Stefan Lederer

Minimally-invasive treatment of three- and four-part fractures of the proximal humerus in elderly patients

The surgical treatment of three- and four-part fractures of the proximal humerus in osteoporotic bone is difficult and there is no consensus as to which technique leads to the best outcome in elderly patients. Between 1998 and 2004 we treated 76 patients aged over 70 years with three- or four-part fractures by percutaneous reduction and internal fixation using the Humerusblock. A displacement of the tuberosity of > 5 mm and an angulation of > 30 degrees of the head fragment were the indications for surgery. Of the patients 50 (51 fractures) were available for follow-up after a mean of 33.8 months (5.8 to 81). The absolute, age-related and side-related Constant scores were recorded. Of the 51 fractures, 46 (90.2%) healed primarily. Re-displacement of fragments or migration of Kirschner wires was seen in five cases. Necrosis of the humeral head developed in four patients. In three patients a secondary arthroplasty had to be performed, in two because of re-displacement and in one for necrosis of the head. There was one case of deep infection which required a further operation and one of delayed healing. The mean Constant score of the patients with a three-part fracture was 61.2 points (35 to 87) which was 84.9% of the score for the non-injured arm. In four-part fractures it was 49.5 points (18 to 87) or 68.5% of the score for the non-injured arm. The Humerusblock technique can provide a comfortable and mobile shoulder in elderly patients and is a satisfactory alternative to replacement and traditional techniques of internal fixation.

Long-term investigation of nonsurgical treatment for thoracolumbar and lumbar burst fractures: an outcome analysis in sight of spinopelvic balance

The nonsurgical treatment of thoracolumbar (TLB) and lumbar burst (LB) fractures remains to be of interest, though it is not costly and avoids surgical risks. However, a subset of distinct burst fracture patterns tend to go with a suboptimal radiographic and clinical long-term outcome. Detailed fracture pattern and treatment-related results in terms of validated outcome measures are still lacking. In addition, there are controversial data on the impact of local posttraumatic kyphosis that is associated, in particular, with nonsurgical treatment. The assessment of global spinal balance following burst fractures has not been assesed, yet. Therefore, the current study intended to investigate the radiographical and clinical long-term outcome in neurologically intact patients with special focus on the impact of regional posttraumatic kyphosis, adjacent-level compensatoric mechanisms, and global spine balance on the clinical outcome. For the purpose of a homogenous sample, strong in- and exclusion criteria were applied that resulted in a final study sample of 21 patients with a mean follow-up of 9.5 years. Overall, clinical outcome evaluated by validated measures was diminished, with 62% showing a good or excellent outcome and 38% a moderate or poor outcome in terms of the Greenough Low Back Outcome Scale. Notably, vertebral comminution in terms of the load-sharing classification, posttraumatic kyphosis, and an overall decreased lumbopelvic lordosis showed a significant effect on clinical outcome. A global and segmental curve analysis of the spine T9 to S1 revealed significant alterations as compared to normals. But, the interdependence of spinopelvic parameters was not disrupted. The patients’ spinal adaptability to compensate for the posttraumatic kyphotic deformity varied in the ranges dictated by pelvic geometry, in particular the pelvic incidence. The study substantiates the concept that surgical reconstruction and maintenance of a physiologically shaped spinal curve might be the appropriate treatment in the more severely crushed TLB and LB fractures.

Restoration of Anterior Glenoid Bone Defects in Posttraumatic Recurrent Anterior Shoulder Instability Using the J-Bone Graft Shows Anatomic Graft Remodeling

Background: The J-bone graft technique has previously been reported for anatomic restoration of the bony glenoid surface in cases of posttraumatic recurrent anterior shoulder instability with significant glenoid bone loss. Purpose: To analyze the physiological remodeling process of the J-bone graft over time. Study Design: Case series; Level of evidence, 4. Methods: Thirty-one consecutive patients treated with anatomic glenoid restoration surgery using the J-bone graft for posttraumatic recurrent anterior shoulder instability with a significant bony glenoid defect were included in this study. Twenty patients received 3-dimensional computed tomography scans of the affected shoulder preoperatively, postoperatively, and at 1-year follow-up. On “en face” views of the glenoid, the change over time of the glenoid diameter, glenoid area, and glenoid defect size in relation to a best-fit circle indicating 100% was measured. Results: The average glenoid diameter increased from 81.0% preoperatively to 110.4% postoperatively (P < .001). At 1-year follow-up, the diameter had decreased significantly to 100.6% (P < .001), which is concordant to a theoretical perfect glenoid diameter of 100% (P = .73). The average glenoid surface area increased from 80.8% preoperatively to 110.0% postoperatively (P < .001). At 1-year follow-up, a decrease to 102.2% (P < .005) was measured, which again is close to a theoretical perfect glenoid surface area of 100% (P = .15). By applying the J-bone graft, the average missing surface area of the glenoid was reduced from 19.2% preoperatively to 3.9% postoperatively (P < .001). At 1-year follow-up, an average of 3.6% was calculated, indicating no statistically significant change over time (P = .90). Conclusion: Anatomic glenoid reconstructive surgery using the J-bone graft technique benefits from a physiological remodeling process, molding the bone graft closely into the original shape of an uninjured anterior glenoid rim. While parts of the graft lying inside the projected former surface area of the glenoid are preserved, the parts lying outside are resorbed over time, suggestive of strain-adapted graft remodeling.

