Lucas Vogels

Percutaneous treatment of displaced intra-articular calcaneal fractures

BackgroundThe outcome after displaced intra-articular calcaneal fractures is influenced by the condition of the surrounding soft tissues. To avoid secondary soft tissue complications after surgical treatment, several less-invasive procedures for reduction and fixation have been introduced. The percutaneous technique according to Forgon and Zadravecz is suitable for all types of displaced intra-articular calcaneal fractures and was therefore introduced in our clinic. The aim of this study was to evaluate the long-term outcome of percutaneous treatment according to Forgon and Zadravecz in patients with displaced intra-articular calcaneal fractures.MethodsA cohort of patients with displaced intra-articular calcaneal fractures treated with percutaneous surgery was retrospectively defined. Clinical outcome was evaluated by standardized physical examination, radiographs, three published outcome scores, and a visual analogue scale of patient satisfaction.ResultsFifty patients with 61 calcaneal fractures were included. After a mean follow-up period of 35 months, the mean values of the Maryland foot score, the Creighton-Nebraska score, and the American Orthopaedic Foot and Ankle Society score were 79, 76, and 83 points out of 100, respectively. The average visual analogue scale was 7.2 points out of 10. The average range of motion of the ankle joint was 90% of normal and subtalar joint movements were almost 70% compared with the healthy side or normal values. Superficial wound complications occurred in seven cases (11%) and deep infections in two (3%). A secondary arthrodesis of the subtalar joint was performed in five patients and was scheduled in four patients (15%).ConclusionsCompared with the outcome of historic controls from randomized trials and meta-analyses, this study indicates favorable results for the percutaneous technique compared with the open technique. Despite similar rates of postoperative infection and secondary arthrodesis, the total outcome scores and preserved subtalar motion are overall good to excellent.

Percutaneous Reduction and Fixation of Intraarticular Calcaneal Fractures

ObjectivePercutaneous reduction by distraction and subsequent percutaneous screw fixation to restore calcaneal and posterior talocalcaneal facet anatomy. The aim of this technique is to improve functional outcome and to diminish the rate of secondary posttraumatic arthrosis compared to conservative treatment and, secondly, to reduce infectious complications compared to open reduction and internal fixation (ORIF).IndicationsSanders type II–IV displaced intraarticular calcaneal fractures.ContraindicationsIsolated centrally depressed fragment.Patients who are expected to be noncompliant.Surgical TechniqueFour distractors (Synthes®) are positioned, two on each side of the foot, between the tuberosity of the calcaneus and talus and between the tuberosity and cuboid. A distracting force is given over all four distractors. A blunt drifter is then introduced from the plantar side to unlock and push up any remaining depressed parts of the subtalar joint surface of the calcaneus. The reduction is fixated with two or three screws inserted percutaneously.Postoperative ManagementDirectly postoperatively, full active range of motion exercises of the ankle joint can start, with the foot elevated in the 1st postoperative week. Stitches are removed after 14 days. Implant removal is necessary in 50–60% of patients.ResultsBetween 1999 and 2004, 59 patients with 71 fractures were treated by percutaneous skeletal triangular distraction and percutaneous fixation. A total of 50 patients with 61 fractures and a minimum follow-up of 1 year were available for follow-up. According to the American Orthopaedic Foot and Ankle Society Hindfoot Score, 72% had a good to excellent result. A secondary subtalar arthrodesis was performed in five patients and planned in four (total 15%). Böhlers angle increased by about 20° postoperatively.Sagittal motion was 90% and subtalar motion 70% compared to the healthy foot.ZusammenfassungOperationszielPerkutane Distraktion und anschließende perkutane Schraubenfixierung zur Wiederherstellung der Anatomie der Facetten des Fersenbeins und des hinteren Sprungbeins. Ziele dieser Technik sind eine Verbesserung des funktionalen Ergebnisses und eine Verminderung der Häufigkeitsrate der sekundären posttraumatischen Arthrose im Vergleich zur konservativen Behandlung sowie eine Senkung infektiöser Komplikationen im Vergleich zur offenen Reposition und inneren Fixation (ORIF).IndikationenDislozierte intraartikuläre Kalkaneusfrakturen Typ Sanders II–IV.KontraindikationenIsoliertes, zentrales Depressionsfragment.Patienten, bei denen mangelnde Mitarbeit zu erwarten ist.OperationstechnikEs werden vier Distraktoren (Synthes®) positioniert, zwei auf jeder Seite des Fußes, jeweils zwischen der Tuberositas des Fersenbeins und des Sprungbeins sowie zwischen der Tuberositas und dem Kuboid. Bei allen vier Distraktoren wird Zugkraft eingesetzt. Ein Einschlaginstrument wird dann plantar angesetzt, um die verbleibenden zertrümmerten Teile der subtalaren Gelenkoberfläche des Kalkaneus zu lösen und jegliche verbleibenden Teile heraufzuschieben. Die Reposition wird mit zwei oder drei perkutan eingebrachten Schrauben stabilisiert.WeiterbehandlungUnmittelbar postoperativ kann mit Übungen des oberen Sprunggelenks begonnen werden, wobei der Fuß in der 1. Woche hochgelagert wird. Die Fäden werden nach 14 Tagen entfernt. Eine Schraubenentfernung ist bei 50–60% der Patienten erforderlich.ErgebnisseZwischen 1999 und 2004 wurden 59 Patienten mit 71 Frakturen mittels perkutaner dreiseitiger Distraktion und perkutaner Fixation behandelt. Insgesamt 50 Patienten mit 61 Frakturen und einer Mindestnachsorge von 1 Jahr standen bei der Nachuntersuchung zur Verfügung. Laut dem American Orthopaedic Foot and Ankle Society Hindfoot Score wiesen 72% der Patienten ein gutes bis ausgezeichnetes Ergebnis auf. Eine sekundäre subtalare Arthrodese wurde bei fünf Patienten durchgeführt und war bei vier Patienten geplant (insgesamt 15%). Der Böhler-Winkel stieg postoperativ um rund 20°. Im Vergleich zum gesunden Fuß lagen der sagittale Bewegungsumfang bei 90% und der subtalare Bewegungsumfang bei 70%.

