Roman C. Ostermann

Anterior screw fixation of odontoid fractures comparing younger and elderly patients.

Study Design. A retrospective, comparative study. Summary of Background Data and Objectives. Anterior screw fixation has become an accomplished treatment option for the management of odontoid fractures. In younger patients, it has shown encouraging results with low complication rates; whereas in geriatric trauma victims, it remains the subject of controversy. The purpose of this study was to determine functional and radiographic results after anterior screw fixation of Type II odontoid fractures, with the particular interest to compare the outcome between younger and elderly patients. Material/Methods. We reviewed clinical and radiographic records of 110 patients with an average age of 54 years at the time of surgery after anterior double screw fixation of their odontoid fractures between 1990 and 2004. To compare functional and radiographic results between nongeriatric and geriatric patients, they were divided by age into 2 groups: Group A included patients 65 years of age or younger and Group B contained patients older than 65 years. Results. A total of 95 patients had returned to their preinjury activity level and were satisfied with their treatment. The Smiley-Webster scale showed an overall outcome score of 1.42 with similar results in both groups (Group A, 1.34; Group B, 1.50). Bony fusion was achieved in 102 patients, failures of reduction or fixation occurred in 12 patients. Comparing between the 2 groups, we had a nonunion rate of 4% in younger individuals and a significantly higher rate of 12% in geriatric patients. Reoperation due to nonunion or technical failures was necessary in 8 patients. Conclusion. We had encouraging results using anterior screw fixation for surgical treatment of odontoid fractures and favor this method as preferred management strategy for stabilization of these fractures. Comparing between age groups, we had similar results on cervical spine function. With regards to fracture healing as well as morbidity and mortality, younger patients had a superior outcome.

Management and outcome of interprosthetic femoral fractures.

INTRODUCTION Interprosthetic femoral fractures following ipsilateral hip and knee arthroplasty are a rare but serious complication in clinical practice. In most cases, adequate management of these injuries might constitute a challenging problem. However, the literature provides only few data regarding the treatment and outcome of interprosthetic femoral fractures, and there are only few classifications available, which might assist in finding an appropriate treatment concept. The purpose of this study was to analyse our experience in the management of interprosthetic femoral fractures following ipsilateral hip and knee joint replacement. MATERIALS AND METHODS We reviewed the clinical and radiographic records of 23 patients (15 female and eight male, average age: 79.2 years) with an interprosthetic fracture after ipsilateral hip and knee joint replacement between 1992 and 2008. For the classification of interprosthetic femoral fractures, the fractures were divided into three types, depending on the fracture site and the adjacency to the prostheses. All patients underwent operative stabilisation, either by lateral plate fixation (n=19), by revision arthroplasty using a long stem (n=2) or by plate fixation and revision arthroplasty (n=2). RESULTS Referring to the clinical outcome, 16 patients returned to their pre-injury activity level and were satisfied with their clinical outcome. In six patients, we saw a relevant decrease of hip or knee function and severe limitations in gait and activities of daily living. We had a mean Harris Hip Score (HHS) of 78.4 points, and a mean Knee injury and Osteoarthritis Outcome Score (KOOS) of 71.8 points. Relating to the radiographic outcome, successful fracture healing was achieved in 19 of 22 patients (86%) within 6 months. Failures of reduction and fixation were noted in four (18%) of 22 patients. CONCLUSION We had a satisfactory outcome following individualised treatment of interprosthetic femoral fractures following ipsilateral hip and knee joint replacement. Compared to the rare data in current literature, we had promising functional result and high rate of bony fusion. Regarding the complexity and challenges in many of these cases, interprosthetic fractures require an adequate analysis of the fracture aetiology and a suitable transfer into the best possible treatment concept.

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.

Clinical and functional outcome after anterior cruciate ligament reconstruction using the LARS™ system at a minimum follow-up of 10 years.

BACKGROUND Since the 1980s several artificial ligaments were used for reconstruction of the anterior cruciate ligament (ACL) serving different complications. The aim of this study was to assess the clinical and functional outcomes of primary ACL reconstruction using the Ligament Augmentation Reconstruction System (LARS™) with a minimum follow-up of 10-years. The LARS™ presents a synthetic material consisting of non-absorbing polyethylene terephthalate fibres used for ligament reconstruction. METHODS Outcomes of 18 patients who underwent arthroscopic ACL reconstruction using the LARS™ system between 2000 and 2004 with a minimum follow-up of 10 years were observed. The International Knee Documentation Committee score (IKDC), Visual Analog Scale (VAS), Lysholm score, and Tegner Activity Scale were assessed. Clinical assessment was performed by Lachman testing, assessment of side-to-side difference on KT-2000 testing and plain radiography evaluation of osteoarthritis. RESULTS There were seven males and 11 females, mean age 29 years (range, 18 to 44 years) and a mean follow-up of 151.5 months. Five patients (27.8%) sustained a re-rupture of the LARS™ system and underwent revision surgery after a mean time of 23 months and four patients (22.2%) presented with a re-rupture. The average IKDC score was 76.60 ± 18.18, the average Lysholm score was 88.00 ± 10.07 and the average Tegner activity score was five at final follow-up. CONCLUSION Our results indicate that the LARS™ system should currently not be suggested as a potential graft for primary reconstruction of the ACL. In special cases, however, the LARS™ system can serve as an alternative graft.

