K. M. Stürmer

Die bipolare Radiuskopfprothese bei nicht rekonstruierbaren Radiusköpfchentrümmerfrakturen: Indikation,Behandlung und Ergebnisse nach 5 Jahren

ZusammenfassungBei Trümmerfrakturen des Radiusköpfchens mit ligamentären oder ossären Begleitverletzungen auf der ulnaren Seite lassen sich durch die Radiusköpfchenresektion meist keine befriedigenden Ergebnisse erzielen. Neben Instabilität des Ellbogengelenkes und Bewegungslimitierung werden Proximalisierung des Radius,Arthrose und Schmerzen im Ellbogengelenk beschrieben. Ziel dieser Arbeit ist es, Ergebnisse nach Implantation einer bipolaren Radiuskopfprothese bei nicht rekonstruierbaren Radiusköpfchentrümmerfrakturen zu untersuchen.Zwischen 1995 und 1997 wurden 11 Radiuskopfprothesen bei 10 Patienten mit Radiusköpfchentrümmerfraktur und ligamentären oder ossären Begleitverletzungen auf der ulnaren Seite implantiert.8 Patienten mit 9 Prothesen konnten nach durchschnittlich 5 Jahren nachuntersucht werden, eine Patientin war verstorben, ein Patient lehnte bei subjektiver Beschwerdefreiheit die Nachuntersuchung ab.Nach dem Morrey-Score fanden sich 2 sehr gute, 5 gute und 2 mäßige Ergebnisse. Bei allen Patienten bestanden stabile Gelenkverhältnisse. Radiologisch konnten bei keinem Patienten Lockerungszeichen nachgewiesen werden.Die bipolare Radiusköpfchenprothese ist eine empfehlenswerte Alternative zur Resektion bei osteosynthetisch nicht rekonstruierbarer Radiusköpfchentrümmerfraktur mit Begleitverletzung auf der ulnaren Seite und ist der Resektion vorzuziehen.AbstractThe treatment of comminuted fractures of the radial head with concomitant injuries of the ulnar complex by resection of the radial head usually does not provide satisfactory long-term results.Other than joint instability in the elbow and a limited range of motion, radius proximalisation in the sense of ulnocarpal impingement, osteoarthritis and pain in the elbow have been described.Between 1995 and 1997, 11 radial head prostheses were implanted in ten patients who had sustained a comminuted fracture of the radial head with concomitant injury to the ulnar complex. A follow-up survey was conducted with the patients on average 5 years after the injury. Eight patients with nine implants participated in the follow-up, one patient had died and another refused to participate but declared that he did not suffer from any impairment.According to the Morrey score, two of the results were found to be very good, five to be good, one to be fair and one to be poor.Despite the severe injuries sustained by the elbow, neither joint instability in the elbow nor proximalisation of the radius, cubitus valgus, ulnar nerve syndrome, nor loosening of the prosthesis were found in any of the patients.In the event of comminuted fractures of the radial head which are impossible to reconstruct by osteosynthesis and which occur with concomitant ulnar ligamentous or osseous injury, the implantation of a prosthesis is preferred over the resection of the head of the radius.

Refixation of osteochondral fragments using absorbable implants. First results of a retrospective study

