Evaluation of the ankle brachial index and toe brachial index for peripheral arterial disease diagnosis in patients over 70 years with lower limb ulcers.

OBJECTIVE: The aim of our study was to evaluate the diagnostic performance of the ankle brachial index using pulsed Doppler, and the toe brachial index using laser Doppler, in comparison with the arterial Doppler ultrasound of the lower limbs as a reference test, in a population of non-diabetic subjects over 70 years old with lower limb ulcers and without chronic renal failure. METHODS: We included 50 patients, 100 lower limbs from the vascular medicine department of the Paris Saint-Joseph hospital from December 2019 to May 2021. RESULTS: We found a sensitivity of 54.5% for the ankle brachial index and a specificity of 67.6%. Regarding the toe brachial index, the sensitivity was 80.3% and the specificity 44.1%. We could explain the low sensitivity of the ankle brachial index in our population by the mediacalcosis of elderly subjects, avoidable with the measurement of the toe blood pressure index, which had a better sensitivity. CONCLUSION: In a population of subjects over 70 years of age with a lower limb ulcer, without diabetes and without chronic renal failure, it would seem judicious to use the ankle brachial index in association with the toe brachial index for the diagnosis of peripheral arterial disease, followed by an arterial Doppler ultrasound of the lower limbs in order to evaluate the lesion profile of patients with a result of less than 0.7 of toe brachial index.

Conservative versus tailored surgical treatment in patients with first time lateral patella dislocation: a randomized-controlled trial.

BACKGROUND: Patellar instability has a high incidence and occurs particularly in young and female patients. If the patella dislocates for the first time, treatment is usually conservative. However, this cautious approach carries the risk of recurrence and of secondary pathologies such as osteochondral fractures. Moreover, there is also risk of continuous symptoms apparent, as recurrent patella dislocation is related to patellofemoral osteoarthritis as well. An initial surgical treatment could possibly avoid these consequences of recurrent patella dislocation. METHODS: A prospective, randomized-controlled trial design is applied. Patients with unilateral first-time patella dislocation will be considered for participation. Study participants will be randomized to either conservative treatment or to a tailored patella stabilizing treatment. In the conservative group, patients will use a knee brace and will be prescribed outpatient physical therapy. The surgical treatment will be performed in a tailored manner, addressing the pathologic anatomy that predisposes to patella dislocation. The Banff Patellofemoral Instability-Instrument 2.0, recurrence rate, apprehension test, joint degeneration, and the Patella Instability Severity Score will serve as outcome parameters. The main analysis will focus on the difference in change of the scores between the two groups within a 2-year follow-up. Statistical analysis will use linear mixed models. Power analysis was done for the comparison of the two study arms at 2-year follow-up with regard to the BPII Score. A sample size of N = 64 per study arm (128 overall) provides 80% power (alpha = 0.05, two-tailed) to detect a difference of 0.5 standard deviations in a t-test for independent samples. DISCUSSION: Although several studies have already dealt with this issue, there is still no consensus on the ideal treatment concept for primary patellar dislocation. Moreover, most of these studies show a unified surgical group, which means that all patients were treated with the same surgical procedure. This is regarded as a major limitation as surgical treatment of patella dislocation should depend on the patient's anatomic pathologies leading to patellar instability. To our knowledge, this is the first study investigating whether patients with primary patella dislocation are better treated conservatively or operatively with tailored surgery to stabilize the patella. TRIAL REGISTRATION: The study will be prospectively registered in the publicly accessible database www.ClinicalTrials.gov .

Static patella tilt and axial engagement in knee extension are mainly influenced by knee torsion, the tibial tubercle-trochlear groove distance (TTTG), and trochlear dysplasia but not by femoral or tibial torsion.

PURPOSE: The aim of this study was to investigate the association of femoral (FT), tibial (TT), and knee torsion (KT) on the patella tilt (PT), the axial engagement index (AEI), and the tibial tuberosity-trochlear groove distance (TTTG). METHODS: Femoral torsion, tibial torsion, knee torsion, patella tilt, the axial engagement index, the TTTG, and trochlear dysplasia were retrospectively evaluated on 59 patients suffering from recurrent patella instability or anterior knee pain with 118 torsional lower limb magnetic resonance imaging studies. RESULTS: FT and TT did not show any significant associations with TTTG, PT, and AEI (n.s.). KT was significantly associated with a higher TTTG, higher PT, and lower AEI (all, p < 0.001). Higher grade trochlear dysplasia was associated with a higher PT and lower AEI (both, p < 0.001). The Dejour classification showed no significant association with FT, TT, KT, and TTTG (n.s.). All measurement parameters showed an excellent interrater agreement (ICC 0.89-0.97). CONCLUSIONS: Static patella tilt and patellofemoral axial engagement in knee extension are mainly influenced by knee torsion, TTTG, and trochlear dysplasia but not by femoral or tibial torsion. These findings help to understand the underlying reasons for the patella position in knee extensions in CT and MRI investigations in patients suffering from patella instability and patellofemoral pain syndrome. LEVEL OF EVIDENCE: III.

