Jonas Andermahr

Elastic stable intramedullary nailing of midclavicular fractures with a titanium nail.

This study presents the results of a minimally invasive operative treatment for markedly displaced midclavicular fractures. In all patients a flexible titanium nail was inserted in an unreamed technique from the sternal end of the clavicle. The result of surgery was determined with clinical and radiographic controls. The clinical outcome was evaluated 12 months after hardware removal using the scoring system of Constant and Murley. Fifty-eight fractures in 55 patients were treated with intramedullary fixation. Postoperatively on Day 3, the mean subjective pain was significantly lower and range of motion was improved compared with the day before surgery. One nonunion occurred. There was no infection and no implant displacement or refracture. Intramedullary nailing of midclavicular fractures with a flexible titanium nail is a safe minimally invasive surgical technique with excellent functional and cosmetic results compared with plate fixation or conservative treatment. Marked pain reduction along with early restoration of shoulder function and early mobilization are advantageous for patients. This technique can be used as an alternative treatment to conservative procedures or plate fixation in patients with markedly displaced midclavicular fractures, multiple trauma, fractures of the lower extremities, or associated shoulder girdle injuries.

Association between injury pattern of patients with multiple injuries and circulating levels of soluble tumor necrosis factor receptors, interleukin-6 and interleukin-10, and polymorphonuclear neutrophil elastase.

BACKGROUND Our knowledge about the bidirectional interactions between brain and whole organism after trauma is still limited. It was the purpose of this prospective clinical study to determine the influence of severe head trauma (SHT) as well as trauma in different anatomic injury regions on posttraumatic inflammatory mediator levels from patients with multiple injuries. METHODS Thirty-five healthy controls, 33 patients with an isolated SHT, 47 patients with multiple injuries without SHT, and 45 patients with both SHT and multiple injuries were studied. The posttraumatic plasma levels of soluble tumor necrosis factor receptors p55 and p75, interleukin (IL)-6, IL-10, and polymorphonuclear neutrophil (PMN) elastase were monitored using enzyme-linked immunosorbent assay technique. The influence of head injuries as well as thorax, abdomen, and extremity injuries on the mediator release from patients with multiple injuries was investigated by multivariate linear regression models. RESULTS The soluble tumor necrosis factor receptor p55/p75 ratio was significantly elevated within 3 hours of trauma in all three injury groups and returned to reference ratios after 12 hours. The lowest increase was found in patients suffering from an isolated SHT. Lowest mediator levels in this patient population were also found for IL-6, IL-10, and PMN elastase during the first 36 hours after trauma. Additional injuries to the head, thorax, abdomen, and extremity modulated mediator levels to a different degree. No specific effect was found for SHT when compared with other injury groups. Thorax injuries caused the quickest rise in mediator levels, whereas abdominal injuries significantly increased PMN elastase levels 12 to 24 hours after trauma. CONCLUSION Traumatic injuries cause the liberation of various mediators, without any specific association between anatomic injury pattern and the pattern of mediator release.

Die Technik der intramedullären Osteosynthese der Klavikula mit elastischen Titannägeln

ZusammenfassungAnhand dieser prospektiv kontrollierten Beobachtungsstudie sollten die Ergebnisse der intramedullären Osteosynthese der Klavikula im mittleren Drittel erfasst werden.In Rückenlagerung erfolgt die Eröffnung der ventralen Kortikalis der sternalen Klavikula mit einem 2,5-mm-Bohrer. Der Nagel wird unter Bildwandlerkontrolle nach lateral vorgetrieben und die Fraktur reponiert. Gelingt die geschlossene Reposition nicht, erfolgt eine Hilfsinzision zur direkten Manipulation der Fragmente.In einem Zeitraum von 3,5 Jahren konnte die Technik bei 62 Patienten mit 65 Frakturen angewandt werden. Die subjektive Schmerzempfindung war am 3. postoperativen Tag signifikant (p<0,001) niedriger als präoperativ. Das Bewegungsausmaß im Schultergelenk konnte signifikant (p<0,001) verbessert werden. Wir beobachteten eine Pseudarthrose. Implantatdislokationen, Infekte, und Refrakturen traten nicht auf. Der mittlere Wert des Constant-Score betrug 6 Monate nach der Metallentfernung 96,9±3,3 Punkte.Die intramedulläre Schienung der Klavikulafraktur ist eine sichere, minimal-invasive Operationstechnik, die funktionell und kosmetisch zu guten Resultaten führt.AbstractThis prospective controlled clinical trial was performed to assess fracture healing and clinical outcome after intramedullary nailing of midclavicular fractures.Within 3,5 years elastic-stable intramedullary nailing was performed in 62 patients with 65 midclavicular fractures. Surgery was performed in supine position. The ventral cortex of the proximal clavicle was opened using a 2,5 mm drill. The nail was advanced laterally under fluoroscopic control. If closed reduction failed, an additional incision was made to enable direct manipulation of the fragments.There were no infections, no implant displacements or refractures. Postoperatively, the mean subjective pain was significantly lower, and the range of motion improved. We observed one nonunion. The mean Constant-score 6 months after hardware removal was 96.9 ± 3,3 points.Intramedullary fixation of midclavicular fractures with an elastic titanium nail is a safe minimally invasive surgical technique, producing excellent functional and cosmetic results.

