Increased injury severity and hospitalization rates following crashes with e-bikes versus conventional bicycles: an observational cohort study from a regional level II trauma center in Switzerland.

BACKGROUND: As electric bicycles (e-bikes) become increasingly popular, reports of injuries associated with e-bike usage are also rising. Patterns, characteristics, and severity of injuries following e-bike crashes need further investigation, particularly in contrast to injuries from conventional bicycle crashes. METHODS: This prospective observational study included 82 patients treated at a Level II trauma center for injuries resulting from an electric or conventional bicycle crash. Data were collected over one year (05.09.2017-19.09.2018) during in- and outpatient visits. A study-specific case report form was used to identify the bicycle type, cycling behavior (e.g., use of a helmet, safety gear, alcohol), and circumstances of the crash (e.g., road conditions, speed, cause of the incident, time of day, season). Additional information about patient demographics, treatment, and injury characteristics, such as the Injury Severity Score (ISS) and body region injured, were documented. Results were analyzed using chi-square, Fisher's exact, or Wilcoxon tests. Simple logistic or linear regression models were used to estimate associations. RESULTS: Of the 82 patients, 56 (67%) were riding a conventional bike and 27 (33%) were using an e-bike. Most incidents were either single-bicycle crashes (66%) or automobile collisions (26%), with no notable difference in prevalence rates between groups. Although a higher proportion of conventional bikers were male (67% vs. 48%), the difference was not significant. E-bikers were older (median 60 years (IQR 44-70) vs. 45 years (IQR 32-62); p = 0.008), were hospitalized more often (48% vs. 24%, p = 0.025), and had worse ISS (median 3 (IQR 2-4) vs. 1 (IQR 1-3), p < 0.001), respectively. Body regions most affected were the extremities (78%) and external/skin (46%), and these were distributed similarly in both groups. Concomitant injury patterns of the thorax/chest with external/skin were higher among e-bikers (p < 0.001). When we controlled for the difference in the median age of the two groups, only the injury severity score of e-bikers remained significantly worse. CONCLUSIONS: Hospitalization and chest trauma rates were higher among e-bikers. After controlling for the older age of this group, the severity of their injuries remained worse than in conventional cyclists. Initial clinical assessments at trauma units should include an evaluation of the thorax/chest, particularly among elderly e-bikers. LEVEL OF EVIDENCE: Level III.

Perioperative blood transfusions in hip and knee arthroplasty: a retrospective assessment of combined risk factors.

INTRODUCTION: Accurate identification of patients at risk of blood transfusion can reduce complications and improve institutional resource allocation. Probabilistic models are used to detect risk factors and formulate patient blood management strategies. Whether these predictors vary among institutions is unclear. We aimed to identify risk factors among our patients who underwent total hip (THA) or knee (TKA) arthroplasty, and combine these predictors to improve our model. MATERIALS AND METHODS: We retrospectively assessed risk factors among 531 adults who underwent elective THA or TKA from January 2016 to November 2018. Using relevant surgical and patient characteristics gathered from electronic medical records, we conducted univariable and multivariable analyses. For our logistic regression model, we measured the impact of independent variables (age, gender, operation type (THA or TKA) and preoperative hemoglobin concentration) on the need for a transfusion. RESULTS: Of the 531 patients, 321 had THA (uncemented) and 210 had TKA. For the selected period, our transfusion rate of 8.1% (10.6% THA and 4.3% TKA) was low. Univariable analyses showed that lower BMI (p < 0.001) was associated with receiving a transfusion. Important factors identified through logistic regression analyses were age (estimated effect of an interquartile range increase in age: OR 3.89 [CI 95% 1.96-7.69]), TKA (OR - 0.77 [CI 95% - 1.57-0.02]), and preoperative hemoglobin levels (estimated effect of interquartile range increase in hemoglobin: OR 0.47 [CI 95% 0.31-0.71]). Contrary to findings from previous reports, gender was not associated with transfusion. CONCLUSIONS: Previously published predictors such as advanced age, low preoperative hemoglobin, and procedure type (THA) were also identified in our analysis. However, gender was not a predictor, and BMI showed the potential to influence risk. We conclude that, when feasible, the determination of site-specific transfusion rates and combined risk factors can assist practitioners to customize care according to the needs of their patient population. LEVEL OF EVIDENCE: Level 3, retrospective cohort study.