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.

A bigger suture diameter for anterior cruciate ligament all-inside graft link preparation leads to better graft stability: An anatomical specimen study

BACKGROUND In anterior cruciate ligament reconstruction, different suture types are used for graft link preparation. Thus the aim of this study was to determine whether differences in the diameter of the suture used influence biomechanical stability of the prepared graft. We hypothesized that the use of a greater suture diameter leads to a higher load to failure rate in tested graft links. METHODS In an anatomic specimen study, ligament preparation was enrolled in 15 cadaveric knees. The material used was the semitendinosus/gracilis tendon, which was fresh frozen (-80°) after harvesting for four weeks. The grafts were then defrosted, randomized into two groups and prepared with the same technique: 12 with a suture; FiberWire No. 2 and 12 with a FiberWire No. 0. RESULTS Overall, the group using FiberWire No. 2 presented with a mean load to failure rate of 730.67N, mean overall final elongation of the graft was 5.98mm. In the FiberWire No. 0 group mean load to failure was with a mean overall elongation of the graft of 6.96mm. Significant differences (P=0.006) between the two groups with regard to the load to failure rate were found, with FiberWire No. 2 withstanding forces better. There was no difference in elongation of the grafts or mode to failure between the two groups. CONCLUSIONS Graft preparation with a bigger suture type is recommended to gain better load to failure rates, also in smaller-diameter grafts. Regarding the elongation rate, different suture types did not influence the outcome. LEVEL OF EVIDENCE Anatomical specimen study, Level III.

An Arthroscopic Knotless Technique for Anatomical Restoration of the Rotator Cuff and Superior Capsule: The Double-Layer Cinch Bridge

Rotator cuff repairs are the most common procedures in shoulder surgery, but still show long-term retear rates of up to 70%. Nonanatomic reconstruction is one possible cause of repair failure. The rotator cuff histologically consists of 5 separate layers of which 2 are macroscopically identifiable: the superior or tendinous layer and the inferior or capsule-ligamentous layer. In case of rotator cuff tears, these layers are often retracted to different degrees. The intraoperative detectable prevalence of rotator cuff delamination reaches up to 85%. Anatomical rotator cuff repair, which also includes restoration of the layered structure, could re-establish native tendon morphology and thus potentially decreases retear rates. The use of a knotless construct to avoid cuff strangulation and maintaining tendon perfusion could further decrease the risk of repair failure. Double-layer reconstructions are challenging and time consuming because each layer needs to be penetrated separately. Only few studies reported about double-layer reconstruction of the posterosuperior rotator cuff. This Technical Note is the first to present an arthroscopic knotless transosseous-equivalent double-layer repair technique.

The use of the LARS system in the treatment of AC joint instability – Long-term results after a mean of 7.4 years

BACKGROUND The acromioclavicular (AC) joint is of great importance for shoulder stability and one of the most frequently injured regions of the shoulder. HYPOTHESIS AC joint reconstruction with the ligament augmentation & reconstruction system (LARS™) leads to a good-to-excellent outcome at long-term follow-up. PATIENTS AND METHODS This study was performed as a retrospective single-centre data analysis of a level-I trauma centre. All patients treated operatively for an acute AC dislocation with the LARS™ between 2003 and 2013 were included. RESULTS The study group consisted of three female (6%) and 44 male patients (94%) with an average age of 37 years and a minimum follow-up of two years. The overall mean clinical outcomes at latest follow-up were: Constant 93, DASH 2.64, ASES 96, SST 97, UCLA 34 and VAS 0.4-representing a good-to-excellent outcome in all patients. Overall, 45 patients (96%) reported to be very satisfied with the achieved result at latest follow-up. In five patients, (11%) complications occurred during the follow-up period, requiring surgical revision in four of the five patients (80%). CONCLUSION AC joint reconstruction with the LARS™ achieves good-to-excellent clinical and functional outcomes at long-term follow-up with a surgical revision rate of 8.5%. LEVEL OF EVIDENCE Retrospective follow-up study, case series, level IV.