Richard K. Kdolsky

Cyclops and cyclopoid formation after anterior cruciate ligament reconstruction: clinical and histomorphological differences

Abstract Prospectively, 119 patients were pursued clinically and by follow-up-arthroscopy for the occurrence of a “cyclops syndrome” after ACL reconstruction with a patellar tendon autograft, augmented by LAD. Twenty-one patients showed nodular formations. Ten of these (group 1) developed early clinical evidence of a “cyclops syndrome” with a mean extension deficit of 19° before follow-up-arthroscopy, on average 5.9 months after the index operation. The nodular formations found and excised during débridement had a hard consistency. Histomorphological undecalcified microtome section evaluation of six specimens revealed fibrocartilagineous tissue with active bone formation in the center. The other 11 patients showed no clinical symptoms (group 2). A similar but soft nodulous scar formation was detected at follow-up-arthroscopy, on average 9.5 months after the index operation. Histomorphologically these so-called “cyclopoid” formations were only built-up fibrocartilagineous islands surrounded by granulation tissue. Neither remnants of tendon graft fibers nor old bone particles were found in specimens of either group. It can be concluded that both the hard cyclops and the soft “cyclopoid” are de novo scar formations.

Predictive Factors Influencing the Outcome After Gunshot Injuries to the Head: A Retrospective Cohort Study

BACKGROUND Civilian gunshot injuries to the head are relatively rare in the irenical European Union, and studies of treatment and outcomes are seldom for this region in the current literature. METHODS A cohort of 85 patients with civilian head gunshot injuries, who were admitted to our University hospital over a period of 16 years, was reviewed retrospectively. Clinical manifestation, computed tomography scan findings, and surgical treatment were described, with special regard to prognostic factors and outcome. RESULTS The mean age was 48 years (range, 17.8-98.4 years), and 87% were men. Sixty patients sustained penetrating craniocerebral injuries (P-group) and 25, nonpenetrating gunshot wounds (NP-group). The overall mortality was 87% in the P-group and 4% in the NP-group. The Glasgow Coma Scale (GCS) score at admission was recorded to be 3 to 5 in 58 patients (96%) and 7 patients (28%) in the P-group and NP-group, respectively. Only 8 patients (13%) survived in the P-group compared with 24 patients (96%) in the NP-group. Excluding wound debridement, there were 16 surgical procedures in the P-group and 8 in the NP-group, with a mortality rate of 63% and 13%, respectively. CONCLUSIONS Glasgow Coma Score at admission and the status of pupils and hemodynamic situation seem to be the most significant predictors of outcome in penetrating craniocerebral gunshot wounds. Computed tomography scans, bi- or multilobar injury, and intraventricular hemorrhage were correlated with poor outcome. Patients with a GCS score >8, normal pupil reaction, and single lobe of brain injury may benefit from early aggressive management.

Spine injuries in polytraumatized pediatric patients: characteristics and experience from a Level I trauma center over two decades.

BACKGROUND Spine injuries, a common component in polytrauma, are relatively rare in pediatric patients. Previous studies mainly described injuries to the cervical region, whereas information of injury patterns to the thoracic and lumbosacral region lack in the current literature. The aim of this study was to determine the incidence and characteristics of polytraumatized children and associated spine injuries in different pediatric development ages. METHODS A cohort review of all pediatric patients with the diagnosis of polytrauma and associated spine injury, admitted to a urban Level I trauma center, was conducted over an 18-year period from January 1992 to December 2010. Patients were stratified into four developmental age groups: infants/toddlers (age 0–4 years), preschool/young children (age 5–9 years), preadolescents (age 10–14 years), and adolescents (age 15–17 years). Demographics, clinical injury data, patterns of spine injuries, associated injuries, treatment, and outcome were abstracted and analyzed. RESULTS From a database of 897 severely (Injury Severity Score ≥ 16) injured pediatric patients, 28 children met the inclusion criteria. The mean age was 12.7 years (range, 1.3–16.7 years), and there were 18 males and 10 females. Younger children (age 0–9 years) sustained more injuries to the upper spine region, whereas injuries to the lumbar region were only seen in adolescents. Nine (32%) patients received surgical treatment for spine fracture or subluxation, and 15 (54%) were treated by nonoperative means. Four patients (14%) received only palliative treatment due to medical futility. Overall, the most commonly associated injury was thoracic injury (89%) followed by traumatic brain injury (64%). CONCLUSION The age-related anatomy and physiology predispose younger children to upper spine injuries in contrast to lower spine injuries seen in adolescents. Predictors of mortality include pathologic pupillary light reflex, high Injury Severity Score and Abbreviated Injury Scale score, and a low Glasgow Coma Scale score at admission. Thoracic injuries were the most common associated injuries followed by traumatic brain injury. LEVEL OF EVIDENCE Prognostic study, level III.

Synthetic augmented repair of proximal ruptures of the anterior cruciate ligament. Long-term results of 66 patients.

The long-term results (five-to eight-year follow-up evaluation) of 66 patients with high proximal ruptures of the anterior cruciate ligament (ACL) who were treated operatively are presented in a retrospective and uncontrolled study. Technique of surgery was the reinsertion of the ACL in a multiple suture loop technique, augmented with Kennedy-LAD (ligament augmentation device) on over the top route in temporary double-end fixation. This technique was used in patients with proximal rupture of the anterior cruciate ligament found at arthroscopy. In the follow-up as well as in instrumented measurement, 97% of the knee joints have normal joint laxity. According to the evaluation sheet designed by the Orthopädische Arbeitsgemeinschaft Knie (OAK), excellent or good results were found in 86% of the patients. Nine percent had limited range of motion. The ACL reconstruction technique allowed 75% of the patients to regain their preinjury sports activity level. The potential advantages of synthetic augmented reinsertion of the ACL are anatomic reconstruction without destruction of other anatomic structures as grafts; securing early rehabilitation with weight bearing of the operated limb depending on individual pain tolerance; and presenting excellent long-term results of normal joint laxity.

