Characteristics of bouldering injuries based on 430 patients presented to an urban emergency department.

INTRODUCTION: Bouldering is a climbing sport that has been attracting a greater number of recreational and professional athletes over recent decades, which has led to an increase in sport-related injuries. The aim of this study was to determine the characteristics and the types of acute injuries caused by bouldering. Further athlete-specific factors and covariates for the trauma types were investigated. MATERIALS AND METHODS: In this retrospective analysis, all patients presented to the level 1 trauma center at the hospital of the Technical University of Munich after an acute trauma related to bouldering were identified via the hospital documentation system. The period of observation was ten years, from 2010 until 2020. Epidemiological and injury-specific information as well as the initial treatment were registered. In a second step, the affected patients were invited to participate in an online survey in order to collect information about their skills, experience, and details about the trauma. RESULTS: A total of 430 patients with 447 acute injuries were identified. There were 244 injuries among female and 203 injuries among male patients. The most common anatomical region affected was ankle (36.7%), knee (16.8%), elbow (12.3%), spine (7.2%) and shoulder (6.3%). The majority of 273 (61.1%) injuries were located at the lower extremities. The most frequent types of injury were sprains (53.0%), fractures (22.8%) or joint dislocations (11.9%). Surgical treatment was necessary for 89 (19.9%) patients. A return to bouldering was more likely in male patients 50 (75.8%) than in females 47 (59.5%) (p = 0.038). Subjectively, inexperienced boulderers were also less likely to return to the sport than advanced boulderers with greater experience (p = 0.001) CONCLUSION: The incidence of bouldering injuries is rising. Typical bouldering injuries could be identified and quantified at least for those patients who were presented to a hospital emergency department. Injuries in this setting do differ from the injury types known from rock climbing injuries as they are located on the lower extremity more often. Injuries of the fingers and hand, which are common climbing injuries, have been barely encountered in the emergency center.

Reconstruction or replacement? A challenging question in surgical treatment of complex humeral head fractures in the elderly.

INTRODUCTION: Surgical treatment of complex humeral head fractures in the elderly is challenging due to osteoporotic bone, comorbidities and reduced compliance. The treatment strategy (reconstruction versus replacement) should allow for a functional aftercare and result in a high patient satisfaction. Major complications leading to surgical revision are crucial and should be avoided. The purpose of this study was to analyse the major complication rate leading to surgical revision and the patient-based outcome in complex humeral head fractures of the elderly population treated either using locking plate fixation (LCP) or reversed total shoulder arthroplasty (rTSA). MATERIALS AND METHODS: All patients older than 65 years surgically treated due to a four-part fracture of the proximal humerus between 2003 and 2015 were enrolled in our retrospective study. Major complications and revision rates were recorded and functional outcome was assessed using the Munich Shoulder Questionnaire (MSQ) allowing for qualitative self-assessment of the Shoulder Pain and Disability Index (SPADI), of the Disability of the Arm, Shoulder and Hand (DASH) score and of the Constant Score. RESULTS: A cohort of 103 patients with a mean age of 73.4 ± 6.2 years suffering from four-part fractures of the humeral head were enrolled. 63 patients were treated using the LCP fixation compared to 40 rTSAs. There were no significant differences in the patient-reported functional outcome. The revision rate was significantly higher in the LCP group (10/63; 15.9%) compared to the rTSA group (1/40; 2.5%). Reasons for revision were avascular head necrosis, cut-out of screws, secondary dislocation of the greater tuberosity and hypersensitivity to metal. CONCLUSIONS: Reversed total shoulder arthroplasty and locking plate fixation are both established surgical procedures for the management of complex proximal humerus fractures in the elderly leading to similar functional results. However the revision rate in the rTSA group was significantly lower. Primary rTSA should, therefore, be favoured in multimorbid elderly patients with an increased complication risk to avoid repeated anaesthesia.

Prospective outcome analysis following tenodesis of the long head of the biceps tendon along with locking plate osteosynthesis for proximal humerus fractures.

