Operative Treatment of Acute Patellar Tendon Ruptures.

BACKGROUND: The gold standard for patellar tendon repair is a transosseous technique. Suture anchor repair has gained popularity, with recent biomechanical studies demonstrating significantly less gap formation during cyclic loading and significantly higher ultimate failure loads as compared with transosseous repair. These findings have not been substantiated in a large clinical cohort. PURPOSE: To report demographic and epidemiologic data, clinical and surgical findings, and outcomes and complications of anchor and transosseous suture repairs of acute patellar tendon ruptures. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All patients who underwent a primary repair of a traumatic patellar tendon rupture within 45 days of injury between 2006 and 2016 were retrospectively reviewed. Surgery was performed at a multisurgeon (120 surgeons) multicenter (14 centers) community-based integrated health care system. Patient demographic information, repair type, complications, and time from surgery to release from medical care were recorded. RESULTS: A total of 361 patients (374 knees) met our inclusion criteria. The mean age was 39.8 years (range, 9-86 years), and 91.7% were male. There were 321 transosseous and 53 anchor repairs. There was no significant difference in the mean age (P = .27), sex (P = .79), tourniquet time (P = .93), or body mass index (P = .78) between the groups. There was a significant difference in rerupture rate between transosseous and anchor repairs (7.5% vs 0%, respectively; P = .034). Based on logistic regression, transosseous repair had 3.24 times the odds of reoperation verseus anchor repair (95% CI, 0.757-13.895; P = .1129). The infection rate was 1.6% for transosseous repair and 7.5% for anchor repair (P = .160). There was no difference in time to release from medical care: 18.4 weeks for anchor and 17.1 weeks for transosseous repairs (P = .92). CONCLUSION: Anchor repair demonstrated a significant decrease in rerupture rate when compared with transosseous repair. There was no difference in reoperation rate, infection rate, or time to release from medical care.

Influence of aortic neck characteristics on successful aortic wall penetration of EndoAnchors in therapeutic use during endovascular aneurysm repair.

OBJECTIVE: This study sought to quantify EndoAnchor (Medtronic Vascular, Santa Rosa, Calif) penetration into the aortic wall in patients undergoing endovascular abdominal aortic aneurysm repair and to assess predictors of successful penetration and its relationship to postprocedural type IA endoleak. METHODS: A subset of patients from the Aneurysm Treatment Using the Heli-FX Aortic Securement System Global Registry (ANCHOR) were included if they met the following criteria: the indication for EndoAnchor use was to treat a type IA endoleak, and postprocedure contrast-enhanced computed tomography (CT) scans of sufficient quality were available for core laboratory review. Patients undergoing implantation of cuffs or stents during the EndoAnchor implantation procedure were excluded. Baseline anatomic characteristics were recorded. The cohort was divided into patients with and without persistent type IA endoleaks at the first postoperative CT scan. Penetration of each EndoAnchor measured on this CT scan was defined as good penetration when the EndoAnchor penetrated ≥2 mm into the aortic wall, borderline penetration when EndoAnchor penetration was <2 mm or a gap remained between the endograft and aortic wall, or no penetration when the EndoAnchor did not penetrate into the aortic wall. Differences between the groups were analyzed with the Mann-Whitney U test or Fisher exact test. Multivariate analyses were performed to identify independent predictors of EndoAnchor penetration, and procedural success was defined by absence of type IA endoleak. RESULTS: Eighty-six patients of the primary (n = 61 [71%]) and revision (n = 25 [29%]) arms of the ANCHOR registry were included. There were 53 (62%) without and 33 (38%) with persistent type IA endoleaks on the first postprocedural CT scan. The median number of EndoAnchors with good penetration was significantly greater in the cohort without endoleaks, 4 (interquartile range, 3-5) vs 3 (interquartile range, 1.5-4), respectively (P = .002). A multivariate model for EndoAnchor penetration identified use of a Medtronic Endurant endograft as a factor associated with good penetration (P = .001), whereas poor penetration was associated with a larger aortic neck diameter 10 mm distal to the lowest renal artery (P < .001) and greater proximal neck calcium thickness (P = .004). EndoAnchor penetration was the only variable that attained significance (P < .001) in the multivariate model for successful treatment of a type IA endoleak. CONCLUSIONS: Adequate EndoAnchor penetration into the aortic wall is less likely when the aortic neck diameter is large or when the neck contains significant mural calcium. No penetration of the EndoAnchor was the only factor predictive of postprocedural type IA endoleak. This study stresses the importance of careful selection of patients based on preoperative assessment of the infrarenal neck on CT angiography and emphasizes careful deployment of EndoAnchors into the aortic wall to improve successful treatment of type IA endoleaks.

