Wolfgang Grechenig

Minimal-invasive treatment of distal femoral fractures with the LISS (Less Invasive Stabilization System) A prospective study of 30 fractures with a follow up of 20 months

BACKGROUND There is no consensus on the best treatment of distal femoral fractures. PATIENTS AND METHODS In a prospective study, we treated 29 patients with 30 distal femoral fractures with the Less Invasive Stabilization System (LISS) from 1997 to 2000. Almost 1/2 of them had open fractures, 1/3 extraarticular type A and 2/3 articular fractures type C (AO classification) and these had been caused by high-energy trauma with concomitant severe injuries or osteoporosis. RESULTS The follow-up examinations after mean 20 (13-42) months consisted of radiographs, and determination of the Lysholm Knee Score and Knee Society Score (KSS). The outcome correlated with the severity of the fracture, anatomic reduction, exact positioning and fixation of the LISS and concomitant injuries. INTERPRETATION We found the LISS for treatment of distal femoral fractures of all types to be a safe procedure with good results after careful planning and experience with this surgical technique. There is usually no need for primary cancellous bone grafting.

Radial avulsion of the triangular fibrocartilage complex in acute wrist trauma: A new technique for arthroscopic repair

The advantages of arthroscopically assisted treatment of intraarticular distal radius fractures, especially the detection of additional carpal lesions, also focus attention on special surgical techniques for operating on these injuries within the same session. When we consider the biomechanical situation, various kinds of triangular fibrocartilage complex (TFCC) lesions, and their arthroscopic aspects, there are probably two possibilities for surgical treatment that are similar to arthroscopic meniscal surgery: resection of flap tears and the refixation of peripherally disinserted TFCC. Avulsions from the ulnar styloid or from the ulnar collateral ligament and the extensor carpi ulnaris tendon can easily and satisfactorily be treated by convenient arthroscopic suture techniques, whereas the reattachment of the triangular disc in the sigmoid notch is very tricky. This problem is solved by a recently developed procedure using the so-called T-Fix-device (Acufex), which provides the possibility of transosseus refixation by closed arthroscopic procedure and therefore guarantees the principle of minimal invasive surgery.

Differences in length and cross-section of semitendinosus and gracilis tendons and their effect on anterior cruciate ligament reconstruction A CADAVER STUDY

The purpose of this anatomical study was to explore the morphological variations of the semitendinosus and gracilis tendons in length and cross-section and the statistical relationship between length, cross-section, and body height. We studied the legs of 93 humans in 136 cadavers. In 43 specimens (46.2%) it was possible to harvest the tendons from both legs. We found considerable differences in the length and cross-section of the semitendinosus and the gracilis tendons with a significant correlation between the two. A correlation between the length of the femur, reflecting height, and the length of the tendons was only observed in specimens harvested from women. The reason for this gender difference was unclear. Additionally, there was a correlation between the cross-sectional area of the tendons and the length of the femur. Surgeons should be aware of the possibility of encountering insufficient length of tendon when undertaking reconstructive surgery as a result of anatomical variations between patients.

The anatomy of the joint as a risk factor for Lisfranc dislocation and fracture-dislocation: an anatomical and radiological case control study

he anatomy of the mortise of the Lisfranc joint between the medial and lateral cuneiforms was studied in detail, with particular reference to features which may predispose to injury. In 33 consecutive patients with Lisfranc injuries we measured, from conventional radiographs, the medial depth of the mortise (A), the lateral depth (B) and the length of the second metatarsal (C). MRI was used to confirm the diagnosis. We calculated the mean depth of the mortise (A+B)/2, and the variables of the lever arm as follows: C/A, C/B and C/mean depth. The data were compared with those obtained in 84 cadaver feet with no previous injury of the Lisfranc joint complex. Statistical analysis used Students two-sample t-test at the 5% error level and forward stepwise logistic regression. The mean medial depth of the mortise was found to be significantly less in patients with Lisfranc injuries than in the control group. Stepwise logistic regression identified only this depth as a significant risk factor for Lisfranc injuries. The odds of being in the injury group is 0.52 (approximately half) that of being a control if the medial depth of the mortise is increased by 1 mm, after adjusting for the other variables in the model. Our findings show that the mortise in patients with injuries to the Lisfranc joint is shallower than in the control group and the shallower it is the greater is the risk of injury.

