Observations concerning different patterns of bone healing using the Point Contact Fixator (PC-Fix) as a new technique for fracture fixation.

The recent trend in all surgical disciplines has been the development of techniques in minimally invasive surgery and the optimal maintenance of the blood supply to the bone fragments during osteosynthesis. Currently, the Point Contact Fixator (PC-Fix) has been introduced as a new implant for the stabilization of forearm bones. This plate-like splint and screw fixation system, which actually acts as an internal fixator, is characterized by minimized isolated contacts to the bone and proven angular stability of the monocortically locked screws. By using the PC-Fix, a further reduction of damage to the blood supply to the bone is achieved. Since 1994, 38 patients have been treated with this new device; we have reviewed the radiographs of 52 consolidated forearm fractures/osteotomies in accordance with the patterns of bone healing associated with the different methods of implant application according to the fracture type. In the groups in which traditionally precise reduction, interfragmentary compression and stable fixation was achieved (N=31), we found in 71% an absence of periosteal callus (direct bone healing). In the groups in which compression and adaptation were combined, or even main fragments adapted without compression, with wedges remaining unreduced in soft tissue connection (N=21), we found a visible external callus in 81% (indirect healing) (P = 0.002). Indirect healing after internal fixation is no longer regarded as a disturbance to healing, but is a goal in itself. The appearance of callus is a welcome sign indicating a prompt and positive reaction in the course of bone union which will lead to progressive fracture immobilization. When using the PC-Fix in a "biological way", callus formation and solid union take place earlier than in conventional plating. The new internal fixator offers substantial technical and mechanical advantages in fracture treatment. Therefore, it is an ideal implant to satisfy the requirements of modern biological osteosynthesis without compromising the restoration of axial alignment, rotation, length and postoperative functional treatment.

[Carbon frames. Positioning and reduction aids in tibial intramedullary nailing with unreamed technique]. / Karbonrahmen. Lagerungs- und Repositionshilfe bei der Unterschenkelmarknagelung in unaufgebohrter Technik.

Intramedullary stabilisation of long bones is an established treatment option since Küntscher. Especially for tibial nailing different methods were proposed in the past, were as the use of a fracture table was more or less the standard procedure. Since 4 years now we are nailing tibial fractures without fracture table. We are now using more and more a simple carbon fibre-frame, easily assembled by parts of the AO external fixator. So we can minimize the additional iatrogenic soft tissue damage during surgery and the logistic preoperative set-up in the operation theatre is shorter.

[Fractures of the proximal humerus]. / Die Frakturen des proximalen Humerus.

Proximal humeral fractures are common particularly in the elderly. The decision of the optimal treatment is dependent on many factors. On the one hand the biological age of the patient and the bone structure plays a key-role, on the other hand the living conditions and individual needs are of importance. Most fractures with minimal displacement respond satisfactorily to simple conservative treatment including short sling immobilisation and functional aftertreatment under supervision of the physiotherapist. Most recently there is a trend towards more aggressive surgical intervention with percutaneous insertion of cannulated screws also in the slightly displaced fracture situation. This protocol allows for earlier functional and less painful aftertreatment, less risk of displacement of the fracture fragments and better outcome. In severely unstable fractures with marked displacement of the fragments an operative stabilisation is advocated by most surgeons. Again there is a trend from plating towards cannulated screw fixation combined with tension absorbing (resorbable) sutures. In special cases which are described in detail a minimal invasive percutaneous screw technique with less stripping of bone and therefore preservation of the crucial blood supply of the humeral head is recommended. Instead of percutaneous pinning using K-wires only, cannulated screws are inserted today. Plating of proximal humerus joint fractures is the exception in our days, only the subcapital unstable fracture of the elderly would be an indication. LC-condylar plating seems to yield better stability than the conventional T-plate-system. In the most severe fractures of the proximal humerus (4-segment-fractures and dislocation fractures according to Neer, respectively C-2- and C-3-fractures according to the AO-classification) there is still controversy on the best management. Most authors prefer hemiarthroplasty in this situation whereas the other group of orthopaedic surgeons try open reduction and internal fixation particularly in the younger individuals. This stabilisation provides the orthopaedic surgeons with a formidable challenge and requires a lot of experience in this field. Also the understanding of the fracture morphology is needed for optimal results. In spite of good stabilisation techniques often partial or total humeral head necrosis occurs in the most severe fractures. Surprisingly enough results with reasonable function can be obtained even with partial avascular necrosis of the humeral head. A crucial part of the management is team work with the physiotherapist and an individual program for each fracture situation, depending on the stability of the fixation. Close contact between these two professions is of utmost importance. Finally it can be stated that the management of proximal humeral fractures is fairly standardised but it is always dependent on the experience and resources of the attending surgeon and must be tailored to the individual needs of the patient.

