Top of the Tops - Rotterdam 2025

Here we go folks - this is a audio summary of the best papers picked from Rotterdam 2025. We are proud of so many fantastic research. We have the authors (Alessandro Marinelli, Stefan Bauer, Eline Van Es, Bertram The, Arno Macken, Koray Sahin) gathered at one big table and discuss their findings - enjoy! 

music under CC BY-SA 4.0 license: 

Artist Jahzzar, Album: Ashes, Title: Zodiac

Artist Jahzzar, Album: Come, Title: Leith Walk

Transcript

Bertram The: 0:01

B

Robert Hudek: 0:15

So welcome everybody to the next episode of our SESEC podcast and today is a very special episode because we are not sitting at home, everybody online with his computer etc. The dog is barking in the background, something is falling apart, microphone doesn't work. No, we are in a professional studio here on the SESEC Congress in Rotterdam and they have a really fantastic studio so we can gather here all together at the session which is called Top of the tops and we have seen their papers and it's the really best rated papers on this year's CESEC Congress and I have all the authors here not all but almost all some had to travel home again unfortunately but most of them are here so I'm very happy to have them here so I might introduce you now to all these people on my left side is Alessandro Marinelli he's from Italy from Bologna and he's from the Rizzoni Orthopedic Institute then Then we have Stefan Bauer from Morge, which is close to Lausanne in Switzerland. And he's affiliated with the University of Western Australia. And we have Aileen van Es. She's from the Netherlands and she's from the Erasmus Medical Center. And she's a human movement scientist, which I think is fantastic that you are here on Orthopaedic Surgeons Congress, which is really great. And next to her is Bertrand T. He's also Dutch from the Netherlands, from the Amphia Hospital in Breda. and then we have Arno Macken he's also a Dutch from Amsterdam he's working in Amsterdam but this study has been done in the Alps Institute in France and we have Koray Sahin from very beautiful Istanbul in Turkey and he's with Bezemalem University in Turkey so thank you for you being here and I just met Peter Chalmers from America and I have to tell in this podcast so the first podcast session i experienced was with peter chalmers from usa asus and he inspired us a little bit so thanks peter for this inspiration and my name is robert hudeck i'm from the artos clinic fleet in hamburg in germany and we start once with the first paper here which is from alessandro alessandro you did a paper on radial head prosthesis with a really long follow-up why did you do this study what was it about and how did you do it?

Alessandro Marinelli: 2:46

Thank you. The radial head fracture are common fracture and we implant very often radial head prosthesis and many times we know we have to implant also in young patients. Looking at the literature we can see that the number of radial head arthroplasty is more than doubled in the last 10 years. And many of our patients are young, are hand workers, and there is a paper showing that most of them practice sport also after having had their surgery. And so the problem to how can, what happens to an elbow after many, many years of metabolic implant is a problem. And it's a big responsibility when you have a young patient, 25, 28, 30 years to decide if you have to reject, if you cannot fix the fracture. And many times we know that for mid-term follow-up, the radial head prosthesis is a good solution. What we don't know for sure is what happens after many, many years. For this reason, we decided to review our CAVE series, and we were able to collect 39 patients with a long follow-up from 15 to 22 years of follow-up. And we were surprised to see good results, good clinical results, because the radiologic ones are not so good. We observed more than 80% of degenerative arthritis in the elbow, but this arthritis was not clinically significant. And so, based on this study, the message from this study is that when we can fix a complex fracture dislocation, when we can, every time we can fix the right head, we have to go for fixation, but even if the it's not possible to perform a fixation. Even in a young patient, a radial head prosthesis can be a good choice because after 15, 20, 22 years, the clinical results are good. This, I think, is the point of the paper. So,

Robert Hudek: 5:33

wonderful long-term study, really. I think this is something that goes through every surgeon's head who's just operating somebody and you're thinking, oh my God, how long will this thing survive but you tested different implants you have press fit stems you have loose fit stems you have cemented stems which one was the best which one would you take if you would have to operate tomorrow a fracture when you go home to Bologna which stem would you take

Alessandro Marinelli: 6:01

um With our study, we cannot demonstrate that an implant is better than another. At this moment, from our study and from the literature, we can choose between different implants. There is no one better than another. What we can see is that based on our experience and on the literature, all the complication happens in the first two years. So another take-home message may be to strictly follow the patient for the first two years. After two years, maybe the follow-up is not so important.

Robert Hudek: 6:58

Okay, wonderful. So if you think about complications, what complications could that be?

