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Background: Predicting the risk of recurrence is of great interest when counseling patients after primary lateral patellar dislocation (LPD). Purpose: To investigate a multivariate model to predict the individual risk of recurrent LPD. Study Design: Case-control study; Level of evidence, 3. Methods: The study population included patients with primary LPD, knee imaging, and a minimum 2-year follow-up after nonoperative treatment. Data including patient characteristics and anatomic patellar instability risk factors were collected retrospectively from 7 national study centers. Bivariate and multivariate regression analyses were carried out to identify risk factors for recurrent LPD and to generate an accuracy-optimized model for out-of-sample prediction. Results: In total, 115 of 201 patients (57%) experienced recurrent LPD within 2 years after primary LPD. Age ≤16 years at primary LPD (odds ratio [OR], 5.0), history of contralateral instability (OR, 2.4), and trochlear dysplasia (Dejour type B-D: OR, 2.5; lateral trochlear inclination ≤12°: OR, 2.7) were significant risk factors for recurrent LPD ( P < .05). The prediction accuracy including these 3 risk factors was 79%. Patella alta, an increased tibial tubercle to trochlear groove distance, and patellar tilt had neither an association with increased recurrence rates nor an influence on prediction accuracy of recurrent LPD. Conclusion: Young age and trochlear dysplasia are major risk factors for early recurrent LPD. A multivariate model including age at primary LPD, lateral trochlear inclination, and history of contralateral LPD achieved the highest prediction accuracy. Based on these findings, the patellar instability probability calculator is proposed to estimate the individual risk of early recurrence when counseling patients after primary LPD.

The aim of this study was to investigate the association of femoral (FT), tibial (TT), and knee torsion (KT) on the patella tilt (PT), the axial engagement index (AEI), and the tibial tuberosity–trochlear groove distance (TTTG). Femoral torsion, tibial torsion, knee torsion, patella tilt, the axial engagement index, the TTTG, and trochlear dysplasia were retrospectively evaluated on 59 patients suffering from recurrent patella instability or anterior knee pain with 118 torsional lower limb magnetic resonance imaging studies. FT and TT did not show any significant associations with TTTG, PT, and AEI (n.s.). KT was significantly associated with a higher TTTG, higher PT, and lower AEI (all, p

Background:The operative therapy of patellofemoral arthritis requires an individual approach depending on the underlying injury. However, the literature lacks recommendations for its course of action.Purpose:To generate an expert recommendation of therapy for different patellofemoral abnormalities in patients suffering from isolated patellofemoral arthritis.Study Design:Consensus statement.Methods:To generate recommendations, the AGA Patellofemoral Committee performed a consensus process using the Delphi method based on the available literature on isolated patellofemoral arthritis.Results:In most statements and recommendations, a high percentage of consensus could be found. However, also in the expert group of the AGA Patellofemoral Committee, some controversies on the treatment of patellofemoral arthritis exist.Conclusion:The operative therapy of isolated patellofemoral arthritis is a challenging topic that leads to controversial discussions, even in an expert group. With this consensus statement of the AGA Patellofemoral Committee, recommendations on different operative treatment options were able to be generated, which should be considered in clinical practice.

Die Beurteilung der Lebensqualitat und der Ergebnisse operativer Verfahren mit Verwendung spezifischer Fragebogen ist in der orthopadischen Chirurgie von besonderer Wichtigkeit. Zur Lebensqualitatsbewertung fur Patienten mit einer patellofemoralen Instabilitat hat sich der Fragebogen Banff Patellofemorales Instabilitats-Instrument (BPII) 2.0 als valides und reliables Instrument herausgestellt. Die Validierung der deutschsprachigen Version erfolgte in Deutschland, Osterreich und der Schweiz an 64 Patienten mit einer nachgewiesenen patellofemoralen Instabilitat. Hierbei zeigte sich eine ausgezeichnete Test-Retest-Reliabilitat und interne Konsistenz (Cronbachs α). Es bestanden statistisch signifikante Korrelationen des Banff 2.0 mit dem Kujala-Score, NPI-Score, SF-36 und einer visuellen Analogskala (VAS) fur Schmerzen und Funktionseinschrankungen. Die Anwendung der deutschsprachigen Version des Banff 2.0 ist somit zu empfehlen.

Aim of the study was to investigate patient characteristics, survival rates and neurological outcome among hypothermic patients with out-of-hospital cardiac arrest (OHCA) admitted to a trauma center.A review of patients with OHCA and a core temperature ≤32°C admitted to a trauma center between 2004 and 2016.Ninety-six patients (mean temperature 25.8°C±3.9°C) were entered in the study, 37 (39%) of them after avalanche burial. 47% showed return of spontaneous circulation (ROSC) prior to hospital admission. Survival with Glasgow-Pittsburgh Cerebral Performance Category (CPC) scale 1 or 2 was achieved in 25% of all patients and was higher in non-avalanche than in avalanche cases (35.6% vs 8.1%, p=0.002). Witnessed cardiac arrest was the most powerful predictor of favourable neurological outcome (RR: 10.8; 95% Confidence Interval: 3.2-37.1; Wald: 14.3; p0.001), whereas ROSC prior to admission and body core temperature were not associated with survival with favourable neurological outcome. Cerebral CT scan pathology within 12h of admission increased the risk for unfavourable neurological outcome 11.7 fold (RR: 11.7; 95% CI: 3.1-47.5; p0.001). Favourable neurological outcome was associated lower S 100-binding protein (0.69±0.5μg/l vs 5.8±4.9μg/l, p 0.002) and neuron-specific enolase (34.7±14.2μg/l vs 88.4±42.7μg/l, p 0.004) concentrations on intensive care unit (ICU) admission.Survival with favourable neurological outcome was found in about a third of all hypothermic non-avalanche patients with OHCA admitted to a trauma center.

Background Tunnel widening after anterior cruciate ligament reconstruction (ACLR) is influenced by the surgical and fixation techniques used. Computed tomography (CT) is the most accurate image modality for assessing tunnel widening, but magnetic resonance imaging (MRI) might also be reliable for tunnel volume measurements. In the present study tunnel widening after ACLR using biodegradable interference screw fixation was compared with all-inside ACLR using button fixation, with tunnel volume changes being measured on CT and MRI scans. Study design Randomized controlled trial; Level of evidence, 2. Methods Thirty-three patients were randomly assigned to hamstring ACLR using a biodegradable interference screw or all-inside cortical button fixation. CT and MRI scanning were done at the time of surgery and six months after. Tunnel volume changes were calculated and compared. Results On CT, femoral tunnel volumes changed from the postoperative state (100%) to 119.8% with screw fixation and 143.2% with button fixation (P = 0.023). The changes in tibial tunnel volumes were not significant (113.9% vs. 117.7%). The changes in bone tunnel volume measured on MRI were comparable with those on CT only for tunnels with interference screws. Tibial tunnels with button fixation were significantly underestimated on MRI scanning (P = 0.018). Conclusions All-inside ACLR using cortical button fixation results in increased femoral tunnel widening in comparison with ACLR with biodegradable interference screw fixation. MRI represents a reliable imaging modality for future studies investigating tunnel widening with interference screw fixation.

The aim of this study was to adapt, translate, and validate the Banff Patella Instability Instrument (BPII) 2.0 into German, enabling its use by German-speaking professionals for the evaluation of patients who present with patellofemoral instability. Forward and backward translation was performed according to international recommendations. The final German version of the BPII 2.0 was investigated in patients with confirmed diagnoses of recurrent patellofemoral instability in Germany, Austria, and Switzerland. All patients received two packages of questionnaires, each containing the BPII 2.0, Kujala scoring questionnaire, Norwich Patella Instability scoring questionnaire, Short Form-36 (SF-36), and a visual analogue scale (VAS)—scale for pain and disability. The first and second packages of questionnaires were to be completed 7 days apart. The following parameters were assessed: internal consistency, test–retest reliability, floor and ceiling effects, and construct validity. The study population consisted of 64 patients (24 males and 40 females). The average age of the patients was 22 ± 6 years. The internal consistency (Cronbach’s alpha) was excellent at both time points (0.93 and 0.95), and the test–retest reliability (ICC) was good (0.89). There were no floor or ceiling effects. There were statistically significant correlations between the BPII 2.0 and all other outcome measures apart from SF-36 mental health. The BPII 2.0 was successfully adapted into German. It is a reliable and valid instrument for evaluation of German-speaking patients who present with patellofemoral instability. III.

