Christian Boldin

A new locking plate for unstable fractures of the proximal humerus.

In a prospective study, 28 patients with 29 proximal humeral fractures were treated with the Locking Proximal Humerus Plate from 2001-2002. Most of these fractures were complex, Type B (n = 15) and Type C (n = 9) fractures, according to the AO classification. Followups included radiographs, clinical examinations, and recording Constant scores. After 1 year, the average Constant score for all fractures was 74.6 (range, 37-96). For Type A fractures, it was 82.6 (range, 60-96), for Type B it was 78.3 (range, 37-95), and for Type C it was 64.6 (range, 40-91). Complications related to the implant included breakage of the plate in one patient and redislocation of the fracture in four patients (one fracture was associated with deep infection), which required reoperation in two patients. Partial osteonecrosis was seen in two patients, once after deep infection. There were no nonunions. Our data show that using the Locking Proximal Humerus Plate for treatment of proximal humeral fractures of all types is a reliable procedure, with good results being obtained with careful planning and familiarity with the special features of the operative technique. Level of Evidence: Therapeutic study, Level II-1 (prospective cohort study)

The proximal femoral nail (PFN) - a minimal invasive treatment of unstable proximal femoral fractures: A prospective study of 55 patients with a follow-up of 15 months

In 1996, the AO/ASIF developed the proximal femoral nail (PFN) as an intramedullary device for the treatment of unstable per-, intra- and subtrochanteric femoral fractures. In a prospective study, we treated 55 patients having proximal femoral fractures with the PFN from 1997 to 2000. In 34 patients, we achieved what was close to anatomic reduction of the main fracture fragments. Immediate full weight bearing was permitted in 49 patients. During the followup period of 15 months, complications occurred in 12 patients. 2 patients had a cut-out of the implant because we used too short proximal gliding screws. In 5 patients, closed fracture reduction could not be done and open fracture reduction with use of cerclage became necessary. Careful surgical technique and modification of the PFN can reduce the high complication rate. In conclusion, the PFN is a good minimal invasive implant of unstable proximal femoral fractures, if closed reduction is possible. If open reduction of the fracture becomes necessary and several fragments are found (especially of the greater trochanter), we prefer to use a dynamic hip screw (DHS) with the trochanter stablizing plate.

Minimal-invasive treatment of distal femoral fractures with the LISS (Less Invasive Stabilization System) A prospective study of 30 fractures with a follow up of 20 months

BACKGROUND There is no consensus on the best treatment of distal femoral fractures. PATIENTS AND METHODS In a prospective study, we treated 29 patients with 30 distal femoral fractures with the Less Invasive Stabilization System (LISS) from 1997 to 2000. Almost 1/2 of them had open fractures, 1/3 extraarticular type A and 2/3 articular fractures type C (AO classification) and these had been caused by high-energy trauma with concomitant severe injuries or osteoporosis. RESULTS The follow-up examinations after mean 20 (13-42) months consisted of radiographs, and determination of the Lysholm Knee Score and Knee Society Score (KSS). The outcome correlated with the severity of the fracture, anatomic reduction, exact positioning and fixation of the LISS and concomitant injuries. INTERPRETATION We found the LISS for treatment of distal femoral fractures of all types to be a safe procedure with good results after careful planning and experience with this surgical technique. There is usually no need for primary cancellous bone grafting.

Predicting neurologic recovery in cervical spinal cord injury with postoperative MR imaging.

Study Design. Prospective, nonrandomized, observational cohort study. Objectives. To determine whether the presence of spinal cord hemorrhage and length of hematoma on magnetic resonance imaging (MRI) is predictive of recovery in cervical spinal cord injury (SCI). Summary of Background Data. A clear picture of the location, extent, and severity of traumatic cervical cord injury can be obtained with MRI. Several prognostic studies looked for an association between the degree of SCI, as depicted by MRI, and neurologic outcome. Up to now, an association between the length of hemorrhage and the extent of SCI and motor recovery could not be demonstrated. Methods. Twenty-nine patients with acute traumatic cervical spinal cord injury underwent surgery within 2 to 9 hours. MRI was performed within 2 weeks of injury. Neurologic impairment was classified using the ASIA classification. The effects of hemorrhage and length of hematoma on changes in the neurologic impairment were assessed at time of MRI and at median follow-up in 35 months (range, 24–65 months). Results. Patients with hemorrhage were much more likely to have a complete injury at time of follow-up (odds ratio = 2.33, 95% confidence interval, 1.42–3.82). Patients admitted with complete SCI, ASIA A, showed a median length of hematoma of 10.5 mm and a median length of edema of 66.5 mm and no change at follow-up. Patients with incomplete SCI showed a median length of hematoma of 4 mm and small edema. Presence of hemorrhage less than 4 mm was associated with good prognosis. Conclusion. This study indicates that presence of hemorrhage of less than 4 mm was not associated with complete SCI and showed good prognosis.

