Vinzenz Smekal

Elastic Stable Intramedullary Nailing Versus Nonoperative Treatment of Displaced Midshaft Clavicular Fractures : A Randomized, Controlled, Clinical Trial

Objective: To compare elastic stable intramedullary nailing (ESIN) with nonoperative treatment of fully displaced midshaft clavicular fractures in adults. Design: The study was a randomized, controlled, clinical trial. Setting: Level 1 trauma center. Patients and Methods: Sixty patients between 18 and 65 years of age participated and completed the study. They were randomized to either operative or nonoperative treatment with a 2-year follow-up. Intervention: Thirty patients were treated with a simple shoulder sling and 30 patients with ESIN within 3 days after trauma. Main Outcome Measurement: Complications after operative and nonoperative treatments, Disabilities of the Arm, Shoulder and Hand (DASH) score and Constant Shoulder Score for outcome measurement, and clavicular shortening. Results: Fracture union was achieved in all patients in the operative group, whereas nonunion was observed in 3 of 30 patients of the nonoperative group. Two symptomatic malunions required corrective osteotomy in the nonoperative group. Medial nail protrusion occurred in 7 cases in the operative group. Implant failure with revision surgery was necessary in 2 patients after an additional adequate trauma. DASH scores were lower in the operative group throughout the first 6 months and 2 years after trauma, with a significant difference during the first 18 weeks. Constant scores were significantly higher after 6 months and 2 years after intramedullary stabilization. Patients in the operative group showed a significant improvement of posttraumatic clavicular shortening; they were also more satisfied with cosmetic appearance and overall outcome. Conclusions: ESIN of displaced midshaft clavicular fractures resulted in a lower rate of nonunion and delayed union, a faster return to daily activities, and a better functional outcome. Clavicular shortening was significantly lower, and overall satisfaction was higher in the operative group.

Length determination in midshaft clavicle fractures: validation of measurement.

Objectives: To evaluate different methods of length determination in acute displaced midshaft clavicle fractures. Methods: To provide static conditions, 30 patients with healed midshaft clavicle fracture were investigated by comparing all measuring methods described in literature. The investigation included a standardized 15-degree tilted radiograph of the clavicle, a 15-degree up-tilted anteroposterior panorama radiograph of the shoulder girdle, and a posteroanterior thorax radiograph. The difference between both clavicles was also measured clinically with a tape. A computed tomography (CT) scan of the shoulder girdle was conducted with two-dimensional reconstructions of the CT scan serving as a reference method. Shortening was determined as proportional length difference. Clinical measuring was performed by 2 observers, and radiological analyses were performed by 4 independent investigators. Investigators were asked to perform repeated measurements to provide intraobserver data. Results: CT measurements, measurements on a posteroanterior thorax radiograph, and 15-degree up-tilted anteroposterior panorama radiograph of the shoulder girdle showed comparable repeatability. Repeatability for clinical measurements and measurements on 15-degree tilted radiographs of the clavicle were markedly lower. Agreement with CT measurements was highest for the measurements on posteroanterior thorax radiographs. Conclusion: While shortening in clavicle fractures is considered an important parameter in choosing a treatment modality, a standardized method of measurement is essential. Our results suggest determining proportional length differences by taking a posteroanterior thorax radiograph.

