Manfred Greitbauer

Surgical Treatment of Metastatic Fractures of the Femur : A Retrospective Analysis of 142 Patients

BACKGROUND Pathologic fractures of long bones are common complications of the metastatic disease; however, the influence of the primary tumor, the stage of metastatic disease, different surgical techniques, and the postoperative mobility on the postoperative survival has not been clearly defined. The aim of this retrospective study was to evaluate outcome after surgical treatment for pathologic femur fractures. PATIENTS AND METHODS A consecutive series of 142 patients with metastatic fractures of femur were retrospectively studied. The operative treatment was based on intramedullary fixation (n = 94), gliding screws (n = 15), other extramedullary fixation devices (n = 7), and arthroplasty (n = 23). RESULTS Seventeen percent and 6% of the patients survived 1 year and 2 years, respectively, postoperatively. Postoperative survival was higher in patients with pathologic femur fractures because of breast carcinoma than in patients with other primary tumors. The rate of complications for patients with intramedullary stabilization, gliding screw fixation, and endoprosthetic replacement was 3.2%, 20%, and 8.6%, respectively. CONCLUSION Although many studies describe the endoprosthetic replacement as the safer method to treat pathologic femur fractures, our data showed that intramedullary stabilization and endoprosthetic replacement to be safe, and equivalent alternatives to treat complete pathologic fractures of the femur in patients with advanced metastatic disease.

Gamma nailing—Critical overview of 335 cases

SummaryBackgroundThe purpose of this study was to evaluate the rate of intra and postoperative complications due to the Gamma nail® (GN) in 335 cases of proximal, femoral fractures classified according to the “Arbeitsgemeinschaft für Osteosynthesefragen” (AO)/“Association for the study of Internal Fixation” (ASIF)MethodsOnly AO 31 A1-A3 fractures were included. After closed reduction of the fracture site, intramedullary stabilization was performed using the GN. Patients underwent full weight-bearing whenever possible post operation, followed by X-ray examinations.ResultsThe rate of intraoperative complications was 11.34%, and that of postoperative ones 9.55%. Complications occurring during surgical intervention were misdrilling of the distal locking site, shaft fractures distally to the implant, or hardware failure and others. Cranial cutting out of the lag screw was only seen during postoperative mobilization. The infection rate was found to be 3.9%; 2 patients ended up in a girdlestone situation after removal of the implant. 6 cases of thromboembolic complications occurred. All patients showed high “American Society of Anesthesia” (ASA)-scores. Patients in which the primary regimens were not changed progressed to bony union within the follow-up period of 6 months but early full weight-bearing was possible in each of the cases.ConclusionsThe results lend support to the empirical practice of using this intramedullary device in unstable fractures. Its superior biomechanics make the GN a sound option once the early complications of the learning phase have been overcome.ZusammenfassungHintergrundBestimmung der intra- und pospoterativen Komplikationsrate des Gammanagels® (GN) bei 335 Patienten in Fällen proximaler, hüftgelenknaher Frakturen klassifiziert nach AO/ASIF.MethodikVersorgt wurden ausschließlich Frakturen AO 31 A1-A3 durch gedeckte Reposition und anschließende, intramedulläre Stabilisierung. Die frühestmögliche Mobilisierung unter Vollbelastung erfolgte unter physikalischer Therapie und Durchführung regelmäßiger Hüftröntgenkontrollen.ErgebnisseDie Rate intraoperativer Komplikationen betrug 11,34%, die postoperative 9,55%. Intraoperativ traten gehäuft distale Fehlbohrungen, aber auch Schaftfrakturen oder Bohrerbrüche auf. Ein kraniales Durchschneiden der Schenkelhalsschraube durch den Hüftkopf war eine typische Komplikation der postoperativen Phase. Die Infektionsrate betrug 3,9%, bei 2 Patienten führte eine septische Komplikation nach Implantatentfermung schließlich zu einer sogenannten Girdlestone-Hüfte. In 6 Fällen traten thromboembolische Komplikationen auf. Alle Patienten zeigten einen hohen ASA-Score. Bei Patienten ohne erforderlichen Verfahrenswechsel kam es zu knöcherner Konsolidierung innerhalb des Nachuntersuchungszeitraumes von 6 Monaten.SchlußfolgerungenDie Sicherheit der Frakturretention und die biomechanischen Vorteile machen den GN als intramedullären Kraftträger nach Überwindung anfänglicher Handling-bedingter Fehler zum Implantat der Wahl vor allem bei instabilen coxalen Femurfrakturen.

Incidence, characteristics, and long-term follow-up of sternoclavicular injuries: An epidemiologic analysis of 92 cases.

