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Proximal ulna fractures are common injuries and frequently treated with angular stable plating. This surgical option shows good functional results. Relevant drawbacks such as large soft tissue exposure, compromised blood supply of fracture fragments and disturbing osteosynthetic material are described. The aim of this study was to compare a new locked proximal ulna nail with angular stable plating in a biomechanical testing setup for extraarticular proximal ulna fractures. Ten pairs of sawbones with a Jupiter type IIB proximal ulna fracture (OTA 2U1A3.1) were tested after osteosynthesis with the mentioned implants in a servo-pneumatic testing machine. The testing setup simulates physiological joint motion (0°–90°) under cyclic loading (30–300 N). Primary stability and loosening of both constructs were quantified using micromotion video-analysis after 608 test cycles. The micromotion analysis showed significantly higher primary stability of the locked nail (0.29 ± 0.13 mm) compared to the angular stable plate (0.97 ± 0.30 mm, p

IntroductionInfected pubic symphysitis (IPS) is a rare bacterial infection of the pubic symphysis that causes subpubic pain, disability and ultimately permanent immobility. Due to difficult diagnosis, patients present with long-standing complaints and consult several doctors. To date, no validated treatment protocol exists and most patients are treated conservatively with antibiotics. This study was aimed to assess the results after careful surgical debridement and pathogen-specific antibiotic treatment in IPS.Materials and methodsA chart review of eight patients with proven IPS was performed. Five of eight patients filled in a specific own-developed questionnaire and could be examined clinically and radiologically at a mean of 13 months (range: 6–30 months) postoperatively.ResultsThere were six males and two females with an average age of 69 years (range: 55–80 years). The mean duration of symptoms before surgical treatment was 10.5 months (range: 1–30 months). There were no complications due to the surgical debridement. There was no recurrence of infection at the pubic symphysis during the follow-up period. The most common pathogen wasPseudomonas aeruginosain three patients. Mean preoperative pain, measured on the visual analogue scale (VAS, range: 0–10) for the four analysed categories in the five follow-up patients was 7.2, 30 days postoperatively 2.7 and 13 months postoperatively 0.4. There was a steady increase in the quality of life (QoL) 30 days postoperatively and at the 13 months follow-up when compared to preoperative values.ConclusionsSurgical debridement is the keystone for treatment of IPS and should be combined with local and systemic antibiotic therapy.

Introduction Iliosacral screw osteosynthesis is a well-accepted procedure for stabilization of sacral fractures and iliosacral (fracture) dislocations. Materials and Methods In this monocentric study, safety and efficacy of conventional 2D-fluoroscopic-guided iliosacral screw insertion were evaluated. Results During a 10-year period (2005–2014), 98 patients between the age of 18 and 65 years received 207 iliosacral screws in 101 procedures. Average patient age was 43.2 years. There were 46 Type B and 40 Type C injuries in the AO/OTA classification, nine patients had a fragility fracture of the pelvis. In three patients, primary radiological data were missing. The indication for surgical treatment was a sacral fracture in 97 patients, a pure iliosacral dislocation in 37 patients and a fracture-dislocation in 31 patients. 70 procedures were performed with the patient in supine position, 31 with the patient in prone position. Surgery was done in a minimal-invasive technique in 76 patients, in 22 patients an open reduction was necessary before screw insertion. 81 patients received a unilateral, 17 patients a bilateral screw osteosynthesis. 199 screws were inserted in S1, only eight screws in S2. 65 patients received two screws unilaterally, ten patients two screws bilaterally. There were no vascular or neurologic complications. During in-hospital stay, there were seven complications, which needed 12 operative revisions: three wound infections, two hematomas, one screw malalignment and one early screw loosening. In 28 patients with 56 iliosacral screws, a pelvic CT-scan was performed during follow-up. A penetration of a cortical layer was diagnosed in 20 of these screws. All penetrations were seen in double screw osteosynthesis of S1. In none of the patients, complaints could be explained by the malalignment of these screws. Five operative revisions were performed during follow-up: two for screw loosening, two for fracture healing problems and one for screw malalignment. Metal removal was performed in 39 patients with 75 screws. 2D-fluoroscopic-guided iliosacral screw osteosynthesis is a safe and efficient procedure in clinical practice. Discussion A thorough preoperative evaluation of the morphology of the upper sacrum and careful operative procedure are indispensable. Fluoroscopic views in AP, lateral, inlet and outlet must allow recognition of all anatomical landmarks. The indication for double screw osteosynthesis in S1 should be taken with caution. Screw malalignments do not inevitably correlate with complaints.