Isolated medial patellofemoral ligament reconstruction for patella instability is insufficient for higher degrees of internal femoral torsion.

PURPOSE: A medial patellofemoral ligament reconstruction (MPFL) with an additional derotational femoral osteotomy is suggested for patients suffering from patellar instability and an increased internal femoral torsion (IT). This biomechanical study investigated whether an isolated MPFL reconstruction could restore patellofemoral biomechanics for 10° and 20° relatively increased internal femoral torsion. METHODS: Eight fresh-frozen cadaver knees were tested on a specially designed knee simulator, which bend the knee from 0° to 90° flexion. Patellar motion (tilt and shift) and patellofemoral pressure (pressure shift, mean and peak pressure) were evaluated for 0°, 10° and 20° of IT with a native and reconstructed MPFL. RESULTS: An isolated MPFL reconstruction, compared to a native MPFL with the same femoral torsion showed a significant medial shift of the center of force (10° IT p < 0.001; 20° IT p = 0.02) and patella shift (10° and 20° IT p < 0.001) but no significant change in patella tilt (10° IT n.s.; 20° IT n.s.) for 10° and 20° IT. There was a significant medial shift in the center of force for 10° IT (10° IT p = 0.04) and a non-significant lateral shift for 20° IT (20° IT n.s.) in comparison to the native MPFL with 0° of femoral torsion. Patella shift was directed medially for 10° IT (10° IT p = 0.002). In knee flexion angles up to 30°, the patella remained more lateral for 20° IT and showed a different motion pattern (20° IT n.s.). Patella tilt showed a significant lateral tilt for 10° and 20° IT (10° IT p = 0.01; 20° IT p = 0.002). CONCLUSION: MPFL reconstruction as an isolated therapy only appears to be reasonable for 10° increased IT. While for an increased IT of 20°, a lateralizing force vector remains and an additional femoral derotational osteotomy is recommendable. These findings may assist surgeons in the decision making of surgical procedures in patients suffering from patella instability.

The anterolateral ligament and the deep structures of the iliotibial tract: MRI visibility in the paediatric patient.

PURPOSE: To assess the visibility of both the anterolateral ligament (ALL) and the deep structures of the iliotibial tract (ITT) by means of MRI in paediatric patients. To determine reproducibility for such measurements. METHODS: Knee MRI data from patients aged <18a without lesions of the capsule or ligaments, fractures, bone edemas, foreign material or motion artifacts were analyzed by two musculoskeletal radiologists separately and twice. The visibility of the different parts of the ALL was determined (femoral, meniscal, tibial parts). Similarly, the visibility of the different parts of the deep ITT was determined: deep attachments of the ITT to the distal femur (insertion near septum, supracondylar insertion and retrograde insertion) and capsulo-osseous layer of the ITT. RESULTS: We studied 61 cases (36 female, 25 male). Age was 15 years (±2.3). Interobserver agreement was high. Cohen's Kappa was 0.864 (95%CI: 0.715-1.000) for the tibial part of the ALL and 1.0 for the femoral part of the ALL. For the deep attachments of the ITT to the distal femur Kappa was 0.828 (95%CI: 0.685-0.971). Regarding intraobserver agreement, Cohen's Kappa was 1.0 for the femoral part of the ALL and 0.955 (95%CI: 0.867-1.000) for the tibial part of the ALL. For the deep attachments of the ITT to the distal femur Cohen's Kappa was 0.896 (95%CI: 0.782-1.000). CONCLUSION: On the basis of our findings it is concluded that the presence of the anterolateral structures of the knee can be determined by MRI in a pediatric population with substantial inter- and intraobserver agreement. This is true for both the ALL and the deep structures of the ITT. LEVEL OF EVIDENCE: Diagnostic study - Level 3.

Supervised short-stretch compression therapy in mixed leg ulcers.

