Open Reduction and Palmar Plate-Osteosynthesis in Combination with a Nanocrystalline Hydroxyapatite Spacer in the Treatment of Comminuted Fractures of the Distal Radius

In a prospective study, we used the nanocrystalline hydroxyapatite paste Ostim (Osartis, Obernburg, Germany) in combination with a palmar plate to treat comminuted radius fractures with a metaphyseal and articular component in order to examine the clinical use of Ostim as a bone substitute. Twenty-one patients with 22 radius fractures of AO types C2 and C3 were included in the study. The measurements, taken 10.2±1.3 months after the initial treatment, revealed a dorsopalmar tilt of 8.8±3.7°, a radioulnar inclination of 18.8±2.8° and an ulnar variance of 0.8±1.8 mm. According to the Gartland and Werley evaluation, eight of the treated fractures attained an excellent, 11 a good and the remaining three a fair result. The study demonstrates that Ostim, in combination with angularly stable osteosynthesis, can be used as an acceptable bone substitute for the treatment of type C2 and C3 radial fractures.

Prediction of immediate and long-term benefit after kyphoplasty of painful osteoporotic vertebral fractures by preoperative MRI

BACKGROUND

It is unclear if an MR-detectable bone marrow edema is a prerequisite for pain reduction and morphological correction by kyphoplasty. This comparative trial evaluates clinical and radiomorphological outcomes after kyphoplasty of painful osteoporotic vertebral fractures with and without preoperative MR-detectable bone marrow edema for 1 year of follow-up.

METHODS

Preoperative MR-images of 45 patients who received kyphoplasty for treatment of painful osteoporotic vertebral fractures were evaluated with regard to presence (n = 27) or absence (n = 18) of vertebral bone marrow edema. Pain scores (VAS 0-100) and radiomorphological measures (midline vertebral height, kyphosis angle) were analysed at baseline, postoperatively and after 12 months.

RESULTS

In the "bone edema" group, pain scores improved from 72.7 to 46.8 (postoperative) and 48.0 (12 months, P < 0.001, both). In the group without preoperative bone edema, pain score improved from 70.7 to 60.3 (postoperative, P = 0.013) and to 50.1 (12 months, P = 0.001). Pain scores of both groups were significantly different directly postoperative (P = 0.026), but not after 12 months (P = 0.714). Vertebral height restoration was slightly greater in the "bone edema" group (10.2% vs. 7.8%, P = 0.289). Correction of the kyphosis angle was greater in the "bone edema" group (P = 0.014) compared to the "no bone edema" group (P = 0.838).

CONCLUSION

A preoperative MR-detectable vertebral bone marrow edema predicts a better short-term outcome after kyphoplasty, but is not a prerequisite for long-term pain reduction in patients with old, chronically painful osteoporotic vertebral fractures.

Vertebroplasty and kyphoplasty - inefficient treatments for degenerative spine disease

Osteoporotic vertebral fractures and pathological vertebral lesions are frequent clinical situations causing severe back pain. The pharmacological treatment of the underlying disease and the analgetic treatment of the associated back pain usually do not rid the patient's back pain completely and are insufficient to prevent the fracture-weakened vertebral body from further fracturing with long term consequences for the biomechanical competence of the entire spine. In the last 10 years the minimal invasive treatment options vertebroplasty (VP) and balloon kyphoplasty (BK) have spread quickly because these procedures appeared to be promising treatments to stop the fracture and vertebral lesion associated back pain and to internally stabilize a fractured vertebral body. Numerous published reports on VP and BK appeared to support the notion of an immediate and lasting pain reduction after VP and BK in additon to a prevention of further fracturing of the treated vertebrae. The first three randomized controlled and partly blinded trials have been published this year. Two of these trials demonstrate that VP does not result in a better pain control than a sham operation whereas BK was shown to reduce back pain due to verterbal fractures for at least 12 months. Considering that more than 1.5 million people world-wide have been treated with VP and BK until now this work discusses the recent trials and suggests clinical and academic consequences on the basis of the most recent evidence.

Comparison of kyphoplasty with use of a calcium phosphate cement and non-operative therapy in patients with traumatic non-osteoporotic vertebral fractures

One of the current standard treatment options for younger patients with stable traumatic vertebral fractures is conservative treatment using braces. Kyphoplasty as a minimally invasive procedure has been shown to be effective in stabilizing vertebral body fractures, resulting in immediate pain relief and improved physical function. The purpose of this prospective study was to clarify whether patients with acute traumatic vertebral fractures benefit more from kyphoplasty or from conservative treatment with a brace. A prospective study was undertaken in two centers. Forty patients with acute painful traumatic vertebral body fractures type A1-A3 (AO-classification) after adequate trauma, without osteoporosis, suitable for kyphoplasty or therapy by brace were included into the study. Follow-up was 12 months. Patients of the kyphoplasty group showed an immediate beneficial and significant effect postoperatively, and better outcomes 1 and 3 months after operation compared to the conservatively treated group in pain feeling, mobility and vertebral body height. After 12 months the difference between both groups was not significant excepting the vertebral body height. Kyphoplasty provides early and lasting reduction of pain and improvement of daily activity. However, there are clinically asymptomatic cement leakages in up to 45% of which we do not know the consequences in long term. Every patient with traumatic vertebral body fracture treated by kyphoplasty has to be informed about that. Long-time results are outstanding and our findings require confirmation by randomized controlled trials.

[In vitro studies on various PMMA bone cements: a first comparison of new materials for arthroplasty]

AIM

Two clinically established PMMA bone cements (Refobacin Palacos R and Palacos R + G) and two newer cements not yet in widespread clinical use (Refobacin Bone Cement R and SmartSet GHV) were tested in vitro for practically relevant differences.

