H. P. Hofer

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.

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.

Influence of Age on the Release of Reactive Oxygen Species by Phagocytes as Measured by a Whole Blood Chemiluminescence Assay

Polymorphonuclear and mononuclear phagocytes play an important role in host defense, but may also cause tissue injury through excessive inflammation. Reactive oxygen species (ROS) are not only directly ore indirectly involved in a wide variety of clinical disorders, such as atherosclerosis, reperfusion injury, pulmonary toxicity and cancer, but they are also important in the aging process. This process is associated with increasing susceptibility to infection. In this study we investigated the influence of age and sex on phagocyte activation by means of a whole blood chemiluminescence (CL) assay. Circulating phagocyte activity was measured in 55 healthy volunteers (24 females, 31 males) aged from 6 to 92 years. Using an automated luminescence system, phagocytes were stimulated by polystyrene beads and Luminol-enhanced CL was determined in terms of peak height and peak time in freshly withdrawn, peripheral venous whole blood. An extremely significant positive correlation (p < 0.0001) between the maximum of light emission after stimulation and increasing age was found. This finding is true for the total population of blood phagocytes as well as for a single cell. In contrast the time of the appearance of the maximum of light emission showed an extremely significant inverse correlation (p < 0.0003) with increasing age. The influence of sex on the CL-parameters showed no significant difference between women and men. It is concluded that the increased susceptibility of circulating phagocytes to oxidative burst in elderly subjects may be the consequence of several biological events. Senescent cells express more and also have new antigens on their surfaces that trigger an autoimmune response. Cellular senescence appears earlier in old organisms. Therefore phagocytes in aging individuals may be increasingly involved in their scavenger tasks that grow with the catabolic bias in cell turnover. Moreover, atherosclerotic alterations in the intima and endothelial lesions are physiologic concomitants of age and may lead to a stimulation of circulating phagocytes.

Basic fibroblast growth factor (BFGF) immunoreactivity as a possible link between head injury and impaired bone fracture healing

Healing of fractures of long bones or large joints is often accelerated in patients with severe traumatic brain injury (TBI). However, in these patients an early fracture healing is accompanied by hypertrophic callus formation or heterotopic ossifications which might even result in an ankylosis of the affected joints. It seems that enhanced osteogenesis in patients suffering from TBI could be caused by some humoral factors, since the sera of these patients strongly promote the growth of osteoblast cells in vitro. However, humoral growth promoting factors which could perhaps induce enhanced osteogenesis are not yet identified. Hence, the aim of this study was to analyse if basic fibroblast growth factor (bFGF) could be related to the phenomenon of enhanced osteogenesis, since bFGF stimulates the growth of osteoblasts in vitro and could be found both in the brain and the bone tissue. For that purpose the values of bFGF immunoreactivity were determined in the sera of patients with TBI and bone fractures (n = 8) as well as in the sera of patients with either TBI alone (n = 10) or bone fractures alone (n = 7), during a period of three months after injury. Quantification of the bFGF immunoreactivity was done using the ELISA based on monoclonal antibodies raised against the recombinant human bFGF. The bFGF immunoreactivity values obtained were also compared with the values determined in the sera of normal, healthy persons (n = 9). In the group of patients with bone fractures alone only a transient increase of bFGF immunoreactivity (threefold above the normal values) was observed in the second week after injury. A similar increase of the values of bFGF immunoreactivity was also determined in the sera of patients with TBI only, but it lasted longer (from the 1st until the 7th to 8th week after injury). In the case of patients with TBI and bone fractures a specific pattern of post-traumatic dynamic change of the values of serum bFGF immunoreactivity was observed. Namely, the increase of bFGF immunoreactivity (up to seven-fold above the normal values) was determined even during the first week after injury. Afterwards, periods of high values of bFGF immunoreactivity observed during the 2nd, 4th and the 7-10th weeks after injury were interrupted by sudden decreases even to the normal values (during the 3rd and the 5-6th week after injury).(ABSTRACT TRUNCATED AT 400 WORDS)

Supraintercondylar fractures of the distal humerus: results of internal fixation.

