S. Studier-Fischer

Endoprothesenversorgung nach Radiusköpfchentrümmerfrakturen

BACKGROUND For many years, resection was the only therapy used for comminuted fractures of the radial head. When associated with an injury of the collateral ligament, the outcome was often unsatisfactory. Implantation of the modern radial head prosthesis promises a better outcome. METHODS Between June 2001 and January 2005, 30 patients were treated with a modular metallic radial head arthroplasty; 28 patients were available for follow-up. Their mean age was 49 years. The patients were followed for an average of 29 months. The outcomes were assessed on the basis of pain, motion, radiographic findings, and grip strength as measured with the Jamar Dynamometer. The overall outcome was rated using a pain visual analog scale, and the scoring systems described by Radin and Riseborough and by Broberg and Morrey. RESULTS 19 patients achieved excellent or good results, 8 had fair results, and 1 had a poor result as based on the Morrey score. 22 patients showed periprosthetic osteolysis on radiologic examination. CONCLUSION Arthroplasty with a modular metallic radial head combined with ligament reconstruction is an effective alternative to radial head resection. Compared with resection, the results using the EVOLVE prosthesis demonstrate definite advantages with regard to clinical outcome.

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.

Treatment of nonunions in fractures of the humeral shaft according to the Diamond Concept

METHODS Between 2005 and 2012, 50 patients (23 female, 27 male) with nonunion of the humeral shaft were included in this retrospective study. The mean age was 51.3 years (14 to 88). The patients had a mean of 1.5 prior operations (sd 1.2;1 to 8). All patients were assessed according to a specific risk score in order to devise an optimal and individual therapy plan consistent with the Diamond Concept. In 32 cases (64%), a change in the osteosynthesis to an angular stable locking compression plate was performed. According to the individual risk an additional bone graft and/or bone morphogenetic protein-7 (BMP-7) were applied. RESULTS A successful consolidation of the nonunion was observed in 37 cases (80.4%) with a median healing time of six months (IQR 6). Younger patients showed significantly better consolidation. Four patients were lost to follow-up. Revision was necessary in a total of eight (16%) cases. In the initial treatment, intramedullary nailing was most common. DISCUSSION The use of locking compression plates in combination with autologous cancellous bone graft has been shown to be a safe and effective treatment. In more complex cases, the use of the Masquelet technique and BMP-7 may be indicated at the first revision operation. TAKE HOME MESSAGE Our results suggest the Diamond Concept is a successful treatment strategy for nonunions of the humeral shaft.

[Prosthesis after comminuted radial head fractures : midterm results].

BACKGROUND For many years, resection was the only therapy used for comminuted fractures of the radial head. When associated with an injury of the collateral ligament, the outcome was often unsatisfactory. Implantation of the modern radial head prosthesis promises a better outcome. METHODS Between June 2001 and January 2005, 30 patients were treated with a modular metallic radial head arthroplasty; 28 patients were available for follow-up. Their mean age was 49 years. The patients were followed for an average of 29 months. The outcomes were assessed on the basis of pain, motion, radiographic findings, and grip strength as measured with the Jamar Dynamometer. The overall outcome was rated using a pain visual analog scale, and the scoring systems described by Radin and Riseborough and by Broberg and Morrey. RESULTS 19 patients achieved excellent or good results, 8 had fair results, and 1 had a poor result as based on the Morrey score. 22 patients showed periprosthetic osteolysis on radiologic examination. CONCLUSION Arthroplasty with a modular metallic radial head combined with ligament reconstruction is an effective alternative to radial head resection. Compared with resection, the results using the EVOLVE prosthesis demonstrate definite advantages with regard to clinical outcome.

Radiusköpfchenfraktur und Ellenbogenluxation

ZusammenfassungRadiusköpfchenfrakturen können isoliert oder als Begleitverletzung bei komplexen Verletzungsmustern des Ellenbogens auftreten; 10% der Ellenbogenluxationen sind mit einer Radiusköpfchenfraktur assoziiert. In der Diagnostik muss auf Begleitverletzungen geachtet werden, da sie das Therapieregime beeinflussen. Die Einteilung erfolgt nach Mason. Typ-1-Frakturen werden konservativ-frühfunktionell, Typ-2-Frakturen in der Regel mittels Schraubenosteosynthese versorgt. Die operative Rekonstruktion bei Mason-3-Frakturen ist schwierig und chirurgisch anspruchsvoll; hier muss, wie auch bei Typ-4-Frakturen, in der Regel das Radiusköpfchen reseziert werden. Liegt danach eine Gelenkinstabilität vor, ist die Implantation einer Radiusköpfchenprothese indiziert. Abhängig von der Schwere und Komplexität der Verletzung muss mit einem Funktionsverlust gerechnet werden. Neuere Studien zeigen gute Resultate nach Rekonstruktionen auch komplexerer Frakturen; häufig verbleibt ein funktionell unbedeutendes Streckdefizit. Auch die Resektion führt überwiegend zu guten bis akzeptablen funktionellen Ergebnisse. Obwohl Langzeitergebnisse bei den neueren modularen Radiusköpfchenprothesen noch ausstehen, wird in der Mehrzahl von guter Funktion bei niedrigen Lockerungsraten berichtet.AbstractFractures of the radial head can occur isolated or in association with injuries to the elbow (10% of elbow dislocations being combined with fractures of the radial head). Attention to associated injuries is essential during the diagnostic investigations, as they influence the management significantly. These fractures are classified according to the system proposed by Mason. Mason type 1 fractures are managed with conservative and functional treatment. Mason type 2 fractures are treated surgically, normally by internal fixation with screws. The treatment of Mason type 3 or 4 fractures usually involves excision of the radial head. When instability persists after this, implantation of a prosthesis is recommended. Depending on the severity and complexity of the injury, some loss of function must be expected. Recent studies have recorded good results following reconstruction of the radial head, even in the case of comminuted fractures; any deficit remaining is often functionally insignificant. The excision of the radial head also results in good to acceptable outcomes. Although long-term results with the modular prosthesis are still lacking, in the majority of the studies so far good functional results with low rates of loosening have been observed.

