Lutz Besch

Hemiarthroplasty of the shoulder after four-part fracture of the humeral head: a long-term analysis of 34 cases.

OBJECTIVE To assess the treatment outcomes of patients with four-part fracture of the humeral head after primary and secondary hemiarthroplasty. PATIENTS Retrospective long-term analysis of 46 patients from 1996 to 2002 of patients with 47 four-part fractures of humeral head. Patients with malignant disease were excluded. INTERVENTION Aequalis (Tornier, Burscheid, Germany). MAIN OUTCOME MEASUREMENTS Absolute and relative constant scores at 5-year follow-up examination without age or sex normalization, radiographic parameters of calcification, dislocation of tuberosities, prosthetic loosening, and dislocation of joint. RESULTS Eighteen patients treated by primary and 16 patients treated by secondary arthroplasty were assessed clinically and radiologically after a mean follow-up of 64 (60-96) months. The absolute Constant scores at follow-up were 54.9 to 48.5 points, respectively. The relative scores were 61.4% and 57.3%, respectively. Dislocation of tuberosities with severe loss of function was found in five cases treated by primary arthroplasty (13.5%) and in 12 treated by secondary arthroplasty (75.0%). CONCLUSIONS The majority of patients in both groups was free of pain or suffered minor pain as determined by the Constant score. Safe fixation of the tuberosities is a prerequisite for functional exercises and is better achieved in primary arthroplasty. A computed tomography scan before operative therapy aids in making the decision between open reduction and internal fixation or hemiarthroplasty.

The Treatment of Intra-articular Calcaneus Fractures with Severe Soft Tissue Damage with a Hinged External Fixator or Internal Stabilization: Long-term Results

We developed a hinged external fixator for the treatment of dislocated intra-articular calcaneus fractures with severe soft tissue damage. The external fixation was performed with a known external fixator system. The screw insertion points were biomechanically tested by defining a virtual rotation axis through the center of the talus to allow early active motion in the ankle joint. Long-term follow-up was performed after an average of 7.3 years. Results were graded with the American Orthopaedic Foot and Ankle Society (AOFAS) score. Radiographs were reviewed according to Sanders classification. Four open fractures and 33 cases with extremely swollen soft tissue, blisters, or compartment syndromes were treated. In 24 cases (64.9%), the hinged fixator was the final method of treatment (group I). A change to open reduction with internal fixation was performed in 13 fractures (35.1%) when soft tissue problems were minimal (group II). There were no late amputations, osteomyelitis, or malunions. According to Sanders classification, group I consisted of 14 type II, 8 type III, and 2 type IV fractures. Pin loosening or pin infection was seen in 4 cases, but there was no redislocation. The Böhlers angle improved in 43%, gaps in the posterior facet were closed in 41%, and any shortening or deviation of the axis was corrected in 82% of the cases. The AOFAS score for the group averaged 66.5. According to Sanders classification, group II consisted of 8 type II and 5 type III fractures. The Böhlers angle improved in 88%, and gaps in the posterior facet were closed in 87%. Any shortening or deviation of the axis was corrected in 95%, and the AOFAS score averaged 61.3. Significant differences in patient outcome scores between open reduction with internal fixation and hinged fixator were not found. P value was > .05. The hinged external fixator frame can be used in all calcaneus fracture types without soft tissue limitation. The hinged fixator allows early movement in the ankle joint, the risk of infection is minimized, and secondary plate fixation remains possible.

Versorgung pertrochantärer Femurfrakturen

BACKGROUND The primary aim of surgery for pertrochanteric fractures of the femur is to regain preoperative mobility as quickly as possible. The aim of this study was to investigate whether clinical or radiological differences could be found between proximal femoral nails (PFN) and trochanteric gamma nails (TGN), with particular attention given to technical differences in implantation and early complications. PATIENTS AND METHODS This prospective study included 114 patients with PFN or TGN. Their average age was 78.9 years. Clinical and radiological examinations were evaluated over a 24-month period. RESULTS The implantation time for PFN was 20 min less than for TGN in patients with 31A1 (AO) fractures, and 78.5% of all operations were complication-free. Problems occurred in 10 cases (seven PFN, three TGN) during nail insertion and were, in the case of TGN, all caused by fragment dislocation. Postoperative dislocation of the implant was observed in 12 cases [eight PFN (7%), four TGN (3.5%)]. Cut-out occurred in four cases with PFN implants, one of which was attributed to z-effect, and in two cases with TGN. Secondary varus deviation without cut-out occurred in one case with TGN and two cases with PFN. No significant differences in complication rates could be found between the two implants (p>0.05). CONCLUSIONS PFN are better suited to 31A1 fractures because of their higher rotational stability from the use of dual screws. A short femur and high antecurvation can cause insertion problems in PFN because of the nail design. It is advisable to choose the type of implant during preoperative planning after considering fracture type and patient anatomy.

