Search

Background: The incidence of distal biceps tendon ruptures was studied more than 10 years ago in a small patient cohort. Recent diagnostic advancements have improved the ability to detect this rare injury., Hypothesis: The incidence of distal biceps tendon ruptures will be significantly greater than previously reported., Study Design: Descriptive epidemiologic study., Methods: A query of the PearlDiver Technologies national database containing public and private insurance patients was used to estimate the national incidence of distal biceps tendon ruptures in the United States. A retrospective chart review of our local population identified demographic groups and risk factors that increased likelihood of injury., Results: The estimated national incidence of distal biceps tendon rupture was 2.55 per 100,000 patient-years. The local incidence was 5.35 per 100,000 patient-years. The mean and median ages of patients in our regional cohort were 46.3 and 46 years, respectively. Males composed the majority of the injured population (national 95%, regional 96%). Smoking and elevated body mass index were found to be associated with increased likelihood of injury, while diabetes mellitus showed no association., Conclusion: The incidence of distal biceps tendon ruptures in this study was higher than previously reported., (© 2015 The Author(s).)

Objective: The purpose of this study is to compare the efficiency of preoperative embolization on vascular rupture rates during surgery in 13 patients within two groups., Methods: Retrospective medical records of 7 patients who did undergo preoperative tumor embolization and 6 patients who did not undergo embolization were reviewed. All patients underwent surgical resection of a carotid body tumor from 2010 to 2014 within a tertiary care hospital. Demographic data including age, gender, and tumor size were collected. Glomic artery supply was evaluated with digital subtraction angiography in each patient. The degree of flow reduction was calculated instantly following each injection of embolic material. Complications of embolization were also collected. The estimated blood loss and the operation time were obtained from intraoperative records and operative notes dictated at the time of surgery. Operative records were evaluated for carotid artery rupture and Shamblin classification of glomus tumors., Results: The mean patient age was 48.5 years (range 22-70), and 3 patients were male, 10 were female. All of the patients except one had Shamblin classification II. The mean diameter of tumor size was 4.42 cm. Relative rates of blood flow reduction during embolization were greater than 50% in 4 patients and 25-50% in 3 patients. Carotid artery injury was recorded in 4 patients within embolization group and in 1 patient within the other group. There were no significant differences between carotid artery rupture and embolization, blood loss, tumor size, and supplying artery., Conclusion: Transarterial preoperative embolization of carotid body tumor does not seem to be helpful and should be discussed., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Introduction: During vaginal delivery, the risk of obstetric anal sphincter injuries (OASIS) is well-known. Despite sufficient repair, 30-50% of women will experience anal incontinence. Recent studies from Norway have shown a reduction in the incidence of OASIS when the perineum is supported manually. In Denmark, the frequency of OASIS is the highest in Scandinavia and it is increasing. The aim of this study was to reduce the incidence of OASIS through an interventional programme., Methods: We conducted a study inspired by the Norwegian intervention. Our focus was on four points: 1) good communication between the delivering woman and the birth assistant, 2) visualisation of the perineum in the last stages of delivery, 3) support of the perineum during the final minutes of pushing and 4) episiotomy only on indication. A total of 768 primiparous and 1,175 multiparous women were enrolled in this quality improvement cohort study. Data were analysed for association with the occurrence of OASIS., Results: The proportions of parturients with anal sphincter ruptures decreased significantly during the first year of the study from 4.4% to 1.7% (p < 0.001). The decrease was more pronounced for primiparous women: from 7.2% to 2.9% (p = 0.006). A similar decrease was observed for instrumental deliveries although this was not significant for primiparous women, probably due to the size of the study population. Episiotomies increased significantly from 4.4% to 7.1% for all deliveries., Conclusion: After the first year of intervention, our results demonstrate that manual protection of the perineum reduces the overall risk of OASIS significantly., Funding: not relevant., Trial Registration: not relevant.

Background: Total elbow arthroplasty (TEA) is associated with high complication rates compared with other large-joint arthroplasties. The frequency and type of complication may differ, depending on the surgical approach. A comparison of outcomes with triceps-off and triceps-on approaches was investigated., Methods: Seventy-three patients underwent 83 primary TEAs between 2003 and 2012. Forty-six elbows had a triceps-off approach, and 37 had a triceps-on approach. Results were reviewed at a mean of 4.2 years. Cementing technique was graded according to Morrey's criteria, and clinical outcomes were assessed by means of the Mayo Elbow Performance Score., Results: There was no statistically significant difference between the triceps-off and triceps-on groups with regard to the patient's age, gender, preoperative Mayo Elbow Performance Score or range of motion, or previous surgery on the affected elbow. Among patients who underwent a TEA for an inflammatory arthropathy, there was a significant difference in outcome between groups with regard to final flexion, extension, arc of motion, and pronation. Cementing technique in the triceps-off group was adequate in 70%. In the triceps-on group, cementing technique was adequate in 92%. The complication rate in the triceps-off group was 32.6% and included 7 triceps ruptures. Three patients who had attempted repairs of the triceps rupture developed deep infections requiring multiple further surgeries. The complication rate in the triceps-on group was 8.1%., Conclusion: A triceps-on approach in TEA results in consistently good clinical outcomes with no risk of triceps rupture, and the approach does not compromise the cement mantle. We believe that this approach will reduce complication rates in TEA., (Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

This is a descriptive epidemiologic survey on all traumatic and overuse injuries which occurred in 2 groups of male elite road cyclists based on retrospective clinical interviews and physical examinations. The historical group consisted of 65 professional road cyclists surveyed from 1983 to 1995. The contemporary group included 65 elite racers still active and reporting injuries from 2003 to 2009. Injury/cyclist ratio was 1.32 in the historical group and 2.13 in those still active. Traumatic injuries increased from 39.5% (historical) to 53.9% (contemporary) (p<0.05). Severe traumatic lesions decreased from 49.9% in the historical group to 10.5% in the contemporary group (p<0.01). Patellofemoral pain decreased from 28.8% (historical) to 6.1% (contemporary) (p<0.01). Muscle injuries substantially increased from 13.4% to 44.9% (p<0.01). In the historical racers, the rates of risk for traumatic injury were 0.104 per year per cyclist, and 0.003 per 1 000 km of training and competition. These figures increased to 0.287 and 0.009 respectively in the contemporary group. In summary, contemporary professional road cyclists are exposed to double the risk of traumatic injuries than those competing in the 80s and early 90s. However, these lesions have less severity. Overuse injuries had a completely different clinical pattern, with the currently active cyclist exhibiting more muscle injuries and less tendinous lesions., (© Georg Thieme Verlag KG Stuttgart · New York.)

