E. J. Müller

Management of odontoid fractures in the elderly

Odontoid fractures are frequent in patients over 70 years of age, and in patients over 80 years of age they form the majority of spinal fractures. In a retrospective analysis of 23 geriatric (> 70 years) patients with a fracture of the odontoid, we compared some of the clinical features to a contemporary series of patients younger than 70 years of age. Whereas in the younger patients high-energy trauma accounted for the majority of the fractures, low-energy falls were the underlying cause in 90% of the odontoid fractures in the elderly. In contrast to the younger age group, in elderly patients predominantly type II fractures (95%) were identified. Anterior and posterior displacement were recorded with equal frequency on the first postinjury radiograph in the younger age group, whereas in geriatric patients displacement was mainly posterior. The number of associated injuries was significantly higher in younger patients. There was no difference in the occurrence of neurological deficits (13%) between the two age groups, and neurological compromise was mainly related to posterior dislocation of the odontoid in both groups. The overall complication rate was significantly higher in elderly patients (52.2% vs 32.7%), with an associated in-hospital mortality of 34.8%. Loss of reduction and non-union after non-operative treatment, a complicated postoperative course and complications due to associated injuries accounted primarily for this high complication rate. Elderly patients with a fracture of the odontoid are a high-risk group with a high morbidity and mortality rate. An aggressive diagnostic approach to detect unstable fractures and application of a halo device or early primary internal stabilisation of these fractures is recommended.

Midshaft fractures of the clavicle with a shortening of more than 2 cm predispose to nonunion.

Abstract Up to 15% of all fractures involve the clavicle. Nonunion of the clavicle is a rare complication after conservative treatment. It mainly presents as pain at the fracture site and a limited range of motion of the shoulder. The purpose of this study is to define a certain type of fracture of the clavicle that is predisposed to malunion and therefore should be treated surgically after failure of conservative treatment. Thirty-nine patients with delayed or malunion of the clavicle were analyzed. There were 13 women and 26 men. The average age of the male patients was 36.4 years (range 20–59 years) and of the female patients, 43.6 years (range 18–55 years). The mean follow-up period was 2.3 years (range 6 months to 4.2 years). All of them were treated surgically. There were 33 Allman I fractures and 6 Allman II fractures. Of the Allman I fractures, 30 (91%) were shortened by at least 2 cm. Allman I fractures were treated using a reconstruction plate or a dynamic compression plate in combination with bone grafting. The time of operation after fracture ranged from 6 weeks to 8.5 years (average 9.8 months). Pain at the fracture site was the leading symptom in all patients. At 6 months after the operation, 38 patients were free of pain with an unlimited range of motion of the shoulder. One patient (2.6%) complained of a slight weakness on the operated site. One fracture failed to unite (2.6%) and had to be replated. There were no refractures, infections, vessel or nerve lesions. To conclude, in Allman I fractures with a shortening of more than 2 cm, we recommend operative treatment in symptomatic patients if there are no signs of callus formation after 6 weeks.

Traumatic spondylolisthesis of the axis: treatment rationale based on the stability of the different fracture types

