Alexander Brunner

Sports and Recreation Activity of Patients with Femoroacetabular Impingement before and after Arthroscopic Osteoplasty

Background Hip arthroscopy represents a new and minimally invasive method of treating patients with femoroacetabular impingement (FAI). However, participation in popular sports after this procedure has not yet been analyzed. Hypotheses Arthroscopic treatment of FAI increases the level of popular sports activities, and this level of activity correlates with the clinical outcome in terms of pain and function. Study Design Case series; Level of evidence, 4. Methods Fifty-three patients (41 male, 12 female) were evaluated preoperatively and after a mean follow-up of 2.4 years (range, 2-3.2 years) after arthroscopic osteoplasty for cam and mixed FAI. Evaluation included the type and level of sports activities (sports frequency score [SFS]) as well as clinical outcome in terms of pain (VAS) and function (nonarthritic hip score [NAHS]). Results Forty-five of the 53 patients had regularly participated in popular sports until the first occurrence of FAI symptoms. Preoperatively, only 4 of these 45 patients had maintained their accustomed level of activity. At the final follow-up, 31 patients had returned to their full accustomed level of activity. None of the patients who had not been active in sports before the first occurrence of symptoms of FAI (n = 8) had begun participation in sports after arthroscopic osteoplasty. The SFS significantly increased from 0.78 to 1.84 (P < .001), and the mean VAS pain score significantly improved from 5.7 (range, 1-9) to 1.5 (range, 0-6) points (P < .001). The NAHS improved from 54.4 (range, 28.75-92.5) to 85.7 (range, 47.5-100) (P < .001). There was no significant correlation between SFS and NAHS (r = .051, P = .35), as well as between SFS and VAS pain score (r = .159, P = .140) preoperatively, but a significant correlation was seen at the time of the last postoperative follow-up (SFS/NAHS: r = .392, P = .003; SFS/VAS: r = .242, P = .049). The 3 most frequent sports activities postoperatively were biking, hiking, and fitness. Conclusion Arthroscopic osteoplasty can significantly improve the rate and level of popular sports activities in patients with FAI. The level of postoperative sports activity directly correlates with the clinical outcome in terms of pain and function.

Arthroscopic Treatment of Femoral Acetabular Impingement in Patients With Preoperative Generalized Degenerative Changes

PURPOSE The aim of this study was to evaluate the short-term results after arthroscopic femoroacetabular impingement (FAI) correction combined with additional procedures addressing labral and chondral damages in patients who showed generalized severe cartilage lesions intraoperatively. METHODS Between 2004 and 2007, 20 patients (16 men and 4 women) could be included in the study. Clinical parameters, the pain score on a visual analog scale, initial radiologic degenerative changes, the alpha angle, and the Nonarthritic Hip Score were prospectively documented. The study endpoint was the implantation of a total hip arthroscopy or the latest follow-up. RESULTS At a mean follow-up of 3.0 years, 10 patients (50%) had undergone, or planned to undergo, total hip replacement. The remaining patients showed a significant improvement in pain, Nonarthritic Hip Score, and hip flexion and internal rotation. CONCLUSIONS In patients with already marked generalized chondral lesions, arthroscopy does not have any effect beyond the short-term pain relief resulting from debridement. The study underlines the fact that FAI with advanced osteoarthrosis, particularly Tönnis grade III, is not an indication for arthroscopic FAI correction. LEVEL OF EVIDENCE Level IV, therapeutic case series.

The PFNA Proximal Femur Nail in Treatment of Unstable Proximal Femur Fractures : 3 Cases of Postoperative Perforation of the Helical Blade Into the Hip joint

The proximal femur nail antirotation represents a new generation of intramedullary nailing devices for fixation of stable and unstable trochanteric fractures of the proximal femur. We report 3 cases of postoperative perforation of the helical blade through the femoral head into the hip joint without any signs of rotational or varus displacement of the fracture.

Evaluation of a Computed Tomography-Based Navigation System Prototype for Hip Arthroscopy in the Treatment of Femoroacetabular Cam Impingement

PURPOSE The purpose of this study was to investigate the impact of a new computed tomography-based computer navigation system on the accuracy of arthroscopic offset correction in patients with cam type femoroacetabular impingement (FAI), and to evaluate if the accuracy of offset restoration compromises the early clinical outcome. METHODS We prospectively treated 50 patients (25 navigated and 25 non-navigated) by hip arthroscopy and arthroscopic offset restoration for cam FAI. The patients were a mean age 42.9 years, and the average follow-up was 26.7 months, with no patients lost to follow-up. Magnetic resonance imaging scans were performed preoperatively and 6 weeks postoperatively. A postoperative alpha angle of less than 50 degrees or a reduction of the alpha angle of more than 20 degrees was considered to be successful offset restoration. Outcomes were measured with a visual analogue scale for pain, range of motion, and the nonarthritic hip score. RESULTS The mean alpha angle improved from 76.5 degrees (range, 57 degrees to 110 degrees) to 54.2 degrees (range, 40 degrees to 84 degrees). In both the navigated and the non-navigated groups, 6 patients (24%) showed insufficient offset correction. Range of motion, visual analogue scale for pain scores, and nonarthritic hip scores significantly improved in all subgroups. Statistical analysis showed no significant difference regarding the clinical outcome between patients with sufficient and insufficient correction of the alpha angle. CONCLUSIONS In this series, a significant percentage of patients (24%) showed an insufficient correction of the alpha angle after hip arthroscopy for cam FAI. This study shows that the presented navigation system could not improve this rate and that the insufficient accuracy of reduction of the alpha angle does not appear to compromise the early clinical outcome. LEVEL OF EVIDENCE Level II, prospective comparative study.

