[Radial head prosthesis - treatment of comminuted radial head fractures combined with elbow instability]. / Radiuskopfprothese - Behandlung von Radiuskopftrümmerfrakturen mit begleitender Bandinstabilität.

AIM: This cohort study shows the results after treatment of comminuted radial head fractures combined with elbow instability, using radial head arthroplasty. METHOD: Between 2001-2003, 25 patients with an unreconstructible comminuted fracture of the radial head and elbow instability were treated with a bipolar radial head prosthesis. Using the Mason/Johnston classification there were 15 type III and 10 type IV radial head fractures. In 17 cases the operation took place within a week. In 8 cases the prosthesis was implanted after 129 +/- 113 days. The mean follow-up time was 21 +/- 6 months. RESULTS: The range of elbow movement showed a loss of mean extention of 13 +/- 8 degrees and a mean flexion of 126 +/- 12 degrees . The mean pronation was 72 +/- 13 degrees and supination 76 +/- 12 degrees . According to the Morrey score there were 8 excellent results, 13 good, 3 fair and 1 poor. The mean DASH score was 21.3 (0-74). Compared to a reference group, similar in age and gender, the patients showed no notable differences in quality of life. In one case the prosthesis dislocated and another patient experienced an aseptic loosening of the stem. Seven patients were diagnosed with heterotopic ossification, stage I and II on the Ilahi scale. 96 % of patients were able to return to their preoperative working life. A comparison of acute and chronic radial head fractures, treated with prosthesis showed no difference in results. CONCLUSION: An arthroplasty with a radial head prosthesis can be recommended for unreconstructible comminuted radial head fractures with ligament injury.

[Arthroscopically-assisted combined anterior and posterior cruciate ligament reconstruction]. / Arthroskopisch assistierter simultaner vorderer und hinterer Kreuzbandersatz.

BACKGROUND: The best treatment of a combined rupture of the anterior and posterior cruciate ligaments is still unclear. METHODS: Nine patients with unilateral traumatic ruptures of both the anterior and posterior cruciate ligaments were treated by arthroscopically-assisted simultaneous reconstruction. The operation was done using hamstring tendon and patellar tendon autografts, an average of 235 days (range 52-567) after the initial trauma. Patients were followed up for an average of 37 months (range 24-58) after surgery. For this retrospective cohort study, we used the Lysholm knee score, the Tegner activity score, and the SF-36 questionnaire as a means of assessment. RESULTS: The evaluation at follow-up showed an average score of 74 points on the Lysholm scale. Using the IKDC evaluation, four patients could be placed in group B and five patients in group C. A significant increase, from 1.9 points before trauma to 5.0 points at follow-up, was observed on the Tegner activity score. Comparing the operated with the healthy knees, with respect to stability and isokinetic muscle strength, we noted significantly better scores in the healthy knees. Using the SF-36 questionnaire, patients showed a reduced level of physical well-being. CONCLUSION: The treated patients were able to carry out their activities of everyday life. However, none of them returned to their preinjury activity level.

[Balloon kyphoplasty for recent vertebral fractures in the elderly]. / Ballonkyphoplastie frischer Wirbelkörperfrakturen bei alten Patienten.

BACKGROUND: An increasing life expectancy is often accompanied by a possible increase of vertebral fractures. If operative therapy is necessary, open procedures might be problematic for elderly patients. In this case, balloon kyphoplasty might be an alternative. METHODS: We present our prospective data of 30 patients with an average age of 72 years (range 65-82). The patients suffered from isolated thoracic and lumbar fractures (T6-L4) without neurological deficits and were operated on with balloon kyphoplasty. They were followed up an average of 13 months after surgery. RESULTS: Before surgery, the patients' average kyphotic angle was 12 degrees . After reduction with balloon kyphoplasty, this angle was significantly improved to 7 degrees , and at follow-up it was 8 degrees . Back pain, which was determined by a visual analogous scale, showed a significant reduction from 8.2 to 2.6 points at follow-up. No significant relationship between preoperative pain and improvement of the kyphotic angle could be found. Patients with a bad fracture reposition showed significantly more pain at follow-up. However, there was no difference between the reference group and the examined patients' quality of life regarding general health. CONCLUSION: Recent fractures of the thoracic or lumbar spine in elderly patients treated by balloon kyphoplasty showed good early results.

