Thomas M. Tiefenboeck

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.

Clinical and Functional Outcome of All-Inside Anterior Cruciate Ligament Reconstruction at a Minimum of 2 Years’ Follow-up

PURPOSE To evaluate the clinical and functional outcomes for anatomic anterior cruciate ligament (ACL) reconstruction using the all-inside technique with a minimum follow-up of 24 months. METHODS Patients undergoing anatomic ACL reconstruction via the all-inside technique between January 2011 and October 2012 were reviewed for inclusion in this study. Functional outcome measures, including the Lysholm score, International Knee Documentation Committee score, visual analog scale score, and Tegner Activity Scale, were used to evaluate outcomes before surgery and at 3, 6, 12, and > 24 months. At final follow-up, anteroposterior knee stability was assessed with KT-2000 (MEDmetric, San Diego, CA) measurements. RESULTS Of the 92 patients who underwent primary all-inside ACL reconstruction, 79 patients returned to final follow-up with a minimum of 2 years. There were 53 men and 26 women with a mean age of 29 years (range, 18 to 54 years) and a mean follow-up of 29 months (range, 24 to 45 months). The International Knee Documentation Committee score (44.6 v 89.7, P < .0001), Lysholm score (53.4 v 93.1, P < .001), visual analog scale score (5 v 0.1, P < .001), and Tegner activity score (2 v 6, P < .001) showed a significant improvement between baseline and final clinical follow-up. The mean side-to-side KT-2000 difference at final follow-up was 1.7 mm (range; 0 to 6 mm). Overall 10 patients (12.7%) sustained an ACL graft rerupture after a mean of 17.6 months (range, 6.9 to 28.6 months). CONCLUSIONS The current data support our first hypothesis that primary anatomic ACL reconstruction using the all-inside technique leads to improved functional outcomes between baseline and clinical follow-up at 24 months. Further, there was no difference in knee stability between the ACL reconstructed- and the contralateral normal knee at 24 months, which confirms our second hypothesis.

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.

Complete local tumor control after curettage of chondroblastoma–a retrospective analysis

BACKGROUND Chondroblastoma is an uncommon benign bone tumor with an incidence of 1 to 2% among all primary bone tumors. In the past, treatment for chondroblastoma has been highly variable leading to different rates of recurrences. Therefore we aimed to determine: (1) the rate of recurrence, (2) the complication rate, (3) and functional outcome after intralesional curettage of chondroblastoma. HYPOTHESES Intralesional curettage with high speed burring and packing can avoid local recurrences. PATIENTS AND METHODS Experiences of 22 patients with chondroblastoma of the bone were retrospectively reviewed. The patient group consisted of 16 men; 6 women; mean age 24years (range; 12-58years) affecting in 15 the lower- (68%) and in seven the upper extremity (32%). RESULTS There was no local recurrence or malignant transformation. All patients underwent intralesional curettage, followed by defect filling presenting in 19 patients (87%) excellent clinical and oncological results (mean MSTS 98.9). Complications were seen in two patients. Pain was the main revealing symptom of the chondroblastoma (n=16, 73%). Mean follow-up of all patients was 114months (range, 25 to 480months). DISCUSSION Aggressive curettage and packing provided excellent local tumor control and functional results in our patients with chondroblastoma. Malignant transformation is extremely rare, however, present in literature but was not seen in any of our patients. LEVEL OF EVIDENCE Level IV, retrospective study.

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.

Extendible Prostheses for Children After Resection of Primary Malignant Bone Tumor: Twenty-seven Years of Experience

BACKGROUND Endoprosthetic replacement in children following resection of a malignant bone tumor still is controversial because of the high number of reoperations. The aim of this study was to evaluate the long-term outcome with respect to limb-lengthening potential, satisfaction rate, and complications after implantation of extendible devices. METHODS Seventy-one patients with a sarcoma in an extremity who had been followed for more than twenty-four months (mean, 131.6 months; range, 27.2 to 281.8 months) after tumor resection and prosthetic reconstruction with an extendible device were analyzed. The mean age at the time of the operation was ten years (range, four to sixteen years). The complication-free survival rate was evaluated with competing-risk analysis. Clinical outcomes and complications were rated with use of the Musculoskeletal Tumor Society (MSTS) score and a failure mode classification for segmental tumor endoprostheses, respectively. RESULTS Twelve of seventy-one patients died of their disease. The overall MSTS score averaged 87.8% (range, 23.3% to 100%). The most common mode of failure was soft-tissue failure (46%), followed by structural failure (28%), infection (17%), and aseptic loosening (8%); only 2% of the children had local recurrence. An average of 4.4 lengthening operations per patient were required for an average limb elongation of 70.8 mm (range, 0 to 224 mm). An average of 2.5 operations (range, zero to eleven) per patient were performed for complications. CONCLUSIONS Although limb lengthening with an extendible endoprosthesis seems to be effective, many children have related complications. These data will be a source of preoperative information for children and parents, and will provide a benchmark for further clinical improvements.

