Domagoj Delimar

Traumatic and Overuse Injuries Among International Elite Junior Rowers

Background Junior rowers have competed internationally for over 4 decades, and there are no epidemiological data available on traumatic and overuse injury in this population. Objective To define the types of musculoskeletal problems present in international elite-level junior rowers and to determine whether gender, physical stature, rowing discipline, and training programs affect the incidence of reported injuries. Study Design Descriptive epidemiology study. Methods Injury data were obtained from a total of 398 rowers (42% female, 58% male) who completed a 4-page questionnaire on injury incidence while participating at the Junior World Rowing Championships in Beijing, People’s Republic of China, in August 2007. Results Overall, 290 (73.8%) reported injuries involved overuse, and 103 (26.2%) were related to a single traumatic event. Female rowers were injured more frequently than male rowers (110.2 vs 90.5 injuries per 100 rowers). In both genders, the most common injury site was the low back followed by the knee and the forearm/wrist. The severity of reported injuries was incidental in 65.1%, minor in 21.4%, moderate in 10.4%, and major in 3.1% of cases. The rowers with traumatic injuries had less rowing experience than the uninjured rowers (median [C] ± interquartile range [Q] = 3 ± 3 years vs 4 ± 3 years; P = .043, Mann-Whitney test). Sweep rowers who changed rowing side during the current season had significantly more acute-onset low back injuries (P = .012, χ2 test) than those who did not change rowing side during the same period. The incidence of traumatic injuries was significantly lower in rowers who regularly performed more than 10 minutes of posttraining stretching (P = .030, χ2 test). Athletes who ran more than once a week had more overuse knee injuries than those who ran once or less per week (P = .033, χ2 test). Conclusion Elite junior rowers attending the World Rowing Championships reported predominantly overuse injuries of low severity during the current rowing season. Low back injuries were the most frequent complaint of elite-level junior rowers.

Influence of the acetabular cup position on hip load during arthroplasty in hip dysplasia

Placement of the acetabular cup during total hip arthroplasty is of great importance because usually every deviation from the ideal centre of rotation negatively influences endoprosthesis survival, polyethylene wear and hip load. Here we present hip load change in respect to various acetabular cup positions in female patients who underwent total hip replacement surgery due to hip dysplasia. The calculation suggests that, in the majority of cases, for every millimeter of lateral displacement of the acetabular cup (relative to the ideal centre of rotation) an increase of 0.7% in hip load should be expected and for every millimeter of proximal displacement an increase of 0.1% in hip load should be expected (or decreased if displacement is medial or distal). Also, for every millimeter of neck length increase, 1% decrease is expected and for every millimeter of lateral offset, 0.8% decrease is expected. Altogether, hip load decreases when the cup is placed more medially or distally and when the femoral neck is longer or lateral offset is used.RésuméLe positionnement de la cupule acétabulaire durant la réalisation d’une prothèse totale de hanche est très important car une déviation de la position idéale du centre de rotation peut influer de façon négative sur la survie, sur l’usure et sur les vecteurs de forces au niveau de la hanche. Nous présentons une étude qui permet de visualiser les vecteurs de forces en fonction des différentes positions de la cupule chez des patients de sexe féminin qui ont bénéficié d’une prothèse totale de hanche mise en place pour dysplasie. Les calculs permettent de penser que dans la majorité des cas chaque millimètre de latéralisation de la cupule augmente de 0,7% la charge au niveau de la hanche et que chaque déplacement proximal l’augmente de 0,1%. Ainsi chaque augmentation millimétrique de la longueur du col peut entraîner une diminution de 1% des forces, de même en ce qui concerne chaque millimètre d’offset latéral qui permet d’obtenir une diminution de 0,8%. En conclusion, les charges diminuent au niveau de la hanche quand la cupule est placée de façon plus médiane ou distale et quand les longueurs du col fémoral ou de l’offset son utilisées.

Hill-Sachs lesion in recurrent shoulder dislocation: sonographic detection.

In a prospective study 61 patients with recurrent anterior shoulder dislocation were evaluated by sonography, radiography, and surgery to determine the value of sonography in the detection of a HillSachs lesion. The group consisted of 57 male and four female patients with an average age of 27 years. Hill‐Sachs lesion was found in 54 (88%) shoulders of the 61 surgically treated patients. Using surgical findings as the gold standard, we found sonography to be 96% (52 of 54 cases) sensitive, 100% specific (seven of seven cases), and 97% (59 of 61 cases) accurate in the diagnosis of HillSachs lesion. The average size of the lesion measured by sonography was 19.2 mm long, 16.0 mm wide, and 4.1 mm deep. The lesion was of small or medium size (up to 6 mm deep) in 88% of patients. Results of our study show that sonography is a valuable imaging technique in the diagnosis of Hill‐Sachs lesion. It produced only two false‐negative results when compared with surgical findings.

