C. Burger

Minimally invasive intramedullary nailing of midshaft clavicular fractures using titanium elastic nails.

BACKGROUND In up to 31% of cases, nonsurgical treatment of midshaft clavicular fractures leads to unsatisfactory results such as nonunion, brachial plexus irritation, shortening and limited function of the shoulder. To date, various implants have been developed for open reduction including intramedullary wires, screws, and plates. This study discusses elastic stable intramedullary nailing of midshaft clavicular fractures. METHODS Between 2000 and 2005, 31 midshaft clavicular fractures were treated by intramedullary nailing with a titanium elastic nail (TEN). Subjective and clinical outcome were evaluated after an average follow-up of 26 (6-46) months. Patients were divided into three groups: patients with isolated clavicular fractures (group 1, n = 9); patients with additional injuries (group 2, n = 15), and patients with multiple injuries (group 3, n = 7). RESULTS Nonunion was not observed. No patient sustained a refracture after TEN removal. Medial migration of the TEN in seven patients and iatrogenic perforation of the lateral cortex in one patient required secondary shortening on five occasions. Nail breakage after fracture healing was observed twice. Subjective outcome did not differ significantly between the three groups. Constant and Murley Score and the Disability of the Arm, Shoulder, and Hand Questionnaire Score showed no significant difference in the clinical outcome of the three groups. CONCLUSION Intramedullary fixation of midshaft clavicular fractures with a TEN is a safe minimally invasive surgical technique achieving primary stability for practice. It can be seen as an alternative to plate or screw fixation or nonsurgical treatment, as it produces excellent cosmetic and functional results regardless whether patients suffered from isolated clavicular fractures, additional injuries, or multiple traumas.

Time to wound closure in trauma patients with disorders in wound healing is shortened by supplements containing antioxidant micronutrients and glutamine: A PRCT

BACKGROUND & AIMS : We hypothesize that wound closure in trauma patients with disorders in wound healing is accelerated by supplementation of antioxidant micronutrients and glutamine. METHODS In a randomized, double-blind, placebo-controlled trial, 20 trauma patients with disorders in wound healing were orally supplemented with antioxidant micronutrients (ascorbic acid, α-tocopherol, β-carotene, zinc, selenium) and glutamine (verum) or they received isoenergetic amounts of maltodextrine (placebo) for 14 days. Plasma/serum levels of micronutrients, glutamine, and vascular endothelial growth factor-A (VEGF-A) were determined before and after supplementation. In the wound, several parameters of microcirculation were measured. Time from study entry to wound closure was recorded. RESULTS Micronutrients in plasma/serum did not change except for selenium which increased in the verum group (1.1 ± 0.2 vs. 1.4 ± 0.2 μmol/l; P = 0.009). Glutamine decreased only in the placebo group (562 ± 68 vs. 526 ± 55 μmol/l; P = 0.047). The prevalence of hypovitaminoses and the concentration of VEGF-A did not change. Considering microcirculation, only O(2)-saturation decreased in the placebo group (56.7 ± 23.4 vs. 44.0 ± 24.0 [arbitrary units]; P = 0.043). Wound closure occurred more rapidly in the verum than in the placebo group (35 ± 22 vs. 70 ± 35 d; P = 0.01). CONCLUSIONS Time to wound closure can be shortened by oral antioxidant and glutamine containing supplements in trauma patients with disorders in wound healing.

Elastic stable intramedullary nailing of midclavicular fractures in adults: 32 patients followed for 1-5 years.

Background Osteosynthesis of clavicular fractures is sometimes indicated. Since plate fixation may lead to complications, we have used elastic stable intramedullary nailing and report our experience of midclavicular fractures in 32 adults. Patients and methods From 2000 to 2005, we treated 32 adults (26 men), median age 40 (19–66) years, by intramedullary nailing with a titanium elastic nail (TEN). All patients were re-examined after median 27 (12–59) months. Results Nonunion was not observed. 20 clavicles healed without shortening. 12 clavicles healed with shortening of more than 5 mm. Migration of the TEN in 8 patients required secondary shortening of the nail in 5 of them. Nail breakage after fracture healing was observed twice. The nails were removed in 29 patients after a median of 6 (1.3–15) months postoperatively. No patient sustained a re-fracture after TEN removal. The mean Constant score was 95 (SD 1.9) points and the mean DASH score was 5 (SD 2.3) points. Interpretation Intramedullary stabilization of midclavicular fractures with a titanium elastic nail is a minimally invasive technique with good cosmetic and functional results. Intramedullary fixation can be seen as an alternative to plate fixation and nonoperative treatment.

