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Surgical treatment of most displaced proximal humerus fractures is challenging due to osteoporosis. Locking plates are intended to provide superior mechanical stability. In a prospective multicentre study 131 patients were treated with second generation locked plating (NCB-PH, Zimmer, Inc.). The open procedure (n = 78) was performed using a deltopectoral approach; the minimally invasive technique (n = 53) involved percutaneous reduction and an anterolateral deltoid split approach. Clinical and radiological follow-up was obtained. Improvement in function (ROM) was statistically significant. Fracture type (AO) had the most significant impact on the incidence of complications. The most frequent complications detected were intra-articular screw perforation (15%) and secondary displacement (8%). Complication rate and functional outcome of the NCB-PH are comparable to reports in the literature. Not all problems are likely to be solved by this new generation of implants, i.e. secondary dislocation still occurred in 8% of our patients.

Objectives: To describe the minimally invasive treatment of fractures of the proximal humerus using the Non-Contact-Bridging (NCB) plate. The system allows secondary locking of screws to the plate with a locking cap and polyaxial (30 degrees radius) screw placement., Design: Prospective cohort study., Setting: University Level I trauma center., Patients: Fifty-four patients with unstable fractures of the proximal humerus., Intervention: Minimal anterolateral acromial approach to the proximal humerus, percutaneous fracture reduction, and minimally invasive application of the NCB plate., Main Outcome Measurements: Constant Score and radiologic follow-up (anteroposterior and transscapular). Visual Analog Scale for subjective evaluation of pain and function., Results: After 17 months, the average Constant Score was 66.8 points (87% of the age- and sex-related normal values). Implant-related complications (plate impingement, screw perforation into the glenohumeral joint, loosening of screws) occurred in nine cases (17%). The rate of avascular necrosis was low (5.5%) and no cases of nonunion were seen., Conclusions: The effectiveness of the NCB is similar to other published methods of treatment for fractures of the proximal humerus and potentially provides a less invasive option for this problem. Complication rates and functional outcome in this series are comparable to the literature. An important factor in this technique is the process of percutaneous fracture reduction. The NCB plate is suitable for both a minimally invasive technique or standard open reduction and internal fixation through a deltopectoral approach; the surgeon must decide which approach is best for each particular fracture pattern and should be comfortable with both techniques.

Introduction: Proximal humeral fractures are common in the elderly population and are often associated with osteoporosis. Fixation of unstable proximal humeral fractures is problematic due to loss of fixation in osteoporotic bone. Fixed-angle devices are intended to provide superior mechanical stability due to the principle of an internal fixator. The NCB(R)-PH (non-contact-bridging proximal humerus) plate is a new fixed-angle device that locks the screws to the plate by secondary insertion of a locking cap. The aim of this study was to investigate if and to what extent NCB-PH plates applied in the locked mode provide higher mechanical stability in a proximal humerus fracture model., Methods: For this investigation 16 (8 pairs) fresh frozen cadaveric humeri were used. An AO/ASIF 11-B 1 fracture of the proximal humerus was created in each bone and fixed with the NCB-PH plate. In a paired setting one bone was fixed with the plate in the locked mode and the other with the plate in the non-locked mode. The bones were then subjected to 100 cycles of axial loading and interfragmentary motion was measured. Bones surviving this test were subjected to load-to-failure testing and the force at which failure occurred was recorded., Results: Bones fixed with the plate in the locked mode showed a statistically significant lower (51%) interfragmentary rotation compared to bones fixed with the plate in the non-locked mode. There was also a tendency for the bones fixed with the plate in the locked mode to fail first under higher forces (16%) during load-to-failure testing., Conclusion: The NCB-PH plate provides superior interfragmentary stability when used in the locked mode in a human cadaveric proximal humerus fracture model. Therefore, we recommend that all screws should be inserted in the locked mode. The results suggest that the NCB-PH plate in the locked mode provides higher primary postoperative stability thus permitting early functional treatment of the patient.

Proximal tibial epiphyseal injury is a rare finding in adolescents. We report the case of a 13-year-old boy with simultaneous epiphyseal fractures of both proximal tibiae to illustrate appropriate diagnosis and treatment of this condition. The injury occurred while performing a long jump: a Salter-Harris type II fracture of the right proximal tibia was sustained at take-off and a Salter-Harris type III avulsion fracture of the left tibial tuberosity upon landing. Closed reduction and internal fixation using K-wires were performed on the right side, whereas open reduction and internal fixation were done on the left side, using a lag screw and additional McLaughlin wiring.

