M. Königshausen

Clinical outcome and complications using a polyaxial locking plate in the treatment of displaced proximal humerus fractures. A reliable system

INTRODUCTION The surgical treatment of displaced proximal humeral fractures (ORIF) is a perpetual challenge to the surgeon. For this reason, the principle of polyaxiality was developed to provide an improved primary stability of the fracture through better anchorage of the screws, especially in osteoporotic bone. The aim of this study was to present clinical results with the polyaxial locking plate in the operative treatment of proximal humerus fractures in order to determine whether the technique of polyaxiality leads to better functional outcome and lower complication rates in comparison to monoaxial plates in the literature. PATIENTS AND METHODS Seventy-three patients with displaced proximal humeral fractures were treated surgically with the polyaxial locking Suture Plate™ (Arthrex(®)) between 03/2007 and 06/2009. Fifty-two of the patients (mean age, 69.9 ± 12.1) were included in a radiographical and clinical examination using the Constant score (CS) and the Disabilities of the Arm, Shoulder and Hand score (DASH). RESULTS The follow-up examinations were on average 13.9 ± 4.5 months (10-27 months) after surgical treatment. The mean CS of the patients was 66.0 ± 13.7 points, the age- and gender-related CS was 90.9% ± 20.0% and the mean DASH score was 23.8 ± 19.8 points for the injured side. The patients with a nearly anatomical reduction of their fracture (n = 13) reached a significantly higher CS (75.1 ± 8.5; p = 0.004) and DASH-score (13.6 ± 11.6; p = 0.043) and none of these patients had a complication. The complications were identified in 12 (23.1%) cases, 5 of which involved loss of reduction. All of these 5 cases were lacking of initial medial column support and 4 of which were type C2.3 AO-Classification. CONCLUSION The data show that the combination of angular stability with the possibility of variable polyaxial screw direction is a good concept for reduction and fixation of displaced proximal humeral fractures, but anatomical reduction and medial support remain important preconditions for a good outcome. However, a significantly lower rate of complications or better clinical outcome than that reported in the literature could not be found.

Knochenaufbauplastiken am Processus coronoideus ulnae

ZusammenfassungHintergrundDas chronisch dezentrierte Ellenbogengelenk nach einer Luxationsfraktur stellt eine operative Herausforderung dar. Bei einer Insuffizienz des Processus coronoideus über 40 % sind eine Rezentrierung über einen Knochenaufbau sowie eine zusätzliche ligamentäre Stabilisierung erforderlich.MethodenAls mögliche Techniken werden unterschiedliche Allografts und Autografts beschrieben. Der Beckenkammspan ist das am häufigsten verwendete Transplantat und kann gut über einen anterioren Ellenbogenzugang eingebracht werden. In der Akutsituation lassen sich bei einem gleichzeitig frakturierten Radiusköpfchen Teile davon auch als Ersatz des Processus coronoideus verwenden, wobei die radiale Säule dann durch eine Radiusköpfchenprothese oder einen Bewegungsfixateur stabilisiert werden muss.AbstractBackgroundA chronic unstable elbow after a fracture dislocation with a deficient coronoid process is a challenging operative task. A coronoid bone loss of more than 40 % in an unstable elbow needs operative bony and ligamentous reconstruction.MethodsThe possible techniques using various allografts and autografts are described. The most frequently used graft is the iliac bone graft and can be optimally placed by an anterior elbow approach. In the acute fracture situation with involvement of the radial head a fragment of the discarded radial head can be used as a coronoid graft. The radial head has to be replaced by a prosthesis or a hinged external fixator is used to stabilize the lateral pillar.

Combining of small fragment screws and large fragment plates for open reduction and internal fixation of periprosthetic humeral fractures.

Operative treatment of periprosthetic humeral fractures in elderly patients with osteoporotic bone requires a stable fixations technique. The combination of 3.5 cortical screws with washers in a 4.5 Arbeitsgemeinschaft für Osteosynthesefragen, Limited-contact dynamic compression plate or Locking plate, allows a stable periprosthetic fixation with the small 3.5 screws and 4.5 screws above and below the prosthesis, respectively. This combination is a cost-effective technique to treat periprosthetic humeral fractures.

