[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.

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.

[Development of a resorbable temporary skin replacement for large surface burn wounds]. / Entwicklung eines resorbierbaren temporären Hautersatzes für grossflächige Verbrennungswunden.

Most of the temporary dressing used in the treatment of extensive burn wounds pose immunological permeability, or transparency problems. All available dressings must be removed, and removal is often painful and traumatic. The development of biodegradable wound dressings made of copolymers of lactic and caproic acid was part of a research program (BMFT/FRG). Four parameters determine the properties of the copolymers: Purity, mole ratio of monomers, molecular weight, and sequence. Films of these copolymers can be made transparent, permeable, and flexible. They are degraded by hydrolysis and the normal ways of metabolism.

[The effect of an angle-stable plate-screw connection and various screw diameters on the stability of plate osteosynthesis. An FE model study]. / Einfluss einer winkelstabilen Platten-Schrauben-Verbindung und unterschiedlicher Schraubendicken auf die Statik der Plattenosteosynthese. Eine FEM-Studie.

In a finite element model of a human femur with an attached stainless steel six-hole plate exposed to a load equivalent to that set up by standing on one leg, pressures on the face of the screw holes, bending stresses in the screws, and axial bone stresses in the mid-plate transverse section were determined. The calculations were performed for minor thread diameters of 3 mm, 5 mm and 8 mm. Further calculations were done assuming a fixator-like rigid screw-plate connection. As a model of a fracture a medial bone defect was chosen. The results show a definitive influence of the screw diameter and the screw-plate connection on the load distribution in the system. Increasing screw diameter makes for lower bone stresses combined with increased bending stability, a larger part of the load being carried by the plate. The rigid screw-plate connection (plate fixator) causes less bone stresses, but high bending stresses are set up the points of screw-plate fixation. Maximal stresses for screw and bone are found at the end of the plate, caused by the large difference in the E-module between the steel plate and the bone. End-plate bone and screws are loaded in excess of their material limits when 3 mm core diameters are used, and sometimes when 5 mm core diameters are used, under the assumed conditions. When a medial bone defect reducing the bone cross-sectional area by 44% is present, the loads on the inner screws increase by a factor of 3 and the loads of the distant screws, by a factor of only 1.3. The maximal pressure in the bone cross section increases 4-fold.

[Regression trends of neurologic damage in the surgical emergency management of patients with injuries of the cervical vertebrae with spinal cord involvement]. / Die Rückbildungstendenz neurologischer Schäden bei der operativen Sofortversorgung von Halswirbelsäulenverletzten mit Rückenmarksbeteiligung.

Sixty-five patients with cervical spine injuries and varied neurological deficits were treated operatively. Evaluation revealed an improvement in neurological findings dependent upon the promptness of anatomical reduction in patients with incomplete lesions. The more frequent neurological improvement seen with open reduction and internal fixation as compared with closed reduction was not statistically significant but was felt to justify the additional resources required for internal fixation. In complete lesions, there was no evidence that the time of anatomical reduction was related to improvement in neurological findings.