Andreas Paech

Early functional results after Hemiarthroplasty for femoral neck fracture: a randomized comparison between a minimal invasive and a conventional approach

BackgroundA minimal invasive approach for elective hip surgery has been implemented in our institution in the past. It is widely hypothesized that implanting artificial hips in a minimal invasive fashion decreases surgical trauma and is helpful in the rehabilitation process in elective hip surgery. Thereby geriatric patients requiring emergency hip surgery also could theoretically benefit from a procedure that involves less tissue trauma.MethodsSixty patients who sustained a fractured neck of femur were randomly assigned into two groups. In the minimal invasive arm, the so called “direct anterior approach” (DAA) was chosen, in the conventional arm the Watson-Jones-Approach was used for implantation of a bipolar hemi-arthroplasty.Primary outcome parameter was the mobility as measured by the four-item-Barthel index. Secondary outcome parameters included pain, haemoglobin-levels, complications, duration of surgery, administration of blood transfusion and external length of incision. Radiographs were evaluated.ResultsA statistically significant difference (p = 0,009) regarding the mobility as measured with the four-item Barthel index was found at the 5th postoperative day, favouring the DAA. Evaluation of the intensity of pain with a visual analogue scale (VAS) showed a statistically significant difference (p = 0,035) at day 16. No difference was evident in the comparison of radiographic results.ConclusionsComparing two different approaches to the hip joint for the implantation of a bipolar hemi-arthroplasty after fractured neck of femur, it can be stated that mobilization status is improved for the DAA compared to the WJA when measured by the four-item Barthel index, there is less pain as measured using the VAS. There is no radiographic evidence that a minimal invasive technique leads to inferior implant position.Level of Evidence: Level II therapeutic study.

Is non-union of tibial shaft fractures due to nonculturable bacterial pathogens? A clinical investigation using PCR and culture techniques

BackgroundNon-union continues to be one of the orthopedist’s greatest challenges. Despite effective culture methods, the detection of low-grade infection in patients with non-union following tibial fracture still presents a challenge. We investigated whether “aseptic” tibial non-union can be the result of an unrecognized infection.MethodsA total of 23 patients with non-union following tibial shaft fractures without clinical signs of infection were investigated. Intraoperative biopsy samples obtained from the non-union site were examined by means of routine culture methods and by polymerase chain reaction (PCR) for the detection of 16 S ribosomal RNA (rRNA). Control subjects included 12 patients with tibial shaft fractures.Results23 patients (8 women and 15 men; mean age: 47.4 years) were included into this study. Preoperative C-reactive protein levels (mean: 20.8 mg/l) and WBC counts (mean: 8,359/μl) in the study group were not significantly higher than in the control group. None of the samples of non-union routine cultures yielded microorganism growth. Bacterial isolates were found by conventional culturing methods in only 1 case of an open fracture from the control group. In this case, PCR yielded negative results. 16 S rRNA was detected in tissue specimens from 2 patients (8.7%) with non-union. The analysis of these variable species-specific sequences enabled the identification of specific microorganisms (1x Methylobacterium species, 1x Staphylococcus species). Both PCR-positive patients were culture-negative.ConclusionsThe combination of microbiological culture and broad-range PCR seems to substantially add to the number of microbiological diagnoses obtained and may improve the clinican’s ability to tailor therapy to the individual patient’s needs.

Multifragmentary Tibial Pilon Fractures: Midterm Results After Osteosynthesis with External Fixation and Multiple Lag Screws

Osteosynthesis of intraarticular tibial pilon fractures is preferably achieved using locking plates via a minimally invasive technique. If combined with severe soft tissue damage there is a high risk of wound-healing deficits after plate osteosynthesis. Thus our aim was to find an alternative method of treatment for those cases with combined soft tissue injuries. We report on five cases with comminuted fractures of the joint surface combined with critical soft tissue condition that were treated with lag screws and external fixation (AO) applied across the ankle joint. All five patients were followed up, undergoing clinical and radiological examination. Using this approach we achieved fracture healing of comminuted fractures without further complications. Clinical follow-up after an average of 55.6 (36–75) months revealed a mean AOFAS score of 81 (62–100). We therefore propose combined treatment using lag screws with external fixation as a practical treatment option for those fractures for which lag screws combined with a locking plate are not feasible or when there is a high risk of wound-healing deficits due to severe soft tissue damage.

