Nikolaus W. Lang

Management and Outcome of Dens Fracture Nonunions in Geriatric Patients.

BACKGROUND Dens fractures are known to have high rates of pseudarthrosis. The aim of this study was to define clinical and radiographic long-term outcomes, specifically in relation to osseous union, cervical spine movement, neurological sequelae, and quality of life, in a geriatric cohort (sixty-five years of age or older) treated operatively or nonoperatively for a dens fracture nonunion. METHODS Forty-four patients (twenty-eight women and sixteen men; average age, seventy-two years) met the inclusion criteria and were enrolled in this study. Sixteen patients (36%) underwent operative stabilization with posterior cervical arthrodesis, and twenty-eight (64%) were treated nonoperatively with a predefined protocol. All patients had a post-treatment follow-up period of at least five years. RESULTS Radiographic evaluation showed osseous union at the site of the C1-C2 arthrodesis in all sixteen patients who had undergone surgical treatment. Clinical follow-up revealed that fourteen had satisfactory results following postoperative rehabilitation. In contrast, radiographic evaluation of the twenty-eight nonoperatively treated patients showed persistence of the pseudarthrosis of the dens in twenty-six and osseous union of the dens in two. All twenty-eight patients (100%) had a satisfactory clinical outcome. CONCLUSIONS C1-C2 arthrodesis was a reliable treatment option for dens fracture nonunions that were unstable, those associated with neurological symptoms, and those causing persistent pain. Clinical and radiographic monitoring was an acceptable nonoperative treatment option but was associated with a very low rate of osseous union of the dens.

Characteristics and clinical outcome in patients after popliteal artery injury

BACKGROUND The treatment of popliteal artery injury (PAI) caused by blunt or penetrating mechanism is demanding. Concomitant injuries and prolonged ischemia are the major causes of lower extremity morbidity and poor rates of limb salvage. This study assessed the amputation rate and, subsequently, the therapeutic management and clinical outcomes regarding the affect of concomitant injuries among patients with PAI in a setting of central European trauma care. METHODS Sixty-four patients (20 female and 44 male), with an average age of 44 years (range, 17-79 years) at the time of injury, were evaluated for clinical characteristics, concomitant injuries, complications, amputation rates, and functional outcome after traumatic PAI. The mechanism of injury was blunt trauma in 35 patients (54.7%) and penetrating trauma in 29 (45.3%). The Mangled Extremity Severity Score and the Injury Severity Score were assessed initially and the modified Functional Independence Measure (FIM) Score at 12 months after the primary surgery. RESULTS Thirty patients (47%) returned to their normal activity level within 1 year after trauma, and 16 (25%) were limited in their daily activity or suffered from chronic pain symptoms. Within the blunt trauma group 26 of 35 patients (74%) sustained severe concomitant injuries, whereas two of 29 patients (7%) in the penetrating group showed severe concomitant injuries (P < .046). Eleven patients (17%) had to undergo revision surgery due to their associated injuries. The median modified FIM score was 10.3, whereas patients with blunt trauma had significantly lower FIM score (P < .0082). The median Mangled Extremity Severity Score was 6 points (range, 6-16 points). Primary or secondary amputation was required in 18 patients (28%) due to failure of revascularization. Patients who sustained blunt trauma had significantly higher amputation rates than those with penetrating injuries (P < .035). CONCLUSIONS Clinical outcome and limb salvage of patients with PAI were influenced by the mechanism of trauma, concomitant injuries, prolonged ischemia time, and the type of surgical procedure. Patients after blunt trauma had a higher incidence of concomitant injuries, and (comminuted) fractures or knee dislocations and severe soft tissue damage had the highest effect on the amputation rate.

Do patients with ewing's sarcoma continue with sports activities after limb salvage surgery of the lower extremity?

