Andreas Schmelz

Treatment of Tossy III acromioclavicular joint injuries using hook plates and ligament suture.

Objectives: The management of acromioclavicular (AC) injuries has long been debated. We analyzed our results in treating such cases using hook plates and ligament suture. Design: Retrospective nonrandomized study. Setting: Level I Trauma Center (University Hospital). Patients: Twenty-five patients (mean age 41 years) with complete Tossy III AC joint disruptions. Using the Rockwood classification, 15 dislocations were classified as type V injuries, 9 as type III injuries, and 1 as a type IV injury. Intervention: All patients were operatively treated using AC hook plates with ligament suturing after a median delay of 7 days. Main Outcome Measures: Clinical and radiographic evaluation using Constant-Murley functional score and Taft et al criteria. Results: A retrospective clinical and radiographic evaluation of 23 patients was performed after an average follow-up period of 30 months. The mean Constant score was 97 (range, 90-100) points, and the mean Taft score was 10.6 points. All but 1 patient were satisfied with their treatment outcome. Eight cases showed some loss of reduction after plate removal. A poor correlation existed, however, between clinical and radiographic results. Conclusions: The hook plate is a reliable fixation tool for complete AC joint dislocations, ensuring immediate stability and allowing early mobilization with good functional and cosmetic results. Routine plate removal should however be reevaluated.

Improved healing response in delayed unions of the tibia with low-intensity pulsed ultrasound: results of a randomized sham-controlled trial.

BackgroundWe compared the healing response of tibial delayed unions between subjects treated with low-intensity pulsed ultrasound (LIPUS) (n = 51) and subjects treated with a sham device (n = 50). Fracture age was ≥ 4 months in all cases. Study personnel and participants were blinded to random treatment assignment throughout the study.MethodsThis multi-center randomized sham-controlled trial was undertaken at six hospitals in Germany. Adult patients who had sustained a tibial shaft fracture that subsequently showed inadequate progress toward healing (i.e., delayed union) were enrolled and randomized to receive either LIPUS (Exogen 2000/2000+, Smith & Nephew GmbH, Schenefeld, Germany) or an identical nonoperative sham device. The daily treatment duration was 20 minutes, for a period of 16 weeks. Subjects randomly assigned to active treatment had the ultrasound pressure wave signal set at the following parameters: 1.5 MHz frequency, 1 kHz repetition rate, 200 μs pulse duration, 30 mW/cm2 spatial intensity. Progress toward healing was estimated from changes in bone mineral density (BMD) and gap area as determined from computed tomography scans. Intention-to-treat analysis was conducted using a multiple imputation methodology.ResultsBased on log-transformed data, mean improvement in BMD was 1.34 (90% confidence interval (CI) 1.14 to 1.57) times greater for LIPUS-treated subjects compared to sham (p = 0.002). A mean reduction in bone gap area also favored LIPUS treatment (p = 0.014).ConclusionsThese findings demonstrate significantly greater progress toward bone healing after LIPUS treatment compared to no LIPUS treatment in subjects with established delayed unions of the tibia.

Ankle Arthrodesis Using Ilizarov Ring Fixators: A Review of 22 Cases:

Background: Orthopaedic surgeons are being increasingly confronted with complex ankle problems that cannot be reliably treated by conventional arthrodesis procedures. The Ilizarov technique can be an alternative salvage method in such cases. Methods: Twenty-two Ilizarov tibiotalar arthrodeses were retrospectively reviewed. There were 16 men and six women (mean age 49 years). The underlying pathology was infection after internal fixation of ankle or plafond fractures in 16 patients, posttraumatic ankle arthritis in five, and septic arthritis after an infected Achilles tendon repair in one. Five patients had at least one failed previous arthrodesis. Primary iliac crest bone grafting was done in two patients. Proximal tibial lengthening was done in six patients. Results: Twenty-one patients were followed for an average of 29 months. A solid fusion was achieved in all patients by the end of treatment. The external fixation time averaged 27.7 (range 12 to 84) weeks. The mean time spent in a foot frame was 22.3 weeks. Complications occurred in 11 patients, including two nonunions that healed after revision and renewed frame application and four pin track infections. Conclusions: The use of the Ilizarov frame provides a successful salvage method that offers solid bony fusion, optimal leg length, and eradication of infection in complex ankle pathology or failed previous arthrodesis.

Nonsteroidal anti-inflammatory drugs (NSAIDs) in the perioperative phase in traumatology and orthopedics effects on bone healing.

