[Conservative treatment of distal radial fractures]. / Die konservative Behandlung der distalen Radiusfraktur.

OBJECTIVE: Distal fracture of the radius is common in all age groups. Under careful consideration of individual indications and contraindications, conservative treatment with reduction and immobilization can have significant advantages over the frequently applied surgical approach, particularly in older patients. THERAPEUTIC GOAL: Immobilization after closed reduction enables satisfactory wrist function to be achieved according to individual patient expectations. INDICATIONS: A. Patients with a. significant comorbidities, b. high surgical risk from an anesthesiology perspective (ASA > 3), c. low functional requirements, d. low cosmetic expectations regarding residual visible deformity. B. Young patients with an extension fracture and additional a. < 10° dorsal tilt in the case of extraarticular fractures after closed reduction, b. < 5 mm radial shortening after closed reduction, c. < 2 mm intraarticular displacement after closed reduction. CONTRAINDICATIONS: A. Patient age < 65 years with an extension fracture and additional a. > 10° dorsal tilt in the case of extraarticular fractures after closed reduction, b. > 5 mm radial shortening after closed reduction, c. > 2 mm intraarticular displacement after closed reduction. B. Flexion fracture for which ligamentotaxis for closed reduction is not possible. C. Open distal radial fracture. D. Fracture dislocations. E. Impairments of peripheral circulation, motor or sensory function of the hand after reduction. TECHNIQUE: After puncturing the fracture hematoma and infiltrating the fracture gap with local anesthetic, the forearm is suspended using Chinese finger traps on the thumb and middle finger. Constant traction in the longitudinal axis of the forearm is ensured by a weight applied via a wide cushioned cuff to the distal upper arm. Reduction then is enabled with the additional reductive effect of ligamentotaxis. After minimal cushioning of the forearm with cotton wool and crepe bandage, a dorsal gypsum longuette is applied. After the plaster bandage has hardened, peripheral circulation, motor function, and sensitivity are checked. The reduction is controlled by X­ray and documented. POSTPROCEDURAL MANAGEMENT: A. General procedures to reduce swelling; sufficient analgesics should be prescribed. B. The circular plaster cast is applied once swelling has subsided sufficiently, generally after 2-3 days. C. The duration of cast wearing should be planned at 5 weeks. RESULTS: A total of 73 patients (55 women and 18 men) aged 65-88 years were followed up for 12 months to investigate functional outcomes after surgical and conservative therapy. While surgical patients had better functional scores up to 12 weeks after treatment begin, there was no longer a significant difference in the 6­ and 12-month follow-up results. The measured grip strength was consistently better in the surgically treated group. Clinically visible deformities were present in 78% of the conservatively treated patients; however, the patients were satisfied with the functional or cosmetic results. No deformities were seen in the surgically treated patients. All fractures were completely healed after 6 months. The rate of complications was significantly higher in the surgery group, with 13 complications compared to 5 in the conservative treatment group.

Clinical and radiological outcome of Mason-Johnston types III and IV radial head fractures treated by an on-table reconstruction.

BACKGROUND: Only few methods treating comminuted radial head fractures have been established providing sufficient joint reconstruction, restoring radial length and enabling early joint mobilization. When an anatomical reconstruction using open reduction and internal fixation is not possible, radial head resection or primary arthroplasty is often conducted. An "Ex situ/on-table" reconstruction is widely disregarded but can be an option. The purpose of this study was to evaluate the functional and radiological outcome of comminuted radial head fractures treated with an "on-table" reconstruction and internal fixation using a low profile plate. METHODS: Fourteen patients who sustained a radial head fracture (9 Mason-Johnston type III and 5 Mason-Johnston type IV) and were treated with an "on-table" reconstruction between 2010 and 2020 were evaluated retrospectively. The patients mean age was 41.3 years (range 21-69). The clinical evaluation included active range of motion, grip strength, pain level and elbow stability. The functional outcome was assessed using the Disability of Arm, Shoulder and the Hand (DASH) score, Mayo Elbow Performance Index (MEPI), Broberg and Morrey score. The radiological examination included a.p. and lateral views of the injured elbow to evaluate nonunions, loss of reduction, joint alignment, avascular radial head necrosis, heterotopic ossifications and posttraumatic osteoarthritis. RESULTS: The inclusion rate was 74% with a mean follow-up of 50 months (range 16-128). The mean elbow flexion of the injured side was 126° (range110-145°) with an average extension loss of 8° (range 0-40°). Pronation was 65° (15-90°) and supination 66° (5-90°). The mean MEPI was 87 points (range 45-100). The mean DASH score was 13 points (range 1-88). According to the Broberg and Morrey functional scoring system, the average score was 92 points (range 88-100). Complete bone union was achieved in 9 cases, partial union in 4 cases and nonunion in one case. There were no signs of avascular necrosis of the radial head. Signs of post-traumatic osteoarthritis were seen in 11 cases. Five patients needed an implant removal due to a radio-ulnar impingement and one patient a revision surgery due to the nonunion and implant breakage. CONCLUSIONS: An on-table (ex situ) reconstruction of the radial head is a reliable option with a good clinical outcome and low complication rate in the surgical treatment of comminuted radial head fractures. It can restore joint alignment and maintain radial length. The risk for avascular necrosis is neglectable, and the bone healing rate is high.

