Progression of function and pain relief as indicators for returning to sports after arthroscopic isolated type II SLAP repair-a prospective study.

BACKGROUND: One of the currently used surgical techniques in isolated type II SLAP lesions is arthroscopic SLAP repair. Postoperatively, patients tend to suffer from a prolonged period of pain and are restricted in their sports activities for at least 6 months. The aim of this study was to prospectively evaluate the clinical outcome as well as the postoperative course of pain after arthroscopic type II SLAP repair. METHODS: Outcome measures were assessed using the Individual Relative Constant Score (CSindiv), the American Shoulder and Elbow Surgeons (ASES) Score, the Visual Analogue Scale (VAS), and the Short Form 36 (SF-36). Data were collected preoperatively, as well as at 3, 6, 12 and >24 months postoperatively. RESULTS: Eleven patients with an average age of 31.8 years (range: 22.8-49.8 years) underwent arthroscopic repair of isolated type II SLAP lesions. Mean follow-up time was 41.9 months (range: 36.1-48.4 months). 6 months after surgery, there was a statistically significant improvement of function according to the CSindiv (p = 0.004), the ASES Score (p = 0.006), and the SF-36 subscale "physical functioning" (p = 0.014) and a statistically significant decrease of pain according to the VAS (p = 0.007) and the SF-36 subscale "bodily pain" (p = 0.022) compared to preoperative levels. CONCLUSIONS: Arthroscopic repair of isolated type II SLAP lesions with suture anchors leads to a satisfactory functional outcome and return to pre-injury sports levels, with delayed, but significant pain relief observed 6 months after surgery. Thus, a return to sports should not be allowed earlier than 6 months after surgery, when patients have reached pain-free function and recovered strength. TRIAL REGISTRATION: Researchregistry1761 (UIN).

MRI versus radiography of acromioclavicular joint dislocation.

OBJECTIVE: Acromioclavicular joint injuries are usually diagnosed by clinical and radiographic assessment with the Rockwood classification, which is crucial for treatment planning. In view of the implementation of MRI for visualization of the acromioclavicular joint, the purpose of this study was to describe the MRI findings of acromioclavicular joint dislocation in comparison with the radiographic findings. SUBJECTS AND METHODS: Forty-four patients with suspected unilateral acromioclavicular joint dislocation after acute trauma were enrolled in this prospective study. All patients underwent digital radiography and 1-T MRI with a surface phased-array coil. MRI included coronal proton density-weighted turbo spin-echo and coronal 3D T1-weighted fast field-echo water-selective sequences. The Rockwood classification was used to assess acromioclavicular joint injuries at radiography and MRI. An adapted Rockwood classification was used for MRI evaluation of the acromioclavicular joint ligaments. The classifications of acromioclavicular joint dislocations diagnosed with radiography and MRI were compared. RESULTS: Among 44 patients with Rockwood type I-IV injuries on radiographs, classification on radiographs and MR images was concordant in 23 (52.2%) patients. At MRI, the injury was reclassified to a less severe type in 16 (36.4%) patients and to a more severe type in five (11.4%) patients. Compared with the findings according to the original Rockwood system, with the adapted system that included MRI findings, additional ligamentous lesions were found in 11 (25%) patients. CONCLUSION: In a considerable number of patients, the MRI findings change the Rockwood type determined with radiography. In addition to clinical assessment and radiography, MRI may yield important findings on ligaments that may influence management.

Fractures of the head and neck of the femur in children: an outcome study.

Fractures of the head and neck of the femur in children are very rare, occurring only after a high-velocity trauma, e.g. a fall from a height. This analysis shows the clinical course of traumatic femoral head and neck fractures in paediatric patients. Predisposing factors for poor outcome or fracture complications, such as non-union or femoral head necrosis, are described. Between 1993 and 2006, 16 paediatric patients with proximal femoral fractures were treated at the Level One Trauma Centre of the Medical University of Vienna. The minimum follow-up was two years. Inclusion criteria were age less then 16 years, intact growth plate and a proximal femoral fracture according to the classification by Delbet and Colonna. Exclusion criteria were pathological fractures or fractures of the subtrochanteric region (6/16). Ten patients met the inclusion criteria. Two patients were lost to follow-up. Therefore eight patients were included in the study. All patients except one were operated upon within 48 h after the injury ("primary") and healed without further complications. A single case was managed by "secondary" surgical treatment, two weeks after the initial trauma resulting in femoral head necrosis that healed without any subjective complaints. This case series confirms the importance of early surgical fixation of proximal femoral fractures in paediatric patients. An operative intervention later then 48 h after the initial trauma may increase the risk of complications such as femoral head necrosis, particularly in Delbet type I fractures (traumatic slipped capital femoral epiphysis).

