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ZusammenfassungGlenoidfrakturen stellen im klinischen Alltag eine Rarität da. Neben hochenergetischen Traumata finden sich häufig Luxationsereignisse als Ursache. Nicht nur die Frakturmorphologie, sondern auch das zugrunde liegende Trauma haben einen Einfluss auf die richtige Entscheidung für die weitere konservative oder operative Behandlung. Insbesondere für größere anteriore Glenoidfrakturen zeigt die aktuelle Literatur gute Ergebnisse für die konservative Behandlung. Hingegen zeigen kleinere Bony-Bankart-Verletzungen eine höhere Instabilitätsrate beim jungen Patienten unter konservativer Therapie. Für die operativen Versorgungstechniken bieten sich zunehmend, neben offenen Verfahren, eine Reihe arthroskopischer Techniken an.

Introduction: Injuries around the elbow pose a challenging problem for orthopaedic surgeons. The complex bony architecture of the joint should be restored and the thin soft tissue envelope needs to be handled with meticulous care. Elbow instability is a complication seen after dislocations and fractures of the elbow and remains a treatment challenge. The purpose of this study was to provide subjective and objective results following the surgical treatment of unstable elbow dislocations with an external hinged fixation technique. Methods: Forty-six consecutive patients with complex trauma of the elbow with instability after ligament reconstruction were enrolled between January 2017 and December 2019. The parameters used to quantify the subjective and objective functional results were the Mayo Elbow Score (MES, objective) and Oxford Elbow Score (OES, subjective), and clinical stability of the elbow joint. We also performed a radiological follow-up of the fractures. Results: The mean MES and OES scores were good at the 12-month follow-up. We had 38 patients with stable joints and 8 patients with minor instability. Using the stress test, we saw a significant difference in the affected joint under varus stress (6.7 ± 1.8 mm) compared to the healthy joint (5.8 ± 1.2 mm) laterally. Furthermore, medially the gap was significantly larger (5.8 ± 0.8 mm, treated elbow) than the contralateral gap under valgus stress (4.3 ± 0.8 mm) (p

Introduction To date there is no generally accepted specific definition or classification of acromioclavicular (AC) joint osteoarthritis. The aim of this study is to analyze morphological parameters using magnetic resonance imaging (MRI) and to develop a scoring system as a basis for decision making to perform an AC-joint resection. Materials and methods In a retrospective-monocentric matched pair study, healthy and affected subjects were investigated using T2 MRI scans in the transverse plane. There were two groups, group 1 (n = 151) included healthy asymptomatic adults with no history of trauma. In group 2, we included n = 99 patients with symptomatic AC joints, who underwent arthroscopic AC-joint resection. The central and posterior joint space width and the AC angle were measured. Morphological changes such as cartilage degeneration, cysts and bone edema were noted. Malalignment of the joint was defined as: posterior joint space width 12°. A scoring system consisting of the measured morphologic factors was developed. Results Symptomatic and asymptomatic patients showed significant differences in all measured items. We observed a significant difference in the MAC score for symptomatic and asymptomatic patients (mean 10.4 vs. 20.6, p = 0.0001). The ROC (receiver operator characteristic) analysis showed an excellent AUC of 0.899 (p = 0.001). The sensitivity of the MAC score was 0.81 and the specificity 0.86. The MAC score shows a significant moderate correlation with age (r = 0.358; p = 0.001). The correlation of age and the development of symptoms was only weak (r = 0.22, p = 0.001). Symptomatic patients showed significantly more frequent malalignment compared to asymptomatic patients (p = 0.001), but the positive predictive value that a patient with malalignment is also symptomatic is only 55%. Conclusion Patients with symptomatic AC joints showed a typical pattern of morphological changes on axial MRI scans with early posterior contact of the joint surfaces, reduction of joint space and malalignment as the basis for the development of a scoring system. The MAC score shows excellent test characteristics, and therefore, proved to be both an appropriate guidance for clinical practice as well as an excellent tool for comparative studies and is superior to the assessment of malalignment alone. Level of evidence Level IV, retrospective diagnostic study.

