Der richtige Zugang zum Schultergelenk ist entscheidend für eine suffiziente Frakturversorgung und korrekte Implantation einer Endoprothese, aber gleichzeitig auch für das Management der Weichteile, was gerade im Bereich der Endoprothetik einen entscheidenden Einfluss auf die spätere Funktion der Schulter hat. So kann ein ungünstiger Zugang die Frakturversorgung oder Implantation einer Prothese erheblich erschweren bis unmöglich machen oder aufgrund der Schädigung der Muskulatur oder insuffizienter Refixationsmöglichkeit der Sehnen zu starken Bewegungseinschränkungen und reduzierter Kraft des Armes führen. Zum Erreichen eines optimalen Ergebnisses ist eine entsprechende Planung der Operation erforderlich, um einen geeigneten Zugang für die erforderlichen operativen Maßnahmen zu wählen. Abhängig von der geplanten Operation muss der Zugang eine vollständige Darstellung des Humeruskopfes, aber auch gegebenenfalls des Glenoides bieten. Er muss bei Implantation einer Prothese eine achsgerechte Fräsung des Glenoides und anatomische Prothesenpositionierung zulassen. Gleichzeitig dient er der Beseitigung etwaiger bestehender Kontrakturen, wobei es sich in den meisten Fällen um eine Innenrotationskontraktur handelt.

Postoperative cognitive dysfunction (POCD) occurs in up to 26

PurposeIf surgery is indicated for elderly patients suffering a proximal humerus fracture, reverse fracture arthroplasty became the preferred type of treatment due to its good and reliable outcomes over the last decade. Surgeons could choose from a wide range of implants and up to now there was no evaluation, if a change of the manufacturer affects patients` outcome.MethodsThe last 100 patients before and the first 100 after manufacturer change in reverse fracture arthroplasty were evaluated at a level one trauma center, all treated by only 3 senior shoulder surgeons. Clinical as well as radiographic outcome parameters were assessed, perioperative up to 24 months after surgery.ResultsMean age in both groups was nearly 80 years with comparable distribution of gender and comorbidities. A trend to shorter duration of surgery was observed after the change, mainly according to an uncemented fixation of the stem. During follow-up no significant differences, beneficial as well as negative, could be observed regarding clinical and radiographic outcome.ConclusionA manufacturer change on the fly is possible without negative consequences for patients` outcome. Expertise of the whole OR-team as well as standardized training with the new implant seems to be a more important factor than a specific type of implant.

Abstract Background Patient-specific aiming devices (PSAD) may improve precision and accuracy of glenoid component positioning in total shoulder arthroplasty, especially in degenerative glenoids. The aim of this study was to compare precision and accuracy of guide wire positioning into different glenoid models using a PSAD versus a standard guide. Methods Three experienced shoulder surgeons inserted 2.5 mm K-wires into polyurethane cast glenoid models of type Walch A, B and C (in total 180 models). Every surgeon placed guide wires into 10 glenoids of each type with a standard guide by DePuy Synthes in group (I) and with a PSAD in group (II). Deviation from planned version, inclination and entry point was measured, as well as investigation of a possible learning curve. Results Maximal deviation in version in B- and C-glenoids in (I) was 20.3° versus 4.8° in (II) (p < 0.001) and in inclination was 20.0° in (I) versus 3.7° in (II) (p < 0.001). For B-glenoid, more than 50% of the guide wires in (I) had a version deviation between 11.9° and 20.3° compared to ≤ 2.2° in (II) (p < 0.001). 50% of B- and C-glenoids in (I) showed a median inclination deviation of 4.6° (0.0°-20.0°; p < 0.001) versus 1.8° (0.0°-4.0°; p < 0.001) in (II). Deviation from the entry point was always less than 5.0 mm when using PSAD compared to a maximum of 7.7 mm with the standard guide and was most pronounced in type C (p < 0.001). Conclusion PSAD enhance precision and accuracy of guide wire placement particularly for deformed B and C type glenoids compared to a standard guide in vitro. There was no learning curve for PSAD. However, findings of this study cannot be directly translated to the clinical reality and require further corroboration.

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.

Hand and forearm injuries are the most frequent reason for consultations in German emergency departments. Therefore, full recovery has a high social and economic relevance. In this study, data on surgically treated hand injuries in a regional German trauma centre between 01.01.2019 and 31.01.2021 were collected using the new German HandTraumaRegister of the German Society for Hand Surgery. These data were retrospectively analysed and correlated with mobility data of the Bavarian population, the 7-day incidence of Covid-19 infections in Germany and the number of elective hand surgeries. We found that a fall from standing height with consecutive distal radius fracture was the most common injury in women, whereas mechanism of injury and diagnosis were more diverse in men. The populations' mobility correlated well with the number of accidents, which in turn was reciprocal to the 7-day-incidence of Covid-19 infections. The number of elective hand surgeries expectedly dropped significantly during the state-imposed lockdowns. Knowing that mainly young men and elderly women suffer from hand injuries, tailored prevention measures may be elaborated. In order to reduce socioeconomic burden, care for hand injuries and elective hand surgeries must be guaranteed according to the frequency of their occurrence.

