Platelet-rich plasma as a potential prophylactic measure against frozen shoulder in an in vivo shoulder contracture model

INTRODUCTION

Frozen shoulder (adhesive capsulitis) is a common painful and functionally-limiting disease affecting around 2% of the population. So far, therapeutic options are limited and often unsatisfactory. Platelet-rich plasma (PRP) has been used as a treatment option in other orthopedic diseases since it contains growth factors that stimulate tissue repair. So far, the effect of PRP on frozen shoulder lacks evidence. We hypothesized that PRP may be valuable in the prophylaxis and treatment of secondary frozen shoulder due to capsular remodeling.

MATERIALS AND METHODS

An experimental study of an in vivo frozen shoulder model was conducted. Twenty Sprague-Dawley rats underwent surgery in which the body of the scapula was connected to the humerus with a high-strength suture. Two groups of 8 weeks survival time were allocated; a treatment group with one intraoperative injection of PRP into the glenohumeral joint (n = 10) and a control group without PRP (n = 10). The primary outcome was the structural change in the posterior synovial membrane of the posterior and inferior part of the glenohumeral joint using a semi-quantitative grading from 0 (lowest) to 3 (highest).

RESULTS

The posterior synovial membrane structural changes were significantly lower in the PRP group (median = 1 [interquartile range (IQR) = 0-1]) compared to controls (median = 2 [IQR = 1-3]) (p = 0.028). There were no differences for the remaining synovial membrane changes and fibrous capsule responses between groups.

CONCLUSIONS

In this in vivo shoulder contracture model, PRP injections seem to reduce the histological severity grade of some parts (i.e., posterior synovial membrane changes) of the secondary frozen shoulder without causing any side effects. It may be considered to investigate this effect further in future studies as a potential prophylaxis of secondary frozen shoulder (e.g., in operated or immobilized shoulders) or as a treatment option for patients with frozen shoulder in the early stage.

Implementation of new standard operating procedures for geriatric trauma patients with multiple injuries: a single level I trauma centre study

BACKGROUND

The demographic changes towards ageing of the populations in developed countries impose a challenge to trauma centres, as geriatric trauma patients require specific diagnostic and therapeutic procedures. This study investigated whether the integration of new standard operating procedures (SOPs) for the resuscitation room (ER) has an impact on the clinical course in geriatric patients. The new SOPs were designed for severely injured adult trauma patients, based on the Advanced Trauma Life Support (ATLS) and imply early whole-body computed tomography (CT), damage control surgery, and the use of goal-directed coagulation management.

METHODS

Single-centre cohort study. We included all patients ≥65 years of age with an Injury Severity Score (ISS) ≥ 9 who were admitted to our hospital primarily via ER. A historic cohort was compared to a cohort after the implementation of the new SOPs.

RESULTS

We enrolled 311 patients who met the inclusion criteria between 2000 and 2006 (group PreSOP) and 2010-2012 (group SOP). There was a significant reduction in the mortality rate after the implementation of the new SOPs (P = .001). This benefit was seen only for severely injured patients (ISS ≥ 16), but not for moderately injured patients (ISS 9-15). There were no differences with regard to infection rates or rate of palliative care.

CONCLUSIONS

We found an association between implementation of new ER SOPs, and a lower mortality rate in severely injured geriatric trauma patients, whereas moderately injured patients did not obtain the same benefit.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03319381, retrospectively registered 24 October 2017.

Feasibility of iliosacral screw placement in patients with upper sacral dysplasia

Background

Exact knowledge of the sacral anatomy is crucial for the percutaneous insertion of iliosacral screws. However, dysplastic anatomical patterns are common. In addition to a preoperative computed tomography (CT) analysis, conventional radiographic measures may help to identify upper sacral dysplasia and to avoid damage to surrounding structures. Aiming to further increase safety in percutaneous iliosacral screw placement in the presence of sacral dysmorphism, this study examined the prevalence of previously established radiographic signs and, in addition, defined the “critical SI angle” as a new radiographic criterion.

Methods

Pelvic CT scans of 98 consecutive trauma patients were analysed. Next to assessment of established signs indicating upper sacral dysplasia, the critical sacroiliac (SI) angle was defined in standardized pelvic outlet views.

Results

The critical SI angle significantly correlates with the presence of mammillary bodies and an intraarticular vacuum phenomenon. With a cut-off value of − 14.2°, the critical SI angle detects the feasibility of a safe iliosacral screw insertion in pelvic outlet views with a sensitivity of 85.9% and a specificity of 85.7%.

Conclusions

The critical SI angle can support the decision-making when planning iliosacral screw fixation. The clinical value of the established signs of upper sacral dysplasia remains uncertain.

Early Operative Versus Nonoperative Treatment of Fragility Fractures of the Pelvis: A Propensity-Matched Multicenter Study

OBJECTIVE

To compare early operative treatment with nonoperative treatment of fragility fractures of the pelvis regarding mortality and functional outcome.

DESIGN

Retrospective.

SETTING

Two trauma centers.

PATIENTS AND METHODS

Two hundred thirty consecutive patients 60 years of age or older with an isolated low-energy fracture of the pelvis and with a follow-up of at least 24 months. In center 1, treatment consisted of a nonoperative attempt and early operative fixation if mobilization was not possible. In center 2, all patients were treated nonoperatively.

MAIN OUTCOME MEASUREMENTS

Primary outcome was mortality. Secondary outcomes were in-hospital complications. Patients who survived were contacted by phone, and a modified Majeed score was obtained to assess functional outcome at the final follow-up.

RESULTS

At the final follow-up (mean 61 months, SD 24), 105/230 (45.7%) patients had died. One year after the initial hospitalization, 34/148 patients [23%, 95% confidence interval (CI): 17%-31%] of the early operative group and 14/82 patients (17%, 95% CI: 10%-27%) of the nonoperative group had died (P = 0.294). Nonoperative treatment had a protective effect on survival during the first 2 years (hazard ratio of the nonlinear effect: 2.86, 95% CI: 1.38-5.94, P < 0.001). Patients in the early operative treatment group who survived the first 2 years had a better long-term survival. The functional outcome at the end of follow-up as measured by a modified Majeed score was not different between the 2 groups (early operative: 66.1, SD 12.6 vs. nonoperative: 65.7, SD 12.5, P = 0.910).

CONCLUSION

Early operative fixation of patients who cannot be mobilized within 3-5 days was associated with a higher mortality rate and complication rate at 1 year but with a better long-term survival after more than 2 years. Hence, patients with a life expectancy of less than 2 years may not benefit from surgery with regard to survival.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early Operative Versus Nonoperative Treatment of Fragility Fractures of the Pelvis: A Propensity-Matched Multicenter Study

OBJECTIVE

To compare early operative treatment with nonoperative treatment of fragility fractures of the pelvis regarding mortality and functional outcome.

DESIGN

Retrospective.

SETTING

Two trauma centers.

PATIENTS AND METHODS

Two hundred thirty consecutive patients 60 years of age or older with an isolated low-energy fracture of the pelvis and with a follow-up of at least 24 months. In center 1, treatment consisted of a nonoperative attempt and early operative fixation if mobilization was not possible. In center 2, all patients were treated nonoperatively.

MAIN OUTCOME MEASUREMENTS

Primary outcome was mortality. Secondary outcomes were in-hospital complications. Patients who survived were contacted by phone, and a modified Majeed score was obtained to assess functional outcome at the final follow-up.

RESULTS

At the final follow-up (mean 61 months, SD 24), 105/230 (45.7%) patients had died. One year after the initial hospitalization, 34/148 patients [23%, 95% confidence interval (CI): 17%-31%] of the early operative group and 14/82 patients (17%, 95% CI: 10%-27%) of the nonoperative group had died (P = 0.294). Nonoperative treatment had a protective effect on survival during the first 2 years (hazard ratio of the nonlinear effect: 2.86, 95% CI: 1.38-5.94, P < 0.001). Patients in the early operative treatment group who survived the first 2 years had a better long-term survival. The functional outcome at the end of follow-up as measured by a modified Majeed score was not different between the 2 groups (early operative: 66.1, SD 12.6 vs. nonoperative: 65.7, SD 12.5, P = 0.910).

CONCLUSION

Early operative fixation of patients who cannot be mobilized within 3-5 days was associated with a higher mortality rate and complication rate at 1 year but with a better long-term survival after more than 2 years. Hence, patients with a life expectancy of less than 2 years may not benefit from surgery with regard to survival.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Rate of intraoperative problems during sacroiliac screw removal: expect the unexpected

BACKGROUND

The indications for sacroiliac screw (SI) removal have been under debate. Data on complication rates of SI screw removal is missing in the current literature. The objective of this study was to compare the rate of intra- and perioperative problems and complications during SI screw removal to those with SI screw fixation.

METHODS

A retrospective observational study with two interventions in the same cohort was performed. Consecutive patients who underwent both sacroiliac screw fixation for an isolated fracture of the pelvic ring and removal of the same implants between November 2008 and September 2015 (n = 19; age 57.3, SD 16.1 years) were included. Intraoperative technical problems, postoperative complications, duration of surgery, and radiation dose were analysed.

