Radiological, Clinical, and Functional Outcomes of Combined Dorsal and Volar Locking Plate Osteosynthesis for Complex Distal Radius Fractures.

PURPOSE: The purpose of this study was to assess the short- to mid-term radiologic, clinical, and functional outcomes of patients treated with combined dorsal and volar locking plating for internal fixation of complex, comminuted, intra-articular, distal radius fractures. METHODS: We performed a retrospective review of 34 patients treated with combined dorsal and volar locking plates for the internal fixation of complex, comminuted, intra-articular distal radius fractures. Radiographic and clinical parameters were recorded at a mean of 48 months after surgery. Activities of daily living and quality of life were assessed by the Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation questionnaires. RESULTS: Compared with the contralateral wrist, the treated wrist regained 73% of flexion, 81% of extension, 86% of ulnar deviation, 90% of radial deviation, 98% of pronation, 99% of supination, and 93% of grip strength. Mean Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation scores were 11 (range, 0-78) and 11 (range, 0-77), respectively. Radial height and radial inclination were restored anatomically in 24% and 41% of patients, respectively, while volar tilt and ulnar variance were restored in 68% of patients. CONCLUSION: The overall functional and radiologic outcome of patients with comminuted intra-articular complex distal radius fractures treated with the combined dorsovolar plate osteosynthesis was good to excellent. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Dorsal Plate Osteosynthesis in Simple and Complex Fractures of the Distal Radius: A Radiological Analysis of 166 Cases.

Background To report the radiologic outcome and rate of complications of open reduction and internal fixation (ORIF) using a dorsal plate fixation of simple and complex distal radius fractures in adult patients. Methods Patients treated with dorsal ORIF of simple and complex distal radius fractures between December 2008 and April 2013 were included in this single-center retrospective study. Type of fracture, radiographic measurements, and complications were documented. Results One-hundred and sixty-six patients/fractures were included. Restoration of radial inclination (22° ± 3°) was achieved in 38%. Radial height (14 ± 1 mm) was least likely to be restored to normal values postoperative in 25%. Normal ulnar variance (0.7 ± 1.5 mm) could be observed in 60% and adequate volar tilt (11° ± 5°) was achieved in 50% at final follow-up. We observed one loss of reduction in an AO type C2 fracture and a total of 15 nonimplant-related minor clinical complications. Conclusion Our radiographic findings after dorsal plating are comparable to those published on volar plating. The changes in radial height and volar tilt could be attributed to projection-related differences in the radiographs and did not signify a loss of reduction in all cases. Clinical Relevance Dorsal plating of distal radius fractures is safe and remains an important approach in the treatment of complex distal radius fractures. Complications in our study were even less compared to those reported in the literature. Type of Study/Level of Evidence This is a Type IV study. Level of Experience of Surgeons The level of experience of surgeons is III-V.

In-Hospital 3D Printed Scaphoid Prosthesis Using Medical-Grade Polyetheretherketone (PEEK) Biomaterial.

Recently, three-dimensional (3D) printing has become increasingly popular in the medical sector for the production of anatomical biomodels, surgical guides, and prosthetics. With the availability of low-cost desktop 3D printers and affordable materials, the in-house or point-of-care manufacturing of biomodels and Class II medical devices has gained considerable attention in personalized medicine. Another projected development in medical 3D printing for personalized treatment is the in-house production of patient-specific implants (PSIs) for partial and total bone replacements made of medical-grade material such as polyetheretherketone (PEEK). We present the first in-hospital 3D printed scaphoid prosthesis using medical-grade PEEK with fused filament fabrication (FFF) 3D printing technology.

Failure of Osseointegration of a Semiconstrained Finger Prosthesis in a Post-traumatic Metacarpophalangeal Joint Defect: A Case Report.

