[Early functional treatment of intra-articular fractures of the proximal interphalangeal joint of the finger using a modified traction device]

INTRODUCTION

Treatment of intra-articular fractures of the middle phalanx is both difficult and controversial. We report our experience of using a modified dynamic traction device (mTD) utilizing only one pin in the head of the middle phalanx and thus facilitating further open reconstructive surgery at the proximal interphalangeal joint (PIP). The pin does not necessarily have to be inserted in the movement axis of the joint.

AIM OF THE STUDY

The aim of the study was to a) determine the effectiveness of the mTD, particularly in comparison with other distraction systems used in the treatment of middle phalanx fractures as described in the literature, and b) compare the results of patients treated using an mTD only with the results of those treated with an mTD in combination with additional open reconstructive surgery.

PATIENTS AND METHODS

26 patients with a mean age of 37 years were treated for intra-articular fractures of the base of the middle phalanx using an mTD in the period between 2007 and 2011. 13 of these patients also underwent additional open reconstructive surgery. 18 of the 26 patients (69%) were reevaluated after 33 months (range 9-44 months); 10 of these had undergone additional open reconstructive surgery. Follow-up of 14 of the patients included their completion of a structured questionnaire and calculation of their DASH scores as well as radiological and clinical examinations. 4 patients completed the questionnaire and had their DASH score calculated. Measurement of range of motion was performed by the treating general practitioner. Patient records were analysed with a particular focus on complications and duration of therapy.

RESULTS

The mTD was used for an average of 34 days (range 8-53 days) and overall treatment took an average of 74 days (range 66-154 days). 4 pin tract infections were reported. The mean DASH score was 6.4. The mean range of motion in the PIP joint was 70° (range 30-110°). The range of motion of the PIP and DIP joints (61º) was significantly poorer in patients with additional surgery than that (82º) in patients with sole mTD treatment. Treatment with the mTD gave results similar to those obtained with other distraction devices with good subjective evaluation by the patients.

CONCLUSION

Dynamic traction with the help of the modified traction devices is suitable for treating intra-articular fractures of the proximal interphalangeal joint, as demonstrated by a comparison with the literature. Patients who underwent additional open surgery showed less favorable results. The present method has the advantage that only one wire needs to be inserted subcapitaly at a distance from the fracture in the middle finger and this facilitates further surgical interventions.

[Simultaneous reimplantation of both lower legs--5-year follow-up (case report)]

We are reporting the case of a 29 year old male in whom we performed successful reimplantaton of both lower legs following trauma inflicted by a railroad boxcar. Five years after this accident, the patient's walk is almost normal and both deep sensitivity and two point discrimination on the soles of his feet are sufficient. The patient can walk, run and stand very well on one leg, both on even and on uneven ground.He returned to his job with the railroad 8 months after his accident. Originally the patient was employed as a railroad workman, and is now an office employee. His private life is normal and he enjoys hiking and dancing. In our opinion, sufficient function of the tibial nerve in the reconstructed extremity is important for clinically satisfactory long-term results. Both the Mangled Extremity Severity Score (MESS) and the NISSSA are helpful in making the decision on whether to primarily amputate or reconstruct Gustillo IIIC cases. Good long-term results as well as general cost reduction are achievable following reconstruction of extremities. Amputation of an extremity can be predicted with 100% certainty when MESS is 9 or more. Primary shortening and secondary lengthening of an extremity is a good method of treating Gustillo III C fractures.

[Callus development after bored and unbored femoral interlocking nailing. An experimental study]

This was a prospective randomized baboon animal study, the study protocol was approved by the ethical committee according to the international guidelines for animal research projects. In 8 animals a midschaft femoral osteotomy was stabilized with reamed femoral interlocking nailing and in 8 animals by unreamed locked femoral nailing. Polychrome sequence bone labeling was done 5 weeks postop. with calcein-green, 8 weeks postop. with xylenol-orange and 10 weeks postop. with oxytetracycline. 10 weeks postop. the animals were sacrificed, the femurs explanted and planimetric and epifluorescence histomorphometric evaluation of serial transverse sections were done. In planimetric histomorphometric evaluation in unreamed femoral nailing a mean endostal callus formation was recorded with 28.0 +/- 9.9 mm2 per section and in reamed femoral nailing with 11.5 +/- 5.0 mm2 (p < 0.001). Periostal callus formation was recorded in the unreamed group with 238.7 +/- 87.1 mm2 per section and in the reamed group with 142.1 +/- 71.9 mm2 (p < 0.001). In epifluorescence histological evaluation endostal as well as periostal callus formation was more extensive and earlier after unreamed than reamed femoral nailing. Endostal callus formation was found in all animals after unreamed femoral nailing, and was present in 2 out of 8 specimen in the reamed group. Also 1 out of 8 animals in the reamed group developed a non-union. Unreamed femoral nailing with low diameter interlocking nails proved to be safe regarding bone healing in this experimental model with obvious advantages both in amount and time course of callus formation compared to reamed femoral nailing. Based on this results unreamed femoral nailing techniques can be recommended for femoral fractures.