Glenoidale und humerale Revision nach Schulterendoprothese

ZusammenfassungRevisionseingriffe nach anatomischen und inversen Schulterprothesen haben aufgrund der steigenden Primärimplantationen in den letzten Jahren deutlich zugenommen. Der glenoidale und humerale Knochenverlust stellt hierbei die größte Schwierigkeit dar. Durch moderne Revisionstechniken ist jedoch auch nach fehlgeschlagenen inversen Prothesenversorgungen und mehrfachen Revisionen durch einen knöchernen Wiederaufbau glenoidal und auch humeral eine Herstellung der Schulterfunktion möglich. Die Weiterentwicklung von modularen Prothesensystemen auf humeraler Seite und auch in den letzten Jahren auf glenoidaler Seite haben maßgeblich dazu beigetragen Lösungsmöglichkeiten auch für komplexe Defektsituationen zur Verfügung zu haben.AbstractRevision surgery after primary total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA) is becoming an increasing problem due to the increasing numbers of primary implantations during the last few decades. Bone loss on both the glenoid and the humerus are challenging problems. New revision techniques with bone grafts on the glenoid site and revision stems on the humeral site enable restoration of shoulder function. The development of new prosthetic designs with modular revision stems and of modular glenoid base plates during recent years have technically improved complex revision surgery in TSA and RTSA.

Bone grafting in oblique versus prepared rectangular uncontained glenoid defects in reversed shoulder arthroplasty. A biomechanical comparison

Background: How the shape of the glenoid defect being reconstructed influences stability in reversed shoulder arthroplasty has never been evaluated. The purpose of this study was to compare the reconstruction of two different shaped defects in reversed shoulder arthroplasty. Methods: Two groups (ten Sawbone scapulae each) of oblique‐ and rectangular‐shaped glenoid defects were tested biomechanically. On the anterior half of the glenoid, bony defects (rectangular and oblique shaped) were prepared and reconstructed subsequently with a graft and reversed shoulder arthroplasty. As a control group, Sawbones without glenoid deficiency were used. In addition, these tests were reproduced in cadavers. Findings: In Sawbones, no significant difference in initial stability was found between the two groups (p > 0.05). Additionally, in the cadaver tests no significant difference was found between the groups with different defects (p > 0.05). During the preparation, macroscopic loosening of the oblique bone grafts was found in three cases after the performance of the reversed shoulder arthroplasty due to the lack of medial support. The localization of the highest micromotion were measured primarily between the scapula bone and the graft compared to the measured micromotions between glenoid implant and the graft. Interpretation: If the oblique‐shaped bone graft was secured under the baseplate, the rectangular defect preparation did not show a significantly higher primary stability. However, the advantage of medial support in rectangular defects leads to more stability while placing the bone graft and baseplate during the surgical technique and should therefore be considered a preferable option. HighlightsNo difference in micromotion between rectangular and oblique‐shaped defect reconstructions.Rectangular graft leads to higher stability while defect preparation.The highest micromotion is located primarily between the scapula bone and the graft.