Alessandro Marinelli: 7:06

We saw stiffness. The most common complication is stiffness. Obviously, it's not the fault, it's not our responsibility, it's not of the implant. It's because we implanted the redhead prosthesis in a complex fracture dislocation, terrible trial and dislocation, so capsule contracture, heterotopic ossification are not caused by the implant but are caused by the pathology we treated. So it's important I think to explain to the patient in the pre-op that is very common to have a loss of degree in extension especially in extension. How much extension deficit do you tell your patients? It's very common to have a 20, 25, 30 degrees. However, the functional range of movement is conserved. Stefan, you had a question.

Stefan Bauer: 8:15

Yeah, great study. Congrats. A question about factors which could be associated with increased risk of arthritis. Did you look as well at, for example, overstuffing or did you find any factors associated with poor risk after such such a long time?

Alessandro Marinelli: 8:35

We saw, thank you, we saw that complex fracture dislocation like terrible triad presented more arthritis than simple radial head fracture treated with the prosthesis. We didn't have a number to demonstrate that the perfect implant technique is better than overstuffing.

Bertram The: 9:05

Can I also ask you something, Alessandro? A great study, very interesting to see the bigger numbers and the longer follow-up time. Is there anything to be said with regards to the ones that have also suffered from a longitudinal forearm disruption kind of injury, and then in the sense of which types of pathology could you find maybe on the capitellar side in the long run, or is there anything that we can do to prevent that which types of prosthesis fare well and those types of injuries which do not, like monopolar versus bipolar maybe. How do you handle the associated injuries adequately at the time of presentation of those patients?

Alessandro Marinelli: 9:51

Thanks. It's very, very important to the correct treatment of the associated lesions. Many times we think that when we see that the right of head prosthesis fails is because of the implant. Many times it's just because we have not treated correctly the lateral collateral ligament or the medial collateral ligament or it was an excessor presti lesion and we didn't treat the forearm instability. So it's very important not just to put the prosthesis but to recognize and treat the associated treatment lesions. Many times, a suggestion, many times we can see on the capitellum like a chondral lesion during a fracture, a radial head fracture. And it is good to sign, to report this in the description of your surgery because obviously it's more easy to have a degenerative arthritis if you already have a chondral damage. At the moment it's not possible based on our study or the literature specify if the bipolar is better than monopolar.

Robert Hudek: 11:17

Thank you very much. I think we can learn a lot of this study and we have to go on to the next one which is here presented by Stefan Bauer. The title is acute open reduction and internal fixation versus non-operative treatment of scapular spine fracture after reverse shoulder arthroplasty. Well, this is a really threatening complication. Everybody who does reverses knows, oh my God, there's a spinal fracture. And Stefan, you found out what to do. So what should we do if somebody comes with a spinal fracture? Fix it or leave it conservatively?

Stefan Bauer: 11:49

Thank you, Robert. Yeah, I may give you just a bit of background how I got to the study. So as we all know, the complication is well known and was already known with the Gramman design. but was less frequent with the Gramont design. And then for 10 years, I was using a system which was an onlay system with base plate lateralization. And we know from the literature, and I experienced that as well, that the fracture were a little bit more frequent. So literature states about 4% compared to 1%. And as you say, it's a threatening complication because at the beginning when the patient presents and they have a lot of pain and are very unhappy, so I decided to fix one with a double-plate construct. I had over the first three years a case a year, so the first three I fixed and presented them later at a meeting when I met George Athwell, who said, yeah, despite the literature saying we should not operate on them, I recommend to fix them acutely as well. And so we started thinking about putting our cases together. And George mentioned John Levy, who has coined the classification with the Levy 1, 2, 3 classification. And what we thought was we need to fix the twos and threes, which are more medial, not the lateral acromion fractures. And we joined forces and set up, pulled our data. It took a little bit of time. with the ethics but we were able to then do a study on acute fracture fixation that's important that we included only patients which were acutely fixed within the first six weeks and compared them with a match design to non-operatively treated patients.

Robert Hudek: 13:56

But one question in between you said it's type 2 and 3 maybe you can update our listeners again I don't know if everybody is familiar with the Levy classification. So where exactly is the type 2 and type 3 fracture in the spinal?

Stefan Bauer: 14:08

Basically, the type 1 fractures are lateral in the acromion region and at the level of the joint line towards the base of the acromion where the acromion transitions over to the scapular spine is the type 2. And the type 3 is even more medial at the level of the scapular spine. And why fixing the more medial ones? Because they perform worse regarding function. And that has been shown. John Levy has done a big study before on norepinephrine treatment. He had already shown that the conservative treatment works well regarding pain for the lateral fractures, but especially the function is very poor for type 2. and type 3 medial fractures.

