P.A. Grützner

Torsionswinkelbestimmung nach Schaftfrakturen der unteren Extremität – klinische Relevanz und Meßmethoden

Summary. In the treatment of femoral and tibial fractures the frontal and sagittal planes are controlled and documented by conventional X-ray films. Computed tomography permits exact measurement of the coronal plane. Between June 1993 and December 1997, 161 computed tomographic measurements of femoral torsion and 55 of tibial torsion after shaft fracture were carried out. The results were analyzed in a clinical study. A CT examination was carried out if the clinical examination aroused suspicion of a difference in torsion. 28.5 % of the patients examined with femoral fractures and 23.8 % of those with tibial fractures had torsion differences of more than 20 °. Between June 1993 and June 1997, 30 corrective derotating osteotomies of the femur and 9 of the tibia were carried out.The average preoperative difference of torsion of the femur was 29 ° and of the tibia 25 °. After the operation the average femur difference was 7 ° and of the lower leg 6.5 °, which are inside normal physiological limits. The osteotomies were carried out in the metaphysis near the fracture. Additional corrections in other planes were necessary on the femur in 27 % and on the lower leg in 46 %. With the aim of avoiding torsion differences, or at least to recognize them at an early stage, CT measurements of torsion after osteosythetic treatment of fresh unilateral femur-shaft fractures were carried out in 49 patients between October 1996 and December 1997. The torsion measurements during the operations had to be carried out clinically. No sufficiently exact method of measurement is available in the operating room. Three patients with increased differences of 28 °, 26 ° or 19 ° had their osteosyntheses corrected. The measurements after correction were inside the normal spread.Zusammenfassung. Die Achsstellung nach Versorgung von Ober- und Unterschenkelfrakturen in der Frontal- und Sagittalebene wird im konventionellen Röntgenbild kontrolliert und dokumentiert. In der Horizontalebene ist eine genaue Bestimmung nur mit der Computertomographie möglich. In einer klinischen Studie wurden zwischen Juni 1993 und Dezember 1997 200 computertomographische Torsionsmessungen am Ober- und 80 am Unterschenkel nach Schaftfrakturen analysiert. Die Messungen erfolgten beim klinischen Verdacht auf das Vorliegen einer Torsionswinkeldifferenz. Am Oberschenkel wurden in 28,5 %, am Unterschenkel in 23,8 % aller untersuchten Patienten Torsionsdifferenzen von mehr als 20 ° festgestellt. Zwischen Juni 1993 und Juni 1997 wurden 30 derotierende Korrekturosteotomien am Femur und 9 an der Tibia vorgenommen. Die Torsionsdifferenz betrug am Oberschenkel präoperativ durchschnittlich 29,0 ° und am Unterschenkel 25,0 °. Die postoperativen Differenzen lagen am Oberschenkel durchschnittlich bei 7 °, am Unterschenkel durchschnittlich bei 6,5 ° und damit innerhalb der physiologischen Schwankungsbreite. Die Osteotomien erfolgten jeweils in den frakturnahen Metaphysen. Zusätzliche Korrekturen in anderen Ebenen erfolgten am Femur in 27 % und am Unterschenkel in 46 %. Mit dem Ziel, Torsionsdifferenzen zu vermeiden oder zumindest frühzeitig zu erkennen, erfolgte ab Oktober 1996 bei 49 Patienten die computertomographische Torsionsmessung nach osteosynthetischer Versorgung einer frischen unilateralen Femurschaftfraktur. Die Torsionsbestimmung erfolgte intraoperativ jeweils klinisch, da im Operationssaal eine apparative Meßmethode mit hinreichender Genauigkeit nicht zur Verfügung steht. Bei 3 Patienten mit relevanten Differenzen (28 °, 26 ° und 19 °) erfolgte die Korrektur der Osteosynthese. Die Messungen nach Korrektur waren im Bereich der Normalverteilung.

Quality of Reduction Influences Outcome After Locked-Plate Fixation of Proximal Humeral Type-C Fractures.

