[Current trends in reverse fracture arthroplasty]

The reliable results of reverse arthroplasty have made this the preferred treatment method for non-reconstructable proximal humeral fractures. The individual consideration of the patient and the morphological features of the fractures are essential. Computed tomography (CT) images provide crucial information on the perfusion of the humeral head relevant for the prognosis and treatment. In this context a differentiation must be made between hard and soft criteria against a reconstruction. Tuberosities should be reduced whenever possible, because reverse arthroplasty with healed tuberosities provides a better range of motion and more strength for external rotation and anteversion, less complications and longer survival rates. In recent years the trend has been towards anatomical designs of prostheses with a humeral inclination of 135°. Revision rates for primary fracture prostheses are overall low with instability as the main reason for revision surgery, followed by periprosthetic fractures and infections. Reverse fracture arthroplasty has comparable or better clinical results compared to conservative treatment, osteosynthesis for geriatric patients, hemiarthroplasty and prosthesis implantation by elective surgery. Reverse arthroplasties, which were implanted in conditions of fracture sequelae, did not achieve significantly poorer clinical outcome at mid-term follow-up and can significantly improve shoulder function.

[Plate osteosynthesis after patellar fracture - the technique and initial results of a prospective study]

BACKGROUND

Tension band wiring after patellar fractures is related to a high number of implant-related complications (22-53 %). Revision surgery is necessary in 10-55 % of patients mostly with unsatisfactory results. The patella plate is an alternative treatment with the advantages of locked plating. The purpose of this study was to evaluate the first clinical prospective results and complications of this new implant.

MATERIALS AND METHODS

Between April 2013 and May 2015 all patients that were treated with locked plating for patella fractures were included in this prospective study. Patients were followed-up clinically after six weeks and six months.

RESULTS

Included in this study were 17 patients, 6 women and 11 men, with a mean age of 58 years (19-87). The knee range of motion was 120° after 6 weeks and improved to 138° after 6 months, corresponding to 84 % and 97 % of the range of motion of the healthy opposite knee. The Tegner activity scale increased from 2,5 to 3,5 (initial value: 4), the Lysholm score increased from 78 to 92 points (initial value: 97) and the Kujala score increased from 72 to 88 points (initial value: 96). Two complications occurred: one patient had a reactive bursitis prepatellaris and one patient sustained a loss of reduction.

CONCLUSION

Locked plating of patella fractures is a reliable alternative treatment with good functional outcomes and low complication rates.

Cement augmentation of humeral head screws reduces early implant-related complications after locked plating of proximal humeral fractures

Background

Cement augmentation (CA) of humeral head screws in locked plating of proximal humeral fractures (PHF) was found to be biomechanically beneficial. However, clinical outcomes of this treatment have not been well evaluated to date.

Objectives

To assess outcomes of locked plating of PHF with additional CA and to compare them with outcomes of conventional locked plating without CA.

Methods

24 patients (mean age, 74.2 ± 10.1 years; 22 female) with displaced PHF were prospectively enrolled and treated with locked plating and additional CA. The Constant score (CS), the Simple Shoulder Test (SST), and the Simple Shoulder Value (SSV) were assessed 3 and 12 months postoperatively. Fracture healing and potential complications were evaluated on postoperative radiographs. The CS and complications were compared with the outcomes of a matched group of 24 patients (mean age, 73.9 ± 9.4 years; 22 female) with locked plating of displaced PHF without CA.

Results

At the 3‑month follow-up, the mean CS was 59.9 ± 15.6 points, the mean SST was 7.5 ± 2.7 points, and the mean SSV was 63.9 ± 21.7%. All scores significantly improved by the 12-month follow-up (p < 0.05; CS, 72.9 ± 17.7; SST, 9.2 ± 3.2; SSV, 77.2 ± 17.3%). There were two cases (8%) of biological complications (n = 1 varus malunion and n = 1 humeral head necrosis). Compared with locked plating without CA, no significant differences were observed between the CS at the 3‑ (57.8 ± 13.4 points; p = 0.62) and 12-month (73.0 ± 12.8 points; p = 0.99) follow-up. However, patients without CA had a significantly increased risk of early loss of reduction and articular screw perforation (p = 0.037).

Conclusion

Locked plating of proximal humeral fractures with trauma cement augmentation of humeral head screws could be translated from the ex-vivo lab setting into the clinical situation without additional complications. Locked plating of displaced PHF with additional cement augmentation showed similar clinical outcomes but reduced the rate of early implant-related complications compared to locked plating without additional CA.

Neurocognitive deficits in schizophrenia. Are we making mountains out of molehills?

BACKGROUND

Most original studies and all meta-analyses conducted to date converge on the conclusion that patients with schizophrenia display rather generalized neurocognitive deficits. For the present study, we reopen this seemingly closed chapter and examine whether important influences, such as lack of motivation and negative attitudes towards cognitive assessment, result in poorer secondary neuropsychological performance.

METHOD

A sample of 50 patients with an established diagnosis of schizophrenia were tested for routine neurocognitive assessment and compared to 60 nonclinical volunteers. Before and after the assessment, subjective momentary influences were examined (e.g. motivation, concerns about assessment, fear about poor outcome) for their impact on performance using a new questionnaire called the Momentary Influences, Attitudes and Motivation Impact (MIAMI) on Cognitive Performance Scale.

RESULTS

As expected, patients performed significantly worse than controls on all neurocognitive domains tested (large effect size, on average). However, patients also displayed more subjective momentary impairment, as well as more fears about the outcome and less motivation than controls. Mediation analyses indicated that these influences contributed to (secondary) poorer neurocognitive performance. Differences in neurocognitive scores shrank to a medium effect size, on average, when MIAMI scores were accounted for.

