Florian Grubhofer

Reverse total shoulder arthroplasty for acute head-splitting, 3- and 4-part fractures of the proximal humerus in the elderly.

BACKGROUND Anatomic reduction and stable internal fixation of complex proximal humeral fractures in the elderly is challenging. Secondary displacement, screw perforation, and humeral head necrosis are common complications. The outcome of hemiarthroplasty is unpredictable and strongly dependent on the uncertain healing of the greater tuberosity. This multicenter study retrospectively analyzes the midterm results of primary reverse total shoulder arthroplasty for the treatment of acute, complex fractures of the humerus in an elderly population. METHODS Fifty-two shoulders in 51 patients with a mean age of 77 years treated with reverse total shoulder arthroplasty for an acute, complex fracture of the proximal humerus were clinically and radiographically analyzed after a mean follow-up period of 35 months (range, 12-90 months). RESULTS There were no intraoperative complications. Revision surgery was performed in 4 shoulders. At final follow-up, the absolute and relative Constant scores averaged 62 points (range, 21-83 points) and 86% (range, 30%-100%), respectively, with a mean Subjective Shoulder Value of 83% (range, 30%-100%). Of the patients, 92% rated the treatment outcome as excellent or good. Patients with a resected or secondarily displaced greater tuberosity had an inferior clinical outcome to those with a healed greater tuberosity. CONCLUSION The midterm clinical results are predictably good, with low complication rates and a rapid postoperative recovery of painfree everyday function. If secondary displacement of the greater tuberosity occurs, revision surgery may warrant consideration in view of potential improvement of ultimate outcome.

Reverse total shoulder arthroplasty for failed open reduction and internal fixation of fractures of the proximal humerus

BACKGROUND Open reduction and internal fixation (ORIF) of complex fractures of the proximal humerus may yield unsatisfactory results. This study analyzed the results obtained after revision of failed ORIF of proximal humeral fractures using reverse total shoulder arthroplasty (RTSA). METHODS Fifty-four shoulders of 53 patients with a subjectively unacceptable outcome after ORIF of a complex fracture of the proximal humerus were revised with RTSA. At a minimum follow-up of 2 years (mean follow-up, 46 months; range, 24-108 months), 44 shoulders were clinically and radiographically reviewed for the purpose of this study. Six patients had been lost to follow-up, and 4 patients (7%) were excluded from functional analysis because of revision surgeries. RESULTS The mean absolute Constant score improved from 26 (range, 4-54) to 55 (range, 19-80) points; the mean relative Constant score improved from 32% (range, 4%-85%) to 67% (range, 27%-94%) of an age- and gender-matched, normal shoulder. The mean subjective shoulder value improved from 29% (range, 0%-90%) preoperatively to 67% (range, 5%-95%) at final follow-up. Nineteen patients rated their outcome excellent, 16 good, and 7 fair; 2 patients were dissatisfied. CONCLUSION RTSA is a valuable salvage procedure after failed ORIF of a proximal humeral fracture with relatively low revision rates. Shoulder function, patient satisfaction, and pain levels can be reliably improved.

A systematic review of the clinical applications and complications of bone marrow aspirate concentrate in management of bone defects and nonunions

AbstractPurposeFracture healing encompasses a succession of dynamic multifactorial metabolic events, which ultimately re-establishes the integrity of the biomechanical properties of the bone. Up to 10% of the fractures occurring annually will need additional surgical procedures because of impaired healing. The aim of this article is to review the current literature regarding the use of bone marrow aspirate concentrate (BMAC) and its effectiveness in the management of bone defects.MethodsWe have included all published clinical literature investigating the development, techniques and applications of BMAC. Language, design and risk of bias did not deter the initial inclusion of any study. Our search was exclusively limited to studies involving human subjects. A PRISMA compliant search was carried out as published in 2009. This included the online databases: PubMed, EMBASE, clinical trial.gov and the Cochrane library from 1960 to the end of May 2015. MeSH terms used included: “Bone” AND “Marrow” AND “Aspirate” AND “Concentrate” AND “Bone Defects” AND “NONUNION”. Eligible studies were independently appraised by two authors using the Critical Appraisal Skills Program checklist. For the purpose of narrative review, relevant studies were included irrespective of methodology or level of evidence.ResultsThirty-four of the 103 (48 PubMed and 55 EMBASE) results yielded by the preliminary search were included. Exclusions included three duplicate records, six letters, 17 non-orthopaedics related studies and four records irrelevant to our search topic. The CASP appraisal confirmed a satisfactory standard of 31 studies. They all had clearly defined objectives, were well designed and conducted appropriately to meet them. The published studies reported the use of BMAC in non-union and fracture healing (15 studies), bone defects (nine studies), spine fusion (two studies), distraction osteogensis (two studies) and complications related to the use of BMAC (seven studies).ConclusionsStem cells found in BMAC have the potential to self-renew, undertake clonal expansion and differentiate into different musculoskeletal tissues. The commercial processing of BMAC needs to be optimized in order to achieve a consistent end product, which will provide predicable and translatable results. The future potential of cell characterization in order to determine the optimum cell for repair/regeneration of bone also needs to be explored. Level of Evidence: Systematic Review of minimum level IV studies.

