Dietmar Krappinger

A Prospective Randomized Trial Comparing Nonoperative Treatment with Volar Locking Plate Fixation for Displaced and Unstable Distal Radial Fractures in Patients Sixty-five Years of Age and Older

BACKGROUND Despite the recent trend toward the internal fixation of distal radial fractures in older patients, the currently available literature lacks adequate randomized trials examining whether open reduction and internal fixation (ORIF) with a volar locking plate is superior to nonoperative (cast) treatment. The purpose of the present randomized clinical trial was to compare the outcomes of two methods that were used for the treatment of displaced and unstable distal radial fractures in patients sixty-five years of age or older: (1) ORIF with use of a volar locking plate and (2) closed reduction and plaster immobilization (casting). METHODS A prospective randomized study was performed. Seventy-three patients with a displaced and unstable distal radial fracture were randomized to ORIF with a volar locking plate (n = 36) or closed reduction and cast immobilization (n = 37). The outcome was measured on the basis of the Patient-Rated Wrist Evaluation (PRWE) score; the Disabilities of the Arm, Shoulder and Hand (DASH) score; the pain level; the range of wrist motion; the rate of complications; and radiographic measurements including dorsal radial tilt, radial inclination, and ulnar variance. RESULTS There were no significant differences between the groups in terms of the range of motion or the level of pain during the entire follow-up period (p > 0.05). Patients in the operative treatment group had lower DASH and PRWE scores, indicating better wrist function, in the early postoperative time period (p < 0.05), but there were no significant differences between the groups at six and twelve months. Grip strength was significantly better at all times in the operative treatment group (p < 0.05). Dorsal radial tilt, radial inclination, and radial shortening were significantly better in the operative treatment group than in the nonoperative treatment group at the time of the latest follow-up (p < 0.05). The number of complications was significantly higher in the operative treatment group (thirteen compared with five, p < 0.05). CONCLUSIONS At the twelve-month follow-up examination, the range of motion, the level of pain, and the PRWE and DASH scores were not different between the operative and nonoperative treatment groups. Patients in the operative treatment group had better grip strength through the entire time period. Achieving anatomical reconstruction did not convey any improvement in terms of the range of motion or the ability to perform daily living activities in our cohorts.

Elastic Stable Intramedullary Nailing Versus Nonoperative Treatment of Displaced Midshaft Clavicular Fractures : A Randomized, Controlled, Clinical Trial

Objective: To compare elastic stable intramedullary nailing (ESIN) with nonoperative treatment of fully displaced midshaft clavicular fractures in adults. Design: The study was a randomized, controlled, clinical trial. Setting: Level 1 trauma center. Patients and Methods: Sixty patients between 18 and 65 years of age participated and completed the study. They were randomized to either operative or nonoperative treatment with a 2-year follow-up. Intervention: Thirty patients were treated with a simple shoulder sling and 30 patients with ESIN within 3 days after trauma. Main Outcome Measurement: Complications after operative and nonoperative treatments, Disabilities of the Arm, Shoulder and Hand (DASH) score and Constant Shoulder Score for outcome measurement, and clavicular shortening. Results: Fracture union was achieved in all patients in the operative group, whereas nonunion was observed in 3 of 30 patients of the nonoperative group. Two symptomatic malunions required corrective osteotomy in the nonoperative group. Medial nail protrusion occurred in 7 cases in the operative group. Implant failure with revision surgery was necessary in 2 patients after an additional adequate trauma. DASH scores were lower in the operative group throughout the first 6 months and 2 years after trauma, with a significant difference during the first 18 weeks. Constant scores were significantly higher after 6 months and 2 years after intramedullary stabilization. Patients in the operative group showed a significant improvement of posttraumatic clavicular shortening; they were also more satisfied with cosmetic appearance and overall outcome. Conclusions: ESIN of displaced midshaft clavicular fractures resulted in a lower rate of nonunion and delayed union, a faster return to daily activities, and a better functional outcome. Clavicular shortening was significantly lower, and overall satisfaction was higher in the operative group.

Length determination in midshaft clavicle fractures: validation of measurement.