Surgical treatment of the bony mallet thumb: a case series and literature review.

INTRODUCTION: The aim of this study was to provide a more precise statement on the outcome after surgical treatment of a bony mallet thumb and possibly give a treatment recommendation regarding the surgical fixation method. PATIENTS AND METHODS: All patients (n = 16) who underwent a surgical treatment for an acute bony mallet thumb fracture between January 2006 and July 2019 were enrolled. The surgical method, complications, the range of motion, tip pinch, lateral key pinch, overall grip strength, visual analog score, Disability of the Arm, Shoulder and Hand Score, Mayo Wrist Score, Patient-Rated Wrist Evaluation Score, Buck-Gramcko Score and radiologic parameters were evaluated. Further, a comprehensive literature search on PubMed was conducted covering a period from 1956 to 2021 to include all possible matching articles on the treatment of the bony mallet thumb (n = 21 articles). RESULTS: Surgical treatment was very inhomogenous including indirect and direct K-wire fixation, screw fixation, plate fixation and anchor fixation methods. The IP joint range of motion and thumb strength ranged from 66 to 94% in comparison to the contralateral side. An open reduction led to worse functional scores compared to a closed reduction. Treatment methods in the literature were also very inhomogenous with a very low patient count, often even pooling data of bony mallet thumb fractures with bony mallet finger fractures. The risk for infection was higher in K-wire fixation methods than in open reduction and internal fixation methods. CONCLUSION: The evidence for the best treatment of a bony mallet thumb fracture is low. On one hand the functional outcome can be inferior using an open reduction approach, but on the other hand, K-wire fixation methods with a closed reduction approach showed a higher risk for infection. Future multi-center research must be conducted to find the best treatment procedure for the best outcome of the patient.

Arthroscopic debridement of the dorsal capsule in intraarticular distal radius fractures: does it provide superior outcomes?

INTRODUCTION: Distal radius fractures (DRFs) are very common. One of the most significant complications after intraarticular DRF is arthrofibrosis with loss of wrist motion and pain. Wrist arthroscopy has become increasingly popular in the treatment of DRF with the advantage of good visualization of the joint surface and soft tissue injuries. In intraarticular DRFs injuries of the dorsal capsule are a characteristic finding which potentially cause loss of wrist motion. In this study, we investigated if arthroscopic debridement of dorsal capsule injuries at time of surgical fixation provides superior outcomes compared to the same treatment without debridement. MATERIALS AND METHODS: Between 2013 and 2017, we included 42 patients who underwent arthroscopy-assisted palmar plating for intraarticular DRFs in a prospective randomized controlled study. In group A (intervention group), the dorsal capsule tears were debrided during primary surgery, while in group B these were left in place. Active range of motion (AROM), grip strength, subjective outcomes and radiographic results were assessed 3, 6 and 12 months after primary surgery. A subgroup analysis was performed for patient age, fracture severity and duration of immobilization. RESULTS: Arthroscopic debridement of the dorsal capsule improved AROM in patients over 60 years of age, more severe fractures (AO 23 C2/C3) and prolonged postoperative immobilization for more than two weeks, while it was not relevant for younger patients with simple fractures and short immobilization. CONCLUSIONS: Debridement of the injured dorsal capsule in arthroscopic-assisted surgical treatment of intraarticular DRFs can improve surgical performance and optimize patient outcomes in a specific subgroup of patients.