[Pseudoarthrosis of anterior pelvic ring fracture]. / Pseudarthrose nach vorderer Beckenringfraktur.

It is rare for there to be healing problems after anterior pelvic fractures. An internet search produced only a small number of hits. This paper recounts the course in two patients who experienced symptomatic nonunion of anterior pelvic fractures after stable osteosynthesis with locking plates. Stable internal fixation with locking plates eventually led to successful healing after both nonunion of the ischial ramus and nonunion of the transitional zone between the inferior pubic ramus and the ischial ramus, and also of nonunion of the superior pubic ramus, in both patients. The study demonstrates that it is possible to stabilise nonunion of the superior pubic ramus by internal fixation of the ischial ramus and of the transitional zone between the inferior pubic ramus and the ischial ramus with locking plates.

[Quantifying stenosis of the internal carotid artery: which ultrasound criteria are relevant?]. / Quantifizierung von A. carotis interna-Stenosen: Welche Ultraschallkriterien sind geeignet?

UNLABELLED: Therapeutic decisions in cases of arteriosclerotic stenosis of the internal carotid artery usually depend mainly on the degree of stenosis. However, the recommendations with regard to suitable ultrasonographic criteria are so controversial that even authors of repute describe "confusion" and "chaos in methodology". AIM: The aim of this study is to assess which of the most frequently recommended sonographic criteria for stenosis best fulfill the requirements of an exact quantification of stenoses of the internal carotid artery. METHOD: In 42 consecutive cases the preoperative ultrasound findings were compared with the degree of stenosis in surgically removed specimens. The sonographic technique employed consisted of the analysis of 2 direct and 3 indirect hemodynamic criteria of stenosis. In 34 of these cases planimetry was performed, too. The specimens were obtained by eversion thrombendarteriectomy or arteriotomy; for determination of the degree of stenosis a Paladur molded cylinder was prepared and measured. RESULTS: Quantification of the haemodynamic criteria carries provided well with the endarterectomy specimens. Only in two cases there was a deviation of more than 10 %; however, in these two cases a change with time in the degree of stenosis was probably responsible for the discrepancy. In contrast, planimetry usually underestimated the degree of stenosis: In 61 % of the findings the ultrasonographic results differed by more than 10 % from the reference standard. CONCLUSION: Quantification of stenosis of the internal carotid artery should be made using a combination of direct and indirect haemodynamic ultrasonographic criteria.

Dacron vs. polytetrafluoroethylene grafts for femoropopliteal bypass: a prospective randomised multicentre trial.

OBJECTIVES: To compare the patency of PTFE (Polytetrafluoroethylene) and unsealed knitted Dacron femoro-popliteal bypasses. DESIGN: Multi-centre prospective randomised trial. MATERIALS AND METHODS: Of 203 patients randomised, 194 were included in the final analysis (103 Dacron grafts and 91 PTFE grafts). The median follow-up was 36 months (range: 6-72 months); the distal anastomosis was above-knee in 141 and below-knee in 53 cases. Univariate comparisons of patency were made by the Kaplan-Meier method, multivariate calculations on the effects of covariables by a Cox regression analysis. RESULTS: There was no difference regarding primary and secondary patency or limb salvage between Dacron and PTFE. The primary 3-year patency for Dacron grafts was 64% (95% confidence interval [C.I.] 55-74%) and for PTFE grafts 61% (C.I. 49-72%). The corresponding 3-year secondary patency was 81% (C.I. 73-89%) and 75% (C.I. 65-86%) respectively, the limb salvage rate 90% (C.I. 84-96%) and 91% (C.I. 84-97%). Upon multivariate analysis below-knee anastomosis was the principal independent predictor of primary graft failure (risk ratio 1.7 [C.I. 1.05-2.8]), impaired secondary patency was associated with infragenicular bypass (risk ratio 3.3 [C.I. 1.8-6.3]) and distal gangrene (risk ratio [C.I. 1.01-3.8]p=0.048), major amputation was independently predicted by below-knee bypass, tissue necrosis, and poor run-off index. CONCLUSIONS: PTFE and Dacron are equally suitable for femoro-popliteal bypass.

