T. Westphal

Outcome after surgery of distal radius fractures: no differences between external fixation and ORIF

The purpose of this study was to determine the most appropriate surgical treatment from three procedures used for fractures of the distal radius. In a retrospective comparative study, 166 out of 237 patients who underwent surgery for AO/ASIF A3 or C2 distal radius fractures were evaluated. Surgical procedures were external fixation or open reduction and internal fixation with either palmar or dorsal plates. Radiological outcomes were palmar tilt, radial angle, radial length and ulnar variance. Functional outcomes were range of motion and grip strength. In addition, outcomes according to Gartland and Werley and the Disabilities of the Arm, Shoulder and Hand questionnaire were compared. Further outcome criteria were the treatment time and the number of complications. Data were analysed using an analysis of variance statistical procedure respective of the χ2-test. Open reduction and internal fixation, in particular palmar plate fixation, demonstrated the best radiological and functional results. Subjective assessment of ORIF proved better than that of external fixation as treatment time was shorter and complications were more rarely seen. However, most of the differences between groups were not significant. Although there were no significant differences between groups, our data indicates that most dorsally displaced distal radius fractures can be treated successfully by open reduction and internal fixation. Palmar plate fixation seems to have slight advantages compared to both the external fixation and dorsal plate fixation surgical procedure.

Outcome of surgically treated intraarticular calcaneus fractures—SF-36 compared with AOFAS and MFS

Background There is no consensus as to which is the best treatment for intraarticular fractures of the calcaneus. Furthermore, few studies have assessed general health after calcaneus fractures. We therefore measured the state of general health after operation of calcaneal fractures and compared these data with usual foot-scores. Patients and methods We compared the general health of 71 patients with surgically treated calcaneal fractures 2.5 years after injury, with the general health of 71 people from the standard German population (German National Health Survey, 1998) using the SF-36 form. We compared the results of the examination with results of AOFAS Ankle Hindfoot Scale and Maryland Foot Score in the treated patients. Results In patients with calcaneal fractures, there were significant limitations regarding general health in all 9 elements of the SF-36 form. Correlations between SF-36 and foot-scores were strong regarding function and pain scales, but moderate for all other scales. Interpretation Patients face significant limitations regarding general health after calcaneal fractures. The usual foot-scores measure only 2 dimensions of outcome: function and pain. To measure all dimensions of outcome, SF-36 is a better alternative.

[Quality of life after calcaneal fractures. A matched-pairs trial with a standardised German control group].

ZusammenfassungZiel der vorliegenden Studie war die Beurteilung von Einschränkungen der gesundheitsbezogenen Lebensqualität nach operativer Behandlung von Kalkaneusfrakturen und der Vergleich dieser Ergebnisse mit denen gebräuchlicher Fußscores. 55 Patienten mit einseitiger Kalkaneusfraktur und operativer Versorgung durch Plattenosteosynthese wurden 2,9 Jahre nach Unfall mit 55 Probanden der deutschen Normpopulation des Bundes-Gesundheits-Surveys 1998 bezüglich der Lebensqualität durch Befragung mit dem SF-36 verglichen (Wilcoxon-Test). Die Daten des SF-36 der Patienten wurden mit dem Kalkaneusscore nach Zwipp und der AOFAS Ankle Hindfoot Scale korreliert (Spearman-Korrelationskoeffizient). Die Patienten mit Kalkaneusfrakturen zeigten in 9 von 10 Skalen des SF-36 eine signifikante Beeinträchtigung der gesundheitsbezogenen Lebensqualität.Die Daten der untersuchten Fußscores korrelierten lediglich mit den Skalen Schmerz und Körperliche Funktion stark, in allen anderen Fällen fanden sich schwache Korrelationen.Kalkaneusfrakturen hinterlassen messbare Beeinträchtigungen der gesundheitsbezogenen Lebensqualität. Gebräuchliche Fußscores erfassen vorwiegend die Dimensionen “Körperliche Funktion” und “Schmerz”. Für eine umfassende Outcomebewertung ist die Ergänzung durch den SF-36 empfehlenswert. Internationale Vergleiche sowie Vergleiche mit der deutschen Normalbevölkerung sind möglich.AbstractThe purpose of the study was the assessment of the limitations of health related quality of life after open reduction and internal fixation (ORIF) of calcaneal fractures and the comparison of these results with those of normal foot-scores.The quality of life of 55 patients with calcaneal fractures treated by ORIF was compared 2.9 years after injury with that of 55 people from the standardised German population of the German-Health-Survey 1998 using the Short Form 36 (SF-36) (Wilcoxon test).The results of SF-36 of patients were correlated with results of the calcaneus score according to Zwipp and AOFAS Ankle Hindfoot Scale (Spearmans correlation coefficient). Health related quality of life showed significant limitations in patients with calcaneal fractures in 9 of 10 scales of the SF-36.Correlations between SF-36 and foot-scores were strong in the function and pain scale and moderate in all other scales.The quality of life of shows significant limitations after calcaneal fractures. Usual foot-scores measure only the function and pain dimension of the outcome.To measure all dimensions, application of the SF-36 can be recommended. International comparisons of results and comparison with a standardised German population is possible.