Update This article was updated on May 20, 2020, because of a previous error. On page 482, in the legend for Figure 5, the sentence that had read “The Oxford Shoulder Score consists of 12 questions concerning shoulder pain, shoulder function, and activities of daily living and ranges from 12 points (worst) to 60 points (best)” now reads “The Oxford Shoulder Score consists of 12 questions concerning shoulder pain, shoulder function, and activities of daily living and ranges from 0 points (worst) to 48 points (best).” An erratum has been published: J Bone Joint Surg Am. 2020 June 17;102(12):e63. Background: Almost one-third of patients with proximal humeral fractures are treated surgically, and the number is increasing. When surgical treatment is chosen, there is sparse evidence on the optimum method. The DelPhi (Delta prosthesis-PHILOS plate) trial is a clinical trial comparing 2 surgical treatments. Our hypothesis was that reverse total shoulder arthroplasty (TSA) yields better clinical results compared with open reduction and internal fixation (ORIF) using an angular stable plate. Methods: The DelPhi trial is a randomized controlled trial comparing reverse TSA with ORIF for displaced proximal humeral fractures (OTA/AO types 11-B2 and 11-C2) in elderly patients (65 to 85 years of age). The primary outcome measure was the Constant score at a 2-year follow-up. The secondary outcome measures included the Oxford Shoulder Score and radiographic evaluation. Results were reported as the mean difference with 95% confidence interval (CI). The intention-to-treat principle was applied for crossover patients. Results: There were 124 patients included in the study. At 2 years, the mean Constant score was 68.0 points (95% CI, 63.7 to 72.4 points) for the reverse TSA group compared with 54.6 points (95% CI, 48.5 to 60.7 points) for the ORIF group, resulting in a significant mean difference of 13.4 points (95% CI, 6.2 to 20.6 points; p < 0.001) in favor of reverse TSA. When stratified for fracture classification, the mean score was 69.3 points (95% CI, 63.9 to 74.7 points) for the reverse TSA group and 50.6 points (95% CI, 41.9 to 59.2 points) for the ORIF group for type-C2 fractures, which yielded a significant mean difference of 18.7 points (95% CI, 9.3 to 28.2 points; p < 0.001). In the type-B2 fracture group, the mean score was 66.2 points (95% CI, 58.6 to 73.8 points) for the reverse TSA group and 58.5 points (95% CI, 49.6 to 67.4 points) for the ORIF group, resulting in a nonsignificant mean difference of 7.6 points (95% CI, −3.8 to 19.1 points; p = 0.19). Conclusions: At a 2-year follow-up, the data suggested an advantage of reverse TSA over ORIF in the treatment of displaced OTA/AO type-B2 and C2 proximal humeral fractures in elderly patients. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Complex deformities of the distal humerus and forearm of either posttraumatic or hereditary origin have a significant negative impact on the functional integrity of the affected limb. They lead to pain, instability in both the elbow and the proximal/distal radioulnar joint, and profound motion deficit. Corrective procedures and more advanced surgical interventions for the main index procedures at the proximal forearm are extremely challenging for the treating upper extremity specialist due to the complex pathoanatomy in this region. This practical review focuses on the main aspects of correcting deformities of the distal humerus (malunion and non-union), the proximal forearm (differential therapy of chronic radial dislocation in children and adolescents), and the restoration of forearm rotation using rapid prototyping templates and computerized planning as the evolving standard technique in this region. In addition to the technical aspects, focus is put on planning (conventional vs. modern computerized three-dimensional (3D) planning), on different osteotomy techniques, and the surgical armamentarium that the specialist center should have available. Finally, some light is shed on the long-term outcome that can be expected and possible complications that can occur when performing these complex corrective procedures.

Background: Optimal treatment of proximal humeral fractures (PHF) is still controversial. Therefore, we aim to investigate the influence of fracture reduction after intramedullary nailing of a PHF on the clinical outcome. Methods: Patients treated with intramedullary nail for PHF from 2013–2018, (minimum follow-up 12 months) were retrospectively included. Constant Score (CS), DASH and Simple Shoulder Test (SST) were collected. Postoperative radiographs were used to determine head-shaft-alignment (HSA), head-shaft-displacement (HSD), integrity of the medial hinge and the cranialization of the greater tuberosity (CGT). The results of fracture reduction were categorized as either “anatomical”, “acceptable” or as “malreduction”. Malreduction exists when at least one of the following parameters are present: HSA > 150/< 110°, HSD >5 mm, CTM > 5 mm or lack of integrity of the medial hinge. Results: 42 patients (mean age 65.5 ± 14.1 years, 15 male, 27 female) with a mean follow-up time of 43 months were included. The average CS was 60 ± 30, DASH 49.8 ± 24.3 and SST 62.9 ± 26.9. There was an “anatomic” reduction in 9 (21.4%), “acceptable” in 7 (16.6%) and a “malreduction” in 26 (62%) patients. Comparing the combined “anatomical” and “acceptable” reduction group with the “malreduction” group, worse scores were observed in the “malreduction” group (CS 67.2 vs. 55.2, DASH 45.2 vs. 51.9, SST: 69.3 vs. 58.6) without statistical significance (CS: p = 0.095, DASH: p = 0.307, SST: p = 0.400). By means of multiple logistic regression analyses no statistically significant risk factors were identified for lower DASH, CS and SST scores. Conclusions: Anatomical fracture reduction using intramedullary nails has a positive effect on postoperative outcome for the 3 scores recorded, without reaching statistical significance.

Weil in der operativen Frakturbehandlung Lagerung, Durchleuchtung und Instrumente grose Bedeutung haben, werden Instrumente, Lagerungshilfsmittel und das Strahlenschutzgesetz vorgestellt. Die vielfaltigen Implantate und externen Fixateure (Monolateral, Ilizarov, Hexapod) sind Herausforderungen auch an das Pflegepersonal. Das gilt ebenso fur die Stabilisierung von Wirbelsaulen- und Beckenfrakturen, fur Osteosynthesen und Umstellungsosteotomien (Femur, Tibiakopf) und besonders fur Endoprothesen. Gebuhrenden Raum finden die Arthroskopie von Schulter und Knie, die Vorfuskorrekturen und die komplexe Handchirurgie. Dabei wird Wert gelegt auf die instrumentelle Vorbereitung, die operationsspezifische Lagerung und den OP-Ablauf.

Multiple hereditary exostoses (MHE) are a rare disorder characterized by the growth of bony protrusions. Elbow involvement is found in a considerable number of patients and varies from the presence of a simple osteochondroma to severe forearm deformities and radial head dislocation. Patients encounter a variety of symptoms, for example, pain, functional impairment, and cosmetic concerns. Several types of surgical procedures, therefore, can be offered, ranging from excision of symptomatic osteochondromas to challenging reconstructions. In this paper, we will discuss the essential basics of visualizing, planning, and treatment options of forearm deformities in MHE. In more detail, we will describe our current surgical technique as a salvage procedure for Masada type II forearm deformities in patients with MHE.

Complex fracture dislocations of the elbow present a challenge for the upper extremity surgeon. The extent of the osseous and soft tissue injuries determines the stability of the elbow joint. Post-traumatic elbow stiffness is a debilitating complication which poses a major threat to the integrated function of the entire limb. Thus, restoration of motion is the fundamental basic of most reconstructive efforts following traumatic injury to the elbow. More recently, hinged external fixation has become an important tool in both the acute treatment of severe fracture dislocation and post-traumatic reconstruction of the elbow. Its use has expanded from a “last hope effort” to earlier utilization in a standardized protocol, the so- called elbow fixator concept. In this chapter we will describe the philosophy, the operative technique, and the tips and tricks of performing hinged fixation in acute elbow trauma.