CONCLUSIONS

The data argue that performance on measures of neurocognition in schizophrenia are to a considerable extent due to secondary factors. Poor motivation, fears and momentary impairments distinguished patients from controls and these variables heavily impacted performance. Before concluding that neurocognitive deficits in psychiatric patients are present, clinicians should take these confounding influences into account. Although patients with schizophrenia achieved, on average, worse test scores than controls, a large subgroup displayed spared performance.

[Injuries of the acromioclavicular joint: Hook plate versus arthroscopy]

Acute acromioclavicular (AC) joint injuries are common in clinical practice. The hook plate is a well-established conventional operative treatment option for high grade instability; however, arthroscopically-assisted flexible double button techniques are increasingly being used. Both procedures lead to good or excellent results. The advantages of the hook plate are the simple surgical technique and the possibility of an early functional aftercare. The minimally invasive one-step procedure with the possibility of identification and treatment of frequently concomitant glenohumeral pathologies is advantageous for the arthroscopic technique but mobilization is more restrictive. Available comparative studies have shown no significant clinical differences but a tendency towards better results with a higher degree of acceptance among patients for the arthroscopic and minimally invasive non-rigid double button procedures.

Is there any advantage in placing an additional calcar screw in locked nailing of proximal humeral fractures?

BACKGROUND

The objective of this study was to evaluate the biomechanical effect of an additional unlocked calcar screw compared to a standard setting with three proximal humeral head screws alone for fixation of an unstable 2-part fracture of the surgical neck.

HYPOTHESIS

The additional calcar screw improves stiffness and failure load.

METHODS

Fourteen fresh frozen humeri were randomized into two equal sized groups. An unstable 2-part fracture of the surgical neck was simulated and all specimens were fixed with the MultiLoc(®)-nail. Group I represented a basic screw setup, with three locked head screws and two unlocked shaft screws. Group II was identical with a supplemental unlocked calcar screw (CS). Stiffness tests were performed in torsional loading, as well as in axial and in 20° abduction/20° adduction modes. Subsequently cyclic loading and load-to-failure tests were performed. Resulting stiffness, displacement under cyclic load and ultimate load were compared between groups using the t-test for independent variables (α=0.05).

RESULTS

No significant differences were observed between the groups in any of the biomechanical parameters. Backing out of the CS was observed in three cases.

DISCUSSION

The use of an additional unlocked calcar screw does not provide mechanical benefit in locked nailing of an unstable 2-part fracture of the surgical neck.

[Suprapectoral mini-open biceps tenodesis - functional and sonographic results]

BACKGROUND

Aim of this study was to evaluate the effectiveness of a suprapectoral mini-open tenodesis of the long head of the biceps (LHB) tendon with ultrasound assessment. Secondary aim was to compare the results of an extraosseous fixation (group I) to those of an intraosseous fixation technique (group II).

PATIENTS AND METHODS

25 patients (10 female, 15 male) aged 54 ± 8 (36 to 68) years were followed-up 21 ± 4.7 (13 to 32) months postoperatively. Tenodesis fixation was extraosseous in 12 (group I) and intraosseous in 13 patients (group II). Preoperative shoulder function and intraoperative findings were recorded. At the time of follow-up the fixation of the biceps tendon was evaluated by ultrasound examination. Furthermore, the shoulder function, the simple shoulder test (SST), the Constant-Murley score (CMS) and the "long head of the biceps (LHB) score" were assessed.

RESULTS

Failure of tenodesis fixation was observed in 3/12 cases (25 %) of group I and 1/13 cases (8 %) of group II. Shoulder flexion (p < 0.001), abduction (p < 0.001), external rotation (p < 0.001) and the pain level (p < 0.001) improved significantly compared to the preoperative status. At time of follow-up the CMS averaged 79.4 ± 13 points, the age and gender related CMS averaged 95.7 ± 16.4 %. Mean SST was 10.6 ± 2.1 points. No significant difference (p = 0.064) could be observed between the LHB of the affected (88.1 ± 9.7) versus the non-affected shoulder (92.7 ± 13.6 points). Age and gender related CMS (p = 0.96), LHB score (p = 0.16) and SST (p = 0.94) of both groups revealed no significant differences.

CONCLUSION

The intraosseous fixation technique seems favourable with less fixation failure compared to the extraosseous suspension technique. The suprapectoral mini-open tenodesis of the LHB is a valuable alternative tenodesis technique with good to excellent clinical results.

[Corrective osteosynthesis of proximal humeral fractures. Technique and prospective results]

BACKGROUND

Fracture sequelae of proximal humeral fractures arise following nonoperative and operative forms of treatment. Due to a painful restricted range of motion, in most cases shoulder prostheses are implanted. There is a need for joint-preserving alternatives especially for younger patients.

OBJECTIVES

The aim of this study was to evaluate the surgical techniques and prospective results of fracture sequelae of proximal humeral fractures following corrective osteosynthesis.

MATERIAL AND METHODS

A total of 11 patients (4 female) with an average age of 53 years (range 29-71 years) and a mean follow-up of 19.5 months were included prospectively. The preoperative and postoperative ranges of motion of the affected shoulder were compared by statistical means. At the time of follow-up the constant score (CS), the simple shoulder test (SST) and the simple shoulder value (SSV) were assessed.

RESULTS

Fracture sequelae were classified as type II in four patients, as type III in two and as type IV in five patients using the Boileau classification. Shoulder flexion (p = 0.006), abduction (p = 0.003) and external rotation (p = 0.02) improved significantly in the postoperative course. The mean age and gender-adapted CS was 74.8 ± 19.9 % at the time of follow-up, 10.1 out of 12 points were reached in the SST and the mean SSV was 77 %.

