Gerolf Peicha

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.

Radial avulsion of the triangular fibrocartilage complex in acute wrist trauma: A new technique for arthroscopic repair

The advantages of arthroscopically assisted treatment of intraarticular distal radius fractures, especially the detection of additional carpal lesions, also focus attention on special surgical techniques for operating on these injuries within the same session. When we consider the biomechanical situation, various kinds of triangular fibrocartilage complex (TFCC) lesions, and their arthroscopic aspects, there are probably two possibilities for surgical treatment that are similar to arthroscopic meniscal surgery: resection of flap tears and the refixation of peripherally disinserted TFCC. Avulsions from the ulnar styloid or from the ulnar collateral ligament and the extensor carpi ulnaris tendon can easily and satisfactorily be treated by convenient arthroscopic suture techniques, whereas the reattachment of the triangular disc in the sigmoid notch is very tricky. This problem is solved by a recently developed procedure using the so-called T-Fix-device (Acufex), which provides the possibility of transosseus refixation by closed arthroscopic procedure and therefore guarantees the principle of minimal invasive surgery.

Midterm results of arthroscopic treatment of scapholunate ligament lesions associated with intra-articular distal radius fractures.

Abstract Since 1993, we have treated 30 patients with acute intra-articular distal radius fractures using arthroscopic assistance. Concomitant lesions of the intrinsic scapholunate (SL) ligaments were diagnosed in 12 patients (40%). Using the grading system of Geissler et al. [13], the identified lesions included a single grade I tear, three grade II, six grade III, and two grade IV. The grade III and IV lesions were accompanied by intraoperative findings of marked instability. Therefore operative stabilization was performed by temporary scapholunate and scaphocapitate arthrodesis. Seven patients in this group (87.5%) were followed up clinically and radiologically for an average of 3u2002years postoperatively. Clinical examination included range of motion and a subjective questionnaire concerning pain and ability to work. Objective grip strength was measured using a Jamar-tester and compared to the contralateral wrist. Radiological evaluation consisted of posteroanterior and lateral views and of stress views in radial and ulnar deviation. Data were evaluated by the scoring systems of Jakim et al. [21], Cooney et al. [5] and by the demerit point system of Gartland and Werley [12], as modified by Sarmiento et al. [36]. An excellent result was present in 100% of our patients by the Gartland and Werley system, in 86% by that of Jakim et al., and in 60% by that of Cooney et al. Based on a subjective questionnaire, all of the patients had an excellent or good result.

Lesions of the scapholunate ligaments in acute wrist trauma – arthroscopic diagnosis and minimally invasive treatment

Abstract The final result of the treatment of distal intra-articular radius fractures depends both on the accuracy of the fracture reduction and on the presence of additional carpal injuries. In particular, lesions of the intrinsic ligaments usually lead to severe degenerative damage of the wrist joint if they are missed primarily. With the introduction of wrist arthroscopy, these tears can be evaluated and treated earlier. Since 1993 arthroscopically assisted treatment has been performed in 23 patients with distal intra-articular fractures of the radius (mainly C-fractures according to the AO classification system or group VII and VIII fractures according to Frykman). Scapholunate (SL) tears were found in 11 patients (47.8%), 7 of whom showed marked instability intraoperatively and were stabilised at the time of surgery.

Diagnostische Wertigkeit von Nativröntgen, Computer- und Magnetresonanztomographie beim akuten Hyperflexionstrauma des FußesEine prospektive klinische Studie

