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After conservative treatment nonunion (pseudarthrosis) of the clavicle can be observed approximately 10 times more frequently (15-24%) than after surgical treatment (1.4%). Risk factors include the fracture location, displacement, fracture type, sex, the severity of the accident and refractures. The diagnosis of pseudarthrosis of the clavicle can be made by a thorough medical history, clinical examination and imaging procedures. The main symptom is pain, often accompanied by malalignment, instability, neurological symptoms and restricted mobility of the affected shoulder. The diagnosis is confirmed by X‑ray images and, if necessary, a computed tomography (CT) scan. Pseudoarthrosis is classified according to the morphological appearance in X‑ray images and the cause. A differentiation is made between vital and nonvital pseudarthroses. Only symptomatic pseudarthrosis requires treatment. Nonoperative methods, such as magnetic field therapy or ultrasound are minimally effective. Surgical interventions are indicated for pain, movement restrictions or neurovascular problems. The goals of surgical treatment are to restore the vitality, bone length and stability through angular stable osteosynthesis. In cases of surgical pretreatment the anteroinferior plate position offers a good alternative to the superior plate position. In some cases double plating osteosynthesis can be indicated. Autogenous bone material, allogeneic substitute material and vascularized grafts are used for bony defects. Surgical treatment shows high rates of healing but also carries an increased risk of infection., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: ESWT is a non-surgical treatment option but can also be used in addition to surgical treatment (stabilisation, freshening, defect filling, removal of discomforting osteosynthesis material) for the treatment of delayed bone healing (DBH) and non-union (NU). Its value as well as influencing factors on the upper extremity have not been adequately quantified so far., Patients and Methods: Sixty cases were retrospectively studied after application of focused high-energy ESWT with regard to healing rate and consolidation time. The influence of age, location, time of treatment and treatment prior to and concurrent with ESWT were analysed., Results: In 70% of the cases, healing occurred after a median of 2.4 months (DBH) and 2.8 months (NU). The median age of healed (DBH 44 y., non-union 35 y.) and non-healed (DBH 51 y., NU 37 y.) did not differ significantly. The time between trauma/surgery and ESWT was 4.2 months for DBH in healed and 3.7 months in non-healed without a significant difference, and 27 months for NU in both healed and non-healed. Age and smoking status also had no influence. The healing rate was highest at metacarpal bone/finger/thumb (91%), followed by forearm shaft (88%), epiphysis/metaphysis of the forearm (67%), and, lastly, carpal bones (59%). After conservative pre-treatment, 55% healed, compared with 67% after more than two previous surgeries, 73% without any pre-treatment, and 75% after one previous surgery. Further analysis of surgical pre-treatment showed 85% healing after ORIF alone, 64% without previous surgery, and 57% healing after ORIF with bone grafting/debridement. Intraoperative ESWT combined with bone debridement/transplantation and ORIF resulted in 67% healing, compared with 86% in combination with ORIF alone. ESWT alone or with only minimal measures (removal of osteosynthesis material) led to 70% consolidation., Conclusion: ESWT is equally effective at any stage of a bone healing disorder. The principles of stability and filling of bone defects must also be taken into account when using ESWT; then ESWT alone or combined with surgery is equally effective. The negative influence of bone defects/resorption is still detectable even with ESWT. Furthermore, treatment of the scaphoid is more problematic compared with other locations. Previous surgery is not a negative factor, even with osteosynthesis material in situ., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

The diagnosis and treatment of non-unions still represents an interdisciplinary challenge. Therefore, prevention, early detection and specific treatment are of great importance. Non-unions of the upper extremities, although less common than that of the lower extremities, requires special attention for successful treatment due to the central role of the shoulder girdle and arm in day to day activities. Successful treatment of non-unions requires a comprehensive evaluation of the patient's medical history, a thorough clinical examination and in particular radiological imaging. In order to effectively treat the pseudarthrosis it is crucial to distinguish between pseudarthroses that are suspected to be due to infections and those that are not. This article presents a treatment algorithm for managing both pseudarthrosis due to infection and pseudarthrosis without infection in the upper extremities., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Introduction: The overall frequency of proximal femoral fractures means that we are repeatedly confronted with failed healing and implant failure, despite a relatively low nonunion rate especially in intertrochanteric fractures (< 5%). The aim of this paper is to present our approach to treating these nonunions of the proximal femur and discuss the treatment results., Material and Methods: Between 2009 and 2023, patients with nonunion of the proximal femur were retrospectively identified and analyzed. Age, gender, time to revision, the Weber-Cech classification of pseudarthrosis and radiographic imaging before and after revision were analyzed., Results: A total of 66 patients were analyzed. The mean age was 58 years (range 25-88 years). The overall healing rate was 88% with a mean consolidation time of 8 months (range 2-29 months). The main osteosynthesis procedures were plate osteosynthesis (n = 45, of which 44 were blade plates), and nail replacement (n = 12). Other procedures included augmentative plate osteosyntheses (n = 4), isolated cancellous bone graft (n = 2), nail dynamization (n = 2), and the use of a dynamic hip screw (n = 1)., Discussion: The analysis of our treatment data as well as the current literature, revealed a trend towards intramedullary revision procedures. Implants that can be used to correct the CCD angle, such as the blade plate, remain a predictable option to achieve correction, especially in nonunions with an increased degree of varus. Particularly in the subtrochanteric region, fractures can also be treated in a targeted manner by a combination of mechanical and biological methods with a reamed nail change to a larger caliber implant., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Impaired posttraumatic bone healing is a relevant complication of fractures. Usually, the standard treatment is surgical revision. For about 30 years extracorporeal shockwave therapy (ESWT) has emerged as an alternative treatment option with similar consolidation rates but less complications., Objective: This article aims to present our data in context to the current literature MATERIAL AND METHODS: From 2007 to 2016 a total of 97 patients diagnosed with impaired posttraumatic bone healing were treated with ESWT. Clinical and demographic data of this population were retrieved and analyzed retrospectively., Results: The general consolidation rate was 60.8%. Multiple variables were analyzed. A preinterventional bone gap ≥ 5 mm, initial dislocation > ½ of the bone shaft, nicotine consumption and a long time span from fracture to ESWT (> 6 months) were found as factors which significantly impair bone healing after ESWT., Conclusion: ESWT is a safe and promising alternative treatment option for delayed unions. Regarding risk factors of a poor outcome may be identified before and increase the rate of success., (© 2022. The Author(s).)