BackgroundLimb salvage surgery has evolved to become the standard method of treating sarcomas of the extremities with acceptable oncologic results. However, little information exists relative to the activity level or ability to participate in sports after tumor reconstructions.Questions/purposesThe aims of the study were to answer the following questions: (1) Which sports activity levels and what types of sports can be expected in the long term after tumor reconstruction? (2) Which frequency durations are patients with Ewing’s sarcoma able to perform in long-term followup after local control? (3) Do surgical complications affect sports activity level?MethodsThirty patients (13 females, 17 males; mean age, 18 ± 8 years; range, 2–36 years at diagnosis; mean followup 16 ± 6 years [minimum, 5 years]) were included. Tumors were located in the pelvis, femur, tibia, and fibula. Surgical procedures included surgical resections alone (n = 8), surgical resection with biological reconstruction (n = 9), or endoprosthetic reconstruction (n = 13). We assessed UCLA sports activity levels, kinds of sports as well as the frequency per week and the duration of each training unit at long term (minimum followup, 5 years).ResultsIn long-term followup 83% patients (25 of 30) were performing athletic activity regularly. The hours/week of sports depended on type of surgery and were highest after resections in the pelvis and femur (5.8) and were lowest after megaprosthetic reconstruction of the pelvis (1.0). Patients undergoing biologic reconstructions were able to perform high-impact sports. UCLA sports activity levels were high after joint-preserving vascularized fibula for tibia reconstruction (7.4) and after megaprosthetic reconstruction of the lower extremity (6.3–6.4) and were low after tumors located in the fibula (4.2). Complications during followup did not significantly influence sports activity in long-term survivors.ConclusionsLong-term survivors can achieve high levels of sports activity in many instances. Tumor sites are associated with the postoperative sports activity levels. This information can help surgeons counsel patients in terms of athletic expectations after limb salvage reconstruction for patients with Ewing’s sarcoma.Level of EvidenceLevel III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Locking compression plate versus revision-prosthesis for Vancouver type B2 periprosthetic femoral fractures after total hip arthroplasty.

INTRODUCTION Revision arthroplasty is currently the recommended treatment for periprosthetic femoral fractures after primary total hip arthroplasty (THA) and stem loosening (Vancouver B2). However, open reduction and internal fixation (ORIF) utilizing locking compression plate (LCP) might be an effective treatment with a reduced surgical time and less complex procedure in a typically elderly patient collective with multiple comorbidities. The purpose of this study was to compare the functional and radiographic outcomes in two cohorts with Vancouver B2 periprosthetic femoral fractures after primary THA, treated either by ORIF with LCP fixation, or by revision arthroplasty utilizing a non-cemented long femoral stem. MATERIALS AND METHODS 36 patients with Vancouver B2 periprosthetic femoral fractures following THA, who had been treated between 2000 and 2014, were reviewed. Eight fractures were treated with LCP fixation, fourteen fractures with the first-generation revision prosthesis (Helios), and fourteen fractures with the second-generation revision prosthesis (Hyperion). The patients were assessed clinically with the Parker mobility score and radiographically. RESULTS A total of ten males and 26 females formed the basis of this report with an average age of 81 years (range, 64 to 96 years). All fractures treated with LCP fixation alone healed uneventfully and there were no signs of secondary stem migration, malalignement or plate breakage. The average surgical time was shorter in the ORIF cohort; however, the results were not statistically significant. The postoperative Parker mobility score at latest follow-up showed no difference between the groups. CONCLUSIONS According to the results of the current study, we conclude that the use of LCP fixation can be a sufficient option for the treatment of Vancouver B2 periprosthetic femoral fractures correspondingly with femoral stem loosening.

A comparison of anterior screw fixation and halo immobilisation of type II odontoid fractures in elderly patients at increased risk from anaesthesia

AIMS We performed a retrospective, comparative study of elderly patients with an increased risk from anaesthesia who had undergone either anterior screw fixation (ASF) or halo vest immobilisation (HVI) for a type II odontoid fracture. PATIENTS AND METHODS A total of 80 patients aged 65 years or more who had undergone either ASF or HVI for a type II odontoid fracture between 1988 and 2013 were reviewed. There were 47 women and 33 men with a mean age of 73 (65 to 96; standard deviation 7). All had an American Society of Anesthesiologists score of 2 or more. RESULTS Patients who underwent ASF had a significantly better outcome than those who were treated by HVI. There was a rate of nonunion of 10% after ASF and 23% after HVI. Failure of reduction or fixation occurred in 11 patients (15%) but there was no significant difference between the two groups. Mortality rates were also similar: 9% (n = 3) after ASF and 8% (n = 4) after HVI. CONCLUSION We conclude that ASF is the preferred method of treatment in this group of elderly patients, having a significantly higher rate of fusion, better clinical outcome and a similar rate of general and treatment-related complications. Cite this article: Bone Joint J 2016;98-B:1222-6.

