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Acetabular fractures in elderly patients are associated with high rates of complications during the initial admission

Background

Acetabular fractures among the elderly are common. Identification of risk factors predisposing elderly patients to in-hospital complications is critical to mitigating morbidity and mortality.

Methods

A retrospective cohort study was performed including 195 patients ≥60 years old who sustained acetabulum fractures treated at a single level 1 trauma center. Operative (n=110, 56.4%) or non-operative management was undertaken, and complications during the index hospitalization were defined.

Results

Seventy-three patients (37%) developed a complication during their hospitalization. Most common complications were acute respiratory failure: 13.3%, pneumonia: 10.3%, urinary tract infection: 10.3%, cardiac dysrhythmia: 9.7%, and acute kidney injury: 6.2%. On multivariable analysis, factors associated with in-hospital complications were increased age (adjusted OR (AOR): 1.06, 95% CI: 1.01 to 1.11, p=0.013), more comorbidities (AOR: 1.69, 95% CI: 1.07 to 2.65, p=0.024), operative management (AOR: 0.3, 95% CI: 0.12 to 0.76, p=0.011), and increased length of stay (AOR: 1.34, 95% CI: 1.2 to 1.51, p<0.001).

Conclusions

Acetabular fractures in the elderly are associated with high rates of in-hospital complications. Advanced age, more medical comorbidities and longer lengths of stay predicted higher risk of developing complications. Whereas operative management was associated with lower risk of developing complications during the initial admission, it is important to note the selection bias in which healthier patients with improved baseline functionality may be more likely to undergo operative management.

Level of evidence

Level III therapeutic.

All-arthroscopic anatomic repair of an avulsed popliteus tendon in a multiple ligament-injured knee

Multiple ligament-injured knees are a heterogeneous group of knee injuries that lack a clear consensus on optimal treatment. Current areas of controversy include optimal timing of surgery, ligamentous repair vs reconstruction, and combined vs staged procedures. In addition, multiple open, arthroscopic, and arthroscopic-assisted techniques exist for repair and reconstruction of the injured stabilizers of the knee.Many open posterolateral corner reconstruction techniques have been described, and this article represents the first description of an arthroscopic technique for repair of an avulsed popliteus tendon. This was performed with a standard anterolateral portal in addition to anterior and posterior superolateral portals. Nonabsorbable sutures were passed through the avulsed popliteus tendon in an outside-in technique using a suture shuttle. The nonabsorbable sutures were threaded though a tibial Beath pin, which was then passed through the prepared popliteus footprint and brought out medially. The final position of the popliteus was confirmed arthroscopically, and the sutures were tied medially over a screw post with a washer.Arthroscopic popliteus repair has many possible advantages. Because the popliteus tendon insertion is intracapsular, open repair necessitates a capsulotomy, with the potential for complications such as postoperative wound drainage, intra-articular sinus formation, infection, and stiffness. Arthroscopic repair may avoid these complications. The current case was performed in conjunction with an open but extracapsular posterolateral corner repair. Further experience with this technique is required to determine its safety and efficacy.

Arthroscopic ACL reconstruction with reverse "Y"-plasty grafts and fixation in the femur with either a bioabsorbable interference screw or an Endobutton

We propose a new reverse "Y"-plasty graft for use in anterior cruciate ligament (ACL) reconstruction that involves double tibial tunnels and a single femoral tunnel. With this technique, the hamstrings were used as autografts and fixed separately with bioabsorbable interference screws (group A) or Endobuttons (group B) in femurs. A prospective series of 63 patients underwent primary reconstruction of the ACL; all procedures were performed by the same surgeon. Group A included 35 patients (22 male, 13 female), with a mean age of 25.5 (17-40) years, who were followed up for 28.5 (12-48) months. Group B included 28 patients (17 male, 11 female), with a mean age of 24.3 (18-38) years, who were followed up for 29.5 (12-46) months. Lysholm, International Knee Documentation Committee (IKDC) and Larson scoring were used to compare the therapeutic effects experienced at the knee. Lysholm scores were 93.26±2.67 (group A) and 93.81±2.42 (group B); Larson scores were 91.91±2.29 (group A) and 92.81±2.39 (group B); IKDC scores were 93.89±1.88 (group A) and 94.15±1.77 (group B). None of the scoring differences between groups were statistically significant (T(1)=0.849, P(1)=0.399, T(2)=1.506, P(2)=0.137, T(3)=0.560, P(3)=0.578). The Lachman test was negative in 46 patients (90.2%) and 51 knees, including 25 (89.3%) of the 28 knees in group A and 21 (91.3%) of the 23 knees in group B. Negative Pivot shift was present postoperatively in 49 knees of 51 patients (96.1%), including 27 (96.4%) of the 28 knees in group A and 22 (95.7%) of the 23 knees in group B. All of the patients in both groups achieved full extension and at least 135° of knee flexion. This novel technique involves the creation of double tibial tunnels and a single femoral tunnel. In the tibia, there was a bone bridge, ranging from 2 to 3mm, between the two bundles, which are tensioned at different degrees of flexion to maintain the stability of the knee. In the femur, the grafts were fixed with bioabsorbable interference screws or Endobuttons. The outcomes show that normal function and joint stability were achieved in both groups, as compared with preoperative measurements. Although the outcomes in group A (grafts fixed with the bioabsorbable interference screws in the femur) was better than those observed in group B (grafts fixed with Endobuttons), there was no statistical difference between the groups.

[Rupture of the anterior cruciate ligament. Diagnostics and therapy]

Rupture of the anterior cruciate ligament (ACL) is the most common ligamentous knee injury. The knee is stabilized by the cruciate ligaments and the collateral ligaments. The ACL originates from the inner surface of the lateral condyle of the femur, runs in an anterior medial direction and inserts at the tibial plateau in the intercondyle area. The most common injury is an indirect knee trauma, typically a joint torsion in sports. Patients often describe a snapping noise followed by hemarthrosis. Concomitant injuries are lesions of the medial collateral ligament, the medial meniscus (unhappy triad) and chondral fractures. The age peak is between 15 and 30 years with a higher incidence in females. The cardinal symptom of the ACL rupture is the giving way phenomenon. The clinical diagnosis is provided by a positive Lachman test, a positive pivot shift test and the anterior drawer test. Fractures can be excluded by X-ray examination. Magnetic resonance imaging (MRI) allows the evaluation of the internal knee structures. ACL repair is carried out by arthroscopically assisted bone-tendon-bone or semitendinosus grafting techniques. Early rehabilitation is important for a good functional outcome.