Background Increased internal femoral torsion is regarded as a risk factor for patellar instability. Biomechanical investigations confirming this hypothesis are missing. Methods Eight fresh-frozen cadaver knees were tested on a specially designed simulator. Patellar motion and patellofemoral pressure were evaluated for 0°, 10°, and 20° of increased internal and external femoral torsion with native and with transected medial patellofemoral ligaments used to simulate patellar instability. A regression analysis was used for statistical analysis. Findings In native medial patellofemoral ligaments, there were no significant changes in mean or peak pressures for any torsional states ( P ≥ 0.07). At 20° increased internal femoral torsion, there was a significant center of force shift towards the lateral side ( P = 0.01). Patellar shift was directed laterally at low knee flexion angles up to 30°. Lateral patellar tilt increased significantly at 10° and 20° of increased internal femoral torsion ( P ≤ 0.004). In transected medial patellofemoral ligaments, mean pressure (P ≤ 0.005) and peak pressure ( P ≤ 0.02) decreased significantly for all torsional states. There was a significantly greater lateral center of force shift with increased internal femoral torsion ( P ≤ 0.04). Lateral patellar tilt increased significantly ( P P ≥ 0.30). Interpretation In a native medial patellofemoral ligament, 20° of increased internal femoral torsion can be regarded as a significant risk factor for patellar instability. With an insufficient medial patellofemoral ligament, 10° of increased internal femoral torsion already represents a significant risk factor.

This chapter illustrates the measurement method of lower limb torsion, reports on the indication for a femoral or tibial derotational osteotomy and demonstrates the surgical technique including its aftercare and reported outcome. It is very important to measure torsional malalignment with always the same method and according to normal values given by this method. Radiological measurement should be performed by the surgeon for planning of correction. Correction at the level of the femur and tibia can be necessary if excessive internal torsion of the femur and external torsion of the tibia is present. In many cases it is useful to use a lateral distal approach especially as a lateral lengthening is often necessary and a MPFL reconstruction is recommended in all cases of recurrent patella dislocation. Be aware that derotation potentially changes your leg axis. This should be checked and corrected to prevent reoperation and failure. Derotation and correction of varus/valgus alignment can reproducibly be performed with a biplanar technique as described above. The level of the osteotomy on the femur should be as low as possible in the metaphysical bone to prevent bone healing problems. For the same reason compress your osteotomy with your plate. The popliteal vessels must always be protected by a Hohman retractor at the posterior border of the femur at the level of the osteotomy. On the tibial side the medial collateral ligament has to be protected from the saw. With a correct measurement and a standardized controlled technique excellent results can be achieved with a low rate of complications.

The aim was to assess the influence of femoral derotational osteotomy on patella tilt (PT), axial patella engagement (AEI) and tibial tuberosity trochlear groove distance (TTTG). Derotational femoral osteotomy was performed on ten lower limbs of body donors embalmed with alcohol–glycerine. Femoral torsion, tibial torsion, knee torsion, PT, AEI and TTTG were evaluated on axial CT slices for an absolute femoral torsion of 15°, 20°, 25°, 30°, 35° and 40°. A linear mixed model analysis was used to estimate the effect of femoral torsion on PT, AEI, TTTG and knee torsion adjusted for correlation due to repeated observations. Estimates with 95% confidence intervals were used to represent the mean change in the dependent variables for one unit of change (degree, mm or AEI) in the predictor variable. A significant correlation was observed between femoral torsion and AEI (p

To compare tunnel widening and clinical outcome after anterior cruciate ligament reconstruction (ACLR) with interference screw fixation and all-inside reconstruction using button fixation. Tunnel widening was assessed using tunnel volume and diameter measurements on computed tomography (CT) scans after surgery and 6 months and 2 years later, and compared between the two groups. The clinical outcome was assessed after 2 years with instrumented tibial anteroposterior translation measurements, hop testing and International Knee Documentation Committee (IKDC), Lysholm and Tegner activity scores. The study population at the final follow-up was 14 patients with screw fixation and 16 patients with button fixation. Tibial tunnels with screw fixation showed significantly larger increase in tunnel volume over time (P = 0.021) and larger tunnel diameters after 2 years in comparison with button fixation (P

To assess the visibility of both the anterolateral ligament (ALL) and the deep structures of the iliotibial tract (ITT) by means of MRI in paediatric patients. To determine reproducibility for such measurements.Knee MRI data from patients aged18a without lesions of the capsule or ligaments, fractures, bone edemas, foreign material or motion artifacts were analyzed by two musculoskeletal radiologists separately and twice. The visibility of the different parts of the ALL was determined (femoral, meniscal, tibial parts). Similarly, the visibility of the different parts of the deep ITT was determined: deep attachments of the ITT to the distal femur (insertion near septum, supracondylar insertion and retrograde insertion) and capsulo-osseous layer of the ITT.We studied 61 cases (36 female, 25 male). Age was 15 years (±2.3). Interobserver agreement was high. Cohen's Kappa was 0.864 (95%CI: 0.715-1.000) for the tibial part of the ALL and 1.0 for the femoral part of the ALL. For the deep attachments of the ITT to the distal femur Kappa was 0.828 (95%CI: 0.685-0.971). Regarding intraobserver agreement, Cohen's Kappa was 1.0 for the femoral part of the ALL and 0.955 (95%CI: 0.867-1.000) for the tibial part of the ALL. For the deep attachments of the ITT to the distal femur Cohen's Kappa was 0.896 (95%CI: 0.782-1.000).On the basis of our findings it is concluded that the presence of the anterolateral structures of the knee can be determined by MRI in a pediatric population with substantial inter- and intraobserver agreement. This is true for both the ALL and the deep structures of the ITT.Diagnostic study - Level 3.

Purpose To investigate whether temporary postoperative compartment-unloading therapy after arthroscopic partial meniscectomy (APM)—with either knee braces or wedge insoles—leads to superior clinical outcome as compared to controls. This difference in clinical outcome was tested in the form of two knee scores, physical activity and general health outcome over the first postoperative year. Methods Sixty-three patients who underwent arthroscopic partial meniscectomy (APM) were randomized to one of the following three groups: 12 weeks postoperative knee compartment-unloading therapy with either a knee brace (brace group) or wedge insoles (insole group) or no specific postoperative therapy (control group). Patient-reported outcome was assessed with the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC Score), the Knee Injury and Osteoarthritis Outcome Score (KOOS), the MARX score (physical activity) and the SF-12 (general health). Results Sixty-three patients were available for analysis. Except for the SF-12 mental score, all other scores showed significant improvement over time. With regard to the hypotheses proposed, no significant group * time interactions were observed for any of the outcome parameters. This means that the group (i.e. the type of postoperative treatment) was not related to the degree of improvement of any of the scores. Conclusions It was concluded that 12 weeks of compartment-unloading therapy—with either a knee brace or wedge insoles—is ineffective with regard to clinical outcome after APM. This applies to the knee score outcome, physical activity and general health outcome over the first year following APM. Level of evidence Randomized controlled trial, Level I.

Purpose To evaluate the outcome after different types of revision operations for blade ‘cut-out’ and ‘cut-through’ after fixation of trochanteric fractures with proximal femoral nail antirotation (PFNA) or a trochanter fixation nail (TFN). Methods Twenty hospitals participated in this multicentre study. A total of 4109 patients were retrospectively screened for cut-out or cut-through complications after nailing of trochanteric fractures using PFNA or TFN. Fifty-seven patients (28 with ‘cut-through’ and 29 with ‘cut-out’) were included in the study. In the ‘cut-through’ group, 16 patients underwent a blade exchange, six patients had a blade exchange with bone cement augmentation, and six received total hip arthroplasty (THA). In the ‘cut-out’ group, three patients had a blade exchange, one had a blade exchange with augmentation, three underwent re-nailing of the fracture with a new PFNA, one had a girdlestone procedure and 21 had THA procedures. Results In the ‘cut-through’ group, eight patients who had a blade exchanges (50%) and two patients with blade exchange and augmentation (33%) required further revision operations. THA was the definite treatment in all 6 cases. In the ‘cut-out’ group, two patients (66%) who had blade exchanges and two (66%) who underwent re-nailing required additional revision operations during the subsequent course. One patient (4%) who had total hip arthroplasty needed revision surgery for acetabular replacement. Overall, a total of 81 revision procedures were performed. Conclusion Based on the data from this study, we recommend THA as the only valid salvage procedure for ‘cut-out’ and ‘cut-through’ of helical blades after fixation of trochanteric fractures with the PFNA and TFN.

