Duration of incapacity of work after tibial plateau fracture is affected by work intensity

BACKGROUND

Tibial plateau fractures requiring surgery are severe injuries of the lower extremity. Tibial plateau fractures have an impact not only on physically demanding jobs but notably on general professional life too. The aim of this study was to assess how the professional activity of patients will be affected after a tibial plateau fracture.

METHODS

39 consecutive patients (ages 20-61 years) were retrospectively included in the study and were clinically examined at a minimum of 14 month postoperatively. Inclusion criteria were surgical treatment of tibial plateau fractures between November 2009 and December 2012. The clinical evaluation included the Lysholm score and the Oxford Knee Score. Fractures were classified and analyzed using the AO classification. Intensity of work was classified as established by the REFA Association. The patients themselves provided postoperative duration of the incapacity of work and subjective ratings.

RESULTS

17 (43.6%) women and 22 (56.4%) men were examined with a mean follow-up of 29.7 ± 10.4 months (range 14-47). According to the AO classification there were 20 (51.3%) B-type-fractures and 19 (48.7%) C-type-fractures. The median incapacity of work was 120 days (range 10-700 days) with no significant differences between B- and C-type-fractures. Four (10.3%) patients reduced their working hours by 10.5 h per week on average. Patients with low workload (REFA 0-1, median incapacity of work 90 days, range 10-390 days) had a significant shorter incapacity of work than patients with heavy workload (REFA 2-4, median incapacity of work 180 days, range 90-700 days) (p < 0.05). The median Lysholm score decreased significantly from 100 points (range 69-100) before the injury to 73 points (range 23-100) at the time of the follow-up. All patients received postoperative physiotherapy (median 25 appointments, range 6-330), with a significant higher number of appointments for C-type-fractures than for B-type-fractures (p = 0.004).

CONCLUSION

A relationship was found between workload and the duration of incapacity of work after tibial plateau fractures. The post-injury shift to less demanding jobs and the reduction of working hours highlight the impact of a tibial plateau fracture on a patient's subsequent physical ability to work.

Obesity causes poorer clinical results and higher re-tear rates in rotator cuff repair

BACKGROUND

The purpose of this retrospective study was to report on the functional outcome after both open and arthroscopic rotator cuff (RC) repair in normal weight, pre-obese and obese patients. It was hypothesized that obesity is a negative prognostic factor for clinical outcome and failure for the RC repair.

METHODS

One hundred and forty-six patients who underwent either open or arthroscopic rotator cuff repair between 2006 and 2010 were included in this study. Seventy-five patients (56.7 ± 10.1 years of age) after open RC repair and 71 patients (59.0 ± 9.1 years of age) treated arthroscopically were available for evaluation. In both groups a double-row reconstruction was performed. Patients were divided in three groups according to their body-mass index. The mean follow-up was at 43 ± 16 (minimum 24) months. At follow-up, the clinical outcome was assessed by the DASH and Constant score. An ultrasound of both shoulders was performed in all patients.

RESULTS

The mean BMI was 28.3 ± 5.3 in the arthroscopic group and 27.7 ± 4.3 in the open group. Overall, in both groups similar clinical results were noted [Constant-Murley score 78.3 ± 18.2 arthroscopic vs. 77.0 ± 21.8 for open surgery; DASH 12.7 ± 18.2 arthroscopic vs. 15.6 ± 21.6 for open surgery (p = 0.81)]. Both the failure rate and the clinical outcome were significantly worse for obese patients (BMI > 30, p = 0.007). The failure rate was 15.8% for the normal-weight patients, 8.2% in the pre-obese group and in the obese group 28.6%. The RC repair failure occurred in 11 cases in both groups after arthroscopic or open treatment (15.0%).

CONCLUSIONS

Both the arthroscopic and the open approach showed equivalent clinical results and failure rates. Obesity (BMI > 30) causes less favorable results in the Constant and DASH scores and showed higher re-tear rates.

[Balloon osteoplasty as reduction technique in the treatment of tibial head fractures]

BACKGROUND

Tibial plateau fractures requiring surgery are severe injuries of the lower extremities. Depending on the fracture pattern, the age of the patient, the range of activity and the bone quality there is a broad variation in adequate treatment. 