METHODS

The tests included chemical analyses, handling properties and testing according to the ISO standard for PMMA bone cements.

RESULTS

The results obtained indicate clearly that the copolymers used in Refobacin Bone Cement R and SmartSet GHV differ from those used in the Palacos cements. There were also significant differences in viscosity behaviour and waiting time (p < 0.01 for Palacos cements versus Refobacin Bone Cement R) as an expression of different handling properties. The hardening times under ISO 5833 conditions also differed significantly (p < 0.01 and p < 0.05 for Palacos cements compared with Refobacin Bone Cement R and p < 0.01 for Refobacin Bone Cement R compared with SmartSet GHV).

CONCLUSION

In view of these differences in material properties, the clinical data from long-term use of the bone cements Refobacin Palacos R and Palacos R + G cannot be extrapolated to the newly developed PMMA cements Refobacin Bone Cement R and Smart GHV. Before broad clinical use of these cements, prospective clinical studies using RSA or DEXA and, as a second step, statistically powerful prospective comparative studies should be performed. Until these data are available, patients in whom Refobacin Bone Cement R and SmartSet GHV are used should be informed that the material employed deviates from the standard procedures for cemented joint replacement in the Scandinavian arthroplasty registers and that the long-term consequences cannot, in the final instance, be foreseen. This is essential in order to avoid later malpractice claims on the grounds of inadequate information.

[Balloon kyphoplasty in the therapy of vertebral fractures]

Approximately 500,000 vertebral fractures occur as a result of osteoporosis every year in Europe. One third of the patients thus affected complain of severe back pain and seek treatment. In the past, the treatment of such fractures was limited to conservative methods, such as the use of braces and analgesics and long-term immobilisation followed by physiotherapy. Since 1998 balloon kyphoplasty, a minimally invasive procedure, has also been available for their treatment. During balloon kyphoplasty a balloon system is introduced into a fractured vertebral body to achieve bitranspedicular augmentation, after which low-viscosity bone cement is injected into the vertebral body, where it sets very quickly. In general the patient can be fully mobilized 24-48 h after the procedure and in most cases the symptoms are then considerably attenuated; many patients are actually free of pain. Published studies and our own experience indicate that balloon kyphoplasty is a safe method of treating painful vertebral compression fractures sustained in various ways and that complications are rare with this procedure.

[Balloon kyphoplasty in the treatment of vertebral fractures]

Approximately 500,000 vertebral fractures occur as a result of osteoporosis every year in Europe. One third of the patients thus affected complain of severe back pain and seek treatment. In the past, the treatment of such fractures was limited to conservative methods, such as the use of braces and analgesics and long-term immobilisation followed by physiotherapy. Since 1998 balloon kyphoplasty, a minimally invasive procedure, has also been available for their treatment. During balloon kyphoplasty a balloon system is introduced into the fractured vertebral body to achieve bitranspedicular augmentation, after which low-viscosity bone cement is injected into the vertebral body, where it sets very quickly. In general the patient can be fully mobilized 24-48 h after the procedure and in most cases the symptoms are then considerably attenuated; many patients are actually free of pain. Published studies and our own experience indicate that balloon kyphoplasty is a safe method of treating painful vertebral compression fractures sustained in various ways and that complications are rare with this procedure.

[Balloon kyphoplasty in the treatment of back pain]

BACKGROUND

Experience of just under 5 years has shown that balloon kyphoplasty can be just as successfully employed as the longer-stablished vertebroplasty for the treatment of back pain due to recent or prior osteoporotic fractures as well as new traumatic fractures.

MATERIAL AND METHOD

Among 345 patients with a total of 690 treated vertebral bodies, the change in pain symptomatology was analyzed for a follow-up period of 12 months in 40 study patients who underwent kyphoplasty and a control group of 20 patients. In addition, the pain experienced by a further 29 patients with new traumatic vertebral body fractures was monitored over a 12-month period. These fractures were partly managed by fixateur interne alone and by a combination of fixateur interne and kyphoplasty.

RESULTS

The 40 patients treated by kyphoplasty had a baseline VAS score of 26.2+/-2.00, which increased to 44.4+/-3.11 after 12 months, while the respective scores for the control group were 33.6+/-4.21 and 34.3+/-4.35. In the 29 patients with new traumatic vertebral body fractures, the initial VAS score was 62 and after 12 months a distinct reduction of pain was noted with a score of 20 (100 = maximum pain, 0 = no pain). The number of times that the 40 patients managed by kyphoplasty had to consult their general practitioner was significantly reduced by the pain therapy.

CONCLUSION

Balloon kyphoplasty verifiably improved the pain symptomatology after vertebral fracture over a period of 12 months. Comparison with the control group, which received the same osteoporosis drug therapy, confirmed the effect of this minimally invasive treatment form.

Problems and costs associated with alcohol and drug abuse in emergency medicine

Preclinical care refers to patients with life-threatening conditions. It remains unclear how alcohol and drug abuse contribute to the frequency and severity of emergency cases. This study evaluated the influence of these psychotropic substances on preclinical emergencies and the social security costs arising from this. The records of 400 emergency patients were analyzed prospectively regarding type and severity of emergency, intake of psychotropic substances before the emergency, and their influence on patients' outcome. Psychotropics were detected in 19% of patients; 84% of these patients (vs. 55% overall) were scored below 4 (not life threatening) on the National Advisory Committee for Aeronautics scale and therefore did not require a physician on-site. Alcohol or drug intake frequently causes emergencies with physicians on-site; retrospectively 84% of these interventions were thus found to be unnecessary, caused by difficulties in recognizing the severity of the disorder, especially in mental or respiratory disorders. Extrapolated to Germany overall this means 675,000 drug-related emergencies yearly, costing euro 310,000,000.