Lessons learned with the Cobra prosthesis in elderly patients with complex distal radius fractures-a retrospective follow-up study.

INTRODUCTION: Recently, the Cobra prostheses were introduced in the treatment of distal radius fractures (DRF) of elderly patients. Fracture prostheses provide an alternative treatment option for complex fractures where conservative therapy seems not acceptable and osteosynthesis seems not possible. Data reporting the feasibility of the Cobra prosthesis are sparse. Therefore, this retrospective follow-up study investigated the clinical and radiological mid-term outcome of the Cobra implant in complex DRFs of elderly patients. MATERIALS AND METHODS: Thirteen patients (mean age 73.5 years, range 65-87 years) were retrospectively evaluated with at least a 1-year follow-up after surgery. Objective and subjective clinical parameters as well as the radiological outcome and complications were analyzed. RESULTS: The mean follow-up period was 31.2 months. Seven cases required a cemented prosthesis. The mean relative range-of-motion compared to the healthy side was 72.3% and 51.8% for extension and flexion, respectively, and 87.9% and 85.7% for pronation and supination, respectively. The mean grip strength was 78.3% compared to the non-operated side. Eight patients were very satisfied, five patients were partly satisfied with the result. The DASH, PRWE, MHQ and Lyon-Scores averaged 39.1, 36.2, 64.9 and 63.3 points, respectively. The mean VAS-Score for pain was 1.1 at rest and 3.2 during activities. Perioperative complications included one dissection of the extensor pollicis longus tendon, one heterotopic ossification, one radiocarpal dislocation and two cases of an ulnar impaction syndrome due to implant subsidence. CONCLUSION: The prosthetic treatment of complex DRFs in elderly patients with the Cobra implant led to clinically and radiologically satisfactory mid-term results. The Cobra prosthesis still does not represent a gold standard but can be regarded as a feasible salvage option for complex DRFs when osteosyntheses may not be possible and non-operative treatment will lead to further functional restrictions and wrist pain during performing activities of daily life in high functional demand patients.

Retrospective comparison of conservative treatment and surgery for widely displaced olecranon fractures in low-demanding geriatric patients.

INTRODUCTION: The aim of this study was to evaluate the difference of the clinical outcome of elderly patients who were treated surgically or conservatively for a displaced olecranon fracture (Mayo type IIA or IIB). PATIENTS AND METHODS: Patients above the age of 70 years who were treated surgically (n = 11) for a displaced Mayo type IIA and IIB olecranon fracture between July 2015 and February 2019 were retrospectively compared with patients who were treated conservatively (n = 6). The range of motion, elbow strength, grip strength, VAS, DASH, OES, MEPI and Broberg and Morrey scores were evaluated. RESULTS: The conservative group showed a non-union with a persistent fracture gap of 17 mm (SD 12 mm) at the articular rim and 31 mm (15 mm) at the dorsal rim while there was no case of non-union in the surgical group. The arch of motion was 120° in the conservative group and 136° in the surgical group. There was no obvious difference in elbow extension strength in comparison to the healthy contralateral side (p = 0.20; 88% group I/87% group II). There was no difference in the OES (p = 0.30; 42 (SD 7) vs. 45 (SD 5)) and MEPI score (p = 0.46; (SD 8) vs. 96 (SD 19)). The conservative group presented a slightly worse DASH [p = 0.10; 26 (SD 25) vs 7 (SD 14)] and a significantly worse Broberg and Morrey score (p = 0.02; 84(SD 9) vs. 95 (SD 7)). The conservative group presented one complication (ulnar nerve palsy), while the surgical group presented two cases (prolonged lymphedema; blocked forearm rotation due to screw length with consecutive revision surgery). CONCLUSION: Widely displaced olecranon fractures can successfully be treated conservatively in low-demanding geriatric patients with a satisfactory outcome. Patient selection is essential as patients that are more active might benefit from surgical treatment. Yet, treatment risks and benefits need to be balanced carefully in regard to the patient`s demands and requests.

Acute Tennis Injuries in the Recreational Tennis Player.