Humeral shaft fractures: retrospective results of non-operative and operative treatment of 186 patients.

BACKGROUND Humeral shaft fractures account for 1-3% of all fractures and 20% of the fractures involving the humerus. The aim of the current study was to compare the outcome after operative and non-operative treatment of humeral shaft fractures, by comparing the time to radiological union and the rates of delayed union and complications. METHODS All patients aged 16 years or over treated for a humeral shaft fracture during a 5-year period were included in this retrospective analysis; periprosthetic and pathological fractures were excluded. Radiographs and medical charts were retrieved and reviewed in order to collect data on fracture classification, time to radiographic consolidation and the occurrence of adverse events. RESULTS A total of 186 patients were included; 91 were treated non-operatively and 95 were treated operatively. Mean age was 58.7 ± 1.5 years and 57.0% were female. In 83.3% of the patients, only the humerus was affected. A fall from standing height was the most common cause of the fracture (72.0%). Consolidation time varied from a median of 11-28 weeks. The rate of radial nerve palsy in both groups was similar: 8.8% versus 9.5%. In 5.3% of the operatively treated patients, the palsy resulted from the operation. Likewise, delayed union rates were similar in both groups: 18.7% following non-operative treatment versus 18.9% following surgery. CONCLUSION The data indicated that consolidation time and complication rates were similar after operative and non-operative treatment. A prospective randomised clinical trial comparing non-operative with operative treatment is needed in order to examine other aspects of outcome, meaning shoulder and elbow function, postoperative infection rates, trauma-related quality of life and patient satisfaction.

