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Operative Orthopadie Und Traumatologie | 2010

Treatment of the complex intraarticular fracture of the distal humerus with the latitude elbow prosthesis

Klaus J. Burkhart; Lars Peter Müller; Christina Schwarz; Stefan G. Mattyasovszky; Pol Maria Rommens

ZusammenfassungOperationszielStabile und schmerzfreie Funktion durch primäre Implantation einer totalen Ellenbogenprothese nach intraartikulärer Trümmerfraktur des distalen Humerus bei älteren Patienten. Der künstliche Gelenkersatz kann als gekoppelte oder ungekoppelte Totalendoprothese mit oder ohne Radiuskopfersatz sowie als Hemiendoprothese verwendet werden.IndikationenIntraartikuläre Trümmerfrakturen des distalen Humerus mit schlechter Knochenqualität, die keine primäre stabile Osteosynthese zulassen. Versagen einer Osteosynthese ohne Möglichkeit einer Revisionsosteosynthese. Posttraumatische Arthrose und rheumatoide Arthritis.KontraindikationenOffene Frakturen (Typ II oder III nach Gustilo-Anderson) und infizierte Wundverhältnisse, z.B. nach fehlgeschlagener Osteosynthese, sollten nicht initial prothetisch versorgt werden. Nach Konsolidierung der Weichteilsituation kann die Prothesenimplantation in Betracht gezogen werden. Fehlende Mitarbeit des Patienten, hoher Funktionalitätsanspruch. Paralyse des Bizepsmuskels.OperationstechnikRückenlagerung. Zugang nach Bryan-Morrey. Anteriore Transposition des Nervus ulnaris. Darstellen des Trizepsansatzes an der Insertion am distalen Humerus, an der Kapsel und der proximalen Ulna. Ablösen desselben mitsamt dem Periost und der Unterarmfaszie. Versuch der Rekonstruktion der Kondylen, um eine ligamentäre Stabilität herzustellen und die Prothese ungekoppelt einbringen zu können. Wenn dies technisch nicht möglich ist, müssen die Prothesenkomponenten am Ende der Operation gekoppelt werden. Entfernung der Gelenkfragmente. Bestimmung der Prothesengröße. Ermittlung der Extensions- Flexions-Achse. Eröffnung des Markraums des Humerus. Ermittlung des Offsets. Präparation des humeralen Prothesenlagers. Einsetzen der Probeprothese. Potentiell Implantation einer Hemiendoprothese bei guten Knorpelstrukturen ulnar und radial sowie intakten Ligamenten. Anderenfalls nun Präparation des ulnaren Prothesenlagers. Falls der Radiuskopf keine Läsionen aufweist, kann er erhalten werden. Ansonsten wird er reseziert und möglichst prothetisch ersetzt. Einbringen der ulnaren und radialen Probeprothesenkomponenten. Nach korrekter Probereposition Einzementieren aller definitiven Komponenten mit Anlagerung eines Knochenspans hinter dem anterioren Flansch. Refixation des Trizeps und der Ligamente. Liegt am Ende der Operation keine ausreichende Stabilität vor, muss die Prothese mit der Ulnakappe gekoppelt werden.WeiterbehandlungAm Ende der Operation beugeseitige Gipsschiene in Streckstellung. Selbstständige Bewegungsübungen. Keine aktive Extension für 6 Wochen, Vermeidung des Hebens von Gewichten > 5 kg, keine wiederholten Dauerbelastungen > 1 kg und keine forcierten Bewegungen im Ellenbogengelenk, z.B. Schlagsportarten.ErgebnisseIn den Jahren 2007 und 2008 wurden in der Unfallchirurgischen Abteilung des Universitätsklinikums Mainz 15 Latitude- Ellenbogenprothesen bei folgenden Indikationen implantiert: Frakturen (n = 7), Pseudarthrosen (n = 4), posttraumatische Arthrosen (n = 3) und rheumatoide Arthritis (n = 1). Es wurden sechs Hemiendoprothesen, zwei ungekoppelte und sieben gekoppelte Totalendoprothesen eingebaut. Das durchschnittliche Alter der Patienten betrug 67 Jahre (31–88 Jahre). Bei der primären Frakturversorgung wurde die Indikation nur bei älteren Patienten gestellt. Das mittlere Alter betrug hier 77 Jahre (66–88 Jahre). Elf dieser 15 Patienten wurden nach durchschnittlich 13,5 Monaten (6–23 Monate) nachuntersucht. Das mittlere Extensionsdefizit lag bei 15° (0–30°), die mittlere Flexion bei 119° (95–140°). Die mittlere Pronation betrug 78° (60–90°), die mittlere Supination 79° (50–90°). Nach