AbstractAn osteochondral lesion in a weight bearing joint causes therapeutic problems. Surgical therapy focuses on the restoration of the articular surface, unlimited motion of the joint and prevention of cartilaginous degeneration. A causal therapy to prevent posttraumatic osteoarthritis is the fixation of osteochondral fragments. Various absorbable implants for the purpose of refixation are available, but only a few have proved to be biocompatible. This retrospective study presents the preliminary results after refixation of osteochondral fragments of the ankle and knee joints. We used self-reinforced absorbable pins, nails and screws made of polylactide acid. The results for 15 patients with 17 fractures of 16 joints were evaluated. All patients were scored by the Tegner-activity-level, the McDermott-score and the DGKKT-score, and 13 of them were monitored by postoperative magnetic resonance imaging (MRI). The follow-up extended for an average of 14.3 months (range: 4-43 months). The clinical results for all patients were good (McDermott-score: Ø 89 points, DGKKT-score: Ø 78.8 points, Tegner: pre-op vs post-op=Ø 4.6 vs Ø 5.1) and the surgical therapy proved to be successful. The MRI showed the complete incorporation and vitality of the fragment as well as a congruence of the joint surface. The clinical course and the MRI gave little reference to an inflammatory reaction due to the implants that complicated the course of two patients. These results indicate that absorbable implants made of polylactide acid are biocompatible and effective in the fixation of osteochondral fragments. ZusammenfassungEin osteochondraler Schaden in der Belastungszone eines Gelenkes ist weiterhin ein therapeutisches Problem. Das Ziel der Therapie ist die Wiederherstellung der Knorpeloberfläche mit normaler Gelenkfunktion, freier schmerzloser Beweglichkeit und Verhinderung einer weiteren Knorpeldegeneration. Dies lässt sich vielfach dadurch erreichen, dass osteochondrale Fragmente refixiert werden. Hierfür stehen resorbierbare Implantate aus verschiedenen Materialien zur Verfügung, die jedoch nicht alle gut biokompatibel sind. In der vorliegenden Arbeit werden die kurz- und mittelfristigen Ergebnisse einer retrospektiven Studie nach Fixation osteochondraler Frakturen traumatischer Genese an Knie- und Sprunggelenk dargestellt. Verwendet wurden Stifte, Nägel und Minischrauben aus “selbstverstärktem” Polylaktid. Fünfzehn Patienten mit 17 Frakturen an 16 Gelenken konnten wir nachuntersuchen und einer Scorebeurteilung unterziehen. Bei 13 Patienten erfolgte ergänzend eine Magnetresonnanztomographie. Die klinischen Ergebnisse im McDermott-Score (Ø 89 Pkt.), DGKKT-Score (Ø 78,8) und Tegner-Aktivitätsscore (Ø 4,6 vs. 5,1) waren bei einem durchschnittlichen Follow-up von 14,3 Monaten (4–43) gut, bestätigt durch eine vollständige Integration des vitalen Fragmentes mit Wiederherstellung der Oberflächenkongruenz in der MRT. Weder klinisch noch kernspintomographisch fanden sich ossär, extraartikulär und intraartikulär/synovial Hinweise auf lokale Fremdkörperreaktionen. Lediglich bei 2 Kniegelenken zeigte sich ein gering bis mäßig ausgeprägter Gelenkerguss bei den spät resorbierbaren Implantaten. Unseren Ergebnissen zufolge sind die verwendeten Implantate aus Polylaktid biokompatibel und effektiv für die Refixation osteochondraler Fragmente.

Die Balser-Platte mit Bandnaht Eine zuverlässige Stabilisierungsmethode des Akromioklavikulargelenks

