Florian Kutscha-Lissberg

Cartilage T2 Assessment at 3-T MR Imaging: In Vivo Differentiation of Normal Hyaline Cartilage from Reparative Tissue after Two Cartilage Repair Procedures—Initial Experience

PURPOSE To prospectively compare cartilage T2 values after microfracture therapy (MFX) and matrix-associated autologous chondrocyte transplantation (MACT) repair procedures. MATERIALS AND METHODS The study had institutional review board approval by the ethics committee of the Medical University of Vienna; informed consent was obtained. Twenty patients who underwent MFX or MACT (10 in each group) were enrolled. For comparability, patients of each group were matched by mean age (MFX, 40.0 years +/- 15.4 [standard deviation]; MACT, 41.0 years +/- 8.9) and postoperative interval (MFX, 28.6 months +/- 5.2; MACT, 27.4 months +/- 13.1). Magnetic resonance (MR) imaging was performed with a 3-T MR imager, and T2 maps were calculated from a multiecho spin-echo measurement. Global, as well as zonal, quantitative T2 values were calculated within the cartilage repair area and within cartilage sites determined to be morphologically normal articular cartilage. Additionally, with consideration of the zonal organization, global regions of interest were subdivided into deep and superficial areas. Differences between cartilage sites and groups were calculated by using a three-way analysis of variance. RESULTS Quantitative T2 assessment of normal native hyaline cartilage showed similar results for all patients and a significant trend of increasing T2 values from deep to superficial zones (P < .05). In cartilage repair areas after MFX, global mean T2 was significantly reduced (P < .05), whereas after MACT, mean T2 was not reduced (P > or = .05). For zonal variation, repair tissue after MFX showed no significant trend between different depths (P > or = .05), in contrast to repair tissue after MACT, in which a significant increase from deep to superficial zones (P < .05) could be observed. CONCLUSION Quantitative T2 mapping seems to reflect differences in repair tissues formed after two surgical cartilage repair procedures. (c) RSNA, 2008.

T2 mapping in the knee after microfracture at 3.0 T: correlation of global T2 values and clinical outcome – preliminary results

OBJECTIVE The aim of our study was to correlate global T2 values of microfracture repair tissue (RT) with clinical outcome in the knee joint. METHODS We assessed 24 patients treated with microfracture in the knee joint. Magnetic resonance (MR) examinations were performed on a 3T MR unit, T2 relaxation times were obtained with a multi-echo spin-echo technique. T2 maps were obtained using a pixel wise, mono-exponential non-negative least squares fit analysis. Slices covering the cartilage RT were selected and region of interest analysis was done. An individual T2 index was calculated with global mean T2 of the RT and global mean T2 of normal, hyaline cartilage. The Lysholm score and the International Knee Documentation Committee (IKDC) knee evaluation forms were used for the assessment of clinical outcome. Bivariate correlation analysis and a paired, two tailed t test were used for statistics. RESULTS Global T2 values of the RT [mean 49.8ms, standards deviation (SD) 7.5] differed significantly (P<0.001) from global T2 values of normal, hyaline cartilage (mean 58.5ms, SD 7.0). The T2 index ranged from 61.3 to 101.5. We found the T2 index to correlate with outcome of the Lysholm score (r(s)=0.641, P<0.001) and the IKDC subjective knee evaluation form (r(s)=0.549, P=0.005), whereas there was no correlation with the IKDC knee form (r(s)=-0.284, P=0.179). CONCLUSION These findings indicate that T2 mapping is sensitive to assess RT function and provides additional information to morphologic MRI in the monitoring of microfracture.

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.

Clinical outcome after microfracture of the knee: a meta-analysis of before/after-data of controlled studies

PurposeThe aims of this study were to systematically review the medical literature, in order to find controlled studies about microfracture in the treatment of patients with full-thickness cartilage lesions of the knee, to statistically combine these studies in order to determine a best estimate of the average treatment effect, and to gather information to detect cartilage-specific and patient-specific factors that might have an influence on the clinical outcome.MethodsWe searched four electronic databases for controlled clinical trials or controlled prospective observational studies. We pooled before/after-data of study arms using the term microfracture.ResultsWe calculated an overall best estimate of 1.106, with [0.566; 1.646] as 95% confidence interval of the mean standardized treatment effect for a representative patient population.ConclusionsOur meta-analysis revealed a clinically relevant improvement of the postoperative clinical status as compared to the preoperative status. An increase of 22 overall KOOS points may provide a rough estimate for the mean expected treatment effect achieved by microfracturing.