[Proximal femur fractures: results and complications after osteosynthesis with PFN and TGN].

BACKGROUND The primary aim of surgery for pertrochanteric fractures of the femur is to regain preoperative mobility as quickly as possible. The aim of this study was to investigate whether clinical or radiological differences could be found between proximal femoral nails (PFN) and trochanteric gamma nails (TGN), with particular attention given to technical differences in implantation and early complications. PATIENTS AND METHODS This prospective study included 114 patients with PFN or TGN. Their average age was 78.9 years. Clinical and radiological examinations were evaluated over a 24-month period. RESULTS The implantation time for PFN was 20 min less than for TGN in patients with 31A1 (AO) fractures, and 78.5% of all operations were complication-free. Problems occurred in 10 cases (seven PFN, three TGN) during nail insertion and were, in the case of TGN, all caused by fragment dislocation. Postoperative dislocation of the implant was observed in 12 cases [eight PFN (7%), four TGN (3.5%)]. Cut-out occurred in four cases with PFN implants, one of which was attributed to z-effect, and in two cases with TGN. Secondary varus deviation without cut-out occurred in one case with TGN and two cases with PFN. No significant differences in complication rates could be found between the two implants (p>0.05). CONCLUSIONS PFN are better suited to 31A1 fractures because of their higher rotational stability from the use of dual screws. A short femur and high antecurvation can cause insertion problems in PFN because of the nail design. It is advisable to choose the type of implant during preoperative planning after considering fracture type and patient anatomy.

Die Behandlung intraartikulärer Fersenbeinfrakturen mit einem gelenkübergreifenden Fixateur externe

ZusammenfassungDiskussionen über die Behandlung von Fersenbeinfrakturen verlaufen weiterhin kontrovers. Um Weichteilprobleme zu minimieren, wurde in der Klinik für Unfallchirurgie der Universität Kiel eine optimierte Montageform eines Fixateur externe zur primären Frakturbehandlung entwickelt. Verwendet wird eine bilaterale Rahmenkonstruktion mit Schanz-Schraubenfixierung in der Tibia und im Tuber calcanei. Sie ermöglicht eine effiziente Reposition über Ligamentotaxis, eine stabile Fixation und vor allem die aktive Bewegung im OSG.Es wurden 40 Patienten mit 45 Kalkaneusfrakturen mit dem Fixateur externe stabilisiert; 25 Frakturen konnten damit ausbehandelt werden. In 20 Fällen erfolgte sekundär ein Verfahrenswechsel zur internen Osteosynthese; 35 Patienten mit 40 Frakturen konnten mit Hilfe des “Kieler Kalkaneusscore” nachuntersucht werden. Patienten nach Definitivversorgung mit dem Fixateur externe weisen im Mittel ein besseres Spätergebnis auf als Patienten mit späterem Verfahrenswechsel.Mit der vorgestellten besonderen Montageform ist eine definitive Behandlung des Fersenbeinbruchs möglich. Die Indikation liegt in der ersten Notfallbehandlung von Frakturen mit Weichteilproblemen.AbstractOperative treatment of the calcaneus is still in discussion. For a better management of soft tissue problems an optimized fixator frame for primary treatment of calcaneus fractures was developed in the Dept. of trauma surgery University of Kiel. A one-plane bilateral construction with one insertion point in the tibia and two in the tuberosity of calcaneus is used. It allows efficient reduction by ligamentotaxis, stable fixation and active motion in ankle joint.We treated 40 patients with 45 calcaneus fractures. In 25 cases the fixator was definite and later plate or screw fixation was performed 20 times. 35 patients with 40 fractures were examined by means of the “Kiel score for calcaneus fractures”. Patients who were treated definite reached better longterm-results on average than patients who underwent a secondary open osteosynthesis. Concrete guidelines for the therapy of intraarticular calcaneus fractures are presented.

