Nikica Daraboš

Staged management of knee dislocation in polytrauma injured patients

INTRODUCTION Knee dislocation in the polytrauma setting is rare. The optimal method that this injury should be managed remains controversial. We therefore undertook a study to evaluate the incidence and outcomes of knee dislocation in polytrauma patients treated in our institution. PATIENTS AND METHODS From January 2005 to February 2011, two hundred-seventy five polytrauma patients were managed in our institution. Knee dislocation was present in 14 patients (4%): 4 females, mean age 46 years (range 19-52), mean ISS 24 (range 18-34) and 10 males, mean age 45 years (18-48), mean ISS 28 (range 18-48). Knee dislocation was classified according to the Schenck classification. MRI was used routinely for accurate assessment of the knee lesions. Treatment protocol consisted of initially management with the ATLS guidelines, neurovascular assessment, emergency surgical care simultaneously with reanimation procedures and hospitalization at ICU. Upon full evaluation and stabilization of the patients physiological status and acquisition of a knee MRI scan, one- to three-stage operative treatment was performed. Decision for one- or more-stage treatment was based on the evaluation of the systemic and local clinical status, injury classification, timing of surgery, and consequences that remained after associated injuries. Clinical outcome was evaluated by IKDC 2000 Subjective knee evaluation, IKDC Clinical Examination Scales and the Tegner-Lysholm scale. A specific accelerated rehabilitation program was completed according to the surgical treatment. The mean follow up was 2 years (range 19-48 months). RESULTS Patients had a different type of knee dislocations: five KD II, six KD III, two KD V2 and one KD V3. Clinical results were low in patients that underwent the three-staged protocol, and good and high in one- or two-staged operative treatment respectively at the two year follow up. The difference between the results in three groups of treated patients was visible but not statistically significant. CONCLUSION The physiological state of the patient along with the type of knee lesion dictates a timing and type of stage treatment. The best postoperative clinical results are fulfilled with the one-stage treatment and it should be the first choice of knee dislocation therapy. Two-stage treatment should be performed only if the general clinical status of polytrauma injured patient or local knee status does not allow a complete knee reconstructive surgery. Three-stage treatment results with the worst outcome and it should be avoided.

Combined surgical therapy and orthotic management of stress and tuberosity avulsion fracture of the fifth metatarsal bone : a case report

The incidence of fifth metatarsal fracture is somewhat common in sports and can be complicated in nature. Fractures of the fifth metatarsal can occur at a number of locations. Although some of these fractures respond well to conservative treatment, others have been notoriously hard to heal, with high rates of nonunions and other complications. Foot orthotic devices are commonly used as aids in the treatment of foot problems. In our case, we considered the combined effect of the surgical treatment and application of the custom-made foot orthoses. Special attention was taken with adjustments to the orthotic devices along and beneath the affected regions of the foot for adequate pain management and quick recovery to return to normal sports activities. Requirements for computer aided design/computer aided manufacturing orthotic design and manufacturing in this case were specific and considerably different from the usual procedure.

Regional bone loss following femoral neck fracture: A comparison between cemented and cementless hemiarthroplasty

The aim of this prospective, randomised study was to measure and evaluate regional bone mineral changes and clinical results following the use of cemented and cementless hemiarthroplasty (HA) for treatment of femoral neck fracture in elderly patients. The study comprised 60 patients, 30 with cemented HA (group A) and 30 with cementless HA (group B). All patients underwent osteodensitometry of the contralateral hip, lumbar spine and bilateral distal femur. Dual-energy x-ray absorptiometry (DEXA) was scheduled at 1 month, 6 months and 1 year after surgery. Harris Hip Score (HHS) was used for functional assessment. Overall mortality rate was 20.3% within 1 year after surgery. There were no significant differences in morbidity, mortality and hospital stay between the two groups of patients. The implantation of cemented prosthesis took statistically significantly longer than that of cementless prosthesis (79.03±3.59 vs 68.02±5.97min; p=0.00). Functional score in patients treated with cemented HA was significantly higher compared with those with cementless HA. There was a trend of less intensive reduction of bone mineral density (BMD) in regions of interest of the lumbar spine and ipsilateral distal femur in patients with cemented HA (group A), whereas bone loss was less pronounced for the contralateral hip and distal femur in patients treated with cementless HA (group B). Management of displaced femoral neck fractures in elderly patients with cemented and cementless HA provides a comparable outcome with regard to morbidity and mortality; however, functional outcome of patients treated with cementless HA tends to be lower. There is less intensive BMD reduction in lumbar spine and ipsilateral distal femur in patients treated with cemented HA, whereas BMD reduction in patients treated with cementless HA is more likely to be less intensive in contralateral hip and distal femur.