We investigated the epidemiology of total Achilles tendon ruptures and complication rates after operative and nonoperative treatments over a 33-year period in Oulu, Finland. Patients with Achilles tendon ruptures from 1979 to 2011 in Oulu were identified from hospital patient records. Demographic data, treatment method, and complications were collected retrospectively from medical records. Overall and sex- and age-specific incidence rates were calculated with 95% confidence intervals (CIs). The overall incidence per 100,000 person-years increased from 2.1 (95% CI 0.3-7.7) in 1979 to 21.5 (95% CI 14.6-30.6) in 2011. The incidence increased in all age groups. The mean annual increase in incidence was 2.4% (95% CI 1.3-4.7) higher for non-sports-related ruptures than for sports-related ruptures (P = 0.036). The incidence of sports-related ruptures increased during the second 11-year period whereas the incidence of non-sports-related ruptures increased steadily over the entire study period. Infection was four times more common after operative treatment compared with nonoperative treatment, re-rupture rates were similar. The incidence of Achilles tendon ruptures increased in all age groups over a 33-year period. Increases were mainly due to sports-related injuries in the second 11-year period and non-sports-related injuries in the last 11-year period., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Diagnostic imaging represents the fastest growing segment of costs in the US health system. This study investigated the cost-effectiveness of alternative diagnostic approaches to meniscus tears of the knee, a highly prevalent disease that traditionally relies on MRI as part of the diagnostic strategy., Purpose: To identify the most efficient strategy for the diagnosis of meniscus tears., Study Design: Economic and decision analysis; Level of evidence, 1., Methods: A simple-decision model run as a cost-utility analysis was constructed to assess the value added by MRI in various combinations with patient history and physical examination (H&P). The model examined traumatic and degenerative tears in 2 distinct settings: primary care and orthopaedic sports medicine clinic. Strategies were compared using the incremental cost-effectiveness ratio (ICER)., Results: In both practice settings, H&P alone was widely preferred for degenerative meniscus tears. Performing MRI to confirm a positive H&P was preferred for traumatic tears in both practice settings, with a willingness to pay of less than US$50,000 per quality-adjusted life-year. Performing an MRI for all patients was not preferred in any reasonable clinical scenario. The prevalence of a meniscus tear in a clinician's patient population was influential. For traumatic tears, MRI to confirm a positive H&P was preferred when prevalence was less than 46.7%, with H&P preferred above that. For degenerative tears, H&P was preferred until the prevalence reaches 74.2%, and then MRI to confirm a negative was the preferred strategy. In both settings, MRI to confirm positive physical examination led to more than a 10-fold lower rate of unnecessary surgeries than did any other strategy, while MRI to confirm negative physical examination led to a 2.08 and 2.26 higher rate than H&P alone in primary care and orthopaedic clinics, respectively., Conclusion: For all practitioners, H&P is the preferred strategy for the suspected degenerative meniscus tear. An MRI to confirm a positive H&P is preferred for traumatic tears for all practitioners. Consideration should be given to implementing alternative diagnostic strategies as well as enhancing provider education in physical examination skills to improve the reliability of H&P as a diagnostic test., Clinical Relevance: Alternative diagnostic strategies that do not include the use of MRI may result in decreased health care costs without harm to the patient and could possibly reduce unnecessary procedures., (© 2014 The Author(s).)

Proximal humerus fractures and rotator cuff tears have been shown to have increasing rates with advancing age, theoretically leading to significant overlap in the 2 pathologies. The goal of this study was to examine the prevalence, associated factors, and effect on treatment of rotator cuff tears in surgically treated proximal humerus fractures. A retrospective review was performed of all patients who had surgery for a proximal humerus fracture from January 2007 to June 2012 in the shoulder department of a large academic institution. Patient demographics, the presence and management of rotator cuff tears, and surgical factors were recorded. Regression analysis was performed to determine which factors were associated with rotator cuff tears. This study reviewed 349 fractures in 345 patients. Of these, 30 (8.6%) had concomitant rotator cuff tears. Those with a rotator cuff tear were older (average age, 68.7 vs 63.1 years), were more likely to have had a dislocation (40% vs 12.5%), and were more likely to have undergone subsequent arthroscopic repair or reverse total shoulder arthroplasty than those without a rotator cuff tear. Most (22 of 30) were treated with suture repair at the time of surgery, but 5 patients underwent reverse total shoulder arthroplasty based primarily on the intraoperative finding of a significant rotator cuff tear. A concomitant rotator cuff tear in association with a proximal humerus fracture is relatively common. Rotator cuff tears are associated with older patients and those with a fracture-dislocation. In rare cases, these cases may require the availability of a reverse shoulder prosthesis., (Copyright 2014, SLACK Incorporated.)

Objective: To evaluate factors related to meniscal pathology and their effect on clinical outcome in dogs treated for cranial cruciate ligament (CCL) disease., Study Design: Prospective cross-sectional study., Animals: Dogs (n = 163) with CCL disease (n = 223 stifles)., Methods: CCL disease was treated by (1) arthroscopy and TightRope (TR) stabilization; (2) arthroscopy and tibial plateau leveling osteotomy (TPLO); or (3) open arthrotomy and TPLO. Incidences of concurrent and subsequent meniscal tears, meniscal treatments, mid-(6 months) and long-(>1 year) term outcomes by owner assessment were compared among surgical treatment groups., Results: Concurrent meniscal tears were diagnosed in 83% of stifles assessed by arthroscopy and 44% of stifles assessed by arthrotomy, with concurrent tear diagnosis being 1.9 times more likely by arthroscopy than arthrotomy (P < .001). Incidence of diagnosis of subsequent meniscal tears was 6.7% with median time to diagnosis of 5.8 months. Differences in proportion of subsequent meniscal tears among treatment groups were not significant (P = .69). Subsequent meniscal tears were diagnosed in 21% of cases without concurrent meniscal tears, but only 1.3% of cases with concurrent meniscal tears (P < .001). Cases treated with meniscal release did not have subsequent meniscal tears, whereas dogs not treated with meniscal release had a subsequent meniscal tear rate of 11% (P = .0013). Cases diagnosed and treated for concurrent meniscal tears were 1.3 times more likely to have a successful long-term outcome (P = .007)., Conclusions: CCL surgical technique did not affect subsequent meniscal tear rate or mid-term or long-term functional outcomes, whereas diagnosis and treatment of concurrent meniscal tears did significantly affect both., (© Copyright 2014 by The American College of Veterinary Surgeons.)

Objective: After shoulder trauma, most fractures and dislocations are easily recognized on radiographic examination; however, the opposite is true for rotator cuff injuries. As a consequence, shoulder complaints may persist or arise due to unrecognized cuff injury. The objective of this study was to investigate the prevalence of shoulder pain and symptomatic rotator cuff ruptures 1 year after shoulder trauma without fracture or dislocation., Patients and Methods: This prospective descriptive study included all the patients presented at our emergency department between January 2007 and January 2008 after a trauma to the shoulder without fracture or dislocation. One year after trauma, this cohort was interviewed by telephone and re-examined at the outpatient clinic on indication., Results: Of the 217 patients included, all had been pain-free before the trauma. One year after trauma, 69 patients (32%) were still suffering from shoulder pain. Of these patients, 31 were re-examined and 27 had already been re-examined in the meantime. In total, 20 of these 58 patients (34%) were diagnosed with a symptomatic rotator cuff rupture, representing a prevalence of 9% among the included patients., Conclusion: Emergency physicians should be aware that normal radiography does not exclude the presence of a rotator cuff tear in patients with a history of shoulder trauma. Regular follow-up is essential for discovering rotator cuff injuries. In this study, 32% still suffered from shoulder pain 1 year after shoulder trauma, and re-examination revealed a prevalence of 9% symptomatic rotator cuff ruptures.

Knowing the relationship between diagnoses is important in knee arthroscopy in terms of defining possible treatment modalities preoperatively. The purpose of our study was to define the diagnoses made intraoperatively through knee arthroscopy and the relationships between them. We evaluated the results of knee arthroscopies performed over a 10-year period. The sites and sizes of chondral lesions, the existence of anterior cruciate ligament (ACL) injury, and the sites of meniscal lesions were noted for a total of 1,774 patients. The relationships between these lesions were evaluated statistically. Chondral lesions and posterior medial meniscal tears were predominant in females, whereas complete ACL tears were predominant in males. ACL tears were commonly accompanied by medial and lateral meniscal bucket-handle tears. In cases with advanced chondral lesions, medial and lateral posterior meniscal and lateral anterior meniscal tears were more common. According to our results, posterior tears of the medial menisci, medial and lateral femoral condyles, lateral tibial plateau type 3 or 4 cartilage lesions, and the rate of diagnostic arthroscopy were higher in females, while middle substance and bucket-handle tears of medial menisci and total rupture of the ACL were more common in males. ACL injuries were seen to coexist with medial or lateral menisci bucket-handle tears, with no relationship between the site or size of the chondral lesions. A relationship between medial and lateral meniscal tears and the site of femoral and tibial chondral surface lesions was detected.