CONCLUSION

Corrective osteosynthesis of fracture sequelae (Boileau types II-IV) of proximal humeral fractures appears to be a good alternative to implantation of shoulder prostheses, especially in younger patients (< 60 years of age).

Influence of rupture patterns of the medial patellofemoral ligament (MPFL) on the outcome after operative treatment of traumatic patellar dislocation

PURPOSE

Patellar dislocation usually occurs to the lateral side, leading to ruptures of the medial patellofemoral ligament (MPFL) in about 90 % of all cases. Reliable prognostic factors for the stability of the patellofemoral joint after MPFL surgery and satisfaction of the patient have not been established as yet.

METHODS

This multicentric study retrospectively included 40 patients with a mean age of 22.4 ± 8.1 years (range 9-48) from 5 German Trauma Departments with first-time traumatic patellar dislocation and operative treatment. Surgery was limited to soft tissue repairs, and a preoperative magnetic resonance imaging (MRI) was performed in all cases. Evaluation of the MRI included sulcus angle, dysplasia of the trochlea, depth and facet asymmetry of the trochlea, Insall-Salvati index, Tibial tuberosity to trochlear groove (TTTG) distance, and rupture patterns of the MPFL. Patients were interrogated after 2 years about recurrent dislocation, satisfaction, and the Kujala score.

RESULTS

Trochlea facet asymmetry was significantly lower in patients with redislocation (23.5 ± 18.8) than in patients without redislocation (43.1 ± 16.5, p = 0.03). Patients with a patellar-based rupture were significantly younger (19.5 ± 7.2 years) than patients without patellar-based rupture (25.4 ± 8.1 years, p < 0.02). Patients with femoral-based ruptures were significantly older (25.7 ± 9.2 years) than patients without femoral-based rupture (19.7 ± 6.1 years, p < 0.02), and had a significantly higher TTTG distance (10.2 ± 6.9 vs. 4.5 ± 5.5, p < 0.02). Patients with incomplete ruptures of the MPFL had a significantly lower Insall-Salvati index (1.2 ± 0.2 vs. 1.4 ± 0.2, p = 0.05). The Kujala score in patients with redislocations was significantly lower (81.0 ± 10.5 points) than in patients without redislocation (91.9 ± 9.2 points, p < 0.02).

CONCLUSION

Younger patients more often sustain patellar-based ruptures following first-time traumatic patella dislocation, while older patients more often sustain femoral-based ruptures of the MPFL. Incomplete MPFL ruptures are correlated with lower Insall-Salvati indices. Low trochlear facet asymmetry is correlated with higher rates of redislocation. These results may be of relevance for the operative and postoperative treatment in the future.

LEVEL OF EVIDENCE

Prognostic study, Level IV.

Operative vs conservative treatment of traumatic patellar dislocation: results of a prospective randomized controlled clinical trial

INTRODUCTION

Patellar dislocation is a common knee injury with mainly lateral dislocations, leading to ruptures of the medial patellofemoral ligament in most of the cases. Even though several prognostic factors for patellofemoral instability have been identified so far, the appropriate therapy for patients with patellar dislocation remains a controversial issue. The purpose of this study was to compare the outcome after conservative or operative treatment in patients after first-time patellar dislocation.

PATIENTS AND METHODS

This randomized controlled clinical trial was designed multicentric including patients from six German orthopaedic and trauma departments. Twenty patients with a mean age of 24.6 years with first-time traumatic patella dislocation were included and randomized into either a conservative arm or an operative arm. Plain X-ray images of the knee joint (a.p. and lateral view and tangential view of both patellae) were performed in all cases prior to therapy to exclude osteochondral fragments requiring refixation. An MRI was recommended, but not compulsory. Patients were consulted after 6, 12, and 24 months with a questionnaire including the criteria of the Kujala score, recurrent dislocation, and satisfaction.

RESULTS

The mean Kujala score of the conservative vs operative treatment group was 78.6 vs 80.3 after 6 months (p = 0.842), 79.9 vs 88.9 after 12 months (p = 0.165), and 81.3 vs 87.5 after 24 months (p = 0.339). Redislocation rate after 24 months was 37.5 % in the conservative group and 16.7 % in the operative group (p = 0.347). Due to the small number of patients that could be included, no significant difference between the groups could be detected. We see a tendency towards better results after operative treatment.

CONCLUSION

Our multicentric prospective randomized controlled trial revealed no significant difference between conservative and operative treatment for patients after first-time traumatic patellar dislocation. However, a tendency towards a better Kujala score and lower redislocation rates for patients with operative treatment was observed. The small number of patients is a limiting factor of the study, leading to results without statistical significance. A meta-analysis including other study's level I data is desirable for the future.

[Shoulder stiffness]

Primary shoulder stiffness is idiopathic. Due to coincidence with other diseases, a systemic genesis with hormonal influence is discussed. The result of chronic inflammation with fibroblastic proliferation is a fibrotic capsule, atrophy of ligaments, and muscular dysbalance. The main symptom is painful restricted passive and active shoulder motion. There is a high rate of unsatisfactory courses. Therapy depends on the phase and duration of shoulder stiffness. Primary treatment of choice is oral steroid therapy, followed by physical and physiotherapy. Steroids can be applied intraarticular, as an alternative. If conservative treatment fails after a period of 6 months, arthroscopic arthrolysis is indicated. Secondary shoulder stiffness often results from traumatization or operation of the shoulder. Primary treatment is also conservative, but operative intervention should be performed early after unsuccessful therapy. Intensive, passive mobilization is necessary after arthrolysis.