Autologous chondrocyte transplantation for the treatment of articular cartilage defects inf the knee joint. Techniques and results

ZusammenfassungHintergrundZur Behandlung umschriebener Defekte des artikulären Kniegelenkgelenkknorpels wird der Einsatz autologer Knorpelzellen zunehmend als neue biologische Methode empfohlen.MethodenDie Technik der autologen Chondrozytentransplantation (ACT) und deren Modifikationen als matrixassoziierte autologe Chondrozytentransplantation (MACT) werden dargestellt. Es erfolgt ein Überblick über die experimentellen und klinischen Ergebnisse mit der Darstellung der häufigsten Komplikationen und den derzeit gültigen Indikationsrichtlinien.ErgebnisseUnter Verwendung qualitativ hochwertiger Zellen zeigen besonders posttraumatische Knorpeldefekte bei jüngeren Patienten eine hohe Erfolgsquote mit der Ausbildung eines hyalinartigen Regeneratgewebes. Die häufigsten Komplikationen der ACT sind Periosthypertrophie, Delamination des Transplantats, intraartikuläre Adhäsionen und Transplantatversagen. Die derzeit wichtigsten Limitierungen stellen die Osteoarthrose und ein höheres Patientenalter dar.SchlussfolgerungenBei richtiger Indikationsstellung und operativer Technik kann die ACT als effiziente und sichere Therapieoption für die Behandlung großer und tiefer Knorpeldefekte des Kniegelenks angesehen werden.AbstractBackgroundCurrently the use of autologous chondrocytes as a cartilage-repair procedure for the repair of injured articular cartilage of the knee joint, is recommended.MethodsThis review presents the technique of autologous chonrocyte transplantation (ACT) and their modifications as matrix-associated autologous chondrocyte transplantation (MACT). Beside the surgical procedure the experimental and clinical results are discussed. Furthermore the major complications and the indication guidelines are presented.ResultsArticular cartilage in adults has a poor ability to self-repair after a substantial injury. Surgical therapeutic efforts in treating cartilage defects have focused on bringing new cells capable of chondrogenesis into the lesions. With ACT good to excellent clinical results are seen in isolated posttraumatic lesions of the knee joint in the younger patient with the formation of hyalinelike repair tissue. The major complications are periosteal hypertrophy, delamination of the transplant, arthrofibrosis and transplant failure. The current limitations include osteoarthritic defects and higher patient age.ConclusionWith the right indication and operative technique ACT is an effective and save option for the treatment of large full thickness cartilage defect of the knee joint.

Incidence and analysis of radial head and neck fractures

AIM To investigate several complications like persistent radial head dislocation, forearm deformity, elbow stiffness and nerve palsies, associated with radial head fractures. METHODS This study reviewed the clinical records and trauma database of this level I Trauma Center and identified all patients with fractures of the radial head and neck who where admitted between 2000 and 2010. An analysis of clinical records revealed 1047 patients suffering from fractures of the radial head or neck classified according to Mason. For clinical examination, range of motion, local pain and overall outcome were assessed. RESULTS The incidence of one-sided fractures was 99.2% and for simultaneous bilateral fractures 0.8%. Non-operative treatment was performed in 90.4% (n = 947) of the cases, surgery in 9.6% (n = 100). Bony union was achieved in 99.8% (n = 1045) patients. Full satisfaction was achieved in 59% (n = 615) of the patients. A gender related significant difference (P = 0.035) in Mason type distribution-type III fractures were more prominent in male patients vs type IV fractures in female patients-was observed in our study population. CONCLUSION Mason type I fractures can be treated safe conservatively with good results. In type II to IV surgical intervention is usually considered to be indicated.

Plate fixation of odontoid fractures without C1-C2 arthrodesis: practice of a novel surgical technique for stabilization of odontoid fractures, including the opportunity to extend the fixation to C3.

OBJECTIVESurgical treatment of odontoid fractures that do not allow interfragmentary fracture compression involves either posterior atlantoaxial arthrodesis or additional anterior stabilization using a plate construct. The purpose of this study was to determine the clinical and radiographic outcome after anterior plate fixation of odontoid fractures that were not suitable for anterior screw fixation. METHODSWe reviewed the clinical and radiographic records of 9 patients with an average age of 54 years at the time of surgery who had undergone anterior plate fixation of an odontoid fracture. Indications for using a plate construct were odontoid fractures with anterior oblique fracture lines, fractures with comminution or major displacement, and pathological fractures. RESULTSEight patients returned to their preinjury activity level and were satisfied with their treatment. One patient reported chronic pain symptoms and a notable decrease in cervical spine motion. Using the Smiley-Webster Scale to quantify their clinical outcome, we achieved an overall outcome score of 1.6. Bony fusion was achieved in all patients. Reduction or fixation failed in 2 patients. Reoperation for technical failures was not necessary in any of the patients. CONCLUSIONWe had promising results using anterior plate fixation for surgical treatment of odontoid fractures that did not allow interfragmentary fracture compression. Because this method avoids the rigid fixation of the atlantoaxial joint in contrast to techniques of posterior cervical arthrodesis, it seems to be a practical option for the management of fracture types that require additional stabilization of the odontoid.