Intraoperative control of rotational malalignment poses a big challenge for surgeons when using modern MIPO (minimally invasive plate osteosynthesis) techniques. We hypothesized that distal femoral fractures treated with MIPO technique are more often fixed in malrotation than those treated with open reduction internal fixation (ORIF). In this retrospective study, we identified 20 patients who met the inclusion criteria and agreed to take part in the study. In ten patients MIPO was applied, in the other ten ORIF was used. Mean age was 44.8 (19–71 years). Functional status was assessed using clinical scores (Harris Hip Score, WOMAC Hip, KS Score, WOMAC Knee, Kujala Score). Rotational alignment was assessed with magnetic resonance imaging and compared to the opposite leg. We discovered a significant difference in the mean rotational difference between the MIPO group (14.3°) and the ORIF group (5.2°). Functionally, patients in the ORIF group outperformed patients in the MIPO group in all clinical scoring systems although no one proved to be statistically significant. MIPO technique was associated with significantly more rotational malalignment compared to ORIF in distal femur fracture fixation. However, implant failure and nonunion was more common in the ORIF group, with a revision rate of 3 versus 1 in the ORIF group. Clinical scoring did not significantly different between both groups. Taking into account the undisputable advantages of minimally invasive surgery, improved teaching of methods to avoid malrotation as well as regular postoperative investigations to detect any malrotation should be advocated.

Isolated tibial plateau impression fractures can be reduced through minimally invasive techniques using balloon inflation and cement augmentation. No evidence exists yet if an additional fixation at all and which method of fixation is necessary in the treatment of these fractures. The purpose of this study was to compare a locking plate and a screw raft for additional fixation after balloon reduction and cement augmentation in isolated tibial plateau impression fractures. Loss of reduction was subsequently analysed without additional fixation.Lateral tibial plateau impression fractures were created in eight matched pairs of human cadaveric tibiae. Reduction was performed using a balloon inflation system, followed by cement augmentation. Additional fixation was performed with a lateral locking plate or a screw raft (four 3.5-mm screws). Specimens were cyclically loaded at 20-240N, 20-360N and 20-480N. Subsequently, additional fixation was removed and the last cyclic interval (20-480N) repeated. Loss of reduction was assessed by measuring subsidence of the subchondral bone.Fractures treated with plate fixation exhibited less subsidence at higher loads compared with those treated with screw raft fixation (P0.05). Loss of reduction significantly increased after removal of the additional fixation.This experimental study suggests that loss of reduction can be minimised by using locking plate fixation after balloon reduction and cement augmentation in the treatment of isolated tibial plateau impression fractures.

A medial patellofemoral ligament reconstruction (MPFL) with an additional derotational femoral osteotomy is suggested for patients suffering from patellar instability and an increased internal femoral torsion (IT). This biomechanical study investigated whether an isolated MPFL reconstruction could restore patellofemoral biomechanics for 10° and 20° relatively increased internal femoral torsion. Eight fresh-frozen cadaver knees were tested on a specially designed knee simulator, which bend the knee from 0° to 90° flexion. Patellar motion (tilt and shift) and patellofemoral pressure (pressure shift, mean and peak pressure) were evaluated for 0°, 10° and 20° of IT with a native and reconstructed MPFL. An isolated MPFL reconstruction, compared to a native MPFL with the same femoral torsion showed a significant medial shift of the center of force (10° IT p

New strategies for dynamic intraligamentary stabilization (DIS) in the primary repair of anterior cruciate ligament (ACL) ruptures are currently under debate. It has been proposed that these might serve as alternative techniques to conventional ACL reconstruction procedures using tendon autografts. The aims of the present investigation were to evaluate the functional results and critically assess the complication rate following primary ACL repair with DIS and to review existing reports of favourable clinical results with the method in relation to knee joint stability and patient satisfaction. Fifty-nine patients received dynamic intraligamentary stabilization a mean of 14 days after ACL rupture. Fifty-seven patients (96.6%, male:female = 37:20; mean age 27.6 years) were available for follow-up examinations including the Tegner activity level, anteroposterior stability in comparison with the uninjured knee, subjective satisfaction, and range of knee motion. Complications after 3 and 12 months were also analyzed. Associated lesions requiring surgical measures were found in 30 patients. A statistically significant decrease in Tegner activity levels was detected between the preoperative status (median 7) and the 12-month follow-up (median 5). The overall complication rate was 57.9%, including rerupture or non-healing (n = 10, 17.5%), repeat arthroscopy (n = 13, 22.8%) as a result of meniscus tears (n = 2, 15.4%), cyclops syndrome (n = 4, 30.8%) or restricted range of motion (n = 7, 53.8%), arthrofibrosis (n = 3, 5.3%), and implant interference (n = 7, 12.3%). Anteroposterior KT-1000 stability of 3 mm or below was achieved in 29 (50.9%) patients. The DIS procedure does not appear to be appropriate for providing predictable results in a young and active cohort of patients following ACL rupture, as it has an unacceptably high complication rate and leads to residual anteroposterior knee joint laxity of 3 mm or more in 28 (49.1%) of cases. IV (prospective case series).

Background: Cortical button fixation at the femoral side and interference screws within the tibial bone tunnel are widely used for anterior cruciate ligament graft fixation. Using a bone socket instead of a full tunnel allows cortical button fixation on the tibial side as well. If adjustable-length loop cortical button devices are used for femoral and tibial fixation, the tendon graft has to be secured with sutures in a closed tendon loop. The increased distance of fixation points and potential slippage of the tendon strands at the securing sutures might lead to greater risk of postoperative graft elongation when compared with conventional graft preparation with tibial interference screw fixation. Hypothesis: Compared with an anterior cruciate ligament graft with tibial adjustable-length loop cortical button fixation, a graft with tibial interference screw fixation will show less graft elongation during cyclic loading and lower ultimate failure loads. Study Design: Controlled laboratory study. Methods: Grafts with tibial adjustable-length loop cortical button fixation and grafts with tibial interference screw fixation were biomechanically tested in calf tibiae (n = 10 per group). Femoral fixation was equivalent for both groups, using an adjustable-length loop cortical button. Specimens underwent cyclic loading followed by a load-to-failure test. Results: Grafts with screw fixation showed significantly less initial elongation (cycles 1-5: 1.46 ± 0.26 mm), secondary elongation (cycles 6-1000: 1.87 ± 0.67 mm), and total elongation (cycles 1-1000: 3.33 ± 0.83 mm) in comparison with grafts with button fixation (2.47 ± 0.26, 3.56 ± 0.39, and 6.03 ± 0.61 mm, respectively) ( P < .001). While pull-out stiffness was significantly higher for grafts with screw fixation (309.5 ± 33.2 vs 185.6 ± 16.4 N/mm) ( P < .001), grafts with button fixation were able to withstand significantly higher ultimate failure loads (908 ± 74 vs 693 ± 119 N) ( P < .001). Conclusion: Grafts with tibial adjustable-length loop cortical button fixation resulted in higher graft elongation during cyclic loading and showed higher ultimate failure loads in comparison with conventional graft preparation with tibial interference screw fixation at time zero. Clinical Relevance: The results of this biomechanical study suggest that grafts with tibial interference screw fixation provide better knee stability at time zero because of reduced graft elongation and greater stiffness in comparison with grafts with tibial adjustable-length loop cortical button fixation.

Background Ideal diameter for tibial interference screw fixation of the anterior cruciate ligament (ACL) graft remains controversial. Tibial graft fixation with screws matching the tunnel diameter vs. one-millimetre oversized screws were compared. Methods In 32 cadaveric porcine tibiae, bovine extensor tendons with a diameter of eight millimetres were fixed in (I) a primary ACL reconstruction scenario with eight-millimetre tibial tunnels (pACL), with eight-millimetre (pACL-8) vs. nine-millimetre (pACL-9) screws, and (II) a revision ACL reconstruction scenario with enlarged tunnels of 10 mm (rACL), with 10-mm (rACL-10) vs. 11-mm (rACL-11) screws. Specimens underwent cyclic loading with low and high load magnitudes followed by a load-to-failure test. Graft slippage and ultimate failure load were recorded. Results In comparison with matched-sized screws (pACL-8), fixation with oversized screws (pACL-9) showed with significantly increased graft slippage during cyclic loading at higher load magnitudes (1.19 ± 0.23 vs. 1.98 ± 0.67 mm; P = 0.007). There were no significant differences between the two screw sizes in the revision scenario (rACL-10 vs. rACL-11; P = 0.38). Graft fixation in the revision scenario resulted in significantly increased graft slippage in comparison with fixation in primary tunnels at higher loads (pACL vs. rACL; P = 0.004). Pull-out strengths were comparable for both scenarios and all screw sizes (P > 0.316). Conclusions Matched-sized interference screws provided better ACL graft fixation in comparison with an oversized screw diameter. In revision cases, the fixation strength of interference screws in enlarged tunnels was inferior to the fixation strength in primary tunnels.

