Overlooked Hoffa Fracture in a Patient With Neurofibromatosis-1.

Hoffa fractures are rare fractures of either one or both femoral condyles in the coronal plane. They usually occur as a result of high-velocity, high-energy trauma with axial compression of the lower limb and a typically flexed position of the knee. The lateral condyle is affected more frequently. Diagnosis of a coronal fracture is often missed in conventional radiography, so additional CTs of the knee are highly recommended in unclear cases. Because of permanent shearing forces, fracture healing is unlikely without surgical treatment. In the case we present here, the Hoffa fracture occurred after minimal trauma and was associated with an ipsilateral patellar dislocation and a meniscal tear. The fracture was initially overlooked. Bone quality was affected by a preexisting neurofibromatosis-1 condition.

The Arthroscopic All-Inside Tibial-Inlay Reconstruction of the Posterior Cruciate Ligament: Medium-Term Functional Results and Complication Rate.

The present study evaluates the medium-term functional and radiological outcome as well as complications following an arthroscopic tibial inlay reconstruction of the posterior cruciate ligament (PCL). A total of 39 patients (mean age: 32.6 ± 12.4 years) with acute and chronic PCL instabilities received a single-bundle all-inside arthroscopic tibial inlay reconstruction with quadriceps tendon autograft and were available for clinical follow-up on average after 3.8 ± 1.8 years. Assessment was conducted utilizing visual analogue scale (VAS), International Knee Documentation Committee (IKDC), Tegner, Lysholm, and knee injury and osteoarthritis outcome (KOOS) scores. VAS, Tegner, Lysholm, and subjective IKDC-scores averaged to 2.75 ± 1.95, 4 (1-9), 77.19 ± 17.54, and 75.18 ± 19.29 points, respectively. Mean KOOS results were 80.66 ± 1.98 for pain, 74.72 ± 17.72 for symptoms, 88.44 ± 13.95 for activities of daily life, 65.35 ± 27.96 for sports and recreation, and 60.01 ± 25.36 for quality of life. Overall IKDC-score rating was A2, B28, C5, and D4. The overall complication rate of 5.4% was caused by one superficial infection, one patellar fracture, and one lesion to the popliteal artery. Arthroscopic tibial inlay reconstruction is a valuable procedure regarding medium-term subjective and objective outcome measures. Return to sports, subjective satisfaction, and objective stability are predictable. The complication rate is acceptable but particular precaution is recommended to protect the popliteal artery and adjacent structures at risk.

Hip fracture incidence 2003-2013 and projected cases until 2050 in Austria: a population-based study.

OBJECTIVES: Elevated hip fracture incidence is a major public health problem looming to aggravate in industrialized countries due to demographic developments. We report hip fracture incidence and expected future cases from Vorarlberg, the westernmost province of Austria, results potentially representative of Central European populations. METHODS: Crude and standardized hip fracture incidence rates in Vorarlberg 2003-2013 are reported. Based on the age-specific incidence in 2013 or trends 2003-2013, we predict hip fractures till 2050. RESULTS: Female age-standardized hip fracture incidence decreased 2005-2013, whereas for men, the trend was rather unclear. Uncorrected forecasts indicate that by 2050, female and male cases will each have more than doubled from 2015 in all demographic core scenarios. Corrected by incidence trends before 2013, cases are expected to drop among women but rise among men. CONCLUSIONS: We anticipate rising hip fracture numbers in Vorarlberg within the next decades, unless prevention programs that presumably account for decreasing incidence rates, particularly among women since 2005, take further effect to counteract the predicted steady increase due to demographic changes. Concomitantly, augmented endeavors to target the male population by these programs are needed.

Femoral and tibial graft tunnel parameters after transtibial, anteromedial portal, and outside-in single-bundle anterior cruciate ligament reconstruction.

