David Otto

Development and Initial Validation of a Risk Score for Predicting In-Hospital and 1-Year Mortality in Patients With Hip Fractures†

Our objectives were to better define the rates and determinants of in‐hospital and 1‐year mortality after hip fracture. We studied a population‐based cohort of 3981 hip fracture patients. Using multivariable regression methods, we identified risk factors for mortality (older age, male sex, long‐term care residence, 10 prefracture co‐morbidities) and calculated a hip fracture‐specific score that could accurately predict or risk‐adjust in‐hospital and 1‐year mortality. Our methods, after further validation, may be useful for comparing outcomes across hospitals or regions.

Integration of hamstring tendon graft with bone in reconstruction of the anterior cruciate ligament

Anterior cruciate ligament (ACL) reconstruction using four-strand hamstring graft with round-headed, cannulated, interference (RCI) screw fixation requires osteointegration of the tendon graft. This report describes the histology at the bone-tendon junction of two specimens retrieved from patients undergoing revision surgery after traumatic mid-substance ACL graft rupture at 6 and 10 weeks after initial reconstruction. Revision was performed at 12 and 15 weeks. Integration of the graft was evident by observation of collagen fiber continuity between bone and tendon. This histology plus the low incidence of early graft failure suggest that free tendon autograft attached to bone by RCI screw allows adequate osteointegration between 6 and 15 weeks after surgery.

Functional Outcome and Health-Related Quality of Life after Surgical Repair of Full-Thickness Rotator Cuff Tear Using a Mini-Open Technique:

Background Rotator cuff tear, a common shoulder injury, can lead to shoulder pain and functional loss. Hypothesis Surgical repair of full-thickness rotator cuff tears using the mini-open surgical technique will improve shoulder function and health-related quality of life. Study Design Cohort study. Level of evidence, 2. Methods Patients with a full-thickness rotator cuff tear who underwent a mini-open repair were evaluated for (1) active shoulder range of motion preoperatively, and 6 months and 12 months postoperatively and (2) health-related quality of life preoperatively, 6 months postoperatively, and annually up to 5 years postoperatively. Satisfaction with the repair and return to work status were ascertained 1 year postoperatively. A subgroup analysis of tear size and patient age was also undertaken. Results Of the subjects, 61 (73%) were men, and the average age was 53.2 (±9.9) years. According to repeated-measures analysis of variance, shoulder range of motion (flexion and external rotation) improved significantly from before surgery to 1 year after surgery (P < .001). The mean American Shoulder and Elbow Surgeons scores improved from 53.3 (±20.6) preoperatively to 90.6 (±11.7) 1 year postoperatively (P < .001). The mean Western Ontario Rotator Cuff scores also improved from 43.2 (±20.2) preoperatively to 87.2 (±14.3) 1 year postoperatively (P < .001). No differences were seen in either the American Shoulder and Elbow Surgeons scores or Western Ontario Rotator Cuff scores between the 1-year examination and the last follow-up assessment undertaken at a median of 5 years postoperatively (P > .05). Ninety-six percent of patients were satisfied or very satisfied with the results of their repair; 78% of patients who were working before surgery returned to work without modification by 1 year postoperatively. For the most part, patient age and size of tear did not influence postoperative range of motion or health-related quality of life. Conclusion Mini-open rotator cuff repair led to improved shoulder function and health-related quality of life up to 5 years postoperatively.

Recurrent Dislocation of the Tibialis Posterior Tendon

Traumatic dislocations of the tibialis posterior tendon are extremely rare when not associated with a fracture, with only 7 cases reported in the English literature. In addition, the bursal sac that contains the dislocated tendon has been described only once in the English literature. Because of the infrequent occurrence of this entity, a delay in diagnosis can occur. Therefore, it is important to add recurrent dislocation of the tibialis posterior tendon to the differential diagnoses of ankle pain. Various causes of this dislocation have been described, including ruptured flexor retinaculum, incompetent flexor retinaculum, and hypoplastic flexor sulcus. The present case report adds another case to the short list of trauma-induced tibialis posterior tendon dislocations and describes the tendon location after dislocation as well as a surgical repair technique.