Traumatic lesions of the olecranon bursa (OB) and prepatellar bursa (PB) are injuries commonly seen in orthopaedic trauma units. These injuries are associated with a high rate of complications. At present, only little is known about the incidence, complication rate, and treatment approaches in patients with acute open bursae.A total of 552 patients who had been treated for acute traumatic lesions of either the olecranon bursa or the prepatellar bursa, or both at our department were retrospective identified in the years between 2009 and 2014. An analysis of the medical history of these patients was carried out to investigate the incidence of bursa injuries, circumstances, concomitant injuries, complication rate, and treatment approaches. In addition, a systematic literature search on PubMed was conducted.The incidence of traumatic lesions of the OB or PB in trauma patients was 0.2% (198/100,000; 62% OB, 38% PB). Bursectomy was performed in 83.7%. Concomitant injuries were present in 41% of the cases, with no significant influence on the complication rate (P = 0.367). The overall complication rate was 19.7%. Revision surgery was necessary in 4.5% of the patients. No significant differences between OB and PB injuries were noted with regard to the complication rate (P = 0.221). There were also no significant differences in the complication rate between patients who received bursectomy and those with conservative treatment (P = 0.364). Regression analyses showed that prophylactic antibiotic administration significantly reduced the risk of infection (P = 0.04).Traumatic lesions of the OB and PB are associated with a high risk of complications. Prophylactic antibiotic therapy can potentially reduce the risk of infection and the need for revision surgery.

The aim of this study was to present clinical experience and outcomes of intramedullary nailing of proximal, midshaft and distal tibia fractures with the Expert Tibia Nail (ETN; Synthes GmbH, Switzerland), an implant offering a wide range of proximal and distal locking options in multiple planes to increase stability of the implant and bone construct.180 patients with 185 tibia fractures were enclosed between July 2004 and May 2005 from ten trauma units (Levels I, II and III) and treated with intramedullary reamed and unreamed nailing with the ETN. Patients attended examinations at 12 weeks and 1 year. The occurrence of postoperative complications was documented as well as the outcomes of fracture healing, primary and secondary malalignment, implant failure, rate of infection and the need for reoperation.The 1-year follow-up rate was 81 %. At 1 year, the prevalence of delayed union was 12.2 % and higher for open fractures (18.2 %) compared to closed fractures (9.7 %). According to the fracture location, the percentage of delayed union was 5.9, 16.7 and 10.5 % in proximal third, midshaft and distal third cases, respectively. Patients with a plated fibula fracture had an eightfold higher risk of delayed union. The rate of malalignment5° in any plane 1 year after surgery was 5.5 %. Proximal third fractures were at a higher risk of postoperative malalignment (17.6 %). The rate of secondary malalignment was 1.4 %. The risk of unplanned reoperation was 9.2 %.Intramedullary ETN fixation of tibia fractures results in low rates of delayed union, primary and secondary malalignment, implant-related complications, and secondary surgery. Fibula plating had a negative effect on the healing of the tibia.

BACKGROUND:: Severe pelvic hemorrhage after low-energy trauma has been described in some reports of single cases only. However, it might not be as rare and unique as generally expected. The aim of this study was therefore to present a case series of 11 patients with severe pelvic hemorrhage after sustaining low-energy trauma and to discuss relevant considerations for the management of these patients. METHODS:: A consecutive series of eleven patients with pelvic hemorrhage and the need for arterial embolization after sustaining low-energy pelvic trauma was identified. A contrast-enhanced computed tomography (CT) scan was performed in all patients, if pelvic hemorrhage was suspected due to a relevant hemoglobin (Hb) drop. After the CT scans showed active arterial bleeding, arterial embolization was immediately performed. RESULTS:: All patients sustained low-energy pelvic injuries after simple falls from standing height. The mean initial Hb level was 13.0 g/dL. Contrast-enhanced CT scans were performed after a mean of 14.3 hours after trauma and showed contrast medium extravasations in all patients. The mean Hb level at the time of CT scan was 9.0 g/dL. Embolization was successfully performed in all patients within a mean of 4.5 hours. CONCLUSIONS:: Geriatric patients are prone to arterial hemorrhage after low-energy pelvic trauma. They should be admitted as an inpatient for observation with repeated control of the Hb level to diagnose hemorrhage at an early stage. Contrast-enhanced CT scans is the preferred imaging method for the assessment of pelvic hemorrhage, whereas arterial embolization is highly successful in terms of hemostasis. Language: en

Hohere Stabilitat von Marknagelosteosynthesen durch winkelstabile Verriegelung zwischen Marknagel und Verriegelungsbolzen. Ein neuartiges Schrauben-Dubel-System (ASLS®, Synthes GmbH Oberdorf, Schweiz) wird dabei in ubliche, kanulierte Nagel eingesetzt. Die Entscheidung kann intraoperativ erfolgen. Erweiterte Marknagelindikationen. Je kleiner und instabiler das zu verriegelnde Fragment ist, desto eher ist die Indikation zur winkelstabilen Verriegelung des proximalen und/oder distalen Fragments angezeigt. Femur-, Tibia- und Humersfrakturen, Marknagelosteosynthese im osteoporotischen Knochen sowie ante- und retrograd eingebrachte Nagel. Besonders bei retrograd eingebrachten Nageln wird das Wackeln des Nagels im Schaftbereich nachhaltig abgestellt. Keine. Durchbohren mit dem ersten Bohrer, welcher die Starke des Kerndurchmessers des Schraubenschafts hat. Aufbohren der zugewandten Kortikalis auf den Ausendurchmesser der Hulse. Dann Aufstecken der Hulse auf die Spitze der Schraube. Die Schrauben-Hulsen-Kombination wird durch das grosere zugewandte Loch vorgeschoben bis die mit der Hulse besetzte Schraubenspitze im Loch des Verriegelungsmarknagels sitzt. Vordrehen der Schraube. Das dann im Kerndurchmesser groser werdende Gewinde des Schraubenschafts expandiert die Hulse und fuhrt zum winkelstabilen Formschluss. Die Schraube wird dann bis zum Aufsitzen des Schraubenkopfs auf der zugewandten Kortikalis vorgeschraubt. Das zugewandte erweiterte Loch wird mit dem erweiterten Anteil des Gewindeschafts unter dem Schraubenkopf besetzt. Die 1–3 notwendigen Gewindegange werden durch die selbstschneidende Nut bei diesem Gewindesprung selbst geschnitten. Durch die winkelstabile Verriegelung kann nach bisheriger Erfahrung das Behandlungsregime nach Nagelung in Richtung fruhere und/oder starkere Teilbelastung oder fruhere Vollbelastung erweitert werden. Ansonsten gelten die Richtlinien der Nachbehandlung bei Marknagelung. Die multizentrische Pilotstudie hat gezeigt, dass die Technik reproduzierbar und einfach ist. Komplikationen bei der Operationstechnik sind nicht aufgetreten. Biomechanische Laborstudien haben ergeben, dass die Stabilitat bei axialer und drehender Belastung statisch und dynamisch deutlich hoher ist als mit einer konventionellen Verriegelung. Versagenszustande treten spater ein. Wie gros die klinischen Vorteile endgultig sind, werden weitere Anwendungen und die Ergebnisse einer derzeit laufenden prospektiv randomisierten Studie zeigen.

Wiederherstellung der Form und Lange der fehlverheilten Klavikula zur Linderung der Symptome und zur Verbesserung des funktionellen und asthetischen Ergebnisses. Symptomatische fehlverheilte Klavikulafraktur mit Schmerzen uber der fehlverheilten Klavikula, Schwache und rascher Ermudung der Muskulatur des betroffenen Schultergurtels, Einschrankungen der Uberkopfmobilitat, Taubheitsgefuhl und Schmerzen vor allem bei Uberkopfaktivitaten durch eine Irritation des Gefas-Nerven-Bundels (Thoracic-Outlet-Syndrom), Unzufriedenheit mit der Asthetik des betroffenen Schultergurtels. Atrophe Pseudoarthrose. Osteoporose. Asymptomatische Fehlverheilung. 5 cm lange Hautinzision uber der prominenten Fehlverheilung. Osteotomie der Fehlverheilung mit einer oszillierenden Sage und Aufbohren beider Osteotomieenden unter Bildwandlerkontrolle mit einem 2,7-mm-Bohrer. Hautinzision und Eroffnung der ventralen Kortikalis uber dem sternalen Klavikulaende. Einfuhren eines 2,5 mm dicken Titannagels. Unter rotierenden Bewegungen Vortreiben des Titannagels bis zur Osteotomie. Uberfuhren des Nagels in das distale Fragment. Moglichst plane Ruckkurzung des proximalen Nagelendes. Wundverschluss. Keine Ruhigstellung. Schmerzorientierte aktive Bewegungsubungen. Belastung ab gesicherter knocherner Heilung. Bei 5 Patienten mit symptomatischer Fehlverheilung (3 Manner, 2 Frauen) wurde eine Korrekturosteotomie der fehlverheilten Klavikula und eine intramedullare Osteosynthese mit einem elastischen Titannagel (elastisch stabile intramedullare Nagelung, ESIN) durchgefuhrt. Das Durchschnittsalter betrug 34 Jahre (23–44 Jahre). Nach 6 Monaten waren alle Osteotomien verheilt (durchschnittlich nach 4,4 Monaten), und die Implantate konnten entfernt werden. Es traten keine Komplikationen auf. Der DASH-Score und der Constant-Score waren nach 12 Monaten signifikant besser als vor der Operation. Die Patienten waren mit dem asthetischen und funktionellen Ergebnis signifikant zufriedener.

