Philipp Moroder

Secondary Intracranial Hemorrhage After Mild Head Injury in Patients With Low-dose Acetylsalicylate Acid Prophylaxis

BACKGROUND Low-dose acetylsalicylate acid (LDA) therapy is accepted as a major risk factor for intracranial hemorrhages (ICH) in head injuries. Coincidentally, patient admissions that might be indicated for in hospital observation of neurologic function causes increased health care costs. In the literature, there is no evidence concerning the incidence of secondary intracranial hemorrhagic events (SIHE) in patients with LDA prophylaxis that had negative primary computed tomography (CT)-scan of the head. METHODS In this prospective study, we enrolled 100 consecutive trauma patients older than 65 years presenting in a Level I urban trauma center after a mild head injury (Glasgow Coma Scale score of 15) who had LDA prophylaxis. Patients included had a negative primary head CT-scan concerning ICH. For analysis of the incidence of SIHEs patients had routine repeat head CT (RRHCT) after 12 hours to 24 hours. RESULTS Sixty-one patients were women and 39 men. Mean age was 81 years +/- 10 years. Injury mechanism was a level fall in 84 cases and others in 16. In four patients (4%) an SIHE was detected in the RRHCT (p < 0.00001). In two patients (2%) major secondary ICH had occurred without neurologic deterioration at the time of RRHCT with fatal outcome in one patient and neurosurgical intervention in another. The remaining two patients (2%) had minor SIHE with an uneventful clinical course. CONCLUSION The incidence of SIHE has been neglected until now. The current study revealed that patients with LDA prophylaxis after mild head injury with negative primary head CT should be subjected to RRHCT within 12 hours to 24 hours to accurately identify SIHE. Alternatively to RRHCT, patients should be subjected to a prolonged in-hospital observation for at least 48 hours.

No Increased Occurrence of Osteoarthritis After Anterior Cruciate Ligament Reconstruction After Isolated Anterior Cruciate Ligament Injury in Athletes

PURPOSE To evaluate the long-term radiographic and clinical results of anterior cruciate ligament (ACL) reconstruction by comparing the injured knee with the contralateral knee in athletes with isolated ACL tear returning to preinjury sports. METHODS Twenty-eight patients with isolated ACL tears without concomitant injuries at baseline returning to previous sports were selected. ACL reconstruction was performed with patella or hamstring tendon graft. Conventional radiographs and a 3-T magnetic resonance imaging study of both knees were obtained at a mean follow-up of 10 years after ACL reconstruction and were compared with each other. The International Knee Documentation Committee score and Tegner activity index were used for clinical evaluation and the Knee Injury and Osteoarthritis Outcome Score for evaluating self-reported knee function. RESULTS The 3-T magnetic resonance imaging study showed positive signs of osteoarthritis in 33% of operated knees and 39% of nonoperated knees (P = .64). Conventional radiographs showed ongoing signs of radiographic osteoarthritis in 14% of uninjured knees according to Kellgren and Lawrence, in comparison with 21% of injured knees (P = .73). The functional outcomes between the injured knee and uninjured knee did not show any statistical differences. The mean postoperative International Knee Documentation Committee score was 89.2 ± 9.3 points, and the total Knee Injury and Osteoarthritis Outcome Score was 92.7 ± 7.8. The median preinjury Tegner score was 8 ± 2, corresponding to 7 ± 2 at follow-up. In 68% of patients, the Tegner score was unchanged from preinjury to follow-up. CONCLUSIONS Athletes with an isolated ACL rupture showed no increased risk of the development of post-traumatic osteoarthritis in the long-term after ACL replacement when compared with the uninjured contralateral knee. Our findings support the evidence to perform ACL replacement in athletes. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Restoration of Anterior Glenoid Bone Defects in Posttraumatic Recurrent Anterior Shoulder Instability Using the J-Bone Graft Shows Anatomic Graft Remodeling

