Sven-Oliver Dietz

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.

Fractures of the distal humerus in the elderly. Pros and cons of endoprosthetic replacement

The intraarticular fracture of the distal humerus in an elderly patient remains a challenge for trauma surgeons. In case of severe co-morbidities and/or osteoporosis stable fixation with screws and plates is difficult and in some cases can be impossible. Even if osteosynthesis is feasible the clinical outcome is still incalculable due to delayed or non-union of the fracture fragments. Endoprosthetic replacement of the elbow joint for comminuted distal humerus fractures has been used for almost 20 years. The clinical results are predominantly excellent or good and better predictable than those of osteosynthesis. There still is no guideline when a prosthesis for the elbow joint should be used. We reviewed the literature and outline the current recommendations for diagnostics and surgical therapy for distal humerus fractures in the elderly.

Frakturen des Ellenbogengelenkes

Fractures around the elbow joint comprise fractures of the distal humerus, the radial head, the olecranon and the coronoid process. Combined lesions are particularly demanding for the surgeon. Accurate knowledge of the anatomy and of the biomechanics is an essential requirement for a specific diagnosis and therapy. A stable and painless movable elbow joint is essential for most of the activities of daily living. Risk factors for the development of posttraumatic elbow joint arthrosis are non-anatomically reconstructed joint surfaces, axial malalignment of the joint axis and untreated concomitant injuries. Modern angular stable and anatomically preshaped implants facilitate a biomechanically adequate osteosynthesis and avoid or decrease functional impairment. In consideration of an increasing number of osteoporotic elbow joint fractures, endoprosthetic replacement has gained significance.ZusammenfassungZu den Frakturen des Ellenbogengelenkes zählen die Frakturen des distalen Humerus, des Olekranons, des Radiuskopfes und des Processus coronoideus. Insbesondere Kombinationsverletzungen stellen eine Herausforderung für den Operateur dar. Die genaue Kenntnis der Gelenkanatomie und der Biomechanik sind eine entscheidende Voraussetzung für eine gezielte Diagnostik und Therapie. Ein stabiles und schmerzfrei zu bewegendes Ellenbogengelenk ist essenziell für die meisten Alltagstätigkeiten. Risikofaktoren für die Entwicklung einer posttraumatischen Ellenbogengelenkarthrose sind nichtanatomisch rekonstruierte und ausgeheilte Gelenkflächen, Achsfehlstellungen und unbehandelte Begleitverletzungen. Moderne winkelstabile, anatomisch vorgeformte Implantate erleichtern eine biomechanisch adäquate Frakturstabilisierung und helfen, Funktionseinschränkungen des Ellenbogengelenkes zu verringern. In Anbetracht der steigenden Zahl an osteoporotischen Ellenbogengelenkfrakturen hat auch die endoprothetische Versorgung einen zunehmenden Stellenwert erlangt.AbstractFractures around the elbow joint comprise fractures of the distal humerus, the radial head, the olecranon and the coronoid process. Combined lesions are particularly demanding for the surgeon. Accurate knowledge of the anatomy and of the biomechanics is an essential requirement for a specific diagnosis and therapy. A stable and painless movable elbow joint is essential for most of the activities of daily living. Risk factors for the development of posttraumatic elbow joint arthrosis are non-anatomically reconstructed joint surfaces, axial malalignment of the joint axis and untreated concomitant injuries. Modern angular stable and anatomically preshaped implants facilitate a biomechanically adequate osteosynthesis and avoid or decrease functional impairment. In consideration of an increasing number of osteoporotic elbow joint fractures, endoprosthetic replacement has gained significance.

Distale Humerusfraktur beim älteren Menschen

The intraarticular fracture of the distal humerus in an elderly patient remains a challenge for trauma surgeons. In case of severe co-morbidities and/or osteoporosis stable fixation with screws and plates is difficult and in some cases can be impossible. Even if osteosynthesis is feasible the clinical outcome is still incalculable due to delayed or non-union of the fracture fragments. Endoprosthetic replacement of the elbow joint for comminuted distal humerus fractures has been used for almost 20 years. The clinical results are predominantly excellent or good and better predictable than those of osteosynthesis. There still is no guideline when a prosthesis for the elbow joint should be used. We reviewed the literature and outline the current recommendations for diagnostics and surgical therapy for distal humerus fractures in the elderly.

Long-term outcome after operative treatment of traumatic patellar dislocation in adolescents.