[Subscapularis tendon lesions. Anatomy, diagnosis and importance of arthroscopic treatment]

The subscapularis tendon is involved in up to 43% of arthroscopically treated rotator cuff lesions. Due to the close anatomic relationship, participation of the long head of the biceps and supraspinatus tendon is common. Subscapularis tendon lesions are often not primary diagnosed correctly. Using specific clinical tests and modern sectional imaging, the percentage of correct diagnoses can be increased. Convincing clinical results, advantages of minimally invasive surgery, and superior visualization compared to the open approach argue for arthroscopic treatment of subscapularis lesions. Awareness of the footprint allows anatomic reconstruction. In case of planned open treatment, arthroscopy should precede as particularly articular-sided lesions might be missed otherwise.

[Comparison of results after primary and secondary shoulder arthroplasty for proximal humeral fractures]

BACKGROUND

The purpose of this retrospective cohort study was to evaluate, compare and discuss the results and complications after primary and secondary shoulder arthoplasty in proximal humeral fractures.

PATIENTS AND METHODS

Thirteen consecutive patients (mean 76 years [range, 65-85] years) were at a mean of 29 (8-37) months after primary humeral head replacement (group 1), and 15 patients (mean 74 years [range, 43-80] years) at a mean of 18 (7-36) months after secondary shoulder arthoplasty (n = 8 anatomic prostheses, n = 7 reversed prostheses) due to complications/fracture sequelae (group 2) examined clinically and radiologically according to a standardised follow-up protocol. Patient satisfaction, the simple shoulder test (SST), the American shoulder elbow score (ASES) as well as the Constant score (CS) were assessed, and radiological parameters as well as complications analysed.

RESULTS

85 % of patients in group 1 and 73 % in group 2 were satisfied with the results. The SST did not show a significant difference between both groups. The adjusted ASES did not differ significantly with 70 (27-95)% in group 1 and 73 (28-100)% in group 2, as well as the adjusted CS with a mean of 53 (27-83)% in group 1 and of 49 (27-87)% in group 2. Radiological analysis resulted in a correctly centred prosthesis in 6/13 patients, and healed tuberosities in 7/13 of group 1. In group 2 4/8 anatomic prostheses were centered and 7/8 showed healed tuberosities. In the subgroup of the reversed prostheses 6/7 were centered, 3/7 patients had an inferior "notching". The rate of complications and revisions were 2/13 (15 %) in group 1 and 1/15 (7 %) in group 2.

CONCLUSION

In summary, the functional results did not differ significantly between primary and secondary shoulder arthroplasty after proximal humeral fractures. The relatively low expectation of elderly patients is reflected in a high rate of patient satisfaction in spite of moderate functional results. The primary humeral head replacement showed higher rates of complications and revisions compared to secondary arthroplasty.

[How to become a trauma surgeon: analysis of the current situation and concepts for career development in the new common field of orthopaedics and trauma surgery--part I]

The lack of clinical residents especially in the surgical domains, including orthopaedics and trauma surgery, is not only omnipresent but also a topic of lively discussions. This lack originates from sociopolitical and healthcare policy issues as well as from a loss of attractiveness of all surgical disciplines. The loss is caused by the high workload and disadvantageous working hours especially in those disciplines with a high rate of emergencies, e.g. trauma surgery. Moreover, it is caused by the poorly structured and unpredictable period of residency. In order to anticipate the bottleneck in supply due to the lack of trainees, a number of structural and contextual measures have to be taken to improve both undergraduate und postgraduate surgical training. Due to the numerous facets of the topic the first part of this analysis refers to the period until the trainee decides on the field of training.A basic insight into the field of orthopaedics and trauma surgery can already be offered far before the period of medical studies itself. During undergraduate medical education the existing structures should be modified, the characteristics of the discipline should be emphasized and the charm of combining theory and practical skills should be highlighted in order to enhance student's perception of the discipline. This might begin during preclinical training and should be continued throughout clinical training and elective courses (basic wound care, TEAM approach, AO course for students and seminars for M.D. candidates). Contextual and structural improvements of the practical year are indispensable to arouse students' interest in our discipline. These options conjoined with the actual offers for students provided by our scientific society, such as guided tours during the annual congress, travelling grants and the recently inaugurated summer school, might provide the basis for clearly structured information and offer a distinct stimulus to apply for residency in our field.

[Early functional treatment and full weight-bearing of surgically treated isolated ankle fractures in the elderly]

QUESTION

Fractures of the ankle joint belong to the most often occurring injuries. The aftercare in plaster lasts several weeks and is problematic especially in elderly patients.

METHODS

In a retrospective study patients over the age of 50 years who underwent surgical treatment of ankle fractures and early functional mobilization were examined in a follow-up. The range of motion, the circumferential measurements and the radiological course were examined by comparing preoperative and postoperative X-ray images after 13-24 months. The subjective results were collected using the Olerud-Molander score (OMS).

RESULTS

A total of 30 out of 42 patients who qualified for the follow-up were included in the study. The distribution of the gender was equal as was the right/left distribution and the mean age was 68 years. The magnitude of movement and comparison between the two sides showed no significant differences. The average score for subjective satisfaction was 90 in the OMS. The radiological results showed few changes and no deviations from the axis. No redislocations or implant fractures could be observed. Early functional full weight-bearing showed satisfactory preliminary results.

CONCLUSION

This treatment concept can be recommended because patient comfort is increased and the risk of immobilization is excluded.

