M. Petri

[Development of compartment syndrome after intravenous administration of an X-ray contrast medium. Recommendations on acute therapy regimens].

The incidence of extravasation of contrast medium is reported in the literature to be between 0.2u2009% and 0.9xa0%. A rare consequence of this could be compartment syndrome of the affected limb which requires immediate treatment.We report the case of a patient who developed acute compartment syndrome of the forearm after intravenous injection of radiographic contrast medium in a radiovolar vein during a computed tomography (CT) scan for multiple trauma. The clinical symptoms with pain, loss of range of motion and sensitivity functions, measurement of compartment pressure and radiological images confirmed the diagnosis. After emergency dermatofasciotomy of the forearm the full range of motion and sensitivity functions could be restored.ZusammenfassungDie Inzidenz von Kontrastmittelparavasaten wird in der Literatur mit 0,2–0,9u2009% angegeben. Eine seltene Folge kann ein Kompartmentsyndrom der betroffenen Extremität sein, welches sofortiger Behandlung bedarf.Wir berichten über einen Patienten, dem im Rahmen eines Polytrauma-CT-Scans Kontrastmittel radiovolar i.xa0v. appliziert wurde. Im Verlauf kam es durch Paravasation von Kontrastmittel zu einem Kompartmentsyndrom. Sowohl das klinische Beschwerdebild mit deutlicher Schmerzsymptomatik, als auch der Verlust von motorischen und sensiblen Funktionen, wie auch die Kompartmentdruckmessung und die radiologische Bildgebung sicherten die Diagnose. Durch die notallmäßig durchgeführte Dermatofasziotomie erhielt der Patient eine völlige Wiederherstellung der zuvor verlorengegangenen motorischen und sensiblen Funktion.AbstractThe incidence of extravasation of contrast medium is reported in the literature to be between 0.2u2009% and 0.9xa0%. A rare consequence of this could be compartment syndrome of the affected limb which requires immediate treatment.We report the case of a patient who developed acute compartment syndrome of the forearm after intravenous injection of radiographic contrast medium in a radiovolar vein during a computed tomography (CT) scan for multiple trauma. The clinical symptoms with pain, loss of range of motion and sensitivity functions, measurement of compartment pressure and radiological images confirmed the diagnosis. After emergency dermatofasciotomy of the forearm the full range of motion and sensitivity functions could be restored.

Kompartmentsyndrom nach paravasaler Applikation von Röntgenkontrastmittel

The incidence of extravasation of contrast medium is reported in the literature to be between 0.2u2009% and 0.9xa0%. A rare consequence of this could be compartment syndrome of the affected limb which requires immediate treatment.We report the case of a patient who developed acute compartment syndrome of the forearm after intravenous injection of radiographic contrast medium in a radiovolar vein during a computed tomography (CT) scan for multiple trauma. The clinical symptoms with pain, loss of range of motion and sensitivity functions, measurement of compartment pressure and radiological images confirmed the diagnosis. After emergency dermatofasciotomy of the forearm the full range of motion and sensitivity functions could be restored.ZusammenfassungDie Inzidenz von Kontrastmittelparavasaten wird in der Literatur mit 0,2–0,9u2009% angegeben. Eine seltene Folge kann ein Kompartmentsyndrom der betroffenen Extremität sein, welches sofortiger Behandlung bedarf.Wir berichten über einen Patienten, dem im Rahmen eines Polytrauma-CT-Scans Kontrastmittel radiovolar i.xa0v. appliziert wurde. Im Verlauf kam es durch Paravasation von Kontrastmittel zu einem Kompartmentsyndrom. Sowohl das klinische Beschwerdebild mit deutlicher Schmerzsymptomatik, als auch der Verlust von motorischen und sensiblen Funktionen, wie auch die Kompartmentdruckmessung und die radiologische Bildgebung sicherten die Diagnose. Durch die notallmäßig durchgeführte Dermatofasziotomie erhielt der Patient eine völlige Wiederherstellung der zuvor verlorengegangenen motorischen und sensiblen Funktion.AbstractThe incidence of extravasation of contrast medium is reported in the literature to be between 0.2u2009% and 0.9xa0%. A rare consequence of this could be compartment syndrome of the affected limb which requires immediate treatment.We report the case of a patient who developed acute compartment syndrome of the forearm after intravenous injection of radiographic contrast medium in a radiovolar vein during a computed tomography (CT) scan for multiple trauma. The clinical symptoms with pain, loss of range of motion and sensitivity functions, measurement of compartment pressure and radiological images confirmed the diagnosis. After emergency dermatofasciotomy of the forearm the full range of motion and sensitivity functions could be restored.