Objectives: Retrospective evaluation of the long-term outcomes after surgical treatment of traumatic patellar dislocations in adolescents and identification of possible predictive factors of poor outcomes. Design: Retrospective clinical study. Setting: University Clinic, Level I Trauma Center. Patients: All 33 adolescents, with a mean age of 14.8 years, who were treated surgically after traumatic patellar dislocation between 1994 and 2006, were involved in this study. Intervention: Mini-open medial reefing and arthroscopic lateral release. Main Outcome Measurements: The clinical outcome was evaluated with the visual analogue scale, the Lysholm score, the Kujala score, and the Tegner activity level scale. On preoperative radiographs and magnetic resonance imaging scans, trochlear dysplasia and patella alta were assessed. The variables analyzed were sex, associated osteochondral injuries, the number of redislocations before surgery, and the number of redislocations after surgery. Results: At the mean follow-up of 9.8 years, the mean Lysholm score was 82.6, the mean Kujala score was 84.4, the mean Tegner activity level was 4.8, and the mean visual analogue scale was 0.2. We found no significant differences in the subgroups regarding functional outcomes. Fifteen patients with patella alta and 4 patients with trochlear dysplasia were assessed radiologically. Redislocations after surgery were observed in 4 patients, 2 of them were female patients who exhibited quadriceps angles requiring tibial tubercle osteotomy to be performed after maturation. Conclusions: The techniques of mini-open medial reefing and lateral release demonstrate a good functional long-term outcome and effectively prevent recurrent instability. The major predictive factor for poor outcomes and redislocations is an inadequately addressed pathology. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Retrograde nailing versus locking plate osteosynthesis of proximal humeral fractures: a biomechanical study

BACKGROUND In locking plate osteosynthesis of proximal humeral fractures, secondary varus malalignment is a specific complication. Retron nails (Tantum AG, Neumunster, Germany), among others, have been designed to improve medial support of the calcar humeri. The aim of our biomechanical study was to examine whether Retron nails provide increased stiffness for axial loads and adequate stiffness for torsional loads when compared with Philos plates (Synthes AG, Umkirch, Germany). MATERIALS AND METHODS Twenty-two fresh-frozen paired humeri were collected. After potting the specimens, intact bones were exposed to sinusoidal axial (10-120 N) and torsional (±2.5 Nm) loading for 8 cycles to calculate the initial stiffness and exclude pairs with differences. Afterward, an unstable proximal humeral fracture (AO 11-A3) was created by means of an oscillating saw, and the respective osteosynthesis devices were implanted. After another 4 cycles, initial changes in stiffness were measured. Subsequently, all specimens were tested for 1,000 cycles of loading before final stiffness was assessed. RESULTS We found no statistically significant differences between Retron and Philos specimens after 4 or 1,000 cycles of loading. CONCLUSION Our study suggests that retrograde nailing provides sufficient stability for axial and torsional loading in 2-part fractures of proximal humeri.

