Open reduction and internal fixation of unstable distal radius fractures: results using the trimed fixation system

OBJECTIVE

The purpose of this study was to evaluate the early results of patients with displaced and unstable distal radius fractures treated with fragment-specific fixation. DESIGN Prospective and consecutive.

SETTING

Private orthopaedic practice.

PATIENTS/PARTICIPANTS

Twenty-five patients with 27 fractures with an average follow-up of 29 months (range 24-36 months) treated with fragment-specific fixation for unstable radius fractures.

MAIN OUTCOME MEASUREMENTS

Clinical and radiographic examination. Disabilities of the arm, hand, and shoulder and patient-rated wrist evaluation outcome measures. RESULTS Patients had an average 61 degrees of dorsiflexion and 54 degrees of palmarflexion at the wrist. Twenty-five fractures healed in acceptable alignment, with one loss of reduction and one patient death. Mean +/- standard deviation DASH score was 17 +/- 18, and PRWE score was 19 +/- 22.

CONCLUSION

Unstable distal radius fractures can be reliably and anatomically reduced and stabilized using fragment-specific fixation. Fixation of markedly comminuted fractures is secure enough to allow immediate motion and does not require casting or external fixation. Preliminary clinical and radiographic results are excellent, and patient satisfaction is high. Anatomic reduction with early motion can be achieved in a routine fashion on unstable distal radius fractures using the described technique.

Fluoroscopic validation of electrogoniometrically measured femorotibial translation in healthy and ACL deficient subjects

Equipment which measure femorotibial motions indirectly by using a patellar pad are reported to have errors caused by deformation of soft tissues and slippage of the device. For the purpose of validation, the tibial translation in relation to the femur per degree of knee extension was estimated from the slope coefficients of the flexion-displacement curve, obtained by both fluoroscopic and electrogoniometric tests, in the knee of the dominant limb in healthy subjects and in both knees of patients with unilateral anterior cruciate ligament (ACL) deficiency. In addition, the anterior and posterior static knee laxity limits and the tibial resting position were evaluated. Within all knee groups, the tibia moved posteriorly in relation to the femur during extension. The measured movement was similar both with the electrogoniometer and with fluoroscopy thereby indicating that sagittal plane knee translation measurements with the CA-4000 electrogoniometer are reliable and in good agreement with the X-ray measurements, even though the measurements were made separately. The ACL injured knees showed approximately 20% smaller posterior movement of tibia in relation to femur per degree change of knee extension than the non-injured or control knees (p < 0.05) and a more anterior resting position of the tibia relative to femur as compared to the contralateral healthy knee during knee laxity testing (p = 0.002).

[Sagittal plane rotational and translational motion of lumbar segments with decreascd intervertebral disc height]

PURPOSE

Employing a precise measurement protocol, it was investigated whether decreased height of lumbar discs is related to an increase of sagittal plane segmental motion or to a displacement of the cranial vertebra into a retrolisthesis position.

METHODS

The height of the intervertebral discs, the dorsoventral displacement of the cranial vertebra and the range of sagittal plane rotational and transitional motion were measured for all segments of the lumbar spine from flexion-extension views of 30 patients. In each patient, at least one lumbar disc exhibited a significant height decrease. The measurement was performed using a new protocol compensating for distortion in central projection, off-centre position, axial rotation and lateral tilt of the spine. Measured data on retrolisthesis position, rotational and translational motion were compared with previously compiled age- and gender-appropriate normal data.

RESULTS

In the cohort investigated there was no statistically significant relation between a decrease of disc height and segmental hypermobility with respect to sagittal plane rotation or translation. There was no relation between a decrease of disc height and a displacement of the adjacent cranial vertebra into a retrolisthesis position.

CONCLUSIONS

The results challenge the often postulated relation between low disc height and segmental hypermobility ("instability") and retrolisthesis position of the cranially adjacent vertebra.

