Low-profile double plating versus dorsal LCP in stabilization of the olecranon fractures.

INTRODUCTION: Proximal ulna fractures are common in orthopaedic surgery. Comminuted fractures require a high primary stability by the osteosynthesis, to allow an early functional rehabilitation as fast as possible, to reduce long-term limitations of range of motion. Classical dorsal plating is related to wound healing problems due to the prominence of the implant. New low-profile double plates are available addressing the soft tissue problems by positioning the plates at the medial and lateral side. This study analysed whether, under high loading conditions, these new double plates provide an equivalent stability as compared to the rigid olecranon locking compression plate (LCP). MATERIALS AND METHODS: In Sawbones, Mayo Type IIB fractures were simulated and stabilized by plate osteosyntheses: In group one, two low-profile plates were placed. In group two, a single dorsal plate (LCP) was used. The bones was than cyclically loaded simulating flexion grades of 0°, 30°, 60° and 90° of the elbow joint with increasing tension forces (150 , 150 , 300  and 500 N). The displacement and fracture gap movement were recorded. In the end, in load-to-failure tests, load at failure and mode of failure were determined. RESULTS: No significant differences were found for the displacement and fracture gap widening during cyclic loading. Under maximum loading, the double plates revealed a comparable load at failure like the single dorsal plate (LCP). The double plates failed with a proximal screw pull-out of the plate, whereas in the LCP group, in 10 out of 12 specimens the mode of failure was a diaphyseal shaft fracture at the distal plate peak. CONCLUSION: Biomechanically, the double plates are a good alternative to the dorsal LCP providing a high stability under high loading conditions and, at the same, time reducing the soft tissue irritation by a lateral plate position.

Clinical implications of fracture-associated vascular damage in extremity and pelvic trauma.

BACKGROUND: Vascular damage in polytrauma patients is associated with high mortality and morbidity. Therefore, specific clinical implications of vascular damage with fractures in major trauma patients are reassessed. METHODS: This comprehensive nine-year retrospective single center cohort study analyzed demography, laboratory, treatment and outcome data from 3689 patients, 64 patients with fracture-associated vascular injuries were identified and were compared to a control group. RESULTS: Vascular damage occurred in 7% of patients with upper and lower limb and pelvic fractures admitted to the trauma room. Overall survival was 80% in pelvic fracture and 97% in extremity fracture patients and comparable to non-vascular trauma patients. Additional arterial damage required substantial fluid administration and was visible as significantly anemia and disturbed coagulation tests upon admission. Open procedures were done in over 80% of peripheral extremity vascular damage. Endovascular procedures were predominant (87%) in pelvic injury. CONCLUSION: Vascular damage is associated with high mortality rates especially in combination with pelvic fractures. Initial anemia, disturbed coagulation tests and the need for extensive pre-clinical fluid substitution were observed in the cohort with vascular damage. Therefore, fast diagnosis and early interventional and surgical procedures are necessary to optimize patient-specific outcome.

Grade of retraction and tendon thickness correlates with MR-spectroscopically measured amount of fatty degeneration in full thickness supraspinatus tears.

BACKGROUND: The amount of fatty degeneration (FD) has major impact on the clinical result and cuff integrity after rotator cuff repair. A quantitative analysis with magnet resonance imaging (MRI) spectroscopy was employed to analyze possible correlation of FD with tendon retraction, tendon thickness and patients' characteristics in full thickness supraspinatus tears. METHODS: Forty-two patients with full-thickness supraspinatus tears underwent shoulder MRI including an experimental spectroscopic sequence allowing quantification of the fat fraction in the supraspinatus muscle belly. The amount of fatty degeneration was correlated with tendon retraction, tendon thickness, patients' age, gender, smoker status, symptom duration and body mass index (BMI). Patients were divided in to three groups of retraction (A) 0-10 mm (n=), (B) 11-20 mm (n=) and (C) < 21 mm (n=) and the means of FD for each group were calculated. RESULTS: Tendon retraction (R = 0.6) and symptom duration (R = 0.6) correlated positively, whereas tendon thickness correlated negatively (R = - 0.6) with the amount of FD. The fat fraction increased significantly with tendon retraction: Group (A) showed a mean fat mount of 3.7% (±4%), group (B) of 16.7% (±8.2%) and group (C) of 37.5% (±19%). BMI, age and smoker-status only showed weak to moderate correlation with the amount of FD in this cohort. CONCLUSION: MRI spectroscopy revealed significantly higher amount of fat with increasing grade of retraction, symptom duration and decreased tendon thickness. Thus, these parameters may indirectly be associated with the severity of tendon disease.