RESULTS

Intraoperative technical problems occurred in 1/19 patients (5%) during SI screw fixation and in 7/19 cases (37%) during SI screw removal (p = .021). Postoperative complications were seen in 3/19 patients after SI screw fixation and in 1/19 patients after SI screw removal (p = 0.128). The surgical time needed per screw was longer for screw removal than for implantation (p = .005). The amount of radiation used for the whole intervention (p = .845) and per screw (p = .845) did not differ among the two interventions.

CONCLUSIONS

Intraoperative technical problems were more frequent with SI screw removal than with SI screw fixation. Most of the intraoperative technical problems in this study were implant-related. They resulted in more surgical time needed per screw removed but similar radiation time.

Correlation of radiographic variables to guide safe implant positioning during acetabular surgery and hip replacement: a retrospective observational study

Background

Knowledge of periacetabular anatomy is crucial for prosthetic cup placement in total hip arthroplasty and for screw placement in anterior fixation with acetabular fractures. It is known that degree of hip dysplasia correlates with medial bone stock and that medial bone stock shows a weak correlation to Lequesne’s acetabular index (AI). Aim of this study was to investigate a possible correlation between AI and the newly proposed medial safe zone.

Methods

AI and the medial save zone were measured on 419 hips using a computed-tomography scan of the pelvis. AI was assessed on a 2D reconstructed anterior-posterior view of the pelvis using VOXAR™. Correlation was measured using the Pearson correlation coefficient.

Results

Mean AI was 4.2 degrees (SD 4.9 degrees). Mean medial safe zone was 8.1 mm (SD 1.9 mm). There was a significant correlation between AI and medial save space with a Pearson correlation coefficient r = 0.33 (p = .001).

Conclusion

There is a weak correlation between AI and medial safe zone. AI should not be used to predict medial safe zone. Due to the weakness in correlation AI is not suited for predicting medial safe zone. However, a low or negative AI can be a warning sign for less medial safe zone, prompting surgeons to take care when reaming in THA or placing periacetabular screws.

Mid-term follow-up after surgical treatment of fragility fractures of the pelvis

INTRODUCTION

Early operative treatment of fragility fractures of the pelvis (FFP) has been suggested to reduce pain and allow for earlier mobilization. The aim of this study was to determine mortality and functional outcome after operative treatment.

PATIENTS AND METHODS

Patients aged ≥60 years (n = 60; mean age 79 years, 53 female) who had operative treatment of a FFP and a follow-up of at least 2 years were identified and mortality was assessed using a national social insurance database. Those who had survived were contacted by phone and a modified Majeed Score was obtained.

RESULTS

At final follow up (62 months, range, 29-117), 32 patients (53.3%) had deceased. One-year-mortality rate was 28.3% and 2-year mortality was 36.7%. Mortality was not linked to fracture type (p > .05). Complications during hospitalization occurred in 26/60 patients (43.3%). Patients with a bilateral FFP had a longer hospitalization (18 vs. 11 days; p = .021). The mean modified Majeed score of surviving patients was 65 points (85.5% of achievable maximum).

CONCLUSION

Mortality and in-hospital complications remain high among patients with FFP even when treated operatively. A longer hospitalization can be expected in patients with posterior bilateral fractures.

Standards for external fixation application: national survey under the auspices of the German Trauma Society

INTRODUCTION

External fixation is widely accepted as a provisional or sometimes definitive treatment for long-bone fractures. Indications include but are not limited to damage control surgery in poly-traumatized patients as well as provisional bridging to definite treatment with soft tissue at risk. As little is known about surgeon's habits in applying this treatment strategy, we performed a national survey.

METHODS

We utilized the member database of the German Trauma Society (DGU). The questionnaire encompassed 15 questions that addresses topics including participants' position, experience, workplace, and questions regarding specifics of external fixation application in different anatomical regions. Furthermore, we compared differences between trauma centre levels and surgeon-related factors.

RESULTS

The participants predominantly worked in level 1 trauma centres (42.7%) and were employed as attendings (54.7%). There was widespread consensus for planning and intra-operative radiographical control of external fixation. Surgeons appointed at a level I trauma centre preferred significantly more often supra-acetabular pin placement in external fixation of the pelvis rather than the utilization of iliac pins (75.8%, p = 0.0001). Moreover, they were more likely to favor a mini-open approach to insert humeral pins (42.4%, p = 0.003). Overall, blunt dissection and mini-open approaches seemed equally popular (38.2 and 34.1%). Department chairmen indicated more often than their colleagues to follow written pin-care protocols for minimization of infection (16.7%, p = 0.003).

CONCLUSION

Despite the fact that external fixation usage is widespread and well established among trauma surgeons in Germany, there are substantial differences in the method of application.

Medial acetabular wall breach in total hip arthroplasty - is full-weight-bearing possible?

BACKGROUND

A breach of the medial acetabular wall is a phenomenon seen frequently due to over-reaming during total hip arthroplasty (THA). The consequences of this issue are not fully understood particularly in cementless THA. A retrospective study was performed to answer whether: immediate postoperative full-weight-bearing in the presence of a medial acetabular wall breach after THA results in more short-term revisions of the acetabular component, and increases the risk for migration of the acetabular component?

HYPOTHESIS

Immediate full-weight-bearing in the presence of a medial breach is not associated with an increased likelihood for acetabular-related revision surgery or migration of the cup.

PATIENTS AND METHODS

In this retrospective cohort study, consecutive patients (n=95; mean age 68±13 years; 67 female) who underwent THA with an uncemented acetabular component were identified and a retrospective chart review was performed (follow-up 23±17 months, range 6 to 79 months). The presence of a postoperative radiographic medial acetabular breach was documented and the need for revision surgery and the rate of acetabular component migration were assessed during follow-up.

RESULTS

Some extent of radiographic medial acetabular wall breach was seen in 26/95 patients (27%). With regard to the primary outcome, 2/95 patients (2%) required revision surgery during follow-up. All revision surgeries occurred in the group without a medial breach (p=0.280) for causes related to the femoral or the head components. Persistent pain was present in 1/26 patients (3.8%) in the medial breach group and 8/69 patients in the control group (11.6%; p=0.436). In the radiographic follow-up (n=81), there was no significant difference between the control group and the medial breach group with regard to cup migration (Δ ilio-ischial overlap [distance between the ilio-ischial line and a parallel line tangential to the acetabular cup on AP views]: -0.5±0.9mm [range, -2.9 to 0.8] vs. -0.3±1.7mm [range, -1.9 to 2.2], Δ overlap tangent [defined as the distance between the two crossings of ilio-ischial line and the acetabular component on AP views]: -2.2±6.1mm [range, -21.4 to 0.0] vs. 0.4±6.9mm [range, -6.2 to 17.6]). Similarly, according to variation in the ilio-ischial overlap distance between postoperative and follow-up on pelvic AP views, 0/56 hips (0%) had cup migration ≥ 5mm in the control group versus 1/25 (4%) in the medial breach cohort (p=0.3).

DISCUSSION

In this retrospective observation of patients with immediate postoperative full-weight-bearing after THA, a radiographic breach of the medial acetabular wall was not associated with an increased risk for short-term revision surgery or radiographic migration at follow-up. According to the findings of this study and in the light of previous biomechanical studies, there is no clear evidence for postoperative partial weight-bearing in case of a medial breach as far as the surgeon feels that the acetabular component is stable.

LEVEL OF EVIDENCE

IV, Retrospective cohort study.

Which pre-hospital triage parameters indicate a need for immediate evaluation and treatment of severely injured patients in the resuscitation area?

PURPOSE

To find ways to reduce the rate of over-triage without drastically increasing the rate of under-triage, we applied a current guideline and identified relevant pre-hospital triage predictors that indicate the need for immediate evaluation and treatment of severely injured patients in the resuscitation area.

METHODS

Data for adult trauma patients admitted to our level-1 trauma centre in a one year period were collected. Outpatients were excluded. Correct triage for trauma team activation was identified for patients with an ISS or NISS ≥ 16 or the need for ICU treatment due to trauma sequelae. In this retrospective analysis, patients were assigned to trauma team activation according to the S3 guideline of the German Trauma Society. This assignment was compared to the actual need for activation as defined above. 13 potential predictors were retained. The relevance of the predictors was assessed and 14 models of interest were considered. The performance of these potential triage models to predict the need for trauma team activation was evaluated with leave-one-out cross-validated Brier and logarithmic scores.

RESULTS

A total of 1934 inpatients ≥ 16 years were admitted to our trauma department (mean age 48 ± 22 years, 38% female). Sixty-nine per cent (n = 1341) were allocated to the emergency department and 31% (n = 593) were treated in the resuscitation room. The median ISS was 4 (IQR 7) points and the median NISS 4 (IQR 6) points. The mortality rate was 3.5% (n = 67) corresponding to a standardized mortality ratio of 0.73. Under-triage occurred in 1.3% (26/1934) and over-triage in 18% (349/1934). A model with eight predictors was finally selected with under-triage rate of 3.3% (63/1934) and over-triage rate of 10.8% (204/1934).