Posttraumatische Fehlstellungen und Pseudarthrosen des proximalen Humerus

BACKGROUNDnAccording to the future demographic trends the incidence of proximal humeral fractures and subsequent posttraumatic malunions and nonunions of the proximal humerus are expected to substantially increase.nnnOBJECTIVESnThis article reviews the indications, techniques and outcomes of corrective osteotomy for the treatment of posttraumatic nounions and malunions of the proximal humerus.nnnMETHODSnA selective literature search was performed and personal surgical experiences are reported.nnnRESULTSnMalunions of the proximal humerus can occur after both surgical and conservative management of fractures. Due to the complex anatomy of the proximal humerus, malunions have to be systematically assessed regarding epiphyseal and metaphyseal malpositioning. Furthermore, the objective anatomical disorder has to be completely correlated with the subjective patient complaints. The associated soft tissue structures, such as the glenohumeral joint capsule and ligaments, long head of the biceps tendon, rotator cuff and muscles inserting in the metaphysis, can independently cause discomfort to the patient and need to be meticulously identified as such.nnnCONCLUSIONnA variety of corrective surgical strategies are available, which are indicated depending on the location and extent of the malunion. The depicted single-cut osteotomy technique represents an elegant therapeutic option for multidimensional deformities of the proximal humerus. Nonunions of the proximal humerus can usually be successfully managed with autologous cancellous bone grafting and locking plate osteosynthesis.ZusammenfassungHintergrundAufgrund der demographischen Entwicklung ist zukünftig mit einer deutlichen Zunahme der Inzidenz proximaler Humerusfrakturen und konsekutiv posttraumatischer Fehlstellungen und Pseudarthrosen zu rechnen.FragestellungDiese Übersichtsarbeit stellt Indikation, Technik und Ergebnisse von Korrekturosteotomien für Patienten mit posttraumatischer Fehlstellung oder Pseudarthrose nach proximaler Humerusfraktur dar.MethodenEs erfolgte eine selektive Literaturrecherche unter Berücksichtigung eigener Erfahrungen.ErgebnisseFehlstellungen des proximalen Humerus können nach konservativer und operativer Therapie entstehen. Aufgrund der komplexen Geometrie des proximalen Humerus muss die Analyse der Fehlstellung systematisch erfolgen (epi-, metaphysär). In einem nächsten Schritt muss evaluiert werden, inwieweit die objektivierte Fehlstellung für die vom Patienten berichteten Beschwerden verantwortlich gemacht werden kann. Die benachbarten Weichteilstrukturen (glenohumeraler Kapsel-Band-Apparat, lange Bizepssehne, Rotatorenmanschette, an der Metaphyse inserierende Muskulatur) können unabhängig von der Fehlstellung zu Beschwerden führen und müssen als solche identifiziert werden.SchlussfolgerungenIn Abhängigkeit von der Lokalisation und dem Ausmaß der posttraumatischen Fehlstellung kommen prinzipiell diverse Korrekturverfahren als Option in Frage. Die hier vorgestellte Single-cut-Osteotomie stellt eine elegante Möglichkeit zur Korrektur mehrdimensionaler Fehlstellungen am proximalen Humerus dar. Pseudarthrosen des proximalen Humerus können durch eine Spongiosaplastik und winkelstabile Plattenosteosynthese in der Vielzahl der Fälle erfolgreich saniert werden.AbstractBackgroundAccording to the future demographic trends the incidence of proximal humeral fractures and subsequent posttraumatic malunions and nonunions of the proximal humerus are expected to substantially increase.ObjectivesThis article reviews the indications, techniques and outcomes of corrective osteotomy for the treatment of posttraumatic nounions and malunions of the proximal humerus.MethodsA selective literature search was performed and personal surgical experiences are reported.ResultsMalunions of the proximal humerus can occur after both surgical and conservative management of fractures. Due to the complex anatomy of the proximal humerus, malunions have to be systematically assessed regarding epiphyseal and metaphyseal malpositioning. Furthermore, the objective anatomical disorder has to be completely correlated with the subjective patient complaints. The associated soft tissue structures, such as the glenohumeral joint capsule and ligaments, long head of the biceps tendon, rotator cuff and muscles inserting in the metaphysis, can independently cause discomfort to the patient and need to be meticulously identified as such.ConclusionA variety of corrective surgical strategies are available, which are indicated depending on the location and extent of the malunion. The depicted single-cut osteotomy technique represents an elegant therapeutic option for multidimensional deformities of the proximal humerus. Nonunions of the proximal humerus can usually be successfully managed with autologous cancellous bone grafting and locking plate osteosynthesis.

