Michael Skutek

Outcome after primary and secondary hemiarthroplasty in elderly patients with fractures of the proximal humerus

Thirty-nine consecutive patients with 3- and 4-part proximal humeral fractures and fracture dislocations were treated with hemiarthroplasty. After an average of 42 months (range 5 to 98 months) of follow-up, 17 women and 8 men (average age 64.5 years) were evaluated with the University of California-Los Angeles (UCLA) scale, the Constant-Murley scale, the Hospital for Special Surgery (HSS) scale, and the visual analogue scale. Fair, good, or excellent results were achieved in 80% of the patients on the UCLA and Visual scales, in 72% of the patients on the HSS scale, and in 44% of the patients on the Constant-Murley scale. The highest correlation was between the HSS score and the Visual analogue score. According to the UCLA and Constant-Murley results, the outcome after early (<4 weeks) humeral head replacement was significantly better than after late (> or =4 weeks) humeral head replacement (UCLA score, P=.02; Constant-Murley score, P=.01). After early hemiarthroplasty active forward flexion was significantly better (P=.035). Thus the decision to perform prosthetic humeral head replacement in elderly patients should be made as early as possible after trauma.

Proprioception after rehabilitation and reconstruction in knees with deficiency of the anterior cruciate ligament : a prospective, longitudinal study

We assessed proprioception in the knee using the angle reproduction test in 20 healthy volunteers, ten patients with acute anterior instability and 20 patients with chronic anterior instability after reconstruction of the anterior cruciate ligament (ACL). In addition, the Lysholm-knee score, ligament laxity and patient satisfaction were determined. Acute trauma causes extensive damage to proprioception which is not restored by rehabilitation alone. Three months after operation, there remained a slight decrease in proprioception compared with the preoperative recordings, but six months after reconstruction, restoration of proprioception was seen near full extension and full flexion. In the mid-range position, proprioception was not restored. At follow-up, 3.7 +/- 0.3 years after reconstruction, there was further improvement of proprioception in the mid-range position. There was no difference between open and arthroscopic techniques. The highest correlation was found between proprioception and patient satisfaction. After reconstruction of the ACL reduced proprioception may explain the poor functional outcome in some patients, despite restoration of mechanical stability.

Outcome analysis following open rotator cuff repair. Early effectiveness validated using four different shoulder assessment scales.

Abstract Evaluation of upper extremity function after reconstructive surgery is increasingly important both to predict outcome and for the control of cost-effectiveness. Three validated, self-administered shoulder questionnaires were applied prospectively in 23 otherwise healthy patients with rotator cuff deficiency and correlated to the Constant-Murley Shoulder Score and a visual analogue scale for satisfaction. Seven women and 16 men with combined tears of supraspinatus and infraspinatus (mean age 55.3 ± 10.5 years, r/l: 14/9, follow-up 57.8 ± 15.7 weeks) were gathered prospectively and evaluated pre- and postoperatively with the American Shoulder and Elbow Surgeons (ASES) Shoulder Index, the Simple Shoulder Test (SST) and the Disabilities of the Arm, Shoulder and Hand Module (DASH questionnaire). Additionally, a visual analogue scale for satisfaction was employed. All four scores and the visual analogue scale revealed improvement at a statistically significant level (P < 0.01) after surgery. All questionnaires showed a significant correlation with the Constant-Murley Shoulder Score (ASES: r = 0.871, P < 0.01; DASH: r = –0.758, P < 0.01, SST: r = 0.494, P < 0.05, Pearson’s correlation coefficient). Taken together, all questionnaires were easy to apply, and reliable evaluation of shoulder function was possible with significant correlation to the Constant-Murley Shoulder Score postoperatively. The SST was easy to apply, and compound outcome analysis was possible with the ASES Shoulder Index and DASH questionnaire. The DASH scale was the most complex evaluation instrument. The Constant-Murley Shoulder Score comprises a physical examination, which is advantageous but restricts the application to the office. For postoperative assessment without the patient having to return to the clinic, the ASES Shoulder Index is preferred because of its good correlation to the Constant-Murley Shoulder Score (r = 0.871) and the visual analogue scale for satisfaction (r = 0.762).

Extension osteotomy in malunited clavicular fractures

The association of a malunited clavicular fracture with a pattern of disability that includes not only pain but also impairment of shoulder function is rare. But in cases where such an association exists, correction of the clavicular deformity should be considered. We report on 4 patients with a malunited fracture of the clavicle after nonoperative treatment. In all 4 patients fracture union had occurred with shortening associated with pain and ipsilateral glenohumeral dysfunction. The deformity was not associated with neurovascular dysfunction. On preoperative radiographs the shortening of the malunited clavicle was between 0.9 and 2.2 cm compared with the contralateral clavicle. all patients underwent an extension osteotomy of the clavicle with interposition of an autogenous iliac crestbone graft secured with a plate and screws. The length of follow-up was 1 to 4 years in 3 cases and 6 weeks in 1 case. The functional outcome was evaluated with the Constant-Murley and University of California-Los Angeles scales. All patients had immediate pain relief after osteotomy and correction of the deformity. Shoulder function rapidly improved and functional outcome was good in 3 of the 4 patients. In cases of shoulder function impairment associated with malunited clavicular fractures, extension osteotomy combined with autogenous bone grafting is likely to produce good results.

