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Background: Clavicular shortening often occurs after midclavicular fractures and its impact on functional outcomes has thus far been evaluated solely by radiographic and surgeon-based measures, with divergent findings.

Hintergrund: Komplexe Sprunggelenksfrakturen sind haufige Verletzungen des alten Menschen. In der eigenen Klinik wurde in diesem Patientengut in Einzelfallen eine Diskrepanz zwischen den praoperativ erhobenen Befunden der konventionellen Rontgenaufnahmen und den intraoperativen Befunden hinsichtlich der Frakturmorphologie beobachtet. Es wurde deshalb die Hypothese formuliert, dass bei alteren Patienten viele therapierelevante Verletzungen im Rontgenbild nicht erkannt werden. Die Dokumentation einer mehrfragmentaren Fraktursituation am oberen Sprunggelenk ist erlosrelevant. Material und Methoden: Fur die Untersuchung konnten die kompletten Daten und praoperativen Rontgenbilder von 84 Patienten mit Sprunggelenksfrakturen in einem Alter von uber 60 Jahren retrospektiv ausgewertet werden. Hierbei handelte es sich um 59 Frauen und 25 Manner im mittleren Alter von 69,9 Jahren (Range 60–90 Jahre). Die OP-Berichte und die praoperativen konventionellen Rontgenbilder wurden hinsichtlich folgender Kriterien analysiert: mehrfragmentare Ausenknochelfraktur, Innenknochelfraktur, posteriores Kantenfragment, knocherner Ausriss der vorderen Syndesmose. Es wurden die Sensitivitat, die Spezifitat, der positiv pradiktive Wert, der negativ pradiktive Wert, die Pravalenz sowie die Genauigkeit berechnet. Ergebnisse: Die Pravalenz der einzelnen Lasionen betrug in dem hier analysierten Kollektiv fur eine mehrfragmentare Ausenknochelfraktur 24 %, fur eine Innenknochelfraktur 38 %, fur eine Beteiligung des hinteren Volkmann-Dreiecks 25 % und fur einen knochernen Ausriss der vorderen Syndesmose 22,6 %. Mehrfragmentare Ausenknochelfrakturen (Sensitivitat 0 %) und knocherne Ausrisse der vorderen Syndesmose (Sensitivitat 5 %) wurden im konventionellen praoperativen Rontgenbild kaum erkannt. Innenknochelfrakturen und Frakturen des hinteren Volkmann-Dreiecks wurden im konventionellen Rontgenbild mit einer ausreichenden Sensitivitat (96,8 %/76,2 %) und Spezifitat (jeweils 100 %) erkannt. Schlussfolgerungen: Die hier vorliegende Untersuchung hat gezeigt, dass bei alteren Patienten in einem Viertel der Falle mit komplexen Sprunggelenksfrakturen zu rechnen ist. Mehrfragmentare Ausenknochelfrakturen entziehen sich dem Nachweis auf dem konventionellen Rontgenbild. Die Indikation zur praoperativen CT-Untersuchung sollte groszugig gestellt werden, um intraoperativ nicht von einer mehrfragmentaren Situation uberrascht zu werden. Der MDK sollte bei Fallprufungen auf den intraoperativ dokumentierten Befund und nicht auf den praoperativen Rontgenbefund zuruckgreifen, wenn es darum geht zu entscheiden, ob eine mehrfragmentare Sprunggelenksfraktur vorliegt.

Das Ziel der hier vorliegenden Untersuchung bestand in einer patientenorientierten Erfassung der Schulterfunktion und der verbliebenen Beschwerden nach diaphysaren Klavikulafrakturen in Bezug auf eine Verkurzungsfehlstellung. Grundlage der hier vorgestellten Analyse sind die Daten eines Kollektivs von 172 erwachsenen Patienten (Alter 39 ± 14 Jahre) mit verheilten Klavikulafrakturen, die operativ (n = 108) oder konservativ (n = 64) behandelt wurden. Als Vergleichskollektiv dienten 35 schultergesunde Erwachsene und 25 Patienten mit Pseudarthrosen nach konservativer Behandlung. Erfasst wurden die subjektive Einschatzung der Schmerzstarke auf einer visuellen Analogskala (VAS 0–100 Punkte), der relative Constant-Score, der Kolner Klavikulascore, der DASH-Score (Disabilities of the Arm, Shoulder and Hand) sowie die Langendifferenz der Klavikula im Seitenvergleich. Patienten mit einer Klavikulalangendifferenz ≥ 2 cm beklagten signifikant (p

Background: Clavicular shortening often occurs after midclavicular fractures and its impact on functional outcomes has thus far been evaluated solely by radiographic and surgeon-based measures, with divergent findings.

Das Ziel dieser Arbeit bestand in der Erstellung eines Scores zur Beurteilung der Behandlungsergebnisse von Frakturen des mittleren Klavikuladrittels. Hierzu wurden 172 Patienten im Mittel 15 Monate nach dem Unfallereignis untersucht. Als Kontrollgruppe dienten 45 gesunde Probanden. Der sog. „Klavikulascore“ basiert auf einem System aus 3 Partneritems plus der Beurteilung des Rontgenbildes. Als Partneritems wurden die Elemente mit den signifikantesten Mittelwertveranderungen bezogen auf die Einteilung der objektiven Partner ermittelt. Scorewertbeurteilungsgrenzen (sehr gut, gut, masig, schlecht) wurden festgelegt. Zur Validierung des Bewertungssystems wurde eine lineare Regressionsanalyse bezogen auf 2 etablierte Bewertungssysteme (Constant-Score/DASH-Score) durchgefuhrt. Mit einem Korrelationskoeffizienten R=0,756 (Constant) und R=0,687 (DASH) wurde gezeigt, dass die Aussagen valide sind. Zur Prufung der Reliabilitat wurde der Reliabilitatskoeffizient Cronbach’s α gebildet, der mit einem Wert von 0,8241 eine hohe Reliabilitat zeigt. Der Klavikulascore ist ein wenig aufwendiges, valides und reliables Instrument zur Beurteilung der Behandlungsergebnisse nach Frakturen des mittleren Klavikuladrittels.