BACKGROUND: Epidemiological studies on tennis injuries are mainly conducted in either elite professional or junior players. Injury patterns might differ in the recreational tennis player. PURPOSE: To investigate acute injuries in the recreational tennis-playing population with an additional focus on acute injuries that require surgical treatment. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective data analysis was conducted among patients who sustained an acute tennis injury between January 2013 and December 2018 and who had treatment administered at a single university hospital. Demographic data, diagnosis, body region of the trauma, injury mechanism, and treatment methods were recorded. Data were evaluated using descriptive statistics. RESULTS: A total of 449 patients sustained 467 injuries (148 female, 301 male; mean age, 43.6 years; range, 8.2-84.4 years). The injuries occurred throughout the year, with an increased prevalence in the summer months. Injuries occurred in the lower extremity in 59%, the upper extremity in 30%, and the head and trunk in 11%. The main reason for an injury was a twist of a specific joint (n = 194) or a fall (n = 102). Harmless contusion or strains were the most common injury (49%). Ankle sprains were the most common serious injury, occurring in 11% of patients. Fractures occurred in 54 cases (12%). Overall, 9% of patients were treated surgically (fractures, n = 13; meniscal tears, n = 8; Achilles tendon ruptures, n = 6), and surgery was advised to another 1% who did not receive surgery at the study hospital. CONCLUSION: Typical acute injuries in recreational tennis players differ from acute injuries in elite and junior players, with an increased fracture occurrence. The main causes of acute tennis injuries are falls and twists, with 10% of injuries needing surgical treatment, mainly for fractures, meniscal tears, and Achilles tendon ruptures.

Clinical results of the BoneWelding®Fiji® anchor for the treatment of Stener lesions of the thumb.

INTRODUCTION: A new technology (Sportwelding®) was recently presented, which uses ultrasonic energy to meld a resorbable suture anchor at the interface with the host bone. A standardized clinical use was not investigated yet. This study prospectively evaluated the surgical and clinical outcomes of the Fiji Anchor® (Sportwelding®, Schlieren, Switzerland) in the repair of an ulnar collateral ligament lesion of the metacarpophalangeal joint of the thumb. MATERIAL AND METHODS: The range of motion, grip and pinch strength, disability of arm, shoulder and the hand (DASH) and patient rated evaluation (PRWE) score, pain, satisfaction, complications and adverse events were assessed in 24 patients after surgical treatment for an acute displaced rupture or avulsion of the ulnar collateral metacarpophalangeal ligament of the thumb using the Fiji Anchor® after 6, 12 and 52 weeks. RESULTS: At final follow up, the range of motion of the metacarpophalangeal joint reached almost the contralateral side (49.3° SD 11.7°). Thumb opposition showed a Kapandji score of 9.7 (SD 0.5; range 9-10). Grip strength, the lateral, tip and the three jaw pinch showed nearly similar values compared to the contralateral side (83-101%). Pain was low (0.2 SD 0.7 at rest and 0.6 SD 1.0 during load). The DASH score was 5.0 (SD 7.3) and the PRWE score was 4.1 (SD 9.0). 81% of patients were very satisfied at final follow-up. Two patients were rated unstable during the follow-up period due to a second traumatic event. Three cases experienced difficulties during anchor insertion, whereby incorrect anchor insertion resulted in damage to the suture material; however, this was resolved after additional training. CONCLUSION: One advantage of this anchor appears to be its stable fixation in cancellous bone. The surgical treatment of an ulnar collateral ligament lesion of the thumb using the Fiji Anchor® can lead to an excellent clinical outcome with a minor complication rate; however, long-term dangers and the cost effectiveness of the procedure are not known yet.

[3D Imaging for the analysis of scaphoid fractures and non-unions]. / 3D-Bildgebung in der Analyse von Frakturen und Pseudarthrosen des Kahnbeins.

The aim of the present study is to give an overview over the possibilities of 3D imaging in the analysis of scaphoid fractures and non-unions and to discuss them on the base of case studies and literature.

[Treatment of scaphoid non-union: vascularised iliac crest graft or medial femur condyle graft?] / Die Behandlung der avaskulären Kahnbeinpseudarthrose: gefäßgestielter Knochenspan vom Beckenkamm oder vom medialen Femurkondyl?