Background: The J-bone graft technique has previously been reported for anatomic restoration of the bony glenoid surface in cases of posttraumatic recurrent anterior shoulder instability with significant glenoid bone loss. Purpose: To analyze the physiological remodeling process of the J-bone graft over time. Study Design: Case series; Level of evidence, 4. Methods: Thirty-one consecutive patients treated with anatomic glenoid restoration surgery using the J-bone graft for posttraumatic recurrent anterior shoulder instability with a significant bony glenoid defect were included in this study. Twenty patients received 3-dimensional computed tomography scans of the affected shoulder preoperatively, postoperatively, and at 1-year follow-up. On “en face” views of the glenoid, the change over time of the glenoid diameter, glenoid area, and glenoid defect size in relation to a best-fit circle indicating 100% was measured. Results: The average glenoid diameter increased from 81.0% preoperatively to 110.4% postoperatively (P < .001). At 1-year follow-up, the diameter had decreased significantly to 100.6% (P < .001), which is concordant to a theoretical perfect glenoid diameter of 100% (P = .73). The average glenoid surface area increased from 80.8% preoperatively to 110.0% postoperatively (P < .001). At 1-year follow-up, a decrease to 102.2% (P < .005) was measured, which again is close to a theoretical perfect glenoid surface area of 100% (P = .15). By applying the J-bone graft, the average missing surface area of the glenoid was reduced from 19.2% preoperatively to 3.9% postoperatively (P < .001). At 1-year follow-up, an average of 3.6% was calculated, indicating no statistically significant change over time (P = .90). Conclusion: Anatomic glenoid reconstructive surgery using the J-bone graft technique benefits from a physiological remodeling process, molding the bone graft closely into the original shape of an uninjured anterior glenoid rim. While parts of the graft lying inside the projected former surface area of the glenoid are preserved, the parts lying outside are resorbed over time, suggestive of strain-adapted graft remodeling.

Arthroscopic Stabilization of Chronic Acromioclavicular Joint Dislocations Triple- Versus Single-Bundle Reconstruction

Background: Arthroscopically assisted single-bundle (SB) or double-bundle coracoclavicular (CC) ligament reconstruction using autologous tendon grafts has been reported to provide acromioclavicular (AC) joint (ACJ) stability in chronic instability cases. Recently, additional AC ligament reconstruction to provide triple-bundle (TB) stabilization has been introduced but lacks a comparison of clinical and radiological outcomes. Hypothesis: Arthroscopically assisted anatomic TB CC and AC reconstruction yields superior clinical and radiological results when compared with nonanatomic SB CC reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: Twenty-six patients (mean [±SD] age, 46.9 ± 12.8 years) suffering from chronic high-grade ACJ instability underwent ACJ stabilization using autologous hamstring grafts. Twelve patients underwent combined anatomic TB CC and AC reconstruction using a semitendinosus tendon with clavicular interference screw fixation (TB group), and 14 underwent isolated SB CC reconstruction using the AC GraftRope system with a gracilis tendon (SB group). After a minimum follow-up of 2 years (mean, 29.0 ± 7.4 months), patients were evaluated radiologically and clinically using the Constant, American Shoulder and Elbow Surgeons (ASES), Taft, and Acromioclavicular Joint Instability Score (ACJI) outcome measures. Results: The mean Constant score increased significantly in both groups, from 71.6 preoperatively to 88.8 postoperatively in the TB group and from 67.8 to 82.6 in the SB group (P ≤ .009). No intergroup difference was found regarding the final Constant or ASES scores. Regarding the ACJ-specific scores, the final outcomes were significantly different: 10.9 (TB group) versus 9.0 (SB group) for the mean Taft score (P = .018) and 84.7 versus 58.4, respectively, for the mean ACJI score (P = .0001). No significant radiological difference was found regarding the mean CC distance (10.7 mm [TB group] vs 13.1 mm [SB group]). The TB group showed superior horizontal ACJ stability (P = .011), which was associated with a better clinical outcome according to the ACJI and Taft scores. In the SB group, the rate of ACJ instability recurrence was higher (21% vs 8% [TB group]). Conclusion: Combined arthroscopically assisted anatomic TB CC and AC ligament reconstruction using an autologous semitendinosus tendon graft provides superior clinical and radiological results compared with isolated nonanatomic SB CC ligament reconstruction using the AC GraftRope system. In particular, the TB technique can better restore horizontal ACJ stability, which is associated with superior ACJ-specific outcome scores.

A prospective study of downhill mountain biking injuries

Background Downhill mountain biking (DMB) has become an increasingly popular extreme sport in the last few years with high velocities and bold manoeuvres. The goal of this study was to provide information on the pattern and causes of injuries in order to provide starting points for injury prevention measures. Methods We performed a monthly e-mail-based prospective survey of 249 riders over one summer season ranging from April until September 2011. Results A total of 494 injuries occurred during the 29 401 h of downhill exposure recorded, of these 65% were mild, 22% moderate and 13% severe, of which 41% led to a total restriction greater than 28 days. The calculated overall injury rate was 16.8 injuries per 1000 h of exposure. For experts it was 17.9 injuries per 1000 h of exposure, which is significantly higher than the 13.4 for professional riders (OR 1.34; 95% CI, 1.02 to 1.75; p=0.03). A significantly higher rate of injury was reported during competition (20 per 1000 h) than during practice (13 per 1000 h) (OR 1.53; 95% CI, 1.16 to 2.01; p=0.0022). The most commonly injured body site was the lower leg (27%) followed by the forearm (25%). Most frequent injury types were abrasions (64%) and contusions (56%). Main causes of injury reported by the riders were riding errors (72%) and bad trail conditions (31%). Conclusions According to our data DMB can be considered an extreme sport conveying a high risk of serious injury. Strategies of injury prevention should focus on improvements in riders’ technique, checking of local trail conditions and protective equipment design.