Stress Fractures in Sport (ICL 5)

Stress fractures arise from the inability of bone to tolerate repeated mechanical loading and are characterized by damage to the bone’s micro-architecture. Repeated mechanical loading can cause an uncoupling of osteoblast bone formation and osteoclast bone resorption [1]. This can lead to bone loss and subsequent micro-damage that can result in localized bone weakening, resulting in stress fracture development. The etiology of stress fractures is multifactorial. The rate of occurrence depends on the bone composition, vascular supply, surrounding muscle attachments, systemic factors, and type of athletic activity. From a biomechanical standpoint, stress fractures may be the result of muscle fatigue, which leads to the transmission of excessive forces to the underlying bone. Muscles may also contribute to stress injuries by concentrating forces across a localized area of bone, thus causing mechanical insults that exceed the stress-bearing capacity of the bone (Table 5.1) [2, 3].

Upper Limb Injuries in Athletes

Upper extremity injuries usually occur in the shoulder, elbow, or wrist of the athletic population, especially in overhead disciplines. Traumas, biomechanical imbalance due to improper technique, and overuse cover the majority of the epidemiological factors in this population. Common types of injury include tendon problems, bone fractures, sprains, and dislocations.

V 40 Intraartikuläres ACS (Orthokin) reduziert die Bohrkanalerweiterung und verbessert klinisches Outcome nach rekonstruktiver Kreuzbandersatzplastik im Vergleich zu Placebo. Eine prospektive, randomisierte Doppelblindstudie im Parallelgruppendesign

Fragestellung Pro-inflammatorische Zytokine wie II-1 spielen eine Schlusselrolle in der Pathogenese der Osteoarthritis (OA) sowie, neben mechanischen und operationstechnischen Problemen, auch bei postoperativen Bohrkanalerweiterungen nach Rekonstruktionsoperationen am vorderen Kreuzband. Eine neuen Ansatz in der Arthrosetherapie und nach Eingriffen an Knorpeloberflachen stellt die intraartikulare Applikation von Autologem Conditioniertem Serum (ACS, hergestellt mit dem Orthokin-Therapiesystem) mit erhohten Mengen anti-inflammatorischer Zytokine wie IL-1Ra und weitere Wachstumsfaktoren (z.B. IGF, PDGF, TGFβ, HGF etc.) dar. Ziel der vorliegenden Studie war die vergleichende Beurteilung einer standardisierten intraartikularen Injektionsbehandlung mit 1. ACS (Orthokin) und 2. Placebo (physiologische Kochsalzlosung, NaCl) nach ACL-Rekonstruktion in Bezug auf radiologische Verlaufsparameter und klinisch funktionelle Ergebnisse. Methodik Insgesamt 62 Patienten wurden in dieser prospektiven, randomisierten, placebo-kontrollierten Doppelblindstudie im Parallelgruppendesign zunachst operiert und anschliesend uber ein Jahr nachuntersucht. Die intraartikularen Injektionen wurden intraoperativ und postoperativ am 1., 2., 6., 10. und 42. Tag verabreicht. Verlaufsparameter waren die radiologische Untersuchung per CT (Messung der Bohrkanalweite, Beschreibung der Bohrkanalkonfiguration) und klinisch funktionelle Erhebungsinstrumente (WOMAC, IKDC 2000, standardisierte klinische Untersuchung) direkt pra- und postoperativ, sowie 6 und 12 Monate nach Kreuzbandersatzplastik. Ebenfalls gemessen wurden die Veranderung der Bohrkanalweite im Vergleich zu den initialen Messungen als Funktion der Zeit, Behandlungsgruppe und verwendetem Implantat (HS=Hanstring, BTB=Bone Tendon Bone [in mm]). Ergebnisse Der operative Kreuzbandersatz und die nachfolgenden intraartikularen Injektionsbehandlungen fuhrten im Verlauf des Nachuntersuchungszeitraumes von einem Jahr zu signifikanten Beschwerdeverbesserungen in beiden Gruppen verglichen mit den Ausgangswerten. Im postoperativen Verlauf zeigte jedoch die Gruppe der mit Orthokin nachbehandelten Patienten in allen erhobenen Scores konsistent grosere Beschwerdeverbesserung und eine grosere Zufriedenheit mit dem Therapieerfolg, sowie eine statistisch signifikant geringere Progression der Bohrkanalerweiterung als die Placebogruppe. Schlussfolgerung Die Studie zeigt, dass die postoperative Applikation von Autologem Conditionierten Serum (ACS, Orthokin) mit erhohten Mengen anti-inflammatorischer Zytokine und Wachstumsfaktoren die Regeneration nach Kreuzbandersatzplastik beschleunigen und eine Bohrkanalerweiterung verlangsamen kann. Weitere klinische Studien werden folgen, um diese Mechanismen naher zu untersuchen.