More than 200 years have passed since Colles described a fracture of the distal end of the radius. It is remarkable that this common fracture remains one of the most challenging of fractures treated by orthopedic, general, and hand surgeons. Although the pendulum of evidence toward operative treatment in this enigmatic injury seems to be swinging back to a more conservative approach (due to a lack of evidence of functional outcome improvement in our patients), in recent years upper extremity specialists and hand surgeons are facing a range of complications, both from operative or nonoperative treatment. While malunion with (or without) functional impairment presents as the main complication after conservative treatment, there is a large variety of complications on display after operative treatment. In this review we focus on three facets of posttraumatic reconstruction after distal radius fractures, i. e., the correction of extra- and intra-articular malunion, resolving problems of the distal radioulnar joint, and the treatment of pain as major complaint (denervation vs. arthrodesis).

Multiple osteochondromas (MO) are a rare autosomal dominant disorder characterized by the presence of osteochondromas located on the long bones and axial skeleton. Patients present with growth disturbances and angular deformities of the long bones as well as limited motion of affected joints. Forearm involvement is found in a considerable number of patients and may vary from the presence of a simple osteochondroma to severe forearm deformities and radial head dislocation. Patients encounter a variety of problems and symptoms e.g., pain, functional impairment, loss of strength and cosmetic concerns. Several surgical procedures are offered from excision of symptomatic osteochondromas to challenging reconstructions of forearm deformities. We describe visualizing, planning and treating these forearm deformities in MO and, in particular, a detailed account of the surgical correction of Masada type I and Masada type II MO forearm deformities.

Complex posttraumatic forearm deformities have a significant impact on the integrity of the upper extremity leading to pain, instability in both the proximal and/or distal radioulnar articulation, and reduced range of forearm motion. Corrective osteotomy or more advanced procedures for malunited fractures or other posttraumatic deformities of the upper extremity, especially in the forearm are challenging procedures. In this review we will discuss the essential aspects of anatomy and pathomechanics, clinical and radiological assessment and the pathway from preoperative planning to the actual deformity correction surgery, either with one-stage correction or using gradual lengthening with external fixation ("callotasis techniques") and finally the functional outcome we can expect for our patients. In addition we will analyze the modern computer-assisted techniques available to date.Komplexe posttraumatische Deformitäten im Bereich des Unterarmeshaben einen signifikant negativen Effekt auf die funktionelle Integrität der betroffenen oberen Extremität. Sie können Schmerzen, Instabilität im proximalen/und oder distalen Radioulnargelenk und eine bedeutende Bewegungseinschränkung verursachen. Korrektureingriffe in diesem Indikationsberich sind gerade im Bereich des Unterarms aufgrund seiner komplexen Pathoanatomie eine echte Herausforderung für den behandelnden Chirurgen. In diesem Übersichtsartikel versuchen wir die essentiellen Aspekte der anatomischen Besonderheiten, der Pathomechanik, die klinischen und radiologischen Untersuchungen und schlieβlich den Weg von der präoperativen Planung über den geeigneten Korrektureingriff (als einzeitige Korrektur mit oder ohne aufwendige computergestützte Planung oder graduell mithilfe von Fixateursystemen („Kallotasis- Techniken“) bis zum erwartbaren funktionellen Ergebnis aufzuzeigen.

Bone regeneration represents a complex process, of which basic biologic principles have been evolutionarily conserved over a broad range of different species. Bone represents one of few tissues that can heal without forming a fibrous scar and, as such, resembles a unique form of tissue regeneration. Despite a tremendous improvement in surgical techniques in the past decades, impaired bone regeneration including non-unions still affect a significant number of patients with fractures. As impaired bone regeneration is associated with high socio-economic implications, it is an essential clinical need to gain a full understanding of the pathophysiology and identify novel treatment approaches. This review focuses on the clinical implications of impaired bone regeneration, including currently available treatment options. Moreover, recent advances in the understanding of fracture healing are discussed, which have resulted in the identification and development of novel therapeutic approaches for affected patients.

Closed and open dislocations of the knee joint with vascular and nerve injuries are treated immediately and may present an indication for external fixation. In acute trauma definitive treatment and reconstruction of the complex capsule and ligamentous injuries are often impossible. The application of a medial transarticular external fixator with motion capacity combines the treatment of remaining joint instability with the benefit of early joint movement. Disadvantages of prolonged joint immobilisation until definitive stabilisation of the knee are reduced.

Background Fractures of the tuberosity of the fifth metatarsal are common after foot twisting injuries, and operative treatment is recommended in cases of displacement. The purpose of this study was to report the radiologic outcome and clinical results of displaced fractures of the tuberosity of the fifth metatarsal treated using fine-threaded K-wires (FFS). Methods In 3 years' time, in a total of 35 cases, patients had an initial fracture displacement of more than 2 mm for isolated extraarticular fractures and an involvement of the cuboidal joint surface of more than 30%. After 15 months to 60 months (mean, 30.6), 32 of these patients participated in a clinical follow-up examination and questionnaire according to a clinical rating system for midfoot fractures. Radiologic outcome measurements were the remaining postoperative intraarticular step off and the healing time. Results The mean midfoot scale score was 96.5 points. All the patients returned to prior activities after operative treatment. Seven patients reported minor pain during longer periods of walking. One patient with secondary wound healing experienced frequent pain. Radiologically, in 32 of 35 patients, there was a remaining step off of less than 1 mm and in three patients less than 3 mm. All fractures except one healed within the first 3 months to 6 months. Conclusion Operative treatment of displaced proximal fifth metatarsal fractures using the FFS system leads to a good clinical and radiologic outcome. The FFS system provides a new treatment option for this fracture type.

