A. Prokop

Malunion of the clavicle causes significant glenoid malposition: a quantitative anatomic investigation

ObjectiveAn experimental cadaver model was used to assess the effects of a malunited fracture of the middle third of the clavicle on the functional anatomy of the shoulder joint.MethodAnatomic samples were prepared with simulated shortening and axial malposition of the clavicle. From these, alterations in glenoid fossa position were measured and depicted graphically.ResultsHealing of clavicle fractures with bony shortening leads to a ventromedialcaudal shift in glenoid fossa position. The following malpositions of the clavicle lead to the respective glenoid fossa positional changes: caudal deviation leads to a mediocaudal shift, cranial deviation leads to a dorsolateral shift of the glenoid fossa, ventral deviation causes a ventrolateral shift, dorsal deviation leads to mediocaudal shift of the fossa, cranial rotation leads to ventrolateral shift in fossa position, and caudal rotation leads to a dorsomedial shift in glenoid fossa position.ConclusionClinical implication of these data is that bony shortening in combination with caudal displacement leads to distinct functional deficits in abduction, particularly overhead motion. Using the above data, a vector model was created to calculate position of the glenoid fossa dependent on clavicle position/malposition. The model is a valuable tool to be used for planning open reduction and fixation of clavicular fractures or malunions.

Soft tissue reactions of different biodegradable polylactide implants.

Soft tissue reactions resulting from biodegradable polylactide implants to bone have not been adequately examined during their 3-year degradation period. An osteotomy was performed on the medial femoral condyle of 36 sheep and secured by either three poly-L-DL-lactide pins (70/30) (Polypin) or three composite pins [10% beta-tricalcium phosphate (beta-TCP) (90/10)]. A histological examination was performed on the synovial membrane and lymph nodes after 3, 18 and 36 months. After 18 months two non-specific, minor reactions of the synovial membrane were observed in the composite pin group. In both groups different reactions of both inguinal lymph nodes were observed. These had no statistical relevance and could not be clearly attributed to the implants. Due to the slow degradation process of biodegradable polylactide implants, there is no clinically relevant inflammation of either joint or lymph nodes. The addition of 10% beta-TCP did not result in any significant enhancement.

[Reconstruction of shoulder-girdle symmetry after midclavicular fractures. Stable, elastic intramedullary pinning versus rucksack bandage].

ZusammenfassungDas Ziel dieser Untersuchung war der Vergleich der mittelfristigen Behandlungsergebnisse von 2 verschiedenen Behandlungsstrategien bei Klavikulafrakturen des mittleren Drittels. In Gruppe 1 wurden alle Patienten konservativ mit einem Rucksackverband behandelt. In Gruppe 2 wurde die Klavikulafraktur minimal invasiv mit einem ungebohrten elastischen Titannagel intramedullär geschient. Es konnten signifikant bessere Ergebnisse in der Gruppe der operierten Patienten hinsichtlich des Constant-Score, der Schulterfunktion und des kosmetischen Ergebnisses festgestellt werden. Die mittlere Verkürzung der Klavikula war in der konservativen Gruppe signifikant höher als in der operierten Gruppe. Der Wert des absoluten Constant-Score war in der Gruppe 1 signifikant niedriger als in Gruppe 2. Es konnte ein signifikanter Unterschied festgestellt werden zwischen Patienten, die eine Verkürzung der Klavikula von weniger als 1 cm aufwiesen, und Patienten mit einer Verkürzung von 1 cm oder mehr. In Gruppe 1 wurden 2 Pseudarthrosen beobachtet, während in Gruppe 2 alle Frakturen verheilt waren. Refrakturen wurden in beiden Gruppen nicht beobachtet. Die bisherigen Ergebnisse der elastisch stabilen intramedullären Osteosynthese bei Klavikulafrakturen des mittleren Drittels zeigen, dass dieses Verfahren sicher ist und funktionell sowie kosmetisch mittelfristig zu besseren Resultaten als die Behandlung im Rucksackverband führt.AbstractThe aim of this study was to compare the results achieved in two groups of 20 patients treated for midclavicular fracture. The first group (mean age 36 years) was treated non-operatively with a rucksack bandage, whereas the second group (mean age 37 years) underwent intramedullary fixation with a titanium pin using a minimally invasive, unreamed technique. At follow-up, which averaged 3.1±0.9 years in group 1 and 2.9±0.7 years in group 2, the result of treatment, as indicated by the Constant score, functional outcome and cosmetic outcome, was significantly better in the group undergoing operative treatment. Clavicle shortening was significantly (P=0.027) higher in patients treated with a rucksack bandage. The absolute Constant score averaged 78±23 in group 1 and 97±4 in group 2 (P=0.001). The Constant rating scale showed a significant difference between patients with clavicle shortening of less than 1 cm and 1 cm shortening or more. There were two non-unions in group 1 but none in group 2. Refractures were not observed in either group. According to these results, intramedullary fixation with a titanium pin seems to be more advantageous in midclavicular fractures than non-operative treatment. As the operation is well received by the patients, it should be offered to them as an alternative treatment to the rucksack bandage.