Abstract Thirty-nine consecutive patients, 22 male and 17 female with an average age of 37.6 years, with traumatic spondylolisthesis of the axis were reviewed. The cause of injury in 75% of the patients was a road traffic accident. The fractures were classified according to Effendi et al., the type II fractures were further divided into three subgroups: flexion, extension and listhesis injuries. There were 10 type I (25.7%) and 29 type II fractures (74.4%); of these, 12 (30.8%) were classified as flexion-type, 2 (5.1%) as extension-type and 15 (38.5%) as listhesis-type. We did not identify any case of ¶type III injury. Overall, 43.5% of the patients had sustained a significant head or chest trauma, with the highest incidence for type II listhesis injuries. Significant neurological deficits occurred in four patients (10.3%); in all four,the fracture was classified as a type II listhesis. All ten type I injuries were successfully treated with a cervical orthosis. Ten of the¶12 type II flexion injuries demonstrated significant angulation. Two were treated with internal stabilisation, in seven with a halo device and one with a minerva plaster of Paris (PoP). Healing was uneventful in all ten patients. For the remaining two stable type II flexion injuries, application of a hard collar was adequate, as was the case for the two stable type II extension injuries. Six of the 15 type II spondylolisthesis injuries underwent primary internal stabilisation, and healing was uneventful in all cases. In four (44.4%) of the nine injuries that were primarily treated with a halo device/minerva PoP, secondary operative stabilisation had to be performed. The classification of Effendi et al. provides a complete description of the different fractures. However, further distinction of the type II injuries regarding their stability is mandatory. Type II spondylolisthesis injuries are unstable, with a high number of associated injuries, a great potential for neurological compromise and significant complications associated with non-operative treatment. The majority of type II extension and type II flexion injuries can be successfully treated with non-rigid external immobilisation.

Prosthetic replacement of the head of the radius: which clinical results are to expect?

SummaryWe report our results after primary implantation of 30 radial head prostheses in a retrospective study from 1978 to 1996. If there was intraoperatively a remaining instability of the elbow after resection of the radial head, we implanted a prosthesis. The average age of our patients was 40.7 years. The results were evaluated concerning the recommendations of Radin and Riseborough. In 22 patients (73 %) we found good to satisfactory results, in 8 patients (27 %), there was a free range of motion. Heterotopic ossifications with a remarkable decrease in the range of motion were discovered in 3 patients (10 %). The implant had to be removed in three (10 %) patients (2 incorrect implantations, one broken prosthesis). To conclude, the primary implantation of a radial head prosthesis after a strict indication improves the clinical benefit for the patient. A correct surgical technique avoids unneccessary complications.ZusammenfassungIm Rahmen einer retrospektiven Nachuntersuchung wurden die Ergebnisse nach primärer Implantation einer Speichenköpfchenprothese aus dem Zeitraum 1978–1996 bei 30 Patienten ausgewertet. Die Indikation zur Implantation der Prothese wurde intraoperativ bei einer verbliebenen Instabilität im Ellenbogengelenk nach Radiusköpfchenresektion gestellt. Das Durchschnittsalter der Patienten betrug 40,7 Jahre. Die Bewertung der Ergebnisse erfolgte nach den Kriterien von Radin und Riseborough. Von den 30 nachuntersuchten Patienten fanden sich bei 22 (73 %) gute bis befriedigende Ergebnisse, bei 8 (27 %) konnte eine freie Beweglichkeit nachgewiesen werden. Bei 3 Patienten (10 %) zeigten sich postoperativ periartikuläre Verkalkungen, die zu einer weitgehenden Bewegungseinschränkung führten. Bei weiteren 3 Patienten (10 %) mußte die Prothese wieder entfernt werden (2 Implantations-, 1 Materialfehler). Nach Auswertung der Ergebnisse ist festzustellen, daß bei strenger Indikationsstellung die Implantation einer Speichenköpfchenprothese einen klinischen Nutzen für den Patienten bedeutet. Eine exakte Implantationstechnik läßt unnötige Fehlergebnisse vermeiden.

10-Jahres-Ergebnisse knochenmarkstimulierender Therapie der Osteochondrosis dissecans tali

