Reto Babst

Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis

Objectives: The goal of this study is to evaluate the incidence of complications and the functional outcome after open reduction and internal fixation with the proximal humeral locking plate (Philos). Design: Prospective case series. Setting: Multicenter study in 8 trauma units (levels I, II, and III) with recruitment between September 12, 2002, and January 9, 2005. Patients: One hundred fifty-seven patients with 158 fractures. Intervention: Open reduction and internal fixation with a Philos plate. Main Outcome Measurements: Occurrence of postoperative complications up to 1 year and active follow-up for 1 year with radiologic assessment to observe fracture healing, alignment, reduction, avascular necrosis, and functional outcome measurements including Constant, Disabilities of the Arm, Shoulder, and Hand, and Neer scores. Results: One-year follow-up rate was 84%. The incidence of experiencing any implant-related complication was 9% and 35% for nonimplant-related complications. Primary screw perforation was the most frequent problem (14%) followed by secondary screw perforation (8%) and avascular necrosis (8%). After 1 year, a mean Constant score of 72 points (87% of the contralateral noninjured side), a mean Neer score of 76 points, and a mean Disabilities of the Arm, Shoulder, and Hand score of 16 points were achieved. Conclusions: Fixation with Philos plates preserves achieved reduction, and a good functional outcome can be expected. However, complication incidence proportions are high, particularly due to primary and secondary screw perforations into the glenohumeral joint, with an overall complication rate of 35%. More accurate length measurement and shorter screw selection should prevent primary screw perforation. Awareness of obtaining anatomic reduction of the tubercles and restoring the medial support should reduce the incidence of secondary screw perforations, even in osteopenic bone.

Locking compression plate loosening and plate breakage: a report of four cases.

The Locking Compression Plate (LCP) system offers a number of advantages in fracture fixation combining angular stability through the use of locking screws with traditional fixation techniques. This makes the implant particularly suitable for use in poor bone stock and complex joint fractures, especially in the epimetaphyseal area. However, the system is complex, requiring careful attention to biomechanical principles, and a number of potential pitfalls need to be considered. These pitfalls are illustrated in the 4 cases described herein, in which treatment was unsuccessful due to implant breakage or loosening. In each case, treatment failure could be attributed to the choice of an inappropriate plate and/or fixation technique, rather than to the features of the Locking Compression Plate system itself. Such experiences highlight the importance of detailed understanding of the biomechanical principles of plate fixation as well as careful preoperative planning for the successful use of the Locking Compression Plate system.

The PFNA Proximal Femur Nail in Treatment of Unstable Proximal Femur Fractures : 3 Cases of Postoperative Perforation of the Helical Blade Into the Hip joint

The proximal femur nail antirotation represents a new generation of intramedullary nailing devices for fixation of stable and unstable trochanteric fractures of the proximal femur. We report 3 cases of postoperative perforation of the helical blade through the femoral head into the hip joint without any signs of rotational or varus displacement of the fracture.

Treatment of supra- and intra-articular fractures of the distal humerus with the LCP Distal Humerus Plate: a 2-year follow-up

BACKGROUND The LCP Distal Humerus Plate (DHP) system represents an angular stable fixation system consisting of 2 anatomically pre-shaped orthogonal plates intended for the treatment of fractures of the distal humerus. The purpose of this retrospective study was to evaluate the clinical and radiologic outcome after a minimum follow-up of 2 years after open reduction and fixation of distal humeral fractures with this device. METHODS Twenty-two consecutive patients with distal humeral fractures were treated with the DHP system between January 2004 and June 2006. Of these, 16 could be clinically and radiologically evaluated after a mean follow-up of 30.5 months. Follow-up included anteroposterior and lateral radiographs; assessment of range of motion; pain according to a VAS; Disabilities of the Arm, Shoulder and Hand score; and Mayo Elbow Performance Score. RESULTS All fractures showed satisfactory articular reduction. One patient showed preoperative sensory ulnar neuropathy, which recovered incompletely, and two patients showed sensory ulnar neuropathy postoperatively, requiring revision surgery in one patient. Mean range of motion was as follows: flexion, 129°; extension, -16°; pronation, 82°; and supination, 71°. The mean visual analog scale score was 1 point; the mean Disabilities of the Arm, Shoulder and Hand score, 23.3 points; and the mean Mayo Elbow Performance Score, 84.7 points. CONCLUSION The DHP system represents a valuable tool to perform internal fixation of complex fractures of the distal humerus. In contrast to conventional plating, we did not observe any case of secondary fracture displacement, even in elderly patients with potentially reduced bone mass. The multiple angular stable point fixation also of small distal fragments seems to be effective in the application of this system.