Purpose: To evaluate whether a vascularized bone graft from the medial femur condyle (MFC) can successfully be used to reconstruct small bone defects (< 4 cm) on the upper extremity other than the scaphoid., Patients and Methods: In 7 patients at the age of 28 to 66 years 8 vascularized bone grafts from the MFC were used to reconstruct bone defects on the upper extremity other than the scaphoid. Bone healing, complications, donor side morbidity, and patient´s satisfaction were evaluated. Follow-up was 3 to 40 months. Indications were: two nonunion of the distal radius in spite of several surgical procedures, one defect of the distal radius following a radius fracture with osteoarthritis of the radiocarpal joint, one acute trauma with partial loss of the carpus and radius due to an explosion injury, reconstruction of the first metacarpal (MC) following resection of a giant cell tumour, and three fusions between the 1 st and 2 nd MC as a salvage procedure after several surgical procedures at the saddle joint., Results: There was a regular bony healing in 4 of the 8 cases; delayed bony healing was seen in three cases after 7, 8, and 9 months. In one case there was only a partial bony healing. Two donor side haematomas required surgical revision. Patient's satisfaction was high with 7 painless cases., Conclusion: Free vascularized bone grafts from the medial femur condyle can successfully be used to reconstruct bone defects up to 4 cm of the upper extremity other than the scaphoid., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

This article describes our algorithm for approaching and fixing scaphoid fractures and non-unions., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Objective: Minimally invasive arthroscopically assisted reconstruction of scaphoid nonunions., Indications: Delayed union or nonunion of the scaphoid with sclerosis and with indication for bone transplantation. Limited arthritic changes at the radial styloid., Contraindications: Severe humpback deformity with dorsal intercalated segment instability. Midcarpal arthritic changes., Surgical Technique: Supine position with the forearm upright and in neutral position, the elbow flexed by 90°, axial traction of 3 to 4 kg. Standard wrist arthroscopy via the 3-4 and the 4-5 portal and the midcarpal joint via the radial and ulnar portal, respectively, with sodium chloride as arthroscopy medium. Change of the optic to the ulnar midcarpal portal and opening of the nonunion with an elevator via the radial midcarpal portal. Resection of the sclerosis with a 3.0 mm burr while irrigating the joint. Harvesting of cancellous bone via the second extensor compartment. On the hand table, closed reduction by joy-stick K‑wires if needed and insertion of K‑wires for the scaphoid screw. Insertion of the screw without entering of the distal thread into the bone. Arthroscopic insertion of the bone transplant by a blunt drill sleeve via the radial portal with steady compression by the obturator. Complete insertion of the screw under arthroscopic control of the compression of the nonunion space with arthroscopic control of stability with the probe., Postoperative Management: Six weeks forearm cast including the thumb metacarpophalangeal joint, radiographic control and non-load bearing movements for two more weeks, CT scan in the oblique sagittal plane after 8 weeks, and increase of load, as well as physiotherapy on demand depending on the radiographic results., Results: To date, 17 patients with a mean age of the nonunion of 18 months were treated. In 14 patients, bony union was achieved after 8 weeks. In one patient, an extraosseous screw placement was corrected. In another patient with extraosseous screw placement, persisting nonunion was treated with an angular stable plate. One scaphoid demonstrated an asymptomatic tight nonunion after 14 months, while one scaphoid with sclerosis of the proximal pole did not heal., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Non-union represents a severe complication and a major socioeconomic challenge in orthopedics and trauma surgery. Timely and reliable diagnostics are obligatory to be able to carry out the treatment of non-unions in a patient-specific and efficient manner. Contrast-enhanced ultrasound (CEUS) is an important interface between clinical signs, imaging investigations and the results of the paraclinical diagnostics, e.g. C‑reactive protein (CRP) and leukocyte count. It can display the microperfusion inside the non-union gap in real time and provide valuable information for exclusion of an infection or on the healing progress after revision surgery. An establishment of this diagnostic modality in routine orthopedic trauma surgery contributes to optimization of the treatment of non-unions., (© 2021. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

The odd shape of the scaphoid is a challenge to our spatial sense. Computer assistance is of an unmatched value when reconstructing a non-united scaphoid: From CT data a true 3-D-model can be generated, fully interactive; thus it can be moved, manipulated and of course also printed for hands-on experience. Comparing the virtual 3-D-models of the nonunion with the healthy contralateral scaphoid, the exact amount of the deformity is calculated which allows for the planning of an anatomically precise reconstruction of the scaphoid shape. Finally, computer generated patient specific instruments will facilitate the implementation of this planning intraoperatively. This proceeding enables us to reconstruct the non-united scaphoid markedly more accurately and with this reliably normalize wrist kinematics. Meanwhile we have applied this technique successfully in more than 50 cases of scaphoid-nonunions presenting with significant deformity., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Since 2008 we have been using many free vascularized medial femoral condyle grafts for reconstruction of difficult scaphoid non-unions. This article aims to report our results and experiences., Patients and Methods: Until the end of 2019 a total of 287 patients had a microvascular scaphoid reconstruction, 158 with use of a corticocancellous, and 129 using an osseocartilaginous graft. Complete analysis of all of these patients was impossible. This manuscript is based on a retrospective analysis of 28 out of 42 patients with corticocancellous grafts operated on between 2008 and 2010 with a mean follow-up time of 6.1 years as well as another 44 out of 76 patients with an osseocartilaginous graft operated on between 2011 and 2016 with a mean follow-up time of 44 months. Follow-up included clinical parameters, conventional x-rays, a DASH-Score and a modified Mayo wrist score. Additionally, the authors report their personal experiences - necessarily without quantification. In view of this incomplete data-pool statistical analysis was not reasonable., Results: In the group with corticocancellous reconstructions bony healing was achieved in 69 %, salvage operations were required in 9,5 %. The 28 patients had a mean DASH-Score of 11, a mean modified Mayo wrist score of 83 points, a mean ROM of 86° and a mean grip strength of 89 % of the contralateral side. In the group with osseocartilaginous reconstructions complete bony healing was seen in 80 %, partial healing in 5 %, and salvage procedures were required in 11 %. The remaining 39 patients had a mean DASH-Score of 15, a mean modified Mayo wrist score of 80 points, a mean ROM of 90° and a grip strength of 81 % of the contralateral hand. A specific complication was an ossification of the pedicle, but the main problem was a satisfying reconstruction of the shape of the scaphoid and reestablishment of carpal stability in far advanced cases. We could not identify factors reliable for the persisting non-unions., Conclusions: These operations combine great chances for healing with considerable risks for serious complications. So future patients have to be fully informed, so that their decision for such a procedure is based on realistic expectations., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Focused, high energy shock wave therapy (ESWT) stimulates bone healing by neo-angiogenesis and activating osteocytes. This study investigates if applying an ESWT intraoperatively improves and accelerates the healing of a scaphoid nonunion after reconstruction using a non-vascularized bone graft., Patients and Methods: In this prospective, ongoing study, patients with a scaphoid reconstruction using a non-vascularized bone graft and stabilization for non-union, are randomized for having additionally an intraoperative ESWT (intervention group) or not (control group). In 6 weeks-intervals, patients have a clinical and radiological follow-up, including a CT scan at 12, 18, and if needed 24 weeks postoperatively. The intervention group and the control group are compared with regard to the proportion of the bridged contact area between scaphoid and the bone graft at 12, 18, and 24 weeks postoperatively and the rate of the healed scaphoids at the final follow-up. At time of this data analysis, 35 patients of the intervention group and 33 patients of the control group had passed all of their scheduled follow-ups., Results: Twenty-four weeks postoperatively, the scaphoids of 27 patients (77 %) in the intervention group and those of 20 patients (61 %) in the control group were healed. At 12, 18, and 24 weeks, the contact area between scaphoid and the bone graft proximally was bridged by 80 %, 84 %, and 86 % respectively in the intervention group, and 74 %, 81 %, and 84 % in the control group. Distal to the bone graft, the gap was bridged by 91 %, 94 %, and 95 % for the intervention group and 77 %, 90 %, and 94 % for the control group. At 12 weeks postoperatively, the proportional healing distal to the bone graft was significantly higher after ESWT., Conclusion: A single, intraoperative ESWT improves the healing rate of scaphoid reconstruction with a non-vascularized bone graft and accelerates the gap bridging during the first 12 weeks after surgery., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Stem cells are becoming increasingly more important in the field of regenerative medicine. Adult mesenchymal stem cells (MSCs) are harvested predominantly from bone marrow or adipose tissue, are already being used in the clinical setting and have a low potential for side effects. In orthopedics, experience has been gained in the treatment of bone defects, non-unions, cartilage defects, osteoarthritis and tendon pathologies. The current data are derived from case studies and randomized controlled trials are missing; therefore, there are many open questions concerning the optimal cell source, number of cells, administration technique (e.g. injections and matrices) or combinations with growth factors; however, it is evident from the data that MSCs have a positive effect on tissue regeneration and are safe to use.

