Tobias M. Kraus

Comminuted fractures of the proximal ulna—Preliminary results with an anatomically preshaped locking compression plate (LCP) system

INTRODUCTION The purpose of this investigation was to review the preliminary results and patients outcome following treatment with an anatomically preshaped LCP in patients with comminuted fractures of the proximal ulna. We hypothesized that this fixation system provides equal or superior results in fracture care when compared with other available plating devices, but results in better patients comfort due to its low-profile design. PATIENTS AND METHODS Between 2007 and 2009, 15 patients with comminuted fractures of the proximal ulna including three posterior Monteggia fractures were managed with the preshaped LCP olecranon plate. The patients were invited for clinical examination at a mean duration of 16 months, retrospectively. Validated patient-oriented assessment scores involving the Mayo Elbow Performance Index (MEPI) and the shortened Disability of the Arm, Shoulder and Hand (Quick-DASH) score, postoperative range of motion, objective muscle-strengths testing and patients satisfaction were evaluated. All patients had follow-up radiographs. RESULTS Fourteen patients were available for evaluation. The mean arc of elbow motion was 129°. The mean MEPI was 97 with good results in two patients and excellent results in 12 patients. The mean Quick-DASH was 13. Thirteen of fourteen patients documented satisfaction with their elbow outcome. There was one patient with symptomatic hardware and one patient complained about deficit of motion. In four patients the hardware was removed including two patients with elective removal. Fourteen fractures healed with ulnohumeral congruity after a mean time to union of 11 weeks. One fracture non-union occurred without mechanical failure or loss of reduction. CONCLUSION Anatomically preshaped LCP olecranon plating is an effective fixation method for comminuted fractures of the proximal ulna allowing reliable stability for early elbow motion. The functional results are comparable with formerly described plating systems. A low rate of symptomatic hardware removal suggests better patients compatibility.

Return to sports activity after tibial plateau fractures: 89 cases with minimum 24-month follow-up.

Background: Tibial plateau fractures requiring surgery are severe injuries. For professionals, amateurs, and recreational athletes, tibial plateau fractures might affect leisure and professional life. Hypothesis: Athletic patients will be affected in their sporting activity after a tibial plateau fracture. Despite a long rehabilitation time and program, physical activity will change to low-impact sports. Study Design: Case series; Level of evidence, 4. Methods: A total of 89 consecutive patients (age range, 14-76 years) were included in the study and were surveyed by a questionnaire. Inclusion criteria were surgical treatment of tibial plateau fractures between 2003 and 2009 with a minimum follow-up of 24 months. The sporting activity was determined at the time of injury, 1 year postoperatively, and at the time of the survey at an average of 52.8 months postoperatively. The clinical evaluation included the Lysholm score, the Tegner activity scale, the activity rating scale (ARS), and a visual analog scale (VAS) for pain perception. Fractures were classified and analyzed using both the Arbeitsgemeinschaft für Osteosynthesefragen (AO) and the Schatzker classifications. Results: At the time of injury, 88.8% of all patients were engaged in sports compared with 62.9% 1 year postoperatively and 73.0% at the time of the survey. Of the professional or competitive athletes (n = 11 at the time of injury), only 2 returned to competition at the time of the survey. The number of different sporting activities declined from 4.9 at the time of injury to 3.6 at the time of the survey (P < .001). The sports frequency and the activity duration per week, being 2.8 sessions and 4.5 hours at the time of injury, respectively, declined to 2.4 sessions and 3.8 hours (P < .001 and P = .007, respectively) at the time of the survey, respectively. The Lysholm score (98.7 points before accident) and the VAS for pain perception (0.2 before accident) illustrated significant declines to 76.6 points for the Lysholm score and 2.6 for the VAS (P < .001 and P < .001, respectively) at the time of the survey. The high-energy traumas, Schatzker IV to VI, had significant worse results in the clinical scores compared with the low-energy traumas (Lysholm, P < .001; Tegner, P = .027). Conclusion: The majority of patients could not return to their previous level of activity, and for patients playing competitive sports, this injury can be a career ender. Overall, we noticed a postinjury shift toward activities with less impact. However, at the time of the survey, 73% of all patients were engaged in sports.