Functional Outcomes and Health-Related Quality of Life After Surgical Repair of Full-Thickness Rotator Cuff Tears Using a Mini-Open Technique A Concise 10-Year Follow-up of a Previous Report

Background: Although good short-term and midterm outcomes are reported for mini-open rotator cuff repair, few prospective studies have investigated long-term results. Hypothesis: Function and health-related quality of life (HRQL) outcomes would be maintained 10 years after mini-open rotator cuff repair. Study Design: Cohort study; Level of evidence, 2. Methods: Patients with a confirmed full-thickness rotator cuff tear who underwent mini-open repair between April 1997 and July 2000 were evaluated preoperatively as well as 1 year and 10 years postoperatively for (1) pain, function, and HRQL using the American Shoulder and Elbow Surgeons (ASES) score and Western Ontario Rotator Cuff Index (WORC) score; (2) active shoulder range of motion (ROM) using goniometry; and (3) satisfaction by an independent evaluator. Changes in function, HRQL, and ROM over time were analyzed using repeated-measures analysis of variance. Results: A total of 84 patients were enrolled, of which 61 (73%) were men; the mean (±SD) age was 53.0 ± 9.9 years. At 10 years, 4 (5%) patients were deceased, and 4 (5%) had symptomatic retears. Fifty-nine (74%) patients were evaluated, composed of 43 (73%) men; 26 (44%) were younger than 60 years. Function and HRQL significantly improved over the course of follow-up (P < .001), primarily within the first postoperative year. At 10 years, the mean ASES score was 90.4 ± 19.4, similar to the 1-year score of 91.1 ± 12.0 (P = .83). The mean WORC score at 10 years was 88.7 ± 17.8, with no change from the 1-year score of 88.4 ± 13.6 (P = .93). This relationship did not change after adjusting for age and tear size. Shoulder ROM was also maintained over 10 years. Flexion ROM improved in the first postoperative year, and this improvement was sustained at 10 years after surgery (P ≥ .30). External rotation ROM was slower to improve postoperatively, and significant improvements were seen between 1 and 10 years (P < .01). Fifty-three patients (90%) were satisfied or very satisfied with their results. Tear size, workers’ compensation board claimant status, sex, and smoking status did not influence HRQL or shoulder ROM (P > .06). Conclusion: Postoperative improvements in function and HRQL after mini-open rotator cuff repair were retained at 10 years.

Antegrade Tibial Tunnel Technique for Posterior Cruciate Ligament Reconstruction

Posterior cruciate ligament (PCL) reconstruction remains a difficult procedure even in experienced hands because there is a lack of consensus regarding the most reliable and least technically challenging technique. The commonly used retrograde anteromedial tibial tunnel leads to excessive angulation at the posterior tibia and risks catastrophic neurovascular complications. We present a technique of drilling the transtibial PCL tunnel in an antegrade fashion through a posteromedial portal. This technique offers the advantage of an anterolateral route to reduce graft angulation, as well as drilling away from the important posterior neurovascular structures.

Recurrent Instability Episodes and Meniscal or Cartilage Damage After Anterior Cruciate Ligament Injury: A Systematic Review

Background: Delayed anterior cruciate ligament (ACL) reconstruction may be associated with increased risk of subsequent knee joint damage and osteoarthritis (OA). The relationship between recurrent instability episodes and meniscal or cartilage damage after first-time ACL injury is unknown. Purpose: To assess the association between recurrent knee instability episodes and prevalence of meniscal lesions, cartilage damage, and OA after first-time ACL injury. Study Design: Systematic review; Level of evidence, 4. Methods: Six electronic databases were systematically searched using keywords and Medical Subject Heading terms. Studies selected were of English language, included original data, had a prospective design, and provided an outcome of recurrent instability and meniscal lesions, cartilage damage, or OA after first-time ACL injury. Adjusted odds ratios (ORs) were extracted or unadjusted ORs (95% CI) were calculated. PRISMA guidelines were followed, and 2 independent raters assessed study quality using Downs and Black criteria. Results: Of 905 potentially relevant studies, 7 were included. Sample sizes ranged from 43 to 541, and Downs and Black scores ranged from 2 to 12. Clinical and methodological heterogeneity precluded meta-analysis. Six studies reported a positive association between recurrent instability episodes and medial meniscal damage (OR range, 3.46 [95% CI, 1.24-9.99] to 11.56 [1.37-521.06]). The association between instability episodes and lateral meniscal or cartilage damage was inconsistent. No studies examined the association between instability episodes and OA. Conclusion: This systematic review provides preliminary evidence that recurrent instability episodes after first-time ACL injury may be associated with increased odds of medial meniscal damage. This highlights the importance of early diagnosis, education, and treatment for individuals with ACL injury, all of which must include a specific focus on the prevention and management of instability episodes. High-quality, prospective cohort studies are needed that assess the effects of diagnostic and treatment delay, recurrent instability episodes on secondary meniscal and cartilage damage, and OA after an initial ACL injury.