Angular stable fixation of proximal humeral fractures.

BACKGROUND: Proximal humeral fractures requiring surgical stabilization remain a therapeutic challenge. High rates of treatment-related complications have been reported to be associated, particularly in elderly patients with unstable fracture types and diminished bone quality. In recent years, angular stable implants have been introduced to improve the patients' outcome. The purpose of this study was to assess the clinical and radiographic long-term results after angular stable plate fixation of proximal humeral fractures at this Level I trauma center, with special emphasis on fracture healing, functional outcome and treatment related complications. METHODS: We retrospectively analyzed functional and radiographic results of 42 patients (average age: 57.8 years) after angular stable plate fixation of proximal humeral fractures at an average time of 3.2 (+/-0.8) years after trauma. Functional results were defined by the Constant shoulder score (CS) and the individual Constant score (CSindiv). Radiographic results were assessed by a three-view trauma series (anteroposterior, lateral, and axillary view). For operative treatment, two different angular stable implants were used. Twenty-seven patients were stabilized by a HOFER plate, fifteen patients by a Locking Proximal Humerus Plate. RESULTS: Clinical results revealed an average CS of 74.0 points and an average individual CSindiv of 79.2% points. Fourteen patients had an excellent functional outcome, eight patients a good outcome and fourteen patients had moderate functional results. Six patients (14%) had a poor outcome with less than 55% on CSindiv. Regarding the radiographic outcome, we had an overall union rate of 95% (40 of 42). Failures of reduction and fixation occurred in fourteen patients (33%), and in nine patients (21%) we had signs of a humeral head necrosis. Re-operation due to treatment-related complications was necessary in two patients (5%). Statistical analysis revealed that the fracture type and the age of the patients had a significant influence on the clinical outcome and on the incidence of treatment-related complications. CONCLUSION: With regards to fracture healing and functional outcome of the patients, we had a satisfactory outcome after angular stable plate fixation of proximal humeral fractures. However, we experienced a notably high rate of technical failures and partial humeral head necrosis. Advanced surgical skills and experiences are necessary to achieve correct anatomic reduction and implant fixation, to reduce the risk of these treatment-related complications.

Displaced fractures of the greater tuberosity: a comparison of operative and nonoperative treatment.

BACKGROUND: Displaced two-part fractures of the greater tuberosity requiring surgical intervention are rare and the literature gives only few data of functional results after operative treatment. The purpose of this study was to analyze functional and radiographic long-term results in patients who had undergone surgical treatment of displaced greater tuberosity fractures and to compare those results with the results of patients who had been treated nonoperatively. MATERIAL: From a prospectively gathered database, we retrospectively analyzed functional and radiographic results of 52 patients with operative treatment of displaced greater tuberosity fractures at an average time of 5.5 years (range, 2-11 years) after trauma. Those results were compared with the functional and radiographic outcome of nine patients with equal injuries, who had been treated nonoperatively. Functional results were defined by three supplementary shoulder scores: the Vienna Shoulder Score (VSS), the Constant Score (CS), and the University of California, Los Angeles (UCLA)-Score. Radiographic results were assessed based on accurate radiographs in two planes (anteroposterior and axillary). Patients underwent either open reduction and internal fixation (n = 30) or closed reduction and percutaneous internal fixation (n = 22). RESULTS: Thirty-four patients (65%) achieved good functional results (CS >80 points, VSS <8 points, UCLA >28 points) and eight patients (15%) had excellent results with a maximum of points on two of three shoulder scores. Ten patients (20%) experienced satisfactory results with two-thirds points on two of three shoulder scores. All fractures healed without any signs of nonunion or relevant loss of reduction. In nine patients (17%) we had a minimal loss of reduction (<5 mm) to superior, but there was no significant influence on shoulder function. In comparison of the operative techniques, patients with open reduction and internal fixation had slightly better functional results than did those with closed reduction and percutaneous internal fixation, but this was statistically not significant (p > 0.05). In comparison of the results of the surgical study group and the nonoperative control group, patients with reduction and fixation of greater tuberosity fractures had significantly better results on shoulder function than did those with conservative treatment (p < 0.05). CONCLUSION: Surgical treatment of displaced greater tuberosity fractures revealed good functional and radiographic results. Reduction and fixation of those fractures is recommended because patients with nonoperative treatment showed significantly worse results. Similar results can be achieved for open reduction and internal fixation, or closed reduction and percutaneous fixation.