Operative Management of Acute Triceps Tendon Ruptures: Review of 184 Cases.

BACKGROUND: Distal triceps tendon ruptures are rare. The authors present a series of 184 surgically treated, acute, traumatic triceps tendon avulsions and compare the complications between those treated with anchors (A) versus transosseous (TO) suture repair. HYPOTHESIS: No difference exists in the retear rate between TO and A repairs. Study Designed: Cohort study; Level of evidence, 3. METHODS: All patients who underwent an open primary repair of a traumatic triceps tendon avulsion within 90 days of injury, between 2007 and 2015, were retrospectively reviewed. Surgeries were performed within a multisurgeon (75 surgeons), multicenter (14 centers), community-based integrated health care system. Patient demographic information, type of repair, complications, and time from surgery to release from medical care were recorded. RESULTS: 184 triceps tears in 181 patients met the inclusion criteria. The mean age was 49 years (range, 15-83 years). There were 169 males. The most common mechanisms of injury were fall (56.5%) and weight lifting (19%). Mean time from injury to surgery was 19 days (range, 1-90 days); in 74.5% of cases, surgery was performed in 3 weeks or less. There were 105 TO and 73 A repairs. No significant difference was found between the two groups in the mean age ( P = .18), sex ( P = .51), completeness of tears ( P = .74), tourniquet time ( P = .455), and prevalence of smokers ( P = .64). Significant differences were noted between TO and A repairs in terms of reruptures (6.7% vs 0%, respectively; P = .0244), overall reoperation rate (9.5% vs 1.4%; P = .026), and release from medical care (4.3 vs 3.4 months; P = .0014), but no difference was seen in infection rate (3.8% vs 0%; P = .092). No difference was noted in release from medical care in patients who underwent surgery 3 weeks or less after injury compared with those undergoing surgery more than 3 weeks after injury (3.90 vs 4.09 months, respectively; P = .911). CONCLUSION: Primary repair of triceps ruptures with TO fixation has a significantly higher rerupture rate, higher reoperation rate, and longer release from medical care than does repair with A fixation. Implementation of suture anchors in triceps repairs offers a lower complication rate and earlier release from medical care.

Surgical Treatment of Distal Biceps Tendon Ruptures: An Analysis of Complications in 784 Surgical Repairs.

BACKGROUND: Distal biceps brachii tendon ruptures lead to substantial deficits in elbow flexion and supination; surgical repair restores muscle strength and endurance. PURPOSE: To examine clinical and surgical outcomes for distal biceps tendon repairs in a large, multispecialty, integrated health care system. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Retrospective cohort study of distal biceps tendon repairs performed between January 1, 2008, and December 31, 2015. The repair methods were classified as double-incision approach using bone tunnel-suture fixation or anterior single-incision approach. Anterior single incisions were further classified according to the fixation method: cortical button alone, cortical button and interference screw, or suture anchors alone. Patient demographics, surgeon characteristics, range of motion, and complications were analyzed for all repair types. RESULTS: Of the 784 repairs that met the inclusion criteria, 639 (81.5%) were single-incision approaches. When comparing double-incision and single-incision repairs, there was a significantly higher rate of posterior interosseous nerve palsy (3.4% vs 0.8%, P = .010), heterotopic bone formation (7.6% vs 2.7%, P = .004), and reoperation (8.3% vs 2.3%, P < .001). The most common nerve complication encountered was a lateral antebrachial cutaneous nerve palsy (n = 162), which was significantly more common in the single-incision repairs than in the double-incision repairs (24.4% vs 4.1%, P < .001). When excluding lateral antebrachial cutaneous nerve palsies, there was no significant difference in the overall nerve palsies between single-incision and double-incision (5.8% vs 6.9%, P = .612). The overall rate of tendon rerupture was 1.9% (single incision, 1.6%; double incision, 2.8%; P = .327). The overall rate of postoperative wound infection was 1.5% (single incision, 1.3%; double incision, 2.8%; P = .182). The average time from surgery to release from medical care was 14.4 weeks (single incision, 14 weeks; double incision, 16 weeks; P = .286). Patients treated with cortical button plus interference screw were released significantly sooner than were patients with other single-incision repair types (13.1 ± 8.01 weeks, P = .011). There were no significant differences in rates of motor neurapraxia, infection, rerupture, and reoperation with regard to surgeon's years of practice, fellowship training, or case volume. CONCLUSION: The surgical repair of distal biceps tendon ruptures has an overall low rate of serious complications, regardless of approach or technique. However, the double-incision technique has a higher rate of posterior interosseous nerve palsy, heterotopic bone formation, and reoperation rate. Surgeon's years of practice, fellowship training, and case volume do not affect the rate of major complications.