Background: A number of reports have been published on the effectiveness and design of intervention programs for the prevention of rupture of the anterior cruciate ligament (ACL) in female athletes. The purpose of this study was to systematically review the literature to determine the effectiveness of neuromuscular training programs in preventing ACL injury in female athletes., Methods: A systematic review was performed with use of the PubMed, MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases. The search terms included "anterior cruciate ligament" and "ACL" combined with "prevention" and "intervention." The searches included material indexed by September 30, 2013. Data concerning study design, the characteristics of participants, the details of the neuromuscular programs, the types of sports, and number of ACL ruptures were extracted from the studies. Study heterogeneity was assessed with funnel plot and Egger regression methods. Pooled effects were calculated with use of a DerSimonian-Laird random-effects model. The number needed to treat was calculated on the basis of pooled incidence data., Results: The risk of ACL rupture was 1.83 times higher for female athletes who did not participate in neuromuscular ACL-prevention training programs (odds ratio [OR], 1.83; 95% confidence interval [95% CI], 1.08 to 3.10; p = 0.02). In studies that focused exclusively on soccer, the risk of ACL rupture was 2.62 times higher for nonparticipating athletes (OR, 2.62; 95% CI, 1.59 to 4.32; p < 0.01). When the data were analyzed according to the timing of the intervention, no significant effects were found. In studies in which the program took place both preseason and in-season, the risk (odds ratio) of ACL rupture for nonparticipating athletes was 2.34 (95% CI, 0.82 to 6.7; p = 0.11). In studies in which the intervention took place in-season only, the risk (odds ratio) of ACL rupture for nonparticipating athletes was 1.25 (95% CI, 0.23 to 6.75; p = 0.8). The number needed to treat to prevent a single ACL rupture was 128.7 athletes. We found no significant heterogeneity among the included studies. The I value was 35.40% (p = 0.11). No significant publication bias was found in our included studies., Conclusions: The results of this systematic review and meta-analysis favor a protective effect of neuromuscular training programs on the risk of ACL rupture in female athletes. This protective effect is more pronounced in soccer players. Additional research is needed to design the optimal training program., Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

Background: There has been an increased emphasis on improving the level of evidence used as the basis for clinical treatment decisions. Several journals now require a statement of the level of evidence as a basic gauge of the study's strength., Purpose: To review the levels of evidence in published articles in the clinical sports medicine literature and to determine if there has been an improvement in the levels of evidence published over the past 15 years., Study Design: Systematic review., Methods: All articles from the years 1995, 2000, 2005, and 2010 in The American Journal of Sports Medicine (AJSM), Arthroscopy, and sports medicine-related articles from The Journal of Bone and Joint Surgery-American (JBJS-A) were analyzed. Articles were categorized by type and ranked for level of evidence according to guidelines from the Centre for Evidence-Based Medicine. Excluded were animal, cadaveric, and basic science articles; editorials; surveys; special topics; letters to the editor; and correspondence. Statistical analysis was performed with chi-square., Results: A total of 1580 articles over the 4 periods met the inclusion criteria. The percentage of level 1 and 2 studies increased from 6.8% to 12.6%, 22.9%, and 23.5%, respectively (P < .0001), while level 4 and 5 studies decreased from 78.9% to 72.4%, 63.9%, and 53.0% (P < .0001). JBJS-A had a significant increase in level 1 and 2 studies (4.1%, 5.1%, 28.2%, 27.8%; P < .0001), as did AJSM (9.4%, 17.1%, 36.1%, 30.1%; P < .0001). Arthroscopy showed no significant change over time. Diagnostic, therapeutic, and prognostic studies all showed significant increases in level 1 and 2 studies over time (P < .05)., Conclusion: There has been a statistically significant increase in the percentage of level 1 and 2 studies published in the sports medicine literature over the past 15 years, particularly in JBJS-A and AJSM. The largest increase was seen in diagnostic studies, while therapeutic and prognostic studies demonstrated modest improvement. The emphasis on increasing levels of evidence to guide treatment decisions for sports medicine patients may be taking effect., (© 2014 The Author(s).)

Background: Rotator cuff tears are a common cause of pain and disability of the shoulder. Information on the prevalence and identification of potential risk factors could help in early detection of rotator cuff tears and improve treatment outcome., Hypothesis: Patients treated for a symptomatic rotator cuff tear on one side have a higher prevalence of rotator cuff tears and decreased shoulder function on the contralateral side compared with an age- and sex-matched group of healthy individuals., Study Design: Case control study; Level of evidence, 3., Methods: One group consisted of 55 patients who had been arthroscopically treated on one shoulder for rotator cuff tear (tear group). In this group, the nonoperated contralateral shoulder was examined. For comparison, the matching shoulder in a control group consisting of 55 subjectively healthy individuals matched by age (±1 year) and sex to the tear group was included. Diagnosis of a rotator cuff tear was made by ultrasound. Outcomes were measured using the Constant score., Results: The prevalence of supraspinatus tears was significantly higher (P < .0001) in the tear group (67.3%) compared with the control group (11.0%). The Constant score for the activities of daily living subscale, however, was significantly lower (18.4) in the tear group compared with the control group (19.9; P = .012). No other subcategory score nor the overall score showed a significant difference. There was a significantly higher tear prevalence in the tear group of patients aged between 50 and 59 years (P < .001) and 60 and 69 years (P = .004). No tear was diagnosed in the control group in individuals younger than 60 years., Conclusion: Patients treated for partial and full-thickness rotator cuff tears have a significantly higher risk of having a tear on the contralateral side and have noticeable deficits in their shoulder function regarding activities of daily living even if the tear is otherwise asymptomatic.

Background: Graft rupture of the same knee or injury to the anterior cruciate ligament (ACL) in the contralateral knee is a devastating outcome after ACL reconstruction surgery. While a number of factors have been identified as potentially increasing the risk of subsequent ACL injury, the literature is far from definitive., Purpose: To determine the rates of graft rupture and contralateral ACL injury in a large cohort and to investigate patient characteristics that may be associated with these., Study Design: Case-control study; Level of evidence, 3., Methods: A consecutive cohort of 750 patients who had undergone primary ACL reconstruction surgery with a minimum 3-year follow-up were questioned about the incidence of ACL graft rupture, contralateral ACL injury, family history of ACL injury, and current activity level. Patient databases provided details for age, sex, original injury mechanism, meniscus or articular surface injury, and graft diameter., Results: Responses were received from 561 patients (75%) at a mean ± SD follow-up time of 4.8 ± 1.1 years. Anterior cruciate ligament graft ruptures occurred in 25 patients (4.5%), and contralateral ACL injuries occurred in 42 patients (7.5%). The highest incidence of further ACL injury occurred in patients younger than 20 years at the time of surgery. In this group, 29% sustained a subsequent ACL injury to either knee. The odds for sustaining an ACL graft rupture or contralateral injury increased 6- and 3-fold, respectively, for patients younger than 20 years. Returning to cutting/pivoting sports increased the odds of graft rupture by a factor of 3.9 and contralateral rupture by a factor of 5. A positive family history doubled the odds for both graft rupture and contralateral ACL injury., Conclusion: Patients younger than 20 years who undergo ACL reconstruction are at significantly increased risk for both graft rupture and contralateral ACL injury. Whether age per se is a risk factor or age represents a proxy for other factors remains to be determined.

Background: Prior to 1994, plantar fascia ruptures were considered as an acute injury that occurred primarily in athletes. However, plantar fascia ruptures have recently been reported in the setting of preexisting plantar fasciitis. We analyzed risk factors causing plantar fascia rupture in the presence of preexisting plantar fasciitis., Methods: We retrospectively reviewed 286 patients with plantar fasciitis who were referred from private clinics between March 2004 and February 2008. Patients were divided into those with or without a plantar fascia rupture. There were 35 patients in the rupture group and 251 in the nonrupture group. The clinical characteristics and risk factors for plantar fascia rupture were compared between the 2 groups. We compared age, gender, the affected site, visual analog scale pain score, previous treatment regimen, body mass index, degree of ankle dorsiflexion, the use of steroid injections, the extent of activity, calcaneal pitch angle, the presence of a calcaneal spur, and heel alignment between the 2 groups., Results: Of the assessed risk factors, only steroid injection was associated with the occurrence of a plantar fascia rupture. Among the 35 patients with a rupture, 33 had received steroid injections. The odds ratio of steroid injection was 33., Conclusion: Steroid injections for plantar fasciitis should be cautiously administered because of the higher risk for plantar fascia rupture., Level of Evidence: Level III, retrospective comparative study.