Value of a combined ossification prophylaxis with indomethacin and radiotherapy for acetabular fractures

ZusammenfassungHintergrundIn der Azetabulumchirurgie gelten heterotope Ossifikationen (HO) als eine wesentliche zugangsabhängige Komplikation. Es stellte sich die Frage, ob eine Kombinationsprophylaxe mit Indometacin und Bestrahlung der Monoprophylaxe beim dorsalen, erweiterten iliofemoralen oder kombiniertem Zugang überlegen ist.Material und Methoden24xa0Patienten mit Kombinationsprophylaxe wurden nach 24xa0Monaten retrospektiv untersucht. Anhand einer systematischen Literaturrecherche erfolgte die vergleichende Auswertung unterschiedlicher Prophylaxeregime. Eigene Ergebnisse wurden in den Vergleich integriert.ErgebnisseIm eigenen Krankengut entwickelte ein Patient eine HO. Die Literaturanalyse zeigte die niedrigsten Ossifikationsraten nach Kombinationsprophylaxe. In den untersuchten Gruppen waren die Unterschiede in den Häufigkeiten statistisch signifikant (p<0,01, χ2-Test).SchlussfolgerungAufgrund unserer und anderer publizierter Daten gibt es Hinweise dafür, dass eine Kombinationsprophylaxe anderen Regimen überlegen ist.AbstractBackgroundHeterotopic ossification is a complication in patients with surgically treated acetabular fractures. The incidence is related to the surgical approach (extended iliofemoral, posterior or a combined approach). The objective of this study was to evaluate the incidence of heterotopic ossification in patients with acetabular fractures who received a combined prophylaxis with both a single dose of radiation and indomethacin compared to those who received only a prophylaxis with radiation or indomethacin.Patients and MethodsA total of 24 patients with a combined prophylaxis after surgery were examined retrospectively 24xa0months after trauma. A systematic literature review was performed and our own results were compared with different methods for prophylaxis of heterotopic ossification from the literature.ResultsOnly one patient developed a heterotopic ossification. In accordance with the literature, combined prophylaxis showed the least incidence of ossification compared to the other methods. Differences in incidence frequencies were significant between the different prophylaxis methods.ConclusionA combined prophylaxis for heterotopic ossification in surgically treated acetabular fractures seems to be a better alternative than a prophylaxis with radiation or indomethacin alone.