ZusammenfassungZielErreichen eines analgetischen, antiphlogistischen und antipyretischen Effekts in der Traumatologie und Orthopädie ohne oder mit möglichst wenig Nebenwirkungen, unter spezieller Berücksichtigung der Knochenheilung.IndikationenAkute und chronische Entzündungen, z. B. Rheuma, Spondylitis ankylosans.Degenerative Gelenkerkrankungen.Posttraumatische und postoperative Schmerzen, Ödem oder Fieber.Prophylaxe gegen heterotope Ossifikationen.KontraindikationenÜberempfindlichkeit.Gastrointestinale Ulzeration oder Blutung.Schwere Leber- oder Nierenfunktionsstörung.ErgebnisseNichtsteroidale Antirheumatika (NSAR) sind wertvolle Medikamente in der Behandlung verschiedener muskuloskelettaler Erkrankungen. Neben der sehr guten analgetischen Potenz sind ihre antiphlogistischen Effekte vorteilhaft in der Behandlung des traumatischen und postoperativen Ödems. Darüber hinaus haben NSAR einen hemmenden Effekt auf die Ausbildung heterotoper Ossifikationen in der Hüftendoprothetik. Im Rahmen tierexperimenteller Studien konnte aber eine Verzögerung der Knochenbruchheilung nachgewiesen werden. Auch wenn der eindeutige Nachweis dieser Wirkung am Menschen in klinischen Studien nicht vorliegt, empfehlen die Autoren, bei weiteren Risikofaktoren, die möglicherweise die Frakturheilung beeinträchtigen können, wie Rauchen, Diabetes mellitus oder eine periphere arterielle Verschlusskrankheit, die Indikation zur Gabe von NSAR als reine Schmerzmedikation unbedingt streng zu stellen. Bei diesen Patienten sollten therapeutische Alternativen wie zentral wirksame Medikamente (z. B. schwache Opioide) erwogen werden.AbstractObjectiveTo achieve analgesic, anti-inflammatory and antipyretic effects in traumatology and orthopedic surgery without side effects or with the least possible side effects, with special emphasis on bone healing.IndicationsAcute and chronic inflammatory conditions, e. g., rheumatoid arthritis, ankylosing spondylitis.Degenerative joint disease.Posttraumatic and postoperative pain, edema, or fever.Prevention of heterotopic bone formation.ContraindicationsHypersensitivity.Gastrointestinal ulceration or bleeding.Severe hepatic or renal impairment.ResultsNonsteroidal anti-inflammatory drugs (NSAIDs) are invaluable in treating a variety of musculoskeletal conditions. As well as their excellent analgesic potency their anti-inflammatory effects are beneficial in treating posttraumatic and postoperative edema. In addition, NSAIDs inhibit heterotopic bone formation after hip arthroplasty. Animal studies, however, have demonstrated that they cause delayed fracture healing. Although clinical studies have not yet supplied unequivocal evidence of this effect in human subjects, the authors recommend that in the presence of other risk factors which may adversely affect fracture healing, such as smoking, diabetes mellitus or peripheral arterial occlusive disease, the indication of NSAID use for analgesia should be strictly limited. Therapeutic alternatives such as centrally acting agents (e. g., weak opioids) should be considered in these patients.

