Maximilian Petri

Alcohol intoxication in road traffic accidents leads to higher impact speed difference, higher ISS and MAIS, and higher preclinical mortality

Alcohol is one of the most important personal risk factors for serious and fatal injuries, contributing to approximately one third of all deaths from accidents. It is also described that alcohol intoxication leads to a higher mortality in the clinical course. In this study, we hypothesized that alcohol intoxication leads to different accident kinematics, a higher ISS (Injury Severity Score), and higher preclinical mortality compared to sober patients. A technical and medical investigation of alcohol intoxicated road users was performed on the scene of the crash and at the primary admitting hospital. Alcohol testing was performed with either breath alcohol tests or measurement of blood alcohol concentration (BAC) in a standard laboratory test. Between 1999 and 2010, 37,635 road traffic accidents were evaluated by the Accident Research Unit. Overall 20,741 patients were injured, 2.3% of the patients were killed. Among the injured patients, 2.2% with negative BAC were killed, compared to 4.6% fatal injuries in patients with a positive BAC (p < 0.0001). Of the patients with a positive BAC, 8.0% were severely injured, compared to 3.6% in the BAC negative group (p < 0.0001). Regarding the relative speed at impact (Δv for motorized drivers, vehicle collision speed for pedestrians and bikers), there was a significant higher difference for BAC positive patients (30 ± 20) compared to the BAC negative patients (25 ± 19, p < 0.0001). Alcohol intoxication in trauma patients leads to higher preclinical mortality, higher impact speed difference, and higher injury severity. The subgroup analysis for different alcohol concentrations shows no difference in ISS, MAIS, and relative speed, but a correlation of increasing age of patients with higher alcohol concentrations.

Arthroscopic Superior Capsule Reconstruction for Irreparable Rotator Cuff Tears

Massive irreparable rotator cuff tears in young patients are a particular challenge for the orthopaedic surgeon. Surgical treatment options include debridement, partial rotator cuff repair, patch-augmented rotator cuff repair, bridging rotator cuff reconstruction with graft interposition, tendon transfer, and reverse total shoulder arthroplasty. Recently, reconstruction of the superior glenohumeral capsule using a fascia lata autograft has been suggested to reduce superior glenohumeral translation and restore superior stability. Promising clinical results have been reported in 1 case series of 23 patients, indicating that superior capsular reconstruction may be a promising tool to manage massive irreparable rotator cuff tears. This article describes our preferred technique for arthroscopic superior capsule reconstruction.

Massive rotator cuff tears: pathomechanics, current treatment options, and clinical outcomes.

Rotator cuff tear size has an important effect on clinical outcomes after repair. Management options for massive rotator cuff tears are numerous, and selection of the most appropriate treatment method for individual patients can be a challenge. An understanding of the pathomechanics, treatment, and clinical outcomes in patients with massive rotator cuff tears can serve as a guide for clinical decision-making. The purpose of this article was to review treatment options and clinical outcomes for the management of massive rotator cuff tears.

Biomechanical Properties of Suture Anchor Repair Compared With Transosseous Sutures in Patellar Tendon Ruptures A Cadaveric Study

Background: Ruptures of the patellar tendon are debilitating injuries requiring surgical repair. Reliable data about the most appropriate suture technique and suture material are missing. The standard procedure consists of refixing the tendon with sutures in transpatellar tunnels, sometimes combined with augmentation. Hypothesis: Suture anchors provide at least equal results concerning gap formation during cyclic loading and ultimate failure load compared with transosseous suture repair. Study Design: Controlled laboratory study. Methods: A total of 30 human cadaveric patellar tendons underwent tenotomy followed by repair with 5.5-mm titanium suture anchors, 5.5-mm resorbable hydroxyapatite suture anchors, or transpatellar suture tunnels with No. 2 Ultrabraid and the Krackow whipstitch technique. Biomechanical analysis included pretensioning the constructs at 20 N for 30 seconds and then cyclic loading of 250 cycles between 20 and 100 N at 1 Hz in a servohydraulic testing machine with measurement of elongation. After this, ultimate failure load and failure mode analysis was performed. Results: Compared with transosseous sutures, tendon repairs with suture anchors yielded significantly less gap formation during cyclic loading (P < .05) and resisted significantly higher ultimate failure loads (P < .05). Common failure mode was pullout of the eyelet within the suture anchor in the hydroxyapatite anchor group and rupture of the suture in the titanium anchor group and—at lower load to failure—in the transosseous group. Conclusion: Patellar tendon repair with suture anchors yields significantly better biomechanical results than repair with the commonly applied transosseous sutures. Clinical Relevance: These findings may be of relevance for future clinical treatment of patellar tendon ruptures. Randomized controlled clinical trials comparing suture anchors to transosseous suture repair are desirable.