BACKGROUND: Anatomic graft tunnel placement is recommended in anterior cruciate ligament (ACL) reconstruction to restore knee joint stability and function. Transtibial (TT), anteromedial portal (AMP), and outside-in (OI) retrograde drilling surgical techniques have been described for tibial and femoral bone tunnel preparation. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the bone tunnel parameters and compare the ability of 3 different surgical techniques to achieve placement of the ACL femoral and tibial bone tunnels at the center of the native ACL femoral and tibial attachment sites. The hypothesis was that tunnel placement using an AMP or OI technique would result in optimized tunnel parameters and more closely reconstruct the center of the native ACL femoral attachment site. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The study population consisted of 100 patients undergoing anatomic single-bundle ACL reconstruction using multiple-stranded hamstring tendon grafts. In group 1 (n = 36), the femoral tunnel was drilled using a TT surgical technique; in group 2 (n = 32), the femoral tunnel was drilled through an AMP; and in group 3 (n = 32), the femoral tunnel was created by use of an OI technique with retrograde drilling. Computed tomography (CT) scans were obtained postoperatively, and characteristics of femoral and tibial tunnel apertures were correlated to femoral and tibial measurement grid systems. The position of the resulting tibial and femoral bone tunnels for each group was compared with the center of the native ACL attachment sites. RESULTS: There were statistically significant differences (P < .05) for the ACL femoral tunnel between the 3 groups with respect to intercondylar height, total tunnel length, graft fixation length, tunnel axis, and tunnel entry angle. Statistically significant differences (P < .05) were found for the ACL tibial tunnel with respect to anteroposterior tunnel position and sagittal tunnel axis between the TT and both the OI and AMP techniques. The OI surgical technique produced more oblique and anatomically correct femoral tunnel apertures and longer femoral tunnel lengths compared with the AMP technique. Both AMP and OI techniques resulted in a more precise replication of intercondylar tunnel depth and height. There was no statistically significant difference for graft fixation length between the AMP and OI techniques. CONCLUSION: The AMP and OI surgical techniques were superior in positioning the ACL femoral tunnel at the center of the native ACL attachment site compared with the TT technique. An acceptable graft fixation length was obtained for all 3 surgical techniques.

Quantification of tibial bone loss in antegrade versus retrograde tunnel placement for anterior cruciate ligament reconstruction.

PURPOSE: Tibial bone destruction during primary graft tunnel placement and tibial bone loss following tunnel enlargement represent major challenges in revision reconstruction of the anterior cruciate ligament (ACL). Initial all-inside ACL reconstruction facilitates the preparation of tibial bone sockets rather than full tunnels that potentially preserve tibial bone stock. The purpose of this study was to comparatively assess length, diameter and volume of tibial graft tunnels following all-inside and conventional ACL reconstruction. METHODS: Postoperative computed tomography (CT) scans of 59 patients were assessed following ACL reconstruction. In 35 patients we used conventional antegrade tibial tunnel drilling and in 24 all-inside retrograde tibial bone sockets. Imaging analysis included total, minimal and maximal tunnel length and tunnel diameter. Tunnel volumes were calculated corresponding to these parameters. RESULTS: Statistically significant group differences (p < 0.01) could be detected for tibial tunnel volume, length and diameter between conventional antegrade and all-inside retrograde tibial bone tunnels and sockets, respectively. CONCLUSIONS: Compared with conventional techniques, all-inside retrograde drilling of tibial bone sockets is effective in preserving significant bone stock, which might be beneficial for revision reconstruction in cases of eventual primary graft failure.

The predictive effect of anatomic femoral and tibial graft tunnel placement in posterior cruciate ligament reconstruction on functional and radiological outcome.

