Orthopaedic and Trauma Surgery

MRI in patients with Haglund’s deformity and its influence on therapy Abstract Introduction Heel pain is one of the common reasons why patients consult orthopaedic surgeons in an outpatient setting. The dorsal heel pain is often caused by a Haglund’s deformity which is an exostosis of the posterior superior calcaneus. It often leads to Haglund’s syndrome with calcaneal bursitis and Achilles tendinosis. This study aims to investigate the roll of MRI in diagnosis of Haglund’s syndrome and its influence on therapy. Materials and methods We retrospectively analysed data of 45 patients which clinically and radiologically confirmed Haglund’s deformity. Patients were divided into two groups that either did not receive MRI (MRI_0) or received MRI (MRI_1). To evaluate the significance, Fisher´s test was used. A statistical significance was assumed at p < 0.05. Results The average age was 57.0 years. There was no significant difference in therapy comparing the groups MRI_0 and MRI_1. Haglund’s syndrome was detected in 86.7% of all patients with Haglund’s deformity. Conclusion MRI does not influence the therapy of patients with Haglund’s deformity. Therefore, the resources of this cost-intensive and limited type of investigation should be used elsewhere. In cases of atypical heel pain, the MRI might be useful.

Displaced distal radius fracture presenting with neuropraxia of the dorsal cutaneous branch of the ulnar nerve (DCBUN) Abstract Nerve injuries, mostly to the median nerve, are common following distal radius fractures. Ulnar nerve injuries are rarely encountered, with only few case reports of motor or motor and sensory loss described in the literature. In this paper, we report two consecutive cases of young patients with a distal radius fracture and a pure sensory ulnar neuropathy. Both patients had a radially displaced fracture and presented with sensory loss and paresthesia in the distribution of the dorsal cutaneous branch of the ulnar nerve (DCBUN), which resolved after fracture reduction. We believe this clinical scenario is the result of traction or compressive neuropraxia of the DCBUN in the subcutaneous tissue around the ulnar styloid—a neurologic injury which had not yet been described for distal radius fractures.

Intra-articular injection of mesenchymal stem cells for clinical outcomes and cartilage repair in osteoarthritis of the knee: a meta-analysis of randomized controlled trials Abstract Introduction Mesenchymal stem cells (MSCs) have gained popularity for articular cartilage repair. However, efficacy of intra-articular MSCs in osteoarthritis remains unclear. In the setting of a meta-analysis of randomized controlled trials (RCTs), we aimed to investigate the efficacy of intra-articular MSCs on clinical outcomes and cartilage repair in patients with knee osteoarthritis. Materials and methods PubMed, EMBASE, Cochrane Library, CINAHL, and Scopus were searched from inception to March 31, 2017. This study included RCTs using cell population containing MSCs for treatment of knee osteoarthritis. The quality was assessed by Cochrane Collaboration`s risk of bias tool. For meta-analysis, data on clinical outcomes measured by visual analog scale (VAS), Lysholm score, WOMAC and data on cartilage repair measured by MOCART and WORMS were extracted. In studies with several cell concentrations, outcomes of recommended concentration were used mainly to ensure robustness. Results A total of five RCTs (220 patients) were included. Two studies were deemed to have low risk of bias. In pooled analysis, there was significant difference in VAS score (mean difference [MD], − 9.2; 95% CI: − 17.21, − 1.20) and Lysholm score (MD, 8.70; 95% CI 0.06, 17.34), but not WOMAC (MD, − 7.44; 95% CI − 20.38, 5.50). In cumulative functional analysis using Lysholm score and WOMAC in recommended concentration, there was a significant improvement (standard mean difference [SMD], 0.53; 95% CI 0.13, 0.94) after treatment. In cartilage repair assessed by MRI, there was no significant difference (SMD, 0.53; 95% CI− 0.28, 1.34). Conclusions This meta-analysis demonstrated that intra-articular MSCs have a limited evidence in pain relief and functional improvement in knee osteoarthritis. While MSCs may result in favorable clinical outcomes with a recommended concentration, use of concomitant treatment should be considered. In addition, current evidence does not support the use of intra-articular MSCs for improving cartilage repair in knee osteoarthritis. Level of evidence Systematic review of Level-II studies.