Robert Hudek: 15:04

So if you compare the operated ones, all plate fixations, and the conservative ones, how were they treated conservatively?

Stefan Bauer: 15:14

They were treated with symptomatic treatment, basically with abduction, sling, some rest, anti-inflammatories, and then according to what was tolerated, physical therapy, pain allowed.

Robert Hudek: 15:33

So what did you find out? What would you recommend our listeners and the SESEC Society to do with a spinal fracture?

Stefan Bauer: 15:42

Basically we had a group of 58 non-operatively treated patients and 16 operatively treated patients in three centers. And the outcome parameters were pain, so the visual analog scale, the ASES score, subjective shoulder value and function, especially active forward elevation. and there was a significant difference in favor of the acute operative treatment for all before matching for all outcome parameters. We matched them for five criteria. We matched for age, sex, preoperative diagnosis before reverse arthroplasty, such as CTA, catheter arthropathy, osteoarthritis, and as well for the Levy classification 2 and 3 We matched them as well, and we were able to match 14 patients one to one. And this showed that the pain is not significant anymore after matching, meaning that the patient after conservative treatment, they get better regarding pain. But the big difference between two groups is the function. It's the forward elevation, the ASES score as well, subjective shoulder value, because patients obviously are already relieved if they have no pain anymore but they are not so happy that they can't raise their arm properly anymore and that was the big difference and there's one last factor we looked at as well radiographically is the union so the union rate in the open reduction group was over 90% whereas in the non-operative group the union rate of these displaced fractures to start with was only 30%.

Robert Hudek: 17:29

So if I call you and I have a a spinal fracture after I did a reverse and it has a type 2 or 3 you would definitely recommend me to plate it.

Stefan Bauer: 17:39

There is one last factor we need to factor the patient condition and the bone stock into account and we were successful I was successful in double plating George Uswell uses a hook plating construct which worked as well and And John Levy as well, double plating. And if you want to do a double plating, you need lateral fixation in the acromion. If there is no acromion there anymore, insufficient bone stock, and you can't get screws in, then you should maybe not operate on them. So these patients need 3D CT assessment of the bone stock to be successful with a double plate fixation construct. And one last factor is really as well that when we fix them and when we can't at lateral fixation you should span with one plate the full scapular spine not to run into problems with the stress riser and a plate adjacent fracture.

Robert Hudek: 18:43

Okay, thank you very much. I think this is also very interesting. I always treated my spinal fractures conservatively but now I'm starting to think about maybe I should really call you and ask especially which plate to take because this is very different. Okay, I think we have to move on to the next study and the next one is Aileen Farnes. You brought us something very special because it's the forearm. It is well connected to the elbow so you are part of the elbow on the forearm and it's all about radial or forearm correction osteotomy. So can you explain us what exactly was this study and why did you do it? How did you conduct this?

Eline van Es: 19:26

What we did was a randomized controlled trial in which we looked at the added value of patient-specific 3D-printed guides. And these are guides that can be used during surgery, corrective osteotomy. And indeed, I did this study on forearm malunions. And I worked closely together with Dr. Joost Colaris, who is a forearm surgeon, and Professor Denise Eigendael, who you all know, of course. And I did this study on forearm malunions. And we included patients with a malunion, a symptomatic malunion of the forearm. And the symptoms were especially that they had a limitation in pronation and their supination, so a severe limitation. And all of our patients were at least six years old. And because we planned this surgery in three dimensions, and we think it's very important to plan these kind of corrections in three dimensions because the bones can be translated or angulated or even translated toward each other after a malunion or after a fracture and after the healing of the fracture. So we think it's essential to look at these kind of malunions in three dimensions. So we analyzed all of our patients with a CT scan and we created 3D bone models and after that we made a CT scan of both forearms so one of the forearms had to be without any abnormalities and we mirrored the non-affected forearm over the affected forearms for the radius and the ulna separately and that helped us to analyze the malunion in detail and from A previous study that we performed, we know that it's very helpful if you plan a correction of such a malunion, that it's very helpful to use patient-specific guides. And these are guides that can be placed on the bone during surgery and that helps the surgeon to drill and cut through that guide and to perform the correction as precise as possible as planned before and in our previous study we had very good results but this kind of innovative techniques that are expensive and at the moment it's not reimbursed by the insurance companies especially in the Netherlands but as I heard in many countries in in Europe. And in literature there's a lack of randomized control trials to look at the added value of this kind of techniques. So that's why we set up our RCT and we randomized between patients that were operated on with the guides and patients that were operated on without these kind of guides.