A systematic review of the concept and clinical applications of bone marrow aspirate concentrate in tendon pathology

Tendon pathologies are a group of musculoskeletal conditions frequently seen in clinical practice. They can be broadly classified into traumatic, degenerative and overuse-related tendinopathies. Rotator cuff tears, Achilles tendinopathy and tennis elbow are common examples of these conditions. Conventional treatments have shown inconsistent outcomes and might fail to provide satisfactory clinical improvement. With the growing trend towards the use of mesenchymal stem cells (MSCs) in other branches of medicine, there is an increasing interest in treating tendon pathologies using the bone marrow MSC. In this article, we provide a systematic literature review documenting the current status of the use of bone marrow aspirate concentrate (BMAC) for the treatment of tendon pathologies. We also asked the question on the safety of BMAC and whether there are potential complications associated with BMAC therapy. Our hypothesis is that the use of BMAC provides safe clinical benefit when used for the treatment of tendinopathy or as a biological augmentation of tendon repair. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist while preparing this systematic review. A literature search was carried out including the online databases of PubMed, EMBASE, ClinicalTrial.gov and the Cochrane Library from 1960 to the end of May 2015. Relevant studies were selected and critically appraised. Data from eligible studies were extracted and classified per type of tendon pathology. We included 37 articles discussing the application and use of BMAC for the treatment of tendon pathologies. The Critical Appraisal Skills Program (CASP) appraisal confirmed a satisfactory standard of 37 studies. Studies were sub-categorised into: techniques of extraction, processing and microscopic examination of BMAC (n = 18), where five studies looked at the evaluation of aspiration techniques (n = 5), augmentation of rotator cuff tears (n = 5), augmentation of tendo-achilles tendon (n = 1), treatment of gluteal tendon injuries (n = 1), management of elbow epicondylitis (n = 2), management of patellar tendinopathy (n = 1) and complications related to BMAC (n = 5). Multiple experimental studies investigated the use of BMAC for tendon repair; nonetheless, there are only limited clinical studies available in this field. Unfortunately, due to the scarcity of studies, which were mainly case series, the current level of evidence is weak. We strongly recommend further future randomised controlled studies in this field to allow scientists and clinicians make evidence-based conclusions.

Current concepts in locking plate fixation of proximal humerus fractures

Despite numerous available treatment strategies, the management of complex proximal humeral fractures remains demanding. Impaired bone quality and considerable comorbidities pose special challenges in the growing aging population. Complications after operative treatment are frequent, in particular loss of reduction with varus malalignment and subsequent screw cutout. Locking plate fixation has become a standard in stabilizing these fractures, but surgical revision rates of up to 25% stagnate at high levels. Therefore, it seems of utmost importance to select the right treatment for the right patient. This article provides an overview of available classification systems, indications for operative treatment, important pathoanatomic principles, and latest surgical strategies in locking plate fixation. The importance of correct reduction of the medial cortices, the use of calcar screws, augmentation with bone cement, double-plate fixation, and auxiliary intramedullary bone graft stabilization are discussed in detail.