CONCLUSION

The trauma team activation criteria could be reduced to eight predictors without losing its predictive performance. Non-relevant parameters such as EMS provider judgement, endotracheal intubation, suspected paralysis, the presence of burned body surface of > 20% and suspected fractures of two proximal long bones could be excluded for full trauma team activation. The fact that the emergency physicians did a better job in reducing under-triage compared to our final triage model suggests that other variables not present in the S3 guideline may be relevant for prediction.

Anterior subcutaneous internal fixation of the pelvis - what rod-to-bone distance is anatomically optimal?

INTRODUCTION

Anterior fixation of the pelvis using subcutaneous supra-acetabular pedicle screw internal fixation (INFIX) has proven to be a useful tool by avoiding the downsides of external fixation in patients where open fixation is not suited. The purpose of this study was to find a rod-to-bone distance for the INFIX that allows for minimal hazard to the inguinal neuro-vascular structures and, at the same time, as little as possible interference with the soft tissues of the proximal thigh when the patient is sitting.

METHODS

An INFIX was applied to 10 soft-embalmed cadaver pelvises with three different rod-to-bone distances. With each configuration, the relations of the rod to the neuro-vascular and the muscular surroundings were measured in supine and sitting position.

RESULTS

Except for the femoral artery, vein and nerve, all investigated anatomical structures of the groin were under compression with a rod-to-bone distance of 1cm. With a rod-to-bone distance of 2cm most of the anatomical structures were safe in supine position, although less than with 3cm. With hip flexion some structures got under compression, especially the lateral femoral cutaneous nerve (LFCN, 80%) and the anterior cutaneous branches of the femoral nerve (ACBFN, 35%). With a rod-to-bone distance of 3cm almost all anatomical structures were safe in supine position, while with hip flexion most superficial structures of the proximal thigh got under compression, especially the LFCN (75%) and the ACBFN (60%).

CONCLUSIONS

Aiming for a rod-to-bone distance of 2cm is the safest way with regard to compression of the femoral neuro-vascular bundle and at the same time leads to the least compression of more superficial structures like the LFCN, the ACBFN, or the sartorius and the rectus femoris muscles in sitting position.

Current concepts in locking plate fixation of proximal humerus fractures

Despite numerous available treatment strategies, the management of complex proximal humeral fractures remains demanding. Impaired bone quality and considerable comorbidities pose special challenges in the growing aging population. Complications after operative treatment are frequent, in particular loss of reduction with varus malalignment and subsequent screw cutout. Locking plate fixation has become a standard in stabilizing these fractures, but surgical revision rates of up to 25% stagnate at high levels. Therefore, it seems of utmost importance to select the right treatment for the right patient. This article provides an overview of available classification systems, indications for operative treatment, important pathoanatomic principles, and latest surgical strategies in locking plate fixation. The importance of correct reduction of the medial cortices, the use of calcar screws, augmentation with bone cement, double-plate fixation, and auxiliary intramedullary bone graft stabilization are discussed in detail.

Computed tomography-based three-dimensional visualisation of bone corridors and trajectories for screws in open reduction and internal fixation of symphysis diastasis: a retrospective radiological study

INTRODUCTION

Typical stabilisation of pelvic open book injuries consists of plate fixation of the symphysis. No previous literature has been published about the evaluation of screw placement and their trajectory with four oblique 4.5 mm screws using a four-hole plate in symphysis diastasis. The aim of this study was to define insertion points and angles of trajectory for crossed screw placement regardless of any plate design based on an analysis of three-dimensional computed tomography data sets.

METHODS

One hundred human pelvic CT data sets were collected. Unilateral and bilateral placements of crossed 4.5 mm screws were simulated. Primary outcome measure was successful simulated screw placement without cortical breach. Secondary outcome measures included the anatomical measurements of the screw positions.

RESULTS

Simulated screw placement of two oblique screws on each side of the pubic symphysis without cortical breach was achieved in all (100 %) cases. There were a total of 400 screw simulations. Medial screws were longer, lateral screws had higher coronal angles, and the distance between both screws was higher on the right side (p < 0.001 each). The lengths of the right lateral, right medial, left lateral, and left medial screws were 44.9, 65.8, 45.4, and 67.4 mm, respectively. The sagittal angles to the dorsal surface area of the pubic rami were 10.5°, 11.1°, 9.0°, and 11.0°. The coronal angles to the vertical axis of the symphysis measured 39.5°, 16.0°, 33.8°, and 16.8°. The distances between these screws and the medial edge of the pubic crest were 33.5, 8.6, 29.5, and 7.3 mm. Furthermore, certain sex- and side-related differences were noted.

CONCLUSIONS

This series provides results about the feasibility and a detailed anatomical description of crossed screw placement. This is of special interest in pelvic surgery for choosing the entry points, safe screw channel parameters, and trajectories.

Resuscitation with polymeric plasma substitutes is permissive for systemic inflammatory response syndrome and sepsis in multiply injured patients: a retrospective cohort study

Objective

Multiple trauma is often accompanied by systemic inflammatory response syndrome (SIRS). The aim of this study was to investigate the impact of polymeric plasma substitutes on the development of SIRS or sepsis.

Methods

We included 2969 patients aged ≥16 years with an Injury Severity Score (ISS) >16 in this study. The sample was subdivided into three groups: patients who did not receive colloids and those who received <5L colloids and >5L colloids within the first 48 h. Data were analyzed using IBM SPSS^® for Windows version 22.0; analysis of variance was used for continuous normally distributed data and Kruskal–Wallis test for categorical data. The predictive quality of colloid treatment was analyzed using the receiver operating characteristic (ROC) curves. Independent predictively was analyzed by binary logistic regression. Data were considered significant if P < 0.05. Data are presented as the mean ± standard deviation.

Results

The SIRS score increased with the amount of colloid used (1.9 ± 1.4 vs. 2.4 ± 1.2 vs. 3.2 ± 0.9; P < 0.001). However, the predictive quality was low, with an area under the ROC of 0.693 for SIRS and 0.669 for sepsis (P < 0.001). Binary logistic regression revealed colloids as an independent factor for the development of SIRS and sepsis (odds ratios: SIRS 3.325 and sepsis 8.984; P < 0.001).

Conclusion

Besides other factors, colloids have a significant permissive effect and are independent predictors for the development of SIRS and sepsis in multiply injured patients.

Trial registration ‘Retrospektive Analysen in der Chirurgischen Intensivmedizin’ No. St. V. 01-2008

Is total hip arthroplasty safely performed in lung transplant patients? Current experience from a retrospective study of the Zurich lung transplant cohort

Background

In recent years, the number of lung transplants has increased rapidly, with higher quality of life and improved survival rates in transplant recipients, including patients with advanced age. This, in turn, means that more transplant recipients will seek musculoskeletal care to treat degenerative joint disease and also trauma incidents. Safety concerns regarding elective and posttraumatic hip arthroplasty in transplant patients include an increased risk of infection, wound healing problems, periprosthetic fractures and loosening of the implants.

Methods

Clinical outcomes and safety aspects were retrospectively reviewed for five primary total hip arthroplasties (THA) in lung transplant recipients with minimal follow-up of two years at average of 2.6 (2–11) years. Patients were recruited from the Zurich Lung Transplant Center comprising of a cohort of 253 patients between January 1st, 2004 and December 31st, 2013.

Results

All five patients subjectively reported excellent outcomes after THA with a final average Harris Hip Score of 97 (86–100). One 71-year-old patient died 26 months after THA unrelated to arthroplasty. One superficial wound healing disturbance was documented. No periprosthetic fractures, no dislocations, no periprosthetic infections, no further revision surgery, no implant loosening was observed.

Conclusions

In conclusion, THA can be safely and successfully performed even in lung transplant patients under long-term immunosuppressive therapy and polymedication, provided a multidisciplinary approach can be granted.

Correlation Between Arthroscopy Simulator and Video Game Performance: A Cross-Sectional Study of 30 Volunteers Comparing 2- and 3-Dimensional Video Games

PURPOSE

To investigate the association between arthroscopy simulator performance and video game skills.

METHODS

This study compared the performances of 30 volunteers without experience performing arthroscopies in 3 different tasks of a validated virtual reality knee arthroscopy simulator with the video game experience using a questionnaire and actual performances in 5 different 2- and 3-dimensional (D) video games of varying genres on 2 different platforms.

RESULTS

Positive correlations between knee arthroscopy simulator and video game performances (ρ = 0.63, P < .001) as well as experiences (ρ = 0.50, P = .005) were found. The strongest correlations were found for the task of catching (hooking) 6 foreign bodies (virtual rings; "triangulation") and the dribbling performance in a sports game and a first-person shooter game, as well as the meniscus resection and a tile-matching puzzle game (all ρ ≥ 0.60, P < .001). No correlations were found for any of the knee arthroscopy simulator tasks and a strategy game.