PURPOSE: Biomechanical reports have advocated anatomic graft tunnel placement for reconstruction of the posterior cruciate ligament (PCL) to restore knee joint stability and facilitate optimal functional outcome. However, in vivo investigations that correlate tunnel position to functional results are lacking so far. This study evaluates the anatomic accuracy of femoral and tibial tunnel apertures on postoperative computed tomography (CT) scans and compares these findings to subjective and objective clinical outcome parameters. METHODS: After single-bundle PCL reconstruction, 29 patients were stratified into several subgroups according to the anatomic accuracy of femoral and tibial tunnel apertures measured on postoperative CT scans. A threshold value for the centres of the tunnel apertures was determined using a measurement grid system as a radiographic reference. To evaluate the functional and radiological results, visual analogue scale, International Knee Documentation Committee (IKDC), Tegner, Lysholm, Knee Injury and Osteoarthritis Outcome Score and osteoarthritis scores were obtained. RESULTS: Comparison between functional outcome and tunnel position yielded a statistically significant difference for subjective IKDC score and angle segment α and for objective stability and tunnel position P3 but no statistically significant difference with respect to intercondylar depth, intercondylar height and tibial tunnel position P2. No correlation was found between anatomic tunnel position and present or progressive osteoarthritis on follow-up. Of the patients, 72 % classified their result as excellent and good and 90 % would repeat surgical treatment. CONCLUSIONS: Despite a small sample size and subject to the threshold values we used, our data indicate a potentially minor effect of anatomic tunnel placement on midterm functional outcome following PCL reconstruction.

Complication rate following high tibial open-wedge osteotomy with spacer plates for incipient osteoarthritis of the knee with varus malalignment.

PURPOSE: Medial open-wedge high tibial osteotomy (HTO) with spacer plates is recommended to correct varus malalignment of the knee with symptomatic overload of the medial compartment. METHODS: Fifty-five knees in 50 patients were assessed. Intra- and post-operative complications were recorded, and Tegner, Lysholm and IKDC scores were used to evaluate functional results. Radiological parameters consisted of medial proximal tibial angle (aMPTA), femorotibial angle (aFTA), posterior proximal tibial angle, lateral distal femur angle, mechanical axis deviation (MAD) and osteoarthritis score (Jäger and Wirth). RESULTS: Duration of follow-up was 5.0 ± 1.4 years. Overall and implant-related complication rates were 27.3 and 10.9 %, respectively. No statistical association could be detected between overall and implant-related complication rates and age, gender, wedge size, angle of correction or body mass index. Mean improvement in Lysholm score was 26.8. Overall IKDC scores at follow-up were A25, B26, C2 and D2. Post-operative correction of MPTA and FTA averaged to 89.6° and 173° and to 89° and 173.5° at follow-up, respectively. Initial MAD of 21.8 mm was corrected to 11.8 mm at follow-up. Osteoarthritis score increased from 1.4 ± 0.9 to 1.9 ± 0.9 points. CONCLUSIONS: HTO with spacer plates improves knee function and is an effective procedure in selected patients. Overall and implant-related complication rates should be considered and seem to be lower with a smaller angle of correction corresponding to incipient osteoarthritis and less varus deformity. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

In vivo evaluation of femoral and tibial graft tunnel placement following all-inside arthroscopic tibial inlay reconstruction of the posterior cruciate ligament.

BACKGROUND: The arthroscopic all-inside tibial inlay technique represents a novel procedure for posterior cruciate ligament (PCL) reconstruction. However, in vivo investigations that evaluate the accuracy of this technique regarding anatomic graft tunnel placement are few. The objective of this study was to analyse the femoral and tibial tunnel apertures using computed tomography (CT) and compare these findings to recommendations in the literature. METHODS: CT scans were obtained in 45 patients following single-bundle PCL reconstruction. The centres of the tibial and femoral tunnel apertures were correlated to measurement grid systems used as a radiographic reference. RESULTS: The centre of the femoral tunnel aperture was located at 42.9% ± 9.4% of the total intercondylar depth and at 12.9% ± 7.2% of the total intercondylar height. The angle α for the femoral tunnel position was measured at 64.2° ± 10.0°. The centre of the tibial tunnel aperture was found at 51.8% ± 4.1% of the total mediolateral diameter of the tibial plateau. The superoinferior distance of the tibial tunnel aperture to the joint line was 9.6 mm ± 4.4 mm on frontal and 9.3 mm ± 3.4 mm on sagittal 3D-CT scans. The distance of the tibial tunnel aperture to the former physis line averaged to 0.8 mm ± 3.4 mm. Comparison to the corresponding reference values revealed no statistically significant difference. CONCLUSION: Arthroscopic tibial inlay reconstruction is an efficient procedure for precise replication of the anatomical footprint of the PCL. LEVEL OF EVIDENCE: IV, prospective case series.