OBJECTIVES: This study was conducted to determine hemodynamic and clinical tolerance under short-stretch compression therapy in elderly patients suffering from mixed-etiology leg ulcers. DESIGN: Transversal observational study conducted in 25 hospitalized patients with a moderate peripheral arterial occlusive disease defined as an ankle-brachial pressure index>0.5, an ankle pressure of>70mmHg and a toe cuff pressure (TP)>50mmHg. MATERIAL AND METHODS: Short-stretch bandages were applied daily with pressures from 20 to 30mmHg. Ankle-brachial pressure, great toe laser Doppler flowmetry (LDF) and transcutaneous oxygen pressure (TcPO2) on dorsum of the foot were measured at baseline and after its removal at 24hours. Great toe LDF was also measured at 10minutes after bandage application. Compression pressure (CP) was measured with a sub-bandage device at baseline, at 10minutes and before bandage removal at 24hours. Clinical tolerance was evaluated taking into account the patient's pain and skin tolerance. RESULTS: Mean age of patients was 80±15 years. Median duration of ulcers was 18 months. Hypertension was highly prevalent. One third of patients had diabetes. Toe pressure index and TcPO2 values did not significantly change under compression therapy (P=0.51 and P=0.09, respectively) whereas CP decreased significantly during 24hours. The loss of CP was significant 10minutes after bandage application (P<0.001). Nearly all ulcers were painful prior to placement of compression therapy and required level 1 analgesics. One patient required level 2 analgesic for pain relief. No increase in pain and no ischemic skin damage occurred under compression therapy. CONCLUSIONS: In elderly patients with mixed leg ulcers and with an absolute TP>50mmHg, short-stretch compression of up to 30mmHg does not adversely affect arterial flow and appears clinically well tolerated. Such bandages with appropriate levels of compression may aid ulcer healing by treating the venous part of the disease.

[When to ask for a skin biopsy in a patient with leg ulcer? Retrospective study of 143 consecutive biopsies]. / Quand poser l'indication d'une biopsie cutanée chez un patient porteur d'ulcère de jambe ? Étude rétrospective sur 143 biopsies consécutives.

OBJECTIVE: A vascular cause is found in around 85% of leg ulcer patients, but non-vascular causes are also observed. Their diagnosis is based on a set of clinical arguments and skin biopsy with histological analysis. The aim of this study was to analyze the results of these biopsies and to find common criteria for ulcers whose skin biopsies had led to the diagnosis of a non-vascular ulcer. MATERIAL AND METHOD: A retrospective study was carried out on the analysis of 143 skin biopsies of leg ulcers. The reasons for the biopsy were mainly atypical clinical signs and/or the lack of improvement in care after 6 months, as advocated by the French health authorities. RESULTS: The skin biopsies led to a diagnosis of non-vascular ulcer in 4.9% of cases (7/143), including skin cancer (n=5, 3.5%), cutaneous leishmaniasis (n=1, 0.7%) and Pyoderma gangrenosum (n=1, 0.7%). The univariate statistical analysis revealed that an elevated rim and abnormal excessive granulation tissue were significantly more frequently found in these ulcers. All patients with a positive skin biopsy had associated vascular involvement. CONCLUSION: This study found a 5% rate of non-vascular causes of ulcers, mainly skin cancer. Elevated rims and abnormal excessive granulation tissue were the unusual features most commonly found in these ulcers. All patients whose skin biopsy revealed a non-vascular cause had associated vascular involvement. This information confirms the need to perform a skin biopsy, even in the presence of a vascular disease.

Ranibizumab and digital ischemia.

Case report of a patient with age-related macular degeneration whose digital ischemia can most plausibly be attributed to ranibizumab. PURPOSE: To report ranibizumab as the probable cause of digital ischemia in a patient treated for age-related macular degeneration. METHODS: Single-patient case report. RESULTS: An 83-year-old woman with an unremarkable medical history suffered acute ischemia in her left hand with necrosis of the distal phalange of the fifth finger after six intravitreal injections of ranibizumab. Her etiological work-up was negative. Her condition improved after endovascular revascularization and remained good at six months' follow-up after three months of dual antithrombotic therapy (low molecular weight heparin then rivaroxaban, both with aspirin) followed by rivaroxaban alone and four courses of intravenous iloprost. CONCLUSION: The increased incidence of peripheral arterial thromboembolic events in patients under ranibizumab treatment is slight but significant, with 0.8-5% of patients affected, most of which suffer strokes. These events seem to occur at a random time after ranibizumab treatment is initiated and no reliable marker has yet been identified. The most probable cause of digital ischemia in our patient was ranibizumab.