Die elastisch stabile intramedullare Nagelung bei Klavikulafrakturen des mittleren Drittels ist ein sicheres Operationsverfahren bei Frakturen der Typen A und B nach der Orthopaedic-trauma-association- (OTA-)Klassifikation. Im vorliegenden Fall fuhrten die Verwendung eines Kirschner-Drahts sowie die nicht korrekte Durchfuhrung der Operationstechnik zu einer Pseudarthrose. Nach Revision und Anwendung eines elastischen Titannagels kam es zur knochernen Ausheilung.

Nonoperative treatment has long been the norm for clavicle fractures. However, more recent evidence indicates that shortening or poorly healed fractures lead to considerable loss of arm function. A logical treatment algorithm for clavicle fractures based on up-to-date scientific data was developed, and the operative technique of intramedullary nailing of the clavicle is here described and demonstrated with instructive diagrams. Along with surgical indications, the preoperative, perioperative, and postoperative management is detailed. Operative hints and tricks are explained, the known complications and pitfalls of the procedure are analyzed, and avoidance strategies are offered.

Tibial plateau fracture classification systems have limited interobserver reliability and new systems emerge. The purpose of this study was to compare the reliability of the Luo classification and the Schatzker classification for two-dimensional computed tomography (2DCT) and to study the effect of adding three-dimensional computed tomography (3DCT). Eighty-one observers, orthopedic surgeons and residents, were randomized to either 2DCT or 2D- and 3DCT evaluation of a spectrum of 15 complex tibial plateau fractures using web-based platforms in order to classify according to the Schatzker and according to Luo's Three Column classification. Reliability was calculated with the use of Siegel and Castellan's multirater kappa measure. Kappa values were interpreted according to the categorical rating by Landis and Koch. Overall interobserver reliability of the Schatzker classification was significantly better compared to the Luo classification (kSchatzker=0.32 and kLuo=0.28, P=0.021), however, 'fair' for both fracture classification systems. For the Schatzker classification observers agreed significantly better on 2DCT compared to 2D- and 3DCT (k2DCT=0.37 and k2D+3DCT=0.29, P

Background: Although the anatomy and physiology of the venous circulation of the ankle and midfoot are well documented, the physiologic importance of forefoot mobility has not been reported in the literature. The question of this study was whether the first metatarsophalangeal (MTP) joint may operate, like the ankle, as a “pump” to encourage venous return. Methods: Forty-nine cadaver foot specimens were examined using dissection, plastination, vessel infiltration, and maceration, and radiographic (including venography, MRI, and magnetic resonance angiography) techniques. The anatomy and physiology were described and compared to the ankle joint. Forty patients had biphasic Doppler flow studies. Results: The major finding was the medial drainage of the plantar venous sinus, which is fibrotically bound to the joint capsule. Functional venous valves were evident distally and within fibrous vascular lumens. Mobilization of the first MTP joint led to compression and emptying of the veins. Passive mobilization of the first MTP joint led to an average flow increase of 55% ± 7 ( p < 0.0001), while active movement led to an average increase of 78% ± 7 ( p < 0.0001). Conclusions: Our described connection between the joint capsule and veins indicates a “toe-ankle pump” with a significant increase of venous blood flow during motion of the MTP joint. Possible clinical applications for an external MTP pump include anti-edema or thromboprophylactic therapy, especially in patients with foot or ankle injuries. A new toe-pump has been designed based on these results.

Trotz der gunstigen Prognose weisen 10–30% der konservativ behandelten Patienten mit Klavikulafraktur unbefriedigende Ergebnisse auf. Die vorgestellte Technik der intramedullaren Osteosynthese beruht auf einer langstreckigen intramedullaren Stabilisierung durch die elastische Verspannung eines geraden Titannagels in der S-formig gebogenen Klavikula nach dem Prinzip der „elastisch stabilen intramedullaren Nagelung“. Bei mit dieser Methode versorgten 132 Patienten (136 Klavikulafrakturen) zeigte sich, dass die Reposition der Fraktur und die Herstellung einer elastischen Stabilitat am Frakturspalt Voraussetzung fur eine rasche postoperative Schmerzfreiheit und Beweglichkeit der verletzten Schulter sind. In einer prospektiv vergleichenden Untersuchung konnten 53 Patienten mit Klavikulafraktur frei zwischen konservativer und operativer Behandlung wahlen (27 konservativ/26 operativ). Hinsichtlich Schmerzen, subjektiver Zufriedenheit, asthetischem und funktionellem Ergebnis, Arbeitsunfahigkeit, Langendifferenz, Constant- und DASH-Score waren die Resultate nach Operation signifikant besser als nach konservativer Behandlung. Die vorgestellte Methode ist somit bei Klavikulafrakturen des mittleren Drittels der Typen A und B der OTA-Klassifikation am ausgewachsenen Skelett indiziert.

Avascular necrosis is a well-known, severe complication postfracture or subluxation of the talus. Type and localization of injury often permit conclusions regarding the probability of bone necrosis. In the following case, talar neovascularization was demonstrated after severe trauma, resulting in an open pilon fracture of the right tibia and complete talar dislocation with consequent destruction of the most relevant blood supply. This example shows that even after apparently irreversible injury to the arterial circulation, immediate bony reconstruction with comprehensive soft tissue management is indicated and can lead to bony healing. The anatomy of intraosseus vascularization is reviewed and discussed.

