Titanium as the leading implant material in locked plating is challenged by polymers such as carbon fiber-reinforced polyetheretherketone (CFR-PEEK), which became the focus of interest of researchers and manufacturers in recent years. However, data on human tissue response to these new implant materials are rare. Osteosynthesis plates and peri‑implant soft tissue samples of 16 healed proximal humerus fractures were examined (n = 8 CFR-PEEK, n = 8 titanium). Soft tissue was analyzed by immunohistochemistry and µCT. The entrapped foreign bodies were further examined for their material composition by FTIR. To gain insight into their origin and formation mechanism, explanted and new plates were evaluated by SEM, EDX, profilometry and HR-CT. In the peri‑implant soft tissue of the CFR-PEEK plates, an inflammatory tissue reaction was detected. Tissues contained foreign bodies, which could be identified as tantalum wires, carbon fiber fragments and PEEK particles. Titanium particles were also found in the peri‑implant soft tissue of the titanium plates but showed a less intense surrounding tissue inflammation in immunohistochemistry. The surface of explanted CFR-PEEK plates was rougher and showed exposed and broken carbon fibers as well as protruding and deformed tantalum wires, especially in used screw holes, whereas scratches were identified on the titanium plate surfaces. Particles were present in the peri‑implant soft tissue neighboring both implant materials and could be clearly assigned to the plate material. Particles from both plate materials caused detectable tissue inflammation, with more inflammatory cells found in soft tissue over CFR-PEEK plates than over titanium plates. STATEMENT OF SIGNIFICANCE: Osteosynthesis plates are ubiquitously used in various medical specialties for the reconstruction of bone fractures and defects and are therefore indispensable for trauma surgeons, ENT specialists and many others. The leading implant material are metals such as titanium, but recently implants made of polymers such as carbon fiber-reinforced polyetheretherketone (CFR-PEEK) have become increasingly popular. However, little is known about human tissue reaction and particle generation related to these new implant types. To clarify this question, 16 osteosynthesis plates (n = 8 titanium and n = 8 CFR-PEEK) and the overlying soft tissue were analyzed regarding particle occurrence and tissue inflammation. Tissue inflammation is clinically relevant for the development of scar tissue, which is discussed to cause movement restrictions and thus contributes significantly to patient outcome.

Background Open reduction and internal fixation (ORIF) of humeral head split fractures is challenging because of high instability and limited visibility. The aim of this retrospective study was to investigate the extend of the approach through the rotator interval (RI) on the reduction quality and functional outcome. Methods 37 patients (mean age: 59  ±  16 years,16 female) treated by ORIF through a standard deltopectoral (DP) approach were evaluated. The follow-up period was at least two years. In 17 cases, the approach was extended through the RI. Evaluation was based on radiographs, Constant scores (CS) and DASH scores. Results In group DP, “anatomic” reduction was achieved in 9 cases (45%), “acceptable” in 5 cases (25%), and “malreduced” in 6 cases (30%). In group RI, “anatomic” reduction was seen in 12 cases (71%), “acceptable” in 5 cases (29%), and “malreduced” in none (p  =  0.04). In the DP group, the CS was 60.2  ±  16.2 and the %CS was 63.9  ±  22.3, while in the RI group, the CS was 74.5  ±  17.4 and the %CS was 79.1  ±  24.1 (p  =  0.07, p  =  0.08). DASH score was 22.8  ±  19.5 in DP compared to RI: 25.2  ±  20.6 (p  =  0.53). Conclusions The RI approach improves visualization as it enhances quality of fracture reduction, however functional outcomes may not differ significantly. Type of study and level of proof Retrospective, level III