Osteoporosis associated vertebral fractures—Health economic implications

Introduction Osteoporosis-associated vertebral fractures represent an increasing clinical and public health problem, one with important socioeconomic effects within western countries. The purpose of this study was to analyse demographic, medical, gender and socioeconomic aspects of osteoporotic vertebral fractures of the thoracic or lumbar spine over a period of at least 10-years. Material and methods Included for analysis were 694 patients who had suffered a vertebral fracture due to primary or secondary osteoporosis, and who were treated at our Level-I trauma center between 2000 and 2013. Collected data included demographic, medical and socioeconomic aspects. Results Clinical results revealed that 669 patients (96%) were treated conservatively. The remaining 25 patients (4%) underwent surgical therapy: 4 were treated with vertebroplasty, 15 with kyphoplasty and 6 patients with posterior stabilization. The mean age was 75.6 years (range: 50–98), with the vast majority of patients being female (n = 515). A statistically significant demographic difference (i.e., increase) in fractures was observed between the age groups 60–69 and 70–79 (p = 0.041). Concerning socioeconomic aspects, statistical analysis showed that the number of sick leaves and the need for professional domestic help was higher in female patients. Concerning treatment costs, statistical analysis did not reveal any significant differences between female and male patients. Conclusion Significant gender differences–to the detriment of the female population–could be demonstrated within this study. A regrettably low rate of adequate treatment after diagnosis of osteoporosis and its associated fractures–specifically relating to primary and secondary prevention–could also be identified. To prospectively avoid complications and consequential cost increases, more awareness of the necessity for prevention, early diagnosis and adequate treatment of osteoporosis and its related fractures should be considered.

Does an additional antirotation U-Blade (RC) lag screw improve treatment of AO/OTA 31 A1-3 fractures with gamma 3 nail?

INTRODUCTION Poor bone quality and unstable fractures increase the cut-out rate in implants with gliding lag screws. The U-Blade (RC) lag screw for the Gamma3® nail was introduced to provide monoaxial rotational stability of the femoral head and neck fragment. The purpose of this study was to evaluate whether the use of the U-Blade (RC) lag screw is associated with reduced cut-out in patients with OTA/AO 31A1-3 fractures. MATERIAL & METHODS Between 2009 and 2014, 751 patients with OTA/AO 31A1-3 fractures were treated with a Gamma3® nail at our institution. Out of this sample 199 patients were treated with U-blade (RC) lag screws. A total of 135 patients (117 female, 18 male) with standard lag screw (treatment group A) were matched equally regarding age (±4 years) sex, fracture type and location to 135 patients with U-blade (RC) lag screw (treatment group B). Within a mean follow up of 9.2 months (range 6-18 months) we assessed the cut-out rate, the calTAD, lag screw migration, the Parkers mobility score and the Parkers ratio at postoperatively, six and 12 months following surgery. Furthermore we recorded all complications, ASA-Score, hospital stay and duration of surgery retrospectively. RESULTS The most common fracture among group B with a cut-out of the lag screw were AO/OTA 2.3 and 3.2 fractures whereas in group A cut-out was most commonly seen in AO/OTA 2.1, 2.2 and 2.3 fractures, there was no significant reduction of the cut-out rate in group B 2.2% (n=3) compared to group A 3.7% (n=5). The duration of surgery was significantly shorter in group A (p<0.05). There was no significant difference in lag screw placement, the Parkers ratio and mobilization. CONCLUSION In our study the U-Blade (RC) lag screw did not reduce the cut-out in treatment of OTA/AO 31A1-3 fractures at all. Considering the longer duration of surgery and the higher costs of the U-Blade (RC) lag screw, our results do not justify its use. However, further prospective randomized studies will be necessary.

Treatment of primary total distal biceps tendon rupture using cortical button, transosseus fixation and suture anchor: A single center experience

INTRODUCTION There remains as of yet no consensus on the optimal treatment for total or partial distal biceps tendon repairs. As such, the purpose of this study was to assess functional outcome, the impact of complications and cost effectiveness, in patients undergoing primary distal biceps tendon repair by either cortical button (CB), transosseous suture (TO) or suture anchor (SA). HYPOTHESIS There is no difference in functional outcome and cost effectiveness, in patients undergoing distal biceps tendon repair. MATERIAL & METHODS A retrospective analysis was performed on prospectively collected data from 47 consecutive patients treated for total or partial distal biceps tendon rupture. Functional outcome was assessed by the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Strength measurements (e.g., flexion, supination and pronation) in the operated and non-operated extremities were recorded with the use of a dynamometer. Furthermore, all complications, as well as their impact on functional outcome and costs for surgical intervention were evaluated. RESULTS Minimum follow-up time was 35 weeks, average 46.3±13.8 weeks. The overall DASH score was 7.9±4.7. There were no differences in functional outcome (i.e., DASH score) between CB, TO, SA (p=0.32), nor were there differences in regards to strength (supination, flexion and pronation) (p=0.60) and ability to return to work & sports activity. The total complication rate was 21.6%. Complications had a significant impact on functional outcome (p=0.003). Re-rupture occurred 2 times in the SA group. In 5 patients, revisional surgery had to be performed. The shortest operation times and the lowest material costs were observed in the TO group (p=0.004). DISCUSSION All reported fixation methods for total or partial distal biceps tendon rupture yielded good functional results. However, transosseous suture fixation for total distal biceps tendon rupture, performed through a double incision approach by an experienced surgeon, seems to be a simple, inexpensive and successful method, offering satisfying clinical results. LEVEL OF EVIDENCE IV, a retrospective, comparative study.