CASE: Post-traumatic defects of the metacarpophalangeal joint (MCPj) remain challenging for hand surgeons. Restoration of stability and motion are difficult to achieve because of the complex anatomy and kinematics. The Robert Mathys (RM) semiconstrained prosthesis offers good intrinsic stability and mobility and therefore seems suitable. We report on a patient where the RM prosthesis was used for a traumatic destroyed ring finger MCPj reconstruction but failed because of aseptic loosening. We discuss possible reasons in light of the current literature on post-traumatic MCPj arthroplasties and the RM prosthesis in particular. CONCLUSION: The RM proximal interphalangeal prosthesis does not seem suitable for post-traumatic replacement of the MCPj.

The Retinaculum Flap for Dorsal Fixation of Distal Radius Fractures.

In spite of the more popular volar approach for plating of distal radius fractures (DRFs), there are still indications for dorsal plating and even combined dorsovolar plating in complex DRFs. Dorsal plating carries a concern for complications such as tenosynovitis, extensor tendon adhesions, and delayed extensor tendon ruptures. These risks can be minimized by use of modern low-profile plates and the use of an extensor retinaculum flap to cover the distal plate and screws. We describe the technique of the dorsal retinaculum flap for dorsal plating of DRFs.

A three-dimensional printed patient-specific scaphoid replacement: a cadaveric study.

We present our first cadaveric test results of a three-dimensional printed patient-specific scaphoid replacement with tendon suspension, which showed normal motion behaviour and preservation of a stable scapholunate interval during physiological range of motion.

Corrective Osteotomy for Symptomatic Clavicle Malunion Using Patient-specific Osteotomy and Reduction Guides.

Midshaft clavicular fractures are often treated nonoperatively with good reported clinical outcome in a majority of patients. However, malunion with shortening of the affected clavicle is not uncommon. Shortening of the clavicle has been shown to affect shoulder strength and kinematics with alteration of scapular position. Whereas the exact clinical impact of these factors is unknown, the deformity may lead to cosmetic and functional impairment as for example pain with weight-bearing on the shoulder girdle. Other reported complications of clavicular malunion include thoracic outlet syndrome, subclavicular vein thrombosis, and axillary plexus compression. Corrective osteotomy has therefore been recommended for symptomatic clavicular malunions, generally using plain x-rays for planning the necessary elongation. Particularly in malunited multifragmentary fractures it may be difficult to exactly determine the plane of osteotomy intraoperatively to restore the precise anatomic shape of the clavicle. We present a technique for corrective osteotomy using preoperative computer planning and 3-dimensional printed patient-specific intraoperative osteotomy and reduction guides based on the healthy contralateral clavicle.

That's my STYLEoideum - Symptomatic os styloideum in an adolescent male.

We present a 15-year-old male patient with persistent localized pain on the dorsal side of the left wrist between the base of the 2nd and 3rd metacarpal bones and over the third carpometacarpal joint. It was diagnosed as an accessory metacarpal bone -Os styloideum. This entity may be detected on plain radiographs and in ultrasound examination and is often asymptomatic. Symptomatic os styloideum occurs more frequently in the dominant hand and may be treated conservatively with corticosteroid infiltration. A palpable prominence on the dorsal side of the wrist and focal pain evoked anxiety of the adolescent patient who searched medical consultation. In the clinical examination, a bony protrusion was confirmed and different possible diagnoses have been considered. After treatment with a corticosteroid infiltration of the third carpometacarpal joint under fluoroscopy the pain resolved completely. We would like to draw attention of clinicians and radiologists to this rare anatomical variant that normally is asymptomatic, and therefore not immediately recognized. Acquaintance with this entity and its early detection may lead to conservative treatment instead of surgical excision. A comprehensive literature search, review and discussion about os styloideum are provided in the article.

A Simple 3-Dimensional Printed Aid for a Corrective Palmar Opening Wedge Osteotomy of the Distal Radius.

The reconstruction of malunited distal radius fractures is often challenging. Virtual planning techniques and guides for drilling and resection have been used for several years to achieve anatomic reconstruction. These guides have the advantage of leading to better operative results and faster surgery. Here, we describe a technique using a simple implant independent 3-dimensional printed drill guide and template to simplify the surgical reconstruction of a malunited distal radius fracture.