Polyaxial locking plate fixation in periprosthetic, peri-implant and distal shaft fractures of the femur : a comparison of open and less invasive surgical approaches.

Polyaxial locking plate fixation is a widely performed treatment for femoral shaft, periprosthetic, and peri-implant fractures in elderly patients. This study's purpose was to compare patient outcomes following the open technique (OT) and less invasive techniques (LIT). Data were gathered from 44 patients with 46 fractures treated with polyaxial locking plate between 2010-2015. Twenty fractures underwent the OT and 26 had a LIT. Long-term assessments for 83% of the fractures were done at a median of 23 months postoperatively. Bone healing rates were 82% in the OT and 100% in the LIT group (p=0.0688). The difference in the median duration of the surgery (OT 120 minutes, LIT 73 minutes) (p< 0.001) was the main statistically significant finding. Both surgical techniques resulted in similarly favourable outcomes. The LIT would be the preferred operating technique, especially when treating patients more susceptible to intra- and/or postoperative morbidity.

A retrospective analysis of surgical outcomes following direct anterior hip arthroplasty with or without a surgical extension table.

PURPOSE: Using a surgical extension table during total hip arthroplasty (THA) is widely considered state-of-the-art. However, intra-operative leg positioning requires additional time and leg length determination can be challenging. Our study's aim was to compare patient outcomes, particularly leg length precision, following surgery with or without an extension table. METHODS: This retrospective study included data from medical records of 324 patients who underwent THA using the direct anterior approach by one surgeon at a Swiss cantonal hospital (2015-2017). Patients were grouped by table type-standard (TS) or extension table (TE). Variables analyzed were demographics, operative/anaesthetic conditions, and medical outcomes. The leg length was measured pre- and post-operatively with mediCAD Classic®. RESULTS: An extension table was used in 161 (49.7%) patients. The median operative duration (minutes) was shorter in TS (55 (interquartile range (IQR) 48-67) than TE (60 (IQR 54-69)) (p = 0.002) and blood loss (ml) was lower (TS = 400 (IQR 300-500), TE = 500 (IQR 300-600), p = 0.0175). The median post-operative leg length discrepancy (mm) was less in TS (TS = 1 (IQR 0-3), TE = 2 (IQR 0-4), p = 0.0122). All four dislocations occurred in TE, and 7.4% of patients had complications (TS = 7%, TE = 7.5%, p = 0.99). CONCLUSION: We found that operating on a standard table during THA resulted in slightly more favourable outcomes. Given the added expenses, human resources, and time associated with an extension table, opting for a standard table remains a sensible choice.

Reconstrucción anatómica del Acromion en casos de fracturas traumáticas y posterior a artroplastia reversa del Hombro. Reporte de Casos / Anatomic reconstruction of the acromion in cases of traumatic fractures after reverse shoulder arthroplasty. Report of a series of cases

Introducción Tanto las fracturas traumáticas del acromion, así como las fracturas acromiales por insuficiencia posterior a artroplastia reversa del hombro, son entidades poco frecuentes. Con la ampliación des los criterios operativos para la artroplastia reversa del hombro, es de suponer un aumento en el caso des las fracturas acromiales por insuficiencia posteriores a dicho procedimiento quirúrgico. Al ser estas entidades poco frecuentes hacen falta en la literatura recomendaciones basadas en la evidencia para el manejo de estas, las cuales representan un reto para el especialista tratante. Materiales y Métodos Reporte de seis casos entre 2013 y 2016 en el hospital cantonal de Frauenfeld (Suiza) de dos grupos de pacientes con fracturas del Acromion. En el grupo A se clasificaron tres pacientes que presentaron fractura por insuficiencia del acromion posterior a artroplastia reversa del Hombro. En el grupo B clasificaron tres pacientes con fracturas traumáticas del acromion en las cuales el manejo conservador no fue exitoso. Los dos grupos de pacientes fueron sometidos al mismo método quirúrgico con reducción abierta y reconstrucción anatómica del Acromion por medio de fijación con placa y tornillos interfragmentarios. Resultados Posterior a la intervención quirúrgica, la función del hombro se recuperó en todos los pacientes del Grupo A. La flexión anterior aumentó en promedio de 53° a 127°, y la abducción mejoró de 52° a 125°. Las mediciones posteriores al año de la intervención mostraron puntajes constantes entre 55-71, así como un valor subjetivo de hombro (SSV) de 50-90. En el Grupo B, el rango de movimiento preoperatorio se mantuvo constante. La flexión hacia delante mejoró de 133° a 157° y la abducción aumentó de 147° a 153°. Un año después de la cirugía, los puntajes de Constant en el grupo B variaron de 70 a 86 y el SSV se encontró entre 80 a 100. Los tres pacientes del Grupo B consiguieron retomar sus actividades diarias sin dolor y pudieron regresar al trabajo. La extracción de la placa fue necesaria en la mitad de los pacientes de la cohorte (Grupo A n=1, Grupo B n=2). Discusión La fractura del acromion es una condición seria que puede causar daño significativo al funcionamiento del hombro. Tanto en pacientes con ARH así como en pacientes sin ARH previa, nuestra técnica operativa abierta de reconstrucción anatómica del acromion mostró buenos resultados. Recomendamos el manejo quirúrgico por medio de reconstrucción con placa y clavos de fijación. Nivel de evidencia: IV

