Steffen Rosslenbroich

Minimally Invasive Acromioclavicular Joint Reconstruction (MINAR)

ZusammenfassungOperationszielReposition und Retention einer akromioklavikulären Luxation mit einer Kippanker/Fadenkordel-Cerclage (Flip tack, Fa. Karl Storz, Tuttlingen).IndikationenAkute, höhergradige Luxationen des Akromioklavikulargelenks (AC-Gelenk) vom Typ III und V nach Rockwood.Chronische Instabilitäten des AC-Gelenks in Kombination mit einem Bandersatz.Laterale Klavikulafraktur mit Ruptur der akromioklavikulären Bänder.KontraindikationenAllgemeine Kontraindikationen gegen chirurgische Eingriffe.Lokale Weichteilinfektion.Geringgradige AC-Gelenk-Verletzungen vom Typ Rockwood I und II.Schaftfraktur der Klavikula.Chronische Instabilitäten ohne Bandersatz.OperationstechnikÜber einen ca. 3 cm langen Hautschnitt wird der Processus coracoideus so weit dargestellt, dass mit Hilfe eines speziellen Zielgeräts ein Loch für die Passage des Kippankers gebohrt werden kann. Die Fadenkordel wird mit zwei Kippankern armiert. Anschließend wird ein Kippanker mit einem speziellen Applikationsgerät durch den Processus coracoideus gestoßen und auf diese Weise die Fadenkordel fixiert. Der andere Fadenanker wird durch ein weiteres Bohrloch in der Klavikula gezogen. Über diesem Anker wird die Kordel nach Reposition der AC-Gelenk-Luxation verknotet.Weiterbehandlung4 Wochen Lagerung auf einem Abduktionskissen (15°).Ergebnisse23 Patienten mit einer bis zu 2 Wochen alten Luxation des AC-Gelenks wurden minimalinvasiv mit einer korakoklavikulären Kippankercerclage behandelt, davon fünf Patienten mit Typ-III- und 18 Patienten mit Typ-V-Verletzung nach Rockwood. Die Operationszeit betrug durchschnittlich 28,6 min. Peri- oder postoperative Komplikationen traten nicht auf. Nach 23,3 Monaten (18–28 Monate) betrug der Constant-Score durchschnittlich 94,1 Punkte (73–100 Punkte). In zwei Fällen fand sich ein Repositionsverlust von etwa einer halben Schaftbreite der Klavikula im Vergleich zur Gegenseite.AbstractObjectiveReduction and retention of an acromioclavicular (AC) joint dislocation with a button/suture augmentation cerclage (Flip tack, Karl Storz, Tuttlingen, Germany).IndicationsDislocation of the AC joint (Rockwood III and V).Chronic instabilities in combination with autogenous replacement of the coracoclavicular ligaments.Lateral clavicular fracture with rupture of the coracoclavicular ligaments.ContraindicationsPatients in poor general condition.Local soft-tissue infection.Low-degree dislocation of AC joint (Rockwood I und II).Fracture of the clavicular shaft.Chronic instabilities without ligament replacement.Surgical TechniqueThe coracoid process is exposed by a 3 cm long skin incision. A hole is drilled through the coracoid process with the help of a specific aiming device. The suture cerclage is connected to two buttons. One of the buttons is then pushed through the coracoid process. The button is flipped and the suture thereby fixed to the coracoid process. The other anchor is pulled through a hole in the clavicle and the cerclage is secured with a surgical knot after reduction of the AC joint.Postoperative ManagementApplication of an abduction splint for 4 weeks (15°).Results23 patients with an acute luxation of the AC joint were operated with a minimally invasive coracoclavicular cerclage (five patients with Rockwood type III and 18 patients with Rockwood type V). Mean operative time was 28.6 min. Perior postoperative complications such as nerve and vascular injuries, thoracic injuries, infection, thrombosis, and embolism did not occur. The mean Constant Score was 94.1 points (73–100 points) after a mean of 23.3 months (18–28 months). In two cases, a slight loss of reposition of less than half of the clavicle width in comparison with the contralateral side was observed.