[Unreamed antegrade humeral interlocking nailing]

In a prospective clinical study 111 fractures of the humerus in 109 consecutive patients were stabilized with unreamed antegrade interlocking nailing. 97 patients were evaluated with individual follow-up, in the mean at 24.2 months postoperatively. Mean fracture consolidation time was 12.3 weeks (9-16 weeks). Five patients presented a non union. At follow-up 19 patients had a limitation in motion of the shoulder, in the mean with 20% compared to the opposite side. Eight patients had permanent shoulder pain, in nine patients shoulder pain occurred during manual strain of the upper limb. Neither limitation of motion nor pain at the elbow region was present in all cases at follow-up. Ultrasound examination revealed in six cases a lesion of the rotator cuff, which was linked in these cases with permanent pain at the shoulder joint. In five patients a prominent nail tip at the entrance point caused a lesion of the rotator cuff with impingement syndrome. Eight out of nine preoperative palsies of the radial nerve recovered within a mean period of 4.3 months without operative measurements. Unreamed antegrade interlocking nailing of humeral fractures is a safe technique regarding consolidation rate with advantages regarding early mobilization of the upper limb. Careful suturing of the rotator cuff and countersinking of the proximal nail tip at the entrance point is a prerequisite in avoiding permanent lesions of the rotator cuff and shoulder pain.

Intramedullary pressure and bone marrow fat extravasation in reamed and unreamed femoral nailing

This study was designed to investigate whether intramedullary pressure and embolization of bone marrow fat are different in unreamed compared with conventional reamed femoral nailing in vivo. In a baboon model, the femoral shaft was stabilized with interlocking nailing after a midshaft osteotomy. Intramedullary pressure was measured in the distal femoral shaft fragment at the supracondylar region. Extravasation of bone marrow fat was determined by the modified Gurd test (range: 0-5) with blood samples from the vena cava inferior. Data were monitored in eight unreamed and eight reamed intramedullary femoral nailing procedures. Intramedullary pressure increased in the unreamed group to 76 +/- 25 mm Hg (10.1 +/- 3.3 kPa) during insertion of 7-mm nails and in the reamed group to 879 +/- 44 mm Hg (117.2 +/- 5.9 kPa) during reaming of the medullary cavity. Insertion of 9-mm nails after the medullary cavity had been reamed to 10 mm produced an intramedullary pressure of 254 +/- 94 mm Hg (33.9 +/- 12.5 kPa) (p < 0.05). Fat extravasation in the unreamed group was recorded with a score of 2.9 +/- 0.4 for the Gurd test during nailing with 7-mm nails, whereas in the reamed group significantly more fat extravasation was noticed during the reaming procedures, with a score of 4.6 +/- 0.1. Liberation of fat during insertion of 9-mm nails after reaming was recorded with a score of 3.5 +/- 0.4. In both groups, a positive correlation of fat extravasation with the rise in intramedullary pressure was found (reamed group: r(s) = 0.868; unreamed group: r(s) = 0.698), resulting in significantly less liberation of bone marrow fat in the unreamed stabilized group than in the reamed control group (p < 0.05). The data indicate that fat embolization during nailing procedures after femoral osteotomy increases with increasing intramedullary pressure and occurs in a lesser degree in unreamed than in reamed intramedullary femoral shaft stabilization.

Intramedullary pressure and bone marrow fat intravasation in unreamed femoral nailing

OBJECTIVE

To investigate whether intramedullary pressure and bone marrow fat embolization are different in unreamed compared with conventional reamed femoral nailing. The null hypothesis is that there is no difference between the two techniques.

DESIGN

A prospective consecutive nonrandomized clinical trial.