The effectiveness of skeletal imaging for quality assessment in posterior cruciate ligament reconstruction: reliability and validity of radiographs and computed tomography.

PURPOSE: For intra- and postoperative evaluation of precise and anatomic graft tunnel position, radiographs (XR) and computed tomography (CT) scans have been suggested. The purpose of this study was to evaluate the reliability and validity of XR and CT for quality assessment following PCL reconstruction. METHODS: Postoperative radiographs and CT scans were obtained in 45 consecutive patients following a standard single-bundle PCL reconstruction. Femoral and tibial tunnel apertures were correlated to femoral and tibial measurement grid systems. To assess the reliability and validity of XR and CT scans three independent observers evaluated radiographic and CT images for the position of femoral and tibial tunnel apertures. RESULTS: Almost perfect inter- and intra observer agreement (0.79-0.99) was found for all CT measurements except for the distance of the tunnel position to the previous physis line. Almost perfect and strong inter- and intraobserver agreement (0.70-0.98) was found for all tibial measurements on XR which tended to increase with repeated interpretation and to decrease with low levels of observer qualification. Femoral measurements yielded only poor-to-moderate reliability (0.02-0.5) between raters on XR but strong intraagreement within experienced observers (0.45-0.86). Specificity for XR was calculated with 75.7 % for P2 and P3 and with 71 % for femoral tunnel depth and height. CONCLUSION: XR and CT represent complementary imaging modalities and both offer considerable accuracy and precision for the determination of femoral and tibial tunnel apertures following PCL reconstruction and can be recommended for intra- and postoperative quality assessment.

Skeletal imaging following reconstruction of the posterior cruciate ligament: in vivo comparison of fluoroscopy, radiography, and computed tomography.

OBJECTIVE: Intra- and postoperative validation of anatomic footprint replication in posterior cruciate ligament (PCL) reconstruction can be conducted using fluoroscopy, radiography, or computed tomography (CT) scans. However, effectiveness and exposure to radiation of these imaging modalities are unknown. The objective of this study was to evaluate the comparative effectiveness of fluoroscopy, radiography, and CT in detecting femoral and tibial tunnel positions following an all-inside reconstruction of the PCL ligament in vivo. The study design was a retrospective case series. MATERIALS AND METHODS: Intraoperative fluoroscopic images, postoperative radiographs, and CT scans were obtained in 50 consecutive patients following single-bundle PCL reconstruction. The centers of the tibial and femoral tunnel apertures were identified and correlated to measurement grid systems. The results of fluoroscopic, radiographic, and CT measurements were compared to each other and accumulated radiation dosages were calculated. RESULTS: Comparing the imaging groups, no statistically significant difference could be detected for the reference of the femoral tunnel to the intercondylar depth and height, for the reference of the tibial tunnel to the mediolateral diameter of the tibial plateau and for the superoinferior distance of the tibial tunnel entry to the tibial plateau and to the former physis line. Effective doses resulting from fluoroscopic, radiographic, and CT exposure averaged 2.9 mSv, standard deviation (±SD) 4.1 mSv, to 1.3 ± 0.8 mSv and to 3.6 ± 1.0 mSv, respectively. CONCLUSIONS: Fluoroscopy, radiography, and CT yield approximately equal effectiveness in detecting parameters used for quality validation intra- and postoperatively. An accumulating exposure to radiation must be considered.