Objectives: To evaluate different methods of length determination in acute displaced midshaft clavicle fractures. Methods: To provide static conditions, 30 patients with healed midshaft clavicle fracture were investigated by comparing all measuring methods described in literature. The investigation included a standardized 15-degree tilted radiograph of the clavicle, a 15-degree up-tilted anteroposterior panorama radiograph of the shoulder girdle, and a posteroanterior thorax radiograph. The difference between both clavicles was also measured clinically with a tape. A computed tomography (CT) scan of the shoulder girdle was conducted with two-dimensional reconstructions of the CT scan serving as a reference method. Shortening was determined as proportional length difference. Clinical measuring was performed by 2 observers, and radiological analyses were performed by 4 independent investigators. Investigators were asked to perform repeated measurements to provide intraobserver data. Results: CT measurements, measurements on a posteroanterior thorax radiograph, and 15-degree up-tilted anteroposterior panorama radiograph of the shoulder girdle showed comparable repeatability. Repeatability for clinical measurements and measurements on 15-degree tilted radiographs of the clavicle were markedly lower. Agreement with CT measurements was highest for the measurements on posteroanterior thorax radiographs. Conclusion: While shortening in clavicle fractures is considered an important parameter in choosing a treatment modality, a standardized method of measurement is essential. Our results suggest determining proportional length differences by taking a posteroanterior thorax radiograph.

Management of hemorrhage in severe pelvic injuries.

BACKGROUND Major pelvic trauma results in high mortality. No standard technique to control pelvic hemorrhage has been identified. METHODS In this retrospective study, the clinical course of hemodynamically instable trauma patients with pelvic fractures treated according to an institutional algorithm focusing on basic radiologic diagnostics, external fixation, and early angiographic embolization was evaluated. Study variables included demographics, data on the type and extent of injury, achievement of time from admission to hemorrhage control, complications of angiography, red blood cell needs, and outcome. Standard statistical tests were used. RESULTS Of 1,476 pelvic fracture patients, 45 fulfilled the inclusion criteria. Two patients presented with severe intra-abdominal hemorrhage and underwent emergency laparotomy with pelvic packing. Forty-two patients underwent angiographic embolization before (n = 24) or after (n = 18) a computed tomography scan. Applying the clinical algorithm, pelvic hemorrhage was controlled in all but one patient who died before any intervention could be initiated (97.8%). The hourly need for red blood cell transfusions decreased during 24 hours after angiographic embolization when compared with before the procedure (3.7 +/- 3.5 vs. 0.1 +/- 0.1 U/h; p < 0.001). In patients undergoing angiographic embolization, the mean time to hemorrhage control was 163 minutes +/- 83 minutes. Hospital mortality was 26.2%. Two patients required reembolization because of hemorrhage from other than the primary bleeding site. One patient developed gluteal necrosis, and nine subsequently required renal replacement therapy. CONCLUSION Application of a clinical algorithm focusing on basic radiologic diagnostics, external fixation, and early angiographic embolization was effective and safe to rapidly control hemorrhage in hemodynamically instable trauma patients with pelvic fractures.

Low-energy osteoporotic pelvic fractures

The vast majority of pelvic fractures in geriatric patients are classified as stable injuries. The current treatment strategies of these fractures involve pain management and mobilization. Pain-related immobility may pose a serious hazard to patients with severe preexisting comorbidities. There is paucity of literature on the outcome and mortality after osteoporotic pelvic fractures in the elderly. This review aims to provide an overview of epidemiology, injury mechanism, fracture patterns, management and outcome after osteoporotic pelvic fractures.

Elastic stable intramedullary nailing is best for mid-shaft clavicular fractures without comminution: Results in 60 patients