Aim To propose a surgical technique to treat the traumatic acromion fractures, as well as acromion fractures before reverse total Shoulder Replacement (TSR). Methods Six patients were treated with the same fixation technique between December 2013 and December 2016. Three patients had acromial insufficiency fractures (type II) following TSR (Group A). The other three patients, who had traumatic acromion fractures, underwent unsuccessful conservative treatment (Group B). Surgical treatment involved reconstruction of the acromion using an open technique with plate and interfragmentary screw fixation. Results Following reconstruction, shoulder function was regained in all patients in Group A. Forward flexion increased, on average, from 53° to 127°, and abduction improved from 52° to 125°. Measurements at one-year follow-up were Constant scores from 55-71, and subjective shoulder value (SSV) from 50-90. In Group B, preoperative range of motion was not substantially diminished. Forward flexion improved from 133° to 157°, and abduction increased from 147° to 153°. One year following surgery, the Constant scores in Group B ranged from 70-86, and SSV was 80-100. All three patients performed daily activities without pain, and were able to return to work. Plate removal was necessary in half the patients in the cohort (Group A n=1; Group B n=2). Conclusion An acromion fracture is a serious condition that can cause significant damage to shoulder functioning. In patients with or without previous TSR, this fixation technique was used successfully to reconstruct the anatomic lateral and basal acromion. Evidence Level: IV

The traumatic acromion fracture: review of the literature, clinical examples and proposal of a treatment algorithm.

PURPOSE: Traumatic acromion fractures are rare and typically occur in patients with multiple fractures, which often delays diagnosis. Limited guidance exists on the treatment of these fractures. We present a review of the literature from the last 20 years and describe our experience in treating five patients-two conservatively and three with open reduction and internal fixations (ORIF). METHODS: We used the U.S. National Library of Science database, MEDLINE®, to search for all pertinent publications from January 1999 to December 2017. Included were retrospective or prospective studies, including case series and case reports, describing treatment for traumatic acromion fractures and clinical and/or radiological outcomes. For our case reports, we present five patients with traumatic acromion fractures who were treated at our institution between 2013 and 2017. RESULTS: Through our review of 14 publications, we found that current recommendations are often based on a limited number of cases. No gold standard to treat these fractures exists. Most authors recommend anatomic reconstruction, especially for dislocated fractures, persistent symptomatic non-unions or additional injuries to the superior shoulder suspensory complex. There is no clear trend in terms of the operative technique. With regard to our five clinical examples that were all initially treated conservatively, two were successful and three eventually required reconstruction with ORIF. Based on the findings of this review, we proposed a treatment algorithm for traumatic acromion fractures. CONCLUSIONS: A classification system providing clear guidance on treatment options is needed. Although the non-union rate with conservative treatment is relatively high, it is not always painful or limiting to shoulder function, especially in elderly or less active patients. Fixation seems to be a more suitable treatment option for active patients who are more likely to require revision of symptomatic non-unions.

Decision-making for complex scapula and ipsilateral clavicle fractures: a review.