Treatment of scaphoid non-unions is still challenging for responsible hand surgeons, especially in cases of avascular proximal pole non-unions or failed prior surgeries. Several surgical procedures treating scaphoid non-unions have been established. These aim to restore correct anatomy to provide stability and adequate blood flow. Treatment options range from avascular to free, vascularized bone grafts. The two most used free vascularized bone grafts derive from the iliac crest and the medial femoral condyle. The vascular anatomy of the medial femoral condyle graft is more constant, the donor site morbidity lower and the healing rate higher in comparison to the iliac crest graft. It is easier to harvest the femoral condyle graft and additionally, it can be harvested as a cortico-cancellous or osteochondral graft. Looking at all advantage, we come to the conclusion that the free vascularized medial femoral condyle graft is our method of choice for the treatment of a avascular proximal pole non-union of the scaphoid.

Clinical and radiological results of the vascularized medial femoral condyle graft for scaphoid non-union.

INTRODUCTION: This study evaluated the use of a free vascularized bone graft with and without cartilage from the medial femoral condyle (MFC) in patients with recalcitrant scaphoid non-union, with a special focus on union rates and the osteochondral graft for proximal pole destruction. MATERIALS AND METHODS: Thirty-eight avascular scaphoid non-unions in 37 patients who were treated with a free osteoperiosteal or osteochondral MFC graft were retrospectively evaluated (mean follow-up 16 months). Bone union, the scapholunate and the radiolunate angles were evaluated on X-ray images. The range of motion, grip strength, VAS, DASH and PRWE scores were evaluated clinically. RESULTS: The overall union rate was 95%. Bone union was achieved in 27 out of 29 (93%) scaphoids treated with a free osteoperiosteal MFC grafts and in 9 out of 9 (100%) scaphoids treated with a free osteochondral MFC graft. The range of motion remained almost unchanged, while grip strength increased significantly (34 kg vs. 44 kg) and the VAS (22-5), DASH (59-19) and PRWE (62-30) score decreased significantly. The scapholunate (71°-65°) and radiolunate (28°-18°) angle decreased. No major donor site morbidity was observed. Postoperative complications were observed in eight cases (21%). CONCLUSIONS: The vascularized medial femoral bone graft leads to a good functional outcome in the treatment of scaphoid non-unions. The graft provides adequate blood supply and structural stability to the scaphoid. A proximal pole destruction can be replaced using an osteochondral graft with promising short-term results preventing carpal osteoarthritis and collapse.

Arthroscopic assisted treatment of distal radius fractures and concomitant injuries.

Wrist arthroscopy is mainly used to assist fracture reduction and fixation and to diagnose and treat concomitant injuries mainly to the scapholunate (SL), lunotriquetral (LT) ligament and the triangular fibrocartilage complex (TFCC). Arthroscopy is beneficial in improving anatomical reduction of fracture steps and gaps in intra-articular distal radius fractures (DRFs). Yet, the literature that the functional outcome correlates with the use of arthroscopy, is limited. Non-surgical treatment and immobilization is recommended for Geissler grade I-III Sl-ligament injuries, while open reduction, ligament suture and/or K-wire pinning is mandatory for complete ligament tears according to Geissler grade IV. This manuscript describes the current literature and gives insight into the authors' opinions and practice.

Time-Dependent Recovery of Outcome Parameters in Ulnar Shortening for Positive Ulnar Variance: A Prospective Case Series.

BACKGROUND: This study evaluates the results of ulnar shortening using the ulna osteotomy locking plate system (UOL; I.T.S. GmbH, Graz, Austria) with special regard to the time-dependent recovery of subjective and objective outcome parameters and surgeons' experiences. METHODS: Ulnar shortening using the UOL was performed on 11 patients (3 men, 8 women) with an average age of 47 ± 19.6 years. Range of motion (ROM) and grip strength were compared with the contralateral hand. Patient-rated outcomes were measured using a visual analogue scale (VAS) for pain and the Disability of the Arm, Shoulder and Hand (DASH) and the Patient Rated Wrist Evaluation (PRWE) survey for subjective outcomes. Ulnar variance and bony union were assessed using conventional wrist radiographs. The surgeons evaluated intraoperative handling through a standardized feedback form. RESULTS: ROM improved and grip strength increased significantly between preoperative values and final follow-up. Flexion and supination improved significantly between weeks 8 and 12 and grip strength from week 8 onward. Patient-rated outcomes changed significantly with a final DASH score of 14.2 ± 12.4 and a PRWE score of 24.3 ± 17.0. Pain levels improved significantly with no pain at rest and a mean VAS of 0.8 ± 1.2 during activity. The average amount of shortening was 4.0 ± 1.9 mm with a final ulnar variance of 0.2 ± 1.8 mm. All osteotomies healed with 2 cases of delayed union. CONCLUSIONS: In ulnar shortening with the UOL, wrist function recovered after an initial decrease from week 8 onward. Subjective outcome parameters showed early recovery and improved continuously over time.