Background: Fractures of the pubic ramus without involvement of the posterior pelvic ring represent a minority of fragility fractures of the pelvis (FFP). The natural history of patients suffering this FFP Type I has not been described so far. Material and methods: All patients, who were admitted with isolated pubic ramus fractures between 2007 and mid-2018, have been reviewed. Epidemiologic data, comorbidities, in-hospital complications, and one-year mortality were recorded. Of all surviving patients, living condition before the fracture and at follow-up was noted. Mobility was scored with the Parker Mobility Score, quality of life with the European Quality of Life 5 Dimensions 3 Level (EQ-5D-3L), subjective sensation of pain with the Numeric Rating Scale (NRS). Results: A consecutive series of 138 patients was included in the study. There were 117 women (84.8%) and 21 men (15.2%). Mean age was 80.6 years (SD 8.6 years). 89.1% of patients presented with comorbidities, 81.2% of them had cardiovascular diseases. Five patients (4%) died during hospital-stay. Median in-hospital stay was eight days (2&ndash, 45 days). There were in-hospital complications in 16.5%, urinary tract infections, and pneumonia being the most frequent. One-year mortality was 16.7%. Reference values for the normal population of the same age are 5.9% for men and 4.0% for women. One-year mortality rate was 22.2% in the patient group of 80 years or above and 8.8% in the patient group below the age of 80. The rate of surviving patients living at home with or without assistance dropped from 80.5% to 65.3%. The median EQ-5D-Index Value was 0.62 (0.04&ndash, 1, IQR 0.5&ndash, 0.78). Reference value for the normal population is 0.78. Average PMS was 4 and NRS 3. Within a two-year period, additional fragility fractures occurred in 21.2% and antiresorptive medication was taken by only 45.2% of patients. Conclusion. Pubic ramus fractures without involvement of the posterior pelvis (FFP Type I) are serious adverse events for elderly persons. During follow-up, there is an excess mortality, a loss of independence, a restricted mobility, and a decreased quality of life. Pubic ramus fractures are indicators for the need to optimize the patient&rsquo, s general condition.

Fragility fractures of the pelvis (FFP) are an increasing entity among elderly persons. Characteristics are different from high-energy pelvic trauma. Little is known about the natural course of FFP in conservative and after operative treatment. Materials and methods Medical charts and radiologic data of 148 patients with an FFP, who were admitted in a 3-year period, were analysed retrospectively. Incidence and characteristics of fracture progression (FP) were noted. Results Patients presenting early after a traumatic event had more often non-displaced fractures, fractures with lower FFP Type classification and were more frequently treated conservatively. FP was observed in 21 cases (14.2%), twenty times after conservative and once after operative treatment. FP under conservative treatment occurred in female patients only. Patients with FP were younger than patients without. FP occurred in all fracture types, most frequently in FFP Type I. A second CT scan was positive for FP in 39.2% of patients with prolonged pain or restricted mobility. Conclusion FP is a real phenomenon, occurring in a minority of FFP patients. Female patients are at highest risk. Repeated CT scan is positive in nearly 40% of patients with continuing pain or restricted mobility. Operative treatment is a good preventive measure of FP as FP does only exceptionally occur after operative fixation of FFP.