Transarterial embolization of primary and secondary tumors of the skeletal system

Percutaneous transcatheteral embolizations of primary and secondary bone tumors are important minimal invasive angiographic interventions of the skeletal system. In most of the cases embolization is performed for preoperative devascularization or as a palliative measure to treat tumor-associated pain or other tumor bulk symptoms. The transarterial embolization of primary and secondary tumors of the skeletal system has been developed to a safe and very effective method. Indications, techniques, results and complications of this minimal invasive interventional therapy for treatment of primary and secondary bone tumors are described and discussed and compared with the newer literature and our own results.

CT volumetry of intravertebral cement after kyphoplasty. Comparison of polymethylmethacrylate and calcium phosphate in a 12-month follow-up

This study was intended to measure the volume of intravertebral cement after balloon kyphoplasty with high resolution computed tomography (CT) and dedicated software. Volume changes of biocompatible calcium phosphate cement (CPC) were detected during a follow-up of 12 months. Measurements were compared with a control group of patients treated with polymethylmethacrylate (PMMA). Twenty-three vertebrae (14 CPC, 9 PMMA) of 12 patients were examined with CT using an identical imaging protocol. Dedicated software was used to quantify intravertebral cement volume in subvoxel resolution by analyzing each cement implant with a density-weighted algorithm. The mean volume reduction of CPC was 0.08 ml after 12 months, which corresponds to an absorption rate of 2 vol%. However, the difference did not reach significance level (P>0.05). The mean error estimate was 0.005 ml, indicating excellent precision of the method. CT volumetry appears a precise tool for measurement of intravertebral cement volume. CT volumetry offers the possibility of in vivo measurement of CPC resorption.

Detection of high-energy phosphates in cortical bone as an indicator of bone healing and remodelling: use of a rabbit model

PURPOSE; To study high-energy phosphates in cortical bone through experiments on inbred white New Zealand rabbits.

METHODS

Tibial fractures were induced in 80 rabbits and then stabilised by screw osteosynthesis. After 3 (group A; n=40) or 7 days (groups B; n=40), the defective tissue was covered by local muscle flaps. At increasing intervals (from 1 to 16 weeks), the screws were removed and the animals were euthanised (n=8 per group). The bone was removed and analysed histomorphologically; adenosine triphosphate (ATP) levels were determined by high-performance liquid chromatography.

RESULTS

The mean ATP concentration in healthy cortical bone at 16 weeks was 0.092 (standard error, 0.009) nmol/mg dry mass, which was significantly higher than that in the group with delayed healing: 0.081 (0.011) nmol/mg in group A and 0.005 (0.001) nmol/mg in group B (paired t test, p<0.05). Earlier healing led to lower rates of necrosis (0 vs 38; groups A vs B) and osteomyelitis.

CONCLUSION

Early muscle-flap coverage can revascularise the cortical bone, which is reflected in the higher ATP content in the cortical bone measured by high-performance liquid chromatography. Measuring changes of ATP levels can help investigate the metabolism of the pathological bone.

Die Wertigkeit der Ballonkyphoplastie bei der osteoporotischen Wirbelkörperfraktur

BACKGROUND DATA

Patients with osteoporotic vertebral compression fractures frequently complain of pain and a loss of function and mobility. Such fractures are associated with an increased mortality. The common treatment with bed rest, bracing or osteosynthesis does not lead to satisfying results. With two new surgical techniques, vertebroplasty and kyphoplasty, an internal stabilisation of osteoporotic vertebral fractures is possible.

METHODS

All patients were treated by kyphoplasty. With a minimal invasive dorsal approach, an inflatable bone tamp is placed in the fractured vertebral body. This tamp can restore the vertebral body height and create a cavity, which is filled with bone cement under low pressure. The advantage of kyphoplasty compared to vertebroplasty is the restoration of the vertebral height and a decreased cement leakage rate. We performed a prospective, interdisciplinary study with a follow-up of 12 months. We treated 192 vertebral fractures in 102 patients. Augmentation was performed with polymethylmethacrylate in 138 cases and with a new injectable calcium phosphate-cement in 54 vertebral bodies. Outcome data were obtained with two different spine-scores and by the radiomorphometric evaluation of x-rays before and after treatment.

RESULTS

We noticed a significant improvement in pain and function in 89% of the patients. All patients showed a regain of vertebral height of on average 17%. In 7% of all treated vertebral bodies, we noticed cement leakage, which was, however, far below the rates published for vertebroplasty (20-70%). There were two complications, bleeding due to an unknown coagulopathy and a violation of the myelon by malpunction.

CONCLUSION

Kyphoplasty is a reliable and minimally invasive method for stabilizing fractured osteoporotic vertebral bodies. Improvement of pain and function and a regain in height of the treated vertebral body can be accomplished.

Bestimmung der Tibiatorsion - Vergleich von klinischen Winkelmessungen zur Computertomographie

PURPOSE

To determine variability between clinical goniometric methods and computed tomography (CT) in measuring posttraumatic malrotation of the tibia.

MATERIALS AND METHODS

In a prospective study, absolute tibial torsion of both legs after unilateral fracture of the tibia as well as the difference between both legs (intra-individual torsional difference) was postoperatively determined with two goniometric and two CT methods in 40 patients (female : male = 16 : 24, mean age = 46 +/- 34 years).

RESULTS

The mean difference between goniometric and CT methods in determining intra-individual torsional difference was not significant. Nevertheless, variance of values was higher in goniometric measurement (up to +/- 11 degree), with the measurements of torsional difference showing two times greater standard deviation in interobserver variability of goniometric methods as compared to CT.

CONCLUSION

Goniometric methods do not significantly differ from the CT methods for determination of intraindividual torsional difference. The higher variance of interobserver values limits accuracy of goniometric methods. Therefore, goniometric determination of tibial torsion can only be considered an estimate but not a precise measurement.