Operative treatment is considered to be the primary method of treatment for supraintercondylar fractures of the distal end of the humerus. Anatomical reduction and stable fixation of the fracture allows for early postoperative functional treatment and, subsequently, better results than other methods. Two series of patients with supraintercondylar fractures of the humerus, one from 1969 to 1980, and the second from 1981 to 1988, are presented. Although these series do not differ widely in their final outcomes, certain philosophies and operative techniques did change for the better.

Blood Polymorphonuclear Leukocyte Activation in Atherosclerosis: Effects of Aspirin

The aim of the study was to demonstrate an activation of polymorpho-nuclear leukocytes (PMNs) in chronic progressive atherosclerosis (ATH). A group of patients with ATH, and a group of ATH patients under aspirin (ASA) therapy were compared with control persons without atherosclerotic alterations (healthy controls). Each group comprised 15 male age-matched subjects. The following inflammatory parameters related to PMN activities were measured: the polymorphonuclear leukocyte (PMN) blood count; blood PMN migration and reactive oxygen species release in vitro; the blood levels of PMN elastase, malondialdehyde, antibodies to oxidized LDL and soluble ICAM-1. In ATH patients, the PMN blood counts and the share of blood PMNs migrating upon platelet activating factor and leukotriene B4 stimulation were significnatly above the values of the healthy controls, while the other parameters were not significantly altered. ASA treatment attenuated the inflammatory response and reduced the differences between ATH and the healthy controls. It can be concluded that, in patients with chronic progressive atherosclerosis, PMNs are involved in the inflammatory process underlying the disease.

Post-traumatic dynamic change of carboxyterminal propeptide of type I procollagen, alkaline phosphatase and its isoenzymes as predictors for enhanced osteogenesis in patients with severe head injury

Patients suffering from severe head injury and fractures of long bones or large joints often show enhanced osteogenesis, with hypertrophic callus formation and/or heterotopic ossifications. The advantage of this phenomenon is early consolidation of the fractures. An extreme disadvantage is extensive periarticular calcification, resulting in complete ankylosis of the affected joint. In spite of numerous efforts aimed at clarifying the way in which severe head injury can influence osteogenesis at a distant site, this phenmenon is still not understood. The process, once started seems irreversible, but if diagnosed in time, could be prevented with non-steroid anti-inflammatory drugs that inhibit development of heterotopic ossifications. The major prerequisite for testing this possibility is to define parameters of an early diagnosis of enhanced osteogenesis. Thus, the aim of this study was to test whether serum values of some parameters related to bone regeneration could allow an early prediction of enhanced ossification following bone fracture in patients with severe head injury. Samples of sera were obtained from three groups of injured patients: fractures of long bones or large joints only (n=6), severe head injury only (n=8), severe head injury and fractures of long bones and large joints (n=7) and from a group of apparently healthy volunteers (n=10). The values for alkaline phosphatase (ALP), the bone isoenzyme, and the carboxy terminal propeptide of type I procollagen (PICP) were significantly higher (5–20 times as high) in patients with severe head injury and bone or joint fractures than in any other group. Significantly increased concentrations of PICP were already found in the 1st week after injury, and those of ALP and of the bone isoenzyme increased during the 2nd week after injury. Results show that these parameters are helpful for an early diagnosis of enhanced osteogenesis and heterotopic ossifications in patients with severe head injury and bone fractures. Further studies are necessary to verify these findings, while analysis of reasons for the specific patterns of dynamic change of these parameters could lead to better understanding of the mechanisms underlying the uncontrolled bone formation.

Interbody fusion of the lower cervical spine: a dangerous surgical method?