Introduction: The aim of this study was to create a novel complication classification for osteosynthesis-related complications following angular stable plating of the proximal humerus subsuming the influence of these complications on clinical outcome in relation to fracture morphology and consequent revision strategies. A total of 1047 proximal humerus fractures with overall 193 osteosynthesis-associated complications (24.5%) were included. The following complication types could be clarified: complication Type 1 is defined by mild varus (<20°) or valgus displacement of the humeral head without resulting in a screw cutout through the humeral head cortex. Type 2a is defined by varus displacement (<20°) of the humeral head associated with screw cutout through the humeral head cortex. Type 2b complication is limited to displacement of the greater tuberosity, lesser tuberosity, or both tuberosities. Complication Type 2c is defined by severe varus dislocation (>20°) of the humeral head with screw cutout at the humeral head cortex. Complication Type 3 describes a displacement of the angular stable plate in the humeral shaft region with associated shaft-sided screw cutout, while the position of the humeral head remains static. Complication Type 4 is characterized by the occurrence of AVN with or without glenoidal affection (4a/b). Clinical outcome according to the constant score was mainly affected by type 2–4, leading to a deteriorated result. Depending on the type of complication, specific revision strategies can be considered. Additionally, more complex fracture patterns fostered the incidence of complications.

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

BACKGROUND:The best surgical management of displaced proximal humeral fractures remains a matter of considerable debate. This study presents mid-term functional outcome (median 4 years) after locking plate osteosynthesis for displaced proximal humeral fractures. METHODS:Between February 2002 and December 2014 1031 patients with 1047 displaced proximal humeral fractures were treated by open reduction and locking plate fixation with the same implant and received consecutive prospective follow up at least 24 months after surgical treatment. Clinical follow-up consisted of Constant Murley score (CS), Disabilities of the Arm, Shoulder and Hand score (DASH), and Short Form 36 questionnaire (SF-36). Complete follow-up could be performed in 557 (53.2%) cases, with a mean follow-up of 4.0 ± 2.7 years. RESULTS:Of 557 patients (67% women; mean age at time of osteosynthesis: 68.3 ± 15.5 years) absolute CS of all patients 4 ± 2.7 years after surgery was 68.4 ± 20.3 points. Normalized CS according to Katolik was 80.4 ± 23.8 points, and CS in percentage to the contralateral side (%CS) was 87.2 ± 27.9%. DASH score was at 23.8 ± 20.8 points. Osteosynthesis related complications (secondary displacement, screw cutout, avascular necrosis (n = 117 patients) were associated with lower functional scores (mean CS was 54.5 ± 19.0 p.; nCS 64.5 ± 22.9 p.;%CS 71.2 ± 25.0%; DASH score 31.9 ± 22.4 p.). The SF 36 was 66.5 points in the case cohort and a vitality mean of 69.4 points. Patients with a complication showed lower results (SF 36 56.7; vitality mean 64.9 points). CONCLUSIONS:Overall, patients following locking plate osteosynthesis of displaced proximal humeral fractures showed good to moderate outcomes four years after surgery. Mid-term functional outcomes correlate significantly with those at 1 year postoperatively. Furthermore, there is a significant negative correlation of midterm functional outcome with the occurrence of complications. LEVEL OF EVIDENCE:Level III, prospective nonconsecutive patients.

