Subjektives und funktionelles Outcome nach akut-ligamentärer Ellenbogenluxation

Background

Conservative treatment of simple elbow dislocations is promoted; however, the importance of primary surgical treatment for these injuries has not been evaluated.

Objectives

The objective of this study was to assess the results of the surgical and nonsurgical treatment of simple elbow dislocations regarding subjective patient satisfaction and joint stability.

Materials and methods

Patients with surgically and nonsurgically treated simple elbow dislocations were included into this study. The elbow function was assessed by the Elbow Self-Assessment Score (ESAS). For objective evaluation, an ultrasound evaluation of the affected and the contralateral healthy elbow was performed.

Results

A total of 20 patients with an average age of 47?±?13.1 years were clinically and sonographically assessed. The mean follow-up was 44?±?18.5 months (range 15–84 months); 10 patients were treated nonsurgically and 10 surgically. The ESAS was not significantly different between the nonsurgical (91.8?±?18.5 points) and the surgical treatment group (91.6?±?15.5 points; n.?s.). In addition, the ultrasound evaluation showed no instability in either treatment group.

Conclusions

Both nonsurgical and surgical treatment can lead to high patient satisfaction and sonographic stability in simple elbow dislocations. Regarding the joint stability, the subjective perception does not necessarily correlate with the ultrasound findings.

     

Can the gracilis replace the anterior cruciate ligament in the knee? A biomechanical study

Purpose

The purpose of this study was to determine whether a four-strand gracilis-only construct possesses the biomechanical properties needed to act as an anterior cruciate ligament (ACL) reconstruction graft.

Methods

This was a pilot study with 32 cadaver specimens. The biomechanical properties of three types of grafts were determined using validated tensile testing methods: patellar tendon (BTB), both hamstring tendons together (GST4) and gracilis alone (G4).

Results

The maximum load at failure of the G4 was 416.4 N (±187.7). The GST4 and BTB had a maximum load at failure of 473.5 N (±176.9) and 413.3 N (±120.4), respectively. The three groups had similar mean maximum load and stiffness values. The patellar tendon had significantly less elongation at failure than the other two graft types.

Conclusions

The biomechanical properties of a four-strand gracilis construct are comparable to the ones of standard grafts. This type of graft would be useful in the reconstruction of the anteromedial bundle in patients with partial ACL ruptures.

     

Cross-cultural adaptation and validation of the Italian versions of the Kujala,Larsen, Lysholm and Fulkerson scores in patients with patellofemoral disorders

Background

The Kujala, Fulkerson, Larsen and Lysholm questionnaires have been demonstrated to be reliable and sensitive in assessing patients with patellofemoral pathology. The purpose of this study is to translate and cross-culturally adapt into Italian the English versions of the Kujala, Fulkerson, Larsen and Lysholm questionnaires, and undertake reliability and validity evaluations of the Italian versions of these scores in patients with patellofemoral pathology.

Materials and methods

The cross-cultural adaptation process was carried out following the simplified Guillemin criteria. The questionnaires were administered to 63 patients with either patellar instability or painful patella syndrome. To assess the validity of the questionnaires, they were compared with the Oxford knee score. The questionnaires were administered to a subsample of 33 patients 5 days later to assess test–retest reliability.

Results

The interclass coefficient correlation was 0.96 for the Kujala score, 0.92 for the Larsen score, 0.96 for the Lysholm score, 0.94 for the Fulkerson score (P < 0.01), and 0.83 for the Oxford score. Pearson’s correlation was0.96 between the Kujala and Oxford scores, 0.90 between the Larsen and Oxford scores, 0.94 between the Lysholm and Oxford score, and 0.93 between the Fulkerson and Oxford scores. Responsiveness, calculated by standardized response mean, was 1.2, and effect size was 1.4.

Conclusions

The Italian versions of the Kujala, Larsen, Lysholm and Fulkerson scoring systems were shown to be equivalent to their English versions and demonstrated good validity, reliability and responsiveness to surgical treatment of patellofemoral pathology. To the best of the authors’ knowledge, this is the first attempt to adapt four of the most common patellofemoral-specific scoring scales to the Italian language.

Level of evidence

Level II.