Wiederherstellung der Symmetrie des Schultergürtels bei Klavikulafrakturen

ZusammenfassungDas Ziel dieser Untersuchung war der Vergleich der mittelfristigen Behandlungsergebnisse von 2 verschiedenen Behandlungsstrategien bei Klavikulafrakturen des mittleren Drittels. In Gruppe 1 wurden alle Patienten konservativ mit einem Rucksackverband behandelt. In Gruppe 2 wurde die Klavikulafraktur minimal invasiv mit einem ungebohrten elastischen Titannagel intramedullär geschient. Es konnten signifikant bessere Ergebnisse in der Gruppe der operierten Patienten hinsichtlich des Constant-Score, der Schulterfunktion und des kosmetischen Ergebnisses festgestellt werden. Die mittlere Verkürzung der Klavikula war in der konservativen Gruppe signifikant höher als in der operierten Gruppe. Der Wert des absoluten Constant-Score war in der Gruppe 1 signifikant niedriger als in Gruppe 2. Es konnte ein signifikanter Unterschied festgestellt werden zwischen Patienten, die eine Verkürzung der Klavikula von weniger als 1 cm aufwiesen, und Patienten mit einer Verkürzung von 1 cm oder mehr. In Gruppe 1 wurden 2 Pseudarthrosen beobachtet, während in Gruppe 2 alle Frakturen verheilt waren. Refrakturen wurden in beiden Gruppen nicht beobachtet. Die bisherigen Ergebnisse der elastisch stabilen intramedullären Osteosynthese bei Klavikulafrakturen des mittleren Drittels zeigen, dass dieses Verfahren sicher ist und funktionell sowie kosmetisch mittelfristig zu besseren Resultaten als die Behandlung im Rucksackverband führt.AbstractThe aim of this study was to compare the results achieved in two groups of 20 patients treated for midclavicular fracture. The first group (mean age 36 years) was treated non-operatively with a rucksack bandage, whereas the second group (mean age 37 years) underwent intramedullary fixation with a titanium pin using a minimally invasive, unreamed technique. At follow-up, which averaged 3.1±0.9 years in group 1 and 2.9±0.7 years in group 2, the result of treatment, as indicated by the Constant score, functional outcome and cosmetic outcome, was significantly better in the group undergoing operative treatment. Clavicle shortening was significantly (P=0.027) higher in patients treated with a rucksack bandage. The absolute Constant score averaged 78±23 in group 1 and 97±4 in group 2 (P=0.001). The Constant rating scale showed a significant difference between patients with clavicle shortening of less than 1 cm and 1 cm shortening or more. There were two non-unions in group 1 but none in group 2. Refractures were not observed in either group. According to these results, intramedullary fixation with a titanium pin seems to be more advantageous in midclavicular fractures than non-operative treatment. As the operation is well received by the patients, it should be offered to them as an alternative treatment to the rucksack bandage.

Biodegradable implants for pipkin fractures

The current study was designed to clarify whether biodegradable poly-L/DL lactide pins provide an operative alternative for fixation of Pipkin fractures. Nine patients with Pipkin fractures (one with Pipkin Type I, one with Pipkin Type II, and seven with Pipkin Type IV fractures) were treated surgically between 1996 and 2002. In all patients, the femoral head fractures were fixed with biodegradable, 2.7-mm and 2.0-mm polylactide pins. Eight patients were followed up for an average of 54.2 months. One patient died before the final followup. Eight fractures healed uneventfully. In one patient, a persisting femoral head defect led to posttraumatic arthritis requiring insertion of a femoral endoprosthesis at 1 year. The average range of motion of the affected hips of all patients at followup was 109°-0°-0° in flexion and extension. External and internal rotation averaged 37°-0°-29°. One patient had Brooker Grade I heterotopic ossification develop, and another had a Grade II heterotopic develop. Merle d’Aubigné and Postel ratings showed two excellent and five satisfactory results (average score, 13.1). Adverse effects from the polylactide implants were not observed. Pipkin fractures can be fixed successfully with biodegradable polylactide pins.

