Ulrich Holz

Anterior retropharyngeal fixation C1-2 for stabilization of atlantoaxial instabilities: study of feasibility, technical description and preliminary results

Posterior transarticular screw fixation C1-2 with the Magerl technique is a challenging procedure for stabilization of atlantoaxial instabilities. Although its high primary stability favoured it to sublaminar wire-based techniques, the close merging of the vertebral artery (VA) and its violation during screw passage inside the axis emphasizes its potential risk. Also, posterior approach to the upper cervical spine produces extensive, as well as traumatic soft-tissue stripping. In comparison, anterior transarticular screw fixation C1-2 is an atraumatic technique, but has been neglected in the literature, even though promising results are published and lectured to date. In 2004, anterior screw fixation C1-2 was introduced in our department for the treatment of atlantoaxial instabilities. As it showed convincing results, its general anatomic feasibility was worked up. The distance between mid-sagittal line of C2 and medial border of the VA groove resembles the most important anatomic landmark in anterior transarticular screw fixation C1-2. Therefore, CT based measurements on 42 healthy specimens without pathology of the cervical spine were performed. Our data are compiled in an extended collection of anatomic landmarks relevant for anterior transarticular screw fixation C1-2. Based on anatomic findings, the technique and its feasibility in daily clinical work is depicted and discussed on our preliminary results in seven patients.

Operative treatment of distal femoral fractures above total knee arthroplasty with the indirect reduction technique: a long-term follow-up study.

The complication rate of conventional plate osteosynthesis (CPO) of periprosthetic femoral fractures above total knee arthroplasties (TKA) is high. Indirect reduction techniques were introduced to reduce surgical dissection at the fracture site. Twenty-one patients (4 men and 17 women) with femoral fractures above well-fixed total knee arthroplasties were consecutively treated with the indirect reduction technique. AO/ASIF (Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of the Problems of Internal Fixation) Type 33A fractures were included. The mean age was 78 years (range, 67-94 years). Four fractures were stabilised with bone grafts, three in combination with bone cement. Nineteen of the patients were seen at a 1-year follow-up, 15 were seen after a long-term follow-up of 9 years (range, 7-12 years). There was only one implant failure in a comminuted fracture with severe osteoporosis, no infection, and no non-union. At the 1-year follow-up malalignment of 5 degrees varus occurred in one patient. The mean range of motion of the eighteen patients was 98 degrees (range, 65-110 degrees). The mean knee society score was 74 (range, 62-84), the mean function score was 52 (range, 39-72). At the long-term follow-up, the mean range of motion of the patients was 101 degrees (range, 65-115 degrees). The mean knee society score was 77 (range, 65-88), the mean function score was 55 (range, 40-75). Our results suggest the 95 degrees condylar blade plate in the indirect reduction technique is still a good implant with good long-term results. It works best in proximal fractures when there is minimal comminution of the distal fragment in the hands of an experienced trauma surgeon. Knee function and range of motion increased less over time.

Regression and correlation analysis of preoperative versus intraoperative assessment of axes during navigated total knee arthroplasty.

Objective: Modern computer assisted surgery (CAS) systems allow accurate positioning of the implants in navigated Total Knee Arthroplasty (TKA). However, when an operation is performed with a navigation system, it is important to know if the anatomical situation of the knee is reflected equally in both the preoperative image (e.g., CT) and the intraoperative navigation setup. In this study, we compared the preoperative anatomical situation to the virtual intraoperative situation of the navigation setup. Material and Methods: We analyzed 24 navigated operations. Intraoperatively, the condylar twist angle (CTA) was documented with the navigation system by measuring the angle between the transepicondylar axis (TEA) and posterior condyle axis (PCA). This data was compared with the preoperative data from the CT scan. Results: Statistical analysis revealed that there was no correlation between the pre- and intraoperative data (r = 0.095).Conclusions: Statistically, there is no possibility of collecting the same angles and axes when using the two different methods (CT and navigation) on the same knee. It is not possible to copy the preoperative anatomical situation exactly with the virtual intraoperative data. Reasons for this include systematic errors, as well as inter- and intraobserver errors in both methods.

