Stefan G. Mattyasovszky

Mid- to long-term results after bipolar radial head arthroplasty

BACKGROUND Radial head arthroplasty is considered the treatment of choice for unreconstructable radial head fractures in the acute fracture situation. Although short-term results in the current literature are promising, replacement of the radial head remains controversial as long-term results are still missing. We report our 8.8-year results after treatment with a bipolar radial head prosthesis by Judet. MATERIALS AND METHODS In our department, 19 patients were treated with bipolar radial head arthroplasty between 1997 and 2001. Seventeen of these patients-14 men and 3 women-were examined retrospectively after 106 months (range, 78-139). Of these, 9 patients were treated primarily, 7 patients secondarily, and 1 because of a tumor. RESULTS On the Mayo Elbow Performance Score, 6 patients achieved excellent results, 10 good, and one fair. The mean DASH score was 9.8 (range, 0-34). No differences were seen between primary and secondary implantation. Flexion averaged 124° (range, 110-150°), the extension deficit was 21° (range, 0-40°), pronation 64° (range, 30-90°), and supination 64° (range, 30-90°). The following complications were seen: 2 dislocations and 8 cases of degenerative changes of the capitellum, 1 with severe erosion. Signs of ulnohumeral arthrosis were found in 12 patients. No evidence of loosening, radiolucencies, or proximal bone resorption was detected. CONCLUSION Despite major primary complications and high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judets bipolar prosthesis.

Treatment of the complex intraarticular fracture of the distal humerus with the latitude elbow prosthesis

