Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

BackgroundFractures of the pelvic ring including disruption of the posterior elements in high-energy trauma have both high morbidity and mortality rates. For some injury pattern part of the initial resuscitation includes either external fixation or plate fixation to close the pelvic ring and decrease blood loss. In certain situations – especially when associated with abdominal trauma and the need to perform laparotomies – both techniques may put the patient at risk of either pintract or deep plate infections. We describe an operative approach to percutaneously close and stabilize the pelvic ring using spinal implants as an internal fixator and report the results in a small series of patients treated with this technique during the resuscitation phase.FindingsFour patients were treated by subcutaneous placement of an internal fixator. Screw fixation was carried out by minimally invasive placement of two supra-acetabular iliac screws. Afterwards, a subcutaneous transfixation rod was inserted and attached to the screws after reduction of the pelvic ring. All patients were allowed to fully weight-bear. No losses of reduction or deep infections occurred. Fracture healing was uneventful in all cases.ConclusionMinimally invasive fixation is an alternative technique to stabilize the pelvic ring. The clinical results illustrate that this technique is able to achieve good results in terms of maintenance of reduction the pelvic ring. Also, abdominal surgeries no longer put the patient at risk of infected pins or plates.

BackgroundOdontoid fractures account for approximately 20% of all fractures of the cervical spine. They represent the most common cervical spine injury for patients older than 70 years, the majority being type II fractures (65-74%), which are considered to be relatively unstable. The management of these fractures is controversial. Possible treatment options are either conservative or surgical. Surgical procedures include either anterior screw fixation of the odontoid or posterior C1/C2 fusion. The aim of this study was to compare the outcome of the three treatment modalities in elderly patients.MethodsBetween June 2004 and February 2010, all patients older than 65 years (n = 47) with type II fractures of the odontoid according to the Anderson and D’Alonso classification were retrospectively reviewed.ResultsIn the non-operatively managed cohort, 11 patients (79%) died postoperatively within a mean period of 23 months. In all other cases (n = 3), radiographs demonstrated non-union. The mean lateral displacement was 1.9 mm (range 0–5,8 mm) and a mean angulation of 29,1° (range 0-55°) was found.Anterior screw fixation was carried out in 17 patients. The non-union rate in this cohort was 77%. In patients with a posterior C1-C2 fusion, a bony fusion of the posterior elements was found in 15 of 16 cases (93%). Survival rates were significantly higher among the group of patients who were treated with anterior screw fixation or posterior C1/C2 fusion compared to the conservatively treated group.ConclusionWe found the best clinical results with low rates of non-union as well as low mortality rates following posterior C1/C2 fusion making this our treatment of choice especially in an elderly patient collective.

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Introduction. Sternal fractures often occur together with serious and life-threatening additional injuries. This retrospective study was designed to assess concomitant injuries and develop a correlation between fracture location and the severity of injury. Methods. All patients (n = 58) diagnosed with a fracture of the sternum by means of a CT scan were analysed with respect to accident circumstances, fracture morphology and topography, associated injuries, and outcome. Results. Isolated sternal fractures occurred in 9%. In all other admissions, concomitant injuries were diagnosed: mainly rip fractures (64%), injury to the head (48%), the thoracic spine (38%), lumbar spine (27%), and cervical spine (22%). Predominant fracture location was the manubrium sterni. In these locations, the observed mean ISS was the highest. They were strongly associated with thoracic spine and other chest injuries. Furthermore, the incidence of head injuries was significantly higher. ICU admission was significantly higher in patients with manubrium sterni fractures. Conclusion. Sternal fractures are frequently associated with other injuries. It appears that the fracture location can provide important information regarding concomitant injuries. In particular, in fractures of manubrium sterni, the need for further detailed clinical and radiologic workup is necessary to detect the frequently associated injuries and reduce the increased mortality.

Background: Subgroup analyses of the Latarjet procedure have suggested that age over 40 years is a risk factor for dislocation arthropathy. Purpose: To analyze long-term results of the open Latarjet procedure for recurrent anterior shoulder dislocation in patients at least 40 years of age. Study Design: Case series; Level of evidence, 4. Methods: A total of 39 consecutive patients (40 shoulders) with a mean age of 48 years (range, 40-66 years) at surgery were evaluated at a mean follow-up of 11.0 years (range, 8-16 years). Of these, 15 patients (38%) had undergone previous soft tissue stabilization surgery. Long-term results were assessed clinically and radiographically, including computed tomography scanning at final follow-up. Results: No recurrence of dislocation was noted. Subluxation had occurred in 3 patients (8%), and apprehension persisted in 5 patients (13%). The total Walch-Duplay score averaged 89 points at the final follow-up, and the mean Subjective Shoulder Value (60%-91%) had improved significantly ( P < .001). In total, 36 patients rated their result as excellent, 3 as good. Further, 6 patients (15%) underwent joint-preserving reoperation, and 1 patient (3%) had reverse total shoulder arthroplasty for severe dislocation arthropathy. Dislocation arthropathy was severe in 14 patients (37%) and had progressed by at least 2 grades in 17 patients (45%). Patients with severe dislocation arthropathy had already shown degenerative changes preoperatively as opposed to those who ultimately had no or moderate dislocation arthropathy (n = 24) ( P < .001). Progression of dislocation arthropathy was associated with lateral (>1 mm) graft positioning ( P < .001) and older age at surgery ( r = 0.58; P < .001). Conclusion: The open Latarjet procedure for recurrent anterior shoulder instability in patients older than 40 years reliably restores stability and leads to high patient satisfaction. This procedure is, however, associated with a substantial rate of advanced but clinically mild symptomatic dislocation arthropathy, which is associated with the degree of preoperative joint degeneration, older age at surgery, and lateral graft placement.

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