Background: The purpose of this study was to describe our experience with traumatic diaphragmatic rupture (TDR). Very little has been written about this condition in the pediatric age group., Methods: Between January 2000 and December 2011, data on twenty-two patients with TDR were analyzed, and clinical data were recorded. The patients were divided into subgroups based on injury type and ISS values., Results: Four patients were female, and eighteen were male. Mean age was 9.4 years (range 2-15 years). TDR was left-sided in twenty (91%) patients and right-sided in two (9%). The mean ISS (Injury Severity Score) was 19 (range 11-29). No significant difference in morbidity was noted between firearm and other injuries (p=0.565) or between ISS values below and above 16 (p=0.565). Seven patients (32%) had isolated diaphragmatic injury, while the other fifteen cases had additional associated injuries. Diagnoses were determined via a chest radiograph alone in the majority of cases, while suspected cases were confirmed by multidetector computed tomography if the patients were hemodynamically stable. Herniation was observed in twenty patients. Primary suture of the diaphragm and tube thoracostomy were performed in all patients. Postoperative complications included ileus (two cases), intussusception (one case), empyema (one case), and one patient succumbed during the operation., Conclusions: TDR, while uncommon, should be considered in cases of thoracoabdominal injury. All patients should undergo meticulous examination preoperatively. When the chest radiograph does not provide a definitive diagnosis, multidetector computed tomography, including multiplanar reconstruction or volume rendering, may be beneficial for confirming suspicion of diaphragmatic rupture., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background/purpose: Adrenocortical tumors (ACTs) are rare in children and the extent to which histopathological features can predict clinical behavior remains uncertain. The aim of this study was to investigate the relationship between histopathological features (Weiss score), surgical approach, tumor size, underlying genetic predisposition syndrome, and outcome., Methods: Twenty-nine ACTs treated at our institution between 1987 and 2011 were identified from a histopathology database. The histological features were categorized using the Weiss scoring system. For tumor staging, the UKCCSG staging system was utilized., Results: At a median follow-up of 25 months, 19 patients (65.5%) survived without evidence of disease and 10 patients (35.5%) had died. There was a strong association between high Weiss score and both large tumor size (P<0.01) and adverse outcome (P<0.01). Outcome for stage I and IIA disease was significantly better compared to higher stage disease and/or tumor rupture (P<0.01)., Conclusion: There is an association between high Weiss score, large tumor size, underlying genetic predisposition syndrome and an adverse outcome for pediatric ACTs. Regardless of histopathological findings, complete surgical resection, without tumor spillage, is optimal for survival. Genetic evaluation is recommended in patients with ACTs, particularly those with a high Weiss score., (© 2014.)

This study aimed to investigate rupture rates following primary flexor tendon repair and to identify potential risk factors of rupture. Fifty-one patients with 100 flexor tendon injuries who underwent primary repair over a one-year period were reviewed. We collected demographic and surgical data. Causes of rupture were examined. Ruptured primary tendon repairs were compared with those that did not rupture. Univariate and multivariate analysis were undertaken to identify significant risk factors. Eleven percent of repaired tendons ruptured with a higher rupture rate noted in the non-dominant hand (p value = 0.009), in Zone II (0.001), and when more than 72 hours surgical delay occurred (0.01). Multivariate regression analysis identified repair in Zone II injuries to be the most significant predictor. Our rate of rupture of 11% was associated with delay in surgery, repair on non-dominant hand, and Zone II repairs. Careful consideration of these factors is crucial to reduce this rate.

The natural history of the echinococcosis can be studded with multiple complications; the most formidable is sudden death. We studied the epidemiological, pathological, and thanatological features of 34 sudden deaths due to hydatid cyst. The mean age was 33.2 years. A male predominance was observed with a sex ratio of 1.8. Most of our victims were from rural areas (79.4%). Sudden death was preceded by prodromal symptoms in 61.7% of cases. The most common was dyspnea (23.5%), followed by hemoptysis (11.8%). In 85.3% of cases, the cyst location was liver. It was cracked in 25 cases and broken in 6 cases. The rupture was spontaneous in 25 cases (73%). It was preceded by trauma in 7 cases. Death was related to an anaphylactic shock in 82.3% of cases, infection in 14.7%, and respiratory distress in 3% of cases. Sudden death is a serious and not exceptional complication of hydatid cyst. Several mechanisms may explain the sudden death.

Objective: To examine the seasonal distribution of tendon ruptures in a large cohort of patients from Vancouver, Canada., Design: Retrospective chart review., Setting: Acute Achilles tendon rupture cases that occurred from 1987 to 2010 at an academic hospital in Vancouver, Canada. Information was extracted from an orthopaedic database., Participants: No direct contact was made with the participants. The following information was extracted from the OrthoTrauma database: age, sex, date of injury and season (winter, spring, summer and autumn), date of surgery if date of injury was unknown and type of injury (sport related or non-sport related/unspecified). Only acute Achilles tendon rupture cases were included; chronic cases were excluded along with those that were conservatively managed., Primary and Secondary Outcomes: The primary outcome was to determine the seasonal pattern of Achilles tendon rupture. Secondary outcomes, such as differences in gender and mechanism of sport (non-sport vs sport related), were also assessed., Results: There were 543 cases in total; 83% of the cases were men (average age 39.3) and 17% were women (average age 37.3). In total, 76% of cases were specified as sport related. The distribution of injuries varied significantly across seasons (χ(2), p<0.05), with significantly more cases occurring in spring. The increase in the number of cases in spring was due to sport-related injuries, whereas non-sport-related cases were distributed evenly throughout the year., Conclusions: The seasonality of sport-related Achilles tendon ruptures should be considered when developing preventive strategies and when timing their delivery.

Background: An acute infection after arthroscopic shoulder surgery is a rare but serious complication. Previous studies estimating the incidence of infections after arthroscopic surgery have been conducted, but the majority of these had either relatively small study groups or were not specific to shoulder arthroscopic surgery., Purpose: To investigate the incidence of acute infections after arthroscopic shoulder surgery and compare infection rates by age group, sex, geographic region, and specific procedures., Study Design: Case series; Level of evidence, 4., Methods: A retrospective review of a large insurance company database was performed for all shoulder arthroscopic surgeries performed in the United States between 2004 and 2009 that required additional surgery for infections within 30 days. The data were stratified by sex, age group, and region. Data were also stratified for specific procedures (capsulorrhaphy, treatment for superior labrum anterior-posterior tears, claviculectomy, decompression, and rotator cuff repair) and used to assess the variation in the incidence of infections across different arthroscopic shoulder procedures. Linear regression was used to determine the significance of differences in the data from year to year. χ(2) analysis was used to assess the statistical significance of variations among all groups. Poisson regression analysis with exposure was used to determine significant differences in a pairwise comparison between 2 groups., Results: The total number of arthroscopic shoulder surgeries performed was 165,820, and the number of infections requiring additional surgery was 450, resulting in an overall infection rate of 0.27%. The incidence of infections varied significantly across age groups (P < .001); the infection rate was highest in the ≥60-year age group (0.36%) and lowest in the 10- to 39-year age group (0.18%). The incidence of infections also varied by region (P < .001); the incidence was highest in the South (0.37%) and lowest in the Midwest (0.11%). The incidence of infection treatments was also significantly different between different arthroscopic procedures (P < .01) and was highest for rotator cuff repair (0.29%) and lowest for capsulorrhaphy (0.16%). The incidence did not significantly vary by year or sex., Conclusion: The overall infection rate for all arthroscopic shoulder procedures was 0.27%. The incidence was highest in elderly patients, in the South, and for rotator cuff repair. The incidence was lowest in young patients, in the Midwest, and for capsulorrhaphy. In general, shoulder arthroscopic surgery in this study population had a low rate of reoperation in the acute period.