dem Mayo-Elbow-Performance-Score erreichten drei Patienten ein sehr gutes, sieben ein gutes und ein Patient ein befriedigendes Ergebnis. Der Mittelwert lag bei 89,2 Punkten (74–100 Punkte). Der mittlere DASHScore (Disabilities of the Arm, Shoulder and Hand) lag bei 8,4 Punkten (0–28 Punkte).AbstractObjectiveTherapy of comminuted intraarticular distal humerus fractures in elderly patients with primary total elbow arthroplasty to achieve stable and painless function. Use of “third-generation” elbow prosthesis with the following options: – linked total elbow arthroplasty, – unlinked total elbow arthroplasty, – either with or without radial head replacement, – hemiarthroplasty.IndicationsComminuted intraarticular distal humerus fractures with poor bone quality, in which stable osteosynthesis is impossible. Failure of internal fixation without the technical possibility of revision osteosynthesis. Posttraumatic osteoarthritis or rheumatoid arthritis.ContraindicationsOpen fractures (Gustilo-Anderson type II or III) or contaminated wounds should not initially be treated with total elbow arthroplasty. Prosthetic replacement may be considered after consolidation of the soft tissue. Low compliance, high functional demands. Paralysis of the biceps muscle.Surgical TechniqueSupine positioning of the patient. Surgical approach after Bryan-Morrey. Anterior transposition of the ulnar nerve. Preparation of the insertion of the triceps at the distal humerus, capsule and proximal ulna. Reflection of the triceps in continuity with the ulnar periosteum and the forearm fascia. Attempt at reconstruction of the epicondyles to achieve ligamentary stability and to implant an unlinked prosthesis. If this is technically not possible, the prosthesis is linked at the end of the operation. Removal of the distal humerus fragments. Determination of the prosthesis size. Detection of the extension-flexion axis. Opening of the humeral intramedullary canal. Determination of the offset. Preparation of the humeral prosthesis repository. Placement of the trial prosthesis. Potential implantation of a hemiprosthesis, if radial head, proximal ulna and ligaments are unaffected. Otherwise preparation of the ulnar prosthesis repository. If the radial head is unaffected, it can be preserved. Otherwise it has to be resected and preferably replaced. Placement of the ulnar and radial trial prosthesis. After correct trial reposition cementing of all definitive prosthesis components with attachment of a cortical bone graft behind the ventral flange of the humeral component. If there is no sufficient stability at the end of the operation, the prosthesis must be linked by insertion of the ulnar cap.Postoperative ManagementPostoperative anterior upper-arm splint in full extension. Active motion. No active extension for 6 weeks. Avoidance of single-event weight lifting > 5 kg, no repetitive weight lifting > 1 kg, and no forced elbow movements, e.g., racquet sports.Results15 Latitude elbow prostheses were implanted in 2007 and 2008 at the Department of Trauma Surgery of the University Hospital Mainz, Germany, due to the following indications: fractures (n = 7), pseudarthrosis (n = 4), posttraumatic osteoarthritis (n = 3), and rheumatoid arthritis (n = 1). Six hemiprostheses, two unlinked and seven linked prostheses were implanted. The mean age of patients was 67 years (31–88 years). For the treatment of acute fractures, the indication was made only in elderly patients. The mean age was 77 years (66–88 years). Eleven of these 15 patients were reexamined after 13.5 months (6–23 months). The mean extension deficit was 15° (0–30°), the mean flexion 119° (95–140°). The mean pronation was 78° (60–90°), the mean supination 79° (50–90°). According to the Mayo Elbow Performance Score, three patients achieved an excellent, seven a good, and one a fair result. The mean Mayo Score was 89.2 (74–100). The mean DASH (Disabilities of the Arm, Shoulder and Hand) Score was 8.4 (0–28).