Das Ziel der hier vorliegenden Untersuchung besteht in einer vergleichenden Analyse des Regeneratgewebes in einem chondralen Knorpeldefekt der Schafsfemurkondyle nach autologer De-novo-Knorpeltransplantation. Bei 48 Schafen wurde an der medialen Femurkondyle ein chondraler Knorpeldefekt mit einem Durchmesser von 4 mm platziert. 12 Defekte wurden der spontanen Heilung uberlassen, 16 Defekte mit einem Periostlappen bedeckt, und 20 Defekte wurden mit einem autologen De-novo-Knorpeltransplantat gefullt. Im Vergleich zu den Kontrollgruppen wurde die Transplantatgruppe sowohl nach 26 Wochen als auch nach 52 Wochen signifikant (p

An experimental cadaver model was used to assess the effects of a malunited fracture of the middle third of the clavicle on the functional anatomy of the shoulder joint. Anatomic samples were prepared with simulated shortening and axial malposition of the clavicle. From these, alterations in glenoid fossa position were measured and depicted graphically. Healing of clavicle fractures with bony shortening leads to a ventromedialcaudal shift in glenoid fossa position. The following malpositions of the clavicle lead to the respective glenoid fossa positional changes: caudal deviation leads to a mediocaudal shift, cranial deviation leads to a dorsolateral shift of the glenoid fossa, ventral deviation causes a ventrolateral shift, dorsal deviation leads to mediocaudal shift of the fossa, cranial rotation leads to ventrolateral shift in fossa position, and caudal rotation leads to a dorsomedial shift in glenoid fossa position. Clinical implication of these data is that bony shortening in combination with caudal displacement leads to distinct functional deficits in abduction, particularly overhead motion. Using the above data, a vector model was created to calculate position of the glenoid fossa dependent on clavicle position/malposition. The model is a valuable tool to be used for planning open reduction and fixation of clavicular fractures or malunions.

Fractures of the distal end of the radius are common injuries and are the commonest bony injury around the wrist. Management of these fractures has remained controversial as far as modality of treatment is concerned. There are aggressive concepts with open reduction and internal fixation with plates and minimally invasive pinning after closed reduction. The latter treatment concept is evaluated using own data and results from the literature. Percutaneous pinning is used as treatment alternativ in ASIF A2 and A3 fractures. In C3 type fracture they can play an important part as supplementary adjunct in combination with external fixation or plates. Furthermore percutaneous pinning techniques can be used in distal radius fractures in children with dislocation. Elderly patients with type C fractures do gain superior results in functional outcome using this technique than with reduction and casting alone. Percutaneous pinning is very cost-effective in comparison to plating. When using correct indications this technique can provide excellent functional results.

Intramedullary fixation is used increasingly to treat clavicular fractures. Anatomical variations in the clavicle of relevance to this procedure are analyzed. The length, diameters and curvature of the clavicle were measured in 196 specimens from the dissecting room. The calcium bone density was analyzed in 300 cross-sectional samples of 100 specimens. The thickness of cortical and medullary bone of 70 slices was analyzed from freshly plastinated clavicles with implants in place. The female clavicle was shorter, less curved, and had a lower concentration of calcium than the male clavicle. Measurement of cortical thickness showed a mean value of 1.05 +/- 0.23 mm at the most sternal measuring point, 2.05 +/- 0.29 mm at the midpoint of the clavicle, and 0.95 +/- 0.35 mm at the acromial end. The thinnest regions were the medial ventral cortex and the dorsal acromial cortex. These measurements explain clinical observations on nail perforation. The diameter of the medullary canal measured 6.7 +/- 2.6 mm at its narrowest part, so that reaming (i.e., predrilling the medullary canal) prior to 3.5 mm titanium nail insertion is not necessary. The main difficulties encountered when placing a nail are secondary to the S-curvature of the clavicle. In 80% of fractures, the break is located at the narrowest diameter of the medullary canal. Thus, the clavicle displays definite gender- and side-specific anatomical features in terms of length, diameter, curvature, and calcium concentration. These should be considered when performing intramedullary fixation.

Eighteen patients with intraarticular calcaneal fractures treated with open reduction and internal fixation and augmentation with an injectable carbonated apatite cement. Functional follow-up studies using the Zwipp Foot Score and densitometry were performed at 6-month intervals postoperatively. Histological samples of biopsies obtained at the time of hardware removal (6 months postoperatively) were also analyzed. The use of bone cement led to intermediate-term functional outcomes that were no better than those reported with conventional surgical procedures using bone graft. Patients demonstrated postoperative difficulties similar to those seen in other studies of this fracture, including pain, subtalar motion restrictions, peroneal impingement, and difficulties on uneven terrain and with toe- and heel-walking. However, compared to patients treated surgically without injectable carbonated apatite cement, full weight bearing on the affected extremity was regained at an average 4 weeks postoperatively. In addition, autogenous bone graft was not required to fill the osseous defect using this technique, minimizing morbidity and discomfort. During the present observation period of 3 years, only a slight decrease in the density of the peripheral zones of the cement block was observed. Histological examination revealed fibrous bone formation resulting from remodelling processes. Complete resorption and remodeling of the bone cement were not complete at 3 years. One patient developed a postoperative wound infection. Another displayed cement loosening secondary to failure of bony ingrowth.

Reduction and intramedullary fixation of midclavicular fractures with an elastic titanium nail with the goal to reduce pain and to quickly resume activities of daily living postoperatively. Midclavicular fractures types A and B according to the OTA (Orthopaedic Trauma Association) classification of fractures. Surgery > 3 weeks after trauma. Fractures type C according to the OTA classification. Osteoporosis. Skin incision just above the sternal end of the clavicle. Approximately 1 cm lateral to the sternoclavicular joint, a hole is drilled into the anterior cortex. A titanium nail varying in diameter between 2.5 to 3.5 mm is mounted on a universal chuck with a T-handle. With oscillating movements the titanium nail is advanced until it reaches the fracture site. If closed reduction maneuvers are unsuccessful, an additional skin incision has to be made at the level of the fracture site enabling direct manipulation of the fragments. Postoperatively, no immobilization is performed. Patients are encouraged to move the arm as much as tolerated and to use it in daily activities. Intramedullary fixation was applied to 136 clavicle fractures in 132 patients (89 men, 43 women, mean age 32.9 years). In 78 fractures closed reduction was successful. Average subjective pain assessment using a visual analog scale decreased from 72.4 points preoperatively to 18.9 points 3 days postoperatively. Average shoulder abduction increased significantly. The average Constant-Murley clinical outcomes score 1 year after implant removal was 97.1 points.

