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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.

ObjectiveTo optimize anastomotic technique and gastric conduit perfusion with hyperspectral imaging (HSI) for total minimally invasive esophagectomy (MIE) with linear stapled anastomosis.Summary Background DataEsophagectomy is the mainstay of esophageal cancer treatment but anastomotic insufficiency related morbidity and mortality remain challenging for patient outcome.MethodsA live porcine model (n=50) for MIE was used with gastric conduit formation and linear stapled side-to-side esophagogastrostomy. Four main experimental groups differed in stapling length (3 vs. 6 cm) and anastomotic position on the conduit (cranial vs. caudal). Tissue oxygenation around the anastomotic site was evaluated using HSI and was validated with histopathology.ResultsThe tissue oxygenation (ΔStO2) after the anastomosis remained constant only for the short stapler in caudal position (−0.4± 4.4%, n.s.) while it dropped markedly in the other groups (short-cranial: -15.6± 11.5%, p=0.0002; long-cranial: -20.4± 7.6%, p=0.0126; long-caudal: -16.1± 9.4%, pConclusionsTissue oxygenation at the anastomotic site of the gastric conduit during MIE is influenced by stapling technique. Optimal oxygenation was achieved with a short stapler (3 cm) and sufficient distance of the anastomosis to the cranial end of the gastric conduit. HSI tissue deoxygenation corresponded to histopathologic necrotic tissue changes. These findings allow for optimization of gastric conduit perfusion and anastomotic technique in MIE.Level of EvidenceNot applicable. Translational animal science. Original article.

Seit 2015 konnen Ellenbogenendoprothesen und Radiuskopfprothesen inklusive der Hemiprothese des distalen Humerus und des Capitulumersatzes im Ellenbogen im Ellenbogenendoprothesenregister der Deutschen Vereinigung fur Schulter- und Ellenbogenchirurgie e. V. (DVSE) dokumentiert werden. Die bis 2018 dokumentierten Primarbogen wurden fur die vorliegende Arbeit ausgewertet. Insgesamt wurden 73 Ellenbogenendoprothesen und 56 Radiuskopfprothesen erfasst. Bei den Ellenbogenendoprothesen wurden eine Hemiprothese des distalen Humerus, 63 gekoppelte Totalendoprothesen ohne und 9 Totalendoprothesen mit Radiuskopfersatz implantiert. Von den 56 Radiuskopfprothesen wurde eine Monobloc- und 55 modulare Prothesen implantiert. Daten zur Geschlechterverteilung, Alter, Operationsindikation, operationstechnischen Details und Fruhkomplikationen wurden ausgewertet. Die bereits dokumentierten 73 Ellenbogenendoprothesen und 56 Radiuskopfprothesen stellen bereits einen guten Anfang dar. Die detaillierte Datenerhebung wird uns bei guter Dokumentation in Zukunft Analysen an groseren Kohorten erlauben.

Background/purpose The dissemination of laparoscopic liver resection (LLR) has been based on non-randomized studies and reviews of these. Aim of this study was to evaluate if the randomized evidence comparing LLR to open liver resection (OLR) supports these findings. Methods A prospectively registered (reviewregistry866) systematic review and meta-analysis following Cochrane and PRISMA guidelines comparing LLR to OLR for benign and malignant diseases was performed via Medline, Web of Science, CENTRAL up to 31.12.2020. The main outcome was postoperative complications. Risk of bias was assessed with the Cochrane Risk of Bias tool 2.0, certainty of evidence was assessed using the GRADE approach. Results The search yielded 2080 results. 13 RCTs assessing mostly minor liver resections with 1457 patients were included. There were reduced odds of experiencing any complication (Odds ratio (OR) [95% confidence interval (CI)]: 0·42 [0·30, 0·58]) and severe complications (OR[CI]: 0·51 [0·31, 0·84]) for patients undergoing LLR. LOS was shorter (Mean difference (MD) [CI]: −2·90 [-3·88, −1·92] days), blood loss was lower (MD: [CI]: −115·41 [-146·08, −84·75] ml), and functional recovery was better for LLR. All other outcomes showed no significant differences. Conclusions LLR shows significant postoperative benefits. RCTs assessing long-term outcomes and major resections are needed.

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.