     

Dislocation and its recurrence after revision total hip arthroplasty

Purpose

Dislocation is a leading cause of failure after revision total hip arthroplasty (THA). This study was conducted to examine the risk factors for dislocation as well as their recurrence after revision THA.

Methods

We retrospectively reviewed 178 revision THAs in 162 patients between 1998 and 2013. The mean patient age was 65.2 years at operation and the mean follow-up period was 6.7 years. Multivariate logistic regression was performed to identify risk factors for dislocation, and further comparison was made between patients with single and recurrent dislocations.

Results

Sixteen hips in 15 patients (9.0 %) dislocated at a mean of 9.1 months (range, 0–83 months) after revision THA. Multivariate analysis identified advanced age (odds ratio [OR]?=?2.94/10 years) and osteonecrosis of the femoral head (OR?=?7.71) as the independent risk factors for any dislocations. Risk factors for recurrent dislocations, which were observed in eight hips (50 %), were later dislocations (≥4 months) and lower BMI.

Conclusion

Dislocation is a serious problem after revision THA with multiple risk factors. Although our findings were limited to revision THAs done through posterolateral approach, recognition of these factors is helpful in patient education and surgical planning.

     

No difference in flexion power despite iliopsoas fatty degeneration in healed hip fractures with large lesser trochanter displacement

Objective

To evaluate iliopsoas atrophy and loss of function after displaced lesser trochanter fracture of the hip.

Design

Cohort study.

Setting

District hospital.

Patients

Twenty consecutive patients with pertrochanteric fracture and displacement of the lesser trochanter of?>?20 mm.

Intervention

Fracture fixation with either an intramedullary nail or a plate.

Outcome measurements

Clinical scores (Harris hip, WOMAC), hip flexion strength measurements, and magnetic resonance imaging findings.

Results

Compared with the contralateral non-operated side, the affected side showed no difference in hip flexion force in the supine upright neutral position and at 30° of flexion (205.4 N vs 221.7 N and 178.9 N vs. 192.1 N at 0° and 30° flexion, respectively). However, the affected side showed a significantly greater degree of fatty infiltration compared with the contralateral side (global fatty degeneration index 1.085 vs 0.784), predominantly within the psoas and iliacus muscles.

Conclusion

Severe displacement of the lesser trochanter (>?20 mm) in pertrochanteric fractures did not reduce hip flexion strength compared with the contralateral side. Displacement of the lesser trochanter in such cases can lead to fatty infiltration of the iliopsoas muscle unit. The amount of displacement of the lesser trochanter did not affect the degree of fatty infiltration.

Level of evidence

II.

     

Cause of infection in proximal tibial endoprosthetic reconstructions

Introduction

The underlying cause of proximal tibial prosthetic failure by infection is unclear. We asked: (1) Is resection amount related to prosthetic infection? (2) What other risk factors are related with infection? (3) What are the survivorship and functional outcomes of proximal tibial endoprosthetic reconstruction?

Methods

Sixty-two patients who underwent modular proximal tibial megaprosthesis reconstruction were analyzed. Follow-up duration averaged 98 months (range 26–240 months). Associations between prognostic variables and prosthesis survival were assessed.

Results

The 10-year prosthetic survival of the 62 implants was 73.9 ± 11.7%. Prostheses were removed in 16 (25.8%) patients for infection and 3 of the 16 underwent amputation. Resection of >37% (P = 0.016) of the tibia was found to be related to infection. Application of chemotherapy (P = 0.912) and use of synthetic material to fix the patella tendon (P = 0.2) were not found to influence prosthetic survival. Functional outcomes (determined by the MSTS system) of the 52 patients that maintained a mobile joint averaged 24.2 (81%) (range 18–28).

Conclusions

Our study suggests that the amount of bone resection is related with prosthetic failure by infection, however, the contribution of other risk factors should not be underestimated.

     

Die palmare winkelstabile Plattenosteosynthese bei Extensionsfrakturen des distalen Radius

Objective

Bony healing of dislocated distal radius fractures after open reduction and internal stabilization by locking screws/pins using palmar approach.

Indications

Extraarticular distal radius fractures type A2/A3, simple extra- and intraarticular fractures type C1 according to the AO classification, provided a palmar approach is possible.

Contraindications

Forearm soft tissue lesions/infections. As a single procedure if a volar approach not possible.

