Axel Jubel

Elastic stable intramedullary nailing of midclavicular fractures with a titanium nail.

This study presents the results of a minimally invasive operative treatment for markedly displaced midclavicular fractures. In all patients a flexible titanium nail was inserted in an unreamed technique from the sternal end of the clavicle. The result of surgery was determined with clinical and radiographic controls. The clinical outcome was evaluated 12 months after hardware removal using the scoring system of Constant and Murley. Fifty-eight fractures in 55 patients were treated with intramedullary fixation. Postoperatively on Day 3, the mean subjective pain was significantly lower and range of motion was improved compared with the day before surgery. One nonunion occurred. There was no infection and no implant displacement or refracture. Intramedullary nailing of midclavicular fractures with a flexible titanium nail is a safe minimally invasive surgical technique with excellent functional and cosmetic results compared with plate fixation or conservative treatment. Marked pain reduction along with early restoration of shoulder function and early mobilization are advantageous for patients. This technique can be used as an alternative treatment to conservative procedures or plate fixation in patients with markedly displaced midclavicular fractures, multiple trauma, fractures of the lower extremities, or associated shoulder girdle injuries.

Die Technik der intramedullären Osteosynthese der Klavikula mit elastischen Titannägeln

ZusammenfassungAnhand dieser prospektiv kontrollierten Beobachtungsstudie sollten die Ergebnisse der intramedullären Osteosynthese der Klavikula im mittleren Drittel erfasst werden.In Rückenlagerung erfolgt die Eröffnung der ventralen Kortikalis der sternalen Klavikula mit einem 2,5-mm-Bohrer. Der Nagel wird unter Bildwandlerkontrolle nach lateral vorgetrieben und die Fraktur reponiert. Gelingt die geschlossene Reposition nicht, erfolgt eine Hilfsinzision zur direkten Manipulation der Fragmente.In einem Zeitraum von 3,5 Jahren konnte die Technik bei 62 Patienten mit 65 Frakturen angewandt werden. Die subjektive Schmerzempfindung war am 3. postoperativen Tag signifikant (p<0,001) niedriger als präoperativ. Das Bewegungsausmaß im Schultergelenk konnte signifikant (p<0,001) verbessert werden. Wir beobachteten eine Pseudarthrose. Implantatdislokationen, Infekte, und Refrakturen traten nicht auf. Der mittlere Wert des Constant-Score betrug 6 Monate nach der Metallentfernung 96,9±3,3 Punkte.Die intramedulläre Schienung der Klavikulafraktur ist eine sichere, minimal-invasive Operationstechnik, die funktionell und kosmetisch zu guten Resultaten führt.AbstractThis prospective controlled clinical trial was performed to assess fracture healing and clinical outcome after intramedullary nailing of midclavicular fractures.Within 3,5 years elastic-stable intramedullary nailing was performed in 62 patients with 65 midclavicular fractures. Surgery was performed in supine position. The ventral cortex of the proximal clavicle was opened using a 2,5 mm drill. The nail was advanced laterally under fluoroscopic control. If closed reduction failed, an additional incision was made to enable direct manipulation of the fragments.There were no infections, no implant displacements or refractures. Postoperatively, the mean subjective pain was significantly lower, and the range of motion improved. We observed one nonunion. The mean Constant-score 6 months after hardware removal was 96.9 ± 3,3 points.Intramedullary fixation of midclavicular fractures with an elastic titanium nail is a safe minimally invasive surgical technique, producing excellent functional and cosmetic results.

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.

Transplantation of De Novo Scaffold-Free Cartilage Implants Into Sheep Knee Chondral Defects

Background New cell-based treatments for articular cartilage repair are needed. As the optimal scaffold for cartilage repair has yet to be developed, scaffold-free cartilage implants may remove the complications caused by suboptimal scaffolds. Hypothesis The implantation of a scaffold-free, autologous de novo cartilage implant into standardized full-thickness cartilage defects of femoral condyles in sheep leads to a qualitatively better regenerative tissue than does periosteal flap alone or no treatment. Study Design Controlled laboratory study. Methods Chondral defects 4 mm in diameter (1 per sheep) were created in the center of 1 medial femoral condyle of 48 sheep. Twelve defects were allowed to heal spontaneously, 16 defects were covered with periosteal flaps alone, and 20 defects were filled with autologous de novo cartilage graft and overlaid with a periosteal flap. Differences were assessed macroscopically using the International Cartilage Repair Society score and microscopically using the International Cartilage Repair Society histological score and Mankin score at 26 and 52 weeks. Results The results of the International Cartilage Repair Society Cartilage repair assessment showed that the transplant group was better than was the untreated control at both time periods but not significantly different than was the periosteal flap group. Implanted groups demonstrated a marked improvement in grade of defect filling, cartilage stability, cell distribution, and matrix assessments in each method of assessment. In the transplant group, 2 defects were filled with hyaline cartilage, 5 with mixed hyaline and fibrocartilage, and 2 with fibrocartilage alone. Conclusion Chondral defects treated with de novo cartilage transplantation show qualitatively better microscopic and macroscopic regeneration than do those treated with periosteal flaps alone. Clinical Relevance Results of the current study show that third-generation autologous chondrocyte transplantation is a promising development in the field of biologic cartilage regeneration. Future studies should compare this technique with the original Brittberg technique.