Primary hemiarthroplasty in four-part fractures of the proximal humerus: randomized trial of two different implant systems.

The objective of this study was to determine the effect of different prosthetic systems on the functional and radiographic outcomes after shoulder arthroplasty for fractures. This study comprised 35 patients (28 women and 7 men) with a mean age of 74 years (range, 56-88 years) who sustained 4-part fractures of the proximal humerus and were randomly allocated to 2 different groups regarding the type of prosthesis. The 2 systems used differ mainly in the type of fixation of the tuberosities. In group 1 (EPOCA), the fixation was achieved with wire cables through a medial and a lateral hole in the stem, whereas in group 2 (HAS), the fixation was performed by use of transosseous braided sutures. After a follow-up of 1 year, the functional and radiographic outcomes were evaluated. The retrieved data demonstrate that rigid fixation and anatomic positioning of the tuberosities (group 1) increase the rate of bony healing superior to all other factors. There was a statistically significant difference regarding the relative individual Constant score (P = .001) and the mean active range of motion (flexion, P < .001; abduction, P = .001; external rotation in adduction, P = .01; and external rotation in 90 degrees abduction, P = .001) when both groups were compared, showing a better outcome in the EPOCA group for all parameters. Radiologic findings, like heterotopic ossification, glenoid erosion, or subluxation, had no significant influence on the outcome in this study. Accurate placement of the tuberosities and healing at the bone-bone interface of the rotator cuff seem to be the most important factors influencing the outcome in prosthetic care of fractures.

Surgical treatment of dens fractures in elderly patients.

BACKGROUND: A dens fracture is the most common cervical fracture in elderly patients. The purposes of this study were to analyze the functional and radiographic results after surgical treatment of dens fractures in patients over sixty-five years of age and to compare the two methods that were used for operative treatment. METHODS: We reviewed the cases of fifty-six patients, with an average age of 71.4 years at the time of surgery, who had undergone surgical treatment of a dens fracture from 1988 to 2002. Thirty-seven fractures were stabilized with anterior screw fixation, and nineteen fractures had posterior cervical arthrodesis. RESULTS: Forty-five patients returned to their preinjury activity level and were satisfied with their treatment. Thirty-five patients had a full range of neck movement, and forty-seven patients were free of pain. Technical failures occurred in eight patients. The thirty-seven patients treated with anterior screw fixation had a good clinical outcome, with fracture-healing in thirty-three patients (89%) and technical failure in five patients (14%). All nineteen patients treated with posterior cervical arthrodesis had fracture union, with technical failure in three patients, but the functional results were worse than those after anterior screw fixation. With the inclusion of the six patients who had been excluded from the clinical and radiographic review, the overall morbidity rate was 16% (ten of sixty-two patients) and the overall mortality rate was 6% (four of sixty-two patients). CONCLUSIONS: A satisfactory outcome can be achieved with surgical treatment of a dens fracture in geriatric patients. It appears that anterior screw fixation may maintain better mobility of the cervical spine, but it appears to be associated with a higher rate of fracture nonunion and a greater potential for reoperation.

Management of bite wounds in children and adults-an analysis of over 5000 cases at a level I trauma centre.

