Publications by authors named "Rony-Orijit Dey Hazra"

19 Publications

  • Page 1 of 1

Arthroscopic Treatment of Snapping Scapula Syndrome With Scapulothoracic Bursectomy and Partial Scapulectomy.

Arthrosc Tech 2022 Jul 14;11(7):e1175-e1180. Epub 2022 Jun 14.

Steadman Philippon Research Institute, Vail, Colorado, U.S.A.

Snapping scapula syndrome (SSS) is a painful and debilitating condition that occurs as a result of disruption of normal scapulothoracic articulation and inflammation of numerous soft tissue and bursal structures that function to facilitate scapulothoracic motion. Historically, when nonoperative management of SSS failed, patients progressed to open surgical management. However, as arthroscopic techniques have evolved, the condition has been increasingly treated arthroscopically because of the minimally invasive nature, periscapular muscle-preserving approach with decreased risk to surrounding neurovascular structures, better intraoperative visualization, and quicker patient recovery and rehabilitation. The objective of this Technical Note is to describe our arthroscopic approach for the management of SSS using two portals to complete a scapulothoracic bursectomy and partial scapulectomy of the superomedial scapula. Level of Evidence: Level I: shoulder.
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http://dx.doi.org/10.1016/j.eats.2022.02.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9353079PMC
July 2022

Glenoid retroversion does not impact clinical outcomes or implant survivorship after total shoulder arthroplasty with minimal, noncorrective reaming.

JSES Int 2022 Jul 18;6(4):596-603. Epub 2022 Mar 18.

The Steadman Clinic, Vail, CO, USA.

Hypothesis: Both clinical outcomes and early rates of failure will not be associated with glenoid retroversion.

Methods: All patients who underwent an anatomic total shoulder arthroplasty with minimal, noncorrective reaming between 2006 and 2016 with minimum 2-year follow-up were reviewed. Measurements for retroversion, inclination, and posterior subluxation were obtained from magnetic resonance imaging or computerized tomography. A regression analysis was performed to assess the association between retroversion, inclination and subluxation, and their effect on patient reported outcomes (PROs). Clinical failures and complications were reported.

Results: One hundred fifty-one anatomic total shoulder arthroplasties (90% follow-up) with a mean follow-up of 4.6 years (range, 2-12 years) were assessed. The mean preoperative retroversion was 15.6° (range, 0.2-42.1), the mean posterior subluxation was 15.1% (range, -3.6 to 44.1%), and the mean glenoid inclination was 13.9° (range, -11.3 to 44.3). All median outcome scores improved significantly from pre- to post-operatively ( < .001). The median satisfaction was 10/10 (1st quartile = 7 and 3rd quartile = 10). Linear regression analysis found no significant association between retroversion and any postoperative PRO. A total of 5 (3.3%) failures occurred due to glenoid implant loosening (3 patients) and Cutibacterium acnes infection (2 patients) with no association between failure causation and increased retroversion or inclination. No correlation could be found between the Walch classification and postoperative PROs.

Conclusion: Anatomic total shoulder replacement with minimal and noncorrective glenoid reaming demonstrates reliable increases in patient satisfaction and clinical outcomes at a mean of 4.6-year follow-up in patients with up to 40° of native retroversion. Higher values of retroversion were not associated with early deterioration of clinical outcomes, revisions, or failures. Long-term studies are needed to see if survivorship and outcomes hold up over time.
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http://dx.doi.org/10.1016/j.jseint.2022.02.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9264025PMC
July 2022

Minimum 2-year results of the second-generation CFR-PEEK locking plate on the proximal humeral fracture.

Eur J Orthop Surg Traumatol 2022 May 27. Epub 2022 May 27.

Department of Orthopedic and Trauma Surgery, Diakovere Friederikenstift and Henriettensift, Humboldtstraße 5, 30169, Hannover, Germany.

Purpose: The aim of this study was to analyse and compare the 24-month range of motion results of patients treated with CFR-PEEK2 versus conventional titanium plate osteosyntheses (TAL-P). We hypothesized similar clinical outcomes but a better range of motion in the CFR-PEEK2 group than the TAL-P group in the 2-year follow-up.

Methods: This retrospective study analysing prospectively collected data included all patients that presented with a PHF and were treated with CFR-PEEK2 between November 2016 and April 2018. Follow-up was performed after a minimum of 24 months, evaluating the functional degree of movement functional scores, including the Subjective Shoulder Value (SSV) as well as an age- and sex-adapted Constant-Murley score (CMS). The 2-year results were compared to the results of a matched pair group comprising patients that were treated with TAL-P during the same period.

