Arthroscopic rotator cuff repair using a single-row of triple-loaded suture anchors with a modified suture configuration

Achieving an adequate restoration of the muscle–tendon–bone unit and the anatomical footprint is essential for a successful outcome in open and arthroscopic rotator cuff repair. The described suture grasping technique using triple-loaded suture anchors might combine high initial fixation strength with good footprint coverage. It describes two mattress’ stitches medial at the articular margin of the tendon. Additionally, a third mattress stitch is performed laterally to increase footprint contact and avoid dog-ear deformity. The triple-mattress repair is easy to perform and might be a good alternative in either arthroscopic or open rotator cuff repair.     

Behavioral development in mice: Effects of maternal environment and the albino locus

We examined the interaction of the albino locus with the maternal environment on the behavioral development of two coisogenic strains of mice. Subjects of the pigmented C57BL/6 strain (=B6^+/+) and of the albino C57BL/6^c2J strain (=B6^c/c) were either fostered by a mother of their own strain or cross-fostered at birth to an F₁ hybrid dam. They were compared for the amount and daily distribution of activity displayed during 48 h in a seminatural device at weaning and when 75 days old. Food hoarding in the nest and food consumption at the food-search place were also recorded in adult subjects. When animals were fostered by a mother of their own strain, albino mice were more active and less nocturnal than pigmented mice at both ages. They hoarded less food in the nest and ate more at the food-search place. Most of these differences disappeared when both strains were fostered by an F₁ dam. The amount of activity displayed during 48 h increased between 21 and 75 days of age. This increase was affected by cross-fostering to an F₁ dam in B6^c/c mice only. The developmental pattern of daily distribution of activity was changed by F₁ dams in B6^+/+ mice only. Whereas these influences of F₁ dams produced subjects resembling the mother's phenotypic score, maternal effects on hoarding behavior in B6^c/c mice produced subjects which did not resemble their foster mother. The results are discussed in terms of different possible ways of hereditary transmission of behavior and some methodological consequences are emphasized.     

Damage control orthopaedics in polytraumatized patients- current concepts

The principles of fracture management in patients with multiple injuries continue to be of crucial importance. Early treatment of unstable polytraumatized patients with head, chest, abdomen or pelvic injuries, with blood loss followed by immediate fracture fixation (Early Total Care -ETC) may be associated with secondary life threatening posttraumatic systemic inflammatory response syndrome (SIRS). Development of SIRS is typically a function of the type and severity of the initial injury (the “first hit”). Immediate Fracture fixation, using reamed nails or plates, in such unstable patients with multiple injuries is subsequently defined as the “second hit” and may be associated with development of acute respiratory distress syndrome (ARDS) and multiple organ failure (MOF), with relatively high morbidity and mortality.The other alternative for long bone fracture fixation in unstable polytraumatized patients is based on immediate treatment of life threatening conditions related to the injuries, followed by the initial use of minimally invasive modular external frames for long bone fractures and is called Damage Control Orthopedics (DCO) and is widely accepted. In order to refine the DCO concept and to avoid an overuse of external fixation, the “Safe Definitive Surgery” (SDS) concept has been introduced, which is a dynamic synthesis of both strategies (ETC and DCO). The SDS strategy employs clinical parameters and includes repeated assessment of patients. The following paper is going to summarize historical backgrounds and recent concepts in treatment of polytraumatized patients.     

Safety of selective nonoperative management for blunt splenic trauma: the impact of concomitant injuries

Background

Nonoperative management for blunt splenic injury is the preferred treatment. To improve the outcome of selective nonoperative therapy, the current challenge is to identify factors that predict failure. Little is known about the impact of concomitant injury on outcome. Our study has two goals. First, to determine whether concomitant injury affects the safety of selective nonoperative treatment. Secondly we aimed to identify factors that can predict failure.