Are there concepts in treatment of metacarpale fractures? Own results and a review of the literature of last 12 years

SummaryAs the treatment of metacarpal fractures is today still a controversial subject, we conducted an analysis of the literature in order to present the different therapy guidelines, indications, and their results. The data from the follow-up of 1602 patients was taken from literature which dated from 1 January 1984 to 31 March 1996. A total of 522 patients who underwent surgery received K-wires, screws or external minifixateur. The conservative approaches ranged from immobilization to various methods of mobilization with different aids or without fixation of the fracture. The mobilization in a brace provided good to excellent results in 95 % of the cases; however, the failure rate of therapy was 23 % because of local bruises and skin necrosis (3 %). The mobilization with handcast, tape etc. attained good to excellent results in 94 % of the cases. Here, no complications occurred. Both the immobilization treatment and the surgery provided good to excellent results in 85 % of the cases. The reposition of fractures of the fifth metacarpal was successful in only 15 % of the cases. Fractures with dislocations below 30 °, a shortening of less than 5 mm, no rotational displacement or that below 10 °, no articular incongruency, and no relevant soft tissue trauma do not need surgery according to our results and should be treated with early mobilization as suggested by the survey. Beyond these limits a primary surgical therapy is justified. The immobilization of metacarpal fractures over a period of more than 3–4 weeks is not necessary.ZusammenfassungDa auch heutzutage die Behandlung der Mittelhandbrüche kontrovers diskutiert wird, wurde eine Literaturanalyse durchgeführt, um die unterschiedlichen Therapien, Indikationen und deren Ergebnisse aufzuzeigen. Aus der Literatur vom 1. 1. 1984–31. 03. 1996 wurden Daten von 1602 nachuntersuchten Patienten verglichen; 522 operativ versorgte Patienten wurden mit Kirschner (K)-Drähten, Schrauben, Plättchen, Cerclage oder Minifixateur externe behandelt. Die konservativen Ansätze reichen von der Immobilisation bis hin zu unterschiedlichsten frühfunktionellen Methoden mit verschiedensten Hilfsmitteln oder gar ohne jede Fixation des Bruches. Die frühfunktionelle Therapie mit einem Brace kam bei 95 % zu sehr guten und guten Ergebnissen, hatte aber eine Therapieabbruchrate von bis zu 23 % aufgrund von lokalen Druckstellen und Hautnekrosen (3 %). Die teilweise Ruhigstellung mit unterstützendem Handcast, Tape etc. kam bei 94 % zu sehr guten und guten Ergebnissen. Hierbei traten keine Komplikationen auf. Jeweils 85 % sehr gute und gute Resultate erzielten die operativen Verfahren und die Immobilisationsbehandlung. Die Reposition von Mittelhandknochen (MHK)-V-Frakturen hatte nur bei 15 % der Patienten Erfolg. Metarkapalefrakturen mit Dislokationen unter 30 °, einer Verkürzung von weniger als 5 mm, einer Rotationsfehlstellung unter 10 °, keiner Gelenkstufe und ohne relevantes Weichteiltrauma benötigen nach unseren Ergebnissen keine Operation und sollten auch nach den Ergebnissen der Literaturrecherche frühfunktionell behandelt werden. Bei Überschreitung dieser Grenzen ist eine primäre operative Therapie gerechtfertigt. Die Immobilisation von Mittelhandfrakturen über mehr als 3–4 Wochen ist nicht sinnvoll.

