Osteochondral Shearing Fracture of the Humeral Head Associated with Traumatic Anterior Shoulder Dislocation: A Case Report.

CASE: Osteochondral shearing fracture of the humeral head after an anterior shoulder dislocation is a condition that has rarely been reported in literature. We report a case of a large posteriorly located fragment of such a fracture in a 23-year-old man. We performed open reduction and internal fixation with resorbable pins through a deltopectoral approach and subscapularis tenotomy. CONCLUSION: In our case of a large osteochondral fracture of the posterior humeral head, treatment by open reduction and internal fixation showed an excellent radiographic result at 1 year and clinical result up to 5 years postoperatively.

Outcomes of Management of Proximal Humeral Fractures with Patient-Specific, Evidence-Based Treatment Algorithms.

BACKGROUND: Previous studies have identified risk factors for different types of treatment of proximal humeral fracture (PHF) and allowed the development of a patient-specific, evidence-based treatment algorithm with the potential of improving overall outcomes and reducing complications. The purpose of this study was to evaluate the results and complications of treating PHF using this algorithmic approach. METHODS: All patients with isolated PHF between 2014 and 2017 were included and prospectively followed. The initial treatment algorithm (Version 1 [V1]) based on patients' functional needs, bone quality, and type of fracture was refined after 2 years (Version 2 [V2]). Adherence to protocol, clinical outcomes, and complications were analyzed at a 1-year follow-up. RESULTS: The study included 334 patients (mean age, 66 years; 68% female): 226 were treated nonoperatively; 65, with open reduction and internal fixation (ORIF); 39, with reverse total shoulder arthroplasty (RTSA); and 4, with hemiarthroplasty. At 1 year, the preinjury EuroQol 5-Dimension (EQ-5D) values were regained (0.88 and 0.89, respectively) and the mean relative Constant Score (CS) and Subjective Shoulder Value (SSV) (and standard deviation [SD]) were 96% ± 21% and 85% ± 16%. Overall complications and revision rates were 19% and 13%. Treatment conforming to the algorithm outperformed non-conforming treatment with respect to relative CS (97% versus 88%, p = 0.016), complication rates (16.3% versus 30.8%, p = 0.014), and revision rates (10.6% versus 26.9%, p < 0.001). CONCLUSIONS: Treating PHF using a patient-specific, evidence-based algorithm restored preinjury quality of life as measured with the EQ-5D and approximately 90% normal shoulders as measured with the relative CS and the SSV. Adherence to the treatment algorithm was associated with significantly better clinical outcomes and substantially reduced complication and revision rates. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Stand-alone coracoclavicular suture repair achieves very good results in unstable distal clavicle fractures at a minimum follow-up of 1 year.

BACKGROUND: The treatment of unstable (Neer type IIB and V) extra-articular distal clavicle fractures remains challenging, especially when encountering a small lateral fragment which does not allow for sufficient screw purchase. It was the purpose of this study to present the clinical and radiologic outcome of a consecutive series of patients treated by a stand-alone coracoclavicular stabilization using a so-called cow-hitch technique with a suture anchor. METHODS: Nineteen patients were treated with a specific surgical technique for distal clavicle fractures (11 left, 8 right) with either rupture or bony avulsion of the coracoclavicular ligaments. Fourteen patients were examined in our outpatient clinic for the purpose of this study after a mean follow-up of 5 years (1-12.2 years). The examination included scoring according to Constant Murley score (CMS), the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), the Subjective Shoulder Value (SSV), and follow-up radiographs. Two additional patients were amenable to a telephone interview. RESULTS: All patients reported very good subjective results, with a mean SSV of 92% and a mean ASES score of 96%. The CMS resulted in average absolute values of 92 points. Fractures consolidated in 95% of cases. One patient developed an asymptomatic pseudarthrosis. The coracoclavicular distance was restored from 21 mm preoperatively to 11 mm at the final follow-up and finally showed an average side-to-side difference of +1.8 mm. Sports activities were fully resumed after an average of 4.7 months. CONCLUSION: The coracoclavicular stand-alone cow-hitch suture repair for unstable distal clavicle fractures is a minimally invasive fixation technique without prominent hardware that allows for an anatomic reduction and stable fixation with a low complication and high bony union rate. Both radiographic and clinical long-term results are very satisfactory.