Surgical technique

Palmar approach to the distal radius and fracture. Open reduction. Palmar fixation of the plate to radial shaft with single screw. After fluoroscopy, distal fragments fixed using locking screws.

Postoperative management

Below-the-elbow cast for 2 weeks. Early exercise of thumb and fingers, wrist mobilization after cast removal. Complete healing after 6–8 weeks.

Results

Ten patients averaged 100?% range of motion of the unaffected side after 43±21 months. No complications observed. DASH score averaged 12±16 points; Krimmer wrist score was excellent in 7, good in 2, and fair in one.

     

Preservation of the articular capsule and short lateral rotator in direct anterior approach to total hip arthroplasty

Introduction

In total hip arthroplasty via a direct anterior approach, the femur must be elevated at the time of femoral implant placement. For adequate elevation, division of the posterior soft tissues is necessary. However, if we damage and separate the posterior muscle tissue, we lose the benefits of the intermuscular approach. Furthermore, damage to the posterior soft tissue can result in posterior dislocation. We investigate that protecting the posterior soft tissue increases the joint stability in the early postoperative period and results in a lower dislocation rate.

Methods

We evaluated muscle strength recovery by measuring the maximum width of the internal obturator muscle on CT images (GE-Healthcare Discovery CT 750HD). We compared the maximum width of the muscle belly preoperatively versus 10 days and 6 months postoperatively. As clinical evaluations, we also investigated the range of motion of the hip joint, hip joint function based on the Japanese Orthopaedic Association hip score (JOA score), and the dislocation rate 6 months after surgery.

Results

The width of the internal obturator muscle increased significantly from 15.1?±?3.1 mm before surgery to 16.4?±?2.8 mm 6 months after surgery. The JOA score improved significantly from 50.8?±?15.1 points to 95.6?±?7.6 points. No dislocations occurred in this study.

Conclusions

We cut only the posterosuperior articular capsule and protected the internal obturator muscle to preserve muscle strength. We repaired the entire posterosuperior and anterior articular capsule. These treatments increase joint stability in the early postoperative period, thus reducing the dislocation rate.

Level of evidence

Therapeutic, Level IV.

     

Does the Utilization of Allograft Tissue in Medial Patellofemoral Ligament Reconstruction in Pediatric and Adolescent Patients Restore Patellar Stability?

Background

Medial patellofemoral ligament (MPFL) reconstruction is one of several surgical procedures used to treat patellofemoral instability. Use of allograft tissue can preserve autogenous tissue and may be preferable in patients with connective tissue disorders or ligamentous laxity. Although there are successful reports in adults, it is unclear if the use of allograft tissue in MPFL reconstruction can restore patellofemoral stability in children and adolescents.

Questions/purposes

(1) Does allograft tissue in MPFL reconstruction in pediatric and adolescent patients restore patellar stability? (2) What complications were associated with allograft MPFL reconstructions in children and adolescents?

Methods

Between June 2012 and August 2015, one surgeon (NKP) performed 26 MPFL reconstructions in 23 patients with gracilis allograft for traumatic patellar instability. Of those, 25 (96%) were available for followup more than 1 year later (mean, 24 months; range, 12–44 months). During this time, the surgeon suggested reconstruction to patients who had recurrent dislocation or subluxation after 6 weeks of bracing, physical therapy, and activity modification if they were noted to have a torn or attenuated MPFL on MRI. During that period, this was the only surgical technique the surgeon used to treat traumatic patellar instability. Patients undergoing concurrent bony procedures were ineligible for inclusion. The mean age of the patients in the series was 16.0 (± 2) years. Age, sex, skeletal maturity, presence of trochlear dysplasia, and additional arthroscopic procedures at the time of reconstruction were collected. Postoperative notes and imaging were reviewed for presence of complications defined as recurrent dislocation, recurrent subluxations, fractures, infection, or arthrofibrosis. These complications were identified by chart review by the senior surgeon (NKP) and study personnel (EH) not involved in clinical care of the patients or by patient-reported complications. Recurrent subluxation or dislocation was patient-reported at the time of the clinic visit or followup phone/email contact. Fractures were defined as any cortical disruption in the femur or patella that required treatment (change in postoperative protocol), infection requiring treatment (antibiotics and/or return to the operating room), or arthrofibrosis (stiffness that necessitated a change in the postoperative protocol or manipulation under anesthesia).