Background: Nonunion of the scaphoid as a result of proximal fractures, failed surgical reconstruction, and especially avascular fragment necrosis are possible indications of vascularized bone grafts. Various techniques of vascularized (pedicled and free) grafts have been described. Pedicled grafts from the direct vicinity of the wrist provide several benefits. Harvest-site morbidity is reduced and preserved graft perfusion, without the need for blood vessel anastomosis, may lead to an improved consolidation., Methods: A common pedicled vascularized bone graft for reconstruction of the scaphoid was first described by C. Zaidemberg and colleagues in 1991. We describe 49 consecutive patients, who underwent vascularized bone-grafting, pedicled on the 1.2 intercompartmental, supraretinacular artery in a modified technique based on Zaidemberg's description. The fixation of the bone graft was performed by Kirschner wires., Results: A consolidation was detected in 37 cases, and 9 cases showed a persistent nonunion (3 patients did not follow up). According to the classification of Herbert, 44 patients had a nonunion grade D2 or higher, of which 36 patients showed a bony consolidation (8 non-consolidated). Complications occurred in individual cases (1x intraoperative fracture of the radius, 4x transient irritations of the superficial branch of the radial nerve). A loss in the range of motion of the affected wrist was frequent. An indication for a pedicled graft was seen if the preoperative contrast-enhanced MRI showed an impaired perfusion of scaphoid fragments., Discussion: The more advanced the changes in MRI, the more frequently treatment failed. The vascularized bone graft from the dorsal distal radius described by C. Zaidemberg et al. is one of several ways to address a circulation-impaired nonunion of the scaphoid.

Background: Avascularity of fragments is a common problem in treatment of scaphoid nonunion. Therefore, vascularised bone grafts have gained increasing importance. Especially the free vascularised femoral trochlea flap has become the subject of special interest because of its particular characteristics in the last few years., Objectives: Indications for and the technique of free vascularised corticocancellous as well as osteocartilagineous femoral trochlea flap are reported according to the author's practice combined with an evaluation of these methods considering current literature., Results: Indications for the free vasscularised corticocancellous femoral trochlea flap include scaphoid nonunion with avascular proximal fragment combined with humpback deformity, previous operations, extensive bone defect, and long standing nonunion. The free vascularised osteocartilagineous medial trochlea flap may replace a destroyed proximal scaphoid pole. The literature reports only a few patients with healing rates between 80 and 100 %., Conclusions: Both corticocancellous and osteocartilagineous free vascularised medial trochlea flap improve therapeutic options in treatment of difficult scaphoid nonunion. Until now only the results of a few patients have been published. Therefore, a final evaluation will be possible when long-term results in a reasonable number of patients are available.

Background: The medical literature recommends plate osteosynthesis (PO) for complex displaced midshaft clavicular fractures (DMCF) OTA type 15B3 and for heavy workers with displaced clavicular fractures. Recovery of DMCF treated with intramedullary stabilisation (IMS) will be examined and compared to published data for duration of inability to work (DIW) after conservative treatment as well as after PO, with respect to the DIW., Patients and Methods: Between 09/2009 and 07/2015, the DIW of 58 patients (8 f, 50 m, mean age 38.4 [20-59] years) with DMCF treated with open reduction and IMS (Titanium Elastic Nail [TEN], Synthes, Umkirch, Germany) was determined. Inclusion criteria were the presence of closed unilateral DMCF and presence of a job with national insurance at the time of accident. DIW was counted in days, starting with the accident, and ending on the last day before resumption of full work. All patients were functionally treated for 6 weeks postoperatively without weights for the shoulder and with a maximum of 90° abduction/flexion. The workload was classified in accordance with REFA criteria: group 0-1 (low physical workload) and group 2-4 (high physical workload). Fracture patterns (simple vs. complex) and postoperative physiotherapy (yes vs. no) were investigated for both REFA groups, as these factors may influence DIW. Fracture classification was performed in accordance with the OTA classification, as simple fractures (OTA type 15B1 and 15B2), and complex fractures (OTA type 15B3). Effects were concerned significant if p ≤ 0.05., Results: Median DIW was independent of physical workload, with 39.86 (3-150) days (n = 58). Patients with low physical workload (REFA 0-1; n = 33) had shorter duration of DIW, with an average of 32.48 (3-136) days than patients with higher physical workload (REFA 2-4; n = 25), with 49.6 (14-150) days (p = 0.02). The fracture type did not influence this significantly (simple fractures [n = 35]: average 40.54 [3-150] days; complex fractures [n = 23]: average 38.82 [14-136] days, p = 0.85). Within each REFA group, differences in DIW for each fracture type were greater, but did not attain statistical significance. Patients without postoperative PT (n = 30) had a shorter DIW, with an average of 30.5 (3-84) days, than patients with postoperative PT (n = 28), with an average of 49.89 (14-150) days (p = 0.021). Within both REFA groups, DIW changed similarly with postoperative PT, in some cases with statistical significance., Conclusion: DIW after IMS of DMCF does not depend on the complexity of the fracture. For heavy workers, DIW after IMS is significantly longer than for light physical workers. IMS of DMCF permits immediate pain-adapted movement of the shoulder, with a maximal abduction/flexion up to 90°, no matter what the fracture type. Patients given additional professional PT showed longer DIW than those without such treatment., (Georg Thieme Verlag KG Stuttgart · New York.)

Fractures of the clavicle can often be treated conservatively. For severely dislocated but simple fractures in which conservative treatment often fails, intramedullary nailing with titanium elastic nails (TEN) shows similar results to stable plate osteosynthesis. We present the case of a 28-year-old female patient who had been treated with TEN osteosynthesis 4 years previously but clavicular non-union developed. Due to a new traumatic incident, the implanted intramedullary titanium nail was bent and migrated into the manubrium sterni. We were able to remove the wire and stable plate osteosynthesis was carried out. Bending and migration of titanium wires used in clavicular fractures are relatively rare complications and patients must be informed accordingly. These complications can be avoided by removal of the wire 3-12 months after implantation when the fracture has healed.

Background: According to the future demographic trends the incidence of proximal humeral fractures and subsequent posttraumatic malunions and nonunions of the proximal humerus are expected to substantially increase., Objectives: This article reviews the indications, techniques and outcomes of corrective osteotomy for the treatment of posttraumatic nounions and malunions of the proximal humerus., Methods: A selective literature search was performed and personal surgical experiences are reported., Results: Malunions of the proximal humerus can occur after both surgical and conservative management of fractures. Due to the complex anatomy of the proximal humerus, malunions have to be systematically assessed regarding epiphyseal and metaphyseal malpositioning. Furthermore, the objective anatomical disorder has to be completely correlated with the subjective patient complaints. The associated soft tissue structures, such as the glenohumeral joint capsule and ligaments, long head of the biceps tendon, rotator cuff and muscles inserting in the metaphysis, can independently cause discomfort to the patient and need to be meticulously identified as such., Conclusion: A variety of corrective surgical strategies are available, which are indicated depending on the location and extent of the malunion. The depicted single-cut osteotomy technique represents an elegant therapeutic option for multidimensional deformities of the proximal humerus. Nonunions of the proximal humerus can usually be successfully managed with autologous cancellous bone grafting and locking plate osteosynthesis.