Inflammatory abdominal aortic aneurysm: A postoperative course of retroperitoneal fibrosis.

PURPOSE: The long-term outcome and the development of retroperitoneal fibrosis after surgery on an inflammatory aortic aneurysm was studied. METHODS: Between 1989 and 1997, 1035 patients underwent surgery for an abdominal aneurysm, 42 of whom (4.1%) had typical signs of inflammation. All patients underwent computed tomography (CT) scans before operation, and 26 patients were followed up with a CT scan after a median of 36 months (range, 10 to 91 months). RESULTS: The inflammatory layer resolved completely in only 23% of the patients. One patient had marked progression, 35% of patients showed improvement, and the remaining patients had no change, compared with the preoperative findings. Although clinical symptoms subsided in 90% of patients, in five cases an involvement of the ureter or intestine that did not exist at the time of operation developed. Although ureteral involvement to the inflammation tends to subside after surgery, persisting fibrosis was associated with ureteral entrapment in 30% of these cases and resulted in renal compromise in 49%. Hydronephrosis that was not present at the time of operation was found in 19% of patients, despite improving or stable inflammatory lesions. CONCLUSION: This case-control study supports the findings that retroperitoneal fibrosis persists longer than previously thought, and progression might even occur. Formerly uninvolved organs might become included in the process despite regression of the layer, leading to considerable problems if the condition is not treated in institutions familiar with this complex disease. We advocate a moderated follow-up scheme, as in the case of ordinary abdominal aortic aneurysm, and the need for long-term surveillance of inflammatory aneurysms.

Fracture reduction and deformity correction with the hexapod Ilizarov fixator.

A configuration for the Ilizarov external fixator with six distractors and 12 ball joints in the form of a hexapod was developed. The system allows for six degrees of freedom bone fragment displacement by controlling the distractors. Using this assembly, universal three-dimensional corrections or reductions are possible without the need for complicated joint mechanisms. The device was used in 16 patients: five had displaced tibial fractures with severe soft tissue damage, 10 had deformities or pseudarthroses subsequent to treatment of tibial fractures, and one had an axis deviation in the course of tibial lengthening. Translational (to 40 mm) and rotational deformities (to 33 degrees) were corrected. Final radiographic examinations after the correction procedure was complete showed median residual deformities of 3.5 mm (range, 0-5 mm) and 1 degree (range, 0 degree-4 degrees) in the anteroposterior projection and of 1.5 mm (range, 0-6 mm) and less than 1 degree (range, 0 degree-9 degrees) in the lateral projection. The construction is a useful and important addition to the Ilizarov fixator system. As a bone fixation device it is unique in that its optimal use depends on the availability of computer software.

[Corrective osteotomies of the lower extremities following posttraumatic deformities]. / Posttraumatische Fehlstellung der unteren Extremität--Korrekturen im Bereich der langen Röhrenknochen.

PURPOSE: As part of a retrospective analysis of posttraumatic malunions of the lower extremity, the causes for deformity, as well as indications and methods for corrective osteotomies are reviewed. METHODS: From January 1992 until December 1996, a total of 115 patients underwent corrective osteotomies of the lower extremity secondary to posttraumatic deformities. The 89 adult patients with tibial (n = 54) or femoral (n = 35) malunion were analyzed as part of this study. RESULTS: The primary fracture treatment consisted of an intramedullary stabilization in 19 instances, a plate osteosynthesis in 22 and an external fixateur in 14 cases. Other forms of treatment were choosen in the remaining (n = 34) instances. Torsional deformities were seen after primary intramedullary nailings, while plate osteosynthesis lead to angulation in the frontal plane in the majority of the treated patients. In 43 instances uniplanar and in 46 cases multiplanar deformities had to be corrected. The correction was carried out with the help of an Ilisarow-ring fixator in 37 instances. As an internal stabilizer, 9 nails, 2 dynamic compression screws and 38 AO-plates were used. A bone graft was carried out primarily 33 times. CONCLUSIONS: The review of the literature, as well as of our own results, shows that deformities in the frontal plane should be corrected if they exceed 10 degrees of varus or 15 degrees of valgus. Malunions of more than 15 degrees in the sagittal and 15-20 degrees in the transverse plane should also be considered for correction, while a shortening of more than 3 cm represents an indication for corrective osteotomy. Callus distraction techniques have proven valuable in the correction of posttraumatic malunions of the lower leg, especially when soft tissue compromise is evident.