Conversion of traditional osseointegrated bone-anchored hearing aids to the Baha® attract in four pediatric patients.

Bone-anchored hearing aids are external devices attached to the skull via a titanium implant, and can be used for multiple types of hearing loss. Traditionally, osseointegrated implants have been coupled to the external processor with a percutaneous abutment, but more recently, a fully implanted, transcutaneous magnet-based system has become available. Skin reactions from the percutaneous portion are a common complication that can prevent use of the device during critical windows of language development and learning in children. We describe our experience replacing the Baha® abutment system with the Baha® Attract in four pediatric patients. Specific operative considerations for incision placement, and magnet and implant coverage are discussed. All patients maintained osseointegration, had excellent long-term wound healing without post-operative infection, and were able to wear their devices more consistently.

Anchor suture fixation of distal pole fractures of patella: twenty seven cases and comparison to partial patellectomy.

PURPOSE: Partial patellectomy (PP) and reattachment of the patellar ligament with transosseous suturing is the mainstay of surgical treatment for distal pole patellar fractures. An anchor suturing (AS) technique has recently been reported as an alternative to PP in such fractures and allows for bone-to-bone interface and possibly superior fracture healing than bone-to-tendon interface with PP. We present our experience with AS and compare it to PP. METHODS: Between 2006 and 2011, 60 patients with distal pole patellar fracture underwent either AS (n = 27) or PP (n = 33). We retrospectively gathered their demographic data and information on fracture type, fixation technique, operation time, postoperative complications and knee range of motion. A telephone survey was performed to grade functional outcomes with standard questionnaires (the SF-12 for quality of life, the Kujala score for patellofemoral function and a visual analog scale [VAS] pain score). RESULTS: AS was equivalent to PP in terms of residual pain and functional outcomes (VAS: 2.45 vs. 2.26, p = 0.83 and Kujala score: 74.3 vs. 69, p = 0.351, respectively) as well as for knee range of motion. Complications included three cases of infection in each group, two cases of early hardware failure and one case of non-union in the AS group. Operation time was significantly shorter for AS compared to PP (68.5 vs. 79.1 min, p = 0.03). CONCLUSIONS: AS is non-inferior to PP for function and pain after distal pole patellar fractures and is superior to PP with regard to operative time. Common complications of this technique are hardware failure and infections. LEVEL OF EVIDENCE: Therapeutic Level III.

Radiofrequency thermotherapy vs bone-anchored suspension for treatment of lateral nasal wall insufficiency: a randomized clinical trial.

