Imaging Following Fractures of and Around the Knee.

Related to fractures of and around the knee, inappropriate technical factors related to the surgery, severe comminution of the fracture, early overly arduous rehabilitation of the patient, and patient-related noncompliances may have the potential for the risk of inadequate fixation and other complications. Loss of fixation, malunion/nonunion, infection, arthritis, arthrofibrosis, and symptomatic hardware are among postsurgical complications that may necessitate further reconstructive techniques. In this review, complications that may be encountered in the postsurgical period of fractures involving the patella, supracondylar femur, and tibial plateau are described.

Acromioclavicular joint dislocation treated with Bosworth screw and additional K-wiring: results after 7.8 years - still an adequate procedure?

BACKGROUND: The acromioclavicular (AC) joint dislocation is a major reason for shoulder instability. Different concepts of treatment and surgical methods are described in the literature. Thus, the purpose of this study was to present our data of long-term follow-up of patients having undergone treatment of acromioclavicular (AC) joint dislocation using the Bosworth Screw with additional K-wiring. METHODS: This study was conducted as a retrospective single centre data analysis. All patients treated operatively for AC joint dislocation with a Bosworth screw and additional K-wire fixation at our Department were asked to participate in this study. RESULTS: The study population consisted of 22 patients, 20 male and 2 female, with a mean age of 40 years ±15.6 years. Three grade-II lesions, 13 grade-III lesions, four grade-IV lesions and two grade-V lesions according to the Rockwood classification were found. The overall mean clinical outcome at the latest follow up was: Constant 95, DASH 6.4, ASES 94.6, SST 99.02, UCLA 33.1, ACJI 91.82 and VAS 0.29 - representing a good-to-excellent long-term outcome in all patients after at least 2 years follow-up (range; 2 - 19 years). Overall, 19 patients (86%) reported to be very satisfied with the achieved result, 15 patients (68%) reported to be able to participate in every sports activity and 16 patients (73%) reported to be able to perform their daily work without limitations. Overall, complications occurred in three patients (14%). Only one patient remained unsatisfied with the achieved result. CONCLUSION: Summarizing, our reported results showed that surgical fixation of acute AC joint dislocation with a Bosworth screw and additional K-wire fixation leads to good-to-excellent functional outcome and highly satisfactory results in the majority of patients. Despite its complications, in accordance with our results, Bosworth screw fixation with additional K-wiring in AC joint dislocation represents an adequate surgical procedure. LEVEL OF EVIDENCE: Level IV, retrospective study.

Displaced juvenile Tillaux fractures : Surgical treatment and outcome.

BACKGROUND: Approximately 15 % of all juvenile injuries of the long bones involve the epiphyseal growth plate, and 2.9 % of these are juvenile Tillaux fractures. The Tillaux fracture is of great importance because it involves a major weight-bearing articular surface. Treatment protocols in the literature are not uniform for this kind of fracture, and numerous case reports can be found describing various treatment methods. The aim of this study was to present the clinical outcome at long-term follow-up after treatment of displaced Tillaux fractures. METHODS: In all, 168 children and adolescent patients with physeal injuries of the distal tibia were treated from 2003 to 2012. Seven patients were identified as having Tillaux fractures requiring surgical treatment and therefore were included in our study and evaluated retrospectively. RESULTS: Seven patients with Tillaux fractures underwent surgical reconstruction by open or closed reduction. Excellent results were achieved in 90 % of the patients, with a mean Foot and Ankle Score at the last follow-up of 98.71. CONCLUSION: Anatomical reduction is required for every displaced epiphyseal fracture via open reduction and internal fixation, especially in cases with ≥2 mm fragment displacement. Plaster cast immobilization and non-weight-bearing mobilization for at least 4 weeks might be a good way of ensuring optimal surgical results and preventing complications.

Treatment of proximal humerus fractures in children and young adolescents.