Die isolierte Ellenbogenluxation stellt im Kindesalter ein seltenes Verletzungsmuster dar. Das Behandlungsergebnis ist insbesondere vom Ausmas der ligamentaren Verletzungen und von der Anwesenheit knocherner Begleitverletzungen abhangig, weshalb diesen bei der Diagnostik besondere Beachtung geschenkt werden muss. Ziel dieses Fallberichts ist die Darstellung der Behandlung und des Verlaufs einer isolierten traumatischen Ellenbogenluxation im Kindesalter. Bei einem 6-jahrigen Madchen bestand nach einem Sturz mit dem Tretroller eine komplette Ellenbogenluxation links. Die Diagnostik konnte eine knocherne Begleitverletzung ausschliesen. Nach geschlossener Reposition zeigte sich eine isolierte mediale Instabilitat mit Subluxationsneigung, die sich im Magnetresonanztomogramm (MRT) als Abriss des medialen Kollateralbandes darstellte. Nach einer 6-tagigen Ruhigstellung im Oberarmgips konnte mit einer funktionellen Nachbehandlung begonnen werden. Sechs Wochen postoperativ zeigte sich eine schmerzfreie Bewegung mit freiem Bewegungsausmas. Die isolierte kindliche Ellenbogenluxation ohne knocherne Begleitverletzungen konnte in unserem Fall durch Gipsruhigstellung und anschliesende funktionelle Therapie erfolgreich therapiert werden. Entscheidend bei der Behandlung dieser Verletzung ist die sorgfaltige Diagnostik und Behandlung von Begleitverletzungen. Eine eingeschrankte Beweglichkeit oder persistierende Instabilitat als Spatfolge ist sehr selten.

Background and purpose — The most frequent cause of arthroplasty failure is aseptic loosening—often induced by particles. Abrasion material triggers inflammatory reactions with lymphocytic infiltration and the formation of synovial-like interface membranes (SLIM) in the bone–implant interface. We analyzed CD3 quantities in SLIM depending on articulating materials and possible influences of proven material allergies on CD3 quantities. Patients and methods — 222 SLIM probes were obtained from revision surgeries of loosened hip and knee arthroplasties. SLIM cases were categorized according to the SLIM-consensus classification and to the particle algorithm. The CD3 quantities were analyzed immunohistochemically, quantified, and correlated to the particle types. Results — Metal–metal pairings showed the highest CD3 quantities (mean 1,367 counted cells). CD3 quantities of metal–polyethylene (mean 243), ceramic–polyethylene (mean 182), and ceramic–ceramic pairings (mean 124) were significantly smaller. Patients with contact allergy to implant materials had high but not statistically significantly higher CD3 quantities than patients without allergies. For objective assessment of the CD3 response as result of a pronounced inflammatory reaction with high lymphocytosis (adverse reaction), a defined CD3 quantity per high power field was established, the “CD3 focus score” (447 cells/0.3 mm2, sensitivity 0.92; specificity 0.90; positive predictive value 0.71; negative predictive value 0.98). Interpretation — The high CD3 quantities for metal–metal pairings may be interpreted as substrate for previously described adverse reactions that cause severe peri-implant tissue destruction and SLIM formation. It remains unclear whether the low CD3 quantities with only slight differences in the various non-metal–metal pairings and documented contact allergies to implant materials have a direct pathogenetic relevance.

Comminuted proximal ulna fractures are rare and reconstruction of these fractures is discussed controversially. The aim of this study was to test three currently available plate devices in a standardized comminuted four-part fracture model created in proximal ulna sawbones.A standardized four-part fracture of the proximal ulna was created in 80 sawbones. Reconstruction was performed by five experienced test surgeons according to a standardized reconstruction protocol. Each surgeon reconstructed 4 fractures with a 3.5mm eight-hole reconstruction plate, 4 fractures with seven-hole third-tubular double plates and 4 fractures with a 3.5mm anatomical seven-hole locked angle proximal ulna plate. 4 more fractures were reconstructed with simple K-wires as a reference construct for further experiments. Outcome measurements were time for reconstruction, quality of reconstruction and stability of the reconstruction. Stability testing was done in 90° and 30° flexion of the elbow. Testing in 30° flexion was done to test the anteroposterior stability regarding the fixed coronoid process.Time for reconstruction was significantly less for K-wire fixation than for the plate devices. Time for reconstruction plating and locked angle plating was significantly lower than for double plating (p0.005). Quality of reduction did not differ between the three plate systems (p0.05). K-wire fixation showed the best quality of reduction (p0.005). In 90° of elbow flexion the anatomic locked angle olecranon plate showed a significantly higher stability compared to the other devices. Furthermore the tubular double plating was significantly more stable than reconstruction plating or K-wire fixation (p0.05). In anteroposterior loading at 30°, the stability did not differ between the 4 different fixation techniques (p0.05). For all devices the testing in 30° flexion showed a significantly higher rigidity compared to 90° flexion.The locked angle plate system showed the highest stability in 90° of elbow flexion. Each implant was more stable in 30° flexion than in 90° flexion. Testing of the anterior stability of the elbow did not show any differences between the different implants. Because of the superior stability of this device, we conclude that locked angle plating should be preferred for reconstruction of monteggia like complex proximal ulna fractures.