[Proximal humeral fracture]

Fractures of the proximal humerus are very common in elderly people with an increasing incidence. Complex fracture-patterns are observed. For radiological examination x-rays in 2 planes are mandatory. Often an additive CT-scan can be useful for a better understanding of the whole fracture-character. Limits of accepted fracture displacement decrease and reconstructive surgery is induced more frequently. Advantageous are the functional after-treatment and the early reintegration to the activities of daily living after osteosyntheses. Locking nail- and platesystems are competing standard-implants, whereas plate osteosynthesis is preferred in higher-part-fractures. Non-reconstructable fractures should be treated with a primary head replacement, in the form of a reverse prosthesis in patients older than 75 years.

Arthroscopic treatment of multidirectional glenohumeral instability in young overhead athletes

Purpose:

This prospective case series evaluates the outcome, and the return to sports of young overhead athletes with a persistent, symptomatic multidirectional instability (MDI) with hyperlaxity type Gerber B5 treated with an arthroscopic anteroposteroinferior capsular plication and rotator interval closure.

Methods:

9 young overhead athletes (10 shoulders) with the rare diagnosis of MDI (Gerber B5) and an indication for operative treatment, after a failed physiotherapy program were physically examined 3, 6 and 12 months postoperatively by a physical examination, and got a final phone interview after median 39 months.

Results:

At the final follow-up all patients were satisfied; Rowe Score showed 7 “excellent” and “good” results; Constant Score was “excellent” and “good” in 6, and “fair” in 1 patient. 7/9 returned to their previous sports, 3/9 at a reduced level.

Conclusion:

Symptomatic MDI requires an individual indication for surgical treatment after a primary conservative treatment. The described arthroscopic technique stabilizes glenohumeral joint. A return to overhead sports is possible but often at a reduced level; returning to high-performance sports cannot be recommended because of the high risk of reinstability.

[Primary hemiarthroplasty in proximal humerus fractures]

The surgical treatment of complex proximal humerus fractures is still a great challenge. Not all fracture types can be successfully reconstructed. Indications for a primary joint replacement arise from critical fracture patterns and defined predictors of ischemia in the elderly (age >60 years). If good functional results are to be achieved a soft-tissue-preserving surgical technique, secure tuberosity attachment and accurate soft tissue balancing of the rotator cuff, correct restoration of height, retrotorsion and offset, and appropriate physiotherapy afterwards are essential. In multicentre studies in patients who had undergone primary hemoarthroplasty average Constant-Murlay Scores of 56.0-73.5 point were recorded. At follow-up, 79% of the patients reported only mild pain or none at all, and the ROM was acceptable (41.9% anteversion >90 degrees , 34.7% abduction >90 degrees ). Generally, subjective evaluations were much better than the objective results.The incidence of complications after humeral head replacement is still relatively high, whereas the 10-year survival rate of shoulder hemiarthroplasties has been found in a recent study to be 100%.

Komplikationsmanagement nach winkelstabiler Plattenosteosynthese am proximalen Humerus

PURPOSE

In this prospective study, complications observed after angularly stable proximal humerus plate fixation (locking proximal humerus plate) were analysed by deriving specific therapies.

PATIENTS

Fifty patients (median age 65 years, range 25-84 years, 39 female, 11 male) with displaced proximal humerus fractures (seven single, 36 double, and seven triple fractures) were evaluated 3, 6, and 12 months after angularly stable plate fixation using a standard protocol.

RESULTS

Age- and gender-matched median constant scores 12 months postoperatively showed for the three fracture types 86, 87, and 55 points and complication rates of 14, 19, and 100%, respectively. There were seven primary and seven secondary implant displacements, five humeral head necroses, four osseous malalignments, two nonunions, two deep infections, and one heterotopic ossification. Nine reoperations were required in six patients: implant removal (n=3), reosteosynthesis (n=2), revision because of nonunion (n=2), and deep infection (n=2).

CONCLUSIONS

Differentiated analysis of complications and the development of specific prevention and therapeutic strategies considering surgical technique, implant, fracture morphology, and humeral head perfusion minimize the rate of complications observed after angularly stable locking proximal humerus plate fixation.

The V-ATPase from etiolated barley (Hordeum vulgare L.) shoots is activated by blue light and interacts with 14-3-3 proteins

The vacuolar H(+)-ATPase (V-ATPase) is a key enzyme that controls the electrochemical proton potential across endomembranes. Although evidence suggests that V-ATPase is important for photo-morphogenesis, little is known about short-term regulation of V-ATPase upon initiation of the photo-morphogenetic programme by exposure of dark-grown plants to light. In this study, etiolated coleoptiles were given a short blue light treatment and V-ATPase characteristics were determined. The effectiveness of the light treatment was assessed by means of fusicoccin binding to the plasma membrane; this increased 5-fold. The short light treatment also induced a 2-fold to 3-fold increase in the hydrolytic activity of V-ATPase. Members of the 14-3-3 protein family are involved in both blue light perception and the subsequent activation of the P-type ATPase. We provide evidence that 14-3-3 proteins specifically interact with the catalytic A-subunit of the V-ATPase. First, the isolated V1-part of the V-ATPase co-purifies with 14-3-3 on a gel filtration column. Secondly, in an overlay experiment, 14-3-3 interacts with a 68 kDa band that was identified as the V1 A-subunit by mass spectrometry. Thirdly, in 14-3-3 affinity chromatography, both A- and B-subunits of the catalytic moiety of the V-ATPase were identified by matrix-assisted laser desorption ionization tandem time of flight mass spectrometry (MALDI TOF/TOF MS) as 14-3-3-interacting proteins. It was shown that the A-subunit can be phosphorylated in vitro by a tonoplast-bound kinase, whose properties are affected by blue light. Taken together, the data show that besides the P- and F-type H(+)-ATPases, the V-type H(+)-ATPase also interacts with 14-3-3 proteins.