Objectives: To describe a minimal anterolateral acromial approach for minimally invasive (MI) treatment of fractures of the proximal humerus (PH) with the Non-Contact-Bridging (NCB) plate., Design: 1) Cadaver study and 2) clinical case series., Setting: 1) University Institute of Anatomy and the 2) University Level I trauma center. SPECIMENS/PATIENTS: 1) Ten fresh frozen human humeri and 2) 22 patients with 22 isolated proximal humeral fractures., Intervention: 1) Minimal anterolateral acromial approach with MI application of the NCB-PH plate followed by dissection of the axillary nerve and 2) MI fracture fixation using this approach and technique of plate insertion., Main Outcome Measures: 1) Integrity of the axillary nerve and evaluation of its relationship to the implant, and 2) early postoperative functional results., Results: In the cadaver study, the nerve directly crossed over the percutaneously inserted plate in all the arms. The nerve then divided into two branches anterior to the plate in eight arms and divided into two branches directly over the plate in two arms. One branch of the axillary nerve in one arm was injured. In the clinical case series, no intraoperative complications relating to the approach or the implant occurred. No symptoms of axillary nerve lesion have been detected so far in the early follow-up., Conclusions: The minimal anterolateral acromial approach is suitable for MI technique to apply the NCB-PH. The relationship of the axillary nerve to the plate is anatomically close. We recommend that strict bone contact be maintained during plate insertion and that screw insertion complies with the guidelines provided for this technique. In a small clinical cases series, the plate and screws were inserted in accordance with these guidelines and no axillary nerve lesions have yet been detected.

Deep infection is one of the most devastating complications after knee fractures. It may be related to the initial fracture status or, more commonly, the surgical intervention. From 1991 to 2003, 12 patients underwent knee fusion to treat resistant infection after complex knee fractures or arthrodesis fractures using the Ilizarov method and frame. There were 9 men and 3 women (mean age, 39.7 years). Two-thirds of the patients had long-standing infection and 5 patients had undergone earlier attempts at knee arthrodesis. Correction of concurrent malalignment was achieved in 2 patients. Bone transport using the same arthrodesis frame was necessary in 2 patients to overcome large bony defects. Solid fusion was achieved in all patients by the end of treatment. The average duration of external fixation was 22 weeks (range: 11-44 weeks). No patients required secondary bone grafting to achieve union. Complications occurred in 6 (50%) patients. The most common problem seen was pin tract infection, but only 2 patients required surgical intervention for its treatment. The study emphasizes the clinical success of the Ilizarov method in knee arthrodesis after infected fractures.

Endoscopic minimally invasive techniques have become an established method of fracture stabilisation in the spine. In view of this fact, anterior stabilisation strategies must be reconsidered, as monosegmental A 3.1 compression fractures are increasingly being stabilised endoscopically from the anterior aspect using minimally invasive techniques. This study investigated the biomechanical necessity of anterior two-point or four-point stabilisation in the instrumentation of mono- and bisegmental fractures. In three biomechanical in vitro studies, burst fracture stabilisation was simulated, and anterior short fixation devices were tested under load with pure moments up to 3.75 Nm to evaluate the biomechanical stabilising characteristics of different kinds of instrumentations in flexion/extension, lateral bending, and axial rotation. Only anterior four-point stabilisation resulted in sufficient primary stability both in mono- and bisegmental instrumentation and therefore represents the standard procedure in open as well as in minimally invasive spinal surgery.

The indications for physiotherapy after supracondylar humeral fractures in children are not clear in the literature, even in the presence of an active or passive limitation of elbow joint motion. The authors therefore performed a prospective randomized study to assess the effectiveness of physiotherapy in improving the elbow range of motion after such fractures. The authors studied two groups of 21 and 22 children with supracondylar humeral fractures Felsenreich types II and III, all without associated neurovascular deficits. All children were treated by open reduction and internal fixation with Kirschner wires inserted from the radial side of the humerus. Postoperative follow-up at 12 and 18 weeks showed a significantly better elbow range of motion in the group with weekly physiotherapy, but there was no difference in elbow motion after 1 year. In each group, one child had an extension deficit of 15 or 20 degrees. The authors conclude that postoperative physiotherapy is unnecessary in children with supracondylar humeral fractures without associated neurovascular injuries.