Robert Hudek: 22:57

And how did you randomize? Patients picked a number?

Eline van Es: 23:01

No, it was computer-based randomization.

Robert Hudek: 23:04

So what did you find? So you were looking on post-operative outcomes, right? So the guided group with the cutting guide versus the same operation without the guide. And would you recommend to use the guide? Is the guide group better?

Eline van Es: 23:22

Yes, it was better. So we included 30 patients, 15 in both groups but I have to say that also in the group without guides we analyzed the deformity in 3D and we planned a correction and that's because of ethical reasons so the surgeons didn't want to correct the bones only based on conventional x-rays but yeah so we included 30 patients and we saw that in the group with the guides that there was an around 15 degrees better total elbow rotation after one year so at baseline both groups had around 50% of total elbow rotation and one year after so our primary outcome was the gain in rotation so after one year we saw in the group with the guides that they reached 95% of the of the contralateral side. But also the group without the guides did perform well. They came to 84%. Yeah,

Robert Hudek: 24:41

fantastic. So may I ask, how much does such a guide cost in the Netherlands?

Eline van Es: 24:50

Yeah, that's around 2,500 euros or 3,000 euros if we outsource it. But yeah, our hospital I am the one who is doing all that kind of planning and I designed that guide but it's a full time job

Robert Hudek: 25:09

so it's 15 degrees for 2500 I think it's a good investment yeah if you would ask me okay you want to have 15 degrees more it costs 2500 I think I would pay it but Bertram you have a question

Eline van Es: 25:26

yeah

Bertram The: 25:26

maybe just to add but it's just an opinion and perspective I I think that the actual results that you may get with this technique are actually better than what you are able to present now. First of all, because what you said, that you have done some planning, so it's actually like the use of the jigs, which are of added value, apparently. But the planning itself, probably as well. We don't know how much, but yeah, it may be. I think so. And the other thing is that your group is a group of experts, very experienced experts like Joost Colaris, Denise Eigendaal. And there are also people, many people who are much less experienced and are going either to take it on and may not get the same results. So the difference would be even better if you would add these kind of guides, et cetera, which makes it more probable that they would also reach a good result. And the other one is that I also see a couple of patients who come to my clinic for the same reason, but they have been refused surgery elsewhere because they say like, yeah, this is not, we can't do it reliably, so we're not going to do it. And they're sent off. And all these things make that, I think that you're actually even underestimating the impact that you're making with this technique. It's my opinion.

Eline van Es: 26:54

Yeah, I fully agree with that. Indeed, we have a very experienced team And we also get patients from all over the country that are sent to us because other surgeons who do not use this kind of techniques do not want to perform this kind of correction. And that's the reason that we are not able to do it without 3D analyzing. But I think it's underestimated... therefore and the other thing is that we also had a shorter surgical time in the group with the kites a shorter incision length and we also had two patients who had a revision surgery within one year and both of these two patients were in the group without kites and we did intermediate analysis of these patients and we saw that the correction was not correctly as planned before. So we corrected them within one year with the guide. So that's also estimated to our final result, I think.

Robert Hudek: 28:12

Okay, Eileen, thank you very much for this beautiful study and we go to the next one and Bertram, you have presented us the long-term results, long-term clinical outcomes of the distal biceps tendon reconstruction using fasciolata allograft. Can you tell us

Bertram The: 28:28

more about it? Yes, that's correct. Yeah, we thoughts to do this study to get real insights in the group of patients that present too late with a complete tear of the distal biceps with the retraction of the muscle belly so not amenable to primary repair expecting one thing but getting something else out of this study in the end so we had a group of in the end it was I think 27 patients who consented to participate in this study from the 39 that we had. And they came in an average about three, four months after tearing their distal biceps. But it was a wide variety actually, some a bit earlier, some of them a couple of years down the line as well. And because of that last part, the retraction, the muscle belly that you can't get back to where it belongs. I was expecting that the functional results would be inferior, maybe mediocre with respect to what you would get with a primary repair. But I knew that those patients in general, how they reported in the outpatient clinic were happy enough. The fact was that, in the end, the results pointed in a different direction, actually. Functionally, they were good, which still surprises me a bit. Apparently, we have a bit more margin than we think, and losing part of the contractile properties of this muscle belly, apparently, we can do without it. But the ones who were really dissatisfied with this technique were dissatisfied because of the cosmetic result. Um... And we thought that we informed them very well at the start, but apparently this is a lesson. We don't do that well enough because they were unhappy up to the extent that some of them said that they wouldn't do it again, actually. And those patients were also patients that had scored very high on the functional scale. Surprising to me. And it's not just bodybuilders. They were also just, let's say, regular patients. people like you and me who were really upset by the cosmetic end result.