A secure arthroscopic knot

The proposed arthroscopic knot tying technique procedure is simple, easy to master, time saving, and the knot formed is not bulky. The initial tie loop holding capacity securely overcomes tension force between structures repaired. The completed know, secured with additional two throw square knot or with a three half-hitches incorporating the post switching and/or loop direction reversal, will fail by breakage rather than by slippage (for the most commercially available 0, 2/0, 3/0, absorbable and nonabsorbable, monofilament and braided sutures.

Adverse effects of posterior lumbar interbody fusion using rhBMP-2.

To the Editor We read with great interest the recent article on the use of recombinant human bone morphogenetic protein 2 soaked into an absorbable collagen sponge (rhBMP-2/ ACS) in the posterior lumbar interbody fusion (PLIF) written by Meisel et al. [13]. However, a few corrections and clarifications are required to update this otherwise exceptionally significant article. Meisel et al. [13] mentioned a sheep distal femur model in which transient peri-implant osteolysis with regard to BMP overfilling and hyper-concentration has been observed [1], but several examples are present in the literature that clarify the pathophysiology and the relevance of the vertebral osteolysis much better. For instance, Seeherman and Wozney [15] have shown that a collagen sponge soaked with rhBMP-2 and placed in contact with trabecular bone of the distal femoral core defect in nonhuman primates resulted in significant transient bone resorption at 2 weeks after the surgery. This was not the case when they used a carrier with slower release of rhBMP (calcium phosphate matrix). The rapid release of rhBMPs at the bone surface which is in contact with the collagen sponge creates favorable conditions for significant osteoclastic reaction prior to the bone formation phase. According to a review of the interaction of BMPs with osteoclast lineage cells, BMPs in most of the reports had a stimulatory effect that up-regulated formation of osteoclasts, their bone resorptive capacity, or both of these phenomena [5]. As Meisel et al. [13] emphasized the note of Boden et al. [1] that parity between the distal femur and the central region of the vertebra may not be fully warranted as a clinically relevant spine model, we would like to emphasize a very significant article published by Laursen et al. [10] in this very Journal 10 years ago which definitively presents a relevant spinal model. It was the first report of trabecular bone resorptions after a clinical application of rhBMPs/ACS in proximity of vertebral bodies. The first report of trabecular bone resorptions after a clinical application of rhBMPs to our best knowledge was identified in a manuscript of Howell et al. [8]. The loss of bone volume in some of the cases after the rhBMP-2/ACS local alveolar ridge preservation or augmentation was noted between the 4and 8-week time points. Anyway, Laursen et al. [10] treated five patients with single-level unstable burst fracture and no neurological impairment with intracorporal rhBMP-7 transplantation, posterior fixation and posterolateral fusion. Radiographic and computed tomography (CT) evaluation after 3 and 6 months showed severe resorption of the whole anterior column at the site of transplantation, but after a year, new bone had started to fill in at the area of resorption. In all cases, there was a loss of correction with regard to anterior and middle column height and sagittal balance at the latest follow-up. Based on the obtained data, the authors by ethical obligation discontinued and redesigned the study. At this moment, we are interested in whether or not Meisel et al. [13] considered discontinuing and redesigning their study after they faced such vertebral resorptions in their patients at 3 months postoperatively (enrollment of the patients lasted from January until June of 2004). We had to emphasize that back in 2004 only a few researchers had some information about the resorptions and their clinical impacts, but that information for some reason has not been presented to T. Smoljanovic (&) I. Bojanic D. Delimar Department of Orthopaedic Surgery, Clinical Hospital Center Zagreb, School of Medicine, Zagreb University, Zagreb, Croatia e-mail: drsmoljanovic@yahoo.com

A composite forearm free flap for the secondary repair of the ruptured achilles tendon

Full-thickness defects of the posterior heel constitute a reconstructive challenge owing to a lack of regional soft tissue and often a long tendon gap. The remaining tendon is usually short and frayed in the distal segment, and insetting of tendon graft could be unexpectedly difficult. Wound closure and tendon reconstruction will need to be secure enough concerning future demands of full weight-bearing gait. For secondary reconstruction of Achilles tendon defects, various reconstructive approaches have been described. Reconstruction by reflection of a fascio-aponeurotic flap from the gastrocnemius muscle, 1, 2 nonvascularized 3 and vascularized 4-6 fascial or tendon grafts, or with artificial substances such as Marlex mesh 7 have been performed. However, in cases with associated skin loss, these techniques require multiple operations to reconstruct composite defects and are inherently prone to excessive scarring with resultant decreased tendon motion. Free composite flaps enable simultaneous vascularized tendon graft transfer (with its investment of paratenon) and well-vascularized skin cover. We have recently used a vascularized brachioradialis tendon in septofasciocutaneous forearm free flap attached to a distal part of a radial bone for reconstruction of an Achilles tendon rupture with skin loss and have obtained a very satisfactory result.