Synovial C-reactive protein as a marker for chronic periprosthetic infection in total hip arthroplasty

The aim of this study was to assess the role of synovial C-reactive protein (CRP) in the diagnosis of chronic periprosthetic hip infection. We prospectively collected synovial fluid from 89 patients undergoing revision hip arthroplasty and measured synovial CRP, serum CRP, erythrocyte sedimentation rate (ESR), synovial white blood cell (WBC) count and synovial percentages of polymorphonuclear neutrophils (PMN). Patients were classified as septic or aseptic by means of clinical, microbiological, serum and synovial fluid findings. The high viscosity of the synovial fluid precluded the analyses in nine patients permitting the results in 80 patients to be studied. There was a significant difference in synovial CRP levels between the septic (n = 21) and the aseptic (n = 59) cohort. According to the receiver operating characteristic curve, a synovial CRP threshold of 2.5 mg/l had a sensitivity of 95.5% and specificity of 93.3%. The area under the curve was 0.96. Compared with serum CRP and ESR, synovial CRP showed a high diagnostic value. According to these preliminary results, synovial CRP may be a useful parameter in diagnosing chronic periprosthetic hip infection.

Clinical and Anatomic Predictors of Outcomes After the Latarjet Procedure for the Treatment of Anterior Glenohumeral Instability With Combined Glenoid and Humeral Bone Defects

Background: The Latarjet procedure for the treatment of recurrent anterior shoulder instability is highly successful, but reasons for failure are often unclear. Measurements of the “glenoid track” have not previously been evaluated as potential predictors of postoperative stability. Hypothesis: There are clinical and anatomic characteristics, including the glenoid track, that are predictive of outcomes after the Latarjet procedure. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent the Latarjet procedure for anterior shoulder instability with glenoid bone loss before October 2012 were assessed for eligibility. Patient-reported subjective data that were prospectively collected and retrospectively reviewed included demographic information, patient satisfaction, pain measured on a visual analog scale (VAS), questions regarding instability, Single Assessment Numeric Evaluation (SANE) scores, American Shoulder and Elbow Surgeons (ASES) scores, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores, and Short Form–12 Physical Component Summary (SF-12 PCS) scores. Anatomic measurements were performed of the coracoid size (surface area and width), width of the conjoined tendon and subscapularis tendon, estimated glenoid defect surface area, Hill-Sachs interval (HSI), and projected postoperative glenoid track engagement. Failure was defined as the necessity for revision stabilization or continued instability (dislocation or subjective subluxation) at a minimum of 2 years postoperatively. Results: A total of 38 shoulders in 38 patients (33 men, 5 women) with a mean age of 26 years (range, 16-43 years) were included. The mean follow-up for 35 of 38 patients (92%) was 3.2 years (range, 2.0-7.9 years); 25 of 38 had undergone prior stabilization surgery, and 6 had workers’ compensation claims. All mean subjective outcome scores significantly improved (P < .05), with a high median satisfaction score of 9 of 10. Eight patients had failures because of continued instability. Patients with moderate or higher preoperative pain scores (VAS ≥3) had a negative correlation with postoperative SF-12 PCS scores (ρ = 0.474, P = .022). Patients with outside-and-engaged (Out-E) or “off-track” lesions were 4.0 times more likely to experience postoperative instability (relative risk, 4.0; 95% CI, 1.32-12.2; P = .33). The width of patients’ coracoid processes was also directly associated with postoperative stability (P = .014). Moreover, 50% (4/8) of failures demonstrated Out-E glenoid tracks (off-track lesions) versus 16% (4/25) of those without recurrent instability (P = .033). Five of 8 failures were considered as such because of subjective subluxation events, not frank dislocations. Four of the 6 patients with workers’ compensation claims had failed results (P = .016). Conclusion: Workers’ compensation claims were associated with continued instability, and patients with higher preoperative pain levels demonstrated lower SF-12 PCS scores postoperatively. The concept of the glenoid track may be predictive of stability after the Latarjet procedure and may be helpful in surgical decision making regarding the treatment of Hill-Sachs lesions at risk for persistent engagement. Although stability and patient satisfaction are high after the Latarjet procedure, subjective complaints of subluxation may be more common than previously estimated.

Preliminary Results of a New Test for Rapid Diagnosis of Septic Arthritis with Use of Leukocyte Esterase and Glucose Reagent Strips

