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Management of complex acetabular fractures in the geriatric patient requires a better understanding of a different spectrum and frequency of fracture patterns, surgical techniques, and even treatment principles than in younger patients. Although joint replacement plays a role in certain elderly patients with acetabular fractures, open reduction internal fixation is the preferred treatment strategy, and must be executed even when combined with arthroplasty. Patient baseline functional status must be considered in choosing treatment goals, as well as their frailty and comorbidities. There are typical injury characteristics that must be recognized which require treatment-specific strategies. Lengthy reconstructions in this fragile patient population are to be avoided, and therefore single nonextensile approaches limiting blood loss are most appropriate, considering that the patient''s physiological reserve is lesser than younger counterparts. Although obtaining an anatomic reduction of the acetabulum is of paramount importance in the physiologically young who can withstand greater demands of surgery and who will require greater functional demands, the physiologically old patient requires stability to allow mobility and a surgery to mitigate their surgical risks. [Copyright &y& Elsevier]

Summary: Identification of information on a specific topic of interest can be a difficult and time-consuming task. The key to successful and time-efficient article identification is to use easily accessible, complete, and most up-to-date information sources and to perform a focused search that minimises hits without missing relevant articles. Pre-appraised articles and databases allowing “pre-filtering” techniques for high level evidence are useful for a quick search for the best available evidence. For a more comprehensive review, a combination of MEDLINE, EMBASE and meeting abstract databases is usually more than sufficient. Full-text publications can be obtained from the Cochrane library and from OVID. [Copyright &y& Elsevier]

The treatment of tibial plafond fractures is challenging and often is complicated by the compromise of the anterior ankle soft-tissue envelope and a high degree of fracture comminution. Many of these injuries are nonreconstructable and posttraumatic osteoarthritis of the tibiotalar joint is unavoidable. These patients may benefit from a salvage procedure using a posterior blade plate fusion of the tibiotalar joint. This procedure avoids the compromised anterior ankle soft-tissue envelope and allows simultaneous reconstruction of the metaphyseal defect as well as fusion of the tibiotalar joint. Indications include the acute treatment of severely comminuted tibial plafond fractures that appear nonreconstructable, management of posttraumatic tibiotalar osteoarthritis that is associated with significant compromise of the anterior ankle soft tissue envelope, and salvage of distal metaphyseal nonunions or delayed unions that are associated with posttraumatic tibiotalar osteoarthritis. We suggest posterior blade plate fusion as a standard procedure for these patient populations. Further clinical trials are required to investigate the clinical long-term outcomes in these patients. [Copyright &y& Elsevier]

Extra-anatomical fixation techniques are widely performed in anterior cruciate ligament (ACL) reconstruction. In particular, the EndoButton represents a popular device for femoral graft fixation not only in ACL single-bundle but also more recently in ACL double-bundle reconstruction techniques. Few technical pitfalls of the EndoButton technique have been reported in ACL single-bundle reconstruction. We present a case demonstrating an intraarticular EndoButton displacement of the posterolateral bundle at the metaphyseal cortex, which seems to be a specific complication in anatomic ACL double-bundle reconstruction. By addressing the anatomic femoral footprint of the posterolateral bundle, the exit of the femoral tunnel for the posterolateral bundle usually is located at the thinner metaphyseal cortex compared with the thicker diaphyseal cortex, which may represent a weak spot for the femoral graft fixation. In anatomic ACL double-bundle reconstruction, this metaphyseal location of the EndoButton may constitute a potential pitfall in restoration of the posterolateral bundle. [Copyright &y& Elsevier]

Recurrent instability after primary single-bundle anterior cruciate ligament (ACL) reconstruction is predominantly caused by technical errors. Delayed biological incorporation and traumatic reinjury represent other factors of ACL graft failure. However, there are patients with an intact single-bundle ACL graft complaining of recurrent instability where imaging studies lack inappropriate positioning of the tunnels and other technical errors. This recurrent instability may be caused by an incomplete restoration of the native ACL because biomechanical studies have shown only partial restoration of normal kinematics in single-bundle ACL reconstruction. We present 2 cases of recurrent instability after primary single-bundle ACL reconstruction that demonstrated an intact ACL graft. We performed an augmentation of the intact ACL graft representing the anteromedial bundle by reconstruction of the posterolateral bundle. This novel technique may address a (partially) recurrent instability after primary ACL reconstruction. [Copyright &y& Elsevier]