Comparison of theoretical fixation stability of three devices employed in medial opening wedge high tibial osteotomy: a finite element analysis.

BACKGROUND: Medial open wedge high tibial osteotomy is a well-established procedure for the treatment of unicompartmental osteoarthritis and symptomatic varus malalignment. We hypothesized that different fixation devices generate different fixation stability profiles for the various wedge sizes in a finite element (FE) analysis. METHODS: Four types of fixation were compared: 1) first and 2) second generation Puddu plates, and 3) TomoFix plate with and 4) without bone graft. Cortical and cancellous bone was modelled and five different opening wedge sizes were studied for each model. Outcome measures included: 1) stresses in bone, 2) relative displacement of the proximal and distal tibial fragments, 3) stresses in the plates, 4) stresses on the upper and lower screw surfaces in the screw channels. RESULTS: The highest load for all fixation types occurred in the plate axis. For the vast majority of the wedge sizes and fixation types the shear stress (von Mises stress) was dominating in the bone independent of fixation type. The relative displacements of the tibial fragments were low (in µm range). With an increasing wedge size this displacement tended to increase for both Puddu plates and the TomoFix plate with bone graft. For the TomoFix plate without bone graft a rather opposite trend was observed.For all fixation types the occurring stresses at the screw-bone contact areas pulled at the screws and exceeded the allowable threshold of 1.2 MPa for at least one screw surface. Of the six screw surfaces that were studied, the TomoFix plate with bone graft showed a stress excess of one out of twelve and without bone graft, five out of twelve. With the Puddu plates, an excess stress occurred in the majority of screw surfaces. CONCLUSIONS: The different fixation devices generate different fixation stability profiles for different opening wedge sizes. Based on the computational simulations, none of the studied osteosynthesis fixation types warranted an intransigent full weight bearing per se. The highest fixation stability was observed for the TomoFix plates and the lowest for the first generation Puddu plate. These findings were revealed in theoretical models and need to be validated in controlled clinical settings.

The biomechanical characteristics of arthroscopic tibial inlay techniques for posterior cruciate ligament reconstruction: in vitro comparison of tibial graft tunnel placement.

PURPOSE: The hypothesis of the present study was that the biomechanical properties of arthroscopic tibial inlay procedures depend on tibial graft bone block position. METHODS: Five paired fresh-frozen human cadaveric knee specimens were randomized to a reconstruction with quadriceps tendon placing the replicated footprint either to the more proximal margin of the remnants of the anatomical PCL fibrous attachments (group A) or to the distal margin of the anatomical PCL fibrous attachments at the edge of the posterior tibial facet to the posterior tibial cortex in level with the previous physis line (group B). The relative graft-tibia motions, post cycling pull-out failure load and failure properties of the tibia-graft fixation were measured. Cyclic displacement at 5, 500 and 1,000 cycles, stiffness and yield strength were calculated. RESULTS: The cyclic displacement at 5, 500 and 1,000 cycles measured consistently more in group A without statistically significant difference (4.11 ± 1.37, 7.73 ± 2.73 and 8.18 ± 2.75 mm versus 2.81 ± 1.33, 6.01 ± 2.37 and 6.46 ± 2.37 mm). Mean ultimate load to failure (564.6 ± 212.3) and yield strength (500.2 ± 185.9 N) were significantly higher in group B (p < 0.05). CONCLUSION: Replicating the anatomical PCL footprint at the posterior edge of the posterior tibial facet yields higher pull-out strength and less cycling loading displacement compared to a tunnel position at the centre of the posterior tibial facet.

Posterolateral corner of the knee: microsurgical analysis of anatomy and morphometry.