Die Candida-albicans-induzierte Spondylodiszitis der Halswirbelsäule bei einem polytraumatisierten Patienten

With the increasing occurrence of predisposing factors, invasive candidiasis is being diagnosed more frequently. Based on a review of only a few previous reported cases, we describe and discuss the unusual case of candidal cervical spondylodiscitis in a 36 year old man who had sustained a polytrauma, complicated through a Candida albicans pneumonia. The main symptom was disabling neck pain. Clinical, laboratory and radiological findings were unspecific. The definitive diagnosis was determined by MRI imaging and biopsy. The early diagnosis and surgical treatment with a sufficient debridement and stabilisation of the affected segment combined with a prolonged antifungal therapy lead to good results.

Welche Vorteile bietet die volare Plattenosteosynthese gegenüber der Kirschner-Drahtstabilisierung bei distalen Radiusextensionsfrakturen des alten Menschen?

PURPOSE

The purpose of this retrospective study was to compare the outcome of open reduction and internal fixation (ORIF) followed immediately by physiotherapy and of percutaneous K-wire-fixation and casting for unstable distal radius fractures in elderly patients, considering the results both in general, for all such fractures, and selectively for A3 and C2 fractures.

METHODS

Follow-up examinations were performed 26 (18-48) months after surgery in 43 patients (median age 67 (60-83) years) treated with K-wire fixation and 9 (5-17) months after surgery in 46 patients (median age 76 (60-90) years) treated with ORIF, and the outcome of each was recorded as Disabilities of the Arm, Shoulder and Hand (DASH), Gartland-Werley and Castaing scores; the radiological loss of correction was also assessed. Statistical analysis was performed first without reference to the specific type of fracture for the K-wire- and the total ORIF -groups, and then selectively for A3 and C2 -fractures only; in the second analysis the patients were divided into three groups: KD, ORIF with and ORIF without angular stability.

RESULTS

The Garland-Werley and Castaing scores do not indicate any significant difference between the procedures specified. According to the Garland-Werley score 37 patients (86%) treated by K-wire fixation and 39 (85%) treated by ORIF achieved "excellent" and "good" results; according to the Castaing score there were 33 (77%) "good" results after K-wire fixation and 34 (74%) good results after ORIF. The radiological loss of correction (K-wire fixation/ORIF) as measured by the radial inclination (median 2/2.5 degrees), the palmar tilt (median 3/5 degrees) and the radial shortening (median 1/1 degrees mm) do not differ significantly. Suboptimal radiological results do not always correlate with results that are only "fair" or "poor". The non-fracture-specific DASH score suggests a higher degree of patient satisfaction after K-wire fixation (7 [0-87] points) than after ORIF (17 [0-82] points), which is not confirmed by fracture-specific evaluation. There is a significantly earlier return to the "activities of daily living" (4 as against 8 weeks) after ORIF.

CONCLUSION

All the treatments compared are suitable for the treatment of A3 and C2 fractures. The important advantages of ORIF are the early functional physiotherapy without casting and without obligatory second surgery and the earlier return to "activities of daily living", which are all of decisive importance for older patients, who are the ones most frequently affected.

[The chronic central fracture dislocation of the hip]

The acetabulum fracture with chronic dislocation of the femoral head is relatively uncommon. Due to complex morphology and bone defect of the acetabular dome, stable internal fixation is difficult. Primary total hip arthroplasty represents an alternative treatment. We report the case of a 66-year-old patient with a 3-month history of acetabular fracture with central dislocation of the femoral head. The patient was treated with cemented total hip arthroplasty and cancellous bone grafting of the central dome defect for stable cup fixation.

[A bilaterally dislocated intraarticular calcaneus fracture in a 13-year old boy]

Bilaterally dislocated intraarticular calcaneus fractures in childhood are rare. This case report shows that adequate preoperative tissue management, open anatomical reduction, and lateral plate osteosynthesis by an experienced surgeon according to the principles of adult surgery achieve a good functional result.

[Injuries of the elbow joint]

Injuries of the elbow joint increase along with increased athletic activity and life expectancy. Knowledge of anatomy and biomechanics is important for understanding injury patterns, specific diagnosis, and therapy. Here we classify the most frequent elbow injuries such as dislocation, ligamentous instability, and fracture of the radial head, processus coronoideus, olecranon, and distal humerus based on joint anatomy, biomechanics, clinical examination, and imaging. Specific therapies are described.

Monteggia-Verletzungen im Erwachsenenalter

BACKGROUND

Complications, revision surgery, and unsatisfactory functional results after operative management of Monteggia fractures are frequent. Moreover, hardly any studies exist that deal exclusively with the therapeutic concept for adults.

PATIENTS AND METHODS

Between January 1988 and December 2001, 68 patients with Monteggia fractures or equivalent injury were surgically treated. A total of 49 patients could be followed up after 83 months (25-176). Fracture type was assessed according to Bado's classification, functional results according to the Mayo elbow performance score, and the extent of osteoarthritis based on the criteria of Baird and Johnson.

RESULTS

The median age of the follow-up patients was 38 years (18-89, 31 men, 18 women). Corresponding to Bado's classification the following injuries were observed: 18 cases of type 1, 22 of type 2, 5 of type 3, and 4 cases of type 4. After surgical intervention, 14 patients achieved "very good", 21 "good", 9 "satisfactory", and 5 "poor" results. Of the 14 patients with either "satisfactory" or "poor" results, 9 manifested a type 2 injury. Complications requiring revision surgery occurred in 14 patients and complications not requiring revision in another 14. Severe osteoarthritic changes in the humeral or radioulnar joint were observed in 4 cases.