Results: Of the 35 patients included (mean age: 61.2 [18-78] years), 30 (86%) patients completed the 24-month follow-up in the CFR-PEEK2-group. After 24 months, the mean CMS was 89.9 points (pt) (44.5-100 pt) and the mean SSV was 86.7% (35-100%). Compared to the matched-pair TAL-P cohort, the 24-month follow-up showed similar results (CMS: 88.6 pt. (40.5-100 pt.) [p = 0.9]; SSV: 76% (30-100%) [p = 0.05]). However, significantly better degrees of forward flexion and internal rotation as well as a better range of motion in abduction was recorded in patients treated with CFR-PEEK2 plates than TAL-P.

Conclusion: At the 24-month follow-up, patients who received treatment with CFR-PEEK2 compared to those that received TAL-P showed enhanced range of motion whilst having similar clinical scores.
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http://dx.doi.org/10.1007/s00590-022-03298-9DOI Listing
May 2022

Are Patient-Reported Outcome Scores a Reasonable Substitute for Clinical Follow-up After Surgically Managed Acromioclavicular Joint Injuries?

Orthop J Sports Med 2022 May 13;10(5):23259671221094056. Epub 2022 May 13.

DIAKOVERE Friederikenstift, Hannover, Germany.

Background: Various clinical outcome scores have been described to evaluate postoperative shoulder function after operatively treated acromioclavicular joint (ACJ) instability. Clinical outcome scores can be divided between patient-reported outcome measures (PROMs) and examiner-dependent outcome measures (EDOMs) after a clinical examination by a physician. The correlation between PROMs and EDOMs, and thus their interchangeability with regard to operatively treated ACJ instability, has not yet been evaluated.

Purpose: To investigate whether PROMs are a reasonable substitute for EDOMs. Correlations between global shoulder (GS) and ACJ-specific outcome measures were also investigated.

Study Design: Cohort study (diagnosis); Level of evidence, 3.

Methods: Included in this study were 131 consecutive patients with operatively treated ACJ instability between 2011 and 2017. Postoperative shoulder function was measured using PROMs, including the Subjective Shoulder Value (SSV), Subjective Shoulder Test, and Nottingham Clavicle Score (NCS), and EDOMs, including the Constant-Murley score (CMS), Taft score, ACJ instability (ACJI) score, and SICK Scapula Score (SSS). Associations between PROM and EDOM scores were calculated using the Pearson and Spearman correlation coefficients for linear and nonlinear variables, respectively, and were interpreted using the Cohen classification. The scores were further stratified into GS versus ACJ-specific measures.

Results: A strong correlation was observed between several PROMs and EDOMs (CMS vs SSV [ = 0.59; = .02] and CMS vs NCS [ = 0.79; ≤ .001]) and between several GS and ACJ-specific scores (CMS vs NCS; CMS vs ACJI [ = 0.69; < .001]; and CMS vs SSS [ = -0.68; < .001]).

Conclusion: Based on the results of this study, PROMs such as the SSV (a GS measure) and the NCS (an ACJ-specific measure) can substitute for EDOMs.

Clinical Relevance: PROMs that can be substituted for EDOMs can enable the conduct of clinical studies in circumstances in which in-person clinical follow-up of the patient by a physician is not possible.
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http://dx.doi.org/10.1177/23259671221094056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9112419PMC
May 2022

Anatomic safe zones for arthroscopic snapping scapula surgery: quantitative anatomy of the superomedial scapula and associated neurovascular structures and the effects of arm positioning on safety.

J Shoulder Elbow Surg 2022 May 9. Epub 2022 May 9.

Steadman Philippon Research Institute, Vail, CO, USA; The Steadman Clinic, Vail, CO, USA. Electronic address:

Background: Neurovascular anatomy has not been previously quantified for the arthroscopic snapping scapula approach with the patient in the most frequent patient position ("chicken-wing" position). The purposes of this study were (1) to determine anatomic relationships of the superomedial scapula and neurovascular structures at risk during arthroscopic surgical treatment of snapping scapula syndrome (SSS), (2) to compare these measurements between the arm in the neutral position and the arm in the chicken-wing position, and (3) to establish safe zones for arthroscopic treatment of SSS.