In the past several decades, there have been many advances in the diagnosis, surgical care, and rehabilitation of anterior cruciate ligament (ACL) injuries. However, there are few data in the literature as to whether these advances have successfully improved clinical outcomes following anterior cruciate ligament reconstruction. Thus, future research efforts should focus on the valid evaluation of clinical outcomes after ACL reconstruction. This article reviews the relevant clinical outcome measures for the evaluation of patients with anterior cruciate ligament injuries. The outcome evaluation of anterior cruciate ligament injuries should include measures of structure and function of the knee as well as measures of activity and participation of the individual. Measures of structure and function of the knee most directly related to injury of the ACL include measures of laxity and degeneration of the joint over time. Activity and participation can be measured by observing performance of the individual during a variety of activities or through the use of general and knee-specific a patient-reported measures of health related quality of life. When evaluating clinical outcomes following ACL injury, validated measures with established reliability and responsiveness must be used. [Copyright &y& Elsevier]

Navigation systems improve the accuracy of surgical procedures. In the field of knee surgery, they are mainly used for navigated total knee replacement. Commercially available applications also include navigated anterior cruciate ligament replacement. The planning and drilling of the bone tunnels can be performed using navigation. Navigation systems also are excellent measurement tools, and navigation systems can potentially be used to analyze the preoperative and postoperative 3-dimensional knee kinematics and stability. Intraoperative analyses of stability, impingement, and range of motion can be directly compared with the preoperative analysis, which allows immediate modifications if necessary. Furthermore, this set-up also can be used for the evaluation of outcomes. [Copyright &y& Elsevier]

Incorporation of the tendon graft within the bone tunnel is crucial for a successful outcome after anterior cruciate ligament reconstruction. Previous studies demonstrated that the incorporation of the tendon graft may take up to several months. Thus, it is of concern whether the early tendon–bone interface is strong enough to tolerate accelerated early postoperative rehabilitation. Biological solutions to enhance tendon healing within the bone tunnel may allow further advances in anterior cruciate ligament surgery. Previous studies emphasized the important role of bone growth factors. In animal models, successful stimulation of graft incorporation has been achieved by the application of bone morphogenetic protein-2. Moreover, periosteal enveloping of the tendon graft has shown to improve the healing response of the tendon graft within the bone tunnel, and preliminary clinical results appear promising. Further advances may be achieved by the use of tissue-engineered ligaments. Successful tissue engineering of ligaments requires optimized structural scaffolds, tissue specific cells, biological stimulation by growth factors, and mechanical stimulation by cyclic stretching. [Copyright &y& Elsevier]

Rearthroscopy after anterior cruciate ligament (ACL) as the result of significant postoperative inflammation lacking bacterial or fungal infection after single bundle reconstruction are commonly reported in techniques using artificial ACL augmentation devices. Recently, novel techniques of ACL double-bundle reconstructions were introduced. However, most of these techniques require a significant modification in the graft preparation of the semitendinosus and the gracilis tendon. Compared with ACL single-bundle reconstructions, the prepared tendon grafts for ACL double-bundle reconstructions are much shorter since the grafts are not only used for restoration of the anteromedial bundle but also for the posterolateral bundle. Therefore, the sutures of the tibial suture-postfixation may be located intra-articularly. We present a case of an intra-articular location of the tibial fixation suture causing a significant synovitis 3 weeks after anatomic ACL double bundle reconstruction. The inflammation was successfully treated by arthroscopic debridement and irrigation. The suture and the post-fixation were preserved because of incomplete incorporation of the graft at the time of rearthroscopy. [Copyright &y& Elsevier]

The range of load that can be applied to a knee joint without causing structural or metabolic failure can be termed envelope of function. Injuries to the knee joint, such as anterior cruciate ligament (ACL) injuries, may significantly diminish the envelope of function. The goal of a successful treatment program for patients with ACL injuries is to restore normal physiologic knee function and thus restore the physiologic envelope of function. Recent advances have improved the outcomes in ACL surgery. However, full restoration of physiologic knee function and normal knee kinematics usually is not achieved. Therefore, surgical approaches that restore the normal anatomy of the ACL may further contribute to the improvement of outcomes and may further diminish the discrepancy between the postoperative envelope of function and the physiologic envelope of function. [Copyright &y& Elsevier]