[Implant-free tibial fixations of the posterior cruciate ligament. Development and biomechanical testing].

BACKGROUNDnA secure tibial press fit technique in posterior cruciate ligament reconstructions may be a relevant alternative to common techniques because no hardware is necessary. Up to the present point in time no biomechanical data exist for a tibial press fit posterior cruciate ligament (PCL) reconstruction. This study compares the biomechanical properties of hamstring and quadriceps tendon grafts using a press fit technique with those of an interference screw fixation.nnnMETHODSnQuadriceps and hamstring tendons of 20 human cadavers (age 49.2±18.5 years) were used. A press fit fixation with a knot in the semitendinosus tendon (K) and a quadriceps tendon bone block graft (Q) were compared to an interference screw fixation (I) in 27 porcine tibiae. In each group, nine constructs were cyclically stretched and then loaded until failure. Maximum load to failure, stiffness and elongation during failure testing and cyclical loading were investigated.nnnRESULTSnThe maximum load to failure was 518±157xa0N (387-650xa0N) for the K group, 558±119xa0N (466-650xa0N) for the I group and 620±102xa0N (541-699xa0N) for the Q group. The stiffness was 55±27xa0N/mm (18-89xa0N/mm) for the K group, 117±62xa0N/mm (69-165xa0N/mm) for the I group and 65±21xa0N/mm (49-82xa0N/mm) for the Q group. The stiffness of the I group was significantly larger (ANOVA on ranks, P=0.01). The elongation during cyclical loading was significantly larger for all groups from the 1st to the 5th cycle compared to the elongation in between the 5th and the 20th cycle (P<0.03).nnnCONCLUSIONnAll techniques exhibited larger elongation during initial loading. Load to failure and stiffness were significantly different between the fixations. The Q fixation showed equal biomechanical properties compared to a pure tendon fixation (I) with an interference screw. The results of group K were inferior. All three investigated fixation techniques exhibit comparable biomechanical properties. Preconditioning of the constructs is critical. Future randomized, clinical trials have to investigate the biological effectiveness of these fixation techniques.ZusammenfassungEinleitungEine stabile Press-fit-Fixierung des hinteren Kreuzbandes (HKB) ist aufgrund der Implantatfreiheit eine in Betracht zu ziehende Technik zur ligamentären Kniegelenkrekonstruktion. Bis zum jetzigen Zeitpunkt existieren keine biomechanischen Daten bezüglich einer Press-fit-Fixierung zur Rekonstruktion des HKB. Zweck dieser Studie war es, die biomechanischen Eigenschaften von Hamstring- und Quadrizepssehnentransplantaten in Press-fit-Technik mit denen einer Interferenzschraubenfixierung zu vergleichen.Material und MethodenInsgesamt wurden Hamstring- und Quadrizepssehnentransplantate von 20 Leichenkniegelenken verwendet, deren Alter 49,2±18,5xa0Jahre betrug. Eine Press-fit-Fixierung der Semitendinosussehne (K) und eine Quadrizeps-Knochenblock-Fixierung (Q) wurden mit der Fixierung mittels Interferenzschraube (I) verglichen. Es wurden 3xa0Gruppen á 9xa0Präparate gebildet, die an insgesamt 27 porcinen tibiaezyklischen Dehnungen ausgesetzt und anschließend bis zum Versagen belastet wurden. Die maximale Versagenslast, das Dehnungsverhalten und die Elongation während der Belastung wurden untersucht.ErgebnisseDie maximale Versagenslast betrug 518±157 (387–650) N für die K-Gruppe, 620±102 (541–699) N für die Q-Gruppe und 558±119 (466–650) N für die I-Gruppe. Die Steifigkeit betrug 55±27 (18–89) N/mm für die K-Gruppe, 65±21 (49–82) N/mm für die Q-Gruppe und 117±62 (69–165) N/mm für die I-Gruppe. Die Elongation zeigte für alle Gruppen einen signifikanten Größenunterschied zwischen dem 1. und 5. Zyklus im Vergleich zur Elongation zwischen dem 5. und 20. Zyklus (p<0,03).SchlussfolgerungAlle Techniken wiesen die größte Längenänderung während der initialen zyklischen Belastung auf. Die maximale Versagenslast und das Dehnungsverhalten zeigten signifikante Differenzen zwischen den unterschiedlichen Fixierungstechniken. Die Q-Fixierung wies vergleichbare biomechanische Eigenschaften auf wie eine reine Sehnenfixierung mit einer Interferenzschraube (I). Die biomechanischen Eigenschaften der K-Gruppe waren schlechter.AbstractBackgroundA secure tibial press fit technique in posterior cruciate ligament reconstructions may be a relevant alternative to common techniques because no hardware is necessary. Up to the present point in time no biomechanical data exist for a tibial press fit posterior cruciate ligament (PCL) reconstruction. This study compares the biomechanical properties of hamstring and quadriceps tendon grafts using a press fit technique with those of an interference screw fixation.MethodsQuadriceps and hamstring tendons of 20 human cadavers (age 49.2±18.5 years) were used. A press fit fixation with a knot in the semitendinosus tendon (K) and a quadriceps tendon bone block graft (Q) were compared to an interference screw fixation (I) in 27 porcine tibiae. In each group, nine constructs were cyclically stretched and then loaded until failure. Maximum load to failure, stiffness and elongation during failure testing and cyclical loading were investigated.ResultsThe maximum load to failure was 518±157xa0N (387–650xa0N) for the K group, 558±119xa0N (466–650xa0N) for the I group and 620±102xa0N (541–699xa0N) for the Q group. The stiffness was 55±27xa0N/mm (18–89xa0N/mm) for the K group, 117±62xa0N/mm (69–165xa0N/mm) for the I group and 65±21xa0N/mm (49–82xa0N/mm) for the Q group. The stiffness of the I group was significantly larger (ANOVA on ranks, P=0.01). The elongation during cyclical loading was significantly larger for all groups from the 1st to the 5th cycle compared to the elongation in between the 5th and the 20th cycle (P<0.03).ConclusionAll techniques exhibited larger elongation during initial loading. Load to failure and stiffness were significantly different between the fixations. The Q fixation showed equal biomechanical properties compared to a pure tendon fixation (I) with an interference screw. The results of group K were inferior. All three investigated fixation techniques exhibit comparable biomechanical properties. Preconditioning of the constructs is critical. Future randomized, clinical trials have to investigate the biological effectiveness of these fixation techniques.