AIM

This article reports on an innovative treatment concept to address split depression fractures (Schatzker type II) and depression fractures (Schatzker type III) of the tibial head using the balloon osteoplasty technique for fracture reduction.

METHODS

Using the balloon technique achieves a precise and safe fracture reduction. This internal osteoplasty combines a minimal invasive percutaneous approach with a gently rise of the depressed area and the associated protection of the stratum regenerativum below the articular cartilage surface. This article lights up the surgical procedure using the balloon technique in tibia depression fractures.

CONCLUSION

Using the balloon technique a precise and safe fracture reduction can be achieved. This internal osteoplasty combines a minimally invasive percutaneous approach with a gentle raising of the depressed area and the associated protection of the regenerative layer below the articular cartilage surface. Fracture reduction by use of a tamper results in high peak forces over small areas, whereas by using the balloon the forces are distributed over a larger area causing less secondary stress to the cartilage tissue. This less invasive approach might help to achieve a better long-term outcome with decreased secondary osteoarthritis due to the precise and chondroprotective reduction technique.

Acute MCL and ACL injuries: first results of minimal-invasive MCL ligament bracing with combined ACL single-bundle reconstruction

BACKGROUND

There is an on-going discussion whether to operatively treat combined grade II and III lesions of the medial collateral ligament (MCL) with anterior cruciate ligament (ACL) in the acute phase rather than conservative treatment of the MCL lesion with a delayed unitary ACL replacement. Another issue is the question how to technically address these MCL lesions. The aim of this study was, therefore, to analyze the results of simultaneous ACL replacement (hamstrings) in a single-bundle technique with a simultaneous MCL ligament bracing procedure.

METHODS

In this prospective non-randomized trial,, 16 patients were included with grade II and III lesions of the MCL. Surgical treatment was performed within 14 days (mean 10.4 days, SD ±2.3 days) by one single expert orthopedic surgeon using the semitendinosus tendon and Rigidfix® system for femoral and tibial fixation and 3.5 mm screws with one 1.3 mm PDS Cord for minimal-invasive MCL ligament bracing with screw fixation. Knee stability was measured with the Rolimeter® and KT-1000®. MCL stability was assessed in clinically and radiographically with valgus stress projections.

RESULTS

The mean patient age was 36.4 with six female and ten male patients. There were no surgical complications such as infections or healing disturbances. Mean operation time was 64 ± 6 min. The arthrofibrosis rate was 0 %. Medial knee stability was normal in full extension for all cases with no intra-individual side-to-side difference. Radiological assessed MCL stability revealed Δ values with a mean of 1.1 ± 1.3 mm compared to the contra-lateral side. The Lachman Test revealed a side-to-side difference of 1.6 mm with the KT-1000® and 2.6 ± 0.9 mm when measured with the Rolimeter®. Subjective clinical assessment revealed good results with a mean Lysholm Score of 89.1 points.

CONCLUSION

Acute ACL replacement and MCL ligament bracing with this novel technique revealed in this study good clinical results and objective restored knee stability without cases of knee stiffness or arthrofibrosis. The remarkable shortcoming is the small cohort number making further studies necessary.

Stem cells and bFGF in tendon healing: Effects of lentiviral gene transfer and long-term follow-up in a rat Achilles tendon defect model

BACKGROUND

The influence of stem cells and lentiviral expression of basic fibroblastic growth factor (bFGF) on tendon healing and remodelling was investigated in an in-vivo long-term (12 weeks) rat Achilles tendon defect model.

METHODS

In sixty male Lewis rats, complete tendon defects (2.4 mm) were created and either left untreated (PBS) or treated by injection of stem cells lentivirally expressing the enhanced green fluorescence marker gene eGFP (MSC-LV-eGFP) or basic fibroblast growth factor bFGF (MSC-LV-bFGF). Tendons were harvested after 12 weeks and underwent biomechanical and (immuno)-histological analysis.

RESULTS

After 12 weeks the mean ultimate load to failure ratio (treated side to contralateral side) in biomechanical testing reached 97 % in the bFGF-group, 103 % in the eGFP-group and 112 % in the PBS-group. Also in the stiffness testing both MSC groups did not reach the results of the PBS group. Histologically, the MSC groups did not show better results than the control group. There were clusters of ossifications found in all groups. In immunohistology, only the staining collagen-type-I was strongly increased in both MSC groups in comparison to PBS control group. However, there were no significant differences in the (immuno)-histological results between both stem cell groups.

