Does the magnitude of injuries affect the outcome of proximal humerus fractures treated by locked plating (PHILOS)?

PURPOSE: Health-related quality of life (HRQoL) becomes increasingly relevant in an aging society. Functional outcome (FO) and the patient-reported outcome (PRO) after surgical treatment of proximal humerus fractures (PHF) depends on numerous factors, including patient- and injury-specific factors. There is little evidence on how the FO and the PRO vary in different settings such as monotrauma or multiple injuries, even though the PHF is one of the more frequent fractures. In addition, to a previous study, on multiple injured patients and upper extremity injuries, the aim of the current study was to investigate the impact of multiple injuries, quantified by the ISS, on the FO and PRO after surgically treated PHF by PHILOS. METHODS: A retrospective cohort-study was conducted with an additional follow-up by a questionnaire. HRQoL tools such as range of motion (ROM), the Quick-Disability of Arm Shoulder and Hand score (DASH), EuroQol Five Dimension Three Levels (EQ-5D-3L), and EuroQol VAS (EQ-VAS) were used. The study-population was stratified according to ISS obtained based on information at discharge into Group I/M-H (ISS < 16 points) and Group PT-H (ISS ≥ 16). Median outcome scores were calculated and presented. INCLUSION CRITERIA: adult patients (> 18 years) with PHF treated at one academic Level 1 trauma center between 2007 and 2017 with Proximal Humeral Inter-Locking System (PHILOS) and preoperative CT-scan. Group stratification according Injury Severity Score (ISS): Group PT-H (ISS ≥ 16 points) and Group I/M-H (ISS < 16 points). EXCLUSION CRITERIA: oncology patients, genetic disorders affecting the musculoskeletal system, paralysis or inability to move upper extremity prior or after injury, additional ipsilateral upper limb fractures, open injuries, associated vascular injuries as well brachial plexus injuries and nerve damages. Follow-up 5-10 years including PRO: EQ-5D-3L and EQ-VAS. FO, including DASH and ROM. The ROM was measured 1 year after PHILOS. RESULTS: Inclusion of 75 patients, mean age at injury was 49.9 (± 17.6) years. The average follow-up period in Group I/M-H was 6.18 years (± 3.5), and in Group PT-H 5.58 years (± 3.1). The ISS in the Group I/M-H was 6.89 (± 2.5) points, compared to 21.7 (± 5.3) points in Group PT-H (p ≤ 0.001). The DASH-score in Group I/M-H was 9.86 (± 13.12 and in Group PT-H 12.43 (± 15.51, n.s.). The EQ-VAS in Group I/M-H was 78.13 (± 19.77) points compared with 74.13 (± 19.43, n.s.) in Group PT-H. DASH, EQ-VAS as well as ROM were comparable in Groups I/M-H and PT-H (9.9 ± 13.1 versus 12.4 ± 15.5, n.s.). The EQ-5D-3L in Group I/M-H was 0.86 (± 0.23) points compared to Group PT-H 0.72 (± 0.26, p ≤ 0.017). No significant differences could be found in Group I/M-H and PT-H in the severity of traumatic brain injury (TBI). A multivariable regression analyses was performed for DASH, EQ-5D-3L and EQ-VAS. All three outcome metrics were correlated. There was a significant difference between the EQ-5D-3L and the ISS (Beta-Coefficient was 0.86, 95% low was 0.75, 95% high was 0.99, p ≤ 0.041). No significant correlation could be found comparing DASH, EQ-5D-3L and EQ-VAS to age, gender and TBIs. CONCLUSION: Multiple injuries did not affect the DASH, ROM or EQ-VAS after PHILOS; but a higher ISS negatively affected the EQ-5D-EL. While the ROM and DASH aim to be objective measurements of functionality, EQ-5D-3L and EQ-VAS represent the patients' PRO. The FO and PRO outcomes are not substitutable, and both should be taken into consideration during follow-up visits of multiple injured patients. Future research should prospectively explore whether the findings of this study can be recreated using a larger study population and investigate if different FO and PRO parameters come to similar conclusions. The gained information could be used for an enhanced long-term evaluation of patients who suffered a PHF from multiple injuries to meet their multifarious conditions. LEVEL OF EVIDENCE: II