Contamination rate of the surgical gowns during total hip arthroplasty Abstract Introduction Surgical instrument contamination during total joint replacement is a matter of major concern. Available recommendations suggest changing suction tips, gloves and avoiding light handle manipulation during the procedure. There is a paucity of data regarding surgical gown contamination. The aim of the present study was to evaluate the contamination rate of surgical gowns (SGs) during total hip arthroplasty (THA) and secondarily compare it with other orthopedic procedures. Materials and methods One hundred and forty surgical gowns (from 70 surgeries) were screened for bacterial contamination using thioglycolate (a high-sensitivity culture broth). The THA contamination rate was compared with those of knee and spine procedures. Controls were obtained at the beginning of every surgery and from the culture broth. The procedure’s duration and the level of training of the surgeon were evaluated as potential risk factors for contamination. Results Bacterial contamination was identified on 12% of surgical gowns (22% of surgical procedures). The contamination rate during THA was 4.1% (2% in primary THA and 8.3% in revisions) vs 21.67% during other surgeries (spine and knee) (OR 6.15, p = 0.012). There were no contaminated SGs during THAs performed in ≤ 2 h (0/33 SGs) vs 7.5% (3/40) for THAs that took ≥ 2 h (p = 0.25). Conclusion There was a high rate of SG contamination during orthopedic procedures that was higher during non-arthroplasty procedures and prolonged THAs. There were no contaminated surgical gowns in THAs under 120 min, efforts should point keeping primary THAs under this cutoff time. As a general recommendation, SGs should be changed every time there is concern about potential contamination.

Biceps tenodesis versus tenotomy in isolated LHB lesions: a prospective randomized clinical trial Abstract Introduction Currently there exists no clear evidence concerning the surgical treatment of LHB lesions with either tenotomy or tenodesis. The aim of the study is therefore to evaluate elbow flexion and forearm supination force as well as the biceps muscle distalization according to both techniques in isolated LHB lesions. Methods Consecutive patients aged 40–70 years with shoulder arthroscopies for isolated SLAP or biceps pulley lesions were prospectively randomized to arthroscopic suprapectoral intraosseous LHB tenodesis or tenotomy. Pre-, 6 and 12 months postoperatively, the SST, ASES, Constant–Murley and LHB scores were recorded. The elbow flexion force was measured in 10°/90° flexion, the supination force in neutral/pronation position. In addition, the maximum upper-arm circumference and its position relative to the radial epicondyle of the humerus were evaluated preoperatively and in follow-up. Results 20/22 patients (mean age 52.0 ± 8.5; range 36–63 years, 11 male) completed the follow-up. 9/20 were treated with LHB tenodesis (mean age 51.5 ± 9.5; range 37–63 years, 7 male) and 11/20 with tenotomy (mean age 52.8 ± 8.0; range 36–62 years, 4 male). The force measurements and scores showed no significant difference after 12 months. Tenodesis achieved a significant increase in force 6 months postoperatively compared to preoperatively. One tenodesis patient and three tenotomy patients showed a postoperative popeye-sign deformity. Conclusion This prospective randomized study comparing LHB tenodesis and tenotomy in isolated LHB lesions has shown no significant difference in elbow flexion and forearm supination force and clinical scores after 12 months. After LHB tenotomy, there was a non-significant trend for a higher rate of popeye-sign deformities of the upper arm and biceps muscle cramps.

