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Purpose To develop and validate an elbow self-assessment score considering subjective as well as objective parameters. Methods Each scale of the American Shoulder and Elbow Surgeons-Elbow Score, the Broberg and Morrey rating system (BMS), the Patient-Rated Elbow Evaluation (PREE) Questionnaire, the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score (OES) and the Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) was analysed, and after matching of the general topics, the dedicated items underwent a fusion to the final ESAS’s item and a score containing 22 items was created. In a prospective clinical study, validity, reliability and responsiveness in physically active patients with traumatic as well as degenerative elbow disorders were evaluated. Results Validation study included 103 patients (48 women, 55 men; mean age 43 years). A high test–retest reliability was found with intraclass correlation coefficients of at least 0.71. Construct validity and responsiveness were confirmed by correlation coefficients of −0.80 to −0.84 and 0.72–0.84 ( p  <0.05). Correlation coefficients of the ESAS and well-established elbow rating systems BMS, PREE, MEPS, OES and Quick-DASH were between 0.70 and 0.90 ( p  < 0.05). Conclusions With this novel Elbow Self-Assessment Score (ESAS), a valid and reliable instrument for a qualitative self-assessment of subjective and objective parameters (e.g. range of motion) of the elbow joint is demonstrated. Quantitative measurement of elbow function may not longer be limited to specific elbow disorders or patient groups. The ESAS seems to allow for a broad application in clinical research studying elbow patients and may facilitate the comparison of treatment results in elbow disorders. The treatment efficacy can be easily evaluated, and treatment concepts could be reviewed and revised. Level of evidence Diagnostic study, Level III.

Background Radio frequency ablation devices have found a widespread application in arthroscopic surgery. However, recent publications report about elevated temperatures, which may cause damage to the capsular tissue and especially to chondrocytes. The purpose of this study was the investigation of the maximum temperatures that occur in the ankle joint with the use of a commercially available radio frequency ablation device. Methods Six formalin-fixed cadaver ankle specimens were used for this study. The radio frequency device was applied for 120 s to remove tissue. Intra-articular temperatures were logged every second for 120 s at a distance of 3, 5 and 10 mm from the tip of the radio frequency device. The irrigation fluid flow was controlled by setting the inflow pressure to 10 mmHg, 25 mmHg, 50 mmHg and 100 mmHg, respectively. The controller unit voltage setting was set to 1, 5 and 9. Results Maximum temperatures exceeding 50 °C/122 °F were observed for all combinations of parameters, except for those with a pressure of 100 mmHg pressure. The main critical variable is the pressure setting, which is highly significant. The controller unit voltage setting showed no effect on the temperature measurements. The highest temperature was 102.7 °C/215.6 °F measured for an irrigation flow of 10 mmHg. The shortest time span to exceed 50 °C/122 °F was 3 s. Conclusion In order to avoid temperatures exceeding 50 °C/122 °F in the use of radio frequency devices in arthroscopic surgeries of the ankle joint, it is recommended to use a high irrigation flow by setting the pressure difference across the ankle joint as high as feasible. Even short intervals of a low irrigation flow may lead to critical temperatures above 50 °C/122 °F. Level of Evidence Level II, diagnostic study.