Three-year results of proximal tibia fractures treated with the LISS.

Proximal tibia fractures present a difficult treatment challenge with historically high complication rates. In a prospective study, we asked whether the Less Invasive Stabilization System (LISS) plate can adequately treat extraarticular and complex intraarticular proximal tibia fractures and provide low complication rates and acceptable long-term functional outcomes. We prospectively observed 25 patients with 26 proximal tibia fractures (AO type A2, A3, C1, C2, or C3) treated with the LISS. Consecutive 3-year followup included radiographs and clinical examinations using Knee Society scores and Hospital for Special Surgery scores for extraarticular and intraarticular fractures. No loss of reduction occurred in patients with extraarticular fractures, whereas varus malalignment occurred in one patient with an intraarticular fracture. Two patients with AO 41 C 3.3 fractures had severe knee arthrosis develop and had total knee replacements. The mean Knee Society scores and final average Hospital for Special Surgery scores were similar for extraarticular and intraarticular fractures. Complications related to the surgery included one delayed union and implant removal in two patients. The LISS provided stable fixation of extraarticular and intraarticular proximal tibia fractures and good functional outcomes with a low complication rate. In complex articular fractures additional screws should be used. Level of Evidence: Therapeutic study, Level II (lesser quality randomized controlled trial [eg, < 80% followup, no blinding, or improper randomization]). See the Guidelines for Authors for a complete description of levels of evidence.

Cadaveric-biomechanical evaluation of bone-implant construct of proximal humerus fractures (Neer type 3).

BACKGROUND A biomechanical cadaver study was performed to test the stability and strength of screw osteosynthesis of surgical neck fractures of the humerus. METHODS After bone density measurement, 64 cadaver proximal humerus bones were bent to create a subcapital fracture. The fracture was then stabilized by means of screw osteosynthesis randomly assigned to subgroups of screw positioning, size of screw, and stress test (torsion/bending). RESULTS Two screws applied laterally and parallel were 34.2% more stable than the normal arrangement. Bone density had a dominant role with regard to maximal bending and torsion force, but no significance was found with respect to additional screws through the major tuberculum or diameter of screws. CONCLUSION Two of the smaller 4.5-mm cannulated screws should be applied parallel from the lateral direction. Only range-of-motion exercises that produce a bending stress should be considered early after surgery, avoiding axial stress.

Foreign-body reaction after reconstruction of complete acromioclavicular dislocation using PDS augmentation

More than 60 different operative techniques for reconstruction of complete acromioclavicular dislocation have been published. The disadvantage of using plates, Kwires, or screws is the necessity of removing the implant. In contrast, absorbable polydioxanone (PDS; Ethicon, Somerville, NJ) augmentation avoids implant removal. Furthermore, PDS has no risk of movement or breakage of implants. Since 1998, 21 patients with complete acromioclavicular dislocation have been treated with PDS as an additional coracoclavicular ligamentous augmentation. We report a case of foreign-body reaction after reconstruction of complete acromioclavicular dislocation with PDS augmentation.

Traumatic unilateral facet dislocation of the lumbosacral junction.

An 18-year-old man was involved in a high-energy motor vehicle accident. Examination immediately after the injury revealed multiple bony injuries (face, right clavicle, ribs, left radius and ulna) with no neurological deficit and free fluid in the peritoneal cavity. CT showed a laceration of the liver, a fracture of the right transverse process of L5, and a complete right-sided lumbosacral facet dislocation without a fracture of the facets. The spinal injury was missed on initial radiographs taken in the emergency room (Figs. 1 and 2). The laceration of the liver was repaired with tissue adhesive at laparotomy. The patient was placed on bed rest in the intensive care unit. Five days after the injury, open reduction of the lumbosacral dislocation was performed through a posterior midline approach. The radiological findings of intact right fifth lumbar and first sacral articular processes were confirmed. There was great difficulty in disimpaction and reduction, which was achieved only after excision of the tip of the superior facet of S1. Posterolateral instrumented fusion of L5/S1 was carried out using computer-guided placement of pedicle screws. MR imaging on the fifth postoperative day showed no disc lesion at L5/S1. Radiographs at 6-month followup demonstrated no instability and the patient was pain-free and maintaining normal work and sporting activities.