ZusammenfassungVon Juni 1990 bis Dezember 1997 wurden in unserer Klinik insgesamt 116 Patienten mit einer kompletten Akromioklavikulargelenksprengung operativ behandelt. Nach den Klassifikationen von Tossy handelt es sich dabei ausschließlich um Typ-III- und nach Rockwood um Typ-III-, -IV- und -V-Verletzungen.Seit September 1994 bis Dezember 1997 wurden im Rahmen einer prospektiven Studie die operative Versorgung des verletzten AC-Gelenks bei 68 Patienten durch Balser-Platte und Naht der korakoklavikulären Bänder, des Lig. Acromioclaviculare, ggf. des Diskus und der AC-Gelenkkapsel vorgenommen. Als Kontrollgruppe wurden 48 Patienten gewählt, die zwischen Juni 1990 und August 1994 operiert worden waren. Hier erfolgte die Stabilisierung des AC-Gelenks in 31 Fällen mit Drahtcerclage, bei 14 Patienten mit PDS-Kordel und bei 3 mit einer Kombination aus Kirschner-Drähten und PDS-Kordel. Bei der Kontrollgruppe erfolgte postoperativ eine Ruhigstellung der verletzten Schulter von durchschnittlich 2,3 Wochen, während bei der Balser-Platte keine postoperative Ruhigstellung erforderlich war. Die Armbelastung dieser Patienten war sofort bis 5 kg und einer Abduktion von 90° freigegeben. Die Metallentfernung (nicht bei PDS-Kordel) erfolgte in beiden Gruppen nahezu zum gleichen Zeitpunkt (2,9 bzw. 2,3 Monate).Als Komplikationen traten bei den Alternativverfahren 8 Reluxationen und 10 oberflächliche Wundinfekte, nach Balser-Platte 4 oberflächliche Wundinfekte und 2 Hämatome auf. Bei letzteren kam es jedoch zu keiner Reluxation. Die Nachuntersuchungsrate beträgt in der Balser-Platten Gruppe 57 von 68 Patienten nach durchschnittlich 24,6 Monaten und in der Kontrollgruppe 30 von 48 Patienten nach durchschnittlich 50,1 Monaten.Bewertet werden der funktionelle Befund, das subjektive Beschwerdebild und die AC-Gelenksonographie mit und ohne 10 kg Belastung. Freie Beweglichkeit haben 87,7% der Patienten nach Balser-Platten gegenüber 67,7% der Patienten nach Alternativverfahren. Unter Belastungs- und Bewegungsschmerzen leiden 14,2 bzw. 11,4% der Balser-Platten-Patienten gegenüber jeweils 17,4% der Kontrollgruppe.Sonographisch zeigt sich im Seitenvergleich gesunder zu verletzter Schulter mit und ohne 10 kg Belastung bei den Balser-Platten-Patienten eine Höhendifferenz der Klavikula von durchschnittlich 0,3 bzw. 0,6 mm im Vergleich zu 3,0 und 2,5 mm bei den Alternativverfahren. Auch die AC-Gelenkweite ist bei den Alternativverfahren deutlich erhöht: Während 50,2% der Balser-Platten-Patienten in Ruhe eine physiologische Weite des AC-Gelenks haben, haben dies nur 36,6% der anderen. Unter Belastung vergrößert sich diese Differenz zusätzlich. Subjektiv sind 63,2% der Balser-Platten-Patienten gegenüber nur 43,3% der anderen mit dem Behandlungsergebnis sehr zufrieden (p<0,05). Völlig unzufriedene Patienten finden wir nur in der Alternativverfahren Gruppe (20%), wobei hier auch das schlechte kosmetische Ergebnis (subjektiv 40%) mit ein Grund war.AbstractBetween June 1990 and December 1997 116 patients with complete dislocation of the acromio-clavicular joint were treated operatively. According to the classification of Tossy and Rockwood all patients had type Tossy III or Rockwood III, IV and V of lesion.The retrospective part of the study from June 1990 to August 1994 represents 48 patients treated in 31 cases with wire-cerclage, in 14 cases with PDS-cerclage and in 3 cases with a combination of Kirschner wires and PDS. In a second group between September 1994 and 1997 68 patients were treated operatively with a special hook-plate, called Balser-plate, combined with suture of the korakoclavicular ligaments, the articular capsule and the intraarticular discus.In the first group there was a postoperative immobilisation of the injured shoulder for 2,3 weeks necessary; in comparison to non immobilisation at the Balser-plate group. The range of motion in the Balser-plate Group was free up to 90 degrees abduction. The removal of implants was performed in both groups after approximately 3 month. Postoperative complications were 8 reluxations at the acromio-clavicular joint and 10 superficial infects at the Non-Balser group and 4 superficial infects and 2 subcutaneus haematoma in the Balser group. We saw no reluxation in the Balser group.We examined 30 of 48 patients of the Non Balser group after average 50.1 month and 57 of 68 patients of the Balser group after 24.6 month. We compared the functional result, a questionaire and the ultrasound examination of the acromio-clavicular joint with and without 10 kg weight bearing of the arm. 87.7% of the Balser patients and 67.7% of the Non-Balser-patients had free movement of the injured shoulder. Another 14.2% and 11.4% of the Balser group complained on shoulder pain with weight bearing and extreme moval in comparison to 17.4% of the Non-Balser group.At ultrasound examination comparing the injured to the non injured arm with and without 10 kg weight bearing there was a clavicula-elevation of 0.3 mm and 0.6 mm at Balser-patients and 3.0 mm and 2.5 mm at Non-Balser-patients for the injured side. In normal position the acromio-clavicular width was physiological in 50.2% of Balser patients in comparison to 36.6% of Non-Balser-patients. Under weight bearing the acromio-clavicular width increases in both groups. 63.2% of the Balser-group patients are satisfied with the result of operation, but only 43.3% of the other group (p<0.05). Completely dissatisfied were 20% of the Non-Balser group, paticularily because of the bad cosmetic result (40%).