BACKGROUND: Fractures of the proximal humerus are often associated with lesions of the long head of the biceps (LHB) tendon. This often leads to prolonged shoulder pain. Hence, many surgeons decide to perform a tenodesis of the LHB tendon simultaneous to ORIF. The purpose of this study was to evaluate the postoperative outcome after interlocking plate fixation and biceps tenodesis for treating proximal humerus fractures. METHODS: 56 patients (38 females, 18 male) suffering from proximal humerus fractures who underwent surgery were retrospectively included. 26 of these 56 patients (19% Neer II, 38% Neer III, 43% Neer IV) were treated with simultaneous tenodesis of the LHB tendon when ORIF using interlocking plate fixation was performed. 30 patients (17% Neer II, 40% Neer III, 43% Neer IV) served as control group receiving only interlocking plate fixation. The patients were asked to complete the Munich Shoulder Questionnaire (MSQ) for evaluation of postoperative shoulder function. Results of the Disabilities of the Arm, Shoulder and Hand (DASH) Score and Shoulder Pain and Disability Index (SPADI) were calculated from the MSQ. Patients were clinically evaluated for a positive O'Brien test and Popeye sign. RESULTS: The tenodesis group demonstrated significant superior outcome regarding the MSQ (mean 90.47 points vs. 79.41 points, p = 0.006), DASH Score (mean 4.2 points vs. 16.81 points, p = 0.017) and SPADI (mean 94.59 points vs. 83.56, p = 0.045). Flexion, external rotation and the capability of throwing a soft ball were significantly improved in the tenodesis group compared to the control group. The O'Brien test as indicator for lesions of the LHB was positive in fewer patients of the tenodesis group (2/26, vs. 21/30, p = 0.001). There was no significant difference of a positive Popeye Sign. CONCLUSION: Our results show evidence of an improved shoulder function when a simultaneous tenodesis of the LHB tendon is performed during treatment of proximal humerus fractures using interlocking plate fixation.

Closure simulation for reduction of emergency patient diversion: a discrete agent-based simulation approach to minimizing ambulance diversion.

BACKGROUND: The city of Munich uses web-based information system IVENA to promote exchange of information regarding hospital offerings and closures between the integrated dispatch center and hospitals to support coordination of the emergency medical services. Hospital crowding resulting in closures and thus prolonged transportation time poses a major problem. An innovative discrete agent model simulates the effects of novel policies to reduce closure times and avoid crowding. METHODS: For this analysis, between 2013 and 2017, IVENA data consisting of injury/disease, condition, age, estimated arrival time and assigned hospital or hospital-closure statistics as well as underlying reasons were examined. Two simulation experiments with three policy variations are performed to gain insights on the influence of diversion policies onto the outcome variables. RESULTS: A total of 530,000+ patients were assigned via the IVENA system and 200,000+ closures were requested during this time period. Some hospital units request a closure on more than 50% of days. The majority of hospital closures are not triggered by the absolute number of patient arrivals, but by a sudden increase within a short time period. Four of the simulations yielded a specific potential for shortening of overall closure time in comparison to the current status quo. CONCLUSION: Effective solutions against crowding require common policies to limit closure status periods based on quantitative thresholds. A new policy in combination with a quantitative arrival sensor system may reduce closing hours and optimize patient flow.

[Determination of training costs associated with surgical procedures during specialization as an orthopaedic and trauma surgeon]. / Ermittlung der operationsbezogenen Ausbildungskosten zum Facharzt für Orthopädie und Unfallchirurgie.