Abstract Background Posttraumatic shoulder stiffness remains a problem after proximal humerus fracture (PHF) despite good healing rates. The aim of this pilot study was to determine whether the implant material and overlying soft tissue have an effect on shoulder range of motion (ROM) before and after implant removal (IR). Methods 16 patients (mean age 55.2 ± 15.3 (SD) years; 62.5% female) were included who underwent operative treatment with locking plates of either carbon fiber reinforced Polyetheretherketone (PEEK) (PEEKPower® humeral fracture plate, Arthrex, Naples, Florida, USA, n = 8) or titanium alloy (Ti) (Philos®, DePuy Synthes, Johnson & Johnson Medical, Raynham, Massachusetts, USA, n = 8) for PHF. All patients presented with a limited ROM and persistent pain in everyday life after the fracture had healed, whereupon IR was indicated. ROM before and after IR were compared as well as the Constant Score (CS) and the CS compared to the contralateral shoulder (%CS) 1 year after IR. Results In group PEEK, elevation was 116.3° ± 19.2° pre- and 129.4° ± 23.7° post-IR (p = 0.027). External rotation was 35.0° ± 7.6° pre- and 50.6° ± 21.8° post-IR (p = 0.041). External rotation with the humerus abducted 90° was 38.8° ± 18.1° pre- and 52.5° ± 25.5° post-IR (p = 0.024). In group Ti, elevation was 110.0° ± 34.6° pre- and 133.8° ± 31.1° post-IR (p = 0.011). External rotation with the humerus at rest was 33.8° ± 23.1° pre- and 48.8° ± 18.7° post-IR (p = 0.048). External rotation with the humerus abducted 90° was 40.0° ± 31.6° pre- and 52.5° ± 22.5° post-IR (p = 0.011). Comparison of the two implant materials showed no significant difference. The overall CS was 90.3 ± 8.8, the %CS was 91.8% ± 14.7%. Conclusion There was no significant difference in ROM, CS and %CS with respect to plate materials, although lower cell adhesion is reported for the hydrophobic PEEK. However, all patients showed improved functional outcomes after IR in this pilot study. In patients with shoulder stiffness following locked plating for PHF, implants should be removed and open arthrolysis should be performed, independently from the hardware material. Level of evidence II

Die demographische Entwicklung führt zu einer Zunahme hochbetagter Patienten, die aufgrund niedrigenergetischer Traumata, z. B. eines Stolpersturzes, in der unfallchirurgischen Notaufnahme behandelt werden. Diese leichten Unfälle führen oft zu Fragilitätsfrakturen, die klassisch im Bereich des proximalen Humerus, des distalen Radius, der Wirbelsäule, des Beckens sowie hüftgelenknah lokalisiert sind. Vorerkrankungen, Polypharmazie und eine allgemeine Gebrechlichkeit erhöhen das Risiko für Fragilitätsfrakturen in diesem Patientenkollektiv. Oft können alterstraumatologische Frakturen und insbesondere Insuffizienzfrakturen des hinteren Beckenrings mittels Röntgenuntersuchung nur schwer oder nicht diagnostiziert werden. Deshalb sollte bei alterstraumatologischen Patienten zur sicheren Beurteilung einer fraglichen Fraktur frühzeitig eine Schnittbildgebung, z. B. eine Computertomographie (CT), eine Dual-Energy-CT (DECT) oder eine Magnetresonanztomographie (MRT), erwogen werden. Hierdurch lassen sich auch ältere Frakturen abgrenzen. Insbesondere bei kognitiv eingeschränkten älteren Patienten, erschwerten Untersuchungsbedingungen oder einem unklaren Sturzereignis sollte eine frühzeitige Indikation zur Schnittbildgebung gestellt werden. Diese kann aber auch Risiken beinhalten, z. B. im Rahmen von Untersuchungen mit Kontrastmittel bei eingeschränkter Nierenfunktion, sodass individuell abgewogen werden muss. Ferner sind die Diagnose und Therapie der Osteoporose, die als Grunderkrankung zu Fragilitätsfrakturen führt, von besonderer Bedeutung. In der Diagnostik ist die Knochendichtemessung mittels Dual Energy X‑ray Absorptiometry (DXA) die Standardmethode gemäß Leitlinie. Für einzelne Fragestellungen kann auch eine hochauflösende periphere quantitative CT (HR-pQCT) zur Anwendung kommen. Um Fragilitätsfrakturen trotz aller Herausforderungen richtig zu erfassen und rasch eine adäquate Therapie einleiten zu können, ist eine gute Zusammenarbeit zwischen Radiologen und Unfallchirurgen notwendig.