Calcaneus fractures are a major cause of accident- related invalidity. Long-term results are unsatisfactory with various therapy concepts as reported in the literature. Objective of this study is the long-term clinical and radiological outcome of a patient group treated with a low contact plate. Subjective assessment of function by the patient was an important evaluation criterion. From 01/92 to 12/98 a total of 182 patients with 209 calcaneus fractures were treated. Out of them 95 patients with 109 calcaneus fractures had a follow-up over a period ranging from 6 to 88 months (average 37.9 months). Severe impairment of walking was reported by 34.7 % of the patients. Severe impairment for work was declared by 68.4 % of the patients. 74.7 % of the patients complained middle or severe burden-pain. 64.3 % of the patients felt their quality of life impaired. After the injury 75.8 % of the patients were still employed. Arthrosis of the inferior ankle joint was found in 91.5 % of the cases. Within this collective three patient groups were formed with different follow-up periods to evaluate the temporal course, showing no significant differences. Frequently good functional and subjective results cannot be expected even with standardized operative procedures.

Nine patients with instability and one patient with degeneration of the iliosacral joint were treated surgically. The posterior pelvic ring was stabilized with the assistance of an optoelectronic navigation system. Registration was ensured by using fiducial screws in the iliac crest or by collecting landmarks on the external fixator. Computed tomography scans taken postoperatively provided additional information regarding implant localization in all patients. Accurate placement of 21 of 22 implanted iliosacral screws was observed. Two of the 21 screws touched the wall of the second sacral foramen without perforating the canal. One screw perforated the anterior wall of the sacrum because the navigated guide wire was bent during implantation. The initial results indicate that computer-aided frameless navigation in surgery of the iliosacral joint can facilitate surgical performance during screw stabilization in selected patients. Two important issues must be considered in the clinical application of this technique: first, any relative migration of the iliac and sacral bone structures between computed tomography scans taken preoperatively and intraoperative navigation may result in an intolerable inaccuracy of computer guidance. Second, bending of the guide wire of the tracked power drive, which cannot be accommodated by the navigation system, will lead to misguidance; therefore, only navigated drill sleeves should be used.

Introduction: Femoral head-preserving treatment for femoral neck fractures with cancellous screws is a method widely performed, but its success depends on the quality of primary reduction. The goal of our study was to evaluate the relevance of reduction quality on the clinical outcome., Patients and Methods: We retrospectively analyzed the postoperative reduction result of 39 patients. The angular rotation and the inferior displacement of the proximal fracture fragment were digitally assessed from AP radiographs. The clinical outcome was recorded by a follow-up after a mean 5.5 years., Results: Unsuccessful healing was observed in eight patients, femoral head necrosis in three patients, non-union in two patients, implant loosening in one patient, and posttraumatic arthritis in two patients, all resulting in the need for a total hip replacement. This clinical course was strongly associated with a primary reduction in varus position, whereas reduction in anatomic or valgus angulation had no negative effect on the clinical outcome. An inferior offset was no negative predictor for successful healing., Conclusion: We conclude that a non-anatomic reduction in varus angulation significantly increases the risk of healing failure and therefore should be avoided. Reduction in valgus position should be performed if secondary redislocation is imminent.

Objective: Current recommendations for spinal implant testing do not consider the determination of axial compression forces of the overbridging implant on the strut graft. No direct data exist on the influence of load transfer through the strut graft and of the kind of instrumentation, especially in thoracolumbar corpectomy models., Design: Therefore in this biomechanical in vitro study a method for measurement of the axial compression force acting across the strut graft in different thoracolumbar instrumentations was developed., Methods: In this in vitro study, a corpectomy model was simulated and anterior, posterior and combined short fixation devices currently available were tested under pure moments to evaluate their biomechanical stabilizing characteristics. Range of motion, neutral zone and the axial compressive force acting on the strut graft were measured continuously in the three primary directions., Results: Without loads, the combined stabilization and followed by anterior instrumentation created a higher axial compression force than the dorsal instrumentation on the strut graft. Especially during maximal extension there was no axial compression of the dorsal instrumentation on the strut graft, which resulted in an increase of the range of motion., Conclusion: The feasibility of the new method was demonstrated in this study. For the purpose of standardization and comparison it should be considered in spinal implant testing.

Due to the lack of an appropriate instrumentation system for minimally invasive procedures to treat spinal fracture, a new thoracoscopically implantable stabilization system was developed. This report describes the new implant design and implantation technique. In a biomechanical in vitro study, an anterior corpectomy model representing the worst case of burst fracture instability was simulated, and the primary stability parameters of the new system were evaluated in comparison to a dorsal stabilization system. With the interbody graft and fixation, the new system demonstrated higher stabilizing effects in flexion/extension and lateral bending and restored axial stability beyond the intact spine and the dorsal stabilization system. Considering all the advantages of the endoscopic procedure and this biomechanical characterization, the clinical trial is warranted; its usefulness has been demonstrated in more than 150 cases in a multicenter study to date.

