Primary resective shortening followed by distraction osteogenesis for limb reconstruction: a comparison with simple lengthening.

Resective distraction osteogenesis is a new approach to treat segmental diaphyseal bone defects by primary limb shortening and secondary distraction osteogenesis from the same site. A rabbit model was introduced to compare the bone-regeneration characteristics of this technique with those of simple lengthening procedures. Twenty-four skeletally mature New Zealand White rabbits were divided into two equal groups. In the test group, limbs were lengthened after a 10-mm segmental diaphyseal bone resection and limb shortening. In the control group, a simple subperiosteal osteotomy for limb lengthening was performed without resection. New bone formation was evaluated mechanically, radiologically, histomorphometrically, and densitometrically. Bone bridging occurred in all animals. Normalized mechanical values for the newly reconstructed tibiae demonstrated similar torsional stiffness (71+/-3.3 compared with 71+/-8.2%; p = 0.95) and strength (64+/-5.3 compared with 68+/-7.3%; p = 0.66) in the two groups. The average normalized callus diameter was significantly greater in the test group than in the control group (p < 0.01). The remodeling index calculated from densitometry, however, showed a significantly less progressed stage of remodeling in the test group (p < 0.05). Histomorphometric analysis of the callus center supported this finding, showing significantly lower values for trabecular thickness (p < 0.05) and total bone volume (p < 0.01) in the test group. The results demonstrated the possibility of new bone formation after resection and monofocal shortening. This suggests a new therapeutic option to treat diaphyseal segmental bone defects.

Distraction osteogenesis after acute limb-shortening for segmental tibial defects. Comparison of a monofocal and a bifocal technique in rabbits.

BACKGROUND: Segmental bone defects can be treated with immediate limb-shortening followed by monofocal or bifocal distraction osteogenesis. In the present study, the efficacy of monofocal distraction osteogenesis was compared with that of bifocal distraction osteogenesis in a rabbit model. METHODS: Twenty-four skeletally mature New Zealand White rabbits were divided into two equal groups: one group had monofocal distraction osteosynthesis, and the other had bifocal distraction osteosynthesis. In both groups, a one-centimeter-long segment of bone was resected from the midpart of the tibial shaft. In the monofocal reconstruction group, the limb was immediately shortened to close the segmental defect and the defect was allowed to heal for ten days. Lengthening was then begun at this site, with use of a specially designed external fixator, at a rate of 0.5 millimeter per twelve hours. In the bifocal reconstruction group, the segmental defect was closed immediately and the fragments were fixed with microplates. A subperiosteal osteotomy was performed proximal to the tibiofibular junction, and lengthening was performed at the site of the osteotomy. The animals in both groups were killed twenty days after the lengthening was completed. New-bone formation then was evaluated with use of radiographs, densitometry, biomechanical testing, and histological and histomorphometric analysis. RESULTS: Osseous consolidation occurred in all but one of the animals. Biomechanical testing demonstrated that the tibiae that had been treated with use of the simple monofocal reconstruction technique tended to have greater torsional stiffness (p = 0.14) and strength (p = 0.09). Follow-up radiographs revealed that both groups had a significant decrease in radiolucent area (p < 0.05), which occurred at essentially the same rate after lengthening. No significant differences were found between the groups with respect to new-bone mineral density, new-bone area, or the amount of callus. Thus, after resection of a diaphyseal bone segment comprising 10 percent of the original length of the tibia and acute shortening, limb reconstruction was completed successfully through distraction osteogenesis with use of either a monofocal or a bifocal technique in rabbits. CONCLUSIONS: In the present study, both monofocal and bifocal techniques of shortening and distraction osteogenesis were effective for the reconstruction of segmental bone defects. Under some conditions, the monofocal method may provide a simpler means of treating such defects. CLINICAL RELEVANCE: Damage to the soft-tissue envelope as well as venous and lymphatic stasis impose limits on the amount of limb-shortening that can be achieved with use of the monofocal method and also influence the indications for this procedure in the clinical setting.

A target device for placement of implants in the thoracolumbar pedicles.

Posterior spinal instrumentation with the placement of intrapedicular implants has become an important technique. We have designed a hand-held target device to facilitate the open or percutaneous location and penetration of the thoracolumbar pedicles. A cylindrical pin guide incorporates two metal rings and can be moved under image intensifier control until the rings are superimposed to show correct alignment. The radiation dosage for the surgeon is minimal; the device allowed accurate placement of 106 consecutive pedicle screws.

Penetration of ciprofloxacin into bone: a new bioabsorbable implant.

