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Purpose: Optimal surgical treatment of high-grade acromioclavicular joint dislocations is still controversially discussed. The purpose of the present controlled laboratory study was to evaluate whether a polydioxansulfate (PDS(®)) cord augmentation with separate reconstruction of the coracoclavicular (CC) ligaments and the acromioclavicular (AC) complex provides sufficient vertical stability in a biomechanical cadaver model., Methods: Twenty-four shoulders of fresh-frozen cadaveric specimen were tested. Cyclic loading and load to failure protocol was performed in vertical direction on 12 native AC joints and repeated after reconstruction. The reconstruction of the coracoclavicular ligament was performed using two CC PDS cerclages and an additional AC PDS cerclage., Results: In static load testing for vertical force, the native AC joint complex measured 590.1 N (±95.8 N), elongation 13.4 mm (±2.1 mm) and stiffness 48.7 N/mm (±12.0 N/mm). The mean maximum load to failure in the reconstructed joints was 569.9 N (±97.9 N), elongation 18.8 mm (±4.7 mm) and stiffness 37.9 N/mm (±8.0 N/mm). During dynamic testing of the reconstructed AC joints, all specimens reached the critical elongation of 12.0 mm, defined as clinical failure between 200 and 300 N. The mean amount of repetitions at clinical failure was 305. A plastic deformation of the reconstructed specimens throughout cyclic loading could not be detected., Conclusion: The AC joint reconstruction with acromioclavicular and coracoclavicular PDS cord cerclages did not provide the aspired vertical stability in a cadaver model., Level of Evidence: Basic Science Study.

Background: The aim of this study was to compare the outcome of open reduction versus closed reduction of midclavicular fractures using elastic stable intramedullary nailing (ESIN) in both groups., Methods: Titanium elastic nails were used to treat 40 patients undergoing minimally invasive ESIN between December 2006 and July 2009. A total of 19 patients were treated with a closed reduction and 21 patients required open reduction., Results: The Constant Score revealed no significant differences between the two groups (closed 87.4±9.0; open 85.3±7.1) nor did the DASH Score (closed: 5.0±6.5; open 5.8±7.3). The strength measurement of shoulder abduction was consistent in each group: 75.7±22.0 N in the closed reduction group and 74.2±26.0 N in the group with open treatment., Conclusion: There was no difference comparing right- and left-sided injuries and the outcomes were consistent irrespective of the treatment method. When appropriately indicated open and closed intramedullary nailing are very successful modalities of treatment. There were no significant differences in shoulder function after either procedure.

Background: Fractures of the medial clavicle third are rare injuries. Even in case of significant fracture displacement, their therapeutic management has been nonoperative. Recently, surgical intervention has become mandatory for displaced fractures types to prevent non-union and functional complaints, but the optimal operative strategy is being discussed controversially., Case Presentation: We describe the case of a 63-year-old male patient with a significantly displaced medial clavicle fracture after failed conservative treatment resulting in restricted, painful shoulder function. The patient underwent open reduction and osteosynthesis with an anatomically precontoured locking compression plate (LCP). One year after surgery the patient is free of complaints and has returned to his preinjury activity level without any functional restrictions., Conclusion: As a not yet reported operative approach, anatomically preshaped locking plating seems to be an effective fixation method for displaced fractures of the medial clavicle third. The operative management is described in detail and discussed with the current literature. Based on the presented case, we underline the statement that displaced medial clavicle fractures should be surgically addressed to avoid late damage.