Perkutane Reposition und Fixation intraartikulärer Kalkaneusfrakturen

ObjectivePercutaneous reduction by distraction and subsequent percutaneous screw fixation to restore calcaneal and posterior talocalcaneal facet anatomy. The aim of this technique is to improve functional outcome and to diminish the rate of secondary posttraumatic arthrosis compared to conservative treatment and, secondly, to reduce infectious complications compared to open reduction and internal fixation (ORIF).IndicationsSanders type II–IV displaced intraarticular calcaneal fractures.ContraindicationsIsolated centrally depressed fragment.Patients who are expected to be noncompliant.Surgical TechniqueFour distractors (Synthes®) are positioned, two on each side of the foot, between the tuberosity of the calcaneus and talus and between the tuberosity and cuboid. A distracting force is given over all four distractors. A blunt drifter is then introduced from the plantar side to unlock and push up any remaining depressed parts of the subtalar joint surface of the calcaneus. The reduction is fixated with two or three screws inserted percutaneously.Postoperative ManagementDirectly postoperatively, full active range of motion exercises of the ankle joint can start, with the foot elevated in the 1st postoperative week. Stitches are removed after 14 days. Implant removal is necessary in 50–60% of patients.ResultsBetween 1999 and 2004, 59 patients with 71 fractures were treated by percutaneous skeletal triangular distraction and percutaneous fixation. A total of 50 patients with 61 fractures and a minimum follow-up of 1 year were available for follow-up. According to the American Orthopaedic Foot and Ankle Society Hindfoot Score, 72% had a good to excellent result. A secondary subtalar arthrodesis was performed in five patients and planned in four (total 15%). Böhlers angle increased by about 20° postoperatively.Sagittal motion was 90% and subtalar motion 70% compared to the healthy foot.ZusammenfassungOperationszielPerkutane Distraktion und anschließende perkutane Schraubenfixierung zur Wiederherstellung der Anatomie der Facetten des Fersenbeins und des hinteren Sprungbeins. Ziele dieser Technik sind eine Verbesserung des funktionalen Ergebnisses und eine Verminderung der Häufigkeitsrate der sekundären posttraumatischen Arthrose im Vergleich zur konservativen Behandlung sowie eine Senkung infektiöser Komplikationen im Vergleich zur offenen Reposition und inneren Fixation (ORIF).IndikationenDislozierte intraartikuläre Kalkaneusfrakturen Typ Sanders II–IV.KontraindikationenIsoliertes, zentrales Depressionsfragment.Patienten, bei denen mangelnde Mitarbeit zu erwarten ist.OperationstechnikEs werden vier Distraktoren (Synthes®) positioniert, zwei auf jeder Seite des Fußes, jeweils zwischen der Tuberositas des Fersenbeins und des Sprungbeins sowie zwischen der Tuberositas und dem Kuboid. Bei allen vier Distraktoren wird Zugkraft eingesetzt. Ein Einschlaginstrument wird dann plantar angesetzt, um die verbleibenden zertrümmerten Teile der subtalaren Gelenkoberfläche des Kalkaneus zu lösen und jegliche verbleibenden Teile heraufzuschieben. Die Reposition wird mit zwei oder drei perkutan eingebrachten Schrauben stabilisiert.WeiterbehandlungUnmittelbar postoperativ kann mit Übungen des oberen Sprunggelenks begonnen werden, wobei der Fuß in der 1. Woche hochgelagert wird. Die Fäden werden nach 14 Tagen entfernt. Eine Schraubenentfernung ist bei 50–60% der Patienten erforderlich.ErgebnisseZwischen 1999 und 2004 wurden 59 Patienten mit 71 Frakturen mittels perkutaner dreiseitiger Distraktion und perkutaner Fixation behandelt. Insgesamt 50 Patienten mit 61 Frakturen und einer Mindestnachsorge von 1 Jahr standen bei der Nachuntersuchung zur Verfügung. Laut dem American Orthopaedic Foot and Ankle Society Hindfoot Score wiesen 72% der Patienten ein gutes bis ausgezeichnetes Ergebnis auf. Eine sekundäre subtalare Arthrodese wurde bei fünf Patienten durchgeführt und war bei vier Patienten geplant (insgesamt 15%). Der Böhler-Winkel stieg postoperativ um rund 20°. Im Vergleich zum gesunden Fuß lagen der sagittale Bewegungsumfang bei 90% und der subtalare Bewegungsumfang bei 70%.