Robert Hudek: 30:58

A technical question Bertram, how did you harvest fascia lata, how long was it and how did you fix it to the

Bertram The: 31:04

retracted muscle belly? Yeah, so in general for most cases it was a let's say intermediate so that's like a 10 centimeter, just a 10 centimeter tissue, piece of tissue that you use as a wrap around construct and then we would use two rows of a non-absorbable suture going towards the insertion site and then back again. And that turned out with regards to re-tear rates to be sufficient. So we don't really see that actually. And it gives you the opportunity to sort of fine tune, to taper the end of the distal biceps, but make it strong enough at the proximal part of the interface. And what about complications? Is there more? Yeah, this is a worry in this group because it's very different from primary repairs. We saw actually tons of the complications that were not deemed to be the severe adverse events, but still, and usually it's like temporary loss of LABCN function, so they have a loss of sensory function in the forearm. It almost all recovers within, let's say, three to six months, but it's there. The severe adverse events were mostly related to infections, which is also something that we see with allografts. I didn't realize it was this big a problem because we had three patients, but five complications in three patients, so one of them had three times an extra intervention because of the infection, either surgical or antibiotics. So that is severe. And that is a problem and worthwhile consulting the patient about.

Robert Hudek: 33:04

You have an explanation why out of a sudden infection in the elbow, it's much less than in the shoulder in comparison. Is there any

Bertram The: 33:11

explanation? I'm not 100% sure. So these numbers are affected highly by this one patient who had three adverse events in one arm. starting with the intervention being the third one performed in his arm. And we were getting in at that point. So it was already infected, and then we tried to fix it or reconstruct it and handle the infection, but it wasn't a success. So he ended up being operated on a couple of times. If you take that one away, we are left with one infection in the whole group and one wound deosin. So... I'm not sure if this is fully representative of how future series would perform. But it is a thing that sticks with me, obviously, because they're debilitating these complications.

Robert Hudek: 34:03

And were you able to compare the fascia lata group to a conventionally treated group when you try to get the biceps down as good as possible? Were you able to compare that

Bertram The: 34:17

somehow? Actually, not in the sense that we have done a couple of other constructs, but those were in low numbers, such as the autolycus grafts. And at one time when there wasn't even a fascia lata, we used a different one. We've used the Achilles tendon as well. One reason for our choice was very ordinary, actually, and that's costs. This was the cheapest one, much cheaper than Achilles tendon in our case. It saved us about 40%. While not adding to extra comorbidity by taking the tendon from the patient itself. So it was a bit of a choice more than that it's right or wrong, I would say.

Robert Hudek: 35:01

Yeah, important point in our business. I mean, we have to respect that. I mean, society and insurances and social system is paying for that, at least in many European countries. So it's always an important point. But if I would, again, question again, imagine I would call you, yeah, your phone rings. I say, hi, here's Robert from Hamburg. I have a patient with distal biceps rupture and I'm not sure whether to use a fasciolata allograft or not. What would be the ideal patient for a fasciolata

Bertram The: 35:36

allograft? So it should be retracted for a while, this patient. It should be ideally someone who is not prone to infections, those kind of things, who's able to abide by the rules because we are not just with these reconstructions but with the primary repairs as well. We're rather strict. I'm not sure if we should always be that strict, but we tend to be. I know that Greg Bain, for example, he laughed a bit at the protocols that most of us use, I guess, because he sees those ones in remote areas and says, I'm just fixing it and off you go. But we tend to be very serious about the post-surgery rehab period and the restrictions that we demand from the patient. So yeah, I would find that argument to go in for it after consulting about all the things that I've learned from this study as well. And I'm probably stressing what they also should expect with regard to cosmesis, because that's apparently a reason for them to consider it a failure, even though functionally it could perform well.

Robert Hudek: 36:40

Bertram, thank you very much for your beautiful insights to this topic of distal bites with brushes. An infection is a good mark to fade over to the next... author here and this is Arno Maken from Amsterdam. We introduced you already. You have presented a study about preparations of the skin and preoperative preparations to reduce cutibacterium acnes, right? Can you give us some more insights and a comprehensive review of what you did and why did you do it?