Compartment syndrome of the thigh is a rare condition, potentially resulting in devastating functional outcome. Increasing intracompartmental pressure which suppresses microcirculation and capillary perfusion may lead to cellular anoxia and muscle ischemia. The muscle compartments in the thigh have a more compliant fascia and blend anatomically into the open compartments of the pelvis, thus compensating higher volumes than the compartments in the lower leg. We present a previously unreported case in which the limb of a 36-year-old man was run over by a 25-ton truck. He presented with a sensomotor deficit in his left lower leg with full paralysis of the shank muscles and absence of all foot pulses. CT scan showed a huge haematoma in the thigh with active bleeding out of the popliteal artery into the haematoma which has already expanded into the muscle compartments of the lower leg. The limb had a disastrous compartment syndrome of the thigh and lower leg with disruption of the popliteal neurovascular bundle; however, no bones in the limb were fractured. A complete fasciotomy of all the lower limb muscle compartments was immediately performed. The artery was reconstructed with interposition of the smaller saphenous vein, which was already interrupted through the initial trauma.

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.

The optimal treatment for proximal humeral fractures is controversial. Few data exist concerning the influence of the surgical approach on the outcome. The purpose of this study was to evaluate the clinical and radiological outcomes of proximal humeral fractures treated with locking plate fixation through a deltopectoral vs an anterolateral deltoid-splitting approach. Of 86 patients who met the inclusion criteria, 70 were available for follow-up examination. Thirty-three patients were treated through a deltopectoral approach and 37 through an anterolateral deltoid-splitting approach. In all cases, open reduction and internal fixation with a PHILOS locking plate (Synthes, Umkirch, Germany) was performed. Clinical follow-up included evaluation of pain, shoulder mobility, and strength. Constant score and Disabilities of the Arm, Shoulder and Hand (DASH) score were assessed. A clinical neurological examination of the axillary nerve was also performed. Consolidation, reduction, and appearance of head necrosis were evaluated radiographically. After a mean follow-up of 33 months, Constant scores, DASH scores, and American Shoulder and Elbow Surgeons scores showed no significant differences between the groups. Clinical neurologic examination of the axillary nerve revealed no obvious damage to the nerve in either group. Deltopectoral and anterolateral detoid-splitting approaches for plate fixation of proximal humeral fractures are safe and provide similar clinical outcomes. The results of this study suggest that the approach can be chosen according to surgeon preference., (Copyright 2012, SLACK Incorporated.)

Purpose: In 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., Methods: Between 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)., Results: The 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%)., Conclusion: Open 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 Evidence: Case series, Level IV.

Purpose: Fractures of the tibial plateau are among the most severe injuries of the knee joint and lead to advanced gonarthrosis if the reduction does not restore perfect joint congruency. Many different reduction techniques focusing on open surgical procedures have been described in the past. In this context we would like to introduce a novel technique which was first tested in a cadaver setup and has undergone its successful first clinical application., Methods: Since kyphoplasty demonstrated effective ways of anatomical correction in spine fractures, we adapted the inflatable instruments and used the balloon technique to reduce depressed fragments of the tibial plateau., Results: The technique enabled us to restore a congruent cartilage surface and bone reduction., Conclusions: In this technique we see a useful new method to reduce depressed fractures of the tibial plateau with the advantages of low collateral damage as it is known from minimally invasive procedures.