Das Ziel der hier vorliegenden Untersuchung bestand in der prospektiven Erhebung der Ergebnisse nach der elastisch stabilen intramedullaren Nagelung von Klavikulapseudarthrosen. In einem Zeitraum von 2,5 Jahren konnten 14 Patienten in die Untersuchung einbezogen werden. Ausschlusskriterien waren Pseudarthrosen bei pathologischen Frakturen, Infektpseudarthrosen, atrophe Pseudarthrosen, knocherne Defekte, vorausgegangene operative Masnahmen, ein Patientenalter 70 Jahre. Die Ergebnisse wurden nach 3, 6, 12 und 18 Monaten evaluiert. Die subjektive Schmerzempfindung, die Zufriedenheit der Patienten, der Constant- und DASH-Score waren ab dem 3. postoperativen Monat signifikant (p

The objective of this retrospective study was to compare the results of two operative techniques used for the treatment of distal radius fractures classified as AO type A3. Patients were treated with either fixed-angle volar plates or intrafocal Kirschner wires (K-wires) using a Kapandji-like technique. The functional results were determined with the Gartland & Werley Score as well as the DASH Score after an average follow-up of 28 months. 55 patients were included in the study. Of these, 33 were female and 22 male, with an average age of 59 years. In patients < 60 years, the Gartland Score was 1.4 points in the fixed-angle volar plate group, and 4.6 points in the Kapandji group. In patients ≥ 60 years, no significant difference between the therapy groups could be ascertained. The DASH Score measured 17 points in each group. In all cases, a satisfactory reduction was obtained. The Kapandji group experienced significantly more loss of reduction position at follow-up in terms of volar tilt and radioulnar inclination than the fixed-angle volar plate group. These results show that intrafocal K-wire fixation in older patients is a suitable method to attain and hold sufficient bony reduction. However, younger patients achieve better radiologic and functional results when treated with open reduction using the 3.5-mm LCP fixed-angle volar plate.

Biodegradierbare Implantate ermoglichen eine Fixierung osteochondraler Frakturen ohne spatere Metallentfernung. Je nach Implantatzusammensetzung und -abbaugeschwindigkeit werden Fremdkorper- und Weichteilreaktionen unter der Degradation beschrieben. Einem Polyl-L/DL-Laktid-Stift (Polypin) wurden 10% Trikalziumphosphat beigesetzt, um die Degradationseigenschaften zu verbessern. Im Tierversuch uber 3 Jahre konnten ein vollstandiger Abbau der Implantate und Ersatz des Lagers mit Knochen oder Narbe belegt werden. Anschliesend wurden 78 Patienten operiert und im Mittel nach 39 Monaten (1,5–85 Monaten) klinisch und konventionell radiologisch nachuntersucht. An der Schulter wurden 5, am Ellenbogen 42, an der Hufte 12, am Knie 7 und am Fus 12 Patienten mit biodegradierbaren Implantaten versorgt. Alle Frakturen heilten ohne Dislokation mit guten funktionellen Ergebnissen aus. Fremdkorper- oder Weichteilreaktionen aufgrund der Implantate wurden nicht beobachtet. Verglichen mit den Literaturwerten waren die klinischen Ergebnisse gleichwertig oder besser.

To investigate the role of linezolid in the treatment of skeletal methicillin-resistant Staphylococcus aureus (MRSA) infections in a university clinic for trauma surgery with regard to treatment results, side effects, practicability, and costs. Data were recorded retrospectively in a single center over a 1-year period. Four patients with MRSA osteitis/infected pseudarthrosis of the upper extremity following prolonged fracture treatment were administered linezolid, after therapy with established antibiotics such as vancomycin had failed. In two patients with vertebral osteitis due to progressive spondylodiscitis, linezolid was used as the only effective antibiotic with oral availability, when intravenous application was technically impossible (central venous line complications/vena cava thrombosis). Adequate surgical treatment (debridement, stabilization, osteosynthesis) was performed in all patients. Linezolid was administered for a mean of 2.2 months (1.5–3 months). Side effects of intravenous or oral linezolid treatment were not seen. One patient died after 6 weeks (heart failure). Mean follow-up time was 17.4 months (13–24 months). MRSA arthritis after 12 months was observed in one patient. A second critically ill patient was diagnosed with MRSA infection of a prosthetic hip 15 months later. Reinfection was excluded in four patients. High daily costs also of oral linezolid application compete with advantages of an early ambulatory treatment. Linezolid is a potent antibiotic that should be left to skeletal MRSA infection after stabilization and debridement if (1) vancomycin treatment has failed and (2) intravenous application of vancomycin is not possible.

In a prospective study 23 patients were operated with a new intramedullary tibia nail (Sirus® intramedullary cannulated nail for tibia) since 1st May 2002. Nailing could be performed reamed or unreamed. The cannulated nail was inserted by means of a guide wire. Proximal and also distal four interlocking bolts could be positioned. There were 13 type A, 5 type B and 5 type C fractures (CCF classification). Reamed nailing was performed in 16 patients (operation time 85 minutes), an unreamed procedure was done in 7 cases (operation time 63 minutes). All patients were followed up after 3, 6,12 and 24 weeks. 20 patients were observed longer than 6 months (mean observation time 8 months). Fracture union was seen after within 3 months in all cases of reamed nailing and weight bearing was reached after the 1st week (mean). Unreamed nailing led to 3 delayed unions that were treated with dynamisation in two and a corticocancellous bloc in one case. Change to a reamed nail led to the consolidation of one pseudarthrosis (A3 fracture). Weight bearing following unreamed nailing was reached after 7 weeks (mean). Initially observed problems with the cap screws were not seen any more when the thread was improved. The Sirus® intramedullary cannulated nail for tibia can be used for reamed and unreamed nailing for fractures of from the 2nd to the 4th fifth of tibia shaft. A nonreamed procedure should be chosen as reserved as using comparable unreamed nail systems because of an increase of disturbed union.