Transosseous repair of patellar tendon ruptures

ZusammenfassungOperationszielWiederherstellung der aktiven Streckung und Belastungsfähigkeit des Beins.Vorbeugung einer sekundären Patella alta.IndikationenAkute Patellarsehnenruptur innerhalb von 3–5 Tagen.Chronische Patellarsehnenruptur.KontraindikationenVitale Gefährdung des Patienten durch Grunderkrankungen oder Begleitverletzungen.Schlechte lokale Weichteilverhältnisse.OperationstechnikDarstellung der Ruptur und Anlegen eines queren Bohrkanals im unteren Patellardrittel und an der Tuberositas tibiae. Korrekte Höheneinstellung der Patella. Patellotibiale Fixierung mit 1,25-mm-Cerclagedraht (monofil), Labitzke-Draht (geflochten) oder PDS-Kordel, alternativ transossäre Naht ohne Drahtsicherung. Adaptierende Naht der Sehne und Naht des medialen und lateralen Retinakulums. Überprüfung der Festigkeit. Schichtweiser Wundverschluss über Redon-Drainagen.WeiterbehandlungVollbelastung mit Oberschenkeltutorschiene.Woche 0–2: Flexion maximal 30°, isometrisches Quadrizepstraining.Woche 2–4: Flexion maximal 60°, Beübung der Abduktoren und Hüftextensoren.Woche 4–6: Flexion maximal 90°.Ab Woche 6: Abnahme der Tutorschiene, gezieltes Muskelaufbautraining; bei transossärer Naht ohne Drahtsicherung Freigabe der Bewegungsausmaße; mit Drahtsicherung weiterhin Beschränkung auf 90° Flexion.Ab Woche 12: Volle Belastung im Alltag und beim Sport.Nach 12 Wochen ggf. Entfernung des Cerclagedrahts.ErgebnisseDie Auswertung der Literatur ergibt eine niedrige Rerupturrate, selten Bewegungseinschränkungen und selten Kraftminderungen im Vergleich zur Gegenseite.AbstractObjectiveRestoration of active knee extension.Restoration of active knee stabilization.Avoiding secondary patella alta.IndicationsAcute rupture of the patellar tendon within 3–5 days.Chronic rupture of the patellar tendon.ContraindicationsCompromised general health status or associated injuries.Compromised local soft-tissue situation.Surgical TechniqueExposure of the ruptured tendon. Coronal drill hole through the distal third of the patella and coronal drill hole through the tibial tuberosity. After anatomic positioning of the patella (adjusting correct height), patellotibial fixation with monofil or woven (Labitzke) cerclage wire or PDS cord.Suture repair of the patellar tendon and repair of the ruptured medial and lateral retinaculum. Drain insertion. Wound closure in layers.Postoperative ManagementFull load bearing in cylinder cast.Week 0–2: flexion restricted to 30°, quadriceps muscle isometry.Week 2–4: flexion restricted to 60°, strengthening of hip abductors and extensors.Week 4–6: flexion restricted to 90°.After week 6: removal of cylinder cast.After week 12: return to sporting activities, removal of the cerclage wire.ResultsGood results after surgical therapy.Low rate of secondary rupture.Low rate of muscle weakness.OBJECTIVE Restoration of active knee extension. Restoration of active knee stabilization. Avoiding secondary patella alta. INDICATIONS Acute rupture of the patellar tendon within 3-5 days. Chronic rupture of the patellar tendon. CONTRAINDICATIONS Compromised general health status or associated injuries. Compromised local soft-tissue situation. SURGICAL TECHNIQUE Exposure of the ruptured tendon. Coronal drill hole through the distal third of the patella and coronal drill hole through the tibial tuberosity. After anatomic positioning of the patella (adjusting correct height), patellotibial fixation with monofil or woven (Labitzke) cerclage wire or PDS cord. Suture repair of the patellar tendon and repair of the ruptured medial and lateral retinaculum. Drain insertion. Wound closure in layers. POSTOPERATIVE MANAGEMENT Full load bearing in cylinder cast. Week 0-2: flexion restricted to 30 degrees , quadriceps muscle isometry. Week 2-4: flexion restricted to 60 degrees , strengthening of hip abductors and extensors. Week 4-6: flexion restricted to 90 degrees . After week 6: removal of cylinder cast. After week 12: return to sporting activities, removal of the cerclage wire. RESULTS Good results after surgical therapy. Low rate of secondary rupture. Low rate of muscle weakness.

The role of intramedullary nailing in treatment of open fractures

The management of open fractures remains one of the greatest challenges to orthopedic trauma surgeons. Damage to the soft tissue envelope together with periosteal stripping are the most important factors making open fractures prone to complications such as nonunion and infection. Urgent and thorough soft tissue debridement, proper surgical fracture stabilization as well as the administration of intravenous and local antibiotics as adjunctive therapy are mandatory to reduce the risk of infection. Intramedullary nail osteosynthesis has become an accepted treatment method of open long bone fractures. Especially at sites of sparse soft tissue coverage like the proximal and distal tibia, early intramedullary stabilization proved advantageous for its superior biomechanical stability, the chance of early soft tissue reconstruction, shorter healing times, and quicker rehabilitation. However, due to a potential risk of deep infection, especially when a reamed technique is applied, nailing of open fractures remains contentious. In this review, we focus on the current evidence of nail osteosynthesis in open fractures and delineate its value with respect to other possible treatment options.

Haemorrhage in fragility fractures of the pelvis.

IntroductionFragility fractures of the pelvis (FFP) are one of the most visible and debilitating consequences of osteoporosis. In contrast to pelvic ring fractures of the young, fragility fractures are caused by falls from a standing height or even by repetitive physiological loads. Even though haemorrhage is rarely found in fragility fractures of the pelvis, one must be aware of the potential risk.Materials and methodsIn a computer literature search, we identified eight papers about patients with haemorrhage and/or haemodynamic instability as a complication of a low-velocity pelvic ring fracture, all of which were case reports.ConclusionIn our review, an overview of the case reports is provided, risk factors identified and a recommendation for the treatment and clinical observation given.

