Plate fixation of proximal humeral fractures with indirect reduction: surgical technique and results utilizing three shoulder scores.

To determine the outcome after indirect reduction and buttress plate fixation of displaced and unstable proximal humeral fractures, we retrospectively evaluated 98 patients, an average of 34 months (range 24-72 months) after fracture fixation. The patients were reviewed and results were evaluated clinically according to the Neer, UCLA and Constant score. A radiographic evaluation of fracture healing, avascular necrosis and degenerative changes of the shoulder joint was performed in all patients. Any complications of treatment were assessed. Results were, according to the UCLA-rating system, good to excellent in 76% of fractures. According to the Constant-score and the Neer score, good to excellent results were obtained in 69 and 59% of fractures, respectively. Poor results were mainly due to secondary malunion. The avascular necrosis rate was 4%. Non-union was seen in one case. Secondary varus deformity and retroversion of the humeral head as a result of lack of rotational and angular stability of the plate developed in twelve (12%) and eight (8%) cases, respectively. Plate fixation is an adequate procedure for treating unstable and displaced two- to four-part fractures of the proximal humerus, enabling early functional after-treatment. The incidence of avascular necrosis and nonunion are low, when fracture reduction is performed indirectly. Poor rotational and angular instability can lead to a loss of reduction.

[Calcaneus cyst--an indication for surgery? Case report and review of the literature]. / Die Kalkaneuszyste--Eine Indikation zur Operation? Fallbericht und Literaturübersicht.

Simple bone cysts are asymptomatic, benign lesions which are usually an incidental finding on a radiograph. Etiology and treatment are controversially discussed. The weight-bearing status of the calcaneus and possible pathologic fracturing lead many authors to recommend therapeutic measures after diagnosis has been made. We present a case report of an intact unicameral bone cyst of the calcaneus concomitant with tibial and talar fractures following crush trauma. Several types of treatment for simple bone cysts of the calcaneus have been suggested. The question whether treatment is unconditionally necessary is controversially discussed. It is the author's opinion, that asymptomatic bone cysts of the calcaneus require no further treatment.

Operative treatment of displaced proximal humeral fractures: two-year results in 99 cases.

The operative treatment of comminuted and displaced fractures of the proximal humerus has been evolving in recent years. Classical open reduction and internal fixation techniques have an increased risk of avascular necrosis. Minimal osteosynthesis procedures often result in a suboptimal fracture reduction and require postoperative immobilization of the arm in some cases. This study reviewed ninety-nine out of 142 patients (70%), an average of 30 months (range 12 to 72 months) after indirect reduction and internal fixation of two-, three- or four-part fractures of the proximal humerus. The surgical procedure includes indirect fracture reduction with no manipulation of the different fracture fragments and subsequent buttress-plate fixation, using a limited deltopectoral approach. Mean age of patients was 63 years (range 17 to 85 years). Twenty percent of patients had associated lesions. Five patients presented with fracture-dislocations. Results were, according to the UCLA- and the Constant-rating system good to excellent in 76 and 69% of cases. Twelve patients had a poor functional outcome. The indirect reduction technique reduces the opening of the fracture site to minimum and thereby limits the risk of iatrogenic damage to local vascularity and the rotator cuff. Complete and partial humeral head necrosis developed in 3% and 1% of cases respectively. Non-union occurred in one case. Plate fixation is an adequate procedure for treating unstable and displaced two- to four-part fractures of the proximal humerus. The incidence of avascular necrosis and non-union are low, when fracture reduction is performed indirectly. Plate fixation enables an early functional treatment, with no need for postoperative immobilization.

Fracture healing in biological plate osteosynthesis.

In order to gain a better understanding of the healing processes after plate fixation and indirect reduction, Baumgaertel designed a reproducible fracture model for the sheep femur in 1992 so that the differences between anatomical (rigid) and biological (bridging) fixation could be investigated. It was demonstrated that indirect reduction and bridge plating was superior to direct fragment reduction and anatomical fixation in respect to radiology, biomechanics and microangiography. In this study, it was shown that bony bridging of the fracture gap and mineralization of callus occurred faster and more efficiently after indirect than after direct and anatomical reduction. Bone healing was identified as beginning in the 2.-3. week after indirect and only in the sixth week after direct reduction. The increased breaking strength of the indirectly reduced femora at 8 weeks can be attributed to this process. In addition, the consequences of applying the PC-Fix for biological plating were investigated. The values for bone healing were improved by applying a plate with only point contact to the bone, thus conserving the periosteal blood supply.

Knee arthrodesis with a unilateral external fixator.