BACKGROUND Most currently used tools to diagnose septic arthritis are either not readily available or fail to provide real-time results. Reagent strip tests have identified infections in various body fluids. We hypothesized that combined leukocyte esterase and glucose strip tests can aid in diagnosing septic arthritis in native synovial fluid because (1) leukocyte esterase concentrations would be elevated at the infection site because of secretion by recruited neutrophils, and (2) glucose concentrations would be reduced because of bacterial metabolism. METHODS We prospectively investigated synovial fluid from consecutive patients with an atraumatic joint effusion who underwent arthrocentesis in our emergency department during a one-year period. Leukocyte esterase and glucose strip tests were performed on the synovial fluid. Synovial fluid leukocyte count, crystal analysis, Gram staining, culture, and glucose concentration results were also assessed. RESULTS Nineteen fluids were classified as septic and 127 as aseptic. Considering septic arthritis to be present when the leukocyte esterase reading was positive (++ or +++) and the glucose reading was negative (-) yielded a sensitivity of 89.5% (95% confidence interval [CI], 66.9% to 98.7%), specificity of 99.2% (95% CI, 95.7% to 99.9%), positive predictive value of 94.4% (95% CI, 72.7% to 99.9%), negative predictive value of 98.4% (95% CI, 94.5% to 99.8%), positive likelihood ratio of 114, and negative likelihood ratio of 0.11. The synovial leukocyte counts and polymorphonuclear cell percentages were consistent with the semiquantitative readings on the leukocyte esterase strip tests, and the glucose concentrations were consistent with the glucose strip test results. CONCLUSIONS Combined leukocyte esterase and glucose strip tests can be a useful additional tool to help confirm or rule out a diagnosis of septic arthritis.

Patch-Augmented Rotator Cuff Repair and Superior Capsule Reconstruction

Background: Massive rotator cuff tears in active patients with minimal glenohumeral arthritis remain a particular challenge for the treating surgeon. Methods: A selective literature search was performed and personal surgical experiences are reported. Results: For patients with irreparable rotator cuff tears, a reverse shoulder arthroplasty or a tendon transfer are often performed. However, both procedures have rather high complication rates and debatable long-term results, particularly in younger patients. Therefore, patch-augmented rotator cuff repair or superior capsule reconstruction (SCR) have been recently developed as arthroscopically applicable treatment options, with promising biomechanical and early clinical results. Conclusion: For younger patients with irreparable rotator cuff tears wishing to avoid tendon transfers or reverse total shoulder arthroplasty, both patch-augmentation and SCR represent treatment options that may delay the need for more invasive surgery.

Current Concepts for Patellar Dislocation

Context: Patellar dislocation usually occurs to the lateral side, leading to ruptures of the Medial Patellofemoral Ligament (MPFL) in about 90% of the cases. Even though several prognostic factors are identified for patellofemoral instability after patellar dislocation so far, the appropriate therapy remains a controversial issue. Evidence Acquisition: Authors searched the Medline library for studies on both surgical and conservative treatment for patellar dislocation and patellofemoral instability. Additionally, the reference list of each article was searched for additional studies. Results: A thorough analysis of the anatomical risk factors with a particular focus on patella alta, increased Tibial Tuberosity-Trochlear Groove (TT-TG) distance, trochlear dysplasia as well as torsional abnormalities should be performed early after the first dislocation to allow adequate patient counseling. Summarizing the results of all published randomized clinical trials and comparing surgical and conservative treatment after the first-time patellar dislocation until today indicated no significant evident difference for children, adolescents, and adults. Therefore, nonoperative treatment was indicated after a first-time patellar dislocation in the vast majority of patients. Conclusions: Surgical treatment for patellar dislocation is indicated primarily in case of relevant concomitant injuries such as osteochondral fractures, and secondarily for recurrent dislocations.

Bicyclist–Bicyclist Crashes—A Medical and Technical Crash Analysis

Background: The purpose of this study was to analyze the actual injury situation of bicyclists focusing on accidents involving more than one bicyclist. A medical and technical analysis was performed as a basis for preventive measures. Methods: Technical and medical data were collected at the scene, shortly after the accident. Technical analysis included speed at crash, type of collision, impact angle, environment, lane used, and relative velocity. Medical analysis included injury patterns and severity (Abbreviated Injury Scale [AIS], Injury Severity Score [ISS]). Results: Five hundred seventy-eight injured bicyclists in 289 accidents from 1999 to 2008 were included into the study. Sixty-one percent were male (n = 350) and 39 percent were female (n = 228). Sixty-seven percent ranged between 18 and 64 years of age, 12 percent each between 13 and 17 years of age and older than 65 years, 8 percent between 6 and 12 years, and 1 percent between 2 and 5 years. Ninety-two percent of crashes took place in urban areas and 8 percent in rural areas. Ninety-seven percent of crashes occurred in dry conditions and 3 percent in wet conditions. Eighty-three percent of all accidents occurred during the daytime, 10 percent at night, and 7 percent at dawn. The helmet use rate was only 7.5 percent for all involved bicyclists. The mean Abbreviated Injury Scale (AIS) score was 1.31. Conclusion: The prevalence of bicycle-to-bicycle crashes is high. Most of these accidents occur in urban areas. Bicyclists should be considered as minimally or unprotected road users, with an unsatisfactorily low rate of helmet use. Though the average level and patterns of injuries is moderate, most of the severe injuries involved the head and extremities. However, there was no significant correlation between frequent helmet use and sustained injuries to the head of major AIS.