Mark Schurz

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.

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

BACKGROUND Since the 1980s 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.

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.

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

PurposeThe 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.MethodsAt 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.Results15 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.ConclusionWe 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.

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.

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

ZusammenfassungEINLEITUNG: Der zweizeitige Wechsel der Hüftgelenkstotalendoprothese stellt eine anerkannte Methode nach tiefem, chronischem Infekt dar. Allerdings gibt es weder einheitliche Empfehlungen zur Technik der zementfreien Reimplantation noch klinische und radiologische Langzeitergebnisse. MATERIAL UND METHODEN: Unser Protokoll beinhaltet eine Kurzzeitantibiose und eine zementlose Verwendung von Implantaten mit poröser Oberfläche, welche für eine primäre Implantation konzipiert wurden. Zur Anwendung kam diese Methode nach chronischen, tiefen Infekten bei liegender Totalendoprothese des Hüftgelenkes. Klinische und radiologische Langzeitergebnisse von 14 Patienten wurden retrospektiv untersucht. ERGEBNISSE: In einem Nachuntersuchungszeitraum von mindestens fünf Jahren nach Reimplantation der Totalendoprothese kam es bei zwei Patienten zu einer persistierenden Infektion. In drei Fällen kam es zu einer Luxation der Hüfte, welche in zwei Fällen mit einer Reoperation und in einem Fall mit einem Hüft Brace erfolgreich behandelt werden konnten. In keinem der Fälle wurde eine Lockerung der Komponenten beobachtet. Lediglich drei Patienten hatten ein gutes oder sehr gutes, 11 Patienten ein ausreichendes oder schlechtes klinisches Ergebnis. Wir konnten einen signifikanten Zusammenhang zwischen der Länge des Intervals zwischen Explantation und Reimplantation und klinischem Ergebnis feststellen. SCHLUSSFOLGERUNG: Wir gehen von einem deutlich gesteigerten Komfort für den Patienten durch ein kurzes, CRP abhängiges Intervall zwischen Explantation und Reimplantation aus. Das klinisch funktionelle Ergebnis ist signifikant besser je kürzer das Zeitintervall zwischen Explantation und Reimplantation der Prothese ist. Die Reinfektionsrate bzw. Rate an persistierenden Infektionen ist mit derer von zementierten Prothesen nach langfristigem Intervall zwischen Explantation und Reimplantation vergleichbar. Als Vorteil der zementfreien Reimplantation sind ein geringerer Verlust an Knochen und ein besseres knöchernes Einheilverhalten hervorzuheben. Als Grund für die hohe Rate an Luxationen nach Reimplantation sind Veränderungen der Weichteile und der knöchernen Gelenkpfanne zu nennen. Die anhaltend schlechten klinischen Ergebnisse sind durch Glutealinsuffizienz durch die wiederholten operativen Eingriffe und durch Immobilisierung erklärbar, die es möglich kurz zu halten gilt.SummaryBACKGROUND: 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 THRs 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.

Imaging Following Fractures of and Around the Knee

Abstract 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.

The use of the LARS system in the treatment of AC joint instability – Long-term results after a mean of 7.4 years

BACKGROUND The acromioclavicular (AC) joint is of great importance for shoulder stability and one of the most frequently injured regions of the shoulder. HYPOTHESIS AC joint reconstruction with the ligament augmentation & reconstruction system (LARS™) leads to a good-to-excellent outcome at long-term follow-up. PATIENTS AND METHODS This study was performed as a retrospective single-centre data analysis of a level-I trauma centre. All patients treated operatively for an acute AC dislocation with the LARS™ between 2003 and 2013 were included. RESULTS The study group consisted of three female (6%) and 44 male patients (94%) with an average age of 37 years and a minimum follow-up of two years. The overall mean clinical outcomes at latest follow-up were: Constant 93, DASH 2.64, ASES 96, SST 97, UCLA 34 and VAS 0.4-representing a good-to-excellent outcome in all patients. Overall, 45 patients (96%) reported to be very satisfied with the achieved result at latest follow-up. In five patients, (11%) complications occurred during the follow-up period, requiring surgical revision in four of the five patients (80%). CONCLUSION AC joint reconstruction with the LARS™ achieves good-to-excellent clinical and functional outcomes at long-term follow-up with a surgical revision rate of 8.5%. LEVEL OF EVIDENCE Retrospective follow-up study, case series, level IV.

Treatment of proximal humerus fractures in children and young adolescents

SummaryBackgroundFractures 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.MethodsClinical 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.ResultsA 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.ConclusionConservative 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.

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.