IMPORTANCE: Lateral nasal wall insufficiency is a common problem with little consensus on optimal treatment. OBJECTIVE: To assess the efficacy of radiofrequency (RF) thermotherapy for the treatment of lateral nasal wall collapse. DESIGN, SETTING, AND PARTICIPANTS: A prospective randomized trial comparing RF thermotherapy with bone-anchored suspension technique (BAST) for lateral nasal wall collapse in 13 patients was conducted, with recruitment occurring between March 1, 2010, and February 28, 2012, and follow-up of 1 year. The setting was a tertiary care facial plastic and reconstructive surgery clinic at an academic hospital. Eligible patients had lateral nasal wall insufficiency and met study inclusion criteria. INTERVENTIONS: Participants were randomized to receive either BAST of the lateral nasal wall or RF thermotherapy to the lateral nasal wall. MAIN OUTCOMES AND MEASURES: Outcomes were assessed 1, 3, 6, and 12 months after surgery using 2 subjective patient outcomes surveys (the Nasal Obstructive Symptom Evaluation and a visual analog scale) and a physician-derived assessment of lateral wall collapse. RESULTS: Significant improvements in symptom scores were seen postoperatively for both treatment arms, though more consistently in the radiofrequency group. One month postoperatively, the mean (SD) drop in NOSE scores was 52.5 ± 22.2 and 51.7 ± 26 (P = .96) for the BAST and RF groups, respectively. Similar results were noted at 6 and 12 months postoperatively (56.7 ± 38.2 vs 50 ± 14.7 [P = .76] and 53.3 ± 20.2 vs 56.7 ± 18.9 [P = .84] at 6 and 12 months, respectively). No statistical difference in change in NOSE scores occurred between the 2 groups at 1, 6, or 12 months postoperatively. Likewise, the drop in VAS scores between the 2 treatment groups was similar at each time point. One month postoperatively, the mean (SD) drop in VAS scores was 5.1 ± 2.8 and 4.8 ± 2.6 (P = .90). Similar results were noted at 6 and 12 months postoperatively (5.8 ± 3.4 vs 4.9 ± 3.1 [P = .72] and 5.5 ± 3.1 vs 5.4 ± 1.3 [P = .96] at 6 and 12 months, respectively). Using a physician-derived score, significant improvement was seen in patients in the RF group at 1 month (P = .005), 6 months (P = .002), and 12 months (P = .03). For the BAST group, significant improvement was noted only at the 1-month postoperative visit (P = .007). Comparison of RF vs BAST revealed significant improvement in the RF group over the BAST group at 12 months (P = .04). The other periods revealed no significant differences between the two. CONCLUSIONS AND RELEVANCE: Radiofrequency thermotherapy is a viable alternative option for lateral nasal wall collapse, both in terms of improvements in symptoms and physical examination, with suggested evidence for efficacy at least as good as that for bone-anchored suspension. LEVEL OF EVIDENCE: 1. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN14219489.

Isolated plantar dislocation of the 1st metatarsophalangeal joint.

Plantar dislocation of the 1st metatarsophalangeal joint is an extremely rare injury. To the best of our knowledge, there are no previous reports in the literature of an isolated dislocation of this type requiring open reduction and surgical repair. In this case report, we describe the clinical and operative findings and discuss in detail our surgical technique for the successful management of this unusual injury.

Effectiveness of low-profile supplemental fixation in anterior cruciate ligament reconstructions with decreased bone mineral density.

PURPOSE: The purpose of this study was to compare anterior cruciate ligament (ACL) fixation using a bioabsorbable interference screw (BIS) and a supplemental low-profile suture anchor (PushLock 4.5-mm polyetheretherketone anchor; Arthrex, Naples, FL) with a standard BIS fixation to determine if fixation methods were dependent on tibial bone mineral density (BMD). METHODS: Ten matched pairs of fresh-frozen human female knee specimens (20 total) were harvested with specimen ages ranging from 40 to 65 years. The BMD for each specimen was determined with a dual-energy x-ray absorptiometry scanner. The specimens were divided into 2 groups, 1 with a BIS and the other with a BIS plus a PushLock. Tibial-sided ACL fixation with hamstring tendon grafts was performed on all the specimens. Then, load to failure and stiffness were biomechanically tested. RESULTS: The BIS-plus-PushLock specimens had a significantly higher mean yield load compared with specimens with the BIS alone (702 N v 517 N, P = .047). However, in samples with lower bone density, there was no statistically significant difference in failure loads between fixation techniques (P = .8566 at BMD of 0.5 g/cm(2)). As the bone density of the samples increased, the failure loads increased for both techniques (P < .0001 for PushLock and P = .0057 for BIS). This BMD-associated increase was greater for the PushLock (P = .0148), resulting in a statistically significant difference in failure load at the upper range tested (P = .0293 at BMD of 0.9 g/cm(2)). CONCLUSIONS: Supplemental fixation of ACL reconstructions with a PushLock is beneficial in persons with a normal BMD of the proximal tibia, but at a lower BMD, there was no difference in our study. CLINICAL RELEVANCE: Individuals with normal BMDs may benefit from this supplemental fixation. However, caution should be used in postmenopausal women or individuals with chronic ACL injuries when using this fixation strategy.