BACKGROUND: Trauma surgery is a discipline in which the training phase for specialization requires a technical and time-intensive learning curve, including the repetitive training of manual skills. This results in prolonged operation times and thus elevated costs. OBJECTIVES: The present study retrospectively examines operations in trauma surgery and orthopaedics at a Munich university hospital according to the required curriculum for further specialist training. The duration of procedures at the various training levels and the resulting costs were compared. MATERIAL AND METHODS: Based on digital surgical records, more than 2,000 surgical interventions were analysed and checked that they fulfilled the practical requirements. Patients with multiple injuries and polytrauma, in addition to irregularly complex cases, were removed from the calculation to ensure high comparability of the individual cases. This yielded more than 1,000+ cases for evaluation. The per-minute cost was calculated to allow for the translation of operating time into costs. RESULTS: The study shows a prolonged duration of operating time of 19.75 % when the procedure was conducted by residents. This prolongation can be split into 37 subgroups according to body region and type of procedure. The prolongation of operation time could be quantified as a specific prolongation per cluster, in addition to cumulative prolongation. By including the operating costs, the operation-dependent training costs are shown as an exact sum of Euros. CONCLUSION: Surgical training of residents costs hospitals the appropriate amounts of time and money and reduces the overall number of procedures performed, justifying special consideration of the financing of training hospitals.

[Osteosynthesis of distal fibular fractures with IlluminOss : Video article]. / Osteosynthese einer distalen Fibulafraktur mithilfe von IlluminOss : Videobeitrag.

OBJECTIVE: The aim was minimally invasive osteosynthesis of a distal fibular fracture under the premises of poor soft tissue conditions and existing chronic comorbidities to enable rapid recovery and to reduce soft tissue stress in order to avoid postoperative infections and achieve early weight bearing. INDICATIONS: This involved a distal fibula fracture, classified as 44 B1.1, B1.2, B1.3 according to the working group for osteosynthesis (AO) or a B fracture after Danis and Weber with indications for surgery (cortical disruption and shaft offset > 5 mm), age > 65 years, poor soft tissue conditions and a Charlson score ≥ 1. CONTRAINDICATIONS: Acute or incompletely healed infection in the implantation area, allergy to dental adhesive or implant material, open fractures, multifragmentary and severely dislocated fractures. SURGICAL TECHNIQUE: The surgical technique is demonstrated in detail with the help of a video of the operation and which is available online. A 1-2 cm long incision at the distal pole of the fibula, insertion of an intramedullary wire, reaming of the medullary canal and insertion of the IlluminOss balloon implant, filling the balloon with monomer and curing using visible blue light (436 nm), shortening of the implant, radiological control and wound closure. FOLLOW-UP: Postoperative cooling and elevation of the affected limb, free mobility after postoperative day 1, pain-adjusted full load bearing in VacoPed boot for 6 weeks (depending on pain and swelling). RESULTS: Study currently ongoing, no complications or revisions so far.

Pseudoaneurysm of the anterior tibial artery after interlocking tibial nailing: an unexpected complication.

Anterior tibial pseudoaneurysm is a rare complication after interlocking screw insertion in tibial nailing. We present the case of a 28-year-old male patient with this complication with a 6-week delay after tibial nailing of a right tibial fracture type 42-A1 of the Association for the Study of Internal Fixation (AO/ASIF) classification. On presentation to our emergency department, the patient's complaints were solemnly intermittent pain and occasional swelling of his proximal lower leg. Deep vein thrombosis, compartment syndrome, and implant dislocation were ruled out, and the patient was discharged after his symptoms improved without further intervention. Four weeks later, the patient was readmitted for similar symptoms. A computed tomography (CT) angiography then revealed a pseudoaneurysm of the anterior tibial artery at the level of the proximal interlocking screw insertion. Aneurysmal sac excision with vessel repair was performed while reconstructing the additional dislocated proximal fibular fracture using standard AO/ASIF plating. Postoperatively, sufficient flow through the repaired vessel was documented using Doppler ultrasound and CT angiography. However, the patient sustained a temporal damage to the peroneal nerve after surgery. This case highlights the risk of a pseudoaneurysm of the anterior tibial artery after interlocking screw insertion as a rare but major complication of a routine surgical procedure. Early ultrasound diagnostics, CT angiography, or magnetic resonance (MR) angiogram should be performed to prevent the delay in diagnosis and treatment of such complications.