BACKGROUND: Fractures of the proximal humerus in children are rare and represent approximately 0.45% of all paediatric fractures. These injuries are common in patients up to an age of 16 years. The treatment of displaced subcapital fractures is still controversially discussed in literature. Therefore the aim of this study was to evaluate the short-term outcome and to provide guidelines for surgical treatment of these fractures in children and adolescents. METHODS: Clinical and radiological results of 231 patients between 0 and 17 years with subcapital humerus fractures were evaluated. Patients were devided according to their treatment as followed (1) conservative treatment group (2) operative treatment group. RESULTS: A total of 191 patients (82.7%) underwent conservative treatment and 40 (17.3%) underwent operative treatment. Surgical treatment consisted of open reduction and internal fixation (ORIF) (35.0%) or closed reduction and internal fixation (CRIF) (52.5%). In all operated patients an axial deviation of more than 20° was observed preoperatively. According to our groups; the surgical group presented in 90% (N = 36) of the patients with an excellent result, in 5% (N = 2) an average result was observed and in 5% (N = 2) a poor result according to Constant Murley Score was achieved. In the conservative treatment group in 185 patients (96.9%) excellent results were achieved and in 6 patients (3.1%) an average result in the Constant Murley Score was achieved. CONCLUSION: Conservative treatment in children < 10 years and an angulation angle < 20°, as well as surgical treatment with ORIF or CRIF in patients > 10 years and with an angulation angle > 20° leads to excellent short-term outcome. However, studies with longer observation time are needed to evaluate long-term complications like limb length discrepancy.

Clinical and Functional Outcome of All-Inside Anterior Cruciate Ligament Reconstruction at a Minimum of 2 Years' Follow-up.

PURPOSE: To evaluate the clinical and functional outcomes for anatomic anterior cruciate ligament (ACL) reconstruction using the all-inside technique with a minimum follow-up of 24 months. METHODS: Patients undergoing anatomic ACL reconstruction via the all-inside technique between January 2011 and October 2012 were reviewed for inclusion in this study. Functional outcome measures, including the Lysholm score, International Knee Documentation Committee score, visual analog scale score, and Tegner Activity Scale, were used to evaluate outcomes before surgery and at 3, 6, 12, and > 24 months. At final follow-up, anteroposterior knee stability was assessed with KT-2000 (MEDmetric, San Diego, CA) measurements. RESULTS: Of the 92 patients who underwent primary all-inside ACL reconstruction, 79 patients returned to final follow-up with a minimum of 2 years. There were 53 men and 26 women with a mean age of 29 years (range, 18 to 54 years) and a mean follow-up of 29 months (range, 24 to 45 months). The International Knee Documentation Committee score (44.6 v 89.7, P < .0001), Lysholm score (53.4 v 93.1, P < .001), visual analog scale score (5 v 0.1, P < .001), and Tegner activity score (2 v 6, P < .001) showed a significant improvement between baseline and final clinical follow-up. The mean side-to-side KT-2000 difference at final follow-up was 1.7 mm (range; 0 to 6 mm). Overall 10 patients (12.7%) sustained an ACL graft rerupture after a mean of 17.6 months (range, 6.9 to 28.6 months). CONCLUSIONS: The current data support our first hypothesis that primary anatomic ACL reconstruction using the all-inside technique leads to improved functional outcomes between baseline and clinical follow-up at 24 months. Further, there was no difference in knee stability between the ACL reconstructed- and the contralateral normal knee at 24 months, which confirms our second hypothesis.

Clinical and functional outcome after anterior cruciate ligament reconstruction using the LARS™ system at a minimum follow-up of 10 years.

BACKGROUND: Since the 1980's several artificial ligaments were used for reconstruction of the anterior cruciate ligament (ACL) serving different complications. The aim of this study was to assess the clinical and functional outcomes of primary ACL reconstruction using the Ligament Augmentation Reconstruction System (LARS™) with a minimum follow-up of 10-years. The LARS™ presents a synthetic material consisting of non-absorbing polyethylene terephthalate fibres used for ligament reconstruction. METHODS: Outcomes of 18 patients who underwent arthroscopic ACL reconstruction using the LARS™ system between 2000 and 2004 with a minimum follow-up of 10 years were observed. The International Knee Documentation Committee score (IKDC), Visual Analog Scale (VAS), Lysholm score, and Tegner Activity Scale were assessed. Clinical assessment was performed by Lachman testing, assessment of side-to-side difference on KT-2000 testing and plain radiography evaluation of osteoarthritis. RESULTS: There were seven males and 11 females, mean age 29 years (range, 18 to 44 years) and a mean follow-up of 151.5 months. Five patients (27.8%) sustained a re-rupture of the LARS™ system and underwent revision surgery after a mean time of 23 months and four patients (22.2%) presented with a re-rupture. The average IKDC score was 76.60 ± 18.18, the average Lysholm score was 88.00 ± 10.07 and the average Tegner activity score was five at final follow-up. CONCLUSION: Our results indicate that the LARS™ system should currently not be suggested as a potential graft for primary reconstruction of the ACL. In special cases, however, the LARS™ system can serve as an alternative graft.