Characteristics and outcome of patients with hypothermic out-of-hospital cardiac arrest: Experience from a European trauma center.

BACKGROUND: Aim of the study was to investigate patient characteristics, survival rates and neurological outcome among hypothermic patients with out-of-hospital cardiac arrest (OHCA) admitted to a trauma center. METHODS: A review of patients with OHCA and a core temperature ≤32°C admitted to a trauma center between 2004 and 2016. RESULTS: Ninety-six patients (mean temperature 25.8°C±3.9°C) were entered in the study, 37 (39%) of them after avalanche burial. 47% showed return of spontaneous circulation (ROSC) prior to hospital admission. Survival with Glasgow-Pittsburgh Cerebral Performance Category (CPC) scale 1 or 2 was achieved in 25% of all patients and was higher in non-avalanche than in avalanche cases (35.6% vs 8.1%, p=0.002). Witnessed cardiac arrest was the most powerful predictor of favourable neurological outcome (RR: 10.8; 95% Confidence Interval: 3.2-37.1; Wald: 14.3; p<0.001), whereas ROSC prior to admission and body core temperature were not associated with survival with favourable neurological outcome. Cerebral CT scan pathology within 12h of admission increased the risk for unfavourable neurological outcome 11.7 fold (RR: 11.7; 95% CI: 3.1-47.5; p<0.001). Favourable neurological outcome was associated lower S 100-binding protein (0.69±0.5µg/l vs 5.8±4.9µg/l, p 0.002) and neuron-specific enolase (34.7±14.2µg/l vs 88.4±42.7µg/l, p 0.004) concentrations on intensive care unit (ICU) admission. CONCLUSIONS: Survival with favourable neurological outcome was found in about a third of all hypothermic non-avalanche patients with OHCA admitted to a trauma center.

Sesamoid bone transfer for metacarpophalangeal hyperextension instability of the thumb: A CT-osteoabsorptiometry study.

BACKGROUND AND AIM: Hyperextension instability of the metacarpophalangeal (MCP) joint of the thumb may result in pain, malfunction, and accelerated osteoarthritis in the carpometacarpal (CMC) joint. One method of treatment is sesamoid arthrodesis. The aim of this study is to investigate if a sesamoid transfer as a treatment of hyperextension instability of the thumb MCP joint leads to an altered distribution of the subchondral mineralisation and a negative clinical outcome. METHODS: Sesamoid transfer was performed on 12 patients with hyperextension instability of the MCP joint of the thumb. The range of motion (ROM) and radiologic outcome were assessed. Pinch and power grip strength were measured and compared to the nonoperated side. To determine the areas of maximum subchondral mineralisation in the joint, computed tomography (CT)-osteoabsorptiometry was performed to determine the long-term stress distribution within the joint. RESULTS: The distributions of the stress zones in the operated and nonoperated thumbs were not statistically different a median of 5 years following the sesamoid transfer procedure. There was no difference in the functional and radiological results between the operated and nonoperated thumbs. CONCLUSION: If it is assumed that the nonoperated thumb represents the normal condition for each individual, then it may be deduced that the operation achieves good clinical results, and the distribution of the subchondral mineralisation does not change.

The effect of delayed treatment on clinical and radiological effects of anterior wedge grafting for non-union of scaphoid fractures.