Study Goals: The aim of the study was to evaluate the therapeutic benefit of CaReS®, a type I collagen hydrogel-based autologous chondrocyte implantation technique, for the treatment of osteochondral defects of the knee (Outerbridge grades III and IV) within a prospective multicenter study., Material and Methods: A total of 116 patients in 9 clinical centers were treated with CaReS between 2003 and 2008. The Cartilage Injury Evaluation Package 2000 of the International Cartilage Repair Society (ICRS) was employed for data acquisition and included the subjective International Knee Documentation Committee score (IKDC score), the pain level (visual analog scale, VAS), the physical and mental SF-36 score, the overall treatment satisfaction and the functional IKDC status of the indexed knee. Follow-up evaluation was performed 3, 6 and 12 months after surgery and annually thereafter., Results: The mean defect size treated was 5.4 ± 2.7 cm(2) with 30% of the cartilage defects being  ≤4 cm(2) and 70%  ≥4 cm(2). The mean follow-up period was 30.2 ± 17.4 months (minimum 12 months and maximum 60 months). The mean IKDC score significantly improved from 42.4 ± 13.8 preoperatively to 70.5 ± 18.7 (p < 0.01) in the mean follow-up period. Global pain level significantly decreased (p < 0.001) from 6.7 ± 2.2 preoperatively to 3.2 ± 3.1 at the latest follow-up. Both the physical and mental components of the SF-36 score significantly increased. At the latest follow-up 80% of the patients rated the overall treatment satisfaction as either good or very good. The functional IKDC knee status clearly improved from preoperative to the latest follow-up when 23.4% of the patients reported having no restriction of knee function (I), 56.3% had mild restriction (II), 17,2% had moderate restriction (III) and 3.1% revealed severe restriction (IV)., Conclusions: The CaReS technique is a clinically effective and safe method for the reconstruction of isolated osteochondral defects of the knee joint and reveals promising clinical outcome up to 5 years after surgery. A longer follow-up period and larger patient cohorts are needed to evaluate the sustainability of CaReS treatment.

Background: Fracture-healing depends on interfragmentary motion. For improved osteosynthesis and fracture-healing, the micromotion between fracture fragments is undergoing intensive research. The detection of 3D micromotions at the fracture gap still presents a challenge for conventional tactile measurement systems. Optical measurement systems may be easier to use than conventional systems, but, as yet, cannot guarantee accuracy. The purpose of this study was to validate the optical measurement system PONTOS 5M for use in biomechanical research, including measurement of micromotion., Methods: A standardized transverse fracture model was created to detect interfragmentary motions under axial loadings of up to 200 N. Measurements were performed using the optical measurement system and compared with a conventional high-accuracy tactile system consisting of 3 standard digital dial indicators (1 μm resolution; 5 μm error limit)., Results: We found that the deviation in the mean average motion detection between the systems was at most 5.3 μm, indicating that detection of micromotion was possible with the optical measurement system. Furthermore, we could show two considerable advantages while using the optical measurement system. Only with the optical system interfragmentary motion could be analyzed directly at the fracture gap. Furthermore, the calibration of the optical system could be performed faster, safer and easier than that of the tactile system., Conclusion: The PONTOS 5 M optical measurement system appears to be a favorable alternative to previously used tactile measurement systems for biomechanical applications. Easy handling, combined with a high accuracy for 3D detection of micromotions (≤ 5 μm), suggests the likelihood of high user acceptance. This study was performed in the context of the deployment of a new implant (dynamic locking screw; Synthes, Oberdorf, Switzerland).

Recent publications suggested that monocytes might be an attractive cell type to transdifferentiate into various cellular phenotypes. Aim was, therefore, to evaluate the potential of blood monocytes to transdifferentiate into osteoblasts. Monocytes isolated from peripheral blood were subjected to two previously published treatments to obtain unique, multipotent cell fractions, named programmable cells of monocytic origin (PCMOs) and monocyte-derived mesenchymal progenitor cells (MOMPs). Subsequently, MOMPs and PCMOs were treated with osteogenic differentiation medium (including either vitamin D or dexamethasone) for 14 days. Regarding a variety of surface markers, no differences between MOMPs, PCMOs, and primary monocytes could be detected. The treatment with osteogenic medium neither resulted in loss of hematopoietic markers nor in adoption of mesenchymal phenotype in all cell types. No significant effect was observed regarding the expression of osteogenic transcription factors, bone-related genes, or production of mineralized matrix. Osteogenic medium resulted in activation of monocytes and appearance of osteoclasts. In conclusion, none of the investigated monocyte cell types showed any transdifferentiation characteristics under the tested circumstances. Based on our data, we rather see an activation and maturation of monocytes towards macrophages and osteoclasts.

