Dynamic intraligamentary stabilization: novel technique for preserving the ruptured ACL.

PURPOSE: Replacement of the torn anterior cruciate ligament (ACL) with a transplant is today`s gold standard. A new technique for preserving and healing the torn ACL is presented. HYPOTHESIS: a dynamic intraligamentary stabilization (DIS) that provides continuous postinjury stability of the knee and ACL in combination with biological improvement of the healing environment [leucocyte- and platelet-rich fibrin (L-PRF) and microfracturing] should enable biomechanically stable ACL self-healing. METHODS: Ten sportive patients were treated by DIS employing an internal stabilizer to keep the unstable knee in a posterior translation, combined with microfracturing and platelet-rich fibrin induction at the rupture site to promote self-healing. Postoperative clinical [Tegner, Lysholm, International Knee Documentation Committee (IKDC), visual analogue scale patient satisfaction score] and radiological evaluation, as well as assessment of knee laxity was performed at 6 weeks, 3, 6, 12, and 24 months. RESULTS: One patient had a re-rupture 5 months postoperative and was hence excluded from further follow-ups. The other nine patients presented the following outcomes at 24 months: median Lysholm score of 100; IKDC score of 98 (97-100); median Tegner score of 6 (range 9-5); anterior translation difference of 1.4 mm (-1 to 3 mm); median satisfaction score of 9.8 (9-10). MRI showed scarring and continuity of the ligament in all patients. CONCLUSIONS: DIS combined with microfracturing and L-PRF resulted in stable clinical and radiological healing of the torn ACL in all but one patient of this first series. They attained normal knee scores, reported excellent satisfaction and could return to their previous levels of sporting activity. LEVEL OF EVIDENCE: Case series with no comparison group, Level IV.

[Free microvascular fibula graft for skeletal reconstruction of the distal radius: 5 years follow-up after en-bloc resection of a giant cell tumour]. / Rekonstruktion des distalen Radius mittels freiem mikrovaskulären Fibulatransplantat: 5-Jahres-Resultat nach en-bloc-Resektion eines Riesenzelltumors.

A giant cell tumour of the distal radius or of the carpal bones, verified by incisional biopsies, should be approached as a low-grade malignancy. Lesions that arise in the bones of the hand or the wrist have a greater propensity to metastasise, and have a higher risk of local recurrence. In this case report we describe a 54-year-old women with a giant cell tumour of the distal radius (Campanacci grade III lesion), having a follow-up of five years without signs of local recurrence or metastatic disease. The general principles of and options for surgical treatment are discussed.

Percutaneous cement augmentation for the treatment of depression fractures of the tibial plateau.

The management of insufficiency fractures of the tibial plateau in osteoporotic patients can be very challenging, since it is difficult to achieve a stable fixation, an essential condition for the patients' early mobilization. We present a minimally invasive technique for the treatment of proximal tibial plateau fractures, "tibiaplasty", using percutaneous polymethylmethacrylate augmentation. Five osteoporotic patients (7 fractures) with a non-traumatic insufficiency tibial plateau fracture were treated with this technique at the authors' institution from 2006 to 2008. The patients' median age was 79 (range 62-88) years. The intervention was performed percutaneously under general or spinal anesthesia; after the intervention, immediate full weight bearing was allowed. The technique was feasible in all patients and no complications related to the intervention were observed. All patients reported a relevant reduction in pain, were able to mobilize with full weight bearing and would undergo the operation again. No secondary loss of reduction or progression of arthrosis was observed in radiological controls; no revision surgery was required. Our initial results indicate that tibiaplasty is a good treatment option for the management of insufficiency in tibial plateau fractures in osteoporotic patients. The technique is minimally invasive, safe and allows immediate mobilization without restrictions. In our group of patients, we found excellent early to mid-term results.

Total-body digital X-ray in trauma. An experience report on the first operational full body scanner in Europe and its possible role in ATLS.