Background Due to our ageing population, the number of elderly patients who are treated in the emergency department due to low-energy trauma (e.g., tripping) continues to rise. These minor accidents often result in fragility fractures classically located in the proximal humerus, distal radius, spine, pelvis, and near the hip joint. Pre-existing conditions, polypharmacy, and general frailty increase the risk of fragility fractures in this patient population. Methods Geriatric trauma fractures and especially insufficiency fractures of the posterior pelvic ring are often difficult to diagnose by plain X-ray. Therefore, in geriatric trauma patients, cross-sectional imaging, e.g., computed tomography (CT), dual-energy CT (DECT), or magnetic resonance imaging (MRI), should be considered early for reliable evaluation of a suspected fracture. This also allows for the identification of older fractures. Particularly in cognitively impaired elderly patients, difficult examination conditions or an unclear fall event, cross-sectional imaging is often indicated. However, this may also involve risks, e.g., use of contrast medium in patients with impaired renal function, so that each case must be considered individually. Furthermore, the diagnosis and treatment of osteoporosis, which is an underlying disease that leads to fragility fractures, is of particular importance. In the diagnostic workup, measurement of bone density using dual energy X-ray absorptiometry (DXA) is the standard method according to guidelines. In specific situations, high-resolution peripheral quantitative CT (HR-pQCT) may also be used. Conclusion Due to the special challenges of correctly detecting fragility fractures and being able to quickly initiate adequate therapy, good cooperation between radiologists and trauma surgeons is necessary.

The reconstruction of large osteochondral defects is still a challenge in musculoskeletal surgery. Fresh frozen allografts are a frequently used resource for the treatment of such tissue defects. Furthermore, 3D-printed models enable multiple options in the preoperative planning and intraoperative adaptation of the allografts, so that healing is optimal and the best functional outcome for the patient is achieved.

Background: The aim of this study was to evaluate functional outcomes in patients with varus malposition following open reduction and internal fixation of displaced proximal humeral fractures. Methods: Data of 685 patients with a mean age of 67 +/- 15.8 years (67% female), that were treated by open reduction and internal fixation for a displaced proximal humeral fracture at a level 1 trauma center, were analyzed. On standardized x-ray imaging, the degree of varus displacement was measured over a minimum of two years follow-up and patients were divided into three groups. Group A: anatomic or <10 degrees of varus or valgus malposition, group B: 10-20 degrees of varus malposition and group C: >20 degrees varus malposition, while anatomic head-shaft-angle was defined 135 degrees The groups were compared with regards to functional outcomes by means of the Constant Score (CS). Results: In 565 patients with anatomic to minor <10 degrees varus or valgus malposition (Group A), the mean CS was 72.5 +/- 18.8 points. The %CS to the uninjured side was 87.2 +/- 24.1 and the age and gender normalized nCS was 84.7 +/- 21.7. In comparison, in group B (10-20 degrees varus) the mean CS was 64.7 +/- 16.9, the mean %CS was 84.5 +/- 18.3 and the mean nCS was 76.2 +/- 20.6. In group C (>20 degrees varus) the mean CS was 54.1 +/- 19.5, the mean was %CS: 72.3 +/- 26.4 and the mean nCS was 64.8 +/- 23.8 (p = 0.02, p = 0.03, p = 0.01). Overall, the CS, %CS and nCS correlated significantly with the degree of varus position (Pearson correlation, r = 0.23, r = 0.21, r = 0.25). Conclusion: Varus malposition is related to inferior functional outcomes compared to anatomic healing in patients treated by open reduction and internal fixation for proximal humeral fractures. The data supports suggestions to prevent varus malposition in open reduction and internal fixation. In severe >20 degrees of varus malposition, revision surgery should be considered. (C) 2020 Elsevier Ltd. All rights reserved.

Fragestellung Ziel dieser prospektiv randomisierten Studie war der Vergleich der winkelstabilen Plattenosteosynthese mit PMMA-Schraubenspitzenaugmentation versus den multiplanaren Verriegelungsmarknagel in der Versorgung von 2 Segment-Frakturen des proximalen Humerus beim älteren Patienten.