Reconstruction of the posterolateral corner (PLC) of the knee is essential to restore knee joint function. Controversy exists regarding a standardized nomenclature, the connective attachments and the relationships between them, and the frequency of occurrence among all structures of the PLC. Thirty human cadaveric knee specimens were investigated. The lateral collateral ligament, popliteus tendon, popliteofibular ligament, fabellofibular ligament, arcuate ligament, oblique popliteal ligament, posterior meniscofemoral ligament, and popliteal hiatus (including the popliteomeniscal ligaments) were studied. The length, diameter, variations, course, and morphology of these structures, as well as the position and dimension of the insertion, were measured and referenced the footprints to adjacent bony landmarks. Compared with existing studies, the lateral collateral ligament footprint was more proximal to the lateral femoral epicondyle (average, 3.61 ± 0.75 mm) and the popliteus tendon insertion was more distal and anterior to the lateral collateral ligament footprint (average, 5.69 ± 1.36 mm and 4.97 ± 1.73 mm, respectively). Only minor data have been published on the fabellofibular ligament (average length, 33.79 ± 4.98 mm; average diameter, 4.04 ± 1.22 mm), arcuate ligament (average length, 31.54 ± 2.82 mm; average diameter, 7.27 ± 1.56 mm), oblique popliteal ligament (average length, 45.56 ± 4.67 mm; average diameter, 14.90 ± 4.67 mm), posterior meniscofemoral ligament (average length, 23.75 ± 3.17 mm; average diameter, 3.62 ± 1.03 mm), and popliteomeniscal ligaments (average mediolateral popliteal hiatus diameter, 9.83 ± 2.16 mm; average superoinferior popliteal hiatus diameter, 8.23 ± 1.86 mm).

Locking versus nonlocking palmar plate fixation of distal radius fractures.

This study compared functional and radiological outcomes after treatment of extension-type distal radius fractures with conventional titanium nonlocking T-plates or titanium 1.5-mm locking plates. A total of 60 patients were included and followed for 4 to 7 years after receiving nonlocking T-plates (group A; n=30) or locking plates (group B; n=30) with and without dorsal bone grafting. Bone grafting was significantly more often performed in the nonlocking group to increase dorsal fracture fixation and stability (P<.003). Pre- and postoperative and follow-up values for palmar tilt, radial inclination, radial shortening, and ulnar variance were recorded. Age, sex, and fracture type were similarly distributed between the 2 groups. Postoperative and follow-up evaluation revealed equal allocation of intra-articular step formation and osteoarthritic changes to both groups. The overall complication rate was 25%. Compared with the nonlocking system, patients undergoing locking plate fixation presented with statistically significantly better values for postoperative palmar tilt (5.53° vs 8.15°; P<.02) and radial inclination (22.13° vs 25.03°; P<.02). However, forearm pronation was significantly better in group A (P<.005). At follow-up, radial inclination tended to approach a statistically significant difference in favor of group B. All clinical assessment, including Mayo wrist score, Disabilities of the Arm, Shoulder, and Hand score, Green and O'Brien score, Gartland and Werley score, visual analog scale score, and grip strength, yielded no statistically significant difference between the 2 groups. Locking plates seem to provide benefits regarding surgical technique and comfort, improvement in implant anchorage (especially in osteoporotic bone), and reduce the necessity of additional bone grafting.

Anatomic characteristics and radiographic references of the anterolateral and posteromedial bundles of the posterior cruciate ligament.