A new Micromanipulator System for middle ear surgery

In this article, a new Micromanipulator System (MMS-II) for middle ear surgery is presented. The purpose of this work was to develop a simple but effective manipulator that would enable the surgeon to move standard surgical instruments in a precise way even under non-ergonomic conditions. The MMS-II is lightweight, small, and easy to use; it requires no PC, besides a small microcontroller-based joystick console. Such features, together with a practicable sterilization concept and the availability of a multiplicity of surgical instruments, allow the system to be used in standard surgical procedures.

Reconstruction of displaced acromio-clavicular joint dislocations using a triple suture-cerclage: description of a safe and efficient surgical technique

PurposeIn this retrospective study we investigated the clinical and radiological outcome after operative treatment of acute Rockwood III-V injuries of the AC-joint using two acromioclavicular (AC) cerclages and one coracoclavicular (CC) cerclage with resorbable sutures.MethodsBetween 2007 and 2009 a total of 39 patients fit the inclusion criteria after operative treatment of acute AC joint dislocation. All patients underwent open reduction and anatomic reconstruction of the AC and CC-ligaments using PDS® sutures (Polydioxane, Ethicon, Norderstedt, Germany). Thirty-three patients could be investigated at a mean follow up of 32±9 months (range 24–56 months).ResultsThe mean Constant score was 94.3±7.1 (range 73–100) with an age and gender correlated score of 104.2%±6.9 (88-123%). The DASH score (mean 3.46±6.6 points), the ASES score (94.6±9.7points) and the Visual Analogue Scale (mean 0.5±0,6) revealed a good to excellent clinical outcome. The difference in the coracoclavicular distance compared to the contralateral side was <5 mm for 28 patients, between 5-10 mm for 4 patients, and more than 10 mm for another patient. In the axial view, the anterior border of the clavicle was within 1 cm (ventral-dorsal direction) of the anterior rim of the acromion in 28 patients (85%). Re-dislocations occured in three patients (9%).ConclusionOpen AC joint reconstruction using AC and CC PDS cerclages provides good to excellent clinical results in the majority of cases. However, radiographically, the CC distance increased significantly at final follow up, but neither the amount of re-dislocation nor calcifications of the CC ligaments or osteoarthritis of the AC joint had significant influence on the outcome.Level of evidenceCase series, Level IV

Brachial artery transection caused by closed elbow dislocation in a mature in-line skater: a case report with review of the literature

PurposeRegarding skating injuries, isolated cases of closed elbow dislocations are reported only for children or teenage patients. Due to the anatomic proximity of neurovascular structures, elbow dislocations run the risk of concomitant injury, but its occurrence remains very rare.MethodWe describe the case of an advanced mature in-line skater with a complete disruption of the brachial artery caused by a closed elbow dislocation. The patient underwent emergency repair of the arterial injury with an autologous saphenous vein bypass.ResultsOne year after surgery, the patient recovered without any complaints and has returned to all activities of daily living as well as sporting activities.ConclusionThis case should sensitize the readers for concomitant vascular lesions when confronted with elbow dislocations. The mechanism of closed elbow dislocation in relation to skating sports is discussed with the current literature. We hold the view that accurate clinical assessment by orthopedic and vascular surgeons is absolutely necessary and immediate operative approach is the only acceptable treatment.

Dynamic-locking-screw (DLS)–leads to less secondary screw perforations in proximal humerus fractures

BackgroundLoss of reduction and screw perforation causes high failure rates in the treatment of proximal humerus fractures. The purpose of the present study was to evaluate the early postoperative complications using modern Dynamic Locking Screws (DLS 3.7) for plating of proximal humerus fractures.MethodsBetween 03/2009 and 12/2010, 64 patients with acute proximal humerus fractures were treated by angular stable plate fixation using DLSs in a limited multi-centre study. Follow-up examinations were performed three, six, twelve and twenty-four weeks postoperatively and any complications were carefully collected.Results56 of 64 patients were examined at the six-month follow-up. Complications were observed in 12 patients (22%). In five cases (9%), a perforation of the DLS 3.7 occurred.ConclusionsDespite the use of modern DLS 3.7, the early complications after plating of proximal humerus fractures remain high. The potential advantage of the DLS 3.7 regarding secondary screw perforation has to be confirmed by future randomized controlled trials.