The implantation of antibiotic-containing cement beads became standard adjuvant local antibiotic therapy of chronic osteomyelitis. The new developed bioabsorbable drug carrier system of polyglycolic acid with the antibiotic Ciprofloxacin was tested in vitro and in vivo. The goal of this study was to determinate the penetration depth of Ciprofloxacin into bone cortex and marrow. Two monofil, PGA cylinders, 3.2 x 5 mm in size, containing 3 mg of Ciprofloxacin each, were implanted into the proximal part of both femora of 18 rabbits (New Zealand white). After sacrifice, the concentration of Ciprofloxacin in micrograms/g cortex and marrow was measured with high-performance liquid chromatography in relation to the distance from the test material at day 2, as well as at 1, 2, 3, 4, and 6 weeks postimplantation. For a distance up to 5 mm, marrow levels of the drug exceeded cortical levels at day 2 (5000 to 240 micrograms/g). At a distance of 5-10 mm, cortex levels were similar to marrow levels after 2 weeks and were higher than marrow levels at week 3. This observation could be made at a distance between 10 and 15 mm only after 2 days. Later, marrow concentrations again exceeded that in cortex. At a distance of more than 15 mm, antibiotic levels were low and approximated. After 6 weeks, at 5 mm distance, a bactericidal drug concentration of about 2 micrograms/g in bone marrow could be measured. Drug penetration into cortical bone in bactericidal concentrations of about 2 micrograms/g was achieved at up to 30 mm in the first few days.(ABSTRACT TRUNCATED AT 250 WORDS)

A severe infection following endoscopic carpal tunnel release.

A 59-year-old patient underwent endoscopic carpal tunnel release by Chow's two-portal technique. He developed a pyogenic tenosynovitis and an infection within the ulnar and radial bursae, an abscess in the middle palmar, thenar and Parona's space, and a pyogenic wrist arthritis. Surgical treatment included a wide exposure of the infected region, débridement, irrigation, application of a resorbable collagen sponge containing gentamicin, insertion of two drains and primary wound closure. The infection was brought under control and hand function restored.

[Therapeutic concept and results of treatment of subcutaneous extensor tendon rupture of the finger end joint]. / Therapiekonzept und Ergebnisse in der Behandlung der subcutanen Strecksehnenruptur am Fingerendglied.

This study covers treatment and after-treatment of 95 extensor tendon injuries of the DIP-joint in 94 patients over a period of 3 years. Tendon injuries were classified into 4 types according to Suckert et al. and the final results were evaluated using a modified Riedeberger and Zeumer scale. In recent subcutaneous tendon injuries conservative therapy is indicated, depending on the primary extension deficit (less than 20 degrees = modified Stack splint, greater than 20 degrees = Mommsen plaster of Paris or special dressing). Chip fractures should be stabilized by pull-out suture.

[Principles of secondary soft tissue reconstruction after open fractures of the tibia]. / Prinzipien der sekundären Weichteilrekonstruktion des Unterschenkels nach offenen Frakturen.

Course and prognosis of open lower leg fractures are significantly influenced by the concomitant soft tissue injury. Selection and timing of therapeutic procedures determine the final outcome. Fracture stabilisation takes priority. Early soft tissue coverage should be achieved by local cutaneous or fasciocutaneous flaps. Exposed bone can be covered by transposed local musculature. Especially in the distal third as well as in extensive soft tissue loss the microsurgical transplantation of free flaps is advantageous. Tissue expansion can provide skin for secondary replacement of instable scars.

[Transposition of the extensor indicis tendon in reconstruction of thumb extension after rupture of the extensor pollicis longus tendon]. / Die Transposition der Sehne des Extensor indicis zur Wiederherstellung der Daumenstreckung nach Ruptur der Sehne des Extensor pollicis longus.

During a period of 13 years we performed 56 extensor indicis proprius (EIP) transpositions for reconstruction of the ruptured or severed extensor pollicis longus tendon. The open injuries (n = 9) involved failed primary repair or untreated tendon injuries. The subcutaneous ruptures occurred after distal radius fractures (n = 17) or other closed injuries of the wrist (n = 10), without trauma in 14 patients and in 6 patients by rheumatoid synovialitis or collagenosis. 35 patients returned for follow-up examination 8 months to 10.5 years after operation. According to the evaluation scheme suggested by Geldmacher et al. we report 13 excellent, 19 good and 3 satisfactory results. Although several authors prefer EPL reconstruction with an intercalated tendon graft, we recommend the EIP transposition as a simple procedure with predictable satisfactory results.