[First experiences with unreamed AO intramedullary nail in treatment of femoral shaft fractures]. / Erste Erfahrungen mit dem unaufgebohrten AO-Marknagel (UFN) in der Behandlung von Oberschenkelfrakturen.

The unreamed femoral nail (UFN) system, with its numerous proximal interlocking options, allows a minimal invasive surgical procedure for the treatment of nearly all femoral fracture patterns. Sixty-six fractures, 5 cases of osteolysis or pathologic fractures, 2 limb shortenings and 1 lengthening (monorail technique) and 3 cases of pseudarthrosis were stabilised with the UFN from July 1994 to December 1996. The fractures were analysed according to the AO classification. We found 31 polytrauma patients with an mean ISS of 21.8 and a mean PTS of 25.4. Most of the multiply injured patients (n = 26) were stabilised with the UFN primarily. Follow-up of 44 patients ranged from 4 to 18 months postoperatively. According to our clinical and radiological score the results were excellent in 34% of cases, good in 36.3%, poor in 20.4% and bad in 9%. Average fracture healing time was about 9.8 weeks.

[The UFN-system (unreamed femoral nail)--avoidable intra- and postoperative complications]. / Das UFN-System--Vermeidbare intra- und postoperative Komplikationen.

We give an account of the first Austrian clinical results of a prospective study dealing with fractures of the femoral shaft treated with the UFN-system, the intraoperative handling especially considering the intra- and postoperative complications. The UFN-system combines the advantages of numerous proximal interlocking options for the treatment of nearly all femoral fracture patterns with that of the unreamed nailing (biological osteosynthesis, primary stability with individual after-treatment, high patient's comfort and early mobilisation). Within two years (VII/94-VII/96) sixty closed and four second degree open fractures were stabilized with the unreamed femoral nail. In twelve cases we used the spiral blade interlocking technique. Five times we changed from external fixator to the UFN. The fractures were classified according to the AO-classification. In 64 implanted UFN there occurred twelve intraoperative and four postoperative complications. In five cases reoperation was necessary. Failings in the operative technique, numerous different experienced surgeons and a deficient after_treatment led to our pitfalls.

[UFN system. A method of minimal invasive surgical management of femoral shaft fractures]. / UFN-System. Eine Methode der minimalinvasiven chirurgischen Versorgung von Oberschenkelschaftfrakturen.

The aim of this study is to present our early clinical experience using the Unreamed AO Femoral Nail (UFN). The UFN system combines the advantages of numerous proximal interlocking options for the treatment of nearly all femoral fractures patterns with those of unreamed nailing (biological osteosynthesis, preservation of the cortical blood supply, closed mediate reduction, primary stability, high degree of patient comfort). Operation time and blood loss are reduced by eliminating the reaming procedure. The risk of infection is minimized by avoiding dead space. The positioning of the patient on the operating table without the use of traction allows for a minimally invasive surgical procedure. Our report deals with intraoperative handling, intra- and postoperative complications and the prospective clinical outcome in using the solid femoral nail system in Austria. Within nearly 2 years (August 1994-April 1996) 52 closed fractures and four second-degree open fractures were stabilized using the unreamed femoral nail. In 12 cases we used the spiral blade interlocking technique. Four times we changed from external fixation to the UFN. According to the AO classification, we found 8 fractures of the proximal femur (A 1/1: 1; A3/1: 2; A3/3: 5) and 48 diaphyseal fractures (A1:4; A2: 7; A3: 16; B1: 5; B2: 6; B3: 6; C1: 1; C2: 2; C3: 1). Thirty patients were followed up over an average period of 9.1 months postoperatively. The clinical and radiological results were excellent in 20 cases; average fracture healing time was about 10.6 weeks.

[Development of trauma surgery and the Graz trauma surgery university clinic]. / Zur Entwicklung der Unfallchirurgie und der unfallchirurgischen Universitätsklinik in Graz.

The relatively late achievement of independence of the traumatological Department from the Department of Surgery at the University of Graz is described, as well as the development of the operative trauma school in Graz/Austria for the management of injuries. Despite the lack of staff, space and equipment international accepted contributions in research, teaching and specialized treatment of trauma patients have been established.

Early detection of delayed union in lower leg fractures using a computerised analysis of mechanical vibration reactions of bone for assessing the state of fracture healing.