Background: Fractures of the subcapital and proximal humerus shaft region are common fractures of the human skeleton. Their treatment should provide an early functional after-care of the shoulder joint, that is prone to arthrofibrosis. Although the upper extremity is not weight-bearing the occurrence of proximal humerus non-unions leads to severe impairment with inability to work and restrictions of activity of daily life. The aim of this study was to investigate whether an operative revision of proximal humerus non-unions with reosteosynthesis and application of distant autologous bone grafts can lead to sufficient bone healing. The second aim was to find out whether patients achieved an acceptable functional outcome, as alternatively patients could be treated by reconstruction with a shoulder prosthesis., Patients and Methods: 27 patients (female = 15, male = 12) with reosteosynthesis of the proximal humerus and proximal humeral shaft due to non-union after initially operative fracture treatment were included between 2008 and 2014. Average age of patients was 56 years (23-87), 48% had no comorbidities, while 52% of the patients had at least 1 comorbidity such as diabetes, hypertension or nicotine abusus. The mean number of prior surgical intervention was 1.2 (1-3). The mean time between initial surgery and re-osteosynthesis was 12.3 months. Patients with signs of infection pseudarthrosis were excluded. The initial type of osteosynthesis was with plates (n = 16; thereof PHILOS Plate n = 14), and intramedullary nails (T2, Targon Nail, PHN, Seidel Nail; n = 11). Revision surgery was done with plate osteosynthesis (n = 26; thereof PHILOS Plate n = 4; LC Plate n = 10; angle plate n = 12). In 23 patients (89%) a distant bone transplantation was done from the iliac crest, and 1 patient received allogenous bone. Three patients (11%) received bone morphogenetic protein 7 (BMP 7) in combination with distant bone graft. Intraoperative swabs from the pseudarthrosis area showed no bacterial pathogen after 14 days of incubation. DASH score and Constant score were used to evaluate the functional outcome after revision surgery. Bone healing was determined by standard X-rays and evaluated by a modified radiological score., Results: 89% of the patients could be followed for an average of 28 months and the radiological follow-up was at 9 months. The radiological score showed very good (50%), or good results, and a sufficient bone healing was shown in 25 of 27 patients (93%). The pseudarthrosis revision surgery failed in two cases (n = 1 persisting non-union; n = 1 humeral head necrosis after re-operation with angle plate). DASH scores provided a mean of 40 ± 28.8 with a range from 0-97 points, and the results from the Constant score provided 45 ± 25.4. The analysis with variation of age showed a trend for better results in female patients < 60 years of age. As complications after bone graft 3 patients had persistent local dysesthesia (11%), in one case fracture of the iliac bone occurred that healed with conservative treatment., Conclusion: The pseudarthrosis revision surgery with humeral head preserving re-osteosynthesis with bone transplantation is an effective treatment for non-unions of the proximal humerus and the proximal humeral shaft and the current results showed high bone consolidation rates. As the functional results remained limited after revision an individual treatment decision should be made concerning the most appropriate therapy. While a shoulder prosthesis may be considered in the aged patient, a revision strategy with reosteosynthesis should be considered particularly in younger patients., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective: The Stoppa approach in its modified form is an intrapelvine approach for the treatment of acetabular fractures. It is an alternative to the ilioinguinal approach. Goals are the gentle soft-tissue preparation, anatomic reduction and stable internal fixation. Here, the approach is described in detail together with possible expansion possibilities., Indications: The Stoppa approach in particular is used for the treatment of fractures of the anterior column with participation of the quadrilateral surface, transverse fractures, T-type fractures, but also 2-column fractures when the main pathology is located in anterior portions of the acetabulum., Method: This intrapelvic approach allows a direct view of the quadrilateral surface and the direct reduction of these fragments. In contrast to the ilioinguinal access the Stoppa approach dispenses with the preparation of the 2nd window with exposure of the vessels. The preparation is carried out via a Pfannenstiel access following transection of the median line alba. The further dissection is performed along the anterior pubic ramus, on the pelvic rim, towards the ipsilateral sacroiliac joint., Conclusion: The modified Stoppa approach is a soft-tissue-friendly approach for the treatment of acetabular fractures. With its options for expansion, possibility for osteotomy of the anterior superior iliac spine and the use of the first ilioinguinal window, almost all types of fractures of the acetabulum whose primary pathology is on the anterior side can be treated., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Malunion or nonunion of central talar fractures lead to significant impairment, pain and decreased motion of the foot and ankle. In a 20-year period from 1994 to 2013 at the Trauma Department of the University Hospital Carl Gustav Carus of the Technical University of Dresden we treated a total of 25 patients with secondary anatomical reconstruction of the talus., Method: The mean age of the patients was 39.9 years (range 15-71 years) and only 4 out of the 25 patients were female. Of these patients 11 patients were treated conservatively, 3 minimally invasive with external fixation and were admitted on average 7.6 months (range 1.5-42 months) after the initial fracture. Of the patients 11 had previously been treated in another hospital by open surgery on average 8.4 months (range 1-24 months) months before. There were 9 malunions or nonunions of talar fractures of the shaft, 14 of the neck and 2 of the head. Only 3 cases were old fractures ≥ 6 weeks and 22 were malunions or nonunions ≥ 3 months. According to an in-house classification 12 malunions (type I), 5 nonunions (type II), and 8 malunions/nonunions with partial necrosis (type III) were treated., Results: Of the patients 21 out of 25 needed a bilateral approach and 6 additionally an osteotomy of the medial malleolus.The mean follow-up of 22 out of 25 patients was 5.4 years (range 1.0-21.5 years). The preoperative American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score increased on average from 36.6 to 86.7 points (p<0.001) at the time of follow-up.

Background: Multifragmentary sesamoid bones of the hallux have established the concept of sesamoidea multipartita which is explained as a congenital characteristic of these bones. Sesamoid bones although fragmented are often asymptomatic as are, for example fragmented patellae. Evidence shows, however, that fragmentation of sesamoid bones is significantly more frequent in young people active in sports (soccer). The diagnosis of traumatic fractures and subsequent pain and disability is a challenge. Patients often present to physicians relatively late and are, therefore, treated in the acute phase long after onset of pain., Method: Inquisitive interview of the patient and precise examination together with a detailed radiological investigation (computed tomography) are essential to be able to determine a causal relation to the fragmentation of sesamoid bones. Treatment consists of an anatomical reconstruction of vital bone fragments possibly augmented with an autologous cancellous bone graft after debridement. Surgical approaches are longitudinal medial for the medial sesamoid bone and longitudinal plantar for the lateral sesamoid bone. The means of fixation mostly involves two 1.5 mm screws for optimal mechanical stability.

Inveterated fractures or dislocations of the foot which are defined as being more than 6-12 weeks old can be secondarily reconstructed anatomically in only very rare cases. All other cases need reorientation of all axes of the foot requiring single or combined joint fusion. In cases of significant posttraumatic bone necrosis the dead bone has to be radically resected and substituted by an autogenous bone graft from the iliac crest. Old cases of dislocation, for example after subtalar dislocation without anatomical reduction, need reorientation of the foot axes by performing arthrodesis. Subluxation of the medial Lisfranc joint after an unrecognized rupture of Lisfranc ligament can be controlled later by anatomical repair of this ligament by using half of the extensor digitorum longus tendon and thus avoiding arthrodesis.