Universal or selective screening of the neonatal hip using ultrasound? A prospective, randomised trial of 15,529 newborn infants

The aim of this study was to evaluate whether universal (all neonates) or selective (neonates belonging to the risk groups) ultrasound screening of the hips should be recommended at birth. We carried out a prospective, randomised trial between 1988 and 1992, including all newborn infants at our hospital. A total of 15 529 infants was randomised to either clinical screening and ultrasound examination of all hips or clinical screening of all hips and ultrasound examination only of those at risk. The effect of the screening was assessed by the rate of late detection of congenital or developmental hip dysplasia in the two groups. During follow-up of between six and 11 years, only one late-detected hip dysplasia was seen in the universal group, compared with five in the subjective group, representing a rate of 0.13 and 0.65 per 1,000, respectively. The difference in late detection between the two groups was not statistically significant (p = 0.22). When clinical screening is of high quality, as in our study, the effect of an additional ultrasound examination, measured as late-presenting hip dysplasia, is marginal. Under such circumstances, we consider that universal ultrasound screening is not necessary, but recommend selective ultrasound screening for neonates with abnormal or suspicious clinical findings and those with risk factors for hip dysplasia.

Capitellum fractures: a biomechanical evaluation of three fixation methods

OBJECTIVE

To determine the relative stability of three fixation methods for displaced capitellum fractures.

DESIGN

Twelve matched pairs of embalmed humeri were divided into two equal groups and simulated capitellum fractures created. The first group compared cancellous lag screws placed in an anteroposterior direction to screws placed in the posteroanterior direction. The second group compared the Acutrac compression screw, inserted anteroposteriorly, to the more stable construct from the first test group.

METHODS

All specimens were cyclically tested with simulated physiologic loading. Both displacement of the capitellum over a range of cycles and the number of cycles to failure were recorded.

RESULTS

Fixation with posteroanteriorly directed cancellous lag screws was significantly more stable than anteroposteriorly directed screws at 2000 cycles (p = 0.007); loads to failure were not statistically different. Fixation by the Acutrac screws was significantly more stable than posteroanterior cancellous screws at 2000 cycles (p = 0.03). The Acutrac fixation had a higher failure load; however, this was not statistically significant.

CONCLUSION

The headless screws tested in this biomechanical study provided more stable fixation of capitellum fractures in the cadaveric specimens than four-millimeter partially threaded cancellous lag screws and may do so in the clinical setting. When the cancellous lag screws were tested, insertion in the posteroanterior direction provided more stable fixation than the anteroposterior direction and has clinical benefit of not violating the articular surface. Ultimately, the decision of which method to use lies with the attending surgeon and the technique with which he or she feels most comfortable.

Ultrasonography of the infant hip: the significance of provokable instability with normal morphology

The hips of infants 2- to 4-weeks-old were investigated with ultrasonography. In all cases, ultrasonography verified morphologically normal hips; however, either a bilateral or unilateral instability of the hip could be provoked as demonstrated by ultrasonography. The first series of 27 infants (41 hips) were treated with abduction splint (Frejkas pillow) for 16 weeks. The second series of 28 infants (44 hips) were left untreated. All infants had repeat ultrasonography at 2 and 16 weeks and radiographs at 16 weeks. At 2 weeks, provokable instability was still seen in 10 hips in the treated group and 12 hips in the untreated group. At 16 weeks, all hips were ultrasonographically stable. The morphology was evaluated by alpha and beta angles by ultrasonography and also acetabular index by radiographs at 16 weeks. In all cases, normal hip development was noted with no differences between the two groups. Therefore, sonographically, instability in morphologically normal or immature hips has no clinical significance.

Long-term results after repair and augmentation ligamentoplasty of rotatory subluxation of the scaphoid

Twenty-two patients had scapholunate ligament repairs combined with a new augmentation ligamentoplasty for chronic scapholunate dissociation. All were evaluated by physical and radiologic examination after a mean postoperative follow-up period of 63 months (range, 12-134 mo). According to Green and O'Brien and Johnson and Carrera scores 5/8 had excellent, 13/12 good, and 4/2 fair results. Thirteen were free of pain; 6 had mild pain and 3 had moderate pain. Nineteen returned to their original occupation. There was an average loss of 10 degrees of flexion, 9 degrees of extension, and 11% of grip force compared with the opposite wrist. Radiologic examination showed an average decrease of 12 degrees of the scapholunate and 10 degrees of the radiolunate angles compared with the levels before surgery. No signs of degenerative osteoarthritis were found in 16 (73%) cases. Five wrists showed a distinct pattern of midcarpal degeneration correlating with notable dorsal intercalated segment instability after surgery, and 2 cases had signs of radioscaphoid degeneration.