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

in den letzten Jahren haben wir einen rasanten Zugewinn wissenschaftlicher Erkenntnisse zum Thema Sehnenverletzungen an der Schulter erlebt. Er beeinflusst unser Verständnis der pathophysiologischen Grundlagen und ermöglicht die Weiterentwicklung einer zielgerichteten Diagnostik sowie moderner konservativer und operativer Therapieoptionen. Anlass genug, Sehnenverletzungen an der Schulter in einem eigenen Leitthema zu beleuchten! Sehnenpathologien an der Schulter umfassen ein breites Spektrum und betreffen sowohl junge wie auch alte Menschen. Wenngleich die Schulter auf unterschiedlichste Art Schaden nehmen kann, lassen sich doch typische Sehnenpathologien immer wieder beobachten. Dazu zählen Verletzungen der langen Bizepssehne (LBS) und Risse der Rotatorenmanschette (RM). Intrinsische Mechanismen der Sehnenschädigung lassen sich von extrinsischen Auslösern (mechanischer Reizung) unterscheiden. Einigen Sehnenpathologien liegen spezifische Bewegungsabläufe zugrunde, wie z.B. die Wurfausholbewegung beim Überkopfsportler oder die händische Tätigkeit bei abduzierterArmposition.Währendbeim jungen Patienten zwischen repetitiven Mikrotraumen und einem einzeitigen Makrotrauma meist unterschieden werden kann, liegt beim älteren Patienten häufiger eine Kombination aus akuter Verletzung der chronisch vorgeschädigten Sehne vor. Vollständige Sehnenrupturen scheinen dabei in einem relevanten Anteil aus Partialrupturen hervorzugehen, was bedeutsam für das therapeutische Vorgehen ist. Bei der Behandlung von Sehnenverletzungen an der Schulter müssen deshalb die Anamnese und das biologische Potenzial der Sehne berücksichtigt werden. Sehnenverletzungen an der Schulter verlaufen mitunter asymptomatisch, komplexe Rupturen beeinträchtigen aber häufig die motorische, zentrierende bzw. stabilisierende Funktion und führen dadurch zu Schmerzen, Bewegungsund Krafteinschränkungen. Die LBS kann von ihrer Verankerung (SLAP d. Red.) bis zum Austritt aus dem Schultergelenk strukturell geschädigt sein. An der RM lassen sichTendopathienundPartialrupturen einzelner Sehnen desM. subscapularis, M. supraspinatus, M. infraspinatus und M. teres minor von transmuralen Rupturen und Massenrupturen mit fortgeschrittenen degenerativen Veränderungen voneinander unterscheiden. Seltener, aber leicht zu übersehen sind Verletzungen der Pectoralissehne und der Sehne des M. teres major. Das therapeutische Vorgehen erfolgt pathologieund patientenspezifisch in Abhängigkeit von der Pathomorphologie, der klinischen Symptomatik und dem funktionellen Anspruch des Patienten. Ziel dieses Leitthemas ist es, eine Übersicht der häufigsten Sehnenverletzungen an der Schulter zu geben und die Aufmerksamkeit für ihre pathologischen Zusammenhänge zu schärfen. Für diese Aufgabe konnten herausragende Experten gewonnen werden, denen ich an dieser Stelle herzlich für ihre prägnanten Beiträge zum aktuellen Wissensstand dieser Verletzungen danke. Wissenschaftlicher Erkenntnisgewinn baut auf den Grundlagen unserer Wegbereiter auf und ist fortwährend.

The Coronavirus Disease 2019 (COVID-19) may result not only in acute symptoms such as severe pneumonia, but also in persisting symptoms after months. Here we present a 1 year follow-up of a patient with a secondary tension pneumothorax due to COVID-19 pneumonia. In May 2020, a 47-year-old male was admitted to the emergency department with fever, dry cough, and sore throat as well as acute chest pain and shortness of breath. Sputum testing (polymerase chain reaction, PCR) and computed tomography (CT) confirmed infection with the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2). Eleven days after discharge, the patient returned to the emergency department with pronounced dyspnoea after coughing. CT showed a right-sided tension pneumothorax, which was relieved by a chest drain (Buelau) via mini open thoracotomy. For a period of 3 months following resolution of the pneumothorax the patient complained of fatigue with mild joint pain and dyspnoea. After 1 year, the patient did not suffer from any persisting symptoms. The pulmonary function and blood parameters were normal, with the exception of slightly increased levels of D-Dimer. The CT scan revealed only discrete ground glass opacities (GGO) and subpleural linear opacities. Tension pneumothorax is a rare, severe complication of a SARS-CoV-2 infection but may resolve after treatment without negative long-term sequelae. V.

Tendon pathologies are a frequent cause of shoulder pain and can lead to significant decline in the quality of life. Conservative treatment is suitable for most tendon pathologies. In addition to classical conservative treatment options, such as physiotherapy, oral analgesia and infiltrations, there are a number of additive treatment options to promote structural tendon healing and clinical outcome. Furthermore, there are approaches to improve the results of the surgical treatment of tendon injuries by biological augmentation. The objective of this article is to give an overview of biological and regenerative therapeutic options in the treatment of tendon injuries of the shoulder. Therefore, the anatomical and molecular biological principles of the tendon structure and their importance for tendon healing are explained in order to highlight the various therapeutic options for daily practice. Biological augmentation procedures and regenerative medicine represent a promising therapeutic option for tendon injuries of the shoulder, however, the benefits are so far supported by little or no evidence at all.

