[High bone consolidation rates after humeral head-preserving revision surgery in non-unions of the proximal humerus]. / Hohe knöcherne Ausheilungsraten nach kopferhaltender Revision von proximalen Humeruspseudarthrosen.

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.

[Percutaneous stabilization of thoracolumbar fractures. Techniques of fracture reduction and spinal cord decompression]. / Perkutane dorsale Instrumentierung der thorakolumbalen Wirbelsäule. Technik der geschlossenen Frakturreposition bei gleichzeitiger Dekompression des Spinalkanals.

Minimally invasive percutaneous instrumentations are increasingly being used for stabilization of thoracolumbar fractures, mainly due to the advantages of reduced soft tissue damage. While percutaneous instrumentation can be generally used in less displaced fractures, it remains controversial whether such techniques should also be performed in patients with severe fracture dislocation. This includes patients with severe traumatic kyphosis and/or dislocation in the coronar plane, particularly in concomitant neurological deficits that require additional decompression surgery. Here we show the different indirect fracture reduction techniques in three cases with severe fracture dislocation and discuss the use of percutaneous stabilization techniques in combination with an additional midline approach for decompressing laminectomy.

Injection of a polymerized hyaluronic acid/collagen hydrogel matrix in an in vivo porcine disc degeneration model.

INTRODUCTION: Disc degeneration and re-herniation after nucleotomy procedures are common problems. Simultaneous application of hyaluronic acid (HA)-based matrix has been proposed to limit disc degeneration. This, however, is hampered by loss of the substituted matrix out of the disc. Hence, in situ polymerization of the injected matrix with ultraviolet light (UVL) directly used after injection may be useful. Therefore, this study evaluates a new HA/collagen hydrogel matrix with in situ polymerization after implantation in an established porcine nucleotomy model. MATERIALS AND METHODS: 12 mature minipigs were used. A total of 60 lumbar discs were analyzed. 36 discs underwent partial nucleotomy with a 16G biopsy needle. Of those, 24 discs received matrix (porcine nucleus pulposus collagenous scaffold component and chemically modified HA) which was in situ polymerized using UVL immediately after transplantation. 12 nucleotomized discs and 24 non-nucleotomized discs served as controls. After 24 weeks, animals were killed. X-rays, MRIs, histology, and gene expression analysis were done. RESULTS: Disc height was reduced equally after sole nucleotomy and nucleotomy with HA treatment and in MRIs signal intensity decreased. For both nucleotomy groups, the nucleus histo-degeneration score showed a significant increase compared to controls. In histology, HA treatment resulted in more scarring and inflammation in the annulus. Gene expression of catabolic MMPs was up-regulated, whereas IFN-gamma, IL-6, and IL-1b were unchanged. CONCLUSION: Although nucleotomy and administration of the implant material did not cause generalized inflammation of the disc, localized annular damage with annulus inflammation and scarring resulted in detrimental degenerative disc changes. As a result, therapeutic strategies should strongly focus on the prevention of annular damage or techniques for annular repair to remain disc integrity.

[Total hip replacement for coxarthrosis following acetabular fracture. Significance of age and injury severity]. / Hüftendoprothese bei koxarthrose nach azetabulumfrakturen. Bedeutung von alter und verletzungsschwere.

AIM: this study analyzed factors influencing prosthetic hip function after total hip replacement surgery (THR) including the initial acetabular fracture type, patient age, and the acetabular reconstruction component. MATERIAL AND METHOD: a total of 45 patients with secondary arthritis due to acetabular fracture and THR were prospectively selected from our total hip arthroplasty register between July 1999 and December 2005. The initial acetabular fracture was classified according to the AO system and the statistical analysis of the preoperative and postoperative Harris hip score (HHS) was correlated with age, type of fracture and acetabular reconstruction component. RESULTS: of the fractures 44 could be classified and 39 patients were included in the study. Median follow-up period was 15 months. HHS increased on average from 35 to 91. Only type C fractures showed statistical relevance and age had no influence on the median increase in HHS (53-55). Most important was the preoperative HHS and the restoration of proper hip anatomy and rotational alignment. CONCLUSION: patient age and injury severity influenced the preoperative function and hence the HHS after THR; however, these factors had no influence on the individual increase in the HHS.

[Outcome between surgical and non-surgical treatment of metastatic tumors of the spine: a retrospective study of 259 patients]. / Vergleich zwischen operativen und nicht-operativen Verfahren bei Wirbelsäulenmetastasen: Eine retrospektive Studie an 259 Patienten.

AIM: The purpose of this study was to evaluate the clinical outcome of patients with metastatic tumors of the spine after surgical and non-surgical treatment. METHODS: The charts of 259 patients with metastatic tumors of the spine were reviewed retrospectively to define predictors of outcome. Our data included patient demographics, primary tumor, location of the metastatic tumor within the spine, indication for surgical or non-surgical treatment, type of surgical and non-surgical intervention, post-treatment outcome in terms of neurology, use of adjuvant radiation therapy or systemic therapy. RESULTS: The most frequent indication for surgical treatment was the combination of neurological deficit (ND), pathological vertebral fracture, and pain (50 %). Surgical intervention was performed by the posterior approach in 67 %, by the anterior approach in 13 %, and by an anterior/posterior approach in 10 %. The post-surgical outcome, depending on the type of surgical approach in terms of ND, was for the posterior approach 29 % improved, for the anterior approach 53 % improved, and for the anterior/posterior approach 15 % improved. DISCUSSION: Our data suggest that the indications for metastatic tumor surgery in the spine depend on the location of the metastatic tumor in the spine, clinical symptoms, and prognosis.