Augmentation von Wirbelkörperfrakturen mit einem neuen Calciumphosphat-Zement nach Ballon-Kyphoplastie

QUESTION

Can the same levels of pain reduction and increase in function be achieved in kyphoplasty procedures with Calcibon as with polymethylmethacrylate (PMMA) cement?

PATIENTS AND METHODS

In a prospective, interdisciplinary single-center study, 99 patients (173 vertebral fractures) were treated with kyphoplasty. Augmentation was performed with PMMA in 66 cases (127 vertebral bodies) and with Calcibon in 33 patients (46 vertebral bodies). Outcome data were obtained with a VAS spine score and by radiomorphometric evaluation of X-rays before and after treatment.

RESULTS

Pain and function improved in 87% of the patients; an average of 16% of the lost vertebral height was regained. A 9% cement leakage rate was observed with PMMA and 10% with Calcibon. There was no significant difference in pain reduction and radiomorphometric evaluation between the two techniques.

CONCLUSION

Kyphoplasty is a reliable, minimally invasive method to stabilize fractured vertebral bodies. Augmentation with Calcibon improves pain and function and enables the treated vertebral body to regain of height.

Kyphoplastie und Vertebroplastie bei Frakturen im hohen Lebensalter

Kyphoplasty and vertebroplasty are two minimally invasive percutaneous techniques used for treatment of osteoporotic vertebral compression fractures in the thoracic and lumbar spine. The injection of polymethylmetacrylate (PMMA) is often a final attempt at therapeutic treatment of complications due to such fractures. Vertebroplasty involves injection of cement via one or both pedicles under high pressure, thus filling and stabilizing the vertebra without reduction of fracture. Extravertebral cement leakage is a common complication: an intact posterior wall normally prevents cement leakage into the epidural space. Kyphoplasty involves transpedicular inflation of balloon tamps, thus creating a cavity which is then filled with PMMA under low pressure. Restoration of vertebral height is possible and the potential for extravertebral cement leakage lessened.

Thermodiffusion for the quantification of tissue perfusion in skeletal muscle--clinical evaluation in standardized traumatological procedures with tourniquet and potential application in the diagnosis of compartment syndrome

The quantification of tissue perfusion in different parenchymal organs like liver, kidney, and brain by means of thermodiffusion has recently been validated experimentally and was introduced into clinical practice. Traumatology and plastic surgery deal as well with issues of microcirculation. Therefore, it was the aim of this study to validate thermodiffusion for use in skeletal muscle. Eighteen patients were studied during knee arthroscopic procedures that utilized a tourniquet. A thermodiffusion probe was inserted in the tibialis anterior muscle of the side under treatment. Measurement started before the initiation of limb ischemia (by tourniquet) and continued throughout the procedure until tissue perfusion returned to normal values postoperatively. Furthermore, an example of clinical applicability of this technique is given by monitoring muscle tissue perfusion in 3 patients with imminent compartment syndrome. Preoperative values of muscle tissue perfusion in the patients undergoing arthroscopic procedures were 17.74 +/- 4.27 ml/min 100 g. After initiation of tourniquet perfusion quickly decreased to 3.59 +/- 3.53 ml/min 100 g. Upon reperfusion tissue perfusion increased to values above normal for a few minutes and then returned to preischemic values of 20.86 +/- 7.01 ml/min 100 g. There was no significant difference between pre- and postoperative values (P=0.154) but tissue perfusion during tourniquet was significantly reduced (P=0.0001). In 3 patients presenting with the clinical signs of imminent compartment syndrome, thermodiffusion measurement was applied and showed microcirculatory impairment of different degrees. Fasciotomy was followed by a prompt increase of muscle microcirculation to levels slightly above normal. In summary, valid and stable measurements of tissue perfusion in skeletal muscle by means of thermodiffusion are possible under clinical circumstances. Thermodiffusion allows for on-line monitoring of muscle microcirculation, e.g., in compartment syndrome. The clinical potential of thermodiffusion measurements in trauma surgery needs further prospective evaluation.

[Case management and functional outcome in persons aged 65 years and over with hip fracture]

The goal of the investigation was to study case management and functional outcome in older patients with hip fracture. A prospective observational survey was performed, including all patients aged 65 years and over presenting with hip fracture in Heidelberg, from 1 July 1999 to 30 June 2000. All patients were reassessed by telephone calls 6 months post-fracture. A total of 331 patients were included (mean age 81.5 years, 81% female,23.8% nursing home residents). Hip fracture incidence per 1,000 was 7.8/year, and nursing home residents had a six times higher incidence rate than those living at home. Prior to the fracture, half of the patients were dependent in ambulation and a third needed support in basic activities. With substantial comorbidity (42% cognitive impairment), complications were common. Geriatric care was needed for 82% of the survivors. In-hospital treatment costs were about 10,000 Euro per fracture. Mortality at 6 months was 19.9%. The majority of survivors showed loss of competence and mobility. Functional outcome in older patients with hip fracture is disappointing. As the majority of the patients are frail, clinical treatment is complicated by "geriatric" problems. Thus, improved interdisciplinary care, with close cooperation between geriatricians and surgeons might result in a better functional outcome.

Laser doppler flow imaging of open lower leg fractures in an animal experimental model

PURPOSE

Open lower leg fractures are frequently associated with severe soft tissue damage, followed by osteomyelitis. Using an animal experimental model, we investigated the effect of timing of coverage of a tibial fracture with a local muscle flap.

METHODS

80 rabbits had a tibial fracture induced in a standardised fashion, which was stabilised by screw osteosynthesis. After 3 (group A; n=40) and 7 days (group B; n=40), respectively, the tissue defect was covered by a local gastrocnemius flap. In increasing intervals from 1 to 2, 4, 8, and 16 weeks, the rabbits from each group were killed and the bone fracture was analysed histomorphologically. Cortical microcirculation was measured by 2-channel laser doppler flowmetry.