INTRODUCTION: Complex scapula with ipsilateral clavicle fracures remains a challange and treatment recommendations are still missing.  This review provides an overview of the evolution of the definition, classification and treatment strategies for complex scapula and ipsilateral clavicle fractures. As with other rare conditions, consensus has not been reached on the most suitable management strategies to treat these patients. The aim of this review is twofold: to compile and summarize the currently available literature on this topic, and to recommend treatment approaches. MATERIALS AND METHODS: Included in the review are the following topics: biomechanics of scapula and ipsilateral clavicle fractures, preoperative radiological evaluation, surgical treatment of the clavicle only, surgical treatment of both the clavicle and scapula, and nonsurgical treatment options. RESULTS: A decision-making algorithm is proposed for different treatment strategies based on pre-operative parameters, and an example of a case treated our institution is presented to illustrate use of the algorithm. DISCUSSION: The role of instability in complex scapula with ipsilateral clavicle fractures remains unclear. The question of stability is preoperatively less relevant than the question of whether the dislocated fragments lead to compromised shoulder function.

Anatomical reconstruction to treat acromion fractures following reverse shoulder arthroplasty.

PURPOSE: Scapular fractures after reverse shoulder arthroplasty (RSA) are often associated with substantial shoulder impairment. Patient outcomes following either conservative or operative treatment have not been favourable, and consensus is lacking on the best treatment approach. We describe a technique for anatomic reconstruction of fractured lateral and basal acromion in patients at higher risk for diminished function or those for which conservative treatment has already failed. METHODS: Of the 95 patients who underwent RSA at our institution between December 2013 and December 2016, three had post-operative acromion fractures (type II). Two of these patients had secondary dislocation and one underwent conservative treatment that failed. In all three cases, the acromion was reconstructed using an open technique with plate and interfragmentary screw fixation. RESULTS: After the acromial fracture and prior to reconstructive surgery, the shoulder function decreased substantially in all three cases. Following reconstruction, forward flexion improved from 53.0° to 127°, and abduction improved from 52.0 to 125°. The range of the Constant scores at the one year follow-up was 55-71, and the subjective shoulder value (SSV) was 50-90. One patient reached the same active range of motion (ROM) as her pre-fracture status, and the two other patients improved but did not regain the previous ROM level. CONCLUSION: Acromion fractures after RSA are serious complications that have the potential to cause severe shoulder function impairment. Our fixation technique for anatomic lateral and basal acromion reconstruction was used safely to treat three patients with poor shoulder function due to secondary dislocation or non-unions.

Short- and long-term outcomes following hallux-valgus correction: a modified Kramer osteotomy.

BACKGROUND: Short- and long-term assessments were performed of a modification to the Kramer osteotomy that developed to stabilize the metatarsal head using an angular implant, the LINK(®) internal hallux fixator (Waldemar LINK GmbH & Co. KG, Hamburg, Germany). METHODS: For this retrospective study, radiological assessments were used to measure outcomes in 72 feet with hallux valgus treated from 2006 to 2011. The hallux-valgus angle, the intermetatarsal angle between the first and second intermetarsal shaft axes, and the distal metatarsal articular angle were measured at short- and long-term intervals. Long-term clinical assessments included results of the Foot Function Index and the American Orthopedic Foot and Ankle Society Forefoot Score. RESULTS: Of the 72 feet treated, 12 were done as bilateral operations. Fifty-five patients at a mean age of 52 years (±12; range 22-78) were included in short-term assessments. Significant improvements in angular measurements were made (p < 0.001) between baseline and 3 month assessments. Three postoperative complications occurred and 40 % (29/72) of the implants were eventually removed. Fifty-five of the 72 feet were available for long-term assessments at a median of 5 years postoperatively (IQR 5-7; range 3-9). No significant loss of correction was detected (p = 0.373). Clinical assessments indicated successful outcomes in 86 % (47/55) of the feet, with slightly better results in older patients (p = 0.033; OR 1.1, CI 95 % 1.01-1.15). CONCLUSION: This technique can achieve normal angular configuration, even with severe deformities, without significant long-term loss of correction. Patients should be informed of potential discomfort necessitating hardware removal, although the likelihood of complications is low. LEVEL OF EVIDENCE: Level III study.

Mid-term results of a less-invasive locking plate fixation method for proximal humeral fractures: a prospective observational study.