Methods: Eight fresh-frozen cadaveric hemi-torsos (mean age, 55.8 years; range, 52-66 years) were dissected to ascertain relevant anatomic structure locations including the (1) spinal accessory nerve, (2) dorsal scapular nerve, and (3) suprascapular nerve. A coordinate measuring device was used to collect data on the relationships of anatomic landmarks and at-risk structures during the surgical approach.

Results: The dorsal scapular nerve was a mean of 24.4 mm medial to the superomedial scapula in the neutral position and 33.1 mm medial in the chicken-wing position (P < .001); the dorsal scapular nerve was 21.7 mm medial to the medial border of the scapular spine in the neutral position and 35.5 mm medial in the chicken-wing position (P < .001). The mean distance from the superomedial angle to the spinal accessory nerve intersection at the superior scapular border was 16.5 mm in the neutral position and 15.0 mm in the chicken-wing position (P = .031). The average distance from the superomedial angle to the closest point of the spinal accessory nerve was 11.6 mm and 10.4 mm in the neutral position and chicken-wing position, respectively (P = .039).

Conclusion: Neurologic structures around the scapula vary significantly between the neutral arm position and the chicken-wing position commonly used in the arthroscopic treatment of SSS. The chicken-wing position improves safe distances for the dorsal scapular nerve during medial-portal placement and should be considered as a primary position for arthroscopic management of SSS.
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http://dx.doi.org/10.1016/j.jse.2022.03.029DOI Listing
May 2022

Arthroscopically assisted single tunnel reconstruction for acute high-grade acromioclavicular joint dislocation with an additional acromioclavicular joint cerclage.

Eur J Orthop Surg Traumatol 2022 May 7. Epub 2022 May 7.

Department for Orthopaedic Surgery and Traumatology, DIAKOVERE Friederikenstift, Humboldtstraße 5, 30169, Hannover, Germany.

Purpose: Purpose of this study was to demonstrate that a single tunnel reconstruction of high-grade acromioclavicular (AC) joint instabilities with implants of the second generation is sufficient for stabilisation, especially in combination with an AC cerclage.

Methods: Patients with an acute AC-joint dislocation type Rockwood III-B and V were included. Besides clinical follow-up examination, radiographs were analysed. The functional outcome measures were Constant Score (CS), Taft score (TS), ACJI score and patient's satisfaction. Horizontal instability was evaluated by clinical examination and radiological with an Alexander view.

Results: Thirty-five patients with a mean follow-up of 29 months were included. Ninety-seven per cent were satisfied with their result, with an average Subjective Shoulder Value of 90%. The CS averaged at 90 ± 10 points, TS at 11 ± 1 points and ACJI at 78 ± 18 points. Radiologically, 3 of 29 patients (10%) showed a persisting horizontal instability. The coracoclavicular (CC) distance improved from 22 preoperative to 10 mm postoperative, which was comparable to the contralateral side (10 mm, p = 0.103). At follow-up the CC distance increased to 13 mm (p = 0.0001).

Conclusion: AC-joint stabilisation with a single tunnel reconstruction using a second-generation implant results in good to excellent clinical results with high patient satisfaction. The additional AC augmentation improves stability in horizontal instable AC-joints and is recommended in all high-grade AC joint stabilisations. Nonetheless, reduction was slightly lost over time due to an elongation or suture failure of the coraco-clavicular fixation.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00590-022-03271-6DOI Listing
May 2022

Editorial Commentary: Current Indications for Lateral Acromioplasty Include Patients With Elevated Critical Shoulder Angle Plus Subacromial Impingement With Rotator Cuff Pathology or Previous Rotator Cuff Repair.

Arthroscopy 2022 03;38(3):716-718

Vail, Colorado.