CONCLUSIONS

Although knee arthroscopy performances do not correlate with 2-D strategy video game skills, they show a correlation with 2-D tile-matching puzzle games only for easier tasks with a rather limited focus, and highly correlate with 3-D sports and first-person shooter video games. These findings show that experienced and good 3-D gamers are better arthroscopists than nonexperienced and poor 3-D gamers.

LEVEL OF EVIDENCE

Level II, observational cross-sectional study.

Synthetic meshes in the treatment of postoperative fascial dehiscence of the spine

BACKGROUND

A fascial dehiscence after spinal instrumentation is usually located at the mechanically stressed interscapular thoracic spine and often causes cosmetic impairment and pain. However, therapy options remain barely discussed. Synthetic meshes have been successfully used in the treatment of abdominal hernias.

OBJECTIVE

It was hypothesized that synthetic meshes are a successful treatment option for spinal fascial dehiscence.

METHODS

This retrospective study of a prospective database investigated all consecutive patients who received a synthetic mesh for a fascial dehiscence of the spine between 2010 and 2014 after prior spinal instrumentation. Primary outcomes were healing of the fascial dehiscence, recurrence, infection, revision, subjective satisfaction on a visual analog scale (VAS), and the Oswestry Disability Index (ODI). Among others, secondary outcomes consisted of seroma formation and return to work. The evaluated risk factors consisted of the body mass index (BMI), outer abdominal fat (OAF), back tissue, smoking, immunomodulatory therapy, preoperative radiation dose, and instrumented levels.

RESULTS

Sixteen patients with a mean follow up of 24 months were included. Every fascial dehiscence successfully healed with the synthetic mesh and there were no recurrences, infections or revisions. The mean subjective satisfaction level was VAS 7.3 and the mean ODI was 26%. Five (31%) patients had a seroma postoperatively, but did not show any differences in the outcome (e.g. ODI of 28%). In the patient group < 65 years (n = 12), all but two patients, who had work restrictions due to other diseases, regained at least some capacity to work. Worse ODI scores were found for patients with increased BMI, OAF, back tissue, cortisone therapy, instrumented levels, preoperative radiation dose, and for smokers.

CONCLUSION

Synthetic meshes are a successful treatment option for spinal fascial dehiscence, even seemingly in patients with a higher risk profile such as obese and immunocompromised patients as well as in revision procedures. They are associated with respectable cosmetic results, pain relief and clinical outcome. Postoperatively, it is recommended to leave drains for more than five to seven days in order to avoid seroma formation and to avoid weight training for six weeks. Further prospective, comparative studies are recommended.

The value of modular hemiarthroplasty for unstable femoral neck fractures in elderly patients with coxarthrosis

Background

Displaced femoral neck fractures are common in the elderly patient. The surgical treatment options consist of a hemiarthroplasty (HA) or total hip arthroplasty (THA). However, the best surgical choice is still under debate. Bipolar HAs do not address preexisting arthritic changes of the acetabulum, which may lead to an unfavorable clinical outcome. The purpose of the present study was to conduct a long term follow-up analysis of the bipolar hemiarthroplasty with particular focus on the influence of preoperative acetabular osteoarthritis on the functional outcome.

Methods

In a retrospective observational study, the medical charts of consecutive patients treated with a bipolar hemiarthroplasty at a level one trauma center between 2004 and 2008 were reviewed before a final radiographic and clinical follow-up was performed. The outcome variables consisted of arthritic findings on the pre- and postoperative x-rays with particular focus on double fond osteophyte (DFO) and posterior wall sign (PWS) as well as the revision rate and functional scores.

Results

This study included 102 patients with a mean age of 77.2 years. Most patients (75 %) had a Kellgren-Lawrence grading scale (KLGS) of 2 or 3. While only 30 % of patients had a DFO, most patients (73 %) had a PWS. The DFO correlated significantly with the KLGS, but no correlation was seen with the clinical outcome. Most patients showed a decreased offset by a mean of −7.8 mm. The mean modified Harris Hip Score (HHS) of 90.3 and the mean Merle d'Aubigné score of 10.8 correlated significantly. Despite a significant correlation of the HSS subcategory of pain and the preoperative KLGS, there was no statistical relationship between the arthritic x-ray measurements and the clinical outcome.

Conclusions

In the presented study population, the presence of radiographic acetabular osteoarthritis did not influence the clinical outcome after bipolar hemiarthroplasty for displaced femoral neck fractures.

Safety of total hip arthroplasty for femoral neck fractures using the direct anterior approach: a retrospective observational study in 86 elderly patients

BACKGROUND

The femoral neck fracture is one of the most common fractures in the elderly. A variety of methods and approaches are used to treat it. Total hip arthroplasty is a preferred approach in independent, mobile, elderly patients, given its more favorable long-term outcome. Our hypothesis is that the direct anterior approach in geriatric trauma patients has a lower dislocation-rate with the advantage of early recovery due to a muscle sparing approach and therefore early possible full weight-bearing.

METHODS

Patients were retrospectively sought who suffered a femoral neck fracture from 2008 to 2013. All patients were treated through a direct anterior approach and using the same brand of implants. Medical history, standardized physical exam, conventional pelvic plain and axial hip x-rays, Harris Hip Score, Merle D'Aubigné and Postel and SF-36 were assessed.

RESULTS

Eighty-six patients were included in the study with a mean age of seventy-five years. The mortality rate was 16.7 %. Complications were encountered in nineteen patients (22.0 %) who needed operative revision and one postoperative complication (1.2 %) which could be handled conservatively. There were five intraoperative complications (5.8 %), two dislocations (2.3 %), one aseptic loosening in a non-cemented stem (1.2 %), six periprosthetic fractures in non-cemented stems (6.9 %), one displacement of a non-cemented cup (1.2 %), two early infections (2.3 %) and three hematomas (3.5 %) recorded.

CONCLUSIONS

Although the direct anterior approach is associated with a rather long learning curve we have found it to preserve the soft-tissues with no injury to abductors. It therefore shows an early advantage in elderly patients in terms of early recovery and therefore early possible full weight-bearing. Fracture treatment with dual mobility cups might lead to lower dislocation rates, but are associated with higher costs. Due to higher complication rates in non-cemented versus cemented shafts, we have changed our practice towards favoring cemented femoral stems in patients with suspected or manifest osteoporosis.

Fresh frozen plasma is permissive for systemic inflammatory response syndrome, infection, and sepsis in multiple-injured patients

BACKGROUND

The correction of coagulopathy with fresh frozen plasma (FFP) is one of the main issues in the treatment of multiple-injured patients. Infectious and septic complications contribute to an adverse outcome in multiple-injured patients. Here, we investigated the role of FFP in the development of inflammatory complications given within the first 48 hours.

METHODS

A total of 2033 patients with multiple injuries and an Injury Severity Score greater than 16 points and aged 16 years or older were included. The population was subdivided into 2 groups: those who received FFP and those who did not. The data were analyzed using SPSS version 22.0. Associations between the data were tested using Pearson correlation. Independent predictivity was analyzed by binary logistic regression and multivariate regression. Data were considered as significant if P<.05.

RESULTS

The prothrombin time at admission was significantly lower (68.5%±23.3% vs 81.8%±21.0% normal; P<.001) in the group receiving FFP. The application of FFP led to a more severe systemic inflammatory response syndrome (SIRS) grade (3.0±1.2 vs 2.2±1.4; P<.001), to a higher infection rate (48% vs 28%; P<.001), and to a higher sepsis rate (29% vs 13%; P<.001) in the patients receiving FFP. The correlations between SIRS and the incidence of infections and sepsis increased with the amount of FFP applied (P<.001).

CONCLUSIONS

Treatment with FFP of bleeding patients with multiple injuries enhances the risk of SIRS, infection, and sepsis; however, a multifactorial genesis has to be postulated.

Echinomycin did not affect the safety of fracture healing: an experimental pilot study on a murine femur fracture model

Background

There is a need for effective drugs in the prevention and treatment of heterotopic ossifications (HO) after fractures. Echinomycin has been shown to prevent formation of HO in an animal model. However, before it may be considered as an option against HO, it needs to be studied whether it prevents fracture healing similar to non-steroidal anti-inflammatory drugs (NSAIDS). Therefore, the hypothesis was that echinomycin prevents fracture healing and callus formation.

Methods

In an experimental murine pilot study, standard blunt femur fractures were induced and retrograde intramedullary compression fixation of the femur was performed. The treatment group (n = 8) received echinomycin (0.3 mg/kg body weight) and the control group (n = 8) did not receive echinomycin. The fractures and implant positions were verified by conventional X-rays immediately postoperatively. As the primary outcome variable, fracture healing (osseous consolidation) was evaluated by conventional X-rays and micro-computed tomography (CT) scans after ten weeks and graded as healed, partial or complete pseudarthrosis. The secondary outcome, callus formation, was graded semi-quantitatively from 0 (mostly absent) to 3 (maximum).