Introduction Microcirculatory alterations are key mechanisms in sepsis pathophysiology leading to tissue hypoxia, edema formation, and organ dysfunction. Hyperspectral imaging (HSI) is an emerging imaging technology that uses tissue-light interactions to evaluate biochemical tissue characteristics including tissue oxygenation, hemoglobin content and water content. Currently, clinical data for HSI technologies in critical ill patients are still limited. Methods and analysis TIVITA® Tissue System was used to measure Tissue oxygenation (StO2), Tissue Hemoglobin Index (THI), Near Infrared Perfusion Index (NPI) and Tissue Water Index (TWI) in 25 healthy volunteers and 25 septic patients. HSI measurement sites were the palm, the fingertip, and a suprapatellar knee area. Septic patients were evaluated on admission to the ICU (E), 6 h afterwards (E+6) and three times a day (t3-t9) within a total observation period of 72 h. Primary outcome was the correlation of HSI results with daily SOFA-scores. Results Serial HSI at the three measurement sites in healthy volunteers showed a low mean variance expressing high retest reliability. HSI at E demonstrated significantly lower StO2 and NPI as well as higher TWI at the palm and fingertip in septic patients compared to healthy volunteers. StO2 and TWI showed corresponding results at the suprapatellar knee area. In septic patients, palm and fingertip THI identified survivors (E-t4) and revealed predictivity for 28-day mortality (E). Fingertip StO2 and THI correlated to SOFA-score on day 2. TWI was consistently increased in relation to the TWI range of healthy controls during the observation time. Palm TWI correlated positively with SOFA scores on day 3. Discussion HSI results in septic patients point to a distinctive microcirculatory pattern indicative of reduced skin oxygenation and perfusion quality combined with increased blood pooling and tissue water content. THI might possess risk-stratification properties and TWI could allow tissue edema evaluation in critically ill patients. Conclusion HSI technologies could open new perspectives in microcirculatory monitoring by visualizing oxygenation and perfusion quality combined with tissue water content in critically ill patients – a prerequisite for future tissue perfusion guided therapy concepts in intensive care medicine.

Objective: To examine whether robotic-assisted training as a supplement to usual therapy is safe, acceptable and improves function and patient reported outcome after proximal humeral fractures (PHF). Design: Multicentre, assessor-blinded, randomised controlled prospective trial. Setting: Three different rehabilitation hospitals in Germany. Subjects: In total 928 PHF patients between 35 and 70 years were screened. Forty-eight participants were included in the study (intervention group n = 23; control group n = 25). Intervention: The control group received usual occupational and physiotherapy over three weeks, and the intervention group received additional 12 robot-assisted training sessions at the ARMEO®-Spring. Main measures: Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH), the Wolf Motor Function Test-Orthopaedic, active range of motion and grip strength were determined before and after intervention period. The DASH was additionally obtained postal 6 and 13 months following surgery. Results: The mean age of participants was 55 ± 10 years and was similar in both groups ( p > 0.05). The change in DASH as the primary endpoint in the intervention group after intervention was −15 (CI = 8–22), at follow-up six month −7 (CI = −2 to 16) at follow up 13 month −9 (CI = 1–16); in control group −14 (CI = 11–18), at follow-up six month −13 (CI = 7–19) at follow up 13 month −6 (CI = −3 to 14). No difference in the change was found between groups ( p > 0.05). None of the follow-up time points demonstrated an additional benefit of the robotic therapy. Conclusion: The additional robot-assisted therapy was safe, acceptable but showed no improvement in functional shoulder outcome compared to usual therapy only.

