Incidence, characteristics, and long-term follow-up of sternoclavicular injuries: An epidemiologic analysis of 92 cases.

BACKGROUND: The majority of published studies concerning sternoclavicular injuries are case series or systematic reviews. Prospective studies on the subject are hindered by the low incidence of these lesions. The aims of the present study were to provide an overview of this rare entity compared with those described in the literature and to present the long-term clinical outcome. METHODS: We performed a retrospective data analysis of all sternoclavicular injuries treated at a single Level I trauma center from 1992 to 2011. Long-term clinical outcome was assessed using the ASES [American Shoulder and Elbow Surgeons], SST [Simple Shoulder Test], UCLA [University of California-Los Angeles] Shoulder Scale, and VAS [Visual Analog Scale] at latest follow-up. RESULTS: We detected an overall incidence of 0.9% of sternoclavicular injuries related to all shoulder-girdle lesions. Ninety-two patients (52 males and 40 females) with a mean (SD) age of 39.2 (19.5) years (median, 41 years; range, 4-92 years) were included in this study. The main trauma mechanism was fall. Classification was performed according to Allman, the time point of treatment after initial trauma, and the direction of the dislocation. Nine patients of the 15 Grade III lesions were treated conservatively by closed reduction and immobilization, while four patients were treated surgically by open reduction and internal fixation. Forty-nine percent of the patients were available for long-term follow-up at a median of 11.3 years (range, 5.3-22.6 years) with a mean ASES score of 96.21, SST score of 11.69, UCLA score of 31.89, and VAS score of 0.47. CONCLUSION: We found an overall incidence of 0.9% of sternoclavicular joint injuries related to all shoulder-girdle lesions and of 1.1% related to all dislocations, which is slightly lower compared with those described in the literature. Furthermore, we observed a high number of physeal sternoclavicular injuries with a percentage of 16% and overall good-to-excellent results at long-term follow-up. LEVEL OF EVIDENCE: Epidemiologic study, level IV.

Surgery for pathological proximal femoral fractures, excluding femoral head and neck fractures: resection vs. stabilisation.

Pathological femoral head and neck fractures are commonly treated by arthroplasty. Treatment options for the trochanteric region or below are not clearly defined. The purpose of this retrospective, comparative, double-centre study was to analyse survival and influences on outcome according to the surgical technique used to treat pathological proximal femoral fractures, excluding fractures of the femoral head and neck. Fifty-nine patients with 64 fractures were operated up on between 1998 and 2004 in two tertiary referral centres and divided into two groups. One group (S, n = 33) consisted of patients who underwent intramedullary nailing alone, and the other group (R, n = 31) consisted of patients treated by metastatic tissue resection and reconstruction by means of different implants. Median survival was 12.6 months with no difference between groups. Surgical complications were higher in the R group (n = 7) vs. the S group (n = 3), with no statistically significant difference. Patients with surgery-related complications had a higher survival rate (p = 0.049), as did patients with mechanical implant failure (p = 0.01). Survival scoring systems did not correlate with actual survival. Resection of metastases in patients with pathological fractures of the proximal femur, excluding femoral head and neck fractures, has no influence on survival. Patients with long postoperative survival prognosis are at risk of implant-related complications.

Surgical treatment of metastatic fractures of the femur: a retrospective analysis of 142 patients.

BACKGROUND: Pathologic fractures of long bones are common complications of the metastatic disease; however, the influence of the primary tumor, the stage of metastatic disease, different surgical techniques, and the postoperative mobility on the postoperative survival has not been clearly defined. The aim of this retrospective study was to evaluate outcome after surgical treatment for pathologic femur fractures. PATIENTS AND METHODS: A consecutive series of 142 patients with metastatic fractures of femur were retrospectively studied. The operative treatment was based on intramedullary fixation (n = 94), gliding screws (n = 15), other extramedullary fixation devices (n = 7), and arthroplasty (n = 23). RESULTS: Seventeen percent and 6% of the patients survived 1 year and 2 years, respectively, postoperatively. Postoperative survival was higher in patients with pathologic femur fractures because of breast carcinoma than in patients with other primary tumors. The rate of complications for patients with intramedullary stabilization, gliding screw fixation, and endoprosthetic replacement was 3.2%, 20%, and 8.6%, respectively. CONCLUSION: Although many studies describe the endoprosthetic replacement as the safer method to treat pathologic femur fractures, our data showed that intramedullary stabilization and endoprosthetic replacement to be safe, and equivalent alternatives to treat complete pathologic fractures of the femur in patients with advanced metastatic disease.

Angular stable fixation of proximal humeral fractures.