Das Ziel dieser Untersuchung war die Erfassung der intra- und postoperativen Komplikationen der elastisch stabilen intramedullaren Nagelung (ESIN) bei kindlichen Femurfrakturen. 47 Kinder, mittleres Alter 6 Jahre, wurden bis zur Implantatentfernung regelmasig klinisch und radiologisch, danach jahrlich klinisch untersucht. Die Nachbeobachtungszeit betragt 37 Monate. Intraoperativ trat eine Kortikalisperforation und die Aussprengung eines Knochenfragments auf. 4 Kinder beklagten schmerzhafte Weichteilirritationen. Bei 1 Kind mussten die Implantate sekundar gekurzt werden. Bei jeweils 1 Implantatdislokation und 1 inakzeptablen Fehlstellung waren Korrekturoperationen erforderlich. Infektionen, Pseudarthrosen, Refrakturen oder korrekturbedurftige Wachstumsstorungen wurden nicht beobachtet. Die ESIN ist ein sicheres Verfahren zur Behandlung kindlicher Femurfrakturen. Die meisten Komplikationen lassen sich durch eine sorgfaltige Indikationsstellung und eine korrekte Operationstechnik vermeiden.

Lower leg fractures localised in the middle three fifths of tibial shaft are stabilised by intramedullary nailing. Patients' positioning on an extension table involves a loss of time and causes an increase of intramedullary pressure. The alternative positioning on a normal table requires an additional assistant to hold the leg and is associated with spontaneous and unwanted movements in the leg. Furthermore, there is a unnecessary need for personal capacities. A variable positioning of the leg can be easily reached by means of a frame made of carbon fixateur rods. Reduction and nailing can be performed by a single operator without help of a further surgeon. Fifty lower leg fractures have been operated since 1996 by means of this positioning aid. Mean operation time was 63 min for reamed and 55 min for unreamed nailing.

The goal of this prospective study was the compilation of data concerning the complications as well as the medium-term functional outcomes obtained when using the technique of elastic stable intramedullary nailing (ESIN) for cases of diaphyseal forearm fractures in children. 51 children, average age of 8 years, were treated with elastic titanium nails for displaced forearm fractures between January 1997 and December 2001. The average period of follow-up was 38 months. The average duration of fluoroscopy was 2.2 minutes. Four cases required open manipulation for reduction. The average duration of in-hospital stay for cases without polytraumic injuries was 2 days. 8 cases resulted in painful soft-tissue irritation at the insertion point of the nail. All of the fractures healed in a timely manner. There were no cases of infection of poor wound healing. Removal of implants was performed at an average of 5.4 months post-insertion. No clinical limitations regarding angulation or rotational malposition greater than 10° were observed. Limitations of pronation and/or supination between 10 and 30° were measured in three cases, and an elbow extension deficit of 10° was measured in one case. The results here show that intramedullary stabilization with elastic titanium nails is a biologic, secure and suitable mode of therapy for the treatment of diaphyseal forearm fractures of children.

Can distal radius fractures be held in place with palmar locking compression plates (LCPs) and heal completely without an additional bone transplant? From 1 March 2001 to 1 September 2002, 40 patients with distal radius fractures (CCF: 2× A2, 13× A3, 2× C1, 22× C2 and 1× C3 fractures) were treated with locking compression small fragment titanium plates. In 37 cases, the plates were inserted in a palmar direction without an additional corticocancellous bone graft. All patients received a follow-up check-up after an average of 12.1 months. On this occasion, the range of motion, grip strength and radiological result were measured and rated according to the Gartland and DASH score. All fractures healed completely. In one case, a re-osteosynthesis was carried out after the plate had bent because full load was placed on it prematurely. An average of 5.1 points was achieved in the Gartland and 12.6 points in the DASH score. An extremely good result was achieved in 19 cases, a good result in 15 and a satisfactory result in 6. At the follow-up examination, the average range of motion was 52°-0°-50° for stretching and bending in the wrist, 20°-0°-27° for radial and ulnar deviation and 82°-0°-78° for pronation and supination. On the radiographs, the average radiocarpal angle in the anteroposterior projection was 22° with a palmar tilt of an average of 5°. Radius fractures with metaphyseal, one-sided comminuted zones can be treated with locking compression plates with good results using a palmar approach without a cancellous bone graft.

Soft tissue reactions resulting from biodegradable polylactide implants to bone have not been adequately examined during their 3-year degradation period. An osteotomy was performed on the medial femoral condyle of 36 sheep and secured by either three poly- l - dl -lactide pins (70/30) (Polypin ® ) or three composite pins [10% β -tricalcium phosphate ( β -TCP) (90/10)]. A histological examination was performed on the synovial membrane and lymph nodes after 3, 18 and 36 months. After 18 months two non-specific, minor reactions of the synovial membrane were observed in the composite pin group. In both groups different reactions of both inguinal lymph nodes were observed. These had no statistical relevance and could not be clearly attributed to the implants. Due to the slow degradation process of biodegradable polylactide implants, there is no clinically relevant inflammation of either joint or lymph nodes. The addition of 10% β -TCP did not result in any significant enhancement.

As a response to research investigating the intraosseous vascularization and the special biomechanics of the calcaneus, a new theory of calcaneal cyst development was generated (retrospective patient study, n=4). A disturbance in local blood circulation occurs, due to, i. e., microembolus, thrombosis, or hematoma, at the neutral triangle where the major vessels penetrate the bone and separate. Following the disturbance in local blood flow, damaged tissues are resorbed. Due to the special biomechanics of the area, resorption is followed not by osseous remodelling, but instead by cyst formation. The two processes are histologically identical, including the presence of neovascularization, cholesterol plaques, hemosiderin and osteoid-lined cyst walls. Because of its sclerosed external wall, the benign calcaneal cyst is stable with normal biomechanics; however, eccentric weight-loading can lead to fractures.