Pectoralis-major-Transfer bei chronischer Subskapularisinsuffizienz

ZusammenfassungOperationszielSchmerzfreie Beweglichkeit und Stabilität des Schultergelenks durch Wiederherstellung eines muskulären Gleichgewichts zwischen Innen- und Außenrotatoren.Beseitigung eines ventralen Impingements.IndikationenNicht mehr rekonstruierbarer Riss der Subskapularissehne beim aktiven Patienten.KontraindikationenWenig aktiver Patient ab einem Alter von ca. 60 Jahren.Zusätzliche Infraspinatussehnenruptur.Schultersteife.Cuffarthropathie.OperationstechnikAllgemeinnarkose und „Beach-Chair-Position“ mit frei beweglichem Arm. Deltoideopektoraler Zugang. Darstellung des Tuberculum minus und der gemeinsamen Sehne des Musculus coracobrachialis und des Caput breve musculi bicipitis. Die Hälfte bis zwei Drittel des Ansatzes des Musculus pectoralis major am Humerusschaft werden proximal abgelöst, mit Haltefäden angeschlungen und unter der gemeinsamen Sehne durchgeführt. Schließlich wird die Sehne am Tuberculum minus transossär fixiert, und das Bewegungsausmaß wird geprüft. Dabei muss eine Außenrotation spannungsfrei bis 30° gewährleistet sein.NachbehandlungPostoperativ wird ein Schultergurt für 6 Wochen angelegt, und ab dem 2. postoperativen Tag wird mit passiver Bewegungstherapie begonnen. Die Außenrotation darf erst ab der 7. Woche beübt werden.Ergebnisse23 Patienten konnten zu einer Nachuntersuchung herangezogen werden. In 13 Fällen handelte es sich um einen anterosuperioren Defekt mit nicht mehr rekonstruierbarer Supraspinatussehne. Der präoperative Constant- Score von 35 Punkten konnte postoperativ auf 68 Punkte transverbessert werden. Eine kraftvolle Innenrotation war nicht mehr zu erlangen. Die präoperativ bestehende Impingementsymptomatik wurde behoben.AbstractObjectivePain-free movement and stability of the shoulder joint after restoration of muscular balance between the internal and external rotators.Eradication of anterior impingement.IndicationsIrreparable rupture of the subscapularis tendon in active patients.ContraindicationsLess active patients who are older than about 60 years.Concomitant infraspinatus tendon rupture.Frozen shoulder.Rotator cuff arthropathy.Surgical TechniqueGeneral anesthetic and beach-chair position with the arm freely mobile. Deltopectoral approach. Exposure of the lesser tubercle and the conjoined tendon of coracobrachialis and the short head of the biceps. Half to two thirds of the insertion of pectoralis major at the humeral shaft are detached proximally, held in a suture loop, and passed under the conjoined tendon. The tendon is then fixed transosseously to the lesser tubercle, and range of motion is evaluated. External rotation of up to 30° without tension must be confirmed.Postoperative ManagementA shoulder strap is worn for 6 weeks and passive physiotherapy is commenced on day 2 postoperatively. External rotation can only be practiced after week 7.Results23 patients were available to follow-up. There were 13 cases of anterosuperior defect with irreparable supraspinatus tendon. The preoperative Constant Score of 35 points improved to a postoperative score of 68 points. It was not possible to restore powerful internal rotation. Preoperative impingement syndrome was eradicated.

Severely Comminuted Bicondylar Tibial Plateau Fractures in Geriatric Patients: A Report of 2 Cases Treated With Open Reduction and Postoperative External Fixation

We present 2 cases of C3-type fractures of the tibial plateau in geriatric patients. Our treatment concept-in particular the use of postoperative external fixation-is not yet described in the recent literature and includes initial external fixation, internal fixation after soft tissue consolidation using a median incision, filling of the metaphyseal comminution zone with allogenic cancellous bone obtained from a femoral head, anteromedial and anterolateral fixed-angle double plating, and external fixation postoperatively until osseous healing. The described treatment plan does not provide a valid alternative for the treatment of bicondylar fractures in younger patients. It may be an option for the treatment of C3-type fractures in geriatric patients only.

Transpatellare Refixation der frischen patellanahen Quadrizepssehnenruptur mittels FiberWire