Redifferentiation of aged human articular chondrocytes by combining bone morphogenetic protein-2 and melanoma inhibitory activity protein in 3D-culture

Melanoma inhibitory activity (MIA) affects the differentiation to hyaline cartilage and can inhibit the osteogenic potential of bone morphogenetic protein (BMP)-2 in mesenchymal stem cells (MSC). The aim of this study was to investigate if MIA also inhibits the osteogenic potential of BMP-2 in human articular chondrocytes during redifferentiation, which may lead to a higher grade of differentiation without calcification. HAC of four female patients (mean age: 73.75 ±6.98) were seeded into 3D culture for 28 days; after adding the recombinant proteins, four groups were formed (Control, BMP-2, MIA, BMP-2+MIA). Samples were analysed for gene expression, glycosaminoglycan (GAG) content and histology on day 0, 14 and 28. Collagen type 2 (COL2A1) was significantly increased in the BMP-2 containing groups on day 28; BMP-2 (100-fold, p = 0.001), BMP-2+MIA (65-fold, p = 0.009) and similar to the level of native cartilage. Higher aggrecan (Agg) levels were present in the BMP-2 (3-fold, p = 0.007) and BMP-2+MIA (4-fold, p = 0.002) group after 14 days and in the BMP-2 (9-fold, p = 0.001) group after 28 days. Collagen type 10 (COL10A1) was increased in the BMP-2 containing groups (6-fold, p = 0.006) but these levels were significantly below native cartilage. Alkaline phosphatase (ALP), collagen type 1 (COL1A1) and the glycosaminoglycan (GAG) content did not reveal any relevant differences between groups. BMP-2 is a potent inducer for differentiation of HAC. A significant enhancement of this effect in combination with MIA could not be observed. Furthermore no significant reduction of osteogenic markers during re-differentiation of chondrocytes was present combining BMP-2 and MIA.

What Sport Activity Levels Are Achieved in Patients After Resection and Endoprosthetic Reconstruction for a Proximal Femur Bone Sarcoma

BackgroundLimited information is available about sports activities of survivors after resection and reconstruction of primary malignant bone tumors with megaprostheses. Because patients often ask what activities are possible after treatment, objective knowledge about sports activities is needed to help assess the risks of sports participation and to help guide patients’ expectations.Questions/purposesThe aims of this study were to evaluate (1) what proportion of patients with proximal-femoral megaprostheses placed as part of tumor reconstructions can perform sports; (2) what activity levels they achieved; and (3) whether sports activity levels are associated with an increased likelihood of revision.MethodsThis retrospective study considered all 27 living patients in our institutional tumor registry with enduring proximal-femoral reconstructions performed more than 5 years ago who were between the ages of 11 and 49 years at the time of the reconstruction; seven were lost to followup and one was excluded because of paraplegia as a result of a car accident and another because of senile dementia; another two were excluded from statistics because of growing prostheses and skeletal immaturity at the time of followup, leaving 16 (11 male, five female) for analysis. Their mean age was 26 ± 12 years (range, 11–49 years) at surgery, and the mean followup was 18 ± 7 years (range, 5–27 years). Types of sports, frequency per week, duration of each sports session as well as the UCLA and modified Weighted Activity Score were assessed retrospectively by an independent assessor a median of 18 years (range, 5.3–27 years) after surgery.ResultsPatients recalled that preoperatively 14 were practicing sports 5 (± 4) hours/week. At followup, 11 of the patients were practicing one or more sports activities 2 (± 3) hours/week on a regular basis. The preoperative UCLA and modified Weighted Activity Score levels of 9 and 6 fell to levels of 6 (p = 0.005) and 3 (p = 0.025), respectively, at followup. With the numbers of patients available for study, we could not determine that prosthetic failures were associated with sport activity levels.ConclusionsPatients who survive primary malignant bone tumors in the proximal femur reconstructed by megaprostheses are able to perform some sports activities. The estimates of activity levels made in this study probably are best-case estimates, given that some patients were lost to followup; patients unaccounted for might not be doing as well as those represented here. Also, the degree to which sports participation influences implant durability remains, for the most part, unanswered; studies with more patients and longer followup will be needed to determine to what degree prosthesis survivorship relates to sporting activity levels. Most patients perform low-impact sports and at a lower level than they had preoperatively. Because this is a preliminary study of a select group of patients, further information is necessary to weight the benefits of higher sports activity levels against potential risks. If this can be confirmed in a larger number of patients, the information may guide surgeons in their discussion with patients preoperatively and give them some objective assessment of what to expect regarding sports activities.Level of EvidenceLevel IV, therapeutic study.