Herbert Resch

Percutaneous fixation of three- and four-part fractures of the proximal humerus.

Untreated 3- and 4-part fractures of the proximal humerus have a poor functional outcome. Open operation increases the risk of avascular necrosis and percutaneous reduction and fixation may be preferable. We report 27 patients, 9 with 3-part and 18 with 4-part fractures, treated by percutaneous reduction and screw fixation. Thirteen of the 4-part fractures were of the valgus type with no significant lateral displacement of the articular segment, and five showed significant shift. Instruments were introduced into the fracture through small incisions so that the fragments could be manoeuvred under the control of an image intensifier, taking advantage of ligamentotaxis as far as possible. A good reduction was achieved in most cases. The average follow-up was 24 months (18 to 47). All the 3-part fractures showed good to very good functional results, with an average Constant score of 91% (84% to 100%), and no signs of avascular necrosis. Good radiological results were achieved in 4-part fractures when impacted in valgus except for one patient with partial avascular necrosis of the head. In those with lateral displacement of the head, revision to a prosthesis was required in one patient because of avascular necrosis and in another because of secondary redisplacement of the fracture. Avascular necrosis was seen in 11% of 4-part fractures. The average Constant score in patients with 4-part fractures who did not need further operation was 87% (75% to 100%).

Outcome after primary hemiarthroplasty for fracture of the head of the humerus: A RETROSPECTIVE MULTICENTRE STUDY OF 167 PATIENTS

We have examined 167 patients who had a hemiarthroplasty for three- and four-part fractures and fracture-dislocations of the head of the humerus in a multicentre study involving 12 Austrian hospitals. All patients were followed for more than a year. Anatomical healing of the tuberosity significantly influenced the outcome as measured by the Constant score and subjective patient satisfaction. With regard to pain, the outcome was generally satisfactory but only 41.9% of patients were able to flex the shoulder above 90 degrees. The age of the patient and the type of prosthesis significantly influenced the healing of the tuberosity, but bone grafting did not. Achievement of healing of the tuberosity was inferior in institutions at which less than 15 hemiarthroplasties had been performed (Mann-Witney U test, p = 0.0001).

Rockwood type III acromioclavicular dislocation: Surgical versus conservative treatment

The best treatment for Rockwood type III injuries is still controversial. During a retrospective study, 24 patients who were treated surgically with a hook plate and 17 conservatively treated patients were examined with a mean follow-up of 34 months. The Oxford Shoulder Score, Simple Shoulder Test, and Constant score were assessed at the follow-up examination. Stress radiographs of both shoulders were taken, and the coracoclavicular distance, as well as the width of the acromioclavicular joint, was measured. The mean Constant score was 80.7 in the conservatively treated group and 90.4 in the group that underwent surgery. The mean coracoclavicular distance was 15.9 mm in the conservatively treated group and 12.1 mm in the surgically treated group. These differences were significant (P < .05, Mann-Whitney U test and Student t test). In this study, better results were achieved by surgical treatment with the hook plate than by conservative treatment.

Reconstruction of the valgus-impacted humeral head fracture.

Between 1985 and 1991, 22 patients (average age 52 years, range 26 to 65 years) with severely impacted humeral head fractures were operated on with the aim of preserving the humeral head. All 22 cases showed no significant lateral displacement. Thus it was assumed that the periosteum leading medially to the humeral head was intact and that the vessels passing through the periosteum would ensure survival of the humeral head segment. All patients underwent treatment with open reduction. The impacted segment of the humeral head was raised, the tuberosities were relocated, and the void was filled with chips of cancellous bone. This procedure provided fixation with minimal osteosynthesis. At follow-up evaluation (minimum 18 months, average 36 months) one patient had sequestration of the head segment, and another patient had clinically asymptomatic partial necrosis. None of the remaining 20 patients showed signs of necrosis. Slight arthrosis was present in two patients, and moderate arthrosis was present in one. A correlation was found between the functional result and the quality of reduction. Where anatomic reconstruction had been successful, the long-term functional result was almost identical with the nontraumatized side.

Semitendinosus Tendon Graft Versus a Modified Weaver-Dunn Procedure for Acromioclavicular Joint Reconstruction in Chronic Cases A Prospective Comparative Study