Therapy-resistant nephrolithiasis following renal artery coil embolization

BackgroundTranscatheter renal artery embolization is an effective and minimally invasive treatment option for acute renal bleeding. Early post-interventional complications include groin hematoma, incomplete embolization, coil misplacement and coil migration. Late complications are rare and mostly related to coil migration.Case presentationA 22-year-old woman with a history of recurrent stone disease and a lumbal meningomyelocele underwent bilateral open pyelolithotomy for bilateral staghorn calculi. Post-operatively, acute hemorrhage of the left kidney occurred and selective arterial coil embolization of a lower pole interlobular renal artery was performed twice.Four years after this intervention the patient presented with a new 15.4 mm stone in the lower calyx of the left kidney. After two extracorporeal shock wave lithotripsy treatments disintegration of the stone was not detectable. Therefore, flexible ureterorenoscopy was performed and revealed that the stone was adherent to a partially intraluminal metal coil in the lower renal calyx. The intracalyceal part of the coil and the adherent stone were successfully removed using the holmium laser.ConclusionTherapy-resistant nephrolithiasis was caused by a migrated metal coil, which was placed four years earlier for the treatment of acute post-operative renal bleeding. Renal coils in close vicinity to the renal pelvis can migrate into the collecting system and trigger renal stone formation. Extracorporeal shock wave lithotripsy seems to be inefficient for these composite stones. Identification of these rare stones is possible during retrograde intrarenal surgery. It also enables immediate stone disintegration and removal of the stone fragments and the intraluminal coil material.

Compressive Stockings After Hindfoot and Ankle Surgery

Background: Swelling and pain are common after foot and ankle procedures. We hypothesized that compressive stockings (CS) treatment after hindfoot surgery would positively influence patient outcomes. Methods: We undertook this randomized controlled trial in 87 consecutive patients to analyze the clinical effect of CS after hindfoot and ankle surgery and evaluate CS-wearing compliance using sensors that were implanted into CS. Ankle swelling, pain status, quality of life (SF-36 score), and the American Orthopaedic Foot & Ankle Score (AOFAS) were set as the primary end points. The CS wearing time in hours and percentage were investigated as the secondary end points. All participants with CS (group I) were informed about the implanted sensor after the CS were taken off. A subgroup analysis of group I was performed to detect differences between patients with high vs low compliance. Results: At 12 weeks, the results of ankle swelling (mean 234 mm in group I and 232 mm in group II), pain in the visual analog scale (1.7 group I vs 1.9 in group II), the SF-36 score (38 points in group I vs 30 points in group II), and the AOFAS score (a mean of 76 points in both groups) showed no statistical differences between the 2 groups. The mean wearing time was 136 (range, 0-470) hours, which corresponds to a compliance rate of 65%. Sixteen participants had high compliance (>80%, >170 hours), and 21 patients had low or noncompliance. The clinical results of patients with high wearing compliance were not significantly better compared to the results of patients with low compliance. Conclusion: CS therapy after ankle and hindfoot surgery was associated with a low wearing compliance and did not influence ankle swelling, function, pain, and the quality of life compared to the control group. Furthermore, the clinical results of patients with high compliance were not better compared to the results of patients with low or noncompliance wearing behavior. Level of Evidence: Level II, prospective randomized study of lower quality.

Mechanical properties of Triclosan sutures: MECHANICAL PROPERTIES OF TRICLOSAN SUTURES

To avoid infections and wound healing disorders, Triclosan coated sutures have been invented. Little is known of these sutures regarding their tensile properties. Three different Triclosan coated sutures (Vicryl 1 plus, PDS 0 plus, Monocryl 3‐0 plus) were tested at several time points over 42 days regarding load to failure, strain, and stiffness compared to their non‐coated versions (Vicryl 1, PDS 0, Monocryl 3‐0). Four different measurement points were made. Suture loops were fixed in a material testing machine over two metal bars which were moved apart creating a stress to the fiber. Unpaired, two‐tailed t‐test were performed for each group (untreated and treated) while level of significance was defined at a level of p < 0.05. Vicryl 1 was significantly stronger on day 14 than Vicryl 1 plus (p = 0.033). On day 28, significant changes were found in PDS 0 which was weaker compared to PDS 0 plus (p = 0.039) and Vicryl 1 which was stronger than Vicryl 1 plus (p = 0.032). We have seen that Vicryl 1 plus sutures are significantly weaker according to loading to failure after 14 and 28 days, which might cause incisional hernias. PDS 0 sutures are used to reconstruct tendons, therefore a longer durableness might be of interest as re‐ruptures of tendons are problematic. Our in vitro findings support, the use of Triclosan coated PDS plus sutures and Vicryl sutures as they show a longer resistance.