CONCLUSION

The biomechanical and (immuno)-histological results did not show positive effects of the MSC groups on tendon remodelling in a long-term follow-up. Interestingly, in later stages stem cells had hardly any effects on biomechanical results. This study inspires a critical and reflected use of stem cells in tendon healing.

Coracoid graft positioning in the Latarjet procedure

PURPOSE

The success of shoulder stabilization with the Latarjet procedure depends on the correct positioning of the coracoid graft at the glenoid. The aim of this study was to assess intra-observer reproducibility and inter-observer reproducibility of a new standardized CT scan analysis for coracoid graft positioning in the axial plane after the Latarjet procedure and to assess the positioning in the study group.

METHODS

A consecutive series of 27 patients (22 men, 5 woman, 26.1 ± 6.4 years-13 right, 14 left shoulders) were followed up with CT scans between 2010 and 2012. The analysis of the CT scans (2.4 ± 0.7 months postoperatively) was performed with Osirix™ software. The assessment included two criteria in the axial plane: relation of the graft to the articular surface of the glenoid and impingement of the graft with the maximal humeral head circumference. Grafts were judged to be lateral, congruent, flush or medial. The strength of intra-observer agreement and inter-observer agreement was measured by the Kappa coefficient.

RESULTS

The Kappa coefficient for intra-observer agreement was "substantial" (K = 0.64 ± 0.14, z = 4.6) to "almost perfect" (K = 0.81 ± 0.14, z = 5.7). The Kappa coefficient for inter-observer variability was "substantial" (K = 0.59 ± 0.14, z = 4.3) to "almost perfect" (K = 0.89 ± 0.14, z = 6.0). In our study, in the axial plane, 3 (11 %) transplants were lateral; 6 (22 %) transplants were congruent; 16 (60 %) flush and 2 (7 %) medial.

CONCLUSION

This standardized CT scan analysis after Latarjet procedure has shown to accurately describe graft positioning in the axial plane with both good intra-observer reproducibility and inter-observer reproducibility.

LEVEL OF EVIDENCE

Case series, treatment study, Level IV.

Double intramedullary cortical button versus suture anchors for distal biceps tendon repair: a biomechanical comparison

PURPOSE

The aim of this biomechanical in vitro study was to compare the novel technique of double intramedullary cortical button (DICB) fixation with the well-established method of suture anchor (SA) fixation for distal biceps tendon repair.

METHODS

A matched-pair analysis (24 human cadaveric radii) was performed with respect to cyclic loadings and failure strengths. Twelve specimens per group were cyclically loaded for 1,000 cycles at 1.5 Hz from 5 to 50 N and from 5 to 100 N, respectively. The tendon-bone displacement was optically analysed using the Image J Software (National Institute of Health). Afterwards, all specimens were pulled to failure. Maximum load to failure and mode of failure were recorded.

RESULTS

All DICB constructs passed the cyclic loading test, whereas 4 of the 12 specimens within the SA group failed by anchor pull-out. Cyclic loading showed a mean tendon-bone displacement of 0.6 ± 1.4 mm for the DICB group and 1.4 ± 1.4 mm for the SA group (n.s.) after 1,000 cycles with 50 N, and a mean displacement of 2.1 ± 2.4 mm for the DICB group and 3.5 ± 3.7 mm for the SA group (n.s.) after 1,000 cycles with 100 N. Load to failure testing showed a mean failure load of 312 ± 76 N and a stiffness of 67.1 ± 11.7 N/mm for the DICB technique. The mean load to failure for the SA repair was 200 ± 120 N (n.s.) and the stiffness was 55.9 ± 21.3 N/mm (n.s.).

CONCLUSIONS

The novel technique of DICB fixation showed small tendon-bone displacement during cyclic testing and reliable fixation strength to the bone in load to failure. Moreover, all DICB constructs passed cyclic loadings without failure. Based on the current findings, a more aggressive postoperative rehabilitation may be allowed for the DICB repair in clinical use.