Magnetic resonance imaging-controlled results of the pectoralis major tendon transfer for irreparable anterosuperior rotator cuff tears performed with standard and modified fixation techniques

HYPOTHESIS Irreparable ruptures of the subscapularis tendon lead to impaired function of the shoulder joint. In such cases, transfer of the pectoralis major tendon has led to encouraging results. The procedure fails periodically, typically associated with insufficient in-growth of the transferred tissue. We hypothesized that tendon harvest with chips of cancellous bone would improve the tendon-bone interface. MATERIALS AND METHODS Of 62 consecutive pectoralis tendon transfers, 54 shoulders were followed-up at an average of 35 months. In all shoulders, the transferred tendon was rerouted behind the conjoint tendon and fixed by transosseous sutures. In 29 shoulders, the tendon was harvested with a cuff of cancellous bone. In 25 shoulders, the conventional technique with sharp detachment of the tendon was used. Apart from detailed clinical examination of all shoulders, a magnetic resonance image (MRI) was available in 52 shoulders. RESULTS The overall Constant score had improved from an average of 38.8 points preoperatively to 63.4 points at follow-up. Shoulders treated with the new fixation technique scored 64.4 compared with 62.2 for the conventional fixations. The MRI showed intact tendons and muscles in 80.8% of shoulders. In 7 shoulders (13.5%), the transferred tendon was ruptured. Two of these were treated with the new fixation technique. Mean patient satisfaction score was 8.2 points. DISCUSSION A secure method of fixation that avoids secondary ruptures despite insufficiency of the transferred tendon is of great importance. Also the rerouting of the transferred tendon under the conjoined tendon is essential to imitate the natural force vector and the function of an intact subscapularis tendon. Patients in this investigation were also monitored by MRI to verify the integrity of the transferred tendon. CONCLUSION As a salvage procedure, the pectoralis major tendon transfer provides good results in most cases. Sufficient in-growth of the transferred tissue is essential for the success of the procedure. This seems to be facilitated by both methods.

In vivo analysis of atlantoaxial motion in individuals immobilized with the halo thoracic vest or Philadelphia collar.

Study Design. In vivo biomechanical comparison of the halo thoracic vest (HTV) and the Philadelphia collar (PC). Objective. To delineate the capacity of both orthoses for immobilization of the atlantoaxial complex (AAC), e.g., for their use in odontoid fracture care. Summary of Background Data. Stable odontoid fractures can be treated with external immobilization using, e.g., a PC or a HTV. Although the HTV confers higher morbidity, particularly in elderly patients, with a similar union-rate in odontoid fracture care compared with the PC, many surgeons are still prone to use the HTV instead of the PC because the former is thought to accomplish increased rigidity at the AAC. Because application of the HTV using pins is an invasive procedure, there is a lack of biomechanical in vivo data on the “real” rigidity conferred by a HTV in comparison with a PC. Methods. Twenty volunteers were subjected to flexion/extension radiographs immobilized in a modified HTV or a PC. The radiographs were performed in extreme position of flexion in sitting position and extension in standing position. The PC was fitted as usual. The 4 cortical pins of a normal clinically used HTV were replaced by 12 modified distance pins. The halo-ring was fixed to the head by tightening of the 12 pins in an alternating fashion, thus yielding a hexapod-like strong fixation between the head and the HTV. The procedure was uncomfortable but there were no adverse events from the HTV placement. Radiographs were analyzed for the segmental rotation angle of C1–C2 in sagittal plane (SRA C1–C2) and the absolute rotation angle of C2–C7 (ARA C2–C7) using the Harrison tangent method. Separation angles (rSRA C1–C2 and rARA C2–C7) were calculated from flexion/extension views. Two observers measured all angles. The means of the measurements were used for statistical analysis. The interobserver reliability was expressed by calculating intraclass correlation coefficients (ICCs). Results. Mean age of 20 volunteers was 30.9 ± 4.2 years. Calculation of the ICCs showed good to excellent interobserver reliability for all angular measurements (ICC = 0.95–0.98). Concerning restriction of subaxial sagittal plane motion, the HTV was more effective than the PC. The difference for the rARA C2–C7 between the PC (mean 20.7°) and HTV (mean 9.2°) yielded significance (P = 0.01). But, concerning restriction of flexion/extension at the AAC, there was no statistical significant difference for the rSRA C1–C2 between the PC and HTV (P = 0.3). The PC (mean 1.3°) was even superior to the HTV (mean, 3.3°) in restricting sagittal motion at C1–C2. In comparison to normal atlantoaxial motion was restricted by 88.5% with the PC and 70.8% with the HTV. In light of the results and a selected review of literature, a treatment algorithm for the elderly patient with odontoid fracture is presented. Conclusion. Under the extremes of flexion and extension bendings, the current study demonstrated that there was no significant difference in restriction of sagittal motion at C1–C2 when using the PC instead of the HTV in a group of 20 young normal adults. In light of the current biomechanical data and a selected review of literature, it is concluded that the use of a PC is sufficient for the treatment of stable odontoid fractures.