CONCLUSIONS

Monteggia fractures in adults are fraught with complications despite good functional results in the majority of cases. The patient should be made aware early on of the risk of residual functional deficits and the need for further surgical intervention.

Fresh meniscal allograft transplantation and autologous ACL/PCL reconstruction in a patient with complex knee trauma following knee dislocation--a case report

Instability of the knee joint, particularly in combination with the loss of one meniscus, regularly leads to the early development of arthritis. This paper describes the case of a 19-year-old male with ruptures of the anterior (ACL) and posterior cruciate ligament (PCL) along with the loss of the medial meniscus due to knee dislocation. Combined, time-delayed reconstruction of both the ACL and PCL and the allogenic fresh meniscal transplantation of the medial meniscus without bone plugs were performed. The control arthroscopy performed 6 months post-transplantation revealed good vitality and integration of the grafts as assessed both macroscopically and histologically. A small portion of the posterior horn had to be refixated, and the anterior horn was atrophic. At 24 months after trauma and 13 months following meniscal transplantation, the patient achieved a Lysholm score of 88 points and clinical examination indicated a stable knee. Fresh meniscal allograft transplantation, in combination with autologous ACL and PCL reconstruction, constitutes--in specialized centers--an alternative treatment option for complex trauma of the knee joint with loss of a meniscus.

Die winkelstabile Plattenosteosynthese (LPHP®) proximaler Humerusfrakturen über den kleinen anterolateralen Delta-Splitting-Zugang - Technik und erste Ergebnisse

The Locking-Proximal-Humerus-Plate (LPHP) was slided from proximally to distally through a small anterior-lateral-deltoid-splitting-approach following a closed reduction. Additional tension band wiring for the rotator cuff was fixed at the plate after screw insertion. The prospective study included 35 patients (age median: 63 years, range: 33-92; male: 13, female: 22) from 08/01-05/02. The follow-up period was set to 3 months postoperatively, whereas 29 patients were able to attend. The patient-group with 2-part fractures (n = 8) showed an average Constant score of 77.6 points (+/- 10.7, "good"), the patients with 3-part fractures (n = 16) an average score of 75.1 points (+/- 14.4, "good") and the patients with 4-part fractures (n = 5) an average score of 64.8 points (+/- 10. 4, "moderate"). Specific, approach-related problems were not observed. Almost all fractures revealed bony union during the first 3 months and only one loss of reduction was found. A screw loosening in 2 cases and a break of the plate in 3 cases were seen as implant related problems, and furthermore in 5 cases the screws placed in the humeral head were too long. Only one early re-osteosynthesis with the same plate was necessary due to an initial non-correct reposition. As demonstrated by these good short-term results, this technique seems to be a suitable procedure for displaced humeral head fractures.

[Arthroscopy for anterior joint pathology at the upper ankle joint --pathogenesis, therapy and results]

The conservative treatment of chronic ankle pain and at the so-called "footballer's joint" is of limited success. Arthroscopy is a possibility of operative treatment. 25 arthroscopies were carried out at the upper ankle joint at anterior joint pathology from January 1998 to June 1999. 21 patients could be examined in a median follow-up of 16 months (4-24). The median age was 31 years (17-56; female: 6, male: 15). Synovilitis was found in all cases. In 9 cases exophytes of the tibia, in 10 cases osteochondral lesions and in 7 cases antero-lateral impingement ware seen. The preoperative Score of Mazur of median 63 (21-85) points showed a significant raise (p < 0.05) in follow-up to median 93 (81-100) points. The complete athletic rehabilitation could be restored in 2/3 of the patients. The conservative therapy represents a good method of treatment chronic troubles in the upper ankle joint. Arthroscopy is indicated if no recovery can be attained.

Proximal humeral fractures: how stiff should an implant be? A comparative mechanical study with new implants in human specimens

BACKGROUND

The objective of this study was to determine the in vitro characteristics of the clinically used and newly developed implants for the stabilization of proximal humeral fractures under static and cyclic loading. The goal was to optimize implant stiffness for fracture stabilization even in weak bone stock.

METHODS

In a laboratory study using 35 fresh human humeri, the specimens were randomized into 5 groups, which included the clinically used humerus T-plate (HTP), the cross-screw osteosynthesis (CSO), the unreamed proximal humerus nail with spiral blade (UHN), the recently developed Synclaw Proximal Humerus Nail (Synclaw PHN) and the angle-stable Locking Compression Plate Proximal Humerus (LCP-PH). The implant stiffness was determined for three clinically relevant load cases: axial compression, torsion and varus bending. In addition, a cyclic varus-bending test was performed to determine the implant properties under cyclic loading.

RESULTS

In contrast to a rather elastic and minimally invasive implant(LCP-PH), the conventionally designed ones (Synclaw PHN, CSO, HTP, UHN) showed rather high stiffness values under static loading. In cyclic loading, a strong decrease in stiffness ( p<0.05) was found for the rigid implants HTP and UHN. In comparison with the other implants, only the elastic implant (LCP-PH) showed a significantly lower load reduction in a weak bone stock (17+/-6.2%).

CONCLUSION

The high initial stiffness of rigid implants led to an early loosening and failure of the implant-bone interface under cyclic loading. Implants with low stiffness and elastic characteristics, however, appear to minimize the peak stresses at the bone-implant interface, making them particularly suitable for fracture fixation in osteoporotic bone.

