Jan-Philipp Imiolczyk

Zusammenfassung: Hintergrund: Die ärztliche Tätigkeit ist zunehmend von strukturellem Druck geprägt. Hohe Arbeitsbelastung, Personalmangel und ein kontinuierlich wachsender bürokratischer Aufwand bestimmen den klinischen Alltag und tragen zu einem Attraktivitätsverlust des Berufs bei. Methode: Mittels standardisierter Online-Fragebögen (52 bzw. 75 Items, Single‑/Multiple-Choice und Freitext) wurden Humanmedizin-Studierende sowie Ärzt:innen per E‑Mail befragt. Erhoben wurden demographische Angaben, Motivation für Studium und Beruf, Erwartungen, gewünschte Arbeitsbedingungen, idealer Zeitaufwand für Beruf und Privatleben sowie positive und negative Einflussfaktoren auf die Berufszufriedenheit. Ergebnisse: Insgesamt gingen 668 auswertbare Fragebögen ein, davon 504 von Studierenden und 164 von Ärzt:innen. Rund 65 % der befragten Ärzt:innen arbeiten regelmäßig ≥ 50 h pro Woche (davon 37 %: 50–59 h, 25 %: 60–79 h, 3 %: ≥ 80 h) und damit deutlich über den tariflich vorgesehenen Arbeitszeiten. Lange Arbeitszeiten (52 %), eine unzureichende Work-Life-Balance (52 %) sowie die mangelnde Vereinbarkeit von Beruf und Familie (34 %) werden als zentrale Belastungsfaktoren benannt. Die Chirurgie zeigt dabei die Nachwuchsproblematik: 65 % der Studierenden würden sich für operative Fächer begeistern, jedoch nur 32 % der befragten Ärzt:innen arbeiten in einem chirurgischen Fach. Schlussfolgerung: Die Ergebnisse machen deutlich, dass lange Arbeitszeiten, hohe bürokratische Belastungen und insbesondere die Fehlallokation ärztliche Arbeitszeit zentrale strukturelle Ursachen für Unzufriedenheit und Attraktivitätsverlust darstellen. Vor dem Hintergrund des demographischen Wandels und des bevorstehenden Verlusts erfahrener ärztlicher Expertise besteht ein dringender Handlungsbedarf für eine tiefgreifende Neugestaltung, um die zukünftige medizinische Versorgung nachhaltig zu sichern. Graphic

Introduction: In reverse shoulder arthroplasty (RSA) new designs enable greater amounts of lateralization to prevent instability and scapular notching and increase range of motion, however, excessive lateralization leads to stress upon the acromion that can result in scapular spine fatigue fractures. Aim of this study was to gender- and size-specifically assess the influence of glenosphere size and different humeral designs on lateralization, distalization, and bony impingement-free range of motion (ROM) in patients undergoing RSA. Methods: Computed tomography scans from 30 osteoarthritic patients (f:15, m:15) and 20 cuff tear arthropathy patients (f:10, m:10) were used to virtually simulate RSA implantation. The efficacy of an inlay Grammont-type system vs. an onlay lateralizing system combined with different glenosphere sizes (36 mm vs. 42 mm) in achieving ROM, lateralization, and distalization was evaluated. Moreover, gender and patient’s constitution were correlated to humeral size by radiologically measuring the best-fit circle of the humeral head. Results: A different amount of relative lateralization was achieved in both genders using large glenospheres and onlay designs. Latter yielded a higher ROM in all planes for men and women with a 42 mm glenosphere; with the 36 mm glenosphere, an increased ROM was observed only in men. The 155° inlay design led to joint medialization only in men, whereas all designs led to lateralization in women. When adjusting the absolute amount of lateralization to humerus’ size (or patient’s height), regardless of implant type, women received greater relative lateralization using 36 mm glenosphere (inlay: 1%; onlay 12%) than men with 42 mm glenosphere (inlay: -3%; onlay: 8%). Conclusion: The relative lateralization achieved using onlay design is much higher in women than men. Small glenospheres yield greater relative lateralization in women compared to large glenospheres in men. Humeral lateralization using onlay designs should be used cautiously in women, as they lead to great relative lateralization increasing stress onto the acromion. Level of evidence: Basic Science Study, Computer Modeling.