Assessment of a synthetic anterior cervical ligament in a spinal fusion model in sheep

BACKGROUND CONTEXT

The anterior cervical ligament is routinely excised during cervical interbody fusion. Loss of this ligament may predispose to instability at the fusion site. Anterior plating restores stability but leads to a risk of stress shielding. An alternative approach would be to use a less rigid fixation system that would provide anterior support while allowing micromotion that could enhance bone healing within the fusion site.

PURPOSE

To determine whether augmentation of an interbody fusion with a synthetic ligament enhances fusion.

STUDY DESIGN

Prospective randomized study in a large animal model of cervical fusion.

OUTCOME MEASURES

The primary outcome was evidence of interbody fusion, as determined by radiography, computed tomography (CT), histology and biomechanical testing.

METHODS

Twelve skeletally mature sheep underwent single level (C2-3) anterior discectomy and interbody fusion using fresh frozen allograft. In six animals, the fusion was augmented with a braided polyethylene device rigidly fixed to C2 and C3 with screws. Sheep were euthanized 12 weeks postoperatively. Specimens were radiographed and then examined by CT. Six fusion sites (three control, three augmented) were used for nondestructive biomechanical testing to assess the stability of the fusion site. The remaining specimens were processed for undecalcified histology.

RESULTS

As determined by radiography, the augmented group had 83% solid union as compared with 67% in the control group (p<.05). There was no difference regarding bone graft dislodgment between the two groups. The extension stiffness of the augmented group was significantly higher (p<.05) than that of controls, but there was no significant difference between the two groups in flexion stiffness. There was no significant difference in bone formation in the two groups as determined by CT and histology, although there was a trend for increased endochondral ossification in the augmented repairs. There was no evidence of significant adverse tissue reactions to the ligament.

CONCLUSIONS

Use of a synthetic ligament was associated with a moderate increase in fusion rate and a statistically significant increase in fusion site stiffness in extension. The use of an augmentation device, such as this synthetic ligament, may be beneficial in cervical fusion, especially when multilevel surgery is being contemplated.

Segmental lumbar spine instability at flexion-extension radiography can be predicted by conventional radiography

AIM

To identify plain radiographic findings that predict segmental lumbar spine instability as shown by functional flexion-extension radiography.

MATERIALS AND METHODS

Plain radiographs and flexion-extension radiographs of 215 patients with clinically suspected lumbar spine instability were analysed. Instability was classified into anterior or posterior sliding instability. The registered plain radiographic findings were traction spur, spondylarthrosis, arthrosis of facet joints, disc degeneration, retrolisthesis, degenerative spondylolisthesis, spondylolytic spondylolisthesis and vacuum phenomena. Factors reaching statistical significance in univariate analyses (P < 0.05) were included in stepwise multiple logistic regression analysis.

RESULTS

Degenerative spondylolisthesis (P = 0.004 at L3-4 level and P = 0.017 at L4-5 level in univariate analysis and odds ratio 16.92 at L4-5 level in multiple logistic regression analyses) and spondylolytic spondylolisthesis (P = 0.003 at L5-S1 level in univariate analyses) were the strongest independent determinants of anterior sliding instability. Retrolisthesis (odds ratio 10.97), traction spur (odds ratio 4.45) and spondylarthrosis (odds ratio 3.20) at L3-4 level were statistically significant determinants of posterior sliding instability in multivariate analysis.

CONCLUSION

Sliding instability is strongly associated with various plain radiographic findings. In mechanical back pain, functional flexion-extension radiographs should be limited to situations when symptoms are not explained by findings of plain radiographs and/or when they are likely to alter therapy.

Fibro-cartilaginous lesions of the glenoid labrum in shoulder instability: a proposed classification using sagittal-oblique arthro-MRI

PURPOSE

To propose a graded classification of lesions of the fibrocartilaginous glenoid labrum in traumatic dislocations of the shoulder, based on arthro-MRI in sagittal-oblique views.

MATERIALS AND METHODS

Seventy-one patients with histories of chronic post-traumatic shoulder instability were studied from May 2000 to May 2001. MR images were obtained using superconducting magnets operating at 1 and 1.5 Tesla, with a dedicated shoulder coil. The study was carried out in combination with arthrography, with axial sections oriented perpendicularly to the longitudinal axis of the glena, oblique coronal sections parallel to the course of the supraspinous muscle tendon and oblique sagittal sections with axis parallel to the longitudinal axis of the glena.