RESULTS

Muscle flaps after 3 days improved perfusion significantly as compared with 7 days (24 Flux [standard error, 5 Flux] versus 10 Flux [3 Flux]; baseline, 1.4 Flux). Group A animals also displayed a lower rate of necrosis (0 versus 38). The incidence of osteomyelitis was higher in group B than in group A (24% versus 0%).

CONCLUSION

Laser doppler flowmetry was proven to be a reliable, minimally invasive means for identifying avital tissue, leading to reduction in the loss of vital bone tissue in experimental settings.

[Suture of fresh Achilles tendon rupture. Comparison of open with percutaneous suture technique]

INTRODUCTION

The open repair of the acute Achilles' tendon rupture reduces the incidence of rerupture compared with nonsurgical treatment; however, it yields more surgical complications. Early mobilization of the patients improves the postoperative outcome. Percutaneous suture techniques have a low incidence of rerupture and improve the conditions for early mobilization.

METHODS

This study includes all patients (n = 97) with acute subcutaneous rupture of the Achilles' tendon with surgical treatment at the University of Heidelberg from 1992 to 1999. Open surgical repair and postoperative immobilization has been compared with a percutaneous suture technique and postoperative early mobilization. Altogether, 77 patients (80%) have been interviewed and 62 patients (65%) have undergone a clinical examination.

RESULTS

There were local complications in 18% of the patients after open repair (n = 49) compared with 6% of the patients after percutaneous suture. In both groups there were two patients (4%) who sustained a rerupture. In the control group there were two patients with deep vein thrombosis (4%) and 1 lung embolism (2%). The clinical examination revealed no difference between open and percutaneous repair except for some disturbances in sensitivity of the sural nerve after percutaneous repair. The lower expenditure of therapy in percutaneous versus open sutures show the comparison of the hospitalization rates (29% versus 88%) and the rates of endotracheal anesthesia (53% versus 90%).

CONCLUSION

Percutaneous suture technique for the repair of the Achilles' tendon is a simple and safe surgical procedure which allows early mobilization with a low rerupture rate. Thus this method should be performed as standard procedure for acute subcutaneous rupture of the Achilles' tendon.

[Angle- and rotation-stable internal fixation of proximal humerus fractures with the humerus fixator plate. Early clinical experience with a newly developed implant]

INTRODUCTION

The Humerus Fixator Plate is presented as a new implant for angle- and rotation-stable internal fixation for the operative treatment of proximal humerus fractures at the surgical neck.

METHODS

In an ongoing two-centre study, 47 patients were treated with the new implant. To date, 31 patients had clinical and radiological postoperative follow-up examinations with a mean interval of 10 months (range: 6-14 months).

RESULTS

In 46 patients (97.9%), complete angle and rotational stability was achieved without limiting the range of motion or requiring immobilization. Good pain relief was obtained in 43 patients (91.5 %), and 3 patients (6.4%) showed moderate pain relief following surgery. There was one implant failure. Utilizing the Constant-Raw score (without any correction factors), a mean result of 82.8 points (range: 46-100 points) was ascertained. The majority of the patients (87.1%) achieved "excellent" or "good" clinical results. X-ray analysis revealed no non-union nor humerus head necrosis. In 4 cases (12.9%), protrusion of a humerus head screw was observed which mandated removal of the implant.

CONCLUSION

The first clinical investigations of the novel Humerus Fixator Plate are encouraging and provide essential advances in the treatment of unstable proximal humerus fractures.

[Psychotropic substances in the area of preclinical intensive care medicine]

The aim of preclinical intensive care is to prevent severe consequences by providing immediate therapeutic aid to emergency patients in a life-threatening condition. We investigated how the abuse of drugs and alcohol influences the frequency and the category of emergency cases as well as the patient outcome. 250 emergency cases were analysed in a prospective study in the area of Heidelberg, Germany, from the summer of 1995 to the spring of 1999. The analysis is based on patient data obtained from the German standardised Emergency Record and on the clinical outcome and influence of drugs and alcohol. A serious level of drugs or alcohol was detected in 17% of the patients (the average level of alcohol was 1.97 promille). 81% of these intoxicated patients were given a NACA (National Advisory Committee for Aeronautics) score of less than 4 (not life-threatening) and therefore were not in need of the a presence of a physician.

[The long gamma nail--indications, technique and results]

The introduction of the Gamma nail (GN) as an intramedullar implant for pertrochanteric femoral fractures that allowed full weight bearing decreased the death rate from 17% (methods without full weight bearing) to 6%. The long Gamma nail (LGN) is a logical supplement of the standard version, designed to treat unstable per-, subtrochanteric and segmental fractures. This study evaluated 44 consecutive operations. Seventy percent of the patients had to be classified ASA III and IV, due to their high morbidity. The median age was 73.5 years. Multiple injuries occurred in 30.2%. All fractures were considered unstable. Surgery was usually performed within 24 h. The median duration of the surgical treatment was 120 min. In five cases technical problems were observed. Radiological controls showed a good positioning of the head screw. Early complications consisted of four local wound infections, three of them deep infections with a osteomyelitis. Deep venous thrombosis was observed in four cases, two of which included a pulmonary embolism (conservative treatment). The 30-day death toll was 2.3% (one patient). The median survival time (using Kaplan-Meier) in the study was 46 months, compared to 80 months in a matched population. This difference has to be linked to high premorbidity. The median duration of admission was 15 days. Mobilisation with full weight bearing was theoretically possible in all cases, but additional injuries or preoperatively impaired walking ability prevented full mobilisation in 15 cases. Functional assessment uncovered a decrease in Merle d,Aubigne score of 26.7% due to an impaired walking ability. Seventy-three percent of the patients regained their preoperative social status. In conclusion the long Gamma nail is a universal, less invasive implant with high early weight bearing. It thus allows early remobilization and reduces lethality in the treatment of complex, unstable coxal fractures.