Standard X-ray techniques are used to follow up the healing process of bone fractures. However, these methods allow only indirect conclusions about the stability of the healing bone, depending on the experience of the clinician. In addition, by radiologic means, delayed union or non-union can only be diagnosed on the basis of the absence of specific changes such as callus formation. Therefore, efforts have been made to develop alternative methods for monitoring the healing process. The measuring principle of a non-invasive method is based on evaluation of changes in mechanical vibration reactions. The measuring system is composed of two sound transducers, an amplifier module and an AD converter attached to a PC. The assessment of 150 healthy individuals as well as an initial measuring series after treatment of tibial fractures with an external fixator system revealed highly significant differences between intact and fractured tibias. Thus, computerised sonometry is capable of supplying quantitatively recordable information about the stability of a fractured bone at any time in the healing process. Furthermore, this non-invasive technique allows early diagnosis of disorders in the repair process by the absence of change in the parameters.

[Computerized sonometry--use of a noninvasive procedure for evaluating stability after fractures]. / Computerisierte Sonometrie--die Anwendung eines nicht-invasiven Verfahrens zur Stabilitätsbeurteilung nach Frakturen.

Common techniques to assess the healing process of fractures are usually related to the experience of the clinician. However, standard x-rays allow only indirect conclusions on the stability of the healing bone. In addition to the radiological examination delayed union or non-union can only be diagnosed in the absence of specific changes such as callus formation. Computerised sonometry comprises the analysis of mechanical vibration as well as sound transmission during or after bone healing. This non-invasive method allows for assessing the stiffness of the bone quantitatively and gives objective data on bone stability.

Proximal humeral fractures. Management techniques and expected results.

During a ten-year period (1978-1988), 143 of 1386 patients with proximal humeral fractures were treated with internal osteosynthesis. Ninety-seven proximal humeral osteosynthesis cases had adequate documentation, and 77 (80%) were available for clinical review. The 97 fractures were graded by the AO/ASIF classification and included 44 Group A, 32 Group B, and 21 Group C fractures. Exercise-stable osteosynthesis using T-plate, cloverleaf plate, or small condylar plate was performed in 70% of patients. In the remaining patients, a less rigid fixation, with Kirschner wires or screws and cerclage wires, was used. Fifty-two percent of the patients had excellent and good results, 15% had fair results, and 33% had poor results. Most poor results occurred in patients with four-part fractures (61% of poor results). Of the cases involving four-part fractures, however, 22% had an excellent result after internal fixation. Displaced four-part fractures or fracture-dislocations should be treated by reconstruction of the proximal humerus, especially in young patients. The use of minimal fixation rather than rigid fixation is considered after careful assessment of the condition of the soft tissue and blood supply of the humeral head fragments. Primary treatment with endoprostheses is required when internal fixation is impractical in AO/ASIF fracture Types C 2/3 and C3 fractures. Improved clinical results may be achieved, particularly in the more severe fracture types, with increased experience in techniques of internal fixation of proximal humeral fractures.

[Conservative and semiconservative treatment of calcaneus fractures]. / Die konservative und semikonservative Behandlung der Kalkaneusfraktur.

The functional closed and percutaneous techniques for the treatment of fractures of the os calcis are described. We compare the different classifications, reduction techniques, advantages and disadvantages, as well as the results, after open reduction and internal fixation in an attempt to determine the special indications.

Fractures of the humerus.

Early active mobilization of sporting injuries is usually necessary for good functional results. Stable fixation, especially in severe joint fractures, should therefore be achieved. Indications according to the different fracture types using the AO-Classification and the fixation techniques, are described for proximal, shaft and distal humeral fractures.

Eighty-five talus fractures treated by ORIF with five to eight years of follow-up study of 69 patients.

Four types of talus fractures can be distinguished and the prognosis predicted on the basis of vascular patterns before and after injury. Early decompression of the soft tissues or anatomic reduction by closed or (if not possible) open methods is indicated. Stable fixation by lag screws and functional aftertreatment help to improve the prognosis. The late results with reference to necrosis, posttraumatic arthrosis, secondary arthrodesis, and functional outcome show that open reduction and internal fixation, applied early, can produce better functions than was heretofore thought possible. Special emphasis is placed on careful indications, operative techniques, and postoperative treatment--particularly the time of partial weight-bearing with a caliper brace.

[Etiology, pathophysiology and anatomical location of the compartment syndrome]. / Atiologie, Pathophysiologie und anatomische Lokalisationen des Kompartmentsyndroms.

Tissue pressure elevation may be caused by diminution of the compartment (operative closure of fascial defects, the presence of tight bandages or air-splints or by prolonged localized external pressure, as in unconscious patients), and/or by an increase in its contents (hemorrhage or the various conditions causing increased capillary permeability, e.g. postischemic swelling, fractures, surgical orthopedic procedures) or increased capillary pressure, e.g. after exercises. Additional elevation of an injured limb may cause a compartmental syndrome by lowering capillary pressure, especially in shock patients.