Knorpeltrauma bei Schulterluxation

ZusammenfassungAufgrund der anatomischen Besonderheiten sind Luxationen des Glenohumeralgelenks häufig. Verschiedene Prädispositionsfaktoren einer möglichen Dislokationsarthropathie werden in der Literatur diskutiert. Grundsätzlich entsteht der größte Knorpelschaden im Rahmen des sog. „first hit“, der traumatischen Erstluxation. Das Alter zum Zeitpunkt der Erstluxation und auch zum Zeitpunkt einer operativen Stabilisierung scheint einen Einfluss auf die Entstehung einer möglichen Arthropathie zu haben. Nicht die Dauer einer möglichen Instabilität vor operativer Stabilisierung, sondern vielmehr die rezidivierenden Luxationen haben einen weiteren Einfluss auf den Gelenkverschleiß. Eine operative Stabilisierung stellt, sofern technisch gut ausgeführt, kein erhöhtes Arthroserisiko dar, ist jedoch nicht in der Lage, eine Entwicklung der Arthropathie zu verhindern. Es gelingt jedoch, durch diese eine Rezidivluxation zu vermeiden und somit den Schweregrad einer Dislokationsarthropathie zu verringern. Bei der Planung einer möglichen Stabilisierung ist es essenziell, den Knorpelschaden im Bereich des Humeruskopfes sowie im Bereich des Glenoids zu evaluieren („bipolar bone loss“) und das dynamische Verhältnis dieser Läsionen zueinander zu berücksichtigen.AbstractDislocation of the shoulder joint is a frequent occurrence due to the anatomical features. Various predisposing factors that determine the prevalence of dislocation athropathy have been discussed in the literature. Principally, the greatest chondral damage occurs during the initial traumatic shoulder dislocation, the so-called first hit. The age of the person at the time of the first hit and age at the time of surgery in particular seem to influence the development of dislocation arthropathy. The duration of shoulder instability before surgery does not seem to affect the incidence of athropathy. An operation, if technically well performed, does not increase the risk of arthropathy and furthermore, it prevents redislocation and therefore decreases the risk of dislocation athropathy. What is important is how often redislocation occurs. When planning a possible surgical stabilization of the shoulder it is crucial to assess the degree of damage in the region of the humeral head and the glenoid cavity (bipolar bone loss) and the dynamic interrelationship of these lesions.

Treatment of Chronic Acromioclavicular Joint Dislocation in a Paraplegic Patient with the Weaver-Dunn Procedure and a Hook-Plate

In case of patients with spinal cord injury and concomitant acromioclavicular (AC) joint-dislocation the treatment is challenging, as in this special patient group the function of the shoulder joint is critical because patients depend on the upper limb for mobilization and wheelchair-locomotion. Therefore the goal of this study was to examine, if the treatment of chronic AC-joint dislocation using the Weaver-Dunn procedure augmented with a hook-plate in patients with a spinal cord injury makes early postoperative wheelchair mobilization and the wheelchair transfer with full weight-bearing possible. In this case the Weaver-Dunn procedure with an additive hook-plate was performed in a 34-year-old male patient with a complete paraplegia and a posttraumatic chronic AC-joint dislocation. The patient was allowed to perform his wheelchair transfers with full weight bearing on the first post-operative day. The removal of the hook-plate was performed four months after implantation. At the time of follow-up the patient could use his operated shoulder with full range of motion without restrictions in his activities of daily living or his wheel-chair transfers.

Isolated pediatric radial head and neck fractures. A rare injury. Analysis and follow up of 19 patients

PURPOSE Isolated pediatric radial head and neck fractures are rare. In recent literature, their incidence is estimated to be around 1% of all fractures. High rates of complications are reported. Beside non-operative treatment, head fractures are treated with k-wires, mini-screws or polypins, whereas neck fractures are treated more and more with elastic stable intramedullary nailing (ESIN). Purpose of the study was to evaluate the operative management, complications and clinical outcomes of these injuries. METHODS Retrospective analysis between 2002 and 2014. 19 children with isolated radial head and neck fractures were treated in our institution. Age averaged 11 years (range 6-16). Operative treatment with elastic stable intramedullary nailing (ESIN) was performed in 13 patients, in one patient with an additional k-wire; two screw, two k-wire and one polypin fixation was performed in the others. One child was treated non-operatively. RESULTS Follow up averaged 19 months (2-89). Initial complications occurred in nine children such as fracture dislocation (1), nonunion (1), malunion (1), elbow ankylosis (1), infection (1), crossunion (2), intraarticular screw penetration (1) and radial nerve irritation (1). ESIN lead a complication rate of 36%, mini-screw fixation and k-wire fixation showed a complication rate of 100%. All children (100%) with an open reduction maneuver and 36% children with closed or percutaneous reduction developed a complication. Secondary surgeries included ESIN removal and k-wire fixation (1), open arthrolysis (1), debridement (1), removal of crossunion (1), radial head removal plus arthrolysis (3) and screw removal (1). Subsequently 74% (14) children showed a free or <20° limited range of motion on final follow up. Implant removal was performed after an average of 8 weeks (5-12). Three patients were transferred to our surgical department after a complication following initial treatment. Excluding these, an overall complication rate of 37.5% was noted. CONCLUSIONS Radial head injuries in children are rare. In this population, neck fractures occur more frequently. If conservative treatment is not possible, ESIN seems to be a simple and protective procedure for neck fractures; polypins or screws can be used for complicated radial head fractures. Complications occur frequently after open reduction. If closed reduction and internal fixation is possible, range of motion can be completely restored.