The clinical value of procalcitonin and neopterin in predicting sepsis and organ failure after major trauma

We examined whether procalcitonin (PCT) or neopterin (NT) are useful in predicting sepsis, multiple organ failure (MOF), or death after multiple trauma (MT). In a prospective clinical study, a total of 137 consecutive trauma patients (mean age 39 years, median injury severity score [ISS] 27 points) and 34 healthy volunteers were enrolled. Blood samples were collected on arrival in the emergency room until day 28 after trauma. Plasma NT was detected by enzyme-linked immunoassay and PCT plasma levels were determined using an immunoluminometric assay. The incidence of sepsis was 65%, MOF 48%, and death in hospital within 28 days 11%. After adjustment for age, gender, and ISS, PCT and NT levels during the first 2 days after injury were unable to differentiate between patients who developed sepsis or not. On the contrary, patients who developed MOF had higher PCT plasma levels on day 0 (0.60 vs. 0.15 ng/mL), and on days 1 and 2 combined (1.95 vs. 0.32 ng/mL). This difference remained significant in multivariate logistic regression (P = 0.01) and additional subgroup analyses for early and late MOF (P = 0.048 and 0.002). For NT, smaller differences were observed (4.39 vs. 3.68 nmol/L, and 7.20 vs. 5.79 nmol/L), which lost significance in multivariate analysis. On the basis of PCT, ISS, and age, a MOF prediction rule was developed and had a good predictive power (area under the curve: 0.77; P < 0.001). These findings demonstrate that high plasma concentrations of PCT in the early posttraumatic phase are an independent predictor of MOF but not of sepsis.

Malunion of the clavicle causes significant glenoid malposition: a quantitative anatomic investigation

ObjectiveAn experimental cadaver model was used to assess the effects of a malunited fracture of the middle third of the clavicle on the functional anatomy of the shoulder joint.MethodAnatomic samples were prepared with simulated shortening and axial malposition of the clavicle. From these, alterations in glenoid fossa position were measured and depicted graphically.ResultsHealing of clavicle fractures with bony shortening leads to a ventromedialcaudal shift in glenoid fossa position. The following malpositions of the clavicle lead to the respective glenoid fossa positional changes: caudal deviation leads to a mediocaudal shift, cranial deviation leads to a dorsolateral shift of the glenoid fossa, ventral deviation causes a ventrolateral shift, dorsal deviation leads to mediocaudal shift of the fossa, cranial rotation leads to ventrolateral shift in fossa position, and caudal rotation leads to a dorsomedial shift in glenoid fossa position.ConclusionClinical implication of these data is that bony shortening in combination with caudal displacement leads to distinct functional deficits in abduction, particularly overhead motion. Using the above data, a vector model was created to calculate position of the glenoid fossa dependent on clavicle position/malposition. The model is a valuable tool to be used for planning open reduction and fixation of clavicular fractures or malunions.

Immunologic alterations associated with high blood transfusion volume after multiple injury: effects on plasmatic cytokine and cytokine receptor concentrations.