Zusammenfassung: Patienten mit rezidivierenden, anteroinferioren Schulterluxationen und bipolarem Knochendefekt lassen sich zum Teil nicht mit reinen Weichteilstabilisierungen erfolgreich behandeln und benötigen oftmals knöcherne Augmentationen. Insbesondere Patienten mit Epilepsie oder fraglichen Krampfanfällen in der Vorgeschichte stellen aufgrund der oftmals massiven humeralen knöchernen Defekte eine Herausforderung dar. Zudem sollten mögliche weitere Luxationsereignisse bei einem erneuten Krampfanfall vom behandelnden Chirurgen antizipiert werden. Im Falle einer erneuten Luxation könnte es zu Implantat-assoziierten Komplikationen kommen. In diesem Fallbericht wird ein Patient mit bilateraler anteriorer Schulterinstabilität mit großem bipolarem Knochendefekt vorgestellt. Rechts wurde zweifach erfolglos eine weichteilige Stabilisierungsoperation durchgeführt. Als Stabilisierungsverfahren wurde glenoidal eine implantatfreie, knöcherne Rekonstruktion mittels J‑Span-Plastik und humeral eine metallfreie Defektauffüllung mittels Fresh-Frozen-Femurkopf-Allograft sowie Biokompressionsschrauben beidseits durchgeführt. Im 2‑Jahres-Follow-up zeigte sich beidseits eine stabile Schulter sowie eine gute Einheilung der knöchernen Rekonstruktion glenoidal und humeral mit entsprechender Remodelierung. Die kombinierte glenoidale Augmentation mit J‑Span-Plastik und der humerale Aufbau mittels Femurkopf-Allograft stellt eine gute Therapieoption für Patienten mit anteriorer Schulterinstabilität und großen bipolaren Knochendefekten dar. Insbesondere bei Patienten mit rezidivierenden Krampfanfällen ist diese glenoidal implantatfreie und humeral metallfreie operative Option erstrebenswert.

Aims: Current diagnostic tools are not always able to effectively identify periprosthetic joint infections (PJIs). Recent studies suggest that circulating microRNAs (miRNAs) undergo changes under pathological conditions such as infection. The aim of this study was to analyze miRNA expression in hip arthroplasty PJI patients.Methods: This was a prospective pilot study, including 24 patients divided into three groups, with eight patients each undergoing revision of their hip arthroplasty due to aseptic reasons, and low- and high-grade PJI, respectively. The number of intraoperative samples and the incidence of positive cultures were recorded for each patient. Additionally, venous blood samples and periarticular tissue samples were collected from each patient to determine miRNA expressions between the groups. MiRNA screening was performed by small RNA-sequencing using the miRNA next generation sequencing (NGS) discovery (miND) pipeline.Results: Overall, several miRNAs in plasma and tissue were identified to be progressively deregulated according to ongoing PJI. When comparing the plasma samples, patients with a high-grade infection showed significantly higher expression levels for hsa-miR-21-3p, hsa-miR-1290, and hsa-miR-4488, and lower expression levels for hsa-miR-130a-3p and hsa-miR-451a compared to the aseptic group. Furthermore, the high-grade group showed a significantly higher regulated expression level of hsa-miR-1260a and lower expression levels for hsa-miR-26a-5p, hsa-miR-26b-5p, hsa-miR-148b-5p, hsa-miR-301a-3p, hsa-miR-451a, and hsa-miR-454-3p compared to the low-grade group. No significant differences were found between the low-grade and aseptic groups. When comparing the tissue samples, the high-grade group showed significantly higher expression levels for 23 different miRNAs and lower expression levels for hsa-miR-2110 and hsa-miR-3200-3p compared to the aseptic group. No significant differences were found in miRNA expression between the high- and low-grade groups, as well as between the low-grade and aseptic groups.Conclusion: With this prospective pilot study, we were able to identify a circulating miRNA signature correlating with high-grade PJI compared to aseptic patients undergoing hip arthroplasty revision. Our data contribute to establishing miRNA signatures as potential novel diagnostic and prognostic biomarkers for PJI.Cite this article: Bone Jt Open 2024;5(6):479–488.

The current literature suggests that up to 55% of complications after plate osteosynthesis treatment for patients with proximal humerus fractures are attributed to the surgical procedure. The hypothesis of this study was that a standardized surgical protocol would minimize surgery-related adverse events. This prospective cohort study included 50 patients with a mean age of 63.2 (range 28–92) years treated by one single surgeon using a previously published standardized surgical protocol. Clinical and radiological follow-up examinations were conducted for up to 24 months using Constant–Murley Score (CS), Subjective Shoulder Value (SSV) and radiographs in true anteroposterior, axial and y-view. Finally, CS was 73.9 (standard deviation [SD]: 14.0) points (89% compared to the uninjured shoulder), and SSV was 83.3% (SD: 16.7) at two years of follow-up. Postoperative radiologic evaluation revealed no primary surgical-related or soft-tissue-related complications (0%). The main complications were secondary, biological complications (20%), largely represented by avascular necrosis (8%). Eight patients underwent revision surgery, mainly for implant removal. In addition, a total of four patients were revised using a hemiarthroplasty (n = 2), reverse shoulder arthroplasty (n = 1) or re-osteosynthesis. The use of our standardized surgical technique on proximal humerus fractures improves fixation with regard to primary stability and prevents primary, surgical-technique-related complications. The subjective grading of a high level of difficulty surgery was associated with more complications.