When patients enter our emergency room with suspected multiple injuries, Statscan provides a full body anterior and lateral image for initial diagnosis, and then zooms in on specific smaller areas for a more detailed evaluation. In order to examine the possible role of Statscan in the management of multiply injured patients we implemented a modified ATLS((R)) algorithm, where X-ray of C-spine, chest and pelvis have been replaced by single-total a.p./lat. body radiograph. Between 15 October 2006 and 1 February 2007 143 trauma patients (mean ISS 15+/-14 (3-75)) were included. We compared the time in resuscitation room to 650 patients (mean ISS 14+/-14 (3-75)) which were treated between 1 January 2002 and 1 January 2004 according to conventional ATLS protocol. The total-body scanning time was 3.5 min (3-6 min) compared to 25.7 (8-48 min) for conventional X-rays, The total ER time was unchanged 28.7 min (13-58 min) compared to 29.1 min (15-65 min) using conventional plain radiography. In 116/143 patients additional CT scans were necessary. In 98/116 full body trauma CT scans were performed. In 18/116 patients selective CT scans were ordered based on Statscan findings. In 43/143 additional conventional X-rays had to be performed, mainly due to inadequate a.p. views of fractured bones. All radiographs were transmitted over the hospital network (Picture Archiving and Communication System, PACS) for immediate simultaneous viewing at different places. The rapid availability of images for interpretation because of their digital nature and the reduced need for repeat exposures because of faulty radiography are also felt to be strengths.

Patient characteristics differently affect early cup and stem loosening in THA: a case-control study on 7,535 patients.

We postulated that certain patient characteristics have different effects on early THA component loosening. With two matched case-control studies we assessed 3,028 cups and 5,224 stems. Loosening was defined using signs of mechanical component failure on routine follow-up radiographs or revision for aseptic loosening. Women and men had similar cup-loosening odds, but women had lower odds for stem loosening (p < 0.0001). Odds for cup loosening decreased by 2.1% per additional year of age (p = 0.0004), those for stem loosening by 2.4% (p < 0.0001). Each additional kilogram of weight decreased cup loosening odds by 1.3% (p = 0.0051). Each additional unit of BMI increased stem loosening odds (p = 0.0109). Charnley classes B and C were protective factors against loosening of both components. There were no risk differences for the various main diagnoses. Certain patient characteristics differently affected early cup and stem loosening, although some characteristics had the same protective or harmful effect on component survival.

Avoiding misclassification bias with the traditional Charnley classification: rationale for a fourth Charnley class BB.

Long-term follow up of patients with total hip arthroplasty (THA) revealed a marked deterioration of walking capacities in Charnley class B after postoperative year 4. We hypothesized that a specific group of patients, namely those with unilateral hip arthroplasty and an untreated but affected contralateral hip was responsible for this observation. Therefore, we conducted a study taking into consideration the two subclasses that make up Charnley class B: patients with unilateral THA and contralateral hip disease and patients with bilateral THA. A sample of 15,160 patients with 35,773 follow ups that were prospectively collected over 10 years was evaluated. The sample was categorized into four classes according to a new modified Charnley classification. Annual analyses of the proportion of patients with ambulation longer than 60 min were conducted. The traditionally labeled Charnley class B consists of two very different patient groups with respect to their walking capacities. Those with unilateral THA and contralateral hip disease have underaverage walking capacities and a deterioration of ambulation beginning 3 to 4 years after surgery. Those with bilateral THA have stable overaverage walking capacities similar to Charnley class A. An extension of the traditional Charnley classification is proposed, taking into account the two different patient groups in Charnley class B. The new fourth Charnley class consists of patients with bilateral THA and was labeled BB in order to express the presence of two artificial hip joints and to preserve the traditional classification A through C.

Sports related maxillofacial injuries: the first maxillofacial trauma database in Switzerland.

BACKGROUND: With the increase in the amount of medical data handled by emergency units, advances in computerisation have become necessary. New computer technology should have a major influence on accident analysis and prevention and the quality of research in the future. OBJECTIVES: To investigate the occurrence of sports related maxillofacial injuries using a newly installed relational database. To establish the first sports trauma database in Switzerland. METHODS: The Qualicare databank was used to prospectively review 57 248 case histories of patients treated in the Department of Emergency Medicine between January 2000 and December 2002. Pre-defined key words were used to collect data on sports related maxillofacial injuries. RESULTS: A total of 750 patients with maxillofacial injuries were identified. Ninety (12%) were sports related maxillofacial fractures. Most (27%) were sustained during skiing and snowboarding, 22% during team sports such as soccer or ice hockey, and 21% were from cycling accidents. Sixty eight per cent of the cyclists, 50% of the ice hockey players and soccer players, and 48% of the skiers and snowboarders had isolated fractures of the midface. Fractures of the mandible were noted predominantly in contact sports. CONCLUSIONS: Computerisation of trauma and emergency units and the introduction of customised software can significantly reduce the workload of researchers and doctors. The effective use of new computer technology should have a considerable influence on research and the quality of future prospective and retrospective studies.