Posttraumatische „frozen shoulder“

ZusammenfassungAuftretenSekundäre Schultersteifen können posttraumatisch und postoperativ auftreten, wobei unterschiedliche Pathogenesen nach einem definierten Erkrankungsauslöser unterschieden werden können. TherapiewahlDie zugrunde liegende Pathologie bestimmt die Therapieoptionen, somit sind eine differenzierte Anamnese, Schulteruntersuchung und zielführende Diagnostik erforderlich. Konservative TherapieIm Gegensatz zur primären idiopathischen Erkrankungsform weisen die sekundären Schultersteifen eine nur geringe Selbstheilungstendenz auf. Konservative Therapieversuche beschränken sich daher bei fehlender Besserungstendenz auf wenige Wochen bis Monate. Operative TherapieJe nach vorliegender Pathologie erfolgt die in den meisten Fällen notwendige operative Behandlung als arthroskopische oder offene Arthrolyse. Knöcherne oder artikuläre Bewegungshindernisse müssen möglichst frühzeitig operativ korrigiert werden, um sekundäre Vernarbungen und Kapselkontrakturen zu vermeiden. PräventionVon grundlegender Bedeutung ist es, das Risiko posttraumatischer und postoperativer Schultersteifen durch kurze Immobilisierungsphasen und frühzeitige Beübung der Schulter unter ausreichender Analgesie zu minimieren.AbstractOccurrenceIn contrast to the primary frozen shoulder, secondary posttraumatic and postsurgical shoulder stiffness evolves from a defined traumatic event or after a surgical procedure.Treatment selectionThe different basic pathologies for secondary shoulder stiffness determine the selection of the treatment concept and therapeutic options. Therefore, a differentiated case history, physical examination, and imaging studies are required.Conservative treatmentContrary to primary frozen shoulder, secondary shoulder stiffness is rarely self-limiting. The conservative treatment approach is restricted to a couple of weeks to months without any positive trend towards regaining shoulder mobility or pain reduction.Surgical treatmentDepending on the pathology, surgical treatment is required in most cases either arthroscopically or as an open surgical release. Skeletal or articular deformities as the mechanical reason for shoulder stiffness must be addressed and corrected as early as possible to avoid secondary soft tissue scaring.PreventionThe prevention of developing secondary shoulder stiffness is an important issue and may be achieved with short immobilization, early physical therapy, and sufficient analgesia.

Primäre Schulterendoprothetik nach Trauma

ZusammenfassungDie primäre Frakturendoprothetik der Schulter ist in den letzten Jahren aufgrund der verbesserten Osteosyntheseverfahren mit kleinfragmentären, winkelstabilen Plattensystemen eher rückläufig. Die Schwierigkeit bei der 4-Fragment-Fraktur bei erhaltener Kopfkalotte liegt in der Reposition und Retention der Tuberkel in anatomischer Position. Diese Problematik wird durch die Frakturprothetik nicht gelöst. Bei kompletten Head-Split-Frakturen ist der Ersatz der Kalotte durch eine Prothese indiziert. Das Problem der stabilen Tuberkelrefixation und knöchernen Integration bleibt jedoch bestehen. Neue Prothesendesigns verbessern die Tuberkelrefixationsmöglichkeit und die korrekte Positionierung der Prothese. Eine anatomische Frakturrekonstruktion ist immer primäres Ziel und sollte nicht zu früh verlassen werden.AbstractIndications for primary shoulder prosthesis in displaced four-part fractures has decreased in recent years due to new techniques in fracture reconstruction using angle-stable plate osteosynthesis. The challenge of four-part fractures with an intact head fragment is the anatomic reconstruction and fixation of the tuberosities. Using a fracture prosthesis does not solve this problem. In complex head-split fractures arthroplasty is indicated, but the difficulty of tuberosity refixation and healing remains. New prosthetic designs improve tuberosity fixation and healing, as well as correct placement and orientation of the prosthesis. Anatomic fracture reconstruction should always be the goal and this goal should not be abandoned too easily.