Background: The only curative treatment for most esophageal cancers is radical esophagectomy. Minimally invasive esophagectomy (MIE) aims to reduce postoperative morbidity, but is not yet widely established. Linear stapled anastomosis is a promising technique for MIE because it is quite feasible even without robotic assistance. Aim of the present study is to compare total MIE with linear stapled anastomosis to open esophagectomy (OE) with circular stapled anastomosis with special regard to postoperative morbidity in an expertise-based randomized controlled trial (RCT). Methods/design: This superiority RCT compares MIE with linear stapled anastomosis (intervention) to OE with circular stapled anastomosis (control) for Ivor-Lewis esophagectomy. It was initiated in February 2019 and recruitment is expected to last for 3 years. For inclusion, patients must be 18 years of age or more with a resectable primary malignancy in the distal esophagus. Participants with tumor localizations above the azygos vein, metastasis or infiltration into adjacent tissue will be excluded. In an expertise-based approach the allocated treatment will only be carried out by the single most experienced surgeon of the surgical center for each respective technique. The sample size was calculated with 20 participants per group for the primary endpoint postoperative morbidity according to comprehensive complication index (CCI) within 30 postoperative days. Secondary endpoints include anastomotic insufficiency, pulmonary complications, other intra- and postoperative outcome parameters such as estimated blood loss, operative time, length of stay, short-term oncologic endpoints, adherence to a standardized fast-track protocol, postoperative pain, and postoperative recovery (QoR-15). Quality of life (SF-36, CAT EORTC QLQ-C30, CAT EORTC QLQ-OES18) and oncological outcomes are evaluated with 60 months follow-up. Discussion: MIVATE is the first RCT to compare OE with circular stapled anastomosis to total MIE with linear stapled anastomosis exclusively for intrathoracic anastomosis. The expertise-based approach limits bias due to heterogeneity of surgical expertise. The use of a dedicated fast-track protocol in both OE and MIE will shed light on the role of the access strategy alone in this setting. The findings of this study will serve to define which approach has the best perioperative outcome for patients requiring esophagectomy. Trial registration: German Clinical Trials Register DRKS00016773. Registered on February 18th, 2019.

Background The only curative treatment for most esophageal cancers is radical esophagectomy. Minimally invasive esophagectomy (MIE) aims to reduce postoperative morbidity, but is not yet widely established. Linear stapled anastomosis is a promising technique for MIE because it is quite feasible even without robotic assistance. The aim of the present study is to compare total MIE with linear stapled anastomosis to open esophagectomy (OE) with circular stapled anastomosis with special regard to postoperative morbidity in an expertise-based randomized controlled trial (RCT). Methods/design This superiority RCT compares MIE with linear stapled anastomosis (intervention) to OE with circular stapled anastomosis (control) for Ivor-Lewis esophagectomy. It was initiated in February 2019, and recruitment is expected to last for 3 years. For inclusion, patients must be 18 years of age or more with a resectable primary malignancy in the distal esophagus. Participants with tumor localizations above the azygos vein, metastasis, or infiltration into adjacent tissue will be excluded. In an expertise-based approach, the allocated treatment will only be carried out by the single most experienced surgeon of the surgical center for each respective technique. The sample size was calculated with 20 participants per group for the primary endpoint postoperative morbidity according to comprehensive complication index (CCI) within 30 postoperative days. Secondary endpoints include anastomotic insufficiency, pulmonary complications, other intra- and postoperative outcome parameters such as estimated blood loss, operative time, length of stay, short-term oncologic endpoints, adherence to a standardized fast-track protocol, postoperative pain, and postoperative recovery (QoR-15). Quality of life (SF-36, CAT EORTC QLQ-C30, CAT EORTC QLQ-OES18) and oncological outcomes are evaluated with 60 months follow-up. Discussion MIVATE is the first RCT to compare OE with circular stapled anastomosis to total MIE with linear stapled anastomosis exclusively for intrathoracic anastomosis. The expertise-based approach limits bias due to heterogeneity of surgical expertise. The use of a dedicated fast-track protocol in both OE and MIE will shed light on the role of the access strategy alone in this setting. The findings of this study will serve to define which approach has the best perioperative outcome for patients requiring esophagectomy. Trial registration German Clinical Trials Register DRKS00016773. Registered on 18 February 2019.

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.

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.

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.

The Wolf motor function test (WMFT) evaluates the upper extremity performance of patients with neurological disorders and traumatic brain injuries by assessing time and functional capacity. It was later modified to also measure the quality of the performed movements. This study aimed to adapt the WMFT for patients with shoulder injuries and to evaluate the inter-rater and intra-rater reliability of this adapted version. A total of 20 individuals with a median age of 80.5 years were assessed using a test-retest design after surgical or conservative treatment of shoulder injuries. Two raters rated performance to determine inter-rater reliability. One rater rated the performance again to determine intra-rater reliability. Both inter-rater and intra-rater agreement were determined by weighted Cohen’s kappa statistics with corresponding confidence intervals. Cronbach’s alpha was calculated to determine internal consistency. The inter-rater Cohen’s kappa values ranged from 0.84–1.00 for functional capacity and from 0.79–1.00 for quality of movement. For intra-rater reliability the Cohen’s kappa ranged from 0.71–1.00. Cronbach’s alpha was >0.94 for functional capacity and >0.96 for quality of movement. The adapted version of the WMFT shows high intra-rater and inter-rater reliability for patients with shoulder injuries.