Hemi-Castaing ligamentoplasty for the treatment of chronic lateral ankle instability: a retrospective assessment of outcome

PurposeIn the treatment of chronic ankle instability, most non-anatomical reconstructions use the peroneus brevis tendon. This, however, sacrifices the natural ankle stabilising properties of the peroneus brevis muscle. The aim of this study was to evaluate the functional outcome of patients treated with a hemi-Castaing procedure, which uses only half the peroneus brevis tendon.MethodsWe performed a retrospective cohort study of patients who underwent hemi-Castaing ligamentoplasty for chronic lateral ankle instability between 1993 and 2010, with a minimum of one year follow-up. Patients were sent a postal questionnaire comprising five validated outcome measures: Olerud-Molander Ankle Score (OMAS), Karlsson Ankle Functional Score (KAFS), Tegner Activity Level Score (pre-injury, prior to surgery, at follow-up), visual analog scale on pain (VAS) and the Short Form 36 (SF-36).ResultsTwenty patients completed the questionnaire on functional outcome. The OMAS showed good to excellent outcome in 80% and the KAFS in 65%, the Tegner Score improved from surgery but did not reach pre-injury levels, the VAS on pain was 1 of 10 and the SF-36 returned to normal compared with the average population.ConclusionsEven though most patients were satisfied with the results, outcome at long-term follow-up was less favourable compared with the literature on anatomical reconstructions. In accordance with the literature, we therefore conclude that the initial surgical treatment of chronic lateral ankle instability should be an anatomical repair with augmentation (i.e. the Broström-Gould technique) and the non-anatomical repair should be reserved for unsuccessful cases after anatomical repair or in cases where no adequate ligament remnants are available for reconstruction.

Rigidity of unilateral external fixators--a biomechanical study.

INTRODUCTION External fixation is the primary choice of temporary fracture stabilisation for specific polytrauma patients. Adequate initial fracture healing requires sufficient stability at the fracture site. The purpose of this study was to compare the rigidity of the Dynafix DFS(®) Standard Fixator (4 joints) with the Orthofix ProCallus Fixator(®) (2 joints), which differ in possibilities for adapting the configuration for clinical needs. MATERIALS AND METHODS Both devices were tested 10 times in a standardised model. In steps of 10N, loading was increased to a maximum of 160N in parallel, transversal and axial direction (distraction and compression). Translation resultant and rotation resultant were calculated. RESULTS With a force of 100N in parallel direction the mean translation resultant (Tr(mean)) of the Dynafix DFS(®) Standard Fixator (6.65±1.43mm) was significantly higher than the ProCallus Fixator(®) (3.29±0.83mm, p<0.001; Students t-test). With a maximum load of 60N in transverse direction the Tr(mean) of the Dynafix DFS(®) Standard Fixator was significantly lower (8.14±1.20mm versus 9.83±0.63mm, p<0.005). Translation was significantly higher with the Dynafix DFS(®) Standard Fixator, for both distraction (2.13±0.32mm versus 1.69±0.44mm, p<0.05) and compression (1.55±1.08mm versus 0.15±0.33mm, p<0.005). The mean rotation resultant (Rr(mean)) at 160N distraction was lower for the Dynafix DFS(®) Standard Fixator (0.70±0.17° versus 0.97±0.21°, p<0.005). CONCLUSIONS Both fixators were most sensitive to transverse forces. The Dynafix DFS(®) Standard Fixator was less rigid with parallel and axial forces, whereas transverse forces and rotation at distraction forces favoured the Dynafix DFS(®) Standard Fixator. Repeated heavy loading did not influence the rigidity of both devices.

Closing the medullary canal after retrograde nail removal using a bioabsorbable bone plug: technical tip

We describe a simple technique for closure of the intra-articular opening after the removal of a retrograde femur nail. With the use of a gelatine bioabsorbable bone plug the medullary canal is closed, reducing leakage of blood and cancellous bone particles from the bone into the knee joint.

Beenverlenging met Intramedullary Skeletal Kinetic Distractor

Een belangrijke verbetering in de behandeling van beenlengteverschil is de introductie van de Intramedullary Skeletal Kinetic Distractor (iskd). Deze voor femur en tibia geschikte grendelpen combineert de voordelen van intramedul-laire fixatie met de mogelijkheid van beenverlenging. De relatief hoge kosten van de pen wegen op tegen de reductie van het aantal complicaties bij gebruik van een fixateur externe ten behoeve van beenverlenging.1