[Reconstruction of an iatrogenic acromial pseudarthrosis: a case report].

ZusammenfassungDie Fraktur des Akromions ist eine seltene, aber schwerwiegende Komplikation, die im Rahmen einer subakromialen Dekompression auftreten kann. Wir berichten über einen Patienten mit Pseudarthrose des Akromions, der bei Schmerzpersistenz mehrfach operiert wurde, bis es schließlich zur Diagnose „Pseudarthrose“ kam. Die Pseudarthrose wurde erfolgreich durch Osteosynthese mit einer distalen Radiusplatte und einem monokortikalen Beckenkammspan therapiert. Zwei Jahre nach der Operation sind die Fraktur verheilt und die Beschwerden des Patienten erheblich gebessert. Im Constant Score erreicht der Patient 58xa0Punkte (präoperativ 25xa0Punkte) und im Subjective Shoulder Rating System (SSRS) 65 Punkte (präoperativ 25xa0Punkte). Die Beweglichkeit ist postoperativ deutlich verbessert und beträgt für aktive Abduktion/Adduktion 50/0/25º (30/0/20° präoperativ), für Außenrotation/Innenrotation 35/0/45º (30/0/30° präoperativ) und für Anteversion/Retroversion 60/0/35° (35/0/20° präoperativ).AbstractAcromial fractures are rare but severe complications which can occur during subacromial decompression. We report a case of acromial pseudarthrosis which was discovered belatedly due to persistent pain after several operations. The pseudarthrosis was successfully treated by osteosynthesis with a distal radius plate and implantation of a monocortical bone graft from the iliac crest. Two years after surgery, the fracture has healed and the patient’s pain improved significantly. In the constant score the patient achieved postoperatively 58xa0points compared to 25xa0points before surgery and 65xa0points compared to 25xa0points preoperatively in the subjective shoulder rating system (SSRS). Postoperatively, the patient had a better range of motion with active abduction/adduction of 50/0/25º (30/0/20° preoperatively), outward rotation/inward rotation of 35/0/45º (30/0/30° preoperatively) and anteversion/retroversion of 60/0/35° (35/0/20° preoperatively).Acromial fractures are rare but severe complications which can occur during subacromial decompression. We report a case of acromial pseudarthrosis which was discovered belatedly due to persistent pain after several operations. The pseudarthrosis was successfully treated by osteosynthesis with a distal radius plate and implantation of a monocortical bone graft from the iliac crest. Two years after surgery, the fracture has healed and the patients pain improved significantly. In the constant score the patient achieved postoperatively 58xa0points compared to 25xa0points before surgery and 65xa0points compared to 25xa0points preoperatively in the subjective shoulder rating system (SSRS). Postoperatively, the patient had a better range of motion with active abduction/adduction of 50/0/25º (30/0/20° preoperatively), outward rotation/inward rotation of 35/0/45º (30/0/30° preoperatively) and anteversion/retroversion of 60/0/35° (35/0/20° preoperatively).

