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Background The re-tear rate after supraspinatus tendon (SSP) repair is high despite optimization of surgical techniques. The critical shoulder angle (CSA) > 35° has been identified as a risk for re-tear. Surgical reduction of the CSA performing additional lateral acromioplasty (ALAP) is intended to reduce the risk. Objective We aimed to evaluate the effect of ALAP on the re-tear rate in patients with a CSA > 35° after SSP repair. Patients and methods The study included 49 shoulders fulfilling predefined inclusion criteria. The patients were assigned to two groups; group I (25 SSP) was additionally treated with an ALAP. In group II (24 SSP) standard acromioplasty was performed during reconstruction. Magnetic resonance imaging and a clinical examination (Constant Score; CS) were performed 12 months after surgery. Results After 15 months group I showed a re-tear rate of 20%, a decreased CSA (mean 38.0° preoperatively vs. 34.5° postoperatively) and an increase in CS (mean 53.9 vs. 84.6). After 16 months group II showed a re-tear rate of 16.7%, no difference between pre- and postoperative CSA (37.8° vs. 37.6°), and an increase in CS (48.9 vs. 84.5). There was no difference between the groups in terms of re-tears and postoperative CS (p = 0.4557), but there was a significant difference in postoperative CSA (p 35° did not have a worse clinical outcome and no increased rate of re-tears compared with patients with a mechanically reduced CSA. Conclusion Additive lateral acromioplasty does not decrease the re-tear rate after arthroscopic SSP repair. However, ALAP significantly decreases the CSA to normal values.

Background The etiology of degenerative supraspinatus tendon (SSP) tear is still subject to discussion. Objectives Our objective was to correlate clinical, radiological, and intraoperative signs of mechanical outlet impingement in patients with degenerative SSP tears. Materials and methods This prospective study included 100 patients with degenerative SSP tears that required surgery. Preoperatively, clinical impingement signs and radiological parameters (critical shoulder angle [CSA], acromion type according to Bigliani, acromion index [AI]) were recorded. Intraoperatively, the extent of the rupture and grinding marks on the bottom of the acromion were assessed. Results Of the 100 patients, 59 had clinical impingement signs preoperatively; 90 patients had at least one positive radiological sign (CSA > 35°, AI > 0.67, acromion type II or III). In 23 patients a partial tear, in 55 patients a full thickness tear, and in 22 patients an additional infraspinatus tendon tear were found. In 10 cases no grinding marks at the bottom of the acromion during arthroscopy were found. In 75 cases moderate grinding marks and in 15 cases severe marks with bare bone at the bottom of the acromion were found. There was no statistically significant correlation between preoperative impingement signs and arthroscopic grinding marks (p = 0.83) or between clinical signs and radiological parameters (p = 0.44). There was no significant correlation between extent of the rupture, extent of grinding marks or radiological impingement parameters (p = 0.16; p = 0.26). Conclusion We could not verify a correlation between clinical and radiological impingement sign and arthroscopic impingement parameters. Based on our study, degenerative SSP tear cannot be characterized as the result of a mechanical outlet impingement.

Fur die Unterscheidung zwischen degenerativen und traumatischen Rotatorenmanschettenlasionen (RML) sind Kenntnisse uber Anatomie und Biomechanik sowie der Atiologie mit aktuellem wissenschaftlichem Hintergrund unabdingbar. Ziel ist eine Aufstellung der Evidenz zur Unterscheidung traumatischer und degenerativer RML in Form von praktischen Entscheidungshilfen. Es erfolgte eine Auswertung der Literatur bezuglich traumatischer RML und deren Differenzierung zu degenerativen Schaden unter besonderer Berucksichtigung der Evidenz. Im Rahmen einer strukturierten Analyse sollten 4 Themenfelder unabhangig voneinander auf Indizien gepruft werden. Wahrend die Vorgeschichte und das Unfallereignis meistens nur schwache Indizien fur eine degenerative Veranderung vor dem Trauma aufweisen, konnen das klinische Verletzungsbild (mit zeitlichem Verlauf) und v. a. pathomorphologische Zeichen in der Magnetresonanztomographie (MRT) sowie intraoperativ und histologisch gewonnene Befunde als praktische Entscheidungshilfen dienen. Zur Begutachtung von RML mussen multimodale Faktoren unter Berucksichtigung ihrer wissenschaftlichen Belastbarkeit berucksichtigt werden.

Subacromial decompression is one of the most frequently performed procedures in the setting of arthroscopic shoulder surgery and typically includes acromioplasty. However, the indication for acromioplasty remains a subject of debate. Possible complications involve deltoid muscle insufficiency due to an excessive removal of the anterior acromion. This case report is intended to draw attention to this particular complication and its management.

Calcifying tendinitis is a very common pathology in the shoulder region, which may be acute or chronic. The rotator cuff, particularly the supraspinatus tendon, is most frequently affected. The tendons of the rotator cuff undergo a natural cycle of destruction and regeneration. The development of calcifying tendinitis is caused by defective tendon repair. Typical is a chronic course with acute pain exacerbation, which leads to medical presentation. Treatment options range from conservative therapy including rest, physical therapy, nonsteroidal anti-inflammatory drugs, and shock wave therapy, to surgical therapy with arthroscopic removal of the calcific focus. This article discusses the current stage-dependent therapeutic concepts and provides a treatment recommendation.

BackgroundThe aim of this study was to examine whether dynamic fluoroscopy is reliable for assessment of medial elbow stability in the presence of radial head resection and different stages of medial collateral ligament (MCL) dissection in a cadaveric elbow model.Materials and methodsSix intact elbow specimens were measured for joint angulation while applying valgus stress in four examination conditions (Examiner 1, Examiner 2, 1 Nm, 2 Nm) in four different elbow positions (fully pronated or supinated at 0° of elbow extension and 30° of elbow flexion). The elbow specimens were examined for valgus stress in three stages: (1) intact, (2) after radial head resection, and (3) after subsequent dissection of the complete MCL. Anteroposterior radiographs of the elbow were made at each stage to determine joint angulation. Intraclass correlation coefficients (ICCs) were calculated.ResultsIn intact elbows, mean joint angulation ranged from 2.2° ± 2.0 (1 Nm) to 5.2° ± 2.3 (Examiner 1). Radial head resection did not increase joint angulation during valgus stress, regardless of joint position and examination condition (Examiner 1: 5.5°; Examiner 2: 5.0°; 1 Nm: 2.6°, 2 Nm: 3.9°). Additional dissection of the MCL led to significantly higher joint angulation during measurements with the standardized torques (1 Nm: 12.4°; 2 Nm: 23.3°). Very good to excellent ICCs for joint angulation between Examiner 1 and Examiner 2 (0.861 to 0.959) were found.ConclusionDynamic fluoroscopy is a reliable diagnostic tool for determining medial elbow stability in the presence of radial head resection and different stages of MCL dissection.

Background The clinical and radiographic results of an all-polyethylene glenoid with variable backside curvature adapted to the individual anatomy were compared with a standard all-polyethylene glenoid. Methods This retrospective study included 87 patients with primary glenohumeral osteoarthritis and anatomic shoulder replacement with a short-stem prosthesis and cemented all-polyethylene glenoid. In all, 42 patients with a mean age of 67 ± 8 years were treated with an all-polyethylene glenoid without variable curvature (group 1) and 45 patients with a mean age of 68 ± 10 years were treated with an all-polyethylene glenoid with individualized curvature (group 2). Clinical outcome was determined by range of motion, Constant Score (CS) age- and sex-adjusted Constant Score (CS%), and Subjective Shoulder Value (SSV). Radiographs were analyzed for the occurrence of radiolucent lines according to the method of Mole. Results After a mean follow-up of 31 months (range, 24–50) a significant improvement was achieved in all clinical parameters in both groups (p p = 0.713). At the final follow-up, the radiolucent line scores were 1.2 ± 2.0 in group 1 and 0.9 ± 1.1 in group 2 (p = 0.410). In five patients (12%) from group 1 and four patients from group 2 (9%), the radiolucent line score increased over time. One patient in group 1 (2%) exhibited radiographic glenoid loosening. Conclusion The all-polyethylene glenoid with individualized curvature showed promising short-term clinical and radiographic results. Further studies with a longer follow-up are necessary to evaluate whether the new all-polyethylene glenoid is superior to the standard all-polyethylene glenoid.