Background: Since its introduction in Germany, the DRG (Diagnosis-Related Groups) system is often fraught with negative connotations. Frequent points of criticism are a deterioration of patient care by decreasing length of stay (LOS) in hospital and a decline in reimbursement. The following investigation analyzes and compares the development of length of stay and reimbursement in hand surgery based on the 3 most common elective procedures., Material and Methods: The main diagnoses scaphoid nonunion (PSA), Dupuytren's contracture (DK) and rhizarthrosis (RIA) were evaluated for number of cases, length of stay, reimbursement per day and total reimbursement in 2000 as well as 2010 based on the data of our clinic. Patients covered by the Employers' Liability Insurance were not included. Only inpatient cases were considered., Results: In PSA and RIA an increase in the number of cases is reported (PSA: +11 cases; RIA: +26 cases) and a decrease in DK ( - 7 cases). The sum of the total hospital days declined despite rising case numbers predominantly between 65 (RIA) and 260 days (DK). The average LOS decreased by 3.1 days at DK (48.4%) to 4.1 days at PSA (52.6%). Average revenues per day in 2000 amounted to 379 €, which corresponds to 442 € adjusted for inflation in 2010. Average revenue per day in 2010 was 755 € (RIA), 797 € (PSA) and 876 € (DK). Revenue per case in 2010 were only higher than in 2000, when 5 (RIA) or 6 hospital days (DK and PSA) were not exceeded., Conclusion: With declining revenue per case, the average income per day increased by a reduction in hospital days. A positive or at least equivalent revenue situation can thus only be achieved by a distinct concentration of labor and reduction of hospital days under the DRG-system., (© Georg Thieme Verlag KG Stuttgart · New York.)

Carpal instability can be understood as a disturbed anatomical alignment between bones articulating in the carpus. This disturbed balance occurs either only dynamically (with movement) under the effect of physiological force or even statically at rest. The most common cause of carpal instability is wrist trauma with rupture of the stabilizing ligaments and adaptive misalignment following fractures of the radius or carpus. Carpal collapse plays a special role in this mechanism due to non-healed fracture of the scaphoid bone. In addition degenerative inflammatory alterations, such as chondrocalcinosis or gout, more rarely aseptic bone necrosis of the lunate or scaphoid bones or misalignment due to deposition (Madelung deformity) can lead to wrist instability. Under increased pressure the misaligned joint surfaces lead to bone arrosion with secondary arthritis of the wrist. In order to arrest or slow down this irreversible process, diagnosis must occur as early as possible. Many surgical methods have been thought out to regain stability ranging from direct reconstruction of the damaged ligaments, through ligament replacement to partial stiffening of the wrist joint.

In critical size bone defects resulting from failed fracture healing or pseudarthrosis surgery is usually required. In this context, autologous bone grafts and callus distraction represent the gold standard, while sometimes even vascularised bone transfer is mandatory including microsurgical techniques. The availability of donor sites for such procedures is limited and the resulting morbidity significant. Therefore, synthetic bone grafts have been developed as an alternative. They consist of a broad range of different materials such as natural and synthetic polymers, ceramic and compound materials, aiming to mimic the three-dimensional character of autografts. In addition, they may act as a delivery vehicle for growth factors, antibiotics or cells. Their main limitation has been the lack of an intrinsic blood supply, limiting the potential for transplantation. This review provides an overview of matrices, cells and other therapeutic substances in the field of bone tissue engineering., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Scaphoid fractures represent the most common carpal bone fractures. These fractures may be overlooked due to insufficient diagnostics and lead to non-union and disability. A standardized diagnostic procedure with X-ray examinations, CT scans and/or MRI is recommended. We report on a case where a scaphoid fracture was overlooked, probably because of an incorrect technique of the computed tomography., Case Report: A 42-year-old man was admitted to our emergency room after a fall on the out-stretched wrist. X-rays showed no evidence of a bony lesion. In the follow-up examination on the next day, a scaphoid fracture was still suspected clinically. Because of that a CT scan in thin slice technique with axial layers and multiplanar reconstruction was performed but showed no sign of a fracture. Six weeks after the trauma the patient presented with persistent wrist pain. X-rays and a CT scan of the wrist now demonstrated an old waist fracture of the scaphoid. -Operative treatment with iliac crest bone grafting and screw fixation was performed., Discussion: Early diagnosis and a correct description of the fracture pattern are of high value in the treatment of scaphoid fractures. X-rays combined with a CT scan or an MRI scan of the affected wrist are considered as the diagnostic standard. The reported case demonstrates that even with a thin thickness layer CT scan in axial planes, a scaphoid fracture can be overlooked. Therefore we recommend after primarily inconspicuous X-rays a CT scan with primary -oblique-sagittal layers in the longitudinal axis of the scaphoid. If this shows no fracture and the clinical suspicion persists, an MRI scan should be performed., (Georg Thieme Verlag KG Stuttgart, New York.)

Objective: Bony healing and reconstruction of the scaphoid with use of a reverse-flow pedicle vascularized bone graft from the dorsal aspect of the distal radius. Revitalization of the proximal fragment in case of avascular necrosis., Indications: Scaphoid nonunion, especially of the proximal pole. Nonunion after failed attempts of autogenous nonvascularized bone grafting. Avascular necrosis of the scaphoid (Preiser's disease). Avascular osteonecrosis of other carpal bones (i.e., Kienböck's disease stage II and IIIa). However, these will not be addressed in this paper., Contraindications: Advance carpal collapse (SNAC [scaphoid nonunion advanced collapse] wrist stage II and III). Avascular necrosis with broken proximal pole of the scaphoid. Malformation, disease or previous injury of the vascular system., Surgical Technique: Reconstruction of the scaphoid by interposition of a vascularized bone graft from the dorsum of the distal radius, where several vascularized bone grafts can be harvested, and fixation by a scaphoid screw., Postoperative Management: Management Immobilization for 6 weeks in a forearm cast including the first phalanx of the thumb., Results: 48 scaphoid nonunions were treated with 1,2-ICSRA-based (intercompartmental supraretinacular artery) vascularized bone grafts: 34 scaphoid nonunions went on to union at an average of 15.6 weeks after surgery.

Objective: The goal of the procedure is osseous healing of the scaphoid in an anatomic position and replacement of necrotic bone at the site of the scaphoid nonunion by a vascularized iliac bone graft., Indications: Scaphoid nonunion with necrotic fragment in SNAC (scaphoid nonunion advanced collapse) < 1. Nonunion following previous surgery., Contraindications: Pattern of advanced carpal collapse (SNAC > 1). Malformation, disease or previous injury of the vascular system. Poor compliance. Reduced general health., Surgical Technique: Principles of the surgical technique according to Pechlaner et al.: harvesting of a corticocancellous bone graft from the anterior iliac crest with a nutrient vascular bundle from the deep circumflex iliac artery, debridement of the necrotic scaphoid, press-fit fixation of the tailored graft, pin fixation, and microvascular anastomosis to the radial artery., Postoperative Management: Fixation in an upper-arm cast for 4 weeks, followed by lower-arm cast fixation including the thumb to the interphalangeal joint until week 12. Physiotherapy. Wrist splinting in patients enforced to heavy manual load., Results: The described procedure has been practiced at the own institution since 1985 and evaluated in different studies. Using a free vascularized iliac bone graft, union could be achieved in 85% of patients with avascular scaphoid nonunion and in 80% with avascular proximal pole nonunion. The nonunion can be bridged in 93% following failed previous scaphoid screw fixation.