Biomedizinische Technik | 2010

Influence of formalin fixation on the biomechanical properties of human diaphyseal bone

Klaus J. Burkhart; Tobias E. Nowak; Jochen Blum; Sebastian Kuhn; Marcel Welker; Werner Sternstein; Lars P. Mueller; Pol Maria Rommens

Abstract Owing to the lack of fresh human bones, formalin-fixed specimens are frequently used in biomechanical testing. However, formalin fixation is assumed to affect the biomechanical properties of bone. The aim of this study was to compare axial and torsional stiffness and bone mineral density in fresh and embalmed human bones. The subtrochanteric regions of 12 pairs of fresh human femora were randomised into two groups for paired comparison. After bone mineral density measurement, one group was preserved in 4% formalin. After 6 weeks, bone mineral density was remeasured and each specimen underwent axial and torsional loading. The formalin group showed significant higher stiffness values for torsional and axial loads than the fresh group. Axial stiffness increased by 14.1%, whereas torsional stiffness increased by 14.3%. These differences were not reflected in bone mineral density values. Formalin fixation significantly influences the stiffness of human cadaveric bones. Fresh bones represent the in vivo conditions better than formalin fixed bones.


Operative Orthopadie Und Traumatologie | 2010

Behandlung der komplexen intraartikulären Fraktur des distalen Humerus mittels Latitude-Ellenbogenprothese

Klaus J. Burkhart; Lars Peter Müller; Christina Schwarz; Stefan G. Mattyasovszky; Pol Maria Rommens