Computer tomography aided 3D analysis of the distal dorsal radius surface and the effects on volar plate osteosynthesis

The aims of this study were to measure the size of Lister’s Tubercle, the extent of the extensor pollicis longus (EPL) groove and the dihedral angle of the distal dorsal radius. Computer tomography scans of 30 forearms were performed by using a 64-slice Siemens SOMATOM Sensation® CT system (Resolution 0.6 mm). DICOM raw data were calculated to 3D by MIMICS® software (Materialise, Leuven, Belgium). The size of Lister’s Tubercle varied from 1.4 to 6.6 mm (average 3.3 mm) in height radial to the tubercle, and from 5.6 to 18.6 mm (average 13.2 mm) in length. The depth of the EPL groove varied from 0.6 to 3.2 mm (average 1.6 mm). The height on the ulnar side, between the depth of the groove and the tip of the tubercle, varied from 2.2 to 5.8 mm (average 3.4 mm). The dihedral angle of the distal dorsal radius varied from 110° to 135° (average 123°). The variations in height of Lister’s Tubercle and in depth of the EPL groove are considerable. This needs to be taken into account when performing volar plating of distal radius fractures otherwise screws may inadvertently penetrate the dorsal cortex of the radius potentially leading to EPL rupture.

The influence of lateral and anterior angulation of the proximal ulna on the treatment of a Monteggia fracture: AN ANATOMICAL CADAVER STUDY

We have investigated the anatomy of the proximal part of the ulna to assess its influence on the use of plates in the management of fractures at this site. We examined 54 specimens from cadavers. The mean varus angulation in the proximal third was 17.5 degrees (11 degrees to 23 degrees ) and the mean anterior deviation 4.5 degrees (1 degrees to 14 degrees ). These variations must be considered when applying plates to the dorsal surface of the ulna for Monteggia-type fractures. A pre-operative radiograph of the contralateral elbow may also be of value.

Delayed hypopharyngeal and esophageal perforation after anterior spinal fusion: primary repair reinforced by pedicled pectoralis major flap.

Study Design. This report documents a case of delayed hypopharyngeal and esophageal perforation after anterior spinal fusion and reviews relevant literature. Objectives. Presentation of an alternative solution of primary repair and reinforcement of a delayed esophageal and hypopharyngeal perforation after anterior spinal fusion. Summary of Background Data. Anterior plating is generally used for stabilization after cervical spine trauma. Esophageal and hypopharyngeal perforation is a rare but potentially life-threatening complication due to mediastinitis with consecutive septic shock and multiorgan failure. Methods. Our patient was operated on after cervical trauma caused by car accident. The neurologic condition did not improve in the postoperative period. About 4 months later, the patient had increasing dysphagia as well as episodes of odynophagia. Flexible esophagoscopy showed a perforation of a part of the plate from the hypopharynx down to the proximal esophagus. Primary repair reinforced by a pedicled pectoralis major flap was done without complications. Results. Postoperative fluoroscopy as well as endoscopy showed no signs of perforation. Swallowing was possible without any further episodes of dysphagia or odynophagia. Neck movement was unconfined. Conclusions. Primary repair reinforced by pedicled pectoralis major flap has been shown to be an alternative in case of combined hypopharyngeal and esophageal perforation due to orthopedic spine stabilization. Advantage of the pectoralis major muscle flap is no functional loss of neck movement.

Morphometric Analysis of Lister's Tubercle and Its Consequences on Volar Plate Fixation of Distal Radius Fractures

PURPOSE The objective of this study was to measure the size and shape of Listers tubercle and the depth of the extensor pollicis longus (EPL) groove to assess the risk of injury to the EPL tendon when performing volar plating of distal radius fractures. METHODS The length and height of Listers tubercle and the depth of the EPL groove were measured in 100 cadavers. RESULTS The size of Listers tubercle varied from 2 to 6 mm (average, 3.6 mm) in height radial to the tubercle and from 6 to 26 mm (average, 18.3 mm) in length. The depth of the EPL groove varied from 1 to 5 mm (average, 2.8 mm), with 63% being greater than 2 mm in depth. The height between the depth of the groove and the tip of the tubercle varied between 4 and 10 mm (average, 7.1 mm). No correlation was found with gender or right-side or left-side specimens. CONCLUSIONS The individual and combined height of Listers tubercle and the depth of the EPL groove are considerable. This fact needs to be considered when performing volar plating of distal radius fractures because of the possibility that it might be difficult to determine precisely the presence and amount of past-pointing of the distal screws.