INTRODUCTION Elastic stable intramedullary nailing (ESIN) of displaced mid-shaft clavicular fractures is a minimally invasive technique which was reported to be an easy procedure with low complication rates, good cosmetic and functional results, restoration of clavicular length and fast return to daily activities. Recent studies, however, also report on higher complication rates and specific problems with the use of this technique. This prospective study compares ESIN with non-operative treatment of displaced mid-shaft clavicular fractures. METHODS Between December 2003 and August 2007, 120 patients volunteered to participate. Of these, 112 patients completed the study (60 in the operative and 52 in the non-operative group). Patients in the non-operative group were treated with a simple shoulder sling. In the operative group, intramedullary stabilisation was performed within 3 days of the trauma. Clavicular shortening was determined after trauma and after osseous consolidation on thorax posteroanterior radiographs as the proportional length difference between the left and right side with the uninjured side serving as a control for clavicular length (100%). Radiographic union was assessed every 4 weeks on 20 degrees cephalad anteroposterior and posteroanterior radiographs of the clavicle. Constant shoulder scores and DASH scores (DASH, disabilities of the arm, shoulder and hand) were assessed at final follow-up after 2 years. RESULTS ESIN led to faster osseous healing and better restoration of clavicular length in simple fractures. We were not able to restore clavicular length in comminuted fractures using ESIN. Functional outcome at a mean follow-up of 24 months (range: 22-27 months) was better in the operative group. Delayed union and non-union accounted for the majority of complications in the non-operative group. In the operative group, telescoping was the main complication, which occurred in complex fractures with severe post-traumatic shortening only. CONCLUSION We recommend ESIN for all simple displaced mid-shaft clavicular fractures in order to minimise the rate of delayed union, non-union and symptomatic mal-union. We also recommend ESIN in comminuted fractures with moderate (< or = 7%) post-traumatic shortening, as they will heal with moderate shortening. In comminuted fractures with severe shortening, however, we recommend plate osteosynthesis in order to provide for stability, clavicular length and endosteal blood supply.

Minimally invasive transiliac plate osteosynthesis for type C injuries of the pelvic ring: a clinical and radiological follow-up.

Objective: To evaluate radiological and functional outcome in patients treated with minimally invasive transiliac plate osteosynthesis for unstable pelvic injuries. Design: Retrospective analysis of a prospective treatment protocol in a consecutive patient series. Setting: Level 1 trauma center. Patients: Between January 1998 and December 2005, 31 patients with type C injuries of the pelvic ring were treated with minimally invasive transiliac plate osteosynthesis. According to the AO classification, 16 patients had a C1-injury, 9 had a C2 fracture, and 6 patients sustained a C3 injury of the pelvic ring. Anterior-posterior, inlet, and outlet radiographs were obtained preoperatively, immediately postoperatively, and during follow-up. Clinical outcome was determined according to the Hannover pelvic outcome score. Intervention: Posterior plate osteosynthesis for type C injuries of the pelvic ring. Main Outcome Measurement: Preoperative and postoperative dislocation of the posterior pelvic ring, loss of reduction, implant failure, implant removal, clinical results of the pelvic injury and general limitations following the trauma. Results: Maximum average dislocation of the posterior pelvic ring was 16.1 mm preoperatively; postoperatively, it was 6.1 mm. A total of 23 patients (74.2%) could be followed up after an average of 20 months (range 7-57 months). Seven patients underwent follow-up treatment at other hospitals closer to their respective residences, whereas 1 patient passed away in the early postoperative phase due to multiorgan failure. Loss of reduction occurred in 2 cases. The clinical outcome regarding the pelvis was very good in 8 cases, good in 9 cases, fair in 4 cases, and poor in 2 cases. Social reintegration according to the Hannover pelvic outcome score was complete in 9 cases, poor in 10 cases, and incomplete in 10 cases. Conclusion: Posterior plate osteosynthesis is a sufficiently stable method for the treatment of unstable pelvic ring injuries with a low risk of iatrogenic nervous tissue and vascular lesions. The disadvantages are limited reduction possibilities, the necessity of bilateral bridging of the sacroiliac joint in a unilateral injury, as well as a higher rate of symptomatic hardware.

A Randomized Study of the Effectiveness of Suprascapular Nerve Block in Patient Satisfaction and Outcome After Arthroscopic Subacromial Decompression