Results

Ninety-two percent (23 of 25) of patients reported no further instability episodes after MPFL reconstruction. Sixteen percent (four of 25) of patients had complications: two repeat episodes of patellar instability, one patella fracture, and one symptomatic hardware requiring interference screw removal. No patients developed arthrofibrosis or infection.

Conclusions

In this small case series, we found that MPFL reconstruction using allograft tissue in children and adolescents resulted in a low risk of recurrent instability, perhaps comparable to what has been published by others who have used autograft tissue. Longer followup is needed, because in some orthopaedic applications, allograft ligaments have been observed to attenuate over time. Future studies might compare these techniques using patient-reported outcomes scores as well as use a control group of patients with autograft tissue.

Level of Evidence

Level IV, therapeutic study.

     

Die perkutane Kalkaneusverschiebeosteotomie

Objectives

Correction of calcaneal malalignment as part of a hindfoot correction procedure.

Indications

Varus and valgus malalignment of the calcaneus, increased calcaneal pitch.

Contraindications

Osteoarthritis of the subtalar joint. Fixed and symptomatic deformities of the subtalar joint.

Surgical technique

After having identified and marked the desired planes of the osteotomy under image intensifier, a percutaneous v?shaped calcaneal osteotomy is performed. The osteotomy allows 3?dimensional correction of the calcaneus by defining the planes of the osteotomy. The procedure allows correction of varus and valgus deformities, as well as a change of the calcaneal pitch. The osteotomy is fixed by percutaneous screws.

Postoperative management

Postoperative care includes a 6-week period of partial weight bearing with 10 kg. The ankle joint should be mobilized. After x?ray control of sufficient bone healing, weight bearing can be increased stepwise over another 4?week period up to full body weight. A full length orthotic is recommended for at least 12 months with heel cup and good medial support.

Results

The procedure allows correction of calcaneal deformities with preservation of soft tissue, normally as part of a hindfoot correction, e.?g., in posterior tibial tendon insufficiency, varus deformities or total ankle replacement. In the literature and in our patients, the rate of injuries of the neurovascular bundle was not increased compared to open surgery. The average calcaneal shift was 1 cm, when necessary an additional correction was realized by rotation of the tuber calcanei.

     

Fistelreifung: Vorhersage durch intraoperative Flussmessung

Background

The autogenous arteriovenous fistula (AVF) is the access of choice for hemodialysis therapy. Its timely and successful creation is particularly important to avoid hemodialysis catheters; however, according to the literature primary failure occurs in 20–50?% of newly created AVF.

Objective

To identify factors influencing AVF maturation and thus identify predictors of successful fistula creation.

Methods

We report on a prospective cohort study of 41 patients undergoing the first upper extremity AVF placement. Primary endpoint of the study was successful fistula maturation after 6 weeks and several constitutional, demographic, hemodynamic and technical factors were investigated.

Results

The most significant predictive parameter for fistula maturation was flow volume measured in the access vein during surgery. The receiver operating characteristic (ROC) curve analysis showed a cut-off value of 170 ml/min for the blood flow volume with the best possible sensitivity (85?%) and maximum specificity (80?%) for prediction of fistula failure within 6 weeks.

Conclusion

Intraoperative transit time flow measurement is easy to perform and can be used anytime to reliably predict successful AVF maturation.

     

Patellaformen

Background

Patella height is discussed as a possible factor in the development of osteoarthritis of the knee.

Methods

PubMed literature search

Results

Contradictory results are found in the literature.

Conclusion

According to the literature, there is currently no evidence that abnormal patella height can induce osteoarthritis of the knee.

     

Functional outcomes and complications of open elbow dislocations

Background

The current study investigated the clinical outcome of open elbow dislocations, focusing on the influence of associated soft tissue and bone injury.

Patients and methods

From October 2008 to August 2015, 230 patients with elbow dislocations were treated at the study center. Our retrospective study comprised 21 cases of open elbow dislocations. The mean age of patients was 49 years (20–83 years); there were six (29%) female and 15 (71%) male patients. The range of motion (ROM) of the injured and uninjured elbow was measured, and the Mayo Elbow Performance Score (MEPS), Mayo Wrist Score (MWS), and Disability of Arm, Shoulder and Hand (DASH) score were assessed. Complications and revision surgeries were recorded. The influence of the severity of soft tissue injury (I°/II° open vs. III° open) and type of dislocation (simple vs. complex) was evaluated.

