S. Gehrmann

Distal radius fracture management in elderly patients: a literature review.

Distal radius fracture management in elderly patients remains without consensus regarding the appropriate treatment or anticipated outcome. Forty-one studies that included at least 10 patients with a minimum mean age of 65 years and that were indexed in Medline or Embase were reviewed. Treatment methods included pins and plaster, external fixation, K-wires, bone cement, and open reduction and internal fixation with plates. The methodological quality of each study was evaluated through use of a grading scale. Despite study heterogeneity, higher rates of infection were noted with external fixation and K-wire stabilization. Stratifying patients into low-demand and high-demand groups may improve the management of distal radius fractures in elderly patients. In sedentary patients with low demands, functional outcomes are good despite the presence of deformity. Patients with higher demands may benefit from fracture stabilization with locking volar plates. Volar plating with fixed-angle screws may be particularly suitable for elderly patients who may take longer to heal a fracture, be more susceptible to pin-track infection, and demonstrate earlier tendon irritation leading to rupture.

Isolated subtalar dislocation.

BACKGROUND Little attention has been devoted to subtalar dislocations without an associated bone injury in the literature to date. The aim of this study was to assess the functional and subjective results of a cohort of patients with this injury. METHODS A total of ninety-seven patients with a subtalar dislocation were treated at two major university trauma centers from January 1994 to March 2007. Computed tomographic scans indicated a subtalar dislocation without associated bone injury in twenty-three of these patients. Clinical and radiographic examinations were performed on all twenty-three patients at an average of 58.3 months after the completion of treatment. The postoperative clinical examination was supplemented by the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, and the degree of arthritis was assessed radiographically. RESULTS The average score on the AOFAS ankle-hindfoot scale score was 82.3 points. Twenty-one patients achieved a good result, and two patients had a satisfactory result. The range of motion of the subtalar joint was an average of 41.3 degrees. No difference between the results of the medial and lateral subtalar dislocations was observed. Only six patients had minor radiographic changes. CONCLUSIONS The intermediate-term results for a subtalar dislocation without an associated osseous injury are good, and the direction of the dislocation does not appear to make a difference with regard to clinical or radiographic outcome.

Variability of Precision Pinch Movements Caused by Carpal Tunnel Syndrome

PURPOSE Carpal tunnel syndrome (CTS) impairs the performance of fine motor tasks of the hand, leading to clumsiness. Precision pinch by the thumb and index finger is a frequent task that requires the fine control of each digit as well as the coordination of the 2 digits. The purpose of this study was to examine the performance of precision pinch movements impaired by CTS. METHODS Sixteen CTS subjects and 16 gender- and age-matched control subjects were instructed to repetitively perform the precision pinch movement with the thumb and index finger. A marker-based motion analysis method was used to obtain the kinematic data of the thumb and index finger during the precision pinch movements. Pinch performance was quantified by the variability of tip positions, joint angles, and tip distance at the pinch closures in the repeated movements. RESULTS The CTS subjects performed the precision pinch movements less consistently compared with performance of the control subjects. The inconsistency was demonstrated by the increased variability of the tip positions of the 2 digits and the joint angles of the index finger. However, the variability of thumb joint angles was not significantly different between the 2 groups. The tip-to-tip distance, an indicator of thumb and index finger coordination, was relatively reproducible for both groups. Still, the CTS subjects showed a 50% greater variability of the tip distance compared with that of the control subjects. CONCLUSIONS Carpal tunnel syndrome impairs the performance of precision pinch movement as indicated by the increased variability. The results correlate with the observed clumsiness or lack of dexterity for patients with CTS.

Reconstruction of septic diaphyseal bone defects with the induced membrane technique

Septic segmental bone voids of the diaphysis are difficult to manage. The induced membrane technique by Masquelet has been successfully used to reconstruct segmental defects more than 20 cm. Our article describes a series of 13 cases with extensive posttraumatic bone loss of the metatarsal, tibial, femoral and radial bones after septic injuries followed by multiple surgical interventions. Antibiotic-impregnated polymethyl methacrylate (PMMA) cement spacers were implanted after successful eradication of bacterial infections of soft tissue and bones. After a mean of 9.8 weeks, body-induced membranes were established and the cements spacers removed. To fill up the bone void, cancellous bone autografts were implanted into the membranes. The follow-up examination after 24 months revealed bony union in all cases and favorable functional results. The induced membrane technique has shown to be effective in treating bone defects of upper and lower extremity bone defects.