Experience with elastic stable intramedullary nailing (ESIN) of shaft fractures in children

The aim of this prospective clinical controlled trial was to investigate the early and midterm results of shaft fractures in children treated with elastic stable intramedullary nailing (ESIN). From January 1997 to December 2001, elastic stable intramedullary nailing was carried out on 112 children with 118 diaphyseal fractures. The mean age was 7.7 years. There were 51 fractures of the lower arm, 46 femoral fractures, 14 of the lower leg, and 7 of the humerus. A total of 92 children have been followed up for more than 12 months. The mean time of follow-up was 38 months.The mean time of fluoroscopy was 2.2 min. Open reduction was necessary in 3.4 %. In children with injuries of the lower extremity, full weight bearing was achieved after a mean period of 9.3 days. In 1.8% of the children, reoperation was necessary within the first 10 days after the operation. In 3.6 % there was painful skin irritation due to the protruding end of a nail. No infection or delayed union was observed. Implant removal was done after a mean time of 5.6 months. There was no rotational or angular deformity of more than 5 degrees in children with isolated fractures of the lower extremity. Mean lengthening of the injured leg was 2.4 mm. In three children who had fractures of the upper extremity, a deficit in range of motion of the adjacent joints was detected. The current results show that intramedullary fixation of displaced diaphyseal fractures in children with a flexible titanium nail is a safe, minimally invasive surgical technique producing excellent functional and cosmetic results.

Functional Outcome Following Fixed-Angle Volar Plating or Intrafocal K-Wire Fixation for Extraarticular Fractures of the Distal Part of the Radius A Retrospective Analysis of Treatment Outcomes

Purpose:The objective of this retrospective study was to compare the results of two operative techniques used for the treatment of distal radius fractures classified as AO type A3.Patients and Methods:Patients were treated with either fixed-angle volar plates or intrafocal Kirschner wires (K-wires) using a Kapandji-like technique. The functional results were determined with the Gartland & Werley Score as well as the DASH Score after an average follow-up of 28 months.Results:55 patients were included in the study. Of these, 33 were female and 22 male, with an average age of 59 years. In patients < 60 years, the Gartland Score was 1.4 points in the fixed-angle volar plate group, and 4.6 points in the Kapandji group. In patients ≥ 60 years, no significant difference between the therapy groups could be ascertained. The DASH Score measured 17 points in each group. In all cases, a satisfactory reduction was obtained. The Kapandji group experienced significantly more loss of reduction position at follow-up in terms of volar tilt and radioulnar inclination than the fixed-angle volar plate group.Conclusion:These results show that intrafocal K-wire fixation in older patients is a suitable method to attain and hold sufficient bony reduction. However, younger patients achieve better radiologic and functional results when treated with open reduction using the 3.5-mm LCP fixed-angle volar plate.

[New biodegradable polylactide implants (Polypin-C) in therapy for radial head fractures].

ZusammenfassungBei dislozierter Radiuskopffraktur Typ Mason II können an dem nur gering auf Scherung belasteten Radiuskopf biodegradable Implantate erfolgreich angewendet werden. Sie lösen sich nach der Frakturheilung vollständig auf, sodass ein Folgeeingriff zur Metallentfernung entfällt. Einem Poly-L/DL-Lactid-Stift wurde 10% β-Tricalciumphosphat beigesetzt, um eine kontrollierte langsame und nebenwirkungsarme Degradation zu erreichen. Dieser Polypin®-C-Stift wurde prospektiv bei 35 Patienten mit Radiuskopffrakturen eingesetzt. Nach durchschnittlich 38,2 Monaten wurden 34 der 35 Patienten klinisch und konventionell radiologisch nachuntersucht. In 29 Fällen konnte zusätzlich ein CT angefertigt werden. Zweimal wurden zwischen dem 18. und 24. Monat asymptomatische Osteolysen 1. Grades um die Stiftköpfe beobachtet, die sich im weiteren Verlauf vollständig zurückbildet hatten. Nach dem Broberg-Score konnten bei der Abschlussuntersuchung im Mittel 96 von 100 möglichen Punkten erreicht werden. Ab dem 24. Monat waren die Stifte im konventionellen Röntgenbild nicht mehr sichtbar. Im CT waren in den ehemaligen Stiftkanälen nach 3 Jahren ähnliche Dichtewerte wie bei spongiösem Knochen messbar. Bei den guten klinischen Ergebnissen eignen sich Polypin®-C-Stifte zur Behandlung dislozierter Radiuskopffrakturen.AbstractDislocated radial head fractures of the type Mason II are usually treated with screws and buttress plates. The implants are generally removed at a later date. Biodegradable implants can be applied successfully for the reduction of small radial head fractures subject to shearing forces and slight loads. The implants are completely absorbed once the fracture has healed, making a second operation for the removal of the implant unnecessary. The Polypin C-Pin is made of poly(L, DL-lactide) mixed with 10% β-tricalcium phosphate to ensure controlled, slow degradation with no significant side effects. This new Polypin C fixation pin was clinically tested on 35 patients with radial head fractures (CCF 21B2.1 and 21B2.2) from 31.10.1996 until 1.4.2002. A total of 34 of the patients (97.1%) underwent a clinical and conventional radiological follow-up examination after an average of 38.2 months. In 29 cases a CT was also carried out. Between 18 and 24 months, two cases of grade 1 osteolysis were observed around the pin head. No trace of osteolysis was observed at the final examination in either case. According to the Broberg score, an average of 96 out of a possible 100 points were attained at the final examination (31 excellent, 2 good, 1 unsatisfactory). After a period of 24 months, the pins were no longer visible on a conventional x-ray. A CT evaluation showed a density similar to that of spongioid bone in the original pin cavities after 3 years. These excellent clinical results prove that the Polypin C is a good method to treat dislocated radial head fractures.