The anatomy of the joint as a risk factor for Lisfranc dislocation and fracture-dislocation: AN ANATOMICAL AND RADIOLOGICAL CASE CONTROL STUDY

he anatomy of the mortise of the Lisfranc joint between the medial and lateral cuneiforms was studied in detail, with particular reference to features which may predispose to injury. In 33 consecutive patients with Lisfranc injuries we measured, from conventional radiographs, the medial depth of the mortise (A), the lateral depth (B) and the length of the second metatarsal (C). MRI was used to confirm the diagnosis. We calculated the mean depth of the mortise (A+B)/2, and the variables of the lever arm as follows: C/A, C/B and C/mean depth. The data were compared with those obtained in 84 cadaver feet with no previous injury of the Lisfranc joint complex. Statistical analysis used Students two-sample t-test at the 5% error level and forward stepwise logistic regression. The mean medial depth of the mortise was found to be significantly less in patients with Lisfranc injuries than in the control group. Stepwise logistic regression identified only this depth as a significant risk factor for Lisfranc injuries. The odds of being in the injury group is 0.52 (approximately half) that of being a control if the medial depth of the mortise is increased by 1 mm, after adjusting for the other variables in the model. Our findings show that the mortise in patients with injuries to the Lisfranc joint is shallower than in the control group and the shallower it is the greater is the risk of injury.

Diagnostische Wertigkeit von Nativröntgen, Computer- und Magnetresonanztomographie beim akuten Hyperflexionstrauma des FußesEine prospektive klinische Studie

ZusammenfassungUm zufriedenstellende Ergebnisse in der Behandlung von akuten Hyperflexionstraumen des Fußes erzielen zu können, ist eine exakte Primärdiagnostik zwingend erforderlich, da Verletzungen des Tarsometatarsalgelenkes (Lisfranc-Gelenks) bei alleiniger Verwendung konventioneller Röntgendiagnostik häufig übersehen werden. Ziel vorliegender prospektiver Studie war es, die diagnostische Kapazität von Nativröntgen, CT und MRT in der klinischen Anwendung beim akuten Fußtrauma zu vergleichen.Dazu wurden 75 konsekutive Patienten nach akutem Hyperflexionstrauma (Niedrigenergietrauma) des Fußes in die Studie eingeschlossen. Es handelte sich um 47 Männer und 28 Frauen mit einem Durchschnittsalter von 38 Jahren. Es wurden primär a.-p., seitliche und 45°-Schrägaufnahmen sowie Belastungsaufnahmen im Seitenvergleich angefertigt. Des Weiteren wurden eine Computer- und eine Magnetresonanztomographie durchgeführt.Durch die Nativröntgenaufnahmen konnten 48 metatarsale und 24 tarsale Frakturen sowie Störungen des Gelenksalignments bei 17 Patienten festgestellt werden. Die Belastungsaufnahmen erbrachten keine Erweiterung der Diagnose. Computertomographisch wurden 86 metatarsale und 74 tarsale Frakturen, sowie 31 Fälle von Sub- bzw. Luxationen im Lisfranc-Gelenk und 4 knöcherne Avulsionen des Lisfranc-Ligaments diagnostiziert. Die Magnetresonanztomographie konnte 85 metatarsale und 100 tarsale Frakturen, sowie 31 Alignmentstörungen des Lisfranc-Gelenks und 22 komplette oder partielle Rupturen des Lisfranc-Bands diagnostizieren.Die vorliegende Studie zeigte die klare Überlegenheit von Computer- und Magnetresonanztomographie, verglichen mit der konventionellen Röntgendiagnostik in der Evaluation von knöchernen und ligamentären Verletzungen des Lisfranc-Gelenks. Deshalb muss die Forderung nach Durchführung einer erweiterten Diagnostik beim Hyperflexionstrauma des Fußes gestellt werden.AbstractIn order to gain satisfying results in the treatment of acute hyperflexion trauma to the foot, it is absolutely necessary to achieve an exact primary diagnosis because injuries to the tarsometatarsal joint are frequently missed primarily. Aim of this prospective clinical study was to evaluate the diagnostic reliability of conventional radiography, CT and MRI compared to each other.75 consecutive patients after hyperflexion trauma to the foot were included. There were 47 males and 28 females with a mean age of 38 years. After admittance, pa-, lateral and 45° oblique radiographs were taken as well as stress views in comparison to the contralateral foot. Furthermore, CT and MRI were performed in any patient.By conventional radiography, 48 metatarsal and 24 tarsal fractures were diagnosed as well as 17 cases of malalignment of the Lisfranc joint. Stress radiographies were not able to provide a more accurate diagnosis. By CT scans, however, 86 metatarsal and 74 tarsal fractures were detected. Moreover, we found malalignment in 31 and bony avulsions of Lisfrancs ligament in 4 patients. By MRI, finally, 85 metatarsal, 100 tarsal fractures and 31 cases of malalignment were diagnosed. Additionally, partial or complete tears of Lisfrancs ligament were depicted in 22 patients.The present study could clearly show the superiority of CT and MRI to conventional radiography in diagnosis of bony and ligamentous disorders of the Lisfranc joint. Therefore, extended diagnosis has to be demanded in all cases of hyperflexion trauma to the foot.