Ursachlich fur die Ellenbogensteife sind haufig Trauma, Verbrennungen oder Koma. Eine Bewegungseinschrankung lasst sich gerade am Ellenbogen gelegentlich schwer verhindern, und die Therapie ist anspruchsvoll. Neben einer detaillierten, individualisierten Analyse der Entstehung der Bewegungseinschrankung ist die genaue diagnostische Aufarbeitung vor jeder chirurgischen Intervention wichtig. Ellenbogensteife, definiert als Streckdefizit von mehr als 30° oder Beugung im Humeroulnargelenk von weniger als 130°. Die meisten Aktivitaten des taglichen Lebens spielen sich in einem Bewegungsausmas von 100° ab. Patienten mit eingeschrankter Compliance, schlecht eingestelltem Diabetes mellitus, Hepatitis-B- und -C-Infektionen, HIV-Infektionen sowie akuten Gelenkinfektionen. Die geschlossene Distraktion des Ellenbogengelenks mit Fixateur externe (Arthrodiatasis) wird vorgestellt und bewertet. Die Arthrolyse des Ellenbogengelenks ist technisch aufwendig. Wenn Indikation und Verfahren richtig angewendet werden und Operateur, Physiotherapeut und nicht zuletzt der Patient mit dem Verfahren und der Nachbehandlung vertraut sind, lassen sich gute Langzeitergebnisse erzielen. Die Behandlungsergebnisse zeigten bei einer Nachuntersuchungszeit von 5 Jahren bei 14 Kindern und Heranwachsenden in Bezug auf Extension und Flexion eine Verbesserung des praoperativen Bewegungsumfangs von 37° auf 108° (75–130°) postoperativ.

Chronic dislocation of the elbow is an exceedingly disabling condition associated with severe instability, limitation of elbow function and significant pain. Due to the potentially conflicting goals of restoring elbow stability and regaining a satisfactory arc of motion, successful treatment is a challenge for the experienced trauma surgeon. We report our treatment strategy in three patients suffering from chronically unreduced fracture-dislocations of the elbow. The treatment protocol consists of in situ neurolysis of the ulnar nerve, distraction and reduction of the joint using unilateral hinged external fixation and repair of the osseous stabilizers. A stable elbow was achieved in all patients, without the need of reconstruction of the collateral ligaments. At final follow-up, the average extension/flexion arc of motion was 107 degrees (range, from 100 degrees to 110 degrees ). The average MEPI score at follow-up was 93, and the average DASH score was 19. This is a promising treatment protocol for the treatment of chronically unreduced complex elbow dislocations to restore elbow stability and regain an excellent functional outcome.

This study aims to describe the first clinical results in the treatment of dislocated olecranon fractures with 2.2-mm, fine-threaded wires with a washer. Furthermore, in the second part of the article, the stability of these new implants has been compared to standard tension band wiring in a sawbone model. Patients The radiological and clinical outcomes in 24 patients (mean age: 53.6 years) with 24 isolated Mayo type I and II fractures of the olecranon were evaluated in a prospective study after open reduction and internal fixation (ORIF) with a new fixation device (FFS; Orthofix™). The quality of reduction with the implementation of 24 FFS constructions was compared with 24 tension band-wiring procedures performed by six different surgeons in a standard sawbone Mayo type IIa fracture model. Stability was tested in all constructs using a single cycle load to failure protocol (group I), cyclic loading for 300 cycles between 10 and 500 N (group II) and incremental sinusoidal loading from 10 to 200 N with an incremental increase of 10 N per cycle (group III) in a laboratory study. Results The Morrey elbow score was excellent in 23 patients and good in one patient, with mean DASH score of 1.6. No implant migration, secondary dislocation or nonunion was observed. In the sawbone model, the quality of reduction was the same with the FFS implants compared to the tension band wiring in the sawbone model. Here, bending moments in all three groups showed no significant difference, whereas displacement at failure was significantly greater in the tension band-wiring group at a single cycle load (p = 0.017). Conclusion Clinical results were comparable to tension band wiring and stability of the implants in the sawbone model was the same; thus, we conclude that the FFS technique can serve as an alternative treatment option for isolated olecranon fractures.

Correct placement of the tibial and femoral bone tunnel is prerequisite to a successful anterior cruciate ligament (ACL) reconstruction. This study compares the resulting radiographic femoral bone tunnel position of two commonly used techniques for arthroscopically assisted drilling of the femoral bone tunnel: the transtibial approach or drilling through the anteromedial arthroscopy portal. The resulting bone tunnel position was assessed in postoperative knee radiographs of 70 patients after ACL reconstruction. Three independent observers identified the femoral bone tunnel and determined its position in the lateral and A-P view. Differences in femoral tunnel position between transtibial and anteromedial drilling were evaluated. In the sagittal plane, significantly more femoral bone tunnels were positioned close to the reference value using an anteromedial drilling technique (86%) when compared to transtibial drilling (57%). Drilling through the transtibial tunnel resulted in a significantly more anterior position of the femoral tunnel. In the frontal plane, femoral bone tunnels which were placed through the anteromedial arthroscopy portal displayed a significantly greater angulation towards the lateral condylar cortex (50.92 degrees ) when compared to transtibial drilling (58.82 degrees ). In conclusion, drilling the femoral tunnel through the anteromedial arthroscopy portal results in a radiographic femoral bone tunnel position which is suggested to allow stabilization of both anterior tibial translation and rotational instability when using a single bundle reconstruction technique. Further studies may evaluate if there are any clinical advantages using the anteromedial portal technique.