Akutstationäre Behandlungskosten polytraumatisierter Patienten

ZusammenfassungDeckt die Erstattung der Beträge durch die Krankenkasse die anfallenden Kosten eines polytraumatisierten Patienten?Für 71 polytraumatisierte Patienten wurden retrospektiv die akutstationären Behandlungskosten bestimmt und mit den von den Krankenkassen rückerstatteten Beträgen verglichen.Der Altersdurchschnitt betrug 38,0 Jahre und der mittlere “Injury Severity Score” (ISS) lag bei 23,0 Punkten. Der durchschnittliche Krankenhausaufenthalt war im Schnitt 25,9 Tage. Die errechneten Gesamtkosten beliefen sich pro Patient auf durchschnittlich 21866,30 EUR. Von den Krankenkassen wurden pro Patient lediglich 16863,03 EUR zurückerstattet. Dies bedeutete ein Defizit von ca. 5000 EUR pro Patient bzw. 167 EUR pro Pflegetag und für die Stichprobe einen Jahresverlust von insgesamt ca. 35.5000 EUR.Um den noch hohen Versorgungsstandard bei Polytraumatisierung aufgrund defizitärer Therapiekostenerstattung nicht zu gefährden, ist u. a. die Implementierung einer Polytraumapauschale in Abhängigkeit der Verletzungsschwere und der Aufenthaltsdauer zu überdenken. Die sinnvolle Verbringung polytraumatisierter Patienten in dafür vorgesehene Zentren, wo unter bestmöglichen Bedingungen ein optimales outcome erreicht werden kann, führt aber gerade in diesen Häusern zu einem ansteigenden Defizit. Dies kann sich in Zukunft deletär auf die finanzielle Situation solcher “Traumazentren” auswirken.Bei einer optimalen Polytraumaversorgung lassen sich aber auch indirekte Kosten senken, die durch Arbeits-, Berufs- und Erwerbsunfähigkeit entstehen, und aus volkswirtschaftlicher Sicht ebenfalls von großer Bedeutung sind.AbstractAre the costs required for a polytraumatised patient sufficiently paid by the health care companies?The study population consisted of 71 polytrauma patients. The treatment-costs were calculated and compared with the reimbursements. The mean patient age was 38.0 years with a mean injury severity score (ISS) of 23.0 points. The mean duration of hospitalisation was 25.9 days and the mean calculated cost per patient was Euro 21,866.30. The reimbursement was only Euro 16,863.03/patient. This leads to a financial deficit of approximately Euro 5,000/patient (Euro 167/polytrauma patient/hospital day) and nearly Euro 355,000 for all patients during the period of 1 year.The introduction of the DRG system endangers the high standard of polytrauma treatment because of insufficient reimbursement.It is necessary to consider the implementation of an additional polytrauma-reimbursement based on the injury severity and duration of hospitalisation. The concentration of the patients in trauma centres, where the optimum of therapy is guarantied, leads in these hospitals to a continuously increasing deficit. The latter may be deleterious for the concept of “trauma centers” in the future.

[Do injuries of the upper extremity in geriatric patients end up in helplessness? A prospective study for the outcome of distal radius and proximal humerus fractures in individuals over 65].

ZusammenfassungIn einer prospektiven Studie wurden 104 Patienten ≥65 Jahre mit distaler Radiusfraktur (DRF) (n=52) und proximaler Humerusfraktur (PHF) (n=52) über den Zeitraum von 4 Monaten nach der Verletzung untersucht. Die Studie griff als Inzeptions-Kohortenstudie nicht in den Behandlungsablauf ein, sondern beobachtete lediglich den Verlauf.53% der DRF und 74% der PHF wurden operativ therapiert. Bezüglich der Bewältigung des Alltagslebens (IADL) ergaben sich bei beiden Frakturformen keine signifikanten Veränderungen im Verlauf. Funktionelle Ergebnisse waren bei den DRF schlechter als bei den PHF.Die PHF-Patienten zeigten im Verlauf der Studie eine konstant hohe Sturzangst, bei den DRF stieg diese im Beobachtungszeitraum signifikant an. Im Beobachtungszeitraum verstarben insgesamt 4% der DRF und 9,6% der PHF-Patienten. 6% der DRF und 17% der PHF-Patienten mussten den eigenen Haushalt aufgeben.Ein Drittel beider Patientengruppen erhielt keine Krankengymnastik. Nur bei 12% der DRF-Patienten und 6% der PHFPatienten wurde eine Osteoporose behandelt.Bei beiden Patientengruppen kam es zu einer signifikanten Verschlechterung der Gehfähigkeit im Beobachtungszeitraum, was bei 24% der DRF und 28% der PHF-Patienten zu zwei und mehr erneuten Sturzereignissen im Beobachtungszeitraum führte.SummaryIn a prospective study 104 patients ≥65 years with distal radius fractures (DRF; n=52) and proximal forearm fractures (PHF; n=52) were followed up for a period of 4 months after injury. As an inception- cohort study, influence on treatment pattern was not part of the examination.A total of 53% of the DRF and 74% of the PHF patients underwent surgery. There were no significant changes in the ability of daily living management (IADL) with either fracture form. Functional outcome was better in PHF than DRF patients.PHF patients showed a high incidence in “fear of falling” throughout the whole study, whereas fear of falling rose significantly in DRF patients. 4% of DRF and 9.6% of PHF patients died during the observation period, while 6% of DRF and even 17% of PHF patients had to give up their own housekeeping.One third of both patient groups did not receive physiotherapy. In only 12% of DRF and 6% of PHF patients was osteoporosis treated. In both groups of patients there was a significant worsening in the ability of walking after injury, leading to two or more new falls in 24% of DRF and 28% of PHF patients.