Rotator cuff tears (rct) subsequent to glenohumeral dislocation are relevant concomitant injuries, can lead to impaired shoulder function and increase risk of recurrent dislocation. The aim of this study was to determine the functional outcome, recurrent dislocation rate and tendon integrity after rotator cuff repair after primary traumatic shoulder dislocation. In this retrospective case series, 23 patients (age 56.4 years ± 6.3) who underwent a rotator cuff reconstruction after primary traumatic shoulder dislocation with confirmed combination of full-thickness RCT and Bankart lesion were enrolled after a minimum follow-up of 2 years. Clinical outcome (age and gender adjusted Constant Murley Score (CMS), DASH, Rowe Score) (n = 23) and sonographic tendon integrity (n = 19) were studied. After a mean follow-up of 58 ± 32 months, a CMS of 85.1% ± 14.7, DASH of 14.2 ± 20.5, and Rowe Score of 82.4 ± 15.2 indicated good functional outcome. In 4 of 19 patients (21.1%) a re-tear was found during sonographic evaluation. In 3 cases (13%), a revision was performed (2 × stiff shoulder, 1 × postoperative infection). One patient had a single traumatic re-dislocation (4.3%). Patients undergone reconstruction of the rotator cuff following a primary traumatic shoulder dislocation can achieve good functional results and a low rate of recurrent dislocation. Postoperative tendon integrity is comparable with known data about non traumatic tears.

Purpose To compare and evaluate knee laxity and functional outcomes between autologous bone graft and silicate-substituted calcium phosphate (Si-CaP) in the treatment of tunnel defects in 2-stage revision anterior cruciate ligament reconstruction (ACLR). Methods This prospective, randomized controlled trial was conducted between 2012 and 2015 with a total of 40 patients who underwent 2-stage revision ACLR. The tunnels were filled with autologous iliac crest cancellous bone graft in 20 patients (control group) and with Si-CaP in the other 20 patients (intervention group). After a minimum follow-up period of 2 years, functional outcomes were assessed by KT-1000 arthrometry (side-to-side [STS] difference), the Tegner score, the Lysholm score, and the International Knee Documentation Committee score. Results A total of 37 patients (follow-up rate, 92.5%) with an average age of 31 years were followed up for 3.4 years (range, 2.2-5.5 years). The KT-1000 measurement did not show any STS difference between the bone graft group (0.9 ± 1.5 mm) and the Si-CaP group (0.7 ± 2.0 mm) (P = .731). One patient in the intervention group (5%) had an STS difference greater than 5 mm. Both groups showed significant improvements in the Tegner score, Lysholm score, and International Knee Documentation Committee score from preoperative assessment to final follow-up (P ≤ .002), without any difference between the 2 groups (P ≥ .396). Complications requiring revision occurred in 4 control patients (22%) and in 2 patients in the intervention group (11%) (P = .660). No complications in relation to Si-CaP were observed. Conclusions Equivalent knee laxity and clinical function outcomes were noted 3 years after surgery in both groups of patients. Si-CaP bone substitute is therefore a safe alternative to autologous bone graft for 2-stage ACLR. Level of Evidence Level I, prospective, randomized controlled clinical trial.

Revision surgery after failed primary anterior cruciate ligament reconstruction is technically demanding. In cases in which the tunnels of the primary anterior cruciate ligament reconstruction are widened to greater than 10 mm and/or are incorrectly positioned, a 2-stage procedure enables restoration of bone stock and thus free placement of the tunnels during the revision. The gold standard for tunnel augmentation is an autologous iliac crest cancellous bone graft. However, harvesting the graft is associated with high morbidity. This article describes an alternative method for managing bone deficiencies using the synthetic bone graft substitute silicate-substituted calcium phosphate.

Introduction The aim of this study was to evaluate the intraoperative revision rate and reasons for revision following 3D imaging in the management of dislocated articular tibial plateau fractures based on a large patient sample. Methods This retrospective cohort study included all patients who underwent open reduction and internal fixation due type B or C tibial plateau fracture according to the AO/OTA classification between August 2001 and December 2017 using intraoperative cone beam CT (3D imaging) for the analysis of fracture reduction and implant placement. The findings of the 3D scan were categorized regarding the amount and type of revision. Furthermore, demographic data was examined. Results Five hundred and fifty-nine consecutive fractures were included in the study. Evaluation of the image data records revealed an intraoperative revision due to the usage of 3D imaging in 148 out of 559 cases (26.5%). The most common reasons for an intraoperative revision were insufficient fracture reduction (114 cases) and screw length (21 cases). Conclusion This study reveals indications for a limited analysis of fracture reduction and implant placement during the operative treatment of dislocated articular tibial plateau fractures using conventional fluoroscopy. In view of the high revision rate during open reduction and internal fixation of tibial plateau fractures due to 3D imaging the usage of intraoperative cone beam, CT may be considered. If this is not possible, a postoperative computed tomography may therefore be reasonable.

The aim of the study is to identify an ideal location to measure fibular rotation in the ankle joint using axial computed tomography (CT) scans. Another objective was to detect the average fibular rotation in the uninjured ankle joint in a large cohort. Standardised axial CT with coronal/sagittal reconstructions was performed in healthy ankle joints. Three investigators performed the measurements. In the axial view, each investigator appointed the ideal location to measure the angle of fibular rotation with the use of reference lines either 4, 6, 8 or 10 mm distal from the talar joint line. Inter- and intraobserver reliability, as well as the intraclass correlation coefficient, were determined. CT scans of one hundred individuals—78 males and 22 females—were analysed. The most common locations for measuring the fibular rotation were in 31% of cases 4 mm and in 51% of cases 6 mm distal the talar joint line. The external rotation of the fibula averaged 8.42° ± 4.86° (range 0°–26°). The intraclass coefficient correlations (ICC) for interrater and intrarater reliability were 0.75. The results of the study demonstrate a reproducible location to measure the fibular rotation in the ankle joint. The most convenient location to measure fibular rotation with a high reliability was 6 mm distal to the talar joint line.

Background Several short-stemmed press-fit humeral components have been developed in recent years for anatomic total shoulder arthroplasty (TSA) as well as reverse shoulder arthroplasty (RSA). Varying radiographic outcomes have been reported, with some studies reporting concerning rates of aseptic loosening. This study analyzed the radiographic findings of a press-fit convertible short-stemmed humeral component in both TSA and RSA. Methods There were 150 anatomic TSAs (group 1) and 77 RSAs (group 2) analyzed radiographically at a minimum follow-up of 2 years postoperatively. Plain radiographs were reviewed for stem loosening, alignment, signs of stress shielding, and the filling ratio. Results At final follow-up, 49% of group 1 and 65% of group 2 had no evidence for radiographic changes. In those with radiographic changes, low bone adaptions were found in 83% and high adaptions in 17% in both groups. Larger stem sizes with higher filling ratios were associated with high radiographic adaptions in both groups (P = .02). The overall filling ratios were higher in group 2 (P = .002). Cortical contact of the stem led to higher bone adaptions (P = .014). Conclusions The short humeral component analyzed in this study showed encouraging survival rates without aseptic loosening. Radiographic changes are associated with a higher filling ratio and cortical contact of the stem. Surgeons should aim to achieve fixation with the minimal required canal filling to minimize radiographic changes with the uncemented humeral component used in this study.

Introduction The objective of the study was to compare the radiologic and clinical outcome of patients with an isolated displaced talus fracture treated intra-operatively with either conventional fluoroscopy or additional cone beam computed tomography (CT). Methods Conventional intraoperative fluoroscopy was performed in group 1 and cone beam CT was added in group 2. Clinical outcome was assessed using the Foot Function Index (FFI), American Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, and the Short-Form 12 (SF-12) survey. In addition, the Kellgren-Lawrence score using X-rays was determined. Results Overall, 24 cases were examined (group 1: 8 cases; group 2: 16 cases), with a mean follow up of 6.66 years. The FFI (group 1: 28.85 ± 22.78; group 2: 14.96 ± 15.11 points; p = 0.768), the AOFAS (group 1: 69.00 ± 24.71; group 2: 78.79 ± 17.07 points; p = 0.438), and the physical and mental component of the SF-12 (group 1: 44.79 ± 12.55; group 2: 47.63 ± 10.69 points; p = 0.136) (group 1: 46.19 ± 9.72; group 2: 53.57 ± 8.51; p = 0.242) did not differ significantly. Osteoarthritis of the talonavicular, subtalar, and ankle joints assessed using the Kellgren-Lawrence score appeared to be minor in the cone beam CT group but did not show significant differences (p = 0.309; p = 0.663; p = 0.082 respectively). Discussion Intraoperative cone beam CT in addition to conventional fluoroscopy might be beneficial in the operative treatment of talar fractures but a statistical significance could not be demonstrated.