Background: Intramedullary fixation of midclavicular fractures may be a better option than non-operative treatment for high performance/professional athletes because of the potential reduction in recovery time. Objectives: To evaluate the effectiveness of intramedullary fixation in high performance athletes and the time required to return to sporting activity. Methods: Data were taken from a prospective study on intramedullary fixation techniques using the elastic stable Ti nail (TEN, Synthes) for the treatment of displaced midclavicular fractures, initiated in 1996. The patients in 12 cases were classified as high performance/professional athletes. These cases were used to evaluate the technique specifically in this population. Fractures were classified according to the Orthopaedic Trauma Association (OTA) system. Patients were evaluated before and after surgery for shoulder function and subjective pain. After the operation, radiological assessments documented fracture healing, and clinical outcomes scores were obtained. Time required to return to training and competition was documented. Results: All fractures were transverse or oblique. Mean (SD) shoulder abduction increased from 36.3 (8)° before surgery to 154.2 (17)° afterwards (p

In sportsmen, one of the most frequently observed injuries is a midclavicular fracture. As the absence from their discipline until the time of fracture healing comprises the risk of significant financial loss, the fracture of the clavicle is of prominent importance to top-performance and professional sportsmen. This study presents the results of a minimally invasive operative treatment of midclavicular fractures in patients working as top-performance or professional sportsmen. Within five years the intramedullary osteosynthesis was applied to 80 patients with 84 fractures of the clavicle. Out of these patients, 12 were top-performance or professional sportsmen. These 12 patients - 2 women and 10 men - were aged 24.8 ± 10 years. Preoperatively, the sportsmen presented an abduction of the shoulder joint averaging out at 36.3 ± 8°, postoperatively, averaging out at 154.2 ± 17°. On a visual-analog scale (0 to 100 points), the subjective pain, preoperatively, revealed 71.7 ± 18 points. This was found to be significantly higher than the subjective pain on the third day after surgery: 19.2 ± 6 points. After the operation the sportsmen d their training, on average, after 5.9 ± 1 days. Attendance at contests was, on average, continued after 16.8 ± 5 days. All of the sportsmen's fractures healed. Twelve months after implant removal, the sportsmen's average Constant-Score revealed 98.3 ± 2 points. The elastic stable intramedullary osteosynthesis of midclavicular fractures offers sportsmen the chance of quickly resuming training and competition. This treatment should be offered to the patients as an alternative to conservative treatment. Training stops and financial losses of the person concerned and of the sponsors can be minimised.

Bei dislozierter Radiuskopffraktur Typ Mason II konnen an dem nur gering auf Scherung belasteten Radiuskopf biodegradable Implantate erfolgreich angewendet werden. Sie losen sich nach der Frakturheilung vollstandig auf, sodass ein Folgeeingriff zur Metallentfernung entfallt. Einem Poly-L/DL-Lactid-Stift wurde 10% β-Tricalciumphosphat beigesetzt, um eine kontrollierte langsame und nebenwirkungsarme Degradation zu erreichen. Dieser Polypin®-C-Stift wurde prospektiv bei 35 Patienten mit Radiuskopffrakturen eingesetzt. Nach durchschnittlich 38,2 Monaten wurden 34 der 35 Patienten klinisch und konventionell radiologisch nachuntersucht. In 29 Fallen konnte zusatzlich ein CT angefertigt werden. Zweimal wurden zwischen dem 18. und 24. Monat asymptomatische Osteolysen 1. Grades um die Stiftkopfe beobachtet, die sich im weiteren Verlauf vollstandig zuruckbildet hatten. Nach dem Broberg-Score konnten bei der Abschlussuntersuchung im Mittel 96 von 100 moglichen Punkten erreicht werden. Ab dem 24. Monat waren die Stifte im konventionellen Rontgenbild nicht mehr sichtbar. Im CT waren in den ehemaligen Stiftkanalen nach 3 Jahren ahnliche Dichtewerte wie bei spongiosem Knochen messbar. Bei den guten klinischen Ergebnissen eignen sich Polypin®-C-Stifte zur Behandlung dislozierter Radiuskopffrakturen.

The aim of this study was to compare the results achieved in two groups of 20 patients treated for midclavicular fracture. The first group (mean age 36 years) was treated non-operatively with a rucksack bandage, whereas the second group (mean age 37 years) underwent intramedullary fixation with a titanium pin using a minimally invasive, unreamed technique. At follow-up, which averaged 3.1+/-0.9 years in group 1 and 2.9+/-0.7 years in group 2, the result of treatment, as indicated by the Constant score, functional outcome and cosmetic outcome, was significantly better in the group undergoing operative treatment. Clavicle shortening was significantly ( P=0.027) higher in patients treated with a rucksack bandage. The absolute Constant score averaged 78+/-23 in group 1 and 97+/-4 in group 2 ( P=0.001). The Constant rating scale showed a significant difference between patients with clavicle shortening of less than 1 cm and 1 cm shortening or more. There were two non-unions in group 1 but none in group 2. Refractures were not observed in either group. According to these results, intramedullary fixation with a titanium pin seems to be more advantageous in midclavicular fractures than non-operative treatment. As the operation is well received by the patients, it should be offered to them as an alternative treatment to the rucksack bandage.

Conservative treatment of metacarpal fractures is recommended if there is no joint displacement, malrotation, displacement of over 30 degrees ad axim and shortening of over 5 mm. Surgery should be performed in open fractures and serial fractures of metacarpal bone. Early functional treatment should be carried out in stable, not displaced fractures. A cast can be used for a short period in full extended position of fingers and flexion in metacarpo-phalangeal joint in 60 - 90 degrees. Twin-tape fixation allows functional treatment after soft-tissue swelling has disappeared. Closed reduction of displaced fractures of the fifth metacarpal bone (boxer's fracture) is not successful. Cases with displacement of over 30 degrees may be treated surgically by intramedullary stabilisation.