ZusammenfassungOperationszielStabile und schmerzfreie Funktion durch primäre Implantation einer totalen Ellenbogenprothese nach intraartikulärer Trümmerfraktur des distalen Humerus bei älteren Patienten. Der künstliche Gelenkersatz kann als gekoppelte oder ungekoppelte Totalendoprothese mit oder ohne Radiuskopfersatz sowie als Hemiendoprothese verwendet werden.IndikationenIntraartikuläre Trümmerfrakturen des distalen Humerus mit schlechter Knochenqualität, die keine primäre stabile Osteosynthese zulassen. Versagen einer Osteosynthese ohne Möglichkeit einer Revisionsosteosynthese. Posttraumatische Arthrose und rheumatoide Arthritis.KontraindikationenOffene Frakturen (Typ II oder III nach Gustilo-Anderson) und infizierte Wundverhältnisse, z.B. nach fehlgeschlagener Osteosynthese, sollten nicht initial prothetisch versorgt werden. Nach Konsolidierung der Weichteilsituation kann die Prothesenimplantation in Betracht gezogen werden. Fehlende Mitarbeit des Patienten, hoher Funktionalitätsanspruch. Paralyse des Bizepsmuskels.OperationstechnikRückenlagerung. Zugang nach Bryan-Morrey. Anteriore Transposition des Nervus ulnaris. Darstellen des Trizepsansatzes an der Insertion am distalen Humerus, an der Kapsel und der proximalen Ulna. Ablösen desselben mitsamt dem Periost und der Unterarmfaszie. Versuch der Rekonstruktion der Kondylen, um eine ligamentäre Stabilität herzustellen und die Prothese ungekoppelt einbringen zu können. Wenn dies technisch nicht möglich ist, müssen die Prothesenkomponenten am Ende der Operation gekoppelt werden. Entfernung der Gelenkfragmente. Bestimmung der Prothesengröße. Ermittlung der Extensions- Flexions-Achse. Eröffnung des Markraums des Humerus. Ermittlung des Offsets. Präparation des humeralen Prothesenlagers. Einsetzen der Probeprothese. Potentiell Implantation einer Hemiendoprothese bei guten Knorpelstrukturen ulnar und radial sowie intakten Ligamenten. Anderenfalls nun Präparation des ulnaren Prothesenlagers. Falls der Radiuskopf keine Läsionen aufweist, kann er erhalten werden. Ansonsten wird er reseziert und möglichst prothetisch ersetzt. Einbringen der ulnaren und radialen Probeprothesenkomponenten. Nach korrekter Probereposition Einzementieren aller definitiven Komponenten mit Anlagerung eines Knochenspans hinter dem anterioren Flansch. Refixation des Trizeps und der Ligamente. Liegt am Ende der Operation keine ausreichende Stabilität vor, muss die Prothese mit der Ulnakappe gekoppelt werden.WeiterbehandlungAm Ende der Operation beugeseitige Gipsschiene in Streckstellung. Selbstständige Bewegungsübungen. Keine aktive Extension für 6 Wochen, Vermeidung des Hebens von Gewichten > 5 kg, keine wiederholten Dauerbelastungen > 1 kg und keine forcierten Bewegungen im Ellenbogengelenk, z.B. Schlagsportarten.ErgebnisseIn den Jahren 2007 und 2008 wurden in der Unfallchirurgischen Abteilung des Universitätsklinikums Mainz 15 Latitude- Ellenbogenprothesen bei folgenden Indikationen implantiert: Frakturen (n = 7), Pseudarthrosen (n = 4), posttraumatische Arthrosen (n = 3) und rheumatoide Arthritis (n = 1). Es wurden sechs Hemiendoprothesen, zwei ungekoppelte und sieben gekoppelte Totalendoprothesen eingebaut. Das durchschnittliche Alter der Patienten betrug 67 Jahre (31–88 Jahre). Bei der primären Frakturversorgung wurde die Indikation nur bei älteren Patienten gestellt. Das mittlere Alter betrug hier 77 Jahre (66–88 Jahre). Elf dieser 15 Patienten wurden nach durchschnittlich 13,5 Monaten (6–23 Monate) nachuntersucht. Das mittlere Extensionsdefizit lag bei 15° (0–30°), die mittlere Flexion bei 119° (95–140°). Die mittlere Pronation betrug 78° (60–90°), die mittlere Supination 79° (50–90°). Nach dem Mayo-Elbow-Performance-Score erreichten drei Patienten ein sehr gutes, sieben ein gutes und ein Patient ein befriedigendes Ergebnis. Der Mittelwert lag bei 89,2 Punkten (74–100 Punkte). Der mittlere DASHScore (Disabilities of the Arm, Shoulder and Hand) lag bei 8,4 Punkten (0–28 Punkte).AbstractObjectiveTherapy of comminuted intraarticular distal humerus fractures in elderly patients with primary total elbow arthroplasty to achieve stable and painless function. Use of “third-generation” elbow prosthesis with the following options: – linked total elbow arthroplasty, – unlinked total elbow arthroplasty, – either with or without radial head replacement, – hemiarthroplasty.IndicationsComminuted intraarticular distal humerus fractures with poor bone quality, in which stable osteosynthesis is impossible. Failure of internal fixation without the technical possibility of revision osteosynthesis. Posttraumatic osteoarthritis or rheumatoid arthritis.ContraindicationsOpen fractures (Gustilo-Anderson type II or III) or contaminated wounds should not initially be treated with total elbow arthroplasty. Prosthetic replacement may be considered after consolidation of the soft tissue. Low compliance, high functional demands. Paralysis of the biceps muscle.Surgical TechniqueSupine positioning of the patient. Surgical approach after Bryan-Morrey. Anterior transposition of the ulnar nerve. Preparation of the insertion of the triceps at the distal humerus, capsule and proximal ulna. Reflection of the triceps in continuity with the ulnar periosteum and the forearm fascia. Attempt at reconstruction of the epicondyles to achieve ligamentary stability and to implant an unlinked prosthesis. If this is technically not possible, the prosthesis is linked at the end of the operation. Removal of the distal humerus fragments. Determination of the prosthesis size. Detection of the extension-flexion axis. Opening of the humeral intramedullary canal. Determination of the offset. Preparation of the humeral prosthesis repository. Placement of the trial prosthesis. Potential implantation of a hemiprosthesis, if radial head, proximal ulna and ligaments are unaffected. Otherwise preparation of the ulnar prosthesis repository. If the radial head is unaffected, it can be preserved. Otherwise it has to be resected and preferably replaced. Placement of the ulnar and radial trial prosthesis. After correct trial reposition cementing of all definitive prosthesis components with attachment of a cortical bone graft behind the ventral flange of the humeral component. If there is no sufficient stability at the end of the operation, the prosthesis must be linked by insertion of the ulnar cap.Postoperative ManagementPostoperative anterior upper-arm splint in full extension. Active motion. No active extension for 6 weeks. Avoidance of single-event weight lifting > 5 kg, no repetitive weight lifting > 1 kg, and no forced elbow movements, e.g., racquet sports.Results15 Latitude elbow prostheses were implanted in 2007 and 2008 at the Department of Trauma Surgery of the University Hospital Mainz, Germany, due to the following indications: fractures (n = 7), pseudarthrosis (n = 4), posttraumatic osteoarthritis (n = 3), and rheumatoid arthritis (n = 1). Six hemiprostheses, two unlinked and seven linked prostheses were implanted. The mean age of patients was 67 years (31–88 years). For the treatment of acute fractures, the indication was made only in elderly patients. The mean age was 77 years (66–88 years). Eleven of these 15 patients were reexamined after 13.5 months (6–23 months). The mean extension deficit was 15° (0–30°), the mean flexion 119° (95–140°). The mean pronation was 78° (60–90°), the mean supination 79° (50–90°). According to the Mayo Elbow Performance Score, three patients achieved an excellent, seven a good, and one a fair result. The mean Mayo Score was 89.2 (74–100). The mean DASH (Disabilities of the Arm, Shoulder and Hand) Score was 8.4 (0–28).