Posttraumatic nonunions and malunions of the proximal humerus. Possibilities and limitations of corrective osteotomy

BACKGROUNDnAccording to the future demographic trends the incidence of proximal humeral fractures and subsequent posttraumatic malunions and nonunions of the proximal humerus are expected to substantially increase.nnnOBJECTIVESnThis article reviews the indications, techniques and outcomes of corrective osteotomy for the treatment of posttraumatic nounions and malunions of the proximal humerus.nnnMETHODSnA selective literature search was performed and personal surgical experiences are reported.nnnRESULTSnMalunions of the proximal humerus can occur after both surgical and conservative management of fractures. Due to the complex anatomy of the proximal humerus, malunions have to be systematically assessed regarding epiphyseal and metaphyseal malpositioning. Furthermore, the objective anatomical disorder has to be completely correlated with the subjective patient complaints. The associated soft tissue structures, such as the glenohumeral joint capsule and ligaments, long head of the biceps tendon, rotator cuff and muscles inserting in the metaphysis, can independently cause discomfort to the patient and need to be meticulously identified as such.nnnCONCLUSIONnA variety of corrective surgical strategies are available, which are indicated depending on the location and extent of the malunion. The depicted single-cut osteotomy technique represents an elegant therapeutic option for multidimensional deformities of the proximal humerus. Nonunions of the proximal humerus can usually be successfully managed with autologous cancellous bone grafting and locking plate osteosynthesis.ZusammenfassungHintergrundAufgrund der demographischen Entwicklung ist zukünftig mit einer deutlichen Zunahme der Inzidenz proximaler Humerusfrakturen und konsekutiv posttraumatischer Fehlstellungen und Pseudarthrosen zu rechnen.FragestellungDiese Übersichtsarbeit stellt Indikation, Technik und Ergebnisse von Korrekturosteotomien für Patienten mit posttraumatischer Fehlstellung oder Pseudarthrose nach proximaler Humerusfraktur dar.MethodenEs erfolgte eine selektive Literaturrecherche unter Berücksichtigung eigener Erfahrungen.ErgebnisseFehlstellungen des proximalen Humerus können nach konservativer und operativer Therapie entstehen. Aufgrund der komplexen Geometrie des proximalen Humerus muss die Analyse der Fehlstellung systematisch erfolgen (epi-, metaphysär). In einem nächsten Schritt muss evaluiert werden, inwieweit die objektivierte Fehlstellung für die vom Patienten berichteten Beschwerden verantwortlich gemacht werden kann. Die benachbarten Weichteilstrukturen (glenohumeraler Kapsel-Band-Apparat, lange Bizepssehne, Rotatorenmanschette, an der Metaphyse inserierende Muskulatur) können unabhängig von der Fehlstellung zu Beschwerden führen und müssen als solche identifiziert werden.SchlussfolgerungenIn Abhängigkeit von der Lokalisation und dem Ausmaß der posttraumatischen Fehlstellung kommen prinzipiell diverse Korrekturverfahren als Option in Frage. Die hier vorgestellte Single-cut-Osteotomie stellt eine elegante Möglichkeit zur Korrektur mehrdimensionaler Fehlstellungen am proximalen Humerus dar. Pseudarthrosen des proximalen Humerus können durch eine Spongiosaplastik und winkelstabile Plattenosteosynthese in der Vielzahl der Fälle erfolgreich saniert werden.AbstractBackgroundAccording to the future demographic trends the incidence of proximal humeral fractures and subsequent posttraumatic malunions and nonunions of the proximal humerus are expected to substantially increase.ObjectivesThis article reviews the indications, techniques and outcomes of corrective osteotomy for the treatment of posttraumatic nounions and malunions of the proximal humerus.MethodsA selective literature search was performed and personal surgical experiences are reported.ResultsMalunions of the proximal humerus can occur after both surgical and conservative management of fractures. Due to the complex anatomy of the proximal humerus, malunions have to be systematically assessed regarding epiphyseal and metaphyseal malpositioning. Furthermore, the objective anatomical disorder has to be completely correlated with the subjective patient complaints. The associated soft tissue structures, such as the glenohumeral joint capsule and ligaments, long head of the biceps tendon, rotator cuff and muscles inserting in the metaphysis, can independently cause discomfort to the patient and need to be meticulously identified as such.ConclusionA variety of corrective surgical strategies are available, which are indicated depending on the location and extent of the malunion. The depicted single-cut osteotomy technique represents an elegant therapeutic option for multidimensional deformities of the proximal humerus. Nonunions of the proximal humerus can usually be successfully managed with autologous cancellous bone grafting and locking plate osteosynthesis.