Background: Cerebral arteriovenous malformations (AVMs), though relatively rare, have the propensity to cause potentially fatal conditions, such as intracranial hemorrhage., Methods: Online databases were utilized to select and review references to convey recommended treatment options for cerebral AVMs in pregnancy., Results: The presentation of a hemorrhage from an AVM in a pregnant woman warrants the initiation of treatments., Conclusion: An individualized, multimodal therapeutic strategy should be employed for endovascular treatment, such as presurgical embolization., (Copyright © 2014. Published by Elsevier Inc.)

Background: Increased time from anterior cruciate ligament (ACL) injury to surgery is known to be associated with increased medial meniscal tears. Few studies have examined the predictors of meniscal tears and chondral lesions, including instability episodes., Purpose: To examine the predictors of meniscal tears and chondral injuries in patients undergoing ACL reconstruction., Study Design: Case-control study; Level of evidence, 3., Methods: Data were collected prospectively from 541 patients undergoing ACL reconstruction. Logistic regression was used to calculate adjusted odds ratios and 95% confidence intervals for predictors of meniscal tears, tear management, and chondral injuries. Predictors included age, sex, body mass index (25-29.99 and ≥30 vs ≤24.99 kg/m(2)), mechanism (contact vs noncontact) and type (high-impact sports [basketball, football, soccer, and skiing] and other sports vs not sports related) of injury, interval from injury to surgery (≤6 vs >6 weeks and ≤12 vs >12 weeks), and instability episodes (vs none)., Results: A total of 211 lateral meniscal tears (35.3% untreated, 48.3% meniscectomized, 16.4% repaired), 197 medial meniscal tears (25% untreated, 52% meniscectomized, 23% repaired), and 82 chondral injuries occurred. Age predicted chondral injuries. Male sex predicted more lateral meniscal tears overall, untreated lateral tears, and lateral meniscectomies as well as predicting medial meniscal tears overall and medial meniscectomies. Obesity predicted more chondral injuries. Sports-related injuries predicted fewer medial meniscal tears overall and medial meniscectomies. Injuries ≤6 weeks from surgery predicted more lateral meniscal repairs but fewer medial meniscectomies. Injuries ≤12 weeks from surgery predicted more chondral injuries. More instability episodes predicted medial meniscal tears overall, untreated medial tears, medial meniscectomies, and medial repairs., Conclusion: Male sex predicted lateral meniscal tears and management. Male sex, sports, injuries ≤6 weeks from surgery, and preoperative episodes of instability predicted medial meniscal tears and management. Age predicted chondral injuries. This was one of the first studies to examine the number of instability episodes as a predictor of an intra-articular injury.

Background: Meniscus injuries are common in patients with anterior cruciate ligament (ACL) tears. Patient demographics, surgeon characteristics, and concurrent diagnostic factors affecting the prevalence of meniscus repairs in patients undergoing ACL reconstruction (ACLR) by community-based orthopaedic surgeons have not been fully studied., Hypothesis: Patient (age, sex, race, and body mass index [BMI]), surgeon (sports medicine fellowship training status and case volume), and injury characteristics (1 or both menisci injured, injury location, and concurrent cartilage injury) and surgical venue (case volume) are associated with a higher likelihood of meniscus repair., Study Design: Cross-sectional study; Level of evidence, 3., Methods: A cross-sectional study using data from a large community-based ACLR registry was performed. Patients with a meniscus injury and primary ACLR between February 2005 and June 2010 were included in the study. Meniscus repair rates by patient, surgeon, and injury characteristics were described. Associations were evaluated using generalized linear models., Results: During the study period, 5712 primary ACLRs with a meniscus tear diagnosis were registered. There was 1 torn meniscus in 4248 (74.4%) patients, and both menisci were torn in 1464 (25.6%) patients. Medial meniscus tears were repaired in 1192 (31.2%) of 3818 cases; the remaining 2626 (68.8%) tears were not repaired, underwent alternative treatment (meniscectomy, trephination, rasped), or were left in situ. Lateral meniscus tears were repaired in 893 (26.6%) of 3358 cases; the remaining 2465 (73.4%) tears underwent alternative treatment or were left in situ. Adjusted models showed that younger patient age (P < .001), lower patient BMI (P < .001), surgeon's sports medicine fellowship training (P < .001), higher surgeon case volume (P < .001), higher surgical venue volume (P = .019), and medial meniscus tears (P < .001) were all associated with a higher likelihood of a meniscus repair., Conclusion: Younger patient age, lower patient BMI, surgeon's sports medicine fellowship training, higher surgeon case volume, and higher site volume are associated with a higher likelihood of a meniscus repair in patients undergoing primary ACLR in a large cohort from a community-based ACLR registry.

Purpose: To compare surgical complication rates after immediate nephrectomy versus delayed nephrectomy following preoperative chemotherapy in children with non-metastatic Wilms' tumour enrolled in UKW3, both in randomised patients and in those for whom the treatment approach was defined by parental or physician choice., Methods: Records for all patients enrolled into UKW3 were reviewed. Any record of tumour rupture or surgical complication was extracted and comparisons made between the two treatment strategies in both populations of randomised and non-randomised patients., Results: Of 525 children enrolled, 205 patients were randomised to either immediate nephrectomy (n=103) or pre-operative chemotherapy followed by delayed nephrectomy (n=102). Of the 320 children not randomised, data were available on 189 cases treated with immediate nephrectomy and 103 treated with pre-operative chemotherapy. There were significantly fewer surgical complications in randomised children given pre-operative chemotherapy before surgery compared to children undergoing immediate nephrectomy (1% vs. 20.4%, P<0.001); this difference was most marked for tumour rupture (0% vs. 14.6%, P<0.001)., Conclusions: Delayed nephrectomy for Wilms' tumour, preceded by pre-operative chemotherapy was associated with fewer surgical complications compared with immediate nephrectomy., (© 2013.)

Objective: To describe the trends of severe perineal tears in England and to investigate to what extent the changes in related risk factors could explain the observed trends., Design: A retrospective cohort study of singleton deliveries from a national administrative database., Setting: The English National Health Service between 1 April 2000 and 31 March 2012., Population: A cohort of 1 035 253 primiparous women who had a singleton, term, cephalic, vaginal birth., Methods: Multivariable logistic regression was used to estimate the impact of financial year of birth (labelled by starting year), adjusting for major risk factors., Main Outcome Measure: The rate of third-degree (anal sphincter is torn) or fourth-degree (anal sphincter as well as rectal mucosa are torn) perineal tears., Results: The rate of reported third- or fourth-degree perineal tears tripled from 1.8 to 5.9% during the study period. The rate of episiotomy varied between 30 and 36%. An increasing proportion of ventouse deliveries (from 67.8 to 78.6%) and non-instrumental deliveries (from 15.1 to 19.1%) were assisted by an episiotomy. A higher risk of third- or fourth-degree perineal tears was associated with a maternal age above 25 years, instrumental delivery (forceps and ventouse), especially without episiotomy, Asian ethnicity, a more affluent socio-economic status, higher birthweight, and shoulder dystocia., Conclusions: Changes in major risk factors are unlikely explanations for the observed increase in the rate of third- or fourth-degree tears. The improved recognition of tears following the implementation of a standardised classification of perineal tears is the most likely explanation., (© 2013 RCOG.)