BACKGROUND Revision rates following radial head arthroplasty (RHA) for unreconstructible radial head fractures (RHFs) differ vastly in the literature, and little is known about the risk factors that are associated with revision surgery. The purposes of this study were to assess the revision rate following RHA and to determine the associated risk factors. METHODS A total of 122 patients (mean age, 50.7 years; range, 18 to 79 years) with 123 RHAs who underwent RHA for unreconstructible RHFs between 1994 and 2014 and were ≥3 years out from surgery were included. Demographic variables, injury and procedure-related characteristics, radiographic findings, complications, and revision procedures were assessed. Cox regression analysis was performed to identify the risk factors that were associated with revision surgery following RHA. RESULTS The median follow-up for the study cohort was 7.3 years (interquartile range [IQR], 5.1 to 10.1 years). All of the patients had unreconstructible RHFs: Mason-Johnston type-IV injuries were the most prevalent (80 [65%]). One or more associated osseous or ligamentous injuries were seen in 89 elbows (72.4%). The median time to surgery was 7 days (IQR, 3 to 11 days). Implanted prostheses were categorized as rigidly fixed (65 [52.8%]) or loosely fixed (58 [47.2%]). A total of 28 elbows (22.8%) underwent revision surgery at a median of 1.1 years (IQR, 0.3 to 3.8 years), with the majority of elbows (17 [60.7%]) undergoing revision surgery within the first 2 years. The most common reason for revision surgery was painful implant loosening (14 [29.2% of 48 complications]). Univariate Cox regression suggested that Workers' Compensation claims (hazard ratio [HR], 5.48; p < 0.001) and the use of an external fixator (HR, 4.67; p = 0.007) were significantly associated with revision surgery. CONCLUSIONS Revision rates following RHA for unreconstructible RHFs are high; the most common cause for revision surgery is painful implant loosening. Revision surgeries are predominantly performed within the first 2 years after implantation, and surgeons should be aware that Workers' Compensation claims and the use of an external fixator in management of the elbow injury are associated with revision surgery. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The purpose of this study was to compare adverse events and clinical outcomes of geriatric proximal humerus fractures (PHF) involving the anatomical neck (type C according to AO classification) treated with open reduction and internal fixation (ORIF) using locking plate vs. arthroplasty. In this retrospective cohort study, geriatric patients (&gt, 64 years) who underwent operative treatment using ORIF or arthroplasty for type C PHFs were included. Complications, revisions and clinical outcomes using Constant Murley Score (CMS) and Disabilities of the Arm, Shoulder and Hand (DASH) Score were assessed and compared between groups. At a mean follow up of 2.7 ± 1.7 years, 59 patients (mean age 75.3 ± 5.5 years) were included. In 31 patients ORIF was performed and 29 patients underwent arthroplasty. Complications and revision surgeries were significantly more frequent after ORIF (32.6% vs. 7.1%, p = 0.023 and 29.0% vs. 7.1%, p = 0.045). In contrast, clinical outcomes showed no significant differences (DASH 39.9 ± 25.7 vs. 39.25 ± 24.5, p = 0.922, CMS 49.7 ± 29.2 vs. 49.4 ± 25.2, p = 0.731). ORIF of type C PHFs in geriatric patients results in significantly more complications and revision surgery when compared to arthroplasty. Therefore, osteosynthesis of geriatric intraarticular fractures of the proximal humerus must be critically evaluated.

Background: The radiological phenomenon of subsidence following the implantation of uncemented short-stem reverse prostheses (USSP) has not yet been described. The purpose of this study was to describe the rate and potential risk factors for subsidence. We hypothesized that subsidence may be a frequent finding and that a subsidence of &gt, 5 mm (mm) is associated with an inferior clinical outcome. Methods: A total of 139 patients with an average age of 73 &plusmn, 9 years were included. The clinical and radiological outcome was evaluated at a minimum follow-up (FU) of 12 months. Results: No humeral component loosening was present at a mean FU of 18 (range, 12&ndash, 51) months. Mean Constant Score (CS) and Subjective Shoulder Value (SSV) improved significantly from 34.3 &plusmn, 18.0 points and 37.0 &plusmn, 19.5% preoperatively to 72.2 &plusmn, 13.4 points and 80.3 &plusmn, 16.5% at final FU (p &lt, 0.001). The average subsidence of the USSP was 1.4 &plusmn, 3.7 mm. Subsidence of &gt, 5 mm was present in 15 patients (11%). No association between a subsidence &gt, 5 mm and CS or SSV was found (p = 0.456, p = 0.527). However, a subsidence of &gt, 5 mm resulted in lower strength at final FU (p = 0.022). Complications occurred in six cases (4.2%), and the revision rate was 3.5% (five cases). Conclusions: Although subsidence of USSP is a frequent radiographic finding it is not associated with loosening of the component or a decrease in the clinical outcome at short term FU. Level of evidence: Level 4, retrospective study.

Background The purposes of this study were (1) to report functional outcomes; (2) to assess complications, revisions, and survival rate; and (3) to assess differences in functional outcomes between removed and retained radial head arthroplasties (RHAs), early and delayed treatment, and type of RHA used at long-term follow-up after monopolar RHA for unreconstructible radial head fractures or their sequelae. Methods Seventy-eight patients (mean age, 59.2 years) who were at least 6 years postoperatively after monopolar RHA for unreconstructible RHFs or their sequelae were included. The Mayo Elbow Performance Score (MEPS); Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) score; visual analog scale; postoperative satisfaction (1-6, 6 = highly unsatisfied); range of motion; complications; and revisions were assessed. Radiographic findings were reported. Kaplan-Meier survival analysis was performed. Subgroups (RHA type, early vs. delayed surgery, RHA removed vs. retained) were compared. Results At a median clinical follow-up of 9.5 years (range: 6.0-28.4 years), median MEPS was 80.0 (interquartile range [IQR]: 60.0-97.5), median QuickDASH was 22.0 (IQR: 4.6-42.6), median visual analog scale was 1 (IQR: 0-4), median postoperative satisfaction was 2 (IQR: 1-3), and median arc of extension/flexion was 110° (IQR: 80°-130°). Radiographic follow-up was available for 48 patients at a median of 7.0 years (range: 2.0-15.0 years). Heterotopic ossifications were seen in 14 (29.2%), moderate-to-severe capitellar osteopenia/abrasion in 3 (6.1%), moderate-to-severe ulnohumeral degeneration in 3 (6.1%), and periprosthetic radiolucencies in 17 (35.4%) patients. Twenty-nine patients (37.2%) had complications and 20 patients (25.6%) underwent RHA exchange or removal. Kaplan-Meier analysis with failure defined as RHA exchange or removal demonstrated survival of 75.1% (95% confidence interval: 63.7-83.3) at 18 years. The highest annual failure rate was observed in the first year in which the RHAs of 7 patients (9%) were exchanged or removed. No significant differences were detected between type of RHA in MEPS (Mathys: 82.5 [75.0-100] vs. Evolve: 80.0 [60.0-95.0]; P = .341) and QuickDASH (Mathys: 12.5 [0-34.4] vs. Evolve: 26.7 [6.9-46.2]; P = .112). Early surgery (≤3 weeks) yielded significantly superior MEPS (80.0 [70.0-100.0] vs. 52.5 [30.0-83.8]; P = .014) and QuickDASH (18.6 [1.5-32.6] vs. 46.2 [31.5-75.6]; P = .002) compared with delayed surgery (>3 weeks). Patients with retained RHAs had significantly better MEPS (80.0 [67.5-100] vs. 70.0 [32.5-82.5]; P = .016) and QuickDASH (18.1 [1.7-31.9] vs. 49.1 [22.1-73.8]; P = .007) compared with patients with removed RHAs. Conclusions Long-term outcomes for RHA are satisfactory; however, there is a high complication and revision rate, resulting in implant survival of 75.1% at 18 years with the highest annual failure rate observed in the first postoperative year.