Pull-out stability of anchors for rotator cuff repair is also increased by bio-absorbable augmentation: a cadaver study.

INTRODUCTION: Osteoporosis is a highly focused issue in current scientific research and clinical treatment. Especially in rotator cuff repair, the low bone quality of patients suffering from osteoporosis is an important issue. In this context, non-biological solutions using PMMA for anchor augmentation have been developed in the recent past. The aim of this study was to evaluate whether augmentation of suture anchors using bio-absorbable osteoconductive fiber-reinforced calcium phosphate results in improved failure load of suture anchors as well. MATERIALS AND METHODS: Altogether 24 suture anchors (Corkscrew FT 1 Suture Anchors, Arthrex, Naples, FL, USA) were evaluated by applying traction until pullout in 12 paired fresh frozen human cadaver humeri using a servo-hydraulic testing machine. Inclusion criteria were an age of more than 64 years, a macroscopically intact RC and an intact bone. The anchors were evaluated at the anterolateral and posteromedial aspect of the greater tuberosity. 12 suture anchors were augmented and 12 suture anchors were conventionally inserted. RESULTS: The failure load was significantly enhanced by 66.8 % by the augmentation method. The fiber-reinforced calcium phosphate could be easily injected and applied. CONCLUSION: The bio-absorbable cement in this study could be a promising augmentation material for RC reconstructions, but further research is necessary-the material has to be evaluated in vivo.

Reduction and stabilization of radial neck fractures by intramedullary pinning: a technique not only for children.

BACKGROUND: Isolated radial neck fractures occur only in rare cases. The majority of cases are non-displaced or minimally displaced and can be treated conservatively. Conservative treatment, however, might result in secondary displacement and/or malunion. On the other hand, open reduction and internal fixation (ORIF) as standard surgical approach in adults is associated with non-union, implant-related complications and reduced range of motion. For isolated radial neck fractures with an intact radial head, the procedure of centromedullary pinning--as widely used in the treatment of paediatric radial neck fractures--might be an alternative operative technique in adults as well. The purpose of this retrospective case series therefore was to evaluate the functional outcome of radial neck fractures treated by intramedullary pinning. METHODS: Between 02/2009 and 12/2014, a total of eight patients with isolated radial neck fractures (Mason type-III; Judet Type II and III) were treated with centromedullary pinning using titanium elastic nails (TEN). The mean age of the patients was 39 years (range 23-90 years) with a mean interval from injury to surgery of 2.9 days (range 1-7 days). Subjective and objective criteria included patient's satisfaction, pain rating on a visual analogue scale (VAS) and active range of motion (ROM) compared to the contralateral armside. Functional scoring included the Morrey Elbow Score (MEPS), the QuickDASH and the Elbow Self Assessment Score (ESAS). Furthermore, follow-up radiographs were evaluated. RESULTS: Seven of the eight patients were available for follow-up after a mean of 36 months (range 6-64 months). Patients' satisfaction was rated very good in four cases, good in two cases and sufficient in one case. An unrestricted active ROM compared to the contralateral side for extension-flexion arc and for pronation-supination-arc with full strength was rated in all cases. The Elbow Self Assessment Score was 98.52 ± 1.95 (range 96-100), the calculated Mayo elbow performance score was 95.71 ± 7.32 (range 85-100) and the QuickDASH score was 6.81 ± 10.42 (range 0-27). There were no complications as infection, non-union, heterotopic ossifications or secondary loss of reduction of the radial head. Only one patient complained about pain resulting from an affection of the superficial radial nerve. CONCLUSION: In the present cohort, good to excellent results without relevant complications were seen. The technique of intramedullary pinning as described in the treatment of isolated radial neck fractures in children represents a suitable and reliable method in adults as well. In selected cases, this technique can be recommended as an alternative, minimal-invasive approach to the radial head plate osteosynthesis.