ZusammenfassungDie retrospektive Analyse unserer 175 ventralen Spondylodesen der unteren Halswirbelsäule hat den Zweck, Gefahren aufzuzeigen, die bei dieser sehr bewährten Operationsmethode an unserer Klinik auftraten. Im Zeitraum von 1976–1990 wurden 175 Patienten nach dieser Technik operiert, darunter fanden wir 150 Frakturen, Luxationsfrakturen und diskoligamentäre Instabilitäten. In 25 Fällen bestand die Indikation aus Tumoren und Metastasen, entzündlichen oder degenerativen Erkrankungen und chronischen Instabilitäten bei Zustand nach Laminektomien. Der Häufigkeit nach traten folgende intra- und postoperative Komplikationen auf: 4 Infekte, 3 postoperative Redislokationen, 2 ausgedehnte Metallockerungen, 1 einseitige Läsion der A. vertebralis, 1 Pseudarthrose mit Plattenbruch, 1 postoperative radikuläre Störung und 1 sekundär notwendige Erweiterung der ventralen Spondylodese nach primär nicht erkannter Zweisegmentläsion.SummaryOur follow-up study of 175 cases of interbody fusion of the lower cervical spine was conducted to show the complications that occurred in our department with what is considered to be a tried and tested method. From 1976 to 1990, 175 patients were treated with this method. These 175 cases included 150 fractures and/or dislocations. The indications for surgery in the remaining 25 cases were tumors and metastases, inflammatory or degenerative diseases and chronic instabilities following laminectomy. The following complications were seen: 4 cases of infection, 3 postoperative redislocations, 2 cases of extensive loosening of metal, 1 unilateral lesion of the vertebral artery, 1 nonunion with plate fracture, 1 post-operative radicular disorder in an otherwise neurologically normal patient, and 1 secondary extension of the interbody fusion required after failure to recognize a two-segment lesion.

Unstable fractures of the upper thoracic spine

ZusammenfassungInstabile Frakturen der oberen Brustwirbelsäule sind wegen der hohen Inzidenz an Begleitverletzungen und Rückenmarkläsionen eine therapeutische Herausforderung. Diese Kasuistik konzentriert sich auf die operative Therapie solcher Verletzungen. Wir präsentieren 9 Patienten mit instabilen Verletzungen der oberen Brustwirbesäule, nach der Einteilung von Magerl et al. handelt es sich um 7 Typ C- und 2 Typ B-Verletzungen. 8 Patienten hatten komplette Querschnittsläsionen, bei 1 Patient bestand eine unauffällige neurologische Situation. Alle Patienten wiesen Begleitverletzungen auf, 9 hatten Rippenfrakturen, 3 ein frakturiertes Sternum und 3 einen schweren Hämatothorax. Alle wurden operiert; 6 alleinige dorsale Fusionen, 2 alleinige ventrale Fusionen nach Thorakotomien wegen stark blutender rupturierter Interkostalarterien und eine kombinierte Fusion nach fehlgeschlagener posteriorer Stabilisierung wurden ausgeführt. Die Behandlung solcher Patienten sollte individuell gestaltet werden, abhängig von den Begleitverletzungen, vom Blutverlust aufgrund von frakturierten Rippen und rupturierten Gefäßen und vom Schmerz, verursacht durch einen instabilen Thorax. Im allgemeinen bevorzugen wir den dorsalen Zugang bei instabilen Verletzungen der Brustwirbelsäule.AbstractUnstable fractures of the upper thoracic spine are a therapeutic challenge because of the high rate of associated injuries and frequent occurrence of spinal cord lesions. This study focuses on the operative treatment of these injuries. We present nine patients with unstable injuries of the upper thoracic spine. According to the classification of Magerl et al., there are seven type C and two type B fractures. Eight patients had complete transverse lesions of the cord and one had no evidence of spinal cord injury. All patients presented associated injuries: nine patients had fractured ribs, three a fractured sternum and three a severe haemothorax. All underwent operative treatment: six posterior fusions only, two anterior interbody fusions only after thoractotomy owing to severe bleeding from ruptured intercostal arteries, and one a combined fusion after failure of posterior fusion. The treatment of these patients should be individualized, depending on the associated injuries, loss of blood owing to fractured spine and ruptured vessels and depending on the back pain resulting from an unstable thorax. In general, we prefer the posterior approach to unstable fractures of the upper thoracic spine.

