Rib fractures (RF) represent the most common bone fracture after blunt trauma, occurring in 10–20% of all trauma patients and leading to concomitant injuries of the inner organs in severe cases. However, a standardized classification system for serial rib fractures (SRF) does still not exist. Basic knowledge about the facture pattern of SRF would help to predict organ damage, support forensic medical examinations, and provide data for in vitro and in silico studies regarding the thoracic stability. The purpose of our study was therefore to identify specific SRF patterns after blunt chest trauma.

All SRF cases (≥3 subsequent RF) between mid-2008 and end of 2015 were extracted from the CT database of our University Hospital (n=383). Fractures were assigned to anterior, antero-lateral, lateral, postero-lateral, and posterior location within the transverse plane (36° each) using an angular measuring technique (reliability ±2°). Rib level, fracture type (transverse, oblique, multifragment, infracted), as well as degree of dislocation (none, </≥ rib width) were recorded and each related to the cause of accident.

In total, 3747 RF were identified (9.7 per patient, ranging from 3 (n=25) to 33 (n=1)). On average, most RF occurred in crush/burying injuries (15.9, n=13) and pedestrian accidents (12.2, n=14), least in car/truck accidents (8.8, n=76). Altogether, RF gradually increased from rib 1 (n=140) towards rib 5 (n=517) and then decreased towards rib 12 (n=49), showing a bell-shaped distribution. More RF were detected on the left thorax (n=2027) than on the right (n=1720). Overall, most RF were found in the lateral (33%) and postero-lateral (29%) segment. Posterior RF mostly occurred in the lower thorax (63%), whereas anterior (100%), antero-lateral (87%), and lateral (63%) RF mostly appeared in the upper thorax. RF were distributed symmetrically to the sagittal plane, showing a hotspot (up to 98 RF) at rib levels 4 to 7 in the lateral segment and rib level 5 in the antero-lateral segment. In the car/truck accident group, 47% of all RF were in the lateral segment, in case of frontal collision (n=24) even 60%. Fall injuries (n=141) entailed mostly postero-lateral RF (35%). In case of falls >3 m (n=45), 48% more RF were detected on the left thorax compared to the right. CPR related SRF (n=33) showed a distinct fracture pattern, since 70% of all RF were located antero-laterally. Infractions were the most observed fracture type (44%), followed by oblique (25%) and transverse (18%) fractures, while 46% of all RF were dislocated (15% ≥ rib width).

SRF show distinct fracture patterns depending on the cause of accident. Additional data should be collected to confirm our results and to establish a SRF classification system.

Background:

With the increase in the average age of the population, the incidence of symptomatic rotator cuff tears will also increase. Combined with more access to information via the internet etc., the patient population is more informed of the treatment modalities available and is expecting good reproducible results of their surgeries.

Purpose:

The objective of this study was to determine the tensile strength of the different components of the rotator cuff tendons and their relationship to rotator cuff tears.

Purpose:

To determine the insertion of the different layers of the rotator cuff and apply it to rotator cuff tears. Anatomical insertion of the rotator cuff holds the key to a proper anatomical repair.

Loosening of the glenoid component after total shoulder arthroplasty is the most common indication for revision surgery and the reason for 40% of postoperative complications. Presupposing that implants would survive better in areas with higher bone mineral density (BMD), we aimed to determine BMD of the cancellous part of the glenoid and the dimensions of its cortical bone.

Using spiral CT scans of the left and right shoulders of 45 men and 25 women with no shoulder pathology, we assessed the BMD of the anterior, middle and posterior subcortical planes of the cancellous part of the glenoid at the superior, middle and inferior levels. The cortical thickness was measured at corresponding sites.

In both sexes, at all three levels we found the posterior plane had the highest BMD and cortical thickness.

These findings indicate that BMD varies between planes and areas of cancellous bone in the glenoid. This may influence the engineering of future implants.

The objective of this study was to determine the tensile strength of the different components of rotator cuff tendons.

A test bench that performs tests at consistent rupture speed was used to do separate tensile tests on 10-mm strips of capsular and tendinous layers in four fresh frozen cadaveric shoulders. The layers were left attached only on the humeral side.

The maximum force was comparable but the elongation of the outer part of the tendon was greater, indicating that the capsular part would tear first. On average, a 10-mm strip of capsular layer failed at 170N with elongation of 7 mm, while a 10-mm strip of tendinous layer failed at 230N with elongation of 10 mm.