[Long-term results with the cementless CLS stem in hip replacement]. / Langzeitresultate des unzementierten CLS-Schaftes in der Hüftendoprothetik.

OBJECTIVE: The present work aims at evaluating the clinical and radiological long-term results of the cementless CLS stem in hip replacement. METHOD: Sixty-six consecutively operated patients were examined clinically and radiologically at an average follow-up time of 10.7 (7.6 - 13.8) years. The clinical evaluation was done with the Merle d'Aubigné and the Harris hip scores. The radiological evaluation included the evaluation of radiolucencies as well as the occurrence of heterotopic ossifications. RESULTS: A total of four stems had to be revised (two infections, two periprosthetic fractures). No stem revision had to be done because of aseptic loosening. This results in a survival rate of 94.5% according to Kaplan-Meier. The mean Merle d'Aubigné scores increased from 9.0 preoperatively to 16.0 points at follow-up. The mean follow-up Harris hip score was 87.3 points. Periprothetic osteolytic zones were observed in 45% of the cases, particularly in the Gruen zones 1 and 7. These osteolytic zones were mainly found in connection with cementless polyethylene cups. CONCLUSION: The results of this study confirm the positive short and medium-term results with the CLS stem in a long-term process. The formerly described phenomenon of the residual thigh pain with cementless stems was clearly minimized.

Paragliding accidents--the spine is at risk. A study from a Swiss Trauma Centre.

In recent decades, paragliding-like other fashionable activities-has become a part of lifestyle and outdoor activities. The introduction of protective devices has helped to reduce the risk of severe injuries. However, it seems that the spine remains the paraglider's 'Achilles heel'. Better education, training, and the introduction of innovative back protectors are required to reduce the frequency and severity of paragliding injuries.

The validity of clinical examination in the diagnosis of loosening of components in total hip arthroplasty.

We analysed follow-up data from 18,486 primary total hip arthroplasties performed between 1967 and 2001 to assess the validity of clinical procedures in diagnosing loosening of prosthetic components. Sensitivity, specificity and predictive values were estimated with the radiological definition of loose or not loose as the 'gold standard'. The prevalence of acetabular loosening increased from 0.6% to 13.9% during the period of the study and that of femoral loosening from 0.9% to 12.1%. Sensitivities and positive predictive values were low, suggesting that clinical procedures could not replace radiological assessment in the identification of loose prostheses. Specificities and negative predictive values were constantly above 0.86. The possibility of there being a prosthesis which is not loose in asymptomatic patients was consequently very high, particularly during the first five to six years after operation. The necessity of periodic clinical and radiological follow-up examinations of asymptomatic patients during the first five to six years after operation remains questionable. Symptomatic patients, however, require radiological assessment.

Hoof kick injuries in unmounted equestrians. Improving accident analysis and prevention by introducing an accident and emergency based relational database.

OBJECTIVE: To assess injury patterns attributable to horse kicks, to raise the issue of preventive measures, and to evaluate the role of modern accident and emergency department computer software. METHODS: Data analysis using a new kind of full electronic medical record. RESULTS: Seventeen kicked equestrians were unmounted at the time of injury. Eight of seventeen patients sustained contusions of the extremities, the back, and the trunk. In nine patients an isolated facial injury was diagnosed. Five of nine patients needed referrals to the department of plastic surgery because of the complexity of the facial soft tissue wounds. Three underwent maxillofacial surgery. CONCLUSION: Clinical: the equestrian community may underestimate the risk of severe injuries attributable to hoof kicks, especially while handling the horse. Educational lectures and the distribution of educational literature should be promoted. The introduction of additional face shields may be protective. Software related issue: the handling of an increasing amount of medical data makes a development in computerisation of emergency units necessary. Thus the increasing utilisation of new computer technology could have a significant influence on accident analysis and prevention and the quality of research in the future.