BACKGROUND: Bite wounds are among the commonest types of trauma to which man is the subject. They account for 5 % of the total traumatic wounds evaluated in the emergency department (ED) and approximately 1 % of all the ED visits. Early estimation of infection risk, adequate antibiotic therapy and if indicated surgical treatment are the cornerstones of successful cure of bite wounds. METHODS: A total of 5248 consecutive trauma patients were collected prospectively and analysed retrospectively over a period of 15 years in this study at a level I trauma centre, Department of Trauma Surgery, Medical University of Vienna, Austria. RESULTS: The mean age was 33.8 years (range 0-97), 2620 (49.9 %) were male and 2628 (50.1 %) were female individuals. In our study population, a total of 2530 dog bites (48.2 %), 930 cat bites (17.8 %), 357 other animal bites (6.8 %), 426 human bites (8.1 %) and 1005 human self-bites (19.2 %) have been observed. A total of 995 wounds (19.0 %) have been infected. Surgery was done in 132 wounds (2.5 %). CONCLUSION: We could show a six times higher infection rate of cat bites compared to dog bites. Human bites showed a total infection rate of 8.2 %. Observed infection rate of puncture wounds and wounds greater than 3 cm was 1.5 times higher than for all other wounds in the present study. Total infection rates within 24 h to antibiotic administration was 29.3 %, compared to 65.0 % < 48 h and 81.1 % < 72 h. Time interval also influenced the overall outcome showing a 2.6 increase in acceptable and 1.3 increase in poor outcome after 72 h.

Nerve compression and pain in human volunteers with narrow vs wide tourniquets.

AIM: To assess the clinical effects and the morphological grade of nerve compression. METHODS: In a prospective single-center randomized, open study we assessed the clinical effects and the morphological grade of nerve compression during 20 min of either a silicon ring (group A) or pneumatic tourniquet (group B) placement variantly on the upper non-dominant limb in 14 healthy human volunteers. Before and during compression, the median and radial nerves were visualized in both groups by 3 Tesla MR imaging, using high resolutional (2.5 mm slice thickness) axial T2-weighted sequences. RESULTS: In group A, Visual analog pain scale was 5.4 ± 2.2 compared to results of group B, 2.9 ± 2.5, showing a significant difference (P = 0.028). FPS levels in group A were 2.6 ± 0.9 compared to levels in group B 1.6 ± 1, showing a significant difference (P = 0.039). Results related to measureable effect on median and radial nerve function were equal in both groups. No undue pressure signs on the skin, redness or nerve damage occurred in either group. There was no significant difference in the diameters of the nerves without and under compression in either group on T2 weighted images. CONCLUSION: Based on our results, no differences between narrow and wide tourniquets were identified. Silicon ring tourniquets can be regarded as safe for short time application.

Is suprascapular neuropathy common in high-performance beach volleyball players? A retrospective analysis.

BACKGROUND: Pain in the shoulder is a common problem in overhead sports and at times goes along with atrophy of the supra- and infraspinatus muscles. A neuropathy of the suprascapular nerve is one possible reason. The aim of the study was to examine the suprascapular nerve in Austrian high-performance beach volleyball players. METHODS: In this cross-sectional study, 18 high-performance beach volleyball players were included. An electrophysiological examination was performed consecutively. Nerve conduction studies of the suprascapular nerve were performed bilaterally. Needle electromyography was done for the infraspinatus muscle of the dominant arm. Additionally, pain and muscle atrophy were evaluated. RESULTS: No acute or chronic neurogenic changes in the infraspinatus muscle were seen in any player, although atrophy of the suprascapularis innervated muscles was present in five players. CONCLUSIONS: A lesion of the suprascapular nerve could not be shown in any of the players. Therefore, a biomechanical cause has to be considered for the clinical symptoms in the present study population.

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.

Modification of the Constant-Murley shoulder score-introduction of the individual relative Constant score Individual shoulder assessment.

The Constant-Murley shoulder assessment score has proven to be a valuable diagnostic instrument. Thus, in the literature it has been mentioned that the clinical accuracy of this score varies especially when comparing patients in larger, inhomogeneous patient groups. The "relative Constant score" (CS(rel)) tries to minimize these problems by using reference parameters out of healthy age and gender related control groups. The authors of this study tried to show that it is even more accurate to use the functional performance of the uninjured collateral shoulder of the same individual as reference, introducing the "individual relative Constant score" (CS(indiv)). The CS(indiv) and the CS(rel) were compared for 125 consecutive patients with shoulder disorders, and a group of 125 healthy volunteers as a control group. In a non-parametric comparison of the reciever operating characteristics the CS(indiv) shows the higher ability to discriminate between patients and healthy volunteers (p=0.004). This indicates that the individual relative Constant score gives a more accurate view about the functional result for shoulder disorders. It is expected to be more reliable for larger and incoherent patient populations, because specific interindividual differences, regarding the patient's age, gender and constitution are eliminated as well as other individual physiological parameters.