In this retrospective clinical study the incidence of complications in 58 consecutive, with anterior screw fixation stabilized patients after fractures of the odontoid process is evaluated. In 51 patients the fracture has been defined as type II according to Anderson, in 6 patients an oblique type II fracture was present and one patient showed a cephalad type III fracture. Preoperatively, in only 19 % of the patients (n = 11) no dislocation of the dens occurred. 32 patients were treated with single screw osteosynthesis, in 26 patients two screws were implanted. Significant complications with clinical relevance were registered in 14 patients (24 %), in 10 cases (17 %) an operative reintervention was required. Intraoperatively, in one patient a rupture of the carotid artery while winding around the motor drill occurred and in another case a complete malplacement of the screw posteriorly to the odontoid process was observed. A clearly excentric positioning of the implant was evaluated in 5 patients with a consecutive high rate of implant migration (n = 3). Two patients died perioperatively not related to the cervical injury. Postoperatively, one patient with a wound infection due to an iatrogenic perforation of the esophagus required reoperation as well as 4 patients with instability because of implant migration. Patients beyond the age of 65 years (n = 3) were significantly overrepresented in that group. In one case, the secondary intervention was caused by a pseudarthrosis of the dens axis. Complications without any relevance to the clinical and functional long term result were fusions in malposition of the odontoid process in 14 patients (24 %) and 10 (17 %) marginal screw perforations laterally. Differences in the use of one or two screws have not been observed in this study, although the investigations showed a tendency between marginal lateral screw perforations and double screw osteosynthesis and an increasing number of complications in the geriatric cohort.

During a period of 12 years (1983-1994) we operated 13 patients with fractures involving the distal epiphyseal cartilage of the femur. All patients could be followed up in clinical and radiological examination following the completion of growth. By examination no patients had any complaints. The clinical examination revealed no limitation in range of motion of the hip or knee joint compared to the other side in any of the patients. 5 patients out of 13 (38%) were found to have a correct axial alignment with no axis deviation, shortening or lengthening of the leg. The other 8 patients (62%) presented the following one- or multidimensional deformities (compared to the contralateral, uninjured femur): 2 patients had varus deformities, 5 patients had valgus deformities, the axial malalignment in the frontal plane was always less than 10 degrees in all cases. 5 patients were found to have a shortened femur (between 8 and 19 mm), while an elongation of the primarily injured femur (10 and 15 mm) was established in 2 patients. On the basis of this study, we recommend that clinical and, if necessary, radiological and/or sonographic examinations are performed following the completion of growth in all patients with injuries involving the epiphyseal plate of the distal femur.

The anterior interbody fusion with instrumentation seems to be the standard procedure in unstable traumatic lesions of the lower cervical spine. The goal of this study was to objective the outcome of patients, treated by only temporary stabilisation of the injured motion segment (without bone-graft fusion). Between 1990 and 1998 155 patients with traumatic lesions of the cervical spine were treated operatively, in 22 cases transfixation of the injured level without bone-graft application was performed, an implant-removal was carried out in 12 patients so long. Only patients were included into the study, who were less then 45 years old at trauma and who had no trauma related osseous or disc encrouchment of the spinal canal. Not included were patients with degenerative formations of the cervical spine at time of trauma. Until follow up all patients with implantat removal returned back to work in their former profession, 11 of 12 patients classified their result as excellent or good. No secondary instabilities or postraumatic disc prolapse were observed. Restmobility in flexion/extension of the injured level was demonstrated in 8 patients. The preservation of traumatized motion segments may reduce the incidence of degenerative alterations and hypermobilities in adjacent levels. The transfixation technique in anterior procedures leads to a reduced time of spinal exposure, complications as a result of spinal graft manipulation, pseudarthrosis or donor graft site problems are no more relevant.

We report a splint system for a protected mobilization program (termed dynamic treatment) of proximal phalangeal fractures. This program can be used for nonoperative treatment or after operative treatment. Intra-articular fractures of the proximal phalanx at the metacarpophalangeal joint were included. The custom-molded 2-component thermoplastic splint allows motion of the proximal and distal interphalangeal joints. It was developed to allow bone healing and recovery of motion at the same time. We evaluated the clinical and radiologic results of a consecutive series of 48 displaced proximal phalangeal fractures in 45 patients who received dynamic treatment. Fracture consolidation was achieved in all patients and bone healing and recovery of full active motion was achieved simultaneously in all but 4 patients by 6 weeks. The advantage of this splint system is the variability of its application. The splint can be used both for nonsurgical and surgical management. It can be removed to change dressings and for radiologic evaluations. The period of dynamic treatment can be determined individually in each case.