[In vitro and in vivo studies of a temporary absorbable dressing]. / In-vitro- und in-vivo-Untersuchungen einer absorbierbaren temporären Wundabdeckung.

The major advantage of biodegradable synthetic wound dressings compared to other synthetic materials and biological tissue derivatives is avoidance of the necessity to change the dressing. The copolymer films used in this study were made of lactic and caproic acid. They pose no problems concerning immunology or transmission of diseases. Moreover, the substances released by degradation may possibly influence the process of wound healing. The material proved to be non-toxic and was used successfully as a carrier for cell culture with keratinocytes. The permeability for bacteria is determined by degradation. Evaluation of the bacteriological studies indicates secure protection against secondary contamination of the films for at least 15 days, however. Concerning application, dressing properties, wound healing and wound retraction, no disadvantages were found in comparison with the results of the competition's film Opsite. Based on these findings, the films are now used in a clinical study as a wound dressing for split-skin donor sites.

[Change in the treatment method of infected pseudarthrosis with bone loss of the tibia]. / Methodenwechsel in der Behandlung der Infekt-Defektpseudarthrose des Unterschenkels.

AIM OF INVESTIGATION: The treatment of nonunions complicated by infection and bone loss is divided into two stages. Having calmed down the infection by stabilizing, removal of infected and necrotic tissue and local antibacterial measures, the bone loss has to be filled up. Bridging the gap by means of autogenous cancellous bone grafting is complicated by a high rate of refractures depending on the length of bone loss. Therefore after changing the method and using the Ilizarov procedure it is of interest, whether this method offers advantages. Our experience is to be reported and discussed. METHODS: According to the clinical course two groups of patients with nonunions of the tibia complicated by infection and bone loss were compared. 25 previously evaluated patients of the years 1980/81 whose tibial bone loss was bridged by cancellous bone grafting (1st group) were compared with 16 patients who were treated by the Ilizarov method from May 1990 to October 1993 (2nd group). The average age was nearly the same (32.6/32.9 years). In the first group the average of bone loss measured 4 cm, in the second 7.8 cm. The number of initial operations to eliminate infection and the duration of fixator application from the beginning of bridging bone loss were compared as well as early and late complications, especially the rate of refracture and reinfection. RESULTS: 1.2 operations were needed to eliminate infection in the first group, in the second only one was necessary. The handling of the Ilizarov device is more difficult and needs training. The higher rate of early complications at the beginning decreased with increasing experience. The average of fixation time could be reduced by about ten days per cm of bone loss using the Ilizarov technique. By segmental transport new cortical bone is generated which surpasses cancellous bone grafting in regard to stability. This seems to be an important reason that refracture did not occur in the second group. Furthermore, reinfection could be avoided up to now obviously due to sufficient segmental resection of infected and necrotic tissue. Limited stores of autogenous cancellous bone are not to be feared. The total number of operations can be reduced. At the docking side early single cancellous bone grafting is recommended.

[Some references for Ilisarov transosseous osteosynthesis]. / Einige Hinweise zur transossären Osteosynthese nach Ilisarow.

The advantages of secondary bone healing by callus formation--as seen in transosseous osteosynthesis--as against primary bone healing are discussed. With the Ilisarov technique, new callus and bone formation can be achieved under constant tension stress. Observations of the phenomenon of limb lengthening by callus distraction go back to Codivelli. A first apparatus for bone lengthening was described by Block as long ago as 1923. The tremendous merit of Ilisarov's work is based on fundamental research and clinical experience with investigation of the effects of tension stress on several sorts of tissue under different conditions.

[Treatment of femoral fracture with the Ilisarov fixator]. / Die Frakturbehandlung des Femurs mit dem Ilisarow-Fixateur.

