Roman Pavic

Diagnostic value of US, MR and MR arthrography in shoulder instability.

INTRODUCTION The aim of our study was to compare US, conventional MRI and MR arthrography findings in patients with anterior shoulder instability and with a clinical diagnosis of labral capsular ligamentous complex lesion. At the same time we evaluated the accuracy of MR arthrography in the diagnosis of this lesion. METHODS After approval of the local Ethics Committee, our departments Trauma Registry from July 2008 up to February 2012 was retrospectively reviewed to identify all eligible patients. Eligibility criteria included: 1)history of acute or chronic shoulder instability (more than three dislocations over a period of more than two months); 2) diagnosis of labroligamentous lesion. All patients were investigated with plain radiographs, Ultrasound Scans (US), Magnetic Resonance Imaging (MRI) and MR arthrography. Finally, all patients underwent an arthroscopy that confirmed the diagnosis. RESULTS A total of 200 consecutive patients who met the inclusion criteria were included in this study. The mean age was 39 years (range 15 to 83); 147 were male and 133 involved the right shoulder. Chronic instability was documented in 133 patients, whereas acute instability was documented in 67 patients. We detected a statistically significant difference between US and MR arthrography in SLAP (Superior Labrum Anterior to Posterior) lesions (TypeII, III and IV), in Bankart lesions, in glenohumeral ligament lesions (superior, middle, anterior-inferior and anterior inferior glenohumeral ligament) in Hill-Sachs lesions, in diagnosing internal subacromial impingement and in normal findings. MR arthrography was superior to the US. A statistically significant difference was evident between MRI and MR arthrography findings in SLAP lesions (III and IV Type lesions), in glenohumeral ligament lesions (anterior inferior and posterior inferior glenohumeral ligament), in partial rotator cuff ruptures and in normal findings. MR arthrography diagnosed this lesion better than MRI without contrast. We also found a statistically significant difference between US and MRI findings in SLAP Type II lesions, in partial rotator cuff ruptures, in Hill-Sachs lesions and in diagnosing internal subacromial impingement. CONCLUSION The US scan is a valuable diagnostic technique for rotator cuff complete or incomplete ruptures. For evaluating Hill-Sachs lesions or bony Bankart lesions, MRI is more accurate. In the case of labral capsular ligamentous complex lesions, MR arthrography is superior.

Activity cage as a method to analyze functional recovery after sciatic nerve injury in mice

The aim of this paper is to show the activity cage as a viable method for tracking functional nerve recovery. The activity cage measures spontaneous coordinate activity, meaning movement in either the horizontal or vertical plane, of experimental animals within a specified amount of time. This uses a minimum of researcher time conducting functional testing to determine functional recovery of the nerve. Using microsurgical forceps, a crush injury was inflicted unilaterally, on the left side, upon the 4-month-old C3H mice creating a very high degree of pressure for 6 s upon the exposed sciatic nerve. The locomotion function of the mice was evaluated using the activity cage preoperatively, 1, 7, 14, 21, and 28 days after the surgical procedure. We found that using the activity cage functional recovery occurred by 14 days after nerve crush injury. It was also shown that, coinciding with functional recovery, immunohistochemistry changes for GD1a and nNOS appeared at the level of L4, where the sciatic nerve joins the spinal column. GD1a and nNOS have both been linked to regenerative processes in mammalian nervous systems.

The results of 163 Achilles tendon ruptures treated by a minimally invasive surgical technique and functional aftertreatment [Injury 2007;38(7):839-44].

When the Achilles tendon rupture was treated with an open operation, using Bunnels technique, we had damage to the sural nerve in approximately 9-10%, similar to those results in Lansdaals article. But with minimally invasive surgical procedure we have succeeded in avoiding this injury.

Treatment of trans-scaphoid perilunate dislocations using a volar approach with scaphoid osteosynthesis and temporary Kirschner wire fixation.

Trans-scaphoid perilunate fracture dislocations (TSPLD) are uncommon injuries and constitute about 3% of all carpal injuries. Up to 25% of these high energy trauma cases go undiagnosed. Presented are 43 (3 female, 40 male) consecutive patients treated for dorsal TSPLD, all were closed fractures. Patients were between 17 and 66 years old. Twenty male patients were injured in active duty military service. Surgical treatment was made with a volar approach using titanium cannulated headless compression screws (3.2 mm) placed via a guide wire. Repositioning the dislocated carpus is then conducted using 3 temporary fixation Kirschner wires (1.6 mm). The patient had a volar short arm splint for 4 weeks, then given an orthosis. Triple fixation Kirschner wires were removed 6-8 weeks postoperatively. Mean followup period was 29 months (range 20-38). The average Mayo wrist score for all 43 patients is 87 (good) (range 65-99). All patients returned to their previous employment.

