Martinus Richter

Fractures and Fracture Dislocations of the Midfoot: Occurrence, Causes and Long-term Results

Etiology and outcome of 155 patients with midfoot fractures between 1972 and 1997 were analyzed to create a basis for treatment optimization. Cause of injuries were traffic accidents (72.2%), falls (11.6%), blunt injuries (7.7%) and others (5.8%). Isolated midfoot fractures (I) were found in 55 (35.5%) cases, Lisfranc fracture dislocations (L) in 49 (31.2%), Chopart-Lisfranc fracture dislocations (CL) in 26 (16.8%) and Chopart fracture dislocations (C) in 25 (16%). One hundred and forty eight (95%) of the midfoot fractures were treated operatively; 30 with closed reduction, 115 with open reduction, 3 patients had a primary amputation. Seven (5%) patients were treated non-operatively. Ninety seven (63%) patients had follow-up at an average of 9 (1.3–25, median 8.5) years. The average scores of the entire follow-up group were as follows: AOFAS – sum of all four sections (AOFAS-ET): 296, AOFAS-Midfoot (AOFAS-M): 71, Hannover Scoring System (HSS): 65, and Hannover Questionnaire (Q): 63. Regarding age, gender, cause, time from injury to treatment and method of treatment no score differences were noted (t-test: p > 0.05). L, C or I showed similar scores and CL significantly lower scores (AOFAS-ET, AOFAS-M, HSS, Q). The highest scores in all groups were achieved in those fractures treated with early open reduction and operative fixation. Midfoot fractures, particularly fracture dislocation injuries, effect the function of the entire foot in the long-term outcome. But even in these complex injuries, an early anatomic (open) reduction and stable (internal) fixation can minimize the percentage of long-term impairment.

Comparison of Surgical Repair or Reconstruction of the Cruciate Ligaments versus Nonsurgical Treatment in Patients with Traumatic Knee Dislocations

Background: Studies of traumatic knee dislocations have failed to provide a consensus regarding the best method of treatment. Purpose: Our purpose was to evaluate the results after surgical repair or reconstruction versus nonsurgical treatment and to compare the influence of prognostic factors. Study Design: Retrospective study. Methods: Eighty-nine patients were treated for traumatic knee dislocation. Surgical repair or reconstruction of the cruciate ligaments was performed in 63 patients (repair, 49; reconstruction, 14). In 26 patients, nonsurgical treatment was undertaken. Results: At an average follow-up of 8.2 years, the mean Lysholm and Tegner scores were 75 and 3.7, respectively. The outcome in the surgical group was better than in the nonsurgical group. The scores were higher in patients who were 40 years of age or younger, who had sports injuries rather than motor vehicle accident injuries, and who had undergone functional rehabilitation rather than immobilization. Conclusions: Surgical repair or reconstruction of the cruciate ligaments was superior to nonsurgical treatment. Functional rehabilitation was the most important positive prognostic factor. Surgical repair or reconstruction of the cruciate ligaments is mandatory to achieve sufficient stability for functional rehabilitation. In cases of cruciate ligament avulsion, repair with transosseous fixation is a reasonable alternative to reconstruction, provided that it is performed within 2 weeks of trauma.

Achilles Tendon and Paratendon Microcirculation in Midportion and Insertional Tendinopathy in Athletes