BACKGROUND: The optimal treatment for proximal humeral fractures remains under debate. In this article, we report the mid-term results of patients who underwent the less-invasive implantation of a polyaxial locking plate for displaced proximal humeral fractures. METHODS: This study included patients who were treated with a polyaxial locking plate via an anterolateral deltoid split approach from May 2008 to December 2011. We evaluated outcome parameters after a minimum follow-up period of 2.5 years (median 4.5 years, follow-up rate 62 %) including the age- and gender-dependent Constant score, the activities of daily living score, and the visual analog scale for both pain and subjective shoulder function. RESULTS: Of the 140 patients who underwent surgery, 114 were included in the follow-up and 71 completed the questionnaire. Fifteen patients (21 %) exhibited 2-fragment fractures, and 56 patients (79 %) exhibited 3- and 4-part fractures. The Constant score improved significantly (4.5 years: 70 ± 21, p < 0.001) between the first two follow-ups (6 weeks: 35 ± 14, 6 months: 56 ± 18, p < 0.001), and also between 6 months and 4.5 years post-surgery. At the final follow-up, the activities of daily living score had not reached pre-fracture levels (before trauma: 27 ± 5, 4.5 years: 20 ± 8, p < 0.001). A multivariate analysis showed that age has a more significant influence on the final outcome than fracture morphology or gender. CONCLUSION: Although the less-invasive surgical procedure is a feasible treatment option in proximal humeral fractures with acceptable complications and considerable improvement during the first six months, a lengthy recovery time is required. The majority of our patients did not become pain-free or reach pre-fracture activity levels.

Management of periprosthetic acetabular fractures in elderly patients--a minimally invasive approach.

PURPOSE: Periprosthetic acetabular fractures are rare and in the current literature largely underreported. The management is reported to be difficult. Treatment varies from non-operative to open reduction and internal fixation up to revision of the acetabular components. METHODS: A prospective consecutive case series in acetabular fractures was performed in a level 1 trauma centre. All patients with pre-existing total hip replacement were followed up for one year. Perioperative data, complications, radiological results, functional outcome and quality of life were measured. RESULTS: Eight (15%) of 53 patients who were included in the study underwent total hip arthroplasty before and had stable implants at time of fracture. Mean age of the patients was 83 years. All of them were female. Mean operative time was 85 minutes. There were no soft tissue complications like infection or nerve damage in the post-operative course. No revision was needed. Two patients died in between the follow up. The Harris hip score was a mean of 77, with quality of life comparable to persons in the same age. CONCLUSIONS: Minimally invasive reconstruction of the anterior column is a viable method to conserve stable acetabular components in this type of fracture. Short operation time and limited incisions are the most conclusive advantages.

Two-Incision Minimally Invasive Approach for the Treatment of Anterior Column Acetabular Fractures.

INTRODUCTION: We describe an alternative to the Letournel ilioinguinal approach for anterior column acetabular fractures that is performed with a unique retraction device that decreases the rate of soft-tissue complications. STEP 1 POSITION THE PATIENT AND IDENTIFY THE SITES FOR THE INCISIONS: Identify the sites for both incisions with the help of an image intensifier. STEP 2 MAKE THE FIRST INCISION TO EXPOSE THE ANTERIOR COLUMN AND THE LINEA TERMINALIS PELVIC BRIM: Make the first incision to expose the central area of the fracture. STEP 3 MAKE THE SECOND INCISION TO EXPOSE THE SYMPHYSIS AND THE IPSILATERAL PUBIC BONE: Make the second incision to expose the area for the distal plate fixation. STEP 4 MAINTAIN EXPOSURE OF THE LINEA TERMINALIS USING A SOFT-TISSUE RETRACTION SYSTEM: For better visualization, use a soft-tissue retraction system. STEP 5 REDUCE THE FRACTURE: Clean and reduce the fracture through the first incision. STEP 6 FIX THE FRACTURE: Perform temporary and definitive fixation according to the standards for anterior acetabular fracture fixation. STEP 7 CLOSE THE WOUND: After radiographic documentation in three views, close the wound. RESULTS: We reported the results of a case-control study of the first twenty-six patients operated on with the two-incision minimally invasive technique.IndicationsContraindicationsPitfalls & Challenges.

Distal femoral fractures in the elderly: biomechanical analysis of a polyaxial angle-stable locking plate versus a retrograde intramedullary nail in a human cadaveric bone model.