Aim: The aim of the study is to correlate the CT-morphological changes of fractured calcaneus and the classifications of Zwipp and Sanders with the clinical outcome. Method:In a retrospective clinical study, the preoperative CT scans of 75 calcaneal fractures were analysed. The morphometry of the fractures was determined by measuring height, length diameter and calcaneo-cuboidal angle in comparison to the intact contralateral side. At a mean of 38 months after trauma 44 patients were clinically followed-up. The data of CT image morphometry were correlated with the severity of fracture classified by Zwipp or Sanders as well as with the functional outcome. Results: There was a good correlation between the fracture classifications and the morphometric data. Both fracture classifying systems have a predictive impact for functional outcome. The more exacting and accurate Zwipp classification considers the most important cofactors like involvement of the calcaneo-cuboidal joint, soft tissue damage, additional fractures etc. The Sanders classification is easier to use during clinical routine. Conclusion: The Zwipp classification includes more relevant cofactors (fracture of the calcaneo-cuboidal-joint, soft tissue swelling, etc.) and presents a higher correlation to the choice of therapy. Both classification systems present a prognostic impact concerning the clinical outcome.

This prospective controlled clinical trial was performed to assess fracture healing and clinical outcome after intramedullary nailing of midclavicular fractures. Within 3.5 years elastic-stable intramedullary nailing was performed in 62 patients with 65 midclavicular fractures. Surgery was performed in supine position. The ventral cortex of the proximal clavicle was opened using a 2.5 mm drill. The nail was advanced laterally under fluoroscopic control. If closed reduction failed, an additional incision was made to enable direct manipulation of the fragments. There were no infections, no implant displacements or refractures. Postoperatively, the mean subjective pain was significantly lower, and the range of motion improved. We observed one nonunion. The mean Constant-score 6 months after hardware removal was 96.9 +/- 3.3 points. Intramedullary fixation of midclavicular fractures with an elastic titanium nail is a safe minimally invasive surgical technique, producing excellent functional and cosmetic results.

Insertion of titanium nails for type A and B clavicular fractures can fail intraoperatively due to the small diameter or irregular nature of the medullary canal. At present, such failures lead to open reduction and fixation (ORIF) with plates. In type C fractures (comminuted fractures), a telescoping effect is observed so that ORIF is the only suitable alternative besides nonoperative therapy. A suitable minimally invasive solution for type C fractures and as a salvage procedure for failed intramedullary nailing of type A and B fractures is presented here for the first time with a percutaneous application of an LC plate to the clavicle.

Purpose To address the null hypothesis that surgeons shown radiographs of little finger metacarpal neck fractures with measured fracture angulation would recommend surgery as often as surgeons shown unmarked radiographs. Methods Members of the Science of Variation Group, an international collaboration of fully trained orthopedic and trauma surgeons, were asked to review 20 little finger metacarpal neck fracture cases, which included a vignette and 3 high-quality radiographs. Members were then randomized to review radiographs with or without measured fracture angulation on the lateral view and select operative or nonoperative management. Results Surgeons shown radiographs with measured angulation were more likely to recommend surgery, and there was less variability among these surgeons, particularly for fractures with less angular deformity. Conclusions Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures. Copyright (C) 2014 by the American Society for Surgery of the Hand. All rights reserved

Purpose To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive. Methods We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant." Results According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most important factors when evidence shows no difference between 2 surgeries were "fewer complications," "quicker recovery," "burns fewer bridges," "works in my hands" and "familiarity with the procedure." Europeans rated "works in my hands" and "cheapest/most resourceful" of significantly greater importance and "what others are doing," "highest reimbursement," and "shorter procedure" of significantly lower importance than surgeons in the United States. Observers with fewer than 10 years in independent practice rated "what my mentor taught me," "what others are doing" and "highest reimbursement" of significantly lower importance compared to observers with 10 or more years in independent practice. Conclusions Surgeons deciding between 2 treatment options, when the evidence is inconclusive, fall back to factors that relate to their perspective and reflect their culture and circumstances, more so than factors related to the patient's perspective, although this may be different for younger surgeons. Clinical relevance Hand surgeons might benefit from consensus fallback preferences when evidence is inconclusive. It is possible that falling back to personal comfort makes us vulnerable to unhelpful commercial and societal influences.

Midclavicular fractures heal without the doctor, with the doctor, and despite the doctor!” Although this maxim never found its way unto the scientific literature it held sway for many years, with the result that very few patients underwent surgery. Particularly in the past 10 years, however, surgical treatment options have gained increasing importance, with the result that closer attention is being paid to this “trivial” injury. This interest has culminated in the publication of several studies with high levels of evidence. In this review we set out to examine the old maxim in light of recent findings. On the basis of a selective survey of the literature, particular consideration is accorded to recent studies with high evidence levels.

Conservative treatment was long recommended for midclavicular fractures because of the excellent results that were reported in the 1960's and 70's. Recently, however, the rucksack bandage has received competition from surgical treatment. The spectrum of operations ranges from classic plate osteosynthesis to intramedullary techniques and angle-stable implants.We present and evaluate the current treatment options on the basis of a selective review of the literature.Recent studies have confirmed some long-held concepts and refuted others. The risk of non-union after conservative treatment was previously reported as 1% to 2% but has turned out to be much higher in selected subgroups such as in patients with severe displacement, female patients, and patients of advanced age. Furthermore, new implants and techniques have made surgery safer and more likely to result in bony union.In any case of midclavicular fracture, the type of fracture should be precisely analyzed and an individual treatment strategy should be developed in view of the patient's particular situation. Current studies show with a high level of evidence (level 1) that patients with dislocated fractures benefit from surgery.