ZusammenfassungDie optimale Therapie der Osteochondrosis dissecans tali (ODT) wird aktuell sehr kontrovers diskutiert. Neben knochenmarkstimulierenden, faserknorpelinduzierenden Verfahren wie der Abrasionsplastik, Herdanbohrung und Mikrofrakturierung werden in zunehmendem Ausmaß die autologe osteochondrale Transplantation und autologe Chondrozytentransplantation eingesetzt. 10,4 Jahre nach knochenmarkstimulierender Therapie wurden 45 Sprunggelenke von 44 Patienten mit einer ODT im Stadium 3 und 4 nach Berndt und Harty nachuntersucht und die Ergebnisse mit dem AOFAS-Score, Mazur-Score sowie der radiologischen Klassifikation von van Dijk analysiert. An allen Sprunggelenken war das Dissekat entfernt und eine Abrasion des subchondralen Knochens durchgeführt worden sowie in 67% eine zusätzliche antegrade Herdanbohrung erfolgt. Die maximale Ausdehnung der Läsion betrug präoperativ durchschnittlich 1,1 cm. Ein exzellentes funktionelles Resultat wurde im Score von Mazur bei 28 Patienten (62%) beobachtet, bei 12 Patienten (27%) ein gutes und bei 5 (11%) ein mäßiges oder schlechtes Resultat. Der durchschnittliche AOFAS-Score betrug 91 Punkte (66–100 Punkte). An 8 Gelenken (18%) waren innerhalb des Beobachtungszeitraumes weitere operative Eingriffe erforderlich. Progressive osteoarthrotische Veränderungen gemäß der Klassifikation von van Dijk wurden an 7 Sprunggelenken (16%) nachgewiesen. Patienten über 40 Jahre, mit Adipositas sowie vorbestehenden osteoarthrotischen Veränderungen erreichten signifikant schlechtere Ergebnisse im AOFAS- und Mazur-Score. Die knochenmarkstimulierende Therapie der ODT im Spätstadium ist ein günstiges,wenig invasives Verfahren und stellt zumindest bei kleineren ODT-Läsionen eine gute Behandlungsoption dar. Neuere Verfahren wie die autologe osteochondrale Transplantation und autologe Chondrozytentransplantation führen zu überwiegend guten und sehr guten 2- bis 4-Jahres-Ergebnissen, haben jedoch ihre Überlegenheit im Langzeitverlauf noch nachzuweisen.AbstractThe optimal operative therapy for the treatment of osteochondritis dissecans tali is still controversial. Beside bone marrow-stimulating techniques like abrasion arthroplasty, drilling and microfracturing,new techniques like autologous osteochondral transplantation and autologous chondrocyte transplantation are increasingly used. This study reviewed the clinical, radiological and subjective long-term outcome of bone marrowstimulating therapy for 45 ankles with an osteochondritis dissecans tali stage 3 or 4 according to the classification by Berndt and Harty. All ankles were treated by the removal of the dissecate and abrasion of the subchondral bone. In 67%, an additional antegrade drilling of the defect was performed. The average maximum size of the lesion was 1.1 cm. At follow-up examination, 10.4 years (7.1–13.5 years) postoperatively, the average AOFAS-score was 91 points (66–100 points). Using the score of Mazur, the outcome of 28 ankles (62%) was rated excellent, 12 ankles (27%) were rated good and five ankles (11%) fair or poor. Progressive osteoarthritic changes, according to the classification of van Dijk,were seen in seven ankles (16%). Reoperations were necessary in eight cases (18%). Obesity, age older than 40 years and preoperative osteoarthritic changes had a significant negative impact on the clinical outcome. Bone marrow stimulating therapy is an inexpensive, low invasive therapy and a good therapeutic option at least for small Berndt/Harty stage 3 and 4 ODT lesions. Autologous chondrocyte transplantation and osteochondral autografts yield encouraging 2- and 4-year results, but still have to prove their superiority in long-term follow-up studies.