ZusammenfassungUm zufriedenstellende Ergebnisse in der Behandlung von akuten Hyperflexionstraumen des Fußes erzielen zu können, ist eine exakte Primärdiagnostik zwingend erforderlich, da Verletzungen des Tarsometatarsalgelenkes (Lisfranc-Gelenks) bei alleiniger Verwendung konventioneller Röntgendiagnostik häufig übersehen werden. Ziel vorliegender prospektiver Studie war es, die diagnostische Kapazität von Nativröntgen, CT und MRT in der klinischen Anwendung beim akuten Fußtrauma zu vergleichen.Dazu wurden 75 konsekutive Patienten nach akutem Hyperflexionstrauma (Niedrigenergietrauma) des Fußes in die Studie eingeschlossen. Es handelte sich um 47 Männer und 28 Frauen mit einem Durchschnittsalter von 38 Jahren. Es wurden primär a.-p., seitliche und 45°-Schrägaufnahmen sowie Belastungsaufnahmen im Seitenvergleich angefertigt. Des Weiteren wurden eine Computer- und eine Magnetresonanztomographie durchgeführt.Durch die Nativröntgenaufnahmen konnten 48 metatarsale und 24 tarsale Frakturen sowie Störungen des Gelenksalignments bei 17 Patienten festgestellt werden. Die Belastungsaufnahmen erbrachten keine Erweiterung der Diagnose. Computertomographisch wurden 86 metatarsale und 74 tarsale Frakturen, sowie 31 Fälle von Sub- bzw. Luxationen im Lisfranc-Gelenk und 4 knöcherne Avulsionen des Lisfranc-Ligaments diagnostiziert. Die Magnetresonanztomographie konnte 85 metatarsale und 100 tarsale Frakturen, sowie 31 Alignmentstörungen des Lisfranc-Gelenks und 22 komplette oder partielle Rupturen des Lisfranc-Bands diagnostizieren.Die vorliegende Studie zeigte die klare Überlegenheit von Computer- und Magnetresonanztomographie, verglichen mit der konventionellen Röntgendiagnostik in der Evaluation von knöchernen und ligamentären Verletzungen des Lisfranc-Gelenks. Deshalb muss die Forderung nach Durchführung einer erweiterten Diagnostik beim Hyperflexionstrauma des Fußes gestellt werden.AbstractIn order to gain satisfying results in the treatment of acute hyperflexion trauma to the foot, it is absolutely necessary to achieve an exact primary diagnosis because injuries to the tarsometatarsal joint are frequently missed primarily. Aim of this prospective clinical study was to evaluate the diagnostic reliability of conventional radiography, CT and MRI compared to each other.75 consecutive patients after hyperflexion trauma to the foot were included. There were 47 males and 28 females with a mean age of 38 years. After admittance, pa-, lateral and 45° oblique radiographs were taken as well as stress views in comparison to the contralateral foot. Furthermore, CT and MRI were performed in any patient.By conventional radiography, 48 metatarsal and 24 tarsal fractures were diagnosed as well as 17 cases of malalignment of the Lisfranc joint. Stress radiographies were not able to provide a more accurate diagnosis. By CT scans, however, 86 metatarsal and 74 tarsal fractures were detected. Moreover, we found malalignment in 31 and bony avulsions of Lisfrancs ligament in 4 patients. By MRI, finally, 85 metatarsal, 100 tarsal fractures and 31 cases of malalignment were diagnosed. Additionally, partial or complete tears of Lisfrancs ligament were depicted in 22 patients.The present study could clearly show the superiority of CT and MRI to conventional radiography in diagnosis of bony and ligamentous disorders of the Lisfranc joint. Therefore, extended diagnosis has to be demanded in all cases of hyperflexion trauma to the foot.

Detection of pneumoperitoneum by ultrasound examination: an experimental and clinical study

PURPOSE OF THE STUDYnThe aim of the study is to show the value and reliability of ultrasound examination in detecting free intraabdominal air after blunt abdominal trauma.nnnMETHODSnThe experimental part of this study includes the evaluation of the sonographic morphology of air within liquid and solid tissues. Subsequently air was injected into the abdominal cavities of 10 cadavers and sonography utilized for localization and assessment of the minimal detectable air volume. The clinical part of the study reports on the sonographic detection of hollow viscus perforation in 10 patients, who were admitted to our institution because of acute abdominal problems.nnnRESULTSnSonography is a reliable method for the diagnosis of free intraabdominal air. Best position for ultrasound examination of the abdomen is supine with the thorax slightly elevated (10-20 degrees). The optimal probe position is in the right paramedian epigastric area in the longitudinal direction. In all the 10 patients we were able to diagnose pneumoperitoneum preoperatively by ultrasound assessment.

Anatomical and safety considerations in establishing portals used for wrist arthroscopy.