RESULTS

In one case an anatomical variant was found (Buford complex). In 18 patients a simple fissuration of the fibrocartilaginous glenoid labrum was found, whereas 28 patients displayed more extensive lesions affecting the middle-inferior portions of the labrum. In 15 patients the lesion extended to the middle-superior third of the glena, involving the middle glenohumeral ligament. In 9 cases, in addition to a complete lesion of the labrum, with typical "bucket-handle" appearance, a lesion of the superior and middle glenohumeral ligaments was also observed.

DISCUSSION AND CONCLUSIONS

In traumatic shoulder dislocations it is essential to provide the surgeon with precise information regarding the location, extension and degree of damage to the capsule, ligaments and especially the labrum of the glenohumeral joint. On the basis of the results obtained in the sagittal-oblique sections we propose an MR-arthrography classification dividing lesions of the fibrocartilaginous labrum into 4 grades.

Coincidental rupture of the scapholunate and lunotriquetral ligaments with volar intercalated segment instability complicating a closed distal forearm fracture in an adolescent

A 15-year-old boy is described with concomitant scapholunate and lunotriquetral ligament injuries of the wrist, complicating a closed forearm fracture. The rotatory dislocation could be reduced and stabilized with a soft-tissue procedure.

Classification of glenohumeral joint instability

Shoulder instabilities have been classified according to the etiology, the direction of instability, or on combinations thereof. The current authors describe a classification system, which distinguishes between static instabilities, dynamic instabilities, and voluntary dislocation. Static instabilities are defined by the absence of classic symptoms of instability and are associated with rotator cuff or degenerative joint disease. The diagnosis is radiologic, not clinical. Dynamic instabilities are initiated by a trauma and may be associated with capsulolabral lesions, defined glenoid rim lesions, or with hyperlaxity. They may be unidirectional or multidirectional. Voluntary dislocation is classified separately because dislocations do not occur inadvertently but under voluntary control of the patient.

Hip surveillance in children with cerebral palsy. Impact on the surgical management of spastic hip disease

We studied prospectively the impact of a hip surveillance clinic on the management of spastic hip disease in children with cerebral palsy in a tertiary referral centre. Using a combination of primary clinical and secondary radiological screening we were able to detect spastic hip disease at an early stage in most children and to offer early surgical intervention. The principal effect on surgical practice was that more preventive surgery was carried out at a younger age and at a more appropriate stage of the disease. The need for reconstructive surgery has decreased and that for salvage surgery has been eliminated. Displacement of the hip in children with cerebral palsy meets specific criteria for a screening programme. We recommend that hip surveillance should become part of the routine management of children with cerebral palsy. The hips should be examined radiologically at 18 months of age in all children with bilateral cerebral palsy and at six- to 12-monthly intervals thereafter. A co-ordinated approach by orthopaedic surgeons and physiotherapists may be the key to successful implementation of this screening programme.

Characterization of a developing lumbar arthrodesis in a sheep model with quantitative instability

BACKGROUND CONTEXT

Mechanical forces have been considered responsible for stress shielding an arthrodesis, but the biology of a developing lumbar fusion has not been well characterized.

PURPOSE

A large animal model was used to test the hypothesis that mechanical forces modify the biological processes involved in a developing bony fusion.

STUDY DESIGN

Lumbar fusion was performed in an ovine model using custom instrumentation that permitted a controlled degree of anterior-posterior translation after surgery. Fusion sites were evaluated by radiography, microradiography, histology and histomorphometry at time points that corresponded with predicted early and later stages of bone healing.

METHODS

Fourteen skeletally mature ewes underwent lumbar spinal fusion under general anesthesia. In the control (stable) group, the spine was rigidly fixed with a cage anteriorly and pedicle screws posteriorly. In the experimental (unstable) group, the spine was destabilized by an annulectomy (with no anterior implant) and custom pedicle screws that allowed 2 mm of anterior-posterior translation. Animals were euthanized 6 and 12 weeks after surgery.

RESULTS

Radiographs confirmed that the fusion mass had not fully consolidated at either time point. Microradiographs revealed a trend toward increased bone formation at 6 weeks in the stable case as compared with the unstable, but by 12 weeks, this trend had reversed (p=.03). Intramembranous bone formation was the primary mechanism of healing near the transverse process in animals with both stable and unstable fixation. In the area between the two transverse processes, new bone formation occurred primarily through endochondral ossification. At 12 weeks, the stable case had significantly more cartilage formed (p=.023) but less newly formed bone (p=.07) as compared with the quantitatively unstable.