PURPOSE The purpose of this study was to evaluate the efficiency of the suprascapular nerve (SSN) block in pain reduction after arthroscopic subacromial decompression operations and its influence on patient satisfaction. Furthermore, we wanted to evaluate whether better perioperative pain management could positively influence postoperative shoulder function. METHODS In this prospective, randomized, double-blinded clinical trial, 3 groups of patients--each with 15 participants--were treated with SSN block (10 mL of 1% ropivacaine), placebo, or a subacromial infiltration of local anesthesia (20 mL of 1% ropivacaine). Preoperative and postoperative pain was evaluated with a visual analog scale. Functional outcome was measured by the Constant-Murley score, and patient satisfaction was measured anecdotally by interview 2 days, 2 weeks, and 6 weeks after surgery. RESULTS The SSN group reported significantly lower levels of postoperative pain, required significantly less analgesia, had better range of motion, and had higher levels of postoperative satisfaction in comparison to the subacromial infiltration group and placebo group. CONCLUSIONS Patients treated with SSN blocks had less pain overall, which led to a decreased need for analgesics in comparison to the subacromial infiltration and placebo groups. Furthermore, patients in the SSN-blocked group achieved better postoperative ROM and were significantly more satisfied after surgery.

Combined posteroanterior fusion versus transforaminal lumbar interbody fusion (TLIF) in thoracolumbar burst fractures

BACKGROUND The optimal treatment strategy for burst fractures of the thoracolumbar junction is discussed controversially in the literature. Whilst 360° fusion has shown to result in better radiological outcome, recent studies have failed to show its superiority concerning clinical outcome. The morbidity associated with the additional anterior approach may account for these findings. The aim of this prospective observational study was therefore to compare two different techniques for 360° fusion in thoracolumbar burst fractures using either thoracoscopy or a transforaminal approach (transforaminal lumbar interbody fusion (TLIF)) to support the anterior column. METHODS Posterior reduction and short-segmental fixation using angular stable pedicle screw systems were performed in all patients as a first step. Monocortical strut grafts were used for the anterior support in the TLIF group, whilst tricortical grafts or titanium vertebral body replacing implants of adjustable height were used in the combined posteroanterior group. At final follow-up, the radiological outcome was assessed by performing X-rays in a standing position. The clinical outcome was measured using five validated outcome scores. The morbidity associated with the approaches and the donor site was assessed as well. RESULTS There were 21 patients in the TLIF group and 14 patients in the posteroanterior group included. The postoperative loss of correction was higher in the TLIF group (4.9°±8.3° versus 3.4°±6.4°, p>0.05). There were no significant differences regarding the outcome scores between the two groups. There were no differences in terms of return to employment, leisure activities and back function either. More patients suffered from donor-site morbidity in the TLIF group, whilst the morbidity associated with the surgical approach was higher in the posteroanterior group. CONCLUSION The smaller donor-site morbidity in the posteroanterior group is counterbalanced by an additional morbidity associated with the anterior approach resulting in similar clinical outcome. Mastering both techniques will allow the spine surgeon to be more flexible in specific situations, for example, in patients with neurological deficits or severe concomitant thoracic trauma.