ZusammenfassungOperationszielStabile und schmerzfreie Funktion durch primäre Implantation einer totalen Ellenbogenprothese nach intraartikulärer Trümmerfraktur des distalen Humerus bei älteren Patienten. Der künstliche Gelenkersatz kann als gekoppelte oder ungekoppelte Totalendoprothese mit oder ohne Radiuskopfersatz sowie als Hemiendoprothese verwendet werden.IndikationenIntraartikuläre Trümmerfrakturen des distalen Humerus mit schlechter Knochenqualität, die keine primäre stabile Osteosynthese zulassen. Versagen einer Osteosynthese ohne Möglichkeit einer Revisionsosteosynthese. Posttraumatische Arthrose und rheumatoide Arthritis.KontraindikationenOffene Frakturen (Typ II oder III nach Gustilo-Anderson) und infizierte Wundverhältnisse, z.B. nach fehlgeschlagener Osteosynthese, sollten nicht initial prothetisch versorgt werden. Nach Konsolidierung der Weichteilsituation kann die Prothesenimplantation in Betracht gezogen werden. Fehlende Mitarbeit des Patienten, hoher Funktionalitätsanspruch. Paralyse des Bizepsmuskels.OperationstechnikRückenlagerung. Zugang nach Bryan-Morrey. Anteriore Transposition des Nervus ulnaris. Darstellen des Trizepsansatzes an der Insertion am distalen Humerus, an der Kapsel und der proximalen Ulna. Ablösen desselben mitsamt dem Periost und der Unterarmfaszie. Versuch der Rekonstruktion der Kondylen, um eine ligamentäre Stabilität herzustellen und die Prothese ungekoppelt einbringen zu können. Wenn dies technisch nicht möglich ist, müssen die Prothesenkomponenten am Ende der Operation gekoppelt werden. Entfernung der Gelenkfragmente. Bestimmung der Prothesengröße. Ermittlung der Extensions- Flexions-Achse. Eröffnung des Markraums des Humerus. Ermittlung des Offsets. Präparation des humeralen Prothesenlagers. Einsetzen der Probeprothese. Potentiell Implantation einer Hemiendoprothese bei guten Knorpelstrukturen ulnar und radial sowie intakten Ligamenten. Anderenfalls nun Präparation des ulnaren Prothesenlagers. Falls der Radiuskopf keine Läsionen aufweist, kann er erhalten werden. Ansonsten wird er reseziert und möglichst prothetisch ersetzt. Einbringen der ulnaren und radialen Probeprothesenkomponenten. Nach korrekter Probereposition Einzementieren aller definitiven Komponenten mit Anlagerung eines Knochenspans hinter dem anterioren Flansch. Refixation des Trizeps und der Ligamente. Liegt am Ende der Operation keine ausreichende Stabilität vor, muss die Prothese mit der Ulnakappe gekoppelt werden.WeiterbehandlungAm Ende der Operation beugeseitige Gipsschiene in Streckstellung. Selbstständige Bewegungsübungen. Keine aktive Extension für 6 Wochen, Vermeidung des Hebens von Gewichten > 5 kg, keine wiederholten Dauerbelastungen > 1 kg und keine forcierten Bewegungen im Ellenbogengelenk, z.B. Schlagsportarten.ErgebnisseIn den Jahren 2007 und 2008 wurden in der Unfallchirurgischen Abteilung des Universitätsklinikums Mainz 15 Latitude- Ellenbogenprothesen bei folgenden Indikationen implantiert: Frakturen (n = 7), Pseudarthrosen (n = 4), posttraumatische Arthrosen (n = 3) und rheumatoide Arthritis (n = 1). Es wurden sechs Hemiendoprothesen, zwei ungekoppelte und sieben gekoppelte Totalendoprothesen eingebaut. Das durchschnittliche Alter der Patienten betrug 67 Jahre (31–88 Jahre). Bei der primären Frakturversorgung wurde die Indikation nur bei älteren Patienten gestellt. Das mittlere Alter betrug hier 77 Jahre (66–88 Jahre). Elf dieser 15 Patienten wurden nach durchschnittlich 13,5 Monaten (6–23 Monate) nachuntersucht. Das mittlere Extensionsdefizit lag bei 15° (0–30°), die mittlere Flexion bei 119° (95–140°). Die mittlere Pronation betrug 78° (60–90°), die mittlere Supination 79° (50–90°). Nach dem Mayo-Elbow-Performance-Score erreichten drei Patienten ein sehr gutes, sieben ein gutes und ein Patient ein befriedigendes Ergebnis. Der Mittelwert lag bei 89,2 Punkten (74–100 Punkte). Der mittlere DASHScore (Disabilities of the Arm, Shoulder and Hand) lag bei 8,4 Punkten (0–28 Punkte).AbstractObjectiveTherapy of comminuted intraarticular distal humerus fractures in elderly patients with primary total elbow arthroplasty to achieve stable and painless function. Use of “third-generation” elbow prosthesis with the following options: – linked total elbow arthroplasty, – unlinked total elbow arthroplasty, – either with or without radial head replacement, – hemiarthroplasty.IndicationsComminuted intraarticular distal humerus fractures with poor bone quality, in which stable osteosynthesis is impossible. Failure of internal fixation without the technical possibility of revision osteosynthesis. Posttraumatic osteoarthritis or rheumatoid arthritis.ContraindicationsOpen fractures (Gustilo-Anderson type II or III) or contaminated wounds should not initially be treated with total elbow arthroplasty. Prosthetic replacement may be considered after consolidation of the soft tissue. Low compliance, high functional demands. Paralysis of the biceps muscle.Surgical TechniqueSupine positioning of the patient. Surgical approach after Bryan-Morrey. Anterior transposition of the ulnar nerve. Preparation of the insertion of the triceps at the distal humerus, capsule and proximal ulna. Reflection of the triceps in continuity with the ulnar periosteum and the forearm fascia. Attempt at reconstruction of the epicondyles to achieve ligamentary stability and to implant an unlinked prosthesis. If this is technically not possible, the prosthesis is linked at the end of the operation. Removal of the distal humerus fragments. Determination of the prosthesis size. Detection of the extension-flexion axis. Opening of the humeral intramedullary canal. Determination of the offset. Preparation of the humeral prosthesis repository. Placement of the trial prosthesis. Potential implantation of a hemiprosthesis, if radial head, proximal ulna and ligaments are unaffected. Otherwise preparation of the ulnar prosthesis repository. If the radial head is unaffected, it can be preserved. Otherwise it has to be resected and preferably replaced. Placement of the ulnar and radial trial prosthesis. After correct trial reposition cementing of all definitive prosthesis components with attachment of a cortical bone graft behind the ventral flange of the humeral component. If there is no sufficient stability at the end of the operation, the prosthesis must be linked by insertion of the ulnar cap.Postoperative ManagementPostoperative anterior upper-arm splint in full extension. Active motion. No active extension for 6 weeks. Avoidance of single-event weight lifting > 5 kg, no repetitive weight lifting > 1 kg, and no forced elbow movements, e.g., racquet sports.Results15 Latitude elbow prostheses were implanted in 2007 and 2008 at the Department of Trauma Surgery of the University Hospital Mainz, Germany, due to the following indications: fractures (n = 7), pseudarthrosis (n = 4), posttraumatic osteoarthritis (n = 3), and rheumatoid arthritis (n = 1). Six hemiprostheses, two unlinked and seven linked prostheses were implanted. The mean age of patients was 67 years (31–88 years). For the treatment of acute fractures, the indication was made only in elderly patients. The mean age was 77 years (66–88 years). Eleven of these 15 patients were reexamined after 13.5 months (6–23 months). The mean extension deficit was 15° (0–30°), the mean flexion 119° (95–140°). The mean pronation was 78° (60–90°), the mean supination 79° (50–90°). According to the Mayo Elbow Performance Score, three patients achieved an excellent, seven a good, and one a fair result. The mean Mayo Score was 89.2 (74–100). The mean DASH (Disabilities of the Arm, Shoulder and Hand) Score was 8.4 (0–28).

