Norbert P. Südkamp

Open Reduction and Internal Fixation of Proximal Humeral Fractures with Use of the Locking Proximal Humerus Plate: Results of a Prospective, Multicenter, Observational Study

BACKGROUND The treatment of unstable displaced proximal humeral fractures, especially in the elderly, remains controversial. The objective of the present prospective, multicenter, observational study was to evaluate the functional outcome and the complication rate after open reduction and internal fixation of proximal humeral fractures with use of a locking proximal humeral plate. METHODS One hundred and eighty-seven patients (mean age, 62.9 +/- 15.7 years) with an acute proximal humeral fracture were managed with open reduction and internal fixation with a locking proximal humeral plate. At the three-month, six-month, and one-year follow-up examinations, 165 (88%), 158 (84%), and 155 (83%) of the 187 patients were assessed with regard to pain, shoulder mobility, and strength. The Constant score was determined at each interval, and the Disabilities of the Arm, Shoulder and Hand (DASH) score was determined for the injured and contralateral extremities at the time of the one-year follow-up. RESULTS Between three months and one year, the mean range of motion and the mean Constant score for the injured shoulders improved substantially. Twelve months after surgery, the mean Constant score for the injured side was 70.6 +/- 13.7 points, corresponding to 85.1% +/- 14.0% of the score for the contralateral side. The mean DASH score at the time of the one-year follow-up was 15.2 +/- 16.8 points. Sixty-two complications were encountered in fifty-two (34%) of 155 patients at the time of the one-year follow-up. Twenty-five complications (40%) were related to incorrect surgical technique and were present at the end of the operative procedure. The most common complication, noted in twenty-one (14%) of 155 patients, was intraoperative screw perforation of the humeral head. Twenty-nine patients (19%) had an unplanned second operation within twelve months after the fracture. CONCLUSIONS Surgical treatment of displaced proximal humeral fractures with use of the locking proximal humeral plate that was evaluated in the present study can lead to a good functional outcome provided that the correct surgical technique is used. Because many of the complications were related to incorrect surgical technique, it behooves the treating surgeon to perform the operation correctly to avoid iatrogenic errors.

Open Reduction and Internal Fixation of Proximal Humeral Fractures with Use of the Locking Proximal Humerus Plate

BACKGROUND The treatment of unstable displaced proximal humeral fractures, especially in the elderly, remains controversial. The objective of the present prospective, multicenter, observational study was to evaluate the functional outcome and the complication rate after open reduction and internal fixation of proximal humeral fractures with use of a locking proximal humeral plate. METHODS One hundred and eighty-seven patients (mean age, 62.9 +/- 15.7 years) with an acute proximal humeral fracture were managed with open reduction and internal fixation with a locking proximal humeral plate. At the three-month, six month,and one-year follow-up examinations, 165 (88%), 158 (84%), and 155 (83%) of the 187 patients were assessed with regard to pain, shoulder mobility, and strength. The Constant score was determined at each interval, and the Disabilities of the Arm, Shoulder and Hand (DASH) score was determined for the injured and contralateral extremities at the time of the one-year follow-up. RESULTS Between three months and one year, the mean range of motion and the mean Constant score for the injured shoulders improved substantially. Twelve months after surgery, the mean Constant score for the injured side was 70.6 +/- 13.7 points, corresponding to 85.1% +/- 14.0% of the score for the contralateral side. The mean DASH score at the time of the one-year follow-up was 15.2 +/- 16.8 points. Sixty-two complications were encountered in fifty-two (34%) of 155 patients at the time of the one-year follow-up. Twenty-five complications (40%) were related to incorrect surgical technique and were present at the end of the operative procedure. The most common complication, noted in twenty-one (14%) of 155 patients, was intraoperative screw perforation of the humeral head. Twenty-nine patients (19%) had an unplanned second operation within twelve months after the fracture. CONCLUSIONS Surgical treatment of displaced proximal humeral fractures with use of the locking proximal humeral plate that was evaluated in the present study can lead to a good functional outcome provided that the correct surgical technique is used. Because many of the complications were related to incorrect surgical technique, it behooves the treating surgeon to perform the operation correctly to avoid iatrogenic errors.

Biomechanical properties and vascularity of an anterior cruciate ligament graft can be predicted by contrast-enhanced magnetic resonance imaging. A two-year study in sheep.