Background: The Cartilage Regeneration System (CaReS) is a novel matrix-associated autologous chondrocyte implantation (ACI) technique for the treatment of chondral and osteochondral lesions (Outerbridge grades III and IV). For this technology, no expansion of the chondrocytes in a monolayer culture is needed, and a homogeneous cell distribution within the gel is guaranteed., Purpose: To report a prospective multicenter study of matrix-associated ACI of the knee using a new type I collagen hydrogel (CaReS)., Study Design: Case series; Level of evidence, 4., Methods: From 2003 to 2008, 116 patients (49 women and 67 men; mean age, 32.5 ± 8.9 years) had CaReS implantation of the knee in 9 different centers. On the basis of the International Cartilage Repair Society (ICRS) Cartilage Injury Evaluation Package 2000, the International Knee Documentation Committee (IKDC) score, pain score (visual analog scale [VAS]), SF-36 score, overall treatment satisfaction and the IKDC functional status were evaluated. Patient follow-up was performed at 3, 6, and 12 months after surgery and annually thereafter. Mean follow-up was 30.2 ± 17.4 months (range, 12-60 months). There were 67 defects of the medial condyle, 14 of the lateral, 22 of the patella/trochlea, and 3 of the tibial plateau, and 10 patients had 2 lesions. The mean defect size was 5.4 ± 2.4 cm(2). Thirty percent of the defects were <4 cm(2) and 70% were >4 cm(2)., Results: The IKDC score improved significantly from 42.4 ± 13.8 preoperatively to 70.5 ± 18.7 (P < .001) at latest follow-up. Global pain level significantly decreased (P < .001) from 6.7 ± 2.2 preoperatively to 3.2 ± 3.1 at latest follow-up. There also was a significant increase of both components of the SF-36 score. The overall treatment satisfaction was judged as very good or good in 88% by the surgeon and 80% by the patient. The IKDC functional knee status was grade I in 23.4%, II in 56.3%, III in 17.2%, and IV in 3.1% of the patients., Conclusion: Matrix-associated ACI employing the CaReS technology for the treatment of chondral or osteochondral defects of the knee is a safe and clinically effective treatment that yields significant functional improvement and improvement in pain level. However, further investigation is necessary to determine the long-term viability and clinical outcome of this procedure.

Fractures of the radial head and neck are the most common involving the elbow and account for 5 % of all fractures in adult individuals. Due to the complex anatomy and biomechanics of the elbow joint radial head fractures are challenging, particularly the comminuted ones. Detailed knowledge of the complex joint anatomy, biomechanics and operative approaches are indispensable for analysing and building a treatment plan. The aim of radial head fracture treatment is to restore the anatomy and joint kinematics, achieve a stable and pain-free range-of-motion and to avoid posttraumatic degenerative changes. Treatment depends on the type of fracture and accompanying injuries. It ranges from conservative treatment with early initiation of physical therapy to open reduction and internal fixation. Sophisticated reconstructive efforts with combined screw- and plate-osteosynthesis, partial resection or radial head arthroplasty are needed in comminuted fractures. The purpose of this article is to give a detailed review of the anatomy, biomechanics and fracture mechanism. Clinical examination techniques are displayed and operative approaches as well as the conservative and operative treatment algorithms are illustrated., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: In the long-term follow-up after debridement, microfracture, or drilling of osteochondral lesions in the elbow, subsequent osteoarthritis is a problem. Osteochondral transplantation for these defects has become a more common procedure. However, long-term results are unknown., Purpose: This study was undertaken to evaluate long-term clinical and radiologic outcomes of advanced osteochondral lesions in the elbow treated with osteochondral transplantation., Study Design: Case series; Level of evidence, 4., Methods: The study included 8 patients with osteochondral lesions in the elbow who were treated by autologous osteochondral transplantation between 1996 and 2002. Patients (average age, 17 years) were evaluated pre- and postoperatively by Broberg-Morrey score to assess elbow function and by American Shoulder and Elbow Surgeons (ASES) score for pain analysis. In addition, radiographs (at the first postoperative day, and at 5-year and 10-year follow-up) and magnetic resonance images (8 to 12 weeks postoperatively, and at 5-year and 10-year follow-up) were made to evaluate the joint status. At last follow-up (range, 8-14 years postoperatively), 7 of 8 patients were seen for clinical examination and radiologic analysis., Results: The Broberg-Morrey score increased from an average of 75.9 ± 13.1 to 96.4 ± 2.4 and ASES score significantly improved as follows: worst pain, 7.9 ± 1.1 to 1.6 ± 1.9; rest pain, 3.14 ± 2.7 to 0.6 ± 1.5; weight-lifting pain, 7.6 ± 0.8 to 3.1 ± 1.6; and repetitive movement pain, 5.3 ± 2.4 to 1.6 ± 1.5. Compared with the contralateral side, there was a mean preoperative flexion lag of 12.5° ± 11.6°. At the final follow-up, flexion was free. The mean extension lag was reduced from average 5.4° ± 5.7° to 0°. Radiographs of 2 patients made at final follow-up showed mild signs of osteoarthritis (Kellgren and Lawrence grade I). Postoperative magnetic resonance images showed graft viability in all and a congruent chondral surface in 6 of 7 patients., Conclusion: Clinical long-term results after osteochondral transplantation in the elbow are good to excellent and comparable with midterm results in the literature. Therefore, this technique is a reliable option for satisfactory long-term results regarding treatment of advanced osteochondral lesions in the elbow.