Measurement of stress-strain relationship and stress relaxation in various synthetic ligaments.

In an experimental study various synthetic augmentation devices for knee ligament surgery were tested in a servo-mechanical universal tensile testing machine under uniaxial loading. Two tests were done to elucidate the mechanical behaviour: stress relaxation and stress-strain relationship. Regarding the point of failure or rupture, the strongest ligament was the Trevira et 1800 N, followed by the 8-mm-wide Kennedy LAD at 1720 N. At a working load of 500 N the Gore-tex band, the Trevira, and the Kennedy-LAD stretched by between 2% and 3%. For synthetic augmentation in repair of proximally ruptured anterior cruciate ligaments we recommend a synthetic ligament that reaches failure point at a load of more than 1000 N with an alteration in length of less than 5%. Otherwise, stress protection of the biological reconstruction in full extension will be impossible. The requisite criteria were fulfilled by the Trevira, Kennedy-LAD and Gore-tex synthetic ligaments.

Measuring the pressure pattern of the joint surface in the uninjured knee.

ZusammenfassungZiel der StudieÜberprüfung eines intraoperativ einsatzbaren Oberflächendruckmesssystems unter Simulation von Operationssaalbedingungen.Art der StudieLeichenexperiment.Material und MethodenAn fünf Leichen wurden die Messproben (K 6900 quad probes) medial und lateral in das Kniegelenk eingeführt. Das Messsystem ermöglicht Datenerfassung in Echtzeit und EDV-gestützte Datenerfassung (K-scan system,Hersteller: Tekscan Inc., South Boston, MA). Initial befand sich das Knie hängend in 90° Beugung in der selben Position wie in einem leg-holder. Dann wurde das Knie manuell bis 0° gestreckt und wieder in Beugung gebracht. Die Daten werden als Relativwerte angegeben, da sie als Grundlage für intraoperative Messungen dienen sollen. Die Absolutwerte würden während der Arthroskopie durch den Druck der Arthroskopiepumpe laufend verändert werden.ErgebnisseDas initiale Verhältnis des Gelenksflächendrucks in 90° Beugung war 1∶1,5 zwischen dem medialen und dem lateralen Gelenksspalt. Während der Streckung stieg der Druck im medialen Gelenksabschnitt und erreichte 1∶1 bei circa 15°, bei voller Streckung lag das Verhältnis bei 1,8∶1 zwischen medial und lateral. Bei der Rückführung des Unterschenkels wurde eine ähnliche Gelenksflächendruckverteilung aufgezeichnet.ZusammenfassungUnter Operationssaalbedingungen ist die Gelenksflächendruckverteilung zwischen dem medialen und lateralen Kniecompartment ist messbar und reproduzierbar. Der Einsatz der Gelenksflächendruckmessung während der Implantation eines Ersatztransplantates für das vordere Kreuzband könnte Daten für eine intraoperative individuelle Qualitätskontrolle liefern.SummaryPurposeTesting an applicable intraoperative system for measuring surface pressure in knee joints, simulating as accurately as possible operating theatre conditions.Type of studyCadaver study.MethodsPressure probes were introduced into the knee joints medially and laterally (K 6900 quad probes) in five cadavers, providing real-time data with computerized data recording (K-scan system, manuf. Tekscan Inc., South Boston, MA). The initial position of the knee was flexed and hanging, as in a leg holder. In simulation of usual operating theatre procedures, the knee was manually extended to 0° and again brought to hanging position. The data are given as relative-pressure values and shouldserve as the basis for intraoperative use. During arthroscopy, absolute-pressure values would then be influenced by the pressure of the arthroscopy pump.ResultsIn 90° flexion the average pressure ratio between the medial and lateral joint compartments was initially 1∶1.5. When the leg was brought to full extension the pressure in the medial compartment increased, giving a pressure ratio of 1∶1 at about 15° and 1.8∶1 at full extension. When bringing the leg back again to 90° a similar pressure ratio curve was recorded.ConclusionsThe pressure relationship between the medial and lateral knee compartments could be recorded and was found reproducible in simulated operating-theatre conditions. The measurement of joint surface pressure during implantation of an anterior cruciate ligament graft could provide data for individual intraoperative quality control, thus improving surgical results.

Unplanned 10-year retention of an external fixator for a proximal tibial fracture.

A 45-year-old homeless male patient did not return for follow-up for routine removal 72 days after an external fixator had been placed for a grade II open fracture of the proximal tibia. Ten years later, he was accidentally referred to our institution for newly incurred fractures of the femoral neck on the same side and also for an opposite-side medial malleolus fracture. The patient was still homeless, with signs of poor personal hygiene, but the original external fixator was in place. Union of his previous proximal tibia fracture had occurred, and there were no signs of any pin-tract infection. Possibilities for this successful outcome include fracture stability, subsequent healing without pin breakage, and 7 weeks of professional wound care before the patients initial discharge from the hospital, resulting in a scarred skin barrier at the pin-skin interface.