Wertigkeit einer kombinierten Ossifikationsprophylaxe mit Indometacin und Bestrahlung bei Azetabulumfrakturen

ZusammenfassungHintergrundIn der Azetabulumchirurgie gelten heterotope Ossifikationen (HO) als eine wesentliche zugangsabhängige Komplikation. Es stellte sich die Frage, ob eine Kombinationsprophylaxe mit Indometacin und Bestrahlung der Monoprophylaxe beim dorsalen, erweiterten iliofemoralen oder kombiniertem Zugang überlegen ist.Material und Methoden24xa0Patienten mit Kombinationsprophylaxe wurden nach 24xa0Monaten retrospektiv untersucht. Anhand einer systematischen Literaturrecherche erfolgte die vergleichende Auswertung unterschiedlicher Prophylaxeregime. Eigene Ergebnisse wurden in den Vergleich integriert.ErgebnisseIm eigenen Krankengut entwickelte ein Patient eine HO. Die Literaturanalyse zeigte die niedrigsten Ossifikationsraten nach Kombinationsprophylaxe. In den untersuchten Gruppen waren die Unterschiede in den Häufigkeiten statistisch signifikant (p<0,01, χ2-Test).SchlussfolgerungAufgrund unserer und anderer publizierter Daten gibt es Hinweise dafür, dass eine Kombinationsprophylaxe anderen Regimen überlegen ist.AbstractBackgroundHeterotopic ossification is a complication in patients with surgically treated acetabular fractures. The incidence is related to the surgical approach (extended iliofemoral, posterior or a combined approach). The objective of this study was to evaluate the incidence of heterotopic ossification in patients with acetabular fractures who received a combined prophylaxis with both a single dose of radiation and indomethacin compared to those who received only a prophylaxis with radiation or indomethacin.Patients and MethodsA total of 24 patients with a combined prophylaxis after surgery were examined retrospectively 24xa0months after trauma. A systematic literature review was performed and our own results were compared with different methods for prophylaxis of heterotopic ossification from the literature.ResultsOnly one patient developed a heterotopic ossification. In accordance with the literature, combined prophylaxis showed the least incidence of ossification compared to the other methods. Differences in incidence frequencies were significant between the different prophylaxis methods.ConclusionA combined prophylaxis for heterotopic ossification in surgically treated acetabular fractures seems to be a better alternative than a prophylaxis with radiation or indomethacin alone.