[Trans-scaphoid perilunar dislocation of the wrist (de Quervain) as a rare complication of electric injury]

We describe the case of a 67-year-old man with an electricity inflicted injury in the left hand and a transscaphoidal perilunear dislocation of the opposite right hand. On admission, the injury was missed on the standard ap-radiogram of the right hand, so the operative reconstruction was delayed. Later on, the lunate showed aseptic necrosis and wrist collapse as consequence.

Teaching model for intraoperative spinal sonography in spinal fractures. An experimental study

To improve the technique of intraoperative sonography of the spinal canal, a teaching model of the thoracolumbar spine was developed. It allows to simulate the typical spinal stenosis of a vertebral fracture and the sonographic procedure to detect and measure such a lesion. Moreover, partial laminectomy and modification of a fixateur interne set-up, which are preconditions for successful sonography, can be simulated. Independent of the surgical qualification, a high precision in sonographic localisation and measurement of the spinal canal stenosis was achieved by the training. The results could be validated in the cadaveric model. Thus, sonographic expertise acquired with the teaching model proved to be reliable in the clinical situation.

[The subacromial shoulder dislocation]

We report on a case of subacromial shoulder dislocation, which resulted from a combination of a cranial glenoid fracture and an acromial fracture. The patient sustained this rare injury while playing handball. The whole implication of the injury was revealed only after extensive workup with CT scan of the shoulder. After reduction of the shoulder dislocation, the glenoid fracture was stabilized by osteosynthesis. The postoperative results showed anatomical reconstruction of the glenoid joint surface. After completion of therapy, the patient has achieved good functional results with a full range of motion (abduction 180 degrees ) and has been able to work full-time again.

[Pigmented villonodular synovitis. Case reports and review of the literature]

Because this disease is so rare the optimum treatment of pigmented villonodular synovitis (PVNS), in particular the diffuse form differs in the literature. The most important surgical procedures are arthroscopic and open synovectomy. The prevention of disease progression, as well as joint destruction and dysfunction, depends upon the early diagnosis of PVNS. During 1994 and 1995, we treated four cases of PVNS surgically and followed the patients for a time period of more than 12 months. Two patients were treated with complete synovectomy, one patient underwent partial synovial resection, and in the final case an arthrodesis was performed. Our results indicate that an MRI is essential for diagnosis and treatment planning. For the localized form of PVNS, it appears that a partial synovectomy is appropriate. However, in the event of diagnostic uncertainty or obvious diffuse involvement of the synovium, a total synovectomy is indicated because of the high recurrence rate. In our study, all four patients had disease involving secondary bony lesions and, in one case, joint destruction. Based on our findings, it is clear that early surgical therapy is the only recommended curative intervention. The decision regarding the surgical approach, arthroscopic versus open, depends on the form of PVNS, the extent of the disease and secondary changes of the joint.

[3-dimensional ultrasound in clinical diagnosis of meniscus lesions]

AIM

To compare the significance of the two-dimensional and three-dimensional sonography in the diagnosis of meniscal tears under clinical conditions.

METHODS

Sixty menisci of knees with clinical symptoms (44 medial and 16 lateral menisci) were examined by an identical transducer in a two- and three-dimensional sonography technique. The findings were compared with the diagnosis made with subsequent arthroscopy.

RESULTS

In the diagnosis of meniscal lesions the two- and three-dimensional sonography reached a sensitivity of 92% and 100% and a specificity of 83% and 88%, respectively. The positive predictive value of these methods was 58% and 67%. The negative predictive value was 98% and 100%. Because of the good results with the two-dimensional sonography, there were no statistically significant differences between both methods. The three-dimensional sonography, however, proved to be superior, to the two-dimensional sonography in the analysis of subgroups (medial and lateral menisci, menisci with and without clinical symptoms). The negative predictive value of the three-dimensional sonography was 100% for all of these subgroups.

CONCLUSION

Although this study shows no significant difference in the results of two- and three-dimensional sonography, the analysis of subgroups displays a slightly improved significance for diagnosis of meniscal tears by three-dimensional sonography. The high negative predictive value shows that three-dimensional sonography, performed by an experienced examiner, may be useful to exclude meniscal tears. This result may help focus further cost-intensive or invasive examinations.

Ultrasound measurements at the proximal phalanges in healthy women and patients with hip fractures

Measurements of bone mineral density (BMD) are useful for the assessment of fracture risk in osteoporosis. First prospective studies showed that quantitative ultrasound as measured at the calcaneus also predicts future hip fracture risk, independently of BMD and as accurately as BMD. The aim of this study was to compile a reference population for a new ultrasound device that determines amplitude-dependent speed of sound (AD-SOS) through the proximal phalanges of the hand and to prove its ability to distinguish between health volunteers and osteoporotic patients. In a case-control study we examined 139 healthy women aged 21-94 years and a group of 24 female patients aged 69-94 years with recent hip fractures. In the healthy reference population additional BMD measurements were performed with dual-energy X-ray absorptiometry (DXA) and quantitative ultrasound measurements at the calcaneus were carried out. In vivo precision of AD-SOS measurements through the phalanges was 0.52% CV. Simple regression analyses showed a negative correlation with age (r = -0.73, p < 0.001); modest significant correlations with BMD of the lumbar spine (r = 0.36, p < 0.001) and BMD of the femoral neck (r = 0.37, p = 0.002) as measured with DXA were shown. The comparison with another ultrasound device measuring SOS and broadband ultrasound attenuation (BUA) through the calcaneus showed correlation with SOS (r = 0.50, p < 0.001); no significant correlation was found with BUA measurements. Furthermore a dependency of AD-SOS values in anthropometric factors such as body mass index (r = 0.37, p < 0.001), height (r = 0.40, p < 0.001) and weight (r = 0.23, p < 0.05) was shown. First study results on 24 clinically diagnosed osteoporotic patients, defined as patients with recent (< 1 week) pertrochanteric or femoral neck fractures, showed a good separation between age- and sex-matched controls and osteoporotic patients (Z = -2.0 SD). Receiver operating characteristic (ROC) curves showed an area under the fitted curve of 0.83 +/- 0.06. These results are powerful for a device measuring AD-SOS through the proximal phalanges of the hand, and further prospective studies have proven the capability of phalangeal ultrasound in fracture risk assessment.