Abstract: The anterior cruciate ligament consists of 2 functional bundles, the anteromedial and the posterolateral bundle. Anterior cruciate ligament reconstruction has traditionally focused on recreating the anteromedial bundle, while the reconstruction of the posteromedial bundle has not routinely been addressed. The authors, from 2 academic centers, present a technique of arthroscopic anterior cruciate ligament reconstruction that restores both the anteromedial and the posterolateral bundle using either semitendinosus and gracilis autografts or tibialis anterior allografts. This technique represents a novel approach to restore the anteromedial and the posterolateral bundle at their anatomic insertion sites on both the tibia and the femur through separate bone tunnels. We believe that our double-bundle anatomic anterior cruciate ligament reconstruction closely reapproximates the native insertion sites of the anterior cruciate ligament on the tibia and the femur while more closely recreating the biomechanical function of the native ligament. [Copyright &y& Elsevier]

Abstract: Partial anterior cruciate ligament (ACL) tears that result in functional instability are usually the result of a deficiency of the anteromedial bundle (AMB), and are evident arthroscopically by a prominent posterolateral bundle (PLB). As double-bundle ACL reconstructions are being suggested to recreate a more normal anatomy, the roles of each bundle are being more critically questioned. We present a case that describes the appearance of a normal ACL in a posterior cruciate ligament (PCL)-deficient knee in which the PLB of the ACL is prominent, giving the appearance of a complete tear of the AMB of the ACL, and scarring of this bundle to the PCL stump. On further inspection, and when the tibia was reduced, the normal appearance of the ACL returned, with visualization of the AMB obscuring the PLB. We have named this arthroscopic finding the “PLB sign.” This finding confirms the individual roles of each bundle of the ACL. It is important to not misinterpret this abnormal appearance of the ACL as a partial ACL tear in a PCL-deficient knee. [Copyright &y& Elsevier]

Introduction: Well-known risk factors (RF) for soft tissue complications following surgical treatment of fracture of the ankle region include diabetes, smoking, and the local soft tissue status. A weighted analysis might provide a risk profile that guides the surgical treatment strategy. The aim of this meta-analysis was to provide a risk profile for soft tissue complications following closed fractures of the ankle region.Methods: This review provides a meta-analysis of studies that investigate potential risk factors for complications in fractures of the ankle region.Inclusion Criteria: Original articles that were published between 2000 and 2020 in English or German language that calculated odds ratios (OR) of RF for soft tissue complications. Further, this study only includes articles that investigated fractures of the ankle region including pilon fracture, calcaneal fractures, and fractures of the malleoli. This study excluded articles that provide exploratory analyses, narrative reviews, and case reports. RF were stratified as patient specific systemic RF (PSS), patient specific local RF (PSL), and non-patient specific RF (NPS). PSS RF includes comorbidities, American society of anaesthesiology (ASA), requirement of medication, additional injuries, and smoking or substance abuse. PSL RF includes soft tissue status, wounds, and associated complications. NPS RF includes duration of surgery, staged procedure, or time to definitive surgery. Random effect (RE) models were utilized to summarize the effect measure (OR) for each group or specific RF.Results: Out of 1352 unique articles, 34 were included for quantitative analyses. Out of 370 complications, the most commonly assessed RF were comorbidities (34.6%). Local soft tissue status accounted for 7.5% of all complications. The overall rate for complication was 10.9% (standard deviation, SD 8.7%). PSS RF had an OR of 1.04 (95%CI 1.01 to 1.06, p = 0.006), PSL an OR of 1.79 (95% 1.28 to 2.49, p = 0.0006), and NPS RF an OR of 1.01 (95%CI 0.97 to 1.05, p = 0.595). Additional injuries did not predict complications (OR 1.23, 95%CI 0.44 to 3.45, p = 0.516). The most predictive RF were open fracture (OR 3.47, 95%CI 1.64 to 7.34, p < 0.001), followed by local tissue damage (OR 3.05, 95%CI 1.23 to 40.92, p = 0.04), and diabetes (OR 2.3, 95%CI 1.1 to 4.79, p = 0.26).Conclusion: Among all RFs for regional soft tissue complications, the most predictive is the local soft tissue status, while additional injuries or NPS RF were less predictive. The soft tissue damage can be quantified and outweighs the cofactors described in previous publications. The soft tissue status appears to have a more important role in the decision making of the treatment strategy when compared with comorbidities such as diabetes. [ABSTRACT FROM AUTHOR]