Prof. Vatroslav Florschütz and the Balkan beam frame

Prof. Vatroslav Florschütz constructed in 1911 an extension table for repositioning bone fracture fragments of the upper and lower extremities, after which a plaster splint was applied--this later became to be known as the Balkan beam frame. Florschützs personal insistences of new techniques at the beginning of the 1900 have helped shape war surgery and traumatology.

The "silent" compartment syndrome [Injury 2009; 40:220-2].

Comment on The AO/ASIF proximal femoral nail antirotation (PFNA): a new design for the treatment of unstable proximal femoral fractures. [Injury. 2009]

Side distinct sciatic nerve recovery differences between rats and mice

The Sciatic Functional Index (SFI) is widely used to evaluate functional recovery after sciatic nerve injury, primarily in the rat, and more recently shown useful in the mouse. This quantitative, non-invasive method allows tracking of regeneration capability, visible in the gait of the animal. Using a Martin micro needle holder, carrying a force measured to be 49.2 N, the left sciatic nerve was crushed for 60 s. We accumulated data from walking tracks collected preoperatively and 1, 7, 14, 21, and 28 days after injury. SFI values were first calculated in the traditional manner. Then using the preoperative values as the normal value in the postoperative calculations, SFI was again calculated; this isolated the calculations to either injured or contra lateral leg giving a “split” plot. The traditional SFI calculations resulted in typical shaped graphs for both rats and mice. However, the “split” SFI calculations showed how rats and mice differ in their recovery from sciatic nerve injury. The mouse graph shows the intact leg remaining stable and the injured leg having functional impairment, which then recovers. The rat graph showed functional impairment of the injured leg, however, the intact leg had an increase in SFI values as if to compensate until the injured leg showed recovery.

L-S1.2b Operative treatment of the lesser arc wrist injuries

Introduction: These are high energy injuries in which an axial load is applied to a hyperextended and ulnarly deviated wrist, placing the volar structures under tension and dorsal structures under compression and shear. Lesser arc injuries are capsuloligamentous disruptions following four stages: (1) the scapholunate ligament, (2) the space of Poirer, (3) the UTCC and UL ligament, and (4) lunate dislocation. In radiographs we see a difference between lunate dislocation represented by the spilled tea cup and the perilunate dislocation which is represented as a disruption of the lines of Gilula. Materials and Methods: 37 patients are presented, 2 female and 35 male. All patients were operated using a surgical approach that was dorsal, volar or a combination of the two. Using intraoperative fluoroscopy, dislocation reduction and fixation was made with Kirschner wires. Transfixation pins are placed to protect the ligament repairs and to maintain anatomical carpal alignment. In all patients disrupted scapholunate and lunotriquetral ligaments were repaired. Results: Cast or splint was removed between 4 and 6 weeks when the patient was given an orthosis to promote range of motion. Pins were removed between 6 and 8 weeks. All patients returned to normal activities between 6 and 12 months. Conclusion: All lesser arc injuries, ligament injury and bone dislocation, need to be surgically attended to achieve satisfactory range of motion at the end of treatment.

L-S1.2a Operative treatment of the greater arc wrist injuries

Introduction: In these high energy injuries an axial load is applied to a hyperextended and ulnarly deviated wrist, placing the volar structures under tension and dorsal structures under compression and shear. Greater arc injuries involve fractures through the radial styloid, scaphoid, lunate, capitates, triquetrum and ulna, either solely or in combination with lunate or perilunate dislocation. The most often greater arc injury is the trans-scaphoid perilunate dislocation. In a TSPLD the scaphoid remains attached to the lunate with an intact scapholunate ligament. Materials and Methods: In these high energy injuries an axial load is applied to a hyperextended and ulnarly deviated wrist, placing the volar structures under tension and dorsal structures under compression and shear. Greater arc injuries involve fractures through the radial styloid, scaphoid, lunate, capitates, triquetrum and ulna, either solely or in combination with lunate or perilunate dislocation. The most often greater arc injury is the trans-scaphoid perilunate dislocation. In a TSPLD the scaphoid remains attached to the lunate with an intact scapholunate ligament. Results: Immobilization was removed 4 to 6 weeks when the patient was given an orthosis to promote range of motion. Pins were removed between 6 and 8 weeks. All patients returned to normal activities between 6 and 12 months. The average Mayo wrist score was 87 (65-99) which is good. All patients returned to their previous employment. Conclusion: All patients with greater arc injuries need surgical treatment, osteosynthesis, dislocation repositioning and lunotriquetral repair. Range of motion was excellent for patients operated on within 7 days of injury, good for patients operated between 7-45 days of injury. If treatment is delayed beyond 45 days the result of satisfactory range of motion is reduced.

Court-Brown CM, Clement N. Four score years and ten; an analysis of the epidemiology of fractures in the very elderly [Injury 2009;40(October (10)):1111-4].

Comment on Four score years and ten: an analysis of the epidemiology of fractures in the very elderly. [Injury. 2009]