The aim of the study was to evaluate the short-term clinical results of anatomic total shoulder arthroplasty with a short-stem prosthesis in primary osteoarthritis.65 shoulders with a mean age of 70 years (range 47-85 years) were available for minimum follow-up of 24 months. Clinical outcome was determined by range of motion, Constant score (CS) age and sex-adjusted Constant score (CS%), and subjective shoulder value (SSV). The influence of six different factors (high bone adaptations, age 65 years, female gender, dominant side, atrophy of the supraspinatus tendon ≥ grade 2, glenoid type B2/B3) on the clinical outcome was assessed.At mean follow-up of 37 months (range 24-58 months), the CS improved from 36 ± 8 to 75 ± 12 (p 0.001). The shoulder flexion (100° ± 21° to 159° ± 19°) as well as the external rotation (3° ± 11° to 43° ± 18°) improved significantly (p 0.001). Three complications were noted (transient neuropraxia of the radial nerve, subjective instability, hematoma with superficial wound infection) leading to one revision surgery (wound debridement). No stem loosening was observed. High bone adaptation was present in 19 out of 65 shoulders (29%). The clinical outcome was not influenced by high bone adaptations (p ≥ 0.095). Age 65 years (n = 44) and female gender (n = 38) were associated with worse clinical outcome (p ≤ 0.043).In the short term, the clinical results of this anatomical short-stem shoulder prosthesis are encouraging. A low prevalence of high bone adaptations was found without any influence on the clinical outcome and stem loosening was not observed.

The current study investigated the clinical outcome of open elbow dislocations, focusing on the influence of associated soft tissue and bone injury.From October 2008 to August 2015, 230 patients with elbow dislocations were treated at the study center. Our retrospective study comprised 21 cases of open elbow dislocations. The mean age of patients was 49 years (20-83 years); there were six (29%) female and 15 (71%) male patients. The range of motion (ROM) of the injured and uninjured elbow was measured, and the Mayo Elbow Performance Score (MEPS), Mayo Wrist Score (MWS), and Disability of Arm, Shoulder and Hand (DASH) score were assessed. Complications and revision surgeries were recorded. The influence of the severity of soft tissue injury (I°/II° open vs. III° open) and type of dislocation (simple vs. complex) was evaluated.After a 57-month follow-up (range, 24-98 months), the mean DASH score was 20 ± 15, the MEPS was 82 ± 11, and the MWS was 74 ± 22. The ROM of the injured elbow was significantly decreased compared with the uninjured one (arc of ulnohumeral motion: 104° vs. 137°;Favorable clinical outcomes can be achieved after treatment of open elbow dislocations. These injuries are prone to neurovascular damage and complex dislocations are linked to high rates of complications and revision surgeries.Im Rahmen der vorliegenden Studie sollte der Einfluss des Weichteilschadens auf das klinische Ergebnis nach offener Ellenbogenluxation untersucht werden.Von Oktober 2008 bis August 2015 wurden insgesamt 230 Patienten mit Ellenbogenluxation behandelt. Diese retrospektive Studie umfasst 21 Fälle von offenen Ellenbogenluxationen. Das Durchschnittsalter der Patienten betrug 49 Jahre alt (20–83 Jahre), 6 Patienten waren weiblich (29%), 15 männlich (71%). Das Bewegungsausmaß des verletzten und unverletzten Ellenbogens wurde erhoben und das funktionelle Ergebnis u. a. mittels Mayo Elbow Performance Score (MEPS), Mayo Wrist Score (MWS) und dem Disability of Arm, Shoulder and Hand (DASH) Score erfasst. Zusätzlich wurden Komplikationen und Revisionsoperationen aufgezeichnet. Der Einfluss des Weichteilschadens (I°/II° offen vs. III° offen) und des Luxationstyps (einfach vs. komplex) auf das klinische Ergebnis wurde analysiert.Nach einem durchschnittlichen Nachuntersuchungszeitraum von 57 Monaten (24–98 Monate) betrug der DASH-Score 20 ± 15 Punkte, der MEPS 82 ± 11 Punkte und der MWS 75 ± 23 Punkte. Die Beweglichkeit am betroffenen Ellenbogengelenk war im Vergleich zur gesunden Gegenseite signifikant schlechter (Extension/Flexion: 104° vs. 137°;Offene Ellenbogenluxationen können mit einem zufriedenstellenden klinischen Ergebnis einhergehen. Insbesondere komplexe offene Ellenbogenluxationen sind jedoch sehr komplikationsbehaftet, wobei neurovaskuläre Komplikationen am häufigsten auftreten.

This study analyzed the radiographic results of a cemented all-polyethylene keeled glenoid component available in different sizes and multiple backside radiuses of curvature.The study group consisted of 118 cases (114 patients). There were 63 women and 51 men. Mean age at the time of arthroplasty was 68 years (range, 51-85 years). True anterior-posterior radiographs obtained postoperatively and at the final follow-up were analyzed for implant seating and the occurrence of radiolucent lines. Glenoid morphology and fatty infiltration of the rotator cuff muscles were examined using computed tomography scans. Mean follow-up was 38 months (range, 24-70 months).The mean radiolucent line score after surgery was 0.54 points (range, 0-3 points), and 90% had no or only 1 radiolucent line. At the final follow-up, the mean score was 1.06 points (range, 0-3 points), and 74% had no or only 1 radiolucent line. The score increased significantly over time (P .001). No component was at risk for loosening. No correlation was found between patient age, sex, hand dominance, glenoid morphology, or fatty infiltration of the rotator cuff muscles and the occurrence of radiolucent lines.In the short-term, the glenoid component analyzed in this study showed promising radiographic results, with a low number of radiolucent lines without failure. However, the mean radiolucent line score increased significantly over time, and long-term observations are necessary to confirm a possible advantage compared with older component designs.

The objective of our study was to analyze, under fluoroscopy, joint angulation of uninjured elbows and elbows with distinct induced collateral ligament injury.Twelve elbow specimens were tested for varus and valgus joint angulation using 4 different examination methods (application of both varus and valgus stress by each of 2 examiners [Examiner 1 and Examiner 2] and application of 1 and 2 Nm of torque using a calibrated electric force scale) in 4 elbow positions (in full extension with 90° of supination and 90° of pronation, and in 30° of flexion with 90° of supination and 90° of pronation). Six elbow specimens were examined under varus stress at each of 5 sequential stages: (1) intact, (2) transection of the lateral ulnar collateral ligament (LUCL), (3) complete transection of the lateral collateral ligament complex (LCLC), (4) transection of the anterior aspect of the capsule (AC), and (5) transection of the medial collateral ligament (MCL). An additional 6 elbow specimens were examined under valgus stress at 5 sequential stages: (1) intact, (2) transection of the anteromedial collateral ligament (AML), (3) complete transection of the MCL, (4) transection of the AC, and (5) transection of the LCLC. Examinations under fluoroscopy were made to measure the joint angulation. Intraclass correlation coefficients (ICCs) were calculated.Testing of the intact elbow specimen by both examiners showed a joint angulation of5°. Transection of the LUCL led to a varus joint angulation of 4.3° to 7.0°, and transection of the AML resulted in a valgus joint angulation of 4.9° to 8.8°. Complete dissection of the respective collateral ligament complex resulted in a joint angulation of 7.9° to 13.4° (LCLC) and 9.1° to 12.3° (MCL), and additional transection of the AC led to a joint angulation of20° in some positions in both the medial and the lateral series. Under varus stress, elbow dislocations occurred only after dissection of the LCLC+AC (26% of the examinations) and additional dissection of the MCL (59%). Under valgus stress, elbow dislocations occurred only after dissection of the MCL+AC (30%) and additional dissection of the LCLC (47%). Very good to excellent ICCs were found among Examiners 1 and 2 and the tests done with the standardized torques at stages 1 through 4.Dynamic fluoroscopy makes it possible to distinguish among different stages of collateral ligament injury of the elbow and therefore might be helpful for guiding treatment of simple elbow dislocations.Assessment of collateral ligament injury with varus and valgus stress testing under fluoroscopy is an easily available method and is often used as the imaging modality of choice to determine the degree of elbow laxity. The technique and results described in this study should form the basis for additional clinical studies.