Stabilisierung des dorsalen Beckenrings mit eingeschobener Platte

ZusammenfassungOperationszielMinimalinvasive Stabilisierung des dorsalen Beckenrings bei Typ-C-Verletzungen.IndikationenInstabile Typ-C-Verletzungen des Beckenrings, ein- oder beidseitig.−Transsymphysär-transsakrale Instabilität.−Transpubisch-transsakrale Instabilität.−Transsymphysär-transsakroiliakale Instabilität.−Transpubisch-transsakroiliakale Instabilität.KontraindikationenFrakturen im kindlichen Alter.Trümmerfrakturen des Os ilium.Patienten mit schlechten Haut- und Weichteilverhältnissen und lokalen Infekten.Sakrumfrakturen mit neurologischem Defizit stellen keine Kontraindikation dar, da diese unter Distraktion dekomprimiert und in Neutralstellung verplattet werden.OperationstechnikÜber zwei kurze, senkrechte Hautschnitte nutförmige Osteotomie der Spina iliaca posterior superior beidseits. Tunnelierung der Rückenmuskulatur bis zur Gegenseite. Längenbestimmung einer 4,5-mm-Beckenrekonstruktionsplatte. Biegen der Platte über dem lateralen vierten Loch um etwa 70°. Einschieben der Platte und Anbiegen des freien Plattenendes. Besetzen der Plattenlöcher mit Spongiosaschrauben. Refixation der osteotomierten Knochenfragmente über der Platte mit Kleinfragment-Spongiosaschauben.Ergebnisse34 Patienten mit einem Durchschnittsalter von 42,6 Jahren wurden im Zeitraum von 1998 bis 2005 mit der beschriebenen Methode behandelt, 18 waren polytraumatisiert. Bei 28 Patienten wurde auch der ventrale Beckenring operativ stabilisiert, in elf Fällen als erster Eingriff im Zuge eines zweizeitigen Vorgehens. 25 Patienten konnten nach durchschnittlich 17 Monaten klinisch und radiologisch nachuntersucht werden.In der nativradiologischen Kontrolle nach 1 Jahr zeigte sich bei 16 Patienten ein sehr gutes Ergebnis (maximale Dislokation im dorsalen Beckenring < 5 mm) und bei acht Patienten ein gutes Ergebnis (Dislokation 5–10 mm). In zwei Fällen kam es im 1. postoperativen Jahr zu einem Korrekturverlust eines unmittelbar postoperativ sehr guten Repositionsergebnisses (Dislokation < 5 mm), wobei einmal die Dislokation im Ausheilungsbild < 10 mm betrug, in einem weiteren Fall 19 mm.Ein Patient stellte sich 11 Wochen postoperativ mit einem Spätinfekt vor, der nach Implantatentfernung und Wunddébridement ausheilte. Bei zwei weiteren Patienten mussten in Lokalanästhesie jeweils in der 10. postoperativen Woche prominente Schraubenköpfe nach Refixation der osteotomierten Spinae iliacae posteriores superiores entfernt werden. Auch bei diesen beiden Patienten war der weitere Verlauf unauffällig. Bei einem Patienten wurden die Implantate bereits im 5. postoperativen Monat bei reizlosen Weichteilen entfernt, da er angab, in der Tiefe Wärme- und Kältesensationen zu verspüren. Die Platten wurden in weiteren sechs Fällen nach Ausheilung der Fraktur/Instabilität nach durchschnittlich 9–12 Monaten entfernt, in den anderen Fällen wurden sie belassen.AbstractObjectiveMinimally invasive stabilization of the posterior pelvic ring in type C injuries.IndicationsUnstable type C injuries of the pelvic ring, uni- or bilateral.−Transsymphyseal-transsacral instability.−Transpubic-transsacral instability.−Transsymphyseal-transsacroiliac instability.−Transpubic-transsacroiliac instability.ContraindicationsFractures in childhood.Comminuted fractures of the ilium.Patients with skin and soft tissues in a poor condition and/or local infection.Sacral fractures with a neurologic deficit are not a contraindication because they can be decompressed by distraction and stabilized in a neutral position by plate fixation.Surgical TechniqueNut-shaped osteotomy of the posterior superior iliac spine bilaterally through two short, vertical skin incisions. Tunneling through the muscles of the back to the opposite side. Length measurement for a 4.5-mm pelvic reconstruction plate. The plate is bent by about 70° over the fourth lateral hole. Slide-insertion of the plate and bending of the free plate end for close fit. Cancellous bone screws are inserted into the plate holes. Refixation of the osteotomized bone fragments over the plate with small-fragment, cancellous bone screws.Results34 patients with an average age of 42.6 years were treated according to the described method from 1998 to 2005; 18 were polytraumatized. The anterior pelvic ring was also stabilized by surgery in 28 patients for eleven of whom it was the first intervention in a two-stage procedure. 25 papercutients were available for clinical and radiologic follow-up at 17 months, on average.The plain radiographs after 1 year showed a very good outcome in 16 patients (maximal displacement of the posterior pelvic ring < 5 mm) and a good outcome in eight patients (displacement of 5–10 mm). In two patients there was loss of reduction in the 1st postoperative year despite a very good reduction result immediately postoperatively (dislocation < 5 mm), whereby the dislocation for one patient was < 10 mm on the final radiograph and 19 mm for the other.One patient presented with a late infection 11 weeks postoperatively that healed after implant removal and wound debridement. In two other patients, prominent screw heads, which were used for refixation of the osteotomized posterior superior iliac spine, had to be removed under local anesthesia in the 10th postoperative week. The further course for these two patients was uneventful. In one patient the implants were retrieved in the 5th postoperative month because the patient complained of internal hot and cold sensations although the soft tissue was not irritated. The plates were removed in six other cases after the fracture/instability had healed, i. e., after 9–12 months, on average; in all other cases the implants were left in situ.