Outcome of Radial Head Arthroplasty in Comminuted Radial Head Fractures: Short and Midterm Results

Background: Comminuted radial head fractures are often associated with secondary injuries and elbow instability. Objectives: The aim of this retrospective study was to evaluate how well the modular metallic radial head implant EVOLVE® prosthesis restores functional range of motion (ROM) and stability of the elbow in acute care. Patients and Methods: Eighty-five patients with comminuted radial head fractures and associated injuries received treatment with an EVOLVE® prosthesis between May 2001 and November 2009. Seventy-five patients were available for follow-up. On average, patients were followed for 41.5 months (33.0: 4.0 - 93.0). Outcome assessment was done on the basis of pain, ROM, strength, radiographic findings, and functional rating scores such as Broberg and Morrey, the Mayo elbow performance index (MEPI), and disabilities of the arm, shoulder and hand (DASH). Our study is currently the largest analysis of clinical outcome of a modular radial head replacement in the literature. Results: Overall, there were 2 (2.7%) Mason II fractures, 21 (28%) Mason III fractures, and 52 (69.3%) Mason IV fractures. Arbeitsgemeinschaft fur osteosynthesefragen (AO) classification was also determined. Of the 85 patients in our study, 75 were available for follow-up. Follow-up averaged 41.5 months (range, 4 - 93 months). Average scores for the cohort were as follows: Morrey, 85.7 (median 90.2; range 44.4 - 100); MEPI, 83.3 (85.0; 40.0 - 100); and DASH 26.1 points (22.5; 0.0 - 75.8). Mean flexion/extension in the affected joint was 125.7°/16.5°/0° in comparison to the noninjured side 138.5°/0°/1.2°. Mean pronation/supination was 70.5°/0°/67.1° in comparison to the noninjured side 83.6°/0°/84.3°. Handgrip strength of the injured compared to the non-injured arm was 78.8%. The following complications were also documented: 58 patients had periprosthetic radioluceny shown to be neither clinically significant nor relevant according to evaluated scores; 26 patients had moderate or severe periarticular ossification, and scored substantially worse according to MEPI and Morrey. Four patients required revisional surgery due to loosening of the prosthesis and chronic pain. In addition, one patient required a neurolysis of the ulnaris nerve, one developed a neobursa, and one had extensive swelling and blistering. The time interval between injury and treatment appeared to have an effect on results. Thirty-five patients were treated within the first 5 days after accident and showed better results than the 40 patients who were treated after 5 days. Conclusions: Comminuted radial head fractures with elbow instability can be treated well with a modular radial head prosthesis, which restores stability in acute treatment. The modular radial head arthroplasty used in this study showed promising findings in short to midterm results.

Outcome of Early and Late Diagnosed Essex-Lopresti Injury.

Background: The aim of this study was to investigate the outcomes in a large series of Essex-Lopresti injuries (ELIs) and to compare patients with early and late diagnoses. Methods: Thirty-one patients with an ELI (average age and standard deviation [SD], 46 ± 10 years) who were followed for a minimum of 2 years were included in the study. Patients were grouped according to whether the ELI had been diagnosed early (on the day of the injury) or late (>4 weeks after the radial head injury). Acute treatment of early-diagnosed ELI included temporary stabilization of the distal radioulnar joint (DRUJ) by Kirschner wires with the forearm in supination for 6 weeks. Clinical outcomes were assessed on the basis of the range of motion, Mayo Elbow Performance Score (MEPS), Mayo Wrist Score (MWS), visual analog scale (VAS) score for wrist and elbow pain, and Disabilities of the Arm, Shoulder and Hand (DASH) score. Results: The ELI was diagnosed on the day of the injury in 16 patients (52%; the early group) and late (at a mean of 7 ± 7 months; range, 1 to 24 months) in 15 (48%; the late group). After a mean duration of follow-up of 5.3 ± 3.0 years (range, 2.0 to 13.1 years), patients with an early diagnosed ELI had significantly better clinical outcomes, compared with those with a late diagnosis, with regard to the MEPS (91.3 ± 8.7 versus 74.7 ± 15.3, p = 0.003), MWS (81.3 ± 16.5 versus 66.3 ± 17.6, p = 0.019), DASH score (12.5 ± 8.7 versus 45.3 ± 23.5, p = 0.001), VAS elbow pain score (0.7 ± 1.1 versus 3.3 ± 2.1, p = 0.001), and VAS wrist pain score (0.9 ± 1.2 versus 3.9 ± 1.7, p < 0.001). The ranges of motion of the elbow and wrist did not differ significantly between the early and late groups (p > 0.05). A significantly lower percentage of patients had complications or subsequent surgical procedures in the early than in the late group (38% [6 of 16] versus 93% [14 of 15], p < 0.001). Conclusions: Early diagnosis of an ELI with temporary stabilization of the DRUJ leads to satisfactory clinical mid-term results, whereas late diagnosis of an ELI is associated with a deteriorated outcome. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Zusammenhangstrennung der Rotatorenmanschette