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

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.

Methods Between 2005 and 2012, 50 patients (23 female, 27 male) with nonunion of the humeral shaft were included in this retrospective study. The mean age was 51.3 years (14 to 88). The patients had a mean of 1.5 prior operations (sd 1.2;1 to 8). All patients were assessed according to a specific risk score in order to devise an optimal and individual therapy plan consistent with the Diamond Concept. In 32 cases (64%), a change in the osteosynthesis to an angular stable locking compression plate was performed. According to the individual risk an additional bone graft and/or bone morphogenetic protein-7 (BMP-7) were applied. Results A successful consolidation of the nonunion was observed in 37 cases (80.4%) with a median healing time of six months (IQR 6). Younger patients showed significantly better consolidation. Four patients were lost to follow-up. Revision was necessary in a total of eight (16%) cases. In the initial treatment, intramedullary nailing was most common. Discussion The use of locking compression plates in combination with autologous cancellous bone graft has been shown to be a safe and effective treatment. In more complex cases, the use of the Masquelet technique and BMP-7 may be indicated at the first revision operation. Take home message: Our results suggest the Diamond Concept is a successful treatment strategy for nonunions of the humeral shaft. Cite this article: Bone Joint J 2016;98-B:81–7.

Background The incidence of proximal humeral fractures increases with age. The functional recovery of the upper arm after such fractures is slow, and results are often disappointing. Treatment is associated with long immobilisation periods. Evidence-based exercise guidelines are missing. Loss of muscle mass as well as reduced range of motion and motor performance are common consequences. These losses could be partly counteracted by training interventions using robot-assisted arm support of the affected arm derived from neurorehabilitation. Thus, shorter immobilisation could be reached. Thus far, this approach has been tested in only a few small studies. The aim of the present study is to examine whether assistive robotic training augmenting conventional occupational and physical therapy can improve functional shoulder outcomes. Methods/design Patients aged between 35 and 66 years with proximal humeral fracture and surgical treatment will be recruited at three different clinics in Germany and randomised into an intervention group and a control group. Participants will be assessed before randomisation and followed after completing an intervention period of 3 weeks and additionally after 3, 6 and 12 months. The baseline assessment will include cognition (Short Orientation-Memory-Concentration Test); level of pain in the affected arm; ability to work; gait speed (10-m walk); disability of the arm, shoulder and hand (Disabilities of the Arm, Shoulder and Hand Outcome Measure [DASH]); range of motion of the affected arm (goniometer measurement); visual acuity; and motor function of orthopaedic patients (Wolf Motor Function Test–Orthopaedic version [WMFT-O]). Clinical follow-up directly after the intervention will include assessment of disability of the arm, shoulder and hand (DASH) as well as range of motion and motor function (WMFT-O). The primary outcome parameter will be the DASH, and the secondary outcome parameter will be the WMFT-O. The long-term results will be assessed prospectively by postal follow-up. All patients will receive conventional occupational and physical therapy. The intervention group will receive additional robot-assisted training using the Armeo®Spring robot for 3 weeks. Discussion This study protocol describes a phase II, randomised, controlled, single-blind, multicentre intervention study. The results will guide and possibly improve methods of rehabilitation after proximal humeral fracture. Trial registration Clinicaltrials.gov, NCT03100201. Registered on 28 March 2017. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2274-z) contains supplementary material, which is available to authorized users.

Hintergrund Die Resektion des Radiuskopfes war in der Vergangenheit bei nicht rekonstruierbaren Radiuskopffrakturen haufig die einzige Therapieoption. Mit den modernen Prothesen steht nun eine weitere Behandlungsmethode zur Auswahl. Die vorliegende Arbeit befasst sich mit der Frage in welchen Fallen die ersatzlose Resektion noch vertretbar ist.

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.