Methods

From our prospective trauma registry we selected all nonoperatively treated adult patients with blunt splenic trauma admitted between 01.01.2000 and 12.21.2013. All concurrent injuries with an AIS?≥?2 were scored. We grouped and compared patients sustaining solitary splenic injuries and patients with concomitant injuries. To identify specific factors that predict failure we used a multivariable regression analysis.

Results

A total of 79 patients were included. Failure of nonoperative therapy (n =?11) and complications only occurred in patients sustaining concomitant injury. Furthermore, ICU-stay as well as hospitalization time were significantly prolonged in the presence of associated injury (4 versus 13?days,p <?0.05). Mortality was not seen. Multivariable analysis revealed the presence of a femur fracture and higher age as predictors of failure.

Conclusions

Nonoperative management for hemodynamically normal patients with blunt splenic injury is feasible and safe, even in the presence of concurrent (non-hollow organ) injuries or a contrast blush on CT. However, associated injuries are related to prolonged intensive care unit- and hospital stay, complications, and failure of nonoperative management. Specifically, higher age and the presence of a femur fracture are predictors of failure.

     

Assessment of coincidence and defect sizes in Bankart and Hill–Sachs lesions after anterior shoulder dislocation: a radiological study

Objective:

Bankart and Hill–Sachs lesions are often associated with anterior shoulder dislocation. The MRI technique is sensitive in diagnosing both injuries. The aim of this study was to investigate Bankart and Hill–Sachs lesions with MRI to determine the correlation in occurrence and defect sizes of these lesions.

Methods:

Between 2006 and 2013, 446 patients were diagnosed with an anterior shoulder dislocation and 105 of these patients were eligible for inclusion in the study. All patients were examined using MRI. Bankart lesions were classified as cartilaginous or bony lesions. Hill–Sachs lesions were graded I–III using a modified Calandra classification.

Results:

The co-occurrence of injuries was high [odds ratio (OR) = 11.47; 95% confidence interval (CI) = 3.60–36.52; p < 0.001]. Patients older than 29 years more often presented with a bilateral injury (OR = 16.29; 95% CI = 2.71–97.73; p = 0.002). A correlation between a Bankart lesion and the grade of a Hill–Sachs lesion was found (ρ = 0.34; 95% CI = 0.16–0.49; p < 0.001). Bankart lesions co-occurred more often with large Hill–Sachs lesions (OR = 1.24; 95% CI = 1.02–1.52; p = 0.033).

Conclusion:

If either lesion is diagnosed, the patient is 11 times more likely to have suffered the associated injury. The size of a Hill–Sachs lesion determines the co-occurrence of cartilaginous or bony Bankart lesions. Age plays a role in determining the type of Bankart lesion as well as the co-occurrence of Bankart and Hill–Sachs lesions.

Advances in knowledge:

This study is the first to demonstrate the use of high-quality MRI in a reasonably large sample of patients, a positive correlation of Bankart and Hill–Sachs lesions in anterior shoulder dislocations and an association between the defect sizes.A shoulder dislocation is a traumatic event with an incidence of around 24 per 100 000 in North America.^1,2 Anterior shoulder dislocation is the most common direction, and most patients are male.^1–4 The highest incidence (48 per 100 000) was found between the ages of 20 and 29 years.² Anterior dislocation causes a typical impression fracture on the posterior humeral head, known as a Hill–Sachs lesion.^5,6 The labrum or the glenoid itself may also be damaged; these injuries are known as Bankart lesions.⁷Although Hill–Sachs lesions can be found in 47–100% of all patients with first-time or recurrent shoulder dislocation, a distinction must be drawn between cartilaginous and bony Bankart lesions.^8–13 Cartilaginous lesions occur more often than bony ones.¹⁴ However, Bankart and Hill–Sachs lesions do not necessarily occur simultaneously. In 2006, Widjaja et al¹⁵ reported that, if one of the lesions was identified, the other was 2.67 times as likely to be present. Yet, this result failed to reach statistical significance because of the small sample size. Griffith et al¹⁰ evaluated CT scans and found a weak correlation between glenoidal bone loss and the size of the Hill–Sachs lesion (p = 0.030). However, the more frequently occurring cartilaginous Bankart lesion was not considered in this study.The aim of the present study was to evaluate the association between defect sizes in Hill–Sachs and bony as well as cartilaginous Bankart lesions after anterior shoulder dislocation using MRI. We hypothesized that there exists a higher correlation than previously thought between temporal occurrence and defect size of the lesions. The results of this study should help to improve diagnostic and therapeutic procedures.     

