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packing as part of damage control surgery for severe pelvic fractures at the Los Angeles County +
University of Southern California Medical Center from 05/2006-06/2008.
Results: During the study period, 201 patients with pelvic fractures underwent operative intervention.
Treatment of an expanding retroperitoneal hematoma resulting in hemodynamic instability was
required in 33. Five of these patients were adequately stable for angioembolization with a resultant
40% survival. The remaining 28 patients had persistent pelvic hemorrhage and hypotension despite
packing that precluded transport to angiography. These patients underwent damage control BLIA and
packing with pelvic binding (21 patients) or external pelvic fixation (7 patients). The mean ISS of these
patients was 33±10. Techniques utilized for BLIA included suture ligature (n=20), Rummel tourniquet
(n=1) and clip occlusion (n=7). Four patients had subsequent removal of Rummel tourniquet/clips at
24 to 72 hours after initial procedure, with the remainder undergoing permanent ligation. The patients
received a total of 20±13 units packed red blood cells, 13±9 units of fresh frozen plasma and 2±2
units of platelets. Half of the patients received at least one dose of recombinant Factor VII. Overall mortality
after BLIA was 64% (18 of 28). Causes of mortality included: brain death, intra-operative arrest,
refractory coagulopathy, and sepsis. No survivors after BLIA were noted to have adverse ischemic
sequelae.
Conclusion: Ligation of the bilateral internal iliac arteries is a damage control tool potentially useful
for patients with massive retroperitoneal hemorrhage after pelvic fracture. This approach may prove
particularly useful when such a bleeding source is encountered at laparotomy in a patient in extremis
who will not survive to reach angiography, or in environments that lack rapid access to advanced
alternatives. Further study is required to determine the appropriate selection criteria for this potentially
life-saving maneuver.
70.7
Early experience using the ASLS (Angular Stable Locking System) for intramedullary nailing
M. Rudin, T. Hotz, K. Käch (Winterthur)
Objective: Intramedullary nails are widely used for the treatment of long bone fractures. The introduction
of locking screws increased the indications more proximally and distally beyond classic shaft fractures.
Due to the metaphyseal widening of the medullary canal and the thin cortex the classic locking
screws and nails do not always provide sufficient stability. Loose fitting between screws and nail can
lead to loss of reduction and instability which can lead to malunions or pseudoarthrosis. A new screw
type (ASLS) was developed providing an angular stable fixation between nail and screw using a bioresorbable
sleeve acting as an anchor bolt in the locking hole.
Methods: Since March 2009 we have applied the ASLS in eight patients. Five tibial, two humeral and
one femoral fracture were nailed using the Expert-Nail-System enhanced with angle stable locking
screws. Two or three interlocking screws were placed proximally or distally according to the fracture
pattern. Five patients were elderly (76-90y) and suffered from coexisting diseases affecting bone quality
such as metastatic disease or osteoporosis. Two young patients (17/28y) suffered comminuted
open fractures of the distal tibia. One obese middle age patient (45y; BMI 52) presented a proximal
metaphyseal tibia fracture.
Results: Intraoperative handling and implantation was unproblematic in all cases. The interlocking
screws initially seemed to enhance the overall osteosynthesis stability. One patient suffering of severe
osteoporosis however showed early locking screw loosening and a loss of primary reduction.
Two patients did not survive until fracture union due to preexisting diseases. All other fractures healed
uneventfully.
Conclusion: Angular stable screws combined with plate osteosynthesis have succesfully been
introduced and are commonly used. They truly improve fracture treatment options especially in osteoporotic
bone. The classic locking screws for intramedullary nails have stability limitations due to
metaphyseal nail toggling and poor locking screw fixation. The angular stable locking system (ASLS) is
an interesting new development. Nailing indications can possibly be expanded even with poor quality
bone stock. However, limitations are still given by implant-bone anchorage no matter how stable the
individual implant parts interlock.
70.8
The open abdomen, a better outcome following a clear algorithm based on a new classsification
A. Bruhin, S. Feichter, J. Metzger (Luzern)
Objective: The open abdomen is a relatively new and increasingly common therapy concept in treating
abdominal emergencies in trauma and visceral surgery. Different techniques are available to achieve
a better outcome. These techniques include the „Negative Pressure Therapy“ (NPT) giving a more efficient
method to close the abdominal fascia and reduce the rate of complications. The main principle
of this new treatment is based on a new classification.
Methods: This paper presents a new algorithm based on a review of the current literature. As method
of treatment we are using NPT: Classification score runs from grade 1 up to grade 4. First grade means
an open abdomen without adherence or fixation between bowel and abdominal wall, where a primary
delayed fascial closure must be the goal of treatment. Grade 4 describes a frozen open abdomen. In
this situation the goal of treatment is a controlled hernia formation, followed by final reconstruction of
the abdominal wall usually around 6 to 12 months postoperatively.
Results: Despite low level evidence in the literature there is clearly a better outcome regarding the rate
of primary abdominal closure, less complications like fistula formation and a reduced mortality.
Conclusion: The principal goals of these clinical guidelines are to offer a standardised classification
system, which allows to compare results. With a clear strategy and teamwork of trained specialists we
can get a better outcome with less complications and a improve survival. The NPT will become more
and more a standard therapy in the treatment of the open abdomen.
70.9
Treatment of Adductor Longus Ruptures in Athletes: Operative or Nonoperative Management ?