From July 1990 to December 1991, femoral fractures in seven patients were stabilized using the Ilisarov apparatus. Second-degree open communited fractures in four patients were stabilized primarily by this technique. Three other patients suffered from redislocations following internal fixation (n = 2) or a refracture (n = 1). The average duration of fixation in shaft fractures (n = 3) was 21 weeks, in supracondylar fractures (n = 4), 13.5 weeks. The fixation period we observed was thus shorter than that reported for other external fixation devices. Because of the complications that were noticed, however, the Ilisarov technique should only be used in particular cases.

[Treatment of calcaneus and mid-foot fractures using closed reposition and fixation with the Ilisarov fixator]. / Die Frakturbehandlung des Kalkaneus und des Mittelfusses mittels geschlossener Reposition und Fixation im Ilisarow-Fixateur.

Sixteen fractures of the calcaneus involving the subtalar joint were treated by closed reduction and external fixation using the Ilisarov apparatus. Except for four cases in which temporary arthrodesis of the subtalar or ankle joint was used, fixation was usually only used for the calcaneus. The operative technique is described precisely. Initial follow-up examinations (on average after 1 year) show advantages over conservative treatment, e.g. better anatomical reduction. In addition, early mobilization of the joint and early weight-bearing result in less pain from disuse osteoporosis. Furthermore, several case reports demonstrate the efficiency of this method in tarsal and metatarsal fracture-dislocations.

[Treatment of post-traumatic limb shortening]. / Die Behandlung der posttraumatischen Extremitätenverkürzung.

The physiological phenomenon of changes in callus formation during distraction was first described by Codivilla at the beginning of this century. Having investigated and proved the influence of tension stress on callus formation, Ilizarov used this as a method to treat limb shortening and deformities. Because of his remarkable results we introduced this method in our hospital in 1990, using the original Ilizarov ring fixator. From November 1990 to December 1991, we used this technique in 10 cases of combined post-traumatic bone shortening with deformity (the tibia was affected in six patients, the femur in three and the forearm in one). The mean shortening was 3.1 cm, the mean varus or valgus deformity 9.5 degrees, the mean anteflexion or recurvation 8.3 degrees, and the mean rotation deformity 8.5 degrees. Distraction/correction lasted between 8 and 55 days (mean: 37 days). Fixation was necessary for between 60 and 339 days. If corticotomy was performed in the diaphyseal bone, fixation lasted almost twice as long (11.33 days/mm lengthening) as in the metaphyseal area (6.55 days/mm lengthening). There were 14 complications, most of which were considered minor. The latter included pin infections (4), wire breaking (1) and restricted range of motion of the knee or ankle (5). Among the major complications were two nerve irritations, which recovered spontaneously, and two pin-induced local bone infections, which required surgical intervention. Achievement of the goals of treatment-complete correction of shortening and deformity-was not affected by these complications.

[An unusual example of primary weight bearing stability of a limb fracture of the oryx antelope after external fixation with the original Ilisarov fixator]. / Ein aussergewöhnliches Fallbeispiel für die primäre Belastungsstabilität einer Extremitätenfraktur der Oryx-Antilope nach externer Fixation mit dem Original-Ilisarow-Fixateur.

This paper reports the stabilization of an open comminuted fracture of the metatarsus of a rare white Arabian oryx using an original Ilisarov-fixator. The antelope (weighing 75 kg!) walked with its full weight on the stabilized leg immediately after operative treatment, thus demonstrating the high degree of stability of such a system. In our opinion, the Ilisarow technique is, in selected cases, an adequate method for stabilizing highly unstable open fractures in veterinary practice.

[Indications and technique of combined dorso-ventral stabilization of the spine]. / Indikation und Technik der kombiniert dorso-ventralen Stabilisierung an der Wirbelsäule.

In delayed treatment of fracture dislocations or luxation of the cervical spine, combined dorsoventral operative treatment is necessary. After anatomical reduction from dorsal, stabilization is performed from ventral using autologous bone grafting and a plate. The injured intervertebral disk is removed to avoid protrusion. At the thoracolumbar spine this technique includes ventral bone grafting with a corticocancellous sandwich block and dorsal transpedicular fixation using an internal fixator system. This simplifies removal of the implant.