CONCLUSIONS

This clinically realistic animal model allowed characterization of the biology of the developing arthrodesis before fusion. Under stable or unstable conditions, endochondral ossification was the predominant mechanism of new bone formation within the intertransverse process region. This finding, which contrasts with previous reports from small animal models of spine fusion, may reflect a difference in biology that results from the increased size of the intertransverse space in sheep as compared with small animals. Interestingly, mechanical instability increased the formation of new bone within this region, but not at the transverse process. Endochondral ossification therefore appears to respond to mechanical factors in the fusion site. The ovine model shows promise as an alternative to the rabbit model and may provide a more stringent test for potential new surgical and nonsurgical strategies for spine fusion.

Percutaneous compression plating for intertrochanteric hip fractures: treatment rationale

Percutaneous compression plating was developed after thorough consideration of each stage in the surgical procedure for intertrochanteric fractures and the ways in which they might be improved. This system represents a minimally invasive method of fracture stabilization and fixation, providing enhanced rotational stability and bone sparing, which reduces both peri- and postoperative complications including cut outs and fracture collapse.

[Differential therapy of radial head fracture: a critical analysis based on outcome of 53 patients]

We investigated 53 patients with 57 radial head fractures (4 patients with bilateral fractures) treated between 1993 and 1998. We focused on patients with radial head fractures asking about (1) the relation between fracture type and therapy and (2) the correlation between chosen treatment and result. We saw the following fractures: Mason I: 3 cases, Mason II: 26 cases, Mason III: 11 cases, and Mason IV: 15 cases. Good results were achieved by 30 patients with 31 fractures, fair results by 8 patients with 9 fractures, and poor results by 13 patients with 14 fractures. Patients with a Mason I fracture achieved good results with functional therapy. Of the 26 Mason II fractures, 14 were treated with screws, 14% of whom had poor results subjectively. Six patients were treated with a K wire, titanium nail, or prevot nail, none of whom had poor results. Of 11 patients with a Mason III fracture, 10 were treated by resection of the radial head, and in 1 patient we implanted a prosthesis due to an intraoperatively detected elbow instability after resection and achieved good postoperative results. Only one patient (9%) had poor long-term results subjectively. Of 15 patients with a Mason IV fracture, 11 were treated by resection of the radial head: 5 patients (33%) had poor long-term results, only 3 of whom (20%) subjectively considered the results poor.

[Painful or unstable shoulder after coracoid transfer: result of surgical treatment]

INTRODUCTION

The purpose of this study was to investigate the results of revision surgery for complications related to previous coracoïd transfer for recurrent anterior instability of the shoulder.

MATERIALS AND METHODS

Seventeen patients with previous surgery for anterior shoulder instability underwent a new surgical procedure, because of recurrent instability in 10, and painful shoulder with limitation of motion in 7. A soft tissue procedure (Bankart and/or capsuloplasty) was performed in the 10 unstable shoulders, and a joint debridement with removal of the coracoid transfer in the 7 painful shoulders. The subscapularis was found to be normal in only 2 cases, fibrotic in 11, thin in 3, and teared in 1. The interval between the initial procedure and the revision surgery was eleven years on average.

RESULTS

At an average of 21 months follow-up, the patients were evaluated according to the Duplay scoring system. A radiographic analysis was also performed for all the patients, and a CT-examination for fourteen. The results were good or excellent for 11 patients (70% in the soft tissue procedure group, and 57% in the debridement group with removal of the coracoid transfer), fair for 4, and poor for 2. Clinical evaluation of the subscapularis showed a lag of muscle function in 10 patients. Strength in internal rotation was 3.3 kg lesser in the operated shoulder compared to the opposite side. CT-examination showed that 4 patients presented a significantly fatty degeneration of the subscapularis. Finally on radiographic examination, osteoarthritis was present in 9 patients.The most important preoperative factor that affected the final results was the number of previous surgical procedures.

DISCUSSION

Recurrent instability, problems related to the bone graft or ostheosynthesis material, osteoarthritis, and neurological damage can complicate a coracoid transfer procedure. Our study shows that this procedure can also induce irreversible damage to the subscapularis muscle.

CONCLUSION

Revision surgery for complications related to coracoid transfer for anterior shoulder instability is a challenging procedure. Only 2/3 of patients achieved excellent or satisfactory results. Patients with recurrent instability had better results than those with painful impingement and or osteoarthritis. The high rate of late osteoarthritis and irreversible damage of the subscapularis muscle remain sources of concern.