Treatments for Shoulder Impingement Syndrome: A PRISMA Systematic Review and Network Meta-Analysis

AbstractMany treatments for shoulder impingement syndrome (SIS) are available in clinical practice; some of which have already been compared with other treatments by various investigators. However, a comprehensive treatment comparison is lacking.Several widely used electronic databases were searched for eligible studies. The outcome measurements were the pain score and the Constant–Murley score (CMS). Direct comparisons were performed using the conventional pair-wise meta-analysis method, while a network meta-analysis based on the Bayesian model was used to calculate the results of all potentially possible comparisons and rank probabilities.Included in the meta-analysis procedure were 33 randomized controlled trials involving 2300 patients. Good agreement was demonstrated between the results of the pair-wise meta-analyses and the network meta-analyses. Regarding nonoperative treatments, with respect to the pain score, combined treatments composed of exercise and other therapies tended to yield better effects than single-intervention therapies. Localized drug injections that were combined with exercise showed better treatment effects than any other treatments, whereas worse effects were observed when such injections were used alone. Regarding the CMS, most combined treatments based on exercise also demonstrated better effects than exercise alone. Regarding surgical treatments, according to the pain score and the CMS, arthroscopic subacromial decompression (ASD) together with treatments derived from it, such as ASD combined with radiofrequency and arthroscopic bursectomy, showed better effects than open subacromial decompression (OSD) and OSD combined with the injection of platelet-leukocyte gel. Exercise therapy also demonstrated good performance. Results for inconsistency, sensitivity analysis, and meta-regression all supported the robustness and reliability of these network meta-analyses.Exercise and other exercise-based therapies, such as kinesio taping, specific exercises, and acupuncture, are ideal treatments for patients at an early stage of SIS. However, low-level laser therapy and the localized injection of nonsteroidal anti-inflammatory drugs are not recommended. For patients who have a long-term disease course, operative treatments may be considered, with standard ASD surgery preferred over arthroscopic bursectomy and the open surgical technique for subacromial decompression. Notwithstanding, the choice of surgery should be made cautiously because similar outcomes may also be achieved by the implementation of exercise therapy.

Health status as an important outcome factor after hemiarthroplasty.

The goal of this study was to determine functional results of hemiarthroplasty for 3- and 4-part proximal humeral fractures in elderly patients and to analyze factors affecting the outcome. Thirty-eight consecutive shoulders were treated with hemiarthroplasty after proximal humeral fracture. Two groups of patients with different health status were classified. Group I consisted of patients with 2 or less comorbidities and a maximum of 2 medications at the time of injury. Patients in group II had 3 or more comorbidities with a minimum of 3 medications at the time of injury. The mean of the absolute Constant score in group I was 41, compared to 27 in group II (P < .05). Furthermore, compliance of the patient and regular physiotherapy proved to be important prognostic factors. If primary hemiarthroplasty is not likely to be successful with a low functional score, this surgical procedure should be reconsidered especially in patients with more than three comorbidities.

Fractures of the ankle joint: investigation and treatment options.

BACKGROUND Ankle fractures are common, with an incidence of up to 174 cases per 100 000 adults per year. Their correct classification and treatment are of decisive importance for clinical outcome. METHOD Selective review of the literature. RESULTS Ankle fractures are initially evaluated by physical examination and then by x-ray. They can be classified according to either the AO Foundation (Association for the Study of Internal Fixation) or the Weber classification. Dislocated fractures need emergency treatment with immediate reduction; this is crucial for the prevention of hypoperfusion and nerve damage. Weber A fractures can usually be treated conservatively, while Weber B and C fractures are usually treated with surgery. An evaluation of the stability of the syndesmosis is important for anatomical reconstruction of the joint. Wound hematoma and wound-edge necrosis are the most common complications, and the postoperative infection rate is 2%. Up to 10% of patients develop ankle arthrosis over the intermediate or long term. CONCLUSION With properly chosen treatment, a good clinical outcome can be achieved. The long-term objective is to prevent post-traumatic ankle arthrosis. The evidence level for optimal treatment strategies is low.

Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis

Background There are many injection therapies for lateral epicondylalgia but there has been no previous comprehensive comparison, based on the Bayesian method. Methods The MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for appropriate literature. The outcome measurement was the pain score. Direct comparisons were performed using the pairwise meta-analysis, and network meta-analysis, based on a Bayesian model, was used to calculate the results of all of the potentially possible comparisons and rank probabilities. A sensitivity analysis was performed by excluding low-quality studies. The inconsistency of the model was assessed by means of the node-splitting method. Metaregression was used to assess the relationship between the sample size and the treatment effect. Results All of the injection treatments showed a trend towards better effects than placebo. Additionally, the peppering technique did not add additional benefits when combined with other treatments. No significant changes were observed by excluding low-quality studies in the sensitivity analysis. No significant inconsistencies were found according to the inconsistency analysis, and metaregression revealed that the sample size was not associated with the treatment effects. Conclusions Some commonly used injection therapies can be considered treatment candidates for lateral epicondylalgia, such as botulinum toxin, platelet-rich plasma and autologous blood injection, but corticosteroid is not recommended. Hyaluronate injection and prolotherapy might be more effective, but their superiority must be confirmed by more research. The peppering technique is not helpful in injection therapies.