Avascular necrosis (AVN) of the humeral head is a severe complication after proximal humerus fracture dislocations, and leads to a poorer clinical outcome and subsequent revision surgeries. The aim of the current study was to analyze the influence of time to surgery on the AVN rate after locked plating of dislocation fractures of the proximal humerus. This retrospective study included 30 patients with a mean age of 63 ± 14 years with dislocation fractures of the proximal humerus type B3 or C3 according the AO/OTA classification. The rates of AVN of the humeral head were determined clinically and radiographically. In addition, the clinical outcome was determined using the Constant score (CS), the age- and sex-adjusted Constant score (CS%), Disabilities of the Arm, Shoulder, and Hand (DASH) score, the range of motion, and complication and revision rates. Patients were subdivided into groups of subjects operated on early (≤48 h after trauma) and those with late surgery (>48 h after trauma), and the relative risk (RR) for complications and revisions was determined for both groups. After a mean follow-up of 37 months (range: 12–66 month) the mean CS% was 60 ± 24 and the mean DASH score was 32 ± 24 points. Ten patients (33%) developed a symptomatic AVN, and ten patients underwent revision surgery. Early surgery was performed on 25 patients while five patients underwent late surgery. After late surgery, all five patients developed AVN, and patients had a fivefold increased RR for AVN (p = 0.002) and subsequent associated surgical revision (RR = 3.3, p = 0.031). In fracture dislocations of the proximal humerus, early surgery within 48 h of trauma significantly decreases the risk of AVN and subsequent surgery.

In operative treatment of distal radius fractures satisfying outcome mainly relies on anatomical fracture reduction and correct implant placement. Examination with two-dimensional fluoroscopy may not provide reliable information about this. The aim of this study was to determine the effectiveness of additional intraoperative three-dimensional imaging in the operative treatment of comminuted distal radius fractures. From August 2001 to June 2015, patients with a distal radius fracture who were treated operatively and received intraoperative three-dimensional scan were included. The findings of the three-dimensional scan were documented by the operative surgeon and analyzed retrospectively with regard to incidence and the need for intraoperative revisions. Clinical evaluation included the patient’s medical history, the injury pattern of the affected wrist (according to the OTA/AO fracture classification) and concomitant injuries. Intraoperative and postoperative complications and revision surgeries were evaluated as well. Of 4515 operatively treated distal radius fractures, 307 (6.8%) received additional intraoperative three-dimensional imaging during surgery. 263 of 307 patients (85.7%) had a distal radius fracture type C. Intraoperative three-dimensional imaging revealed findings in 125 patients (40.7%) that were not detected on conventional two-dimensional fluoroscopy. In 54 patients (17.6%) these findings led to an immediate revision. Most commonly, revision was done in the case of remaining steps in the articular surface ≥ 1 mm (n = 25, 8.1%) followed by intra-articular screw placement (n = 23, 7.5%). Intraoperative three-dimensional imaging can provide additional information compared to conventional two-dimensional fluoroscopy in the operative treatment of distal radius fractures with the possibility of immediate intraoperative revision.

Purpose A new software application can be used without fixed reference markers or a registration process in wire placement. The aim was to compare placement of Kirschner wires (K-wires) into the proximal femur with the software application versus the conventional method without guiding. As study hypothesis, we assumed less placement attempts, shorter procedure time and shorter fluoroscopy time using the software. The same precision inside a proximal femur bone model using the software application was premised. Methods The software detects a K-wire within the 2D fluoroscopic image. By evaluating its direction and tip location, it superimposes a trajectory on the image, visualizing the intended direction of the K-wire. The K-wire was positioned in 20 artificial bones with the use of software by one surgeon; 20 bones served as conventional controls. A brass thumb tack was placed into the femoral head and its tip targeted with the wire. Number of placement attempts, duration of the procedure, duration of fluoroscopy time and distance to the target in a postoperative 3D scan were recorded. Results Compared with the conventional method, use of the application showed fewer attempts for optimal wire placement (p = 0.026), shorter duration of surgery (p = 0.004), shorter fluoroscopy time (p = 0.024) and higher precision (p = 0.018). Final wire position was achieved in the first attempt in 17 out of 20 cases with the software and in 9 out of 20 cases with the conventional method. Conclusions The study hypothesis was confirmed. The new application optimised the process of K-wire placement in the proximal femur in an artificial bone model while also improving precision. Benefits lie especially in the reduction of placement attempts and reduction of fluoroscopy time under the aspect of radiation protection. The software runs on a conventional image intensifier and can therefore be easily integrated into the daily surgical routine.

Medical images are essential in modern traumatology and orthopedic surgery. Access to images is often cumbersome due to a limited number of workstations. Moreover, due to the tremendous increase of data, the time to review or to communicate images has also become limited. One approach to overcome these problems is to make use of modern mobile devices, like tablet computers, to facilitate image access and associated workflows. Ten orthopedic surgeons were equipped with an Apple iPad mini 2 and specialized viewing software for medical images. The surgeons were able to send images from a workstation onto the tablets or to search for patient images directly. The software enabled the physicians to share images, annotated key slices, and messages instantly with their colleagues. The surgeons carried the tablets within or in the periphery of the hospital. The participants evaluated the software by means of daily questionnaires. Data was collected for a period of 9 months. Nearly 25 images were viewed in total by the surgeons per day. The tablet viewer was used for accessing approximately 30% of these images. On average, the surgeons were asked 1.7 times per day by a colleague for a second opinion. They used the tablets in approximately 29% of these cases. Furthermore, the mean time for accessing images was significantly lower using mobile software compared to conventional methods. Tablet computers can play a vital role for image access and communication in the daily routine of an orthopedic surgeon. Mobile image access is an important aspect for surgeons, especially in larger facilities, to facilitate and accelerate the clinical workflows.

The aim of this study was to investigate the outcomes in a large series of Essex-Lopresti injuries (ELIs) and to compare patients with early and late diagnoses.Thirty-one patients with an ELI (average age and standard deviation [SD], 46 ± 10 years) who were followed for a minimum of 2 years were included in the study. Patients were grouped according to whether the ELI had been diagnosed early (on the day of the injury) or late (4 weeks after the radial head injury). Acute treatment of early-diagnosed ELI included temporary stabilization of the distal radioulnar joint (DRUJ) by Kirschner wires with the forearm in supination for 6 weeks. Clinical outcomes were assessed on the basis of the range of motion, Mayo Elbow Performance Score (MEPS), Mayo Wrist Score (MWS), visual analog scale (VAS) score for wrist and elbow pain, and Disabilities of the Arm, Shoulder and Hand (DASH) score.The ELI was diagnosed on the day of the injury in 16 patients (52%; the early group) and late (at a mean of 7 ± 7 months; range, 1 to 24 months) in 15 (48%; the late group). After a mean duration of follow-up of 5.3 ± 3.0 years (range, 2.0 to 13.1 years), patients with an early diagnosed ELI had significantly better clinical outcomes, compared with those with a late diagnosis, with regard to the MEPS (91.3 ± 8.7 versus 74.7 ± 15.3, p = 0.003), MWS (81.3 ± 16.5 versus 66.3 ± 17.6, p = 0.019), DASH score (12.5 ± 8.7 versus 45.3 ± 23.5, p = 0.001), VAS elbow pain score (0.7 ± 1.1 versus 3.3 ± 2.1, p = 0.001), and VAS wrist pain score (0.9 ± 1.2 versus 3.9 ± 1.7, p0.001). The ranges of motion of the elbow and wrist did not differ significantly between the early and late groups (p0.05). A significantly lower percentage of patients had complications or subsequent surgical procedures in the early than in the late group (38% [6 of 16] versus 93% [14 of 15], p0.001).Early diagnosis of an ELI with temporary stabilization of the DRUJ leads to satisfactory clinical mid-term results, whereas late diagnosis of an ELI is associated with a deteriorated outcome.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Tendon mobility is highly relevant in rotator cuff surgery. Objective data about rotator cuff mobility is rare. Tendon mobility still needs to be evaluated subjectively by the surgeon. This study aims to establish a porcine animal model for mobility analysis of the supraspinatus. In this context, we introduce a sensor-enhanced, arthroscopic grasper (SEAG) suitable for objective intraoperative measurements of tendon mobility in clinical praxis. Tendon mobility of 15 fresh porcine cadaver shoulders with artificial rotator cuff tears was evaluated using the SEAG. Mobility characteristics (load–displacement curves, maximum load, stiffness) were studied and inter- and intraobserver agreement (intraclass correlation coefficient (ICC)) were tested. Factors with a potential adverse effect (plastic deformation and rigor mortis) were also evaluated. All shoulders showed characteristic reproducible load–displacement curves with a nonlinear part at the start, followed by a linear part. Mean maximum load was 28.6 N ± 12.5. Mean stiffness was 6.0 N/mm ± 2.6. We found substantial interobserver agreement (ICC 0.672) and nearly perfect intraobserver agreement (0.944) for maximum load measurement. Inter- (0.021) and intraobserver (0.774) agreement for stiffness was lower. Plastic deformation and rigor mortis were excluded. The animal model demonstrates reliable and in vivo-like measurements of tendon mobility. The SEAG is a reliable tool for tendon mobility assessment.