Severe Fracture of the Tibial Pilon: Results with a Multidirectional Self-locking Osteosynthesis Plate Utilizing a Two-stage Procedure

The objective of this study is to determine the treatment result of severe fractures of the tibial pilon using a two-stage treatment plan with a singular implant type. The setting is a level 1 trauma centre, the design a consecutive series of patients with a retrospective data evaluation. Due to anatomical circumstances, soft-tissue treatment is extremely important for fractures of the tibial plafond. After promising results reported about a two-staged treatment plan with external fixation and secondary internal fixation, we incorporated this method in our treatment protocol. This consisted in a second stage of internal fixation with a specifically developed locked pilon plate with multi-directional applicable screws. Between March 2000 and February 2005, 42 patients with high-energy fractures of the tibial plafond were treated using a two-staged treatment plan: firstly the fracture was stabilized with an external fixator immobilizing the ankle joint. Secondly, after stabilization of the soft-tissue situation (mean 9.2 days) open reduction and internal fixation with a locked-screw plate was performed. Complications experienced included three cases of superficial wound necrosis, in two cases a deep vein thrombosis occurred. All fractures healed but two patients needed an early bone graft because of insufficient bony consolidation. At follow-up, six Patients had no deficit in the range of movement of the ankle compared with the unaffected side, 19 patients experienced a deficit of movement of less then one third compared to the opposite side. In 27 cases no or only mild posttraumatic arthritis of the ankle occurred. There was no secondary loss of reduction or need for arthrodesis. The mean AOFAS score was 73.4 (52–97). A two-stage treatment plan in fractures of the distal lower limb with external fixation followed by locked-plate osteosynthesis reduces local complications with a good functional result.

Frakturversorgung an der oberen Extremität

ZusammenfassungDie subkapitale Humerusfraktur macht etwa 5% aller Extremitätenfrakturen aus, 75% der Betroffenen sind über 65 Jahre alt. Die Frakturen werden nach der Neer-Klassifikation eingeteilt. Bei gering dislozierten und stabilen Frakturen sind durch konservative Behandlung in der Regel gute funktionelle Ergebnisse erzielbar. Die Indikationsstellung zur operativen Versorgung berücksichtigt verschiedenste Parameter, die teils patienten-, teils frakturabhängig sind. Eine ausreichende präoperative Diagnostik samt Bildgebung ist Grundvoraussetzung für ein optimales postoperatives Ergebnis. Die korrekte Rekonstruktion der Rotatorenmanschette ist zwingend erforderlich. Ähnliches gilt hinsichtlich der fragilen Blutversorgung des Humeruskopfes, für welche eine intakte mediale Periostverbindung entscheidend ist. Bei der Wahl der Versorgungsform – Osteosynthese mittels proximalem Humerusnagel, Plattenosteosynthese oder Endoprothese – sollten neben Frakturtyp, -stellung, Zahl der Fragmente usw. auch individuelle Besonderheiten des Patienten selbst sowie dessen Anforderungen berücksichtigt werden, um eine optimale Versorgung zu erreichen.AbstractThe subcapital humerus fracture accounts for approximately 5% of all extremity fractures. Of this patient population 75% are over 65 years. Fractures are classified according to the Neer score. In the case of mildly displaced and stable fractures, good functional results can generally be achieved with conservative therapy. The indication for surgery takes varying parameters -- some fracture-specific, some patient-specific -- into account. Adequate preoperative diagnosis, including imaging, is the basic prerequisite for optimal postoperative results. Correct reconstruction of the rotator cuff is mandatory. The same is true for the fragile blood supply to the humeral head, for which an intact medial periosteal connection is crucial. When choosing the method of treatment -- osteosyntheses using a proximal humerus nail, plate osteosynthesis or endoprostheses -- fracture type and status, number of fragments, etc. as well as the individual characteristics of patients and their expectations should all be taken into consideration in order to provide optimal treatment.