Eight portals are used for wrist arthroscopy, five for the radiocarpal joint and three for the midcarpal space. These portals pass between important vessels and cutaneous nerves and the extensor tendons underlying the extensor retinaculum and permit access to the common pathologies of the wrist joints. The portals can be safely established making precise use of the external landmarks and are associated with little soft tissue damage and few complications when performed gently and through the dorsal side of the wrist. Clin. Anat. 12:179–185, 1999.

Ultrasound diagnosis of the Achilles tendon

ZusammenfassungAufgrund der oberflächlichen, subkutanen Lage ist die Achillessehne der sonographischen Untersuchung gut zugänglich. Durch die Einführung kurzer Schallsonden (10 MHz) kann auch der tendomuskuläre Übergang und der Ansatzbereich der Sehne mit ausreichender Sicherheit dargestellt werden. Die Diagnose der frischen Ruptur ist immer mittels sonographischer Untersuchung möglich. Bei der Beurteilung partieller Rupturen, Rerupturen, Rupturen vorgeschädigter Sehnen und im postoperativen Verlauf müssen die inhomogenen Verdickungen der Sehnenstruktur mit der Möglichkeit der Entstehung von Artefakten und die Differentialdiagnose echodichter und echoarmer Areale Berücksichtigung finden.In jedem Fall ergibt die dynamische Funktionsprüfung im Seitenvergleich die Möglichkeit einer funktionellen Darstellung, wobei auch bei schwierigen Sehnenverhältnissen eine Ruptur in den meisten Fällen sonographisch abgeklärt werden kann.AbstractDue to the superficial position of the Achilles tendon and the development of high-resolution probes with 7.5, 10, and more MHz, which allow the exact depiction of even very small structures, ultrasonography is the method of choice for the diagnosis of acute and chronic Achilles tendon disorders.Using sonography, both chronic achillodynia (disorders of the tendon itself, peritendinous tissue, bursa, and insertion of the tendon at the calcaneus) and ruptures of the Achilles tendon are exactly diagnosed. By sonographic examination, depiction of changes of the tendon itself (rupture, calcification, thickening) and evaluation of the peritendinous soft tissue with dynamic assessment of the gliding sheath are possible. The risk for the less experienced clinician using ultrasonographic assessment of the locomotor system is not to miss pathologic findings, but to overestimate them, due to artifacts. Sufficient knowledge of ultrasound physics as a reason for typical artifacts and the use of a standardized examination technique are necessary. However, by using high-resolution small ultrasound probes, the depiction of “problem areas” (e.g., musculotendinous junction, insertion of the tendon on the calcaneus) has become easier and more accurate.

Transsection of the peroneal nerve complicating knee arthroscopy : Case report and cadaver study

We report the case of a 36-year-old male patient who sustained a hyperextension trauma of the left knee. After performing diagnostic arthroscopy (partial tear of the anterior cruciate ligament) and partial resection of the anterior cruciate ligament, the patient experienced a complete paralysis of the peroneal nerve. One year after the first surgical procedure, a reconstructive repair of the peroneal nerve and a transfer of the anterior tibial muscle was performed. This complication is reported for the first time in literature.

Musculo-tendinous junction of the flexor carpi ulnaris muscle. An anatomical study

The aim of the study was to evaluate the occurrence of the anatomical variations of the musculotendinous junction of the flexor carpi ulnaris (FCU) muscle and the variations of its insertion onto the pisiform. One hundred cadaver specimens preserved according to Thiel’s method were assessed. Following careful dissection, the distance between the musculotendinous junction and the pisiform and the width of the muscle belly were determined. Three typical anatomical variations were found 1) a large muscle belly running distally almost to the insertion onto the pisiform 2) the muscle belly ending more proximally, with some large fibres running parallel to the tendon and almost reaching the pisiform 3) the musculotendinous junction ending more proximally, with only single fibres continuing distally. The length of the tendon was greater than 10 mm. A number of variations of the distal region of FCU were observed. The presence of muscle fibres almost reaching the insertion point onto the pisiform have to be considered when interpreting MRI or ultrasound findings of this region.