Background: Comminuted radial head fractures are often associated with secondary injuries and elbow instability. Objectives: The aim of this retrospective study was to evaluate how well the modular metallic radial head implant EVOLVE® prosthesis restores functional range of motion (ROM) and stability of the elbow in acute care. Patients and Methods: Eighty-five patients with comminuted radial head fractures and associated injuries received treatment with an EVOLVE® prosthesis between May 2001 and November 2009. Seventy-five patients were available for follow-up. On average, patients were followed for 41.5 months (33.0: 4.0 - 93.0). Outcome assessment was done on the basis of pain, ROM, strength, radiographic findings, and functional rating scores such as Broberg and Morrey, the Mayo elbow performance index (MEPI), and disabilities of the arm, shoulder and hand (DASH). Our study is currently the largest analysis of clinical outcome of a modular radial head replacement in the literature. Results: Overall, there were 2 (2.7%) Mason II fractures, 21 (28%) Mason III fractures, and 52 (69.3%) Mason IV fractures. Arbeitsgemeinschaft fur osteosynthesefragen (AO) classification was also determined. Of the 85 patients in our study, 75 were available for follow-up. Follow-up averaged 41.5 months (range, 4 - 93 months). Average scores for the cohort were as follows: Morrey, 85.7 (median 90.2; range 44.4 - 100); MEPI, 83.3 (85.0; 40.0 - 100); and DASH 26.1 points (22.5; 0.0 - 75.8). Mean flexion/extension in the affected joint was 125.7°/16.5°/0° in comparison to the noninjured side 138.5°/0°/1.2°. Mean pronation/supination was 70.5°/0°/67.1° in comparison to the noninjured side 83.6°/0°/84.3°. Handgrip strength of the injured compared to the non-injured arm was 78.8%. The following complications were also documented: 58 patients had periprosthetic radioluceny shown to be neither clinically significant nor relevant according to evaluated scores; 26 patients had moderate or severe periarticular ossification, and scored substantially worse according to MEPI and Morrey. Four patients required revisional surgery due to loosening of the prosthesis and chronic pain. In addition, one patient required a neurolysis of the ulnaris nerve, one developed a neobursa, and one had extensive swelling and blistering. The time interval between injury and treatment appeared to have an effect on results. Thirty-five patients were treated within the first 5 days after accident and showed better results than the 40 patients who were treated after 5 days. Conclusions: Comminuted radial head fractures with elbow instability can be treated well with a modular radial head prosthesis, which restores stability in acute treatment. The modular radial head arthroplasty used in this study showed promising findings in short to midterm results.

Der strukturelle, finanzielle und personelle Aufwand zum vorteilhaften Einsatz ambulanter Eingriffe ist hoch. Diese kosten zwar nur halb so viel wie stationare Operationen, werden aber unter europaischem Durchschnitt vergutet, was bei allen Leistungserbringern zu einer Mindererlossituation fuhrt. Dieser wird momentan klinikseitig haufig mit Kompromisslosungen begegnet, es mussen jedoch tragfahige individuelle Losungen entwickelt werden. Dies wird am Beispiel der BG-Unfallklinik Ludwigshafen erlautert. Bei Beurteilung der Prozessablaufe der dort etablierten ambulanten Operationseinheit stellte sich zum einen die Schnittstelle Mensch („human resource – human interface“) als eine der Herausforderungen beim ambulanten Operieren heraus. Zum anderen zeigte sich, dass durch eine angegliederte ambulante Operationseinheit bei guter Planung und Berucksichtigung des lokalen Umfeldes bestimmte Aspekte im Bereich des Patienten und Prozessmanagements optimiert werden konnen. Ein solcher Ausbau eines Krankenhauses kann aber auch kritisch gesehen werden. Eine Einbeziehung der lokal tatigen niedergelassenen Facharzte ist ebenfalls moglich und sollte gepruft werden.

Radiuskopfchentrummerfrakturen sind haufig mit Begleitverletzungen vergesellschaftet, die zu einer Beeintrachtigung der Ellenbogenfunktion und -stabilitat fuhren konnen. Prothesen neuerer Generation sollen eine Verbesserung der Ergebnisse liefern. Ziel dieser Studie war es, die Ergebnisse der modularen EVOLVE®-Prothese zu evaluieren. Von Juni 2001 bis Januar 2005 wurde bei 30 Patienten mit komplexen Radiuskopfchenfrakturen eine Prothese implantiert; 28 Patienten wurden nachuntersucht. Die mittlere Nachuntersuchungszeit betrug 29 Monate. Insgesamt lag 7-mal (25%) eine Mason-III- und 21-mal (75%) eine Mason-IV-Fraktur vor. Nach den Kriterien des Morrey-Scores wurden 19 Patienten mit sehr gut und gut beurteilt, 8 Patienten wurden mit ausreichend eingestuft und 1 Ergebnis wurde als mangelhaft bewertet. Es wurde keine Instabilitat des Ellenbogengelenks festgestellt. Radiuskopfchentrummerfrakturen mit ligamentaren Begleitverletzungen konnen durch die primare Radiuskopfchenprothese und ligamentare Rekonstruktion mit einem guten funktionellen Ergebnis behandelt werden. Langzeitergebnisse sind zwar noch nicht verfugbar; aus mittelfristiger Sicht ist dies eine effektive Methode zur Wiederherstellung der Gelenkgeometrie bei einer ubungsstabilen Versorgung des Ellenbogengelenks.