The critical shoulder angle (CSA) reflects the lateral extent of the acromion and the inclination of the glenoid. In 2013, CSA was first introduced and its association with rotator cuff (RC) tears and glenohumeral osteoarthritis (GHOA) was shown. It was speculated that with a high CSA, there was an increased superior force vector from the deltoid and that this superior force led to RC tears. Conversely, when the CSA was low, there was a greater compressive force from the deltoid and that this compressive force led to GHOA. CSA serves as a further development of 2 previously reported measurements (glenoid inclination and acromial index). A key potential therapeutic aspect of the CSA is the ability to modify it surgically, which theoretically could protect RC repairs or prevent progression. In our current clinical practice, we perform lateral acromioplasty (LA) in patients undergoing treatment of subacromial impingement with an "at-risk" rotator cuff (partial rotator cuff tear and severe tendinopathy on magnetic resonance imaging) with a CSA > 38° or all patients with a CSA >35° after an RC repair to protect the RC repair construct. The relationships of high and low CSA, the anatomic safe zone, and thus clinical applicability of LA are well established and performed in our daily surgical practice. However, we do not yet have widespread clear clinical evidence on potential benefits regarding the clinical outcome after LA. Finally, at this time, the downsides seem minimal, so we continue to use LA as an adjunct in patients with RC tears and RC tendons that are at risk.
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http://dx.doi.org/10.1016/j.arthro.2021.11.002DOI Listing
March 2022

Age-Independent Clinical Outcome in Proximal Humeral Fractures: 2-Year Results Using the Example of a Precontoured Locking Plate.

J Clin Med 2022 Jan 14;11(2). Epub 2022 Jan 14.

Department of Orthopedic and Trauma Surgery, Diakovere Friederikenstift and Henriettenstift, 30169 Hannover, Germany.

Introduction: The optimal treatment strategy for the proximal humeral fracture (PHF) remains controversial. The debate is centered around the correct treatment strategy in the elderly patient population. The present study investigated whether age predicts the functional outcome of locking plate osteosynthesis for this fracture entity.

Methods: A consecutive series of patients with surgically treated displaced PHF between 01/2017 and 01/2018 was retrospectively analyzed. Patients were treated by locking plate osteosynthesis. The cohort was divided into two groups: Group 1 (≥65 years) and Group 2 (<65 years). At the follow-up examination, the SSV, CMS, ASES, and Oxford Shoulder Score (OS), as well as a radiological follow-up, was obtained. The quality of fracture reduction is evaluated according to Schnetzke et al. Results: Of the 95 patients, 79 were followed up (83.1%). Group 1 consists of 42 patients (age range: 65-89 years, FU: 25 months) and Group 2 of 37 patients (28-64 years, FU: 24 months). The clinical results showed no significant differences between both groups: SSV 73.4 ± 23.4% (Group 1) vs. 80.5 ± 189% (Group 2). CMS: 79.4 ± 21 vs. 81.9 ± 16, ASES: 77.2 ± 20.4 vs. 77.5 ± 23.1, OS: 39.5 ± 9.1 vs. 40.8 ± 8.2; OS: 39.5 ± 9.1 vs. 40.8 ± 8.2. In the radiological follow-up, fractures healed in all cases. Furthermore, the quality of fracture reduction in both groups is comparable without significant differences. The revision rate was 9.5% in Group 1 vs. 16.2% in Group 2.

Discussion: Both age groups show comparable functional outcomes and complication rates. Thus, the locking plate osteosynthesis can be used irrespective of patient age; the treatment decision should instead be based on fracture morphology and individual patient factors.
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http://dx.doi.org/10.3390/jcm11020408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8781715PMC
January 2022

[Arthroscopic-assisted management of intra-articular scapular fractures in a rugby player].

Sportverletz Sportschaden 2022 03 11;36(1):49-54. Epub 2022 Jan 11.

DIAKOVERE Friederikenstift Hospital Hannover, Hannover, Germany.

Scapular fractures are a rare injury entity accounting for 0,4-1 % of all fractures and 3-5 % of fractures involving the shoulder girdle. This study focuses on a 29-year-old male patient who sustained an intraarticular scapular fracture during a "Rugby Bundesliga" match after direct impact with another player. The clinical and radiological examinations showed a dislocated multifragmentary transverse scapular fracture involving the superior border, the medial border and the glenoid (Euler and Rüedi D2b/AO 14 F1.3e). The patient was subjected to arthroscopic surgery and underwent early postoperative functional rehabilitation without weight-bearing and with a limited range of motion of 90° abduction/anteversion. In the first match of the second half of the season (5 months post-operatively), the patient was available to play, and in the clinical follow-up 6 months post-operatively, he was pain-free with excellent clinical results (CS 100 pt, SSV 98 %, OSS 12 pt, ASES 100 pt). No pain or restrictions in the range of motion were reported. In conclusion, the arthroscopic-assisted management of intra-articular scapular fractures is a safe and effective choice of treatment in young and active patients.
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http://dx.doi.org/10.1055/a-1577-7029DOI Listing
March 2022

The Evolution of Arthroscopic Rotator Cuff Repair.