Introduction Osteoporotic posterior ring fractures of the pelvis are common injuries in the elderly, but the treatment of these fractures still remains controversial. Percutaneous iliosacral screw fixation is one surgical option if conservative treatment cannot provide sufficient pain reduction. The aim of this study is to provide short-term results of elderly patients with percutaneous screw fixation. Methods 30 patients with posterior ring fractures were treated between 12/2009 and 01/2014 with percutaneous iliosacral screw fixation. Patients’ mean age was 78.4 years. Concerning short-term outcome, we focused on initial pain level and postoperative pain reduction together with intra- and postoperative complications. Results The average hospital stay was 23.7 days, with surgical treatment performed after an average of 9.2 days. 90% of our patients were female. All 30 patients had a lower level of pain at discharge compared with admission or immediately prior to surgery. The difference in pain level at admission compared with the pain level upon discharge showed a mean reduction from 6.8 to 1.8 with a statistically significant change (P ≤ 0.001). 24 of 30 patients had no registered complications, one screw malpositioning with postoperative nerve irritation occurred. Discussion Conventional percutaneous iliosacral screw fixation is a successful operative treatment for elderly patients with persistent lower back pain after unstable posterior ring fractures of the pelvis. Intra- and postoperative complications are rare, so this treatment can be regarded as a safe procedure. Level of evidence IV (retrospective study).

The purpose of this study was to demonstrate the peri- and intraosseous vascular supply of the proximal ulna. Eleven fresh human cadaveric elbows were sequentially plastinated beginning with arterial injection, followed by block and secondary slice plastination of the whole elbow. With this technique, we obtained completely transparent cadaveric slices in which the peri- and intraosseous vascular architecture could be studied. Proximal ulna vascularization is due to an arterial network: a superior and inferior collateral ulnar artery and the profunda brachial artery climbing to the olecranon from proximal. An anterior artery and a posterior recurrent artery climb up distally to the medial parts of the ulna and an interosseous recurrent artery is responsible for the lateral and posterolateral proximal part of the ulna. The intraosseous vascularization is due to directly penetrating branches out of the posterior recurrent ulnar artery and a vascular plexus at the olecranon tip. In addition, we saw a major distal bone penetration branch coming from the recurrent posterior artery, climbing intraosseously without junction to the proximal penetrating branches. The peri- and intraosseous vascularization of the proximal ulna was shown. A transitional zone of the intraosseous vascularization of the proximal ulna was detected.

Background The aim of this study was to provide subjective and objective results of surgical treatment of unstable elbow dislocations with the hinged external fixation technique. Methods Twenty-six patients were available for re-examination after treatment. Parameters used to quantify the subjective functional results were the Mayo Elbow Performance Score, the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire, and the stability of the elbow joint. In addition, we measured the medial and lateral joint space by varus and valgus stress ultrasound examinations of the elbow. Results The mean Mayo Elbow Performance Score was 93.5 (±8.3 standard deviation), and the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire showed an average of 7.3 points (±8.9 standard deviation). We saw 18 patients with stable joints and 8 patients with slight instability. In the ultrasound stress test, we saw a significant difference of the affected joint under varus stress (7.8 ± 1.7 mm) compared with the healthy joint (5.8 ± 1.2 mm) laterally. Furthermore, medially the gap was significantly larger (4.8 ± 0.9 mm; treated elbow) than contralaterally under valgus stress (3.3 ± 0.7 mm) ( P Conclusion Closed reduction and hinged external fixation of unstable elbow dislocations resulted in good and very good results. We could identify a slight difference in the stability of the affected elbow compared with the contralateral side in all patients without clinical relevance.