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Introduction. Bilateral posterior dislocation of the shoulder is a rare injury, accounted for about 2–5% of all shoulder dislocations. Main courses are electrical shock, epilepsy or extreme trauma with uncontrolled muscle forces. We report about a case of bilateral posterior shoulder dislocation without additional fractures but with a concomitant acromioclavicular joint dislocation. Case presentation. A 46-year-old Caucasian motorcyclist presented to our facility after a fall on slippery ground. He claimed pain in both shoulders with limited range of motion. The initial X-rays were inconclusive, clinical examination showed typical findings of a Rockwood injury with an additional limited external rotation so that a posterior shoulder dislocation was suspected. The CT scan confirmed the clinical suspicion. A closed reduction was performed followed by immobilization in a shoulder abduction pillow for 4 weeks and continuous physiotherapy. Upon follow up normal function with full range of motion was observed. Conclusion. A bilateral posterior shoulder dislocation can be caused by trauma and results in a limited range of motion with often additional injuries. Due to the unusually presentation the risk of missing the injury is increased. Therefore it is most important to consider this rare diagnosis and in case of clinical suspicion perform a careful algorithm of diagnostic. [ABSTRACT FROM AUTHOR]

Introduction: The goal of this study was to provide an insight into the clinical results after modular short-stem shoulder arthroplasty for various indications., Materials and Methods: A consecutive cohort study of 76 patients followed up for 23-55 (mean 31.4) months. 23 anatomical (TSA), 32 reverse (RSA) and 21 hemi-prostheses with a pyrocarbon head (PyC), using a modular short stem with proximal porous coating were implanted. Range of motion, pain and Constant score (CS) were recorded. Comparisons of pre- vs postoperative outcomes, between prosthesis types and indications, were made., Results: All prosthesis types brought about a significant improvement (p < 0.05) in all measured outcomes. TSA had a significantly higher increase in the CS than PyC and RSA (p = 0.002 and 0.003, respectively). TSA produced superior gains in all ROM compared with RSA (p < 0.02). RSA brought about significantly smaller improvements in internal rotation than TSA and PyC (p = 0.0001 and 0.008, respectively). TSA had greater pain relief than PyC (p = 0.02). TSA with Walch A glenoids seemed to improve more than type B in the CS. PyC patients with Walch B glenoids improved more than Walch A (p = 0.03). When implanted due to Osteoarthritis (OA), PyC had a comparable final outcome to TSA (p = 0.95), although the preoperatively worse TSA patients had a greater improvement in the CS (p = 0.026). The outcome of RSA did not differ between indications, but Walch A glenoids tended to improve more., Conclusions: Using a second-generation short-stem shoulder prostheses, TSA achieves the best clinical improvements overall, especially for OA with a Walch A glenoid. Despite refixation of the subscapularis tendon in all cases, RSA has inferior internal rotation than TSA and PyC, suggesting a mechanical limitation. OA, a Walch B glenoid and arthritis caused by instability seem to be ideal indications when considering PyC., (© 2020. The Author(s).)