Die offene Arthrolyse der posttraumatischen Ellenbogensteife

BACKGROUND The incidence of relevant posttraumatic functional deficits in the sense of elbow stiffness with less than 30 degrees in extension or flexion less than 120 degrees , is unknown. A differentiation can be made between intraarticular, extraarticular and combined causes. An open procedure is indicated in elbow stiffness after correct analysis of the situation and failure of conservative treatment. MATERIALS AND METHODS An open procedure was carried out on 35 patients between March 1995 and November 2001, 10 (3-24) months after the trauma. The mean age of the 24 men and 11 women was 45 (range 17-75) years. Of the patients 15 had distal humerus fractures, 10 radius head or neck fractures and 12 proximal ulnar fractures. RESULTS Of the patients 11 (31%) had an excellent result in the Cauchoix and Deburge score, 15 (42%) a good, 4 (11%) a fair, 4 (11%) a bad and 1 (3%) a very bad result after a mean follow-up of 21.5 (range 9-60) months. Of the patients 11 (31%) had an excellent result in the Mayo elbow performance score, 14 (40%) a good, 5 (14%) a fair and 5 (14%) a poor result. CONCLUSION Open arthrolysis for severe posttraumatic elbow stiffness carried out 10 months (range 3-24 months) after the accident led to good results in most cases with a clear improvement in functional mobility.

Die Arthrodese des oberen Sprunggelenks mit Zugschrauben

OperationsprinzipDie Arthrodese bei schmerzhaften Funktionseinschränkungen oder Fehlstellungen des oberen Sprunggelenks stellt einen Eingriff zur funktionellen Verbesserung dar.Der Ausfall des oberen Sprunggelenks wird zum Teil in den übrigen Fußgelenken kompensiert.Die Kompression der Resektionsflächen von Talus und Tibia mit Spongiosaschrauben schafft stabile Verhältnisse und ermöglicht frühzeitig im Unterschenkelgehverband eine volle Belastung.Die Neutralstellung im Sprunggelenk ist im allgemeinen für Frauen und Männer die günstigste Arthrodesenposition [1,13,15].

Intramedullary bone endoscopy (IBE). First results of experimental intramedullary endoscopy of long bone

ZusammenfassungFragestellung. Endoskopie und endoskopische Präparation des Markraums von langen Röhrenknochen ist bislang in der Literatur nicht beschrieben. Die vorliegende Arbeit zeigt erste experimentelle Ergebnisse der intramedullären Endoskopie innerhalb des “geschlossenen Kompartimentes” des langen Röhrenknochens. Methodik. An je 2 Leichenfemora und -tibiae wurde eine intramedulläre Endoskopie durchgeführt. Ergebnisse. In allen Fällen war eine Platzierung des Endoskops und anschließende intramedulläre Endoskopie gut möglich. Mit dem verwendeten Endoskop (Wolf GmbH, Knittlingen) konnte der Markraum problemlos inspiziert und präpariert werden. Schlussfolgerung. Intramedulläre Endoskopie und endoskopische Präparation sind möglich. Innerhalb des geschlossenen Kompartimentes eines langen Röhrenknochens kann ein “Neocavum” geschaffen werden, in dem endoskopische Manipulation gut möglich ist.AbstractIntroduction. Intramedullary preparation and endoscopy of long bone is not mentioned in literature. We present our first results of experimental intramedullary endoscopy of long bone. Methods. Experimental tests were performed at 4 corpse bones (twice tibia, twice femur). Results. Intramedullary endoscopy and preparation was possible in all cases. A good view for inspection of the medullary canal was achieved by using the endoscope (Wolf GmbH, Germany). Conclusion. Endoscopic preparation and intramedullary endoscopy in the long bone ist possible. By using the endoscopic tools, a “neocavum” for endoscopic manipulation could easily be created.

Intramedulläre Knochenendoskopie (IBE)Erste experimentelle Ergebnisse der Endoskopie des langen Röhrenknochens