Background Neovascularisation can be detected qualitatively by Power Doppler in Achilles tendinopathy. Quantitative data regarding tendon microcirculation have not been established and may be substantial. Purpose To assess the microcirculation of the Achilles tendon and the paratendon in healthy volunteers as well as in athletes with either midportion or insertional tendinopathy. Study Design Cohort study; Level of evidence, 2. Methods In 66 physically active volunteers, parameters of Achilles tendon and paratendon microcirculation, such as tissue oxygen saturation, relative postcapillary venous filling pressures, and microcirculatory blood flow, were determined at rest at 2-mm and 8-mm tissue depths. Forty-one patients never had Achilles pain (25 men, 27 ± 8 years), 14 patients had insertional pain (7 men, 29 ± 8 years), and 11 patients had midportion tendinopathy (7 men, 38 ± 13 years, not significant). Results Achilles tendon diameter 2 cm and 6 cm proximal to the insertion was increased in symptomatic tendons. Compared with the uninvolved opposite tendon, deep microcirculatory blood flow was significantly elevated at insertional (160 ± 79 vs 132 ± 42, P<. 05) as well as in midportion tendinopathy (150 ± 74 vs 119 ± 34, P<. 05). The microcirculation in the uninvolved opposite tendon and the normal athlete controls were not significantly different from each other (132 ± 42 insertional asymptomatic vs 119 ± 34 mid-portion vs 120 ± 48 healthy tendon). Insertional paratendon deep microcirculatory flow was elevated in all groups, whereas tissue oxygen saturation and relative postcapillary venous filling pressures were not significantly different. Conclusion Microcirculatory blood flow is significantly elevated at the point of pain in insertional and midportion tendinopathy. Postcapillary venous filling pressures are increased at both the midportion Achilles tendon and the midportion paratendon, whereas tissue oxygen saturation is not different among the studied groups. We found no evidence of an abnormal microcirculation of the asymptomatic limb in Achilles tendinopathy.

Whiplash-type neck distortion in restrained car drivers: frequency, causes and long-term results

Abstract An analysis was made of 1176 whiplash-type neck distortions taken from a total of 3838 restrained car driver incident reports. The percentage of whiplash-type neck distortion among injured drivers increased from less than 10% in 1985 to over 30% in 1997. Most occurred in head-on crashes or crashes with multiple collisions; only 15% occurred in rear-end collisions. More than 1,000 questionnaires were sent to the injured to find out about the duration and type of complaints caused by their cervical spine injury. Although only 138 (12%) returned the questionnaire, which may not be a representative sample, a further analysis was carried out. Of the 138, 121 (88%) indicated that they had suffered or were still suffering from their symptoms. The percentages of the various complaints were as follows: pain (74%), tension (6%) and stiffness (5%) in the head (27%), neck (55%) and shoulder (8%). The duration of the complaints was longest after multiple collisions and when the onset of complaints was longer than 24 h after trauma. Women and elderly persons predominated slightly in the group with longer duration of complaints. A correlation between the severity of the accompanying injuries and duration of complaints was found. Lack of adequate follow-up for patients with less severe injuries posed considerable difficulties for this retrospective study. In order to better evaluate this problem, prospective studies are necessary, with documentation including diagnosis, treatments, complaint duration and type.

Correlation between crash severity, injury severity, and clinical course in car occupants with thoracic trauma: a technical and medical study

BACKGROUND The crash mechanisms and clinical course of car occupants with thoracic injury were analyzed to determine prognostic factors and to create a basis for injury prophylaxis. METHODS A technical and medical investigation of car occupants with a thoracic injury (Abbreviated Injury Scale-thorax [AIS(THORAX)] > or = 1) at the scene of the crash and the primary admitting hospital was performed. RESULTS Between 1985 and 1998, 581 car occupants sustained a thoracic injury. Mean parameter values were as follows: AIS(THORAX), 2.5; Hannover Polytrauma Score (PTS), 21.4; Injury Severity Score (ISS), 24.2; Delta-v, 49.6 km/h (30.8 mph); and extent of passenger compartment deformation (DEF) (scale, 1--9), 4.0. In 19% (n = 112) of patients involved, the clinical course was evaluated: AIS(THORAX), 2.5; PTS, 20.0; ISS, 19.3; Delta-v, 50.1 km/h (31.1 mph); DEF, 3.9; intensive care unit time, 8.3 days; ventilation time, 5.7 days; and hospital stay, 15.3 days. In the groups with higher AIS(THORAX), ISS, PTS, and intensive care unit and ventilation time, higher Delta-v and DEF occurred. In patients with longer hospital stay, higher Delta-v, but no difference in DEF occurred. CONCLUSION The injury severity and the clinical course demonstrated a positive correlation with the crash severity. Therefore, our technical accident analysis allows prediction of the severity of injury and the clinical course. It may consequently serve as a tool for development of more sophisticated injury prevention strategies and may improve passive car safety.