BACKGROUND The majority of published studies concerning sternoclavicular injuries are case series or systematic reviews. Prospective studies on the subject are hindered by the low incidence of these lesions. The aims of the present study were to provide an overview of this rare entity compared with those described in the literature and to present the long-term clinical outcome. METHODS We performed a retrospective data analysis of all sternoclavicular injuries treated at a single Level I trauma center from 1992 to 2011. Long-term clinical outcome was assessed using the ASES [American Shoulder and Elbow Surgeons], SST [Simple Shoulder Test], UCLA [University of California-Los Angeles] Shoulder Scale, and VAS [Visual Analog Scale] at latest follow-up. RESULTS We detected an overall incidence of 0.9% of sternoclavicular injuries related to all shoulder-girdle lesions. Ninety-two patients (52 males and 40 females) with a mean (SD) age of 39.2 (19.5) years (median, 41 years; range, 4–92 years) were included in this study. The main trauma mechanism was fall. Classification was performed according to Allman, the time point of treatment after initial trauma, and the direction of the dislocation. Nine patients of the 15 Grade III lesions were treated conservatively by closed reduction and immobilization, while four patients were treated surgically by open reduction and internal fixation. Forty-nine percent of the patients were available for long-term follow-up at a median of 11.3 years (range, 5.3–22.6 years) with a mean ASES score of 96.21, SST score of 11.69, UCLA score of 31.89, and VAS score of 0.47. CONCLUSION We found an overall incidence of 0.9% of sternoclavicular joint injuries related to all shoulder-girdle lesions and of 1.1% related to all dislocations, which is slightly lower compared with those described in the literature. Furthermore, we observed a high number of physeal sternoclavicular injuries with a percentage of 16% and overall good-to-excellent results at long-term follow-up. LEVEL OF EVIDENCE Epidemiologic study, level IV.

MR imaging vs. stress radiography in diagnosis of ankle inversion trauma

SummaryBackground: Tears of the lateral ligaments of the ankle may be diagnosed by different methods. Stress radiography is the most widely used technique for routine investigation due to ease of performance and its low cost. However, it often yields false-negative results. Methods: A prospective comparison in 63 athletically active patients evaluating stress radiography vs. magnetic resonance (MR) imaging in comparison with clinical findings according to different groups of talar tilting was performed; in the 15 patients (24%) the results of the 2 radiological techniques were compared with the intraoperative findings. Results: Comparing the different groups the correlation actually found was remarkably poor: 32% of all patients had been underdiagnosed, 10% had been overdiagnosed at stress radiography. The sensitivity of MR imaging for the detection of injuries was 93%; specificity was 100%. Conclusions: Despite 10% false negative findings, MRI gives valuable informations on ankle ligament injury.ZusammenfassungGrundlagen: Inversions- oder auch Supinationsverletzungen der lateralen Sprunggelenksbänder können auf vielfältige Art diagnostiziert werden. Die Streßradiographie ist aufgrund ihrer klinischen Praktikabilität und der niedrigen Kosten die am häufigsten angewandte Methode. Allerdings wird damit eine nicht unbeträchtliche Anzahl falsch negativer Resultate erzielt. Methodik: Verglichen wurden im Rahmen einer prospektiven Studie die Ergebnisse von Streßradiographie und Magnetresonanztomographie an insgesamt 63 sportlich aktiven Patienten, unterteilt in Gruppen unterschiedlicher Schweregrade. Bei 15 Patienten (24%) wurden die beiden Techniken mit den intraoperativen Befunden verglichen. Ergebnisse: Der Befundvergleich ergab unerwartete Ergebnisse, da die tatsächlich gefundene Korrelation unerwartet niedrig war. 32% der Patienten wurden anhand der Streßradiographie falsch negativ und 10% falsch positiv beurteilt. Die Sensitivität der MRT lag bei 93% im Erkennen operationswürdiger Befunde, die Spezifität bei 100%. Schlußfolgerungen: Trotz 10% falsch negativer Resultate stellt die MRT eine ausgezeichnete Alternative zur bisherigen Routinediagnostik im Erkennen und Aufzeigen des wahren Ausmaßes ligamentärer Sprunggelenksverletzungen dar.

Septic complications after interlocking nailing of the tibia

SummaryInfection, the primary cause of nonunion and unsatisfactory results in operative fracture treatment, occurs with unsettling frequency in spite of modern surgical methods and antibiotics. In the literature we find infection rates after interlocking nailing (IN) of tibial fractures between 1% (Vécsei, 1981) and 6.3% (4.2% deep infections, Jenny, 1993). In this paper a retrospective study of 334 open and closed tibial fractures treated with Grosse & Kempf Nails (G & K Nails) is presented. There were 5 cases (1.5%) of manifest osseus infection. These cases are classified according to the type of infection, the visible site of infection and predisposing factors for infection. Possible reasons for the infectious process, our therapeutic guidelines and results in the treatment of septic complications of nailed tibia fractures will be discussed.RésuméL’infection, la cause primaire de non consolidation et des résultats insatisfaisants dans le traitement opératoire des fractures, intervient avec une fréquence inquiétante malgré les méthodes de chirurgie moderne et les antibiotiques. Dans la littérature, nous trouvons des taux d’infection, à la suite d’enclouages verrouillés de fractures tibiales, entre 1 % (Vécsei 1981) et 6,3 % (4,2 % d’infections profondes, Jenny 1993). Ce travail présente une étude rétrospective de 334 fractures du tibia ouvertes et fermées traitées par clous vérouillés de Grosse et Kempf. Il y avait 5 cas manifestes d’infection osseuse (1,5 %). Ces cas sont classés dans différents schémas en fonction du type d’infection, de l’emplacement visible de l’infection et des facteurs prédisposants. Cet article expose les raisons possibles d’infection, nos directives thérapeutiques et les résultats obtenus suite au traitement de complications septiques dans le domaine des fractures tibiales traitées par enclouage verrouillé.