Minimalinvasive Techniken zur Therapie der Schultereckgelenksprengung

Sprengungen des Schultereckgelenks gehören zu den häufigsten Verletzungen des Schultergürtels. Neben der Symptomlinderung stehen die Gelenkstabilisierung und Wiederaufnahme körperlicher Aktivitäten im Vordergrund. Zur operativen Versorgung wurden minimalinvasive (arthroskopische bzw. arthroskopisch assistierte) Techniken entwickelt, die sich gegenüber offenen Verfahren als mindestens gleichwertig zeigen. In diesem Beitrag sollen diese minimalinvasiven Techniken detailliert beschrieben werden. Acromioclavicular joint instabilities are one of the most common injuries of the shoulder girdle. Diagnostic measures include the vertical and horizontal components of instability. The main goals of treatment include pain reduction, joint stabilization, and return to physical activity. For operative treatment, there are numerous techniques available. Recently, minimally-invasive techniques were developed and showed equal results as with open approach. These procedures facilitate simultaneous treatment of concomitant shoulder lesions and reduce soft tissue trauma as well as the risk of infection. This article presents an overview of such minimally-invasive techniques for both acute and chronic instabilities. Both techniques address the aspect of horizontal instability, which was found to compromise clinical results. For an acute injury, we describe the use of a low-profile button system combined with an additional acromioclavicular cerclage. In the chronic setting with a bidirectional (vertical and horizontal) instability, a free tendon graft combined with a single TightRope augmentation is recommended

Arthroscopically assisted stabilization of chronic bidirectional acromioclavicular joint instability using a low-profile implant and a free tendon graft

&lt;jats:title&gt;Abstract&lt;/jats:title&gt;&lt;jats:sec&gt; &lt;jats:title&gt;Background&lt;/jats:title&gt; &lt;jats:p&gt;Economic burden and personnel shortages lead to a reduction in the time spent on surgical training of young resident physicians. This underlines the importance of courses for learning and optimizing surgical skills. Particularly for orthopaedic trauma surgery, training on fractured cadaveric specimens has proven highly useful. The present study investigates a method to induce realistic fracture patterns in fresh frozen elbow specimens, leaving the skin and soft tissue envelope intact.&lt;/jats:p&gt; &lt;/jats:sec&gt;&lt;jats:sec&gt; &lt;jats:title&gt;Methods&lt;/jats:title&gt; &lt;jats:p&gt;For fracture simulation, 10 human cadaveric specimens with intact soft tissue envelopes were placed in 90° flexion in a custom-made high-impact test bench and compressed by an impactor. The fractures were subsequently classified using conventional x‑rays.&lt;/jats:p&gt; &lt;/jats:sec&gt;&lt;jats:sec&gt; &lt;jats:title&gt;Results&lt;/jats:title&gt; &lt;jats:p&gt;Of the 10 specimens, 6 could be classified as distal humerus fractures and 4 as olecranon fractures. The fractures of the distal humerus were mainly type C according to &lt;jats:italic&gt;Arbeitsgemeinschaft Osteosynthesefragen&lt;/jats:italic&gt; (AO) criteria, the olecranon fractures were mainly type IIB according to the Mayo classification. Subsequently, all 10 specimens would have been appropriate for use in musculoskeletal trauma courses.&lt;/jats:p&gt; &lt;/jats:sec&gt;&lt;jats:sec&gt; &lt;jats:title&gt;Conclusion&lt;/jats:title&gt; &lt;jats:p&gt;With the given setup it was possible to induce realistic fracture patterns in fresh frozen cadaveric specimens. The advantage of the presented technique lies in the preservation of soft tissue. With their intact soft tissue envelopes, these pre-fractured preparations could be used in courses to precisely train resident physicians directly on human cadaver preparations. Further research should focus on finding reliable predictors to improve the precision of fracture induction in specimens.&lt;/jats:p&gt; &lt;/jats:sec&gt

New Cerebral Microbleeds After Catheter‐Based Structural Heart Interventions: An Exploratory Analysis

Background Cerebral microbleeds (CMBs) are increasingly recognized as “covert” brain lesions indicating increased risk of future neurological events. However, data on CMBs in patients undergoing catheter‐based structural heart interventions are scarce. Therefore, we assessed occurrence and predictors of new CMBs in patients undergoing catheter‐based left atrial appendage closure and percutaneous mitral valve repair using the MitraClip System. Methods and Results We conducted an exploratory analysis using data derived from 2 prospective, observational studies. Eligible patients underwent cerebral magnetic resonance imaging (3 Tesla) examinations and cognitive tests (using the Montreal Cognitive Assessment) before and after catheter‐based left atrial appendage closure and percutaneous mitral valve repair. Forty‐seven patients (53% men; median age, 77 years) were included. New CMBs occurred in 17 of 47 patients (36%) following catheter‐based structural heart interventions. Occurrences of new CMBs did not differ significantly between patients undergoing catheter‐based left atrial appendage closure and percutaneous mitral valve repair (7/25 versus 10/22; P=0.348). In univariable analysis, longer procedure time was significantly associated with new CMBs. Adjustment for heparin attenuated this association (adjusted odds ratio [per 30 minutes]: 1.77 [95% CI, 0.92–3.83]; P=0.090). Conclusions New CMBs occur in approximately one‐third of patients after catheter‐based left atrial appendage closure and percutaneous mitral valve repair using the MitraClip System. Our data suggest that longer duration of the procedure may be a risk factor for new CMBs. Future studies in larger populations are needed to further investigate their clinical relevance. Clinical Trial Registration German Clinical Trials Register: DRKS00010300 (https://drks.de/search/en/trial/DRKS00010300); ClinicalTrials.gov : NCT03104556 (https://clinicaltrials.gov/ct2/show/NCT03104556?term=NCT03104556&draw=2&rank=1)

Functional and Radiologic Outcomes of Degenerative Versus Traumatic Full-Thickness Rotator Cuff Tears Involving the Supraspinatus Tendon.