IntroductionThe aim of the present study was to analyze the injury pattern and thus the dislocation mechanism after simple elbow dislocation using radiographs and magnetic resonance imaging (MRI) data sets.Materials and methodsThe MRI data sets of 64 patients with a mean age of 44 years (18–77 years) were analyzed retrospectively. The inclusion criteria for the study were (1) radiograph with confirmed simple elbow dislocation, (2) low-energy trauma, (3) MRI of the affected elbow ≤ 3 weeks after trauma. The dislocation direction was determined using radiographs. The integrity of the lateral collateral ligament complex (LCLC), common extensor origin (CEO), anterior capsule (AC), medial collateral ligament (MCL), and common flexor origin (CFO) as well as the joint congruity were assessed based on MRI.Results34 patients (53%) had a posterolateral, 26 patients (41%) a posterior, and 4 patients (6%) a posteromedial dislocation. LCLC and AC were affected in 64 out of 64 patients (100%). MCL was affected in 58 patients (91%). CEO were affected in 25 patients (39%) and the CFO in 20 patients (31%). In 11 patients (17%) the injury pattern was more pronounced medially than laterally (MCL, CFO, LCLC), with 2 of these patients exhibiting only a partial LCLC tear. All cases with joint incongruency (n = 12, 19%) showed CEO and/or CFO involvement.ConclusionsSimple elbow dislocation leads to a very heterogeneous spectrum of soft tissue injury pattern. A small proportion of patients showed medially pronounced injury patterns. These findings strongly indicate existence of a “reversed Horii circle” with an underlying valgus mechanism (medial force induction) originating and continuing from medial to anterior.

The aim of this study was to identify to what extent a dissection of the syndesmosis and an avulsed posterior edge of the tibia can change the tibiofibular diastasis and fibular rotation. Three-dimensional scans with a mobile C-arm of 22 cadaver legs were taken of the intact fibula, after dissection of the anterior part of the syndesmosis and the interosseous membrane, osteotomy of the posterior malleolus, and osteosynthesis. The tibiofibular diastasis as well as the angle of fibular rotation was identified in the four steps and the means compared to each other using a t test for paired samples. The distinction between the intact fibula vs. the osteotomy of the posterior tibia was 0.082 ± 0.332 mm for the tibiofibular distance in the incisura tibiofibularis (p 0.261) and 0.046 ± 0.486 degrees for the angle of the fibular rotation (p 0.665). Neither the dissection of the syndesmosis nor the osteotomy of the posterior malleolus significantly influenced the position of the fibula in the incisura tibiofibularis in the cadaveric model. However, in the nonweight-bearing situation, a lesion of the syndesmotic complex might not be evident in intraoperative three-dimensional imaging.

Background: Considering the epidemiology of acromioclavicular (AC) dislocation related to young and active patients, the impact on working capacity is highly relevant. The purpose of this study was to determine the capacity of work and time to return to work (RTW) after AC joint stabilization. We hypothesized that manual working patients show more restrictions returning to work. Methods: In this retrospective case series, pre- and posttraumatic working capacity of 54 patients (FU-rate 80.1%, FU time 23, range 18–45 month) stabilized in single TightRope technique was analyzed. Clinical outcome (DASH, Constant-Murley score) and complications were evaluated in addition. Results: Fifty one of 54 patients (94.5%) were returned to work at final follow-up. The median time to return was 13 (5–143) weeks. Manual working patients showed lower RTW-rates (91.2% vs. 100%; p = .151), longer RTW-time (15.5 vs. 6 weeks; p = .008), and more often persistent shoulder symptoms at work (55.9% vs. 5%; p

We investigated whether mobile C-arm cone beam computer tomography (CBCT) could be used to measure radioulnar translation. The study was conducted on 31 Thiel-fixed intact cadaver arms. Three-dimensional scans of each wrist were carried out in pronation and supination. Four established measurement methods were used (radioulnar line, subluxation ratio, epicentre and radioulnar ratio methods) to measure radioulnar translation. The intraclass correlation coefficient for inter-observer and intra-observer reliability were excellent in three of four methods (>0.94). The reference ranges for physiological radioulnar translation were between −30% and 91% (radioulnar line method), −32% and 87% (subluxation ratio method), −40% and 23% (epicentre method), and 2% and 73% (radioulnar ratio method). Our results indicate that radioulnar translation in the distal radioulnar joint can be determined reliably using mobile C-arm CBCT. The normal values provide a basis for further experimental and clinical studies.

The aim of this study was to analyze sports participation after radial head arthroplasty among recreational athletes.A total of 57 recreational athletes (mean age, 49 years; age range, 18-79 years) treated with radial head arthroplasty for non-reconstructible radial head fractures were included in this retrospective study. The return-to-sports rate and the time to return to sports were analyzed. The clinical and radiologic outcomes were compared between patients who returned to sports (group 1) and those who did not (group 2).After a mean follow-up period of 8.4 years (range, 2.5-16.4 years), 30 of 57 patients (53%) had returned to sports. The mean sports frequency significantly decreased from 5.2 ± 5.0 h/week to 2.2 ± 2.9 h/week after surgery (P.001). In group 1, 83% of patients returned to the same sports activity whereas 17% changed to a less demanding sports activity. The mean time to return to sports was 158 days (range, 21-588 days). Patients who returned to sports had a significantly better Mayo Elbow Performance Score (MEPS) (84 ± 19 points vs. 63 ± 20 points, P.001); Disabilities of the Arm, Shoulder and Hand score (16 ± 17 vs. 46 ± 22, P.001); and arc of flexion (114° ± 32° vs. 89° ± 36°, P = .007). A secondary radial head prosthesis (P = .046) and MEPS lower than 85 points (P = .001) were associated with a significantly lower return-to-sports rate. No differences regarding radiographic changes were found between the 2 groups (P ≥ .256).The return-to-sports rate after radial head replacement is low. A secondary radial head prosthesis and a worse clinical outcome (MEPS85 points) significantly increase the risk of not returning to sports after radial head arthroplasty.

X-ray based measurement and guidance are commonly used tools in orthopaedic surgery to facilitate a minimally invasive workflow. Typically, a surgical planning is first performed using knowledge of bone morphology and anatomical landmarks. Information about bone location then serves as a prior for registration during overlay of the planning on intra-operative X-ray images. Performing these steps manually however is prone to intra-rater/inter-rater variability and increases task complexity for the surgeon. To remedy these issues, we propose an automatic framework for planning and subsequent overlay. We evaluate it on the example of femoral drill site planning for medial patellofemoral ligament reconstruction surgery. A deep multi-task stacked hourglass network is trained on 149 conventional lateral X-ray images to jointly localize two femoral landmarks, to predict a region of interest for the posterior femoral cortex tangent line, and to perform semantic segmentation of the femur, patella, tibia, and fibula with adaptive task complexity weighting. On 38 clinical test images the framework achieves a median localization error of 1.50 mm for the femoral drill site and mean IOU scores of 0.99, 0.97, 0.98, and 0.96 for the femur, patella, tibia, and fibula respectively. The demonstrated approach consistently performs surgical planning at expert-level precision without the need for manual correction.