A comparison of plates with and without locking screws in a calcaneal fracture model.

Background: We compared different plates in an experimental calcaneal fracture model under biocompatible loading. Methods: Four plates were tested: a plate without locked screws (Synthes), and three different plates with locked screws (Newdeal, Darco, Synthes). Synthetic calcanei (Sawbone) were osteotomized to create a fracture model, and the plates were fixed onto them. Seven specimens for each plate model were subjected to cyclic loading (preload 20 N, 1,000 cycles with 800 N, 0.75 mm/s), and load to failure (0.75 mm/s). Motion, forces, plastic deformation of the plate, and consequent depression of the posterior joint facet were analyzed. Results: During cyclic loading, all plates with locked screws showed statistically significant lower displacement in the primary loading direction than the plates without locked screws. Mean values (mm) of maximal displacements for each plate during cyclic loading were as follows: Synthes, 3.5; Darco, 4.5; Newdeal, 5.0; Synthes without locked screws, 7.5; (p < 0.001). No statistically significant differences between the plates were found in relation to loads to failure and corresponding displacement. Conclusion: This is the first biomechanical study to assess the stability of different plates currently in use in our practice for the fixation of calcaneal fractures. Our results showed that plates with locked screws provided greater stability during cyclic loading than the plate without locked screws.

Head Injury mechanisms in helmet-protected motorcyclists : Prospective multicenter study

BACKGROUND In a prospective study, three research groups at Hannover (H) and Munich (M) in Germany and Glasgow (G) in the United Kingdom collected data from motorcycle crashes between July 1996 and July 1998 to investigate head injury mechanisms in helmet-protected motorcyclists. METHODS The head lesions of motorcyclists with Abbreviated Injury Score-Head (AISHead) 2+ injuries and/or helmet impact were classified into direct force effect (DFE) and indirect force effect (IFE) lesions. The effecting forces and the force consequences were analyzed in detail. RESULTS Two-hundred twenty-six motorcyclists (H, n = 115; M, n = 56; and G, n = 55) were included. Collision opponents were cars (57.8%), trucks (8.0%), pedestrians (2.3%), bicycles (1.4%), two-wheel motor vehicles (0.8%), and others (4.2%). In 25.4% no other moving object was involved. The mean impact speed was 55 km/h (range, 0-120 km/h) and correlated with AISHead. Seventy-six (33%) motorcyclists had no head injury, 21% (n = 48) AISHead 1, and 46% (n = 103) AISHead 2+. Four hundred nine head lesions were further classified: 36.9% DFE and 63.1% IFE. Lesions included 20.5% bone, 51.3% brain, and 28.1% skin. The most frequent brain lesions were subdural hematomas (22.4%, n = 47) and subarachnoid hematomas (25.2%, n = 53). Lesions of skin or bone were mainly DFE lesions, whereas brain lesions were mostly IFE lesions. CONCLUSION A modification of the design of the helmet shell may have a preventative effect on DFE lesions, which are caused by a high amount of direct force transfer. Acceleration or deceleration forces induce IFE lesions, particularly rotation, which is an important and underestimated factor. The reduction of the effecting forces and the kinetic consequences should be a goal for future motorcycle helmet generations.

Intraoperative 3D imaging in calcaneal fracture care-clinical implications and decision making.