Background Loss of meniscal tissue is correlated with early osteoarthritis but few data exist regarding detailed biomechanical properties (e.g. viscoelastic behavior) of menisci in different species commonly used as animal models. The purpose of the current study was to biomechanically characterize bovine, ovine, and porcine menisci (each n = 6, midpart of the medial meniscus) and compare their properties to that of normal and degenerated human menisci (n = 6) and two commercially available artificial scaffolds (each n = 3). Methods Samples were tested in a cyclic, minimally constraint compression–relaxation test with a universal testing machine allowing the characterization of the viscoelastic properties including stiffness, residual force and relative sample compression. T-tests were used to compare the biomechanical parameters of all samples. Significance level was set at p < 0.05. Results Throughout cyclic testing stiffness, residual force and relative sample compression increased significantly (p < 0.05) in all tested meniscus samples. From the tested animal meniscus samples the ovine menisci showed the highest biomechanical similarity to human menisci in terms of stiffness (human: 8.54 N/mm ± 1.87, cycle 1; ovine: 11.24 N/mm ± 2.36, cycle 1, p = 0.0528), residual force (human: 2.99 N ± 0.63, cycle 1 vs. ovine 3.24 N ± 0.13, cycle 1, p = 0.364) and relative sample compression (human 19.92% ± 0.63, cycle 1 vs. 18.72% ± 1.84 in ovine samples at cycle 1, p = 0.162). The artificial constructs -as hypothesized- revealed statistically significant inferior biomechanical properties. Conclusions For future research the use of ovine meniscus would be desirable showing the highest biomechanical similarities to human meniscus tissue. The significantly different biomechanical properties of the artificial scaffolds highlight the necessity of cellular ingrowth and formation of extracellular matrix to gain viscoelastic properties. As a consequence, a period of unloading (at least partial weight bearing) is necessary, until the remodeling process in the scaffold is sufficient to withstand forces during weight bearing.

Purpose The aim of this biomechanical in vitro study was to compare the novel technique of double intramedullary cortical button (DICB) fixation with the well-established method of suture anchor (SA) fixation for distal biceps tendon repair. Methods A matched-pair analysis (24 human cadaveric radii) was performed with respect to cyclic loadings and failure strengths. Twelve specimens per group were cyclically loaded for 1,000 cycles at 1.5 Hz from 5 to 50 N and from 5 to 100 N, respectively. The tendon–bone displacement was optically analysed using the Image J Software (National Institute of Health). Afterwards, all specimens were pulled to failure. Maximum load to failure and mode of failure were recorded. Results All DICB constructs passed the cyclic loading test, whereas 4 of the 12 specimens within the SA group failed by anchor pull-out. Cyclic loading showed a mean tendon–bone displacement of 0.6 ± 1.4 mm for the DICB group and 1.4 ± 1.4 mm for the SA group (n.s.) after 1,000 cycles with 50 N, and a mean displacement of 2.1 ± 2.4 mm for the DICB group and 3.5 ± 3.7 mm for the SA group (n.s.) after 1,000 cycles with 100 N. Load to failure testing showed a mean failure load of 312 ± 76 N and a stiffness of 67.1 ± 11.7 N/mm for the DICB technique. The mean load to failure for the SA repair was 200 ± 120 N (n.s.) and the stiffness was 55.9 ± 21.3 N/mm (n.s.). Conclusions The novel technique of DICB fixation showed small tendon–bone displacement during cyclic testing and reliable fixation strength to the bone in load to failure. Moreover, all DICB constructs passed cyclic loadings without failure. Based on the current findings, a more aggressive postoperative rehabilitation may be allowed for the DICB repair in clinical use.

IntroductionFor comminuted and displaced fractures of the radial head open reduction and internal fixation (ORIF) is recommended nowadays as the treatment of choice. Due to the development of locking plates the possibilities of ORIF in complex fracture types were extended. The purpose of this retrospective survey therefore was to review the preliminary subjective and objective results in patients treated by anatomically preshaped locked plating. A reliable fracture healing for these recently introduced plating devices was hypothesized.Materials and methodsSubjective and objective criteria included patient’s satisfaction, pain rating on a visual analogue scale (VAS) and active range of motion (ROM) compared to the contralateral armside. Functional scoring included the Morrey elbow performance score (MEPS), the QuickDASH and the elbow self-assessment score (ESAS). Furthermore, follow-up radiographs were reviewed.ResultsBetween 2011 and 2014 a total of 24 patients were managed with ORIF using anatomically preshaped low-profile locking plates. All patients had suffered from comminuted radial head fractures (type III–IV according to Mason classification). Twenty of 24 patients returned for follow-up examination after a mean of 30 months (range 18–53 months). Patients' satisfaction was rated as highly satisfied in 17 cases and satisfied in 3 cases. An unrestricted ROM for extension-flexion arc and pronation-supination arc was rated in 10 cases. Minor ROM deficiencies with a 5° limited extension compared to the contralateral side was evaluated in 6 cases. Only four patients were rated with and extension and supination deficiency of 10°, one of whom with an additional pronation deficiency of 10°. The calculated MEPS was Ø 98 ± 4 (range 85–100), and the QuickDASH was Ø 3 ± 6 (range 0–21). The ESAS was completed by 18 patients with a mean of Ø 96.54 ± 2.95 (range 94–100) indicating a non-restricted elbow function.ConclusionsThe treatment of comminuted radial head fractures using anatomically preshaped locking radial head plates represents a reliable and safe surgical approach, leading to good to excellent functional results. Being aware of the importance of the radial head for elbow stability, open reduction and internal fixation should be preferred prior to radial head resection or replacement in complex radial head fractures. Further trials with a higher number of patients are needed to confirm the advantages of preshaped radial head plates.