Pearls and pitfalls for the treatment of tibial head fractures

ZusammenfassungHintergrundSchienbeinkopffrakturen gehören zu den schwerwiegenden knöchernen Verletzungen des Kniegelenkes und sind häufig die Folge von Sportunfällen.SchlussfolgerungEine präzise Frakturanalyse ist erforderlich, um ein bestmögliches Outcome für den Patienten erreichen zu können. Neben den allgemeinen perioperativen Komplikationen sind als primäre Komplikationen das Kompartmentsyndrom, eine Läsion des Nervus peroneus, Pininfektionen oder Periimplantatinfektionen mit nachfolgender Tibiakopfosteitis bekannt. An weiteren Komplikationen sind die avaskuläre Tibiakopfnekrose, der sekundäre Repositionsverlust mit Varus- oder Valgusfehlstellung sowie die posttraumatische Gonarthrose beschrieben. Die hohe Anzahl an perioperativen Komplikationen, bis zu 43 % gemäß Literatur, verdeutlicht die Komplexität des Verletzungsbildes und unterstreicht die Notwendigkeit einer fraktur- und pathologieangepassten Versorgungsstrategie. Die langfristigen klinischen Ergebnisse in der Literatur zeigen, dass Schienbeinkopffrakturen einen großen Einfluss auf die zukünftigen Sportaktivitäten, die Freizeit und die berufliche Entwicklung haben. Je schwerwiegender die Fraktur, desto schlechter ist das zu erwartende klinische Outcome. Ein zunehmend verbessertes Verständnis der Frakturen, die obligate systematische intraoperative röntgenologische Fraktur- und Osteosynthesedarstellung, die Weiterentwicklung von Knochenersatzmaterialien und spezielle Rehabilitationsmethoden lassen für die Zukunft eine weitere Verbesserung der Ergebnisse erwarten.AbstractBackgroundTibial plateau fractures requiring surgery are severe injuries of the lower extremity. Depending on the fracture pattern, the age of the patient, the range of activity and the bone quality there is a broad variation in adequate treatment. In the last decade we have had a tremendous development, might it be the angular stable anatomical plates as well as new approaches to the proximal tibia. Nevertheless in the recent literature there are still many complications reported. Not only for sports professionals, recreational athletes or heavy load workers tibial plateau fractures affect leisure, all day activity and professional life.This article reports the treatment algorithm showing different cases, outlines the pitfalls and explains treatment strategies with a detailed x-ray follow-up.ConclusionAfter a tibial plateau fracture patients are affected in their sporting activity due to an impaired knee function. Despite a long rehabilitation time and programs, physical activity changes to lower impact sports.Among the usual perioperative complications there are the specific complications of postoperative malalignment, implant infections, osteitis of the tibial head, compartment syndrome, secondary loss of reduction, avascular tibial head necrosis, secondary varus or valgus deformity, post-traumatic arthrosis and lesions of the peroneal nerve. In the literature in up to 43 % of the cases complications have been noted.Despite surgery the majority of patients cannot return to their previous level of activity. However, overall about 70 % of the patients return to sports after a tibial plateau fracture. For a beneficial outcome a detailed fracture analysis with CT scan and precise planning of the surgical strategies and approaches is mandatory.BACKGROUND Tibial plateau fractures requiring surgery are severe injuries of the lower extremity. Depending on the fracture pattern, the age of the patient, the range of activity and the bone quality there is a broad variation in adequate treatment. In the last decade we have had a tremendous development, might it be the angular stable anatomical plates as well as new approaches to the proximal tibia. Nevertheless in the recent literature there are still many complications reported. Not only for sports professionals, recreational athletes or heavy load workers tibial plateau fractures affect leisure, all day activity and professional life. This article reports the treatment algorithm showing different cases, outlines the pitfalls and explains treatment strategies with a detailed x-ray follow-up. CONCLUSION After a tibial plateau fracture patients are affected in their sporting activity due to an impaired knee function. Despite a long rehabilitation time and programs, physical activity changes to lower impact sports. Among the usual perioperative complications there are the specific complications of postoperative malalignment, implant infections, osteitis of the tibial head, compartment syndrome, secondary loss of reduction, avascular tibial head necrosis, secondary varus or valgus deformity, post-traumatic arthrosis and lesions of the peroneal nerve. In the literature in up to 43% of the cases complications have been noted. Despite surgery the majority of patients cannot return to their previous level of activity. However, overall about 70% of the patients return to sports after a tibial plateau fracture. For a beneficial outcome a detailed fracture analysis with CT scan and precise planning of the surgical strategies and approaches is mandatory.