Knee joint due in children

SummaryAlthough children are injured everyday through accidents, road traffic, leisure or sports activities, internal lesions of the knee joint due to the trauma are rare. Diagnose and therapy follow rather empirical than analytical patterns. A retrospective, controlled study evaluates and recommends ways of treatment. Traumatic internal lesions of the knee where analysed in 76 children up to age 16. The pattern of injury changed with increasing age, the trauma remaining the same. Most common where injuries to the anterior cruciate ligament (ACL). Main cause where sports activities. Operative treatment seems to be the appropriate treatment. Osseous avulsions of the cruciates and collateral ligaments showed good results after transosseous refixation with a suture. Suturing of intraligamentous ACL-ruptures as well as patellar ligaments plasty showed unsatisfactory results. Secondary lesions due to instability of the knee where also observed in children. Children cannot self estimate the severity of the injury so subjective statements are insecure. Trauma, surgery, pain and immobilisation cause a marked malfunction of the senso-motor system which is effectively treated by physiotherapy.ZusammenfassungObwohl täglich Kinder im Straßenverkehr, bei Spiel und Sport verunglücken, sind Kniebinnenschäden keine häufigen Verletzungen, deren Diagnostik und Therapie daher überwiegend empirischen und nicht analytisch gewonnenen Erkenntnissen folgt. Eine retrospektive, kontrollierte Studie evaluiert die Behandlungsverfahren und begründet Empfehlungen. Es wurden Kniebinnenläsionen von 76 unfallverletzten Kinder bis zum 16. Lebensjahr analysiert. Die Verletzungsmuster änderten sich mit zunehmendem Alter der Kinder bei gleichbleibender Unfallursache. Am häufigsten fanden sich durch Sport verursachte Verletzungen des vorderen Kreuzbands (VKB). Die operative Behandlung scheint die Methode der Wahl zu sein. Ossäre Ausrißverletzungen der Kreuz- und Kollateralbänder zeigten bei transossärer Refixation mittels Naht gute Resultate. Nicht zufriedenstellende Ergebnisse wiesen Nähte intraligamentärer Rupturen der VKB und Ersatzplastiken mit dem Lig. patellae auf. Sekundärschäden bei Knieinstabilität traten auch bei Kindern auf. Kinder können den Schweregrad und Zustand ihrer Verletzung nicht einschätzen, so daß subjektive Beurteilungen sehr unsicher sind. Die Überwindung der durch Trauma, Schmerz und Immobilisation verursachten Störung des sensomotorischen Systems wird durch gezielte Krankengymnastik verbessert.

Postoperative aseptic osteonecrosis in a case of kyphoplasty

Aseptic osteonecrosis appears to be an infrequent adverse event after kyphoplasty which has not previously been reported. In the following, we present the case of a 73-year-old female who sustained a compression fracture of the first lumbar vertebra (L1) in a motor vehicle accident. The fracture was treated by kyphoplasty using PMMA cement. Three weeks after hospital discharge the patient was presented with increasing back pain. In imaging, dislocation of the PMMA cement could be shown combined with a total collapse of the L1 vertebra. The resulting significant kyphosis was first reduced by dorsal transpedicular (Th12–L2) internal fixation and stabilized by an anterior cage after total removal of the cement plomb and some remaining bone of the L1 vertebra. Bacterial as well as histological examination of the cement and bone led to the diagnosis of aseptic osteonecrosis. Different underlying events could be discussed. We think it most likely that the osteoporotic bone was unable to interface sufficiently with the PMMA cement and, therefore, disintegrated under loading. Furthermore, the volume of injected cement could have significantly compromised the blood supply within the bone.

Verletzungsmuster—Leitlinie bei der Beurteilung des Mehrfachverletzten?

By means of 468 patients with polytrauma the pattern of injuries were analysed. Separated into body regions the combinations of injuries to skeleton/thorax and skeleton/thorax/abdomen were found most often. A high lethality was evaluated for the combination of skeletal and abdominal injuries. 362 patients of the examined collective survived, 106 patients died. Among the deceased patients with head-injuries intracranial bleeding could be seen much more than in the group of survivors. Patients who died had also more ruptures of liver and other gastrointestinal injuries. Concerning the skeletal patterns of injuries they surprisingly had more fractures of shoulder, forearm and lower leg than the survivor-group. The statistic demonstrates clearly that in pattern of head or abdominal injuries the single diagnosis determines the rate of lethality. This correlation could not be seen in skeletal injuries. The pattern of injuries cannot be used as a guideline for the assessment of therapy of the severe trauma patient.ZusammenfassungBei der nach Körperregionen geordneten Erfassung der Verletzungsmuster von 468 Mehrfachverletzten finden sich die Kombinationen Skelett/Thorax und Skelett/Thorax/Abdomen am häufigsten. Eine höhere Letalität ergibt sich für die Verletzungskombination Skelett/Abdomen. Bei der Feststellung von Einzeldiagnosen im Kollektiv der 106 Verstorbenen zeigt sich im Vergleich mit der Gruppe der 362 Überlebenden bei Kopfverletzungen eine signifikante Häufung intrakranieller Blutungen, bei Abdominalverletzungen von Leberrupturen und Magen-Darm-Verletzungen, bei Skelettverletzungen überraschenderweise von Schulter-, Unterarm-und Unterschenkelbrüchen. Während bei Kopf- oder. Abdominaltraumen die Einzeldiagnose die letale Risikogefährdung wesentlich mitbestimmt, gilt dies für die Verletzung des Thorax und des Stütz- und Bewegungsapparates nicht. Das Verletzungsmuster kann nicht als Leitlinie bei der Bewertung der Mehrfachverletzung verwendet werden.AbstractBy means of 468 patients with polytrauma the pattern of injuries were analysed. Separated into body regions the combinations of injuries to skeleton/thorax and skeleton/thorax/abdomen were found most often. A high lethality was evaluated for the combination of skeletal and abdominal injuries. 362 patients of the examinated collective survived, 106 patients died. Among the deceased patients with head-injuries intracranial bleeding could be seen much more than in the group of survivors. Patients who died had also more ruptures of liver and other gastro-intestinal injuries. Concerning the skeletal patterns of injuries they suprisingly had more fractures of shoulder, forearm and lower leg than the survior-group. The statistic demonstrates clearly that in pattern of head or abdominal injuries the single diagnosis determinates the rate of lethality. This correlation could not be seen in skeletal injuries. The pattern of injuries cannot be used as a guideline for the assessment of therapy of the severe trauma patient.