Minimalinvasive Akromioklavikulargelenkrekonstruktion (MINAR)

ZusammenfassungOperationszielReposition und Retention einer akromioklavikulären Luxation mit einer Kippanker/Fadenkordel-Cerclage (Flip tack, Fa. Karl Storz, Tuttlingen).IndikationenAkute, höhergradige Luxationen des Akromioklavikulargelenks (AC-Gelenk) vom Typ III und V nach Rockwood.Chronische Instabilitäten des AC-Gelenks in Kombination mit einem Bandersatz.Laterale Klavikulafraktur mit Ruptur der akromioklavikulären Bänder.KontraindikationenAllgemeine Kontraindikationen gegen chirurgische Eingriffe.Lokale Weichteilinfektion.Geringgradige AC-Gelenk-Verletzungen vom Typ Rockwood I und II.Schaftfraktur der Klavikula.Chronische Instabilitäten ohne Bandersatz.OperationstechnikÜber einen ca. 3 cm langen Hautschnitt wird der Processus coracoideus so weit dargestellt, dass mit Hilfe eines speziellen Zielgeräts ein Loch für die Passage des Kippankers gebohrt werden kann. Die Fadenkordel wird mit zwei Kippankern armiert. Anschließend wird ein Kippanker mit einem speziellen Applikationsgerät durch den Processus coracoideus gestoßen und auf diese Weise die Fadenkordel fixiert. Der andere Fadenanker wird durch ein weiteres Bohrloch in der Klavikula gezogen. Über diesem Anker wird die Kordel nach Reposition der AC-Gelenk-Luxation verknotet.Weiterbehandlung4 Wochen Lagerung auf einem Abduktionskissen (15°).Ergebnisse23 Patienten mit einer bis zu 2 Wochen alten Luxation des AC-Gelenks wurden minimalinvasiv mit einer korakoklavikulären Kippankercerclage behandelt, davon fünf Patienten mit Typ-III- und 18 Patienten mit Typ-V-Verletzung nach Rockwood. Die Operationszeit betrug durchschnittlich 28,6 min. Peri- oder postoperative Komplikationen traten nicht auf. Nach 23,3 Monaten (18–28 Monate) betrug der Constant-Score durchschnittlich 94,1 Punkte (73–100 Punkte). In zwei Fällen fand sich ein Repositionsverlust von etwa einer halben Schaftbreite der Klavikula im Vergleich zur Gegenseite.AbstractObjectiveReduction and retention of an acromioclavicular (AC) joint dislocation with a button/suture augmentation cerclage (Flip tack, Karl Storz, Tuttlingen, Germany).IndicationsDislocation of the AC joint (Rockwood III and V).Chronic instabilities in combination with autogenous replacement of the coracoclavicular ligaments.Lateral clavicular fracture with rupture of the coracoclavicular ligaments.ContraindicationsPatients in poor general condition.Local soft-tissue infection.Low-degree dislocation of AC joint (Rockwood I und II).Fracture of the clavicular shaft.Chronic instabilities without ligament replacement.Surgical TechniqueThe coracoid process is exposed by a 3 cm long skin incision. A hole is drilled through the coracoid process with the help of a specific aiming device. The suture cerclage is connected to two buttons. One of the buttons is then pushed through the coracoid process. The button is flipped and the suture thereby fixed to the coracoid process. The other anchor is pulled through a hole in the clavicle and the cerclage is secured with a surgical knot after reduction of the AC joint.Postoperative ManagementApplication of an abduction splint for 4 weeks (15°).Results23 patients with an acute luxation of the AC joint were operated with a minimally invasive coracoclavicular cerclage (five patients with Rockwood type III and 18 patients with Rockwood type V). Mean operative time was 28.6 min. Perior postoperative complications such as nerve and vascular injuries, thoracic injuries, infection, thrombosis, and embolism did not occur. The mean Constant Score was 94.1 points (73–100 points) after a mean of 23.3 months (18–28 months). In two cases, a slight loss of reposition of less than half of the clavicle width in comparison with the contralateral side was observed.

Minimally Invasive Coracoclavicular Ligament Reconstruction With a Flip-Button Technique (MINAR) Clinical and Radiological Midterm Results