Transossäre Naht der Patellarsehnenruptur

ZusammenfassungOperationszielWiederherstellung der aktiven Streckung und Belastungsfähigkeit des Beins.Vorbeugung einer sekundären Patella alta.IndikationenAkute Patellarsehnenruptur innerhalb von 3–5 Tagen.Chronische Patellarsehnenruptur.KontraindikationenVitale Gefährdung des Patienten durch Grunderkrankungen oder Begleitverletzungen.Schlechte lokale Weichteilverhältnisse.OperationstechnikDarstellung der Ruptur und Anlegen eines queren Bohrkanals im unteren Patellardrittel und an der Tuberositas tibiae. Korrekte Höheneinstellung der Patella. Patellotibiale Fixierung mit 1,25-mm-Cerclagedraht (monofil), Labitzke-Draht (geflochten) oder PDS-Kordel, alternativ transossäre Naht ohne Drahtsicherung. Adaptierende Naht der Sehne und Naht des medialen und lateralen Retinakulums. Überprüfung der Festigkeit. Schichtweiser Wundverschluss über Redon-Drainagen.WeiterbehandlungVollbelastung mit Oberschenkeltutorschiene.Woche 0–2: Flexion maximal 30°, isometrisches Quadrizepstraining.Woche 2–4: Flexion maximal 60°, Beübung der Abduktoren und Hüftextensoren.Woche 4–6: Flexion maximal 90°.Ab Woche 6: Abnahme der Tutorschiene, gezieltes Muskelaufbautraining; bei transossärer Naht ohne Drahtsicherung Freigabe der Bewegungsausmaße; mit Drahtsicherung weiterhin Beschränkung auf 90° Flexion.Ab Woche 12: Volle Belastung im Alltag und beim Sport.Nach 12 Wochen ggf. Entfernung des Cerclagedrahts.ErgebnisseDie Auswertung der Literatur ergibt eine niedrige Rerupturrate, selten Bewegungseinschränkungen und selten Kraftminderungen im Vergleich zur Gegenseite.AbstractObjectiveRestoration of active knee extension.Restoration of active knee stabilization.Avoiding secondary patella alta.IndicationsAcute rupture of the patellar tendon within 3–5 days.Chronic rupture of the patellar tendon.ContraindicationsCompromised general health status or associated injuries.Compromised local soft-tissue situation.Surgical TechniqueExposure of the ruptured tendon. Coronal drill hole through the distal third of the patella and coronal drill hole through the tibial tuberosity. After anatomic positioning of the patella (adjusting correct height), patellotibial fixation with monofil or woven (Labitzke) cerclage wire or PDS cord.Suture repair of the patellar tendon and repair of the ruptured medial and lateral retinaculum. Drain insertion. Wound closure in layers.Postoperative ManagementFull load bearing in cylinder cast.Week 0–2: flexion restricted to 30°, quadriceps muscle isometry.Week 2–4: flexion restricted to 60°, strengthening of hip abductors and extensors.Week 4–6: flexion restricted to 90°.After week 6: removal of cylinder cast.After week 12: return to sporting activities, removal of the cerclage wire.ResultsGood results after surgical therapy.Low rate of secondary rupture.Low rate of muscle weakness.OBJECTIVE Restoration of active knee extension. Restoration of active knee stabilization. Avoiding secondary patella alta. INDICATIONS Acute rupture of the patellar tendon within 3-5 days. Chronic rupture of the patellar tendon. CONTRAINDICATIONS Compromised general health status or associated injuries. Compromised local soft-tissue situation. SURGICAL TECHNIQUE Exposure of the ruptured tendon. Coronal drill hole through the distal third of the patella and coronal drill hole through the tibial tuberosity. After anatomic positioning of the patella (adjusting correct height), patellotibial fixation with monofil or woven (Labitzke) cerclage wire or PDS cord. Suture repair of the patellar tendon and repair of the ruptured medial and lateral retinaculum. Drain insertion. Wound closure in layers. POSTOPERATIVE MANAGEMENT Full load bearing in cylinder cast. Week 0-2: flexion restricted to 30 degrees , quadriceps muscle isometry. Week 2-4: flexion restricted to 60 degrees , strengthening of hip abductors and extensors. Week 4-6: flexion restricted to 90 degrees . After week 6: removal of cylinder cast. After week 12: return to sporting activities, removal of the cerclage wire. RESULTS Good results after surgical therapy. Low rate of secondary rupture. Low rate of muscle weakness.