INTRODUCTION: Compromised bone quality and the need for early mobilization still lead to high rates of implant failure in geriatric patients with distal femoral fractures. With the newest generation of polyaxial locking plates and the proven retrograde femoral nails today two minimally invasive surgical procedures have been established. Indications for both procedures overlap. This study attempts to define the strength and failure mode of both surgical procedures. MATERIALS AND METHODS: A standardized fracture model was established to simulate an unstable AO/OTA 33-A3 fracture. Eight pairs of human cadaver femora (mean age 79 years, range 63-100 years) with compromised bone quality were used. Osteosyntheses with eight retrograde femoral nails and eight locking plates were randomly performed. A materials testing machine (Instron 5566) was used to perform cyclic stress tests according to a standardized loading protocol, up to a maximum load of 5,000 N. RESULTS: All specimens survived loading of at least 2,500 N. Three nail and one plate construct survived a maximum load of 5,000 N. The mean compressive force leading to failure was 4,400 N (CI 4,122-4,678 N) for nail osteosynthesis and 4,429 N (CI 3,653-5,204 N) for plate osteosynthesis (p = 0.943). Proximal cutting out of the osteosynthesis was the most common reason for interruption in the nail and plate osteosyntheses. Significant differences between the retrograde femoral nail and plate osteosyntheses were seen under testing conditions for plastic deformation and stiffness of the constructs (p = 0.002 and p = 0.001, respectively). CONCLUSION: Based on our results, no statements regarding the superiority of either of the devices can be made. Even though the load to failure values for both osteosyntheses were much higher than the loads experienced during normal walking; however, because only axial loading was applied, it remains unclear whether both osteosyntheses meet the estimated requirements for postoperative full weight-bearing for an average heavy patient with a distal femoral fracture.

Mono- versus polyaxial locking plates in distal femur fractures - a biomechanical comparison of the Non-Contact-Bridging- (NCB) and the PERILOC-plate.

BACKGROUND: The aim of this cadaveric study was to compare a polyaxial (NCB®, Zimmer) to a fixed-angle monoaxial locking plate (PERILOC®, Smith & Nephew) in comminuted fractures of the distal femur regarding stability of the construct. Up to date there is no published biomechanical data concerning polyaxial plating in cadaveric distal femurs. METHODS: Fourteen formalin fixed femora were scanned by dual-energy x-ray absorptiometry. As fracture model an unstable supracondylar comminuted fracture was simulated. Fractures were pairwise randomly fixed either with a mono- (group A) or a polyaxial (group B) distal femur plate. The samples were tested in a servohydraulic mechanical testing system starting with an axial loading of 200 N following an increase of 200 N in every step with 500 cycles in every sequence up to a maximum of 2 000 N. The end points were implant failure or relevant loss of reduction. Data records included for each specimen time, number of cycles, axial load and axial displacement. Statistical analysis was performed using the exact Wilcoxon signed rank test. RESULTS: The mean donor age at the time of death was 75 years. The bone mass density (BMD) of the femurs in both groups was comparable and showed no statistically significant differences. Five bones failed before reaching the maximum applied force of 2000 N. Distribution curves of all samples in both groups, showing the plastic deformation in relation to the axial force, showed no statistically significant differences. CONCLUSIONS: Operative stabilization of distal femur fractures can be successfully and equally well achieved using either a monoaxial or a polyaxial locking plate. Polyaxial screw fixation may have advantages if intramedullary implants are present.

Deltoid-split or deltopectoral approaches for the treatment of displaced proximal humeral fractures?