Frakturen der oberen Extremität beim geriatrischen Patienten – Harmlose Monoverletzung oder Ende der Selbstständigkeit?

ZusammenfassungIn einer prospektiven Studie wurden 104 Patienten ≥65 Jahre mit distaler Radiusfraktur (DRF) (n=52) und proximaler Humerusfraktur (PHF) (n=52) über den Zeitraum von 4 Monaten nach der Verletzung untersucht. Die Studie griff als Inzeptions-Kohortenstudie nicht in den Behandlungsablauf ein, sondern beobachtete lediglich den Verlauf.53% der DRF und 74% der PHF wurden operativ therapiert. Bezüglich der Bewältigung des Alltagslebens (IADL) ergaben sich bei beiden Frakturformen keine signifikanten Veränderungen im Verlauf. Funktionelle Ergebnisse waren bei den DRF schlechter als bei den PHF.Die PHF-Patienten zeigten im Verlauf der Studie eine konstant hohe Sturzangst, bei den DRF stieg diese im Beobachtungszeitraum signifikant an. Im Beobachtungszeitraum verstarben insgesamt 4% der DRF und 9,6% der PHF-Patienten. 6% der DRF und 17% der PHF-Patienten mussten den eigenen Haushalt aufgeben.Ein Drittel beider Patientengruppen erhielt keine Krankengymnastik. Nur bei 12% der DRF-Patienten und 6% der PHFPatienten wurde eine Osteoporose behandelt.Bei beiden Patientengruppen kam es zu einer signifikanten Verschlechterung der Gehfähigkeit im Beobachtungszeitraum, was bei 24% der DRF und 28% der PHF-Patienten zu zwei und mehr erneuten Sturzereignissen im Beobachtungszeitraum führte.SummaryIn a prospective study 104 patients ≥65 years with distal radius fractures (DRF; n=52) and proximal forearm fractures (PHF; n=52) were followed up for a period of 4 months after injury. As an inception- cohort study, influence on treatment pattern was not part of the examination.A total of 53% of the DRF and 74% of the PHF patients underwent surgery. There were no significant changes in the ability of daily living management (IADL) with either fracture form. Functional outcome was better in PHF than DRF patients.PHF patients showed a high incidence in “fear of falling” throughout the whole study, whereas fear of falling rose significantly in DRF patients. 4% of DRF and 9.6% of PHF patients died during the observation period, while 6% of DRF and even 17% of PHF patients had to give up their own housekeeping.One third of both patient groups did not receive physiotherapy. In only 12% of DRF and 6% of PHF patients was osteoporosis treated. In both groups of patients there was a significant worsening in the ability of walking after injury, leading to two or more new falls in 24% of DRF and 28% of PHF patients.

Nichtsteroidale Antirheumatika (NSAR) in der perioperativen Phase in Traumatologie und Orthopädie