Effects of standard unfractionated and low-molecular-weight heparins on platelets of patients undergoing total hip replacement surgery

For prevention of venous thromboembolism in general and in orthopedic surgery, patients are treated prophylactically with standard unfractionated heparins (SH) or with low-molecular-weight heparins (LMWH). Patients (n = 22) undergoing total hip replacement surgery received either 5,000 IU SH (Heparin-Na) three times per day (n = 10 patients) or LMWH (Fraxiparin) once per day (n = 12 patients). Blood samples using CTAD (citrate, theophylline, adenine, dipyridamole) as anticoagulant were collected perioperatively after the first heparin administration, after the operation, and daily until day 4 postoperatively. After cooling at 4 degrees C blood samples were centrifuged, platelet-rich plasmas (PRPs) prepared, and after platelet counting PRPs were divided into platelet sediments (PS) and platelet-poor plasmas (PPP). Cyclic adenosine monophosphate (cAMP), cyclic guanosine monophosphate (cGMP), serotonin, P-selectin, and laminin were analyzed in PPP and in PS after two freezing/thawing cycles. Platelet serotonin contents and serotonin release did not differ in either heparin group (SH and LMWH). In the LMWH group, 72 h postoperatively the intraplatelet cAMP was significantly (p < 0.01) higher. P-selectin values in PPP and platelet P-selectin release did not vary between the SH and the LMWH group; on the contrary, the platelet P-selectin content increased in the LMWH group 72 and 96 h postoperatively, while in the SH group this parameter showed a small decrease. The differences were significant (p < 0.05). The platelet-bound laminin underwent a slight change 48 and 72 h postoperatively in the LMWH group, but in the SH group the platelet-bound laminin increased permanently and significantly (p < 0.05; p < 0.01) until 72 h postoperatively, but 96 h postoperatively there was a small decline. In the SH group, 24-96 h postoperatively the platelet-bound laminin was significantly (p < 0.05; p < 0.005) augmented, compared with the LMWH group. The higher cAMP and P-selectin contents in the LMWH group suggest that platelets are less impaired by LMWH, and the augmented platelet-bound laminin in the SH group could express the platelet impairment evoked by standard unfractionated heparins.

[3-dimensional sonography in the diagnosis of meniscal lesions. An experimental and clinical study]

There is no consensus regarding the clinical significance of conventional two-dimensional ultrasound in the diagnosis of meniscal tears of the knee. Three-dimensional ultrasound spatially reconstructs a transparent image of subsequent ultrasound scans. In an experimental study of 96 menisci, radial and oblique tears were detected more often by three-dimensional ultrasound. In a clinical study of 60 menisci the two- and three-dimensional ultrasound reached a sensitivity of 92% and 100%, a specificity of 83% and 88%, a positive predictive value of 58% and 67%, and a negative predictive value of 98% and 100%, respectively. Altogether, there was no statistically significant difference between both methods. The high negative predictive value, however, shows that the three-dimensional ultrasound may be a clinically relevant examination for special questions in the diagnostics of meniscal tears.

[Experimental study of meniscus lesions. Significance of 3-dimensional ultrasonography]

AIM

The clinical value of two-dimensional ultrasound in examining the menisci of the knee compared to other methods is controversial. We studied the utility diagnosed by three-dimensional sonography in evaluating meniscal tears.

METHOD

96 menisci with standardised artificial lesions were examined in a bath of Ringer solution. Two-dimensional ultrasound was compared to three-dimensional ultrasound, which creates three-dimensional reconstruction of sequential ultrasonographic images.

RESULTS

The three-dimensional ultrasound had a higher sensitivity of 88% vs 69% with a specificity of 83% vs 94% for the diagnosis of meniscal tears compared with the two-dimensional method. The sensitivity in imaging was 54% in each case for longitudinal tears, 63% vs 96% for horizontal tears, 67% vs 37% for oblique tears and 54% vs 0% for radial tears. The difference of these results, however, was not statistically significant. Radial tears were more frequently diagnosed by three-dimensional sonography.

CONCLUSION

In our model, sonographic diagnosis of meniscal tears was improved only partially by using three-dimensional ultrasound. Whether in vivo other factors alter the minimal differences between the two techniques is the subject of ongoing investigation.