[Tibial plateau fracture--biodegradable bonecement-augmentation]

Between October 1996 and January 1999,29 patients (f:16,m:13,age: 22-86) with fractures of the lateral tibial plateau were operated on arthroscopic,fluoroscopic control or were treated with open reduction and internal fixation. 15 of them were retrospective and 14 prospective analysed. The metaphyseal defect after elevation of the depressed fragment was augmented in 11 cases with autologous spongeous bone grafting,in 9 cases with biodegradable bone cement (Norian SRS). Augmentation was unnecessary in 9 cases. The results according to the Lysholm score and the radiological results were good or excellent. Concerning the kind of augmentation no difference was noted. In the Norian SRS-group the duration of postoperative treatment was shorter than in the other group. The duration of partial weight bearing was shorter too. The results of the present study suggest that an injectable calcium phosphate cement may be a competent material for augmentation in lateral tibial plateau fractures because of the application form and the initial high mechanical stability.

[Age- and gender-related distribution of bone mineral density and mechanical properties of the proximal humerus]

PURPOSE

To evaluate age- and gender-related mechanical properties and bone mineral density (BMD) of the proximal humerus at different levels and regions.

MATERIALS AND METHODS

Mechanical indentation testing, DXA, QCT, pQCT and the radiogrammetry (Cortical Index, CI) were carried out in 70 freshly harvested humeri from 46 human cadavers (23 females, 23-males; median age 70.5 years).

RESULTS

In the female group, a high correlation between age and BMD was found (rho = 0.62 to -0.70, p < 0.01) with statistically significant differences between specimens of patients 69 years or younger, and 70 years or older (p < 0.05). In the group of female specimens of age 70 years or older, BMD values were found to be significantly lower compared to their male counterparts (p < 0.05). Regardless of the specimen's age, the highest BMD and bone strength were found in the proximal aspect and in the medial and dorsal regions of the proximal humerus.

CONCLUSION

These findings provide an insight into the fracture mechanism of the proximal humerus and should be the basis for designing structure-oriented implants with improved implant-bone stability in osteoporotic patients.

[Endoscopically assisted minimally invasive reconstruction of the anterior thoracolumbar spine in prone position]

Irrespective of an anterior open or endoscopic approach, the combined postero-anterior instrumentation of thoracolumbar fractures requires time consuming intraoperative maneuvers changing the patients position from prone to lateral.A standardised anterior endoscopically assisted approach for the segments Th4 to L4 is described, allowing the patient to remain in prone position, using a 4-5cm incision combined with a retractor system. The approach to the anterior spine in prone position is feasible by using a self holding retractor system for the region from Th4 to L4. Time of anaesthesia for the one stage combined procedure can be reduced by about 40 min, when changing the position of the patient is no longer necessary. The minimal incision in combination with the retractor system allows mainly the use of conventional instruments and implants, which provides reasonable lower costs. The advantages of the open and the endoscopical technique are combined. The main advantage of the prone position is the opportunity to access the anterior and posterior spine simultaneously, which is extremely helpful in reduction maneuvers.

[Isolated rupture of the subscapularis tendon in the overhead athlete - the result of chronical overuse?]

The case of a 27-year-old overhead athlete with chronic shoulder pain because of an isolated subscapularis tear without trauma is described. Arthroscopy has proven to be the appropriate method for detailed visualisation of the injury and facilitates the operative planning. Furthermore, arthroscopy closes the problem of a "diagnostic gap". In the presented case, the results at the two year follow-up are excellent. The authors conclude that an operative approach is also justified in non-traumatic isolated ruptures of the subscapularis muscle.

Conservative functional treatment of ankle fractures

Thirty-eight patients (mean age 49 years; range 19-91 years; nine of them over 60 years; 28 women, 10 men) suffering from an isolated Weber B fracture with a dislocation of less than 1 mm underwent functional therapy using a pneumatic ankle brace and were included in a prospective study. The clinical outcome was measured according to the Olerud-Molander ankle score. Functional therapy was finished in 34 cases successfully. Twenty-one patients were scored after 17 months on average (range 8-27 months) with the Olerud-Molander ankle score. A very good result was seen in 18 patients, including 12 with 100 points, a complete remission. The remaining 3 patients showed good results (1 had 90, 2 had 85). However, functional treatment failed in 4 cases due to secondary dislocation. These patients underwent surgery without further complications. The control group, 31 operated patients, did not show as good results. Functional therapy of stable Weber-B ankle fractures appears to be superior to surgery. We were able to avoid surgery in 90% of our patients and got better results than with patients undergoing open reduction and internal fixation.

[Conservative or operative treatment of humeral head fractures in the elderly?]

The humeral head fracture in the elderly represents an unresolved problem, which is reflected by the variety of existing therapeutic strategies ranging from conservative treatment to humeral head replacement. The main factors influencing the prognostic outcome are the fracture type, age of the patient and biologic criteria such as osteoporosis, blood supply at the fragments, and the degree of soft tissue trauma. For selection of the optimal treatment, the general condition of the patient, additional injuries and chronic diseases have to be respected as much as the patient's compliance and personal demands. According to experimental and clinical findings, for displaced two- and three-part fractures of the elderly patient minimal osteosynthesis and in the future plate osteosynthesis with angular stability should be preferred. For these fracture types, conservative treatment must be included in the therapeutic spectrum. In contrast, displaced four-part fractures and fracture dislocations are indications for primary humeral head replacement. This is explained by the fact that neither conservative treatment nor surgical reconstruction procedures meet the main goal of primary therapy, aiming for early painless mobilization and for timely discharging the elderly patients in their social environment.