Comparison of polyethylene wear with femoral heads of 22 mm and 32 mm. A prospective, randomised study.

In this prospective, randomised study, we have compared the wear rate of cemented, acetabular polyethylene cups articulating with either a 22 mm or a 32 mm cobalt-chromium head. We evaluated 89 patients who had a total of 484 radiographs. The mean follow-up period was 71.4 months (SD 29.1). All the radiographs were digitised and electronically measured. The linear wear rate was significantly higher during the first two years and decreased after this period to a constant value. We suggest that this is partly due to a 'run-in' process caused by irregularities between surfaces of the cup and head and an initial plastic deformation of the polyethylene. The mean volumetric wear was 120.3 mm/year for the 32 mm head, which was significantly higher than the 41.5 mm3/year for the 22 mm heads. The mean linear wear rate was not significantly different. We were, however, unable to find radiological signs of osteolysis in the patients who had higher wear rates.

Unstable scaphoid fracture nonunion: a medium-term study of anterior wedge grafting procedures.

A retrospective review of 37 patients with scaphoid fracture nonunions treated by interpositional bone grafting and internal fixation was conducted at an average follow-up of 5.7 years. Solid radiographic union was achieved in 35 cases. Preexisting avascular necrosis was a major adverse factor for achievement of union and satisfactory outcome. Based on the modified Mayo wrist-scoring system, 15 patients had an excellent result, 11 had a good result, four had a fair result and seven had a poor result. Patients with preexisting degenerative changes had a significantly worse clinical outcome. The vast majority of the patients had satisfactory correction of scaphoid length and the associated dorsal intercalated segment instability (DISI). Although 30 patients showed radiographic evidence of mild or moderate degenerative changes at their latest follow-up, there was no significant progression of arthrosis and the scaphoid nonunion advanced carpal collapse deformity did not progress after healing of the fracture nonunion.

Maxillofacial injuries related to work accidents: a new concept of a hospital-based full electronic occupational trauma surveillance system.

The objective of this study was to investigate the occurrence of occupational maxillofacial injuries using a newly installed relational database. Twenty-six injuries were identified out of 28,624 patients admitted to the emergency unit during a 12 month period. Falls from height or being struck by moving objects were common causes of these injuries. Two-thirds of those identified were construction workers. This paper demonstrates the power of modern databases to identify specific occurrences that may provide the basis for prevention in the future.

Risk factors for heterotopic ossification in total hip arthroplasty.

This study prospectively evaluated 928 patients with 1318 primary total hip replacements for heterotopic ossification (HO). The mean clinical and radiological follow-up was 2.5 years (range 1.5-3.6 years). HO was noted in 44.6% of all total hips replaced. It was graded as mild (Brooker 1) in 29.2%, moderate (Brooker 2) in 10.5%, and severe (Brooker 3 and 4) in 4.2%. The following factors showed a significantly increased risk of HO: hypertrophic osteoarthritis, HO after contralateral total hip replacement, trochanteric osteotomy, lateral or anterolateral approach, previous hip surgery, subtrochanteric femoral osteotomy, and male gender (p < 0.05 in chi-square analysis of independence and multivariable analysis). Patients with rheumatoid arthritis showed less HO. A combination of any of these factors resulted in a significant increase in the risk of developing HO.

The kick with the stick.

OBJECTIVE: To investigate the incidence and type of severe microscooter related injuries in adults. METHOD: Data were collected between January and September 2000 from the University Hospital Berne, the only referral centre for major trauma in that city, using the software package Qualicare, which connects clinical data with categorised keywords, allowing the immediate localisation of patient groups with defined diagnosis or other clinical information. RESULTS: Only 0.2% of the patients treated had suffered a microscooter accident. There were five head injuries: three facial lacerations, one fractured mandible, and one cerebral concussion. One patient showed clinical signs of a cervical whiplash injury without radiological findings. There were also two cases of finger laceration and two of muscular contusions of the lower extremities. CONCLUSIONS: Although only a small proportion of the trauma cases were the result of riding microscooters, a system of injury surveillance should be started. Furthermore, protective gear should be worn particularly when microscooters are ridden in the street.