Unbehandelter Abriss des Processus styloideus ulnae

ZusammenfassungHintergrundKriterien zur Indikation und Art der Versorgung einer distalen Radiusfraktur sind etabliert. Über die Notwendigkeit einer operativen Versorgung der häufigen Begleitfraktur des Processus styloideus ulnae herrscht jedoch noch Uneinigkeit. Gegenstand der vorliegenden Studie war die Frage der Behandlungsbedürftigkeit dieser Verletzung.MethodenMindestens ein Jahr postoperativ wurden 238 von 480xa0Patienten mit operativ versorgter distaler Radiusfraktur nachuntersucht. Eine Versorgung des Ulnastyloids fand in diesem Zeitraum nicht statt. Die Patienten wurden in 3 Gruppen unterteilt: ohne Ulnastyloidfraktur, mit Spitzen- und mit Basisabriss. Die funktionellen und radiologischen Ergebnisse wurden gemessen. Durch eine multivariate Analyse (MANOVA) wurde ermittelt, ob ein basisnaher oder peripherer Styloidabriss das radiologische oder funktionelle Ergebnis beeinflusst.ErgebnisseWeder das Vorhandensein noch die Lokalisation eines Abrisses des Processus styloideus ulnae hatten einen signifikanten Einfluss auf die funktionellen und radiologischen Ergebnisse (pfunktionell=0,849, pradiologisch=0,330, pScores=0,426, MANOVA).SchlussfolgerungBei anatomischer Reposition und adäquater Refixation der distalen Radiusfraktur erscheint eine operative Versorgung von Spitzenabrissen als auch basisnaher Frakturen des Processus styloideus ulnae nicht notwendig.AbstractBackgroundThere are well-defined criteria for the treatment of distal radius fractures but the impact of an unrepaired fracture of the styloid process of the ulnar on recovery after operative treatment is uncertain. This study evaluated radiological and functional results after different operative treatment procedures of distal radius fractures in patients with an untreated fracture of the styloid process of the ulna and those without such a fracture.MethodsOut of 480 patients with operatively treated distal radius fractures 238 were examined at least 1 year after injury. The fracture of the styloid process of the ulna was not repaired. Three groups (patients without a fracture of the styloid process of the ulna, patients with a tip fracture and those with a basal fracture) were evaluated by multivariate analysis (MANOVA) in order to detect influences of the fracture of the styloid process of the ulna on the radiological and functional results.ResultsNeither the existence nor the location of the fracture of the styloid process of the ulna had a significant effect on the radiological and functional results (pfunction=0,849, pradiology=0,330, pscores=0,426, MANOVA).ConclusionsThe repair of a fracture of the styloid process of the ulna is not necessary if reduction and fixation of the distal radius fracture is anatomical and stable.BACKGROUNDnThere are well-defined criteria for the treatment of distal radius fractures but the impact of an unrepaired fracture of the styloid process of the ulnar on recovery after operative treatment is uncertain. This study evaluated radiological and functional results after different operative treatment procedures of distal radius fractures in patients with an untreated fracture of the styloid process of the ulna and those without such a fracture.nnnMETHODSnOut of 480 patients with operatively treated distal radius fractures 238 were examined at least 1 year after injury. The fracture of the styloid process of the ulna was not repaired. Three groups (patients without a fracture of the styloid process of the ulna, patients with a tip fracture and those with a basal fracture) were evaluated by multivariate analysis (MANOVA) in order to detect influences of the fracture of the styloid process of the ulna on the radiological and functional results.nnnRESULTSnNeither the existence nor the location of the fracture of the styloid process of the ulna had a significant effect on the radiological and functional results (p(function)=0,849, p(radiology)=0,330, p(scores)=0,426, MANOVA).nnnCONCLUSIONSnThe repair of a fracture of the styloid process of the ulna is not necessary if reduction and fixation of the distal radius fracture is anatomical and stable.

Axillary nerve lesions after open reduction and internal fixation of proximal humeral fractures through an extended lateral deltoid-split approach: electrophysiological findings

BACKGROUNDnAxillary nerve injuries after shoulder surgery are rare. In most studies, the frequency of injury is usually determined using clinical examinations, but results from intraoperative neuromonitoring studies have revealed higher than expected rates. Few studies have investigated this topic. Our aim was to determine the frequency of axillary nerve lesions after open reduction and internal fixation of proximal humeral fractures by using electrophysiological assessments and to provide a review of the relevant literature.nnnMETHODSnThis was a retrospective cohort study of 76 consecutive patients who received open reduction and internal fixation of a proximal humeral fracture using a locking plate through a deltoid-splitting approach. We performed a clinical and electrophysiological examination at a minimum follow-up time of 12 months. Functional results were assessed according to the Constant-Murley and Disabilities of the Arm, Shoulder and Hand scores. Electrophysiological examinations comprised electromyography, electroneurography, and motor and somatosensory evoked potentials. The main outcome was the frequency of axillary nerve lesions.nnnRESULTSnForty patients were monitored for an average of 28 months. The mean raw Constant-Murley score was 61 points, the age- and gender-adjusted score was 71%, and the mean Disabilities of the Arm, Shoulder and Hand score was 33 points. Neurapraxia occurred in 1 patient, axonotmesis with incomplete reinnervation occurred in 3, and complete reinnervation occurred in 3. The latter group was classified as having a temporary axillary nerve lesion.nnnCONCLUSIONSnThe 10% rate of permanent axillary nerve lesions in our cohort is higher than expected based on the clinical examination. Electrophysiological assessment is therefore more appropriate to detect axillary nerve injuries.