Glutamine requirements in the generation of lymphokine-activated killer cells

The role of glutamine (GLN) in the generation of lymphokine-activated killer (LAK) cell activity was investigated. LAK cells were derived from healthy donors and peripheral blood mononuclear cells (PBMC) were obtained using either unseparated PMBC or DR(-) CD3(-) CD16(+) CD56(+) enriched cells. PBMC were cultured for 6 or 10 days in medium supplemented with recombinant interleukin-2 (rlL-2; 100 U/ml) in the presence of different concentrations of GLN. K562 (natural killer-NK-sensitive targets), 1301 and U-937 (NK-resistant targets) cells were used as targets in the cytotoxic assays. Furthermore, the limiting dilution (LD) culture system was applied as an alternative to the bulk cell culture system. It was found that GLN affects the lytic potential of cultured cells while the frequency of responding cells did not significantly differ between the compared cell cultures performed in the presence of different amounts of GLN. Data on cell proliferation with IL-2 stimulation showed significant differences in cultures performed in the presence or absence of GLN. The results of present investigation suggest a supportive role of GLN in the generation of LAK cells. GLN deficit affects LAK cell killing activity by limiting the number of generated effector cells while acquisition of broad-range killing capacity was not affected.

Closed reduction and minimally invasive percutaneous fixation of proximal humerus fractures using the Humerusblock.

Objective: To evaluate the results after closed reduction and percutaneous fixation of displaced fractures of the proximal humerus with the Humerusblock system. Design: Prospective case series. Setting: Level 1 trauma center. Patients and Methods: Fifty-eight consecutive patients with displaced proximal humerus fractures were followed over a mean period of 15.2 (12-28) months. Intervention: All patients were treated by closed reduction and percutaneous fixation using the Humerusblock. Main Outcome Measurements: Intra- and postoperative complications, secondary fracture displacement, rate of avascular necrosis, range of motion, pain according to a visual analogue scale, and the Constant-Murley shoulder score. Results: No intra-operative complications occurred. Implant removal was performed 6 to 8 weeks after the initial surgery. In 13 (22%) cases, secondary impaction of the humerus lead to perforation of k-wires through the articular surface requiring premature removal of the entire implant after an average time of 4.9 weeks. Five patients required revision surgery, including open reduction and fixation because of secondary fracture displacement. In five patients, k-wires loosened and backed out laterally, requiring revision surgery and retightening of the clamping screws in three cases and premature implant removal in two. Two patients showed radiologic signs of partial avascular necrosis at the final follow-up. The average range of motion of the operated shoulder was flexion 119.2 degrees, extension 33.5 degrees, internal rotation 64.2 degrees, external rotation 41.4 degrees. and abduction 107 degrees. The mean visual analogue scale pain score was 1.1 points, and the mean Constant-Murley score was 73.6 points, representing 88% of the mean Constant-Murley score of the unaffected shoulder. Conclusion: The Humerusblock system allows reliable minimally invasive fixation of selected displaced proximal humerus fractures, even in elderly patients with potentially reduced bone mass. In this study, postoperative rates of avascular necrosis were lower than that which has been reported after conservative treatment and open anatomic reduction and internal fixation. The overall unplanned re-operation rate of 40% was high, comparable with what has been reported for conventional percutaneous pinning. However, clinical outcome was good in 77% of the patients, and reduction could be held in 91% successfully, including elderly patients with potentially reduced bone mass.

LISS-Traktor Kombination des “less invasive stabilization systems” (LISS) mit dem AO-Distraktor für distale Femur- und proximale Tibiafrakturen

ZusammenfassungDie minimal-invasive Plattenosteosysthese (MIPO) mit dem LISS erfordert vor der Plattenapplikation die Reposition und Retention der Fraktur mit Repositionshilfen wie Fixateur externe, Distraktor und perkutanen Repostionszangen. In Anlehnung an die offene indirekte “biologische” Osteosynthesetechnik wurde das LISS mit einem in die LISS-Platte integrierten A0-Distraktor (LISS-Traktor) kombiniert. Dadurch wird die Reposition gegen die Platte vor einer definitiven Fixation der LISS-Platte möglich.Das LISS-Traktor-Konzept wurde bei 3 Patienten validiert und die Technik wird vorgestellt. Fehlstellungen >5° traten keine auf. Die Durchleuchtungszeit betrug 3,0 (2,1–4,5) min, die Operationszeit 125 (90–150) min. Die Modifikation der bekannten LISS-Technik mit Integration des Distraktors in die LISS-Platte zur Erleichterung der Reposition und zur temporären Retention der Fraktur hat das Potenzial, die Durchleuchtungszeit, die Operationszeit, die Rate an Fehlstellung und die Lernkurve dieser MIPO-Technik zu reduzieren.AbstractMinimally invasive plate osteosynthesis (MIPO) in conjunction with the less invasive stabilization system (LISS) first requires reduction and retention of the fracture using such aids as external fixation, distractors, and percutaneous reduction clamps before the plate can be applied. Based on the open indirect “biological” technique of osteosynthesis, the LISS was combined with an AO distractor (LISS tractor) integrated into the LISS plate. This made reduction possible against the plate before final fixation of the LISS plate.The LISS tractor concept was validated in three patients and we present the technique here. No malalignments >5° occurred. Fluoroscopy lasted 3.0 min (range: 2.1–4.5) and the operation 125 min (range: 90–150). Modification of the well-known LISS technique by integrating the distractor into the LISS plate to simplify reduction and to provide temporary retention of the fracture has the potential to reduce the fluoroscopy time, the operation time, the rate of malalignments, and the learning curve for this MIPO technique.