Quantitative MRI comparison of multifidus muscle degeneration in thoracolumbar fractures treated with open and minimally invasive approach.

BACKGROUND: Minimally invasive pedicle screw fixation has less approach-related morbidity than open screw placement and is allegedly less traumatizing on paravertebral muscles, as there is no requirement to mobilize and retract the adjacent muscle portion. The approach-related long-term effects to the morphology of the paravertebral muscles are unknown. The purpose of this study was to compare the long-term amount of fatty degeneration of the multifidus muscle in patients treated with a classical open or a minimally invasive approach. METHODS: Fourteen Patients meeting inclusion criteria were selected. In all patients a singular fracture of the thoracolumbar spine with a two-level posterior instrumentation was treated, either using an open approach or a minimally invasive approach. All patients underwent quantitative MRI spectroscopy for quantification of the fatty degeneration in the multifidus muscle as a long-term proof for muscle loss after minimum 4-year follow-up. Clinical outcome was assessed using Oswestry Low Back Pain Disability Questionnaire, SF-36 and VA-scale for pain. RESULTS: The minimally invasive approach group failed to show less muscle degeneration in comparison to the open group. Total amount of fatty degeneration was 14.22% in the MIS group and 12.60% in the open group (p = 0.64). In accordance to MRI quantitative results there was no difference in the clinical outcome after a mean follow up of 5.9 years (±1.8). CONCLUSION: As short-term advantages of minimal invasive screw placement have been widely demonstrated, no advantage of the MIS, displaying a significant difference in the amount of fatty degeneration and resulting in a better clinical outcome could be found. Besides the well-known short-term advantage of minimally invasive pedicle screw placement, a long-term advantage, such as less muscle degeneration and thus superior clinical results, compared to the open approach could not be shown.

Six Sesamoid Bones on Both Feet: Report of a Rare Case.

There is a variation of the total number of distinct bones in the human in the literature. This difference is mainly caused by the variable existence of sesamoid bones. Sesamoid bones at the first MTP are seen regularly. In contrast additional sesamoid bones at the second to fifth MTP are rare. We report a case of additional sesamoid bones at every metatarsophalangeal joint (MTP) of both feet. A 22-year-old female Caucasian presented with weight-dependent pain of the second MTP of the left foot. In the radiographs of both feet additional sesamoid bones at every MTP could be seen. This case reports a very rare variation in human anatomy. A similar case has not been displayed to the academic society and therefore should be acknowledged.

[Percutaneous screw fixation of non- or minimally displaced scaphoid fractures]. / Perkutane kanülierte Verschraubung nicht- oder minimal-dislozierter Skaphoidfrakturen.

OBJECTIVE: Providing stability and reduction of the period of immobilisation of non- or minimally displaced scaphoid fractures using a minimally invasive technique. INDICATIONS: Scaphoid fractures of the types A2, B1 and B2 (Herbert's classification) with no or minimal displacement, along with a patient's request for early functional treatment. CONTRAINDICATIONS: Relative contraindications: significant dislocation of the fracture, scaphoid cyst or a too proximal fracture, concomitant fractures of the wrist. Absolute contraindications: pseudoarthrosis, luxation fractures. SURGICAL TECHNIQUE: Minimally invasive percutaneous screw fixation using a double threaded screw. POSTOPERATIVE MANAGEMENT: Postoperative immobilisation in a plaster cast with a thumb inlay for 1-3 weeks until swelling and pain subside. Followed by active physiotherapeutic exercise, however no pressure on the hand for 6 weeks after surgery. RESULTS: Seventy patients with a non- or a minimally displaced scaphoid fracture were treated between 2005 and 2011. We used percutaneous screw fixation as the therapy technique. A total of 57 patients (81%) presented for follow-up. Four patients (5.7%) had an unhealed fracture 6 months postsurgery confirmed. One patient needed revision surgery because of a screw that was too long. None of the patients had a postsurgical infection, haematoma or a complex regional pain syndrome. Smoking and putting pressure on the hand too early have been identified as possible risk factors for the unhealed fractures.