Symptomatic leg length discrepancy after total hip arthroplasty is associated with new onset of lower back pain.

BACKGROUND: Leg length discrepancy (LLD) is common after total hip arthroplasty (THA) with a plethora of clinical consequences. The associations between symptomatic (sLLD; disturbing perception of anatomical leg length discrepancy), anatomical (aLLD; side difference in leg length between the center of rotation of the hip and the center of the ankle joint) and intraarticular (iLLD; side difference between the tear drop figure and the most prominent point of the trochanter minor) LLD and lower back have not yet been reported in the literature. We performed a retrospective study to answer if postoperative (1) symptomatic LLD, (2) anatomic LLD, and (3) a change in intraarticular leg length are associated with lower back pain in patients undergoing THA. Further, we aimed to answer (4) whether symptomatic LLD is associated with the magnitude of anatomical LLD and the change in intraarticular leg length. HYPOTHESIS: LLD after THA is associated with lower back pain. MATERIALS AND METHODS: Seventy-nine consecutive patients were retrospectively analyzed for the presence of aLLD and iLLD using EOS™ and X-rays, and were interviewed for the presence of sLLD and lower back pain using a questionnaire 5 years after primary THA. RESULTS: Postoperative new onset of lower back pain was reported by 9 (11%) patients. Twenty (25%) patients reported sLLD. Anatomical LLD>5mm was present in 44 (56%) (median 8.0 (IQR -3.0 to 12.0; range -22 to 22) mm) and>10mm in 17 (22%) (median 12.0 (IQR 11.0 to 16.5; range -22 to 22) mm) patients. iLLD changed>5mm in 44 (56%) (median 8.5 (IQR 7.0 to 10.0; range -8 to 18) mm) and>10mm in 10 (13%) (median 14.0 (IQR 12.5 to 14.5; range 11 to 18) mm). New onset lower back pain was associated with sLLD (p=0.002) but not with aLLD or iLLD. Patients without preoperative lower back pain had a statistically significant association between presence of sLLD and an aLLD of >10mm (p=0.01). CONCLUSIONS: Symptomatic LLD after primary THA is associated with postoperative new onset of lower back pain irrespective of the magnitude of LLD. In patients without lower back pain prior to THA, symptomatic LLD is associated with anatomical LLD of more than 10mm. LEVEL OF EVIDENCE: IV.

Diurnal T2-changes of the intervertebral discs of the entire spine and the influence of weightlifting.

The purpose was to study if (1) diurnal changes occur in the entire spine and if (2) intervertebral discs (IVDs) of weightlifters (WL) have decreased baseline T2-values in the morning as well as (3) increased diurnal changes throughout the day. This prospective cohort study investigated healthy volunteers between 2015 and 2017. WL were required to have participated in weightlifting ≥ 4×/week for ≥ 5 years, while non-weightlifters (NWL) were limited to < 2×/week for ≥ 5 years. Both groups underwent magnetic resonance imaging (MRI) of the entire spine in the morning and evening. WL were requested to perform weightlifting in-between imaging. IVD regions of interest (nucleus pulposus) were defined and T2-maps were measured. Analysis consisted of unpaired t-test, paired t-test, propensity-score matching (adjusting for age and sex), and Pearson correlation. Twenty-five individuals (15 [60.0%] males) with a mean age of 29.6 (standard deviation [SD 6.9]) years were analyzed. Both groups (WL: n = 12 versus [vs.] NWL: n = 13) did not differ demographic characteristics. Mean IVD T2-values of all participants significantly decreased throughout the day (95.7 [SD 15.7] vs. 86.4 [SD 13.9] milliseconds [ms]) in IVDs of the cervical (71.8 [SD 13.4] vs. 64.4 [SD 14.1] ms), thoracic (98.8 [SD 19.9] vs. 88.6 [SD 16.3] ms), and lumbar (117.0 [SD 23.7] vs. 107.5 [SD 21.6] ms) spine (P < 0.001 each). There were no differences between both groups in the morning (P = 0.635) and throughout the day (P = 0.681), even after adjusting for confounders. It can be concluded that diurnal changes of the IVDs occurred in the entire (including cervical and thoracic) spine. WL and NWL showed similar morning baseline T2-values and diurnal changes. Weightlifting may not negatively affect IVDs chronically or acutely.