BACKGROUND: Anatomic graft tunnel placement is reported to be essential in double-bundle posterior cruciate ligament (PCL) reconstruction. A measurement system that correlates anatomy and radiographs is lacking so far. PURPOSE: To define the femoral and tibial attachments of the anterolateral (AL) and posteromedial (PM) bundles and to correlate them with digital and radiographic images to establish a radiographic anatomy based on anatomic landmarks and evaluate whether radiographs can serve as an accurate method for intraoperative and postoperative assessments of tunnel placement. STUDY DESIGN: Descriptive laboratory study. METHODS: Fifteen human cadaveric knee specimens were used. After preparation, the insertion areas of the 2 fiber bundles were marked with colorants, and high-definition digital images were obtained. With radiopaque tubes placed in the center of each bundle's footprint, anteroposterior and lateral radiographs were created. A measurement grid system was superimposed to determine the position of the AL and PM bundles' femoral and tibial insertion areas on both digital images and radiographs. The measurement zones were numbered 1 to 16, starting in the anterosuperior corner and ending in the posteroinferior corner. RESULTS: On radiographs and digital images, the femoral centers of the AL and PM bundles were found in zones 2 and 7, respectively. The tibial centers of the AL and PM bundles were found at 47.88% and 50.93%, respectively, of the total mediolateral diameter, 83.09% and 92.29%, respectively, of the total anteroposterior diameter, and 3.53 mm and 8.57 mm, respectively, inferior from the tibial plateau on radiographs. CONCLUSION: This study provides a geometric characterization of the AL and PM bundles of the PCL and establishes a reliable and feasible correlation system between anatomy and radiography based on anatomic landmarks. CLINICAL RELEVANCE: Accurate definition of the insertion sites of the PCL is essential for anatomic double-bundle reconstruction. The results of our study may be used as a reference for intraoperative and postoperative assessments of correct femoral and tibial tunnel placements.

Analysis of failure following anterior screw fixation of Type II odontoid fractures in geriatric patients.

Anterior screw fixation of Type II odontoid fractures has been recommended. Only few publications analyse the mechanism of failure in geriatric patients. We reviewed 18 male and 15 female patients aged 65 and above for parameters that influence the development of postoperative loss of correction, delayed union or non-union. Patients were stratified in two groups: 21 cases in Group A (union) and 12 patients in Group B (loss of correction, delayed union, non-union, revision surgery). Statistically significant correlation (p < 0.05) could be detected between failure to heal and: (1) degenerative changes in the atlanto-odontoid joint, (2) severity of osteoporosis in the odontoid process, (3) posterior oblique fracture type, (4) suboptimal fracture reduction, (5) suboptimal position of implant following demanding intraoperative conditions, (6) quality of fracture compression and (7) severity of fracture comminution. The overall morbidity and mortality rates were 29.0 and 8.6%, respectively. Our results indicate that these factors should be addressed regarding the selection of the operative treatment method in the geriatric patient.

Results of open reconstruction of anterior glenoid rim fractures following shoulder dislocation.

INTRODUCTION: The present study evaluates the clinical and radiological outcome following open reconstruction of avulsion fractures of the anterior glenoid rim in traumatic shoulder dislocation. MATERIAL AND METHODS: A total of 20 patients (mean age 49.4 years) were treated with open reduction and cannulated screw fixation. Eighteen patients were available for clinical and radiological follow-up after 3.1 (2.0-6.5) years. RESULTS: The average Constant Score was 78 and the average Rowe Score was 90 points. Documented complications were implant failure in one and neurological dysfunction in one patient. Radiographs revealed the bony fragment located in an unimproved displaced position in one patient and a progress in osteoarthritic changes in three patients. No recurrent subluxation or dislocation was observed. CONCLUSION: Open reconstruction of glenoid rim fractures is a valuable procedure regarding medium-term subjective and objective outcome measures. Recurrent dislocation, glenoid defects and early onset of osteoarthritic degeneration can be avoided.

Os odontoideum with bipartite atlas and segmental instability: a case report.

We report on the case of a 15-year-old adolescent who presented with a transient paraplegia and hyposensibility of the upper extremities after sustaining a minor hyperflexion trauma to the cervical spine. Neuroimaging studies revealed atlantoaxial dislocation and ventral compression of the rostral spinal cord with increased cord signal at C1/C2 levels caused by an os odontoideum, as well as anterior and posterior arch defects of the atlas. The patient underwent closed reduction and posterior atlantoaxial fusion. We describe the association of an acquired instability secondary to an os odontoideum with an anteroposterior spondyloschisis of the atlas and its functional result after 12 months. The rare coincidence of both lesions indicates a multiple malformation of the upper cervical spine and supports the theory of an embryologic genesis of os odontoideum.