Background: Blunt chest trauma represents one of the most common injuries in polytrauma patients. Blunt chest injury complicating polytrauma is associated with significant prolongation of intensive care stay. Further, it has a great impact on the timing of fixation of skeletal injuries, possibly contributing to adverse outcome. The purpose of this study is to assess whether there are any differences in the management and outcome of polytrauma patients with blunt chest trauma between trauma units in two different countries. Detailed information about advantages and disadvantages of these two systems might allow optimising the management of blunt chest trauma. Patients and Methods: This investigation was performed using the polytrauma database of the German Trauma Society and the British Trauma Audit Research Network. After the definition of the inclusion abbreviated injury scale (AIS(chest) > or = 3) and injury severity score (ISS > 16) and exclusion (AIS(head/neck) > or = 2, referral from outside institutions) criteria, patients were recruited solely from these databases. Results: 188 patients from the German database and 181 patients from the British database were enrolled in this study. Demographic data and injury pattern of the two patient populations did not significantly differ. The volume of initial red blood cell transfusion and length of the intensive care stay were significantly higher in Germany (p < 0.05). Mortality in the UK was 9% higher than in Germany (p = 0.057). Time to death in non-survivors was also significantly longer in Germany (p < 0.05). Conclusions: The reasons for the differences regarding survival times and survival rates seem to be multiple. German patients received more red blood cells, had a longer hospital stay in intensive care and a better survival rate. The use of kinetic therapy in Germany, not standard in the UK, may contribute to a more favourable outcome. [ABSTRACT FROM AUTHOR]

Background: The impact of conventional laboratory data to identify polytrauma patients at risk of complications is established. However, it has not been assessed in terms of prognostic accuracy for systemic complications (ARDS, organ failure). We therefore assessed the most predictive parameters for systemic complications and developed a scoring system for early grading of polytrauma patients.Methods: A population based trauma registry was used.Inclusion Criteria: age >16 years, Abbreviated Injury Score (AIS) of the abdomen or chest ≥ 3 points and treatment in an intensive care unit, or Injury Severity Score (ISS) ≥ 16 points. The primary endpoint was hospital mortality. Patients were graded according their risk of death: low risk of death (5-14% mortality), intermediate risk patients (15-39% mortality) and high risk (>40%). Routine clinical and laboratory parameters on admission were assessed to determine their specific relevance to describe the risk profile of the patient. Based on these data, a scoring system for the description of the clinical status was developed. Statistical analysis included uniand multivariate analysis.Results: 11.436 patients were included, the mean ISS was 22.7 ± 11.2 points, 73% were male, and 95.6% had blunt injuries. The most sensitive parameters were found to be the following ones: systolic blood pressure, INR, thrombocytes, base deficit, NISS, packed red blood cells administered. The multivariate analysis revealed the following threshold levels: BP 76-90 mmHg: r = 0.249, OR 1.283: Base deficit 8-10 r = 0.474, OR 1.606; INR 1.4-2 r = 0.160, OR 1.174; NISS 35-39 r = 0.9, OR 2.46; pBRC 3-14: r = 0.671, OR 1.957. The following ranges of score values were found to be associated with different patient status: <6 points: stable patients; 6-11 points: borderline condition; >11 points: unstable patients. When using this score, 80.6% were stable, 14.6% in a borderline condition and 4.8% unstable.Conclusion: We developed a scoring system to discriminate polytrauma patients on admission that are at risk of systemic complications. Systolic blood pressure, INR, thrombocytes, base deficit, NISS, packed red blood cells administered are able to provide a prognosis of patients at risk of posttraumatic complications. Further prospective studies should be performed to verify this new scoring system. [ABSTRACT FROM AUTHOR]