BACKGROUND: Proximal humeral fractures requiring surgical stabilization remain a therapeutic challenge. High rates of treatment-related complications have been reported to be associated, particularly in elderly patients with unstable fracture types and diminished bone quality. In recent years, angular stable implants have been introduced to improve the patients' outcome. The purpose of this study was to assess the clinical and radiographic long-term results after angular stable plate fixation of proximal humeral fractures at this Level I trauma center, with special emphasis on fracture healing, functional outcome and treatment related complications. METHODS: We retrospectively analyzed functional and radiographic results of 42 patients (average age: 57.8 years) after angular stable plate fixation of proximal humeral fractures at an average time of 3.2 (+/-0.8) years after trauma. Functional results were defined by the Constant shoulder score (CS) and the individual Constant score (CSindiv). Radiographic results were assessed by a three-view trauma series (anteroposterior, lateral, and axillary view). For operative treatment, two different angular stable implants were used. Twenty-seven patients were stabilized by a HOFER plate, fifteen patients by a Locking Proximal Humerus Plate. RESULTS: Clinical results revealed an average CS of 74.0 points and an average individual CSindiv of 79.2% points. Fourteen patients had an excellent functional outcome, eight patients a good outcome and fourteen patients had moderate functional results. Six patients (14%) had a poor outcome with less than 55% on CSindiv. Regarding the radiographic outcome, we had an overall union rate of 95% (40 of 42). Failures of reduction and fixation occurred in fourteen patients (33%), and in nine patients (21%) we had signs of a humeral head necrosis. Re-operation due to treatment-related complications was necessary in two patients (5%). Statistical analysis revealed that the fracture type and the age of the patients had a significant influence on the clinical outcome and on the incidence of treatment-related complications. CONCLUSION: With regards to fracture healing and functional outcome of the patients, we had a satisfactory outcome after angular stable plate fixation of proximal humeral fractures. However, we experienced a notably high rate of technical failures and partial humeral head necrosis. Advanced surgical skills and experiences are necessary to achieve correct anatomic reduction and implant fixation, to reduce the risk of these treatment-related complications.

Antibody responses to pneumococcal and hemophilus vaccinations in splenectomized patients with hematological malignancies or trauma.

In this study we addressed the question of whether an underlying hematological malignancy may affect the immune response to vaccination against bacterial polysaccharide antigens (e.g. Haemophilus influenzae type b, Streptococcus pneumoniae) in splenectomized patients. Between 1993 and 2003, 44 splenectomized adults from the outpatient clinic for infectious diseases were prospectively included in the study: 23 patients suffered from hematological malignancies (HM) and had undergone splenectomy; 21 were splenectomized following trauma (T) and served as the control group. Each patient received an intradeltoid injection with 0.5 ml of a single lot of a 23-valent pneumococcal polysaccharide vaccine, and 0.5 ml of a polyribosyl ribitol phosphate capsular polysaccharide vaccine of H. influenzae type b (Hib) into the opposite arm. Blood samples for determination of pneumococcal and Hib antibodies were taken prior to vaccination and again 6-8 weeks later. In assessing responses to the 23-valent pneumococcal polysaccharide vaccine, we found significant differences in antibody titer increase between the HM and T groups (median IgG increase 1.27 [0.7; 2.39] vs. 3.9 [2.1; 15.3], P < 0.001; and median IgM increase 1.33 [1.0;2.67] vs. 5.25 [2.3; 7.78], P < 0.001). In the HM group, only 8/23 and 6/23 showed a titer increase of twice or more the base value for IgG and IgM respectively, whereas in the trauma group an adequate response was shown by 16/21 and 16/20 respectively. Patients with splenectomy and hematological malignancies responded poorly to the 23-valent polysaccharide vaccine. Response to the conjugated Hib vaccine was slightly better, but still significantly lower than in individuals with posttraumatic splenectomy. Data suggest that vaccination response to the polysaccharide vaccines should be evaluated at least in the high-risk group.

[Psychopathologic deficits after polytrauma in childhood and adolescence]. / Psychopathologische Defizite nach Polytrauma im Kindes- und Jugendalter.

PURPOSE: The aim of this report was to evaluate psychological deficits following polytrauma in childhood and adolescence as well as to detect psychological vulnerable phases during the treatment period. METHODS: From 9/92 to 12/98, 41 polytrauma patients (18a or younger) were treated at the University of Vienna Medical School, Trauma Center. Out of the 28 survivors, patients with head injuries and congenital neurological deficits were excluded, leaving 10 young patients that were eligible for psychological testing after a mean follow-up of 3.4 years (range, 1 to 7 years). Besides catamnesis and diagnostic interviews, an evaluation of cognitive functions as well as personality tests were performed. RESULTS: The diagnostic interviews revealed mild psychiatric symptoms in 2/10 patients, but the cognitive functions did not show any deficits compared to normal values. The personality tests presented stress-avoiding strategies and an increased anxiety sensitivity in 2/10 patients. The catamnesis constantly revealed 2 vulnerable phases in all patients: 1. the transfer from the intensive care unit to the normal ward, 2. the retransfer to the domestic field after a long hospital stay. CONCLUSIONS: The present report suggests that the long-term psychological outcome following polytrauma in childhood and adolescence may be good, without any major disorders. The described critical phases during treatment demonstrate that psychological support in the young, severely injured patient should start very early on at the intensive care unit.

[Stabilization of proximal humeral fractures with the intramedullary dynamic titanium helix wire]. / Die Stabilisierung von proximalen Humerusfrakturen mit der intramedullären Titanwendel Helix-Wire.

The implant Helix-Wire is a treatment device that is used since 1997. It provides minimally invasive stabilization of subcapital humeral fractures. The implant is inserted through a small lateral entrance and a cortical hole drilled into the intramedullary space of the proximal humeral shaft and drilled into the humeral head for fracture stabilization. After careful preoperative planning and successful repositioning of the fracture the technique can be performed without difficulty. A review of 35 patients with subcapital humeral fractures, who were operated using the titanium wire helix between 1998 and 2000, was carried out. Clinical and radiological results were documented. After an average time of 11.5 months 13 patients were examined according to the Constant Score: 5 good or excellent, 4 fair and 4 bad results were achieved. We conclude that this implant provides sufficient stabilization of subcapital humeral fractures classified as AO 11 A2, 11 A3.1, 11A3.2, 11B1.1, 11B1.2. It does not offer an advantage for the treatment of unstable fractures with multiple fragments or cancellous bone deficiency (11 A3.3, 11 B2.2, 11 B2.3).