Background: Little is known about the way the newest generation of stems integrate into the proximal humerus and their effect on the surrounding bone. Factors that may influence ingrowth have not been investigated., Methods: A consecutive cohort study was conducted that examined 74 anatomical, reverse, or pyrocarbon hemiprostheses, using a curved modular short stem with a proximal porous coating 2-5 years postoperatively (mean 35 months). X-rays were reviewed by 2 examiners independently. Bone loss was scored with 1 point per zone with partial and 2 points per zone with complete resorption (10 zones). The Constant score was used for clinical correlation. Multiple linear regression was employed to investigate correlations between variables., Results: No subsidence or shift of the stems occurred. Two of 74 patients showed 1 zone of periprosthetic lucency of 1 mm. The filling ratio averaged 0.54 (range: 0.36-0.75). Thirty patients (40.5%) displayed bone resorption, first seen at 16.6 months (range: 3-40 months), commonly in zones 1 and 5. A total of 22 patients had ≥1 zone with partial resorption, and 8 (10.8%) developed full thickness resorption after 32 (range: 10-49) months.One new finding was that female sex and older age accounted for 51% of the variation of the filling ratio. A high filling ratio, especially when >0.55, correlated with bone resorption (P < .001). Age, sex, and prosthesis type did not directly predict bone resorption. Bony sclerosis correlated with a high filling ratio (P = .019) and thereby indirectly with resorption. A direct correlation between sclerosis and resorption was narrowly insignificant (P = .058) once correcting for the filling ratio. Reverse shoulder prosthesis had a higher filling ratio than total shoulder prosthesis patients (P < .001), resulting indirectly in more bone resorption. The preoperative diagnosis did not significantly correlate with the filling ratio (P = .59) or the resorption score (P = .69). A varus or valgus alignment did not predict resorption (P = .21) or the formation of sclerotic lines (P = .93). Bone loss did not correlate with clinical results., Conclusions: These short stems are firmly anchored 2-5 years postoperatively. However, significant bone loss, linked to a high filling ratio (>0.55), is observed proximally around these stems. The development of sclerotic lines around the stem indicates oversizing. Other factors were not found to have a significant effect on stem ingrowth. The implantation of stems with a large filling ratio is more common in older females and in patients receiving reverse shoulder prosthesis. Autologous impaction bone grafting could downsize the required stem. If adequate hold is not afforded by a suitably small stem, cementation is advisable., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Introduction: The purpose of this study was to investigate the effects of alcohol intoxication in trauma patients in regard to its impact on application of computed tomography (CT) and associated radiation exposure., Methods: We conducted a retrospective study from a continuous patient cohort., Inclusion Criteria: admission to the emergency room of an urban Level 1 trauma center with trauma team activation during a 12-month period (Jan 1st-Dec 31st 2012). Patients with incomplete data, age ≤ 12 years and with neurological diseases were excluded. Demographics, mechanisms, severity and patterns of injury (Abbreviated Injury Scale, Injury Severity Score, Glasgow Coma Scale), blood alcohol concentration (BAC, in permille, ‰), imaging studies (head/whole body CT), radiation exposure, and hospital length of stay, surgical procedures and mortality were evaluated with SPSS statistics (Version 25, IBM Inc., Armonk, New York)., Results: A positive BAC (mean 1.80 ± 0.767) was reported in 19.2% (n = 41/214) of the cohort. Alcohol intoxication was associated with higher utilization of head CT (65.9 vs. 46.8%, p = 0.017) and radiation exposure (231.75 vs. 151.25 mAS, p = 0.045; dose-length product, 583.03 vs. 391.04, p = 0.006). In general, the presence of alcohol was associated with over-triage (p = 0.001), despite minor injury severity (ISS < 9) and a comparable rate of head injuries (p = 0.275). Head injury (AIS ≥ 3) and positive BAC (OR 2.34, 95% CI 1.096-5.001) were identified as strongest independent predictors for head CT., Conclusion: Alcohol intoxication is a common finding in trauma patients, and the rate of moderate and serious head injuries seems to be comparable to a more severely injured control group. Furthermore, head CT utilization in intoxicated patients is associated with significant radiation exposure, despite poor image quality, due to motion artifacts (27%). Future strategies are required to exclude head injuries safely, while reducing the rate of head CT and associated radiation exposure in intoxicated patients.