[Double-plate osteosynthesis of the proximal ulna]. / Die Doppelplattenosteosynthese der proximalen Ulna.

OBJECTIVE: Stable osteosynthesis during early postoperative functional treatment, particularly in patients with osteoporosis. INDICATIONS: Metaphyseal fractures, small proximal fragments or avulsion fracture of the triceps tendon, osteotomy of the olecranon, and pseudarthrosis of the olecranon or proximal ulna. CONTRAINDICATIONS: Skin infection, severe soft tissue lesions. SURGICAL TECHNIQUE: Dorsal approach to the olecranon. Open reduction and internal fixation by two side-mounted angular locking compression (double) plates. POSTOPERATIVE MANAGEMENT: Early functional treatment. Full load-bearing after 6-12 weeks postoperatively. RESULTS: A total of 14 patients were treated with double-plate osteosynthesis between 2011 and 2012. Clinical data were analysed retrospectively. The average follow-up was 11.7 months (range, 4-21 months). The mean flexion-extension radius was 123° (100°-140°), the pro-supination radius 166° (160°-170°). Using the Mayo Elbow Performance Score, eight patients had excellent and six good results. The mean Quick-DASH score was 15 (0-50).

Surgical adhesive BioGlue™ does not benefit tendon repair strength: an ex vivo study.

UNLABELLED: Surgical adhesives are useful supplements in surgery, but their benefit in tendon repair is uncertain. The purpose of this study was to evaluate the effect of BioGlue™ on strength of flexor tendon repair. A total of 60 porcine flexor tendons were divided into three groups. In group one, a conventional core and peripheral suture repair was used. In group two, a core suture and BioGlue™ were used. In group three, a conventional core and peripheral suture repair and BioGlue™ were used. We performed static and cyclic axial load testing and measured diameter of the repair site. We found that BioGlue™ did not improve the tensile strength when added to a core and peripheral suture and that there was an increase in bulk at the repair site. We conclude that BioGlue™ application cannot replace a peripheral suture as tensile strength significantly decreases without a peripheral suture, and it does not benefit a tendon already repaired with a core and peripheral suture. LEVEL OF EVIDENCE: n/a.

Treatment of osteoarthritis of the first carpometacarpal joint by resection-suspension-interposition arthoplasty using the split abductor pollicis longus tendon.

OBJECTIVE: Reduction of pain and gain of functionality in symptomatic osteoarthritis of the first carpometacarpal joint. INDICATIONS: Idiopathic, rheumatic, or posttraumatic osteoarthritis of the first carpometacarpal joint. RELATIVE CONTRAINDICATIONS: Poor general condition, poor condition of the hand's soft tissue/skin, chronic regional pain syndrome, current or recent infections of the hand, heavy manual labor (decision on a by-case basis). SURGICAL TECHNIQUE: Supine position, hand pronated or slightly tilted. Upper arm tourniquet (Esmarch's method). Loupe magnification. Incision over the first extensor compartment. Exposure and incision of the thumb's basal joint. Resection of the trapezium. Exposure of the abductor pollicis longus (APL) tendon. Longitudinal split of the tendon harvesting the distally based ulnar part of the tendon. The split APL tendon is wrapped around the flexor carpi radialis (FCR) muscle tendon, suturing it to the tendon and back to itself. The rest of the split APL tendon is placed into the gap between the scaphoid and the first metacarpal bone, which is followed by wound closure. POSTOPERATIVE MANAGEMENT: Plaster cast (thumb abduction splint) for 4 weeks. Stable commercially available wrist brace for at least 2 more weeks. RESULTS: There were no significant differences between the FCR arthroplasty (Epping's method) and the APL arthroplasty (Wulle's technique) regarding pain (visual analog scale), disability/usability (DASH score), or range of motion. Patients who had undergone APL arthroplasty showed significantly better grip and pinch strength. Furthermore, the operating time was significantly shorter and scars were significantly smaller in APL arthroplasty.