Behandlung der komplexen intraartikulären Fraktur des distalen Humerus mittels Latitude-Ellenbogenprothese

ZusammenfassungOperationszielStabile und schmerzfreie Funktion durch primäre Implantation einer totalen Ellenbogenprothese nach intraartikulärer Trümmerfraktur des distalen Humerus bei älteren Patienten. Der künstliche Gelenkersatz kann als gekoppelte oder ungekoppelte Totalendoprothese mit oder ohne Radiuskopfersatz sowie als Hemiendoprothese verwendet werden.IndikationenIntraartikuläre Trümmerfrakturen des distalen Humerus mit schlechter Knochenqualität, die keine primäre stabile Osteosynthese zulassen. Versagen einer Osteosynthese ohne Möglichkeit einer Revisionsosteosynthese. Posttraumatische Arthrose und rheumatoide Arthritis.KontraindikationenOffene Frakturen (Typ II oder III nach Gustilo-Anderson) und infizierte Wundverhältnisse, z.B. nach fehlgeschlagener Osteosynthese, sollten nicht initial prothetisch versorgt werden. Nach Konsolidierung der Weichteilsituation kann die Prothesenimplantation in Betracht gezogen werden. Fehlende Mitarbeit des Patienten, hoher Funktionalitätsanspruch. Paralyse des Bizepsmuskels.OperationstechnikRückenlagerung. Zugang nach Bryan-Morrey. Anteriore Transposition des Nervus ulnaris. Darstellen des Trizepsansatzes an der Insertion am distalen Humerus, an der Kapsel und der proximalen Ulna. Ablösen desselben mitsamt dem Periost und der Unterarmfaszie. Versuch der Rekonstruktion der Kondylen, um eine ligamentäre Stabilität herzustellen und die Prothese ungekoppelt einbringen zu können. Wenn dies technisch nicht möglich ist, müssen die Prothesenkomponenten am Ende der Operation gekoppelt werden. Entfernung der Gelenkfragmente. Bestimmung der Prothesengröße. Ermittlung der Extensions- Flexions-Achse. Eröffnung des Markraums des Humerus. Ermittlung des Offsets. Präparation des humeralen Prothesenlagers. Einsetzen der Probeprothese. Potentiell Implantation einer Hemiendoprothese bei guten Knorpelstrukturen ulnar und radial sowie intakten Ligamenten. Anderenfalls nun Präparation des ulnaren Prothesenlagers. Falls der Radiuskopf keine Läsionen aufweist, kann er erhalten werden. Ansonsten wird er reseziert und möglichst prothetisch ersetzt. Einbringen der ulnaren und radialen Probeprothesenkomponenten. Nach korrekter Probereposition Einzementieren aller definitiven Komponenten mit Anlagerung eines Knochenspans hinter dem anterioren Flansch. Refixation des Trizeps und der Ligamente. Liegt am Ende der Operation keine ausreichende Stabilität vor, muss die Prothese mit der Ulnakappe gekoppelt werden.WeiterbehandlungAm Ende der Operation beugeseitige Gipsschiene in Streckstellung. Selbstständige Bewegungsübungen. Keine aktive Extension für 6 Wochen, Vermeidung des Hebens von Gewichten > 5 kg, keine wiederholten Dauerbelastungen > 1 kg und keine forcierten Bewegungen im Ellenbogengelenk, z.B. Schlagsportarten.ErgebnisseIn den Jahren 2007 und 2008 wurden in der Unfallchirurgischen Abteilung des Universitätsklinikums Mainz 15 Latitude- Ellenbogenprothesen bei folgenden Indikationen implantiert: Frakturen (n = 7), Pseudarthrosen (n = 4), posttraumatische Arthrosen (n = 3) und rheumatoide Arthritis (n = 1). Es wurden sechs Hemiendoprothesen, zwei ungekoppelte und sieben gekoppelte Totalendoprothesen eingebaut. Das durchschnittliche Alter der Patienten betrug 67 Jahre (31–88 Jahre). Bei der primären Frakturversorgung wurde die Indikation nur bei älteren Patienten gestellt. Das mittlere Alter betrug hier 77 Jahre (66–88 Jahre). Elf dieser 15 Patienten wurden nach durchschnittlich 13,5 Monaten (6–23 Monate) nachuntersucht. Das mittlere Extensionsdefizit lag bei 15° (0–30°), die mittlere Flexion bei 119° (95–140°). Die mittlere Pronation betrug 78° (60–90°), die mittlere Supination 79° (50–90°). Nach dem Mayo-Elbow-Performance-Score erreichten drei Patienten ein sehr gutes, sieben ein gutes und