[Surgical treatment and results of healing of de Quervain stenosing tenovaginitis]. / Operative Behandlung und Ausheilungsergebnisse der Tendovaginitis stenosans de Quervain.

Within a period of 6 years we operated on 109 patients with De Quervain's disease. Of the patients 82% recovered completely, 18% had slight residual complaints, e.g. stress-dependent discomfort and irritations of the superficial radial nerve. The operative technique is presented in detail and the frequency of anatomical variations of the first extensor tendon compartment is emphasized.

[Open pelvic fracture--an indication for laparotomy?]. / Die offene Beckenfraktur--eine Indikation zur Laparotomie?

Open pelvic fractures are rare and account for 1-5% of all pelvic fractures. Mortality rates of 50% and even more have been reported. Bleeding and septic complications are the major causes of death. In our retrospective study from 1974 to 1996 the data of 40 patients were analyzed. Five patients died (12.5%); 28 survivors could be investigated with a mean follow-up of 10 years. It is concluded that the comparably low mortality rate is due to a standardized treatment protocol. The main principles of management are emergency stabilization of the unstable pelvis and early laparotomy.

[Ultrasonic welding of bones. Preliminary results]. / Die Ultraschallverschweissung von Knochen. Vorläufige Ergebnisse

Experiments with ultrasonic applied welding, a method first developed in the USSR are reported. In standardized isolated bone preparations stability values could be obtained of 10% [and in one case of 40% (!)] of the stability of the nonfractured bone. With these values the requirements of the method of osteosynthesis are met. Results of in vivo experiments are expected.

[Therapy and prognosis of enchondroma of the hand]. / Therapie und Prognose bei Enchondromen der Hand.

Enchondromas are the most common bone tumors of the hand. In a retrospective study, medical records and radiographs of 112 patients were reviewed. These patients were operated on between January 1973 and June 1997. After extirpation of the tumor, the defect was preferably treated with bone grafting in 102 patients. A malignant transformation (chondrosarcoma) was diagnosed in 2 patients. Follow-up examination of 92 patients with a mean follow-up of 1.6 years (range: 7 months to 14 years) yielded excellent or good results in 76 patients (82.6%), according to the evaluation scheme of Wilhelm and Feldmeier. Four recurrences were probably related to an incomplete resection of the tumor. The authors conclude that enchondromas of the hand should be treated surgically to prove the diagnosis and to prevent a pathologic fracture.

[100 years tendovaginitis stenosans de Quervain--review of the literature and personal results]. / Hundert Jahre Tendovaginitis stenosans de Quervain--Spiegel der Literatur und eigene Ergebnisse.

One hundred years ago, Fritz de Quervain first described the surgical treatment of tendovaginitis of the first dorsal compartment. Since then, various ways of treatment have been pointed out. In a series of 72 patients treated surgically, 82% recovered completely. Postoperative complaints included irritations of the superficial branch of the radial nerve.

[Traumatically-induced thrombosis of the distal ulnar artery. Case report and review of the literature]. / Traumatisch induzierte Thrombose der distalen Arteria ulnaris. Fallbeschreibung und Literaturüberischt.

The authors report on a patient who fell and struck his right hypothenar against a sharp edge. He had immediate pain and reduced circulation in his ring and little fingers. The neurological findings revealed paraesthesia in the two ulnar fingers and loss of abduction strength in the little finger. Treatment was at first conservative, but the symptoms persisted. Four weeks after injury, the patient was referred to our unit. Doppler ultrasound and angiography of the brachial artery were performed, showing an occlusion of the ulnar artery just distal to the space of Guyon. Operative revision was carried out and a 20 mm thrombus removed. Recovery was then uneventful, and all previous symptoms disappeared. A review of the literature is presented and typical symptoms, diagnostic and therapeutic approaches discussed. The need for an early diagnosis and operative revision is demonstrated.

[Tuberculosis of the hand]. / Tuberkulose des Handskeletts.

Skeletal tuberculosis of the hand has become rare. The authors report a 27-year-old female patient with tuberculous osteomyelitis of the middle phalanx of the left ring finger without occupational exposure of the hand and with positive chest roentgenogram. The case shows the diagnostic difficulties of the uncommon manifestation of skeletal tuberculosis in the short tubular bones of the hand. By means of a review of the literature the differential diagnosis, the course and necessary treatment are discussed.

Bundle nailing of diaphyseal fractures of the humerus.