Results

Fracture healing was present in all living cases after ten weeks concerning the treatment group. Partial pseudarthrosis was seen in two cases, one in the treatment and another one in the control group. Complete pseudarthrosis was seen in one case of the control group after an open fracture. Callus formation was similar in both groups with a mean grade of 1.5 within each group. Two cases of the treatment group died.

Conclusion

As a novel finding, echinomycin did not inhibit fracture healing or callus formation in this in vivo murine standard femur fracture model pilot study. Further studies involving a larger number of cases, quantitative assessment with CT scans and histopathological analysis are needed before generalizing the results of this pilot study.

Inclination-dependent changes of the critical shoulder angle significantly influence superior glenohumeral joint stability

BACKGROUND

The critical shoulder angle combines the acromion index and glenoid inclination and has potential to discriminate between shoulders at risk for rotator cuff tear or osteoarthritis and those that are asymptomatic. However, its biomechanics, and particularly the role of the glenoid inclination, are not yet fully understood.

METHODS

A shoulder simulator was used to analyze the independent influence of glenoid inclination during abduction from 0 to 60°. Spindle motors transferred tension forces by a cable-pulley on human cadaveric humeri. A six-degree-of-freedom force transducer was mounted directly behind the polyethylene glenoid to measure shear and compressive joint reaction force and calculate the instability ratio (ratio of shear and compressive joint reaction force) with the different force ratios of the deltoid and supraspinatus muscles (2:1 and 1:1). A stepwise change in the inclination by 5° increments allowed simulation of a critical shoulder angle range of 20° to 45°.

FINDINGS

Tilting the glenoid to cranial (increasing the critical shoulder angle) increases the shear joint reaction force and therefore the instability ratio. A balanced force ratio (1:1) between the deltoid and the supraspinatus allowed larger critical shoulder angles before cranial subluxation occurred than did the deltoid-dominant ratio (2:1).

INTERPRETATION

Glenoid inclination-dependent changes of the critical shoulder angle have a significant impact on superior glenohumeral joint stability. The increased compensatory activity of the rotator cuff to keep the humeral head centered may lead to mechanical overload and could explain the clinically observed association between large angles and degenerative rotator cuff tears.

3D navigation of endoscopic rhizotomy at the lumbar spine

We present a detailed description of the surgical technique and the preliminary results of an endoscopic denervation for patients with chronic low back pain (CLBP) originating from the facet joints (FJ). Endoscopic denervation of the medial branches of the dorsal rami supplying the FJ has recently been appraised as providing excellent intraoperative visualization and long term pain relief for these patients. Conventional endoscopic rhizotomy has been expanded to include a the precise localization of 3D navigation. A surgical description and the results of our first four patients treated with 3D navigated endoscopic rhizotomy (3DNER) are presented. Four patients with a mean age of 59years and a follow-up time of 2months were included. All patients reported pain reduction in the immediate postoperative period, while three patients (75%) had long lasting relief. The patient without persisting relief had previously sustained a lumbar disc prolapse and only achieved minor pain relief with preoperative FJ infiltration, compared to the significant relief that was seen in the other patients. In contrast to conventional rhizotomy, 3DNER enables the surgeon to ablate more precisely and extensively, which is especially useful if scar tissue is present from previous injuries or surgeries. When successful, this technique may provide long lasting pain relief, especially if the preoperative FJ infiltrations are followed by a substantial pain reduction.

Osseous vitality in single photon emission computed tomography/computed tomography (SPECT/CT) after balloon tibioplasty of the tibial plateau: a case series

Background

The minimally invasive, balloon-assisted reduction and cement-augmented internal fixation of the tibial plateau is an innovative surgical procedure for tibial plateau fractures. The close proximity of balloons and cement to the knee joint poses a potential risk for osteonecrosis; especially in the case of thin bone lamellae. However, there are no studies about the vitality of the cement-surrounding tissue after these tibioplasties. Therefore, our goal was to assess the osseous vitality after cement-augmented balloon tibioplasty using single photon emission computed tomography/computed tomography (SPECT/CT) in a series of patients.

Methods

This case series evaluated available consecutive patients, whose tibial plateau fractures were treated with balloon-assisted, cement-augmented tibioplasty and received a SPECT/CT. Primary outcome variables were osseous vitality on SPECT/CTs according to the semiquantitative tracer activity analysis. The mean uptake of eight tibial regions of interest was referenced to the mean uptake count on the same region of the contralateral leg to obtain a count ratio. Osteonecrosis was defined as a photopenic area or cold defect. Secondary variables included clinical and radiological follow-up data. Statistics were carried out in a descriptive pattern.

Results

Ten patients with a mean age of 59 years and a mean follow up of 18 months were included. Calcium phosphate (CaP) substitute bone cement was used in 60 % and polymethyl methacrylate mixed with hydroxyapatite (PMMA/HA) bone cement in 40 %. Normal to high SPECT/CT activity without photopenic areas were observed in all patients and the mean tracer activity ratio was four, indicating vital bone in all patients. There were no postoperative infections and only one 57 year old patient with hemineglect and CaP cement showed failed osseous consolidation. The mean Tegner and Lysholm as well as the Lysholm scores were three and 80, respectively.

Conclusions

This novel study about cement-augmented balloon tibioplasties showed that osseous vitality remains intact according to SPECT/CT analysis; irrespective of the type of cement and even in the presence of thin bone lamellae. This procedure was safe and well-suited for lateral tibial plateau fractures in particular. Surgeons may consider using PMMA/HA bone cement for void filling in elderly fracture patients without concern about bone viability.

Correlation of pelvic incidence with radiographical parameters for acetabular retroversion: a retrospective radiological study

Background

Pelvic incidence (PI) has been linked to several degenerative processes within the spinopelvic system. Acetabular retroversion is a recognised risk factor for osteoarthritis of the hip. We therefore hypothesised that these two factors might be part of a specific anatomical variant associated with degenerative changes. This study was performed to clarify this issue.

Methods

The pelvic incidence was measured on 589 computertomographical data sets acquired between 2008 and 2010. For 220 patients a 2D rendering in an antero-posterior view of the CT data set was performed to evaluate the parameters of acetabular retroversion. Those included the prominence of the ischial spine sign (PRISS), the cross-over sign (COS) and the posterior wall sign (PWS). Between 477 and 478 hips were evaluated depending on the parameter of retroversion.

Results

The mean pelvic incidence was significantly lower in hips positive for the PRISS and the PWS. However, there were no significant differences between hips positive or negative for the COS.

Discussion

As hypothesised, the lower PI values in PWS and PRISS positive hips suggest a link between PI and retroversion of the acetabulum. Whether this is of any clinical relevance remains, however, unknown.

Conclusion

Acetabular retroversion is linked to PI. In hips where the prominence of the ischial spine sign and/or the posterior wall sign was present, the mean pelvic incidence value was lower.

The benefits of elective spinal implant removal: a retrospective study of 137 patients

PURPOSE

While spinal instrumentations are becoming more common, the advantages of elective spinal implant removal remain ambiguous. We hypothesized that elective implant removal of the posterior spine is beneficial.

METHODS

A retrospective study evaluated 137 consecutive trauma patients with elective implant removal of the posterior spine. If additional cages were present, they were not removed. Primary outcomes were the change in pre- and post-operative pain, fingertip-floor distance (FFD), and Cobb angles. Some secondary outcomes consisted of complications, work disability, and pelvic incidence (PI). Different stabilization approaches and cage sizes were compared.

RESULTS

The presence and amount of pain as well as the FFD showed significant improvement. There was no loss of reduction. Delayed wound healing was observed in 9%, but only 3% needed revision. Thoracic fascial dehiscences were seen only in patients (9%) that had stand-alone posterior surgery. Larger cages were associated with increased work disability. An increased PI was associated with less post-operative pain and decreased FFD.

CONCLUSIONS

In this study, trauma patients benefited from elective implant removal of the posterior spine due to lower presence and level of pain, improved function and low revision rates; irrespective of an initial combined or stand-alone posterior approach or varying cage sizes. However, stand-alone posterior instrumentation may be accompanied by increased rates of fascial dehiscence surgeries and larger cages may lead to increased work disability. Increased PI may be associated with less pain after spinal implant removal.

The compliance with and knowledge about radiation protection in operating room personnel: a cross-sectional study with a questionnaire

INTRODUCTION

Radiation protection is becoming more important with an ongoing increase in radiation exposure due to the use of X-rays in minimally invasive procedures in orthopaedic and trauma surgeries. However, sufficient education in medical physics and radiation protection can often be improved.

MATERIALS AND METHODS

A questionnaire consisting of four questions about personal data and ten questions about radiation protection was distributed to lead consultants, consultants, residents, medical students, and medical technical assistants at two institutions, a level 1 trauma center and a children's hospital.