Background: Shoulder pain is the third most common musculoskeletal complaint in orthopedic practice. It is usually due to a defect of the rotator cuff and/or an impingement syndrome., Methods: This review is based on pertinent literature retrieved by a selective search of the Medline database., Results: Patients with shoulder impingement syndrome suffer from painful entrapment of soft tissue whenever they elevate the arm. The pathological mechanism is a structural narrowing in the subacromial space. A multiplicity of potential etiologies makes the diagnosis more difficult; it is established by the history and physical examination and can be confirmed with x-ray, ultra - sonography, and magnetic resonance imaging. The initial treatment is conservative, e.g., with nonsteroidal antiinflammatory drugs, infiltrations, and patient exercises. Conservative treatment yields satisfactory results within 2 years in 60% of cases. If symptoms persist, decompressive surgery is performed as long as the continuity of the rotator cuff is preserved and there is a pathological abnormality of the bursa. The correct etiologic diagnosis and choice of treatment are essential for a good outcome. The formal evidence level regarding the best treatment strategy is low, and it has not yet been determined whether surgical or conservative treatment is better., Conclusion: Randomized controlled therapeutic trials are needed so that a standardized treatment regimen can be established.

Purpose: This study aimed to demonstrate the prevalence of lesions in the biceps pulley complex in a representative, consecutive series of rotator cuff tears and rotator cuff interval treatments. We also analyzed associated tear pattern of rotator cuff injuries and superior labrum anterior-posterior (SLAP) lesions. We evaluated the relationships of these lesions to traumatic genesis and the prevalence of pulley lesions in revision cases., Methods: This retrospective study analyzed all pre- and intra-operative documentation on arthroscopic rotator cuff reconstructions and isolated pulley lesion treatments performed by a single surgeon over 2 consecutive years. According to Habermeyer et al., we classified cases into four groups, based on the presence of additional or related complete or partial rotator cuff tears, SLAP lesions, trauma, and primary or revision surgery., Results: Among 382 patients with rotator cuff tears, 345 (90.3%) had an injured pulley system; 151 (43.8%) had partial tears of the rotator cuff; out of these, 106 (30.6%) were articular-sided. All of these articular-sided partial tears showed extension into the pulley complex. In 154 cases (44.6%), history of shoulder trauma was associated with the beginning of symptoms. In addition, concomitant SLAP lesions occurred in 25-62% of pulley lesions, correlating with the severity of pulley lesions. Among the 345 cases, there have been 32 (9.3%) revision cases where a pulley lesion was intra-operatively identified and addressed., Conclusions: Pulley complex lesions are present in 90.3% of surgically treated rotator cuff lesions, particularly in articular-sided injuries. In addition, we found a significant relationship between the incidence of SLAP lesions and the severity of pulley lesions. It seems reasonable to assume an important role of pulley system injuries in the pathogenesis of rotator cuff lesions.

Purpose: The aim of this study was to analyse possible indicative parameters for percutaneous ilio-sacral stabilisation and to identify parameters associated with screw misplacement., Methods: Cohort study, level I trauma centre., Inclusion Criteria: (1) unstable pelvic injury, (2) percutaneous ilio-sacral screws placement., Exclusion Criteria: (1) sacral dysmorphy, (2) failed closed reduction, (3) navigated techniques. Indicative parameters were age, gender, body mass index, number of screws, screw angulation, fracture type and injury severity. End points were ilio-sacral screw position and associated complications. Screw placement accuracy was graded as follows: grade 0, no perforation; grade 1, perforation <2 mm; grade 2, perforation from 2 to 4 mm; grade 3, ≥4 mm perforation., Results: Between March 2008 and March 2013, 102 (53 women) patients were included (mean age, 48.5 ± 21.4 years). The Injury Severity Score (ISS) and New Injury Severity Score (NISS) were 18.9 ± 9.9 and 22.3 ± 22.3, respectively. The positions of 137 ilio-sacral screws were analysed. Of all screws, 87.6 % (120) were placed satisfactory (<2 mm perforation). The incidence of screw misplacement was significantly higher in the case of two unilateral S1 screws compared with a single screw (failure rate: two unilateral screws 23.1 % vs single screw 7.0 %; p < 0.05). Screw perforation anterior to the lateral mass (in-out-in) represented the most frequent malposition. Revision was necessary in three cases due to malpositioning. Furthermore, no major complication occurred., Conclusions: We conclude, that twofold ilio-sacral screw positioning from one side increases the risk for screw misplacement. In this case, alternative techniques like navigation should be considered. Anterior screw perforation represents a common problem with a high incidence and warrants particular attention.