Arno Macken: 37:14

Yeah, exactly. And thank you for having me on the podcast. So we designed a study to try to reduce the load of C. acnes in shoulder surgery, so we're moving a little bit up from the elbow, which we know causes problems in the shoulder. We don't know exactly what the role is of C. acnes in shoulder complications, infections, and revisions, but this study aimed to try to reduce the load of C. acnes during surgery because we know that the regular disinfectant strategies that we use before surgery are not as effective for C. acnes because it's deeper in the skin, it's in the hair follicles, and several strategies have been tried before, such as trying peroxide, which is lipophilic and penetrates deeper into the skin. And one study previously tried disinfecting the deeper layers after the incision. So when you start the surgery, you do all your prepping, you do the first incision and then you disinfect again, in our case with povidone iodine. You wait for 60 seconds, you clean it out and then you continue. And what we asked ourselves, because all these strategies are still not 100% effective. So we asked ourselves if we combine more strategies together, so we combine those three, regular disinfection, the deeper layers and the peroxide, if that would be even more effective, we can try to reduce the load of C. acnes even more. So what we did is we included 156 patients and randomized them into three groups, one control group, one with the disinfection after incision, and the third group got all three. So they applied peroxide before the surgery and the deeper layers layer disinfection and the regular one. And then we took swaps from the surgical field, the gloves, the materials, but also the deeper layers. And that was the primary aim of this study to look at the cultures from the deeper layers. And what we found was that our triple prevention protocol was effective at reducing C. agnes load, which I think is an interesting result. Of course. And

Robert Hudek: 39:16

can you give us an insight? How was it distributed? So how many Yeah, see, Agnes, did you find in the standard group where you did protocol like always, so without BPO and without povidone-iodine, versus then the second group where you used the povidone-iodine after incision only, and then the third group where you used all of them, like three days, I've read three days of benzoylperxide, then incision, iodine, and then you go deeper.

Arno Macken: 39:52

Exactly. So if we only look at the cultures from the deepest layer, so the interarticular layer, it was for the control group 30% positive for C. agnes, that's not even counting other bacteria. For the double prevention group, so just in disinfection after incision, it was 20%. And then when you go to the triple prevention group, it was 10%, which was a significant difference.

Robert Hudek: 40:18

So you took samples from the very deep of the joint that was the mark where you harvested it. And how did you collect the cultures? And I mean, you took specimen from, I read, many different positions like retractors, gloves. Where did you take all those specimen from?

Arno Macken: 40:43

Yeah, that's actually quite a lot of work. So we took nine swabs per patient, which means in total study that's 1,500 cultures so it's quite a lot of work to get all those done and sent to the lab and analyzed and basically we took swaps of the skin also on the contralateral side and before prepping just have a look if the benzoyl peroxide was effective and also to have a control and then we took swaps from different locations in the surgical field so the retractors the gloves of the surgeon the scalpel and also different layers of the surgery so subcutaneous muscle layer and the interarticular layer.

Robert Hudek: 41:24

And Stefan, you have a question.

Stefan Bauer: 41:27

Just a question. Did you use on the skin films or an iodine film you stuck on? No, we didn't use any. I'm asking that because you said there was a difference between the skin prep and the one who got everything. So I suggest, because I feel always the deep layers of the skin incision where the hair follicles are. This is a big source of cutibacterium acnes. And I try to seal it off with a film that we don't touch anymore the native skin, which you obviously, where you obviously reduce the load of the bacteria with your swabs, proven with your swabs, by your protocol.

Arno Macken: 42:15

Yeah, exactly. And I think, well, there have been some studies on the sticky layer, which I believe haven't been very effective. And I also think that you're cutting through the deeper layers, and I think that's where it's coming from. So covering it on top doesn't do that much because you cut through it anyway.

Stefan Bauer: 42:33

Exactly. And so my protocol was always to cover the skin, not to touch it, and then do the disinfection of the deep layer right after incision. What do you have in your protocol as well?

Robert Hudek: 42:46

I'm also very thankful for your study because the iodine... povidone iodine preparation. This is how I do it in my daily routine since many years. And so I'm thankful that you could show that we have at least less bacteria. But another question, you have open surgeries and arthroscopic surgeries as well inside your group?

Arno Macken: 43:11

Yeah, that's correct. So it's 50-50, open and arthroscopic. Okay, so retractors, did you send them away? I mean, If you take a specimen or some sample from a retractor, did you send the retractor away because now it's missing on your table? No, so for the arthroscopic surgeries, the locations were slightly different, but we tried to take similar positions. So instead of the retractor, we would take the obturator, for example. So for arthroscopic, we had similar positions where we took the swab, and the only thing we would do is to take the material, yeah, rub it with the swab and then send the swab away and then keep continuing the surgery as normal.