BACKGROUND: Proximal humeral fractures are mainly associated with osteoporosis and are becoming more common with the aging of our society. The best surgical approach for internal fixation of displaced proximal humeral fractures is still being debated. QUESTIONS/PURPOSES: In this prospective randomized study, we aimed to investigate whether the deltoid-split approach is superior to the deltopectoral approach with regard to (1) complication rate; (2) shoulder function (Constant score); and (3) pain (visual analog scale [VAS]) for internal fixation of displaced humeral fractures with a polyaxial locking plate. METHODS: We randomized 120 patients with proximal humeral fractures to receive one of these two approaches (60 patients for each approach). We prospectively documented demographic and perioperative data (sex, age, fracture type, hospital stay, operation time, and fluoroscopy time) as well as complications. Followup examinations were conducted at 6 weeks, 6 months, and 12 months postoperatively, including radiological and clinical evaluations (Constant score, activities of daily living, and pain [VAS]). Baseline and perioperative data were comparable for both approaches. The sample size was chosen to provide 80% power, but it reached only 68% as a result of the loss of followups to detect a 10-point difference on the Constant score, which we considered the minimum clinically important difference. RESULTS: Complications or reoperations between the approaches were not different. Eight patients in the deltoid-split group (14%) needed surgical revisions compared with seven patients in the deltopectoral group (13%; p = 1.00). Deltoid-split and deltopectoral approaches showed similar Constant scores 12 months postoperatively (Deltoid-split 81; 95% confidence interval [CI], 74-87 versus deltopectoral 73; 95% CI, 64-81; p = 0.13), and there were no differences between the groups in terms of pain at 1 year (deltoid-split 1.8; 95% CI, 1.2-1.4 versus deltopectoral 2.5; 95% CI, 1.7-3.2; p = 0.14). No learning-curve effects were noted; fluoroscopy use during surgery and function and pain scores during followups were similar among the first 30 patients and the next 30 patients treated in each group. CONCLUSIONS: The treatment of proximal humeral fractures with a polyaxial locking plate is reliable using both approaches. For a definitive recommendation for one of these approaches, further studies with appropriate sample size are necessary. LEVEL OF EVIDENCE: Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Results of titanium locking plate and stainless steel cerclage wire combination in femoral fractures.

BACKGROUND: Some in vitro studies warn combining different metals in orthopedic surgery. The aim of this study is to determine the impact of combining titanium and stainless steel on bone healing and the clinical course of patients undergoing internal fixation of femoral fractures. MATERIALS AND METHODS: 69 patients with femoral fractures had polyaxial locking plate osteosynthesis. The locking plate was made of a titanium alloy. Two different cohorts were defined: (a) sole plating and (b) additional stainless steel cerclage wiring. Postoperative radiographs and clinical followup were performed at 6 weeks, 3 months and 12 months. RESULTS: Cohorts A and B had 36 and 33 patients, respectively. Patient demographics and comorbidities were similar in both groups. In two cases in cohort A, surgical revision was necessary. No complication could be attributed to the combination of titanium and stainless steel. CONCLUSION: The combination of stainless steel cerclage wires and titanium plates does not compromise fracture healing or the postoperative clinical course.

The two-incision, minimally invasive approach in the treatment of acetabular fractures.

OBJECTIVES: To present a novel two-incision minimally invasive (TIMI) method for the treatment of anterior acetabular fractures. DESIGN: Prospective consecutive case series. SETTING: Level I University Trauma Centre. PATIENTS: Twenty-six patients (mean age, 67 ± 19 years). INTERVENTION: The first TIMI-incision is performed by a pararectal approach at the level of the proximal third of the arcuate line of the ilium. After transection of the abdominal wall, the iliac vessels are mobilized medially and the neuromuscular bundle laterally. The second approach lies above the medial pubic bone. The soft tissue is held using a retraction system. After fracture reduction and fixation by isolated screws, a conventional reconstruction plate is inserted for fracture neutralization. MAIN OUTCOME MEASUREMENTS: Perioperative course, postoperative radiological evaluation, functional outcome Harris hip score, and quality of life (EQ 5D). RESULTS: Mean operative time was 109 ± 30 mins. All incisions healed primarily. Postoperative radiological exam revealed an anatomic reduction in 20 fractures and a satisfactory reduction in 6. There were no local soft-tissue complications, and no revisions were needed. Follow-up examinations were performed after a minimum of 12 months in 19 patients (73%). The Harris hip score was 86,6 ± 8. Quality of life was comparable to persons in the same age group. CONCLUSION: The TIMI approach represents a viable alternative to the ilioinguinal approach. Despite the limited incisions, a comparable quality of fracture reduction is achieved. The authors believe this technique would be most useful in those patients with a higher risk for postoperative soft-tissue complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Less invasive polyaxial locking plate fixation in periprosthetic and peri-implant fractures of the femur--a prospective study of 41 patients.