Arthrofibrosis is the result of a T cell mediated immune response

Abstract. It is thought that an excessive fibrotic healing response with diffuse intra-articular scarring leads to arthrofibrosis after trauma and surgery around joints. To clarify the specific cellular mechanism of arthrofibrosis during arthrolysis we took fibrotic tissue samples from 18 patients at varying periods after knee trauma or surgery. Sections were stained with hematoxylin and eosin to study the overall histopathological changes. Major histocompatibility complex (MHC) class II expressing cells as well as CD3, CD4, CD25, CD28, CD68, CD80, and CD83 positive cells were localized immunohistologically. The results demonstrated synovial hyperplasia with fibrotic enlargement of the subintima and infiltration of inflammatory cells. The number of MHC class II expressing cells was increased. Mainly, intimal macrophages and dendritic cells showed positive immunostaining for MHC class II antigens. In the subintima moderate infiltration of T cells including activated T cells (CD25), CD4+ T helper (Th) cells and Th1 and Th2 subsets was detected. There was a slight polarization of the Th1/Th2 balance towards Th1 differentiation. Positive immunostaining for CD80/CD28 indicated the costimulatory signal for T cell activation and clonal expansion. These findings strongly support an immune response as the cause of capsulitis leading to formation of diffuse scar tissue within the knee joint. Based on our immunohistological study we conclude that a T cell mediated immune response plays a crucial role in the mechanism of arthrofibrosis.

Level of physical activity in elderly patients after hemiarthroplasty for three- and four-part fractures of the proximal humerus

Abstract We report on 13 physically active patients who performed sports activities at a weekend or recreational level when they suffered a severe proximal humerus fracture or fracture dislocation. All patients were treated using the NEER II hemiarthroplasty, 9 patients within 4 weeks after trauma and 4 patients 2, 5, 10 and 15 months after trauma. At an average follow-up of 50 (range 6–98) months, all patients were evaluated, both by clinical review and radiographs. Patients obtained 69.0 points using the HSS score (Hospital for Special Surgery) for evaluation. Subjectively, 85% of the patients evaluated the result as ‘good’ or ‘excellent’ on a visual analogue scale for satisfaction. There was no radiographic evidence of implant loosening. At an average period of 33 (range 16–52) weeks 10 patients started with their physical activities again without a change in their participation level.

Posttraumatische Verlängerungsosteotomie der verkürzten Klavikula

ZusammenfassungOperationsziel Wiederherstellung der anatomischen Klavikulalänge zur Beseitigung schmerzhafter Funktionsstörungen des Schultergürtels. Indikationen In Verkürzung verheilte Klavikulafraktur mit schmerzhaften Funktionsstörungen des Schultergürtels körperlich aktiver Patienten. Kontraindikationen Asymptomatische posttraumatische Verkürzung der Klavikula.Schwere Osteoporose.Infiziertes Wundgebiet. Operationstechnik Hautschnitt im Verlauf der Spaltlinien senkrecht zur Klavikula. Osteotomie im ehemaligen Frakturbereich und Anfrischen der Knochenenden. Interposition eines autogenen, kortikospongiösen Spans vom ipsilateralen Beckenkamm entsprechend der vorher ermittelten Längendifferenz. Stabilisierung mit einer 3,5-mm-LC-DC-Platte. Weiterbehandlung Gilchrist-Verband. Ab 1. postoperativen Tag geführte Bewegungen, isometrische Muskelübungen. Aktive Bewegungsübungen 6 Wochen postoperativ. Volle Überkopfaktivität und muskuläre Rehabilitation gegen Widerstand nach Einheilung des Knochenspans (10–12 Wochen postoperativ). Röntgenkontrollen nach 6 und 12 Wochen. Ergebnisse Zwischen Juni 1991 und November 1999 wurden sechs Patienten operiert (männlich/weiblich = 4:2, 29±12 Jahre). Der durchschnittliche Nachuntersuchungszeitraum betrug 3,9±3,2 Jahre (0,4–9 Jahre). Fünf von sechs Patienten erzielten ein sehr gutes Ergebnis. Die Patienten erreichten im Mittel 95±8,4 Punkte im Constant-Murley-Score (maximal 100 Punkte) und 32,5±3,8 Punkte im UCLA-Score (Maximal 35 Punkte).AbstractObjective Restoration of clavicular length by osteotomy, interposition of an iliac crest autograft, and plate fixation to correct glenohumeral and scapulothoracic dysfunction. Indications Posttraumatic shortening of clavicle, accompanied by pain and impairment of glenohumeral function, particularly in overhead manual labor or sporting activities. Contraindications Asymptomatic shortening without functional or neurovascular impairment.Severe osteoporosis.Infection. Surgical Technique Sagittal approach along Langers lines. Osteotomy at fracture site and debridement. Lengthening of clavicle according to preoperative planning and interposition of an iiac crest autograft. Stabilization with 3.5-mm LC-DC plate and screws. Results Between June 1991 and November 1999, six patients (male/female = 4:2, 29±12 years) wich symptomatic shortening of the clavicle were treated by a lengthening osteotomy. The mean follow-up was 3.9±3.2 years (range 0.4–9 years). Based on the Constant-Murley score and the UCLA score, all patients but one had an excellent result. The scores averaged 95±8.4 points (Constant-Murley, maximum 100 points) and 32.5±3.8 points (UCLA, maximum 35 points).