Transforming growth factor β (TGF-β) is a critical regulator of bone density owing to its multiple effects on cell growth and differentiation. Recently, we have shown that TGF-β 1 effectively blocks bone morphogenetic protein (BMP) induced maturation of osteoblasts by upregulating histone deacetylase (HDAC) activity. The current study aimed at investigating the effect of rhTGF-β 1 treatment on the expression of specific HDACs and their cellular effects, e.g., microtubule structures (primary cilia) and mechanosensation. Exposure to TGF-β 1 most significantly induced expression of HDAC6 both on gene and protein level. Being most abundant in the cytoplasm HDAC6 effectively deacetylates microtubule structures. Thus, TGF-β 1 -induced expression of HDAC6 led to deformation and shortening of primary cilia as well as to reduced numbers of ciliated cells. Primary cilia are described to sense mechanical stimuli. Thus, fluid flow was applied to the cells, which stimulated osteoblast function (AP activity and matrix mineralization). Compromised primary cilia in TGF-β 1 -treated cells were associated with reduced osteogenic function, despite exposure to fluid flow conditions. Chemical inhibition of HDAC6 with Tubacin restored primary cilium structure and length. These cells showed improved osteogenic function especially under fluid flow conditions. Summarizing our results, TGF-β 1 impairs human osteoblast maturation partially via HDAC6-mediated distortion and/or shortening of primary cilia. This knowledge opens up new treatment options for trauma patients with chronically elevated TGF-β 1 -levels (e.g., diabetics), which frequently suffer from delayed fracture healing despite adequate mechanical stimulation. Key messages Exposure to TGF-β 1 induces expression of HDAC6 in human osteoblasts. TGF-β 1 exposed human osteoblasts show less and distorted primary cilia. TGF-β 1 exposed human osteoblasts are less sensitive towards mechanical stimulation. Mechanosensation can be recovered by HDAC6 inhibitor Tubacin in human osteoblasts.

Background Biological augmentation of rotator cuff repair is of growing interest to improve biomechanical properties and prevent re-tearing. But intraoperative single shot growth factor application appears not sufficient to provide healing support in the physiologic growth factor expression peaks. The purpose of this study was to establish a sustained release of granulocyte-colony stimulating factor (G-CSF) from injectable vesicular phospholipid gels (VPGs) in vitro and to examine biocompatibility and influence on histology and biomechanical behavior of G-CSF loaded VPGs in a chronic supraspinatus tear rat model. Methods G-CSF loaded VPGs were produced by dual asymmetric centrifugation. In vitro the integrity, stability and release rate were analyzed. In vivo supraspinatus tendons of 60 rats were detached and after 3 weeks a transosseous refixation with G-CSF loaded VPGs augmentation (n = 15; control, placebo, 1 and 10 μg G-CSF/d) was performed. 6 weeks postoperatively the healing site was analyzed histologically (n = 9; H&E by modified MOVIN score/Collagen I/III) and biomechanically (n = 6). Results In vitro testing revealed stable proteins after centrifugation and a continuous G-CSF release of up to 4 weeks. Placebo VPGs showed histologically no negative side effects on the healing process. Histologically in vivo testing demonstrated significant advantages for G-CSF 1 μg/d but not for G-CSF 10 μg/d in Collagen III content (p = 0.035) and a higher Collagen I/III ratio compared to the other groups. Biomechanically G-CSF 1 μg/d revealed a significant higher load to failure ratio (p = 0.020) compared to control but no significant differences in stiffness. Conclusions By use of VPGs a continuous growth factor release could be obtained in vitro. The in vivo results demonstrate an improvement of immunohistology and biomechanical properties with a low dose G-CSF application via VPG. The VPG itself was well tolerated and had no negative influence on the healing behavior. Due to the favorable properties (highly adhesive, injectable, biocompatible) VPGs are a very interesting option for biologic augmentation. The study may serve as basis for further research in growth factor application models.