[Clinical relevance of unloading in cartilage therapy of the knee--shoe insoles, knee braces or additional operative procedure?]

Restoration of a neutral biomechanical environment and reduction of overload is an important factor contributing to the success of any cartilage repair procedure. Reduction of overload can by achieved by so called unloading procedures in order to reduce intraarticular pressure from the repair zone. Unloading can be achieved via loss of weight, wedged shoe insoles, knee braces or via operations such as osteotomies around the knee joint. The cartilage therapy and the concomitant unloading procedure should be adapted to the individual pathology and realistic aims of the patient. Wedged insoles and braces are the least invasive treatment methods. In comparison, however, beneficial effects of braces outline those of laterally wedged heels. Nevertheless long-term compliance with insoles and braces is poor. Concerning braces either because the positive effects of the braces are too small or because the adverse effects are too large. Unloading in the long run may only be achieved through operative procedures. When an osteotomy seems to be too invasive the arthroscopic release of the posterior oblique ligament might be an option. Patients with an intact contralateral chondral status, medium to slight malalignment who want to remain at high activity levels, remain good candidates for unloading osteotomies.

[Duration of inability for work and return to physical work after arthroscopic and open labrum refixation]

BACKGROUND AND INTRODUCTION

The duration of inability for work according to work load and the rate of successful return to work after open and arthroscopic Bankart repair (BR) due to anterior shoulder dislocation has not yet been examined with regard to validated work strain by the REFA classification. Thus, the objective of this study was to determine the duration of inability to work according to work load (REFA criteria) after open and arthroscopic BR as well as the rate of successful return to the original occupation.

PATIENTS AND METHODS

A total of 93 patients (20 f/73 m) with isolated anterior arthroscopic or open BR due to posttraumatic anterior shoulder instability with no items of hyperlaxity were included in this study. There were 72 patients with arthroscopic and 21 patients with open BR. The postoperative aftercare was standardised and identical. The clinical assessment included the Constant and Murley scores, UCLA shoulder and the Rowe score for shoulder instability. Average follow-up time was 48.3 months (SD ± 23.6 months) with a mean age of 37.1 years (SD ± 14.4 years). The work load was classified according to the German REFA Association. Operation time, duration of inability for work and clinical outcome were analysed and compared according to the operation technique.

RESULTS

Mean incapacity for work in the group of arthroscopic BR was 3.3 months (SD ± 2.5) and 2.7 months (SD + 2.3 months; p = 0.37) in the group of open BR demonstrating no statistical difference. Both mean time for surgery (p = 0.0003) and in-hospital stay (p = 0.0083) showed significant differences when comparing patients with low work load (REFA 0-1) and higher work load (REFA 2-4) irrespective of the surgical approach. Overall analysis showed an average time of 2.3 months (SD ± 1.5) to return to work for patients with low work load (REFA 0-1) and 4.2 months (SD ± 2.9) for individuals with high work load (REFA 2-4) revealing significant differences (p = 0.0006). The mean inability for work after arthroscopic BR for patients with REFA 0-1 was 2.4 months (SD ± 1.6) and 4.2 months (± 2,9; p = 0.0053) for patients with REFA 2-4 revealing a significant difference. The mean inability for work after open BR for individuals with REFA 0-1 was 1.8 months (± 1.0) and 4.3 months (± 3.3; p = 0.1196) for individuals with REFA 2-4. Two out of 35 patients (5.7 %) with low work load (REFA 0-1) and 10 out of 37 patients (27 %) with high work load (REFA 2-4) could not return to their original occupation after arthroscopic BR. One out of 14 patients (7.1 %) with low work load (REFA 0-1) and 4 out of 7 patients (57.1 %) with high work load (REFA 2-4) could not return to their original occupation after open BR. Comparing these results between arthroscopic and open BR, no significant differences were obtained (chi-square, Pearson). Recurrent shoulder dislocation occurred in the arthroscopic group in 14.3 % (REFA 0-1) and 8.1 % (REFA 2-4) compared to the open procedure group in 0 % (REFA 0-1) and 14 % (REFA 2-4) revealing no statistically significant differences.