Background New cell-based treatments for articular cartilage repair are needed. As the optimal scaffold for cartilage repair has yet to be developed, scaffold-free cartilage implants may remove the complications caused by suboptimal scaffolds. Hypothesis The implantation of a scaffold-free, autologous de novo cartilage implant into standardized full-thickness cartilage defects of femoral condyles in sheep leads to a qualitatively better regenerative tissue than does periosteal flap alone or no treatment. Study Design Controlled laboratory study. Methods Chondral defects 4 mm in diameter (1 per sheep) were created in the center of 1 medial femoral condyle of 48 sheep. Twelve defects were allowed to heal spontaneously, 16 defects were covered with periosteal flaps alone, and 20 defects were filled with autologous de novo cartilage graft and overlaid with a periosteal flap. Differences were assessed macroscopically using the International Cartilage Repair Society score and microscopically using the International Cartilage Repair Society histological score and Mankin score at 26 and 52 weeks. Results The results of the International Cartilage Repair Society Cartilage repair assessment showed that the transplant group was better than was the untreated control at both time periods but not significantly different than was the periosteal flap group. Implanted groups demonstrated a marked improvement in grade of defect filling, cartilage stability, cell distribution, and matrix assessments in each method of assessment. In the transplant group, 2 defects were filled with hyaline cartilage, 5 with mixed hyaline and fibrocartilage, and 2 with fibrocartilage alone. Conclusion Chondral defects treated with de novo cartilage transplantation show qualitatively better microscopic and macroscopic regeneration than do those treated with periosteal flaps alone. Clinical Relevance Results of the current study show that third-generation autologous chondrocyte transplantation is a promising development in the field of biologic cartilage regeneration. Future studies should compare this technique with the original Brittberg technique.

To localize optimal donor regions for osteochondral graft transplantation, the chondral thickness and the radii of curvature of femoral condyles and the talar trochlea were determined. Optosil impressions of the articular surfaces of ten formalin fixed distal femora and talar domes were prepared. Therefrom, 5-mm thick frontal sections were made in order to measure the radii of curvature. Femoral condyles and talar trochleas were sliced sagittally into 2-mm thick sections. Chondral thickness was measured on x-rays. Talar cartilage thickness measured 0.7 to 2.0 mm. Cartilage thickness of the femoral condyles was 0.7 mm to 3.1 mm. The smallest radial values of the talar surface were proximal and distal. Flattening of the medial and lateral talar margins and of the central articular surface was evident. For the femur, the curvature was greater in the edge areas than in the central region. For talar defects, the grafts should be taken from the condylar edges, where the chondral thickness is decreased.

Objectives: The presented study reveals the singlecentre experiences with the minimally invasive endo-vascular repair for acute traumatic thoracic aortic le-sions in the care of multitrauma patients.Methods: We reviewed ten patients with acute trau-matic thoracic aortic lesions treated with a thoracicaortic stent graft between April 2001 and December2006. The prospective collected data included age,sex, injury severity score, type of endovascular graft,endovascular operation time, length of stay, length ofstay in the intensive care unit, and mortality. Follow-up data consisted of contrast-enhanced spiral com-puted tomography at regular intervals.Results: All patients (m:f 5:5; median age, 46 years;interquartile range [IQR], 29–68.5 years) suffered se-vere traumatic injury, the median Injury Severity Scorewas 39.5 (IQR 37.3–43). All endovascular procedureswere technically successful, and the median operatingtime for the endovascular procedure was 90 min (IQR,65–120 min). The overall hospital mortality was 20%(n = 2), and all deaths were unrelated to the aorticrupture or stent placement. No incidence of paraplegiawas present. No intervention-related mortality oc-curred during a median follow-up of 14.7 months (IQR,9.7–55.8 months).Conclusions: The endovascular approach to acutetraumatic thoracic aortic lesions is feasible, safe, andeffectivein multitrauma patients.The lowendovasculartherapy-related morbidity and mortality in the postop-erative period is encouraging. The results seem to befavorable to those published of open emergency repair.Key WordsBlunt trauma

Patients with traumatic brain injury (TBI) and skeletal injuries have increased rates of excessive bone healing (EH = hypertrophic callus formation and/or heterotopic ossification). Polytrauma patients are often attributed higher rates of delayed fracture union. This study compares 182 total fractures in 29 isolated polytrauma patients (POLY) and 48 patients after TBI and polytrauma (TBI+POLY), examining the clinical parameters of EH versus delay. A subset of 28 patients (13 TBI+POLY, 15 POLY) underwent serological testing for the following bone turnover parameters: carboxy-terminal extension peptide of type 1 procollagen (P1CP), pyridinolene cross-linked carboxy-terminal telopeptide (1CTP), insulin-like growth factor-1 (IGF-1), insulin-like growth factor binding protein-3 (IGFBP-3), and basic fibroblast growth factor (bFGF). There were higher rates of delayed union in the POLY patients (45% vs. 23%) and EH in the TBI+POLY patients (33% vs. 17%) (not significant = NS). More delayed unions were observed in diaphyseal fractures suffered by POLY (28%) than in TBI+POLY (15%) patients (NS). EH after pelvic fracture was apparent in 52% TBI+POLY and in 21% POLY fractures (NS). P1CP levels did not differ between the groups, but the collagen breakdown parameter 1CTP was significantly higher in the POLY group (p = 0.01-0.04). IGF-1 levels were below normal in both groups, and did not differ. IGFBP-3, an IGF-1-inhibiting and collagenase-3-activating protein, was significantly higher in POLY patients (p = 0.017-0.037). bFGF levels did not vary between groups. Increased serum levels of 1CTP and IGFBP-3 in POLY patients suggest that EH in TBI patients is secondary to decreased collagen breakdown rather than increased synthesis.

Biodegradable polylactide implants allow secure fixation of osteochondral fractures. This quasirandomized parallel-group animal study investigates whether a composite implant of poly-L/DL-lactide (PLDLLA) with additional 10% beta-tricalcium phosphate produces an osteoconductive effect, whether the admixture positively influences implant degradation (assessed by comparing time to implant degradation), and whether the pin sites of degraded implants are replaced with bone tissue. On 36 medial femoral condyles of sheep, osteotomies were fixed with either three PLDLLA pins or three composite pins. At 3, 18, and 36 months, the pin sites were measured histologically and the state of degradation assessed according to Pistner's classification. All fractures healed without clinically relevant complications and without displacement. Both pin types led to asymptomatic pin-site enlargement at 18 months, which disappeared by 36 months. At 18 months, 14 of 18 PLDLLA pins were no longer evident, whereas 16 of 18 composite pins showed only peripheral degradation. By 36 months, all implants from both groups were completely degraded and replaced with scar (2/18) or bone tissue (16/18). At 36 months there was no evidence for significant improvement of either degradation performance or osseointegration through use of the 10% TCP composite mixture.