BACKGROUND The aim of this study was to determine if fracture reduction, fracture pattern, and patient-related factors influence clinical outcome after locked-plate fixation of displaced proximal humeral fractures. METHODS Ninety-eight patients (mean age, 61.1 ± 11.2 years) with a proximal humeral fracture involving the anatomical neck (type C according to the OTA/AO classification system) were included. Clinical outcome was determined by age and sex-adjusted Constant score (CS%) and the Disabilities of the Arm, Shoulder and Hand (DASH) score. Fracture reduction was quantitatively determined by 3 parameters (head-shaft displacement, head-shaft alignment, and cranialization of the greater tuberosity), and patients were divided into groups according to anatomical reduction, acceptable reduction, or malreduction. Relative risk (RR) for complications, revision surgery, and inferior clinical outcome (CS of <50%) was determined according to the quality of fracture reduction and fracture pattern (disruption of the medial hinge; type-C3 fracture) and patient-related factors (age; comorbidities). RESULTS After a mean of 3.1 ± 1.5 years, the mean CS% and DASH score were 54.8% ± 28.0% and 31.9 ± 24.8, respectively. The complication rate was 32.7% (n = 32), and 27 patients (27.6%) required revision surgery. Anatomical or acceptable fracture reduction was achieved in 40 (40.8%) of the patients. This resulted in a significantly lower complication rate (20.0% compared with 41.4% among the patients with malreduction; p = 0.027), a trend of lower revision rate (20% compared with 32.8%; p = 0.165), and better clinical outcome (mean CS% of 65.4% ± 28.2% compared with 47.6% ± 25.7%; p = 0.002) without a higher risk for osteonecrosis of the humeral head (5% compared with 10.3%). Cranialization of the greater tuberosity of >5 mm (n = 25), head-shaft displacement of >5 mm (n = 50), and valgus head-shaft alignment (n = 12) all increased the RR for inferior clinical outcome by twofold to threefold. Conversely, a patient age of >65 years (n = 31) and an OTA/AO type-C3 fracture pattern (n = 38) were not significantly associated with complications and inferior clinical outcome (RR, 0.9 to 1.8). CONCLUSIONS Anatomical fracture reduction with a locked plate significantly improved the clinical outcome of unstable and displaced proximal humeral fractures involving the anatomical neck. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Die intraoperative 3D-C-Bogen-Anwendung

Mobile C-arms with the option of 3D imaging like the Iso-C(3D) allow for intraoperative 3D visualization of anatomical areas with complex three-dimensional structures like articular surfaces. In an 8-year period we performed 1,841 intraoperative control scans following osteosynthesis. Among these patients we registered the number of intraoperative adjustments of fracture reduction and implant position in correlation to the area of surgery. The majority of intraoperative examinations in 1,841 patients was performed in fractures of the calcaneus (20.5%) and the upper ankle joint (13.2%). Altogether we improved the reduction or the implant position intraoperatively in 21.5%. The majority of intraoperative revisions was seen in osteosynthesis of the calcaneus (40.3%), the upper ankle joint (30.9%) and fractures of the distal tibia (29%). The rate of revisions over the time was very stable. Intraoperative need for revision of reduction or implant position is not a rare phenomenon in our experience. Intraoperative 3D imaging is a valid tool to recognize and adjust suboptimal reduction or implant positioning. Intraoperative 3D imaging can improve the quality of osteosynthesis especially in fractures of joints and complex anatomical areas.

Postoperative Torsionsdifferenz nach unaufgebohrter antegrader Marknagelosteosynthese des Femurs: eine retrospektive 5-Jahres-Analyse

BACKGROUND Minimally invasive treatment of diaphyseal femur fractures (DFF) with closed reduction and intramedullary nailing is a well established procedure. However, a femoral malrotation after intramedullary nailing is considered to be a substantial problem. Studies have described femoral malrotation (FMR) in 17-35 % after this procedure. Computed tomography (CT) of both femora is accepted as an objective, reproducible measurement method to determine a postoperative femoral malrotation. An anatomic reposition of the centreline of the femur remains of high importance since a malrotation > 15° can lead to a significant limitation of the range of motion (ROM) and to clinical symptomatic constraints. PATIENTS/MATERIAL AND METHODS Between July 2007 and December 2011 patients with unilateral DFF were treated with closed reduction and intramedullary nailing. Exclusion criteria were defined as bilateral or prior treatment for femoral fractures, open epihyseal plate or pregnancy. In all cases a postoperative CT scan of the femora was conducted to analyse a femoral malrotation. The indication for a correction was posed in cases of a malrotation > 15°. The data were not randomised and evaluated retrospectively. RESULTS AND CONCLUSION In total 94 patients with unilateral DFF were included. 21 female and 73 male with an average age of 33.15 ± 14.04 years (range 14-94). In the postoperative CT scan an average FMR of 11.58 ± 9.41° (range 0-44°) was determined. In 15 cases (15.95 %), 10 male (13.7 %) and 5 female (23.81 %) a FMR > 15° (average: 23.66 ± 5.74°) was noticed. A subsequent surgery with a correction in average of 17.53 ± 6.83° was performed. After the correction the malrotation averaged 6.07 ± 5.61°. The results support the existing data that the treatment of DFF with closed reduction and intramedullary nailing may lead to a significant femoral malrotation despite a precise intraoperative monitoring. The data demonstrate that nearly 15 % of all patients appear after closed reduction and intramedullary nailing with a femoral malrotation greater than 15°. A routinely utilised postoperative CT scan provides additional information to discover an occult malrotation. CONCLUSION In spite of diligent attendance to the femoral torsion intraoperatively in DFF a significant femoral malrotation may result after closed reduction and intramedullary nailing. To prevent a limitation of ROM and clinical constraints a routinely performed postoperative CT scan with a adequate surgical correction is recommended.

