Burkhard Wippermann

Fractures and Fracture Dislocations of the Midfoot: Occurrence, Causes and Long-term Results

Etiology and outcome of 155 patients with midfoot fractures between 1972 and 1997 were analyzed to create a basis for treatment optimization. Cause of injuries were traffic accidents (72.2%), falls (11.6%), blunt injuries (7.7%) and others (5.8%). Isolated midfoot fractures (I) were found in 55 (35.5%) cases, Lisfranc fracture dislocations (L) in 49 (31.2%), Chopart-Lisfranc fracture dislocations (CL) in 26 (16.8%) and Chopart fracture dislocations (C) in 25 (16%). One hundred and forty eight (95%) of the midfoot fractures were treated operatively; 30 with closed reduction, 115 with open reduction, 3 patients had a primary amputation. Seven (5%) patients were treated non-operatively. Ninety seven (63%) patients had follow-up at an average of 9 (1.3–25, median 8.5) years. The average scores of the entire follow-up group were as follows: AOFAS – sum of all four sections (AOFAS-ET): 296, AOFAS-Midfoot (AOFAS-M): 71, Hannover Scoring System (HSS): 65, and Hannover Questionnaire (Q): 63. Regarding age, gender, cause, time from injury to treatment and method of treatment no score differences were noted (t-test: p > 0.05). L, C or I showed similar scores and CL significantly lower scores (AOFAS-ET, AOFAS-M, HSS, Q). The highest scores in all groups were achieved in those fractures treated with early open reduction and operative fixation. Midfoot fractures, particularly fracture dislocation injuries, effect the function of the entire foot in the long-term outcome. But even in these complex injuries, an early anatomic (open) reduction and stable (internal) fixation can minimize the percentage of long-term impairment.

Comparison of Surgical Repair or Reconstruction of the Cruciate Ligaments versus Nonsurgical Treatment in Patients with Traumatic Knee Dislocations

Background: Studies of traumatic knee dislocations have failed to provide a consensus regarding the best method of treatment. Purpose: Our purpose was to evaluate the results after surgical repair or reconstruction versus nonsurgical treatment and to compare the influence of prognostic factors. Study Design: Retrospective study. Methods: Eighty-nine patients were treated for traumatic knee dislocation. Surgical repair or reconstruction of the cruciate ligaments was performed in 63 patients (repair, 49; reconstruction, 14). In 26 patients, nonsurgical treatment was undertaken. Results: At an average follow-up of 8.2 years, the mean Lysholm and Tegner scores were 75 and 3.7, respectively. The outcome in the surgical group was better than in the nonsurgical group. The scores were higher in patients who were 40 years of age or younger, who had sports injuries rather than motor vehicle accident injuries, and who had undergone functional rehabilitation rather than immobilization. Conclusions: Surgical repair or reconstruction of the cruciate ligaments was superior to nonsurgical treatment. Functional rehabilitation was the most important positive prognostic factor. Surgical repair or reconstruction of the cruciate ligaments is mandatory to achieve sufficient stability for functional rehabilitation. In cases of cruciate ligament avulsion, repair with transosseous fixation is a reasonable alternative to reconstruction, provided that it is performed within 2 weeks of trauma.

Healing of segmental bone defects with granular porous hydroxyapatite augmented with recombinant human osteogenic protein-1 or autologous bone marrow

Hydroxyapatite is a synthetic bone graft, which is used for the treatment of bone defects and nonunions. However, it is a rather inert material with no or little intrinsic osteoinductive activity. Recombinant human osteogenic protein‐1 (rhOP‐1) is a very potent biological agent, that enhances osteogenesis during bone repair. Bone marrow contains mesenchymal stem cells, which are capable of new bone formation. Biosynthetic bone grafts were created by the addition of rhOP‐1 or bone marrow to granular porous hydroxyapatite. The performance of these grafts was tested in a sheep model and compared to the results of autograft, which is clinically the standard treatment of bone defects and nonunions. A 3 cm segmental bone defect was made in the tibia and fixed with an interlocking intramedullary nail. There were five treatment groups: no implant (n = 6), autograft (n = 8), hydroxyapatite alone (n = 8), hydroxyapatite loaded with rhOP‐1 (n = 8), and hydroxyapatite loaded with autologous bone marrow (n = 8). At 12 weeks, healing of the defect was evaluated with radiographs, a torsional test to failure, and histological examination of longitudinal sections through the defect. Torsional strength and stiffness of the healing tibiae were about two to three times higher for autograft and hydroxyapatite plus rhOP‐1 or bone marrow compared to hydroxyapatite alone and empty defects. The mean values of both combination groups were comparable to those of autograft. There were more unions in defects with hydroxyapatite plus rhOP‐1 than in defects with hydroxyapatite alone. Although the differences were not significant, histological examination revealed that there was more often bony bridging of the defect in both combination groups and the autograft group than in the group with hydroxyapatite alone. Healing of bone defects, treated with porous hydroxyapatite, can be enhanced by the addition of rhOP‐1 or autologous bone marrow. The results of these composite biosynthetic grafts are equivalent to those of autograft.