Evidenzbasierte Indikationsstellung bei Patellaluxation

ZusammenfassungPatellaluxationen treten üblicherweise nach lateral auf und führen in >90% der Fälle zu einer Ruptur des medialen patellofemoralen Ligaments. Verlässliche Daten und Prognosefaktoren für die Stabilität des Patellofemoralgelenks und die Patientenzufriedenheit nach entweder konservativer oder operativer Behandlung sind umstritten. Für rezidivierende Patellaluxationen fehlen randomisierte Studien bislang vollständig. In Zusammenschau der bisherigen randomisierten Studien zur Patellaerstluxation lässt sich kein signifikanter Unterschied zwischen operativer und konservativer Versorgung zeigen. Dies gilt gleichermaßen für Kinder und Jugendliche wie Erwachsene. Es besteht eine deutliche Tendenz zugunsten eines abwartenden Verhaltens und einer zunächst konservativen Therapie bei traumatischer Patellaerstluxation. Eine operative Versorgung ist primär lediglich bei relevanten Begleitverletzungen wie osteochondralen Frakturen und sekundär bei rezidivierenden Luxationen indiziert. Weitere prospektiv-randomisierte Studien mit standardisierten operativen wie konservativen Therapiemaßnahmen und ausreichend großen Fallzahlen sind erforderlich.AbstractPatellar dislocation is a common knee injury with mainly lateral dislocations, leading to ruptures of the medial patellofemoral ligament in most of the cases. Reliable data and prognostic factors for stability of the patellofemoral joint and satisfaction of the patient after either conservative or operative treatment have not been established yet. Until now, there are no randomized controlled trials for recurrent patellar dislocation at all. As a synopsis of the randomized controlled trials about first-time patellar dislocation, no significant difference between operative and conservative management is evident. This applies to both children and adolescents as well as to adults. There is a clear tendency towards first-line conservative therapy after traumatic patellar dislocation. Operative treatment is only required in case of accompanying injuries like osteochondral fractures or in case of recurrent dislocations. Further prospective randomized controlled trials with standardized operative and conservative treatment and patient cohorts of sufficient size are necessary in the future.Patellar dislocation is a common knee injury with mainly lateral dislocations, leading to ruptures of the medial patellofemoral ligament in most of the cases. Reliable data and prognostic factors for stability of the patellofemoral joint and satisfaction of the patient after either conservative or operative treatment have not been established yet. Until now, there are no randomized controlled trials for recurrent patellar dislocation at all. As a synopsis of the randomized controlled trials about first-time patellar dislocation, no significant difference between operative and conservative management is evident. This applies to both children and adolescents as well as to adults. There is a clear tendency towards first-line conservative therapy after traumatic patellar dislocation. Operative treatment is only required in case of accompanying injuries like osteochondral fractures or in case of recurrent dislocations. Further prospective randomized controlled trials with standardized operative and conservative treatment and patient cohorts of sufficient size are necessary in the future.

[Evidence-based treatment protocol to manage patellar dislocation].