ein Patient ein befriedigendes Ergebnis. Der Mittelwert lag bei 89,2 Punkten (74–100 Punkte). Der mittlere DASHScore (Disabilities of the Arm, Shoulder and Hand) lag bei 8,4 Punkten (0–28 Punkte).AbstractObjectiveTherapy of comminuted intraarticular distal humerus fractures in elderly patients with primary total elbow arthroplasty to achieve stable and painless function. Use of “third-generation” elbow prosthesis with the following options: – linked total elbow arthroplasty, – unlinked total elbow arthroplasty, – either with or without radial head replacement, – hemiarthroplasty.IndicationsComminuted intraarticular distal humerus fractures with poor bone quality, in which stable osteosynthesis is impossible. Failure of internal fixation without the technical possibility of revision osteosynthesis. Posttraumatic osteoarthritis or rheumatoid arthritis.ContraindicationsOpen fractures (Gustilo-Anderson type II or III) or contaminated wounds should not initially be treated with total elbow arthroplasty. Prosthetic replacement may be considered after consolidation of the soft tissue. Low compliance, high functional demands. Paralysis of the biceps muscle.Surgical TechniqueSupine positioning of the patient. Surgical approach after Bryan-Morrey. Anterior transposition of the ulnar nerve. Preparation of the insertion of the triceps at the distal humerus, capsule and proximal ulna. Reflection of the triceps in continuity with the ulnar periosteum and the forearm fascia. Attempt at reconstruction of the epicondyles to achieve ligamentary stability and to implant an unlinked prosthesis. If this is technically not possible, the prosthesis is linked at the end of the operation. Removal of the distal humerus fragments. Determination of the prosthesis size. Detection of the extension-flexion axis. Opening of the humeral intramedullary canal. Determination of the offset. Preparation of the humeral prosthesis repository. Placement of the trial prosthesis. Potential implantation of a hemiprosthesis, if radial head, proximal ulna and ligaments are unaffected. Otherwise preparation of the ulnar prosthesis repository. If the radial head is unaffected, it can be preserved. Otherwise it has to be resected and preferably replaced. Placement of the ulnar and radial trial prosthesis. After correct trial reposition cementing of all definitive prosthesis components with attachment of a cortical bone graft behind the ventral flange of the humeral component. If there is no sufficient stability at the end of the operation, the prosthesis must be linked by insertion of the ulnar cap.Postoperative ManagementPostoperative anterior upper-arm splint in full extension. Active motion. No active extension for 6 weeks. Avoidance of single-event weight lifting > 5 kg, no repetitive weight lifting > 1 kg, and no forced elbow movements, e.g., racquet sports.Results15 Latitude elbow prostheses were implanted in 2007 and 2008 at the Department of Trauma Surgery of the University Hospital Mainz, Germany, due to the following indications: fractures (n = 7), pseudarthrosis (n = 4), posttraumatic osteoarthritis (n = 3), and rheumatoid arthritis (n = 1). Six hemiprostheses, two unlinked and seven linked prostheses were implanted. The mean age of patients was 67 years (31–88 years). For the treatment of acute fractures, the indication was made only in elderly patients. The mean age was 77 years (66–88 years). Eleven of these 15 patients were reexamined after 13.5 months (6–23 months). The mean extension deficit was 15° (0–30°), the mean flexion 119° (95–140°). The mean pronation was 78° (60–90°), the mean supination 79° (50–90°). According to the Mayo Elbow Performance Score, three patients achieved an excellent, seven a good, and one a fair result. The mean Mayo Score was 89.2 (74–100). The mean DASH (Disabilities of the Arm, Shoulder and Hand) Score was 8.4 (0–28).