Wrist Circumduction Reduced by Finger Constraints

PURPOSE Assessment of wrist motion is important in diagnosing and treating motion impairment after injuries to the wrist. Little is known of how finger posture influences the movement of the wrist. The aim of this study was to investigate the effect of finger constraints on the maximum circumduction movement of the wrist. METHODS Fifteen male right-handed subjects performed maximal circumferential wrist movements under 4 finger conditions: unconstrained fingers, holding a large cylinder (50 mm diameter), holding a small cylinder (25 mm diameter), and closed fist position. The wrist motion was captured by a surface marker-based motion analysis system. To quantify wrist motion capability, we constructed the maximal boundaries of wrist motion (circumduction envelope) from angular plots in flexion-extension (FE) and radial-ulnar deviation (RUD). The ranges of motion in FE and RUD and the envelope area were calculated. RESULTS Finger constraints significantly reduced motion ranges in flexion and ulnar deviation, but not in extension and radial deviation. In comparison to the unconstrained finger condition, the motion ranges in flexion decreased by 13%, 16%, and 27% for the large cylinder, small cylinder, and fist conditions, respectively. The range of ulnar deviation was reduced by 10% for the large and small cylinder conditions and by 11% for the fist condition. The overall mobility in FE and RUD, as quantified by the area of circumduction envelope, decreased by 15%, 15%, and 23% for the large cylinder, small cylinder, and fist conditions, respectively. CONCLUSIONS Wrist mobility is facilitated by the synergistic motion of finger joints. Constraining fingers in static flexion posture reduces wrist flexion and ulnar deviation without decreasing extension and radial deviation. A clinical implication is that wrist motion should be assessed under standardized finger joint configuration.

The dynamics of proximal femoral nails: a clinical comparison between PFNA and Targon PF.

The objective of this study comparing the proximal femoral nails Targon PF (Aesculap, Tuttlingen, Germany) and Proximal Femoral Nail Antirotation (PFNA; Synthes. Oberdorf, Switzerland) was to observe the complications and postoperative results following pertrochanteric femoral fracture fixation, with special attention devoted to the dynamic properties of both implants under physiological load in vivo. The survey was designed as a randomized, prospective study of 80 patients who had sustained a pertrochanteric femoral fracture (AO type 31.A2). Postoperative radiological and clinical examinations were conducted over a period of 12 months on 40 respective patients treated with a PFNA or a Targon PF nail. Average operative time was 66.2 minutes and average fluoroscopy time was 103.6 seconds in the PFNA group, which was significantly lower than in the Targon PF group (84.7 minutes and 164.5 seconds, respectively). No significant difference was found between the 2 groups in terms of range of motion (P=.26) or Harris Hip Score (P=.83). The femoral neck components of the Targon PF showed a significantly higher sliding ability (14.5 mm; P=.04) than the PFNA (11.1 mm).Both implants are suited to treat pertrochanteric femoral fractures and display comparable clinical results. The Targon PF demonstrates better dynamic properties than the PFNA under physiological load in vivo. A disadvantage of the Targon PF, however, is the more complicated surgical technique and the longer operative time.