The influence of obesity and gender on outcome after reversed L-shaped osteotomy for hallux valgus.

BACKGROUND: Hallux valgus deformity (HV) affects around every fourth individual, and surgical treatment is performed in every thousandth person. There is an ongoing quest for the best surgical management and reduction of undesirable outcomes. The aim was to explore associations of obesity and gender with radiological and clinical outcome after reversed L-shaped osteotomy (ReveL) for HV. MATERIALS AND METHODS: This study was carried out in a retrospective cohort design at a single University Hospital in Switzerland between January 2004 and December 2013. It included adult patients treated with ReveL for HV. The primary exposure was body mass index (BMI) at the time of ReveL. The secondary exposure was gender. The primary outcome was radiological relapse of HV (HV angle [HVA] > 15 degrees [°]) at the last follow-up. Secondary outcomes were improvable patient satisfaction, complication, redo surgery, and optional hardware removal. Logistic regression analysis adjusted for confounders. RESULTS: The median weight, height, and BMI were 66.0 (interquartile range [IQR] 57.0-76.0) kilograms (kg), 1.65 (IQR 1.60-1.71) metres (m), and 24.0 (IQR 21.3-27.8) kg/m2. Logistic regression analysis did not show associations of relapse with BMI, independent of age, gender, additional technique, and preoperative HVA (adjusted odds ratio [ORadjusted] = 1.10 [95% (%) confidence interval (CI) = 0.70-1.45], p = 0.675). Relapse was 91% more likely in males (ORadjusted = 1.91 [95% CI = 1.19-3.06], p = 0.007). Improvable satisfaction was 79% more likely in males (ORadjusted = 1.79 [CI = 1.04-3.06], p = 0.035). Hardware removal was 47% less likely in males (ORadjusted = 0.53 [95% CI 0.30-0.94], p = 0.029). CONCLUSIONS: In this study, obesity was not associated with unsatisfactory outcomes after ReveL for HV. This challenges the previous recommendation that preoperative weight loss may be necessary for a successful surgical treatment outcome. Males may be informed about potentially higher associations with unfavourable outcomes. Due to the risk of selection bias and lack of causality, findings may need to be confirmed with clinical trials.

Radiological and Clinical Outcome After Reversed L-Shaped Osteotomy: A Large Retrospective Swiss Cohort Study.

The objective was to report radiological and clinical outcomes after reversed L-shaped osteotomy (ReveL) for hallux valgus (HV). A retrospective cohort study was performed between January 2004 and December 2013. The primary outcome was radiological recurrence of HV (HV angle [HVA] >15°). There were various exposure and secondary outcome variables. The results showed a median follow-up of 12.0 months (N = 827). Radiological recurrence, limited patient satisfaction, complication, revision surgery, and elective hardware removal were found in 25.0%, 15.3%, 4.6%, 2.5%, and 26.7%. Median pre- to postoperative changes were highest for HVA (delta = -16.7°). Recurrence was more likely in cases with preoperative HVA ≥40° (adjusted odds ratio [ORadjusted]) 3.63, p < .001). Revisions were more likely with concomitant diseases and bilateral surgery (ORadjusted 12.53, p = .010; ORadjusted 3.35, p = .030). Hardware removal was less likely in patients ≥50 years (ORadjusted 0.67, p = .014). In conclusion, ReveL was a good surgical option for HV because of the relatively low rates of unfavorable outcomes.

The impact of biopsy sampling errors and the quality of surgical margins on local recurrence and survival in chondrosarcoma.

PURPOSE: To examine the frequency of computed tomography (CT)-guided biopsy sampling errors in chondrosarcomas, as well as the impact of these errors and the achieved surgical margins on local recurrence-free survival (LRFS) and disease-specific survival (DSS). MATERIAL AND METHODS: A total of 68 consecutive patients treated for chondrosarcoma from 2000-2015 were retrospectively reviewed with a minimum follow-up duration of 2 years. RESULTS: The primary location was at the extremities in 46 patients (67.6%) and at the axial skeleton in 22 patients (32.4%). Seven patients underwent planned intralesional curettage. Surgical margins were assessed in the remaining 53 patients and included 21 wide (39.6%), 25 marginal (47.1%), and seven intralesional (13.2%) resections. Biopsy sampling errors occurred in ten patients (14.7%). LRFS was 82.2±7.8% at 5 years and 76.9±7.8% at 10 years. An intact anatomical barrier was associated with the most preferable LRFS of 89±10.5% after 10 years. DSS was 79.2±8.5% at 5 years and 75.5±6.4% at 10 years. The metric distance of the surgical margin and the presence of a biopsy sampling error did not affect either LRFS or DSS. CONCLUSION: Even though histological grading in chondrosarcoma is difficult, sampling errors in preoperative biopsies are relatively rare and do not adversely affect outcomes. The presence of an anatomical barrier has a greater impact on LRFS than the metric distance of the surgical margins.