Versorgung pertrochantärer Femurfrakturen@@@Proximal femur fractures: Vergleichende Analyse mit PFN vs. TGN@@@Results and complications after osteosynthesis with PFN and TGN

BACKGROUND The primary aim of surgery for pertrochanteric fractures of the femur is to regain preoperative mobility as quickly as possible. The aim of this study was to investigate whether clinical or radiological differences could be found between proximal femoral nails (PFN) and trochanteric gamma nails (TGN), with particular attention given to technical differences in implantation and early complications. PATIENTS AND METHODS This prospective study included 114 patients with PFN or TGN. Their average age was 78.9 years. Clinical and radiological examinations were evaluated over a 24-month period. RESULTS The implantation time for PFN was 20 min less than for TGN in patients with 31A1 (AO) fractures, and 78.5% of all operations were complication-free. Problems occurred in 10 cases (seven PFN, three TGN) during nail insertion and were, in the case of TGN, all caused by fragment dislocation. Postoperative dislocation of the implant was observed in 12 cases [eight PFN (7%), four TGN (3.5%)]. Cut-out occurred in four cases with PFN implants, one of which was attributed to z-effect, and in two cases with TGN. Secondary varus deviation without cut-out occurred in one case with TGN and two cases with PFN. No significant differences in complication rates could be found between the two implants (p>0.05). CONCLUSIONS PFN are better suited to 31A1 fractures because of their higher rotational stability from the use of dual screws. A short femur and high antecurvation can cause insertion problems in PFN because of the nail design. It is advisable to choose the type of implant during preoperative planning after considering fracture type and patient anatomy.

Verletzungsmuster mit Gradation der Verletzungsschwere beim Polytrauma

ZusammenfassungIn einer retrospektiven Analyse werden 114 Mehrfachverletzte untersucht. Nach Körperregionen getrennt, werden Verletzungsmuster gebildet. Am häufigsten mit insgesamt 61 Fällen finden sich die Verletzungskombinationen Kopf-Skelett-Thorax und Kopf-Skelett-Thorax-Abdomen. Die höchste Letalität mit 44,8% besteht für die Verletzung aller 4 Körperabschnitte. Alle anderen Verletzungsmuster haben fast identische Sterberaten. Durch eine additive Bewertung der Einzelverletzungen werden Scorewerte errechnet und den Verletzungsmustern zugeordnet. Nur das Verletzungsmuster Kopf-Skelett-Thorax-Abdomen erreicht durchschnittlich höhere Werte. Eine sichere Risikoabschätzung des Einzelfalles ist lediglich für sehr niedrige oder sehr hohe Wertebereiche möglich. Auch allein aus der schwersten Einzelverletzung kann eine Risikoabschätzung erfolgen. Vor allem an Kopf, Thorax und Becken wird dies durch die Punktebewertung erfaßt.SummarySeparated into body regions the patterns of injury of 114 patients with polytrauma were analyzed by a follow-up examination. In 61 cases the combination of injuries to head-skeleton-thorax and head-skeleton-thorax-abdomen were found most often. The highest lethality (44.8%) was evaluated for injuries of the 4 body regions, all the other patterns of injuries showed nearly identical rates of lethality. By means of additional rating of the single diagnosis scores were calculated and classed with injuring patterns. Only the combination of injuries to head-skeleton-thorax-abdomen got on an average more points. A safe valuation of risk for the single case is merely possible from the upper or lower area of points. Concerning the most severe infraction the risk can be estimated by scoring especially the injuries to head, thorax and pelvis.