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is increasingly being used in the evaluation and management of biliary and pancreatic disorders in children. The aim of this study was to review the pediatric ERCP experience of a large academic referral center affiliated with a tertiary care children's hospital., Methods: This is a retrospective review of medical records, endoscopic and operative reports, and radiography of those patients ages 0 to 21 years who underwent ERCP for any indication between 1993 and 2011 at a tertiary referral center affiliated with a large urban pediatric hospital. ERCP technical success was defined as cannulation of the desired duct. Serious adverse events included bleeding, perforation, pancreatitis, or death., Results: Four hundred twenty-nine ERCPs were performed on 296 patients. The mean age was 14.9 ± 4.8 years (3 months-21 years); 51.1% were boys. Patients with a history of previous liver transplant comprised 13.1% (56) of all ERCPs. Abnormal liver chemistries or suspected choledocholithiasis accounted for half of the indications. A therapeutic intervention was performed in 64.1%. Technical success was achieved in 95.2% of ERCPs. Serious adverse events occurred in 7.7%., Conclusions: Pediatric ERCP is highly efficacious in the pediatric population, with the rates of technical success and use of therapeutic interventions mirroring those in adults. There is a low overall rate of serious adverse events. The overall efficacy and safety support the performance of pediatric ERCP by experienced endoscopists at high-volume centers.

Background: Bone-patellar tendon-bone (BPTB) is a common autograft and allograft source used for anterior cruciate ligament (ACL) reconstruction. Although the failure rate is generally higher for allografts, donor site morbidity and anterior knee pain can be issues with BPTB autografts. Controversy exists regarding the functional outcomes, complications, and knee stability of these grafts, previous comparisons of which have been based on smaller samples of case series., Purpose: To compare BPTB autografts to allografts for ACL reconstruction, specifically with regard to patient satisfaction, return to preinjury activity level, and postoperative functional outcomes., Study Design: Meta-analysis., Methods: A total of 76 studies published between 1998 and 2012, including a total of 5182 patients, were reviewed. It was not required for studies to be comparative in nature. Outcomes evaluated were graft rupture rate, return to preinjury activity level, overall and subjective International Knee Documentation Committee (IKDC), Lysholm, Tegner activity, Cincinnati Knee Rating System, pivot shift, and single-legged hop tests, as well as KT-1000 arthrometer side-to-side difference and presence of anterior knee pain. Summary odds ratios with 95% confidence intervals were calculated to compare BPTB autografts to allografts for each outcome., Results: Outcomes on subjective IKDC, Lysholm, Tegner, single-legged hop, and KT-1000 arthrometer were statistically significantly in favor of autografts. Return to preinjury activity level, overall IKDC, pivot shift, and anterior knee pain were significantly in favor of allografts, although allograft BPTB demonstrated a 3-fold increase in rerupture rates compared with autograft (12.7% vs 4.3%). There was no significant difference between the 2 groups for Cincinnati Knee scores., Conclusion: Patients undergoing ACL reconstruction with BPTB autografts demonstrate lower rates of graft rupture, lower levels of knee laxity, and improved single-legged hop test results and are more generally satisfied postoperatively compared with patients undergoing reconstruction with allograft BPTB.

Purpose: The purpose of this study was to investigate the clinical and sonographic impact on the rotator cuff (RC) of the use of the anterolateral approach for nailing., Methods: A retrospective cohort of 48 patients treated for humeral diaphyseal fractures at the University Hospital of Parma between 2007 and 2011 was analysed. Inclusion criteria were (1) acute humeral shaft fractures treated with T2-proximal humeral nail (PHN) and (2) a minimum follow-up of one year. Exclusion criteria were (1) history of proximal and metaphyseal humeral fractures, (2) pathological fractures or open fractures of the humerus, and (3) RC lesions. Clinical assessment using the Constant score, simple shoulder test and through shoulder examination tests was carried out. The sonographic study investigated the integrity of the RC., Results: Mean score on Constant's scale was 78.21 points, with most patients achieving a good result (79% obtained more than 65 points). One patient had a limited functional outcome (Constant's score of 49 points). The sonographic findings described for supraspinatus tendon were a partial ruptures of less than 30 mm in three patients and a complete tendon rupture in one case., Conclusions: The results of this study suggest that the use of the anterolateral approach for antegrade humeral nailing ensures a good functional result with no significant clinical-sonographic impact on the rotator cuff and a satisfactory long term clinical outcome.

A tibial tuberosity radiolucency is sometimes identified on lateral radiographs of canine stifle joints, however little is known about the cause or significance. The purpose of this study was to describe the prevalence, association with other stifle conditions, and histopathologic characteristics of tibial tuberosity radiolucencies in a group of dogs. Radiographs of all canine stifle joints over 5 years were evaluated. Presence or absence of a tibial tuberosity radiolucency was recorded by an observer who was unaware of clinical status. Patient signalment and presence of other stifle joint conditions were recorded from medical records. A tibial tuberosity radiolucency was found in 145/675 dogs (prevalence = 21.5%). Statistically significant associations were identified between tibial tuberosity radiolucency and stifle condition (P < 0.0001), breed size (P = 0.011), and younger age of presentation (P = 0.001), but not with gender (P = 0.513). Dogs with a tibial tuberosity radiolucency had higher odds of having a medial patellar luxation than dogs without (OR = 9.854, P < 0.0001, 95% CI 6.422-15.120). Dogs with a tibial tuberosity radiolucency had lower odds of having a cranial cruciate ligament rupture than dogs without (OR = 0.418, P < 0.0001, 95% CI 0.287-0.609). Four canine cadavers, two with normal stifles and two with tibial tuberosity radiolucencies, underwent radiographic, computed tomographic, and histologic examination of the stifles. Computed tomography revealed a hypoattenuating cortical defect in the lateral aspect of the proximal tibial tuberosity that corresponded histopathologically to a hyaline cartilage core. Findings indicated that the tibial tuberosity radiolucency may be due to a retained cartilage core and associated with medial patellar luxation in dogs., (© 2013 Veterinary Radiology & Ultrasound.)

Objective: The objective of this study was to determine the prevalence of extrinsic wrist ligament injury by magnetic resonance imaging and its association with intrinsic ligament tears., Methods: We reviewed conventional magnetic resonance images performed over a 5-year period from adult patients in the setting of wrist trauma. Two musculoskeletal radiologists examined the integrity of wrist ligaments and presence of bone abnormalities., Results: In a cohort of 75 subjects, extrinsic ligament injury was present in 75%, with radiolunotriquetral being most frequently affected (45%). Intrinsic ligament injury was present in 60%. Almost half of subjects had combined intrinsic and extrinsic ligament injury. Bone abnormalities were seen in 69%. The rate of extrinsic injury was higher in subjects with bone injury (P = 0.008)., Conclusions: There is high prevalence of extrinsic ligament injury in the setting of wrist trauma, especially in the presence of bone abnormalities, with combined injury of intrinsic and extrinsic ligaments in about half of cases.

The introduction of functional rehabilitation for patients with Achilles tendon rupture has dramatically changed treatment programs for this condition. The authors introduced a functional weight-bearing protocol for patients with an acute Achilles tendon rupture treated operatively and nonoperatively in 2002. They hypothesized that no significant differences would exist in the rerupture rates and functional outcomes between the groups. Between 2002 and 2008, the authors collected data on 80 consecutive patients treated with a weight-bearing functional orthosis for complete Achilles tendon rupture. Following evidence-based counseling, 51 patients chose nonoperative treatment and 29 chose operative treatment. Outcome measures included rerupture rates, other complications, and functional scoring. The nonoperative group was a decade older (median age, 47 years [range, 27-80 years]) than the operative group (median age, 37 years [range, 24-55 years]). Rerupture was noted in 2 (4%) patients in the nonoperative treatment group and 1 (3%) patient in the operative group. Two (7%) patients in the operative group developed superficial wound infections and reported no nerve injuries. Median Achilles Tendon Total Rupture Score was 82 points in the nonoperative group and 94 in the operative group. Median Victorian Institute of Sports Assessment-Achilles tendinopathy questionnaire scores were 60 and 91 for the nonoperative and operative groups, respectively. Both groups had low rerupture rates. Functional scores, using the newly validated Achilles Tendon Total Rupture Score, were lower in the nonoperative group., (Copyright 2013, SLACK Incorporated.)