Bestimmung des Femur-Antetorsionswinkels mit einem fluoroskopiebasierten optoelektronischen Navigationssystem

According to the literature, differences in torsion of 15 degrees and more develop in 20-30% of cases after intramedullary nailing of femoral shaft fractures. A computer-assisted method makes it possible to determine the antetorsion angle during surgery. In this experimental study, the precision of the measurements obtained with the navigation system were checked with a femur model and compared with a CT reference method. The measurements are carried out on a femur model that is equipped with a rotation device in the middle of the shaft. Nine reproducible angles can be set. Two investigators each conduct the measurements of the antetorsion angle ten times. A comparison is drawn between the absolute values of the antetorsion angle measured and the difference values of the adjoining positions. When comparing the absolute values of the navigation and reference systems, the mean deviations of both methods are around 1 degrees (0.35; 1.75) and comparing the differences 0.5 degrees (-0.2; 1.17). The maximum deviation of the absolute values of the CT reference method amounts to 6.4 degrees . Under experimental conditions, measurement of the femoral antetorsion angle proved to be sufficiently precise for clinical specifications in comparison to a CT reference method.

Hüftendoprothese bei Koxarthrose nach Azetabulumfrakturen

AIM this study analyzed factors influencing prosthetic hip function after total hip replacement surgery (THR) including the initial acetabular fracture type, patient age, and the acetabular reconstruction component. MATERIAL AND METHOD a total of 45 patients with secondary arthritis due to acetabular fracture and THR were prospectively selected from our total hip arthroplasty register between July 1999 and December 2005. The initial acetabular fracture was classified according to the AO system and the statistical analysis of the preoperative and postoperative Harris hip score (HHS) was correlated with age, type of fracture and acetabular reconstruction component. RESULTS of the fractures 44 could be classified and 39 patients were included in the study. Median follow-up period was 15 months. HHS increased on average from 35 to 91. Only type C fractures showed statistical relevance and age had no influence on the median increase in HHS (53-55). Most important was the preoperative HHS and the restoration of proper hip anatomy and rotational alignment. CONCLUSION patient age and injury severity influenced the preoperative function and hence the HHS after THR; however, these factors had no influence on the individual increase in the HHS.

Total hip replacement for coxarthrosis following acetabular fracture. Significance of age and injury severity

AIM this study analyzed factors influencing prosthetic hip function after total hip replacement surgery (THR) including the initial acetabular fracture type, patient age, and the acetabular reconstruction component. MATERIAL AND METHOD a total of 45 patients with secondary arthritis due to acetabular fracture and THR were prospectively selected from our total hip arthroplasty register between July 1999 and December 2005. The initial acetabular fracture was classified according to the AO system and the statistical analysis of the preoperative and postoperative Harris hip score (HHS) was correlated with age, type of fracture and acetabular reconstruction component. RESULTS of the fractures 44 could be classified and 39 patients were included in the study. Median follow-up period was 15 months. HHS increased on average from 35 to 91. Only type C fractures showed statistical relevance and age had no influence on the median increase in HHS (53-55). Most important was the preoperative HHS and the restoration of proper hip anatomy and rotational alignment. CONCLUSION patient age and injury severity influenced the preoperative function and hence the HHS after THR; however, these factors had no influence on the individual increase in the HHS.

[Postoperative implant-associated osteomyelitis of the shoulder: Hardware-retaining revision concept using temporary drainage].

BACKGROUND Posttraumatic and postoperative osteomyelitis (PPO) is a subgroup of bone infections with increasing importance. However, to date no standardized reoperation concept exists particularly for patients with PPO of the shoulder region. Therefore the purpose of this study was to evaluate a revision concept including débridement, irrigation, and insertion of temporary drainage with hardware retention until healing. PATIENTS AND METHODS A total of 31 patients with PPO were included with a proximal humerus fracture (n = 14), clavicle fracture (n = 10), or AC-joint separation (n = 7). In all, 27 of these patients could be followed for > 1 year. RESULTS Hardware retention until fracture or ligament healing could be achieved in > 83%. Six patients required follow-up débridement due to recurrent infections, but then were unremarkable. Clinical outcome showed excellent Constant scores (91.6 ± 2.8). CONCLUSION A cost-efficient, simple, and successful revision concept for patients with PPO of the shoulder region is described.