The role of blood pressure, cortisol, and prolactine among soldiers injured in the 1991–1993 war in Croatia

Ninety soldiers with at least three months of combat exposure—60 injured soldiers (30 with permanent disabling and 30 with nondisabling injuries), 30 noninjured soldiers and 30 healthy controls—were interviewed and investigated with physiological (Prolactine, Cortisol, BP, Hb) and psychological tests (MMPI), IES-15 (Impact of Event Scale), PTSS (Post-Traumatic Symptom Scale). Their was related injuries had a different effect on the physiological stress response of the soldiers as reflected in the levels of prolactine, cortisol, hemoglobin and blood pressure.In a report of personality characteristics of the same soldiers, we demonstrated that the experience of posttraumatic stress was not dependent upon physical injury, but rather on the psychological appraisal of the situation. The results of the present article confirm earlier findings that the relationship between physiological and psychological consequences of trauma are complex, and that the perception of an event and the social context within which the traumatized soldier exists is as important as the event itself. The physiological response to the trauma varied greatly among the soldiers regarding the psychosocial impact of the consequence of the injury. So the anticipation of future possible trauma among less severely wounded soldiers (expected to go back to war) was followed by pathological stress responses. Trauma seems to operate somewhat independently from the overt conscious appraisal of the situation and relationship between psychological, psychosocial, and physiological aspects are interrelated in a multifactorial way. An integrative approach is therefore of great importance in assessment as well as in treatment of Posttraumatic Stress Disorder (PTSD).

Current concept in dysplastic hip arthroplasty: Techniques for acetabular and femoral reconstruction

Adult patients with developmental dysplasia of the hip develop secondary osteoarthritis and eventually end up with total hip arthroplasty (THA) at younger age. Because of altered anatomy of dysplastic hips, THA in these patients represents technically demanding procedure. Distorted anatomy of the acetabulum and proximal femur together with conjoined leg length discrepancy present major challenges during performing THA in patients with developmental dysplasia of the hip. In addition, most patients are at younger age, therefore, soft tissue balance is of great importance (especially the need to preserve the continuity of abductors) to maximise postoperative functional result. In this paper we present a variety of surgical techniques available for THA in dysplastic hips, their advantages and disadvantages. For acetabular reconstruction following techniques are described: Standard metal augments (prefabricated), Custom made acetabular augments (3D printing), Roof reconstruction with vascularized fibula, Roof reconstruction with pedicled iliac graft, Roof reconstruction with autologous bone graft, Roof reconstruction with homologous bone graft, Roof reconstruction with auto/homologous spongious bone, Reinforcement ring with the hook in combination with autologous graft augmentation, Cranial positioning of the acetabulum, Medial protrusion technique (cotyloplasty) with chisel, Medial protrusion technique (cotyloplasty) with reaming, Cotyloplasty without spongioplasty. For femoral reconstruction following techniques were described: Distraction with external fixator, Femoral shortening through a modified lateral approach, Transtrochanteric osteotomies, Paavilainen osteotomy, Lesser trochanter osteotomy, Double-chevron osteotomy, Subtrochanteric osteotomies, Diaphyseal osteotomies, Distal femoral osteotomies. At the end we present authors treatment method of choice: for acetabulum we perform cotyloplasty leaving only paper-thin medial wall, which we break during acetabular cup impacting. For femoral side first we peel of all rotators and posterior part of gluteus medius and vastus lateralis from greater trochanter on the very thin flake of bone. This method allows us to adequately shorten proximal femoral stump, with possibility of additional resection of proximal femur. Furthermore, several advantages and disadvantages of this procedure are also discussed.

Femoral Shortening During Hip Arthroplasty Through a Modified Lateral Approach

AbstractWe describe a modification of the direct lateral approach to the hip that provides excellent femoral and acetabular exposure and an easy way to shorten the proximal femur and equalize leg length. The approach also is useful for lower extremity elongation while preserving muscle continuity and minimizing postoperative complications. The exact amount of shortening can be calculated and planned preoperatively and measured and corrected intraoperatively if necessary. It avoids the necessity for osteotomies of the trochanter and transverse cuts or detachment of abductor muscles. Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Acetabular roof reconstruction with pedicled iliac graft: early clinical experience

In the article “Acetabular roof reconstruction with pedicled iliac graft” published in International Orthopaedics [1], we presented a new method for reconstruction of the supero-lateral acetabular rim using a vascularised iliac graft based on the deep-circumflex artery and vein. Pedicled iliac graft is one of the most commonly used grafts, because it provides a strong piece of bone while the vascular pedicle ensures excellent bone potential for rapid bone healing [4, 5]. Standard methods of appropriate cup positioning in patients with inadequate bone stock include cotyloplasty (controlled medialisation) or even placing the cup super-