Magnetic resonance imaging has been used to determine graft integrity and study the remodeling process of anterior cruciate ligament grafts morphologically in humans. The goal of the present study was to compare graft signal intensity and morphologic characteristics on magnetic resonance imaging with biomechanical and histologic parameters in a long-term animal model. Thirty sheep underwent anterior cruciate ligament reconstruction with an autologous Achilles tendon split graft and were sacrificed after 6, 12, 24, 52, or 104 weeks. Before sacrifice, all animals underwent plain and contrast-enhanced (gadolinium-diethylenetriamine pentacetic acid) magnetic resonance imaging (1.5 T, proton density weighted, 2-mm sections) of their operated knees. The signal/noise quotient was calculated and data were correlated to the maximum load to failure, tensile strength, and stiffness of the grafts. The vascularity of the grafts was determined immunohistochemically by staining for endothelial cells (factor VIII). We found that high signal intensity on magnetic resonance imaging reflects a decrease of mechanical properties of the graft during early remodeling. Correlation analyses revealed significant negative linear correlations between the signal/noise quotient and the load to failure, stiffness, and tensile strength. In general, correlations for contrast-enhanced measurements of signal intensity were stronger than those for plain magnetic resonance imaging. Immunohistochemistry confirmed that contrast medium enhancement reflects the vascular status of the graft tissue during remodeling. We conclude that quantitatively determined magnetic resonance imaging signal intensity may be a useful tool for following the graft remodeling process in a noninvasive manner.

Femur-LISS and distal femoral nail for fixation of distal femoral fractures: are there differences in outcome and complications?

We evaluated the functional and radiologic outcomes after stabilization of distal femoral fractures using the distal femoral nail and a less invasive stabilization system to determine if the new implants are superior to other implants (especially the condylar blade plate) regarding the rates of axial deviation, nonunion, and infection and if one of these new implants (Less Invasive Stabilization System, or distal femoral nail) is superior to the other. Two groups, each with 16 patients, were documented prospectively and the results were compared. To record the findings objectively, the Lysholm-Gillquist score was used. A conversion procedure was done in two patients in the plate group and one patient of the nail group. At the 1-year followup mobility of the knee was on average 110° in the plate group and 103° in the nail group. The Lysholm-Gillquist score did not show any significant differences between the groups. There were clinically relevant varus or outer rotation deviations in three patients in the plate group and two patients in the nail group. The two minimally invasive implants used were good in terms of technique and outcome for treatment of distal femoral fractures and did not differ significantly for epidemiology, fracture type, conversion procedures, infection rate, malalignments, and subjective and objective findings at the 1-year followup. They were also superior to the condylar plate in terms of infection and axial malalignments.

Open-wedge osteotomy using an internal plate fixator in patients with medial-compartment gonarthritis and varus malalignment: 3-year results with regard to preoperative arthroscopic and radiographic findings.

PURPOSE Our purpose was to evaluate the 3-year clinical results of patients with medial-compartment osteoarthritis of the knee and varus malalignment who underwent open-wedge high tibial osteotomy (HTO) with an internal plate fixator (TomoFix; Synthes, Solothurn, Switzerland). Clinical results are correlated with arthroscopic and radiographic findings at the time of surgery. METHODS This study included 69 patients with a minimum follow-up of 36 months who underwent open-wedge HTO for medial-compartment osteoarthritis of the knee. Knee function was assessed before surgery and at 6, 12, 24, and 36 months after HTO by use of subjective International Knee Documentation Committee and Lysholm scores. Arthroscopic findings before HTO and radiographic assessment of the metaphyseal deformity of the proximal tibia (tibial bone varus angle) were correlated with clinical outcome. RESULTS A significant continuous increase in International Knee Documentation Committee score from 47.25 ± 18.71 points before surgery to 72.72 ± 17.15 points at 36 months after HTO was found (P < .001). Grade of cartilage damage of the medial compartment and partial-thickness defects of the lateral compartment did not significantly influence clinical outcome (P > .05 at all time points). The tibial bone varus angle was correlated significantly with greater improvement and better clinical outcome after HTO (P < .01). The overall complication rate of 8.6% was mostly related to surgical causes; nevertheless, a high proportion of patients reported discomfort related to the implant at some point during the follow-up period (40.6%). CONCLUSIONS Open-wedge osteotomy by use of the TomoFix system leads to reliable 3-year results. Results do not depend on the severity of medial cartilage defects, whereas partial-thickness defects of the lateral compartment seem to be well tolerated. The prognostic relevance of patellofemoral cartilage defects remains unclear. Local irritation of the implant was observed in a significant number of patients. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Computer-navigated iliosacral screw insertion reduces malposition rate and radiation exposure.