Orthop J Sports Med 2021 Dec 6;9(12):23259671211050899. Epub 2021 Dec 6.

Steadman Philippon Research Institute, Vail, Colorado, USA.

Over the past 30 years, arthroscopic rotator cuff repair (ARCR) has evolved to become the gold standard in treating rotator cuff pathology. As procedural concepts of ARCR continue to improve, it is also continually compared with the open rotator cuff repair as the historical standard of care. This review highlights the evolution of ARCR, including a historical perspective; the anatomic, clinical, and surgical implications of the development of an arthroscopic approach; how arthroscopy improved some of the problems of the open approach; adaptations in techniques and technologies associated with ARCR; future perspectives in orthobiologics as they pertain to ARCR; and lastly, the clinical improvements, or lack of improvements, with all of these adaptations.
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http://dx.doi.org/10.1177/23259671211050899DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8652190PMC
December 2021

Promising Mid-Term Outcomes after Humeral Head Preserving Surgery of Posterior Fracture Dislocations of the Proximal Humerus.

J Clin Med 2021 Aug 27;10(17). Epub 2021 Aug 27.

Department of Orthopedic and Trauma Surgery, Diakovere Friederikenstift and Henriettenstift, 30169 Hannover, Germany.

Background: The aim of this study was to evaluate the clinical outcome after humeral head preserving surgical treatment of posterior fracture dislocations of the proximal humerus.

Methods: Patients with a posterior fracture dislocation of the proximal humerus that were operatively treated in two level-1 trauma centers within a timeframe of 8 years were identified. With a minimum follow-up of 2 years, patients with humeral head preserving surgical treatment were invited for examination.

Results: 19/24 fractures (79.2%; mean age 43 years) were examined with a mean follow-up of 4.1 ± 2.1 years. Of these, 12 fractures were categorized as posteriorly dislocated impression type fractures, and 7 fractures as posteriorly dislocated surgical neck fractures. Most impression type fractures were treated by open reduction, allo- or autograft impaction and screw fixation ( = 11), while most surgical neck fractures were treated with locked plating ( = 6). Patients with impression type fractures showed significantly better ASES scores ( = 0.041), Simple Shoulder Test scores ( = 0.003), Rowe scores ( = 0.013) and WOSI scores ( = 0.023), when compared to posteriorly dislocated surgical neck fractures. Range of motion was good to excellent for both groups with no significant difference.

Conclusions: This mid-term follow-up study reports good to very good clinical results for humeral head preserving treatment.
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http://dx.doi.org/10.3390/jcm10173841DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8432246PMC
August 2021

Double plating - surgical technique and good clinical results in complex and highly unstable proximal humeral fractures.

Injury 2021 Aug 5;52(8):2285-2291. Epub 2021 Jun 5.

Department of Orthopedics and Traumatology, Diakovere Friederikenstift, Humboldtstraße 5, Hanover 30169, Germany.

Introduction: A stable fixation of highly unstable proximal humerus fractures remains challenging and complication rates, especially secondary varus dislocation, remains high. Different techniques of double plate osteosynthesis have been suggested for the treatment of complex proximal humeral fractures as they are well established for other fractures. The aim of this study was to evaluate an operative technique using an angular stable lateral plate supported by a one-third tubular plate positioned anteriorly at the lesser tuberosity for unstable proximal humeral fractures.

Patients And Methods: Retrospectively, patients treated with a double plate osteosynthesis were included between January 2014 and December 2017. Out of 31, 25 patients (80.6%) with an average age of 53.1 years ± 12.5 were available for follow-up. 60% of the patients were male. The clinical evaluation consisted of a physical examination and standardised questionnaire including subjective and objective shoulder scores like the Constant-Murley Shoulder Score, Simple Shoulder Score, and Subjective Shoulder Value.

Results: After a mean follow-up of 30.9 months (range, 12-76 months) eighteen patients (72%) had either excellent or good results regarding the Constant-Murley Shoulder Score with a mean value of 77 points ± 17. Average Simple Shoulder Score was 76% ± 0.2 and Subjective Shoulder Value 72% ± 0.2%. Mean NSA at time of follow-up 135° ± 13°. Nine patients had an implant-removal, five in combination with arthrolysis after a mean of 7.2 months. Three patients underwent surgery for secondary arthroplasty. The study shows a complication rate of 16%. No revision-surgery because of secondary varus dislocation was reported.