The purpose of this study was to develop a two-dimensional density distribution pattern of the subchondral cortical bone of the radial head using subtraction densitometry. The bone density of 32 normal specimens and five with macroscopic signs of osteoarthritis was measured before and after milling off the cortical bone surface. Electronic subtraction gave the density of the subchondral cortical bone. Twenty-one specimens had areas of high bone density in the ulnar-dorsal area, five specimens showed a ventral and ulnar density maximum and six had a density maximum in the center of the radial head joint surface. No density maximum was seen in the lateral part of the joint surface. The density maximum shifted towards the dorsal-ulnar part of the radial head with decreasing total subchondral bone density. Osteoarthritic radial heads had the same distribution as non-arthritic specimens. Eccentric subchondral bone density reflects eccentric radiohumeral force transmission. This could be a reason for development of radiohumeral arthritis or the failure of radial head prostheses. Bone density patterns correlate with the incidence of radial head fractures and fracture line may be positioned between areas of high and low densities.

We have evaluated four different fixation techniques for the reconstruction of a standard Mason type-III fracture of the radial head in a sawbone model. The outcome measurements were the quality of the reduction, and stability. A total of 96 fractures was created. Six surgeons were involved in the study and each reconstructed 16 fractures with 1.6 mm fine-threaded wires (Fragment Fixation System (FFS)), T-miniplates, 2 mm miniscrews and 2 mm Kirschner (K-) wires; four fractures being allocated to each method using a standard reconstruction procedure. The quality of the reduction was measured after definitive fixation. Biomechanical testing was performed using a transverse plane shear load in two directions to the implants (parallel and perpendicular) with respect to ultimate failure load and displacement at 50 N. A significantly better quality of reduction was achieved using the FFS wires (Tukey’s post hoc tests, p < 0.001) than with the other devices with a mean step in the articular surface and the radial neck of 1.04 mm (sd 0.96) for the FFS, 4.25 mm (sd 1.29) for the miniplates, 2.21 mm (sd 1.06) for the miniscrews and 2.54 mm (sd 0.98) for the K-wires. The quality of reduction was similar for K-wires and miniscrews, but poor for miniplates. The ultimate failure load was similar for the FFS wires (parallel, 196.8 N (sd 46.8), perpendicular, 212.5 N (sd 25.6)), miniscrews (parallel, 211.8 N (sd 47.9), perpendicular, 208.0 N (sd 65.9)) and K-wires (parallel, 200.4 N (sd 54.5), perpendicular, 165.2 N (sd 37.9)), but significantly worse (Tukey’s post hoc tests, p < 0.001) for the miniplates (parallel, 101.6 N (sd 43.1), perpendicular, 122.7 N (sd 40.7)). There was a significant difference in the displacement at 50 N for the miniplate (parallel, 4.8 mm (sd 2.8), perpendicular, 4.8 mm (sd 1.7)) vs FFS (parallel, 2.1 mm (sd 0.8), perpendicular, 1.9 mm (sd 0.7)), miniscrews (parallel, 1.8 mm (sd 0.5), perpendicular, 2.3 mm (sd 0.8)) and K-wires (parallel, 2.2 mm (sd 1.8), perpendicular, 2.4 mm (sd 0.7; Tukey’s post hoc tests, p < 0.001)). The fixation of a standard Mason type-III fracture in a sawbone model using the FFS system provides a better quality of reduction than that when using conventional techniques. There was a significantly better stability using FFS implants, miniscrews and K-wires than when using miniplates.

Five different radiographs of distal radial fractures were classified according to the AO/ASIF, Frykman, Fernandez and Older systems by 45 observers (trauma surgeons and residents). The same panel classified the same radiographs in a different order 4 months later. Mean interobserver correlation for all cases was fair to moderate according to the Spearman rank test. However, these classifications showed poor correlation with the gold standard as classified by the senior author. All intraobserver agreements demonstrated a moderate kappa agreement (Kw = 0.52) for the AO/ASIF classification and fair for the Frykman (Kw = 0.26), Fernandez (Kw = 0.24) and Older (Kw = 0.27) classifications. When the group was divided according to years of clinical experience (

The purpose of this study was to describe the anatomy of the intramedullary canal of the radial neck for stem design of radial head prostheses.Radial neck measurement was performed from the proximal edge of the radial tuberosity to the distal border of the articular surface on 40 macerated proximal radii using X-rays and Optosil imprints of the intramedullary canal. Radial neck to shaft angle was measured under image intensification.The neck length was 13.3 mm (range 8.0-20.0 mm) measured on X-rays and 13.5 mm (range 9.9-18.8 mm) on Optosil imprints. Concerning the neck's intramedullary canal we obtained a minimum diameter of 9.7 mm (range 6.3-16.4 mm) on X-ray. Corresponding Optosil imprints had a mean diameter of 11.6 mm (range 6.6-18.6 mm) at their proximal end, 10.5 mm (range 5.5-16.3 mm) in the middle and a minimum of 9.8 mm (range 6.0-16.9 mm) at the distal end. Differences between left and right sides were not significant between X-ray and Optosil imprints, nor between left X-ray and right imprints and vice versa at a P-level of 0.001. Radial neck to shaft angle was 167.8 degrees (range 160.5-178 degrees ) measured under image intensification at a rotation angle of 58.6 degrees (range 50-70 degrees ) supination.Geometry of the radial neck's intramedullary canal has been described for stem design. The minimum diameter was seen at the distal end, just proximal to the radial tuberosity. A forearm rotation of 58.6 degrees to full supination should be considered during implantation of monopolar prostheses. The wide variety of lengths and diameters complicates standard prosthetic design, but ipsilateral and contralateral X-rays can be useful for preoperative stem size calculation.