CONCLUSION

This study showed equivalent results after performing open and arthroscopic BR with significantly shorter operation times and in-hospital stays after arthroscopic BR. Higher work loads caused longer inability for work irrespective of the chosen surgical technique. On the basis of these results we recommend arthroscopic BR as the standard primary procedure, while the overall rate of return to work without restrictions of 81.7 % has to be improved in the future.

Dynamic-locking-screw (DLS)-leads to less secondary screw perforations in proximal humerus fractures

Background

Loss of reduction and screw perforation causes high failure rates in the treatment of proximal humerus fractures. The purpose of the present study was to evaluate the early postoperative complications using modern Dynamic Locking Screws (DLS 3.7) for plating of proximal humerus fractures.

Methods

Between 03/2009 and 12/2010, 64 patients with acute proximal humerus fractures were treated by angular stable plate fixation using DLSs in a limited multi-centre study. Follow-up examinations were performed three, six, twelve and twenty-four weeks postoperatively and any complications were carefully collected.

Results

56 of 64 patients were examined at the six-month follow-up. Complications were observed in 12 patients (22%). In five cases (9%), a perforation of the DLS 3.7 occurred.

Conclusions

Despite the use of modern DLS 3.7, the early complications after plating of proximal humerus fractures remain high. The potential advantage of the DLS 3.7 regarding secondary screw perforation has to be confirmed by future randomized controlled trials.

Stem cells and basic fibroblast growth factor failed to improve tendon healing: an in vivo study using lentiviral gene transfer in a rat model

BACKGROUND

The aim of this controlled study was to investigate the influence of mesenchymal stem cells (MSCs) and lentiviral (LV) expression of basic fibroblast growth factor (bFGF) on tendon remodeling in an in vivo rat model of an Achilles tendon defect.

METHODS

In eighty-four male Lewis rats, complete 2.4-mm tendon defects were created and were either left untreated (the phosphate-buffered saline solution [PBS] group) or were treated with mesenchymal stem cells expressing enhanced green fluorescent protein (the MSC-LV-eGFP group) or with mesenchymal stem cells expressing basic fibroblast growth factor lentivirally (the MSC-LV-bFGF group). After fourteen and twenty-eight days, the tendons were harvested and analyzed biomechanically and immunohistologically.

RESULTS

After fourteen days, both mesenchymal stem cell groups were slightly superior in biomechanical testing. However, only the PBS control group showed a significant increase in biomechanical results over time (fourteen versus twenty-eight days; p = 0.012). Biomechanical results were better after twenty-eight days for the control group than for both MSC groups. However, the difference was significant only with regard to the stiffness results in the comparison of the PBS control and the eGFP stem cell group (p = 0.024). Histologically, the MSC groups had no better results than the control group after fourteen and twenty-eight days. In immunohistology, only labeling for type-I procollagen was strongly increased in both MSC groups in comparison with the PBS control group (p = 0.0009 for the MSC-LV-bFGF group and p = 0.0041 for the MSC-LV-eGFP group at fourteen days, and p = 0.004 and p = 0.132, respectively, at twenty-eight days). There were no significant differences in the immunohistological results between the stem cell groups.

CONCLUSIONS

The biomechanical and immunohistological results showed that mesenchymal stem cells in both groups had only partially positive effects on tendon remodeling in the initial stages; however, in later stages, stem cells had potentially negative effects on biomechanical results. The additional expression of bFGF in stem cells had negligible effects on tendon remodeling.

CLINICAL RELEVANCE

Preliminary studies using stem cells are partially promising; however, there are no relevant clinical data showing that stem cells are of significant benefit. The present study should lead to a more critical evaluation and thoughtful use of stem cells in humans until more clinical data are available.

[Tibial plateau fractures in alpine skiing--return to the slopes or career end?]

BACKGROUND

Fractures of the tibial plateau are among the most severe injuries of the knee joint and are often the result of sports accidents, especially skiing accidents.

PATIENTS/MATERIALS AND METHODS

Between January 2003 and March 2009, a total of 37 skiers with tibial plateau fractures were treated operatively at Klinikum rechts der Isar, Munich (level I trauma center); 28 patients with a minimum follow-up of 24 months were included in this study. Sporting activity was determined at the time of injury and at the time of survey at an average follow-up of 49.0 months postoperatively.