Impact of closed suction drainage after surgical fixation of acetabular fractures Abstract Introduction The purpose of the present study was to evaluate the prevalence of closed suction drainage after a Kocher–Langenbeck (K–L) approach for surgical fixation of acetabular fractures and to determine the impact of closed suction drainage on patient outcomes. Methods This retrospective study reports on 171 consecutive patients that presented to a single level I trauma center for surgical fixation of an acetabular fracture. Medical records were reviewed to evaluate the use of closed suction drains. The primary outcomes measures were rate of packed red blood cell (PRBC) transfusion and length of hospital stay (LOS). Secondary outcome measures were 30-day post-operative wound complication and 1-year deep infection rates. Results Of the 171 patients included in this study, 140 (82%) patients were treated with drains. There was a significant association between the use of closed suction drainage and post-operative blood transfusion rate (p = 0.002). Thirty-five patients (25%) treated with drains required a post-operative blood transfusion compared to 0% in the no drain cohort. Regarding the total number of drains used, for every additional closed suction drain that was placed beyond a single drain, the odds of receiving a blood transfusion doubled (p = 0.002). Use of closed suction drainage was associated with a significantly longer LOS (p = 0.015), and no difference in wound complication or deep infection rates. Conclusion The use of closed suction drains for treatment of acetabular fractures using a K–L approach is associated with increased rates of blood transfusion and increased length of hospital stay, with no impact on surgical site infection rates. The results of this study suggest against routine drain usage in acetabular surgery.

Long-term outcome after surgical treatment of intra-articular tibial plateau fractures in skiers Abstract Introduction Tibial plateau fractures occur frequently during downhill skiing. There is a lack of information about the outcome and development of posttraumatic osteoarthritis after internal fixation of such fractures at long-term follow-up in skiers. Materials and methods A population of 83 skiers was followed up in a case series after internal fixation of intra-articular tibial plateau fractures AO-OTA 41 B1-B3 and C1-C3. Functional outcomes Visual Analog Scale, Tegner Activity Scale, Modified Lysholm Score, Hospital for Special Surgery (HSS) Knee Score and X-ray images of the affected knees (preoperative, postoperative and at time of follow-up) were obtained. Radiological evaluation focused on severity of osteoarthritis according to the Kellgren and Lawrence score of the lateral, medial and retropatellar knee compartments separately. Subgroup analyses for fracture type and age were performed separately. Results Patients age was 49.8 ± 12.9 years (range 19–74 years) at the time of surgery, with a mean follow-up period of 10.3 ± 1.9 years (range 6–14 years). All tibial plateau fractures affected the lateral compartment, while the medial compartment was affected in addition as part of bicondylar fractures in two cases. Both the Tegener Activity Scale and Lysholm Score decreased significantly during the follow-up period and their median values dropped from 6 (range 3–7) to 5 (range 2–7) and from 100 (range 90–100) to 95 (range 58–100), respectively (both p < .01). The median clinical knee function at the time of follow-up revealed an HSS Knee Score of 96.5 points (range 74–100). Among the whole patient population, the radiological evaluation at follow-up revealed a significantly higher grade of osteoarthritis in all compartments of the knee joint compared to the time of the operation (p < .01). The grade of osteoarthritis in the lateral compartment was significantly higher than that in the medial and retropatellar compartments (p < .01). Conclusions In addition to physiologic aging, progression of radiologic signs of osteoarthritis following internal fixation of intra-articular tibial plateau fractures in an athletic population of skiers is most severe in the lateral knee compartment corresponding to fracture location. However, the long-term functional outcomes seem to be very satisfactory.

Weakening of the knee ligament complex due to sequential medial release in total knee arthroplasty Abstract Purpose The purpose of this study was to investigate the effects of sequential medial release on the stiffness and collateral stability of the ligament complex of the knee. Irrespective of the implantation technique used, varus deformity frequently requires release of the capsular ligament complex. Yet, no data are available on how stiffness and stability of the knee ligament complex are weakened by such release. Methods After total knee arthroplasty, ten healthy Thiel-fixed knee joints were subjected to sequential medial release consisting of six release steps. After each step, stiffness and stability were determined at 0°, 30°, 60°, and 90°. Results Sequential medial release increasingly weakened the ligament complex. In extension, release of the anteromedial tibial sleeve 4 cm below the joint line already weakened the ligament complex by approximately 13%. Release 6 cm below the joint line reduced stiffness and stability by 15–20% over the entire range of motion. After detachment of the medial collateral ligament, stability was only about 60% of its initial value. Conclusion Our study showed for the first time the association between medial release and stiffness and stability of the knee ligament complex. To maintain stability, vigorous detachment of the knee ligament complex should be avoided. Release of the anteromedial tibial sleeve already initiates loss of stability. The main stabiliser is the medial ligament, which should never be completely detached. Level of evidence IV.