INTRODUCTION: The aim of the treatment of displaced scaphoid non-unions is the restoration of normal scaphoid anatomy. Restoration of normal scaphoid anatomy at an earlier stage might have functional benefits as maladaptive carpal ligament contractures and the development of preliminary osteoarthritis could be avoided. The purpose of this retrospective study was to determine if late reconstruction (delayed reconstruction group) was as effective as early reconstruction (early reconstruction group) of scaphoid non-union in restoring clinical and radiological outcome. PATIENTS AND METHODS: The early reconstruction group included patients who underwent surgery between 6 and 12 months after the original fracture. This group consisted of 14 male and 2 female patients. The delayed reconstruction group included patients who underwent surgery 12 or more months after the original fracture. This group consisted of 9 male and 1 female patients. Average time from injury to surgery in the early reconstruction group was 10 months (range 6-12 months) and mean postoperative follow-up period averaged 58 months (range 19-72 months). Average time from injury to surgery in the delayed reconstruction group was 69 months (range 12-88 months) and mean postoperative follow-up period averaged 62 months (range 24-80 months). All patients showed a humpback deformity as well as a DISI deformity with the radiolunate angle being greater than 15°. The outcome was assessed on the basis of measurement of active wrist range of motion and grip power. Wrist pain was evaluated using a visual analogue scale. Functional subjective outcome was evaluated with the DASH and PRWE scores. Results were compared to preoperative measurements as well as to the uninjured contralateral side. Pre- and post-operative radiographs were assessed for scapholunate angle (SLA) as a measure of palmar rotation and radiolunate angle (RLA). The presence of DISI was defined by a difference of >60° for the SLA or of >10° for the RLA between the affected and unaffected wrist. RESULTS: In the early reconstruction group bone union and correction of DISI deformity could be achieved for all patients (n = 16). In the delayed reconstruction group bone union could only be achieved without correction of the DISI deformity in six patients (60 %). In four patients (40 %) of the delayed reconstruction group non-union persisted. For the early reconstruction group at final follow-up mean flexion-extension arc, mean ulnar-radial-deviation arc and mean grip strength were 82, 91.5 and 82 % of uninjured side, respectively. Mean pain level decreased from 6 points before surgery to 1 point at final follow-up. The preoperative DASH changed from 48 to 17 and the preoperative PRWE changed from 30 to 14. The SLA changed from 51° to 48° and the RLA from 18° to 9°. Six patients from delayed reconstruction group showed bone union, but no correction of DISI deformity at final follow-up. Functional and radiological results showed only slight improvement. The remaining four patients from delayed reconstruction group with a persistent non-union continued to experience pain, reduced grip strength and limited range of wrist movement and DISI deformity persisted. CONCLUSION: In conclusion, wedge-shaped bone grafting of scaphoid non-union leads to increased functional scores as well as to improved carpal angles as long as bony union can be achieved. Remaining non-union and the inability to correct DISI deformity are severely correlated with an increased time frame between fracture and surgical treatment. Furthermore, the vascularization of the proximal fragment and patients' smoking habits has to be taken into consideration preoperatively.

The exclusive use of coagulation factor concentrates enables reversal of coagulopathy and decreases transfusion rates in patients with major blunt trauma.

BACKGROUND: FFP and coagulation factor concentrates are used to correct trauma-induced coagulopathy (TIC). However, data on coagulation profiles investigating effects of therapy are scarce. METHODS: This is an analysis of 144 patients with major blunt trauma ((ISS)≥15), who were enrolled in a prospective cohort study investigating characteristics and treatment of TIC. Patients who received fibrinogen concentrate and/or prothrombin complex concentrate alone (CF Group) were compared with those additionally receiving FFP transfusions (FFP Group). RESULTS: Sixty-six patients exclusively received CF, while 78 patients additionally received FFP. Overall, patients were comparable regarding age, gender and ISS (CF Group, ISS 37 (29, 50); FFP Group ISS 38 (33, 55), p=0.28). Patients treated with CF alone showed sufficient haemostasis and received significantly fewer units of red blood cells (RBC) and platelets than did those also receiving FFP [(RBC 2(0, 4) U vs. 9 (5, 12) U; platelets 0 (0, 0) U vs. 1 (0, 2) U, p<0.001)]. In addition, fewer patients in the CF Group developed multiorgan failure (MOF) (18.2% vs. 37.2%, p=0.01) or sepsis (16.9% vs. 35.9%, p=0.014) than in the FFP Group. Propensity score-matching (n=28 pairs) used to reduce the impact of treatment selection confirmed that additional FFP administration showed no benefit in restoring haemostasis, but was associated with significantly higher transfusion rates for RBC and platelets. CONCLUSION: The use of CF alone effectively corrected coagulopathy in patients with severe blunt trauma and concomitantly decreased exposure to allogeneic transfusion, which may translate into improved outcome.