Background Elbow contracture is a recognized sequela of elbow injuries in children and adolescents, but previous studies of operative treatment with formal capsular release have demonstrated unpredictable outcomes and unfavorable results. Methods Over a period of five years, fourteen children and adolescents with a mean age of fourteen years who had posttraumatic stiffness of the elbow were managed according to a prospective protocol. Eleven patients had undergone a mean of three previous operative procedures before the index operation. After intraoperative distraction with an external fixator, there was a relaxation phase for six days followed by mobilization of the elbow joint under distraction in the fixator for a mean of seven weeks. Intraoperative range of motion under distraction reached a mean of 100 degrees . Open arthrolysis was not performed, but in four children impinging heterotopic bone was removed through a limited approach. Decompression of the ulnar nerve was performed in seven patients. Results The mean preoperative arc of total elbow motion was 37 degrees . The mean pronation was 46 degrees , and the mean supination was 56 degrees . After a mean duration of follow-up of thirty-four months, all patients but two had achieved an arc of motion of 100 degrees . The mean arc of flexion-extension was 108 degrees (range, 75 degrees to 130 degrees ). The mean range of pronation was 73 degrees (range, 20 degrees to 90 degrees ), and the mean range of supination was 75 degrees (range, 10 degrees to 90 degrees ). There were no pin-track infections or deep infections, and all elbows were stable. At the time of follow-up, three patients had radiographic evidence of humeroulnar degeneration. Conclusions Closed distraction of the elbow joint with use of a monolateral external fixation frame with motion capacity yields more favorable results than other previously reported options for the treatment of posttraumatic elbow contractures in children and adolescents.

Bilateral elbow dislocation is a rare injury and only 11 cases are described in the literature, including 8 patients with isolated ligamentous and 3 patients with an additional osseous injury. We present 2 cases of bilateral posterior elbow dislocations treated with a bilateral hinged elbow fixator with motion capacity to allow for early physiotherapy. Both patients had a high-energy trauma with one who fell off a ladder from a 5 m height and the second from a mountain bike injury during off-road biking. All extremities were neurovascularly intact. In the operating room, severe instability was detected in all 4 elbows: after closed reduction in 3 elbows and open reduction in 1 elbow for a Mason type 4 fracture of the radial head that was internally fixed using fine threaded implants, an elbow fixator with motion capacity was applied in all 4 elbows for a period of 6 weeks. One year after surgery, the active range of motion was 0/10/140 degrees of extension and flexion on the right and 0/0/130 degrees on the left side. The second patient achieved 0/0/125 degrees and 0/10/130, respectively. Pro- and supination was full in both patients. All 4 elbows were stable and there were no radiologic signs of degenerative changes at the 1 year follow-up. Treatment of bilateral elbow dislocation using external fixation with early motion capacity allows for active physiotherapy although maintaining joint stability, thus minimizing complications normally associated with the injury. Using this method resulted in an excellent clinical outcome for both patients.

Elbow contracture is a recognized sequela of elbow injuries in children and adolescents, but previous studies of operative treatment with formal capsular release have demonstrated unpredictable outcomes and unfavorable results.Over a period of five years, fourteen children and adolescents with a mean age of fourteen years who had posttraumatic stiffness of the elbow were managed according to a prospective protocol. Eleven patients had undergone a mean of three previous operative procedures before the index operation. After intraoperative distraction with an external fixator, there was a relaxation phase for six days followed by mobilization of the elbow joint under distraction in the fixator for a mean of seven weeks. Intraoperative range of motion under distraction reached a mean of 100 degrees. Open arthrolysis was not performed, but in four children impinging heterotopic bone was removed through a limited approach. Decompression of the ulnar nerve was performed in seven patients.The mean preoperative arc of total elbow motion was 37 degrees. The mean pronation was 46 degrees, and the mean supination was 56 degrees. After a mean duration of follow-up of thirty-four months, all patients but two had achieved a functional arc of motion of 100 degrees. The mean arc of flexion-extension was 108 degrees (range, 75 degrees to 130 degrees). The mean range of pronation was 73 degrees (range, 20 degrees to 90 degrees), and the mean range of supination was 75 degrees (range, 10 degrees to 90 degrees). There were no pin-track infections or deep infections, and all elbows were stable. At the time of follow-up, three patients had radiographic evidence of humeroulnar degeneration.Closed distraction of the elbow joint with use of a monolateral external fixation frame with motion capacity yields more favorable results than other previously reported options for the treatment of posttraumatic elbow contractures in children and adolescents.

Axotomy of a peripheral nerve causes a complex central response of neuronal perikarya, astroglia and microglia. The signal initiating this axotomy reaction is currently explained either by deprivation of target-derived trophic factors after interruption of transport (trophic hypothesis) or by electrophysiological disturbances of the axotomized neurons (electric hypothesis). In 108 adult Wistar rats we have compared the time course and intensity of the axotomy reaction in the hypoglossal nucleus after (1) resection of the nerve (permanent axotomy), (2) one-time electric stimulation (intact nerve, brief transient electric disturbance), and (3) colchicine block of transport (intact nerve, prolonged transient loss of trophic factors). Nerve resection activated microglia at 2-35 days post-operation (dpo), elevated GFAP in astrocytes at 3-35 dpo and increased CGRP in motoneurons at 2-15 dpo. Fluorogold prelabeling revealed neurophagocytosis and 25% neuron loss at 25 dpo. Colchicine block similarly activated microglia at 5-35 dpo, elevated GFAP at 7-35 dpo and upregulated CGRP at 7-25 dpo. Neurophagocytosis and 15% motoneuron loss were evident at 25 dpo. Electric stimulation (15 min, 4 Hz, 0.1 msec impulse, 2 mAmp) of the intact nerve activated microglia at 1-10 dpo, elevated astroglial GFAP-expression at 7-35 dpo, and upregulated CGRP at 1-10 dpo, but no neuron death and neurophagocytosis were detected. Hence electric stimulation elicited a faster, shorter-lasting response, but transport block as well as axotomy a slower, longer-lasting response. This suggests a dual mode of signaling: Onset and early phase of the axotomy reaction are triggered by electric disturbances, late phase and neuron death by deprivation of trophic factors.