Although fractures of the cuboid are rare, they can be very disabling. The diagnosis is often missed, and overlooked cuboid fractures can lead to severe alterations in foot mechanics and function. We report the case of a displaced compression fracture of the cuboid in an 8-year-old girl after a fall from a height, which we treated by open reduction, bone grafting, and internal fixation. Follow-up examination 2 years after the injury revealed a very good result. Cuboid fractures should be considered in the differential diagnosis of limping toddlers. Children seen with pain, swelling, and inability to bear weight on the lateral aspect of the foot require proper evaluation and treatment.

Fractures of the cuboid are very rare. During the last 10 years four patients with isolated fractures of the cuboid have been treated in our hospital. The displaced fractures were treated by open reduction, bone grafting where necessary, and internal fixation. At the time of follow-up the results concerning pain and function were good to excellent and better than those previously reported for conservative treatment. We recommend this treatment for fractures with displacement of one or more of the articular surfaces or with shortening of the lateral arch of the foot.

Open reduction and internal fixation of intraarticular calcaneus fractures have been increasingly emphasized in recent years. Operation of most of these fractures is via an extended lateral approach. Different implants are used to stabilize the often complex fractures. We have developed a low contact plate that is specially designed for calcaneal fractures. Because the design is based on the anatomy of the calcaneus, all types of fractures can be treated. The plate has a large number of holes to accommodate screw fixation. Our results in 36 cases were comparable to those of other series using open reduction and internal fixation with plates and the demands on the plate were fulfilled.

Quality control after treatment of pelvic injuries is often poor because many criteria of assessment lack objectivity. In order to attain improved comparability of results, we present a scoring system including subjective as well as functional and radiological criteria. The assessment is based on a calculation according to the importance of the criteria. The total score supplies the final result with a breakdown into excellent, good, fair and poor. 33 patients with type B and C injuries (Tile) underwent evaluation with this scoring system. We found 15 excellent, 10 good, 2 fair and 6 poor results. The score showed that patients' most frequent handicap was pain (median 60% of maximum score). Hip mobility was hardly affected, and from the radiological point of view it appeared that alterations of pelvic symmetry and symphysis were most common. Our proposal is to apply this scoring system on a wide basis, because only with a great number of patients can the effectiveness of the score be tested and different ways of treatment assessed with regard to early and late results. Our system could be a useful contribution to sufficient quality control, particularly after such complex and severe injuries.

A wide range of workable instrumentation is available for the treatment of proximal humeral fractures, whereas osteosynthesis of scapular fractures is commonly achieved by plate/screw fixation. Older persons are confronted with a steadily rising incidence of osteoporotic fractures. Especially for this group of patients, minimally invasive and minimally instrumented surgical procedures, such as K-wiring and bone sutures, seem to have superseded plate fixation. For the treatment of scapular fractures, an important question remains: Which fracture types provide better functional results with open reduction and internal fixation, and which with conservative treatment? Our indications for an operative procedure are limited to the floating shoulder, dislocated scapular neck fracture, and dislocated glenoid fracture.

Ten patients who had had osteosynthetic repairs of bone defects carried out by means of bone grafts were studied. It was shown that magnification radiography permitted better and more complete evaluation of the healing process. Trabecular bone structure can be recognised and changes in the configuration and position of the trabeculae during their incorporation into the bone can be evaluated.

"Osteosynthesis" or internal fixation is the term used for operative reduction of bone fragments. The aim of the procedure is to effect such stable fixation that the affected extremity may be moved freely. The paper gives a survey of the technical basis of and indications for modern methods of internal fixation.

The external fixator ("fixateur externe") is today's method of choice in the treatment of lower leg fractures with severe damage to the soft parts. The various application techniques and angles of application of this device entail varying stability and are characterized by certain advantages and drawbacks. Basing on detailed biomechanical studies and experience with patients, the authors prefer the rectangular mode of application using Schanz screws. If the type of fracture allows, a combination of minimal osteosynthesis and external tensor is used; this can significantly enhance the stability. In 42 patients of a total of 56 during 1978-1980 with second-grade and third-grade open fractures of lower leg, combination with minimal osteosynthesis was effected (traction screw). Of 44 patients followed up, 19 achieved stability to load within an average period of 19.8 weeks. If there is no osseous bridging 10-12 weeks after initial treatment, additional measures such as spongiosaplasty and changeover to stable inner fixation with plates become necessary. Following plate osteosynthesis with additional spongiosaplasty, full load was permissible on the average 14 weeks after this procedure in 23 patients. The course was more complicated in the case of the 2 remaining patients; it took up to 45 weeks until full load became permissible.