Erratum to: Staged Revision With Antibiotic Spacers for Shoulder Prosthetic Joint Infections Yields High Infection Control

Background The treatment of periprosthetic joint infection (PJI) of the shoulder with two-stage revision arthroplasty using an antibiotic-loaded cement spacer is established strategy, but there is sparse information regarding the likelihood of infection control and restoration of shoulder. Questions/Purpose (1) What is the likelihood of infection control after two-stage revision using an antibiotic cement spacer for patients with PJI of the shoulder? (2) What are the improvements in Constant and Murley scores at 2 years after these staged revisions? Patients and Methods Between 2000 and 2013, we treated 48 patients with PJI of the shoulder using two-stage revision including an antibiotic-containing cement spacer during the first stage. Of those, 38 (79%) were available for review at a minimum of 24 months (mean, 52 ± 34 months). Ten patients (21%) were excluded because they were deceased (n = 3), moved abroad (n = 4), or refused followup (n = 3), leaving 38 for analysis in this retrospective study. During the first stage, removal of the prosthesis, débridement, and implantation of a gentamicin and vancomycin-filled cement spacer were performed by four different surgeons followed by antibiotic therapy (2 weeks intravenous plus 10 weeks oral). For the second stage, we generally tried a reverse total shoulder arthroplasty (RTSA; n = 26). In case of severe glenoid destruction, hemiarthroplasty (HA; n = 8) was used as a salvage option. In 14 patients the cement spacer was left in place because the patients refused further surgery or were not operable owing to medical reasons. The primary outcome included the proportion of patients achieving infection control 2 years after the second-stage procedure after implantation of the cement spacer. Infection control was determined as the absence of the Musculoskeletal Infection Society PJI criteria. The clinical outcome assessed with the Constant and Murley scores served as the secondary outcome parameter. A subgroup (RTSA; HA, spacer retention) analysis of the Constant and Murley scores was performed. Results Successful infection control was achieved in 36 of 38 patients (95%). Patients who underwent treatment with a cement spacer had increased Constant and Murley scores at latest followup compared with their pretreatment scores (mean ± SD, 27 ± 19 versus 43 ± 20; mean difference, 17; 95% CI, 10-24; p = 0.001). For patients who underwent staged treatment followed by second-stage RTSA (n = 23), the Constant and Murley scores increased (mean ± SD, 31 ± 20 versus 51 ± 20; mean difference, 20; 95% CI, 11-30; p = 0.001). The Constant and Murley scores did not improve in patients who underwent HA (mean ± SD, 22 ±15 versus 24 ± 90; mean difference, 3; 95% CI, -10 to 16; p = 0.509) or who retained the spacer (mean ± SD, 18 ±12 versus 35 ±10; mean difference, 19; 95% CI, -5 to 44; p = 0.093). Conclusion Revision arthroplasty using an antibiotic-loaded cement spacer provided successful infection control in patients with periprosthetic shoulder infections in this small, retrospective series. Functional improvement was obtained after reimplantation of a reverse total shoulder prosthesis but was not seen after HA and cement spacer; however, baseline differences among patient groups very likely contributed to these differences, and they should not be attributed to implant selection alone. Level of evidence Level III, therapeutic study.

Perioperative Use of Anticoagulant and Platelet-inhibiting Medications for Elective Spine Surgery: Results of a Nationwide Survey

Abstract Background and Study Aims Perioperative use of anticoagulant and platelet‐inhibiting agents by patients undergoing spine surgery poses the dilemma of increased risk of hemorrhage. We examined the standards of use for these medications and expert opinions through a nationwide survey. Materials and Methods An online‐based survey was conducted by invitation. A personal token to access the survey was sent to one representative of each neurosurgical and orthopaedic unit performing spine surgery and to all other active members of the Swiss Society of Neurosurgery and the Swiss Society of Spinal Surgery. A total of 97 e‐mail invitations were sent to 19 representatives of neurosurgical or orthopaedic units and 78 registered neurosurgeons and orthopaedic surgeons who potentially perform spine surgery. Results From February to April 2016, 40 surgeons (26 neurosurgeons, 14 orthopaedic surgeons) completed the survey (41%). Among the respondents, 55% prescribed prophylactic heparin preoperatively; depending on the procedure, 83 to 95% prescribed heparin postoperatively. Depending on the type of surgery, 23 to 48% discontinued acetylic acid preoperatively, and 80 to 87% always discontinued clopidogrel preoperatively. On average, platelet inhibition was resumed 4 ± 2.5 days postoperatively. Orthopaedic surgeons recommenced platelet inhibition earlier than neurosurgeons (p = 0.013). Anticoagulation with rivaroxaban was discontinued 3 ± 2 days before surgery. Depending on the indication, 72 to 98% of respondents temporarily replaced traditional anticoagulation therapy (vitamin K antagonists) with heparin perioperatively. Conclusion Administration and discontinuation of anticoagulant and platelet‐inhibiting medications in the perioperative setting of spinal surgery differ vastly between different units and surgeons. Recommendations from the spine surgeon societies may be helpful to develop nationwide guidelines.