Discussion: Arthroplasty is the less favourable treatment for a younger, active cohort of patients with highly unstable proximal humeral fractures as results are not as good and options for revision are limited. Double plate osteosynthesis can be used in addition to calcar screws, bone graft augmentation, cement augmentation and additional free screws for more multidirectional stability and shows good clinical results despite a higher rate of avascular necrosis and high primary stability with comparable complication-rates to single plate osteosynthesis. It seems to be a valid alternative to primary fracture arthroplasty and can prevent secondary varus displacement.
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http://dx.doi.org/10.1016/j.injury.2021.05.047DOI Listing
August 2021

Additional coracoclavicular augmentation reduces revision rates in the treatment of lateral clavicle fractures as compared to angle-stable plate osteosynthesis alone.

Arch Orthop Trauma Surg 2022 Jun 4;142(6):1083-1090. Epub 2021 May 4.

Department of Orthopedics and Traumatology, Diakovere Friederikenstift, Humboldtstraße 5, 30169, Hannover, Germany.

Introduction: There is no uniform approach to the management of lateral clavicle fractures. Recent studies have investigated additive coracoclavicular (CC) augmentation as a treatment option; however, it is unclear whether it is superior to conventional locking plate osteosynthesis.

Methods: We carried out a retrospective analysis of 40 patients with lateral clavicle fracture (Neer type IIb) who were treated between 2014 and 2017 with either a hybrid locking plate osteosynthesis/additive arthroscopy-assisted CC augmentation (HP) procedure or a locking plate osteosynthesis only (PO) approach to determine which strategy was more effective. At follow-up, subjective shoulder value, age- and sex-adjusted Constant-Murley score, Taft (TF) score, American Shoulder and Elbow score, Nottingham clavicle score, and Visual Analogue Scale score were compared between patient groups. A radiologic evaluation was also conducted.

Results: A total of 14/17 patients (83%; 9 male/5 female, mean age: 43 ± 15 years) were followed up in the PO group. The mean follow-up time was 29 ± 12.4 months. In the HP group, 17/23 patients (74%; 9 male/8 female, mean age: 43 ± 17 years) were followed up, with a mean follow-up time of 18 ± 7.1 months. There were no significant differences in clinical parameters between the HP and PO groups; notably, the shoulder girdle-specific TF score was comparable in the 2 groups (HP: 11.3 ± 1.1 points and PO: 10.9 ± 0.9 points). In the HP group, additional pathologies were identified and arthroscopically treated in 35% of cases. Radiologic examination revealed a significant difference between pre- and postoperative CC distance in the HP group (P = 0.001).

Conclusion: Additive CC augmentation in combination with locking plate osteosynthesis seems to improve the vertical stability and reduces the revision rate in patients with a lateral clavicle fracture. Furthermore, an arthroscopy-assisted procedure allows for an intraoperative detection and single-step treatment of accompanying intraarticular pathologies.
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http://dx.doi.org/10.1007/s00402-021-03893-1DOI Listing
June 2022

Latest Trends in the Current Treatment of Proximal Humeral Fractures - an Analysis of 1162 Cases at a Level-1 Trauma Centre with a Special Focus on Shoulder Surgery.

Z Orthop Unfall 2022 06 2;160(3):287-298. Epub 2021 Feb 2.

Orthopaedic and Trauma Clinic, DIAKOVERE Friederikenstift, Hanover, Germany.

Background: The management of proximal humeral fracture (PHF) is not only complex but ever changing. Published epidemiological data are often dated and do not factor in demographic changes or the latest developments in implant material and surgical techniques.

Aims: The primary aim of this study was to evaluate changes in the epidemiology and actual treatment of PHF at a level-1 trauma centre, with a special focus on shoulder surgery.

Hypotheses: 1. Between 2009 to 2012 and 2014 to 2017, an increase in complex PHF entities can be observed. 2. In correlation with fracture complexity, an increasing number of comorbidities, especially osteoporosis, can be observed.

Methods: Between 2014 and 2017, a total of 589 patients (73% female; mean age: 68.96 ± 14.9 years) with 593 PHFs were treated. Patient records and imaging (XRs and CTs) of all patients were analysed. Fractures with ad latus displacement of a maximum of 0,5 cm and/or humeral head angulation of less than 20° were classified as non-displaced. Patients with displaced fractures were included in the analysis of the therapeutic algorithm. These results were compared to those of a cohort 2009 to 2012 (566 patients, 569 PHFs), which used the same inclusion criteria.