First Experiences With a New Adjustable Plate for Osteosynthesis of Scaphoid Nonunions

BACKGROUND Plate osteosynthesis of the scaphoid, as reported earlier by Ender, has lost its importance in the past few years, after Herberts introduction of the simple and successful technique of screw osteosynthesis. Only in rare cases does one encounter failed healing or instability of the fragments. Even with a vascularized bone chip, it is not always possible to achieve consolidation. Particularly in these situations, poor interfragmentary stability seems to be the reason for failed healing. METHODS Between January 2007 and August 2009, we treated 7 men and 4 women of mean age 37 years (22-53 years) by scaphoid plate osteosynthesis. All the patients had fractures of the waist of the scaphoid with established nonunion persisting for at least 6 months after the causative injury, with wrist pain, weakness, or both. All 11 patients had clinical and radiologic follow-up for at least 6 months. RESULTS All the fractures united at a median time from operation of ∼4 months. All patients reported an improvement in their symptoms and function. The mean DASH score was 28 points. CONCLUSIONS Scaphoid plate osteosynthesis should be regarded as a salvage procedure, and the indication for the procedure should be established accordingly. It is a simple procedure in terms of technique. The plate can be adjusted very well to the anatomic shape of the scaphoid, and one can achieve a high degree of stability, particularly rotational stability.

Does the choice of approach for hip hemiarthroplasty in geriatric patients significantly influence early postoperative outcomes? A randomized-controlled trial comparing the modified Smith-Petersen and Hardinge approaches.

BACKGROUND Minimally invasive surgical approaches for total hip replacement, such as the modified Smith-Petersen approach, have been reported to be advantageous over alternative techniques because of reduced soft tissue damage and improved immediate postoperative rehabilitation. This study compares the advantages of the Smith-Petersen approach against the lateral Hardinge approach for femoral neck fractures in geriatric patients. METHODS In a randomized-controlled trial, 48 patients were treated by a hemiarthroplasty of the hip using either a modified Smith-Petersen or a Hardinge approach. Age, American Society of Anesthesiologists score, body mass index, blood loss, pain, and postoperative mobilization were compared between groups to detect statistically significant differences. The same outcome measures were analyzed for significant differences between patients with or without complications in each group. RESULTS The Smith-Petersen approach yielded a statistically significant increase in postoperative pain within the first 4 days and an increase in operation time. Complications were also associated with a significantly higher intraoperative time in the same group. However, 6 months postoperatively, there were no significant differences in the Harris Hip score between groups. CONCLUSIONS Despite early postoperative differences, postoperative mobility does not seem to be greatly influenced by the choice of either an anterior modified Smith-Petersen or a lateral Hardinge approach for hip hemiarthroplasty. Operative time was significantly linked to postoperative complications. In this respect, it can be concluded that it is not be the approach itself that determines the early postoperative result, but the routine the individual surgeon has with it.

Long-Term Outcome After Pectoralis Major Transfer for Irreparable Anterosuperior Rotator Cuff Tears.