BACKGROUND:The aim of this study was to evaluate the functional and radiographic outcome in patients with reverse total shoulder arthroplasty (RSA) for displaced proximal humeral fractures (PHF) with or without tenotomy of the supraspinatus tendon. METHODS:Between June 2011 and June 2018, 159 patients (age >65 years) with a displaced proximal humeral fracture underwent reverse total shoulder arthroplasty (Grammont design) in a single-center study and were longitudinally followed up. In all cases, the tuberosities were attached to the prosthesis in a standardized procedure. Functional outcome, range of motion as well as tuberosity integration, resorption and displacement were assessed at final follow-up. Outcomes were compared between patients that underwent RSA in combination with tenotomy of the supraspinatus (ST) and patients that underwent RSA without supraspinatus tenotomy (NT). RESULTS:At a mean follow up of 22.2 ± 16.4 months 76 patients (mean age 77.1 ± 7.2 years, 83% women) could be evaluated (follow-up rate 47.8%). There were no statistically significant differences between the ST (n = 29) and NT groups (n = 47) in tuberosity integration, resorption ≥50%, or displacement (p = 0.99/0.31/0.7/0.99). Functional outcome was better in ST group (Constant score 76.2 ± 5.9 vs. 64.5 ± 12.8; p < 0.05) especially regarding mean active external rotation (>20°: 65.5% vs. 14.9%, p < 0.05) and active abduction (>120°: 89.7% vs. 21.3%, p < 0.05). Tuberosity integration (ST and NT together: n = 34) showed better functional results than resorption or displacement (p < 0.05). CONCLUSIONS:Tenotomy of the supraspinatus tendon in RSA for displaced PHF leads to similar radiographic results regarding tuberosity integration, resorption and displacement but better functional outcome with regard to range of motion. LEVEL OF EVIDENCE:III.

Introduction This study compared the clinical and radiologic outcomes of screw-tip augmented locking plate osteosynthesis (STA) vs primary reverse total shoulder arthroplasty (RSA) in elderly patients with displaced proximal humeral fractures. Methods 60 patients (age >65 years) with a displaced proximal humeral fracture underwent open reduction and internal fixation with locking plate and fluoroscopy controlled screw-tip augmentation. Sixty matched individuals (age, gender, fracture pattern, and mean follow-up) treated by RSA for fractures were identified from the institutional database and outcomes as well as occurring complications and need for revision surgery were compared. Results At 39 months’ follow-up, 25 patients in the STA group (mean age 74.5 ± 12 years, 76.7% woman) showed a mean Constant Score (CS) of 68 ± 18.8 points. Mean %CS compared to the contralateral side was 81.6 ± 19.8%. Of 60 matched individuals in the RSA group, 22 patients (mean age 78.9 ± 8.2 years, 76.7% woman) showed a mean CS of 60.6 ± 21.2 points (P = .33), and the mean %CS compared to the contralateral side was 81.6 (74.7 ± 18.6)% (P = .14). The overall complication rate in STA group was 32% (secondary varus or valgus displacement >10°, n = 4, avascular necrosis, n = 4). In RSA group, the overall complication rate was 4.5% (P = <.05). We observed one early onset infection. Revision surgery with removal of the prosthesis and PMMA spacer implantation for two-stage revision was necessary. The follow-up rate was 41.7 vs 36.7%. Conclusions Screw-tip augmented locked plating and reverse total shoulder arthroplasty result in comparable satisfying functional outcome 3 years following a displaced proximal humeral fracture in elderly patients. However, we noted a higher complication and revision rate in the STA group. In contrast, primary reversed shoulder arthroplasty resulted in a lower rate of complications and revisions, which may be beneficial in elderly patients.

Sehnenpathologien sind ein häufiger Grund für Schulterschmerzen und können zu einer beträchtlichen Abnahme der Lebensqualität führen. Die meisten Sehnenpathologien sind einer konservativen Therapie gut zugänglich. Neben den „klassischen“ konservativen Therapiemaßnahmen wie Physiotherapie, orale Analgesie und Infiltrationen existiert eine Reihe additiver Therapieoptionen, um die strukturelle Sehnenheilung und das klinische Outcome zu begünstigen. Darüber hinaus existieren Ansätze, durch biologische Augmentation die Ergebnisse operativer Verfahren nach Sehnenverletzung zu verbessern. Ziel der vorliegenden Arbeit ist es, eine Übersicht über biologische und regenerative Therapieoptionen bei der Versorgung von Sehnenverletzungen an der Schulter zu geben. Die anatomischen und molekularbiologischen Grundlagen der Sehnenstruktur sowie deren Bedeutung für die Sehnenheilung werden erläutert, um die verschiedenen Therapieansätze mit Blick auf den Stellenwert für die tägliche Praxis zu beleuchten. Biologische Augmentationsverfahren stellen eine vielversprechende Therapieoption bei Sehnenverletzungen an der Schulter dar, wenngleich ihr Nutzen für bestimmte Verfahren bisher noch mit wenig Evidenz belegt ist oder diese gänzlich fehlt.