Results: The two cohorts showed comparable patient numbers, as well as gender and age distributions. Between 2009 to 2012 and 2014 to 2017, a decrease in 2-part fractures (13.9 to 8.6%) and a simultaneous increase in 4-part fractures (20.4 to 30%), and thus fracture complexity was observed. Further decreases were observed in conservative therapy (27.8 to 20.6%), nail osteosynthesis (10.7 to 2.7%) and anatomic shoulder arthroplasty (5,4 to 1%). Furthermore, there was an increase in the use of locking plate osteosynthesis (43.2 to 56.7%) and reverse shoulder arthroplasty (9 to 18.4%). The general trend shows an increase in surgical therapy between the years (72.2 to 79.4%), as well as an increase in osteoporosis incidence (13 to 20.6%). The greatest numbers of comorbidities were found in 3- and 4-part fractures.

Conclusion: There is an increase in both the complexity of fractures and the number of surgically treated fractures between 2009 and 2012. Furthermore, an increase in osteoporosis numbers can be observed. New implants (PEEK, fenestrated screws for cement augmentation) and new surgical techniques (double plating osteosynthesis) were used as a result of increasing fracture complexity. Moreover, reverse total shoulder arthroplasty was used more commonly.
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http://dx.doi.org/10.1055/a-1333-3951DOI Listing
June 2022

[Injuries of the sternoclavicular joint].

Unfallchirurg 2020 11;123(11):879-889

Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift Hannover, Humboldstr. 5, 30169, Hannover, Deutschland.

Injuries of the sternoclavicular joint (SCJ) are rare accounting for 3% of all injuries to the shoulder girdle and are often overlooked. The SCJ is surrounded by tight ligamentous structures, thus substantial energy with corresponding force vectors is needed to cause dislocation. Causative are mostly high-energy traumas. Anterior dislocation is most common but in rare cases potentially life-threatening posterior dislocation occurs, which requires immediate reduction. The established gold standard is 3D reconstruction in contrast-enhanced computed tomography (CT) for depiction of neurovascular structures. Low-grade instability can initially be treated conservatively. For unsuccessful attempts at reduction, high-grade instability and chronic instability various surgical techniques are established. Next to retentive augmentation with suture materials, in acute cases with chronic instability biological tendon augmentation is preferred. In cases of posttraumatic instability arthritis SCJ resection with or without additive biological augmentation can be carried out. Various study groups have shown good to very good midterm outcome.
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http://dx.doi.org/10.1007/s00113-020-00888-2DOI Listing
November 2020

Innovative Surgical Concept for Septic Sternoclavicular Arthritis: Case Presentation of a Simultaneous Joint Resection and Stabilization with Gracilis Tendon Graft Including Literature Review.

Z Orthop Unfall 2022 02 14;160(1):64-73. Epub 2020 Sep 14.

Orthopaedic and Trauma Surgery, DIAKOVERE Friederikenstift, Hanover.

Introduction: Septic arthritis of the sternoclavicular joint (SCJ) is a rarity in everyday surgical practice with 0.5 - 1% of all joint infections. Although there are several risk factors for the occurrence of this disease, also healthy people can sometimes be affected. The clinical appearance is very variable and ranges from unspecific symptoms such as local indolent swelling, redness or restricted movement of the affected shoulder girdle to serious consequences (mediastinitis, sepsis, jugular vein thrombosis). Together with the low incidence and the unfamiliarity of the disease among practicing doctors in other specialties, this often results in a delay in the diagnosis, which in addition to a significant reduction in the quality of life can also have devastating consequences for the patient.

Patient And Method: According to a stage-dependent procedure, the therapy strategies range from antibiotic administration only to radical resection of the SC joint and other affected structures of the chest wall in severe cases with the following necessity for flap reconstruction. The aspect of possible post-interventional instability after resection of the SCJ receives little or no attention in the current literature. In the present case report of a 51-year-old, otherwise healthy gentleman with isolated monoarthritis of the right SCJ with Escherichia coli (E. coli) shortly after two prostatitis episodes, the possibility of a new surgical approach with a one-stage eradication and simultaneous stabilization of the SCJ is presented. Therefore, a joint resection including extensive debridement is performed while leaving the posterior joint capsule and inserting an antibiotic carrier. In the same procedure, the SCJ is then stabilized with an autologous gracilis tendon graft by using the "figure of eight" technique, which has become well established particularly for anterior instabilities of the SCJ in recent years.