Background: Promising short-term outcomes after pectoralis major tendon transfer for the treatment of an irreparable anterosuperior rotator cuff tear have been reported. The purpose of this study was to evaluate the long-term outcome. Methods: Twenty-seven consecutive patients with irreparable anterosuperior rotator cuff tears without advanced cuff arthropathy or advanced humeral head migration were treated with a partial subcoracoid pectoralis major tendon transfer between 2004 and 2005. At an average of 10 years (range, 9 to 11 years) postoperatively, 22 patients (82%) with an average age of 62 years (range, 42 to 74 years) at the time of surgery had a long-term follow-up examination that included the pain score, strength and range-of-motion assessment, Constant score, Simple Shoulder Test (SST), as well as radiographic and ultrasonographic imaging. The long-term results were compared with the preoperative findings as well as the short-term results that were collected from a previous evaluation. Results: The adjusted Constant score increased from 54% to 87% at the short-term follow-up (p < 0.001) and remained improved at the long-term follow-up, with a mean score of 83% (p = 0.001). While the significant improvement of the pain level at the short-term follow-up was maintained at the time of final follow-up (p = 0.001), the increase in strength returned to the preoperative level (p = 0.178), and the improvement in range of motion diminished again over time despite remaining significantly improved (p = 0.029), especially with regard to internal rotation (p < 0.001). At the long-term follow-up, 77% of the patients were very satisfied with the procedure. A third of the patients had no progression of cuff arthropathy, a third had progression by 1 grade, and a third had progression by ≥2 grades. At the time of final follow-up, 1 patient (5%) had undergone revision surgery to reverse shoulder arthroplasty. Conclusions: Pectoralis major tendon transfer for the treatment of irreparable anterosuperior rotator cuff tears results in a significant clinical improvement even 10 years after surgery, especially with respect to pain and internal rotation. Despite long-term radiographic progression of cuff arthropathy, patient satisfaction remains high over time, with a low rate of salvage with reverse shoulder arthroplasty. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

How severe are initially undetected injuries to the knee accompanying a femoral shaft fracture

BACKGROUND Fractures of the femur are severe injuries that quickly attract the physicians attention. Previous reports have shown that injuries to the ipsilateral knee can occur. In most cases, such injuries were diagnosed on delay. Excluding cases in which a knee injury was apparent already at admission, we sought to investigate the number and severity of initially undetected lesions to the knee concomitant with a femoral shaft fracture and give an overview of the literature referring to these combined injuries. METHODS Charts and X-rays of patients treated for a femoral shaft fracture from January 2000 until December 2007 were reviewed. Patients, in whom any other injury of the affected limb apart from a midshaft femoral fracture was initially diagnosed, were excluded. Also patients, in whom an injury to the knee had been diagnosed at admission, were excluded. RESULTS Fifty-three patients with 55 midshaft femoral fractures were available for analysis. An injury to the knee was diagnosed in three cases (5%). There was one partial tear of the posterior cruciate ligament and two grade two lesions of the medial meniscus. All lesions were conservatively treated without any after-effects. CONCLUSION Physical examinations under anesthesia, arthroscopy and magnetic resonance imaging have shown lesser correlation among each other than one would expect. More severe injuries to the knee with femoral shaft fractures are more likely to be detected early, than minor ones. Pain about the knee communicated by the awake patient should be the indication for further apparative examination by magnetic resonance imaging or arthroscopy.

Extensor pollicis longus rupture after distal radius fracture: results of reconstruction by transposition of the extensor indicis tendon and postoperative dynamic splinting.

ZusammenfassungDie Läsion der Extensor pollicis longus Sehne ist eine der häufigsten Strecksehnenverletzungen nach einer distalen Radiusfraktur. In den Jahren 2003 –2005 haben wir bei 31 Patienten mit Funktionsausfall der EPL–Sehne eine Extensor indicis Plastik mit postoperativer dynamischer Schienenbehandlung durchgeführt. Bei 25 Patienten führte eine operativ versorgte distale Radiusfraktur (bei 23 Patienten Bohrdrahtosteosynthese, bei 2 Patienten Plattenosteosynthese) zur EPL-Ruptur. Bei 6 Patienten war eine konservativ behandelte distale Radiusfraktur ursächlich. Von unseren 25 nachuntersuchten Patienten wiesen 9 (36 %) ein sehr gutes und 15 (60 %) ein gutes Ergebnis im Geldmacher Score auf. Wir konnten in unserem Krankengut keine Rerupturen identifizieren. Bei Läsionen der Extensor pollicis-Sehne ist die Transposition der Extensor indicis-Sehne ein einfaches und komplikationsarmes Verfahren. Durch diese Ersatzplastik kann eine erhebliche Verbesserung der Extension am Daumen erzielt werden.SummaryInjury of the extensor pollicis longus tendon is one of the commonest extensor tendon injuries after distal radius fracture. In 2003–2005 we performed extensor indicis transfer in 31 patients with loss of function of the EPL tendon and postoperative dynamic splinting. In 25 patients, a distal radius fracture managed surgically led to the EPL rupture (wire internal fixation in 23 patients, plate internal fixation in 2 patients). In 6 patients, the cause was a distal radius fracture treated conservatively. Out of our 25 followed-up patients, 9 (36%) had a very good and 15 (60%) a good result in the Geldmacher score. We did not identify any re-rupture. In injuries of the extensor pollicis tendon, transposition of the extensor indicis tendon is a simple and uncomplicated procedure. Considerable improvement of thumb extension can be achieved through this substitution repair.