Results

After a 57-month follow-up (range, 24–98 months), the mean DASH score was 20?±?15, the MEPS was 82?±?11, and the MWS was 74?±?22. The ROM of the injured elbow was significantly decreased compared with the uninjured one (arc of ulnohumeral motion: 104° vs. 137°; p?=?0.001). Patients with I°/II° open elbow dislocations had a better clinical outcome according to the MEPS (86?±?11 vs. 76?±?9; p?=?0.045) and a comparable outcome according to the DASH score (19?±?18 vs. 21?±?9; p?=?0.238). In all, 11 patients (52%) had postoperative complications and 11 patients underwent at least one revision surgery. Complex elbow dislocations had significantly more complications and revision surgeries than simple dislocations (77% vs. 13%; p?=?0.008).

Conclusion

Favorable clinical outcomes can be achieved after treatment of open elbow dislocations. These injuries are prone to neurovascular damage and complex dislocations are linked to high rates of complications and revision surgeries.

     

Allograft augmentation in proximal humerus fractures

Objective

Achieve stable fixation to initially start full range of motion (ROM) and to prevent secondary displacement in unstable fracture patterns and/or weak and osteoporotic bone.

Indications

(Secondarily) displaced proximal humerus fractures (PHF) with an unstable medial hinge and substantial bony deficiency, weak/osteoporotic bone, pre-existing psychiatric illnesses or patient incompliance to obey instructions.

Contraindications

Open/contaminated fractures, systemic immunodeficiency, prior graft-versus-host reaction.

Surgical technique

Deltopectoral approach. Identification of the rotator cuff. Disimpaction and reduction of the fracture, preparation of the situs. Graft preparation. Allografting. Fracture closure. Plate attachment. Definitive plate fixation. Radiological documentation. Postoperative shoulder fixation (sling).

Postoperative management

Cryotherapy, anti-inflammatory medication on demand. Shoulder sling for comfort. Full active physical therapy as tolerated without pain. Postoperative radiographs (anteroposterior, outlet, and axial [as tolerated] views) and clinical follow-up after 6 weeks and 3, 6, and 12 months.

Results

Bony union and allograft incorporation in 9 of 10 noncompliant, high-risk patients (median age 63 years) after a mean follow-up of 28.5 months. The median Constant–Murley Score was 72.0 (range 45–86). Compared to the uninjured contralateral side, flexion was impaired by 13?%, abduction by 14?%, and external rotation by 15?%. Mean correction of the initial varus displacement was 38° (51° preoperatively to 13° postoperatively).

     

Complete excision of the infrapatellar fat pad is associated with patellar tendon shortening after primary total knee arthroplasty

Background

Patella baja is a potentially disabling and difficult-to-treat complication following total knee arthroplasty (TKA). We investigated whether complete or partial excision of the fat pad has an effect on the length of the patellar tendon following TKA.

Methods

A retrospective review of patient radiographs was performed. One hundred and eleven consecutive patients who underwent primary TKA for osteoarthritis using the same components by two consultants were selected. Seventy-two patients underwent complete excision of the fat pad, whilst 39 had partial excision as per consultant practice. Patellar height was measured using the Caton–Deschamps Index (CDI) on immediate postoperative radiographs and at a minimum follow-up of 1 year.

Results

In the complete excision group, the mean CDI changed from 0.54 immediately postoperatively to 0.45 at a minimum follow-up of 1 year (p < 0.0001) indicating shortening of the patellar tendon, and eight patients reported anterior knee pain. The partial excision group’s mean CDI changed from 0.76 to 0.75 (p = 0.231). An analysis of variance showed that the effect of complete fat pad excision on patella tendon length was significant, F(1, 109) = 15.273, p < 0.001.

Conclusion

At a minimum follow-up of 1 year, the patellar tendon length shortened significantly in the group of patients with complete fat pad excision. With partial excision, there was no significant change in tendon length. Complete excision of the fat pad should therefore be avoided wherever possible in an attempt to avoid patella baja.

Level of evidence

II.