Using six fresh frozen cadaveric shoulders, we went on to determine the strength of the rotator hood, a thin layer of tendon extending beyond the tuberosity major and connecting the supraspinatus to the subscapularis via the bicipital tunnel. The rotator hood ruptured at a mean force of 70 N.

We concluded that the two layers of the cuff contribute equally to the strength. It is therefore important to repair both layers. The difference in elongation of the tendinous and capsular layers makes the capsular layer more vulnerable to elongation stress. The rotator hood is a strong and important structure, and it is important to repair it.

After many patients, some of whom were unexpectedly young, had presented with medial migration of the hemi-prosthetic head and erosion of the glenoid, we decided 2 years ago to do preoperative DEXA on all shoulder replacement patients. The aim was first to determine normal bone mineral density (BMD) of the glenoid and secondly to predict which patients would be at risk.

We used the same DEXA method as for the hip. The glenoid was divided into three areas, numbered R1, R2 and R3, and we determined BMD in each of them.

Preliminary studies showed that patients fell into two groups. In one, BMD in the R2 and R3 areas was in the range 0.3 to 0.5. Most often the patients in this group were younger or had acute trauma and the contralateral shoulder was not pathological. BMD in the other group was in the range 0.9 to 1.3. Nearly all patients with OA of the shoulder fell into this group.

In this ongoing study, patients are followed up annually with clinical examination and standard radiographs. Follow-up to date has only been 2 years. So far no medial migration of the hemi-prosthetic head has been noted in patients in the group with BMD between 0.9 to 1.3.

Aims: Firm bandaging of the knee following knee replacement may prevent bleeding into the joint by a tamponade effect, but the presence of a tight bandage around the knee may obstruct venous return and lead to thromboembolic complications. We have studied the pressure required, and then compared clinically the use of a compression bandaging with the use of either a drain, or a standard crepe bandage. Method: Transducers were used to measure the pressure achieved on the surface of the knee under different bandages, and within the knee following release of tourniquet. Three series of 50 patients have been compared: with compression bandaging from toes to mid-thigh, with crepe alone, or with suction drain and crepe. Results: The pressure within the joint at which tamponade occurs is 52–57 mm Hg. The pressure on the skin under a properly applied compression bandage is between 28 and 32 mmHg and this controls bleeding within the joint. Patients treated with compression bandaging recovered quicker from the operation had a shorter hospital stay and a greater range of ßexion on discharge. They had no swelling of the limb, rarely suffered a tense haemarthrosis and had fewer complications. Conclusions: The use of compression bandage incorporating the foot and calf following knee replacement surgery confers speciþc advantages over the use of crepe bandage alone.

Aims: A prospective study of the long term fixation of an all- polyethylene acetabular component with a 2mm rim for cement pressurisation, and methylmethac-rylate spacer beads for optimal cement mantle thickness. Methods: A consecutive series of 1348 hip arthroplasty patients aged between 23 and 94 (average 68 years) has been prospectively studied between 1993 and 2002. The cemented Ultima (De Puy) stem and cup were used via an anterolateral approach by 6 surgeons in a District General Hospital. Clinical and radiological assessment was at 0, 2, 5, 6, 7 and 8 years. Detailed assessment of the cup has been carried out to determine cases of clinical or radiological failure, quality of cement fixation to bone, and the profile of the cement mantle. Results: 875 patients have been followed up for a minimum of 2 years, 52 for a minimum of 8 years. The cumulative survival rate of the cup using revision for aseptic loosening as an endpoint at 8 years was 98% and using radiological evidence of loosening as an endpoint was 96%. There were no cases with less than 2 mm of cement mantle thickness and good quality bone cement interface was seen in all on the initial postoperative films indicating adequate pressurisation. Conclusions: The design of the Ultima polyethylene cup has been successful in achieving good cement pressurisation during implantation, an even cement mantle thickness, and clinical success rates which compare favourably with other cemented acetabular components.

We report on six men and two women (mean age 42.5 years) who had sustained posterior dislocation of the shoulder in motor vehicle accidents (three), falls (two), equestrian accidents (two), cycling accidents (one) and in a fainting spell (one). In four patients, the dislocation was the only injury, but two had humeral shaft fractures, one a humeral neck fracture and the fourth a glenoid and humeral shaft fracture. The mean delay to diagnosis was 14 weeks (2 to 21).