The principles of bundle nailing--jamming of the nails in the cortical window, jamming in the waist of the medullary cavity, spreading the bunch of nails in the metaphysis and filling up the conus of the medullary cavity with short nails-should be observed. Then this method of intramedullary osteosynthesis is of diaphyseal fractures with slight damage to the soft tissues is indicated ideally in the second to fifth sixth of the humerus. The complication rate is low. If there is a primary traumatic lesion of the radial nerve or if there are open fractures and/or multiple fractures in case of polytraumatized patients, operative stabilization is mandatory using plate osteosynthesis or external fixation.

[Multifascicular intramedullary nailing of the forearm]. / Embrochage centro-médullaire multifasciculé de l'avant-bras.

PURPOSE OF THE STUDY: Purpose of the study was to present the advantages of intramedullary nailing of long bones for treatment of fractures of the forearm. These advantages are 1) preserving the fracture-hematoma and 2) non exposure of bone. This technique is based on the technique of bundle nailing developed by Hackethal (1959). MATERIAL AND METHODS: In a 16-year period we performed Hackethal bundle nailing in 94 patients with 159 fractures. Hackethal developed the nailing procedure named after him in 1959. The rationale of Hackethal nailing is based on elastic jamming, which can only be achieved by following four rules: jamming of the nails in the cortical window, jamming then in the waist of the medullary cavity, spreading the bundle of nails in the metaphysis and filling up the conus of the medullary cavity with short nails. We confined Hackethal nailing to closed and first-degree open fractures of the midshaft of the forearm. If closed reduction and nailing were impossible, we performed a plate fixation (AO). Second- or third-degree open fractures were treated with external fixators. RESULTS: In 62.8 per cent patients surgery was performed within the first 8 hours following admission. We used two or three nails passing the fracture and one short nail. Except for 1 case, in which a cast was necessary, we achieved rotational stability. On average, the nails were removed after 11.5 months. The healing and complication rates were assessed by follow-up examination of 77 patients. The results were excellent and good in 75.3 per cent patients, satisfactory 14.3 per cent and poor in 10.4 per cent. Complications consisted of a 0.74 per cent infection rate (osteitis), 2.2 per cent non-union, 1.5 per cent with a synostosis, 0 per cent refracture and 2.2 per cent migration of nails, combined with tendon rupture. We have seen 1 case with metallosis. DISCUSSION: There are four important benefits of this treatment. First with this principle bone healing is achieved after 2.6 month, but with the plate fixation it lasts 7.5 month. Second, the rate of non-union goes down from almost 6 per cent to 1.5 per cent. Third, the postoperative infection rate is reduced (0.74 per cent) and fourth joint motion is preserved. Our bad results are mainly caused by the polytraumatic conditions of some patients. CONCLUSION: In conclusion with our confined spectrum of indications Hackenthal nailing is a low-risk method, which leads to rotational stability and early bone healing.

[The most common tendon injury in sports--hammer finger. Origin, classification, diagnosis and rational therapy]. / Die häufigste Sehnenverletzung beim Sport--der Hammerfinger. Entstehung, Einteilung, Diagnostik und rationale Therapie.

The closed rupture of the distal digital extensor tendon at its attachment on the terminal phalanx the so-called mallet finger - is seen very often in ball games ("basketball finger", "baseball finger"). Closed rupture with and without a bony fragment can be distinguished. We demonstrate a rational and anatomy related way of treatment.

[Polytrauma and femoral fracture]. / Polytrauma und Femurfraktur.

From 1976 to 1986 1.003 polytraumatized patients were treated at our institution. 88% had suffered fractures of spine, pelvis and limbs. Of particular relevance are the femoral fractures (36% of all cases) in the management of those patients. In not adequately immobilized femoral fractures the rate of general and local complications in this group is elevated. Impaired microcirculation and the required high doses of analgesics can lead to an increased risk of eventually lethal ARDS. From 1976 to 1983 we used the conventional approach and stabilized femoral fractures using plates and IM nails. Due to the time required for the operation, the eventual blood loss and the invasiveness of the operation, we could operate only on 44% of the femoral fractures within the first 24 hours. In 1984 we introduced the DAF device in our service and used it in compound femurs and unstable patients with femoral fractures. In the other cases the locking nail (GK Nail) was used. With this concept we managed to increase the rate of surgery of femoral fractures in polytrauma victims within the first 24 hours to 80%. Further assessment of the date showed a significant drop of 27.3% in mortality, mainly due to a decreased rate in late ARDS-related deaths. The advantage of the DAF concept in the stabilization of these fractures in polytrauma victims we see in the less time consuming fixation, the minimal blood loss, easier ICU care and fewer local complications. The DAF device is used as a definitive management tool and does not generally require a change to another method of fixation.