Retrograde cement removal in periprosthetic fractures following hip arthroplasty.

IntroductionRevision of cemented hip arthroplasty after periprosthetic fractures of the femur is a demanding procedure. Many different technical devices have been developed for this purpose. This paper presents a new surgical technique of cement removal avoiding excessive exposure of the fracture site.Materials and methodsIn six patients with periprosthetic fractures of the femur following hip arthroplasty (Johansson Type II and III) cement removal was performed by means of advancing a retrograde nail through the intercondylar notch of the knee.ResultsIn all cases the cement was removed completely. Intraoperative complications or significant knee problems were not observed.ConclusionThe intracondylar approach provides a simple, rapid and less invasive technique for cement removal in revision hip arthroplasty.

Nonunion of an occult fracture in zone III of the sacrum

SummaryFractures in the midline of the sacrum are rare, a pseudarthrosis has not been described previously. We report about a 53-year-old woman with a midline fracture of the sacrum which has not been recognized, although there were indirect fracture signs on the native x-rays and a CT was performed. The surgical treatment with sacral compression bars was successful and pseudarthrosis healing resulted but the patient continued to have mild low back pain. The case reported here confirms that low back pain may caused by pathologic changes of the posterior part of the pelvis. The unusual fracture location could be caused by a bifid spinous process.ZusammenfassungFrakturen in der Mittellinie des Sakrums sind Raritäten, Pseudarthrosen an dieser Stelle bisher nicht beschrieben. Wir berichten über eine 53 jährige Patientin mit einer zentralen Sakrumfraktur, die trotz vorhandener indirekter Frakturzeichen auf dem Nativröntgenbild und trotz daraufhin eingeleiteter CT nicht erkannt wurde und in eine Pseudarthrose mündete. Die operative Versorgung erfolgte mit „sacral bars“ und führte zur knöchernen Konsolidierung, ohne jedoch völlige Beschwerdefreiheit zu erreichen. Der Fall bestätigt, daß anhaltende Kreuzschmerzen nach Trauma ihre Ursache in morphologisch faßbaren Pathologien des hinteren Beckenringes haben können. Für die besondere Frakturlokalisation könnte in Übereinstimmung mit der Literatur eine bei der Patientin vorliegende Bogenschlußstörung ursächlich sein.