In three patients a medical officer, a general practitioner and a radiologist missed the dislocations, but in five orthopaedic surgeons missed them. Four patients had only anteroposterior radiographs of their shoulder taken, one had anteroposterior and lateral scapular views, and three had anteroposterior and lateral radiographs of the humerus.

Four patients underwent hemi-arthroplasties and the other four open reduction and McLaughlin procedures.

Though rare, posterior dislocations are often missed. Careful examination, especially in the absence of external rotation, can eliminate this. In the presence of a fracture, a dislocation or injury to the joint above and below must be excluded. Anteroposterior and lateral scapular views alone are inadequate in trauma cases and an axillary or modified axillary view should be done. If there is any doubt, CT should be performed.

Surgibone (Unilab R) is a dry bone graft substitute prepared from Canadian bovine bone. It contains hydroxyapatite and 20–29% protein. The manufacturer claims that it is biocompatible; does not lead to foreign body reaction and does not produce pyrogenic effects.

We have used Surgibone routinely in revision joint replacement surgery over a 6-year period, to augment autograft in filling osseous defects in the acetabulum and proximal femur. 27 patients who received Surgibone have been reviewed to assess the degree of graft incorporation, any evidence of graft rejection or immunogenic reaction. One patient died and 2 were excluded from the study for early fixation failure. The remaining 24 were studied 6 months to 5 years post surgery.

In 17 patients (71%) there was radiological appearance of complete incorporation of the bone graft within 6 months. In 3 of these patients the graft incorporated as early as 3 months. There were 7 failures (29%). 3 patients have no radiological evidence of graft incorporation up to 3 years post surgery, although 2 have a satisfactory clinical result. Another 3 patients appeared to have graft rejection, and at revision were found to have sterile pus around the graft. These patients had negative responses to skin patch test for allergy to Surgibone. The seventh patient suffered an MRSA deep infection of the prosthesis that resulted in removal of the implants 4 weeks post operatively.

We conclude that the use of xenograft Surgibone in revision hip surgery leads to unacceptable incidence of failure. Although in the majority of cases good incorporation of the graft was observed, there has been a substantial incidence of graft rejection.

We evaluated the effectiveness of arthroscopic repair in patients with shoulder instability owing to a bony fragment as part of the Bankart lesion, using spiked Suretacs, sutures and anchors.

Over a two-year period, we followed up 23 of 25 consecutive cases, all with a bony fragment as part of the Bankart lesion. The mean age of patients, all of whom were male, was 21 years (17 to 35). Almost all injuries were sustained playing sports. Patients were clinically evaluated at six weeks and 20 weeks postoperatively and interviewed telephonically.

Full arthroscopic examination was performed in a lateral decubitus position. The affected capsular structures and labrum, with its attached bony fragment, were fully mobilised. The bony fragment was always attached to the capsular structures, with labral ring intact. We used a spiked Suretac anchor to reattach the bony fragment to its original anatomical position, and Mitek anchors and no. 1 Ticron sutures for individual reattachment of the capsule and ligaments. Postoperatively patients were immobilised in a shoulder sling for six weeks. Early restricted active and passive movements were advised. Patients routinely received postoperative physical and biokinetic rehabilitation. The mean follow up period was 16 months (5 to 29). There was no redislocation or subjective instability.

This technique yields excellent results, but because it is technically difficult should be used only by experienced shoulder arthroscopists with thorough knowledge of pathological shoulder anatomy.

In shoulder arthroplasty the glenoid component remains a problem. Hemi-arthroplasty requires less theatre time and gives rise to fewer complications. The question is whether the results of hemi-arthroplasty are inferior to those of total shoulder arthroplasty.

We assessed 189 patients who since July 1994 had undergone hemi-arthroplasty or total shoulder arthroplasty, excluding patients who suffered fractures, malunion or nonunion. In 77 patients (41%) the glenoid was replaced. The mean age of patients was 62 years. All humeral and glenoid components were cemented. Preoperative and postoperative assessments included pain (visual analogue scale), muscle strength, range of motion, functional activities and Constant shoulder scores.

At this early stage, total shoulder arthroplasty appears to give slightly better functional results than hemi-arthroplasty. However, there were five (6.5%) complications associated with the glenoid components, including glenoid component fracture, loosening and migration. Hemi-arthroplasty eliminates concerns about glenoid wear and glenoid complications, and we believe total shoulder arthroplasty should be reserved for specific problems.