RESULTS

At the time of the survey, 92.9% of all patients were engaged in sports; only 12 of the 28 patients returned to skiing. Of the competitive athletes (n = 5 at time of injury) no patient returned to competition. The number of different sporting activities declined significantly from 6.4 before the injury to 4.6 after the injury. The activity duration per week, being 5.0 hours at the time of injury, declined to 4.4 hours, although the difference is statistically not significant. The Lysholm score, 97.5 points before accident, illustrated a significant decline to 84.4 points. Activity levels according to the Tegner scale declined significantly from 6.1 to 4.7 after the tibial plateau fracture.

CONCLUSION

The majority of patients could not return to their previous level of activity. For patients playing competitive sports, the tibial plateau fracture can be a career ender. Overall, 92.9% of the patients returned to sports, but we noticed a post-injury shift toward activities with less impact. Only 12 of the 28 (42.9%) skiers with tibial plateau fractures returned to skiing.

CT-based quantitative assessment of the surface size and en-face position of the coracoid block post-Latarjet procedure

BACKGROUND

The success of shoulder stabilization with the Latarjet procedure might depend on the size of the bone graft and the positioning of the coracoid at the glenoid. The aim of this study was to quantitatively assess the surface of the coracoid bone graft and to assess its positioning in the en-face view.

METHOD

A series of 21 patients (17 men, 4 women, 26.1 ± 6.8 years-9 right, 12 left shoulders) were prospectively included and followed up with CT scans between December 2010 and April 2012 at an average of 2.4 ± 0.7 months postoperatively. The retrospective analysis of the CT scans was performed with Osirix™ software. The coracoid surface was measured (cm(2)) in the sagittal plane. The positioning in relation to the center of the circumscribed circle of the glenoid was determined in the en-face clock face view of the glenoid.

RESULTS

The grafts had a mean surface of 1.61 ± 0.51 cm(2) (mean ± standard deviation). The coracoid grafts were located between 01:05 hours (32.5°) and 05:33 hours (166.6°). Mean positioning was 02:00 hours (59.8° ± 16.1°) to 04:26 hours (133.0° ± 16.9°). The extent of the grafts was 73.2° ± 14.3°.

DISCUSSION

The positioning of the coracoid graft on the clock face of the glenoid is situated in the decisive zone of 02:30-04:20 hours. The mean surface of the graft is smaller than expected from anatomical studies, but restores in defect situations bone stock in the potential defect areas at the anterior glenoid rim.

LEVEL OF EVIDENCE

Level IV, prospective case series, treatment study.

[Dynamic locking screw 5.0--first clinical experience]

The principle of "biological" plate osteosynthesis describes the optimum interaction between mechanics and biology with the aim to achieve an uneventful consolidation of the fracture by secondary bone healing. The preservation of soft tissue and blood supply are central points in this context. Empirical values show that a too rigid internal fixation can suppress callus formation. The dynamic locking screw - DLS - allows for a decrease of the rigidity of a plate osteosynthesis. The fracture motion is positively affected. The advantages of the angular stability are not affected. In the Trauma Centre Tuebingen 35 patients were treated with the DLS5.0 in the time between November 2011 and October 2012. These first clinical cases with the use of the large fragment DLS showed good results. Handling the DLS5.0 is comparable to the conventional locking screw - LS5.0. Complications were not caused by the DLS and their application.

Treatment for unstable distal clavicle fractures (Neer 2) with locking T-plate and additional PDS cerclage

PURPOSE

The purpose of the current study was to assess the clinical and radiological results after locking T-plate osteosynthesis with coracoclavicular augmentation of unstable and displaced distal clavicle fractures (Neer type 2).

METHODS

Thirty patients, treated between January 2007 and January 2010 were followed up after a median follow-up time of 12.2 months (range 4.7-37.2). The Constant and DASH scores were used to evaluate the clinical outcome, and anterior-posterior and 30° cephalic view radiographs were performed to assess the bony healing.

RESULTS

In all patients, the fracture healing was achieved within the first 10 weeks after surgery. All patients regained good or excellent shoulder function and returned to previous occupation and activity levels. The mean Constant and DASH scores were 92.3 points and 6.2 points, respectively. We did not observe any severe intra- or post-operative complication within the time of follow-up.