Introduction: Elastic stable intramedullary nailing (ESIN) of displaced mid-shaft clavicular fractures is a minimally invasive technique which was reported to be an easy procedure with low complication rates, good cosmetic and functional results, restoration of clavicular length and fast return to daily activities. Recent studies, however, also report on higher complication rates and specific problems with the use of this technique. This prospective study compares ESIN with non-operative treatment of displaced midshaft clavicular fractures. Methods: Between December 2003 and August 2007, 120 patients volunteered to participate. Of these, 112 patients completed the study (60 in the operative and 52 in the non-operative group). Patients in the non-operative group were treated with a simple shoulder sling. In the operative group, intramedullary stabilisation was performed within 3 days of the trauma. Clavicular shortening was determined after trauma and after osseous consolidation on thorax posteroanterior radiographs as the proportional length difference between the left and right side with the uninjured side serving as a control for clavicular length (100%). Radiographic union was assessed every 4 weeks on 208 cephalad anteroposterior and posterioranterior radiographs of the clavicle. Constant shoulder scores and DASH scores (DASH, disabilities of the arm, shoulder and hand) were assessed at final follow-up after 2 years. Results: ESIN led to faster osseous healing and better restoration of clavicular length in simple fractures. We were not able to restore clavicular length in comminuted fractures using ESIN. Functional outcome at a mean follow-up of 24 months (range: 22–27 months) was better in the operative group. Delayed union and non-union accounted for the majority of complications in the non-operative group. In the operative group, telescoping was the main complication, which occurred in complex fractures with severe posttraumatic shortening only. Conclusion: We recommend ESIN for all simple displaced mid-shaft clavicular fractures in order to minimise the rate of delayed union, non-union and symptomatic mal-union. We also recommend ESIN in comminuted fractures with moderate (7%) post-traumatic shortening, as they will heal with moderate shortening. In comminuted fractures with severe shortening, however, we recommend plate osteosynthesis in order to provide for stability, clavicular length and endosteal blood supply.

Hintergrund Fur ein internationales sportliches Grosereignis konnten Einsatzdaten fruherer Grosambulanzen Indikatoren fur die Abschatzung des Patientenaufkommens darstellen.

To assess the feasibility and accuracy of frameless stereotactic two-dimensional fluoroscopy-assisted guide pin (GP) placement in posterior cruciate ligament (PCL) reconstruction in human cadavers.A total of 13 pins were placed in 7 cadaver specimens, using a fluoroscopic-based navigation technique. The knees were fixed noninvasively on a carbon baseplate. Interventions were planned on intraoperatively acquired perpendicular fluoroscopic images. A stereotactic aiming device was mounted to the carbon baseplate and adjusted according to the planned trajectories. GPs were advanced through the aiming device to the precalculated depth. GP positions were verified by image fusion of the fluoroscopic planning and control data, respectively. Measurements were scored on three occasions by one independent observer. In order to assess interobserver reliability, measurements were scored by two further independent observers on one occasion.The femoral cohort included seven GP placements in seven cadavers. Mean GP placement accuracy according to plan was 1.3 mm (SD 0.9 mm, range 0.3-3.8 mm) at the target point. The recorded femoral angular misalignment of GPs was 1.1 degrees (SD 0.9 degrees , range 0.2 degrees -3.3 degrees ). The tibial cohort included six GP placements in six cadavers. Mean GP placement accuracy according to the plan was 1.8 mm (SD 2.1 mm, range 0.3-9.5 mm). The recorded tibial angular misalignment of GPs was 1.4 degrees (SD 1.1 degrees , range 0.1 degrees -5 degrees ). Navigated GP implantation, as planned, was optimal in six out of seven cases in the femoral cohort and in four out of six cases in the tibial cohort.Our preliminary cadaver study suggests that the use of fluoroscopic-based navigation combined with a stereotactic targeting device may be a helpful tool to improve PCL reconstruction. In addition, this method may also be used for other minimal invasive skeletal interventions.

Ubungsstabile Osteosynthese von Unterschenkelfrakturen mit Wiederherstellung der Achsenverhaltnisse, Lange und Rotation der Tibia. Zuverlassige Knochenbruchheilung bei offenen und geschlossenen Frakturen nach fruhfunktioneller Ubungsbehandlung mit Erhalt der Gelenkbeweglichkeit. Geschlossene und offene isolierte Tibia- und Unterschenkelschaftfrakturen (AO 42). Extraartikulare Frakturen der proximalen oder distalen Tibia (AO 41 A2/A3; AO 43 A1/A2/A3). Segmentfrakturen der Tibia. Intraartikulare Frakturen der proximalen oder distalen Tibia (AO 41 C1/C2; AO 43 C1/C2) in Verbindung mit weiteren Implantaten. Stabilisierung bei und nach Segmenttransport/Kallusdistraktion an der Tibia. Patienten in inoperablem Allgemeinzustand. Kniebeugefahigkeit von weniger als 90°. Weichteilinfekt im Bereich des pratibialen Nageleintritts. Markraumphlegmone der Tibia. Komplexe Frakturen der proximalen und/oder distalen Gelenkflache mit Impression. Wenn moglich, geschlossene Reposition der Tibiafraktur, evtl. mit Einsatz von Repositionshilfen uber Stichinzisionen oder in offener Technik. Lagerung auf einem rontgendurchlassigen Tisch; alternativ kann – je nach personlicher Praferenz – auch auf dem Extensionstisch oder mit Hilfe eines Rahmens aus Carbonstangen gelagert werden. Eroffnen der proximalen Tibia in Verlangerung des Markraums. Einbringen des Expert Tibia Nagels® in kanulierter oder Freihandtechnik mit oder ohne Aufbohren des Markraums in Abhangigkeit von Fraktur und Weichteilkondition. Kontrolle der Langsachse, Lange und Rotation der Extremitat. Distale Verriegelung mit dem rontgendurchlassigen Winkelgetriebe. Gegebenenfalls Beseitigung einer Frakturdiastase durch Ruckschlagen des Nagels und proximale Verriegelung uber den Zielbugel. Sofortige Bewegungsubungen des Knie- und oberen Sprunggelenks. Je nach Frakturtyp Mobilisation unter Teilbelastung des Beins mit 20 kg bis zur schmerzabhangigen Vollbelastung an Unterarmgehstutzen. Nach 6 Wochen radiologische Verlaufskontrolle und schrittweise Belastungssteigerung. In eine prospektive, internationale multizentrische Studie wurden zwischen Juli 2004 und Mai 2005 insgesamt 181 Patienten mit 186 Frakturen eingeschlossen. 57 dieser Frakturen (30,7%) waren offen, davon 15 Grad I, 32 Grad II und zehn Grad III. Meist handelte es sich um Tibiaschaftfrakturen (36%). Nach 1 Jahr konnten noch 146 (81%) dieser Patienten klinisch und radiologisch nachuntersucht werden. Die Rate an Pseudarthrosen fur die gesamte Gruppe lag zu diesem Zeitpunkt bei 12,2% (offene Frakturen 18,2%, geschlossene Frakturen 9,7%). Revisionsoperationen einschlieslich Dynamisierungen waren bei 18,8% der Patienten vorgenommen worden. Ohne Berucksichtigung der geplanten Dynamisierungen waren in nur 5,4% Reoperationen notwendig. Eine Fehlstellung in Varus-, Valgusoder Antekurvationsrichtung von mehr als 5° in mindestens einer Ebene auf postoperativen radiologischen Langaufnahmen lag bei 4,3% der Schaftfrakturen, 1,5% der distalen Frakturen und 13,6% der proximalen Frakturen vor. Bolzenbruche fanden sich bei 3,2% der Patienten.

The 22nd Student World Winter Games took place in January 2005 in Innsbruck and Seefeld, Austria. Exactly 1,500 athletes of 50 nationalities competed in 69 events in ten winter sports. A total number of 750 functionaries, 800 volunteers and 85,000 spectators participated in the second largest winter sports event behind the Olympic winter games. The aim of this study was to evaluate the needed resources to ensure traumatological care for an event of that size. At the medical “call-center” all consultations, as well as patient data, diagnosis, and medical treatment were recorded using a preset protocol. Further, all patients treated in the University Hospital Innsbruck were registered with an emphasis on trauma patients. Forty-eight of 65 patients transported to the hospital as a result of the Universiade were trauma patients, 37 of whom were athletes. The gender distribution was 34:14 (m:f). Ice hockey players had the highest rate of injury (25% of all injured athletes), followed by alpine skiers (20.8% of injured athletes). The highest ISS was nine. Forty-three patients got ambulatory treatment, five were admitted to the hospital and surgical treatment was conducted in three cases. Mean patient number was 4.8 per day. No additional personnel, structural, or technical hospital resources were needed to accommodate a large winter sports event like the Universiad. Thus, a level-B trauma center with an emergency room and independent traumatological department with around the clock surgical capability seems to be sufficient to provide traumatological care for an event of this size if the possibility of patient transport to a larger facility exists in the case of catastrophic events.