OBJECTIVE Reconstruction of the extensor mechanism of the knee joint by stable suture of the quadriceps tendon. Early functional treatment. INDICATIONS Acute or partial disruption of the quadriceps tendon close to the proximal patella pole with loss of extensor function of the knee joint. CONTRAINDICATIONS Open rupture of the quadriceps tendon with extended soft-tissue damage and high risk of or ongoing inflammation until healing of the soft tissues. Chronic quadriceps tendon rupture. Ruptures at the musculotendinous junction. SURGICAL TECHNIQUE Supine positioning of the patient on a standard operating table with the knee in 30 degrees of flexion. Securing of the proximal tendon stump with two Bunnell sutures using no. 2 Fiber-Wire (Arthrex GmbH, Karlsfeld/Munich, Germany). Creation of a transverse, central trough in the superior pole of the patella. Transosseous refixation of the quadriceps tendon through longitudinal transpatellar drill holes. Intraoperative evaluation of the stability of the suture at 60 degrees of flexion. Repair of the retinacula with multiple interrupted sutures. POSTOPERATIVE MANAGEMENT Partial weight bearing (15-25 kg) for 6 weeks. Knee orthesis for 6 weeks, with increase of the initially allowed flexion of 30 degrees every 2 weeks by another 30 degrees . Initially, continuous passive motion (CPM) and passive movement exercises up to 60 degrees of flexion. After discharge from hospital, outpatient physical therapy with prone active flexion exercises. At the beginning of the 5th week, start with active and passive extension of the knee joint. From the 7th week on, full weight bearing is allowed and coordinative and strengthening exercises should be commenced. Sport activities can gradually be taken up after 3 months. RESULTS Early diagnosis, timely surgical repair and early functional treatment are important for the outcome of quadriceps tendon ruptures. With the presented method, ruptures close to the upper patella pole can be treated. The majority of quadriceps tendon ruptures takes place in this area since the avascular zone found here predisposes to degenerative changes.ZusammenfassungOperationszielWiederherstellung des Streckapparats an der unteren Extremität durch stabile Naht der Quadrizepssehne. Frühe funktionelle Nachbehandlung.IndikationenAkute ansatznahe vollständige oder partielle Ruptur der Quadrizepssehne mit Verlust der Streckfunktion im Kniegelenk.KontraindikationenOffene Sehnendurchtrennung mit deutlichem Weichteilschaden, drohendem oder manifestem Infekt bis zur Sanierung der Weichteile. Chronische Quadrizepssehnenruptur. Rupturen am muskulotendinösen Übergang.OperationstechnikRückenlagerung und Positionierung des Beins auf einer Knierolle in 30° Flexion. Anschlingen des proximalen Sehnenstumpfs mit zwei FiberWire® (Arthrex GmbH, Karlsfeld/München) der Stärke 2 unter Anwendung der Bunnell-Nahttechnik. Schaffung eines Reinsertionsbetts am proximalen Patellapol durch Fräsen einer zentralen Knochenrinne in der Frontalebene. Transossäre Reinsertion der Quadrizepssehne durch longitudinale transpatellare Bohrkanäle und Verknotung am distalen Pol. Intraoperativ passives Beugen bis 60° und Beurteilung der Stabilität der Naht. Feinadaptation der Sehnenenden und Naht des Reservestreckapparats in Einzelknopftechnik.WeiterbehandlungAbrollende Mobilisation für 6 Wochen (15–25 kg). 6 Wochen Knieorthese, initial auf 30° Flexion limitiert. Motorschiene und passive Bewegungsübungen bis 60°. Nach Entlassung ambulante Physiotherapie und Beginn mit aktiver Flexion aus der Bauchlage heraus. Ab der 3. Woche Freigabe der Orthese auf 60°, ab der 5. Woche auf 90° sowie aktive und passive Streckung unter physiotherapeutischer Anleitung. Ab der 7. Woche Vollbelastung sowie Kraftaufbau und Koordinationstraining. Sportverbot für 3 Monate, anschließend stufenweiser Aufbau der sportlichen Aktivität.ErgebnisseFrühzeitige Diagnosestellung und operative Refixation sowie frühe funktionelle Nachbehandlung sind entscheidend für das Behandlungsergebnis von Quadrizepssehnenrupturen. Die vorgestellte Methode erlaubt die Versorgung von patellanahen Sehnenrissen. Die Mehrzahl der Rupturen kommt in diesem Bereich vor, da die sich hier befindliche avaskuläre Zone zu degenerativen Veränderungen prädisponiert.AbstractObjectiveReconstruction of the extensor mechanism of the knee joint by stable suture of the quadriceps tendon. Early functional treatment.IndicationsAcute or partial disruption of the quadriceps tendon close to the proximal patella pole with loss of extensor function of the knee joint.ContraindicationsOpen rupture of the quadriceps tendon with extended soft-tissue damage and high risk of or ongoing inflammation until healing of the soft tissues. Chronic quadriceps tendon rupture. Ruptures at the musculotendinous junction.Surgical TechniqueSupine positioning of the patient on a standard operating table with the knee in 30° of flexion. Securing of the proximal tendon stump with two Bunnell sutures using no. 2 Fiber-Wire® (Arthrex GmbH, Karlsfeld/Munich, Germany). Creation of a transverse, central trough in the superior pole of the patella. Transosseous refixation of the quadriceps tendon through longitudinal transpatellar drill holes. Intraoperative evaluation of the stability of the suture at 60° of flexion. Repair of the retinacula with multiple interrupted sutures.Postoperative ManagementPartial weight bearing (15–25 kg) for 6 weeks. Knee orthesis for 6 weeks, with increase of the initially allowed flexion of 30° every 2 weeks by another 30°. Initially, continuous passive motion (CPM) and passive movement exercises up to 60° of flexion. After discharge from hospital, outpatient physical therapy with prone active flexion exercises. At the beginning of the 5th week, start with active and passive extension of the knee joint. From the 7th week on, full weight bearing is allowed and coordinative and strengthening exercises should be commenced. Sport activities can gradually be taken up after 3 months.ResultsEarly diagnosis, timely surgical repair and early functional treatment are important for the outcome of quadriceps tendon ruptures. With the presented method, ruptures close to the upper patella pole can be treated. The majority of quadriceps tendon ruptures takes place in this area since the avascular zone found here predisposes to degenerative changes.