METHODS

Intramedullary pressure was measured in the distal femoral fracture fragment at the supracondylar region. Bone marrow fat intravasation was measured by means of the modified Gurd-test. Monitoring was carried out in 31 unreamed and eight reamed intramedullary femoral nailing procedures.

RESULTS

Intramedullary pressure increased in the unreamed group to 82 +/- 11 mm Hg during the insertion of 9-mm and 10-mm nails and in the reamed group to 396 +/- 85 mm Hg during reaming of the medullary cavity. Insertion of nails after reaming led to an increase in intramedullary pressure of 79 +/- 13 mm Hg. A positive correlation between fat intravasation and intramedullary pressure was found in each group (rs = 0.73), resulting in less liberation of bone marrow fat in the unreamed group than in the reamed group.

CONCLUSIONS

Intramedullary pressure increased significantly in the reamed more than in the unreamed group. Bone marrow fat intravasation depended on the rise in intramedullary pressure, and occurred less frequently in unreamed than in reamed intramedullary femoral fracture stabilization.

[Technique, results and risks of endoscopic carpal tunnel release]

Endoscopic carpal tunnel release was performed in 168 cases of carpal tunnel syndrome using the two-portal technique described by Chow. There were 164 cases of idiopathic carpal tunnel syndrome and four cases following a wrist trauma. Sensory symptoms improved within few days in 113 patients (67%) and in 141 cases within eight weeks (84%). Nighttime pain relief was achieved immediately in 87% of the patients and in 94% within eight weeks. Grip strength increased to preoperative values within eight weeks and pinch strength reached preoperative levels within six weeks. In four cases an iatrogenic injury of the superficial palmar vascular arch occurred. In another four patients, open revisional surgery had to be performed. Three of these patients presented an incomplete release of the retinaculum flexorum and in one patient a remaining part of the palmar fascia led to further compression of the median nerve despite complete dissection of the carpal ligament.

Unreamed intramedullary nailing of femoral fractures

Seventy-five patients with 81 femoral shaft fractures were treated with unreamed antegrade intramedullary nailing using a titanium alloy implant (AIM femoral nail, ACE Medical) with static interlocking. There were 73 closed fractures and 8 open fractures. Six patients had bilateral femoral shaft fractures. In two cases there was an ipsilateral fracture of the femoral neck, two patients had an ipsilateral intertrochanteric fracture, in one case there was a concomitant subtrochanteric fracture, and four patients had sustained an ipsilateral fracture of the acetabulum in addition to their femoral shaft fractures. In 43 cases (53%) the fracture of the femoral shaft was a comminuted type fracture. Thirty-nine patients (52%) had suffered multiple injuries; the mean Injury Severity Score was 41.2. Sixty-nine fractures were stabilized primarily within 8 hours after admission and 12 fractures were treated secondarily, in a mean of 5.8 days after injury. Closed intramedullary nailing was performed in 73 femora and open nailing with cerclage wiring was done in 8. All 81 nails were implanted unreamed and static was used in every case. The diameters of the nails used were 9 mm (n = 68) and 10 mm (n = 13). Proximal interlocking was distally directed in 76 cases and proximally directed in 5 cases. Two patients died of severe head injuries and one patient died of multiple organ failure. The infection rate was 0%, and uneventful consolidation of the fractures was seen in all cases within a mean of 3.8 months. Neither in the case of nails nor in the case of interlocking bolts did an implant failure occur.

[Donor site morbidity following radial forearm flap]

The results concerning morbidity of the fasciocutaneous radial forearm flap donor site of 20 patients are presented. The review was carried out with an average time of 4.4 years after raising the flaps, ranging from ten months to eleven years. Range of motion of the wrist joint was limited in extension in two patients with 15 degrees and in one patient with 30 degrees. Pinch and grip strength was found normal in 13 patients and was limited in five cases to 88% of the strength of the opposite limb. Dysesthetic areas were found in three patients on the radial border of the donor site and reduced sensation of the radial nerve was present in four patients.

[Epiphyseal growth after replantation in childhood]

Long-term results in 17 patients with 19 replanted parts of the upper extremity after replantation during childhood are presented. Regarding longitudinal epiphyseal growth, three patients had normal growth. In 15 cases, average length of the replanted digits attained 88.6% of normal and one patient gained overgrowth of 118% of normal. In every case, consolidation of the fracture was seen. Four patients developed a deviation of the replanted finger in the frontal plane. The cause of deviation in every case was incorrect primary reposition and not a disturbance of growth of the replanted epiphysis.