RESULTS

This study consisted of 83 participants. The compliance with radiation protection, i.e., usage of a dosimetry, an apron, and a thyroid shield on a regular basis was only seen in 54 %. Participants from the trauma center wore a dosimeter and thyroid shield significantly more often. The regular use of a thyroid shield differed significantly between job positions. It was observed in 80 % of students, but only 15 % of technical assistants. Only 65 % of all knowledge questions were answered correctly. There was a discrepancy between incorrectly answered knowledge questions (35 %) and those marked as uncertain (20 %). Different job positions did not have an impact on the answers to the questions in most instances.

CONCLUSIONS

The compliance with and the knowledge about radiation protection seems to be unnecessarily low in trauma physicians and technical assistants. The discrepancy in falsely answered questions and those marked as uncertain may suggest that participants may overestimate their knowledge about radiation protection, which is potentially harmful due to the increased radiation exposure. Therefore, we advocate a quick and valuable training of trauma surgeons and medical staff addressing the important preventive measures, some of which are illustrated in the present study. These consist of wearing dosimetry and protection devices, reduction in X-ray duration, preferably antero-posterior C-arm positioning with the image intensifier close to the patient and the surgeon, maximal distance, collimation, and increased voltage. Furthermore, the use of visual feedback on complex and potentially hazardous radiation facts may be useful for training purposes.

STUDY DESIGN

Cross-sectional study with a questionnaire.

Age and gender as independent predictors of violence under the influence of alcohol in Zurich, Switzerland

Violent behaviour associated with alcohol consumption is frequently reported by different media. Clinical data analysing the correlation between alcohol intoxication, age, gender and violence are scarce. The aim of this study was to evaluate the influence of age, gender and blood alcohol content on violent behaviour under the influence of alcohol under central European conditions. Three hundred patients admitted to the emergency department were included into this study in the time period from January 01. to December 31. 2009. The inclusion criteria were a blood alcohol content (BAC) of ≥10 mmol/l, any traumatic injury and an age ≥16 years. Violence was defined as an evitable act committed by others leading to patient's hospitalisation. The data were compared with Wilcoxon and χ2-test for proportions. The data were considered as significant if p<0,05. Predictive quality was evaluated by using receiver operating characteristic (ROC) curve. Independent predictors were analyzed by logistic regression analysis. The average age was 36,9±16,9 years (range: 16-84 years), 259 (86%) males and 41 (24%) females. There was a significant difference in gender (odds ratio for gender male 2,88; CI 95%: 1,24-6,67; p<0,001) and age dependent (odds ratio for each year of age 0,94; CI 95%: 0,93-0,96; p<0,0001) violence with no correlation to blood alcohol content found. Logistic regression analysis revealed male gender and young age as an independent predictor for violence. These results clarify the relationship between alcohol, age, gender and violence and have important implications for municipal-level alcohol policies.

[Sacroiliac joint pain - diagnostic algorithm and therapeutic approaches]

The sacroiliac joints are causative for 13-30% of cases with low back pain and are still disregarded in the differential diagnosis. This is mainly due to its complex anatomy and the variety of pain patterns originating from the SI joints. The broad etiology of low back pain often misleads the physician into inadequate treatments. This article reviews the clinical presentation of patients suffering from a sacroiliac arthropathy and points out therapeutic strategies. It also provides a helpful diagnostic tool in daily routine. Eventually, any patient needs to experience a significant pain reduction resulting from an intrarticular injection before the diagnosis of non-inflammatory SI arthropathy is confirmed. In most cases, nonoperative treatment measures are sufficient. Operative strategies are available in selected cases with unsuccessful conservative therapy.

Comparing the predictive value of the pelvic ring injury classification systems by Tile and by Young and Burgess

INTRODUCTION

Radiology-based classifications of pelvic ring injuries and their relevance for the prognosis of morbidity and mortality are disputed in the literature. The purpose of this study was to evaluate potential differences between the pelvic ring injury classification systems by Tile and by Young and Burgess with regard to their predictive value on mortality, transfusion/infusion requirement and concomitant injuries.

PATIENTS AND METHODS

Two-hundred-and-eighty-five consecutive patients with pelvic ring fractures were analyzed for mortality within 30 days after admission, number of blood units and total volume of fluid infused during the first 24h after trauma, the Abbreviated Injury Severity (AIS) scores for head, chest, spine, abdomen and extremities as a function of the Tile and the Young-Burgess classifications.

RESULTS

There was no significant relationship between occurrence of death and fracture pattern but a significant relationship between fracture pattern and need for blood units/total fluid volume for Tile (p<.001/p<.001) and Young-Burgess (p<.001/p<.001). In both classifications, open book fractures were associated with more fluid requirement and more severe injuries of the abdomen, spine and extremities (p<.05). When divided into the larger subgroups "partially stable" and "unstable", unstable fractures were associated with a higher mortality rate in the Young-Burgess system (p=.036). In both classifications, patients with unstable fractures required significantly more blood transfusions (p<.001) and total fluid infusion (p<.001) and higher AIS scores.

CONCLUSIONS

In this first direct comparison of both classifications, we found no clinical relevant differences with regard to their predictive value on mortality, transfusion/infusion requirement and concomitant injuries.

Mechanical testing of a device for subcutaneous internal anterior pelvic ring fixation versus external pelvic ring fixation

Background

Although useful in the emergency treatment of pelvic ring injuries, external fixation is associated with pin tract infections, the patient’s limited mobility and a restricted surgical accessibility to the lower abdomen. In this study, the mechanical stability of a subcutaneous internal anterior fixation (SIAF) system is investigated.

Methods

A standard external fixation and a SIAF system were tested on pairs of Polyoxymethylene testing cylinders using a universal testing machine. Each specimen was subjected to a total of 2000 consecutive cyclic loadings at 1 Hz with sinusoidal lateral compression/distraction (+/−50 N) and torque (+/− 0.5 Nm) loading alternating every 200 cycles. Translational and rotational stiffness were determined at 100, 300, 500, 700 and 900 cycles.

Results

There was no significant difference in translational stiffness between the SIAF and the standard external fixation when compared at 500 (p = .089), 700 (p = .081), and 900 (p = .266) cycles. Rotational stiffness observed for the SIAF was about 50 percent higher than the standard external fixation at 300 (p = .005), 500 (p = .020), and 900 (p = .005) cycles. No loosening or failure of the rod-pin/rod-screw interfaces was seen.

Conclusions

In comparison with the standard external fixation system, the tested device for subcutaneous internal anterior fixation (SIAF) in vitro has similar translational and superior rotational stiffness.

Histological remodelling of demineralised bone matrix allograft in posterolateral fusion of the spine--an ex vivo study

Background

Demineralised bone matrix (DBM) has shown to be effective in enhancing posterior fusion of the spine. Several animal studies and clinical investigations in humans showed its successful remodelling. The use of allogenic matrix may decrease the need of autologous bone graft and therefore helps prevent corresponding donor site morbidity. Since DBM products are very expensive, the question arises, whether it is completely remodelled into new bone, and therefore truly is comparable to autologous cancellous bone graft. To our knowledge there is no report of a consecutive series of patients where ex vivo histological analysis after postero-lateral fusion of the spine was performed.

Methods

Osseous biopsies of nine consecutive patients who underwent postero-lateral fusion of the spine for trauma were obtained at the time of elective removal of the hardware. Histological samples were then analyzed on ground and thin sections stained with toluidine blue and von Kossa stainings.

Results

Time span between index operation and removal of the metal ranged between 6 and 18 month. Histological analysis showed good incorporation and overall remodelling of DBM into new bone in all patients. No foreign body reaction was visible and new bone formation progressed time dependently with DBM in situ. Four out of nine patients showed more than 50% new bone formation after one year.

Conclusion

DBM shows good overall remodelling properties in histological analysis and therefore seems to be an effective adjunct in postero-lateral fusion of the spine. Furthermore, DBM substitution increases over time.

Increased pelvic incidence may lead to arthritis and sagittal orientation of the facet joints at the lower lumbar spine

BACKGROUND

Correct sagittal alignment with a balanced pelvis and spine is crucial in the management of spinal disorders. The pelvic incidence (PI) describes the sagittal pelvic alignment and is position-independent. It has barely been investigated on CT scans. Furthermore, no studies have focused on the association between PI and facet joint (FJ) arthritis and orientation. Therefore, our goal was to clarify the remaining issues about PI in regard to (1) physiologic values, (2) age, (3) gender, (4) lumbar lordosis (LL) and (5) FJ arthritis and orientation using CT scans.

METHODS

We retrospectively analyzed CT scans of 620 individuals, with a mean age of 43 years, who presented to our traumatology department and underwent a whole body CT scan, between 2008 and 2010. The PI was determined on sagittal CT planes of the pelvis by measuring the angle between the hip axis to an orthogonal line originating at the center of the superior end plate axis of the first sacral vertebra. We also evaluated LL, FJ arthritis and orientation of the lumbar spine.

RESULTS

596 individuals yielded results for (1) PI with a mean of 50.8°. There was no significant difference for PI and (2) age, nor (3) gender. PI was significantly and linearly correlated with (4) LL (p = < 0.0001). Interestingly, PI and (5) FJ arthritis displayed a significant and linear correlation (p = 0.0062) with a cut-off point at 50°. An increased PI was also significantly associated with more sagitally oriented FJs at L5/S1 (p = 0.01).