AbstractInsertion of percutaneous iliosacral screws with fluoroscopic guidance is associated with a relatively high screw malposition rate and long radiation exposure. We asked whether radiation exposure was reduced and screw position improved in patients having percutaneous iliosacral screw insertion using computer-assisted navigation compared with patients having conventional fluoroscopic screw placement. We inserted 26 screws in 24 patients using the navigation system and 35 screws in 32 patients using the conventional fluoroscopic technique. Two subgroups were analyzed, one in which only one iliosacral screw was placed and another with additional use of an external fixator. We determined screw positions by computed tomography and compared operation time, radiation exposure, and screw position. We observed no difference in operative times. Radiation exposure was reduced for the patients and operating room personnel with computer assistance. The postoperative computed tomography scan showed better screw position and fewer malpositioned screws in the three-dimensional navigated groups. Computer navigation reduced malposition rate and radiation exposure. Level of Evidence: Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Long-term Outcomes After First-Generation Autologous Chondrocyte Implantation for Cartilage Defects of the Knee

Background: Autologous chondrocyte implantation (ACI) represents an established surgical therapy for large cartilage defects of the knee joint. Although various studies report satisfying midterm results, little is known about long-term outcomes. Purpose: To evaluate long-term clinical and magnetic resonance imaging (MRI) outcomes after ACI. Study Design: Case series; Level of evidence, 4. Methods: Between January 1997 and June 2001, a total of 86 patients were treated with ACI for isolated cartilage defects of the knee. The mean patient age at the time of surgery was 33.3 ± 10.2 years, and the mean defect size was 6.5 ± 4.0 cm2. Thirty-four defects were located on the medial femoral condyle and 13 on the lateral femoral condyle, while 6 patients were treated for cartilage defects of the trochlear groove and 17 for patellar lesions. At a mean follow-up of 10.9 ± 1.1 years, 70 patients (follow-up rate, 82%) treated for 82 full-thickness cartilage defects of the knee were available for an evaluation of knee function using standard instruments, while 59 of these patients were additionally evaluated by 1.5-T MRI to quantify the magnetic resonance observation of cartilage repair tissue (MOCART) score. Clinical function at follow-up was assessed by means of the Lysholm score, the International Knee Documentation Committee (IKDC) score, and the Knee injury and Osteoarthritis Outcome Score (KOOS). Patient activity was assessed by the Tegner score. In addition, pain on a visual analog scale (VAS) and patient satisfaction were evaluated separately. Results: At follow-up, 77% reported being “satisfied” or “very satisfied.” The mean IKDC score at follow-up was 74.0 ± 17.3. The mean Lysholm score improved from 42.0 ± 22.5 before surgery to 71.0 ± 17.4 at follow-up (P < .01). The mean pain score on the VAS decreased from 7.2 ± 1.9 preoperatively to 2.1 ± 2.1 postoperatively. The mean MOCART score was 44.9 ± 23.6. Defect-associated bone marrow edema was found in 78% of the cases. Nevertheless, no correlation between the MOCART score and clinical outcome (IKDC score) could be found (Pearson coefficient, r = 0.173). Conclusion: First-generation ACI leads to satisfying clinical results in terms of patient satisfaction, reduction of pain, and improvement in knee function. Nevertheless, full restoration of knee function cannot be achieved. Although MRI reveals lesions in the majority of the cases and the overall MOCART score seems moderate, this could not be correlated with long-term clinical outcomes.

Clinical Outcome of Autologous Chondrocyte Implantation for Failed Microfracture Treatment of Full-Thickness Cartilage Defects of the Knee Joint