The operative fusion of the knee joint remains a valuable technique in posttraumatic and infectious destruction of the knee. External fixation is the technique of choice. Due to the benefits of the monofixator in regard to stability, limited damage of soft tissues and high patient comfort, arthrodesis of the knee joint using an anteriorly placed unilateral external fixator is the procedure routinely used at our institution. From 1985 to 1994, 19 knee arthrodesis procedures were performed with a monofixator. Indications for operative fusion of the knee were an infectious destruction of the joint following osteosynthesis (tibial plateau) in 12 cases, posttraumatic arthrosis of the knee joint with chronic infection in 4 cases, flexion ankylosis of the knee in 1 patient, and destructive osteoarthritis of the knee complicated by an empyema in one case. In one patient, a rearthrodesis was performed for a non-union, following an arthrodesis attempt for infected knee arthroplasty. In all cases, stable fusion of the knee joint in a correct position with complete eradication of infection was obtained. Mean fixation time was 22 weeks. The fixator did not need to be removed prematurely.

Treatment of unstable distal clavicular fractures with and without lesions of the acromioclavicular joint.

A series of 39 unstable fractures of the distal one-third of the clavicle is presented. As results after non-operative treatment of these fractures are poor, surgical therapy is indicated. In fractures with a small peripheral fragment or with an associated separation of the acromioclavicular joint, PDS-banding is a valuable technique for stabilization. According to the classification of Neer and Jäger/Breitner, a clear therapeutic strategy for lateral clavicular fractures can be defined. Unstable clavicular fractures with associated acromioclavicular ligament disruption should however be considered as a separate subtype in the existing classifications.

Technique of using the AO-femoral distractor for femoral intramedullary nailing.

Immediate closed interlocking intramedullary (IM) nailing of femoral shaft fractures in polytraumatized patients using the fracture table may be difficult due to concomitant adjacent injury. We report on the technique of using the AO-femoral distractor for femoral IM nailing and our experience with 56 consecutive cases of IM nailing of the femur. The AO distractor is an alternative to the traction table. Unlike the latter, it does not rely on intact adjacent structures to distract the main fragments. Schanz screws are placed into the femur condyle and into the lesser trochanter. The fracture is distracted and reduced by manipulating the mobile elements of the device. The femur is aligned and stabilized while reaming and nailing commence. Between April 1988 and June 1992, 56 IM nailings were performed using the AO distractor for reduction: 41 for acute unstable fractures and 15 for corrective procedures. In 11 of 15 polytraumatized patients, the fractured femurs were nailed immediately. Intraoperatively, the distractor greatly facilitated fracture reduction and presented no problems for proximal or distal interlocking. Intraoperative complications included two fracture extensions during nailing and three rotational malalignments over 15 degrees. One nonunion occurred; otherwise, all fractures were considered healed within 16 weeks. No postoperative nerve palsies were recorded, and no infection occurred. Based on our experience, we believe that the AO distractor is a suitable alternative to the traction table as a distraction and reduction device and can be implemented in all nailing cases. We particularly recommend its use in polytrauma cases in which concomitant injury precludes the initial use of the fracture table.

[The "biological" plate osteosynthesis in multi-fragment fractures of the para-articular femur. A prospective study]. / Die "biologische" Plattenosteosynthese bei Mehrfragmentfrakturen des gelenknahen Femurs. Eine prospektive Studie.

In a prospective study, 24 fractures of the femur were treated by indirect reduction and internal fixation with a condylar plate or a condylar buttress plate. The inclusion criterion was that each patients's fracture(s) should be amenable to indirect reduction. The goal of the study was to determine the value of biological plating techniques incorporating the use of the distractor and the articulating tension device for indirect reduction, bridging of the fracture zone without dissection of the medial cortex, and calculated instability through undetermined axial compression. Most fractures were comminuted (5 type A, 10 type B and 9 type C according to the AO classification); 14 fractures were subtrochanteric, 8 fractures were supra-/intracondylar and 2 were diaphyseal in nature. The average age of the 14 mean and 10 women was 46 years (16-96). In 4 cases the fracture was open; 8 patients had multiple trauma and 6 had further ipsilateral fractures. The fractures were sustained in motor vehicle accidents in 14 cases. In 16 fractures operative treatment was performed within 36 h. All fractures were reduced indirectly, and 21 fractures were put under axial compression. There was no medial cortex dissection and no primary bone grafting. Secondary bone grafting was necessary in 2 patients, while 1 (diaphyseal fracture) had delayed bone union and required interlocking nailing. In 2 patients varus deformities under 10 degrees were present after completion of bone healing. There were no refractures and no implant failures. Full weight-bearing commenced at 14.7 weeks. Bone healing time was 18.7 weeks in the 19 patients followed up.(ABSTRACT TRUNCATED AT 250 WORDS)

[Animal experiment studies of "biological" plate osteosynthesis of multi-fragment fractures of the femur]. / Tierexperimentelle Untersuchungen zur "biologischen" Plattenosteosynthese von Mehrfragmentfrakturen des Femurs.