Eight-year prospective targeted ultrasound screening program for instability and at-risk hip joints in developmental dysplasia of the hip

The use of targeted ultrasound screening for at-risk hips to reduce the rate of surgery in developmental dysplasia of the hip is unproven. A prospective trial was undertaken in an attempt to clarify this matter. This study was undertaken between May 1992 and April 2000. There were 28,676 live births. Unstable and at-risk hips were routinely targeted for ultrasound examination. One thousand eight hundred six infants underwent ultrasound examination (6.3% of the birth population). Twenty-five children (18 with dislocations, 7 with dysplasia) required surgical intervention in the form of open reduction of the hip or pelvic or femoral osteotomy (0.87 per 1,000 births for dysplasia, 0.63 per 1,000 births for dislocation). Targeted ultrasound screening does not reduce the overall rate of surgery compared with the best conventional clinical screening programs. The development of a national targeted ultrasound screening program for at-risk hips cannot be justified on a cost or result basis.

Arthroscopic revision Bankart repair: a prospective outcome study

PURPOSE

The clinical outcome of the revision surgery for the failed Bankart repair is not well known. The purpose of this study was to prospectively analyze a series of patients with recurrent instability after primary Bankart repair that were revised arthroscopically using a suture-anchor technique.

TYPE OF STUDY

Prospective, nonrandomized outcome study.

METHODS

Twenty-three patients with failed Bankart repair were treated with arthroscopic surgery and were followed up for a mean of 36 months (range, 24-52 months; SD, 9 months). There were 21 men and 2 women with the mean age of 24 years (range, 17-34 years; SD, 4.4 years). Eight patients had previously received an open Bankart repair (5 transosseous-suture technique, 3 suture-anchor technique), and 15 had received an arthroscopic repair (10 transglenoid multiple-suture technique, 5 suture-anchor technique). The revision surgery included repair of the anterior labrum using suture anchors and nonabsorbable sutures, capsular plication, and proximal shift of the inferior capsule with or without closure of the rotator interval. The characteristics of the patients, possible modes of failure, surgical findings, shoulder scores (University of California at Los Angeles [UCLA] scale, Simple Shoulder Test, and Rowe score), and clinical outcome were evaluated.

RESULTS

Recurrent instability developed at a mean of 21 months (range, 11-39 months; SD, 8 months) after the initial stabilization. A possible cause of failure in 5 patients was a nonanatomic repair, with the labral tissue fixed proximal or medial to the glenoid margin. At the follow-up, 15 patients had excellent results, 4 good, 3 fair, and 1 poor, according to the UCLA scale. The mean Rowe score improved from 87.3 (range, 30-100; SD, 12.6) to 91.2 (range, 40-100; SD, 14.2) (P =.023). The Simple Shoulder Test responses improved from 8 yes responses preoperatively to 11 postoperatively. Eighteen patients achieved an activity return of more than 90% of preinjury level. Five patients had recurrence after revision surgery (1 frank dislocation, 2 subluxation, 2 positive anterior apprehension sign). Engagement in contact sports was correlated with the recurrence (r =.683, P =.003). With the number available, no significant difference could be detected in the outcome between the types of the primary surgery. Arthroscopic revision Bankart repair did not result in any additional loss of external rotation compared with the contralateral side (P =.723). The most predictable factor for the functional return was preoperative range of external rotation (r =.793, P =.001).

CONCLUSIONS

Arthroscopic revision Bankart surgery using suture anchors can provide a satisfactory outcome, including a low recurrence rate and reliable functional return, in carefully selected patients.

[Scapholunate dissociation: treatment by dorsal capsulodesis]

Between December 1994 and December 1996, 26 patients with a scapholunate ligament injury (three with SLD 1. degrees, 16 with SLD 2. degrees and 7 with SLD 3. degrees ) underwent an operation for dorsal capsulodesis in the Klinik für Handchirurgie, Bad Neustadt/Saale. Mean follow-up was 24 months (16 to 37 months). Follow-up criteria were range of motion, grip strength, pain relief, and X-ray findings. Clinical outcome was evaluated using a personal questionnaire, the DASH- and a modified Cooney-Score. Although significant reduction of joint mobility compared to the opposite site was found in all cases (E/F 32 %, U/R 19 %), the reduction of pain was 30 %. Grip-strength was not altered. Thus, 86 % of the patients were satisfied with the result obtained. On X-ray, the scapholunate angle was raised in the SLD 3. degrees -group by 12 degrees postoperatively; in the group with dynamic instability, X-ray findings were normal. Overall, 19 % (5/26) needed further operations due to persistent pain.