Fehlverheilte Frakturen am Unterarm sind keine Seltenheit und fuhren je nach Ausmas der Fehlstellung, schmerzhafter Bewegungseinschrankung und Kraftverlust zu Problemen am Arbeitsplatz und im Alltag. Kriterien fur die Indikation zur Korrekturosteotomie sind mittlerweile erarbeitet. Beim Kind kann man die weitere Wachstumserwartung in die Therapieplanung mit aufnehmen, muss aber die Grenzen der Korrekturpotenz kennen. Vor der Operation steht eine detaillierte, dreidimensionale Analyse der Fehlstellung mit einer Planungsskizze des erwunschten Operationsergebnisses. Die Studienlage zeigt, dass ein Korrektureingriff in allen Altersgruppen mit verlasslich sicheren Ergebnissen moglich ist. Im Gegensatz zu kongenitalen Fehlstellungen durch Wachstumsstorungen sind posttraumatische Zustande beim Primareingriff vermeidbar. Eine Korrektur bedeutet stets einen Mehraufwand mit hoherem Komplikationsrisiko.

Operative Korrekturen posttraumatischer Veranderungen des Humerus bergen nicht unerhebliche Risiken. Die Ursachen posttraumatischer Oberarmdeformitaten sind jedoch uberwiegend iatrogen und somit vermeidbar. Grundsatzlich sind Korrektureingriffe in jedem Alter moglich. Sie hangen von den Beschwerden des Patienten, der weiteren Wachstumserwartung sowie der Lokalisation der Deformitat ab. Eine operative Korrektur erfordert eine umfangreiche praoperative Analyse des Ist- und Sollzustands; eine praoperative Planung ist daher in jedem Fall erforderlich. Die Korrekturtechnik sollte eine Beseitigung samtlicher Komponenten der Deformitat erlauben. Das Korrekturergebnis muss sicher bis zur Heilung retiniert werden konnen und sollte dem Patienten eine schmerzarme Bewegungsstabilitat gewahren. Im Gegensatz zu Fehlstellungen durch schicksalhafte Wachstumsstorungen konnen iatrogene Deformitaten durch korrekte Repositionen beim Primareingriff vermieden werden. Eine Korrektur bedeutet stets einen zur Primarbehandlung hinzukommenden Mehraufwand.

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.

Fragestellung: Pseudarthrosen des proximalen Humerus sind selten und können entweder endoprothetisch oder kopferhaltend mittels Pseudar- throsenresektion therapiert werden. Im Rahmen dieser Studie sollte untersucht werden, inwieweit eine kopferhaltende Revisionsstrategie bei proximalen Humeruspseudarthrosen[zum vollständigen Text gelangen Sie über die oben angegebene URL], Deutscher Kongress für Orthopädie und Unfallchirurgie (DKOU 2015)

Elbow dislocations with complex elbow instability (CEI) and unstable radial head fractures require reconstruction by open reduction and internal fixation (ORIF) if possible or alternatively by a radial head prosthesis. The aim of this study was to determine the differential outcome of both strategies and to investigate the contribution of prosthesis-related radiographic factors such as oversizing on clinical outcome. A total of 53 patients underwent ligament and coronoid refixation, and radial head reconstruction by ORIF (n = 18; group 1) or by monopolar modular prosthesis (n = 35; group 2). Patients were followed by the Mayo Elbow Performance Score (MEPS) and a radiological score including prosthesis oversizing, joint subluxation, ossifications, capitellar erosions, implant loosening and ulno-humeral osteoarthritis. To investigate the effect of oversizing, group 2 was subdivided by prosthesis overlenghtening ≥ 2 mm. A total of 42 patients (79.2 %) could be followed for 3.0 ± 1.3 years with an average MEPS of 76.8 ± 17.2. Patients with ORIF had slightly better MEPS (82.1 ± 9.9) as compared with group 2 (74.7 ± 19.1) though three ORIF patients required an early conversion to prosthesis. In group 2, oversizing occurred frequently and 50 % showed an overlenghtening ≥ 2 mm. Oversizing significantly decreased MEPS (63.2 ± 21.3 vs 84.7 ± 9.0; p = 0.001) and elbow range of motion and increased the occurrence of other radiological abnormalities and the risk for surgical revisions. The radiological score and prosthesis overlenghtening but not prosthesis diameter showed an inverse correlation with MEPS. In CEI a radial head reconstruction with a prosthesis demonstrates similarly good clinical results as compared to ORIF in anatomically sized prosthesis, but prosthesis oversizing could induce other radiographic abnormalities with then deteriorated outcome.