Objective: Reconstruction of the scaphoid in length and form. Revitalization of the proximal fragment in case of avascular necrosis., Indications: Nonunion of the scaphoid, especially with avascular necrosis of the proximal pole. Persisting nonunion of the scaphoid after operative treatment., Contraindications: Pattern of advanced carpal collapse (SNAC > 1). Malformation, disease or previous injury of the vascular system. Low compliance. Reduced general health., Surgical Technique: Reconstruction of the scaphoid in correct dimension and angulation with use of a vascularized microvascular corticocancellous bone graft from the medial distal femur. Anastomoses to the radial artery or its palmar branch. Fixation by a cannulated scaphoid screw or Kirschner wires., Postoperative Management: Postoperative immobilization in a short cast with thumb support for 6 weeks followed by a removable splint for another 6 weeks. Physiotherapy after cast removal., Results: 15 patients with avascular necrosis of the scaphoid were treated with this technique after a mean of 128 weeks following trauma. In five patients, one to three previous operations had already been performed. 6 months after surgery, osseous healing of the nonunion was registered in all patients. The carpal height ratio according to Nattrass was increased by 0.07. The scapholunate angle had decreased by 10.7 degrees on average. 14 patients had a mean improvement of the Mayo Wrist Score of 13.3 points.

Aim: The aim of the study was to evaluate the application of a locked internal fixator in complex fractures of the proximal femur, in which the internal fixation with standard implants was not possible due to poor quality of bone or already failed internal fixation in the past., Method: Ten patients suffering from a pertrochanteric (n = 5), periprosthetic (n = 1) or subtrochanteric (n = 4) femural fracture between 2003 and 2008 were prospectively registered, underwent open reduction and internal fixation with an "upside-down" femur LISS (less invasive stabilisation system) and were followed up. In all these patients a primary internal fixation had failed or the local bone situation and circulation were poor. The mean follow-up was 14 +/- 25 months. X-ray images and a clinical examination were performed at each appointment., Results: All fractures reached a primarily stable fixation with the locked internal plate fixator. Seven patients showed a complete bone healing after 3 months of follow-up and could bear full body weight afterwards. Three patients with preoperatively existing vascular disease or chronic osteomyelitis showed a deep wound infection postoperatively, which led to the explantation of the implant., Conclusions: The "reversed" locked internal fixator could be a successful alternative implant for stabilisation of proximal femur fractures which could not be fixated by standard implants due to poor bone quality and circulation. It can also be used as a salvage procedure after internal failed fixation in proximal femur fractures., (Georg Thieme Verlag KG Stuttgart, New York.)

Introduction: These case reports describe a mediocarpal arthrodesis with excision of the scaphoid using a cortical bolting chip and screw fixation instead of the use of Kirschner wires or Spider plates., Methods: Four patients with a symptomatic SLAC/SLAC-wrist >or= grade II were treated. The evaluation occurred six months later. For the evaluation the Cooney and Bussey as well as DASH scores were used (pain, strength, range of motion, functional status, possible limitations of quality of life, subjective perception of the patient). The radiological evaluation was performed by conventional wrist X-ray in two projections., Results: All patients were pain-free after the operation. From the radiological point of view a complete osseous consolidation has set in. The mean strength six months after surgical intervention was 53 % (preoperative 52 %) and the total range of motion 47 % (preoperative 59 %) compared to the opposite side. The Cooney and Bussey scores were at 69 (+ 25 %) and the DASH score at 44 (- 28 %) points., Conclusions: In case of an SNAC/SLAC-wrist a motion-preserving operation should always be given preference to a wrist stiffening procedure. The modified mid-carpal partial arthrodesis is an alternative operating procedure for the treatment of SNAC/SLAC-wrists in stage II/III. However, a higher number of cases and comparative studies are needed to confirm this concept.

Delayed and non-union of isolated fractures of the capitate are rare injuries. Initial plain radiographs do not always show the fractures. Especially fractures through the neck of the capitate can lead to delayed union. We report on a patient with persistent localised pain over the capitate 5 months after a fall on the hand. The CT examination showed a delayed union of the capitate, which was treated with an iliac cancellous bone graft and screw osteosynthesis. Bone healing was verified 3 months after operation. Operative therapy is recommended in cases of delayed union or non-union of the capitate.

Background: Correction of severe tibial deformity due to a non-union of the tibia is best achieved by a slow gradual correction which allows the compromised tissue to adapt. The Taylor spatial frame (TSF) is a hexapod-based ring fixator that allows a simultaneous gradual correction of a multiplanar deformity through a virtual hinge. The aim of this study was to demonstrate the application of the TSF and the clinical outcomes of ten patients with a non-union of the tibia., Patients and Method: Ten patients with either a hypertrophic or atrophic non-union of the tibia were treated between 2003 and 2006 with the TSF. The mean age of these patients was 43 years (range: 12-73). There were 5 hypertrophic and 5 atrophic non-unions. Five of the ten fractures were initially open. The mean preoperative magnitude of the angulation deformity was 21.9 degrees (range: 5-44). In nine patients, the correction was performed in a closed manner; one patient had hardware removed prior to the frame application., Results: In all ten patients, the deformities were corrected. The average duration of time that the frame was worn was 158.5 days (range: 89-300). The mean time for gradual correction was 23.1 days (range: 5-43) with an average correction speed of 1.3 mm/day (range: 0.5-2). No additional bone stimulation was performed. In terms of complications, one patient had a residual valgus deformity of 5 degrees , one a pin tract infection, and one a stress fracture next to a pin hole., Conclusion: In patients with either a hypertrophic or oligotrophic non-union of the tibia and severe deformity, the TSF is a powerful tool to correct the deformity in a closed manner which preserves the remaining viability of the non-union.

Aim: Results of shoulder replacement in fracture sequelae are not satisfying. This is due to an insufficient function of the rotator cuff, mostly because of a secondary necrosis of the tubercles. The aim of this study was to investigate if the differentiated use of anatomic and reversed prostheses in dependence of the preoperative anatomic situation is able to optimise the results., Method: The aim of this study was a comparison of 55 patients with secondary trauma prostheses in fracture sequelae. In 36 cases (especially fracture sequelae types 1 and 2 according to Boileau), anatomic head prostheses (Affinis, FU 24 months) and in 19 cases (especially fracture sequelae types 3 and 4 according to Boileau), inversed prostheses (Delta III, FU 18.3 months) were implanted., Results: The Constant score of the patients with fracture sequelae types 1 and 2 according to Boileau and Walch improved from 19 to 68 on average (anatomic prosthesis), and for types 3 and 4 from 9 to 47.5 (inversed prosthesis). For these special indications, fracture sequelae types 3 and 4 show remarkably better results than those with an anatomic head prosthesis mentioned in literature. The preoperative score of the collective of patients we examined was 10 points less than the one in comparable publications. The postoperative improvement is therefore clearly more significant., Conclusion: The differentiated indication of anatomic and reversed shoulder prostheses in fracture sequelae leads to a noticeable improvement of the postoperative results. In slight malformations (fracture sequelae types 1 and 2) the anatomic prosthesis is the better choice. For severe deformations (fracture sequelae types 3 and 4) however, the implantation of a reversed prosthesis is the more convincing intervention. Moreover, the differentiated indication allows for a better prediction of the expected result.