Comparison of speech discrimination in noise and directional hearing with 2 different sound processors of a bone-anchored hearing system in adults with unilateral severe or profound sensorineural hearing loss.

OBJECTIVE: To evaluate and compare the benefit of a bone-anchored hearing implant with 2 different sound processors in adult patients with unilateral severe to profound sensorineural hearing loss (UHL). STUDY DESIGN: Prospective crossover design. SETTING: Tertiary referral center. PATIENTS: Eleven adults with UHL and normal hearing in the contralateral ear were assigned to 2 groups. INTERVENTION: All subjects were unilaterally implanted with a bone-anchored hearing implant and were initially fitted with 2 different sound processors (SP-1 and SP-2). SP-1 is a multichannel device equipped with an omnidirectional microphone and relatively simple digital signal-processing technology and provides a user-adjustable overall gain and tone control with compression limiting. SP-2 is a fully channel-by-channel programmable device, which can be set with nonlinear dynamic range compression or linear amplification. In addition, SP-2 features automatic noise management, an automatic multichannel directional microphone, microphone position compensation, and an implementation of prescription rules for different types of hearing losses, one of them unilateral deafness. After at least 1-month use of the initial processor, both groups were fitted with the alternative processor. MAIN OUTCOME MEASURES: Speech discrimination in noise and localization tests were performed at baseline visit before surgery, after at least 1-month use of the initial processor, and after at least 2-week use of the alternative processor. RESULTS: Relative to unaided baseline, SP-2 enabled significantly better overall speech discrimination results, whereas there was no overall improvement with SP-1. There was no difference in speech discrimination between SP-1 and SP-2 in all spatial settings. Sound localization was comparably poor at baseline and with both processors but significantly better than chance level for all 3 conditions. CONCLUSION: Patients with UHL have an overall objective benefit for speech discrimination in noise using a bone-anchored hearing implant with SP-2. In contrast, there is no overall objective benefit from SP-1. Depending on the speech-in-noise presentation setting, the difference between objective benefit from SP-2 and SP-1 might be mainly attributed to the new technological features in SP-2 unavailable in SP-1 such as 1) automatic noise management reducing the noise in the speech signal and thus improving the signal-to-noise ratio of the resulting signal on the better ear, 2) programmable multichannel sound-processing and nonlinear dynamic range compression offering considerably greater control over signal amplification compared to SP-1, and 3) implementation of a prescription rule for unilateral deafness addressing the specific amplification needs of patients with UHL by reducing amplification in the low frequencies and applying additional gain in the high frequencies. Sound localization is poor but better than chance level in the unaided condition as well as in both bone-anchored hearing system-aided conditions.

Audiologic and surgical outcomes of a novel, nonpercutaneous, bone conducting hearing implant.

OBJECTIVE: To assess the selection criteria, surgical technique, audiologic, and quality of life outcomes for a novel, nonpercutaneous bone conductor hearing aid. STUDY DESIGN: Retrospective case review. SETTING: Secondary otology practice. PATIENTS: Eighteen patients (16 adults and 2 children). INTERVENTION: Implantation of unilateral (n = 16) or bilateral (n = 2) devices. MAIN OUTCOME MEASURES: Mean preoperative and postoperative air conduction and bone conduction free-field testing, BKB-SIN aided and unaided at 0-degree 70 dB SPL, Speech, Spatial, and Qualities of Hearing Scale (SSQ), aided and unaided measures of localization and discrimination in single-sided deafness (SSD), surgical complications. RESULTS: Implants have been fixed under general or local anesthesia without perioperative complications. Two patients noted minor skin irritation only. Audiologic gain was greatest for those with bilateral conductive loss (21.9 ± 10.4 dB HL). For those with bilateral and unilateral mixed loss, gain was 6.2 ± 5.3 dB HL and 5.5 ± 6.5 dB HL, respectively. A greater improvement was seen with BKB-SIN at 70 dB SPL at 0 with all groups except for SSD, gaining statistically significant benefit. Localization and discrimination studies in patients with SSD or unilateral conductive loss failed to detect benefit from aiding. SSQ scores show an improvement in all domains for each patient group. CONCLUSION: The surgical procedure requires no specialized equipment and can be performed as a day case. This device complements treatment for patients requiring bone conduction aids and presents as an alternative to conventional percutaneous bone-anchored implants.