Background Traumatic carotid artery dissections are very rare, often overlooked and life-threatening injuries. Diagnosis and treatment are difficult especially in multiple injured patients. Case presentation We report on a 28-year-old female major trauma patient (injury severity score, ISS 50) who was involved in a motor vehicle accident. She was primarily transferred to a level II trauma center. After initial assessment and operative management, an anisocoria was diagnosed on the intensive care unit. Subsequent CT angiography and extracranial duplex sonography revealed a bilateral internal carotid artery dissection. The patient was transferred to our level I trauma center where conservative treatment with high-dose heparin therapy was started at day two after trauma. Outcome after 6 months was very good. Conclusion Besides presenting the case and outcome of this patient, the article discusses the diagnostic and therapeutic management of this extremely rare and often overlooked dangerous injury. To avoid overlooking carotid artery dissections, CT angiography of the neck region should be generously included into the initial multislice CT whole-body scan, when the injury results from an according trauma. For the best outcome, sites of hemorrhage should be abolished quickly and the anticoagulative therapy should be initiated as soon as possible. Interdisciplinary treatment of trauma surgeons and neurologists is crucial.

Background Tension-band wiring (TBW) is a well-established fixation technique for two-part, transverse fracture types of the olecranon. However, complication rates up to 80 % are reported. By reporting on the enormous impact on the patient if failed the aim of the present report was to emphasize the importance of correct K wire positioning in TBW. Case presentation We present the case of a 49-year-old woman who suffered from a radioulnar synostosis of the forearm due to malpositioned K wires after TBW treatment. The patient was treated by heterotopic bone resection supported by ossification prophylaxis (radiotherapy and Indomethacin). At follow-up of 12 months after revision surgery, elbow motion was unrestricted with a strength grade 5/5. The patient was free of pain and reported no restrictions in daily as well as sporting activities. Radiologic assessment showed no recurrence of heterotopic bone tissue. Conclusion Intraoperative radiographic and clinical examination of the elbow is highly recommended to identify incorrect hardware positioning and, therefore, to avoid serious postoperative complications in TBW.

Purpose This study was designed to present the novel technique of intramedullary cortical button fixation for distal biceps tendon repair via a single-limited anterior portal. Methods To reattach the ruptured biceps tendon at the radial tuberosity, two Bicepsbutton ™ (Arthrex, Naples, FL, USA) were intramedullary positioned to the anterior cortex. The surgical procedure is described in detail. This technique has been performed in a first series of 3 patients with acute distal biceps tendon ruptures. Results All patients were very satisfied after surgery and would undergo the same surgical procedure again. All patients regained full range of elbow motion with comparable strength of forearm supination and elbow flexion measured against the uninjured arm at 6 months of follow-up. No neurovascular complications have been occured. Conclusion Double intramedullary cortical button repair has shown to be a safe and reliable fixation method for distal biceps tendon rupture in a small series of patients. Preliminary results are encouraging. Level of evidence Technical description, case series, Level IV.