Background: There is limited information about Achilles tendon disorders in professional football., Aims: To investigate the incidence, injury circumstances, lay-off times and reinjury rates of Achilles tendon disorders in male professional football., Methods: A total of 27 clubs from 10 countries and 1743 players have been followed prospectively during 11 seasons between 2001 and 2012. The team medical staff recorded individual player exposure and time-loss injuries., Results: A total of 203 (2.5% of all injuries) Achilles tendon disorders were registered. A majority (96%) of the disorders were tendinopathies, and nine were partial or total ruptures. A higher injury rate was found during the preseason compared with the competitive season, 0.25 vs 0.18/1000 h (rate ratio (RR) 1.4, 95% CI 1.1 to 2.0; p=0.027). The mean lay-off time for Achilles tendinopathies was 23±37 (median=10, Q1=4 and Q3=24) days, while a rupture of the Achilles tendon, on average, caused 161±65 (median=169, Q1=110 and Q3=189) days of absence. Players with Achilles tendon disorders were significantly older than the rest of the cohort, with a mean age of 27.2±4 years vs 25.6±4.6 years (p<0.001). 27% of all Achilles tendinopathies were reinjuries. A higher reinjury risk was found after short recovery periods (31%) compared with longer recovery periods (13%) (RR 2.4, 95% CI 2.1 to 2.8; p<0.001)., Conclusions: Achilles tendon disorders account for 3.8% of the total lay-off time and are more common in older players. Recurrence is common after Achilles tendinopathies and the reinjury risk is higher after short recovery periods.

The purpose of this study was to determine the incidence, features, and associated injuries of intraperitoneal (IP) and extraperitoneal (EP) bladder rupture (BR) resulting from blunt trauma. A retrospective study from September 2001 to August 2011 was performed for blunt traumatic BR in adults. Demographics, mean Injury Severity Score (ISS), mean length of stay (LOS), incidence, mortality, operative repair, and associated injuries were evaluated. Of 15,168 adult blunt trauma admissions over 10 years, 54 patients had BR (EP = 22, IP = 27, EP + IP = 5; incidence = 0.36%). Sixty-three per cent were male. The mean age, ISS, and LOS were 40 years, 29, and 15 days, respectively. The mortality rate was 11 per cent. Fifty-two per cent of BR was the result of a motor vehicle crash. Most BRs were diagnosed by computed tomography cystogram. Eighty per cent had pelvic fracture. Hollow viscus injury was present in 34.5 per cent of patients. Colonic injury was seen in 24 per cent and 9.3 per cent had a rectal injury. Although BR is rare in adult blunt trauma, it is associated with high ISS, LOS, and mortality. Pelvic fractures are essentially present in all patients with EP BR. Hollow viscus injuries, especially colonic and rectal injuries, are more prominent in IP BR.

Background: As the availability of imaging modalities has increased, the finding of arachnoid cysts has become common. Accurate patient counseling regarding physical activity or risk factors for cyst rupture or hemorrhage has been hampered by the lack of definitive association studies., Objective: This case-control study evaluated factors that are associated with arachnoid cyst rupture (intracystic hemorrhage, adjacent subdural hematoma, or adjacent subdural hygroma) in pediatric patients with previously asymptomatic arachnoid cysts., Methods: Patients with arachnoid cysts and intracystic hemorrhage, adjacent subdural hygroma, or adjacent subdural hematoma treated at a single institution from 2005 to 2010 were retrospectively identified. Two unruptured/nonhemorrhagic controls were matched to each case based on patient age, sex, anatomical cyst location, and side. Risk factors evaluated included arachnoid cyst size, recent history of head trauma, and altitude at residence., Results: The proportion of imaged arachnoid cysts that presented either originally or subsequently with a rupture or hemorrhage was 6.0%. Larger cyst size, as defined by maximal cyst diameter, was significantly associated with cyst rupture/hemorrhage (P < .001). When dichotomized with a 5-cm cutoff, 9/13 larger cysts ruptured and/or hemorrhaged, whereas only 5/29 smaller cysts ruptured/hemorrhaged (odds ratio = 16.5 (confidence interval [2.5, ∞]). A recent history of head trauma was also significantly associated with the outcome (P < .001; odds ratio = 25.1 (confidence interval [4.0, ∞]). Altitude was not associated with arachnoid cyst rupture or hemorrhage., Conclusion: This case-control study suggests that larger arachnoid cyst size and recent head trauma are risk factors for symptomatic arachnoid cyst rupture/hemorrhage.

Background: Most studies on Achilles tendon ruptures involved US military or European populations, which may not translate to the general US population. The current study reviews 406 consecutive Achilles tendon ruptures occurring in the general US population for patterns in a tertiary care subspecialty referral setting., Methods: An institutional review board-approved, retrospective review of the charts of 331 (83%) males (6 bilateral, nonsimultaneous) and 69 (17%) females diagnosed with Achilles tendon ruptures over a 10-year period was undertaken. Average age was 46.4 years with 310 (76%) ruptures diagnosed and managed acutely (less than 4 weeks), whereas 96 (24%) were chronic (more than 4 weeks since the injury). Patients were assessed for mechanism of injury and previously described underlying risk factors. Results were assessed according to age (greater or less than 55 years), body mass index (BMI), and time to diagnosis., Results: Sporting activity was responsible for 275 ruptures (68%). This was higher in patients younger than 55 years of age (77%) than those older than 55 years (42%). Basketball was the most commonly involved sport, accounting for 132 ruptures (48% of sports ruptures, 32% of all ruptures), followed by tennis in 52 ruptures (13%, 9%), and football in 32 ruptures (12%, 8%). In all, 20 ruptures were reruptures of the same Achilles tendon, of which 17 had previously been treated nonsurgically. In this study, recent quinolone use (2%) and African American race (31%) were not major risk factors for rupture as described in other studies. Older patients and patients with a BMI greater than 30 were more likely to be injured in nonsporting activities and more likely to have their diagnosis initially not recognized resulting in their presentation more than 4 weeks following the injury., Conclusion: In this study, sports participation was the most common mechanism, but not to the same extent seen in the European or US military studies. Basketball was the most commonly involved sport, as compared to soccer in Europe. Age and BMI had a directly proportional correlation with time to diagnosis.

Introduction: The outcomes of perforation during aortocoronary saphenous vein graft (SVG) percutaneous coronary intervention (PCI) are poorly studied., Methods: We reviewed all 12 SVG perforations that occurred between November 2005 and November 2011 at two tertiary referral centers. The acute and long-term outcomes of these patients were examined., Results: The perforation was located in the SVG body (n = 6), aortic (n = 3), or distal (n = 3) anastomosis. Most perforations occurred after stent implantation (n = 5) or after stent postdilation (n = 3). The perforation was Ellis class I in 1 patient, II in 3 patients, III in 4 patients, and III with cavity spilling in 3 patients. The perforation spontaneously sealed without requiring further treatment in 3 patients. In the remaining 9 patients, the perforation was treated with prolonged balloon inflation (n = 2) or covered stent implantation (n = 5), but could not be treated in 2 patients who died during the procedure. Seven of the 10 survivors underwent follow-up angiography 5 months to 2 years after the perforation. The target SVG was occluded in 5 patients and had developed severe stenosis in the remaining 2 patients., Conclusions: SVG perforation during PCI carries a high mortality and frequently requires implantation of a covered stent. Perforated SVGs frequently occlude within 2 years post PCI.

Introduction: Open-globe ocular trauma causes visual deficiency; calculating the magnitude of the latter often misses the estimation in patients without follow-up., Aim: to identify the modification of the postoperative proportion of visual deficiency in open-globe ocular trauma, which would introduce considering the proportion estimated in patients without follow-up., Methods: Non-interventional, retrospective, longitudinal, analytical study. Visual outcome in eyes with open-globe trauma, with and without follow-up, was calculated using the Ocular Trauma Score. The observed postoperative proportion of visual deficiency was identified in eyes with follow-up; in eyes without follow-up, the postoperative proportion of visual deficiency was estimated using an analysis of scenarios: best (Ocular Trauma Score), mean (that of eyes with follow-up) and worst (last observation/no visual improvement). The estimated proportion of visual deficiency was added to that observed in eyes with follow-up, and the resulting proportion was compared with that expected in the sample, using the Ocular Trauma Score (χ(2))., Results: 104 eyes, 70 without follow-up and 34 without it. In eyes with follow-up the expected proportion of visual deficiency was 58.6%, and the observed one was 71.4% (p = 0.1); the estimated proportion of visual deficiency in eyes without follow-up was 76.5%. The resulting postoperative proportion of visual deficiency in the sample would be 73.1%, which would overcome that expected by the Ocular Trauma Score (59.6%, p = 0.04)., Conclusions: In open-globe ocular trauma, the efficacy of surgery to reduce the proportion of visual deficiency would decrease with regard to the standard expected by the Ocular Trauma Score, if the deficiency estimated in eyes without follow-up were considered.

