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.

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.

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

PURPOSE: The 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. METHODS: We 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. RESULTS: We 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. CONCLUSIONS: Our 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.

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 entity's 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.

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.

OBJECTIVE: Surgical 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. METHODS: We 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. RESULTS: Eight 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. CONCLUSION: We 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.

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.

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.

Differentiating normal hyaline cartilage from post-surgical repair tissue using fast gradient echo imaging in delayed gadolinium-enhanced MRI (dGEMRIC) at 3 Tesla.

The purpose was to evaluate the relative glycosaminoglycan (GAG) content of repair tissue in patients after microfracturing (MFX) and matrix-associated autologous chondrocyte transplantation (MACT) of the knee joint with a dGEMRIC technique based on a newly developed short 3D-GRE sequence with two flip angle excitation pulses. Twenty patients treated with MFX or MACT (ten in each group) were enrolled. For comparability, patients from each group were matched by age (MFX: 37.1 +/- 16.3 years; MACT: 37.4 +/- 8.2 years) and postoperative interval (MFX: 33.0 +/- 17.3 months; MACT: 32.0 +/- 17.2 months). The Delta relaxation rate (DeltaR1) for repair tissue and normal hyaline cartilage and the relative DeltaR1 were calculated, and mean values were compared between both groups using an analysis of variance. The mean DeltaR1 for MFX was 1.07 +/- 0.34 versus 0.32 +/- 0.20 at the intact control site, and for MACT, 1.90 +/- 0.49 compared to 0.87 +/- 0.44, which resulted in a relative DeltaR1 of 3.39 for MFX and 2.18 for MACT. The difference between the cartilage repair groups was statistically significant. The new dGEMRIC technique based on dual flip angle excitation pulses showed higher GAG content in patients after MACT compared to MFX at the same postoperative interval and allowed reducing the data acquisition time to 4 min.

Cervical spine injuries in pediatric patients.

BACKGROUND: Cervical spine injuries are uncommon in pediatric trauma patients. Previous studies were often limited by the small numbers of patients available for evaluation. The aim of this study was to determine the incidence and characteristics of pediatric cervical spine injuries at this Level 1 trauma center and to review the authors' experiences with documented cases. METHODS: This study retrospectively analyzed the clinical records of all pediatric trauma patients with skeletal and/or nonskeletal injuries of the spine that were admitted to this Level 1 trauma center between 1980 and 2004. Those with significant injuries of the cervical spine were identified and included in this study. Pediatric patients were defined as patients younger than the age of 17 years. In addition, they were stratified by age into two study groups: group A included patients aged 8 years or fewer and group B contained patients from the ages of 9 to 16 years. RESULTS: We found 56 pediatric patients with injuries of the cervical spine that met criteria for inclusion. Thirty-one female and 25 male patients with an average age of 8.9 years (range, 1-16 years) sustained significant skeletal and/or nonskeletal injuries of the cervical spine and were entered in this study. Thirty patients (54%) were aged 8 years or fewer and entered into study group A, whereas 26 patients (46%) from the ages of 9 to 16 met criteria for inclusion in study group B. An analysis of data revealed that younger patients (group A) showed significantly more injuries of the upper cervical spine, whereas older children (group B) sustained significantly more injuries of the lower level. Spinal cord injuries without radiographic findings were only found in study group A. In addition, younger children were more likely injured by motor vehicle crashes, whereas older children more commonly sustained C-spine injuries during sports activities. Two-thirds of our patients showed neurologic deficits, and the overall mortality was 28%. CONCLUSION: The results of our study were similar to several previous reports, underscoring a low incidence (1.2%) and age-related characteristics. Younger children had a predilection for injuries of the upper cervical spine, whereas children in the older age group sustained significantly more injuries of the lower cervical spine. Spinal cord injuries without radiographic abnormalities were only seen in the younger age group. Despite the low incidence of cervical spine injuries in pediatric patients, increased efforts at prevention are demanded because mortality rate (27%) and incidence of neurologic deficits (66%) were dreadfully high in our series.

Early postoperative adherence of matrix-induced autologous chondrocyte implantation for the treatment of full-thickness cartilage defects of the femoral condyle.

Matrix-induced autologous chondrocyte implantation (MACI) is a tissue-engineering technique for the treatment of full-thickness articular cartilage defects and requires the use of a three-dimensional collagen type I-III membrane seeded with cultured autologous chondrocytes. The cell-scaffold construct is implanted in the debrided cartilage defect and fixed only with fibrin glue, with no periosteal cover or further surgical fixation. In a clinical pilot study, the MACI technique was used for the treatment of full-thickness, weight-bearing chondral defects of the femoral condyle in 16 patients. All patients were followed prospectively and the early postoperative attachment rate, 34.7 days (range: 22-47) after the scaffold implantation, was determined. With the use of high-resolution magnetic resonance imaging (MRI), the transplant was graded as completely attached, partially attached, or detached. In 14 of 16 patients (87.5%), a completely-attached graft was found, and the cartilage defect site was totally covered by the implanted scaffold and repair tissue. In one patient (6.25%), a partial attachment occurred with partial filling of the chondral defect. A complete detachment of the graft was found in one patient (6.25%), which resulted in an empty defect site with exposure of the subchondral bone. Interobserver variability for the MRI grading of the transplants showed substantial agreement (kappa=0.775) and perfect agreement (kappa(w)=0.99). In conclusion, the implantation and fixation of a cell-scaffold construct in a deep cartilage defect of the femoral condyle with fibrin glue and with no further surgical fixation leads to a high attachment rate 34.7 days after the implantation, as determined with high resolution MRI.

The influence of displacement on shoulder function in patients with minimally displaced fractures of the greater tuberosity.

INTRODUCTION: There is little outcome data on functional results after non-operative treatment of greater tuberosity fractures, and no clear evidence in minimally displaced (1-5 mm) fractures of the greater tuberosity showing that the results of non-operative treatments are good enough. This study assesses the relationship between degree of displacement in non-operatively treated patients and shoulder function. MATERIALS AND METHODS: We evaluated the radiographs and function in 135 patients after non-operative treatment of minimally displaced (1-5 mm) fractures of the greater tuberosity at a mean time of 3.7 years (2-20 years) after injury. Shoulder function was assessed using the Vienna Shoulder Score (VSS), the Constant Score (CS) and the UCLA-Score. RESULTS: 97% of the evaluated patients had good or excellent results. Patients with a displacement of more than 3 mm had slightly worse results compared to those with less displacement, but this was not statistically significant. Female patients had significantly better results than male patients, and patients in the eighth and ninth decade had significantly worse results compared to younger patients. CONCLUSION: We recommend non-operative treatment in all patients with minimally displaced fractures of the greater tuberosity, as most obtain very good results. The best results followed treatment with Gilchrist bandages or Mitella slings for 3 weeks, followed by intensive rehabilitation.