Results And Conclusion: One year after operative therapy, the patient presented symptom-free with an excellent clinical result (SSV 90%, CS89 points, CSM 94 points, TF 11 points, DASH 2.5 points). It is concluded that in selected cases with an infection restricted to the SCJ without major abscessing in the surrounding soft tissues, the demonstrated procedure leads to good and excellent clinical results with stability of the joint. If the focus of infection and germ are known, stabilization using an autologous graft can be carried out under antibiotic shielding. To the best of the authors' knowledge, this surgical procedure has not yet been described in the current literature. Depending on the extent of the resection, an accompanying stabilization of the SCJ should be considered to achieve stable conditions and an optimal clinical outcome.
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http://dx.doi.org/10.1055/a-1219-8342DOI Listing
February 2022

Corrective Osteosynthesis in Failed Proximal Humeral Fractures.

Z Orthop Unfall 2020 Oct 21;158(5):524-531. Epub 2019 Oct 21.

Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift, Hannover.

Despite implant improvement and increasing standardisation of operation techniques, the rate of therapy failure of proximal humeral fracture care with primary osteosyntheses is estimated to be 10 to 20%. Most commonly failure is precipitated by: material failure, technical error, non-anatomical repositioning, avascular necrosis, lacking medial support. An additive medial stabilisation of the so-called "calcar region" can decrease failure rates significantly. An early correction osteosynthesis with the purpose of restoring the anatomy is indicated in bony, non-consolidated "fresh" fractures. Bony consolidated fractures should be classified according to Boileau and Walch. The authors of this article advice a structured and classification-adapted approach to treatment with a correction osteosynthesis. Post-traumatic deficits can be augmented utilising the following methods: correction osteosynthesis with allogeneic/autologous bone grafts, correction osteosynthesis with hydroxyapatite grafts. For the additive stabilisation of repositioned and fixated fractures, the following are described: correction osteosynthesis with an additive ventral one-third tubular plate, correction osteosynthesis with cement-augmented screws. Based on results of endoprosthetics following fractures of the proximal humerus, the correction osteosynthesis indeed represents a real therapeutic alternative in patients that are below the age of 60, a good bone mass and with relative functional requirements.
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http://dx.doi.org/10.1055/a-0974-3887DOI Listing
October 2020

Fracture-pattern-related therapy concepts in distal humeral fractures.

Obere Extrem 2018 15;13(1):23-32. Epub 2018 Feb 15.

Department of Orthopedics and Traumatology, Diakovere Friederikenstift, Humboldtstraße 5, 30169 Hanover, Germany.

Around one third of humeral fractures and 2-6% of all fractures occur to the distal part of the humerus. There is a bimodal distribution differentiating between young male patients with high-energy and elderly female patients with low-energy trauma related to osteoporosis. The AO classification and Dubberley subclassification are used in daily routine. Most fractures are diagnosed on radiographs. For further evaluation, three-dimensional computed tomography is recommended, especially for comminuted or complex fractures. Owing to the long immobilization and resultant poor functional outcome, conservative treatment is followed for inoperable patients. The operative approach and osteosynthesis depend on the fracture pattern. In A1 avulsion fractures, open reduction and screw fixation are recommended. In A2/A3 fractures, a triceps-sparing approach following a 90° double-plate construction (radial dorsal/ulnar lateral) with locking plates is favored. Partial articular B1/B2 fractures are exposed via a medial or lateral approach using unilateral locking plates to stabilize the medial/lateral column. Coronal shear fractures (B3) are classified after Dubberley and are treated via an extended Kocher approach and headless compression screws in anteroposterior direction. If there is a further posterior comminution or a lateral column fragment, stabilization is needed for the lateral/medial column with a precontoured locking plate. In solely articular fracture patterns, a dorsal approach with either a 90° or 180° double-plate construction is advised. If a reconstruction is not possible owing to fracture complexity or bone quality, total elbow arthroplasty is a viable option. However, lifelong limitation in weight-bearing up to 5 kg, limited longevity, and the potential for complicated revision surgery should be considered.
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http://dx.doi.org/10.1007/s11678-018-0442-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5834588PMC
February 2018
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