Background: Since the implementation of the diagnosis-related system there has been a continuous lack of finances in the treatment of multiple injured patients. The current investigation summarizes consecutive patients from a level I trauma centre and tests the hypothesis that an injury severity score (ISS) based reimbursement would be an improvement in the cost-effectiveness of this patient population., Methods: The study is based on multiple injured patients admitted to the emergency department in 2009. The ISS, intensive care unit (ICU) stay and cost data were recorded for every patient and two subgroups were formed: group I ISS < 16 and group II ISS ≥ 16., Results: A total of 442 patients with an average age of 40.5 ± 9.1 years (ISS 12) were included. The average amount of coverage during an average length of stay of 13.15 ± 6.3 was -2,752 per patient. Patients in group I (n = 296, ISS 6.3) showed a value of -1,163 with an average length of stay of 8 ± 4.6 days. In group II (n = 146, ISS 23.6) the average amount of coverage was -5,973 during an average hospital stay of 23 ± 8.7 days., Conclusion: Improvements have been made with the recent adjustment of the reimbursement within the last year. Nevertheless, several factors identified in this study require additional adjustment: the ISS, the requirement of blood transfusion and the presence of additional chest trauma should be weighted in the calculation of reimbursement.

Background: The treatment of patients with mild head injury is related to a continuous lack of finances. The current investigation summarises radiological costs of patients from a level I trauma centre and discusses the indication for CT scanning within the G-DRG system., Material and Methods: The study includes all patients who underwent a CCT scan in 2011. Diagnosis, length of stay and cost data were recorded for every patient. Finally, frequent diagnosis groups were summarised to clusters (Basis-DRG/MDC 21A)., Results: A total of 380 patients was treated. Within the largest group (G-DRG B80Z) the costs for a CCT already took up one quarter of the total proceedings. In combination with the high cost for monitoring patients with mild head injuries this causes an ongoing lack of finances., Conclusion: In spite of the often necessary CCT investigation in mild head injuries, the earnings do not cover the costs of the patients. To improve the situation clear guidelines for CCT scanning should be provided and the reimbursement in particular in the diagnosis group of the G-DRG B80Z has to be improved., (Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: The timing of definitive fixation for major fractures in patients with multiple injuries is controversial. To address this gap, we randomized patients with blunt multiple injuries to either initial definitive stabilization of the femur shaft with an intramedullary nail or an external fixateur with later conversion to an intermedullary nail and documented the postoperative clinical condition., Methods: Multiply injured patients with femoral shaft fractures were randomized to either initial (<24 hours) intramedullary femoral nailing or external fixation and later conversion to an intramedullary nail. Inclusion: New Injury Severity Score >16 points, or 3 fractures and Abbreviated Injury Scale score > or =2 points and another injury (Abbreviated Injury Scale score > or =2 points), and age 18 to 65 years. Exclusion: patients in unstable or critical condition. Patients were graded as stable or borderline (increased risk of systemic complications)., Outcomes: : Incidence of acute lung injuries., Results: Ten European Centers, 165 patients, mean age 32.7 +/- 11.7 years. Group intramedullary nailing, n = 94; group external fixation, n = 71. Preoperatively, 121 patients were stable and 44 patients were in borderline condition. After adjusting for differences in initial injury severity between the 2 treatment groups, the odds of developing acute lung injury were 6.69 times greater in borderline patients who underwent intramedullary nailing in comparison with those who underwent external fixation, P < 0.05., Conclusion: Intramedullary stabilization of the femur fracture can affect the outcome in patients with multiple injuries. In stable patients, primary femoral nailing is associated with shorter ventilation time. In borderline patients, it is associated with a higher incidence of lung dysfunctions when compared with those who underwent external fixation and later conversion to intermedullary nail. Therefore, the preoperative condition should be when deciding on the type of initial fixation to perform in patients with multiple blunt injuries.