Several treatment options are available for pain and disability due to posttraumatic arthritis and deformity of the ankle1-5. In cases in which a tibiotalar arthrodesis is sufficient, the procedure is usually performed through an open or arthroscopic approach, with bone graft when required. However, when severe deformity is present or the subtalar joint is also affected, a calcaneotalotibial arthrodesis should be considered. Tibiotalocalcaneal arthrodesis has been accomplished with the use of bone-grafting and a cast, plating, screws, and external fixation1,3,6,7. The combination of blade-plate fixation and morselized bone graft is a preferred method because it provides rigid fixation, avoids a plantar foot incision, and yields good clinical results. Excision of the talus has been associated with unsatisfactory results and has the major drawback of causing shortening8. Screw fixation has been associated with implant migration and a low rate of union9. External fixation is uncomfortable for the patient and has been associated with a high rate of nonunion and infection6. Intramedullary fixation for ankle arthrodesis was first described by Adams in 19483. The use of Steinmann pins for ankle arthrodesis in patients with rheumatoid arthritis was described by Carrier and Harris in 199110. Retrograde locked nailing systems were employed by Kile et al. for posttraumatic arthritis11 and by Pinzur and Kelikian for Charcot arthropathy12. A retrograde locked nailing system for calcaneotalotibial arthrodesis in the posterior-to-anterior plane was introduced by the senior author (D.P.) in order to increase rotational stability and bone purchase. In the present study, a prospective protocol was used to evaluate the efficacy of this minimally invasive method as a salvage procedure for patients with ankle and subtalar joint pathology, including those with severe …

Fractures of the humeral shaft are common, account for approximately 3 % of all orthopedic injuries, and result in a significant burden to society from lost productivity and wages. Nonoperative management continues as the mainstay for treatment of the majority of these injuries, with acceptable healing in the majority patients. Surgical treatment is generally reserved for open fractures, polytrauma patients, ipsilateral humeral shaft and forearm fractures, and cases in which there is a failure to tolerate or maintain alignment in a functional brace. This conservative approach is in contrast to common practice in the Western world, where there is a strong tendency to treat nearly all fractures operatively, driven by aggressive surgeons using the portfolio offered to treat these fractures surgically and strongly assisted in this purpose by the industry. The modern DRG-driven reimbursement policy in addition shifts the pendulum even more toward operative therapy; hence, conservative fracture treatment is very poorly refunded in this system.

Unilateral external fixation requires an anatomically sound implantation of screws into the upper extremity. Detailed knowledge about the anatomical situation in the areas of pin implantation is of great importance. This paper focuses on relevant anatomical landmarks when implanting screws for external fixation in the humerus, the elbow, the forearm and the hand by studying anatomical specimen.

To assess the accuracy of surgeons in identifying elbow rotation axis (RA) on fluoroscopic images and to measure the interobserver variability. Five healthy subjects underwent 3-dimensional computed tomography (CT) analysis of their nondominant elbow. Real-time rotation software enabled surgeons to approximate the elbow RA on CT-reconstructed fluoroscopy, which was repeated twice with different starting positions to increase the number of observations. The surgeons used anatomical landmarks of choice. Analysis of variance (ANOVA) was used to determine structural error differences between surgeons, and intraclass correlation coefficients (ICCs) were used to determine the corresponding interobserver variability. Eight subspecialty-trained trauma surgeons (P.K., N.W.L.S., V.M.d.J., P.J., G.M.K., R.W.P., T.S., B.A.v.D.) participated and attempted to identify the RA on reconstructed fluoroscopy. A total of 15 RA definitions on 5 elbows were recorded per surgeon. The surgeons had a mean rotational error of 5° (range, < 1°-13°) and mean translational error of 1 mm (range, < 1-8 mm), compared with the true elbow RA as measured by the 3-dimensional CT analysis. The ANOVA showed structural differences between surgeons in rotational and translational errors, indicating that some surgeons consistently had more accurately identified the elbow RA than others. The ICC was 0.12 for rotational error and 0.10 for translational error, indicating a large interobserver variability. We show in this in vivo study that identification of the elbow RA on fluoroscopy is associated with substantial rotational errors and large inconsistencies among surgeons. Implementation of standardized anatomical landmarks is required to improve surgeons' accuracy. These landmarks should preferably take into account both the coronal and the sagittal planes, using the orientation of the capitellum and trochlea as well as the posterior distal humeral cortex. Diagnostic II

There are various treatments for skin defects. In our study we used a skin-stretching device for the closure of six skin defects of the hand and wrist (Sure-Closure System, Life Medical Sciences, Inc., Princeton, N.J.). Three defects were closed completely. The size of the other three wounds was reduced by 50 to 70%. We saw no complications. The skin-stretching device helped to close skin defects with local sensate tissue.

Loss of motion of the elbow is not uncommon after trauma, burns, or coma and severely impairs upper limb function. Loss of motion may be difficult to avoid and is challenging to treat. Detailed analysis of the etiology and diagnostic evaluation are of utmost importance for planning any surgical intervention for elbow stiffness. Most activities of daily living are possible, if the elbow has a range of motion of 100 degrees (30-130 degrees of flexion, Morrey's arc of motion).Stiff elbow, usually defined as less than 30 degrees extension or less than 130 degrees flexion.Poor compliance, poorly controlled diabetes mellitus, active hepatitis B and C infection, HIV infection, acute articular infection.Current operative techniques, such as closed distraction with external fixation (arthrodiatasis), are presented and evaluated. Elbow arthrolysis is a technically demanding procedure.If indication and techniques are used correctly and surgeon, physiotherapist, and patient are familiar with the procedure, good long-term results may be achieved.In 14 children and adolescents the results after 5 years showed an increase of preoperative range of motion from 37 degrees to 108 degrees (flexion/extension; 75-130 degrees ) postoperatively.