Journal of Trauma-injury Infection and Critical Care | 2010

New intramedullary locking nail for olecranon fracture fixation--an in vitro biomechanical comparison with tension band wiring.

Tobias E. Nowak; Klaus J. Burkhart; Lars P. Mueller; Stefan G. Mattyasovszky; Torsten Andres; Werner Sternstein; Pol Maria Rommens

BACKGROUND The aim of this study was to determine the difference in displacement of a newly designed intramedullary olecranon fracture fixation device compared with multifilament tension band wiring after 4 cycles and 300 cycles of dynamic continuous loading. METHODS In eight pairs of fresh-frozen cadaver ulnae, oblique olecranon fractures were created and stabilized using either newly designed intramedullary olecranon nail or multifilament tension band wiring. The specimens were then subjected to continuous dynamic loading (from 25 N to 200 N) using matched pairs of cadaveric upper extremities. The Wilcoxon test was used to determine statistical differences of the displacement in the fracture gap. RESULTS After 4 cycles and 300 cycles, the displacement in the fracture model was significantly higher in the tension band wiring group than in the intramedullary nailing group. CONCLUSIONS The newly designed interlocking nailing system showed higher stability in comparison with multifilament tension band wiring after continuous dynamic loading.


Journal of Hand Surgery (European Volume) | 2011

Anatomic Fit of Six Different Radial Head Plates: Comparison of Precontoured Low-Profile Radial Head Plates

Klaus J. Burkhart; Tobias E. Nowak; Yoon-Joo Kim; Pol Maria Rommens; Lars Peter Müller

PURPOSE Bulky implants may lead to symptomatic soft tissue irritation after open reduction and internal fixation of radial head and neck fractures. The purpose of our study was to compare the anatomic fit of precontoured radial head plates. METHODS We stripped 22 embalmed human cadaveric radiuses of soft tissues. We investigated 6 radial head plates: (1) the Medartis radial head buttress plate (MBP), (2) the Medartis radial head rim plate (MRP), (3) the Synthes radial neck plate (SNP), (4) the Synthes radial head plate (SHP), (5) the Acumed radial head plate (AHP), and (6) the Wright radial head plate (WHP). Each plate was applied to each radial head at the place of best fit within the safe zone. We tested 4 parameters of anatomic fit: (1) plate-to-bone distance, (2) plate contact judged by 3 different observers, (3) pin-subchondral zone distance, and (4) plate-to-bone contact after adjustment of the plates. RESULTS The MBP and MRP showed the lowest profile by objective measurements, the SNP and AHP had a moderate profile, and the SHP and WHP demonstrated the bulkiest profile. The subjective assessments also demonstrated the best fit for the MBP, a good fit for the SNP, a moderate fit for the MRP and AHP, and a poor fit for the SHP and WHP. The MBP, MRP, and AHP could always provide pin-subchondral zone contact, unlike the SHP, SNP, and WHP. After bending, significant improvement of plate-to-bone distance could only be seen for the MBP, MRP, and WHP. The ranking among plates remained the same except for the WHP, which showed a significantly lower plate-to-bone distance than the SHP. CONCLUSIONS Currently available radial head implants are heterogeneous. The MBP and MRP showed the lowest profile and best anatomic fit. Owing to the complex radial head anatomy, to date there is no one radial head plate that perfectly fits all radial heads. CLINICAL RELEVANCE Conformance of existing plates to the radial head and neck is not perfect. Careful plate selection and modification, when necessary, may minimize interference of this hardware with the surrounding soft tissues and facilitate recovery of motion.