Do we still need autopsy in times of modern multislice computed tomography?-Missed diagnoses in the emergency room.

INTRODUCTION: In spite of increasing quality of emergency room (ER) assessment in trauma patients and improved accuracy of modern multislice computed tomography (MSCT), the number of potentially missed diagnoses is still controversial. The aim of this study was to compare the initial findings of ER assessment and MSCT to the findings during autopsy in trauma patients not surviving the first 48 h after admission. We hypothesized that autopsy was more accurate than MSCT in diagnosing potentially fatal diagnoses. PATIENTS AND METHODS: Between January 2004 and September 2007, all trauma patients undergoing ER treatment in our institution who deceased within 48 h after admission were analyzed regarding diagnoses from initial ER assessment, including MSCT, and diagnoses from autopsy. Data were prospectively collected and retrospectively analyzed. Autopsy reports were compared to diagnoses of ER assessment and MSCT. Missed diagnoses (MD) and missed potentially fatal diagnoses (MPFD) were analyzed. RESULTS: Seventy-three patients with a mean age of 53.2 years were included into the study. Sixty-three percent were male. Autopsy revealed at least one missed diagnosis in 25% of the patients, with the thoracic area accounting for 67% of these. At least one MPFD was found in 4.1% of the patients, all of them being located in the thorax. Total numbers of MD and MPFD were significantly lower for the newer CT generation (64 MSCT, N = 11), compared to older one (4 MSCT, N = 26). CONCLUSIONS: As determined by autopsy, modern multislice computed tomography is an accurate method to diagnose injuries. However, 25% of all diagnoses, and 4.1% of potentially fatal diagnoses are still missed in trauma patients, who deceased within the first 48 h after admission. Therefore, autopsy seems to be necessary to determine potentially missed diagnoses for both academic and medicolegal reasons as well as for quality control.

PO-47 - Microparticles derived from ovarian cancer cell line contained genomic and biologically active proteins, including tissue factor involved in coagulation.

INTRODUCTION: The microparticles (MPs) are sized vesicles of less than 1 µm, from different cell types upon activation or subsequent to apoptosis. They are involved in the thrombotic process, particularly in cancer. The role of MPs in ovarian cancer and their involvement in thrombosis being poorly understood. AIM: The aim of this study was to identify in vitro the generation of MPs by an human ovarian adenocarcinoma cell line (OVCAR-3). MATERIALS AND METHODS: OVCAR-3 cells were cultured in three conditions [without stimulation, with protein C (PC), and with activated protein C (APC)]. Then, the MPs present in the supernatant, were isolated by ultracentrifugation and were analyzed for their shape and properties by flow cytometry, electron microscopy, cryofracture analysis, DNA and RNA, and proteomic analysis. The level of tissue factor (TF) on MP was evaluated by TF-induced shortening of Ca(2+) plasma coagulation time. RESULTS: Our results demonstrated that 1) 92% of MPs derived from OVCAR-3 were less than 100 nm. 2) As tested by flow cytometry, the MPs contained b2 microglobulin, annexin, DNA fragments and TF that induces a shortening of Ca(2+) -induced plasma coagulation time. When OVCAR-3 were cultured for 18H with PCA, MPs were generated in greater amount than those generated by OVCAR-3 in its absence and their level of TF was increased of 20%. Curiously, in contrast with intact OVCAR-3 cells, the endothelial protein C receptor (EPCR) was not detected in MPs 3) Proteomic analysis show that the MPs contain proteins involved in cancer progression such as mucins (5A and 5B), keratin type-1, actin, annexin (A1, A2, A4), CD44, glypican, heat shock (70kDa and HS90a) proteins, Agrin associated with heparan sulfate proteoglycan abundant in the tumor-specific basement membrane, Ephrin type A receptor, coronin-1C, catenin α, integrin ß-1 and also p-selectin responsible of platelet activation. They also express several DNA associated proteins includingtranscription factors, various polymerases, nucleases, and histones involved in chromosome packaging and transcription in the cell nucleus. CONCLUSIONS: MPs derived from OVCAR-3 have an apoptotic character. They expressed several biologically active proteins, DNA and their associated proteins. Despite the absence of EPCR expression on MPs that was expressed on intact OVCAR-3 cells, they expressed procoagulant TF activity already found on intact ovarian cancer cells. This activity is greater extent in the presence of APC.

Does MIPO of fractures of the distal femur result in more rotational malalignment than ORIF? A retrospective study.