Supplemental bio-tenodesis improves tibialis anterior allograft yield load in extremely low density tibiae.

INTRODUCTION: Improved soft tissue tendon graft mechanical properties have led to their increased use for anterior cruciate ligament (ACL) reconstruction. Because they do not have an osseous component; however, there are greater concerns regarding tibial graft slippage during early postoperative rehabilitation and activities of daily living, particularly in patients with poor bone mineral density (BMD), such as older patients, women, smokers, and patients undergoing revision ACL reconstruction surgery. METHODS: This in vitro biomechanical study attempted to determine the effectiveness of supplemental ACL graft fixation in low BMD tibiae. Eight paired knees (16 specimens) were harvested from female cadavers (mean age = 76, range = 60-88 years). Tibiae were assigned to either a combination bioabsorbable interference screw, bio-tenodesis screw group (Group 1, n = 8, apparent BMD = 0.44 ± 0.13 g/cm(2)) or a bioabsorbable interference screw group (Group 2, n = 8, apparent BMD = 0.44 ± 0.14 g/cm(2)). Double-strand (single loop) tibialis anterior tendon allografts were fixed in matched diameter tibial tunnels. Using a custom 6° of freedom jig, potted constructs were mounted on to a servo hydraulic device with the axial loading force aligned directly with the tibial tunnel. Constructs underwent progressive cyclic tensile loading from 10 to 150 N with a 25 N load increase every 20 cycles. This was followed by yield load to failure testing (20 mm/min). RESULTS: Groups did not display displacement differences during progressive cyclic loading. Group 1 (312.7 ± 67.5 N) displayed 25% greater yield load at failure than Group 2 (235.0 ± 47.6 N), P = 0.045. Both groups displayed fixation levels well below the previously reported minimal safe threshold estimate for early unrestricted weight bearing, accelerated rehabilitation and activities of daily living. CONCLUSION: Supplemental bio-tenodesis fixation may improve early tibial-soft tissue tendon graft fixation in patients that have poor tibial BMD, but study results suggest that both methods may require weightbearing, rehabilitation, and activity of daily living restrictions during the early postoperative period to prevent graft slippage.

Is supplementary fixation necessary in anterior cruciate ligament reconstructions?

BACKGROUND: There has been concern regarding the fixation of anterior cruciate ligament reconstruction, with soft tissue grafts being strong and stiff enough to allow for early accelerated postoperative rehabilitation. Therefore, some have recommended supplementary fixation for soft tissue tibia interference screw fixation with a staple, to improve the strength and stiffness of the fixation. Unfortunately, with staple supplementation, there is a risk for symptomatic hardware, which may require a second surgery to remove the staple. HYPOTHESIS: Supplementary fixation with a bioabsorbable knotless suture anchor will improve the structural properties of soft tissue tibia bioabsorbable interference screw (BIS) fixation and be comparable with supplementary fixation with a staple. STUDY DESIGN: Controlled laboratory study. METHOD: Fifteen porcine tibias and flexor profundus tendons were randomized into 3 fixation study groups: group 1, BIS; group 2, BIS + staple; and group 3, BIS + push-lock screw. The structural properties of the 3 fixation groups were tested under displacement-controlled cyclic loading and load to failure. RESULTS: No significant difference in mean stiffness (N/mm ± SEM) under cyclic loading was found for BIS (335.31 ± 15.43), BIS + staple (344.81 ± 44.97), and BIS + push-lock (353.28 ± 38.93). Under load-to-failure testing, there were no differences found in stiffness, yield load, displacement at yield load, displacement at ultimate load, and energy absorbed among the 3 fixation methods. BIS + push-lock fixation had a significantly higher ultimate load than BIS alone and BIS + staple (917.85 ± 58.30 N vs 479.83 ± 66.04 N, P = .0003 vs 618.89 ± 8.94 N, P = .004). CONCLUSION: Supplementary fixation with staple or push-lock screw did not significantly increase the structural strength and stiffness of the BIS soft tissue graft fixation under cyclic loading, but it did show improvement under load-to-failure testing for ultimate tensile load. CLINICAL RELEVANCE: The indication for supplementary fixation for tibial BIS soft tissue graft fixation depends on the fixation that the BIS achieves at the time of the surgery because the tensile load is transferred to the secondary fixation if and only when there is slippage of graft at the primary fixation. The supplementary fixation may be of value in those cases with poor bone quality, such as revision surgery with tunnel widening and/or graft-tunnel mismatch, or possibly in cases with older patients or patients with disorders affecting bone mineral density.