Open Bankart Repair for the Treatment of Anterior Shoulder Instability without Substantial Osseous Glenoid Defects: Results After a Minimum Follow-up of Twenty Years.

BACKGROUND Neglected osseous glenoid defects are thought to be one of the reasons for the reported high rates of recurrent instability at long-term follow-up after Bankart repair. We hypothesized that open Bankart repair for the treatment of anterior glenohumeral instability in the absence of a substantial osseous glenoid defect would result in a lower long-term recurrence rate than has been reported in previous long-term studies. METHODS Forty-seven patients were treated with a primary modified open Bankart repair for recurrent anterior shoulder instability between 1989 and 1994. Double-contrast computed tomography scanning was used to exclude patients with a substantial osseous glenoid defect. Forty patients (85.1%) were available for subjective and objective follow-up at a minimum of twenty years (maximum, twenty-five years). Twenty-six patients (65%) underwent clinical examination as well as bilateral shoulder radiography, and fourteen (35%) completed a self-assessment questionnaire and were interviewed by telephone. RESULTS Seven patients (17.5%) had a recurrence of instability, and six of them had the instability occur after more than eight years without symptoms. The mean Western Ontario Shoulder Instability Index score (and standard deviation) was 256.7 ± 284.8 points; the mean Rowe score, 88.7 ± 12.0 points; and the mean Subjective Shoulder Value, 90.1% ± 10.5%.The mean range of motion of the affected shoulder was decreased by 4° of abduction (p = 0.009), two levels of internal rotation (p = 0.003), 5° of internal rotation in 90° of abduction (p = 0.005), 7° of external rotation in neutral position (p < 0.001), and 7° of external rotation in 90° of abduction (p = 0.004) compared with the contralateral side. The collective instability arthropathy (CIA) index was 0.92 for the affected side and 0.35 for the contralateral side. CONCLUSIONS Open Bankart repair provides good results twenty years after surgery in terms of subjective and objective outcome measurements. However, the long-term failure rate remains high despite the exclusion of substantial osseous glenoid defects. Recurrence of instability seems to be associated with an increased shoulder-specific activity level. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical and computed tomography–radiologic outcome after bony glenoid augmentation in recurrent anterior shoulder instability without significant glenoid bone loss

BACKGROUND The presence of a significant bony defect in anterior shoulder instability cases warrants glenoid reconstruction surgery typically by means of an autograft. Some surgeons use the same graft techniques even in the absence of a significant bony defect, thus augmenting the glenoid surface. The goal of this study is to investigate the clinical and computed tomography-radiologic outcome after glenoid augmentation surgery. METHODS Between 2006 and 2011, 11 patients with recurrent anterior shoulder instability and glenoid bone loss of 5% or less were treated with an iliac crest autograft. Of the patients, 9 were available for follow-up at a mean of 34.6 months (range, 12 to 80 months), including apprehension testing, Western Ontario Shoulder Instability Index, Rowe score, Simple Shoulder Value, and 3-dimensional computed tomography examination. RESULTS The mean Rowe score achieved was 85.0 points (range, 51 to 100 points); Simple Shoulder Value, 80.5 points (range, 30 to 100 points); and Western Ontario Shoulder Instability Index, 373.5 points (range, 61 to 878 points). Two patients reported a recurrence of instability, and one featured a positive apprehension test. The mean glenoid surface area was 96.5% (95% confidence interval [CI], 95.5% to 97.4%) preoperatively, increased after graft implantation to 119.5% (95% CI, 105.6% to 133.3%), and decreased to 102.8% (95% CI, 98.6% to 107.1%) at follow-up, concordant to an intact glenoid surface area. From preoperatively to follow-up, the mean increase in glenoid surface area was 6.4% (95% CI, 2.1% to 10.6%; P = .008); in concavity diameter, 2.0 mm (95% CI, -0.9 to 4.9 mm; P = .168); in concavity depth, 0.9 mm (95% CI, 0.3 to 1.5 mm; P = .005); and in concavity retroversion, 2.4° (95% CI, -1.2° to 6.1°; P = .178). CONCLUSION Because of anatomic bony remodeling processes, glenoid augmentation surgery seems to be subject to extensive graft osteolysis and, consequently, unsatisfactory clinical outcome in terms of stability in some cases.

Reliability of a new standardized measurement technique for reverse Hill-Sachs lesions in posterior shoulder dislocations.