ZusammenfassungZielErreichen eines analgetischen, antiphlogistischen und antipyretischen Effekts in der Traumatologie und Orthopädie ohne oder mit möglichst wenig Nebenwirkungen, unter spezieller Berücksichtigung der Knochenheilung.IndikationenAkute und chronische Entzündungen, z. B. Rheuma, Spondylitis ankylosans.Degenerative Gelenkerkrankungen.Posttraumatische und postoperative Schmerzen, Ödem oder Fieber.Prophylaxe gegen heterotope Ossifikationen.KontraindikationenÜberempfindlichkeit.Gastrointestinale Ulzeration oder Blutung.Schwere Leber- oder Nierenfunktionsstörung.ErgebnisseNichtsteroidale Antirheumatika (NSAR) sind wertvolle Medikamente in der Behandlung verschiedener muskuloskelettaler Erkrankungen. Neben der sehr guten analgetischen Potenz sind ihre antiphlogistischen Effekte vorteilhaft in der Behandlung des traumatischen und postoperativen Ödems. Darüber hinaus haben NSAR einen hemmenden Effekt auf die Ausbildung heterotoper Ossifikationen in der Hüftendoprothetik. Im Rahmen tierexperimenteller Studien konnte aber eine Verzögerung der Knochenbruchheilung nachgewiesen werden. Auch wenn der eindeutige Nachweis dieser Wirkung am Menschen in klinischen Studien nicht vorliegt, empfehlen die Autoren, bei weiteren Risikofaktoren, die möglicherweise die Frakturheilung beeinträchtigen können, wie Rauchen, Diabetes mellitus oder eine periphere arterielle Verschlusskrankheit, die Indikation zur Gabe von NSAR als reine Schmerzmedikation unbedingt streng zu stellen. Bei diesen Patienten sollten therapeutische Alternativen wie zentral wirksame Medikamente (z. B. schwache Opioide) erwogen werden.AbstractObjectiveTo achieve analgesic, anti-inflammatory and antipyretic effects in traumatology and orthopedic surgery without side effects or with the least possible side effects, with special emphasis on bone healing.IndicationsAcute and chronic inflammatory conditions, e. g., rheumatoid arthritis, ankylosing spondylitis.Degenerative joint disease.Posttraumatic and postoperative pain, edema, or fever.Prevention of heterotopic bone formation.ContraindicationsHypersensitivity.Gastrointestinal ulceration or bleeding.Severe hepatic or renal impairment.ResultsNonsteroidal anti-inflammatory drugs (NSAIDs) are invaluable in treating a variety of musculoskeletal conditions. As well as their excellent analgesic potency their anti-inflammatory effects are beneficial in treating posttraumatic and postoperative edema. In addition, NSAIDs inhibit heterotopic bone formation after hip arthroplasty. Animal studies, however, have demonstrated that they cause delayed fracture healing. Although clinical studies have not yet supplied unequivocal evidence of this effect in human subjects, the authors recommend that in the presence of other risk factors which may adversely affect fracture healing, such as smoking, diabetes mellitus or peripheral arterial occlusive disease, the indication of NSAID use for analgesia should be strictly limited. Therapeutic alternatives such as centrally acting agents (e. g., weak opioids) should be considered in these patients.

Low intensity pulsed ultrasound accelerates macrophage phagocytosis by a pathway that requires actin polymerization, Rho, and Src/MAPKs activity

Phagocytosis is an essential event in the complex process of tissue repair. Here we examined the effect of low intensity pulsed ultrasound (US), which promotes fracture and wound healing, on phagocytosis by mouse macrophage cell line J774A.1 and human monocyte-derived macrophages. First, 10 to 40 min low intensity pulsed US increased uptake of serum opsonized E. coli by J774A.1 cells during a 50 min phagocytosis period. In addition, when the E. coli exposure time was varied between 35 to 80 min, the maximum increase in phagocytosis was observed in the first 35 min upon US exposure. In parallel, US induced robust actin polymerization in a time dependent manner in J774A.1 cells, showing the peak effect 30 min after stimulation. Interestingly, a low concentration of cytochalasin D (0.25-0.5 microM) prevented US-induced phagocytosis of E. coli. Furthermore, we demonstrated US enhanced activation of RhoA. Blocking its downstream effector Rho associated kinase (ROCK) with Y27632 abrogated US-induced phagocytosis. We also show that US induced activation of ERK and p38 MAPK. Pretreatment of the cells with the corresponding inhibitors PD98059 and SB203580 reduced US-induced phagocytosis. In addition, activity of tyrosine kinase Src was required for US-induced phagocytosis. Here Src represents an upstream activator of ERK and p38 MAPK. Depolymerization of actin by cytochalasin D prevented US-induced Src, ERK, and p38 activation. Our data provide a new insight into the cellular and molecular mechanisms by which low intensity pulsed US promotes tissue repair.

Hybrid external fixation for arthrodesis in knee sepsis.

Several techniques for knee fusion have been described with success rates ranging from 29% to 100%, with worse results occurring in patients with joint sepsis. We treated 21 patients with persistent infections using knee arthrodesis with a hybrid Ilizarov frame at our institution. There were 13 men and eight women ranging from 21 to 75 years (mean, 49.7 years). Sixteen patients had chronic osteomyelitis and five had previous fusion trials. Two patients required bone transport using the same arthrodesis frame. We corrected associated malalignment in three patients. Solid knee fusion was achieved in all but one patient after a mean external fixation time of 22.7 weeks (range, 11-47 weeks). Limb shortening averaged 2.8 cm (range, 1.5-5 cm). No patients required secondary bone grafting to achieve fusion. Nine patients had complications develop, three of whom required reresection and frame application to treat persistent infection or delayed union. Our results emphasize the clinical success of using the Ilizarov fixator for knee arthrodesis after persistent sepsis.Level of Evidence: Level IV Therapeutic Study. See the Guidelines for Authors for a complete description of levels of evidence.