[The supra-acetabular pelvic clamp. Emergency treatment for unstable pelvic ring fractures].

Background. The anatomic region on the lateral cortex of the ileum, where a palpable “groove” is formed by angulations of the lateral cortex of the iliac wing, is recommended as the insertion point for the pelvic emergency clamp by many authors. In our opinion this technique often leads to an incomplete closure of the anterior pelvic ring as well as to bacterial contamination of the access for the sacroiliac joint screw fixation and is accompanied by a risk for nerve and vessel injuries. To reduce these risks the pelvic clamp was placed at a supra-acetabular location. The goal of our study was to report on our experiences with the supra-acetabular position of the pelvic emergency clamp and to compare our results with the current literature. Material and method. From September 1998 to February 2006 the pelvic emergency clamp was applied in 15 polytraumatized patients (9 male, 6 female), with a mean age of 46 years (19–93) and a mean injury severity score (ISS) of 40 points (25–66) with mechanically and hemodynamically unstable pelvic ring fractures. According to the AO classification the injury pattern was type B2 in four cases, type B3 in one case, type C1 in seven cases, type C2 in two cases and type C3 in one case. The pelvic clamp was percutaneously applied 2–3 cm cranial to the acetabular roof. The duration from hospital admission until the pelvic emergency clamp was applied amounted to an average of 54 min (15– 150); the procedure itself was performed in all cases in less than 15 min. The mean Hb at arrival in the emergency department was 7.4 (2.4–13.8) mg/dl and the mean systolic blood pressure 69 (0–130) mmHg. Results. In 14 patients a complete closure of the anterior and posterior pelvic ring could be achieved; in 1 patient an overcompression of the anterior pelvic ring was observed. Four patients died due to massive bleeding. Three patients with isolated pelvic ring fractures became hemodynamically stable within 20 min after treatment with the supra-acetabular pelvic clamp. Nine patients needed additional emergency surgery because of intracerebral, intrathoracic or intra-abdominal injuries. On average in the first 6 h, 36.7 (9–175) units of erythrocyte concentrates and 34.5 (4–200) units of fresh frozen plasma were transfused. Conclusions. The supra-acetabular pelvic clamp leads to a homogeneous force distribution to the pelvic ring and enables complete closure of the anterior and posterior pelvic ring in unstable pelvic fractures. Reduction of the intrapelvic volume and compression of the posterior pelvic ring can thus be achieved. Risks for intrapelvic perforation or injuries of vessels and nerves are low. No bacterial contamination of the access for the sacroiliac screw fixation occurs. To avoid overcompression of the unstable pelvic ring, manual or radiological control of the closure of the ventral pelvic ring is necessary.

[A novel knee endoprosthesis with a physiological joint shape. Part 1: Biomechanical basics and tribological studies].

The natural tibiofemoral joint (TFJ) functions according to a roll-glide mechanism. In the stance phase (0-20 degrees flexion), the femur rolls backwards over the tibia plateau, while further flexion causes increased gliding. This kinematics is based on the principle of a quadruple joint. The four morphological axes of rotation are the midpoints of the curvatures of the medial and lateral femoral condyles and the medial and lateral tibia plateau. In addition, the medial and lateral compartments are shifted a few millimetres in a sagittal direction, the medial tibia plateau being concave and the lateral plateau convex. In most knee arthroplasties, these factors are not taken into account; instead they are equipped with symmetrical medial and lateral joint surfaces. Thereby, the midpoints of the curvatures of the sagittal contours of the lateral and medial joint surfaces, on the femoral as well as on the tibial sides, create a common axis of rotation which does not allow a physiological roll-glide mechanism. The goal of this study was therefore to report on the biomechanical basis of the natural knee and to describe the development of a novel knee endoprosthesis based on a mathematical model. The design of the structurally new knee joint endoprosthesis has, on the lateral side, a convex shape of the tibial joint surface in a sagittal cross section. Furthermore, from a mathematical point of view, this knee endoprosthesis possesses essential kinematic and static properties similar to those of a physiological TFJ. Within the framework of the authorization tests, the endoprosthesis was examined according to ISO/WC 14243 in a knee simulator. The abrasion rates were, thereby, lower than or at least as good as those for conventional endoprostheses. The presented data demonstrate a novel concept in knee arthroplasty, which still has to be clinically confirmed by long term results.