BACKGROUND In operative calcaneal fracture care malposition of screws and joint line incongruity frequently remain unrecognized using fluoroscopy intraoperatively, and are frequently only recognized on postoperative computed tomography scans. The purpose of this study was to analyze the feasibility and utility of a new C-arm-based three-dimensional imaging technology for calcaneal trauma care. METHODS The C-arm-based three- dimensional imaging device (ISO-C-3D) was used in 32 patients during a 2-year period. Patients were indicated for open reduction and internal fixation using standard techniques and fluoroscopy. After reduction and implant placement was determined to be correct, the ISO-C-3D procedure was performed. The time for setup and use, and the consequences were recorded. An assessment was obtained from the surgeon regarding the feasibility and the adequacy and quality of the data provided, using a Visual Analog Scale. RESULTS The average total time required for ISO-C-3D use was 610 seconds. The information obtained from the scan led the surgeon to alter the reduction or screw placement during the procedure in 41% of the patients. Surgeons rating according to a Visual Analog Scale: feasibility 9.5, accuracy and quality 9.2, clinical benefit 8.2. CONCLUSION Intraoperative three- dimensional visualization with the ISO-C-3D provides important information in the operative treatment of calcaneal fractures which cannot always be obtained from plain films or standard fluoroscopy alone. The use of the device adds minimal time to the overall procedure, and was found to be extremely useful in evaluating reduction and implant position intraoperatively in calcaneal fractures.

Computer-assisted analysis of lower limb geometry: higher intraobserver reliability compared to conventional method

Exact radiographic evaluation of lower limb alignment, joint orientation and leg length is crucial for preoperative planning and successful treatment of deformities, fractures and osteoarthritis. Improvement of the accuracy of radiographic measurements is highly desirable. To determine the intraobserver reliability of conventional analysis of lower extremity geometry, 59 long leg radiographs were randomly analyzed 5 times by a single surgeon. The measurements revealed a standard deviation between 0.36° and 1.17° for the angles mLPFA, mLDFA, MPTA, LDTA, JLCA and AMA (nomenclature according to Paley), and 0.94 mm and 0.90 mm for the MAD and leg length, respectively. Computer-assisted analysis with a special software significantly reduced the standard deviation of the mLDFA, MPTA, LDTA, JLCA (each p < 0.001), AMA (p = 0.032) and MAD (p = 0.023) by 0.05–0.36° and 0.14 mm, respectively. Measuring time was reduced by 44% to 6:34 ± 0:45 min (p < 0.001). Digital calibration by the software revealed an average magnification of conventional long leg radiographs of 4.6 ± 1.8% (range: 2.7–11.9%). Computer-assisted analysis increases the intraobserver reliability and reduces the time needed for the analysis. Another major benefit is the ease of storage and transfer of digitized images. Due to the varying magnification factors on long leg radiographs, the use of magnification markers for calibration is recommended.

Long-term results after functional nonoperative treatment of achilles tendon rupture.

Background: Nonoperative treatment of complete Achilles tendon ruptures generally involves a long period of cast immobilization and is associated with frequent reruptures. Functional nonoperative treatment of complete Achilles tendon ruptures involves the use of a high-shaft boot with a 3-cm hindfoot elevation, in which physical therapy is begun after 3 weeks of wear. We reviewed our long-term results with this treatment protocol to determine its effectiveness. Methods: The indications for nonoperative treatment, defined by ultrasound, were a distance of 10 mm or less between the tendon ends with the ankle in neutral position and complete apposition of the tendon ends in 20 degrees of plantarflexion. From 1990 to 1996, 168 patients were treated; 125 (74%) were available for followup at a mean of 5.5 (2 to 12.7) years after the injury. Results: Good or excellent results were achieved in 92 (73.5%) with complete rehabilitation and return to sports activity at their pre-injury levels. Satisfactory (9%) and poor results (17.5%) were due to pain in the Achilles tendon region, a lengthened Achilles tendon, markedly reduced strength, or a marked reduction of calf size in 25 patients (76%). Eight patients (6.4%) sustained a rerupture. Conclusions: Functional nonoperative treatment achieved good results in patients who had precise sonographic evaluation and who were compliant. As a result of our study, we modified our protocol: (1) a repeat ultrasound examination is done by an experienced sonographer 2 to 5 days after the first to confirm the indications for nonoperative treatment, (2) the use of the 3-cm hindfoot elevation is extended from 6 to 8 weeks to provide a longer protection of the tendon, and (3) patients then wear shoes with 1-cm hindfoot elevation for another 3 months.