Verletzungen der subaxialen Halswirbelsäule

ZusammenfassungKlassifikationZur subaxialen Halswirbelsäule wird der Abschnitt ab dem Bandscheibenraum C2/C3 bis in den zervikothorakalen Übergang (C7/Th1) gerechnet. Grund für die Unterteilung in Verletzungen der subaxialen HWS und solche der oberen HWS ist der einheitliche anatomische Aufbau unterhalb von C2 mit hieraus gleich wirkenden biomechanischen Grundprinzipien für die einzelnen Bewegungssegmente. Entsprechend ergibt sich eine für alle Verletzungen unterhalb von C2 ähnlich anzuwendende Therapieoption.TherapieIm Gegensatz zu den Verletzungen der oberen HWS steht bei der Behandlung von traumatischen subaxialen Instabilitäten ein primär ventrales Vorgehen im Vordergrund. Dies gilt auch für die Reposition von Subluxationen oder Luxationsverletzungen. Nach einem ventral fusionierenden Eingriff ist ein kombiniertes ventrodorsales Vorgehen erforderlich, wenn eine höhergradige posteriore Instabilität verbleibt.AbstractClassificationInjuries of the cervical spine can be categorized into subaxial injuries and injuries of the upper cervical spine. The subaxial section extends from segments C2/C3 to segments C7/Th1 distally. The reason for this subclassification into upper cervical spine injuries and subaxial injuries is the uniform anatomical morphology from C2 down to Th1. The comparable anatomy of these segments is also reflected in the comparable biomechanics of these segments leading to similar therapeutic options.TherapyIn contrast to the upper cervical spine, the therapeutic management of the subaxial spine is characterized primarily by ventral procedures. Traumatic instabilities and subluxations or luxations can usually be approached ventrally. In cases of persisting instabilities or relevant posterior instabilities a combination of ventral and dorsal approaches can be necessary.

Hohe knöcherne Ausheilungsraten nach kopferhaltender Revision von proximalen Humeruspseudarthrosen

BACKGROUND Fractures of the subcapital and proximal humerus shaft region are common fractures of the human skeleton. Their treatment should provide an early functional after-care of the shoulder joint, that is prone to arthrofibrosis. Although the upper extremity is not weight-bearing the occurrence of proximal humerus non-unions leads to severe impairment with inability to work and restrictions of activity of daily life. The aim of this study was to investigate whether an operative revision of proximal humerus non-unions with reosteosynthesis and application of distant autologous bone grafts can lead to sufficient bone healing. The second aim was to find out whether patients achieved an acceptable functional outcome, as alternatively patients could be treated by reconstruction with a shoulder prosthesis. PATIENTS AND METHODS 27 patients (female = 15, male = 12) with reosteosynthesis of the proximal humerus and proximal humeral shaft due to non-union after initially operative fracture treatment were included between 2008 and 2014. Average age of patients was 56 years (23-87), 48% had no comorbidities, while 52% of the patients had at least 1 comorbidity such as diabetes, hypertension or nicotine abusus. The mean number of prior surgical intervention was 1.2 (1-3). The mean time between initial surgery and re-osteosynthesis was 12.3 months. Patients with signs of infection pseudarthrosis were excluded. The initial type of osteosynthesis was with plates (n = 16; thereof PHILOS Plate n = 14), and intramedullary nails (T2, Targon Nail, PHN, Seidel Nail; n = 11). Revision surgery was done with plate osteosynthesis (n = 26; thereof PHILOS Plate n = 4; LC Plate n = 10; angle plate n = 12). In 23 patients (89%) a distant bone transplantation was done from the iliac crest, and 1 patient received allogenous bone. Three patients (11%) received bone morphogenetic protein 7 (BMP 7) in combination with distant bone graft. Intraoperative swabs from the pseudarthrosis area showed no bacterial pathogen after 14 days of incubation. DASH score and Constant score were used to evaluate the functional outcome after revision surgery. Bone healing was determined by standard X-rays and evaluated by a modified radiological score. RESULTS 89% of the patients could be followed for an average of 28 months and the radiological follow-up was at 9 months. The radiological score showed very good (50%), or good results, and a sufficient bone healing was shown in 25 of 27 patients (93%). The pseudarthrosis revision surgery failed in two cases (n = 1 persisting non-union; n = 1 humeral head necrosis after re-operation with angle plate). DASH scores provided a mean of 40 ± 28.8 with a range from 0-97 points, and the results from the Constant score provided 45 ± 25.4. The analysis with variation of age showed a trend for better results in female patients < 60 years of age. As complications after bone graft 3 patients had persistent local dysesthesia (11%), in one case fracture of the iliac bone occurred that healed with conservative treatment. CONCLUSION The pseudarthrosis revision surgery with humeral head preserving re-osteosynthesis with bone transplantation is an effective treatment for non-unions of the proximal humerus and the proximal humeral shaft and the current results showed high bone consolidation rates. As the functional results remained limited after revision an individual treatment decision should be made concerning the most appropriate therapy. While a shoulder prosthesis may be considered in the aged patient, a revision strategy with reosteosynthesis should be considered particularly in younger patients.