Treatment of supra- and intra-articular fractures of the distal humerus with the LCP Distal Humerus Plate: a 2-year follow-up

BACKGROUND The LCP Distal Humerus Plate (DHP) system represents an angular stable fixation system consisting of 2 anatomically pre-shaped orthogonal plates intended for the treatment of fractures of the distal humerus. The purpose of this retrospective study was to evaluate the clinical and radiologic outcome after a minimum follow-up of 2 years after open reduction and fixation of distal humeral fractures with this device. METHODS Twenty-two consecutive patients with distal humeral fractures were treated with the DHP system between January 2004 and June 2006. Of these, 16 could be clinically and radiologically evaluated after a mean follow-up of 30.5 months. Follow-up included anteroposterior and lateral radiographs; assessment of range of motion; pain according to a VAS; Disabilities of the Arm, Shoulder and Hand score; and Mayo Elbow Performance Score. RESULTS All fractures showed satisfactory articular reduction. One patient showed preoperative sensory ulnar neuropathy, which recovered incompletely, and two patients showed sensory ulnar neuropathy postoperatively, requiring revision surgery in one patient. Mean range of motion was as follows: flexion, 129°; extension, -16°; pronation, 82°; and supination, 71°. The mean visual analog scale score was 1 point; the mean Disabilities of the Arm, Shoulder and Hand score, 23.3 points; and the mean Mayo Elbow Performance Score, 84.7 points. CONCLUSION The DHP system represents a valuable tool to perform internal fixation of complex fractures of the distal humerus. In contrast to conventional plating, we did not observe any case of secondary fracture displacement, even in elderly patients with potentially reduced bone mass. The multiple angular stable point fixation also of small distal fragments seems to be effective in the application of this system.

Closed reduction and minimally invasive percutaneous fixation of proximal humerus fractures using the Humerusblock.

Objective: To evaluate the results after closed reduction and percutaneous fixation of displaced fractures of the proximal humerus with the Humerusblock system. Design: Prospective case series. Setting: Level 1 trauma center. Patients and Methods: Fifty-eight consecutive patients with displaced proximal humerus fractures were followed over a mean period of 15.2 (12-28) months. Intervention: All patients were treated by closed reduction and percutaneous fixation using the Humerusblock. Main Outcome Measurements: Intra- and postoperative complications, secondary fracture displacement, rate of avascular necrosis, range of motion, pain according to a visual analogue scale, and the Constant-Murley shoulder score. Results: No intra-operative complications occurred. Implant removal was performed 6 to 8 weeks after the initial surgery. In 13 (22%) cases, secondary impaction of the humerus lead to perforation of k-wires through the articular surface requiring premature removal of the entire implant after an average time of 4.9 weeks. Five patients required revision surgery, including open reduction and fixation because of secondary fracture displacement. In five patients, k-wires loosened and backed out laterally, requiring revision surgery and retightening of the clamping screws in three cases and premature implant removal in two. Two patients showed radiologic signs of partial avascular necrosis at the final follow-up. The average range of motion of the operated shoulder was flexion 119.2 degrees, extension 33.5 degrees, internal rotation 64.2 degrees, external rotation 41.4 degrees. and abduction 107 degrees. The mean visual analogue scale pain score was 1.1 points, and the mean Constant-Murley score was 73.6 points, representing 88% of the mean Constant-Murley score of the unaffected shoulder. Conclusion: The Humerusblock system allows reliable minimally invasive fixation of selected displaced proximal humerus fractures, even in elderly patients with potentially reduced bone mass. In this study, postoperative rates of avascular necrosis were lower than that which has been reported after conservative treatment and open anatomic reduction and internal fixation. The overall unplanned re-operation rate of 40% was high, comparable with what has been reported for conventional percutaneous pinning. However, clinical outcome was good in 77% of the patients, and reduction could be held in 91% successfully, including elderly patients with potentially reduced bone mass.