Osteochondritis dissecans of the knee joint

ZusammenfassungHintergrundDie Osteochondritis dissecans (OD) ist eine Erkrankung des subchondralen Knochens, die mit einer fortschreitenden Ablösung eines osteochondralen Fragments einhergeht.MethodenDieser Beitrag beschreibt die Epidemiologie, Ätiologie, Klinik und Möglichkeiten der radiologischen Diagnostik sowie die Klassifizierung der OD und stellt die konservativen und operativen Therapietechniken dar.ErgebnisseDie Behandlung der OD ist von der Größe, Lokalisation, Stabilität des Herdes und Skelettreife abhängig. Die meisten jüngeren Patienten können konservativ behandelt werden. Die chirurgischen Interventionen beinhalten die ante- oder retrograde Anbohrung mit optionaler Refixation und die osteochondrale Transplantation sowie autologe Chondrozytentransplantation.SchlussfolgerungDie Ergebnisse der chirurgischen Intervention sind viel versprechend, trotzdem sind weiterführende prospektiv vergleichende Studien zur Beurteilung der Effektivität notwendig.AbstractBackgroundOsteochondritis dissecans (OD) is an affection of the subchondral bone involving progressive detachment of an osteochondral fragment.MethodsThis article describes the epidemiology, etiology, clinical appearance, possibilities for radiological diagnostics, and classification of OD and presents conservative and surgical therapeutic techniques.ResultsTreatment of OD depends on the size, location, stability of the fragment, and skeletal maturity. The majority of young patients can be treated conservatively. Surgical interventions include antegrade or retrograde drilling with optional refixation and osteochondral transplantation as well as autologous chondrocyte transplantation.ConclusionThe results of surgical intervention are quite promising; nevertheless, further prospective comparative studies are necessary to evaluate effectivity.

Incidence and Analysis of Simultaneous Bilateral Radial Head and Neck Fractures at a Level I Trauma Center

BACKGROUND Reviewing the current literature, very few reports are given on simultaneous bilateral radial head and neck fractures. There are no reports on this entitys incidence. Thus, the purpose of this study was to analyze the incidence and outcome of simultaneous bilateral radial head fractures. METHODS This study reviewed the clinical records and trauma database of this Level I Trauma Center and identified all adult patients with fractures of the radial head or neck who were admitted between 1992 and 2007. From a database of 2,296 adult trauma victims with radial head or neck fractures, an analysis of clinical records revealed 34 patients suffering from simultaneous bilateral injuries (68 fractures) being classified according to Mason. For clinical examination, range of motion, local pain, and activities of daily living were assessed. To quantify the clinical results, the patients were asked to grade their functional outcome according to the Mayo Elbow Performance Score (MEPS). RESULTS The incidence of simultaneous bilateral fractures was 1.48%. Nonoperative treatment was performed in 86.8% (n = 59) of the cases. Solid bony union was achieved in all patients. Full satisfaction concerning treatment was achieved in 97% of the patients. The Mayo Elbow Performance Score showed an overall functional outcome score of 97.1. DISCUSSION Reviewing the literature, the frequency of this injury was assessed for the first time. An incidence of 1.48% of all radial head fractures was explored. Our material was representative and included 2,296 injuries covering a 15-year period.

Das Polytrauma in Österreich: Kritische Analyse der notwendigen strukturellen Voraussetzungen und deren Finanzierbarkeit in der Zukunft

ZusammenfassungGrundlagen: Die erhebliche soziale und ökonomische Bedeutung des Traumas für das Individuum und für die Gesellschaft allgemein steht außer Frage. Im Zuge von einem entstandenen Kostenbewußtsein und dringend durchzuführender Einsparungsmaßnahmen im Gesundheitssystem wird sich einmal die Frage nicht mehr nach der Machbarkeit stellen, sondern vielmehr danach, was finanziell realisierbar ist. Methodik: In der vorliegenden Arbeit wird der Zeitraum September 1992 bis Dezember 1996 hinsichtlich der Versorgung polytraumatisierter Patienten (n=165), die an der Universitätsklinik für Unfallchirurgie Wien behandelt wurden, beleuchtet. Ergebnisse: Die optimale Behandlung ist vorrangiges Ziel und gelingt nur unter großem personellem und strukturellem Aufwand. Pro Jahr sind Vorhaltekosten von minimal 24,000.000 ATS zu veranschlagen, um einen polytraumatisierten Patienten optimal kardiorespiratorisch stabilisieren und diagnostisch abklären zu können. Nicht mit in die Berechnungen eingeschlossen sind die erheblich größeren Vorhaltekosten einer funktionierenden Operationseinheit, einer Intensivstation oder der geforderten Vertreter anderer Fachdisziplinen. Schlußfolgerungen: Aufgrund der Kostenschere und der strukturellen Voraussetzungen erscheint die Konzentrierung und Behandlung eines polytraumatisierten Patienten im Zentrum sinnvoller.SummaryBackground: Treatment costs of polytraumatized patients are very high. In this day and age, where cost consciousness and cost saving tend to play a major role in patient treatment, it is important to devise an optimal cost efficient set-up for severely injured patients. Methods: From 1992 to 1996, 165 polytraumatized patients were treated at the University Clinic for Traumatology in Vienna. The strategy of treatment and the performed services are described in the following paper. Results: In order to treat polytraumatized patients adequately, a trauma team and a trauma room are necessary, creating yearly costs of 24,000,000 ATS, for these requirements alone. Furthermore, the initial treatment of a single polytraumatized patient costs an average of 70,000 ATS. Conclusions: By creating a central and optimally equipped trauma center, the total end cost of the increasingly expensive treatment of polytraumatized patients can be reduced, in the long run.