BILDGEBENDE VERFAHREN: Hochauflösende Sonographie zur Erkennung von Fingerverletzungen beim Sportklettern

Zusammenfassung Der Klettersport zeigt eine steigende Popularitat mit einer Tendenz vom elitaren Individualsport zum Breiten- und Schulsport. Klettertypische Beschwerden finden sich besonders im Fingerbereich (“climbers finger”), wobei neben Ringbandverletzungen auch Uberlastungsbeschwerden auftreten. Neben der klinischen Untersuchung, welche in der Akutphase limitiert sein kann, gewahrleistet die bildgebende Diagnostik, wie die Magnetresonanztomographie und die hochauflosende Sonographie, eine exakte Abklarung. Dabei nimmt die hochauflosende Sonographie einen zentralen Stellenwert in der Diagnose bzw. Differentialdiagnose bei Kletterfingerbeschwerden ein und ist somit entscheidend fur ein adaquates therapeutisches Management.

Operative Management of Anterior Glenohumeral Instability

AbstractIntroduction:Management of glenohumeral instability focuses more on operative treatment, while non-operative management, especially in young, active patients, may cause recurrent instability in a high percentage.Aim:Management of anterior glenohumeral instability, their advantages and limitations, the operative techniques and results will be described and discussed.Materials and Methods:A total of 379 patients who were operated between 1985 and 1994 for recurrent shoulder instability were followed up; 110 patients were managed with open Bankart procedure, 165 patients with arthroscopic Bankart and 98 patients were treated with a bone-block procedure. Follow-up evaluation was performed 53 months on average postoperatively. According to Rowe the functional results were classified as excellent and good in 91% with the open Bankart procedure, 80.6% with the arthroscopic Bankart repair and the results using the bone-block were rated as excellent and good in 95.4%. Overall complication rate was 16.3% (arthroscopic), 6.4% (open Bankart) and 4.4% (bone-block group). In patients with long-time results, degenerative signs at the glenoid and/or the humeral head were evaluated on plane radiographs (according to Rosenberg). In 17 long-term results of the bone-block procedure, Stage I osteoarthritis was identified in 25.5%, but no severe osteoarthrosis (stage II or III), while in the open Bankart group an osteoarthrosis rate of 18.6% (stages II and III) was found.Conclusion:Different types and causes of glenohumeral instability recommend different techniques for operative treatment of anterior glenohumeral instability. The bone-block procedure provided the best results regarding stability and function; long-term radiological results indicate that bony repair prevents and does not cause osteoarthrosis.

SCHULTER- UND ELLENBOGENVERLETZUNGEN BEI BALLSPORTARTEN

Zusammenfassung Dieser Artikel soll dem Leser einen Uberblick uber die Abklarung des Schultergelenkes vermitteln. Spezieller Focus des Interesses ist der Ballsportler mit den typischen Pathologien. Zu erwahnen ist, dass hier nur auf die Diagnostik und nicht auf die Pathologie im Speziellen eingegangen werden konnte. Die akute Verletzung, ausgelost durch diverseste Sturze und Anpralltraumen, unterscheidet sich nicht wesentlich von anderen Sportarten. Die chronisch bzw. subakut auftretenden Beschwerden bei Uberkopfballsportlern bzw. Werfern werden ausgelost durch Schadigung der Rotatorenmanschette, der langen Bizepssehne (bzw. Bizepssehnenanker) und des Kapsellabrumkomplexes mit daraus resultierendem Ungleichgewicht zwischen Stabilitat und Mobilitat. Die gebrauchlichsten Tests und Rontgeneinstellungen werden aufgefuhrt.