Introduction This study compared the feasibility of six different CT-based measurement techniques for establishing an indication for derotational osteotomy in the cases of patellar instability or femoral fracture. Materials and methods CT scans of 52 single human cadaver femora were measured using six different torsion measurement techniques (described by Waidelich, Murphy, and Yoshioka on transverse images and Hernandez, Jarrett, and Yoshioka on oblique images). All measurements were performed by four observers twice to assess intraobserver and interobserver agreement. The intraclass correlation coefficient (ICC), ANOVA, and Bonferroni post hoc test were used for the statistical analysis. Results Significant differences (P

Accuracy of implant positioning and reconstruction of the mechanical leg axis are major requirements for achieving good long-term results in total knee arthroplasty (TKA). The purpose of the present study was to determine whether image-free computer navigation technology has the potential to improve the accuracy of component alignment in TKA cohorts of experienced surgeons immediately and constantly. One hundred patients with primary arthritis of the knee underwent the unilateral total knee arthroplasty. The cohort of 50 TKAs implanted with conventional instrumentation was directly followed by the cohort of the very first 50 computer-assisted TKAs. All surgeries were performed by two senior surgeons. All patients received the Zimmer NexGen total knee prosthesis (Zimmer Inc., Warsaw, IN, USA). There was no variability regarding surgeons or surgical technique, except for the use of the navigation system (StealthStation) Treon plus Medtronic Inc., Minnesota, MI, USA). Accuracy of implant positioning was measured on postoperative long-leg standing radiographs and standard lateral X-rays with regard to the valgus angle and the coronal and sagittal component angles. In addition, preoperative deformities of the mechanical leg axis, tourniquet time, age, and gender were correlated. Statistical analyses were performed using the SPSS 15.0 (SPSS Inc., Chicago, IL, USA) software package. Independent t-tests were used, with significance set at P0.05 (two-tailed) to compare differences in mean angular values and frontal mechanical alignment between the two cohorts. To compute the rate of optimally implanted prostheses between the two groups we used the chi(2) test. The average postoperative radiological frontal mechanical alignment was 1.88 degrees of varus (range 6.1 degrees of valgus-10.1 degrees of varus; SD 3.68 degrees ) in the conventional cohort and 0.28 degrees of varus (range 3.7 degrees -6.0 degrees of varus; SD 1.97 degrees ) in the navigated cohort. Including all criteria for optimal implant alignment, 16 cases (32%) in the conventional cohort and 31 cases (62%) in the navigated cohort have been implanted optimally. The average difference in tourniquet time was modest with additional 12.9 min in the navigated cohort compared to the conventional cohort. Our findings suggest that the experienced knee surgeons can improve immediately and constantly the accuracy of component orientation using an image-free computer-assisted navigation system in TKA. The computer-assisted technology has shown to be easy to use, safe, and efficient in routine knee replacement surgery. We believe that navigation is a key technology for various current and future surgical alignment topics and minimal-invasive lower limb surgery.

Background:Cortical button fixation at the femoral side and interference screws within the tibial bone tunnel are widely used for anterior cruciate ligament graft fixation. Using a bone socket instead of a full tunnel allows cortical button fixation on the tibial side as well. If adjustable-length loop cortical button devices are used for femoral and tibial fixation, the tendon graft has to be secured with sutures in a closed tendon loop. The increased distance of fixation points and potential slippage of the tendon strands at the securing sutures might lead to greater risk of postoperative graft elongation when compared with conventional graft preparation with tibial interference screw fixation.Hypothesis:Compared with an anterior cruciate ligament graft with tibial adjustable-length loop cortical button fixation, a graft with tibial interference screw fixation will show less graft elongation during cyclic loading and lower ultimate failure loads.Study Design:Controlled laboratory study.Methods:Grafts wi...

Background Use of a rigid brace or cast immobilization is recommended in conservative treatment or postoperative rehabilitation after a posterior cruciate ligament injury. To prevent the loss of knee joint function and muscle activity often associated with this, a flexible knee brace has been developed that allows an adjustable anteriorly directed force to be applied to the calf in order to prevent posterior tibial translation. The purpose of this biomechanical study was to evaluate the impact of this novel dynamic brace on posterior tibial translation after posterior cruciate ligament injury and reconstruction. Methods A Telos stress device was used to provoke posterior tibial translation in seven human lower limb specimens, and stress radiographs were taken at 90° of knee flexion. Posterior tibial translation was measured in the native knees with an intact posterior cruciate ligament; after arthroscopic posterior cruciate ligament dissection with and without a brace; and after posterior cruciate ligament reconstruction with and without a brace. The force applied with the brace was measured using a pressure sensor. Findings Posterior tibial translation was significantly reduced (P = 0.032) after application of the brace with an anteriorly directed force of 50 N to the knees with the dissected posterior cruciate ligament. The brace also significantly reduced posterior tibial translation after posterior cruciate ligament reconstruction in comparison with reconstructed knees without a brace (P = 0.005). Interpretation Posterior tibial translation was reduced to physiological values using this dynamic brace system that allows an anteriorly directed force to be applied to the calf.

Purpose To investigate the possible relation between femoral anteversion (AV) and trochlear morphology. Methods Among 560 available lower-limb computed tomography (CT) scans, those with previous fracture, arthroplasty, or osteotomy were excluded and 40 cases were randomly selected. The following 4 lines were determined from the CT scans: 1 through the center of the femoral head and neck; 1 through the lesser trochanter and the center of the femoral shaft; 1 as a tangent to the dorsal part of the distal femur, just above the gastrocnemius insertion; and 1 as a tangent to the posterior condyles. Between the respective lines, the following parameters of femoral AV were determined: (1) total AV, (2) proximal AV, (3) diaphyseal AV, and (4) distal AV. Trochlea parameters were determined from 2 separate axial CT slices (proximal trochlea and 5 mm farther distally): trochlea height (medial, central, lateral), transverse trochlea shift, trochlea depth, sulcus angle, lateral trochlea slope, and Dejour trochlea type. To prove or disprove our study hypothesis, a correlation analysis was performed between the variables of AV and trochlear morphology. Results The total AV was significantly correlated with the trochlea parameters trochlea depth ( P = .032), sulcus angle ( P = .05), and lateral trochlea slope ( P = .001). The diaphyseal AV was significantly correlated with the sulcus angle ( P = .009). The distal AV showed significant correlations with medial, central, and lateral trochlea height (.005 P P = .043). Conclusions The morphology of the trochlea is significantly related to femoral AV. Increased AV is associated with a flatter, more dysplastic trochlea. This was particularly true for AV located at the distal femur. Level of Evidence Level III, diagnostic study of nonconsecutive patients.