ZusammenfassungPatellaluxationen treten üblicherweise nach lateral auf und führen in >90% der Fälle zu einer Ruptur des medialen patellofemoralen Ligaments. Verlässliche Daten und Prognosefaktoren für die Stabilität des Patellofemoralgelenks und die Patientenzufriedenheit nach entweder konservativer oder operativer Behandlung sind umstritten. Für rezidivierende Patellaluxationen fehlen randomisierte Studien bislang vollständig. In Zusammenschau der bisherigen randomisierten Studien zur Patellaerstluxation lässt sich kein signifikanter Unterschied zwischen operativer und konservativer Versorgung zeigen. Dies gilt gleichermaßen für Kinder und Jugendliche wie Erwachsene. Es besteht eine deutliche Tendenz zugunsten eines abwartenden Verhaltens und einer zunächst konservativen Therapie bei traumatischer Patellaerstluxation. Eine operative Versorgung ist primär lediglich bei relevanten Begleitverletzungen wie osteochondralen Frakturen und sekundär bei rezidivierenden Luxationen indiziert. Weitere prospektiv-randomisierte Studien mit standardisierten operativen wie konservativen Therapiemaßnahmen und ausreichend großen Fallzahlen sind erforderlich.AbstractPatellar dislocation is a common knee injury with mainly lateral dislocations, leading to ruptures of the medial patellofemoral ligament in most of the cases. Reliable data and prognostic factors for stability of the patellofemoral joint and satisfaction of the patient after either conservative or operative treatment have not been established yet. Until now, there are no randomized controlled trials for recurrent patellar dislocation at all. As a synopsis of the randomized controlled trials about first-time patellar dislocation, no significant difference between operative and conservative management is evident. This applies to both children and adolescents as well as to adults. There is a clear tendency towards first-line conservative therapy after traumatic patellar dislocation. Operative treatment is only required in case of accompanying injuries like osteochondral fractures or in case of recurrent dislocations. Further prospective randomized controlled trials with standardized operative and conservative treatment and patient cohorts of sufficient size are necessary in the future.Patellar dislocation is a common knee injury with mainly lateral dislocations, leading to ruptures of the medial patellofemoral ligament in most of the cases. Reliable data and prognostic factors for stability of the patellofemoral joint and satisfaction of the patient after either conservative or operative treatment have not been established yet. Until now, there are no randomized controlled trials for recurrent patellar dislocation at all. As a synopsis of the randomized controlled trials about first-time patellar dislocation, no significant difference between operative and conservative management is evident. This applies to both children and adolescents as well as to adults. There is a clear tendency towards first-line conservative therapy after traumatic patellar dislocation. Operative treatment is only required in case of accompanying injuries like osteochondral fractures or in case of recurrent dislocations. Further prospective randomized controlled trials with standardized operative and conservative treatment and patient cohorts of sufficient size are necessary in the future.

Rekonstruktion einer iatrogenen Akromionpseudarthrose

ZusammenfassungDie Fraktur des Akromions ist eine seltene, aber schwerwiegende Komplikation, die im Rahmen einer subakromialen Dekompression auftreten kann. Wir berichten über einen Patienten mit Pseudarthrose des Akromions, der bei Schmerzpersistenz mehrfach operiert wurde, bis es schließlich zur Diagnose „Pseudarthrose“ kam. Die Pseudarthrose wurde erfolgreich durch Osteosynthese mit einer distalen Radiusplatte und einem monokortikalen Beckenkammspan therapiert. Zwei Jahre nach der Operation sind die Fraktur verheilt und die Beschwerden des Patienten erheblich gebessert. Im Constant Score erreicht der Patient 58xa0Punkte (präoperativ 25xa0Punkte) und im Subjective Shoulder Rating System (SSRS) 65 Punkte (präoperativ 25xa0Punkte). Die Beweglichkeit ist postoperativ deutlich verbessert und beträgt für aktive Abduktion/Adduktion 50/0/25º (30/0/20° präoperativ), für Außenrotation/Innenrotation 35/0/45º (30/0/30° präoperativ) und für Anteversion/Retroversion 60/0/35° (35/0/20° präoperativ).AbstractAcromial fractures are rare but severe complications which can occur during subacromial decompression. We report a case of acromial pseudarthrosis which was discovered belatedly due to persistent pain after several operations. The pseudarthrosis was successfully treated by osteosynthesis with a distal radius plate and implantation of a monocortical bone graft from the iliac crest. Two years after surgery, the fracture has healed and the patient’s pain improved significantly. In the constant score the patient achieved postoperatively 58xa0points compared to 25xa0points before surgery and 65xa0points compared to 25xa0points preoperatively in the subjective shoulder rating system (SSRS). Postoperatively, the patient had a better range of motion with active abduction/adduction of 50/0/25º (30/0/20° preoperatively), outward rotation/inward rotation of 35/0/45º (30/0/30° preoperatively) and anteversion/retroversion of 60/0/35° (35/0/20° preoperatively).Acromial fractures are rare but severe complications which can occur during subacromial decompression. We report a case of acromial pseudarthrosis which was discovered belatedly due to persistent pain after several operations. The pseudarthrosis was successfully treated by osteosynthesis with a distal radius plate and implantation of a monocortical bone graft from the iliac crest. Two years after surgery, the fracture has healed and the patients pain improved significantly. In the constant score the patient achieved postoperatively 58xa0points compared to 25xa0points before surgery and 65xa0points compared to 25xa0points preoperatively in the subjective shoulder rating system (SSRS). Postoperatively, the patient had a better range of motion with active abduction/adduction of 50/0/25º (30/0/20° preoperatively), outward rotation/inward rotation of 35/0/45º (30/0/30° preoperatively) and anteversion/retroversion of 60/0/35° (35/0/20° preoperatively).