Purpose: This study was designed to present the novel technique of intramedullary cortical button fixation for distal biceps tendon repair via a single-limited anterior portal., Methods: To reattach the ruptured biceps tendon at the radial tuberosity, two Bicepsbutton(™) (Arthrex, Naples, FL, USA) were intramedullary positioned to the anterior cortex. The surgical procedure is described in detail. This technique has been performed in a first series of 3 patients with acute distal biceps tendon ruptures., Results: All patients were very satisfied after surgery and would undergo the same surgical procedure again. All patients regained full range of elbow motion with comparable strength of forearm supination and elbow flexion measured against the uninjured arm at 6 months of follow-up. No neurovascular complications have been occured., Conclusion: Double intramedullary cortical button repair has shown to be a safe and reliable fixation method for distal biceps tendon rupture in a small series of patients. Preliminary results are encouraging.

Background: Extramedullary cortical button-based fixation for distal biceps tendon ruptures exhibits maximum load to failure in vitro but cannot restore the anatomic footprint and has the potential risk for injury to the posterior interosseous nerve., Hypothesis: Double intramedullary cortical button fixation repair provides superior fixation strength to the bone when compared with single extramedullary cortical button-based repair., Study Design: Controlled laboratory study., Methods: The technique of intramedullary cortical button fixation with 1 or 2 buttons was compared with single extramedullary cortical button-based repair using 12 paired human cadaveric elbows. All specimens underwent computed tomography analysis to determine intramedullary dimensions of the radial tuberosity as well as the thickness of the anterior and posterior cortices before biomechanical testing. Maximum load to failure and failure modes were recorded. For baseline measurements, the native tendon was tested for maximum load to failure., Results: The intramedullary area of the radial tuberosity provides sufficient space for single or double intramedullary cortical button implantation. The mean thickness of the anterior cortex was 1.13 ± 0.15 mm, and for the posterior cortex it was 1.97 ± 0.48 mm (P < .001). We found the highest loads to failure for double intramedullary cortical button fixation with a mean load to failure of 455 ± 103 N, versus 275 ± 44 N for single intramedullary cortical button fixation (P < .001) and 305 ± 27 N for single extramedullary cortical button-based technique (P = .003). There were no statistically significant differences between single intramedullary and single extramedullary button fixation repair (P = .081). The mean load to failure for the native tendon was 379 ± 87 N., Conclusion: Double intramedullary cortical button fixation provides the highest load to failure in the specimens tested., Clinical Relevance: Double intramedullary cortical button fixation provides reliable fixation strength to the bone for distal biceps tendon repair and potentially minimizes the risk of posterior interosseous nerve injury. Further, based on a 2-point-fixation, this method may offer a wider, more anatomic restoration of the distal biceps tendon to its anatomic footprint.