Background: Acromioclavicular (AC) joint dislocation is a frequent injury in sports. Hypothesis: A minimally invasive flip-button technique, MINAR (minimally invasive acromioclavicular joint reconstruction), will achieve good clinical and radiographic results in the surgical treatment of high-grade AC joint dislocations. Study Design: Case series; Level of evidence, 4. Methods: In this study, 96 patients with AC joint dislocation grades III through V and minimally invasive flip-button repair were identified. Radiographic assessment was performed by use of the Alexander view and by anteroposterior stress radiograph. Clinical outcomes were assessed with the Constant and Taft scores. Factors that influenced outcomes, such as age, time from trauma to surgery, and degree of dislocation, were evaluated. Results: Of the 96 patients, 83 (86.4%; 3 women and 80 men) were able to participate in clinical and radiographic follow-up. The average age of the participants was 39 years (range, 17-80 years). At a mean follow-up of 39 months (range, 12-78 months), clinical assessment revealed excellent results with a mean Constant score of 94.7 (range, 61-100). Clinical and radiological assessment using the Taft score also showed excellent results, with a mean score of 10.8 (range, 3-12). The mean time period from trauma to surgery was 6 days (range, 0-22 days), and mean duration of surgery was 48 minutes (range, 24-98 minutes). Nine patients (10.8%) underwent revision surgery due to recurrent dislocation (n = 8) or wound infection (n = 1). Radiological assessment showed that 18 patients had sustained a loss of reduction defined as subluxation of 50% of the clavicle shaft width in the vertical plane. However, there was no significant correlation (P = .254) with clinical outcome. Patient age was a relevant factor influencing outcome, as significantly higher outcome values were detected for younger patients (P = .024). No significant influence was shown for the time period from trauma to surgery (P = .336) or degree of dislocation after trauma (P = .987). Conclusion: The MINAR technique is a safe procedure and achieves good to excellent clinical and radiographic results in the surgical treatment of high-grade AC joint dislocations. Despite the simplicity of this technique, the surgeon has to overcome the learning curve to minimize the risk of recurrent dislocation.

Screw augmentation reduces motion at the bone-implant interface: a biomechanical study of locking plate fixation of proximal humeral fractures

BACKGROUND Shear forces at the bone-implant interface lead to a loss of reduction after locking plate fixation of proximal humeral fractures. The aim of the study was to analyze the roles of medial support screws and screw augmentation in failure loads and motion at the bone-implant interface after locking plate fixation of proximal humeral fractures. METHODS Unstable 3-part fractures were simulated in 6 pairs of cadaveric humeri and were fixed with a DiPhos-H locking plate (Lima Corporate, Udine, Italy). An additional medial support screw was implanted in 1 humerus of every donor. The opposite humerus was stabilized with a medial support screw and additional bone cement augmentation of the 2 anteriorly directed head screws. Specimens were loaded in the varus bending position. Stiffness, failure loads, plate bending, and the motion at the bone-implant interface were evaluated using an optical motion capture system. RESULTS The mean load to failure was 669 N (standard deviation [SD], 117 N) after fixation with medial support screws alone and 706 N (SD, 153 N) after additional head screw augmentation (P = .646). The initial stiffness was 453 N/mm (SD, 4.16 N/mm) and 461 N/mm (SD, 64.3 N/mm), respectively (P = .594). Plate bending did not differ between the 2 groups. However, motion at the bone-implant interface was significantly reduced after head screw augmentation (P < .05). CONCLUSION The addition of bone cement to augment anteriorly directed head screws does not increase stiffness and failure loads but reduces motion at the bone-implant interface. Thus, the risk of secondary dislocation of the head fragment may be reduced.

Gentamicin-coated Tibia Nails: Can We Afford NOT to Use Them?

The operative treatment of fractures has made enormous progress over the last decades. Nevertheless, fracture treatment remains a challenge for surgeons, and in particular, the more complicated fractures still harbor the potential for complications that cannot be underestimated. To improve prophylaxis against bacterial colonization of the implant surface, local delivery of antibacterial substances is an effective and promising option. In recent years, a fully resorbable coating for intramedullary nails was developed for the delivery of active substances such as antibiotics to the implantation site. This coating leads to antibiotic concentrations well above the minimal inhibitory concentration of the most commonly encountered bacterial strains in the immediate surroundings of the implant. On the basis of promising data from animal studies, an intramedullary tibial nail with antibiotic coating was developed and approved for clinical use in European countries. The first such implant (UTN PROtect) was released in 2005 and subsequently investigated in a prospective case series, where it proved to be an useful tool in the treatment of tibial fractures in patients presenting a higher risk of developing implant-related infections. Since 2011, a tibial nail of the latest generation design with the same coating is available (Expert Tibial Nail PROtect) and is being used on a broader scale.

Antibiotic Coated Nails

Local delivery of antibacterial substances is an effective and promising option to prevent infection. A dissolving dip-coating for implants for fracture repair was developed. The aminoglycoside Gentamicin showed promising potential. This coating leads to antibiotic concentrations lying well above the minimal inhibitory concentration of the most commonly encountered bacterial strains in the immediate surroundings of the implant. This coating has been tested in multiple pre-clinical studies in rats and rabbits. In 2005, an intramedullary tibia nail with antibiotic coating was developed for human use and proved to be a useful tool in the treatment of tibia fractures in patients with a higher risk of developing implant-related infections. Since 2011, a tibia nail of the latest generation with the same coating is available. The use of a Gentamicin coated tibia nail could reduce the risk of deep infections and prevent long-term external fixation.