BACKGROUND: A great variety of methods for the stabilisation of periprosthetic fractures around total hip (THA) or total knee arthroplasty (TKA) have been described. We present the data of our experience in combining a polyaxial, anatomical locking plate with a standardised less invasive technique in the treatment of periprosthetic and peri-implant (femoral nail) femur fractures in this prospective study. PATIENTS AND METHODS: A consecutive series of 41 patients (33 women; age 79.8±11 years) with 41 fractures (n=17 periprosthetic THA, n=10 periprosthetic TKA, n=3 interprosthetic, n=11 perinail) was treated in a 'mini-open' (MO; direct reduction of the fracture and percutaneous plate fixation in two-part fractures; n=22) or a 'minimally invasive' (MI; indirect reduction and percutaneous fixation; n=19) technique. All patients were followed up for 12 months postoperatively. RESULTS: The polyaxial locking mechanism allowed for the setting of a mean of 5.3 screws around an intramedullary implant. Supported by the less invasive strategy, mainly long plates (n=36; 88% were longer than 24cm) were applied without relevant soft-tissue complication. Five surgical revisions (12.1%) had to be performed. During the first postoperative stay, one seroma was evacuated and in two cases the plate broke due to failed biological healing 6 months after the MO technique. In one case, a revision prosthesis had to be implanted due to ligamentous instability, and in another case, soft-tissue balancing of the patella was performed. In the MO group, four of the five complications requiring surgical revision were seen. There was no infection. No statistical difference was seen between the MO and the MI groups for operating room (OR) time and perioperative need for transfusion. In patients with a poor state of health (n=8; immobile and Glasgow Coma Outcome Scale=3), no local complications were seen. All fractures in the peri-implant fracture group (n=11) healed uneventfully. CONCLUSION: Periprosthetic fracture fixation can be performed as part of a standardised less invasive strategy, but the MI technique should be the preferred treatment. The NCB(®) system allows for a stable plate fixation around an intramedullary implant. With the less invasive technique, long plates can be applied with low rates of soft-tissue complication and implant failure.

Embalmed and fresh frozen human bones in orthopedic cadaveric studies: which bone is authentic and feasible?

BACKGROUND AND PURPOSE: The most frequently used bones for mechanical testing of orthopedic and trauma devices are fresh frozen cadaveric bones, embalmed cadaveric bones, and artificial composite bones. Even today, the comparability of these different bone types has not been established. METHODS: We tested fresh frozen and embalmed cadaveric femora that were similar concerning age, sex, bone mineral density, and stiffness. Artificial composite femora were used as a reference group. Testing parameters were pullout forces of cortex and cancellous screws, maximum load until failure, and type of fracture generated. RESULTS: Stiffness and type of fracture generated (Pauwels III) were similar for all 3 bone types (fresh frozen: 969 N/mm, 95% confidence interval (CI): 897-1,039; embalmed: 999 N/mm, CI: 875-1,121; composite: 946 N/mm, CI: 852-1,040). Furthermore, no significant differences were found between fresh frozen and embalmed femora concerning pullout forces of cancellous screws (fresh frozen: 654 N, CI: 471-836; embalmed: 595 N, CI: 365-823) and cortex screws (fresh frozen: 1,152 N, CI: 894-1,408; embalmed: 1,461 N, CI: 880-2,042), and axial load until failure (fresh frozen: 3,427 N, CI: 2,564-4290; embalmed: 3,603 N, CI: 2,898-4,306). The reference group showed statistically significantly different results for pullout forces of cancellous screws (2,344 N, CI: 2,068-2,620) and cortex screws (5,536 N, CI: 5,203-5,867) and for the axial load until failure (> 7,952 N). INTERPRETATION: Embalmed femur bones and fresh frozen bones had similar characteristics by mechanical testing. Thus, we suggest that embalmed human cadaveric bone is a good and safe option for mechanical testing of orthopedic and trauma devices.

Percutaneous minimally invasive instrumentation for traumatic thoracic and lumbar fractures: a prospective analysis.

Open posterior instrumentation is still the standard procedure for unstable traumatic thoracic and lumbar fractures. There is a general tendency towards minimally invasive approaches in various surgical disciplines. The Sextant II Rod Insertion system is one of these. The authors prospectively studied this system in 51 patients with thoracic and lumbar fractures, between October 2007 and January 2011. Most fractures (31/51) were situated at the lumbar level. In 7 older patients the technique was combined with kyphoplasty and/or cement augmentation of the pedicle screws. The median operative time was 61 minutes (range: 26-130). The median fluoroscopy time was 132 seconds (range: 24-414). Most pedicle screws were correctly placed: 197 out of 204 screws. All fractures showed bony union after 6 weeks, but the multiaxial pedicle screws were not able to conserve the slight correction obtained peroperatively via positioning and longitudinal traction. Percutaneous minimally invasive stabilization of the spine needs further improvement.