Cost savings and health losses from reducing inappropriate admissions to a department of internal medicine

OBJECTIVES: Inappropriate hospital admissions are commonly believed to represent a potential for significant cost reductions. However, this presumes that these patients can be identified before the hospital stay. The present study aimed to investigate to what extent this is possible. METHODS: Consecutive admissions to a department of internal medicine were assessed by two expert panels. One panel predicted the appropriateness of the stays from the information available at admission, while final judgments of appropriateness were made after discharge by the other. RESULTS: The panels correctly classified 88% of the appropriate and 27% of the inappropriate admissions. If the elective admissions predicted to be inappropriate had been excluded, 9% of the costs would have been saved, and 5% of the gain in quality-adjusted life-years lost. The corresponding results for emergency admissions were 14% and 18%. CONCLUSIONS: The savings obtained by excluding admissions predicted to be inappropriate were small relative to the health losses. Programs for reducing inappropriate health care should not be implemented without investigating their effects on both health outcomes and costs.     

Changes of biomechanical parameters in dysplasia of the hip by total hip replacement

AIM: Dysplastic hips or dislocated hips lead to loss of muscle strength claudication, and finally to coxarthrosis. This study analytically compares the hip joint forces in normal, dysplastic hips and hips after implantation of a hip prosthesis for several positions. METHOD: The results of 173 total hip replacements in 153 cases of either severe congenital dysplasia or dislocation were analyzed. A 2 dimensional mathematical model of the hip was developed to evaluate the effects of surgically achievable mechanical alterations such as acetabular placement, femoral shaft-prosthetic neck angle, and neck length of the femoral prosthesis. RESULTS: 63 % of the hip prosthesis were implanted on the right, 72 % on the left. Before implantation, the femoral shaft-prosthetic neck angle in mean was 146 degrees +/- 10 degrees, after implantation it was 135 degrees. The hip centre was displaced on in average 10 mm distally. Postoperatively hip joint force was increased 21 %. CONCLUSION: Minimum joint contact forces occurred when the femoral shaft prosthetic neck angles were small. The loads on the hip were lowered significantly by placing the centre of the acetabulum as far inferiorly and medially as possible. Another important finding is that displacement of the hip centre distally has a great effect on muscle performance and hip joint force.     

59-jähriger Patient mit kutanen Läsionen und erhöhten Eisenstoffwechselparametern

Zusammenfassung Die erh?hten Eisenstoffwechselparameter unseres Patienten bei vorbekannter PCT führten zur Diagnose zweier Mutationen im H?mochromatose-Gen. Er erwies sich als zusammengesetzt heterozygoter Tr?ger der Mutationen Cys282Tyr und His63Asp, die zu einem Verlust bzw. einer Einschr?nkung der Funktion des HFE-Proteins führen. Der Aderlass als symptomatische Monotherapie führte bei unserem Patienten zum Verschwinden der Hautl?sionen und zum Abfall der pathologisch erh?hten Porphyrinausscheidung. Bei der erworbenen Form der PCT sollte deshalb neben der Alkoholanamnese und der Hepatitisserologie auch eine genetische Diagnostik bezüglich der Mutationen im H?mochromatose-Gen durchgeführt werden. Durch das Screening Verwandter von Mutationstr?gern k?nnen au?erdem frühzeitig Personen mit H?mochromatoserisiko erfasst werden.