist score by Krimmer. RESULT: Radial inclination amounted to 24 degrees at the injured side when compared to 27 degrees at the non-injured side, palmar tilt was 3 degrees versus 7 degrees and ulna variance was -2 versus -1 mm. According to the modified wrist score by Krimmer, seven excellent, two good and four fair results were achieved. The range of motion of the injured wrist joint was 149 degrees of rotation, in the sagittal plane 106 degrees , frontal plane 61 degrees and on the non-injured side rotation was 171 degrees , and movement in the sagittal plane was 146 degrees and 79 degrees in the frontal plane. Decreased forearm rotation (107 degrees vs. 162 degrees ) and decreased range of motion in the sagittal plane (77 degrees vs. 114 degrees ) were measured in patient following open reduction and internal fixation of radius and ulna compared to the outcome in patients with open reduction and internal fixation of the radius and closed reduction of the ulna. Grip strength of the injured side averaged 350 N versus 440 N which is 76% of that of the opposite side. All patients stated no pain at rest and some experienced slight pain at work. Three patients had an excellent performance at daily activities, nine patients presented problems with certain activities, and one patient showed severe limitations. CONCLUSIONS: Open reduction and internal fixation of the radius is the keystone in treating distal forearm fracture. In case of stable retention of the ulnar head after closed reduction, cast fixation with or without percutaneus pin fixation is a sufficient method to treat unstable distal forearm fractures. In patients with remaining instability of the distal ulna fracture, ORIF is indicated.

[Pectoralis major transfer in the treatment of chronic subscapularis insufficiency]. / Pectoralis-major-Transfer bei chronischer Subskapularisinsuffizienz.

OBJECTIVE: Pain-free movement and stability of the shoulder joint after restoration of muscular balance between the internal and external rotators. Eradication of anterior impingement. INDICATIONS: Irreparable rupture of the subscapularis tendon in active patients. CONTRAINDICATIONS: Less active patients who are older than about 60 years. Concomitant infraspinatus tendon rupture. Frozen shoulder. Rotator cuff arthropathy. SURGICAL TECHNIQUE: General anesthetic and beach-chair position with the arm freely mobile. Deltopectoral approach. Exposure of the lesser tubercle and the conjoined tendon of coracobrachialis and the short head of the biceps. Half to two thirds of the insertion of pectoralis major at the humeral shaft are detached proximally, held in a suture loop, and passed under the conjoined tendon. The tendon is then fixed transosseously to the lesser tubercle, and range of motion is evaluated. External rotation of up to 30 degrees without tension must be confirmed. POSTOPERATIVE MANAGEMENT: A shoulder strap is worn for 6 weeks and passive physiotherapy is commenced on day 2 postoperatively. External rotation can only be practiced after week 7. RESULTS: 23 patients were available to follow-up. There were 13 cases of anterosuperior defect with irreparable supraspinatus tendon. The preoperative Constant Score of 35 points improved to a postoperative score of 68 points. It was not possible to restore powerful internal rotation. Preoperative impingement syndrome was eradicated.

Is the bare spot a consistent landmark for shoulder arthroscopy? A study of 20 embalmed glenoids with 3-dimensional computed tomographic reconstruction.

PURPOSE: Our aim was to test a published methodology for arthroscopically quantifying glenoid bone loss for its dependability in a cadaver-based anatomic study with 3-dimensional (3-D) computed tomographic (CT) reconstructions of 20 embalmed glenoids. METHODS: Manual macroscopic measurements were made in a standardized fashion. In addition, we marked the center of the visible bare spot in 20 embalmed glenoids with a titanium pin. The shoulder joints were carefully selected for intact rotator cuff, missing capsule-labral deficiency, and absence of severe cartilage degeneration. 3-D reconstructed CT scans were evaluated for consistency of the bare spot. RESULTS: The mean distance from the bare spot to the anterior margin measured manually was 10.9 mm (CT-based, 13.9 mm), to the posterior margin 13.7 mm (CT-based, 16.4 mm), and to the inferior margin 9.7 mm (CT-based, 15.1 mm). Distances were significantly different. CONCLUSIONS: The bare spot did not prove its consistency in 20 carefully selected specimens. Therefore, we conclude that this methodology is not a reliable way to intraoperatively determine bony glenoid deficiency. CLINICAL RELEVANCE: We recommend preoperative bilateral CT scans for evaluation of bony glenoid deficiency for exact quantification of the bone loss.

Alcohol and/or benzodiazepine use: different accidents--different impacts?

1611 patients were included in this investigation. 16.7% of the patients were involved in traffic accidents, 38.2% were injured by a sudden fall, 3.5% were involved in an act of violence, 22.8% were injured by a sports related accident and 18.9% were hurt within a work-related accident. 19.5% of the patients tested positive for alcohol, 5.2% tested positive for benzodiazepines and 1.4% tested positive for both substances. Blood samples were positive for alcohol in 27% males and 7.7% females and for benzodiazepines in 6.3% males and in 3.5% females. The mean blood alcohol concentration (BAC) as well as the mean benzodiazepine plasma level were higher in patients injured in violent accidents compared to the other injury groups. This study provides epidemiologic information about the relationship between specific kinds of accidents and alcohol and/or benzodiazepine use in a large probability sample of emergency room patients. We found a high number of patients using alcohol, and a lower but still relavant number of benzodiazepine users in this large and unselected traumatology ER sample. This study adds evidence to the existing literature about the co-occurance of alcohol and/or benzodiazepine consumption and accident-related injuries.