Power lifting injuries most often involve shoulder injuries with an injury rate of 0.57 to 0.71/1000 hours of power lifting. Wrist injuries are less common in power lifters with 0.05/1000 hours exposure vs. 0.23/1000 h in elite weight lifting men. Often, two contributing factors causing wrist injuries are encountered: a) loss of balance causing the barbell to drift back behind the head of the power lifter, which hyperextends the wrist and b) the maximal weight. We report on an elite power lifting athlete preparing for the World Masters Bench press championships suffering two months of persisting pain during bench press exercise and rest in the snuff-box area following a loss of balance of the bar-bell during bench press with 280 kg load. Following prolonged presentation 2 months after the initial injury with training in the meantime, CT-scan was performed revealing a C-type scaphoid fracture. Surgery was performed as Herbert screw fixation and bone grafting according to the technique of Matti-Russe, followed by an immobilisation of twelve weeks with a plaster. We recommended ending the athletes' power lifting career, however he further exercised with the plaster with consecutive re-operation 3months later and 2nd Matti-Russe and Herbert screw re-do. One year later he became national champion with 240 kg bench pressing. Given the limited scaphoid blood supply and the high complication rate especially among C-type scaphoid fractures, a surgical procedure with bone grafting, Herbert screw fixation and sufficient plaster immobilisation is advocated in scaphoid fractures in elite athletes.

We report on the therapy of two hypertrophic, metaphyseal nonunions of the distal femur by retrograde nailing. Two patients with an old nonunion were successfully treated only by interlocking the retrograde nail according to the principle of transfixation. Both cases illustrate that an angular stable fixation might be critical to bony consolidation in the metaphyseal region. If toggling of the nail within the medullary cavity is limited by interlocking at appropriate positions, retrograde intramedullary nailing will provide angular stable fixation.

Operative treatment of distal tibial fractures remains a challenge for the surgeon even today. The soft tissues demand atraumatic operative techniques, although an anatomical reduction of the articular fracture component is mandatory. The nonunion rate increases with disturbed local blood supply, widened fracture gap, unstable fixation. If a nonunion occurs, an individual treatment concept is required, so that even difficult situations can be successfully managed, as described in our case with bilateral tibial nonunions.

Traditionally acute scaphoid fractures were treated by immobilization. As a consequence we have to deal with a high number of scaphoid non-unions or SNAC wrists. A study of 30 patients with scaphoid non-union showed that only 30% (9 patients) have not seen a doctor, while the majority of the patients (70%, 21 patients) were treated by a physician after trauma. In 15 (71.4%) of these 21 patients a missed diagnosis and in 6 (28.6%) a failed conservative treatment of the scaphoid fracture were the reasons for scaphoid non-union. Therefore, improvements in the diagnosis and therapy of scaphoid fractures are urgently needed. Herbert's classification of scaphoid fractures provides the underlying rationale for treatment according to the fracture type seen on X-ray. Differentiation between stable and unstable fractures sometimes is difficult from conventional X-rays. In these cases we recommend a CT bone scan in the long axis of the scaphoid. According to the CT scan we modified Herbert's classification: undisplaced waist fractures are classified as stable and can be treated conservatively or can be stabilized percutaneously using minimally invasive procedures. Comminuted or displaced fractures are classified as unstable and need operative treatment because of the increased risk of scaphoid non-union after plaster immobilization. Fractures of the proximal pole of the scaphoid should be treated operatively by internal fixation, even if they are not displaced, because of the reduced perfusion. We recommend a CT scan of the scaphoid, if there is any doubt about the diagnosis or the stability of the scaphoid fracture. In any case, a CT scan has to be ordered to justify a conservative treatment.

The proximal row carpectomy (PRC) is a motion preserving procedure which creates a new joint without arthrosis. It is a frequently used procedure in stage II of a posttraumatic degenerative arthrosis of the wrist after scaphoid nonunion or scapholunate ligament instability (SNAC-/SLAC-wrist). In this retrospective analysis the functional postoperative results of this operation are compared in light of a homogenous indication (SNAC-/SLAC-wrist stage II). In 38 patients PRC was performed for a stage II SNAC- (n = 29) or SLAC-wrist (n = 9) between June 1994 and March 2002. Postoperative examination included range of motion and grip strength. Pain was assessed using a visual analogue scale (VAS 0 - 100). The DASH questionnaire (disability of the arm, shoulder and hand) was used to evaluate the disabilities in activities of daily living (ADL). Thirty patients (79 %) with a mean age of 39 years (23 - 59) were evaluated with a mean follow-up of 27 months (6 - 100). Mean extension and flexion of the wrist reached 75 degree which was 57 % of the contralateral hand. Mean radial and ulnar deviation was 33 degree corresponding with 52 % of the contralateral hand. The average grip strength was 50 % of the unaffected side. The postoperative DASH score was 27.4. Pain with strenuous activity was reduced by 40 %, resting pain by 77 %. Three patients showed radiological signs of a radiocapitate arthrosis, one patient needed conversion into a complete wrist arthrodesis. Our results are in concordance with the literature. However, our follow-up time is relatively short and we cannot make any conclusion about the long-term outcome. PRC is a technically straightforward procedure for treatment of carpal collapse. For stage II of the SNAC-/SLAC-wrist we consider the resection of the proximal carpal row an alternative procedure to the midcarpal arthrodesis particularly in patients who require less grip strength and when a shorter postoperative immobilization is reasonable.

Despite the introduction of highly active antiretroviral therapy (HAART), diffuse large B-cell lymphoma (DLBCL) remains a common malignancy in human immunodeficiency virus (HIV)-infected patients, especially the plasmablastic variant. About 50% of lymphomas in HIV patients are extranodal and half of them occur in the head and neck area. The main oral symptoms are pain, swelling, numbness and tooth mobility. We report the case of a 52-year-old patient with a known HIV infection and fracture of the angular region of the mandible. The fracture did not unite following open reduction and osteosynthesis. A biopsy performed at the time of revision revealed the diagnosis of a primary lymphoma in the mandible. After chemotherapy had induced complete remission of the lymphoma and autogenous iliac crest bone grafting had been performed the fracture united. Primary lymphoma in the mandible is a disease that presents with a nonspecific radiological appearance which may mimic osteomyelitis or periodontal pathology. A rapid and accurate diagnosis is critical for the appropriate treatment. In our experience HIV-positive patients with mandibular fracture should be treated according to the guidelines established for HIV-negative patients. However, risky compromises such as intraoral approach or hazardous fracture fixation should be avoided.

The exact and adequate management of diaphyesal fractures of the forearm is necessary to ensure forearm motion. Unsatisfactory treatment can lead to loss of function and disability of forearm and hand movement, resulting in severe patient morbidity. Since the rotational and angulatory stresses at the fracture site are the superior factors which influence the outcome of the forearm fracture healing after surgical treatment, the implants must fulfill some general prerequisites including high biomechanical stability, less invasive surgical approach and adequate biological features. However, less clinical studies are known for cases of complicated ulnar fractures when additional revision surgery is necessary to restore form and function. Thus, the choice of implant in such difficult situations requires a profound knowledge and experience. In a series of seven clinical cases we report about the successful use of the ForeSight-nail in revision surgery of complicated ulnar fractures. The series include cases with refractures after plate removal, in-situ plate brokerage and a critical size bone non-union which were treated with interlocking intramedullary osteosynthesis technique.