PURPOSE: Intraoperative control of rotational malalignment poses a big challenge for surgeons when using modern MIPO (minimally invasive plate osteosynthesis) techniques. We hypothesized that distal femoral fractures treated with MIPO technique are more often fixed in malrotation than those treated with open reduction internal fixation (ORIF). METHODS: In this retrospective study, we identified 20 patients who met the inclusion criteria and agreed to take part in the study. In ten patients MIPO was applied, in the other ten ORIF was used. Mean age was 44.8 (19-71 years). Functional status was assessed using clinical scores (Harris Hip Score, WOMAC Hip, KS Score, WOMAC Knee, Kujala Score). Rotational alignment was assessed with magnetic resonance imaging and compared to the opposite leg. RESULTS: We discovered a significant difference in the mean rotational difference between the MIPO group (14.3°) and the ORIF group (5.2°). Functionally, patients in the ORIF group outperformed patients in the MIPO group in all clinical scoring systems although no one proved to be statistically significant. MIPO technique was associated with significantly more rotational malalignment compared to ORIF in distal femur fracture fixation. However, implant failure and nonunion was more common in the ORIF group, with a revision rate of 3 versus 1 in the ORIF group. Clinical scoring did not significantly different between both groups. CONCLUSION: Taking into account the undisputable advantages of minimally invasive surgery, improved teaching of methods to avoid malrotation as well as regular postoperative investigations to detect any malrotation should be advocated.

[Compression care for venous leg ulcers: Assessment of medical practices in 100 patients]. / La compression dans la prise en charge des ulcères veineux des membres inférieurs. Évaluation des pratiques professionnelles sur 100 patients.

INTRODUCTION: The etiologic treatment of venous ulcers is based on compression therapy in compliance with the new guidelines promulgated by the French National Authority for Health (HAS) in 2010. Prescriptions often originate from a request by the nurse delivering care in the patient's home. A recent French study demonstrated the positive impact of compression therapy on venous ulcer healing. The objective of this study was to evaluate medical practices in order to target corrective actions. MATERIALS AND METHODS: We conducted a single-center prospective observational study, using a standardized questionnaire from January to May 2014. Patients with venous ulcers who had an indication for compression therapy were included consecutively. The questionnaire collected demographic and clinical data and also recorded the results of complementary tests and the characteristics of the compression therapy. RESULTS: One hundred patients were included (61 women and 39 men). The average age was 76 years. Patients were recruited during consultations (n = 69), with a majority of patients living at home (n = 80) and receiving home care delivered by a nurse (n = 81). Thirteen patients were seen for the first time and 87 patients were receiving long-term care. The ulcers evolved for 5.7 years on average. Patients presented peri-lesional edema (n = 58), ankle ankylosis (n = 49), autonomous mobilization (n = 40) and walking problems (n = 60). Physical therapy was prescribed for 39 patients and was effectively carried out for 24. The two main causes were venous varices (n = 66) and post-phlebitis disease (n = 18). Compression therapy was prescribed for 97 patients and the products delivered by the pharmacy were consistent with the prescription for 74 patients. Compliance with compression therapy was faulty for 28 patients because of poor tolerance, misunderstanding, manipulation problems, or inappropriate footwear. At assessment, 66 patients were wearing the bands, but not always correctly (starting at the base of the toes [n = 61], heel included [n = 43], proper stretching [n = 43] up to below the knee [n = 57]). Proper footwear was noted in 70 patients. CONCLUSION: Data are scarce on compliance with compression banding. This study shows that further efforts are needed to ensure proper patient education and professional training for physicians and allied profession concerning the installation of compression therapy. Total compliance was observed in only 35% of patients. In addition, the products delivered by the pharmacy were not consistent with the prescription in 26% of cases. Many discrepancies were observed between what was prescribed and what the patients achieved. Patient adherence is a crucial issue for compression therapy.

[Modified McPeek score in multiple trauma patients. Prospective evaluation of a points system for recording follow-up factors]. / Modifiziertes McPeek-Punkte-System bei Polytraumapatienten. Prospektive Evaluierung eines Punktesystems zur Erfassung von Verlaufsfaktoren.