Arthroscopy of total knee arthroplasties: Indications and technical problems

SummaryBackground: Postoperative complaints after total knee arthroplasty range from restriction in range of motion, recurrent swelling, and soft tissue impingement through to prosthesis failure with no obvious radiological abnormality. This study looks at the indications and technical problems of arthroscopy in the treatment of symptomatic total knee arthroplasty.Methods: Fourteen arthroscopies were performed between 3 days and 10 years following total knee arthroplasty. Six of these cases presented significantly decreased range of motion, four had proximal medial joint line pain, two had pain with no obvious cause, one had a suspected patella incongruence with metal-back contact, and one case had a postoperative haemarthrosis.Results: Arthroscopy revealed adhesions and intra-articular fibrous bands resulting in incongruence of the patellofemoral joint and decreased range of motion. Medial compartment pain was due to pseudomeniscal hypertrophic villous synovium. In one case, the pain was due to chronic infection and open synovectomy was undertaken. A fracture of the polyethylene inlet was found by arthroscopy in one case. The suspected patella malalignment with metal-back contact was confirmed by arthroscopy. Technical problems encompassed mirror images, the possibility of damaging the components by arthroscopic manipulation, and the variants of prosthesis.Conclusions: Arthroscopy of total knee arthroplasties is a good minimally invasive method for the diagnosis and treatment of postoperative dysfunction, such as arthrofibrosis, soft tissue impingement, patella instability, infection, breakdown of implants and haemarthrosis.ZusammenfassungGrundlagen: Postoperative Beschwerden nach endoprothetischen Ersatz des Kniegelenkes reichen von Einschränkungen im Bewegungsumfang, rezidivierende Schwellungszustände, Impingementsyndromen bis zu radiologisch nicht sicher diagnostizierbaren Prothesenversagern. Indikationen und technische Probleme der Arthroskopie von Knietotalendoprothesen sollen aufgezeigt werden.Methodik: Bei 14 Patienten wurde in einem Zeitraum von 3 Tagen bis zu 10 Jahren nach Implantation einer Knietotal-endoprothese eine Arthroskopie durchgeführt. Die Indikation ergab sich in 6 Fällen aufgrund einer deutlichen Bewegungseinschränkung, bei 4 Patienten aufgrund einer lokalisierten Schmerzsymptomatik im Bereich des medialen Gelenkspaltes und in zwei Fällen aufgrund einer radiodiagnostisch und klinisch unklaren Beschwerdesymptomatik. Weiters bestand je einmal der Verdacht auf Patellainkongruenz mit Metal-back-Kontakt sowie ein Fall von unmittelbar postoperativ aufgetretenen Hämarthros.Ergebnisse: Die Arthroskopie ergab Adhäsionen und narbig fibröse Bindegewebszüge mit konsekutiver Inkongruenz im femoropatellaren Gleitlager, welche zu einer zunehmenden Bewegungseinschränkung führten. Schmerzen im medialen Gutter wurden durch pseudomeniskale hypertrophierte Synovialisfalten verursacht. In einem Fall wurde eine offenen Synovektomie aufgrund eines chronischen Infektes durchgeführt. Weiters zeigte sich ein Bruch des Inlets bei präoperativ unauffälligem radiologischen Befund sowie konnte der Verdacht auf Patellainkrongruenz mit Metal-back-Kontakt bestätigt werden. Technische Probleme resultierten aufgrund von Täuschungen durch Spiegelungsartefakte, der Möglichkeit von iatrogenen Schäden am Implantat und der Vielfalt der Prothesen.Schlußfolgerungen: Die Arthroskopie nach Knietotalendoprothesen ist eine gute minimal invasive Methode zur Diagnostik und Therapie von postoperativen Beschwerden und Funktionseinschränkungen, wie Arthrofibrose, Impingementsyndromen, Patellainstabilität, Infektion, Bruch von Implantaten und Hämarthros.

The unreamed intramedullary tibial nail in tibial shaft fractures of soccer players: a prospective study.

Lower leg fractures are common and complex injuries in soccer players. Twenty-five mainly recreational soccer players who sustained a tibial shaft fracture were treated with the AO-UTN (Unreamed Tibial Nail). This prospective series included 25 males with a mean age of 28.1 years. These patients were prospectively followed for a mean period of 4.7 years. Clinical and radiographic data was collected. In addition, 20 patients completed an outcomes based questionnaire. In all but one case, the mechanism of injury was a contact with an opposing player. Shin guards provided little prevention against these fractures. The majority of these tibial shaft fractures were consistent with a short oblique or transverse fracture pattern. All fractures were stabilized with the UTN on the day of injury. Four patients had concurrent compartment syndromes and underwent a fasciotomy. Average time until bony consolidation was 11.3 weeks. No patients returned to competitive soccer activities earlier than five months after the initial injury (average 9.5). Only 11 out of 20 soccer players returned to the same level of sporting activity. Six patients never returned to playing soccer again after this injury, even without complications. The fracture of the tibial shaft in soccer players is a severe injury that can be treated safely with the UTN without major complications, but nevertheless only 50% of a mainly-recreational playing population return to the same competitive level as before the injury.