Es wird uber den Fall einer hochgradigen Deformitat der thorakolumbalen Wirbelsaule nach Resektion eines Sarkoms berichtet. Nach adjuvanter Radiatio bestand ein ausgedehnter Strahlenschaden im Bereich der Haut mit chronischer Fistelung. Es erfolgte die Korrektur uber eine Closing-Wedge-Osteotomie von L3 und Verlangerung der vorhandenen dorsalen Instrumentierung (Th10-L4) auf Th8 und das Os ileum. Am Folgetag erfolgte eine Weichteildeckung durch eine freie Latissimus-dorsi-Lappenplastik, welche an eine arterio-venose Gefasschleife in der Axilla angeschlossen wurde. Durch dieses interdisziplinare Vorgehen konnte eine nahezu vollstandige Korrektur und eine sichere Weichteildeckung erreicht werden.

Sports activity after surgical AC joint stabilisation has not been comprehensively evaluated to date. The aim of this study was to determine rate, level and time to return to sports after AC joint stabilisation and to identify the influence of overhead sports on post-operative sports activity. In this retrospective case series, a total of 68 patients with a high-grade AC joint dislocation (Rockwood type V) were stabilised using a single TightRope technique. Fifty-five patients (80.9 %) with median age of 42.0 (range, 18–65) years completed questionnaires regarding sports activity before and after surgery. Clinical outcome and complications were also evaluated. Forty-three patients participated in sports regularly before injury. Their sports activity was rated according to Allain, and non-overhead and overhead sports were differentiated. At median follow-up of 24 (18–45) months, 41 of 43 patients (95.3 %) had returned to sports. 63 % returned to the same sports activity as before injury. 16.3 % needed to adapt the type of sports to reduce demanding activities. 11.6 % reduced the frequency and 32.5 % the intensity of sports. The median time to return to sports was 9.5 (3–18) months. Overhead athletes (Allain Type III and IV) had to reduce their sports activity significantly more often (11.8 vs. 53.8 %; p = 0.011) and needed more time to return to sports (9.5 vs. 4.5 months; p = 0.009). After stabilisation of AC joint dislocation, the majority of patients returned to sports after a substantial period of time. Overhead athletes, in particular, required more time and had to considerably reduce their sports activity. The findings impact therapeutic decision-making after AC joint injury and help with the prognosis and assessment of rehabilitation progress. IV.

Das Ellenbogengelenk ist eine komplexe Verbindung drei verschiedener Gelenke. Die Kongruenz und Stabilitat hangen von der Integritat der knochernen Artikulationspartner sowie von ligamentaren, kapsularen und muskularen Strukturen ab. Instabilitaten des Ellenbogens resultierten am haufigsten infolge akuter Verletzungen der knochernen und weichteiligen stabilisierenden Strukturen. Rezidivierende Mikrotraumata oder Uberlastungen z. B. bei Wurfsportarten konnen zu chronischen Instabilitaten mit hieraus resultierenden Beschwerden am Ellenbogengelenk fuhren. Das primare Ziel bei der Behandlung von Instabilitaten des Ellenbogengelenkes ist die Wiederherstellung eines kongruenten und stabilen Gelenkes. Im vorliegenden Beitrag werden die wichtigsten diagnostischen und therapeutischen Schritte bei akuten und chronischen Instabilitaten des Ellenbogens dargestellt.

Aims The aim of this study was to evaluate the clinical and radiological outcome of using an anatomical short-stem shoulder prosthesis to treat primary osteoarthritis of the glenohumeral joint. Patients and Methods A total of 66 patients (67 shoulders) with a mean age of 76 years (63 to 92) were available for clinical and radiological follow-up at two different timepoints (T1, mean 2.6 years, sd 0.5; T2, mean 5.3 years, sd 0.7). Postoperative radiographs were analyzed for stem angle, cortical contact, and filling ratio of the stem. Follow-up radiographs were analyzed for timing and location of bone adaptation (cortical bone narrowing, osteopenia, spot welds, and condensation lines). The bone adaptation was classified as low (between zero and three features of bone remodelling around the humeral stem) or high (four or more features). Results The mean Constant score improved significantly from 28.5 (sd 11.6) preoperatively to 75.5 (sd 8.5) at T1 (p Conclusion Total shoulder arthroplasty using a short-stem humeral component resulted in good clinical outcomes with no evidence of loosening. However, approximately 40% of the shoulders developed substantial bone loss in the proximal humerus at between four and seven years of follow-up. Cite this article: Bone Joint J 2018;100-B:603–9.

BACKGROUND A virtual guidance framework is used to assist the conventional method of virtual implant planning system (VIPS). The study null hypothesis was that its screw placement accuracy is equal to that of conventional VIPS. METHODS In 34 distal radius sawbone models, 3D implant planning was performed. A camera attached to the surgical drill was used to support screw positioning. Differences of angles/tip distances between planned and placed screws were identified in intraoperative cone beam Computer tomography (CT) and compared with already existing data from 22 patients treated by conventional VIPS. RESULTS The virtual guidance group showed tip distances of 1.02 ± 0.56 mm, azimuth of 3.69° ± 4.34°, and inclination of 1.75° ± 1.37°, whereas the VIPS group showed tip distances of 2.23 ± 0.99 mm (P

Background: Indirect screw fixation of the sustentaculum tali in the lateral-medial direction can be challenging due to the complex calcaneal anatomy. A novel 2-dimensional (2D) projection-based software application detects Kirschner wires (K-wires) and visualizes their intended direction as a colored trajectory. The aim of this prospectively randomized cadaver study was to investigate whether the software would facilitate the indirect K-wire placement in the sustentaculum tali. Methods: In 20 cadaver foot specimens, K-wires were placed indirectly in the sustentaculum tali by an experienced and an inexperienced surgeon, with and without using the application. Number of placement attempts, duration of procedure, fluoroscopy time, and number of individual fluoroscopy images were recorded. Each wire’s position was analyzed in a 3-dimensional (3D) C-arm scan by an experienced blinded investigator. Results: Use of the software by the inexperienced surgeon significantly reduced the number of placement attempts from 3.2 to 1.2 ( P = .006). The application also reduced operating time, from 273 s to 199 s ( P = .15), and fluoroscopy time, from 41 s to 29 s ( P = .15). Using the software, the experienced surgeon had a longer operating time (139 s to 183 s; P = .30), longer fluoroscopy time (5.6 s to 9.2 s; P = .17), and more individual fluoroscopy images (11.6 to 14.8; P = .30). Wire position did not show significant differences in both cases. Conclusion: During indirect K-wire placement in the sustentaculum tali, the software appeared to be a useful tool for the inexperienced surgeon. In our chosen study setting, the experienced surgeon did not benefit from the software. Clinical Relevance: Possible indications for the software would be fractures of the proximal femur, sacrum, sacroiliac instabilities, vertebral bodies, scaphoid, Lisfranc joint, talus and calcaneus.

Intraoperative mobile C-arm fluoroscopy is widely used for interventional verification in trauma surgery, high flexibility combined with low cost being the main advantages of the method. However, the lack of global device-to- patient orientation is challenging, when comparing the acquired data to other intrapatient datasets. In upper ankle joint fracture reduction accompanied with an unstable syndesmosis, a comparison to the unfractured contralateral site is helpful for verification of the reduction result. To reduce dose and operation time, our approach aims at the comparison of single projections of the unfractured ankle with volumetric images of the reduced fracture. For precise assessment, a pre-alignment of both datasets is a crucial step. We propose a contour extraction pipeline to estimate the joint space location for a prealignment of fluoroscopic C-arm projections containing the upper ankle joint. A quadtree-based hierarchical variance comparison extracts potential feature points and a Hough transform is applied to identify bone shaft lines together with the tibiotalar joint space. By using this information we can define the coarse orientation of the projections independent from the ankle pose during acquisition in order to align those images to the volume of the fractured ankle. The proposed method was evaluated on thirteen cadaveric datasets consisting of 100 projections each with manually adjusted image planes by three trauma surgeons. The results show that the method can be used to detect the joint space orientation. The correlation between angle deviation and anatomical projection direction gives valuable input on the acquisition direction for future clinical experiments.