The treatment of proximal humerus fractures is overshadowed by problems like avascular humeral head necrosis, implant failure in osteopenic bone and moderate outcome, especially in the elderly. More precise imaging, a better understanding of the vascularity of the humeral head leading to indirect reduction techniques and new implants which allow for saver fixation even in osteopenic bone, allowing early functional aftercare, are the new promising factors which have the potential to ameliorate fracture treatment of the humeral head. A prerequisit for sucessful treatment is a thoroughful imaging which allows adequate preoperative planning. The type of stabilisation depends more on the surgeons preference and there are pros and cons with all implants. Functional after treatment however depends on the applied stabilisation principle and should be carefully monitored and adapted according to the bone healing process, monitored by regular postoperative x-ray controls.

Methods: The clinical results after DFN-osteosynthesis of n = 56 AO-classification 33A-fractures (32%), 33C-fractures (43%), 32X-fractures (21%) and treatment of non-union (4%) are presented., Results: Follow-up was available for 54 fractures (96%) after a mean of 1.2 years (range 0.2-2.8 years). 95% of patients showed full-weight-bearing with a knee flexion of 120 (60-140) degrees. Extension-deficit > 10 degrees was observed in 5.4%. All fractures were consolidated. One soft-tissue infection, one partial loss of reduction and one implant failure were observed. A significant axial malalignment was found radiologically in 17%, a loosened spiralblade or locking screw in 7.4%. In 91% of cases the result was judged as good to excellent by patients., Conclusion: The mechanical stability of the implant allows a save osteosynthesis of unstable supracondylar and complete articular femoral fractures without additional bone grafting. Mechanical stability and minimal invasive operative technique permit a safe bone healing without major complications.

One of the procedures for the treatment of scaphoid-nonunion with loss of blood supply to the proximal fragment involves the technique described by Fernandez and Eggli (1995). After resection of the necrotic bone and inserting a corticocancellous bone graft from the iliac crest, the second dorsal intermetacarpal artery is implanted into the proximal fragment of the scaphoid. In our hospital, six patients underwent this procedure from May 1998 to June 2000 because of necrosis of the proximal pole or an unsuccessful previous operation. Union was achieved in five patients. In one case, nonunion persisted and the cystic area increased. The described technique is suitable for improvement of bone healing of the scaphoid in complicated cases. The advantages of this technique lie in the predictable anatomy of the second intermetacarpal artery and the straightforward dissection.

Osteopetrosis is a disease in which a disturbance in the resorption of bone formed by endochondral ossification takes place. The cause of the osteoclast insufficiency is unknown. In the literature, the etiology of the disease is discussed in relation to the complete absence of cathepsin K synthesis, a cysteine protease. In our case report, we demonstrated cathepsin K expression in the osteoclast cells of the benign form of osteopetrosis. We also found the macrophage marker CD 68 in these osteoclast cells, whereas other mononuclear phagocytic cells were not present in the vicinity of osteoclasts. The inhibition of osteoclast cells by phagocytes is unlikely.

Nonunions and malunions around the elbow are often due to incorrect initial treatment of a fracture. We have to differentiate between nonunions and malunion of adults and children. There are general principles for the treatment of nonunions and malunions of the distal humerus. They should not always be treated by decortication, internal fixation and bone graft. Removal of non-united fragments or a correction osteotomy may be good alternatives. A correct surgical approach and a biologically accurate osteosynthesis are necessary for good joint mobility, whereby the most difficult problem is to regain extension. An arthrolysis is not normally necessary during the first operation of a non- or malunion. It can be carried out, if necessary, on removal of implants. If these principles are followed, then the operation is usually successful and the patient satisfied. If treatment fails, the possibility of a joint replacement or an arthrodesis should not be forgotten.

Introduction: Operative treatment of humeral shaft fractures has gained a new impetus with the development of intramedullary interlocking systems for the humerus. Because of the anatomical structure of the humeral marrow cavity, a regular jamming of nail into bone is not to be expected, so that the stability of these systems needs to be achieved through an interlocking mechanism. Among the commercially available interlocking nailing systems the unreamed humeral nail (UHN) and the Seidel-nail (SHN) can be regarded as the standard implants., Design: In a retrospective study comparing two groups of patients, each treated with one of the two systems, problems and advantages, as well as disadvantages were analyzed, and the complications inherent in the systems examined., Patients: Between 1988-1992, 47 patients with humeral shaft fractures were treated with a Seidel interlocking nail: 25 acute and 18 pathological fractures as well as 4 non-unions (Group 1). Between 1997-1999, 34 patients with humeral shaft fractures were treated with the unreamed humeral nail (UHN). A total of thirty-five (n = 35) nailings (30 acute and 4 pathological fractures, as well as one re-osteosynthesis after emergence of a non-union) were carried out. Three primary palsies of the radial nerve ensued: two with loss of sensitivity, and one complete paralysis (Group 2)., Methods: Based on pre- and postoperative X-rays and follow-up examinations, the healing process and complications inherent in each of the systems were evaluated., Results: Intra-operative complications of Seidel-nailing (Group 1) were seen in 5 cases: failure of the proximal target device in 2 (4.2%) cases; the breaking of the long screwdriver during the distal locking in 1 (2.1%) case; blockade of nail-insertion due to the spreading distal lamellas in 1 (2.1%) case; in 1 (2.1%) case it was impossible to find the imbus of the distal locking screw with the screwdriver. Incorrect surgical technique resulting in further fragmentation of the shaft required revisions in 2 (4.2%) cases. In 3 cases (6.4%), the insertion of the nail was insufficient, so that an impingement resulted. In 12 cases, postoperative complications after Seidel-nailing resulted: 3 (6.4%) radial nerve palsies, of which 2 (4.2%) were transitory; 3 (6.4%) infections; in 3 (6.4%) cases, loosening of the locking bolt inserted in the frontal plane; in 1 (2.1%) case, loosening of the distal spreading screw. The system failed in treating 2 (of 4) non-unions, whereas successful ossification and repair occurred in all acute fractures. In Group 2 (UHN) the acute fractures of 33 cases healed without complications. Intra-operative complications of the unreamed nail: in 2 cases (5.6%), failure of the target devices resulted in malpositoning of interlocking screws. The following intra-operative complications of the retrograde technique were observed: burst of a fragment at the insertion site in 1 case (2.8%); intra-articular positioning of the most proximal interlocking screw in another case (2.8%). Postoperative complications of the unreamed nail: breaking of a proximal and a distal interlocking screw in 1 case (2.8%), which had no influence on the healing progress. In 1 case (2.8%) both proximal interlocking screws came loose and a non-union ensued. After re-osteosynthesis with the same technique, bony repair was achieved., Conclusion: The possibilities of operative methods in treatment of humeral shaft fractures are enhanced by intramedullary interlocking systems. Comparing with the Seidel nail, the unreamed humeral nail (UHN) has two advantages: it can be inserted anterogradely as well as retrogradely, and it provides the possibility of compressing the fracture, resulting in a high rotational stability. Due to these results, the application of the UHN is recommended.

A femoral neck fracture combined with an ipsilateral shaft fracture is often primarily not diagnosed. The later treatment is technically more difficult, because in the choice of operative technique for the shaft fracture the neck fracture it was not considered. In this case report the treatment of the shaft fracture with a reamed nail, and the secondary stabilisation of the femoral neck fracture with screws resulted in a pseudarthrosis of the femoral neck with an unfavourable inclination of the fracture plane. Both fractures healed without complications after changing the nail against a bridging plate and an intertrochanteric osteotomy with correction in two planes.