PURPOSE The purpose of this study was to determine whether standardized measurements are more reliable than mere estimation in determining the extent of the defect in reverse Hill-Sachs lesions. METHODS Twelve patients with 13 reverse Hill-Sachs lesions and available computed tomographic scans were included in this study. Based on the computed tomographic scans, estimation and measurement of the defect size in reverse Hill-Sachs lesions using a novel standardized method were carried out twice by 6 observers (3 experts and 3 residents), with an interval of 3 months between observations. To assess and compare the reliability of the estimation of the defect size and the measurement of the defect size, intraclass correlation coefficients were computed. RESULTS Estimation of the defect size showed a low interobserver reliability of 0.61 (95% confidence interval [CI], 0.38 to 0.83) and 0.47 (95% CI, 0.24 to 0.74) and a moderate intraobserver reliability of 0.71 (95% CI, 0.51 to 0.89). The estimations of the different observers showed statistically significant differences (P < .001). The standardized measurements reached high interobserver reliability (at least ≥0.81) and excellent intraobserver reliability (at least ≥0.88). Residents provided less reliable estimations compared with experts; however, they obtained similarly high reliability when applying the standardized measurements. CONCLUSIONS The mere estimation of the size of reverse Hill-Sachs lesions showed poor reliability, raising the concern for potential overestimation or underestimation in clinical practice. Standardized measurements, which showed good reliability, should be used whenever analyzing the size of a reverse Hill-Sachs defect. LEVEL OF EVIDENCE Level IV, diagnostic case series.

Classification of proximal humeral fractures based on a pathomorphologic analysis

BACKGROUND The purpose of this study was to analyze the pathomorphology of proximal humeral fractures to determine relevant and reliable parameters for fracture classification. METHODS A total of 100 consecutive acute proximal humeral fractures in adult patients were analyzed by 2 non-independent observers from a single shoulder department using a standardized protocol based on biplane radiographs and 3-dimensional computed tomography scans. A fracture classification system based on the most reliable key features of the pathomorphologic analysis was created, and its reliability was tested by 6 independent shoulder experts analyzing another 100 consecutive proximal humeral fractures. RESULTS The head position in relation to the shaft (varus, valgus, sagittal deformity) and the presence of tuberosity fractures showed a higher interobserver reliability (κ > 0.8) than measurements for medial hinge, shaft, and tuberosity displacement, metaphyseal extension, fracture impaction, as well as head-split component identification (κ < 0.7). These findings were used to classify nondisplaced proximal humeral fractures as type 1, fractures with normal coronal head position but sagittal deformity as type 2, valgus fractures as type 3, varus fractures as type 4, and fracture dislocations as type 5. The fracture type was further combined with the fractured main fragments (G for greater tuberosity, L for lesser). Interobserver and intraobserver reliability analysis for the fracture classification revealed a κ value (95% confidence interval) of 0.700 (0.631-0.767) and 0.917 (0.879-0.943), respectively. CONCLUSION The new classification system with emphasis on the qualitative aspects of proximal humeral fractures showed high reliability when based on a standardized imaging protocol including computed tomography scans.

Defect Characteristics of Reverse Hill-Sachs Lesions

Background: Little scientific evidence regarding reverse Hill-Sachs lesions (RHSLs) in posterior shoulder instability exists. Recently, standardized measurement methods of the size and localization were introduced, and the biomechanical effect of the extent and position of the defects on the risk of re-engagement was determined. Purpose: To analyze the characteristics and patterns of RHSLs in a large case series using standardized measurements and to interpret the results based on the newly available biomechanical findings. Study Design: Case series; Level of evidence, 4. Methods: In this multicenter study, 102 cases of RHSLs in 99 patients were collected from 7 different shoulder centers between 2004 and 2013. Patient- as well as injury-specific information was gathered, and defect characteristics in terms of the size, localization, and depth index were determined on computed tomography or magnetic resonance imaging scans by means of standardized measurements. Additionally, the position (gamma angle) of the posterior defect margin as a predictor of re-engagement was analyzed. Results: Three types of an RHSL were distinguished based on the pathogenesis and chronicity of the lesion: dislocation (D), locked dislocation (LD), and chronic locked dislocation (CLD). While the localization of the defects did not vary significantly between the subgroups (P = .072), their mean size differed signficantly (D: 32.6° ± 11.7°, LD: 49.4° ± 17.2°, CLD: 64.1° ± 20.7°; P < .001). The mean gamma angle as a predictor of re-engagement was similarly significantly different between groups (D: 83.8° ± 14.5°, LD: 96.5° ± 17.9°, CLD: 108.7° ± 18.4°; P < .001). The orientation of the posterior defect margin was consistently quite parallel to the humeral shaft axis, with a mean difference of 0.3° ± 8.1°. Conclusion: The distinction between the 3 different RHSL types based on the pathogenesis and chronicity of the defect helps identify defects prone to re-engagement. The gamma angle as a measurement of the position of the posterior defect margin and therefore a predictor of re-engagement varies significantly between the defect types.