BACKGROUND: Many commonly available trauma scores predict mortality, but to evaluate the success of a certain therapy or for difficult scientific and epidemiological purposes this may be insufficient in the face of improved survival rates. For outcome analysis of multiple trauma patients, the extent of medical resources needed could be an additional outcome measurement. McPeek et al. developed a potential scoring system for elective surgery patients, which was recently modified for multiple trauma patients. AIM: The current study investigated if the McPeek score could be prospectively used in multiple trauma patients and whether it could become an additional helpful tool in outcome assessment. Applicability was assessed by practical examples. MATERIAL AND METHODS: In this prospective single-centre study at the University Hospital of Innsbruck, Austria, between December 2008 and November 2010 multiple trauma patients (≥ 18 years) with an injury severity score (ISS) ≥ 17 were enrolled. Besides demographic data, prehospital vital parameters and diagnoses, all diagnoses from the trauma, mortality, length of stay in the intensive care unit and the hospital were recorded. The commonly used trauma scores ISS, revised trauma score (RTS), a severity characterization of trauma (ASCOT) and trauma and injury severity score (TRISS) were applied and an observed McPeek score was allocated following end of hospitalization. The McPeek scoring system was used according to the latest modifications. A correlation between trauma scores and the McPeek score was performed. The McPeek score was then predicted by a common trauma score using ordinal regression with the polytomous universal model (PLUM method). By subtracting the predicted from the observed McPeek scores the residual McPeek value was calculated and used for practical examples of outcome analysis with the McPeek scoring system. RESULTS: Out of 406 identified multiple trauma patients during the study phase, 183 had to be excluded due to missing data (mainly prehospital or following transfer). A total of 223 patients (mean ISS 31.2, mean age 47.2 years) were enrolled and assigned to the population-based observed McPeek score (median 4.0). Correlation coefficients were Glasgow coma scale (GCS) 0.59, ISS 0.62, RTS 0.65, TRISS 0.74 and ASCOT 0.77 (p < 0.0001). The TRISS predicted the McPeek score best in ordinal regression (pseudo-R(2) = 0.944, p < 0.0001). The residual McPeek score (observed minus predicted) was used to illustrate the influence of the blood glucose level on admission and the influence of head injury on outcome of multiple injury patients in detail. CONCLUSION: The modified McPeek score is applicable to multiple trauma patients to assess outcome for scientific or epidemiological purposes. Its main advantage is that it quantifies outcome independently of regional or national circumstances.

The influence of distal locking on the need for fibular plating in intramedullary nailing of distal metaphyseal tibiofibular fractures.

Using human cadaver specimens, we investigated the role of supplementary fibular plating in the treatment of distal tibial fractures using an intramedullary nail. Fibular plating is thought to improve stability in these situations, but has been reported to have increased soft-tissue complications and to impair union of the fracture. We proposed that multidirectional locking screws provide adequate stability, making additional fibular plating unnecessary. A distal tibiofibular osteotomy model performed on matched fresh-frozen lower limb specimens was stabilised with reamed nails using conventional biplanar distal locking (CDL) or multidirectional distal locking (MDL) options with and without fibular plating. Rotational stiffness was assessed under a constant axial force of 150 N and a superimposed torque of ± 5 Nm. Total movement, and neutral zone and fracture gap movement were analysed. In the CDL group, fibular plating improved stiffness at the tibial fracture site, albeit to a small degree (p = 0.013). In the MDL group additional fibular plating did not increase the stiffness. The MDL nail without fibular plating was significantly more stable than the CDL nail with an additional fibular plate (p = 0.008). These findings suggest that additional fibular plating does not improve stability if a multidirectional distal locking intramedullary nail is used, and is therefore unnecessary if not needed to aid reduction.

A new radiological method to detect dorsally penetrating screws when using volar locking plates in distal radial fractures. The dorsal horizon view.

Penetration of the dorsal screw when treating distal radius fractures with volar locking plates is an avoidable complication that causes lesions of the extensor tendon in between 2% and 6% of patients. We examined axial fluoroscopic views of the distal end of the radius to observe small amounts of dorsal screw penetration, and determined the ideal angle of inclination of the x-ray beam to the forearm when making this radiological view. Six volar locking plates were inserted at the wrists of cadavers. The actual screw length was measured under direct vision through a dorsal approach to the distal radius. Axial radiographs were performed for different angles of inclination of the forearm at the elbow. Comparing axial radiological measurements and real screw length, a statistically significant correlation could be demonstrated at an angle of inclination between 5° and 20°. The ideal angle of inclination required to minimise the risk of implanting over-long screws in a dorsal horizon radiological view is 15°.

A case of supracondylar humerus fracture with vascular impairment. Open it up?