Reliability of the Crowe und Hartofilakidis classifications used in the assessment of the adult dysplastic hip

ObjectiveTo assess the inter-observer and intra-observer reliability of two commonly used radiographic classification systems in the evaluation of hip dysplasia in skeletally mature adults.DesignThree observers with different levels of training independently classified 62 dysplastic hips on 51 standard anteriorposterior pelvis radiographs according to the criteria defined by Crowe and by Hartofilakidis. To assess intra-observer reliability, the same radiographs were reviewed 3 months later by the same observers.PatientsAt the time of the radiographic examination, the mean age of the 51 patients had been 54 years (range 18–82 years).ResultsA high correlation concerning the inter- and intra-observer reliability of both systems was demonstrated. Inter-observer reliability displayed a weighted kappa coefficient of 0.82 for the Crowe and 0.75 for the Hartofilakidis classification. Intra-observer reliability showed a kappa coefficient of 0.86 and 0.79, respectively.ConclusionsBoth classification systems can be recommended to compare collectives of adult patients with congenital dysplasia of the hip. However, for future clinical practice, it would be advisable to agree on one universally accepted system as a standard in the literature.

Minimally invasive percutaneous plating of proximal humeral shaft fractures with the Proximal Humerus Internal Locking System (PHILOS)

BACKGROUND This study evaluated our results after minimally invasive percutaneous plating of proximal humeral shaft fractures with the Proximal Humerus Internal Locking System (PHILOS, Synthes, Switzerland). MATERIALS AND METHODS Between 2005 and 2008, 15 patients with unilateral displaced proximal humeral shaft fractures were treated and followed up over a median period of 27 months (range, 12-38 months). The final follow-up included anteroposterior and lateral x-rays, range of shoulder motion, pain by visual analog scale (VAS), the Constant-Murley shoulder score, the Disabilities of Arm, Shoulder and Elbow (DASH) score, and the Short Form 36 (SF36) assessment. RESULTS No intraoperative or postoperative complications occurred. No secondary fracture displacement or radial neuropathy was observed postoperatively. One patient had open reduction and internal fixation for pseudoarthrosis 16 months after the initial surgery. At the final follow-up, the median range of motion of the operated shoulder was flexion, 145°; extension, 45°; internal rotation, 40°; external rotation, 70°; and abduction, 135°. Median results on outcome assessments were VAS pain score, 0 points; Constant-Murley score, 74 points, representing 87.5% of the median Constant-Murley score of the unaffected shoulder; DASH score, 34 points, and the SF36, 83 points. CONCLUSION Minimally invasive percutaneous plating with the PHILOS offers a valid option in the treatment of proximal humeral shaft fractures with comparable rates of nonunion and lower rates of radial neuropathy compared with open procedures. Furthermore, the results indicate that this method is associated with lower rates of wound infection and a shorter stay in the hospital for the patient.

The Dorsal Tangential X-Ray View to Determine Dorsal Screw Penetration During Volar Plating of Distal Radius Fractures

PURPOSE To evaluate whether the dorsal tangential view (DTV) allows for reliable and valid in vivo measurement of the distance between screw tips and the dorsal radial cortex (STCD) during volar plating of distal radius fractures. METHODS Subjects included 22 patients with displaced distal radius fractures who had volar plate osteosynthesis. We performed standardized DTV images intraoperatively. After surgery, we performed computed tomography (CT) scans with reconstructions parallel to the distal screws. Three independent observers blinded to the study protocol measured the STCD on the basis of the DTV images and CT reconstructions. We calculated inter- and intraobserver reliability and the correlation between STCD values measured with DTV images and CT scans. RESULTS Eleven screws were changed intraoperatively. We observed no cases of postoperative screw perforations. Inter- and intraobserver reliability of STCD measurement was good when measured with DTV images and excellent when measured on the basis of CT reconstructions. Statistical analysis showed a good correlation between mean STCD values measured with DTV and CT. CONCLUSIONS The DTV allowed in vivo evaluation of the dorsal radial cortex and enabled reliable assessment of the distance between the screw tip and the dorsal cortex. It may allow detection of dorsal screw perforation during volar plating of distal radial fractures.

The Humerusblock NG: a new concept for stabilization of proximal humeral fractures and its biomechanical evaluation

BackgroundThe Humerusblock NG represents a new semi-rigid angular stable fixation device for minimally invasive stabilization of proximal humeral fractures. This study evaluates the function and stability of the Humerusblock NG and its biomechanical properties on the basis of two different fracture models under cyclic loading.MethodsSix fresh frozen human humeri were tested in a dynamic shoulder joint abduction motion test bench, simulating abduction between 15° and 45°. A stable wedge fracture with intact medial hinge and an unstable fracture with 5-mm gap were loaded for 500 cycles. Radiological measurement of implant migration was performed.ResultsThe stable fracture model showed a slow constant fracture settling. The unstable fracture model showed initial fracture settling with closure of the medial fracture gap during the first 20 cycles. Thereafter, a slow constant settling of the fracture was measured comparable to the stable fracture model. Maximum varus tilt was 3.17° for the stable and 3.68° for the unstable fracture pattern. Radiological analysis showed no change in the tip apex distance and a significant settling of the implants fixation pins in the unstable fracture model. None of the specimen failed during the testing.ConclusionThe Humerusblock NG allows for angular stable dynamic fixation of two-part proximal humeral fractures. It enables closure of the fracture gap and maintains fracture compression during loading, a concept already established in the stabilization of femoral neck fractures (dynamic hip screw). Clinical trials will be necessary to evaluate the value of this device in daily practice.Level of evidenceBasic science study.