Background Biomechanical studies comparing various surgical techniques for acromioclavicular joint reconstruction have reported that semitendinosus tendon graft for coracoclavicular ligament reconstruction provides a substantial improvement in initial stability and a load-to-failure equivalent to the intact coracoclavicular ligaments. Although it represents a biomechanical improvement compared with coracoacromial ligament transfer, there is still a lack of prospective comparative studies confirming the clinical relevance of these biomechanical findings. Hypothesis Semitendinosus tendon graft for coracoclavicular ligament reconstruction is associated with superior clinical results compared with a modified Weaver-Dunn procedure in chronic complete acromioclavicular joint dislocation. Study Design Cohort study; Level of evidence, 2. Methods Twenty-four patients (mean age, 42 years) with painful, chronic Rockwood type III through V acromioclavicular joint dislocations were subjected to surgical reconstruction. In 12 patients, a modified Weaver-Dunn procedure was performed; in the other 12 patients, autogenous semitendinosus tendon graft was used. Clinical evaluation was performed using the American Shoulder and Elbow Surgeons shoulder score and the Constant score after a mean follow-up time of 37 months. Preoperative and postoperative radiographs were compared. Results The mean American Shoulder and Elbow Surgeons shoulder score improved from 74 ± 7 points preoperatively to 86 ± 8 points postoperatively in the Weaver-Dunn group, and from 74 ± 4 points to 96 ± 5 points in the semitendinosus tendon group (P < .001 for both techniques). The mean Constant score improved from 70 ± 8 points to 81 ± 8 points in the Weaver-Dunn group, and from 71 ± 5 points to 93 ± 7 points in the semitendinosus tendon group (P < .001). The results in the semitendinosus tendon group were significantly better than in the Weaver-Dunn group (P < .001). The radiologic measurements showed a mean coracoclavicular distance of 12.3 ± 4 mm in the Weaver-Dunn group increasing to 14.9 ± 6 mm under stress loading, compared with 11.4 ± 3 mm increasing to 11.8 ± 3 mm under stress in the semitendinosus tendon group. The difference during stress loading was statistically significant (P = .027). In the semitendinosus tendon group, horizontal displacement of the lateral clavicle end could be reduced in all cases with type IV dislocation. Conclusion Semitendinosus tendon graft for coracoclavicular ligament reconstruction resulted in significantly superior clinical and radiologic outcomes compared to the modified Weaver-Dunn procedure.

Minimally invasive reduction and osteosynthesis of articular fractures of the humeral head

Percutaneous reduction and fixation of severe humeral head fractures would be the treatment of choice since it will not increase the risk of necrosis already inherent in these fractures. Nevertheless, the question arises of whether anatomical reduction is possible with the percutaneous technique and whether the reduced fracture can be adequately stabilized. It is important to study the fracture closely before the operation in order to determine the fracture type and identify the relationship of the individual fragments to each other. Radiographs taken in at least two planes are essential and a CT scan with 3D reconstruction would be desirable. Besides extraarticular fractures, surgical neck fractures with avulsion of the greater tuberosity (B1 and B2 fractures) and valgus impacted fractures (C1 and C2 fractures) are good indications for this method due to the fact that in these cases intact connections to rotator cuff tendons or remnants of intact periosteum between fragments still exist. Less good indications are fractures with severe lateral displacement of the articular segment and severely displaced fracture dislocations (C2 and C3 fractures). From 1990 to 1999, a total of 88 patients with 37 B1 and B2 fractures and 41 C1 and C2 fractures were operated on percutaneously. The initial 27 patients with 9 B1 and B2 and 18 C1 and C2 fractures were followed up. All B1 and B2 fractures showed good to very good functional results (Constant Score 91%). The Constant Score of the C1 and C2 fractures was 87%. The necrosis rate of the C1 and C2 fractures was 11%. In conclusion, it can be said that the presence of soft tissue bridging of the various fragments is crucial for the reduction to gain benefit from the ligamentotaxis effect. Thus, fractures such as valgus impacted or three-part fractures are very good indications for this technique. It can also be stated that the necrosis rate is low or at least not increased compared to cases treated by open reduction. Since the fracture is not exposed, adhesion within the surrounding gliding surfaces is reduced and the rehabilitation period is shorter.

The J-Bone Graft for Anatomical Glenoid Reconstruction in Recurrent Posttraumatic Anterior Shoulder Dislocation

Background Posttraumatic shoulder dislocations with glenoid rim fractures show high rates of dislocation recurrence. For glenoid rim defects exceeding a certain size, several investigators recommend bone grafting. Few reports on anatomical glenoid reconstruction addressing this problem are published. Hypothesis Anatomical glenoid reconstruction by the J-bone graft creates permanent joint stability without a clinically relevant loss of motion. Study Design Case series; Level of evidence, 4. Methods Forty-seven shoulders with glenoid rim fractures after recurrent anterior dislocation were stabilized by a J-bone graft. For clinical outcome, motion and strength compared with the uninjured shoulder, as well as sports activity, were recorded. The Rowe score and the Constant-Murley score were used for scoring. In cases of follow-up exceeding 6 years, computed tomography scans were obtained and compared to preoperative radiographs. Results The mean Rowe score was 94.3 for the affected shoulder and 96.8 for the uninjured side. The Constant score reached 93.5 and 95 points, respectively. Loss of external rotation was 4.36° in adduction and 3.19° at 90° of abduction. The computed tomography evaluation included 24 shoulders at a mean follow-up of 106.2 months. There were no recurrences of instability and 1 traumatic graft fracture. Of the 19 patients in whom arthropathy was present at follow-up, 11 had arthrosis before surgery. Conclusion The J-bone graft is capable of creating a stable shoulder joint without causing extensive loss of motion on the long term in patients with traumatic glenoid rim fractures after shoulder dislocation. In some patients, mild to moderate arthropathy develops despite anatomical glenoid reconstruction.