The initial transfusion therapy after trauma has been identified as an independent risk factor for the incidence of multiple organ failure (MOF). Late occurrence of MOF in severely injured patients may be a clinical consequence of disturbed mediator homeostasis. For this reason, levels of interleukin (IL)-6, IL-10, and soluble tumor necrosis factor receptors (sTNFR) p55 and p75 were analyzed in the plasma of patients with comparable injury severity but with a different supply of packed red blood cells (PRBC). Thirty-eight multiple trauma patients with an injury severity score range of 25–54 points were separated into two groups according to their PRBC supply within the first 24 h after trauma. Patients who received at least 15 units of PRBC were analyzed in group 2 (n = 11); the remaining patients (n = 27) were assigned to group 1. The incidence of MOF was higher (P < 0.05) in group 2 patients. Correspondingly, levels of all assayed mediators were found significantly elevated at several time points in this patient group. We conclude that increases in mediator concentrations may be causally related to the extent of blood transfusion therapy itself or to the conditions for which it was needed.

The vascularization of the os calcaneum and the clinical consequences.

This study was conducted to analyze extraosseous and intraosseous vascularization of the os calcaneum and to elucidate possible clinical manifestations. The arteries of 13 lower leg and foot specimens of human cadavers were injected with a polymer and subjected to maceration or were embedded in plastic. The examination revealed that 45% of the bone is vascularized via medial arteries and 45% via lateral arteries, whereas the remaining 10% is supplied by the sinus tarsi artery. From the medial side, two or three vessels branch off the posterior tibial artery, penetrate the calcaneus below the sustentaculum, and supply the medial part of the posterior joint. The lateral calcaneal artery normally is a branch from the posterior tibial artery. In two of 13 specimens, this lateral supply comes from the peroneal artery. The medial and lateral intraosseous arterial supply for the calcaneus is equal. Inside the bone there is a water-shed zone where the medial and lateral arterial supply meet in the midline. Only 10% of the blood flow is supplied by vessels in the sinus tarsi. Clinically, interruption of the lateral calcaneal artery during the conventional lateral surgical approach for a calcaneus fracture may result in ischemic bone necrosis. The lateral calcaneal artery could supply a local microvascular flap to cover soft tissue defects of the heel. A compartment syndrome after a calcaneus fracture may be caused by bleeding from the medial calcaneal arteries into the quadratus plantae compartment.

[Reconstruction of shoulder-girdle symmetry after midclavicular fractures. Stable, elastic intramedullary pinning versus rucksack bandage].

ZusammenfassungDas Ziel dieser Untersuchung war der Vergleich der mittelfristigen Behandlungsergebnisse von 2 verschiedenen Behandlungsstrategien bei Klavikulafrakturen des mittleren Drittels. In Gruppe 1 wurden alle Patienten konservativ mit einem Rucksackverband behandelt. In Gruppe 2 wurde die Klavikulafraktur minimal invasiv mit einem ungebohrten elastischen Titannagel intramedullär geschient. Es konnten signifikant bessere Ergebnisse in der Gruppe der operierten Patienten hinsichtlich des Constant-Score, der Schulterfunktion und des kosmetischen Ergebnisses festgestellt werden. Die mittlere Verkürzung der Klavikula war in der konservativen Gruppe signifikant höher als in der operierten Gruppe. Der Wert des absoluten Constant-Score war in der Gruppe 1 signifikant niedriger als in Gruppe 2. Es konnte ein signifikanter Unterschied festgestellt werden zwischen Patienten, die eine Verkürzung der Klavikula von weniger als 1 cm aufwiesen, und Patienten mit einer Verkürzung von 1 cm oder mehr. In Gruppe 1 wurden 2 Pseudarthrosen beobachtet, während in Gruppe 2 alle Frakturen verheilt waren. Refrakturen wurden in beiden Gruppen nicht beobachtet. Die bisherigen Ergebnisse der elastisch stabilen intramedullären Osteosynthese bei Klavikulafrakturen des mittleren Drittels zeigen, dass dieses Verfahren sicher ist und funktionell sowie kosmetisch mittelfristig zu besseren Resultaten als die Behandlung im Rucksackverband führt.AbstractThe aim of this study was to compare the results achieved in two groups of 20 patients treated for midclavicular fracture. The first group (mean age 36 years) was treated non-operatively with a rucksack bandage, whereas the second group (mean age 37 years) underwent intramedullary fixation with a titanium pin using a minimally invasive, unreamed technique. At follow-up, which averaged 3.1±0.9 years in group 1 and 2.9±0.7 years in group 2, the result of treatment, as indicated by the Constant score, functional outcome and cosmetic outcome, was significantly better in the group undergoing operative treatment. Clavicle shortening was significantly (P=0.027) higher in patients treated with a rucksack bandage. The absolute Constant score averaged 78±23 in group 1 and 97±4 in group 2 (P=0.001). The Constant rating scale showed a significant difference between patients with clavicle shortening of less than 1 cm and 1 cm shortening or more. There were two non-unions in group 1 but none in group 2. Refractures were not observed in either group. According to these results, intramedullary fixation with a titanium pin seems to be more advantageous in midclavicular fractures than non-operative treatment. As the operation is well received by the patients, it should be offered to them as an alternative treatment to the rucksack bandage.