Robert Hudek: 43:58

So what is your recommended protocol now? After your study, I mean now you're smarter than before. How exactly do you prep the patient now?

Arno Macken: 44:11

So what we currently do in Annecy is exactly the protocol for Group 3. So we do the regular disinfection, disinfection after incision and the peroxide beforehand, the two days before surgery.

Robert Hudek: 44:25

So two days before and you ask the patient to put the peroxide himself on the shoulder two days before surgery and then you take water-based povidone iodine because I think that's important to say because there's also formulations with povidone iodine with alcohol. And with what disinfection, what do you use? You use in... Octenidine or alcohol?

Arno Macken: 44:54

It's water-based povidone iodine, 10%. For

Alessandro Marinelli: 44:58

the skin

Arno Macken: 44:59

as well? So the skin is 5% and after incision it's 10%.

Robert Hudek: 45:02

Skin 5%, after incision 10%, povidone iodine, water-based. That's important information. Stefan, you have a question?

Stefan Bauer: 45:11

Great study. One last question. Since you mentioned that you did an arthroscopy as well, do you have a recommendation how we could protect the sutures from the anchors which will come out of the portal and stay for a while, maybe 10 minutes. Either they lie on the skin or they rub on the portal, on this cut layer of your portal incision. Would you recommend to use more cannulas?

Arno Macken: 45:39

That's an excellent question. And the protocol becomes a bit more difficult in arthroscopic surgery, especially if you're making new portals later, because then you have to go through it again, this effect, until you continue into the joint. So it's a bit less practical. And I think you have to find a way that works for you. For the open surgeries, we wait 60 seconds when applying the iodine. If you keep waiting 60 seconds for every new portal, I think your surgery will take quite long. So we find a practical midway. So we do the stab incision, a quick disinfection, and then we continue into the joint. And hopefully that way your materials are protected as well. Or you try to play them somewhere where it doesn't touch that much because if you look at our study we also find that c-acnes is popping up sometimes everywhere on those gloves on the materials on the table and so uh yeah try to uh to keep them in a place where they don't touch anything

Robert Hudek: 46:37

i tell you we will in a couple of years we will all find out that it is living there even long before the surgeon arrives and this is one hypothesis um which which could be true that it's just living inside the and it's a commensal. Last question before we go to the next author. In my routine I use the water-based povidone iodine not only after the incision but also during surgery. Like imagine the situation you're waiting for the nurse to say give me the base plate and then there's a few seconds or a minute time so I take the iodine and I wash the joint a little bit with iodine. Do you do the same?

Arno Macken: 47:21

sometimes we do but that's not included in this study particularly and I think I would have to dive into the literature to see what the evidence base for that is

Robert Hudek: 47:33

or make a new study exactly thank you very much for this interesting topic and we go to our next author who is Koray Sahin and you are going to tell us something about the treatment of proximal humerus fractures and the sling do we need a sling Koray when I come to Istanbul and I break my proximal humerus what kind of sling would you give me?

Koray Sahin: 47:58

That's a good question and I think you will have to answer after this talk and first of all thank you for having me here in this podcast just let me explain myself how we came up with the idea of this study we are all surgeons we love to operate on patients but Before that, we are all medical doctors, and particularly for proximal humerus fractures, we do not operate majority of the patients. But when we check the literature, surprisingly, the evidence-based data is really limited regarding conservative treatment of these fractures. And immobilization is the first step of conservative treatment. We asked the questions, how can we create a new evidence about these different immobilization methods? And we conducted a prospective trial, randomized trial. We created three separate study groups. Group one with VELPUS link, this is a ducted and internally rotated shoulder immobilization. group two basic arm sling and group three is abduction brace, abduction sling. And the outcome measures were range of motion values, functional scores and pain scores, and minimum follow-up duration was one year. And we also searched, looked for radiological results as well, such as non-union, malunion, and surprisingly couldn't find out any difference, neither clinically or radiologically, between these methods. So for your question, I can say that it depends on you. It depends on the patient. Because sometimes, as you may all agree, these fractures at the very beginning of the follow-up duration, patients have a high amount of pain, and they feel discomfort. So I think it's better to find the best immobilization method for each patient.

Robert Hudek: 50:30

So how many different slings do you have in your study?

Koray Sahin: 50:33

Three.

Robert Hudek: 50:34

Three different slings. And did you randomize the patients?

Koray Sahin: 50:37

Yes, we randomized it. It was a computer-based randomization.