[Hemiplegia and cerebral palsy - multidisciplinary treatment of the spastic upper extremity]. / Hemiplegie und Zerebralparese - multidisziplinäre Behandlung der spastischen oberen Extremität.

Spastic hemiplegia and cerebral palsy often lead to typical deformities of the upper extremity. Muscle- and joint-contractures may be painful and aesthetically unappealing and may interfere with function and hygiene. Within the first weeks after the cerebral incidence the vital threat is dominating and the exact amount of neurologic impairment is not assessable. During this period, conservative treatment should counteract the development of contractures. After spontaneous neurologic recovery, surgical options should be taken into account. When choosing surgical procedures, factors as volitional motor control, sensibility and cognition must be taken into account besides the morphologic changes. This is best achieved in a multidisciplinary setting of neurologists, rehabilitation specialists, physiotherapists and surgeons.

L'hémiplégie spastique et l'infirmité motrice cérébrale ont souvent des déformités typiques du membre supérieur pour résultat. Des contractures musculaires et articulaires peuvent être douloureuses, gênantes pour des raisons ésthétiques et pertubantes pour la fonction, le soin et l'hygiène. Pendant les premières semaines après un incident cérébral la menace vitale est prioritaire et la dimension des conséquences neurologiques n'est pas estimable. Pendant cette phase le développement des contractures articulaires et musculaires doit être combattu avec des mesures conservatrices. Seulement après la réhabilitation neurologique spontanée des mesures chirurgicales peuvent être prises en consideration. Quand on choisit des mesures chirurgicales il ne faut pas prendre en compte seulement les changements morphologiques mais aussi la capacité motrice résiduelle, la sensibilité et la capacité cognitive. Avec une équipe multidisciplinaire comportant des neurologes, des médecins réhabilitateurs, des thérapeutes et des chirurgiens on a la capcité d'offrir une solution vaste pour chaque patient.

Primary flexor tendon repair in zones 1 and 2: early passive mobilization versus controlled active motion.

PURPOSE: To compare early passive mobilization (EPM) with controlled active motion (CAM) after flexor tendon surgery in zones 1 and 2. METHODS: We performed a retrospective analysis of collected data of all patients receiving primary flexor tendon repair in zones 1 and 2 from 2006 to 2011, during which time 228 patients were treated, and 191 patients with 231 injured digits were eligible for study. Exclusion criteria were replantation, finger revascularization, age younger than 16 years, rehabilitation by means other than EPM or CAM, and missing information regarding postoperative rehabilitation. This left 132 patients with 159 injured fingers for analysis. The primary endpoint was the comparison of total active motion (TAM) values 4 and 12 weeks after surgery between the EPM and the CAM protocols. The analysis of TAM measurements under the rehabilitation protocols was conducted using t-tests and further linear modeling. We defined rupture rate and the assessment of adhesion/infection as secondary endpoints. RESULTS: There was a statistically significant difference between the TAM values of the EPM and the CAM protocols 4 weeks after surgery. At 12 weeks, however, there was no significant difference between the 2 protocols. Older age and injuries with finger fractures were associated with lower TAM values. Rupture rates were 5% (CAM) and 7% (EPM), which were not statistically different. CONCLUSIONS: This study showed a favorable effect of CAM protocol on TAM 4 weeks after surgery. The percent rupture rate was slightly lower in the patients with CAM than in the patients with EPM regime. Further studies are required to confirm our results and to investigate whether faster recovery of TAM is associated with shorter time out of work. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Anterior short correction in thoracic adolescent idiopathic scoliosis with mini-open thoracotomy approach: prospective clinical, radiological and pulmonary function results.