Die intramedulläre Osteosynthese der Klavikula mit einem elastischen Titannagel

ZusammenfassungOperationszielRasche Schmerzlinderung, frühzeitige Belastungsstabilität und ein langfristig gutes funktionelles und ästhetisches Ergebnis durch Reposition und elastische Stabilisierung der Fraktur.IndikationenKlavikulafrakturen des mittleren Drittels vom Typ A und B nach der Klassifikation der Orthopaedic Trauma Association (OTA) am ausgewachsenen Skelett.KontraindikationenFrakturen, die älter als 3 Wochen sind.Frakturen vom Typ C der OTA-Klassifikation.Osteoporose der Klavikula.OperationstechnikHautinzision und Eröffnung der ventralen Kortikalis über dem sternalen Ende der Klavikula. Einführen eines 2,5–3,5 mm starken Titannagels unter rotierenden Bewegungen. Geschlossene Reposition oder offene Reposition über einen Hilfsschnitt in Höhe der Fraktur. Kürzung des proximalen Nagelendes. Das überstehende Ende sollte nicht länger als 2–3 mm sein.WeiterbehandlungKeine Ruhigstellung. Schmerzorientierte Belastung. Einschränkung der Elevation des Arms auf 90° bei Frakturen vom Typ B der OTA-Klassifikation.ErgebnisseBei 89 Männern und 43 Frauen mit 136 Klavikulafrakturen wurde eine intramedulläre Osteosynthese durchgeführt. Das mittlere Alter betrug 32,9 Jahre.Bei 78 Frakturen gelang die geschlossene Reposition. Vor der Operation wurden die subjektiven Schmerzen im Mittel mit 72,4 Punkten angegeben. Am 3. postoperativen Tag lag die subjektive Schmerzangabe mit 18,9 Punkten niedriger. Analog hierzu wurde eine Verbesserung der Beweglichkeit des verletzten Schultergelenks festgestellt. Das Implantat wurde im Mittel nach 7,6 Monaten entfernt. Der mittlere Wert des Constant-Scores betrug 12 Monate nach der Materialentfernung 97,1 Punkte. Bei einer polytraumatisierten Patientin trat eine Pseudarthrose auf.AbstractObjectiveReduction and intramedullary fixation of midclavicular fractures with an elastic titanium nail with the goal to reduce pain and to quickly resume activities of daily living postoperatively.IndicationsMidclavicular fractures types A and B according to the OTA (Orthopaedic Trauma Association) classification of fractures.ContraindicationsSurgery > 3 weeks after trauma.Fractures type C according to the OTA classification.Osteoporosis.Surgical TechniqueSkin incision just above the sternal end of the clavicle. Approximately 1 cm lateral to the sternoclavicular joint, a hole is drilled into the anterior cortex. A titanium nail varying in diameter between 2.5 to 3.5 mm is mounted on a universal chuck with a T-handle. With oscillating movements the titanium nail is advanced until it reaches the fracture site. If closed reduction maneuvers are unsuccessful, an additional skin incision has to be made at the level of the fracture site enabling direct manipulation of the fragments.Postoperative ManagementPostoperatively, no immobilization is performed. Patients are encouraged to move the arm as much as tolerated and to use it in daily activities.ResultsIntramedullary fixation was applied to 136 clavicle fractures in 132 patients (89 men, 43 women, mean age 32.9 years).In 78 fractures closed reduction was successful. Average subjective pain assessment using a visual analog scale decreased from 72.4 points preoperatively to 18.9 points 3 days postoperatively. Average shoulder abduction increased significantly. The average Constant-Murley clinical outcomes score 1 year after implant removal was 97.1 points.

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.