Supracondylar humerus fracture is one of the most frequent fractures in childhood. A serious complication is an injury to the neurovascular structures which could potentially result in severe functional impairment. We are presenting the case of a 3-year-old girl with a supracondylar humerus fracture in our emergency department and highlight the diagnostic and therapeutic steps in managing this situation. Initially, the hand was well perfused but showed to be pulseless in the operating theater after preparation for surgery. After open reduction and internal pin fixation the neurovascular structures were explored and the brachial artery was repaired by means of a cephalic vein graft. On follow up the patient presented with normal hand function and without vascular or neurologic deficits. As concomitant vascular injuries after supracondylar humerus fractures are rare, it can be difficult to discriminate a pink pulseless hand from a patient with essential vascular injury. Our case also demonstrates the need for short-term reevaluation of the clinical status. When in doubt there should be no hesitation to perform open surgery and vascular repair.

Is augmentation a possible salvage procedure after lateral migration of the proximal femur nail antirotation?

INTRODUCTION: Failed fracture fixation of proximal femur fractures in the elderly usually results in prosthetic replacement. In case of the proximal femur nail antirotation (PFNA), during lateral blade migration or periimplant fracture at the femoral shaft, the femoral head remains intact and therefore a joint preserving procedure might be performed. However, implant anchorage in the femoral head after the second blade implantation generally results in reduced anchorage in the remaining cancellous bone. Therefore, we hypothesize that in the above mentioned cases augmentation of the PFNA blade could be a treatment option before prosthetic surgery has to be performed. MATERIALS: Biomechanical investigations were performed in eight fresh frozen femoral heads. Implant anchorage in case of blade extraction and reinsertion was investigated by rotation and pull out of a PFNA blade with a servohydraulic testing machine. After reinsertion of the blade and augmentation with bone-cement, the anchorage of the blade was investigated again to observe changes in torque and pull-out force. RESULTS: Rotational stability of the implant significantly increased after augmentation of the prior extracted PFNA blade. Pull-out strength was higher in the revised case than in the initial tests but without statistical significance. After augmentation, correlation between bone mineral density and pull-out strength which was found during initial pull-out disappeared. DISCUSSION: Augmentation of simulated blade exchange after lateral blade migration demonstrated a good anchorage. There was superior rotational stability in the revised case and no inferiority during pull out for the investigated specimens. Furthermore, augmentation could compensate for destroyed trabeculae and poor bone stock. It could furthermore be an option when a failed implant has to be replaced by a long PFNA in case of shaft fracture at the tip of the implant to increase anchorage in the femoral head. From a biomechanical point of view, reosteosynthesis and augmentation in selected cases of PFNA revision could be an alternative to initial prosthetic replacement. In the case of cut-out or medial implant protrusion, the suggested salvage technique is not feasible.

The impact of coagulopathy on the outcome of traumatic epidural hematoma.

PURPOSE: To evaluate the impact of trauma-associated coagulation disorders on the neurological outcome in patients with traumatic epidural hematoma undergoing surgical or non-surgical treatment. A retrospective analysis was performed using prospectively collected data in a consecutive patient series from a level 1 trauma center. METHODS: Eighty-five patients with traumatic epidural hematoma were identified out of 1,633 patients admitted to our emergency room with traumatic head injuries between October 2004 and December 2008. The following prospectively assessed parameters were analyzed: Glasgow Coma Scale, coagulopathy, presence of skull fractures, additional injuries, the Injury Severity Score, hematoma volume and thickness at admission, hematoma volume progression over time and neurologic symptoms. Furthermore, patients were grouped based on whether they had undergone surgical or non-surgical treatment of the epidural hematoma. Clinical outcome was determined according to the Glasgow Outcome Score (GOS) at hospital discharge. RESULTS: Patients with coagulopathy showed significantly lower GOS values compared to patients with intact blood coagulation. Initial and progressive hematoma volumes did not influence neurological outcome. Patients with multiple injuries did not show a worse outcome compared to those with isolated epidural hematoma. There was no difference in patient's outcome after surgical or non-surgical treatment. CONCLUSIONS: Poor outcome after traumatic epidural hematoma was associated with coagulopathy. Progression of epidural hematoma volume was not associated with coagulopathy or with poor neurological outcome. Prospective studies are needed to confirm these results.

[Anatomical double-bundle reconstruction of the medial patellofemoral ligament with a gracilis autograft]. / Anatomische Rekonstruktion des medialen patellofemoralen Bands mit gedoppelter Gracilissehne.