The Composite of Bone Marrow Concentrate and PRP as an Alternative to Autologous Bone Grafting

One possible alternative to the application of autologous bone grafts represents the use of autologous bone marrow concentrate (BMC). The purpose of our study was to evaluate the potency of autologous platelet-rich plasma (PRP) in combination with BMC. In 32 mini-pigs a metaphyseal critical-size defect was surgically created at the proximal tibia. The animals were allocated to four treatment groups of eight animals each (1. BMC+CPG group, 2. BMC+CPG+PRP group, 3. autograft group, 4. CPG group). In the BMC+CPG group the defect was filled with autologous BMC in combination with calcium phosphate granules (CPG), whereas in the BMC+CPG+PRP group the defect was filled with the composite of autologous BMC, CPG and autologous PRP. In the autograft group the defect was filled with autologous cancellous graft, whereas in the CPG group the defect was filled with CPG solely. After 6 weeks radiological and histomorphometrical analysis showed significantly more new bone formation in the BMC+CPG+PRP group compared to the BMC+CPG group and the CPG group. There were no significant differences between the BMC+CPG+PRP group and the autograft group. In the PRP platelets were enriched significantly about 4.7-fold compared to native blood. In BMC the count of mononuclear cells increased significantly (3.5-fold) compared to the bone marrow aspirate. This study demonstrates that the composite of BMC+CPG+PRP leads to a significantly higher bone regeneration of critical-size defects at the proximal tibia in mini-pigs than the use of BMC+CPG without PRP. Furthermore, within the limits of the present study the composite BMC+CPG+PRP represents a comparable alternative to autologous bone grafting.

Venous Graft-Derived Cells Participate in Peripheral Nerve Regeneration

Background Based on growing evidence that some adult multipotent cells necessary for tissue regeneration reside in the walls of blood vessels and the clinical success of vein wrapping for functional repair of nerve damage, we hypothesized that the repair of nerves via vein wrapping is mediated by cells migrating from the implanted venous grafts into the nerve bundle. Methodology/Principal Findings To test the hypothesis, severed femoral nerves of rats were grafted with venous grafts from animals of the opposite sex. Nerve regeneration was impaired when decellularized or irradiated venous grafts were used in comparison to untreated grafts, supporting the involvement of venous graft-derived cells in peripheral nerve repair. Donor cells bearing Y chromosomes integrated into the area of the host injured nerve and participated in remyelination and nerve regeneration. The regenerated nerve exhibited proper axonal myelination, and expressed neuronal and glial cell markers. Conclusions/Significance These novel findings identify the mechanism by which vein wrapping promotes nerve regeneration.

Treatment Strategies for Intramedullary Nailing of Femoral Shaft Fractures

Intramedullary nailing has become the gold standard to treat femoral shaft fractures. It is unknown which nailing technique orthopedic surgeons prefer. The goal of this study was to determine current techniques and perioperative complications of intramedullary nailing of diaphyseal femoral fractures. Fifty-one institutions in 26 countries participated in an international survey to assess detailed descriptions of preferred operative strategies and perioperative complications. Altogether, 517 cases of diaphyseal femoral fractures were collected. The Internet-based survey incorporated information about fracture classification, time to operation, Injury Severity Score, type of nail, and operative technique, as well as perioperative complications such as infection, femoral neck fracture, and hardware failure. The preferred position for implantation was supine (91.1%). Most surgeons used a traction table (57.1%) and an antegrade implantation technique (84.5%). Intraoperative fractures of the femoral neck occurred in 1.2% of cases when a traction table was used and in 0.2% if no traction table was used, but without statistical significance (P>.16). In 59.2% of the cases, an isolated femur fracture was present, while the rest sustained multiple injuries. In polytrauma patients and patients with severe thorax injuries, most surgeons chose a delayed treatment with intramedullary femoral nails. Interestingly, 38.0% of the patients with severe thorax injuries were treated on the first day with intramedullary femoral nails. The total rate of complications for intramedullary femoral nailing was low (4.9%), but a high rate of intraoperative femoral neck fractures was observed (1.4%).

Isolated Fractures of the Capitate: Treatment of Delayed Union

Delayed and non-union of isolated fractures of the capitate are rare injuries. Initial plain radiographs do not always show the fractures. Especially fractures through the neck of the capitate can lead to delayed union. We report on a patient with persistent localised pain over the capitate 5 months after a fall on the hand. The CT examination showed a delayed union of the capitate, which was treated with an iliac cancellous bone graft and screw osteosynthesis. Bone healing was verified 3 months after operation. Operative therapy is recommended in cases of delayed union or non-union of the capitate.