Die Resektion des Fersenbeins als Therapieoption bei Osteitis nach offener Fersenbeinfraktur

ZusammenfassungDie operative Behandlung von Fersenbeinfrakturen ist anspruchsvoll, nicht zuletzt aufgrund des dünnen Weichteilmantels. Bei offenen Frakturen mit unfallbedingten Knochennekrosen stellt die Infektion eine schwere Komplikation dar. Das Auftreten einer Osteitis ist gefürchtet und macht ein konsequentes operatives Regime erforderlich. Persistiert die Infektion, wird nicht selten die Amputation der Gliedmaß mit konsekutiver erheblicher Invalidisierung erforderlich.Wir stellen den Fall eines 37-jährigen Maurers nach Absturztrauma mit einer drittgradig offenen Fersenbeintrümmerfraktur vor, bei dem eine Infektion nach primärer offener Osteosynthese zahlreiche Revisionen und schließlich die Fersenbeinresektion erforderlich machte. Unter Erhalt des Vor- und Mittelfußes und Dank einer suffizienten orthopädischen Schuhversorgung konnte der Patient nach 8 Monaten in seinen Beruf als Maurer zurückkehren.AbstractSurgical treatment of calcaneal fractures is demanding due to the poor musculocutaneous coverage. Infection with osteitis is a severe complication with open fractures. The appearance of osteitis requires aggressive surgical treatmentincluding amputation in case of persistence, leading to considerable invalidism.We report the case of an 37-year-old mason with an grade III open calcaneal fracture caused by a fall. Osteitis appeared after primary osteosynthesis with open reduction and eventually – after several revisions – required a calcanectomy. By preservation of the forefoot and midfoot and thanks to sufficient orthesis treatment the patient was able to return to his profession after eigth months.

Eine neuartige Knieendoprothese mit physiologischer Gelenkform

The natural tibiofemoral joint (TFJ) functions according to a roll-glide mechanism. In the stance phase (0-20 degrees flexion), the femur rolls backwards over the tibia plateau, while further flexion causes increased gliding. This kinematics is based on the principle of a quadruple joint. The four morphological axes of rotation are the midpoints of the curvatures of the medial and lateral femoral condyles and the medial and lateral tibia plateau. In addition, the medial and lateral compartments are shifted a few millimetres in a sagittal direction, the medial tibia plateau being concave and the lateral plateau convex. In most knee arthroplasties, these factors are not taken into account; instead they are equipped with symmetrical medial and lateral joint surfaces. Thereby, the midpoints of the curvatures of the sagittal contours of the lateral and medial joint surfaces, on the femoral as well as on the tibial sides, create a common axis of rotation which does not allow a physiological roll-glide mechanism. The goal of this study was therefore to report on the biomechanical basis of the natural knee and to describe the development of a novel knee endoprosthesis based on a mathematical model. The design of the structurally new knee joint endoprosthesis has, on the lateral side, a convex shape of the tibial joint surface in a sagittal cross section. Furthermore, from a mathematical point of view, this knee endoprosthesis possesses essential kinematic and static properties similar to those of a physiological TFJ. Within the framework of the authorization tests, the endoprosthesis was examined according to ISO/WC 14243 in a knee simulator. The abrasion rates were, thereby, lower than or at least as good as those for conventional endoprostheses. The presented data demonstrate a novel concept in knee arthroplasty, which still has to be clinically confirmed by long term results.