New intramedullary locking nail for olecranon fracture fixation--an in vitro biomechanical comparison with tension band wiring.

BACKGROUND The aim of this study was to determine the difference in displacement of a newly designed intramedullary olecranon fracture fixation device compared with multifilament tension band wiring after 4 cycles and 300 cycles of dynamic continuous loading. METHODS In eight pairs of fresh-frozen cadaver ulnae, oblique olecranon fractures were created and stabilized using either newly designed intramedullary olecranon nail or multifilament tension band wiring. The specimens were then subjected to continuous dynamic loading (from 25 N to 200 N) using matched pairs of cadaveric upper extremities. The Wilcoxon test was used to determine statistical differences of the displacement in the fracture gap. RESULTS After 4 cycles and 300 cycles, the displacement in the fracture model was significantly higher in the tension band wiring group than in the intramedullary nailing group. CONCLUSIONS The newly designed interlocking nailing system showed higher stability in comparison with multifilament tension band wiring after continuous dynamic loading.

Isolated fractures of the greater tuberosity of the proximal humerus: A long-term retrospective study of 30 patients

Background and purpose The diagnosis and treatment of isolated greater tuberosity fractures of the proximal humerus is not clear-cut. We retrospectively assessed the clinical and radiographic outcome of isolated greater tuberosity fractures. Patients and methods 30 patients (mean age 58 (26–85) years, 19 women) with 30 closed isolated greater tuberosity fractures were reassessed after an average follow-up time of 3 years with DASH score and Constant score. Radiographic outcome was assessed on standard plain radiographs. Results 14 of 17 patients with undisplaced or slightly displaced fractures (≤ 5 mm) were treated nonoperatively and had good clinical outcome (mean DASH score of 13, mean Constant score of 71). 8 patients with moderately displaced fractures (6–10 mm) were either treated nonoperatively (n = 4) or operatively (n = 4), with good functional results (mean DASH score of 10, mean Constant score of 72). 5 patients with major displaced fractures (> 10 mm) were all operated with good clinical results (mean DASH score of 14, mean Constant score of 69). The most common discomfort at the follow-up was an impingement syndrome of the shoulder, which occurred in both nonoperatively treated patients (n = 3) and operatively treated patients (n = 4). Only 1 nonoperatively treated patient developed a non-union. By radiography, all other fractures healed. Interpretation We found that minor to moderately displaced greater tuberosity fractures may be treated successfully without surgery.

Inhibition of Contractile Function in Human Joint Capsule Myofibroblasts by Targeting the TGF-β1 and PDGF Pathways

Background Contractile myofibroblasts (MFs) accumulate in the joint capsules of patients suffering from posttraumatic joint stiffness. MF activation is controlled by a complex local network of growth factors and cytokines, ending in the increased production of extracellular matrix components followed by soft tissue contracture. Despite the tremendous growth of knowledge in this field, inconsistencies remain in practice and prevention. Methods and Findings In this in vitro study, we isolated and cultured alpha-smooth muscle actin (α-SMA) positive human joint capsule MFs from biopsy specimens and investigated the effect of profibrotic and antifibrotic agents on MF function. Both TGF-β1 and PDGF significantly induced proliferation and increased extracellular matrix contraction in an established 3D collagen gel contraction model. Furthermore, both growth factors induced α-SMA and collagen type I gene expression in MFs. TGF-β1 down-regulated TGF-β1 and TGF-β receptor (R) 1 and receptor (R) 2 gene expression, while PDGF selectively down-regulated TGF-β receptor 2 gene expression. These effects were blocked by suramin. Interestingly, the anti-oxidant agent superoxide dismutase (SOD) blocked TGF-β1 induced proliferation and collagen gel contraction without modulating the gene expression of α-SMA, collagen type I, TGF-β1, TGF-β R1 and TGF-β R2. Conclusions Our results provide evidence that targeting the TGF-β1 and PDGF pathways in human joint capsule MFs affects their contractile function. TGF-β1 may modulate MF function in the joint capsule not only via the receptor signalling pathway but also by regulating the production of profibrotic reactive oxygen species (ROS). In particular, anti-oxidant agents could offer promising options in developing strategies for the prevention and treatment of posttraumatic joint stiffness in humans.