In three groups (A, B, C) of 12 sheep each, defined, reproducible comminuted subtrochanteric fractures were produced in three steps without devascularization of the bone: (1) longitudinal biocortical osteotomies limited by bore holes as breakpoints, (2) an external fixator producing a static lateral bending load of 0.20 kN, (3) sudden three-point antero-posterior compression. Sheep in group A were treated with direct reduction and anatomical reconstruction of each fracture according to the principles of the AO/ASIF group and with an angle blade plate. In group B the same plate was used, but no attempt was made to reduce fragments anatomically. Length and alignment were restored with indirect reduction techniques (distraction via external fixator and articulating tension device) only. The treatment applied in group C incorporated the same reduction modes as that in group B, but an experimental plate with point bone contact and unicortical, fixed screws were used. After 4, 8 and 12 weeks of full weight-bearing, the femurs were harvested for radiographic analysis and biomechanical testing. Subjective evaluation of fracture healing by 20 independent orthopaedic trauma surgeons resulted in significantly higher ratings for groups B and C than for group A after 8 (p = 0.07) and 12 weeks (p = 0.09). Density scan measurements showed little change in bone density as a percentage of that on the intact side over 12 weeks (108.1, 105.7, 104.4) in group A, but revealed marked changes in groups B and C (95.7, 117.5, 133.6 and 104.2, 125.6, 120.6), reflecting higher masses of callus.(ABSTRACT TRUNCATED AT 250 WORDS)

Two-stage operative treatment of comminuted os calcis fractures. Primary indirect reduction with medial external fixation and delayed lateral plate fixation.

The indication for otherwise established lateral plate fixation in fractures of the calcaneus becomes relative when severe comminution (Sander's Type III and IV) of the bone involves concomitant massive soft-tissue swelling. The calcaneus is shortened, Böhler's angle flattened, and lateral bulging and varus deformity persist throughout the six or more days needed for soft-tissue compromise to recede. Intraoperatively, problems with anatomic reduction are encountered primarily because of soft-tissue shrinkage and muscle contraction, underscoring the rationale for conservative treatment modalities. A two-stage approach--primary medial external fixation and delayed lateral plate fixation--stabilizes the calcaneus in a nearly anatomic position by calculated distraction through medial external fixation, leaving joint congruency to be restored in a secondary procedure, when soft tissues pose no problem for a lateral approach. The two-stage procedure was used in 13 of 49 cases, in which soft-tissue compromise was severe. Anatomic primary reduction greatly facilitated delayed lateral plate fixation. Infection rates were not traced to the external fixation. Massive bone grafting was associated with a high occurrence of complications.

[Diagnosis, classification and surgical indications in acetabulum fractures]. / Diagnostik, Klassifikation und Indikationsstellung bei Acetabulumfrakturen.

Displaced acetabular fractures may lead to posttraumatic arthritis. Consequently, joint congruency must be restored by either conservative or operative measures. Standardized radiographs of the pelvis are prerequisites for the correct evaluation of the hip-joint. The a. p.-pelvis projection and the Judet views (obturator and iliac oblique) showing the whole pelvis are indispensable and demonstrate radiological landmarks typical of anatomical relationships and fracture characteristics. The two dimensional computertomogram is an adjunctive diagnostic measure and facilitates the evaluation of the hip joint itself. The 3DCT allows the imaging of old acetabular fractures and aids in the planning of reconstructive surgery. With the basic three projections of the hemipelvis, Letournel and Judet developed the acetabular fracture classification now accepted world-wide. Assuming the notion that the acetabulum is supported by two columns, five fracture types and five fracture type combinations are described according to involvement of the anterior or posterior columns respectively. The correct classification precedes the choice of surgical approach and is the basis for preoperative planning. The indications for surgery adhere to the principles of joint surgery. Conservative treatment may be considered only if the weight bearing joint surface of the acetabulum is congruent. Otherwise open reduction and internal fixation are indicated.

Pauwels osteotomy for nonunions of the femoral neck.

The concept of the Pauwels osteotomy seems to be a valuable method of treating nonunions of the femoral neck. If there is concomitant avascular necrosis, the involved area should be small and the patient younger than 60 years old.

[Ilizarov's distraction osteogenesis using the mono-fixator system and initial clinical experiences with the injured lower leg]. / Distraktionsosteogenese nach Ilizarov mit dem Monofixateursystem und erste klinische Erfahrungen am traumatisierten Unterschenkel.

Distraction osteogenesis, as developed by Ilizarov, allows the limbs to be lengthened and intercalary defects to be filled by bone transport without the use of bone grafts. In five patients with traumatic sequelae (fractures of the lower leg), unilateral dynamic mono_fixation and a special distraction apparatus were used for application of the Ilizarov technique. With the distraction device, gradual distraction of the osteotomy surfaces (1/3 mm in three steps per day) is easy for the patients to perform. In three cases distraction osteogenesis was used to correct shortening of the lower leg and in two cases for bridging a tibial defect due to an infection in the plate osteosynthesis. In all cases, the course of treatment and bone healing were uneventful. Based on our first clinical experiences, we believe that mono_fixation provides appropriate stability and the distraction apparatus permits appropriate bone transportation for successful distraction osteogenesis in the tibia.