CONCLUSION

The presented technique turned out to be a reliable method providing good results without showing severe complications.

LEVEL OF EVIDENCE

Case series, Level IV.

Return to sports activity after tibial plateau fractures: 89 cases with minimum 24-month follow-up

BACKGROUND

Tibial plateau fractures requiring surgery are severe injuries. For professionals, amateurs, and recreational athletes, tibial plateau fractures might affect leisure and professional life.

HYPOTHESIS

Athletic patients will be affected in their sporting activity after a tibial plateau fracture. Despite a long rehabilitation time and program, physical activity will change to low-impact sports.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 89 consecutive patients (age range, 14-76 years) were included in the study and were surveyed by a questionnaire. Inclusion criteria were surgical treatment of tibial plateau fractures between 2003 and 2009 with a minimum follow-up of 24 months. The sporting activity was determined at the time of injury, 1 year postoperatively, and at the time of the survey at an average of 52.8 months postoperatively. The clinical evaluation included the Lysholm score, the Tegner activity scale, the activity rating scale (ARS), and a visual analog scale (VAS) for pain perception. Fractures were classified and analyzed using both the Arbeitsgemeinschaft für Osteosynthesefragen (AO) and the Schatzker classifications.

RESULTS

At the time of injury, 88.8% of all patients were engaged in sports compared with 62.9% 1 year postoperatively and 73.0% at the time of the survey. Of the professional or competitive athletes (n = 11 at the time of injury), only 2 returned to competition at the time of the survey. The number of different sporting activities declined from 4.9 at the time of injury to 3.6 at the time of the survey (P < .001). The sports frequency and the activity duration per week, being 2.8 sessions and 4.5 hours at the time of injury, respectively, declined to 2.4 sessions and 3.8 hours (P < .001 and P = .007, respectively) at the time of the survey, respectively. The Lysholm score (98.7 points before accident) and the VAS for pain perception (0.2 before accident) illustrated significant declines to 76.6 points for the Lysholm score and 2.6 for the VAS (P < .001 and P < .001, respectively) at the time of the survey. The high-energy traumas, Schatzker IV to VI, had significant worse results in the clinical scores compared with the low-energy traumas (Lysholm, P < .001; Tegner, P = .027).

CONCLUSION

The majority of patients could not return to their previous level of activity, and for patients playing competitive sports, this injury can be a career ender. Overall, we noticed a postinjury shift toward activities with less impact. However, at the time of the survey, 73% of all patients were engaged in sports.

Reconstruction of displaced acromio-clavicular joint dislocations using a triple suture-cerclage: description of a safe and efficient surgical technique

Purpose

In this retrospective study we investigated the clinical and radiological outcome after operative treatment of acute Rockwood III-V injuries of the AC-joint using two acromioclavicular (AC) cerclages and one coracoclavicular (CC) cerclage with resorbable sutures.

Methods

Between 2007 and 2009 a total of 39 patients fit the inclusion criteria after operative treatment of acute AC joint dislocation. All patients underwent open reduction and anatomic reconstruction of the AC and CC-ligaments using PDS® sutures (Polydioxane, Ethicon, Norderstedt, Germany). Thirty-three patients could be investigated at a mean follow up of 32±9 months (range 24–56 months).

Results

The mean Constant score was 94.3±7.1 (range 73–100) with an age and gender correlated score of 104.2%±6.9 (88-123%). The DASH score (mean 3.46±6.6 points), the ASES score (94.6±9.7points) and the Visual Analogue Scale (mean 0.5±0,6) revealed a good to excellent clinical outcome. The difference in the coracoclavicular distance compared to the contralateral side was <5 mm for 28 patients, between 5-10 mm for 4 patients, and more than 10 mm for another patient. In the axial view, the anterior border of the clavicle was within 1 cm (ventral-dorsal direction) of the anterior rim of the acromion in 28 patients (85%). Re-dislocations occured in three patients (9%).

Conclusion

Open AC joint reconstruction using AC and CC PDS cerclages provides good to excellent clinical results in the majority of cases. However, radiographically, the CC distance increased significantly at final follow up, but neither the amount of re-dislocation nor calcifications of the CC ligaments or osteoarthritis of the AC joint had significant influence on the outcome.

Level of evidence

Case series, Level IV