Background: The aim of this study was to determine if fracture reduction, fracture pattern, and patient-related factors influence clinical outcome after locked-plate fixation of displaced proximal humeral fractures. Methods: Ninety-eight patients (mean age, 61.1 ± 11.2 years) with a proximal humeral fracture involving the anatomical neck (type C according to the OTA/AO classification system) were included. Clinical outcome was determined by age and sex-adjusted Constant score (CS%) and the Disabilities of the Arm, Shoulder and Hand (DASH) score. Fracture reduction was quantitatively determined by 3 parameters (head-shaft displacement, head-shaft alignment, and cranialization of the greater tuberosity), and patients were divided into groups according to anatomical reduction, acceptable reduction, or malreduction. Relative risk (RR) for complications, revision surgery, and inferior clinical outcome (CS of 5 mm (n = 25), head-shaft displacement of >5 mm (n = 50), and valgus head-shaft alignment (n = 12) all increased the RR for inferior clinical outcome by twofold to threefold. Conversely, a patient age of >65 years (n = 31) and an OTA/AO type-C3 fracture pattern (n = 38) were not significantly associated with complications and inferior clinical outcome (RR, 0.9 to 1.8). Conclusions: Anatomical fracture reduction with a locked plate significantly improved the clinical outcome of unstable and displaced proximal humeral fractures involving the anatomical neck. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Purpose To evaluate the histologic and radiographic outcomes of using silicate-substituted calcium phosphate (Si-CaP) as bone graft substitute for the augmentation of tunnel defects in 2-stage revision anterior cruciate ligament (ACL) reconstruction. Methods Forty patients undergoing 2-stage revision ACL reconstruction were included in a prospective, randomized controlled clinical trial between 2012 and 2015. The inclusion criteria were tunnel diameter of the tibial and/or femoral tunnel of 10 mm or greater after failed ACL reconstruction. Twenty patients received autologous bone from the iliac crest and 20 patients received Si-CaP as a bone graft substitute for tunnel grafting at the first-stage procedure. Punch biopsy specimens of the augmented tunnels were taken at the second-stage procedure, and histologic examination included quantitative analysis of the area of immature bone formation, lamellar bone, and bone marrow. Radiographic analysis included determination of the filling rates of the tunnels on postoperative computed tomography scans. Results Forty patients with a mean age of 32 years (standard deviation [SD], 11.0 years) were analyzed. Histologic examination of the tunnels filled with Si-CaP showed that 15% (SD, 14%) of the area was covered with immature bone formation, 41% (SD, 10%) with well-organized lamellar bone, and 44% (SD, 8%) with bone marrow. In the control group (autologous bone), 58% (SD, 3%) of the area was covered with well-organized lamellar bone and 42% (SD, 3%) with bone marrow. Quantitative evaluation of the postoperative computed tomography scans showed a trend of better filling rates in patients with Si-CaP for the tibial tunnel (86% [SD, 17%] vs 78% [SD, 14%]; P = .131). Intraoperatively, Si-CaP was completely integrated into the original bone tunnel providing good stability for tunnel placement and tendon graft fixation comparable to autologous bone. Conclusions Si-CaP as bone graft substitute for tunnel augmentation in 2-stage revision ACL reconstruction shows good histologic, radiographic, and intraoperative integration comparable to autologous bone. Level of Evidence Level I, prospective randomized controlled trial.

Ankle fractures are accompanied by a syndesmotic injury in about 10% of operatively treated ankle fractures. Usually, the total rupture of the syndesmotic ligaments with an external rotation force is associated with a Weber type B or C fracture or a Maisonneuve fracture. The clinical assessment should consist of a comprehensive history including mechanism of injury followed by a specific physical examination. Radiographs, and if in doubt magnetic resonance imaging, are needed to ascertain the syndesmotic injury. In the case of operative treatment the method of fixation, the height and number of screws and the need for hardware removal are still under discussion. Furthermore, intraoperative assessment of the accuracy of reduction of the fibula in the incisura using fluoroscopy is difficult. A possible solution might be the assessment with intraoperative three-dimensional imaging. The aim of this article is to provide a current concepts review of the clinical presentation, diagnosis and treatment of syndesmotic injuries.

Determination of the appropriate treatment of unstable simple elbow dislocations is difficult and a topic of ongoing discussion. The aim of this study was to analyse the outcome and complications after surgery and conservative treatment, with special focus on post-traumatic joint laxity. In this retrospective study, 118 consecutive patients with simple elbow dislocations underwent stability testing by fluoroscopy after joint reduction and were assigned to groups 1 (slight), 2 (moderate) or 3 (gross) depending on post-traumatic joint laxity. All patients of group 1 underwent conservative treatment, and of group 3 primary ligament repair. In patients with moderate elbow laxity, the treatment was decided individually. All patients underwent a similar functional rehabilitation programme during treatment. Clinical outcome was determined after an average of 3.4 ± 1.5 years using the Mayo Elbow Performance Score (MEPS), and treatment-associated complications and revisions were recorded. Forty-nine patients (41.5 %) were assigned to group 1, 41 patients (34.7 %) to group 2 and 28 patients (23.7 %) to group 3. In group 2, 22 patients underwent ligament repair, while 19 patients were treated conservatively. On average, an excellent MEPS was achieved in group 1 after conservative treatment (MEPS 95.8 ± 9.0), similar to results after ligament repair of grossly unstable elbows in group 3 (91.6 ± 11.7). Interestingly, in group 2 conservative treatment was associated with a slightly lower MEPS (90.0 vs. 95.7), and significantly fewer patients achieved an excellent MEPS (81.8 vs. 52.6 %, p = 0.045). Similarly, conservative treatment in group 2 was associated with a fivefold to sixfold risk of complications (p = 0.032) and revision surgery (p = 0.023). This study supports the notion that patients with slight elbow laxity can be treated non-operatively, while primary surgical treatment should be performed in patients with moderate and gross laxity to avoid post-traumatic sequelae and decrease revision rates. Retrospective Cohort Study, Level III.

Background Fractures of the extremities are often complicated by a variable degree of swelling secondary to hemorrhage and soft tissue injury. Patients typically require up to 7 days of inpatient bed rest and elevation to reduce swelling to an acceptable level for operative treatment with internal fixation. Alternatively, an intermittent pneumatic compression device, such as the Vascular Impulse Technology (VIT) system, can be used at the injured extremity to reduce the posttraumatic swelling. The VIT system consists of a pneumatic compressor that intermittently rapidly inflates a bladder positioned under the arch of the hand or the foot, which results in compression of the venous hand or foot plexus. That intermittent compression induces an increased venous velocity and aims to reduce the soft tissue swelling of the affected extremity. Methods/design The VIT study is a prospective, monocenter, randomized controlled trial to compare the VIT system with elevation in the treatment of posttraumatic swelling in the case of a fracture of the upper and lower extremity. This study will include 280 patients with fractures of the upper and the lower extremity with nine different injury types. For each of the nine injury types a separate randomization to the two intervention groups (VIT group or control group) will be performed. The primary outcome parameter is the time taken for the swelling to resolve sufficiently to permit surgery. A separate analysis for each of the nine injury types will be performed. Discussion In the proposed study, the effectiveness of the VIT system in the treatment of posttraumatic swelling of upper and lower extremity fractures will be evaluated. Trial registration German Clinical Trial Register, No. DRKS00010510. Registered on 17 July 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1824-8) contains supplementary material, which is available to authorized users.

Background Three-dimensional (3D) imaging with a mobile C-arm has proven to be a valuable intraoperative tool in trauma surgery. However, little data is available concerning its use in the treatment of elbow fractures. The aim of the current study was to determine the intraoperative findings and consequences of 3D imaging in the treatment of elbow fractures. Methods Between 2001 and 2015, prospectively collected data of 36 patients who underwent intraoperative 3D imaging during elbow surgery were recorded. The findings and consequences of the intraoperative 3D scans were analyzed in a retrospective chart review. For clinical evaluation the analysis included the patients’ medical history, the injury pattern of the affected elbow and concomitant injuries. Intraoperative and postoperative complications and revision surgeries were evaluated as well. Results In 6 patients (16.7 %) analysis of the intraoperative 3D scan led to an immediate revision due to the detection of intra-articular screw placement (n = 3, 8.3 %) and remaining intra-articular step of >2 mm (n = 3, 8.3 %). In all of these patients, correct implant positioning and anatomical reduction could be achieved after immediate intraoperative revision, which was verified by a repeated intraoperative 3D scan. None of the 36 patients needed surgical revision based on postoperative radiological examinations due to secondary dislocation, wrong implant placement or remaining steps in the articular surface. Conclusions Intraoperative 3D imaging offers additional information about fracture reduction and implant positioning in the treatment of elbow fractures compared to conventional intraoperative 2D imaging. It may therefore reduce the need for revision surgery. The value of intraoperative 3D imaging for clinical outcomes still needs to be assessed.