Ultrasound velocity of the tibia in normal German women and hip fracture patients

One of the latest developments in quantitative ultrasound (QUS) is the measurement of the speed of sound (SOS) of cortical bone of the midtibia. To determine the diagnostic validity of this method we measured 150 healthy women aged 22-94 years. Additionally, we report on first results of patients with hip fracture. Precision in vivo of the tibial QUS expressed as the percentage coefficient of variation (CV) was 0.39% for the first day and 0.45% after repositioning the second day (mean CV = 0.42%). No significant dependency of tibial SOS was found with weight, height, and body mass index in pre- and postmenopausal women. There was a significant decline of SOS with age in postmenopausal women (SOS = 4225 - 5.3 age, r = -0.46, P < 0. 001), whereas premenopausal women showed no decline (SOS = 3906 + 1. 3 age, r = 0.13, ns) Mean SOS values of premenopausal women were significantly higher than those of postmenopausal women (3960 +/- 78.7 m/second and 3898 +/- 120 m/second, respectively, P < 0.001). Postmenopausal women on estrogen substitution had significantly higher mean tibial SOS values than age-comparable postmenopausal women without estrogen substitution (3980 +/- 99 m/second and 3869 +/- 100 m/second, respectively, P < 0.001). Significant difference between age-matched healthy women, n = 11, and hip fracture patients, n = 13, expressed as z-score of -1.4 SD was found. In conclusion, tibial QUS declines with age and detects higher values in premenopausal women and postmenopausal women on estrogen substitution and lower values in hip fracture patients. Further prospective studies are needed to clarify its role in fracture risk assessment.

External fixation of intra-articular fracture of the distal radius in young and old adults

Forty patients (18-89 years old, mean 58 years) with comminuted intra-articular fractures of the distal radial end (AO-type C 2 or C 3) treated with external fixation could be followed for an average of 2.3 years. After 3 weeks, the distraction was released, and after another 3 weeks, the device was removed. Complications seen were one malunion, one radial shaft fracture caused by excentric drilling of a Schanz screw, one Sudeck atrophy, and one subcutaneous pin-track infection. Radial and ulnar deviations were reduced to 52% and 71% of the untreated wrist, whereas the range of motion in the other planes reached about 80% or more of the healthy side. In all, 82.5% of the patients showed good or excellent radiological and functional results. This study demonstrates that external fixation of distal radial C 2 and 3 fractures for 6 weeks results in good recovery for young patients and elderly patients with osteoporosis.

Bone cement implantation syndrome. A prospective randomised trial for use of antihistamine blockade

Bone cement implantation syndrome (BCIS) is characterised by hypotension, hypoxaemia, cardiac arrhythmias, cardiac arrest or any combination of these, leading to death in 0.6-1% of patients. One of the mechanisms suggested to explain these complications is diffuse microembolisation of the lungs as a consequence of extrusion of the bone marrow content by the pressurised bone cement. By reducing intramedullary pressure and changing the operative technique, BCIS can be diminished, but deaths still occur. An anaphylactoid mechanism as a major factor in BCIS is receiving renewed attention since increased plasma histamine levels were recently demonstrated after the implantation of bone cement and a prosthesis. Therefore, we conducted a prospective, randomised study to demonstrate the potential benefit of histamine-receptor-blocking agents in patients undergoing cemented hip arthroplasty. Thirty patients were divided into two groups: group 1, the control group, received no histamine-receptor-blocking agents; group 2, the antihistamine group, received H1 and H2-receptor-blocking agents in standard dosages preoperatively. Both groups were comparable concerning age, sex and physical status (ASA criteria). There was no hospital mortality in either group. Thirteen patients of group 1 demonstrated a sudden fall by more than 10% of their blood pressure, level of PaO2 or both. Fourteen patients of group 2 showed similar changes. The mean decrease of blood pressure in group 1 was 14.6 mmHg (SD 36.8) and in group 2 20.5 mmHg (SD 33.43). The difference is not significant (P = 0.65). The mean decrease of PaO2 in group 1 was 30.5 mmHg (SD 30.5) and in group 2 33.4 mmHg (SD 34.1). The difference is not significant (P = 0.81). Overall, we found even a slight disadvantage for patients receiving antihistamine drugs (statistically not significant). Therefore, histamine-receptor-blocking agents do not have a prophylactic potential in BCIS.

[Results of "expanded" arthrolysis of the knee joint]

This report shows the results of 20 patients, suffering on severe knee stiffness, who were treated between 1980-1989 at the Berufsgenossenschaftliche Unfallklinik in Tübingen with an expanded knee arthrolysis. The knee stiffness of all patients was caused by trauma (65% polytrauma) or infection. More than 2/3 of the patients (70%) had a preoperative degree of motion which was less than 60 degrees. In average 9 months after the initial trauma the expanded knee arthrolysis was performed. The arthrolysis was in most of the cases (n = 15) combined with a supracondylar correction osteotomy. The average preoperative range of motion from (ext./flex.) 0-15-62 degrees has postoperatively been increased to (ext./flex.) 0-5-92 degrees which corresponds to a relative improvement of motion of 43%. Eleven patients showed good or fair results. The prognosis of knee stiffness is influenced by the etiology, the pre-operative loss of motion and the period of time between initial trauma and arthrolysis, and as well by the intraoperatively achieved range of motion and the post-operative application of continuous passive motion. The expanded arthrolysis of the knee is a usefull instrument in the therapy of severe posttraumatic knee stiffness.

[The pre-positioned intracutaneous suture--a method for treatment of soft tissue defects after fascia splitting in acute compartment syndrome]

In the treatment of the acute compartment syndrome open fasciotomy gives rise to a wide soft tissue opening. The persistence of this opening prevents a timely change to internal osteosynthesis in case of additional fractures usually treated by a fixateur externe. Closure of the skin defect itself requires additional surgery. The cosmetical results particular in cases of a mesh-grafting are unsatisfactory. After open fasciotomy the prepositioned intracutaneous suture is a simple operation technique leading to early wound closure with a good cosmetical result.

[Bilateral Hoffa fracture--a rarity]

The isolated, tangential fracture of the dorsal part of the femoral condylus was first described by Friedrich Busch (1844-1916), a surgeon from Berlin in 1869, and not as always supposed by Albert Hoffa (1859-1907) in 1904. This is a case report describing a bilateral type B3-fracture of the distal femur (AO-fracture-classification) in a 58 year old man. Diagnostic, surgical procedure and outcome are described and discussed.