INTRODUCTION: This is a prospective study of adolescent patients in whom idiopathic thoracic scoliosis was corrected by short anterior fusion through a mini-open thoracotomy approach. Clinical, radiological and pulmonary function results of minimal 2-year (2-6) follow-up are presented. MATERIALS AND METHODS: Consecutive 62 patients with Lenke 1 and 2 curves, having main thoracic scoliosis of up to 75°, were prospectively included. The shoulder imbalance in Lenke 2 patients was less than 20 mm. Thoracic scoliosis was corrected by short anterior fusion. The thoracic spine was exposed by an 8-cm mini-open thoracotomy incision. The operation technique and choosing of fusion levels are thoroughly described. Complete 360° discectomies and convex side vertebral endplates osteotomies are essential for deformity corrections with short fusions. Single-rod 5.5-mm titanium implants were used. The age at the time of operation was mean 15.2 years; 56 patients had a single thoracic curve and 6 patients had a double thoracic curve. There were almost equal numbers of patients with lumbar modifier A, B or C. The average length of fusion was 5.5 (4-7) vertebrae. The average length of fusion was 3.5 (2-6) vertebrae shorter than the average curve length. RESULTS: The instrumented thoracic curves improved by 58.3% at 6 weeks and 56.3% at the last follow-up. Apex thoracic vertebral rotation improved by 73.78% at 6 weeks and 76.24% at the last follow-up. The non-instrumented upper thoracic curve improved by 25% in double thoracic scoliosis, where the mid-thoracic curve was selectively fused, and the non-instrumented lumbar curves improved by 33.9% at the last follow-up. The radiological changes from 6 weeks to the last follow-up were statistically not significant. The clinical rib hump improved by 54% at the last follow-up. There were no significant changes in the pulmonary function. FVC% was 81.04% preoperatively, 76.41% at 6 months and 80.38% at the 2-year follow-up. The results of SRS 24 questionnaire improved from a total of 61.40 points preoperatively to 100.50 points at 6 months and 98.62 points at the 2-year follow-up. There were no neurological or thoracotomy related complications, no pseudarthrosis, no implant pullout or breakage. CONCLUSION: A good deformity correction without loss of correction or adding on, a good cosmetic result and good patient's satisfaction were achieved through shorter than end-to-end thoracic fusions. The radiological residual deformity is acceptable. Anterior correction of thoracic scoliosis with a short spinal fusion is recommended to keep the large part of the spine mobile. A very short fusion, small thoracotomy incision, low-profile implants and complete closure of parietal pleura are keys to prevent reduction in postoperative lung function.

Age-related variation in cell density of human lumbar intervertebral disc.

STUDY DESIGN: changes in cell density of endplate (EP), nucleus pulposus (NP), and anulus fibrosus (AF) during ageing were systematically investigated in defined regions of interest in complete human motion segments. OBJECTIVES: to elucidate cell density and total cell number in distinct anatomic regions of the intervertebral disc; to test effects of gender, level and age on cell density; and to correlate changes in cell density with histologic signs of disc degeneration. SUMMARY OF BACKGROUND DATA: the available information on the cell density within intervertebral discs and its age-related changes is sparse. This knowledge, however, is a crucial prerequisite for cell-based tissue engineering approaches of the intervertebral disc. METHODS: in 49 complete cross-sections from lumbar motion segments (newborn to 86 years) from 22 specimens, cell density was determined by the Abercrombie method in EP, NP, and AF, and total cell number was counted per region of interest. RESULTS: cell density in EP, NP, and AF decreased significantly from 0 to 16 years with the main changes occuring from 0 to 3 years for NP and AF. No significant variations were observed thereafter. We found a significant correlation of cell density and histologic degeneration score between 0 and 1, but not for scores >1. Gender and disc level did not influence cell density. CONCLUSION: This study provides data concerning the total number of cells in the various regions of the intervertebral disc for different age groups. This knowledge will be beneficial for cell-based treatment approaches, which may evolve in the future.

Fixation of subtrochanteric extending/derotational femoral osteotomies with the Locking Compression Plate in ambulatory neuro-orthopaedic patients.