Acta Orthopaedica | 2011

Isolated fractures of the greater tuberosity of the proximal humerus: A long-term retrospective study of 30 patients

Stefan G. Mattyasovszky; Klaus J. Burkhart; Christopher Ahlers; Dirk Proschek; Sven-Oliver Dietz; Inma Becker; Stephan Müller-Haberstock; Lars Peter Müller; Pol Maria Rommens

Background and purpose The diagnosis and treatment of isolated greater tuberosity fractures of the proximal humerus is not clear-cut. We retrospectively assessed the clinical and radiographic outcome of isolated greater tuberosity fractures. Patients and methods 30 patients (mean age 58 (26–85) years, 19 women) with 30 closed isolated greater tuberosity fractures were reassessed after an average follow-up time of 3 years with DASH score and Constant score. Radiographic outcome was assessed on standard plain radiographs. Results 14 of 17 patients with undisplaced or slightly displaced fractures (≤ 5 mm) were treated nonoperatively and had good clinical outcome (mean DASH score of 13, mean Constant score of 71). 8 patients with moderately displaced fractures (6–10 mm) were either treated nonoperatively (n = 4) or operatively (n = 4), with good functional results (mean DASH score of 10, mean Constant score of 72). 5 patients with major displaced fractures (> 10 mm) were all operated with good clinical results (mean DASH score of 14, mean Constant score of 69). The most common discomfort at the follow-up was an impingement syndrome of the shoulder, which occurred in both nonoperatively treated patients (n = 3) and operatively treated patients (n = 4). Only 1 nonoperatively treated patient developed a non-union. By radiography, all other fractures healed. Interpretation We found that minor to moderately displaced greater tuberosity fractures may be treated successfully without surgery.


Deutsches Arzteblatt International | 2015

The treatment of simple elbow dislocation in adults.

Michael Hackl; Frank Beyer; Kilian Wegmann; Tim Leschinger; Klaus J. Burkhart; Lars Peter Müller

BACKGROUND Simple elbow dislocation is a complex soft-tissue injury that can cause permanent symptoms. Its incidence is 5 to 6 cases per 100 000 persons per year. Its proper treatment is debated; options range from immobilization in a cast to surgical intervention. METHODS We systematically reviewed the literature on the treatment of simple elbow dislocation and performed a meta-analysis, primarily on the basis of clinical scores and secondarily with respect to pain, range of motion, and return to work. RESULTS A randomized controlled trial (RCT) showed that clinical results at short-term follow-up were superior for early functional treatment compared to immobilization in a cast. Brief immobilization, however, reduced pain initially, and the long-term results of early mobilization and immobilization in a cast were the same. Our meta-analysis showed that early mobilization enables patients to return to work earlier (difference of mean values -2.91, 95% confidence interval [CI] -3.18 to -2.64), and that the extent of soft-tissue injury is correlated with the clinical outcome (inverse relationship; difference of mean values -12.07, 95% CI -23.88 to -0.26). Surgical and conservative treatment were compared in a single RCT, which revealed no significant difference in outcomes. A meta-analysis of two retrospective comparative studies showed no advantage of immediate ligament repair over delayed surgery. CONCLUSION Early functional treatment is the evidence-based therapeutic standard for simple elbow dislocation. The past few years have seen further developments in surgery for simple elbow dislocation. Further study is needed to determine whether surgery for elbow dislocation with high-grade instability can prevent persistent pain, limitation of motion, and chronic instability.


Strategies in Trauma and Limb Reconstruction | 2012

The Essex-Lopresti lesion

Kilian Wegmann; Jens Dargel; Klaus J. Burkhart; Gert-Peter Brüggemann; Lars Peter Müller

The Essex-Lopresti lesion represents a severe injury of the forearm unit. In the 1940s, it’s pathology and consequences have already been mentioned by several authors. Over the course of time, the pathophysiology of the lesion was displayed in more detail. Therefore, an intensive analysis of the involved anatomic structures was done. The interosseous membrane was shown to play a major role in stabilising the forearm unit, in the situation of a fractured radial head, which is the primary stabiliser of the longitudinal forearm stability. Moreover, biomechanical analyses showed a relevant attribution of the distal radio-ulnar joint to the forearm stability. If, in the case of a full-blown Essex-Lopresti lesion, the radial head, the interosseous membrane and the distal radio-ulnar joint are injured, proximalisation of the radius will take place and will come along with secondary symptoms at the elbow joint and the wrist. According to actual studies, the lesion seems to occur more often than realised up to now. Thus, to avoid missing the complex injury, subtle clinical diagnosis combined with adequate imaging has to be undertaken. If the lesion is confirmed, several operative treatment options are available, yet not proofed to be sufficient.