The influence of the number of screws and additional surgical procedures on outcome in hallux valgus treatment.

BACKGROUND: Surgical treatment of hallux valgus (HV) is one of the major flagships of orthopedic surgeons. Due to relatively unsatisfactory radiological and clinical outcomes, the search for the best surgical technique and causes for unsatisfactory outcomes continues. The objective was to investigate associations of the number of screws and additional surgical techniques for HV with radiological and clinical outcome after reversed L-shaped osteotomy (ReveL). METHODS: A retrospective cohort study of adults from a single University Hospital between 2004 and 2013 was performed. The primary exposure was the number of screws (one vs two) used for osseous fixation after ReveL. The secondary exposure was an additional surgical technique for HV (e.g., Akin osteotomy). The primary outcome was a radiological recurrence of HV (HV angle (HVA) > 15°) at last follow-up. The secondary outcomes were limited patient satisfaction, complication, revision surgery, and elective hardware removal. Odds ratio (OR) and 95% confidence interval (CI) were estimated by logistic regression adjusting for confounders. RESULTS: The recurrence was 45% less likely with the use of one screw, independent of age, sex, additional technique, and preoperative HVA (odds ratio (ORadjusted) = 0.55 [95% CI 0.30-0.98], p = 0.043). The recurrence was 162% more likely with an additional surgical technique for HV (ORadjusted = 2.62 [1.24-5.52], p = 0.011). CONCLUSION: In ReveL for HV, a single screw (instead of two screws) may be sufficient enough for a similar or even better outcome, which may also reduce costs. Additional surgical procedures for HV may be refrained from if possible. Due to limitations of a retrospective study, results may need validation with clinical trials.

Is rivaroxaban associated with higher morbidity and mortality in patients with traumatic head injuries? A retrospective cohort study comparing rivaroxaban, no anticoagulation, and phenprocoumon.

OBJECTIVES: The use of new anticoagulants potentially carries the risk of increased intracranial bleeding, but there is a lack of evidence. The aim of this study was to investigate whether the morbidity and mortality differs in head trauma patients depending on the type of anticoagulation. PATIENTS AND METHODS: A retrospective cohort study was conducted in 2009-2014. Based on sex, age, and Glasgow-Coma Scale (GCS), patients that received rivaroxaban were matched to two control groups, one that received no anticoagulant and another one that received phenprocoumon. The primary outcome was mortality. Among others, secondary outcome variables were the length of stay (LOS) at the hospital and presence of an intracranial injury. RESULTS: Sixty-nine patients (23 patients per group) were analyzed. The characteristics of patients did not differ significantly across groups. There were no significant differences between groups for the primary and secondary outcomes. Two patients died in the rivaroxaban group (one of them likely due to head trauma), while one patient died in the phenprocoumon group (likely not due to head trauma), and no patient died in the no anticoagulatoin group (p = 0.36). The LOS at the hospital was similar (5.0, 4.0, and 5.0 days; p = 0.94). An intracranial injury was observed in a similar number of patients in all groups (n = 11, n = 10, and n = 8; p = 0.75). CONCLUSION: Although limited in size, this study did not observe significant outcome differences in patients with traumatic head injuries, who received rivaroxaban, no anticoagulant or phenprocoumon. Although not significant, the only death likely due to head trauma in the study occurred in the rivaroxaban group. Larger studies are needed before clinical application of these findings.

Local effect of zoledronic acid on new bone formation in posterolateral spinal fusion with demineralized bone matrix in a murine model.