"Ligamentization" in hamstring tendon grafts after anterior cruciate ligament reconstruction: a systematic review of the literature and a glimpse into the future.

PURPOSE: The aims of this study were to provide a systematic review of the literature on "ligamentization" in hamstring tendon (HT) grafts after anterior cruciate ligament (ACL) reconstruction and analyze the postoperative remodeling process in human patients and animal models. METHODS: We performed a search in the Medline, PubMed, Embase and The Cochrane Library databases, followed by a manual search of reference lists to identify relevant articles. Only studies that investigated the ligamentization of hamstring grafts by histologic examination and comprehensively reported on the remodeling process were deemed eligible for review. RESULTS: A total of 4 studies were determined appropriate for systematic review: 2 of the included studies investigated human ACL grafts and 2 were performed in animal models. The studies included the examination of 79 human hamstring graft biopsy specimens and grafts of 27 skeletally mature sheep. To verify the remodeling process, authors reported on various aspects of cellularity, vascularity, and collagen organization. None of the included studies reached a level of evidence higher than 3. CONCLUSIONS: A postoperative ligamentization process can be found in HT grafts after ACL reconstruction and shows a typical progression through 3 distinguishable remodeling phases in humans and in animal models, whereas the progression and intensity of remodeling is distinctly increased in animals. CLINICAL RELEVANCE: Because postoperative remodeling influences biomechanical properties of hamstring grafts, a better understanding of this process and its timing could lead to substantial improvements in postoperative care strategies and indirectly to the optimization of surgical techniques.

Physeal injuries of the proximal humerus: long-term results in seventy two patients.

PURPOSE: The aim of this study was to evaluate our treatment methods of proximal humeral physeal injuries retrospectively and elucidate the relationship between the trauma mechanism, the radiographic injury pattern, the consequent therapy and the functional outcome, and to further deduct and verify prognostic criteria. METHODS: At our Department of Trauma Surgery, 303 children and adolescent patients with fractures of the proximal humeral epiphysis were treated from 1992 to 2009. 72 cases were diagnosed as physeal fractures according to the Salter-Harris classification and were included in our study. RESULTS: 15 physeal fractures of the proximal humerus were reconstructed anatomically by open or closed reduction and produced 93.3% excellent results. 57 physeal fractures were treated in a conservative way and produced 94.7% excellent results. CONCLUSION: We state that epiphyseal injuries should to be treated depending on the age of the patient. This is the only way to decrease the rate of posttraumatic epiphysiodesis with consequent problems, including limb-length discrepancy and/or angular deformities.

Cementless two-staged total hip arthroplasty with a short term interval period for chronic deep periprosthetic infection. Technique and long-term results.

BACKGROUND: The two-staged exchange with delayed reimplantation is the most reliable method to treat a deep periprosthetic infection after a total hip arthroplasty (THR). Nether uniform recommendations for the technique of cementless reimplantation, nor long term clinical and radiological results are reported. MATERIALS AND METHODS: Our protocol is performed under short term antibiosis with cementless primary porous hip implants to treat chronic deep periprosthetic infections following THR. A retrospective study was performed to evaluate the clinical and radiological long term outcome and the rate of persistent infection of 14 patients. RESULTS: In a five year minimum follow up persistent infection was observed twice in a two-staged revision THR. A dislocation of the hip components was observed in three cases, and could be surgically treated in twice and by wearing a hip-brace in one case. We could not find a loosening of THR components. Three patients had a good or excellent, 11 patients a fair or bad functional outcome. There was a significant correlation between functional outcome and length of interval of prosthesis exand reimplantation. CONCLUSION: Patients have an increased comfort resulting from a short, CRP depending time interval between ex- and reimplantation. Functional outcome is the better the shorter the interval is. The reinfection rate is comparable to those of cemented revision THR's with a long term interval. We could observe advantages in a reduced amount of bone loss and better osseous integration of the uncemented implants, compared to cemented implants reviewing literature. Alterations of acetabular bone stock and soft tissue are responsible for a high rate of instability of the THR. An inaccurate gait pattern is caused by gluteal weakness in the majority of patients. Repeated surgical intervention and duration of immobilization have to be minimalized.