Posttraumatische Arthrosen des GlenohumeralgelenksPosttraumatic arthritis of the glenohumeral joint

ZusammenfassungHintergrundDie Therapie der Omarthrose bei jüngeren Patienten mit hohem Aktivitätsniveau stellt eine Herausforderung für den orthopädischen Chirurgen dar. Die Endoprothetik erzielt in diesem Kollektiv häufig nur unbefriedigende klinische Ergebnisse bei begrenzter Standzeit der Prothese.FragestellungDiese Übersichtsarbeit stellt Indikation, Technik und Ergebnisse arthroskopischer gelenkerhaltender Therapieverfahren für Patienten mit Omarthrose dar.MethodenEs erfolgte eine selektive Literaturrecherche unter Berücksichtigung eigener Erfahrungen.ErgebnisseNeben einer relevanten Schmerzreduktion sowie Verbesserung der Beweglichkeit und Patientenzufriedenheit kann durch arthroskopische Verfahren eine teils deutliche Verzögerung der Endoprothesenimplantation erreicht werden. Von besonderer Bedeutung scheint neben der débridierenden Komponente die umfassende Adressierung aller relevanten Begleitpathologien des arthrotisch veränderten Schultergelenks. Eine Weite des glenohumeralen Gelenkspalts von unter 2xa0mm im konventionellen Röntgenbild ist mit deutlich schlechteren Ergebnissen der arthroskopischen Versorgung vergesellschaftet.SchlussfolgerungenArthroskopische Verfahren stellen insbesondere für jüngere Patienten mit hohem Aktivitätsniveau eine gute Therapieoption bei Omarthrose dar. Der Patientenauswahl und dem Konsens der präoperativen Erwartungshaltung kommt eine besondere Bedeutung zu.AbstractBackgroundThe management of glenohumeral osteoarthritis in younger patients with high activity levels remains a challenge to orthopedic surgeons. The clinical results of joint replacement surgery are commonly unsatisfactory in this particular cohort with the associated problem of limited longevity of the implant.ObjectivesThis paper reviews the indications, techniques and outcomes of joint-preserving arthroscopic surgery for the treatment of osteoarthritis of the shoulder.MethodsA selective literature search was performed and personal surgical experiences are reported.ResultsBesides significant pain reduction, improved range of motion and increased patient satisfaction, arthroscopic surgery can delay the need for total shoulder arthroplasty. A comprehensive approach that addresses all concomitant pathologies of the shoulder joint is of particular importance. Recent studies have shown that a glenohumeral joint space of less than 2xa0mm predicts significantly poorer results with arthroscopic therapy.ConclusionArthroscopic procedures are a good option to treat young, active patients with osteoarthritis of the shoulder. Patient selection and setting a consensus for appropriate preoperative expectations are of particular relevance.BACKGROUNDnThe management of glenohumeral osteoarthritis in younger patients with high activity levels remains a challenge to orthopedic surgeons. The clinical results of joint replacement surgery are commonly unsatisfactory in this particular cohort with the associated problem of limited longevity of the implant.nnnOBJECTIVESnThis paper reviews the indications, techniques and outcomes of joint-preserving arthroscopic surgery for the treatment of osteoarthritis of the shoulder.nnnMETHODSnA selective literature search was performed and personal surgical experiences are reported.nnnRESULTSnBesides significant pain reduction, improved range of motion and increased patient satisfaction, arthroscopic surgery can delay the need for total shoulder arthroplasty. A comprehensive approach that addresses all concomitant pathologies of the shoulder joint is of particular importance. Recent studies have shown that a glenohumeral joint space of less than 2xa0mm predicts significantly poorer results with arthroscopic therapy.nnnCONCLUSIONnArthroscopic procedures are a good option to treat young, active patients with osteoarthritis of the shoulder. Patient selection and setting a consensus for appropriate preoperative expectations are of particular relevance.