[Value of plate osteosynthesis in treatment of radius fractures at a typical site]

In the past, distal radius fractures tended to be treated conservatively. Recently, however, unsatisfactory anatomical and functional results have led to an increase in their surgical treatment. Our preferred method of treatment has been percutaneous pin fixation after closed reduction. In our opinion, open reduction and internal fixation with an A0-plate is indicated for Smith fractures (B3 A0-classification), and for any fractures which cannot be ideally reduced (usually C1 to C3 fractures). From 1972 until 1989, 84 patients with distal radius fractures underwent surgical treatment in the Unfallkrankenhaus Salzburg. The procedure was usually performed under brachial plexus or Bier block, and we preferred a palmarly positioned plate for internal fixation. Follow-up of 42 patients showed good results, the functional and subjective results earning higher marks than the X-ray findings.

[Therapy of lunate necrosis]

Out of the multiple methods for treating Lunatum-malacia the following were used in our hospital: shortening of the radius, pisiform-transposition, cancellous bone graft, tendon interposition arthroplasty, intercarpal arthrodesis, prothetic replacement, wrist arthrodesis and denervation of the wrist. Because of non satisfactory results the conservative treatment was abandoned. The indication for one of the different operative methods depended on the radiological Decoulx-Stage, the profession and the age of the patient and his willingness to cooperate. From 1972-1988 36 patients with Kienböck's disease were treated in the Unfallkrankenhaus Salzburg. 20 were seen with an average follow up of 8.7 years. In the early stages of lunate necrosis with a minus variant of the ulna the best results were obtained by shortening of the radius otherwise with the pisiform transposition. The same results could be achieved in intermediate stages although with reservation for the pisiform transposition. Although the other operative methods gave pain relief and an improvement of grip strengths, they showed radiologically a progression of the necrosis. Denervation and wrist arthrodesis are reserved for stage IV. Despite some good results, new operative methods like revascularisation operations of the lunate bone seem promising.

[The diagnostic value of double contrast CT in shoulder dislocation]

The article reports of the indication, technique and results of the shoulder joint double-contrast-computertomography. It discuss its diagnostic value in comparison to other examining methods. As alternative preoperative diagnostic procedures only arthroscopy, arthrography and MRI can be considered. Also discussed are the therapeutic consequences resulting from the nature of the pathological lesions (rupture of the limbus glenoidalis, Hill-Sachs-defect, reversed Hill-Sachs-defect). Especially for the first traumatic dislocations of the shoulder joint, we consider this investigational method an eminent enlargement of the diagnostic spectrum. Therefore, we are generous with its indication, attempting to prevent reluxations by primary diagnostic and therapeutic procedure.

[Comparative study of arthroscopic and open meniscus surgery]

In this paper we compared two groups of 80 patients each with meniscal tears. One group was treated by Arthrotomie and partial meniscectomie and the other group by an arthroscopic procedure also with partial meniscectomie. All patients were seen at a follow up between six and 18 months postoperatively. According to the Gaudernak scale we found in both groups 98% of very good and good results. The duration of hospitalisation and sickleave was reduced by 50% after the arthroscopic operation, which showed a significant difference.

[Malunion and growth disorders following fractures of the condylus radialis humeri in children]

Basing on the results of 46 fractures of the lateral humeral condyle in children possible mal-unions and disturbances of growth after conservative and operative treatment are shown. Varus-tendency of the elbow axis was observated in 23% after conservative treatment of undisplaced fractures and in 37.5% after open reduction and Kirschner wiring of displaced fractures. Fish-tail deformity was seen both after conservative treatment and fixation with Kirschner wires; only open reduction and osteosynthesis with small-fragment screws could avoid this two disturbances of growth. One non-union was seen after conservative treatment.

[A rare combination injury in Alpine skiing]

This is a report on the incidence of associated osseos lesions in Achilles tendon ruptures. From 1967 to 1984 630 patients underwent treatment for closed Achilles tendon ruptures. In 49 cases (7.7%) associated osseos injuries were discovered. In 42 cases (6.6%) fractures of the malleolus medialis were found. Two patients with a rare combination (primarily treatment of osseos lesions, with delayed diagnosis of tendon rupture) deserve special attention. Concerning fractures of the lower leg with associated tendon rupture. Chronology and pattern of the injury are analyzed.