Robert Hudek: 50:42

It's always a little bit hard on the radio to imagine a sling, but you mentioned one sling in the front. Can you maybe describe it a little bit? with your words how these slings were looking like?

Koray Sahin: 50:53

Oh yeah, the first one was a velpo bandage. It holds arm in internal rotation and shoulder in abduction. And the second one, we call it basic arm sling. It's neutral rotation or maybe a slight internal rotation in abducted shoulder. And the third one was abduction brace. It was a sling, not a brace. It holds shoulder and 30 degrees of abduction, abduction and slight external rotation.

Robert Hudek: 51:32

So, and all the functional parameters you tested and all the radiographs you tested. They were all comparable. All the same. Yeah. It's sometimes funny that you see, everybody has sometimes a very strict rule on what type of brace to take. And if you ask some surgeons, they say, no, you only have to use this one and after the end if you compare would it be even possible to use no brace at all? Yeah maybe this might be a future question for a future study why not? So which one of the three is more comfortable for the patient?

Koray Sahin: 52:11

For my personal opinion if you ask it basic arm sling especially fat patients patients with large your waist circumference, they have really difficulty to hold that cushion under abduction sling. They always complain about it. I think we should not insist on, no, you have to keep this on. Our study showed that it changed nothing.

Robert Hudek: 52:38

And how do you treat them? Most of the patients ask, should I wear this also during the night?

Koray Sahin: 52:47

Yeah, in our protocol, We ordered them to put them on regularly 24 hours per day for two weeks. And after two weeks, we made another x-ray examination and we asked patient about their pain. If the pain was resolved and no significant fracture, disinfection or mal-reduction, we stopped immobilization after two weeks.

Robert Hudek: 53:24

Only two weeks? Always only two weeks? And did you do some little active pendulum mobilization

Koray Sahin: 53:32

then after two weeks? After two weeks. First two weeks we just allowed wrist and elbow motion in order to avoid stiffness and after two weeks we started passive range of motion like pendulum exercises.

Robert Hudek: 53:45

And when did you start with active movements for the patient? So really Like, okay, now you can do what you want?

Koray Sahin: 53:52

Again, it was not standard for all patients. It depended on the fracture and the compliance of the patient to the protocol. Depending on the recovery, we started active motion around four to six weeks.

Robert Hudek: 54:13

There's a question

Stefan Bauer: 54:14

over there, Stefan. Very interesting. I wanted to make a comment on Australia, for example, has adopted for other injury patterns like AC joint dislocations, clavicle fractures, as well a broad arm sling, I think the broad arm sling is similar to what you say is probably most comfortable as well for the proximal humerus fractures. Long before Before we adopted other slings in Europe where we used still so-called rucksack orthoses on some of these injuries which were more uncomfortable and interesting that it is here the same. We have got a second question, your fractures. What fracture types

Koray Sahin: 55:06

were they? That's a good question and I think that's one major drawback of our study. We didn't find our study population. We included all available proximal humerus fractures. Maybe we could have performed a subgroup analysis but we didn't have enough patient number to do that.

Stefan Bauer: 55:29

I'm asking this question because there's at times fracture patterns where I've seen non-unions occurring if we move them too quickly especially in the surgical in the in the sub-capital area, not the capital fraction below, so that starts pivoting around if they are too mobile and then later you have a non-union. Do you think that as well? Yeah, we did

Koray Sahin: 55:56

so. We excluded patients when we suspected a possible non-union and we planned an operation, we excluded them.

Robert Hudek: 56:07

Okay, wonderful. So thank you very much for this wonderful meeting here. I took some pictures, maybe you too, and I think we're going to post them on the SESEC website because this is something very special. It's the first time we did an on-Congress interview, and thanks again, first of all, for providing us with such great research, which is really helpful, and I think all of you made a fantastic job, and thanks again for being here on the SESEC podcast. My name is Robert Hudeck. I'm from the Klinik Fleet Insel in Hamburg in Germany. Many thanks.

Arno Macken: 56:43

Thanks, Jan. Thank you.

Robert Hudek: 56:46

And also, of course, many thanks to all those people who help us in the background to produce this podcast. So this would be, first of all, our magician of artwork, Michal Harajimczuk. You're so fantastic. I think you could start being an artist right from this moment. It's really wonderful to see all the beautiful pictures you're doing for us. And also, Soasik Daniel and Marie Bourguin, you two are the, well, souls of our society. You help us so much organizing everything in the background. You're so wonderful. So fantastic ladies, many thanks for all your work.