Background: Although various factors have been identified that influence outcome after autologous chondrocyte implantation (ACI), the relevance of prior treatment of the cartilage defect and its effect concerning the outcome of second-line ACI have not been evaluated to a full extent. Hypothesis: Autologous chondrocyte implantation used as a second-line treatment after failed arthroscopic microfracturing is associated with a higher failure rate and inferior clinical results compared with ACI as a first-line treatment. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 28 patients with isolated cartilage defects at the knee joint were treated with ACI after microfracture as a first-line treatment had failed (failure defined as the necessity of reintervention). These patients were assigned to group A and compared with a matched-pair cohort of patients of identical age, defect size, and defect location (group B) in which ACI was used as a first-line treatment. Failure rates in both groups were assessed. Postoperative knee status was evaluated with the International Knee Documentation Committee (IKDC) score and Knee injury and Osteoarthritis Outcome Score (KOOS), and sporting activity was assessed by use of the Activity Rating Scale. Mean follow-up times were 48.0 months (range, 15.1-75.1 months) in group A and 41.4 months (range, 15.4-83.6 months) in group B. Differences between groups A and B were analyzed by Student t test. Results: Group A had significantly greater failure rates (7 of 28 patients) in comparison with group B (1 of 28 patients; P = .0241). Mean (SD) postoperative IKDC scores revealed 58.4 (22.4) points in group A with a trend toward higher score results (69.0 [19.1] points) for patients in group B (P = .0583). Significantly different results were obtained for KOOS pain and activity of daily living subscales, whereas the remaining KOOS subscales did not show significant differences. Despite the significantly higher failure rate observed in group A, those patients did not participate in fewer activities or perform physical activity less frequently or at a lower intensity. Conclusion: Autologous chondrocyte implantation after failed microfracturing appears to be associated with a significantly higher failure rate and inferior clinical outcome when compared with ACI as a first-line treatment.

Autologous Chondrocyte Implantation for Treatment of Cartilage Defects of the Knee: What Predicts the Need for Reintervention?

Background: Autologous chondrocyte implantation (ACI) is a well-established treatment option for isolated cartilage defects of the knee joint, providing satisfying outcome. However, cases of treatment failure with the need for surgical reintervention are reported; typical patient’s individual and environmental risk factors have previously not been described. Hypothesis: The need for reintervention after ACI is associated with specific preoperative detectable individual risk factors. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 413 patients following ACI (first, second, and third generation) were filtered for those who required revision surgery during their follow-up time (2-11.8 years). Factors were analyzed that might have significant effects on increased revision rate. Using preoperatively collected data, all patients were grouped according to 12 standard prognostic factors. Apart from odds ratio and Pearson χ2 test, statistical analysis of risk factors was performed with multivariate binary logistic regression models and Cox regression, the method of choice for survival time data. Results: After a follow-up of 4.4 ± 0.9 years (limited to 5 years), a total of 88 patients (21.3%) had undergone surgical revision. The time to revision surgery was 1.8 ± 1.1 years. Four prognostic factors associated with a significantly higher risk for reintervention were detected: (1) female gender (Cox survival fit: P = .033), (2) previous surgeries of the affected joint (P = .002), (3) previous bone marrow stimulation (P = .041), and (4) periosteum patch–covered ACI (P = .028). An influence of patient age, body mass index (BMI), defect number, defect size, lesion origin, lesion location, parallel treatment, or smoking on the risk for reintervention could not be observed. Conclusion: The study identifies clear facts that significantly increase the risk of revision surgery. These facts can be easily obtained preoperatively and may be taken into consideration when indicating ACI.

Monteggia fractures in adults: LONG-TERM RESULTS AND PROGNOSTIC FACTORS

The objective of this retrospective study was to correlate the Bado and Jupiter classifications with long-term results after operative treatment of Monteggia fractures in adults and to determine prognostic factors for functional outcome. Of 63 adult patients who sustained a Monteggia fracture in a ten-year period, 47 were available for follow-up after a mean time of 8.4 years (5 to 14). According to the Broberg and Morrey elbow scale, 22 patients (47%) had excellent, 12 (26%) good, nine (19%) fair and four (8%) poor results at the last follow-up. A total of 12 patients (26%) needed a second operation within 12 months of the initial operation. The mean Broberg and Morrey score was 87.2 (45 to 100) and the mean DASH score was 17.4 (0 to 70). There was a significant correlation between the two scores (p = 0.01). The following factors were found to be correlated with a poor clinical outcome: Bado type II fracture, Jupiter type IIa fracture, fracture of the radial head, coronoid fracture, and complications requiring further surgery. Bado type II Monteggia fractures, and within this group, Jupiter type IIa fractures, are frequently associated with fractures of the radial head and the coronoid process, and should be considered as negative prognostic factors for functional long-term outcome. Patients with these types of fracture should be informed about the potential risk of functional deficits and the possible need for further surgery.