Image and Diagnosis Quality of X-Ray Image Transmission via Cell Phone Camera: A Project Study Evaluating Quality and Reliability

Introduction Developments in telemedicine have not produced any relevant benefits for orthopedics and trauma surgery to date. For the present project study, several parameters were examined during assessment of x-ray images, which had been photographed and transmitted via cell phone. Materials and Methods A total of 100 x-ray images of various body regions were photographed with a Nokia cell phone and transmitted via email or MMS. Next, the transmitted photographs were reviewed on a laptop computer by five medical specialists and assessed regarding quality and diagnosis. Results Due to their poor quality, the transmitted MMS images could not be evaluated and this path of transmission was therefore excluded. Mean size of transmitted x-ray email images was 394 kB (range: 265–590 kB, SD ±59), average transmission time was 3.29 min ±8 (CI 95%: 1.7–4.9). Applying a score from 1–10 (very poor - excellent), mean image quality was 5.8. In 83.2±4% (mean value ± SD) of cases (median 82; 80–89%), there was agreement between final diagnosis and assessment by the five medical experts who had received the images. However, there was a markedly low concurrence ratio in the thoracic area and in pediatric injuries. Discussion While the rate of accurate diagnosis and indication for surgery was high with a concurrence ratio of 83%, considerable differences existed between the assessed regions, with lowest values for thoracic images. Teleradiology is a cost-effective, rapid method which can be applied wherever wireless cell phone reception is available. In our opinion, this method is in principle suitable for clinical use, enabling the physician on duty to agree on appropriate measures with colleagues located elsewhere via x-ray image transmission on a cell phone.

Endoprothetischer Ersatz der nicht rekonstruierbaren Radiuskopffraktur (Mason III und IV) mit der bipolaren Radiuskopfprothese nach Judet - Klinische Ergebnisse

AIM Long-term results after resection of comminuted fractures of the radial head (Mason III and IV) may lead to valgus elbow instability, radius proximalisation and rotatory instability. Radial head replacement has been used to prevent and treat these complications. The aim of this study was to define the value of the bipolar radial head prosthesis of Judet for treating comminuted fractures of the radial head. METHOD Over a 5-year period, 14 radial head prosthesis were implanted in 12 patients. Retrospectively, we studied the clinical and radiological results. RESULTS Eleven patients with thirteen implants were analysed at a mean follow-up of 33.4 +/- 20.4 months. In all patients, the elbow was stable. Subjectively, we found good and excellent results with one exception. Compared to the pre-trauma status, the subjective rate was 78 +/- 12 %. According to the score of Radin and Riseborough, five of the results were found to be good and eight to be fair. According to the Broberg and Morrey score, one result was found to be very good, seven to be good and five to be fair. The mean DASH score was 10.2 +/- 10.1 points. Two temporary nerve lesions were observed. CONCLUSION In comminuted fractures of the radial head (Mason III and IV), bipolar radial head replacement with the Judet prosthesis leads subjectively to very good and good and functionally to good and fair results on the medium-term view. Joint stability is achieved and secondary complications like valgus elbow deformity and proximal radial migration are prevented. Patients must be informed about the possibility of temporary nerve lesions, heterotopic ossification causing limitation of motion and the lack of long-term results.

PMMA-augmentation of incompletely cannulated pedicle screws: A cadaver study to determine the benefits in the osteoporotic spine

BACKGROUND Pedicle screw pullout due to poor bone quality, mainly caused by osteoporosis, is a common problem in spine surgery. Special implants and techniques, especially PMMA augmentation, were developed to improve the fixation of pedicle screws. PMMA injection into a pilot hole or through a screw involves the same risks as vertebroplasty or kyphoplasty, regardless of the technique used. Especially when using fully cannulated screws anterior leakage is possible. OBJECTIVE To prove PMMA injection is safe and possible without leakage through an incompletely cannulated screw and also increases pullout forces in the osteoporotic vertebra. METHODS Incompletely cannulated pedicle screws were tested by axial pullout in human cadavers, divided into osteoporotic and non-osteoporotic groups. Non-augmented and PMMA-augmented pedicle screws were compared. Twenty-five human vertebrae were measured by DEXA and divided into osteoporotic and non-osteoporotic groups. In each vertebra both pedicles were instrumented with the new screw (WSI-Expertise 6×45 mm, Peter Brehm Inc. Germany); the right screw was augmented with a 3 mL PMMA injection through the screw. On each screw axial pullout was performed after X-ray and CT scan. RESULTS Radiographs and CT scans excluded PMMA leakage. Cement was distributed in the middle and posterior third of the vertebrae. Pullout forces were significantly higher after pedicle screw augmentation, especially in the osteoporotic bone. All augmented pedicle screws showed higher pullout forces compared with the unaugmented screws. CONCLUSIONS We minimized the risk of leakage by using a screw with a closed tip. On the whole, PMMA augmentation through an incompletely cannulated pedicle screw is safe and increases pullout forces in osteoporotic bone to the level of healthy bone. Therefore the new incompletely cannulated screw can be used for pedicle screw augmentation.