Proximal ulna fractures are common injuries in the upper extremity. The severity of injury ranges from isolated olecranon fractures to complex elbow fracture dislocations. Relevant anatomic features of the proximal ulna for fracture management are presented in the first part of this article. Furthermore, standard and recent techniques of surgical treatment are described in detail for olecranon and Monteggia fractures as well as for fractures of the coronoid process. Functional outcome and complications of fracture treatment are discussed., (© Georg Thieme Verlag KG Stuttgart · New York.)

Fractures of the distal humerus are rare and count only for a small number of all fractures in mature patients. Due to demographic changes surgeons will be faced with an increasing number of complex multifragmentary fractures with diminished bone quality. As conservative treatment frequently leads to limited and painful elbow function, open reduction and stable internal fixation with early range of motion exercises are considered the gold standard. Detailed knowledge of the complex articular anatomy, the biomechanics, operative approaches and available implants is needed for the proper management of these complex fractures., (© Georg Thieme Verlag KG Stuttgart · New York.)

Smokers frequently suffer from impaired fracture healing often due to poor bone quality and stability. Cigarette smoking harms bone cells and their homeostasis by increased formation of reactive oxygen species (ROS). The aim of this study was to investigate whether Quercetin, a naturally occurring antioxidant, can protect osteoblasts from the toxic effects of smoking. Human osteoblasts exposed to cigarette smoke medium (CSM) rapidly produced ROS and their viability decreased concentration- and time-dependently. Co-, pre- and postincubation with Quercetin dose-dependently improved their viability. Quercetin increased the expression of the anti-oxidative enzymes heme-oxygenase- (HO-) 1 and superoxide-dismutase- (SOD-) 1. Inhibiting HO-1 activity abolished the protective effect of Quercetin. Our results demonstrate that CSM damages human osteoblasts by accumulation of ROS. Quercetin can diminish this damage by scavenging the radicals and by upregulating the expression of HO-1 and SOD-1. Thus, a dietary supplementation with Quercetin could improve bone matter, stability and even fracture healing in smokers.

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 patient's 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 patient's 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 patient's compatibility., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Patients under long-term administration of vitamin K antagonists may require temporary interruption of anticoagulation therapy for invasive procedures or trauma surgery. Due to the long half-life of these substances bridging therapy with anticoagulants having a shorter half-life may become necessary. In this situation the risk of bleeding due to the intervention and the risk of thromboembolism due the underlying disease must be assessed. Low molecular weight heparins (LMWHs) are considered to be the medication of choice for bridging anticoagulation, mainly due to practical reasons and as they do not require coagulation monitoring and dose adjustment out of hospital treatment is feasible. Low molecular weight heparins are not authorized for the indication of bridging anticoagulation, however, on the basis of recent studies on large patient cohorts, the evidence of efficacy and safety is significantly better for LMWHs than for unfractionated heparin. New oral anticoagulants will soon become available for stroke prevention in patients with atrial fibrillation and for treatment of venous thromboembolism. Due to the shorter half-lives these compounds will no longer require bridging anticoagulation. However, the trauma surgeon should be familiar with the dosing regimens for different indications in order to adequately decide about the preoperative cessation and the perioperative pause of these anticoagulants.