Minimally invasive percutaneous plating of proximal humeral shaft fractures with the Proximal Humerus Internal Locking System (PHILOS)

BACKGROUND This study evaluated our results after minimally invasive percutaneous plating of proximal humeral shaft fractures with the Proximal Humerus Internal Locking System (PHILOS, Synthes, Switzerland). MATERIALS AND METHODS Between 2005 and 2008, 15 patients with unilateral displaced proximal humeral shaft fractures were treated and followed up over a median period of 27 months (range, 12-38 months). The final follow-up included anteroposterior and lateral x-rays, range of shoulder motion, pain by visual analog scale (VAS), the Constant-Murley shoulder score, the Disabilities of Arm, Shoulder and Elbow (DASH) score, and the Short Form 36 (SF36) assessment. RESULTS No intraoperative or postoperative complications occurred. No secondary fracture displacement or radial neuropathy was observed postoperatively. One patient had open reduction and internal fixation for pseudoarthrosis 16 months after the initial surgery. At the final follow-up, the median range of motion of the operated shoulder was flexion, 145°; extension, 45°; internal rotation, 40°; external rotation, 70°; and abduction, 135°. Median results on outcome assessments were VAS pain score, 0 points; Constant-Murley score, 74 points, representing 87.5% of the median Constant-Murley score of the unaffected shoulder; DASH score, 34 points, and the SF36, 83 points. CONCLUSION Minimally invasive percutaneous plating with the PHILOS offers a valid option in the treatment of proximal humeral shaft fractures with comparable rates of nonunion and lower rates of radial neuropathy compared with open procedures. Furthermore, the results indicate that this method is associated with lower rates of wound infection and a shorter stay in the hospital for the patient.

Glutamine Peptide-Supplemented Long-Term Total Parenteral Nutrition: Effects on Intracellular and Extracellular Amino Acid Patterns, Nitrogen Economy, and Tissue Morphology in Growing Rats

Glutamine (GLN) is a nonessential amino acid that is not included in current regimens for parenteral nutrition because of its chemical instability. This study tested the hypothesis that GLN supplementation during long-term total parenteral nutrition (TPN) (3 weeks) would enhance GLN availability, thereby improving nitrogen economy and growth in a growing rat model: Standard TPN delivering 300 kcal/kg per day (lipid:carbohydrate = 1.1) including 2.1 g of nitrogen per kilogram per day in an all-in-one solution was compared with an isonitrogenous, isocaloric, and isovolemic TPN regimen with 0.29 g of nitrogen per kilogram per day substituted by GLN derived from the dipeptides glycyl-GLN and alanyl-GLN (TPN GLN). Enterally fed controls were included. Analysis was confined to nonbacteremic animals with negative blood culture, in which extracellular and intracellular amino acid concentrations including GLN, nitrogen balance, serum protein concentrations, growth, and histologic sections of liver and small-bowel mucosa (light and scanning electron microscopy) were evaluated. Hepatic intracellular GLN concentrations were significantly lower, in animals receiving GLN-free TPN (11.7 +/- 1.6 nmol/mg fat-free dry and solid tissue mass, n = 9) compared with both GLN-supplemented TPN (16.0 +/- 3.0, n = 7) and enteral feeding (18.2 +/- 1.8, n = 6) (p < .001). Corresponding results were found for intracellular GLN concentrations in skeletal muscle (TPN standard 12.5 +/- 3.1, TPN GLN 14.7 +/- 3.1, enteral control 17.3 +/- 2.3, p < .05), intestinal mucosa, and spleen as well as for plasma concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)

The Dorsal Tangential X-Ray View to Determine Dorsal Screw Penetration During Volar Plating of Distal Radius Fractures

PURPOSE To evaluate whether the dorsal tangential view (DTV) allows for reliable and valid in vivo measurement of the distance between screw tips and the dorsal radial cortex (STCD) during volar plating of distal radius fractures. METHODS Subjects included 22 patients with displaced distal radius fractures who had volar plate osteosynthesis. We performed standardized DTV images intraoperatively. After surgery, we performed computed tomography (CT) scans with reconstructions parallel to the distal screws. Three independent observers blinded to the study protocol measured the STCD on the basis of the DTV images and CT reconstructions. We calculated inter- and intraobserver reliability and the correlation between STCD values measured with DTV images and CT scans. RESULTS Eleven screws were changed intraoperatively. We observed no cases of postoperative screw perforations. Inter- and intraobserver reliability of STCD measurement was good when measured with DTV images and excellent when measured on the basis of CT reconstructions. Statistical analysis showed a good correlation between mean STCD values measured with DTV and CT. CONCLUSIONS The DTV allowed in vivo evaluation of the dorsal radial cortex and enabled reliable assessment of the distance between the screw tip and the dorsal cortex. It may allow detection of dorsal screw perforation during volar plating of distal radial fractures.