Background: Subscapularis (SSC) tendon tears seem to regularly occur combined with lesions of the supraspinatus (SSP) and long biceps (LBS) tendons. The aim of this study was to evaluate the rupture configurations and results after arthroscopic treatment of anterosuperior rotator cuff tears., Patients and Methods: A total of 65 consecutively treated patients [20 female, 45 male, median age 59 (23-80) years] with anterior and anterosuperior rotator cuff tears were examined prospectively. Rupture configurations were evaluated intraoperatively and subjective parameters, clinical function and Constant-Murley score (CMS) were assessed 12 months postoperatively., Results: The SSC tears were isolated in 34 % and combined lesions of SSC and SSP were found in 66 % of patients. Additionally, LBS participation was observed in 65 % of patients and 12 (18%) patients had further concomitant lesions. Clinical function improved significantly and the age and gender-related CMS averaged 89.3 % 12 months postoperatively. Reconstructive treatment of concomitant lesions had a negative influence on outcome. Tenotomy of LBS led to better results than tenodesis. All patients would choose arthroscopic treatment again having knowledge of the postoperative result., Conclusion: Due to convincing short-term clinical results and advantages of minimally invasive surgery, arthroscopic treatment of anterior and anterosuperior rotator cuff tears has become prevalent. Treatment of concomitant LBS tendon pathology seems to play an important role in most patients. Further development of refixation techniques and better means of visualization will increase the trend towards arthroscopic treatment of anterosuperior rotator cuff tears in the future.

Objective: To determine the incidence and risk factors of recurrent anal sphincter rupture (ASR)., Design: Population-based retrospective cohort study., Setting: Data were taken from the National Medical Birth Registry, Denmark., Population: Patients with a first and a second vaginal delivery in the time period 1997-2010., Methods: Univariate analysis and multivariate logistic regression were used to determine risk factors of recurrent ASR., Main Outcome Measures: The incidence of recurrent ASR and odds ratios for possible risk factors of recurrent ASR: age, body mass index, grade of ASR, birthweight, head circumference, gestational age, presentation, induction of labour, oxytocin augmentation, epidural, episiotomy, vacuum extraction, forceps, shoulder dystocia, delivery interval and year of second delivery., Results: Out of 159 446 women, 7336 (4.6%) experienced an ASR at first delivery, and 521 (7.1%) had a recurrent ASR (OR 5.91). The risk factors of recurrent ASR in the multivariate analysis were: birthweight (adjusted OR, aOR, 2.94 per increasing kg, 95% CI 2.31-3.75); vacuum extraction (aOR 2.96, 95% CI 2.03-4.31); shoulder dystocia (aOR 1.98, 95% CI 1.11-3.54); delivery interval (aOR 1.08 by year, 95% CI 1.02-1.15); year of second delivery (aOR 1.06, 95% CI 1.03-1.09); and prior fourth-degree ASR (aOR 1.72, 95% CI 1.28-2.29). Head circumference was a protective factor (aOR 0.91 per increasing cm, 95% CI 0.85-0.98)., Conclusions: The incidence of recurrent ASR was 7.1%. Risk factors of recurrent ASR were excessive birthweight, vacuum extraction, shoulder dystocia, delivery interval, year of second delivery and prior fourth-degree ASR. A larger head circumference reduced the risk of recurrent ASR., (© 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.)

Background: Quinolone antibiotics are associated with increased risk of tendinopathy. Identifying at-risk individuals has important clinical implications. We examined whether age, sex, glucocorticoid use, obesity, diabetes, and renal failure/dialysis predispose individuals to the adverse effects of quinolones., Methods: Among 6.4 million patients in The Health Improvement Network (THIN) database, 28,907 cases of Achilles tendonitis and 7685 cases of tendon rupture were identified in a case-crossover study. For each participant, we ascertained whether there was a prescription of a quinolone and comparison antibiotic within 30 days before the diagnosis of tendon disorder (case period) and a prescription of the same medications within 30 days 1 year before disease diagnosis (control period)., Results: Use of quinolones was strongly associated with an increased risk of Achilles tendonitis (odds ratio [OR], 4.3; 95% confidence interval [CI], 3.2-5.7) and tendon rupture (OR, 2.0; 95% CI, 1.2-3.3). No association was found between the use of other antibiotics and either outcome. The association with Achilles tendonitis was stronger among participants who were aged more than 60 years (OR, 8.3 vs 1.6), who were nonobese (OR, 7.7 vs 2.4), and who used oral glucocorticoids (OR, 9.1 vs 3.2). The association was nonsignificantly stronger in women (OR, 5.0 vs 3.6), diabetic persons (OR, 7.0 vs 4.1), and those in renal failure or receiving dialysis (OR, 20.0 vs 3.9). The effect for tendon rupture was stronger in women, with borderline significance in glucocorticoid users and nonobese persons., Conclusion: Quinolone-associated tendinopathy is more pronounced among elderly persons, nonobese persons, and individuals with concurrent use of glucocorticoids., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objectives: The purpose of this study was to compare the outcome after the operative treatment of patella fractures (PFs) as compared with those of quadriceps tendon and patella tendon (PT) ruptures., Design: This pertains to a retrospective case control., Setting: The setting was in academic teaching hospitals., Patients: Ninety-four patients with 99 extensor mechanism disruptions were treated operatively. Of these, 50 (50%) were PFs; 36 (37%) were quadriceps ruptures; and 13 (13%) were PT ruptures., Main Outcome Measures: The patients were evaluated at 6 and 12 months and were tested for range of motion, quadriceps circumference and strength, SF36, Lysholm, and Tegner outcome scores by independent observers. Radiographs of the knee were obtained to assess bony healing, posttraumatic arthritis, and heterotopic ossification., Results: A minimum of 12-month follow-up (range 12-81 months) was available for 76 patients (77%). PFs were seen more commonly in women (P < 0.001) and PT ruptures tended to occur in younger males (P < 0.001), with no difference in the body mass index. Thigh circumference was significantly smaller than normal in PFs at 1 year as compared with tendon injuries. At latest follow-up, there were no significant differences noted with respect to knee range of motion, radiographic arthritis, Tegner, Lysholm, or SF36 scores., Conclusions: There were no significant differences with regard to outcome in patients sustaining these injuries., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The aim of the study was to examine whether a rupture of the anterior cruciate ligament (ACL) in patients with open growth plates should be treated by surgery or conservatively. An electronic search was performed in MEDLINE, the Cochrane controlled trial register, Embase, and Medpilot. Ten studies including 154 patients were analyzed regarding conservative treatment and 55 studies including 935 patients regarding operative treatment. The mean age for the conservative and operative treatment groups was 12.3 (10-14.4) years and 13.3 (10-15.8) years, respectively. Summing up there were significantly better results concerning Lysholm score (95.5 vs 73.2; p<0.05), instability described by the giving way phenomenon (2.8 vs 89.5%; p<0.05), and regaining former sports activity level (91.2 vs 30.9%; p<0.05) in the operatively treated group. Relative risk for leg length differences more than 1 cm or axis deviation more than 3° after surgery was low (2.1%). Reruptures occurred in 3.8% of the cases. The analyzed data clearly show that operative treatment is superior to conservative management of ACL ruptures in children and adolescents.