Chirurgische Therapie bei Inkongruenzen und Arthrosen am oberen Sprunggelenk

: Joint incongruency, malalignement as well as degenerative changes of the ankle joint may result in disabling pain with a significant decrease in function and mobility. The clinical symptoms may affect all aspects of life. Primary osteoarthritis of the ankle joint is uncommon, and posttraumatic conditions with significant changes in joint mechanics are usually the primary source of joint degeneration with the resultant clinical symptoms. Apart from pain relief and restoration of joint mobility, prevention of joint degeneration or progression of arthrosis should be the main goal in treating such conditions. Arthrodesis of the ankle still is the method of choice for severe osteoarthritis of the ankle, however several surgical treatment options are available to deal with mild to moderate joint degeneration. Restoration of the anatomy and joint alignement in posttraumatic deformities as well as ligament reconstruction in chronic instability are measurements to prevent development or progression of osteoarthritis. Joint debridement is useful in primary anterior joint pathology, in advanced osteoarthritis at least temporary pain relief can be achieved. In severe osteoarthritis arthrodesis of the ankle is the method of choice for long-term pain relief and restoration of mobility.

Suprakondyläre Femurfrakturen bei Knieendoprothesen Stabilisierung mit einem retrograden Verriegelungsnagel

ZusammenfassungDie adäquate Behandlung einer suprakondylären Femurfraktur bei liegender Knieendoprothese ist nach wie vor nicht unproblematisch und wird kontrovers diskutiert.Wir berichten über 6 Patienten, deren Fraktur mit einem retrograden intramedullären Verriegelungsnagel (GSH-Nagel) stabilisiert wurde. Das Durchschnitsalter der Patienten betrug 70,5 Jahre. Die Fraktur ereignete sich im Schnitt 34,5 Monate nach Implantation der Knieendoprothese. Die durchschnittliche Operationsdauer betrug 97,16 min, intra- oder postoperative Komplikationen waren nicht zu verzeichnen. Die zeitgerechte Frakturheilung konnte ausnahmslos dokumentiert werden. Bei einem mittleren Nachbeobachtungszeitraum von 17,3 Monaten entsprach das postoperativ erreichte Bewegungsausmaß bei 5 Patienten dem Status vor der Fraktur. Bei einem Patienten wurde ein Streckdefizit von 10° mit einer Valgusabweichung von ebenfalls 10° festgestellt.Der retrograde Verriegelungsnagel ist eine geeignete Alternative in der Versorgung instabiler suprakondylärer Femurfrakturen bei liegender Knieendoprothese. Das Weichteiltrauma ist gering, die stabile Versorgung erlaubt eine frühfunktionelle Nachbehandlung mit Teilbelastung. Die achsgerechte Ausrichtung der Fraktur ist zu beachten.AbstractThe treatment of supracondylar fractures of the femur in total knee arthroplasty is still challenging, and a variety of methods has been recommended.In a retrospective analysis, we reviewed six patients (average age: 70.5 years) with this type of fracture that had been stabilized with a retrograde intramedullary locking nail [Green-Seligson-Henry (GSH) nail]. The fracture had occurred 34.5 months after implantation of total knee arthroplasty. The average time of the operation was 97.16 min. There were no intra- or postoperative complications. All patients could be followed up at 17.3 months on average. Fracture healing was uneventful in all six cases. The postoperative range of motion was similar to the prefracture level in five patients. One patient demonstrated a loss of extension (10°) associated with a valgus malalignment of 10°.According to our experience, retrograde intramedullary nailing of supracondylar fractures in total knee arthroplasty is a promising alternative, which allows closed reduction and preservation of the soft tissue envelope. Immediate mobilization with partial weight bearing is possible, and the rate of complications is low.