[Artificial synostosis for traumatic metacarpal defect: a case report]. / Artifizielle Synostose zur Rekonstruktion bei traumatischem Metakarpaledefekt: Fallbericht.

Reconstruction of traumatic metacarpal defects is still challenging because of the key function of the architecture of the metacarpus for the function of the entire hand. Especially the exact restoration of the rotation for a parallel finger movement plays an important role. There are less information on this topic in the literature. We present a 28-year old patient with a traumatic almost complete defect of the fourth metacarpal. Reconstruction of the metacarpal arch was achieved with an artificial synostosis between the intact head of the 4th metacarpal and the 3rd metacarpal.

Reconstruction of the thumb tip using palmar neurovascular flaps.

OBJECTIVE: Reconstruction of the tip of the thumb using a neurovascular flap. INDICATIONS: Transverse defects of the thumb's tip or large defects of the palmar pulp (max. 2.0-2.5 cm) with exposure of bone and/or tendons. CONTRAINDICATIONS: Extensive crush injury, heavy wound contamination, circulatory disorders, acute infection, very large defects (> 2.0-2.5 cm finger length), circumferential soft tissue defects, and previous defects/operations (relative). SURGICAL TECHNIQUE: Supine position, hand supinated, tourniquet, loupe magnification. Mid-lateral incisions along both sides of the finger running from the defect to the interphalangeal joint (small defect) or proceeding further proximally. Careful elevation of the flap including both neurovascular bundles leaving dorsal branches of the bundles (long fingers only) and the flexor tendon sheath intact. Suture of the flap in either flexion position (i.e., advancement flap) (Moberg) or by creating an island-flap through an additional transverse skin incision along the flap's base (O'Brien). Finally, closure of the defect at the flap's base using a full thickness skin graft, Z plasty, or V-Y plasty. POSTOPERATIVE MANAGEMENT: Plaster cast (finger slightly flexed) for 2 weeks. RESULTS: Reliable method. Good functional results with good sensibility and only minor reduction in range of motion.

Detection of vascular endothelial growth factor (VEGF) in moderate osteoarthritis in a rabbit model.

INTRODUCTION: Vascular endothelial growth factor (VEGF) is detectable in later stages of human osteoarthritis (OA), but not in the healthy articular cartilage. Due to its capacity to increase matrix metalloproteinases and to decrease their inhibitors (tissue inhibitors of metalloproteinases or TIMPs) VEGF seems to play an important role in the development of osteoarthrosis. In late stages of osteoarthritis, invasion of blood vessels from the subchondral growth plate, synovitis with angiogenesis and osteophyte growth is observable. Several studies have revealed a central role for VEGF in all these phenomena. In order to investigate whether VEGF participates in early changes of OA or may even possess characteristics of a marker of OA, we developed an experimental posttraumatic OA New Zealand White rabbit animal model. MATERIALS AND METHODS: In four skeletally mature New Zealand White rabbits, OA was induced by joint instability after transsection of the anterior cruciate ligament in both knees. After eight weeks the animals were killed. OA was verified histologically using the Mankin scale. Expression of VEGF was detected by immunohistochemistry and RT-PCR. Proteoglycans were evaluated by using HE and safranin-O staining. Four non-surgically treated animals acted as a control. RESULTS: The mean Mankin score was 5.11 (±2.14), corresponding to a moderate OA. VEGF and VEGF transcripts were detectable in the cartilage of early experimental posttraumatic OA rabbits. Control samples remained negative for VEGF mRNA and protein. DISCUSSION: The results of this study are promising concerning the role of VEGF as a diagnostic marker. VEGF could further be participated in early changes of OA. A therapeutic approach by modulation of VEGF production could be a possibility for the future.