OBJECTIVE: Elimination of patellofemoral instability by reconstruction of the medial patellofemoral ligament (MPFL) with a gracilis autograft. INDICATIONS: Recurring lateral luxation and subluxation of the patella, tibial tuberosity-trochlear groove distance (TTTG) < 20 mm, persistent positive apprehension test in up to 45° of flexion, low grade trochlear dysplasia. CONTRAINDICATIONS: Traumatic luxation of the patella without anatomical risk factors, isolated treatment if TTTG > 20 mm, and isolated treatment for high-grade trochlear dysplasia (type B, C, D). SURGICAL TECHNIQUE: Supine postion. Stripping of the gracilis tendon. Drilling of two tunnels into the medial margin of the patella. Insertion of both tendon ends into the tunnels and fixation with resorbable screwlocks. Undermining of the fascia of the medial oblique vastus muscle and insertion of the tendon loop into the femoral point of insertion located at the medial epicondyle. Preparation of the femoral point of insertion and drilling of the femoral tunnel. Insertion of the graft into the femoral tunnel. Positioning of the knee in 30° of flexion. Positioning of the patella and fixation of the graft with a resorbable screw. POSTOPERATIVE MANAGEMENT: Two weeks of partial weight bearing. Knee orthesis for 6 weeks. Passive motion up to 60° of flexion for the first 2 weeks. Three weeks postoperatively unrestricted motion exercises, strengthening of the quadriceps muscle. Unlimited activity is possible 3 months postoperatively. RESULTS: The method presented in this manuscript was performed on 32 patients with recurring patellar luxation; 27 patients were available for clinical assessment at 1 year postoperatively. There were no recorded events of reluxation; the Kujala score increased on average from 61 points preoperatively to 93 points postoperatively.

[Intramedullary nailing of the distal tibia illustrated with the Expert(TM) tibia nail]. / Marknagelung distaler Unterschenkelfrakturen am Beispiel des Expert(TM) Tibianagels.

OBJECTIVE: Restoration of axis, length, and rotation of the lower leg. Sufficient primary stability of the osteosynthesis for functional aftercare and to maintain joint mobility. Good bony healing in closed and open fractures. INDICATIONS: Closed and open fractures of the tibia and complete lower leg fractures distal to the isthmus (AO 42), extraarticular fractures of the distal tibia (AO 43 A1/A2/A3), segmental fractures of the tibia with a fracture in the distal tibia, and certain intraarticular fractures of the distal tibia without impression of the joint line with the use of additional implants (AO 43 C1) CONTRAINDICATIONS: Patient in reduced general condition (e.g., bed ridden), flexion of the knee of less than 90°, patients with knee arthroplasty of the affected leg, infection in the area of the nail's insertion, infection of the tibial cavity, complex articular fractures of the proximal or distal tibia with joint depression. SURGICAL TECHNIQUE: Closed reduction of the fracture preferably on a fracture table or using a distractor or an external fixation frame. If necessary, use pointed reduction clamps or sterile drapery. In some cases, additional implants like percutaneous small fragment screws, poller screws or k-wires are helpful. Open reduction is rarely necessary and must be avoided. Opening of the proximal tibia in line with the medullary canal. Canulated insertion of the Expert(TM) tibia nail (ETN; Synthes GmbH, Oberdorf, Switzerland) with reaming of the medullary canal. Control of axis, length, and rotation. Distal interlocking with the radiolucent drill and proximal interlocking with the targeting device. POSTOPERATIVE MANAGEMENT: Immediate mobilization of ankle and knee joint. Mobilization with 20 kg weight-bearing with crutches. X-ray control 6 weeks postoperatively and increased weight-bearing depending on the fracture status. In cases with simple fractures, good bony contact, or transverse fracture pattern, full weight-bearing at the end of week 6 is targeted. RESULTS: Between July 2004 and May 2005, 180 patients were included in a multicenter study. The follow-up rate was 81% after 1 year. Of these, 91 fractures (50.6%) were located in the distal third of the tibia. In this segment, the rate of delayed union was 10.6%. Malalignment of > 5° was observed in 5.4%. A secondary malalignment after initial good reduction was detected in only 1.1% of all cases. The implant-specific risk for screw breakage was 3.2%. One patient sustained a deep infection. If additional fibula plating was performed an 8-fold higher risk for delayed bone healing was observed (95%CI: 2.9-21.2, p< 0.001). If the fracture of the fibula was at the same height as on the tibia, the risk for delayed healing was even 14-fold (95% CI: 3.4-62.5, p< 0.001). Biomechanically plating of the fibula does not increase stability in suprasyndesmal distal tibia-fibular fractures treated with an intramedullary nail. Using the ETN with its optimized locking options, fibula plating is not recommended, thus, avoiding soft tissue problems and potentially delayed bone healing.