Die direkte Verschraubung von Frakturen des Dens axis

ZusammenfassungRetrospektiv wurden die Ergebnisse nach direkter Verschraubung von Frakturen des Dens axis bei 28 Patienten evaluiert. Bis auf eine Typ-III-Fraktur wurden ausnahmslos Typ-II-Verletzungen osteosynthetisch versorgt. Eine verzögerte Frakturheilung mit persistierender Instabilität trat bei der Typ-III-Fraktur (3,6 %) auf, konsekutiv war eine Reoperation erforderlich. Eine Schraubenfehllage mit nur partiellem Fassen des Densfragments wurde postoperativ bei 3 Patienten (10,7 %) dokumentiert. Eine persistierende Achsabweichung des Densfragments zeigte sich postoperativ in 5 Fällen (17,9 %). Allgemeine kardiopulmonale Komplikationen waren bei 5 Patienten (17,9 %) aufgetreten, insgesamt 4 Patienten (14,3 %) waren in der postoperativen Phase verstorben; 17 Patienten konnten mindestens 1 Jahr postoperativ nachuntersucht werden. Lediglich 3 (17,8 %) Patienten waren beschwerdefrei. Eine signifikante Einschränkung der Rotationsbewegung der HWS war in 44 % der Fälle zu verzeichnen. Die direkte Verschraubung von Typ-II-Frakturen des Dens axis weist eine hohe Konsolidierungsrate auf, ist jedoch technisch anspruchsvoll. Hinsichtlich der funktionellen Ergebnisse ergibt sich kein wesentlicher Vorteil gegenüber anderen etablierten Verfahren.SummaryThe results of anterior screw fixation of odontoid fractures in 28 patients are presented. There were 27 type II- and 1 type III-injuries. Non-union with persistent instability had to be notified in one patient (3.6 %), secondary posterior C1/2 fusion had to be performed. Incorrect positioning of the screws in the odontoid with penetration of the postero-lateral cortex occurred in 3 patients (10.7 %). Malpositioning of the odontoid after screw fixation was documented in 5 cases (17.9 %). Cardiopulmonary complications had to be treated in 5 patients (17.9 %), 4 patients (14.3 %) died in the postoperative period. 17 patients could be followed up. Only 3 patients (17.8 %) were free of symptoms. A significant limitation in ROM of axial rotation was seen in 44 % of the patients. With anterior screw fixation of the odontoid high fusion rates can be achieved, however the procedure is technically demanding. Regarding the functional outcome, there is no significant difference to other established treatment methods.

Ipsilateral fractures of the pelvis and the femur--floating hip? A retrospective analysis of 42 cases.

Abstract A consecutive series of 40 patients, who sustained 42 ipsilateral pelvic and femoral fractures, is reported. There were eight (26.6%) traumatic neurological deficits and three open femoral fractures. Two multiply injured patients died in the postraumatic period because of the severity of their injuries. No associated vascular injuries could be identified. All but two fractures of the femur, 8 of the 15 fractures of the pelvic ring and 17 of the 30 fractures of the acetabulum were treated by internal fixation. In 26 patients internal fixation was performed on both fracture components (in 17 patients this was done under the same period of anaesthesia). Postoperatively, a deep venous thrombosis in three patients, one deep wound infection and five (18.5%) iatrogenic neurological deficits had to be notified. In this series we could not identify any specific associated injuries and complications as known for the floating knee or the floating elbow. The term floating hip is inprecise and misleading, and its use is not recommended. The treatment of this fracture-combination follows the guidelines established for the individual lesions.

Surgical excision of heterotopic bone after hip surgery followed by oral indomethacin application: is there a clinical benefit for the patient?

Abstract The clinical effect of surgical excision of heterotopic bone after hip surgery in combination with an oral indomethacin application was analysed in 21 patients in a retrospective study. Indomethacin (3 × 50 mg) was administered after the first postoperative day for a period of 6 weeks. To avoid gastrointestinal side-effects, a mucoprotectivum (sucralfat, 3 × 1 g) was also applied. One year after surgery, 19 patients (90.4%) had excellent relief of pain, the average improvement of flexion was 40°, of abduction 13°, of internal rotation 8° and of external rotation 14°. Only one patient (4.8%) suffered a recurrence of heterotopic bone formation, and in one patient (4.8%) we observed gastrointestinal side-effects. Thus, we recommend surgical excision of heterotopic bone followed by oral indomethacin therapy as a convenient and reliable strategy to prevent new heterotopic bone formation after hip surgery.