[Recurrent hematomas of the iliopsoas muscle after total hip replacement as a differential diagnosis for chronic groin pain: case series report].

BACKGROUND Chronic and atraumatic groin pain may be due to a variety of pathologies local to and distal from the hip joint. Aside from frequent entities, such as inguinal hernia, impingement of the iliopsoas muscle by the anterior rim of the acetabular component leading to a hematoma can be a potential cause after total hip replacement (THR). MATERIAL AND METHODS This article presents three cases of delayed groin pain after THR received due to osteoarthrosis of the hip joint several years prior to the onset of symptoms. In all three cases the patient suffered from chronic groin pain aggravated by active flexion without direct trauma. After thorough clinical, laboratory and radiological (ultrasound, x-ray, computed tomography) examination a hematoma of the iliopsoas muscle was detected. Furthermore, in all three cases the acetabular component appeared to be slightly malpositioned. Considering the least invasive procedure all cases were treated with an excavation of the hematoma. After recurrence the indications for revision of the malpositioned acetabular component were present. RESULTS All patients clearly showed a reduction of pain after operative revision. There have been no further hematomas and the patients could be easily and rapidly remobilized. CONCLUSIONS Persistent atraumatic groin pain connected to a deficit in hip flexion after THR needs thorough investigation by the treating physician. The differential diagnosis of a delayed hematoma due to impingement of the iliopsoas muscle is a rare but more complex entity. After careful consideration of the perioperative risks an early indication for revision of a malpositioned acetabular component is promising.

[Therapy-resistant tibial pseudarthrosis. Treatment success with BMP-7 combined with autologous bone].

Delayed union or non-union of long bone shaft fractures still presents a surgical challenge. Especially if there is a predisposition for pseudarthrosis such as adiposity, diabetes mellitus, local disruption of blood supply or lack of hormones, the established procedures of autologous cancellous bone grafting or plate fixation with compression often lead to insufficient results. In the following article the successful use of bone morphogenetic protein BMP-7 [recombinant human osteogenetic protein-1 (rhOP-1)], combined with autologous bone grafting for therapy of a therapy-resistant tibial non-union is described. In a patient with multiple risk factors the tibial fracture was completely cured after two attempts of osteosynthesis and autologous bone grafting had failed. The patient achieved self-mobility with full weight bearing and absence of pain 10 months after adjuvant implantation of BMP-7.

Influence of surgical wrist denervation on proprioceptive changes: A systematic review

The denervation of the wrist is a known method to treat the painful wrist. Pain relief and therefore functional improvement is the main goal to be achieved, but very little is known about other effects such the influence on proprioception. There are references that indicate an effect on reflex arcs after a certain stimulus on the wrist, and thus, changes in proprioception may come along with a surgical denervation. This systematic review was conducted to investigate if there is evidence that assesses the influence of surgical wrist denervation on proprioceptive changes and the methods that were used. Very few articles describe an effect of denervation on the proprioception of the wrist. Reliable tests to measure proprioception are rare. Such tests exist but still they comprise bias and lack of minimation of other influences such as optic input. Subject of further investigation should be proprioception itself and methods to test this quality objectively.Level II, risk/prognostic study.