Injuries of the extremities, occurring as isolated or combined injuries, influence functional outcome and are relevant for quality of life. They play a key role in the context of polytrauma. Neurovascular, bony, or soft tissue damage may lead to a complex injury pattern requiring defined treatment structures. Surgical and radiological experience during the initial emergency room treatment is crucial to assess the injury and plan an interdisciplinary emergency treatment. Whereas control of bleeding and immobilization take place during the prehospital phase, emergency room treatment is the first step toward reconstruction; thus, the injuries are assessed and treated in an interdisciplinary manner. Although the influence of extremity trauma on mortality has decreased in recent years and the hemodynamic instability in patients generally arises from other injuries, focusing and structured treatment of extremity trauma is immanent to achieve good life quality and functional results with return to work and sport.

Verletzungen der Extremitäten kommt isoliert wie in Kombination eine wesentliche Bedeutung für das funktionelle Outcome und die Lebensqualität zu, zudem haben sie einen relevanten Einfluss auf die Gesamtverletzungsschwere des polytraumatisierten Patienten. Sie stellen durch neurovaskuläre, knöcherne oder Weichgewebebeteiligungen zuweilen ein Komplexbild dar, dessen Beurteilung und Behandlung definierte Voraussetzungen benötigt. Die Schockraumphase ist dahingehend von großer Bedeutung, dass hier sowohl die notwendige chirurgisch-interventionelle Expertise vorhanden als auch die radiologische Darstellbarkeit der Verletzungen gegeben ist. Sind Maßnahmen wie die erste Blutungskontrolle und Immobilisation präklinische Aufgaben, werden im Schockraum die ersten Weichen für eine Rekonstruktion gestellt und die Verletzungen interdisziplinär beurteilt und versorgt. Auch wenn der Einfluss von Extremitätenverletzungen auf die Mortalität in den letzten Jahrzehnten deutlich abgenommen hat und instabile Patientenzustände meist von anderen Verletzungen herrühren, ist die Fokussierung und Adressierung verletzter Extremitäten im Schockraum unter Berücksichtigung des Ziels einer hohen Lebensqualität mit Rückkehr in den Alltag, Beruf und Sport unverzichtbar.

ZusammenfassungDie Rekonstruktion großer osteochondraler Defekte stellt nach wie vor eine Herausforderung in der muskuloskeletalen Chirurgie dar. Frisch gefrorene Allografts sind eine häufig genutzte Ressource für die Behandlung solcher Gewebedefekte. Darüber hinaus ermöglichen 3D-gedruckte Kunststoffmodelle vielfältige Optionen in der präoperativen Planung und bei der intraoperativen Anpassung der Transplantate, sodass sie optimal einheilen und das bestmögliche funktionelle Ergebnis für den Patienten erreicht wird.

Using tetrastarch for fluid resuscitation after a severe trauma injury may increase risks of death and acute kidney injury. The importance of tetrastarch dose, however, is unknown. A retrospective observational study was performed in two trauma centres using data on type and amount of fluids (balanced crystalloids or tetrastarch) used for pre- and acute in-hospital shock management. We evaluate independent associations between the relative and absolute volumes of tetrastarch and 90-day survival time or the frequency of severe acute kidney failure (AKF). We studied 271 patients who had sustained a severe blunt trauma injury (average predicted mortality according to the Revised Injury Severity Classification Score (RISC) 15.1 ± 1.4% [mean, standard deviation]), and who had required more than 2 days of intensive care therapy. In all, 75.3% of patients had received tetrastarch with a crystalloid/colloid ratio of 2.93 ± 2.60. The 90-day mortality was 11.1%, and 7.8% of the patients developed severe AKF. After adjusting for confounders, we found a U-shaped, nonlinear association between absolute or relative volumes of tetrastarch and survival time (p = 0.003 and 0.025, respectively). Optimal relative volumes of tetrastarch approximately ranged from 20 to 30% of total fluids. Giving less than about 1000 ml, or more than about 2000 ml tetrastarch was significantly associated with an increased risk of developing severe AKF (p = 0.023). There was a complex U‑shaped association between the tetrastarch dose and morbidity/mortality of patients after a severe trauma injury. The optimal crystalloid/tetrastarch ratio for acute shock management appears to range from about 2.5 to 4.0.