A. Platz, A. Babians, Ü. Can (Zürich)
Objective: Acute rupture of the proximal adductor longus tendon is a rare injury in athletes. The operative
treatment is recommended, but also non-operative management seems to achieve comparable
results in selected cases. We analyzed 4 athletes with this injury, all of them were operated with complete
recovery.
Methods: We analyzed retrospectively 4 patients with a mean age of 35 years (26-50 years) with
acute isolated rupture of the proximal adductor longus tendon. 2 patients played handball at a high
level (international level) and 2 patients played football, one at a national level, one in a lower league.
All of them were managed operatively with reattachement of the tendon with Mitek-bone anchors. The
rehabilitation was standardized with max. weight bearing of 20-30 kg for 3 weeks, no active adduction
was allowed. In the next 3 weeks training on the home trainer were allowed. After 6 weeks hip flexion
was 90° and stretching was started. Jogging was allowed after 12 weeks.
Results: In all 4 patients no history of groin pain was present before the rupture. After initial clinical
examination in all patients an MRI examination confirmed the diagnosis of a ruptured adductor longus
tendon. Operative procedure was performed within 1 week after the accident. The follow – up was 4 to
20 months (mean 11 months). All 4 patients reached their full sport activity 4 months after the injury.
No loss of muscle strength was observed. No groin pain was present after the operation.
Conclusion: Although in newer literature complete restoration with conservative treatment is reported,
in our opinion the operative treatment is the treatment of choice in athletes with the goal to reach the
previous full sports activity. We know from tenotomy of the aductor longus tendon for chronic groin
pain, that only 63% of the athletes returned to their previous level of acitvity ! For this reason we recommend
the operative procedure.
70.10
Primary recurrent medial patella sub-/dislocation due to a hypertrophic patello-femoral ligament? A
case report
M. Höckl 1 , C. H. Freuler 1 , H. Bereiter 2 , C. Candrian 1 ( 1 Lugano, 2 Chur)
Objective: Primary medial patellar sub-/dislocation is an extremely rare finding in human beings. In the
only case reported in literature, an excessive femoral antetorsion could be found which was corrected
by successful subtrocanteric-derotational osteotomy. We present a case with recurrent medial sub-/
luxation of the patella without any underlying bony-structural abnormalities, reporting our treatment
and follow-up, with review of the literature and discussing possible underlying causes.
Methods: A case report.
Results: A 15 year’s old girl sustained a skiing injury with a first episode of medial patellar luxation
of her left knee. In the following nine months she reported further ten spontaneous episodes which
resolved with auto reposition. Clinically a slightly medialised patella with a positive apprehension sign
was found in an otherwise normally aligned lower extremity. No pathological findings on standard
x rays MRI showed a slight trochlear dysplasia and a hypoplastic medial condyle. A CT-scan of the
lower extremity including rotational measurements, confirmed regular rotational alignment and physiological
bone axis. After unsuccessful conservative treatment during ten months after the first dislocation,
the girl underwent surgery. A lateral longitudinal parapatellar approach and arthrotomy was
performed: A hypertrophic medial patello-femoral ligament (MPFL),and a particularly distal insertion of
the medial vastus muscle were found. No femoro-patellar dysplasia was observed. Dissection of the
MPFL and a proximalisation of the medial vastus muscle was performed and furthermore the lateral
retinaculum was dissected and distalized. At the end of surgery regular patellar tracking was achieved.
12 months after surgery the patient was symptom free without further episodes of sub-/dislocation. At
the last follow-up she complained terestingly enough about similar recurrent medial patellar dislocation
of the controlateral knee joint. Clinically and radiologically we observed similar findings.
Conclusion: This case of medial patellar dislocation without any underlying bony structural abnormalities
can be considered unique. The intraoperative finding of a hypertrophic MPFL could be the main
cause or the consequence of the recurrent sub-/luxations of the patella respectively of the sustained
trauma, whereas the recurrent patella dislocation of the opposite knee suggests rather a congenital
cause.
70.11
Surgical treatment of posterior clavicle dislocation in sternoclavicular joint via ThightRope fixation
system
R. Fakin, T. Köstler, F. Grafen, K. Horisberger, E. Grossen, O. Schöb (Schlieren)
Objective: Traumatic sternoclavicular joint (SCJ) dislocation is a rare injury, of which a majority of
cases represents the anterior version. Indeed, the diagnosis of a posterior dislocation of SCJ is often
overseen and might lead, mainly due to its anatomical localisation, to numerous severe complications.
Because of relative infrequency of this diagnosis there is a limited amount of knowledge concerning
its therapy and therefore diverse surgical procedures suggested throughout the literature remain controversial.
Methods: Two TightRope ® trans-fixations between left clavicle and manubrium sterni were performed
via subsequent drilling of a 4-mm hole in proximal clavicle in cranio-vertical direction and followed by
another 4-mm drill hole to manubrium. Thereafter, the TightRope ® (fibrewire and endobutton) system
endobutton was threaded into the clavicular hole followed by the manubrium hole. After the flipping
of the endobutton was performed, the system was tightened to its proper length for anatomical joint
alignment. Static and dynamic stability of SCJ was proved.
Results: The patient was discharged home 2 days after the surgery without shoulder immobilizer. Clinical
and radiological follow-up 8 weeks after the surgery showed anatomically correct conditions of
SCJ without restriction in range of motion.
swiss knife 2010; 7: special edition 59