Revaskularisation der Nekrosezone im Talus und Anregung der Knochenneubildung bei Schonung des talaren Knorpeluberzugs durch computerassistierte minimalinvasive Anbohrung oder retrograde Spongiosaunterfutterung des osteochondrotischen Herdes. Osteochondrosis dissecans tali Stadium I–III nach Berndt & Harty. Osteochondrosis dissecans tali Stadium IV nach Berndt & Harty. Allgemeine Kontraindikationen wie z. B. schlechte Haut- und Weichteilverhaltnisse oder schlechter Allgemeinzustand. Praoperativ: Anpassung einer abnehmbaren Schale fur das obere Sprunggelenk (OSG-Fixationsschale), anschliesend Computertomographie des Sprunggelenks mit angelegter OSG-Fixationsschale. Planung der Lage des zentralen Bohrstifts im Talus mit einem Navigationssystem im Labor. Einstellung und Arretierung der Zielvorrichtung. Intraoperativ: Anlage der sterilisierten OSG-Fixationsschale. Retrograde Platzierung des 2,4-mm-Kirschner-Drahts uber die arretierte Zielvorrichtung. Bildwandlerkontrolle der Lage des Kirschner-Drahts. Arthroskopie des OSG; je nach Befund werden weitere Parallelbohrungen gesetzt oder eine retrograde Spongiosaplastik mit Spongiosaentnahme aus dem Kalkaneus durchgefuhrt. Bei retrograder Anbohrung/Parallelbohrung: 1 Woche Teilbelastung mit 30 kg. Bei retrograder Spongiosaplastik: 4 Wochen Teilbelastung mit 15 kg, dann 2 weitere Wochen Teilbelastung mit 30 kg. Physiotherapie. Von Dezember 1999 bis Januar 2005 wurde bei 41 Patienten eine computerassistierte Behandlung der Osteochondrosis dissecans tali zur retrograden Anbohrung oder retrograden Spongiosaplastik gewahlt. Bei 39 der 41 Patienten wurde die osteochondrale Lasion—wie im postoperativen Magnetresonanztomogramm (MRT) verifiziert—erreicht, d. h., der Bohrkanal fuhrte in die Lasion. In zwei Fallen lag intraoperativ ein nicht behebbarer Materialfehler vor, so dass die vorgestellte Methode an 39 Patienten angewendet werden konnte. Fur die ersten 15 Patienten, die eine retrograde Anbohrung/Parallelbohrung mit begleitender Sprunggelenkarthroskopie erhielten und keine retrograde Spongiosaplastik, werden die 1-Jahres-Ergebnisse anhand der MRT-Verlaufskontrolle (Bohrkanallage, Vitalitatsbeurteilung des osteochondrotischen Areals) und eines klinischen Scorings prasentiert. Die vier Frauen und elf Manner waren durchschnittlich 34,1 Jahre alt (14–55 Jahre). Im radiologischen Vergleich zwischen den pra- und postoperativen Stadien der Osteochondrosis dissecans lies sich bei 46,7% der Patienten eine Verbesserung des Stadiums nach Berndt & Harty nachweisen. Bei 40,0% zeigte sich im MRT postoperativ das gleiche Osteochondrosis-dissecans-Stadium, und bei 13,3% verschlechterte es sich um einen Grad. In der klinischen Nachuntersuchung betrug der AOFAS-Score im Mittel 88,9 Punkte.

Background: Angular stable locking of intramedullary nails has been shown to enhance fixation stability of tibial fractures in biomechanical and animal studies. The aim of our study was to assess whether use of the angular stable locking system or conventional locking resulted in earlier full weight-bearing with minimum pain for patients with a distal tibial fracture treated with an intramedullary nail. Methods: A prospective multicenter, randomized, patient-blinded trial was conducted with adults who had a distal tibial fracture. Patients’ fractures were managed with an intramedullary nail locked with either an angular stable locking system or conventional locking screws. Outcomes were evaluated at six weeks, twelve weeks, six months, and one year after surgery. Time to full weight-bearing with minimum pain was calculated with use of daily entries from patient diaries. Secondary outcomes included pain at the fracture site under load, quality of life, gait analysis, mobility, radiographic findings, and adverse events. Results: One hundred and forty-two patients were randomly allocated to two treatment groups: seventy-five to the group receiving intramedullary nailing with the angular stable locking system and sixty-seven to the group receiving conventional intramedullary nailing. No clinically important differences were found for either the primary or secondary outcome parameters between the groups during the entire follow-up period. Conclusions: Use of an angular stable locking system with intramedullary nailing did not improve the outcome compared with conventional locking screws in the treatment of distal tibial fractures. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Performing all-inside anterior cruciate ligament reconstruction using cortical button fixation, the tendon graft has to be secured in a closed loop with sutures. In the present study, the graft secured with four sutures was compared with two reduced-suture material graft preparation techniques. A bovine tendon graft folded over two adjustable-length loop cortical button devices was secured using the following techniques: 1, four buried-knot sutures; 2, two sutures on the tibial end only; and 3, two sutures on the tibial graft end with additional suspension on the tibial cortical button. Each group consisted of eight specimens and underwent cyclic loading followed by a load-to-failure test. The least graft elongation after cyclic loading was observed for the graft with four sutures (6.1 ± 0.6 mm), followed by the graft with two sutures and additional suspension (6.3 ± 0.8 mm) and the graft with two sutures (7.0 ± 0.7 mm). The difference in graft elongation between four sutures and only two sutures was significant (P

Admission blood glucose is known to be a predictor for outcome in several disease patterns, especially in critically ill trauma patients. The underlying mechanisms for the association of hyperglycaemia and poor outcome are still not proven. It was hypothesised that hyperglycaemia upon hospital admission is associated with haemorrhagic shock and in-hospital mortality.Data was extracted from an observational trauma database of the level 1 trauma centre at Innsbruck Medical University hospital. Trauma patients (≥18 years) with multiple injuries and an Injury Severity Score ≥17 were included and analysed.In total, 279 patients were analysed, of which 42 patients (15.1%) died. With increasing blood glucose upon hospital admission, the rate of patients with haemorrhagic shock rose significantly [from 4.4% (glucose 4.1-5.5mmol/L) to 87.5% (glucose15mmol/L), p0.0001]. Mortality was also associated with initial blood glucose [≤5.50mmol/L 8.3%; 5.51-7.50mmol/L 10.9%, 7.51-10mmol/L 12.4%; 10.01-15mmol/L 32.0%; ≥15.01mmol/L 12.5%, p=0.008]. Admission blood glucose was a better indicator for haemorrhagic shock (cut-off 9.4mmol/L, sensitivity 67.1%, specificity 83.9%) than haemoglobin, base excess, bicarbonate, pH, lactate, or vital parameters. Regarding haemorrhagic shock, admission blood glucose is more valuable during initial patient assessment than the second best predictive parameter, which was admission haemoglobin (cut-off value 6.5mmol/L (10.4g/dL): sensitivity 61.3%, specificity 83.9%).In multiple trauma, non-diabetic patients, admission blood glucose predicted the incidence of haemorrhagic shock. Admission blood glucose is an inexpensive, rapidly and easily available laboratory value that might help to identify patients at risk for haemorrhagic shock during initial evaluation upon hospital admission.

Using human cadaver specimens, we investigated the role of supplementary fibular plating in the treatment of distal tibial fractures using an intramedullary nail. Fibular plating is thought to improve stability in these situations, but has been reported to have increased soft-tissue complications and to impair union of the fracture. We proposed that multidirectional locking screws provide adequate stability, making additional fibular plating unnecessary. A distal tibiofibular osteotomy model performed on matched fresh-frozen lower limb specimens was stabilised with reamed nails using conventional biplanar distal locking (CDL) or multidirectional distal locking (MDL) options with and without fibular plating. Rotational stiffness was assessed under a constant axial force of 150 N and a superimposed torque of ± 5 Nm. Total movement, and neutral zone and fracture gap movement were analysed. In the CDL group, fibular plating improved stiffness at the tibial fracture site, albeit to a small degree (p = 0.013). In the MDL group additional fibular plating did not increase the stiffness. The MDL nail without fibular plating was significantly more stable than the CDL nail with an additional fibular plate (p = 0.008). These findings suggest that additional fibular plating does not improve stability if a multidirectional distal locking intramedullary nail is used, and is therefore unnecessary if not needed to aid reduction. Cite this article: Bone Joint J 2014;96-B:385–9.

Background FFP and coagulation factor concentrates are used to correct trauma-induced coagulopathy (TIC). However, data on coagulation profiles investigating effects of therapy are scarce. Methods This is an analysis of 144 patients with major blunt trauma ((ISS) ≥ 15), who were enrolled in a prospective cohort study investigating characteristics and treatment of TIC. Patients who received fibrinogen concentrate and/or prothrombin complex concentrate alone (CF Group) were compared with those additionally receiving FFP transfusions (FFP Group). Results Sixty-six patients exclusively received CF, while 78 patients additionally received FFP. Overall, patients were comparable regarding age, gender and ISS (CF Group, ISS 37 (29, 50); FFP Group ISS 38 (33, 55), p = 0.28). Patients treated with CF alone showed sufficient haemostasis and received significantly fewer units of red blood cells (RBC) and platelets than did those also receiving FFP [(RBC 2(0, 4) U vs. 9 (5, 12) U; platelets 0 (0, 0) U vs. 1 (0, 2) U, p

With the rising number of anterior cruciate ligament (ACL) reconstructions performed, revision ACL reconstruction is increasingly common nowadays. A broad variety of primary and revision ACL reconstruction techniques have been described in the literature. Recurrent instability after primary ACL surgery is often due to non-anatomical ACL graft reconstruction and altered biomechanics. Anatomical reconstruction must be the primary goal of this challenging revision procedure. Recently, revision ACL reconstruction has been described using double bundle hamstring graft. Successful revision ACL reconstruction requires an exact understanding of the causes of failure and technical or diagnostic errors. The purpose of this article is to review the causes of failure, preoperative evaluation, graft selection and types of fixation, tunnel placement, various types of surgical techniques and clinical outcome of revision ACL reconstruction.