ZusammenfassungHat der Patient nach einem angeschuldigten Ereignis persistierende Beschwerden an der Schulter, ist seine Eigenanamnese zu erfragen. Befunde der Gegenseite, der Halswirbelsäule (HWS) und der angrenzenden Gelenke sind zu dokumentieren. Der Unfallhergang ist für die Begutachtung und die Bewertung elementar. Es ist zwingend festzuhalten, ob überhaupt ein Unfall vorliegt oder ob nicht eine willentliche Bewegung erfolgte. Die Richtung der einwirkenden Kraft und Hinweise auf stattgehabte Luxationen sind in jedem Fall bereits im ersten, dem so genannten Durchgangsarztbericht aufzuführen. Eine entsprechende Diagnostik ist ökonomisch einzusetzen und, falls erforderlich, zu wiederholen. 4 Wochen nach dem „Unfall“ sollten die Diagnose feststehen und nach Bedarf eine entsprechende Therapie eingeleitet werden können.AbstractIf a patient has continuous shoulder problems after an injury, the past medical history should be surveyed. Findings at other sites, the neck, and adjacent joints should be documented. Elementary for the appraisal is the mechanism of the injury itself. It is mandatory to know whether there is an injury at all or rather a voluntary motion. The direction of force and the findings of a former luxation are to be reported in the primary physician’s report. Additional tests should be initiated economically and repeated if necessary. Four weeks after the so-called accident, the diagnostics should be completed, and therapy can be started.

Bursitis olecrani@@@Olecranon bursitis: Diagnostisches und therapeutisches Vorgehen@@@Diagnostic workup and treatment

ZusammenfassungDie Bursitis olecrani ist ein häufiges Krankheitsbild, dennoch ist die Behandlung nicht trivial und wird in der Literatur uneinheitlich dargestellt. Die akute, traumatisch bedingte Bursitis olecrani beim jungen Patienten ist in der Regel harmlos und selbstlimitierend. Die eitrige Bursitis ist dagegen rezidivträchtig und komplikationsbehaftet. Die Unterscheidung zwischen der eitrigen und nicht-eitrigen Bursitis olecrani ist grundlegend für eine erfolgreiche Behandlung. Das Ziel der Arbeit ist es daher, die wesentlichen Differenzierungsmerkmale zwischen der eitrigen und der nicht-eitrigen Bursitis darzulegen und einen Therapiealgorithmus vorzustellen, der die gängigen Behandlungskonzepte der jeweiligen Formen beinhaltet.AbstractOlecranon bursitis is a common medical condition. However, treatment is sometimes challenging and the recommendations in the literature are heterogeneous. Acute, posttraumatic olecranon bursitis in the young adult is usually uncomplicated and self-limited. In contrast, the course of septic bursitis can be complicated. Differentiation between septic and aseptic types of olecranon bursitis is fundamental for successful treatment. Therefore, the aim of this review is to present the main characteristics of septic and aseptic olecranon bursitis and to propose a treatment algorithm, which contains the currently accepted treatment recommendations.

[The challenge of auditing by medical health insurance inspectors: development of individual case inspections according to 275ff SGB V].

BACKGROUND The German DRG (diagnosis-related groups) system has changed since the inauguration in 2005, whereby written inquiries and on-site auditing have been carried out by the medical inspection service for health insurance companies (MDK). Modifications in the G-DRG system are reflected in changes in the MDK visitations. This article describes exactly how these examinations have changed over time. In order to achieve this all auditing reports were evaluated. RESULTS In the beginning correct coding and documentation were the most interesting items for the health insurance fund inspectors. Nowadays, length of in-patient treatment and specific points relating to current changes in the G-DRG system are being questioned. All areas of the hospital have now been examined during this period. There was no change in the loss resulting from the regular examinations over the years. However, the effort and input of manpower are extremely high. CONCLUSIONS To cope with the changes in the German DRG system hospitals have to be flexible. The experiences with the regular MDK visitations can positively influence hospital organizational structures.