The tendon defect after anterior cruciate ligament reconstruction using the midthird patellar tendon—a problem for the patellofemoral joint?

Retrospective clinical and radiographic evaluation was performed on 41 patients seen at the Salzburg General Hospital Department of Traumatology on average 2 years following ACL reconstruction. In 26 patients (61%) clinical examination revealed pain trigger points over the donor site of the midthird patellar tendon and in the patellofemoral joint. Functional pain during kneeling activities was observed in 19 patients (46%). Objective measurement of the length of the patellar tendon in bilateral radiographs demonstrated exactly equal patellar tendon length in both knees in 11 patients (27%). The radiographs showed tendon shortening following harvesting of the midthird patellar tendon by 1–3 mm in 7 patients (17%), by 4–6 mm in 16 (39%), and by 6–9 mm in 7 (17%). Average length change in the patellar tendon on the donor side was −3 mm, representing a patellar tendon shortening of 9.8%. On the basis of the OAK score, however, good and very good results were recorded in 33 patients (80%). On the whole, these good overall results were compromised only by patellar tendon defect morbidity. In addition to the local scarring problems at the donor site, shortening of the patellar tendon was observed with changes to patella position and interference with the mechanics of the patellofemoral joint. Tendon shortening can be explained on the basis of cicatricial contraction in the process of autorepair to the tendon defect. The problems affecting the patellofemoral joint are inherent in the therapy and must be treated as a negative factor. In the case of patients whose work requires mainly a kneeling position and those who make significant functional demands of the extension system of the knee, a critical assessment is required of the use of the midthird patellar tendon for anterior cruciate ligament reconstruction.

Minimally-invasive treatment of three- and four-part fractures of the proximal humerus in elderly patients

The surgical treatment of three- and four-part fractures of the proximal humerus in osteoporotic bone is difficult and there is no consensus as to which technique leads to the best outcome in elderly patients. Between 1998 and 2004 we treated 76 patients aged over 70 years with three- or four-part fractures by percutaneous reduction and internal fixation using the Humerusblock. A displacement of the tuberosity of > 5 mm and an angulation of > 30 degrees of the head fragment were the indications for surgery. Of the patients 50 (51 fractures) were available for follow-up after a mean of 33.8 months (5.8 to 81). The absolute, age-related and side-related Constant scores were recorded. Of the 51 fractures, 46 (90.2%) healed primarily. Re-displacement of fragments or migration of Kirschner wires was seen in five cases. Necrosis of the humeral head developed in four patients. In three patients a secondary arthroplasty had to be performed, in two because of re-displacement and in one for necrosis of the head. There was one case of deep infection which required a further operation and one of delayed healing. The mean Constant score of the patients with a three-part fracture was 61.2 points (35 to 87) which was 84.9% of the score for the non-injured arm. In four-part fractures it was 49.5 points (18 to 87) or 68.5% of the score for the non-injured arm. The Humerusblock technique can provide a comfortable and mobile shoulder in elderly patients and is a satisfactory alternative to replacement and traditional techniques of internal fixation.

Dynamic radiologic evaluation of horizontal instability in acute acromioclavicular joint dislocations.

Background: Biplane radiologic evaluation is indispensable for the correct diagnosis of acute acromioclavicular (AC) joint injuries. Thus far, no functional radiographic techniques have been quantified to evaluate horizontal instability in acute AC joint dislocations. Hypothesis: Supine dynamic axillary lateral shoulder views detect horizontal instability of the distal clavicle in patients with acute AC joint dislocations. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: Twenty-five consecutive patients with a mean age of 39 ± 14 years with acute AC joint injury underwent biplane radiologic evaluation, including a conventional Zanca view and an axillary lateral view in a sitting position. In addition, supine axillary lateral views with the arm in 90° of abduction and 60° of flexion and extension were taken to evaluate the horizontal dynamics of the distal clavicle. The gleno-acromio-clavicular angle (GACA) was introduced and used to quantify the horizontal clavicular dynamics in terms of angle differences. The unaffected shoulders served as the control group. Results: Superior dislocation of the lateral clavicle in the Zanca view was classified as Rockwood type II in 7 patients, type III in 15, and type V in 3. The axillary lateral view in a sitting position showed posterior dislocation of the distal clavicle in 8 patients (Rockwood type IV injury). Dynamic radiologic evaluation revealed an average GACA difference between the neutral and anterior position of the arm of 7.1° ± 5.5° for the unaffected shoulder. In the injured AC joints, 11 patients showed no radiologic evidence of horizontal instability (group A) with a GACA difference of 7.1° ± 4.8°. Increased anteroposterior translation was evident in 14 patients (group B) with a GACA difference of 30.3° ± 14.3° (P < .001). Conclusion: Functional axillary radiologic evaluation seems to represent a simple imaging tool to reveal dynamic horizontal instability. Clinical Relevance: Horizontal instability of the distal clavicle in acute AC joint injuries represents an indication for surgical treatment. Dynamic axillary radiologic evaluation may detect previously missed unstable injuries. This evaluation might be relevant when deciding on surgical AC joint stabilization.