Gleichzeitige Frakturen von Acromion und Korakoid

INTRODUCTIONnSimultaneous fracture of the acromion and coracoid process represents axa0double disruption of the superior shoulder suspensory complex (SSSC). To date, the two largest reported series have comprised five and eight cases. The aim of this study was to investigate the functional outcome in patients who sustained this rare injury and to provide axa0review of the relevant literature.nnnMATERIAL AND METHODSnIn this retrospective study, patients who were surgically treated between 2009 and 2014 were identified from medical records and the patients were asked to attend axa0follow-up examination. Functional results, measured as the Constant score and Disabilities of the Arm, Shoulder and Hand (DASH) score, were the main outcomes of the study.nnnRESULTSnAxa0total of six patients underwent surgery for this type of double disruption of the SSSC. All but one patient suffered axa0high-impact trauma with other associated injuries. The coracoid fracture was classified as typexa0I according to Ogawa in all cases, and the acromion fracture was typexa0III according to Kuhn in 5xa0out of 6xa0cases. At least one of the fracture sites was stabilized. Of the patients one showed axa0concurrent lateral clavicle fracture, representing axa0third disruption of the SSSC, and another had axa0fracture of the medial third of the clavicle, representing axa0strut fracture. In these cases, two fracture sites were operated on. At an average follow-up period of 47xa0months all but one fracture had healed. In one patient, asymptomatic non-union of the acromion was found. The average DASH score was 22xa0points and the average Constant score was 74xa0points.nnnCONCLUSIONnThis rare injury pattern is usually caused by high-impact trauma, and concomitant injuries frequently occur. Nevertheless, surgical stabilization of at least one of the fracture sites showed satisfactory functional results.ZusammenfassungHintergrund und FragestellungGleichzeitige Frakturen von Acromion und Korakoid sind eine seltene Variante der Doppelunterbrechung des „superior shoulder suspensory complex (SSSC)“. Die beiden größten bisher publizierten Serien umfassten 5 bzw. 8xa0Fälle. Studienziele waren die Bestimmung funktioneller Ergebnisse bei Patienten mit diesem Verletzungsmuster und die Auswertung der zu dieser Thematik verfügbaren Literatur.Material und MethodenAlle Patienten, die wegen des Verletzungsmusters zwischen 2009 und 2014 operiert wurden, wurden identifiziert und zu einer Nachuntersuchung eingeladen. Die funktionellen Ergebnisse waren Hauptzielgrößen der Studie. Sie wurden durch Bestimmung des Constant- und des DASH(„Disabilities of the Arm, Shoulder and Hand“)-Scores ermittelt.ErgebnisseSechs Patienten wurden wegen dieser Verletzung operiert. Fünf davon erlitten ein Hochenergietrauma mit teilweise erheblichen Begleitverletzungen. Alle Korakoidfrakturen entsprachen dem Typxa0I nach Ogawa und 5xa0Acromionfrakturen dem Typxa0III nach Kuhn. Mindestens eine der beiden Ringunterbrechungen wurde in allen Fällen stabilisiert. Ein Patient hatte zusätzlich eine laterale Klavikulafraktur, was einer 3fachen Ringunterbrechung entspricht. Bei einem weiteren Patienten lag eine Klavikulaschaftfraktur vor, was einer „strut fracture“ (Fraktur der Querverstrebung) entspricht. In diesen beiden Fällen wurden 2xa0Frakturen stabilisiert. Nach durchschnittlich 47xa0Monaten waren 11xa0von 12xa0Frakturen verheilt. Eine asymptomatische Pseudarthrose des Acromions wurde beobachtet. Der mittlere Constant-Score betrug 74xa0Punkte, der mittlere DASH-Score 22xa0Punkte.DiskussionDiese seltene Verletzung wird nahezu immer durch eine hohe Energie verursacht. Häufig sind daher Begleitverletzungen zu beobachten. Die operative Stabilisierung wenigstens einer der beiden Frakturen führte zu guten funktionellen Ergebnissen.AbstractIntroductionSimultaneous fracture of the acromion and coracoid process represents axa0double disruption of the superior shoulder suspensory complex (SSSC). To date, the two largest reported series have comprised five and eight cases. The aim of this study was to investigate the functional outcome in patients who sustained this rare injury and to provide axa0review of the relevant literature.Material and methodsIn this retrospective study, patients who were surgically treated between 2009 and 2014 were identified from medical records and the patients were asked to attend axa0follow-up examination. Functional results, measured as the Constant score and Disabilities of the Arm, Shoulder and Hand (DASH) score, were the main outcomes of the study.ResultsAxa0total of six patients underwent surgery for this type of double disruption of the SSSC. All but one patient suffered axa0high-impact trauma with other associated injuries. The coracoid fracture was classified as typexa0I according to Ogawa in all cases, and the acromion fracture was typexa0III according to Kuhn in 5xa0out of 6xa0cases. At least one of the fracture sites was stabilized. Of the patients one showed axa0concurrent lateral clavicle fracture, representing axa0third disruption of the SSSC, and another had axa0fracture of the medial third of the clavicle, representing axa0strut fracture. In these cases, two fracture sites were operated on. At an average follow-up period of 47xa0months all but one fracture had healed. In one patient, asymptomatic non-union of the acromion was found. The average DASH score was 22xa0points and the average Constant score was 74xa0points.ConclusionThis rare injury pattern is usually caused by high-impact trauma, and concomitant injuries frequently occur. Nevertheless, surgical stabilization of at least one of the fracture sites showed satisfactory functional results.