Tensile strength of flexor tendon repair using barbed suture material in a dynamic ex vivo model.

The purpose of this study was to compare two sutures; a knotted polydioxane with a knotless barbed in a 4-strand Kirchmayr-Kessler suture technique. Human flexor digitorum tendons were separated into four groups. Group 1 - polydioxane; Group 2 - barbed suture; Group 3 and 4 - same as group 1 and 2 with an additional peripheral running suture. In each group the repaired tendons were subjected to linear and cyclical loads. No difference in maximum tensile strength after linear and cyclical force could be detected between the knotted polydioxane suture and the knotless barbed suture. On linear force tests an additional circumferential repair increased the maximum tensile strength of both sutures. Cyclical force loading did not lead to a reduction of maximum strength. Following linear and cyclical loading the 4-strand barbed suture achieved maximum tensile strengths comparable to the 4-strand repair using the polydioxane suture. Barbed suture repair may offer the advantage of knotless suture techniques.

[Soft tissue reconstruction of the distal lower extremity using the 180-degree perforator-based propeller flap]. / Die 180º-Propellerlappenplastik zur Defektdeckung im Bereich des distalen Unterschenkels.

OBJECTIVE: Operative technique of propeller flap reconstruction of soft tissue defects in the distal lower extremity. Soft tissue reconstruction of the distal third of the lower extremity with local, reliable perforator flaps avoiding free tissue transfer. INDICATIONS: Complex wounds (maximum width of 6 cm) of the distal lower extremity with exposed bones, joints, tendons, and neurovascular structures. CONTRAINDICATIONS: Arterial vascular disease (stage III or IV), diabetes mellitus, postthrombotic syndrome, venous ulcers, chronic lymphedema, contusion of adjacent soft tissue, previous radiation, and lack of perforators SURGICAL TECHNIQUE: The perforator represents the pivot point around which rotation of up to 180º of the subfascially harvested flap allows closure of the defect. The proximal donor site can be closed primarily up to a width of 6 cm. POSTOPERATIVE MANAGEMENT: Strict elevation of the extremity for 5 days, then flap conditioning. RESULTS: This technique was used for soft tissue reconstruction in 17 patients. In one patient with diabetes, complete flap necrosis occurred, requiring amputation of the extremity. One case of epidermolysis healed without further surgery.

Experimental fracture model versus osteotomy model in metacarpal bone plate fixation.

Introduction. Osteotomy or fracture models can be used to evaluate mechanical properties of fixation techniques of the hand skeleton in vitro. Although many studies make use of osteotomy models, fracture models simulate the clinical situation more realistically. This study investigates monocortical and bicortical plate fixation on metacarpal bones considering both aforementioned models to decide which method is best suited to test fixation techniques. Methods. Porcine metacarpal bones (n = 40) were randomized into 4 groups. In groups I and II bones were fractured with a modified 3-point bending test. The intact bones represented a further control group to which the other groups after fixation were compared. In groups III and IV a standard osteotomy was carried out. Bones were fixated with plates monocortically (group I, III) and bicortically (group II, IV) and tested for failure. Results. Bones fractured at a mean maximum load of 482.8 N ± 104.8 N with a relative standard deviation (RSD) of 21.7%, mean stiffness was 122.3 ± 35 N/mm. In the fracture model, there was a significant difference (P = 0.01) for maximum load of monocortically and bicortically fixed bones in contrast to the osteotomy model (P = 0.9). Discussion. In the fracture model, because one can use the same bone for both measurements in the intact state and the bone-plate construct states, the impact of inter-individual differences is reduced. In contrast to the osteotomy model there are differences between monocortical and bicortical fixations in the fracture model. Thus simulation of the in vivo situation is better and seems to be suitable for the evaluation of mechanical properties of fixation techniques on metacarpals.