[Interposition-arthroplasty of the elbow in a child as delayed treatment of an unreduced multifragmentary fracture of the distal humerus: result after 77 years--case report and review of the literature]

Post-traumatic stiffness of the elbow joint in children after unreduced multifragmentary fractures of the distal humerus can be successfully treated by interposition arthroplasty. A case with long-term follow up is described, and the literature discussed.

Measurement of anterior-posterior knee laxity: a comparison of three techniques

Several non-invasive techniques have been developed to assess anterior-posterior (A-P) laxity of the knee, however, their accuracy remains unclear. Roentgen Stereophotogrammetry Analysis (RSA) is a three-dimensional motion analysis method that has been shown to be an accurate tool for evaluating joint kinematics. Thus. RSA provides a means that can be used to evaluate other less invasive techniques. The objectives of this study were to compare A-P laxity values as measured using the KT-1000 Knee Arthrometer, planar stress radiography and RSA, and to determine if they detect similar changes in A-P laxity over time in 15 subjects following anterior cruciate ligament reconstruction with patellar tendon autografts. The A-P laxity values of the injured knee were measured immediately following surgery and at their 3-, 6-, and 12-month follow-up visits. A-P laxity was defined as the A-P translation of the tibia relative to the femur that occurred between the posterior and anterior shear load limits of -90 to +130 N, respectively. The values of A-P laxity across all time points were 11.4 +/- 3.0, 10.2 +/- 3.3, and 6.9 +/- 3.0 mm (mean +/- standard deviation) for the KT-1000, planar stress radiography and the RSA methods, respectively. These values were significantly different from each other (p < 0.001). The two-dimensional analyses techniques (planar stress radiography and the KT-1000) consistently over-estimated the true laxity values that were obtained using the three-dimensional RSA technique. Significant increases in A-P laxity values over time were also detected with the KT-1000 (p = 0.04) and the RSA technique (p = 0.04). However, this increase was not evident when using planar stress radiography (p = 0.89). This study determined that the KT-1000 and RSA document temporal changes in A-P laxity following ACL reconstruction that were not documented by planar stress radiography.

[Distal radius fractures and concomitant lesions. Experimental studies concerning the pathomechanism]

Since Colles (1814) first described a distal radius fracture and the publication by Dupuytren (1834), the frequency of and problems surrounding these fractures were increasingly recognised. Not only the treatment but also the formation and type of fracture were repeatedly analysed. The various theories concerning the pathomechanism led to names such as: "tear fracture", "bend fracture", "thrust fracture", "compression fracture", "snap fracture" and others. In our experimental studies we attempted to simulate the pathomechanism of distal radius fractures and present them pictorially. With the help of a materials testing machine, 63 prepared cadaver arms were hyperextended in the wrist joint until a radius fracture occurred. The concomitant lesions were registered radiologically and by dissection. Moreover, additional cadaver arms were deep-frozen and examined by means of computer tomography and cryosection according to Kathrein. Through experimental hyperextension it was possible to generate dorsal, central, and palmar types of fractures. We produced 42 dorsal, 14 central and 7 palmar fractures. Fundamentally, it seems that the fracture depends on the extent in which the carpal bones of the proximal row are pressed against the dorsal, central or palmar part of the articular surface of the distal radius. The subsequent dissection showed in 40 cases (63 %) mostly multiple concomitant lesions and in 23 cases (37 %) none of these. The reason for concomitant lesions may be the proportion of bone stability to the strength of ligaments. Most frequently (27 cases, i.e. 43 %), we found a destabilisation of the articular disk with or without a bony avulsion fragment (fracture of the ulnar styloid). We also commonly found ruptures of the interosseous ligaments between scaphoid and lunate (20 cases, i.e. 32 %) and lunate and triquetrum (11 cases, i.e. 18 %). It is difficult to apply knowledge gained from experimental studies on preserved cadaver arms clinically. There are of course no physiological reflexes and the slow fracture process must be taken into consideration. This holds true not only for concomitant lesions but also for the type of fracture. On the other hand, in these experimental studies it was possible to generate many realistic types of fractures with their concomitant lesions.