Journal of Hand Surgery (European Volume) | 2015

Reliability of Magnetic Resonance Imaging Signs of Posterolateral Rotatory Instability of the Elbow

Michael Hackl; Kilian Wegmann; Christian Ries; Tim Leschinger; Klaus J. Burkhart; Lars Peter Müller

PURPOSE To evaluate radiographic signs of posterolateral rotatory instability (PLRI) on magnetic resonance imaging (MRI). The goal was to establish objective radiographic criteria to aid in the diagnosis of PLRI. METHODS The MRI scans of 60 patients were evaluated retrospectively. Two study groups were compared. Group 1 (n = 30) consisted of unstable elbows in which PLRI was confirmed by clinical examination and arthroscopy. Group 2 (stable; n = 30) served as the control group. Patients in group 2 had transient epicondylitis without clinical suspicion of instability. Joint incongruity was analyzed for sagittal views through the radial head and the coronoid tip and for coronal and axial views. Interobserver and intra-observer reliability were evaluated. RESULTS In the sagittal view through the radial head, average radiocapitellar incongruity differed significantly between groups 1 and 2. In addition, mean ulnohumeral incongruity in an axial view through the motion axis of the distal humerus showed significant differences between groups. Sagittal views through the tip of the coronoid and coronal views did not reveal significant differences in patients with unstable elbows compared with the control group. CONCLUSIONS The current study provides useful MRI criteria indicative of PLRI when combined with physical examination. Cutoff points of 1.2 mm for radiocapitellar incongruity (sagittal view) and 0.7 mm for axial ulnohumeral incongruity (axial view) are suitable to screen for PLRI. Radiocapitellar incongruity greater than 2 mm and axial ulnohumeral incongruity greater than 1 mm are highly suspicious of elbow instability. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic IV.


Injury-international Journal of The Care of The Injured | 2015

The course of the posterior interosseous nerve in relation to the proximal radius: Is there a reliable landmark?

Michael Hackl; Kilian Wegmann; Sebastian Lappen; C. Helf; Klaus J. Burkhart; Lars Peter Müller

PURPOSE The posterior interosseous nerve (PIN) is closely related to the proximal radius, and it is at risk when approaching the proximal forearm from the ventral and lateral side. This anatomic study analyzes the location of the PIN in relation to the proximal radius depending on forearm rotation by means of a novel investigation design. The purpose of this study is to define landmarks to locate the PIN intraoperatively in order to avoid neurological complications. METHODS We dissected six upper extremities of fresh-frozen cadaveric specimens. The mean donor age at the time of death was 81.2 years. The PIN was dissected and marked on its course along the proximal forearm with a 0.3-mm flexible radiopaque thread. Three-dimensional (3D) X-ray scans were performed, and the location of the nerve was analyzed in neutral rotation, supination, and pronation. RESULTS In the coronal view, the PIN crosses the radial neck/shaft at a mean of 33.4 (±5.9)mm below the radial head surface (RHS) in pronation and 16.9 (±5.0)mm in supination. It crosses 4.9 (±2.2)mm distal of the most prominent point of the radial tuberosity (RT) in pronation and 9.6 (±5.2)mm proximal in supination. In the sagittal view, the PIN crosses the proximal radius 61.8 (±2.9)mm below the RHS in pronation and 41.1 (±3.6)mm in supination. The nerve crosses 29.2 (±6.2)mm distal of the RT in pronation and 11.0 (±2.8)mm in supination. CONCLUSION With this novel design, the RT could be defined as a useful landmark for intraoperative orientation. On a ventral approach, the PIN courses 10mm proximal of it in supination and 5mm distal of it in pronation. Laterally, pronation increases the distance of the PIN to the RT to approximately 3cm.

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Tobias E. Nowak

University of Erlangen-Nuremberg

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