Ruptures of the distal biceps tendon are rare injuries which nearly exclusively occur in middle-aged men when eccentric load is applied to the flexed elbow. Operative treatment is supposed to be the most effective method to restore flexion and supination strength. However, there is a wide variety of potential surgical treatment methods. This article is aiming to present the anatomical, pathophysiological and epidemiological basics and to demonstrate the surgical techniques. Not only the approaches but also the differing fixation methods like bone tunnel fixation, endobutton- or suture anchor and interference screw are described in detail. Additionally, rehabilitation protocols and considerations concerning medical expertise are presented.

Compartment syndrome of the thigh is a rare occurrence potentially leading to devastating functional restrictions. There is a wide spectrum of reported conditions leading to increased tissue pressure in the thigh possibly resulting in a compartment syndrome, ranging from deep venous thrombosis to blunt injuries and femoral fractures. We report a case of a delayed development of a compartment syndrome of the thigh secondary to an undisplaced anterior pelvic ring fracture and chronic anticoagulation therapy in a 94-year-old woman. Regarding anticoagulation therapy there are numerous reports about the spectrum of bleeding complications during therapy, however this severe complication has to our knowledge not been reported previously. Treatment consisted in immediate fasciotomy and subsequently secondary wound closure.

Aim: Mesenchymal stem cells have a high therapeutic potential for the reconstruction of articular cartilage defects. In this study, a cartilage-polymer construct using mesenchymal stem cells from trabecular bone and a polylactic acid polymer was fabricated with a press-coating technique. We investigated whether cells from human trabecular bone fragments have the same chondrogenic differentiation potential as mesenchymal stem cells derived from bone marrow and whether it is possible to reconstruct an osteochondral lesion in the nude rat with the fabricated construct., Method: Cells were obtained from the femoral head of patients undergoing total hip arthroplasty. The fabrication of the constructs was performed by centrifugation of 1.5x10(6) cells to a cell pellet which was then placed in a polymer block. The fabricated cell constructs were cultivated for 3 weeks in a serum-free medium, supplemented with transforming growth factor beta1. Every third day, the chondrogenic differentiation was analysed using chondrogenic and osteogenic marker genes. After three weeks the constructs were implanted into 5 mm osteochondral defects of the knee joint of nude rats. After 4 and 12 weeks histochemical and immunohistochemical analyses were performed., Results: At the end of the culture period the constructs showed a proteoglycan-rich extracellular matrix with the expression of collagen types II, IX and X as well as aggrecan und COMP (cartilage oligomeric matrix protein). No osteogenic markers except collagen type I could be detected. The analysis of the in vivo experiment showed a good defect filling with a reconstructed cartilage surface along with increasing resorption of the polymer., Conclusion: We have shown that it is possible to fabricate cartilage-polymer constructs from trabecular bone-derived cells, and that the cells have the same chondrogenic differentiation potential as mesenchymal stem cells derived from bone marrow. With the fabricated cartilage-polymer construct it is possible to reconstruct an osteochondral defect in the knee joint of the nude rat., (Copyright (c) Georg Thieme Verlag KG Stuttgart-New York.)

Introduction: Intra-acetabular localisation of an osteochondroma causing subluxation of the hip joint is a rare entity in children suffering from multiple hereditary exostoses. In literature only 6 operatively treated cases have been reported., Case: We add the case of an 8-year-old boy with an intraarticular exostosis of the left acetabulum causing subluxation of the hip. Using an anterolateral approach to the hip joint this exostosis was removed surgically together with some extraarticular exostoses of the proximal femur. The hip could be re-centered in combination with an additional varus derotation osteotomy of the proximal femur. Intraoperatively the femoral head was only subluxated to minimise the risk of avascular necrosis. After a follow-up of two years the patient has complete remission of symptoms and there is no evidence of avascular necrosis radiologically with good remodelling of the left hip., Conclusion: The operative treatment of an intraarticular exostosis of the hip joint is a difficult and risky surgical procedure. The reported open surgical procedure allowed resection of the intraarticular exostosis in combination with therapy of additional pathologies of the proximal femur.