A B S T R A C T Introduction: Clinical observations together with recent research highlighted the role of coagulopathy in acute trauma care and early aggressive treatment has been shown to reduce mortality. Methods: Datasets from severely injured and bleeding patients with established coagulopathy upon emergency room (ER) arrival from two retrospective trauma databases, (i) TR-DGU (Germany) and (ii) Innsbruck Trauma Databank/ITB (Austria), that had received two different strategies of coagulopathy management during initial resuscitation, (i) fresh frozen plasma (FFP) without coagulation factor concentrates, and (ii) coagulation factor concentrates (fibrinogen and/or prothrombin complex concentrates) without FFP, were compared for morbidity, mortality and transfusion requirements using a matched-pair analysis approach. Results: There were no major differences in basic characteristics and physiological variables upon ER admission between the two cohorts that were matched. ITB patients had received substantially less packed red blood cell (pRBC) concentrates within the first 6 h after admission (median 1.0 (IQR25-75 0-3) vs 7.5 (IQR25-75 4-12) units; p < 0.005) and the first 24 h as compared to TR-DGU patients (median 3 (IQR25-75 0-5) vs 12.5 (8-20) units; p < 0.005). Overall mortality was comparable between both groups whilst the frequency for multi organ failure was significantly lower within the group that had received coagulation factor concentrates exclusively and no FFP during initial resuscitation (n = 3 vs n = 15; p = 0.015). This translated into trends towards reduced days on ventilator whilst on ICU and shorter overall in-hospital length of stays (LOS). Conclusion: Although there was no difference in overall mortality between both groups, significant differences with regard to morbidity and need for allogenic transfusion provide a signal supporting the management of acute post-traumatic coagulopathy with coagulation factor concentrates rather than with traditional FFP transfusions. Prospective and randomised clinical trials with sufficient patient numbers based upon this strategy are advocated. 2011 Published by Elsevier Ltd.

Background: Major pelvic trauma results in high mortality. No standard technique to control pelvic hemorrhage has been identified. Methods: In this retrospective study, the clinical course of hemodynamically instable trauma patients with pelvic fractures treated according to an institutional algorithm focusing on basic radiologic diagnostics, external fixation, and early angiographic embolization was evaluated. Study variables included demographics, data on the type and extent of injury, achievement of time from admission to hemorrhage control, complications of angiography, red blood cell needs, and outcome. Standard statistical tests were used. Results: Of 1,476 pelvic fracture patients, 45 fulfilled the inclusion criteria. Two patients presented with severe intra-abdominal hemorrhage and underwent emergency laparotomy with pelvic packing. Forty-two patients underwent angiographic embolization before (n = 24) or after (n = 18) a computed tomography scan. Applying the clinical algorithm, pelvic hemorrhage was controlled in all but one patient who died before any intervention could be initiated (97.8%). The hourly need for red blood cell transfusions decreased during 24 hours after angiographic embolization when compared with before the procedure (3.7 ± 3.5 vs. 0.1 ± 0.1 U/h; p < 0.001). In patients undergoing angiographic embolization, the mean time to hemorrhage control was 163 minutes ± 83 minutes. Hospital mortality was 26.2%. Two patients required reembolization because of hemorrhage from other than the primary bleeding site. One patient developed gluteal necrosis, and nine subsequently required renal replacement therapy. Conclusion: Application of a clinical algorithm focusing on basic radiologic diagnostics, external fixation, and early angiographic embolization was effective and safe to rapidly control hemorrhage in hemodynamically instable trauma patients with pelvic fractures.

The success of unicompartmental knee arthroplasty (UKA) is highly dependent on the accuracy of the component alignment. Objective of the present study was to evaluate the immediate effect of image-free computer navigation technology on implant accuracy in primary mini-invasive UKA. This study reviews 40 patients with primary isolated arthritis of the medial compartment of the knee that underwent unicompartmental knee arthroplasty through a minimally invasive approach. A cohort of the 20 most recent consecutive UKA’s implanted with standard instrumentation was followed by a cohort of the very first 20 consecutive cases after conversion to the navigated technique. There was no variability regarding implant (Oxford™ meniscal unicompartmental knee system—Biomet Orthopedics, Inc., Warsaw, Indiana 46580, USA), surgeons and surgical technique, except for the use of the navigation system (Treon plus™—Medtronic Inc., Minnesota, MI, USA). The axis alignment and accuracy of implant positioning was measured on postoperative long-leg standing radiographs and standard lateral X-rays with regard to the valgus angle and the coronal and sagittal component angle. In addition, preoperative deformities of the mechanical leg axis, tourniquet time, age, gender, and body mass index were correlated. Statistical analyses were performed using the SPSS 14.0 (SPSS Inc., Chicago, IL, USA) software package. Optimal implant alignment including all measurements in the desired angular range was significantly (P = 0.041) higher in the navigated cohort. Navigation eliminated outliers in the frontal mechanical alignment and coronal orientation of the femoral component totally and significantly (P

This experimental study was designed to compare two different fluoroscopy-based stereotactic surgical techniques for transcutaneous cervical pedicle screw (CPS) placement in the subaxial human cervical spine: (1) a custom-made aiming frame (AF) in combination with conventional fluoroscopy versus (2) a targeting device in combination with a computer-assisted image guidance system [i.e. virtual fluoroscopy (VF)]. Surgery was carried out on six preserved human total body specimens in a laboratory setting. Sixty pedicles (levels C3–C7) were measured in a multislice computed tomography (CT) image data set prior to surgery. Two groups consisting of three specimens and 30 pedicles each were defined according to the surgical technique. The AF consisted of radiolucent components with a fully adjustable arm for carrying the instruments necessary for placing the screws. The arm was angled according to the cervical pedicle axis, as determined by the preoperative CT scans and intraoperative lateral fluoroscopy. For VF, a targeting device was combined with a computer-assisted image-guided surgery unit. For both stereotactic techniques, 3.5 mm screws made of carbon fibre polyetheretherketone (ECF-PEEK) were inserted transcutaneously through stab incisions. Screw placement was assessed using a four-point grading system ranging from ideal (I) to unacceptable (III) where I = screw centred in pedicle, IIa = perforation of pedicle wall is less than one-fourth of the screw diameter, IIb = perforation of the pedicle wall is more than one-fourth of the screw diameter without contact to neurovascular structures, and III = CPS in contact with neurovascular structures. Fifty-eight pedicle screws could be evaluated without interfering metal artefacts according to the same CT protocol that was used preoperatively. The AF technique achieved a significantly smaller number of screws in contact with neurovascular structures compared with the VF technique (P = 0.021; Fisher’s exact test) (Grade I n = 15; 64.3% AF vs. n = 13; 43.3% VF and Grade III n = 2; 7.1% AF vs. n = 10; 33.3% VF). Although neither of the two techniques was capable of completely preventing CPS perforations, transcutaneous CPS placement with a conventional fluoroscopy-based stereotactic AF can be considered a less expensive alternative to VF. This AF technique is able to reduce the number and severity of lateral pedicle wall violations compared to screw placement via the wide standard posterior open midline approach to the subaxial cervical spine. The results of this study are discussed in context with those obtained from different published modifications, since the first technical description of this surgical technique in 1994 by Abumi and co-workers.

Appropriate graft tension and secure graft incorporation in bone tunnels are essential for successful anterior cruciate ligament (ACL) reconstruction using hamstring tendon autografts. Permanent viscoplastic elongation in response to cyclic loading in the early postoperative period and the interposition of suture material in the tendon-bone interface might negatively affect graft function and rigid graft incorporation in the bone tunnels. A modified Prusik knot is an alternative option to the commonly used whipstitch technique for soft tissue fixation in ACL reconstruction. This is a controlled laboratory study. Sixteen formalin-fixed human cadaver semitendinosus tendons were armed with a modified Prusik knot or a whipstitch and tested in a load-to-failure test with a constant displacement rate of 1 mm/s, 14 in the cyclic loading test with 100 cycles from 10 to 50 N followed by 100 cycles from 10 to 75 N. The modified Prusik knot showed smaller force-induced displacements and higher stiffness of the entire construct in the load-to-failure test. Smaller preconditioning displacements were the only significant differences in the cyclic loading test. The modified Prusik knot has equal or superior mechanical properties and provides a larger area in the tendon-bone interface without suture material compared with the whipstitch technique.

Petra Innerhofer , Isabella Westermann , Helmuth Tauber , Robert Breitkopf , Dietmar Fries , Tobias Kastenberger , Rene El Attal , Alexander Strasak , Markus Mittermayr * Clinic of Anaesthesiology and Intensive Care Medicine, Innsbruck Medical University, Innsbruck, Austria Clinic of General and Surgical Intensive Care Medicine, Innsbruck Medical University, Innsbruck, Austria Clinic of Trauma Surgery and Sports Medicine, Innsbruck Medical University, Innsbruck, Austria Department of Medical Statistics, Informatics and Health Economics, Innsbruck Medical University, Innsbruck, Austria