Physeal injuries of the distal tibia: long-term results in 376 patients.

The aim of this study was to evaluate our treatment of distal tibial physeal injuries retrospectively and explain the relationship between the trauma mechanism, the radiographic injury pattern, the subsequent therapy and the functional outcome, as well as to further deduce and verify prognostic criteria. At the Department of Trauma Surgery, Vienna Medical University, 419 children and adolescent patients with physeal injuries of the distal tibia were treated from 1993 to 2007, of these 376 were included in our study and evaluated retrospectively. Seventy-seven displaced physeal fractures of the distal tibia were reconstructed anatomically by open or closed reduction and produced 95% excellent results. A perfect anatomical reduction, if necessary by open means, should be achieved to prevent a bone bridge with subsequent epiphysiodesis and post-traumatic deformities due to growth inhibition and/or retardation.

Delayed Chylothorax Following Blunt Chest Trauma.

Chylothorax is a very rare disease, and its diagnosis following blunt chest trauma is exceptional. Only a small number of cases have been reported in the literature. We report a case of a male patient involved in a car accident presenting a delayed chylothorax after blunt chest trauma with a bilateral serial rib fracture and fracture of the ninth thoracic vertebrae. The therapy includes thorax drainage, dietary modifications with total parenteral nutrition and, in severe cases, PEEP ventilation. Hematological monitoring is mandatory to detect metabolic abnormalities resulting from chyle loss. Surgical treatment is only required in cases of persistent or increasing intrathoracal chyle flow. Thoracoscopic ligation of the thoracic duct is then required.Severe consequences, such as cardiopulmonary abnormalities and metabolic, nutritional and immunologic disorders, can result from chylothorax. Our patient was treated successfully by chest drainage and parenteral nutrition.

Posterior atlanto-axial arthrodesis for fixation of odontoid nonunions.

STUDY DESIGN: A retrospective case series. OBJECTIVE: To determine the clinical and radiographic long-term results after posterior atlanto-axial arthrodesis of odontoid nonunions. SUMMARY OF BACKGROUND DATA: Nonunion of odontoid fractures is a relatively common and dreaded complication after surgical and nonoperative treatment of these injuries. Although there might be a significant rate, which require surgical stabilization due to atlanto-axial instability, only few publications have covered this issue and presented reliable long-term results. METHODS: We retrospectively analyzed the clinical and radiographic records of 9 (4 women and 5 men) patients with an average age of 68 (42-78) years at the time of injury who had undergone posterior atlanto-axial arthrodesis for surgical treatment of odontoid nonunions between 1988 and 2004. For posterior atlanto-axial arthrodesis, we performed either C1-C2 transarticular screw fixation, or posterior wiring and bone grafting, or a combination of these 2 techniques. RESULTS: Eight patients achieved a satisfactory clinical outcome and returned to their preinjury activity level. The Smiley-Webster scale showed an overall functional outcome score of 2.2, which was 0.9 points superior to the outcome score before surgery. Neurologic deficits after operative treatment of the odontoid nonunion were evaluated in 2 patients. In all the other patients with primary neurologic deficits or delayed neurologic sequelae we saw a full recovery. Solid bony fusion of the cervical arthrodesis was achieved in all of the patients. Failures of reduction or fixation were noted in 2 patients, but no reoperations were necessary. CONCLUSION: In summary, we had a satisfactory outcome after surgical treatment of odontoid nonunions in patients with atlanto-axial instability and severe motion pain at the cervical spine. With a bony union rate of 100% and a noticeable improvement of clinical results and neurologic function, posterior atlanto-axial arthrodesis seems to be an appropriate option for nonunited odontoid fractures that require surgical stabilization.