The injury of the calcaneocuboid ligaments.

The selective rupture of the calcaneocuboid ligament is extremely rare and frequently misdiagnosed. This study tries to clarify the mechanism, classification and treatment of this entity. The necessity of radiographs with varus stress and in certain cases of computer tomography (CT) and magnetic resonance imaging (MRI), beside the routine antero-posterior and lateral views, is emphasized. Thirteen cases out of five-hundred-twenty-one sprain injuries of the ankle are described, classified and the therapy discussed: If on varus stress radiographs, there is a calcaneocuboid angle <10 degrees without a bony flake (type 1) strapping for six weeks is indicated. A calcaneocuboid angle >10 degrees with or without a small bony flake of the ligament insertion (type 2) should primarily be treated with a shoe cast for 6 weeks; if there are persistent symptoms a secondary peroneus brevis tendon graft is recommended. A calcaneocuboid angle >10 degrees with a big flake (type 3) should be treated by open reduction and refixation of the ligament. Complex injuries (type 4) are characterised by cuboid compression fracture and ligament rupture.

Wiederherstellung der Symmetrie des Schultergürtels bei Klavikulafrakturen

ZusammenfassungDas Ziel dieser Untersuchung war der Vergleich der mittelfristigen Behandlungsergebnisse von 2 verschiedenen Behandlungsstrategien bei Klavikulafrakturen des mittleren Drittels. In Gruppe 1 wurden alle Patienten konservativ mit einem Rucksackverband behandelt. In Gruppe 2 wurde die Klavikulafraktur minimal invasiv mit einem ungebohrten elastischen Titannagel intramedullär geschient. Es konnten signifikant bessere Ergebnisse in der Gruppe der operierten Patienten hinsichtlich des Constant-Score, der Schulterfunktion und des kosmetischen Ergebnisses festgestellt werden. Die mittlere Verkürzung der Klavikula war in der konservativen Gruppe signifikant höher als in der operierten Gruppe. Der Wert des absoluten Constant-Score war in der Gruppe 1 signifikant niedriger als in Gruppe 2. Es konnte ein signifikanter Unterschied festgestellt werden zwischen Patienten, die eine Verkürzung der Klavikula von weniger als 1 cm aufwiesen, und Patienten mit einer Verkürzung von 1 cm oder mehr. In Gruppe 1 wurden 2 Pseudarthrosen beobachtet, während in Gruppe 2 alle Frakturen verheilt waren. Refrakturen wurden in beiden Gruppen nicht beobachtet. Die bisherigen Ergebnisse der elastisch stabilen intramedullären Osteosynthese bei Klavikulafrakturen des mittleren Drittels zeigen, dass dieses Verfahren sicher ist und funktionell sowie kosmetisch mittelfristig zu besseren Resultaten als die Behandlung im Rucksackverband führt.AbstractThe aim of this study was to compare the results achieved in two groups of 20 patients treated for midclavicular fracture. The first group (mean age 36 years) was treated non-operatively with a rucksack bandage, whereas the second group (mean age 37 years) underwent intramedullary fixation with a titanium pin using a minimally invasive, unreamed technique. At follow-up, which averaged 3.1±0.9 years in group 1 and 2.9±0.7 years in group 2, the result of treatment, as indicated by the Constant score, functional outcome and cosmetic outcome, was significantly better in the group undergoing operative treatment. Clavicle shortening was significantly (P=0.027) higher in patients treated with a rucksack bandage. The absolute Constant score averaged 78±23 in group 1 and 97±4 in group 2 (P=0.001). The Constant rating scale showed a significant difference between patients with clavicle shortening of less than 1 cm and 1 cm shortening or more. There were two non-unions in group 1 but none in group 2. Refractures were not observed in either group. According to these results, intramedullary fixation with a titanium pin seems to be more advantageous in midclavicular fractures than non-operative treatment. As the operation is well received by the patients, it should be offered to them as an alternative treatment to the rucksack bandage.