Head-split fractures are proximal humerus fractures (PHF) that result from fracture lines traversing the articular surface. While head-split fractures are rare, surgical treatment of these complex injuries can be extremely challenging and is associated with high rates of complications. Treatment using primary reverse shoulder arthroplasty (RSA) has been associated with moderate complication rates and reproducible clinical results. The aim of this study was to evaluate clinical and radiographic outcomes, and complication rates of RSA for head-split PHF. Twenty-six patients were evaluated based on Constant Score (CS) and range of motion of both shoulders and Subjective Shoulder Value (SSV). Radiographic analysis evaluated tuberosity healing, prosthetic loosening and scapular notching. Patients achieved good clinical results with a CS of 73.7 points and SSV of 82% after a mean follow-up of 50 months. The relative CS comparing operated versus the unaffected shoulder was 92%. Greater tuberosity healing was achieved in 61%. Patients who suffered a high-energy trauma reached a significantly greater functional outcome. Patients who suffered multifragmentation to the humeral head performed the worst. There were no cases of loosening; scapular notching was visible in two cases. The complication rate was 8%. RSA is an adequate treatment option with for head-split PHF in elderly patients.

Tuberosity healing and stem design can be outcome-dependent parameters in hemiarthroplasty for proximal humerus fractures (PHF). The relevance of fracture-specific stem design in reverse shoulder arthroplasty (RSA) is still a matter of debate. This retrospective study evaluates tuberosity healing and function for fracture specific stems (A) compared to conventional stems (B) in RSA for complex PHF in 26 patients (w = 21, mean age 73.5 years). Clinically, range of motion (ROM), Constant-Murley-Score (CS), Subjective Shoulder Value (SSV), and external rotation lag signs (ERLS) were evaluated. Healing of greater tuberosity (GT) and lesser tuberosity (LT), scapular notching, and loosening were examined radiologically. There were no statistical significant differences with regards to CS (A: 73 ± 11; B: 77 ± 9 points), SSV (A: 78% ± 11%; B: 84% ± 11%), external rotation (A: 18° ± 20°; B: 24° ± 19°), or internal rotation (A: 5.7 ± 2.2; B: 6.7 ± 2.8 CS-points) (p > 0.05). Mean forward flexion was superior for group A (p = 0.036). Consolidation of GT (82%) and LT (73%) was similar in both groups. Anatomical healing was slightly higher in group B (p > 0.05). Scapular notching was found in 27% (A) and 55% (B) (p > 0.05). RSA for PHF provides good to excellent clinical results. The quantitative and qualitative union rate for both cohorts was similar, indicating that fracture stems with open metaphyseal designs to allow for bone ingrowth do not improve tuberosity healing. ERLS correlates with a worse function in CS and ROM in all planes.

Stemless total shoulder arthroplasty is a well-established and reliable surgical treatment option for glenohumeral osteoarthritis resulting in loss of pain and improvement of shoulder function. Currently the two methods for the fixation of the humeral component are either screw fixation or impaction. The purpose of this study is the clinical and radiological comparison of two different stemless designs (screw fixation vs impaction) for total shoulder arthroplasties in patients suffering from primary glenohumeral osteoarthritis. A retrospective cohort study including 39 patients with a mean age of 67 years and a minimum follow-up of 2 years was performed. Patients were separated into two groups based on the selected implant. In group A (n = 18) a screw fixation design and in group B (n = 21) an impaction type design was used. For clinical examination the Constant-Murley-Score (CS) and Subjective-Shoulder-Value (SSV) were evaluated. Radiological examination was performed on true-AP, axial and Y-view radiographs. In group A the CS increased from 27.1 to 65.2 points and SSV from 27.3 to 76.7% (p < 0.05). No osteolysis of the medial calcar or subsidence of the humeral implant were found in this group. In group B the CS increased from 29.0 to 72.6 points and SSV from 33.1 to 85% (p < 0.05). Osteolysis of the medial calcar was present in seven patients in this group. No signs for humeral loosening were found in both groups. Impaction and screw fixation total shoulder arthroplasty for primary glenohumeral osteoarthritis using a stemless device provide reliable clinical results. The screw fixation seems to prevent osteolysis of the medial calcar.