Minimally invasive removal of a broken femoral nail

ZusammenfassungDie Entfernung eines gebrochenen Femurmarknagels, als Folge einer Refraktur oder Pseudarthrose, ist immer eine chirurgische Herausforderung. Insbesondere das distale Fragment ist oftmals nur schwer zu bergen. Wir stellen hier eine weitere minimal-invasive und sichere Methode vor, bei der sowohl der anterograde als auch der retrograde Zugangsweg zum Femur Anwendung findet.AbstractThe removal of a broken femoral nail due to refracture or nonunion is always a surgeon’s challenge. Especially the distal fragment is often difficult to remove. We describe here another minimally invasive and safe method using the antegrade and retrograde approach to the femur.The removal of a broken femoral nail due to refracture or nonunion is always a surgeons challenge. Especially the distal fragment is often difficult to remove. We describe here another minimally invasive and safe method using the antegrade and retrograde approach to the femur.

Systemisches Kapillarlecksyndrom als Ursache eines Kompartmentsyndroms beider Unterschenkel und eines Unterarms@@@Systemic capillary leak syndrome causes a compartment syndrome of both lower legs and a forearm: Vorstellung anhand eines Fallberichts mit Literaturübersicht@@@A case report with a review of the literature

ZusammenfassungDas seltene Krankheitsbild des systemischen Kapillarlecksyndroms verursacht Phasen des hypovolämischen Schocks aufgrund einer stark erhöhten Flüssigkeitsverschiebung in das Interstitium. Wegweisende Laborparameter sind Hämokonzentration, Hypoalbuminämie und eine monoklonale Gammopathie. Eine seltene Manifestation dieses Krankheitsbildes ist das Kompartmentsyndrom mit Rhabdomyolyse und akutem Nierenversagen. Wir beschreiben den Fall eines Patienten, der auf dem Boden eines systemischen Kapillarlecksyndroms ein Kompartmentsyndrom beider Unterschenkel und des linken Unterarms erlitt und diskutieren den pathophysiologischen Hintergrund.AbstractSystemic capillary leak syndrome is a rare disorder which causes recurrent episodes of hypovolemic shock due to a markedly increased plasma shift into the interstitium. Hemoconcentration, hypoalbumimenia and a monoclonal gammopathy are characteristic laboratory findings. A rare manifestation of this disease is a compartment syndrome with rhabdomyolysis and acute renal failure. We describe a patient who suffers from a compartment syndrome of both lower legs and the left forearm secondary to systemic capillary leak syndrome, and discuss the pathophysiological background.

Eine neuartige Kniegelenksendoprothese mit physiologischer Gelenkform

The human medial tibial plateau is concave, whereas the lateral tibial plateau is convex. In a normal knee, the convex femoral condyles roll and glide on the tibia during the standing phase of walking. The designs of most commercially available knee prostheses do not take this morphological feature into consideration. The novel design of the AEQUOS G1 knee replacement prosthesis is based on the natural anatomy of the knee joint, with a convex lateral tibia plateau and a sagittal offset of the medial and lateral compartments. Following extensive development and testing, initial clinical results of the AEQUOS G1 prosthesis in a mulitcenter study are presented. From Mai 2005 to March 2007, 158 patients in 4 clinics underwent total knee arthroplasty with the AEQUOS G1 and agreed to participate in the study. Patients were evaluated preoperatively and at 3, 6 and 12 months of follow-up using a standardized protocol that included the American Knee Society Score (AKSS), the Oxford Knee Score (OKS) and the Visual Analog Scale (VAS) for pain. After 3 months, 151 patients appeared for follow up appointments, after 6 months, 134, and after 12 months, 127. The mean range of motion preoperatively was 97.0 degrees (+/-19.9 degrees ) and 107.5 degrees (+/-15.9 degrees ) 12 months after surgery. The AKSS, as well as the modified OKS, significantly improved (p<0.0001) from preoperative scores of 98.8 (+/-35.8) and 37.3 (+/-6.9) points, respectively, to 165.8 (+/-34.1) and 21.9 (+/-7.8) points, preoperatively, and 12 months postoperatively. The VAS score significantly decreased (p<0.001) from 7.4 (+/-1.8) points preoperatively to 1.9 (+/-2.2) points 12 months postoperatively.One implant was revised because of arthrofibrosis and another due to patellar luxation. Two patients required revision because their implants revealed malalignement with ligamentous instability. No infections, aseptic loosening or other implant-specific complications were observed at this early follow-up. Good clinical results were observed at early follow-up with the AEQUOS G1 knee arthroplasty. However, longer follow-up is necessary for a general evaluation of the implant.