Die westlichen Gesellschaften stehen vor masgeblichen Herausforderungen: der Anteil der Patienten im Rentenalter wird trotz Ruckgang der Gesamtbevolkerungszahl zu einer Zunahme stationarer orthopadisch-unfallchirurgischer Akutfalle fuhren. Parallel dazu muss das Gesundheitswesen vom schrumpfenden Teil der arbeitenden Bevolkerung finanziert werden. Den politischen Wunsch zur flachendeckenden Patientenversorgung trotz Einsparungen will man durch Verweildauerkurzung und Bettenreduktion erreichen. Das Nadelohr der operativen Facher wird bei optimaler Ausnutzung der Bettenkapazitat dann die zur Verfugung stehende Belegungszeit der OPs. Separate ambulante Operationseinheiten an Krankenhausern zur Entlastung des Zentral-OPs konnten uber die Schaffung relevanter Operationskapazitaten damit ein Instrument zur Belegungssteuerung werden. Gerade vor dem soziodemographischen Hintergrund muss daher eine adaquate Diskussion uber die sozialen Rahmenbedingungen und den Wandel unserer Gesellschaft einsetzen.

Seit 2005 finden schriftliche Anfragen und Vor-Ort-Prufungen durch den Medizinischen Dienst der Krankenversicherungen (MDK) statt. Diese spiegeln in ihren Veranderungen sowohl die Erfahrung der Kassen mit dem G-DRG-System (G-DRG German Diagnosis Related Groups) als auch der zustandigen arztlichen Mitarbeiter und des Krankenhauscontrollings wider. Wir wollten aufarbeiten, welche Entwicklung die MDK-Prufungen seit 2005 genommen haben. Hierfur wurden samtliche Prufberichte seit Einfuhrung der Prufungen ausgewertet. Wahrend anfangs hauptsachlich Fragen zur Kodier- und Dokumentationsqualitat erfolgten, werden jetzt uberwiegend Fehlbelegungsprufungen durchgefuhrt. Zwischenzeitlich wurden konsequent die unterschiedlichen Klinikbereiche gepruft. Die Anfragen sind mittlerweile spezifischer und beziehen sich auf aktuelle Veranderungen im Abrechnungssystem. Bei grosem zeitlichem und personellem Aufwand sind die Abschlage gleich geblieben. Anderungen des Abrechnungssystems erfordern Flexibilitat seitens der Leistungserbringer. Erfahrungen mit den MDK-Prufungen konnen dabei hilfreich bei der Organisation klinikinterner Strukturen sein.

Hat der Patient nach einem angeschuldigten Ereignis persistierende Beschwerden an der Schulter, ist seine Eigenanamnese zu erfragen. Befunde der Gegenseite, der Halswirbelsaule (HWS) und der angrenzenden Gelenke sind zu dokumentieren. Der Unfallhergang ist fur die Begutachtung und die Bewertung elementar. Es ist zwingend festzuhalten, ob uberhaupt ein Unfall vorliegt oder ob nicht eine willentliche Bewegung erfolgte. Die Richtung der einwirkenden Kraft und Hinweise auf stattgehabte Luxationen sind in jedem Fall bereits im ersten, dem so genannten Durchgangsarztbericht aufzufuhren. Eine entsprechende Diagnostik ist okonomisch einzusetzen und, falls erforderlich, zu wiederholen. 4 Wochen nach dem „Unfall“ sollten die Diagnose feststehen und nach Bedarf eine entsprechende Therapie eingeleitet werden konnen.