Neue biodegradable Polylactid-implantate (Polypin®-C) zur Therapie von Radiuskopffrakturen

ZusammenfassungBei dislozierter Radiuskopffraktur Typ Mason II können an dem nur gering auf Scherung belasteten Radiuskopf biodegradable Implantate erfolgreich angewendet werden. Sie lösen sich nach der Frakturheilung vollständig auf, sodass ein Folgeeingriff zur Metallentfernung entfällt. Einem Poly-L/DL-Lactid-Stift wurde 10% β-Tricalciumphosphat beigesetzt, um eine kontrollierte langsame und nebenwirkungsarme Degradation zu erreichen. Dieser Polypin®-C-Stift wurde prospektiv bei 35 Patienten mit Radiuskopffrakturen eingesetzt. Nach durchschnittlich 38,2 Monaten wurden 34 der 35 Patienten klinisch und konventionell radiologisch nachuntersucht. In 29 Fällen konnte zusätzlich ein CT angefertigt werden. Zweimal wurden zwischen dem 18. und 24. Monat asymptomatische Osteolysen 1. Grades um die Stiftköpfe beobachtet, die sich im weiteren Verlauf vollständig zurückbildet hatten. Nach dem Broberg-Score konnten bei der Abschlussuntersuchung im Mittel 96 von 100 möglichen Punkten erreicht werden. Ab dem 24. Monat waren die Stifte im konventionellen Röntgenbild nicht mehr sichtbar. Im CT waren in den ehemaligen Stiftkanälen nach 3 Jahren ähnliche Dichtewerte wie bei spongiösem Knochen messbar. Bei den guten klinischen Ergebnissen eignen sich Polypin®-C-Stifte zur Behandlung dislozierter Radiuskopffrakturen.AbstractDislocated radial head fractures of the type Mason II are usually treated with screws and buttress plates. The implants are generally removed at a later date. Biodegradable implants can be applied successfully for the reduction of small radial head fractures subject to shearing forces and slight loads. The implants are completely absorbed once the fracture has healed, making a second operation for the removal of the implant unnecessary. The Polypin C-Pin is made of poly(L, DL-lactide) mixed with 10% β-tricalcium phosphate to ensure controlled, slow degradation with no significant side effects. This new Polypin C fixation pin was clinically tested on 35 patients with radial head fractures (CCF 21B2.1 and 21B2.2) from 31.10.1996 until 1.4.2002. A total of 34 of the patients (97.1%) underwent a clinical and conventional radiological follow-up examination after an average of 38.2 months. In 29 cases a CT was also carried out. Between 18 and 24 months, two cases of grade 1 osteolysis were observed around the pin head. No trace of osteolysis was observed at the final examination in either case. According to the Broberg score, an average of 96 out of a possible 100 points were attained at the final examination (31 excellent, 2 good, 1 unsatisfactory). After a period of 24 months, the pins were no longer visible on a conventional x-ray. A CT evaluation showed a density similar to that of spongioid bone in the original pin cavities after 3 years. These excellent clinical results prove that the Polypin C is a good method to treat dislocated radial head fractures.