BACKGROUND Arthroscopic rotator cuff repair (ARCR) is among the most commonly performed orthopaedic procedures. Several factors-including age, sex, and tear severity-have been identified as predictors for outcome after repair. The influence of the tear etiology on functional and structural outcome remains controversial. PURPOSE To investigate the influence of tear etiology (degenerative vs traumatic) on functional and structural outcomes in patients with supraspinatus tendon tears. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Patients undergoing ARCR from 19 centers were prospectively enrolled between June 2020 and November 2021. Full-thickness, nonmassive tears involving the supraspinatus tendon were included. Tears were classified as degenerative (chronic shoulder pain, no history of trauma) or traumatic (acute, traumatic onset, no previous shoulder pain). Range of motion, strength, the Subjective Shoulder Value, the Oxford Shoulder Score (OSS), and the Constant-Murley Score (CMS) were assessed before (baseline) and 6 and 12 months after ARCR. The Subjective Shoulder Value and the OSS were also determined at the 24-month follow-up. Repair integrity after 12 months was documented, as well as additional surgeries up to the 24-month follow-up. Tear groups were compared using mixed models adjusted for potential confounding effects. RESULTS From a cohort of 973 consecutive patients, 421 patients (degenerative tear, n = 230; traumatic tear, n = 191) met the inclusion criteria. The traumatic tear group had lower mean baseline OSS and CMS scores but significantly greater score changes 12 months after ARCR (OSS, 18 [SD, 8]; CMS, 34 [SD,18] vs degenerative: OSS, 15 [SD, 8]; CMS, 22 [SD, 15]) (P < .001) and significantly higher 12-month overall scores (OSS, 44 [SD, 5]; CMS, 79 [SD, 9] vs degenerative: OSS, 42 [SD, 7]; CMS, 76 [SD, 12]) (P≤ .006). At the 24-month follow-up, neither the OSS (degenerative, 44 [SD, 6]; traumatic, 45 [SD, 6]; P = .346) nor the rates of repair failure (degenerative, 14 [6.1%]; traumatic 12 [6.3%]; P = .934) and additional surgeries (7 [3%]; 7 [3.7%]; P = .723) differed between groups. CONCLUSION Patients with degenerative and traumatic full-thickness supraspinatus tendon tears who had ARCR show satisfactory short-term functional results. Although patients with traumatic tears have lower baseline functional scores, they rehabilitate over time and show comparable clinical results 1 year after ARCR. Similarly, degenerative and traumatic rotator cuff tears show comparable structural outcomes, which suggests that degenerated tendons retain healing potential

Swiss-wide multicentre evaluation and prediction of core outcomes in arthroscopic rotator cuff repair: protocol for the ARCR_Pred cohort study

Introduction In the field of arthroscopic rotator cuff repair (ARCR), reporting standards of published studies differ dramatically, notably concerning adverse events (AEs). In addition, prognostic studies are overall methodologically poor, based on small data sets and explore only limited numbers of influencing factors. We aim to develop prognostic models for individual ARCR patients, primarily for the patient-reported assessment of shoulder function (Oxford Shoulder Score (OSS)) and the occurrence of shoulder stiffness 6 months after surgery. We also aim to evaluate the use of a consensus core event set (CES) for AEs and validate a severity classification for these events, considering the patient’s perspective.Methods and analysis A cohort of 970 primary ARCR patients will be prospectively documented from several Swiss and German orthopaedic clinics up to 24 months postoperatively. Patient clinical examinations at 6 and 12 months will include shoulder range of motion and strength (Constant Score). Tendon repair integrity status will be assessed by ultrasound at 12 months. Patient-reported questionnaires at 6, 12 and 24 months will determine functional scores (subjective shoulder value, OSS), anxiety and depression scores, working status, sports activities, and quality of life (European Quality of Life 5 Dimensions 5 Level questionnaire). AEs will be documented according to a CES. Prognostic models will be developed using an internationally supported regression methodology. Multiple prognostic factors, including patient baseline demographics, psychological, socioeconomic and clinical factors, rotator cuff integrity, concomitant local findings, and (post)operative management factors, will be investigated.Ethics and dissemination This project contributes to the development of personalised risk predictions for supporting the surgical decision process in ARCR. The consensus CES may become an international reference for the reporting of complications in clinical studies and registries. Ethical approval was obtained on 1 April 2020 from the lead ethics committee (EKNZ, Basel, Switzerland; ID: 2019-02076). All participants will provide informed written consent before enrolment in the study.Trial registration number NCT04321005.Protocol version Version 2 (13 December 2019)