CONCLUSION

PI is not correlated with age nor gender. However, this is the first report showing that PI is significantly and linearly associated with LL, FJ arthritis and more sagittal FJ orientation at the lower lumbar spine. This may be caused by a higher contact force on the lower lumbar FJs by an increased PI. Once symptomatic or in the event of spinal trauma, patients with increased PI and LL could benefit from corrective surgery and spondylodesis.

Distraction test of the posterior superior iliac spine (PSIS) in the diagnosis of sacroiliac joint arthropathy

Background

The sacroiliac joint (SIJ) is a frequently underestimated cause of lower back (LBP). A simple clinical test of sufficient validity would be desirable. The aim of this study was to evaluate the diagnostic value of a new PSIS distraction test for the clinical detection of SIJ arthropathy and to compare it to several commonly used clinical tests.

Methods

Consecutive patients, where a SIJ pathology had been confirmed by an SIJ infiltration were enrolled (case group, 61 SIJs in 46 patients). Before infiltration, patients were tested for pain with PSIS distraction by a punctual force on the PSIS in medial-to-lateral direction (PSIS distraction test), pain with pelvic compression, pelvic distraction, Gaenslen test, Thigh Thrust, and Faber (or Patrick’s) test. In addition, these clinical tests were applied to both SIJs of a population of individuals without history of LBP (control group, 64 SIJs in 32 patients).

Results

Within the investigated cohort, the PSIS distraction test showed a sensitivity of 100% and a specificity of 89% for SIJ pathology. The accuracy of the test was 94%, the positive predictive value (PPV) was 90% and the negative predictive value (NPV) was 100%. Pelvic compression, pelvic distraction, Gaenslen test, Thigh Thrust, and Faber test were associated with a good specificity (> 90%) but a poor sensitivity (< 35%).

Conclusions

Within our population of patients with confirmed SIJ arthropathy the PSIS distraction test was found to be of high sensitivity, specificity and accuracy. In contrast, common clinical tests showed a poor sensitivity. The PSIS distraction test seems to be an easy-to-perform and clinically valuable test for SIJ arthropathy.

Use of imatinib in the prevention of heterotopic ossification

BACKGROUND

Heterotopic ossification (HO) is a common complication following orthopedic and trauma surgery, which may have substantial negative effects on the postoperative outcome. Angiogenesis appears to play a critical role in heterotopic ossification. One of the involved signaling molecules is platelet-derived growth factor (PDGF) which may be inhibited by imatinib.

QUESTIONS/PURPOSES

Our goal was to prevent HO by pharmacologically interfering with the molecular signaling pathways involved in the developmental process. We hypothesized that by administering a proven inhibitor of PDGF expression, heterotopic bone formation may be prevented.

METHODS

The effect of imatinib on HO formation was studied in a murine model which reliably produces islets of HO within the soft tissue following Achilles tenotomy. The control group underwent Achilles tenotomy only. The imatinib group received imatinib mesylate. After trial completion, the limbs were harvested and scanned by micro-CT. Heterotopic bone volume was then identified and quantified.

RESULTS

The mean volume of heterotopic bone formed in the control group was 0.976mm(3) compared to 0.221 mm(3) in the imatinib group. The volume of HO in the treatment group was reduced by 85% compared to the control group.

CONCLUSIONS

The administration of imatinib was associated with a significantly reduced volume of HO. This may be due to the inhibitory effect of imatinib on the PDGF signaling pathway during development of HO.

CLINICAL RELEVANCE

The successful reduction of HO formation following imatinib administration has led to further insight concerning the pathogenesis of HO which in the future may lead to new clinical approaches towards the prevention of HO.

C1 fracture in a patient with a congenital cleft in the posterior arch: report on a failed conservative treatment

Unstable burst fractures of the atlas require sufficient immobilisation either with an external device or by surgical fusion. In patients with pre-existing congenital atlantal defects the decision whether to recommend non-operative or operative therapy is difficult. Treatment options are controversially discussed and standardised guidelines are not available. Although most surgeons advise operative fusion or osteosynthesis in atlanto-axial instability, non-operative immobilisation can be successful. We report on a patient with an unstable C1 burst fracture with a congenital posterior cleft in the atlantal arch who was treated with cervical extension and halovest immobilisation. Although callus bridging was initially observed, 9 months after the injury there was no sufficient fracture consolidation and surgical fusion had to be advised. While non-operative treatment may work in patients without congenital defects of the C1 arch, such is not recommended in patients who present with this anomaly.

Vertebral body stenting versus kyphoplasty for the treatment of osteoporotic vertebral compression fractures: a randomized trial

BACKGROUND

In the treatment of vertebral compression fractures, vertebral body stenting with an expandable scaffold inserted before application of the bone cement was developed to impede secondary loss of vertebral height encountered in patients treated with balloon kyphoplasty. The purpose of this study was to clarify whether there are relevant differences between balloon kyphoplasty and vertebral body stenting with regard to perioperative and postoperative findings.

METHODS

In a two-armed randomized controlled trial, patients with a total of 100 fresh osteoporotic vertebral compression fractures were treated with either balloon kyphoplasty or vertebral body stenting. The primary outcome was the post-interventional change in the kyphotic angle on radiographs. The secondary outcomes were the maximum pressure of the balloon tamp during inflation, radiation exposure time, perioperative complications, and cement leakage.

RESULTS

The mean reduction (and standard deviation) of kyphosis (the kyphotic correction angle) was 4.5° ± 3.6° after balloon kyphoplasty and 4.7° ± 4.2° after vertebral body stenting (p = 0.972). The mean pressures were 24 ± 5 bar (348 ± 72 pounds per square inch [psi]) during vertebral body stenting and 16 ± 6 bar (233 ± 81 psi) during balloon kyphoplasty (p = 0.014). There were no significant differences in radiation exposure time.None of the patients underwent revision surgery, and postoperative neurologic sequelae were not observed. Cement leakage occurred at twenty-five of the 100 vertebral levels without significant differences between the two intervention arms (p = 0.230). Intraoperative material-related complications were observed at one of the fifty vertebral levels in the balloon kyphoplasty group and at nine of the fifty levels in the vertebral body stenting group.

CONCLUSIONS

No beneficial effect of vertebral body stenting over balloon kyphoplasty was found among patients with painful osteoporotic vertebral fractures with regard to kyphotic correction, cement leakage, radiation exposure time, or neurologic sequelae. Vertebral body stenting was associated with significantly higher pressures during balloon inflation and more material-related complications.

Echinomycin in the prevention of heterotopic ossification - an experimental antibiotic agent shows promising results in a murine model

BACKGROUND

Heterotopic ossification (HO) frequently causes complications following orthopaedic and trauma surgery and may drastically reduce the postoperative outcome due to pain and joint contracture. Current therapeutic options include NSAID's and local radiation. However, both options of prevention show disadvantages such as delayed fracture healing and impaired ossification as well as other side effects.(9) Our goal was to investigate a novel approach in the prevention of heterotopic ossification by pharmacologically interfering with the molecular signalling pathways involved in this process. Hypoxia leads to numerous effects on a cellular level, one of which is the activation of the transcriptional complex hypoxia-inducible factor (HIF).(19) Among several other actions, the HIF1-α signalling pathway in turn regulates angiogenesis through induction of the expression of vascular endothelial growth factor (VEGF).(21) We hypothesised that by pharmacologically interfering with the HIF-1α signalling pathway, the amount of HO formation may be reduced. Echinomycin is a known inhibitor of HIF-1-alpha and was used in our study with the aim to prevent HO from forming.

METHODS

We examined the effect of Echinomycin on HO formation in a murine model where an Achilles tenotomy was performed. This has previously been shown to reliably produce islets of heterotopic ossification within the soft tissue of mouse hind limbs at 10 weeks after surgery. The control group underwent Achilles tenotomy only, whereas the Echinomycin group additionally received Echinomycin subcutaneously. After trial completion, the limbs were harvested and Micro-CT was performed. Heterotopic bone volume was then identified in 3d images and quantified.

RESULTS

We found a highly significant reduction in the bone volume following subcutaneous administration of Echinomycin compared to the control group.

CONCLUSION

Although a substantial reduction could be achieved, it was not possible to completely prevent heterotopic ossification from forming. Further studies have yet to be conducted to optimise the results by altering the dosage and duration of administration as well as investigate the mechanism by which Echinomycin led to the reduction of HO formation.

Normal values of Wiberg's lateral center-edge angle and Lequesne's acetabular index--a coxometric update

BACKGROUND

The historical pathological cut-off values for Wiberg's lateral center-edge (LCE) angle and Lequesne's acetabular index (AI) are below 20° and above 12° for the LCE and AI, respectively. The aim of this study was to reassess these two angles more than 50 years after their introduction using a standardized conventional radiological measurement method, considering changing social habits and their associated physiological changes.