Alcohol and benzodiazepines in falls: an epidemiological view.

Falls are common at all ages and especially in the elderly; it is important to understand contributing causes. Over a 1-year period we studied blood alcohol (BAC) and benzodiazepine concentrations in patients attending an emergency department because of a fall. The 22% of 615 patients tested were positive for alcohol, 55% were positive for benzodiazepines (BZD) and 1.5% were positive for both substances. A significantly larger proportion of males tested positive for alcohol (40.2%) than females (7.6%). Both in males and females the percentage as well as the extent of blood alcohol levels decreased significantly with age. Benzodiazepines were also consumed more frequently in males (8.5%) than in females (3.2%, p=0.007). Concerning BAC there was no difference between males (1.75+/-0.81 g/l) and females (1.66+/-0.91 g/l). In patients older than 70 years the BAC (1.30+/-0.80 g/l) was lower in comparison to younger ones. All blood samples positive for benzodiazepines could be traced back to diazepam consumption. We found a high number of young and middle aged patients using alcohol (males=49.7%; females=18.9%) and a lower but still relevant number of benzodiazepine users (males=9.5%; females=2.4%). In addition, this study shows that alcohol plays a more important role in patients up to 70 years in fall-related accidents when compared to accidents of other causes.

[The role of alcohol and/or benzodiazepines in occupational accidents compared to accidents due to other causes]. / Alkohol--und/oder Benzodiazepinkonsum bei Arbeitsunfällen im Vergleich zu Unfällen anderer Genese.

All patients who were admitted within one year to the Department of Traumatology of the Innsbruck University Hospital as a result of an accident were included in this epidemiological study: a total of 1611 patients. 18.9% (n = 304) of these patients were injured as a result of a work-related accident and the remaining 81.2% (n = 1307) were involved in accidents due to other causes. Within the group of patients involved in work-related accidents, alcohol consumption was more frequent in males (13.3%) than in females (1.8%) (p = 0.016) and clearly lower than in patients injured by accidents due to other causes. In work--related accidents we found a correlation between the educational standard of patients and the frequency of alcohol consumption. The mean blood alcohol concentration was lower in patients involved in work-related accidents (0.76 +/- 0.58 g/l) compared to other injuries (1.63 g/l +/- 0.74 g/l). No correlations were found concerning benzodiazepine use and demographic variables and all measured benzodiazepine plasma levels were within the therapeutic range.

Alcohol and/or benzodiazepine use in injured road users.

Blood samples of all patients (269) involved in a traffic accident and admitted to the Emergency Room of the University Hospital of Trauma Surgery in Innsbruck were analysed for alcohol and benzodiazepines. The large majority were drivers (55%) followed by passengers (19.7%), cyclists (12.6%) and pedestrians (12.3%). Alcohol was obviously the most commonly found drug in all groups (drivers: 36.9%; passengers: 15.1%; cyclists: 29.4%; pedestrians: 18.2%), with a mean BAC (blood alcohol concentration) high above the legal limit at the time of the study in Austria of 0.8 g/l (drivers: 1.49 +/- 54 g/l; passengers: 1.52 +/- 71 g/l; cyclists: 1.72 +/- 51 g/l; pedestrians: 1.67 +/- 25 g/l). The percentage of alcohol users was highest in drivers. Concerning BAC levels no significant differences were found between the groups. The most commonly detected benzodiazepine was diazepam. Benzodiazepine consumption (drivers: 8.1%; passengers: 5.7%; cyclists: 8.8%; pedestrians: 3%) as well as plasma levels (drivers: 68.7 +/- 62.6 microg/l; passengers: 61.0 +/- 69.3 microg/l; cyclists: 135.7 +/- 118.3 microg/l; pedestrians: 18 microg/l) were nearly equal in all groups. Concerning alcohol or benzodiazepine use, females showed lower frequencies of both alcohol and benzodiazepine positive blood samples. The frequency of alcohol use was higher in patients

The course of the suprascapular nerve in the supraspinatus fossa and its vulnerability in muscle advancement.

Twenty-four cadaveric shoulders were evaluated to assess damage to the suprascapular nerve in relation to Debeyre's advancement of the supraspinatus muscle for rotator cuff repair. In all cases the neurovascular pedicle was tethered at the suprascapular notch and at the periosteum of the supraspinatus fossa. The medial motor branches were directed to the trigonum spinae or the superior angle of the scapula (group 1). The dorsal branches crossed the muscle at the bottom of the supraspinatus fossa (group 2) or directly entered the muscle (group 3). The lateral group remained in the supraspinatus fossa (group 4) or entered the infraspinatus fossa (group 5). The mean distance between the scapular notch and the point of entry of the medial branches into the muscle was 2.9 cm. Branches of group 1 and the main nerve are at risk of injury when detaching muscle from bone. This risk is minimized by subperiosteal detachment. Branches of group 1 are tensioned when advancing the muscle 1 cm laterally.