Influence of the anti‐inflammatory cytokine interleukin‐4 on human joint capsule myofibroblasts

Post‐traumatic joint contracture was reported to be associated with elevated numbers of contractile myofibroblasts (MFs) in the healing capsule. During the physiological healing process, the number of MFs declines; however, in fibroconnective disorders, MFs persist. The manifold interaction of the cytokines regulating the appearance and persistence of MFs in the pathogenesis of joint contracture remains to be elucidated. The objective of our current study was to analyze the impact of the anti‐inflammatory cytokine interleukin (IL)‐4 on functional behavior of MFs. Cells were isolated from human joint capsule specimens and challenged with three different concentrations of IL‐4 with or without its neutralizing antibody. MF viability, contractile properties, and the gene expression of both alpha‐smooth muscle actin (α‐SMA) and collagen type I were examined. Immunofluorescence staining revealed the presence of IL‐4 receptor (R)‐alpha (α) on the membrane of cultured MFs. The cytokine IL‐4 promoted MF viability and enhanced MF modulated contraction of collagen gels. Moreover, IL‐4 intervened in gene expression by up‐regulation of α‐SMA and collagen type I mRNA. These effects could be specifically lowered by the neutralizing IL‐4 antibody. On the basis of our findings we conclude that the anti‐inflammatory cytokine IL‐4 specifically regulates viability and the contractile properties of MFs via up‐regulating the gene expression of α‐SMA and collagen type I. IL‐4 may be a helpful target in developing anti‐fibrotic therapeutics for post‐traumatic joint contracture in human.

Misdiagnosis of Thoracolumbar Posterior Ligamentous Complex Injuries and Use of Radiographic Parameter Correlations to Improve Detection Accuracy

Study Design Retrospective study. Purpose To evaluate radiological parameters as indicators for posterior ligamentous complex (PLC) injuries in the case of limited availability of magnetic resonance imaging. Overview of Literature Traumatic thoracolumbar spinal fractures with PLC injuries can be misdiagnosed on X-rays or computed tomography scans. This study aimed to retrospectively assess unrecognized PLC injuries and evaluate radiographic parameters as indicators of PLC injuries requiring surgery. Methods In total, 314 patients with type A and type B2 fractures who underwent surgical treatment between 2001 and 2010 were included. The frequency of misdiagnosis was reassessed, and radiographic parameters were evaluated and correlated. Results The average age of the patients was 51.8 years. There were 225 type A3/A4 and 89 type B2 fractures; 39 of the type B2 fractures (43.8%) had been misdiagnosed as type A fractures. Type B fractures presented with a significantly higher kyphotic wedge angle and Cobb angle and a lower sagittal index (SI) than type A fractures. In addition, the normalized interspinous distance was higher in type B2 fractures. The significant mathematical indicators for PLC injuries were as follows: Cobb angle+kyphotic wedge angle >29°; Cobb angle2 >170°; and vertebral angle/SI >25. Conclusions The results demonstrated that PLC injuries are frequently misdiagnosed. Correlations between certain radiological parameters associated with PLC injuries can be useful indicators of the presence of such injuries requiring surgery.

Cytokine Interferon-γ suppresses the function of capsule myofibroblasts and induces cell apoptosis

Myofibroblasts (MFs), a contractile subset of fibroblasts, play a pivotal role in physiological wound healing and in the development of many fibroconnective disorders. The complex cytokine network regulating the function of MFs in joint stiffness is still poorly understood. In this in vitro study, we investigated the effect of the cytokine Interferon‐gamma (IFN‐γ) on MFs isolated from human joint capsules. MFs were cultivated either in the presence of increasing concentrations of IFN‐γ alone or in combination with IFN‐γ neutralizing antibodies. Cell viability, cytotoxicity, apoptosis, and mRNA gene expression of the MF markers alpha‐smooth muscle actin (α‐SMA) and collagen type I were analyzed in MF cultures. Contraction potential was analyzed in an established collagen gel contraction assay simulating the extracellular matrix. Using immunofluorescence staining, we could verify that MFs express IFN‐γ‐receptor (R)‐1 on their membrane. IFN‐γ decreased MF viability and significantly elevated the apoptosis rate in a dose‐dependent manner. IFN‐γ down‐regulated α‐SMA and collagen type I mRNA expression which was associated with a diminished MF mediated contraction of the gel matrices. These effects were suppressed by simultaneous treatment of cells with a neutralizing IFN‐γ antibody. Our experiments confirm the hypothesis that the cytokine IFN‐γ is a crucial component of the regulatory network of capsule MFs. IFN‐γ notably influences the ability of MFs to contract collagen matrices by suppressing α‐SMA gene expression. IFN‐γ is toxic for MFs in high concentrations and may negatively regulate the number of pro‐fibrotic MFs during the healing process via induction of cell apoptosis.