Auditory brainstem and cortical potentials following bone-anchored hearing aid stimulation.

Patients suffering from conductive or mixed hearing loss and Single-Sided Deafness may benefit from implantable hearing devices relying on bone conducted auditory stimulation. However, with only passively cooperative patients, objective methods are needed to estimate the aided and unaided pure-tone audiogram. This study focuses on the feasibility aspect of an electrophysiological determination of the hearing thresholds with bone-anchored hearing aid stimulation. Therefore, 10 normal-hearing subjects were provided with a Baha Intenso (Cochlear Ltd.) which was temporarily connected to the Baha Softband (Cochlear Ltd.). Auditory evoked potentials were measured by auditory stimulation paradigm used in clinical routine. The amplitudes, latencies, and thresholds of the resulting auditory brainstem responses (ABR) and the cortically evoked responses (CAEP) were correlated with the respective responses without the use of the Baha Intenso. The recording of ABR and CAEP by delivering the stimuli to the Baha results in response waveforms which are comparable to those evoked by earphone stimulation and appears appropriate to be measured using the Baha Intenso as stimulator. At the ABR recordings a stimulus artifact at higher stimulation levels and a constant latency shift caused by the Baha Intenso has to be considered. The CAEP recording appeared promising as a frequency specific objective method to approve the fitting of bone-anchored hearing aids. At all measurements, the ABR and CAEP thresholds seem to be consistent with the normal hearing of the investigated participants. Thus, a recording of auditory evoked potentials using a Baha is in general possible if specific limitations are considered.

Bone-anchored hearing aid system application for unilateral congenital conductive hearing impairment: audiometric results.

OBJECTIVE: To study the audiologic outcome of bone-anchored hearing aid (BAHA) application in patients with congenital unilateral conductive hearing impairment. STUDY DESIGN: Prospective audiometric evaluation on 20 patients. SETTING: Tertiary referral center. PATIENTS: The experimental group comprised 20 consecutive patients with congenital unilateral conductive hearing impairment, with a mean air-bone gap of 50 dB. METHODS: Aided and unaided hearing was assessed using sound localization and speech recognition-in-noise tests. RESULTS: Aided hearing thresholds and aided speech perception thresholds were measured to verify the effect of the BAHA system on the hearing acuity. All patients fulfilled the criteria that the aided speech reception thresholds or the mean aided sound field thresholds were 25 dB or better in the aided situation. Most patients were still using the BAHA almost every day. Sound localization scores varied widely in the unaided and aided situations. Many patients showed unexpectedly good unaided performance. However, nonsignificant improvements of 3.0 (500 Hz) and 6.9 degrees (3,000 Hz) were observed in favor of the BAHA. Speech recognition in noise with spatially separated speech and noise sources also improved after BAHA implantation, but not significantly. CONCLUSION: Some patients with congenital unilateral conductive hearing impairment had such good directional hearing and speech-in-noise scores in the unaided situation that no overall significant improvement occurred after BAHA fitting in our setup. Of the 18 patients with a complete data set, 6 did not show any significant improvement at all. However, compliance with BAHA use in this patient group was remarkably high. Observations of consistent use of the device are highly suggestive of patient benefit. Further research is recommended to get more insight into these findings.

Open versus percutaneous repair in the treatment of acute Achilles tendon rupture: a randomized prospective study.