PURPOSE: Patients with neuro-orthopaedic disorders often develop hip flexion contractures or rotational hip deformities. Increasing deformities impair the already diminished walking abilities and proximal femoral osteotomies are often performed to maintain/improve walking abilities. Fixation of the osteotomies with condylar plates has been successfully used but does often not allow immediate postoperative full weight bearing. To avoid a substantial postoperative rehabilitation deficit and additional bone loss due to inactivity, a postoperative treatment with full weight bearing is, therefore, wishful. Newer fixed-angled implants with stronger anchoring in osteopenic bone might fit these demands. The objective of this study was to evaluate bone healing and the complication rate after proximal extending and/or derotational femoral osteotomy fixed with 3.5/4.5 Locking Compression Plate (LCP; Synthes(®)) and postoperative full weight bearing in ambulatory neuro-orthopaedic patients. METHODS: Fifteen ambulatory neuro-orthopaedic patients (12 cerebral palsy [CP], 1 trisomy 21, 2 hemiparesis) with a mean age of 13.7 years (range 7-22) with hip flexion contractures and/or rotational deformities underwent subtrochanteric (n = 26) osteotomy between July 2004 and October 2007. All patients were allowed to bear their full weight postoperatively. We investigated the fusion rate, implant failure, and general complication rate until union had occurred. RESULTS: Fourteen patients (mean weight 42.0 kg [range 21.8-59]) uneventfully achieved solid fusion. One patient (19 years of age, 73 kg) needed revision surgery due to implant failure with consecutive varus deformity and achieved solid fusion after the second intervention. Besides one superficial wound infection, no other complications occurred. CONCLUSIONS: Subtrochanteric extending and/or derotational osteotomies fixed with an LCP are a reliable procedure in neuro-orthopaedic patients. Most patients can be treated with early postoperative full weight bearing. However, in heavier patients, possible implant failure must be considered.

Results after delayed axillary nerve reconstruction with interposition of sural nerve grafts.

HYPOTHESIS: Satisfactory results after repair of isolated axillary nerve lesions using sural nerve autografts have been reported, but a delay between injury and surgical repair exceeding 6 months was one of the most important negative predictors of functional outcome. From our experience, we hypothesize that good results can be obtained even after a delay exceeding 6 months and we opted in this study to assess the value of delayed axillary nerve reconstruction. MATERIALS AND METHODS: We evaluated clinical outcome and donor-site morbidity in 12 patients (mean age, 37; range, 19-66 years) who underwent axillary nerve repair with sural nerve graft with an average 11.25-month a delay between trauma and surgery (range, 8-20 months). Follow-up examination at least 24 months after treatment included assessment of shoulder range of motion, deltoid muscle strength in near full extension, deltoid extension lag, and sensibility. Constant Score, subjective shoulder value, and the Disabilities of Arm, Shoulder and Hand score were also assessed. RESULTS: All patients showed an improved deltoid function of at least M3. Postoperative extension lag, as the most specific sign of isolated deltoid function, improved from 57.5 degrees to 14.2 degrees. All stated that they would have identical elective surgery again. Relevant donor-site morbidity was not observed. CONCLUSION: Our data indicate that even delayed axillary nerve grafting may lead to satisfactory functional results with a low morbidity and should therefore be done in selected patients.

Treatment of reduced femoral antetorsion by subtrochanteric rotational osteotomy.

The purpose of this study was to assess bone healing and complication rate following subtrochanteric rotational osteotomy fixed with a 4.5/5.0 Locking Compression Plate (LCP, Synthes) for reduced femoral antetorsion with early full weight bearing. The effects of the osteotomy on the range of internal rotation of the hip and complaints due to reduced antetorsion were also recorded. Between July 2004 and October 2007, 25 children (39 hips) with a mean age of 13 years (range, 9-18 years) were treated for reduced internal rotation of the hip by a subtrochanteric rotational osteotomy. Four patients (six hips) were excluded from this study due to concomitant surgeries prohibiting full weight bearing. Of the 21 patients who were allowed full weight bearing, nine had a unilateral and twelve a single-stage bilateral correction. We investigated time to union, implant failure, and complication rate as well as improvement in the range of internal rotation. All osteotomies healed without secondary displacement or angulation. Internal rotation improved from a mean of 8.6 degrees (-5 degrees to 20 degrees) preoperatively to 37.3 degrees (25 degrees to 60 degrees) postoperatively. We noted no complication related with the femoral osteotomy. Subtrochanteric rotational osteotomy appeared as a reliable procedure to improve internal rotation of the hip. Fixation with 4.5/5.0 LCP allows simultaneous bilateral correction and immediate full weightbearing with crutches, with a minimal risk of implant failure.