METHODS

A total of 1,226 anteroposterior radiographs of the pelvis (2,452 hips) were obtained according to a strict standardized radiographic technique allowing reliable measurements of the LCE angle and the AI.

RESULTS

Distributions of the LCE and AI were pronouncedly Gaussian, with mean values of 33.6° for the LCE and 4.4° for the AI. The 2.5th and 97.5th empirical percentiles were 18.1 and 48.0° for the LCE and -6.9 and 14.9° for the AI. These intervals contained 95 % of the data in our large sample. Small but statistically significant differences between the sexes and right and left hips have been demonstrated. Correlation between age and coxometric indices was low.

CONCLUSION

The above findings do not conflict with the historical benchmarks. Statistical differences between sexes and between right and left hips were not clinically relevant. No conclusion can be drawn about coxometric indices and clinical manifestations of hip dysplasia.

[Osteoporotic fractures of axial skeleton]

Osteoporotic fractures most frequently first occur in the axial skeleton, especially in the vertebral bodies of the thoracolumbar transition. Beside pain, these fractures cause increasing kyphosis leading to changes in statics and a shift of the bodies' center of gravity. This results in physiological, functional as well as neurological consequences that cannot be managed by means of a conservative therapy. The purpose of this article is to provide a brief overview on diagnostics and therapy of such fractures. Furthermore, fractures of the pubic rami need to be mentioned. They pose another frequent location for osteoporotic fractures and are also associated with a high rate of morbidity and mortality.

[Delayed splenic rupture 13 days post-trauma after initially inconspicuous computed tomography examination]

Delayed splenic injuries are rare but nevertheless well known and very dangerous complications after blunt abdominal trauma. The highest incidence is reported between four and eight days after trauma; however some cases with a latent period of weeks have been published. We present a case of delayed splenic rupture 13 days after trauma where most computed tomography (CT) examinations were interpreted as normal and present a review of the pathophysiology of delayed rupture, diagnosis and therapy.

Posterior screw fixation in rotationally unstable pelvic ring injuries

OBJECTIVE

Although the stability of the pelvic ring primarily depends on the integrity of the posterior sacroiliac arch, lateral compression fractures with rotational instability are commonly treated by anterior fixation alone. The objective of the present study was to assess the outcome of patients with these fractures treated by posterior iliosacral screw fixation alone.

METHODS

Patients with rotationally unstable lateral compression fractures of the pelvic ring (Young and Burgess LC I and LC II or AO/Tile B2) treated by percutaneous iliosacral fixation alone were included. Postoperative complications, need for secondary surgery, malunion, secondary fracture displacement and the time to full-weight bearing were documented.

RESULTS

Twenty-five patients (13 female, 26 male; age: 56±20 years) were treated by percutaneous screw fixation (14 bilaterally, 11 unilaterally). Mean follow-up was 6±4 months, mean time to full weight bearing 9±3 weeks. Revision surgery was necessary in two patients (8%) due to nerve irritation; an additional anterior stabilisation was needed in two other patients (8%) due to secondary dislocation. Wound infection or motor weakness were not encountered, non-union of the posterior arch did not occur. Non-union of the pubic rami, however, occurred in two patients. The presence of malunion of the pubic rami did not affect the time to full weight bearing.

CONCLUSIONS

Percutanous iliosacral screw fixation alone is a sufficient technique for the stabilisation of rotationally unstable pelvic fractures with low rates of complications or non-unions. It allows for a minimally invasive treatment thus being a useful option in patients who do not qualify for open anterior fixation.

Avulsion fracture of the dorsal talonavicular ligament: a subtle radiographic sign of possible Chopart joint dislocation

Level of Evidence: V, Expert Opinion

Percutaneous iliosacral screw fixation in S1 and S2 for posterior pelvic ring injuries: technique and perioperative complications

OBJECTIVE

Percutaneous iliosacral screw placement allows for minimally invasive fixation of posterior pelvic ring instabilities. The objective of this study was to describe the technique for screws in S1 and S2 using conventional C-arm and to evaluate perioperative complications.

METHODS

Thirty-eight consecutive patients after percutaneous pelvic ring fixation with cannulated screws in S1 and S2 using conventional C-arm fluoroscopy were analysed. Accuracy of screw placement, nerval lesions, need for second surgery, operation time, and time to full weight bearing were assessed postoperatively and during regular follow-up examinations.

RESULTS

Twenty-one patients underwent unilateral screw fixation and 17 patients underwent bilateral screw fixation. In total, 83 screws were placed. Mean age of the patients was 52 ± 19 years. Mean operation time was 16 ± 7 min/screw. Mean follow-up was 5 ± 3 months. Time to full weight bearing in 28 patients was 9 ± 4 weeks. Eight patients were still not able to support full weight bearing, partially due to concomitant injuries. Patients without concomitant injuries that affected walking were able to bear full weight after 8 ± 4 weeks (n = 17). Two patients had persistent postoperative hypaesthesia. No motor weakness was apparent and no postoperative bleeding was observed. Secondary surgery due to screw malpositioning or loosening had to be performed in four patients. The presence of a screw in S2 was not indicated for perioperative complications.

CONCLUSIONS

Percutaneous iliosacral screw fixation is a rapid and definitive treatment for posterior pelvic ring injuries with a low risk of secondary bleeding during posterior pelvic stabilization. The technique using standard C-arm fluoroscopy was also found to be safe for screws placed in S2.

Diagnostics in suspicion of ankle syndesmotic injury

Ankle sprains are among of the most common injuries seen in daily orthopaedic practice. Beside injuries of the lateral ligament, which is the most frequently injured single structure in the body of athletes, sprains can also affect the tibiofibular syndesmosis. These injuries are known as high ankle sprains. They can occur with or without a bony injury. In this report, we will discuss the high ankle sprain without any bony injury. These kinds of injuries are rare, but often associated with complications and are frequently misdiagnosed or undiagnosed. The purpose of this article is to provide a clear understanding of clinical tests described in the literature for testing of syndesmotic integrity.

Anatomical considerations of the internal iliac artery in association with the ilioinguinal approach for anterior acetabular fracture fixation

INTRODUCTION

Vascular injury may be encountered during an anterior approach to the pelvis or acetabulum-be it due to hematoma decompression, clot dislodgement during fracture manipulation, or iatrogenic. This can be associated with significant bleeding, hemodynamic instability, and subsequent morbidity. If the exact source of bleeding cannot be easily identified, compression of the internal iliac artery may be a lifesaving procedure.

MATERIALS AND METHODS

We describe an extension of the lateral window of the ilioinguinal (or Olerud) approach elaborated on cadavers.

RESULTS

The approach allows emergent access the internal iliac artery and intraoperative cross-clamping of the internal iliac vessels to control bleeding.

CONCLUSION

The approach allows rapid access to the internal iliac artery. The surgeon should be familiar, however, with the surgical anatomy of this region to avoid potential injury to the ureter, peritoneum, lymphatics, and sympathetic nerves overlying the vessels when using the approach described.

Correlation of psychomotor findings and the outcome of a physical therapy program to treat scapular dyskinesis

BACKGROUND

This pilot study was performed to investigate the influence of psychomotor skills on the outcome of a specific nonoperative program (scapular dyskinesis-program) to treat scapular dyskinesis.

MATERIALS AND METHODS

Fifteen patients (group A) with positive and 11 patients (group B) with a negative outcome after physical therapy were included. To test the psychomotor skills of the patients the Motorische Leistungsserie (MLS) was used. The test results of the patients of group A were then compared with those of group B.

RESULTS

For 2 parameters, a significant correlation could be detected. However, due to the small sample size, a clear but statistically insignificant difference could be found for several other factors.

CONCLUSION

We, therefore, hypothesize that psychomotor skills testing is a potential method to predict the outcome of nonoperative treatment for scapular dyskinesis. Further investigations with a larger sample size are necessary to confirm this assumption.

Subacromial pressures vary with simulated sleep positions

HYPOTHESIS

Subacromial impingement is one of the underlying factors of rotator cuff pathologies and is linked to increased subacromial pressures. Because humans spend about one-third of their life sleeping, we hypothesized that distinct shoulder positions while sleeping may considerably influence nocturnal subacromial pressures. Consequently, atrophy and rupture can affect tendon healing after rotator cuff repair, thus potentially discrediting the outcome of surgery.

MATERIALS AND METHODS

We determined the subacromial pressures acting on the rotator cuff in the 4 most common sleep positions and related these pressures to the mean arterial blood pressure and physical examination findings in 20 healthy volunteers.

RESULTS

Subacromial pressures were significantly lower in participants sleeping preferably in a supine position than in participants sleeping in side or prone positions (P < .005).

DISCUSSION

As tendon perfusion is crucial for tendon-to-bone healing during postoperative physical therapy after rotator cuff reconstruction and for prevention of additional damage to healthy or already torn cuffs, potential clinical relevance may emerge from the present study.

CONCLUSION

Distinct shoulder positions considerably influence subacromial pressures. Our findings may be considered in physiotherapeutic concepts after rotator cuff surgery.