Behandlung der komplexen intraartikulären Fraktur des distalen Humerus mittels Latitude-Ellenbogenprothese@@@Treatment of the Complex Intraarticular Fracture of the Distal Humerus with the Latitude Elbow Prosthesis

ZusammenfassungOperationszielStabile und schmerzfreie Funktion durch primäre Implantation einer totalen Ellenbogenprothese nach intraartikulärer Trümmerfraktur des distalen Humerus bei älteren Patienten. Der künstliche Gelenkersatz kann als gekoppelte oder ungekoppelte Totalendoprothese mit oder ohne Radiuskopfersatz sowie als Hemiendoprothese verwendet werden.IndikationenIntraartikuläre Trümmerfrakturen des distalen Humerus mit schlechter Knochenqualität, die keine primäre stabile Osteosynthese zulassen. Versagen einer Osteosynthese ohne Möglichkeit einer Revisionsosteosynthese. Posttraumatische Arthrose und rheumatoide Arthritis.KontraindikationenOffene Frakturen (Typ II oder III nach Gustilo-Anderson) und infizierte Wundverhältnisse, z.B. nach fehlgeschlagener Osteosynthese, sollten nicht initial prothetisch versorgt werden. Nach Konsolidierung der Weichteilsituation kann die Prothesenimplantation in Betracht gezogen werden. Fehlende Mitarbeit des Patienten, hoher Funktionalitätsanspruch. Paralyse des Bizepsmuskels.OperationstechnikRückenlagerung. Zugang nach Bryan-Morrey. Anteriore Transposition des Nervus ulnaris. Darstellen des Trizepsansatzes an der Insertion am distalen Humerus, an der Kapsel und der proximalen Ulna. Ablösen desselben mitsamt dem Periost und der Unterarmfaszie. Versuch der Rekonstruktion der Kondylen, um eine ligamentäre Stabilität herzustellen und die Prothese ungekoppelt einbringen zu können. Wenn dies technisch nicht möglich ist, müssen die Prothesenkomponenten am Ende der Operation gekoppelt werden. Entfernung der Gelenkfragmente. Bestimmung der Prothesengröße. Ermittlung der Extensions- Flexions-Achse. Eröffnung des Markraums des Humerus. Ermittlung des Offsets. Präparation des humeralen Prothesenlagers. Einsetzen der Probeprothese. Potentiell Implantation einer Hemiendoprothese bei guten Knorpelstrukturen ulnar und radial sowie intakten Ligamenten. Anderenfalls nun Präparation des ulnaren Prothesenlagers. Falls der Radiuskopf keine Läsionen aufweist, kann er erhalten werden. Ansonsten wird er reseziert und möglichst prothetisch ersetzt. Einbringen der ulnaren und radialen Probeprothesenkomponenten. Nach korrekter Probereposition Einzementieren aller definitiven Komponenten mit Anlagerung eines Knochenspans hinter dem anterioren Flansch. Refixation des Trizeps und der Ligamente. Liegt am Ende der Operation keine ausreichende Stabilität vor, muss die Prothese mit der Ulnakappe gekoppelt werden.WeiterbehandlungAm Ende der Operation beugeseitige Gipsschiene in Streckstellung. Selbstständige Bewegungsübungen. Keine aktive Extension für 6 Wochen, Vermeidung des Hebens von Gewichten > 5 kg, keine wiederholten Dauerbelastungen > 1 kg und keine forcierten Bewegungen im Ellenbogengelenk, z.B. Schlagsportarten.ErgebnisseIn den Jahren 2007 und 2008 wurden in der Unfallchirurgischen Abteilung des Universitätsklinikums Mainz 15 Latitude- Ellenbogenprothesen bei folgenden Indikationen implantiert: Frakturen (n = 7), Pseudarthrosen (n = 4), posttraumatische Arthrosen (n = 3) und rheumatoide Arthritis (n = 1). Es wurden sechs Hemiendoprothesen, zwei ungekoppelte und sieben gekoppelte Totalendoprothesen eingebaut. Das durchschnittliche Alter der Patienten betrug 67 Jahre (31–88 Jahre). Bei der primären Frakturversorgung wurde die Indikation nur bei älteren Patienten gestellt. Das mittlere Alter betrug hier 77 Jahre (66–88 Jahre). Elf dieser 15 Patienten wurden nach durchschnittlich 13,5 Monaten (6–23 Monate) nachuntersucht. Das mittlere Extensionsdefizit lag bei 15° (0–30°), die mittlere Flexion bei 119° (95–140°). Die mittlere Pronation betrug 78° (60–90°), die mittlere Supination 79° (50–90°). Nach dem Mayo-Elbow-Performance-Score erreichten