A cost-benefit analysis using contingent valuation techniques: a feasibility study in spinal surgery.

OBJECTIVES: To carry out a pilot study to demonstrate the feasibility of the contingent valuation (CV) approach to identify net benefits gained from spinal interventions; and to conduct a formal cost-benefit analysis (CBA) using a retrospective study design. The study design is a CBA feasibility study using a CV survey with ex post willingness-to-pay/willingness-to-accept (WTP/WTA) questions. The CBA study was carried out in the specialty of spinal surgery. SUMMARY OF BACKGROUND DATA: Although increasing data are gathered on the societal costs of low back pain, little information is available on how patients "value" the benefits of surgery or whether interventions in this area are indeed cost-beneficial. CV surveys are used in CBA to elicit the consumer's monetary valuations for program benefits. MATERIALS AND METHODS: A total of 115 patients after lumbar fusion, discectomy, or decompression were asked to respond to an ex post questionnaire on their WTP/WTA for their respective intervention. Additional questions addressed socio-demographics, household income, and clinical outcome. WTP/WTA was related to the actual intervention costs and clinical outcome. The WTP and cost data were then combined within a formal CBA framework with associated 95% confidence intervals generated using bootstrapping methods. RESULTS: The response rate was 91.3% (n = 105). 89.5% were satisfied/very satisfied with the treatment. 76.2% found the result of the operation was good/excellent and 75.7% would choose the operation for a given hypothetical intervention cost. Mean stated WTP was 20% lower than the actual operation costs (not known to respondents) for spinal fusion, although it was 37% higher for discectomy and 10% higher for decompression. The individuals' financial situation was the strongest predictor for WTP. Pain improvement, present pain, duration of hospitalization, and estimated intervention costs were significant independent predictors in the expected direction for the WTP, having controlled for socio-demographic and financial confounding variables. CONCLUSION: This study explored the feasibility of the CV approach for spinal interventions. The approach produced results suggesting positive net benefits with their associated levels of variability for discectomy and decompression, indicating that such surgery is cost-beneficial within a CBA framework, but this conclusion is not supported in the case of spinal fusion. Nevertheless, to improve reliability of the net-benefit estimates for these interventions, we recommend further studies comparing in particular ex ante and ex post WTP methods.

The course of macroscopic degeneration in the human lumbar intervertebral disc.

STUDY DESIGN: Assessment of age-related macroscopic changes in human lumbar intervertebral discs (IVD) and vertebral bodies. OBJECTIVES: To determine the sequence of macroscopic changes during aging/degeneration. SUMMARY OF BACKGROUND DATA: Descriptive studies on macroscopic alterations of the IVD during aging/degeneration are readily available, but quantitative analyses are sparse. METHODS: A total of 248 mid-/parasagittal sections of lumbar IVD and vertebral bodies from 41 routine autopsies (range, 7 months to 88 years) were semiquantitatively assessed for macroscopic parameters and correlated with age. RESULTS: Nuclear fibrous transformation, anular disorganization, endplate, and vertebral body alterations progress predominantly in the first two and in the fifth to seventh decades. In the third and fourth decade, little progression occurs. Nuclear clefts and anular tears appear later, mostly starting in the second decade, with clefts preceding tear formation. Radial and concentric tears develop similarly over time, whereas rim lesions mostly develop after the sixth decade. Significant differences are observed between upper and lower lumbar spine. CONCLUSION: Our data show that fibrous nuclear transformation during aging/degeneration precedes cleft formation. The temporal sequence suggests a strong correlation of cleft and tears formation starting with clefts in the second decade. Our results support the hypothesis that disc degeneration starts in the nucleus. Extensive macroscopic alterations already apparent in the second life decade present a challenge to any tissue engineering and repair attempt.