Peroneal nerve location at the fibular head: an anatomic study using 3D imaging Abstract Introduction Injuries to the peroneal nerve are a common complication in operative treatment of proximal tibial or fibular fractures. To minimize the risk of iatrogenic injury to the nerve, detailed knowledge of the anatomy of the peroneal nerve is essential. Aim of this study was to present a detailed description of the position and branching of the peroneal nerve based on 3D-images to assist preparation for surgical approaches to the fibular head and the tibial plateau. Methods The common peroneal nerve, the deep and the superficial peroneal nerve were marked with a radiopaque thread in 18 formalin-embalmed specimens. Three-dimensional X-ray scans were then acquired from the knee and the proximal lower leg in full extension of the knee. In 3D-reconstructions of these scans, distances of the common peroneal nerve and its branches to clearly defined osseous landmarks were measured digitally. Furthermore, the height of the branching of the common peroneal nerve was measured in relation to the landmarks. Results The mean distance of the common peroneal nerve at the level of the tibial plateau to its posterior osseous limitation was 7.92 ± 2.42 mm, and 1.31 ± 2.63 mm to the lateral osseous limitation of the tibia. In a transversal plane, distance of the common peroneal nerve branching was 27.56 ± 3.98 mm relative to the level of the most proximal osseous extension of fibula and 11.77 ± 6.1 mm relative to the proximal extension of the tibial tuberosity. The deep peroneal nerve crossed the midline of the fibular shaft at a distance of 22.14 mm ± 4.35 distally to the most proximal extension of the fibula, the superficial peroneal nerve at a distance of 33.56 mm ± 6.68. Conclusion As the course of the peroneal nerve is highly variable in between individuals, surgical dissection for operative treatment of proximal posterolateral tibial or fibular fractures has to be done carefully. We defined an area were the peroneal nerve and its branches are unlikely to be found. However, specific safe zones should not be utilized due to the individual anatomic variation.

Sagittal profile has a significant impact on the explantability of well-fixed cemented stems in revision knee arthroplasty: a biomechanical comparison study of five established knee implant models Abstract Background Easy revisability is gaining increasingly in importance. The removal of well-fixed cemented stems is very demanding and is often associated with increased operative morbidity. Implant design may be here a decisive impact factor, and the best way to ascertain it is experimentally. Aim of this study is to assess different cemented stems of established knee revision implants in regard to their removal capability. Methods Based on their sagittal profile, five stem extensions from known manufacturers were divided in conical, conical–cylindrical and cylindrical designs. The pedicles were also characterized in respect to their cross section, diameter and surface roughness. The cemented stems were dismounted six times each in a reproducible biomechanical setup. The explantation energy required was determined and statistical analyzed. Results The conical shaft needed significantly the slightest explantation energy with 19.2 joules (p = 0.004). There was a strong negative linear correlation between conicity proportion and explantation energy of the cemented stems (R2 = 0.983). The removal of the three purely cylindrical shafts—regardless of their differences in diameter, cross-sectional design and surface– was the most demanding (98.3, 105, and 116.7 joules) with only secondary differences between them. Conclusion The longitudinal stem profile may have a primary impact on the explantability of well-fixed cemented shafts with conical designs showing superiority. Cross-sectional profile and surface roughness had here a less decisive influence on the explantability. Surgeons can choose proper implants and removal techniques depending on potential implant-associated revision risks and re-revisions to be expected.