There is no agreement on the ideal type of surgical management for Achilles tendon rupture. The present randomized prospective study was performed to compare outcome data of open and percutaneous repair in the treatment of Achilles tendon rupture. Forty consecutive patients with acute rupture of Achilles tendon were recruited. Patients were randomized to receive open (group A) or percutaneous repair with Tenolig (group B). All patients followed the same rehabilitation protocol except for slight differences in the duration of immobilization. Follow-up included objective evaluation (at 4 and 12 months), subjective evaluation using the SF-12 questionnaire (at 24 months), and bilateral ultrasound scanning and isokinetic testing (at 12 months). The differences in the parameters evaluated clinically were not significant except for ankle circumference, which was significantly greater in group B. There were two minor complications in the open repair group and one case of failed repair in the percutaneous group. SF-12 questionnaire, ultrasound and isokinetic test data did not show significant differences between the groups. The present study demonstrates that the open and the percutaneous technique are both safe and effective in repairing the ruptured Achilles tendon and that both afford the same degree of restoration of clinical, ultrasound and isokinetic patterns. Medium-term results were substantially comparable. Percutaneous repair is performed on a day-surgery basis, it reduces cutaneous complications and operation times, and enables faster recovery, enhancing overall patient compliance. To us, these characteristics make it preferable to open repair in managing subcutaneous ruptures of Achilles tendon in non-professional sports practicing adults.

[Ruptures of the pectoralis major muscle - clinical results after operative and non-operative treatment]. / Rupturen des M. pectoralis major - Klinische Ergebnisse nach operativer und konservativer Behandlung.

AIM: Ruptures of the pectoralis major muscle should be treated operatively due to the expected loss of strength following conservative treatment. Minimal-invasive surgery technique using suture anchors can lead to perfect anatomical refixation of the muscle. We report mid-term clinical results. METHODS: We present clinical results of a comparative study concerning ruptures of the pectoralis major muscle. Between 2001 and 2006 a total number of 9 patients were treated operatively using suture anchors. The surgical procedure is described. A control group (n = 4) consisted of patients being treated conservatively in 1999 und 2000. For evaluation of results Bak's score was used. RESULTS: The mean follow-up-time was six months. We found 4 very good and 4 good results, only one patient showed a satisfying result. Among the patients who had followed the conservative treatment regime only one had a good outcome while three patients remained in a satisfying condition. All type-1-ruptures according to Roller showed postoperatively nearly equal strength conditions for both sides. CONCLUSION: The operative treatment of acute ruptures of the pectoralis major muscle in active people and athletes leads to better results concerning restoration of strength than conservative or delayed treatment. The surgical technique depends upon the type of rupture which has to be determined intraoperatively. The use of suture anchors aiming for intraosseous fixation helps to avoid intraoperative complications and leads to stable conditions with nearly full restoration of strength.

Load bearing capacity of bone anchored fiber-reinforced composite device.

The purpose of this study was to evaluate the push-out load-bearing capacity of threaded fiber-reinforced composite (FRC) devices for use as bone-anchored devices. The purpose was also to evaluate the possibility to use bioactive glass (BAG) granules on the experimental FRC devices in terms the mechanical behavior. Three experimental FRC devices (n = 15) were fabricated for the study: (a) threaded device with smooth surface; (b) threaded device with BAG granules (S53P4, Vivoxid Ltd, Turku, Finland) and supplementary retention grooves, and (c) unthreaded device with BAG granules. Threaded titanium devices were used as controls. The FRC devices were prepared from a light-polymerized dimethacrylate resin reinforced with preimpregnated unidirectional and bidirectional E-glass fibers (EverStick, StickTech Ltd, Turku, Finland). Experimental and control devices were embedded into dental plaster to simulate bone before the mechanical push-out test was carried out. ANOVA and Weibull analysis were used for the statistical evaluation. Threaded FRC devices had significantly higher push-out strength than the threaded titanium device (p < .001). The push-out forces exceeding 2,500 N were measured for threaded FRC devices with supplementary grooves and BAG coating. No thread failures were observed in any FRC devices. The unthreaded FRC devices with BAG lost 70% of glass particles during the test, while no BAG particles were lost from threaded FRC devices. It can be concluded that threaded FRC devices can withstand high push-out forces in the dental plaster without a risk of thread failure under physiological load.