ZusammenfassungFragestellung. Endoskopie und endoskopische Präparation des Markraums von langen Röhrenknochen ist bislang in der Literatur nicht beschrieben. Die vorliegende Arbeit zeigt erste experimentelle Ergebnisse der intramedullären Endoskopie innerhalb des “geschlossenen Kompartimentes” des langen Röhrenknochens. Methodik. An je 2 Leichenfemora und -tibiae wurde eine intramedulläre Endoskopie durchgeführt. Ergebnisse. In allen Fällen war eine Platzierung des Endoskops und anschließende intramedulläre Endoskopie gut möglich. Mit dem verwendeten Endoskop (Wolf GmbH, Knittlingen) konnte der Markraum problemlos inspiziert und präpariert werden. Schlussfolgerung. Intramedulläre Endoskopie und endoskopische Präparation sind möglich. Innerhalb des geschlossenen Kompartimentes eines langen Röhrenknochens kann ein “Neocavum” geschaffen werden, in dem endoskopische Manipulation gut möglich ist.AbstractIntroduction. Intramedullary preparation and endoscopy of long bone is not mentioned in literature. We present our first results of experimental intramedullary endoscopy of long bone. Methods. Experimental tests were performed at 4 corpse bones (twice tibia, twice femur). Results. Intramedullary endoscopy and preparation was possible in all cases. A good view for inspection of the medullary canal was achieved by using the endoscope (Wolf GmbH, Germany). Conclusion. Endoscopic preparation and intramedullary endoscopy in the long bone ist possible. By using the endoscopic tools, a “neocavum” for endoscopic manipulation could easily be created.

Compound osteosynthesis for osteolyses and pathological fractures of the proximal femur.

Due to improved oncological therapeutic procedures with longer survival times, the stabilization of osteolyses and pathological fractures is gaining importance. The proximal femur is often affected by metastases. As femoral stability can be compromised by such bone lesions, stabilization as a palliative measure is indicated to restore function and relieve pain. Besides intramedullary osteosynthesis and endoprosthetic reconstruction, compound osteosynthesis is an alternative method for stabilization of the proximal femur. Between 1994 and 2004, 34 compound osteosyntheses were performed for a tumor-caused lesion compromising mechanical stability of the proximal femur. Of those cases, 22 double-plate compound osteosyntheses and 12 single-plate compound osteosyntheses were performed for 9 pathological fractures and 25 osteolyses. Both techniques provided good primary stability. The average survival time after compound osteosynthesis was 14.2 months (range, 0-72 months). Double-plate compound osteosyntheses showed a lower mechanical failure rate than single-plate compound osteosyntheses (14.3% vs 33.3%) and a higher survival probability after 5 years (76.4% vs 38.6%). No surgical revision was required due to perioperative complications in any case. We conclude that reliable stabilization of extensive osteolyses and pathological fractures of the proximal femur can be achieved with compound osteosynthesis. Our data suggest that double-plate compound osteosyntheses is a more favorable technique than single-plate compound osteosyntheses based on a lower rate of mechanical failure and higher survival probability.

Traumatic Atlantooccipital Dislocation

Traumatic atlantooccipital dislocation (AOD) is a severe injury which functionally separates the head from the spine. Neurological compromise or death is the common sequela. We report on a survivor after AOD, who came back to sportive activities after operative stabilization C0–2. Actually, due to the lack of large single institution series, there are no clearly recommended guidelines concerning diagnostics and treatment of AOD. Overlooking a critical review of literature, the inferences of our case are illustrated and diagnostic as well as operative treatment concepts are discussed.

Open arthrolysis of posttraumatic elbow stiffness

BACKGROUND The incidence of relevant posttraumatic functional deficits in the sense of elbow stiffness with less than 30 degrees in extension or flexion less than 120 degrees , is unknown. A differentiation can be made between intraarticular, extraarticular and combined causes. An open procedure is indicated in elbow stiffness after correct analysis of the situation and failure of conservative treatment. MATERIALS AND METHODS An open procedure was carried out on 35 patients between March 1995 and November 2001, 10 (3-24) months after the trauma. The mean age of the 24 men and 11 women was 45 (range 17-75) years. Of the patients 15 had distal humerus fractures, 10 radius head or neck fractures and 12 proximal ulnar fractures. RESULTS Of the patients 11 (31%) had an excellent result in the Cauchoix and Deburge score, 15 (42%) a good, 4 (11%) a fair, 4 (11%) a bad and 1 (3%) a very bad result after a mean follow-up of 21.5 (range 9-60) months. Of the patients 11 (31%) had an excellent result in the Mayo elbow performance score, 14 (40%) a good, 5 (14%) a fair and 5 (14%) a poor result. CONCLUSION Open arthrolysis for severe posttraumatic elbow stiffness carried out 10 months (range 3-24 months) after the accident led to good results in most cases with a clear improvement in functional mobility.