BACKGROUND: Posterolateral spinal fusion is a common orthopaedic surgery performed to treat degenerative and traumatic deformities of the spinal column. In posteriolateral spinal fusion, different osteoinductive demineralized bone matrix products have been previously investigated. We evaluated the effect of locally applied zoledronic acid in combination with commercially available demineralized bone matrix putty on new bone formation in posterolateral spinal fusion in a murine in vivo model. METHODS: A posterolateral sacral spine fusion in murine model was used to evaluate the new bone formation. We used the sacral spine fusion model to model the clinical situation in which a bone graft or demineralized bone matrix is applied after dorsal instrumentation of the spine. In our study, group 1 received decortications only (n = 10), group 2 received decortication, and absorbable collagen sponge carrier, group 3 received decortication and absorbable collagen sponge carrier with zoledronic acid in dose 10 µg, group 4 received demineralized bone matrix putty (DBM putty) plus decortication (n = 10), and group 5 received DBM putty, decortication and locally applied zoledronic acid in dose 10 µg. Imaging was performed using MicroCT for new bone formation assessment. Also, murine spines were harvested for histopathological analysis 10 weeks after surgery. RESULTS: The surgery performed through midline posterior approach was reproducible. In group with decortication alone there was no new bone formation. Application of demineralized bone matrix putty alone produced new bone formation which bridged the S1-S4 laminae. Local application of zoledronic acid to demineralized bone matrix putty resulted in significant increase of new bone formation as compared to demineralized bone matrix putty group alone. CONCLUSIONS: A single local application of zoledronic acid with DBM putty during posterolateral fusion in sacral murine spine model increased significantly new bone formation in situ in our model. Therefore, our results justify further investigations to potentially use local application of zoledronic acid in future clinical studies.

Correlation Between Arthroscopy Simulator and Video Game Performance: A Cross-Sectional Study of 30 Volunteers Comparing 2- and 3-Dimensional Video Games.

PURPOSE: To investigate the association between arthroscopy simulator performance and video game skills. METHODS: This study compared the performances of 30 volunteers without experience performing arthroscopies in 3 different tasks of a validated virtual reality knee arthroscopy simulator with the video game experience using a questionnaire and actual performances in 5 different 2- and 3-dimensional (D) video games of varying genres on 2 different platforms. RESULTS: Positive correlations between knee arthroscopy simulator and video game performances (ρ = 0.63, P < .001) as well as experiences (ρ = 0.50, P = .005) were found. The strongest correlations were found for the task of catching (hooking) 6 foreign bodies (virtual rings; "triangulation") and the dribbling performance in a sports game and a first-person shooter game, as well as the meniscus resection and a tile-matching puzzle game (all ρ ≥ 0.60, P < .001). No correlations were found for any of the knee arthroscopy simulator tasks and a strategy game. CONCLUSIONS: Although knee arthroscopy performances do not correlate with 2-D strategy video game skills, they show a correlation with 2-D tile-matching puzzle games only for easier tasks with a rather limited focus, and highly correlate with 3-D sports and first-person shooter video games. These findings show that experienced and good 3-D gamers are better arthroscopists than nonexperienced and poor 3-D gamers. LEVEL OF EVIDENCE: Level II, observational cross-sectional study.

Correlation of pelvic incidence with radiographical parameters for acetabular retroversion: a retrospective radiological study.

BACKGROUND: Pelvic incidence (PI) has been linked to several degenerative processes within the spinopelvic system. Acetabular retroversion is a recognised risk factor for osteoarthritis of the hip. We therefore hypothesised that these two factors might be part of a specific anatomical variant associated with degenerative changes. This study was performed to clarify this issue. METHODS: The pelvic incidence was measured on 589 computertomographical data sets acquired between 2008 and 2010. For 220 patients a 2D rendering in an antero-posterior view of the CT data set was performed to evaluate the parameters of acetabular retroversion. Those included the prominence of the ischial spine sign (PRISS), the cross-over sign (COS) and the posterior wall sign (PWS). Between 477 and 478 hips were evaluated depending on the parameter of retroversion. RESULTS: The mean pelvic incidence was significantly lower in hips positive for the PRISS and the PWS. However, there were no significant differences between hips positive or negative for the COS. DISCUSSION: As hypothesised, the lower PI values in PWS and PRISS positive hips suggest a link between PI and retroversion of the acetabulum. Whether this is of any clinical relevance remains, however, unknown. CONCLUSION: Acetabular retroversion is linked to PI. In hips where the prominence of the ischial spine sign and/or the posterior wall sign was present, the mean pelvic incidence value was lower.