[Supination external rotation lesions of the ankle joint in osteoporotic lower leg specimens. Experimental induction and review of the literature]. / Die Supinations-Eversions-Verletzung des OSG in osteoporotischen Unterschenkelpräparaten. Experimentelle Induktion und Literaturübersicht.

BACKGROUND: Knowledge of the pathomechanism and the detailed extent of ankle joint lesions determines adequate therapy and success of treatment. MATERIAL AND METHODS: Supination external rotation lesions were induced in 29 human cadavera with a testing apparatus; 27 of these specimens were from elderly women. Bone mineral density was measured. The literature review includes experimental studies of this fracture entity. RESULTS: We induced stage II in 42%; applying an additional lateral force on the fibula raised the incidence. The syndesmosis stayed intact in 50% although the fibula fractured at the level of the tibial plafond. Stage IV lesions were registered in 25%. The overall low bone mineral density showed a positive correlation to the angle at which the fibula fracture occurred. CONCLUSIONS: We reproduced supination external rotation lesions according to Lauge-Hansen in osteoporotic ankles. There is a certain discrepancy between the obligatory lesion of the inferior anterior tibiofibular syndesmosis at stage II according to Lauge-Hansen, as we observed an intact syndesmosis in 50% at stage II. Stage IV defining medial malleolar fractures were reproduced after Lauge-Hansen and Michelson et al.

[Propeller flaps: the reliability of preoperative, unidirectional Doppler sonography]. / Propeller-Lappenplastiken: die Reliabilität der präoperativen, unidirektionalen Dopplersonografie.

BACKGROUND: Propeller flaps represent an elegant and reliable method for soft-tissue reconstruction of the extremities and trunk, obviating the need for free tissue transfer. Preoperative localisation of perforators adjacent to the defect is important regarding the pivot point and length of the flap. Most commonly unidirectional Doppler sonography is used. The reliability of this method regarding propellerflaps has not thoroughly been evaluated. The aim of this study is to assess the positive predictive value of this method for planning propeller flaps. PATIENTS AND METHOD: In a total of 68 patients, soft-tissue reconstruction using propeller flaps was planned with unidirectional Doppler sonography. Defects were located on the lower extremity in 48 cases, the buttock area in 15 cases and the trunk in 5 cases. RESULTS: In 12 cases no adequate perforators were located intraoperatively despite a positive Doppler signal. In the lower extremity Doppler produced a false-positive result in 21% of the cases, whereas in the buttock region only 13% false positives result were found. The positive predictive value overall was 82%. When no perforator was located, flap coverage was achieved using the reverse sural artery flap in 6 cases, the free peroneal artery perforator flap in 3 cases, local advancement flaps in 2 cases and skin grafting in 1 case. DISCUSSION: The reliability of unidirectional Doppler sonography is inadequate for localisation and selection of the dominant perforator when planning propeller flaps. A high rate of false-positive results needs to be anticipated especially distally in the extremities. In 18% of cases an alternative surgical plan was required to achieve soft tissue coverage. We recommend using colour duplex sonography for a more reliable preoperative localisation of perforators.

[Percutaneous screw osteosynthesis of femoral neck fractures in the elderly. Subtrochanteric fractures as severe complications]. / Schenkelhalsverschraubung beim alten Menschen. Die subtrochantäre Femurfraktur als schwerwiegende Komplikation.

Percutaneous osteosynthesis by cannulated screws is a well established method for the treatment of non-displaced femoral neck fractures, especially in elderly patients with comorbidities due to low operative invasiveness. Optimal screw placement is still under discussion. There are only few literature references concerning the complication of subtrochanteric femoral fractures. We performed a review of the literature and a retrospective analysis of our patients treated by this form of osteosythesis from 01.04.2004 to 30.09.2009 searching for screw placement and the incidence of subtrochanteric femoral fractures. This complication was found in 2 of our 35 patients (5.7%) without adequate trauma, such as a stumble or fall having occurred.