drei Patienten ein sehr gutes, sieben ein gutes und ein Patient ein befriedigendes Ergebnis. Der Mittelwert lag bei 89,2 Punkten (74–100 Punkte). Der mittlere DASHScore (Disabilities of the Arm, Shoulder and Hand) lag bei 8,4 Punkten (0–28 Punkte).AbstractObjectiveTherapy of comminuted intraarticular distal humerus fractures in elderly patients with primary total elbow arthroplasty to achieve stable and painless function. Use of “third-generation” elbow prosthesis with the following options: – linked total elbow arthroplasty, – unlinked total elbow arthroplasty, – either with or without radial head replacement, – hemiarthroplasty.IndicationsComminuted intraarticular distal humerus fractures with poor bone quality, in which stable osteosynthesis is impossible. Failure of internal fixation without the technical possibility of revision osteosynthesis. Posttraumatic osteoarthritis or rheumatoid arthritis.ContraindicationsOpen fractures (Gustilo-Anderson type II or III) or contaminated wounds should not initially be treated with total elbow arthroplasty. Prosthetic replacement may be considered after consolidation of the soft tissue. Low compliance, high functional demands. Paralysis of the biceps muscle.Surgical TechniqueSupine positioning of the patient. Surgical approach after Bryan-Morrey. Anterior transposition of the ulnar nerve. Preparation of the insertion of the triceps at the distal humerus, capsule and proximal ulna. Reflection of the triceps in continuity with the ulnar periosteum and the forearm fascia. Attempt at reconstruction of the epicondyles to achieve ligamentary stability and to implant an unlinked prosthesis. If this is technically not possible, the prosthesis is linked at the end of the operation. Removal of the distal humerus fragments. Determination of the prosthesis size. Detection of the extension-flexion axis. Opening of the humeral intramedullary canal. Determination of the offset. Preparation of the humeral prosthesis repository. Placement of the trial prosthesis. Potential implantation of a hemiprosthesis, if radial head, proximal ulna and ligaments are unaffected. Otherwise preparation of the ulnar prosthesis repository. If the radial head is unaffected, it can be preserved. Otherwise it has to be resected and preferably replaced. Placement of the ulnar and radial trial prosthesis. After correct trial reposition cementing of all definitive prosthesis components with attachment of a cortical bone graft behind the ventral flange of the humeral component. If there is no sufficient stability at the end of the operation, the prosthesis must be linked by insertion of the ulnar cap.Postoperative ManagementPostoperative anterior upper-arm splint in full extension. Active motion. No active extension for 6 weeks. Avoidance of single-event weight lifting > 5 kg, no repetitive weight lifting > 1 kg, and no forced elbow movements, e.g., racquet sports.Results15 Latitude elbow prostheses were implanted in 2007 and 2008 at the Department of Trauma Surgery of the University Hospital Mainz, Germany, due to the following indications: fractures (n = 7), pseudarthrosis (n = 4), posttraumatic osteoarthritis (n = 3), and rheumatoid arthritis (n = 1). Six hemiprostheses, two unlinked and seven linked prostheses were implanted. The mean age of patients was 67 years (31–88 years). For the treatment of acute fractures, the indication was made only in elderly patients. The mean age was 77 years (66–88 years). Eleven of these 15 patients were reexamined after 13.5 months (6–23 months). The mean extension deficit was 15° (0–30°), the mean flexion 119° (95–140°). The mean pronation was 78° (60–90°), the mean supination 79° (50–90°). According to the Mayo Elbow Performance Score, three patients achieved an excellent, seven a good, and one a fair result. The mean Mayo Score was 89.2 (74–100). The mean DASH (Disabilities of the Arm, Shoulder and Hand) Score was 8.4 (0–28).