Pitfalls in automatic limb lengthening – First results with an intramedullary lengthening device

BACKGROUND The treatment of leg length discrepancy and deformities has become more common over the last few decades due to newly developed implants. Lengthening using fully implantable intramedullary nails provides many advantages; however, only little data is available. Therefore, we aimed to determine: (1) safety of the implant, (2) the complication rate and (3) functional outcome after magnetic driven intramedullary bone lengthening with a telescopic implant. HYPOTHESES Automatic bone lengthening with intramedullary nails provide good short-term outcome. PATIENTS AND METHODS Ten patients with limb length discrepancy of lower extremity, treated with an Ellipse PRECICE® nail, were included in this retrospective follow-up study. The mean limb length discrepancy was 4.7cm (range: 2.5-7.0cm). RESULTS In all patients, limb lengthening goals were reached within a range of ±0.5cm after a mean time of 53 days. However, in 2 patients, mechanical failures with unintended shortening were observed. In a further patient nail breakage occurred. Overall, 7 patients presented with complications during the follow-up period. DISCUSSION The PRECICE® nail represents a new, fully implantable, magnetically driven device for limb lengthening. However, due to a high rate of complications, a close follow-up is necessary to identify early implant failures and to avoid severe adverse outcomes. LEVEL OF EVIDENCE Retrospective follow-up study, case series, level IV.

Incidence, characteristics, and long-term follow-up of sternoclavicular injuries: An epidemiologic analysis of 92 cases.

BACKGROUND The majority of published studies concerning sternoclavicular injuries are case series or systematic reviews. Prospective studies on the subject are hindered by the low incidence of these lesions. The aims of the present study were to provide an overview of this rare entity compared with those described in the literature and to present the long-term clinical outcome. METHODS We performed a retrospective data analysis of all sternoclavicular injuries treated at a single Level I trauma center from 1992 to 2011. Long-term clinical outcome was assessed using the ASES [American Shoulder and Elbow Surgeons], SST [Simple Shoulder Test], UCLA [University of California-Los Angeles] Shoulder Scale, and VAS [Visual Analog Scale] at latest follow-up. RESULTS We detected an overall incidence of 0.9% of sternoclavicular injuries related to all shoulder-girdle lesions. Ninety-two patients (52 males and 40 females) with a mean (SD) age of 39.2 (19.5) years (median, 41 years; range, 4–92 years) were included in this study. The main trauma mechanism was fall. Classification was performed according to Allman, the time point of treatment after initial trauma, and the direction of the dislocation. Nine patients of the 15 Grade III lesions were treated conservatively by closed reduction and immobilization, while four patients were treated surgically by open reduction and internal fixation. Forty-nine percent of the patients were available for long-term follow-up at a median of 11.3 years (range, 5.3–22.6 years) with a mean ASES score of 96.21, SST score of 11.69, UCLA score of 31.89, and VAS score of 0.47. CONCLUSION We found an overall incidence of 0.9% of sternoclavicular joint injuries related to all shoulder-girdle lesions and of 1.1% related to all dislocations, which is slightly lower compared with those described in the literature. Furthermore, we observed a high number of physeal sternoclavicular injuries with a percentage of 16% and overall good-to-excellent results at long-term follow-up. LEVEL OF EVIDENCE Epidemiologic study, level IV.

Intramedullary magnetically actuated limb lengthening in a patient with congenital humeral limb shortening

The treatment of leg length discrepancy has become a common procedure in orthopaedic surgery. However, lengthening of humeral deformities is still infrequent. The purpose of this case report was to present humeral lengthening with a new intramedullary lengthening device (PRECICE® P2 for tibia) in a 32 year old female patient with congenital shortening. Hereby the telescopic device presents a promising tool for humeral limb lengthening with excellent outcome at short-term in this case.

The Difference between Growth Factor Expression after Single and Multiple Fractures: Preliminary Results in Human Fracture Healing.

Objectives. Circulating levels of VEGF-A (Vascular Endothelia Growth Factor-A), TGF-β1 (Transforming Growth Factor-beta 1), and M-CSF (Macrophage-Colony Stimulating Factor) were found to be predictors of bone healing and therefore prognostic criteria of delayed bone healing or nonunion. The aim of this study was to evaluate a potential rise of these markers in patients with multiple fractures of long bones compared to patients with single fractured long bone. Methods. 92 patients were included in the study and finally after excluding all female patients 45 male patients were left for final analysis and divided into the single or multiple fracture group. TGF-β1, M-CSF, and VEGF-A serum levels were analysed over a time period of two weeks. Results. MCSF serum concentrations were higher in the group with multiple fractures as also TGF-β1 serum concentrations were at one and two weeks after trauma. No statistically significant difference was observed in the VEGF-A serum concentrations of both groups at either measurement point. Conclusion. We did observe a correlation between the quantity of the M-CSF and TGF-β1 expressions in serum and the number of fractured bones; surprisingly there was no statistically significant difference in the serum levels between patients with single and multiple fractures of long bones.