     

Fixed-bearing versus high-flexion RP total knee arthroplasty (TKA): midterm results of a randomized controlled trial

Background

We compared the midterm results after total knee arthroplasty (TKA) using PFC Sigma RP-F mobile model with PFC Sigma PS fixed model.

Materials and methods

In this randomized controlled trial, we analyzed 50 knees that underwent TKA with PFC Sigma RP-F and 60 knees with PFC Sigma PS fixed model. The follow-up period ranged from 76 to 104 months.

Results

The knee score, function score, and radiographic evaluation were significantly not different between the two groups at final follow-up. No revisions, subluxations, dislocations, or infections were seen. Also, no radiographic evidence of component loosening, osteolysis, or malalignment was observed in any knee. The results for both groups show good patient satisfaction.

Conclusions

The midterm clinical and radiographic results of the two prostheses did not show significant differences between the two groups.

Level of evidence

Level of evidence is level II.

     

Komplikationsmanagement im Internet Marketing

Background

New patients come more and more often over the internet; therefore internet marketing plays an increasingly important role.

Question

How can physicians build an effective internet marketing strategy and avoid complications?

Method

Selection and authorization of a reputable agency.

Results

New customer acquisition through high visibility in the internet, at the same time increasing the image and awareness.

Conclusions

In the overall “marketing mix” internet marketing has become indispensable to physicians who want to be successful. Those who are well positioned in Google are well known by their target audience and thus receive a higher response.

     

Latarjet procedure: is the coracoid enough to restore the glenoid surface?

Purpose

The aim of this study was to establish whether anterior glenoid bone loss in patients with large glenoid rim defects can be restored with a coracoid graft (Latarjet procedure).

Methods

A total of 143 consecutive patients with chronic anterior shoulder instability and glenoid bone deficiency were treated in 2013. A pre-operative computed tomography (CT) scan using the PICO method was obtained to estimate anterior glenoid rim erosion. The 23 patients with anterior glenoid deficiency exceeding 20 % were included in the study. A post-operative CT scan was obtained to establish whether coracoid transfer had fully restored the glenoid surface.

Results

Mean bone loss was 26?±?3.9 % of the glenoid surface (range 20–34 %) compared with the contralateral glenoid. Mean coracoid dimensions were 26.3?±?2.9 mm?×?7.6?±?0.65 mm. The graft successfully restored the glenoid surface in all patients (mean filling, 102.4?±?0.8 %).

Discussion

The Latarjet procedure is a valuable approach to treat patients with chronic shoulder instability and glenoid deficiency.

Conclusion

Coracoid transfer restored the glenoid surface even in patients with large defects. The Eden-Hybinette technique seems to be more appropriate for revision surgery and for patients with a failed Latarjet procedure.

     

Injectable collagenase <Emphasis Type="Italic">Clostridium histolyticum</Emphasis> as a nonsurgical treatment for Dupuytren’s disease

Objective

Nonsurgical treatment of Dupuytren’s disease using collagenase Clostridium histolyticum (CCH).

Indications

Metacarpophalangeal (MP) joint (20–100°) and proximal interphalangeal (PIP) joint (20–80°) contractures.

Contraindications

Pregnancy, previous hypersensitivity to collagenase or excipients, anticoagulant use within 7 days prior to treatment.

Injection technique

CCH injected directly into the Dupuytren’s cord weakening the contracted cord. After injection, the patient returns the following day to allow CCH to lyse the collagen within the cord. An extension force is then applied to the involved finger to disrupt the weakened cord.

Postmanipulation management

Use of extension splint at night, movement instructions during the day.

Results

A total of 120 patients (107 men; 13 women; mean age 62 years, range 30–84 years) were treated. In 49?% the little finger, in 44?% the ring finger, in 4?% the middle finger, and in 3?% the index finger was treated. Full release was achieved in 71?%, partial release in 26?%, and no change in 3?% of patients. The median pretreatment contracture for the MP joint was 37° (range 25–100°) and PIP joint 51° (range 30–97°). At 12 months, the mean contracture for the MP joint was 9° (range 0–25°) and for the PIP joint 21° (range 10–36°). Adverse events observed in 96?% of patients for 3 months . No tendon ruptures, anaphylactic reactions, or nerve or ligament injuries observed.