PMN-related parameters for the monitoring of wound healing in traumatology.

SummaryIn the search for objective methods to monitor the course of wound healing, the proteinase PMN elastase (n=56 pat.), the lipid peroxidation product malondialdehyde (MDA) (n=18 pat.), and polymorphonuclear neutrophil granulocytes (PMN) migratory behaviour were measured [1, 6, 7, 11]. This “stimulated PMN-locomotion” was quantified by a new PMN migration filter assay (n=10 pat.) [2]. We determined the clinical course during “per primam (pp)” wound healing (group 1), “pp” wound healing with secondary inflammatory disease (group 2), manifestation of a bacterial wound infection during healing-“per secundam (ps)” (group 3) and manifest wound infection (“ps”) at the time of admission (group 4).In group 1 PMN elastase returned to normal values on the 10th postsurgical day. Median values in group 3 reflected a highly significant difference (p<0,01) on day 4 and 5 compared with group 1. In group 2 and 4 medians reflected consistent high values without reaching normal ranges throughout. MDA did not exceed the normal range in group 1, in group 3 low levels persisted, and in group 4 a recurring increase was noticed.The total migration index median (TMI) in Group I, which quantifies the percentage of stimulated PMN, reflected its highest value immediately post-surgically and dropped to the lowest on the 13th postsurgical day (decrease by 54%). The mean invasion depth (T/2), a parameter of PMN distribution, showed only slight variation with time. In a group 3-patient, T/2 reflected a maximal migratory stimulation on day 6, 4 days before clinical infection signs could be noticed; then it dropped to the lowest on day 10. This decrease probably reflects a PMN behavioural change from migration to phagocytosis [9].RésuméLa protéinase PMN élastase (n=56 malades), le produit de la peroxidation lipidique malon dialdehyde (MDA) (n=18) aussi bien que la migration des granulocytes neutrophiles polymorphonucléaires (PMN) ont été mesurées dans le cadre de la recherche de méthodes pour surveiller le cours de la cicatrisation. Cette “PMN Locomotion simulée” a été quantifiée par un nouvel essai pour la migration des PMN (n=10). Nous avons déterminé le cours clinique de la cicatrisation dans un groupe de cicatrisation “per primam” (pp) (groupe 1), “pp” cicatrisation et surinfection secondaire (groupe 2), surinfection bactérienne durant la cicatrisation “per secundam” (ps) (groupe 3) et infection initiale au moment de l’admission (groupe 4).Dans le groupe 1 l’élastase PMN est retournée à des valeurs normales au dixième jour après l’intervention. Les valeurs moyennes du groupe 3 ont montré une différence significative (p<0,01) le quatrième et cinquième jour par rapport au groupe 1. Dans les groupes 2 et 4 les moyennes ont montré des valeurs élevées permanentes sans atteindre des valeurs normales. MDA est resté dans les limites de la normale dans le groupe 1; dans le groupe 3 les valeurs sont restées basses et dans le groupe 4 on a pu constater un accroissement répété des valeurs.Dans la migration PMN (concernant le groupe 1), la moyenne de l’index total de migration (TMI), qui mesure le pourcentage de PMN stimulé, présente la valeur la plus élevée immédiatement après l’intervention pour tomber au plus bas le treizième jour après l’intervention (diminution de 54%). La profondeur moyenne d’invasion (T/2), un paramètre de distribution de PMN, a montré seulement une légère variation avec le temps. Avec un malade du groupe 3, T/2 a montré une stimulation migratoire maximale le sixième jour, 4 jours avant que des signes cliniques d’infection aient pu être remarqués; puis T/2 est tombé au plus bas le dixième jour. cette diminution de T/2 reflète probablement des conditions de PMN changeant de la migration à la phagocytose.