The elbow joint is one of the most inherently stable articulations of the skeleton [49]. When in addition to the dislocation of the joint at least one of the osseous or articular component structures that contribute to the stability of the elbow is disrupted, the injury is termed “fracture-dislocation of the elbow” and the risk of recurrent or chronic instability and the development of post-traumtatic arthritis of the elbow are increased [2, 11–13, 17, 18]. Treatment of these injuries is challenging due to difficulties in applying accurate definitions of the patterns of the injury, in evaluating the specific roles of the component structures that contribute to the instability of the elbow and the lack of a standardized rationale for the operative treatment. Soft tissue injury including open wounds and vascular or nerve compromise add to the complexity of the injury. In recent years investigative efforts were put into the definition of the components that contribute to the stability of the elbow and the concept of operative fixation of the osseous and ligamentous lesions (i.e., articular fragments of the distal humerus [7, 20, 31, 32, 35, 36], the radial head [33, 41], the coronoid process [3, 14, 15, 21, 34, 59, 61–64, 72, 75], the olecranon [16, 42, 50, 51, 65, 70] the collateral ligaments [18, 54, 76] and combinations of these lesions [19, 28, 29, 37, 38, 43–45, 58, 60, 67, 68, 78] in order to reconstitute elbow stability. In addition to this more recently the development and use of the trans-articular external fixator with motion capacity of the elbow has extensively broadened the therapeutic spectrum of treating complex elbow trauma and partially changed therapeutic pathways [6, 10, 22–27, 39, 40, 46–48, 52, 55, 57, 66, 69, 71, 77]. The purpose of this lecture is to analyse the ­current literature and own prospective data in order to establish and discuss a strategy in the treatment fracture-dislocations of the elbow (Fig. 1).

Aim The aim of the present study was to compare the primary fixation stability and initial fixation stiffness of two established fixation techniques, the tension band wiring technique and interfragmentary screw fixation, with a mini-screw fragment fixation system in a model of transverse patella fracture. It was hypothesised that the biomechanical loading performance of the fragment fixation system would not significantly differ from the loading characteristics of the two established methods currently investigated. Materials and methods Ninety-six calf patellae were used in this biomechanical model. A standardized transverse patella fracture was induced and three different fixation methods, including the modified tension band wiring technique, interfragmentary screw fixation, and the mini-screw fragment fixation system, were used for fragment fixation. Specimens were mounted to a loading rig which was secured within a material testing machine. In each fixation group, eight specimens were loaded to failure at a simulated knee angle of either 0° or 45°. Another eight specimens were submitted to a polycyclic loading protocol consisting of 30 cycles between 20 N and 300 N at a simulated knee angle of 0° or 45°. The residual displacement between the first and the last cycle was recorded. Differences in the biomechanical performance between the three fixation groups were evaluated. Results No significant differences between the three fixation groups were observed in the parameters maximum load to failure and linear fixation stiffness with monocyclic loading. Specimens being loaded at 45° showed significantly lower maximum failure loads and linear stiffness when compared with 0°. During polycyclic loading, no significant differences in the residual displacement were observed between the groups at 0° loading angle, while at 45°, residual displacement was significantly higher with tension band fixation when compared with interfragmentary screw fixation or the fragment fixation system. Conclusion The biomechanical performance of the fragment fixation system was comparable to interfragmentary screw fixation and superior to the tension band wiring technique. Given the advantages of a system which provides interfragmentary compression and which simplifies fracture fixation after open or closed reduction, we believe the fragment fixation system to be an adequate alternative in the osteosynthesis of transverse patella fractures.

A retrograde nail with posterior-to-anterior (PA) locking into os calcis, talus and tibia was used to correct deformity and achieve fusion after failed fusion. A variety of methods have been published to achieve union of the ankle and subtalar joint in a failed fusion situation. We have studied a retrograde locking nail technique through a 2.5-cm incision in the non-weightbearing part of the sole of the foot. Remaining cartilage in the ankle joint, where necessary, was percutaneously removed through an anterior approach and the locking nail was inserted after reaming of os calcis, talus and tibia. Locking screw insertion was in the sagittal plane (p.a. direction), in talus os calcis and tibial diaphysis using a nail mounted jig. Ten patients were entered in the study (age 27-60 years). The initial aetiology for attempted fusion was post-traumatic in nine cases and rheumatic in one case. There were 25 previous operations in the cohort not leading to fusion. An additional temporary external fixator was used in four cases to reach and maintain the optimum position for the procedure. The intervention time was 30-75 min. Dynamisation of the nail was performed after four months under local anaesthesia. The mean duration of follow-up was 4 years (3-5.5 years). Radiologically and clinically, fusion was achieved in 16 weeks (range, 12-20 weeks). There was no loosening of the implant or implant failure. A leg length discrepancy was avoided using this technique. There was one complication with varus malunion in a heavy smoker which united after corrective osteotomy, revision nailing and bone grafting. Patient satisfaction was measured on a scale (not visual analogue) of 0 (not satisfied) to 10 (completely satisfied); overall satisfaction averaged 9.5 points (range, 6-10 points). The postoperative ankle-hindfoot score of the American Orthopedic Foot and Ankle Society averaged 73.5 points (range, 61-81 points). Retrograde locked nailing with locking in the sagittal plane is a reliable minimally invasive procedure to achieve fusion of the ankle and the subtalar joint after failed fusion.