Foot fractures in restrained front seat car occupants: a long-term study over twenty-three years.

Objectives To analyze the mechanism of injury for foot and ankle fractures resulting from automobile accidents to create a basis for developing an improved design for protection. Design Retrospective. Setting Level I trauma center with accident research unit. Patients Automobile accident reports and medical records of individuals injured in the accidents. Main Outcome Measurements Technical indicators (collision type, impulse angle, &dgr;v, and extent of vehicle deformation) and clinical data (injury location and severity [abbreviated injury scale and injury severity score] and long-term outcome). Results From 1973 to 1996, 15,559 car accidents were analyzed. Two hundred sixty-one front seat occupants sustained fractures of the foot and ankle (ankle, 41 percent; forefoot, 29 percent; midfoot, 20 percent; and hindfoot, 10 percent). Seventy-five percent of the fractures were classified abbreviated injury scalefoot 2. The incidence, location, and abbreviated injury scalefoot category of fractures were similar between driver (n = 210) and front seat passenger (n = 51). Fifty percent of the fractures occurred in head-on collisions and 34 percent occurred in accidents with multiple collisions. The &dgr;v ranged in 82 percent of car crashes between fifteen and sixty kilometers per hour. The &dgr;v and extent of foot compartment deformation correlated with the abbreviated injury scale. During our investigation, &dgr;v increased; the injury severity score decreased; and the extent of deformation did not differ significantly. Conclusions Although overall car passenger safety has improved, the relative incidence of foot and ankle fractures has increased. Comparing drivers and front seat passengers, the foot pedals, steering wheel, or the asymmetric design of the dashboard did not influence injury incidence, mechanism, or severity. Foot fractures are mainly caused by the foot compartment deformation in head-on collisions, and therefore improvements in foot compartments are essential for fracture prevention.

Plantar impact causing midfoot fractures result in higher forces in Chopart's joint than in the ankle joint

Purpose. Force effect (impact, extent of foot compartment deformation) and result (fracture pattern) for midfoot fractures in car occupants is known. An analysis of the processes in the foot was intended to improve car safety.

Plate fixation with hydroxyapatite-coated screws: A comparative loaded study

The authors evaluated whether AO/ASIF screws coated with hydroxyapatite are better fixed than standard screws in a highly loaded plate fixation animal study. Twelve sheep were divided into two groups. The medial tibial middiaphysis was exposed and a 5-mm long bone cylinder was removed. The tibiae were fixed with six-hole dynamic compression plates. Six sheep received standard AO/ASIF stainless steel cortical screws (Group A), and six sheep received AO/ASIF stainless steel cortical screws coated with hydroxyapatite (Group B). Three months after surgery, the sheep were euthanized. The mean screw insertion torque was 4800 ± 768 N/mm in Group A and 4847 ± 450 N/mm in Group B. The mean screw extraction torque was 530 ± 374 N/mm in Group A and 3733 ± 849 N/mm in Group B. Extraction torque of Group A was significantly lower compared with the corresponding insertion torque. In Group B, there were no differences between extraction and insertion torque. Morphologic analyses showed marked fibrous tissue encapsulation in Group A and bone to screw direct contact in Group B. The results confirm that hydroxyapatite-coated AO/ASIF screws prevent deterioration of screw anchorage, even under highly loaded conditions. By using hydroxyapatite-coated screws, complications resulting from inadequate fixation could be avoided.