Cross-Cultural Adaptation and Validation of the Lower Extremity Measure Into German.

INTRODUCTION: The Lower Extremity Measure (LEM) was developed to provide a specific instrument to detect changes in physical function in patients with hip fracture. Of 29 questions, 3 have a valid "not applicable" answer option. The goal of this study was to validate the LEM in German and to determine the added value to the physical functioning (pf) subscale of the Short Form 36 (SF-36). MATERIALS AND METHODS: The LEM was translated according to published guidelines and administered to patients with hip fracture (31 A1-A3 and 31 B1-B3) shortly after surgery (baseline), at 3 months (3M), and for reliability testing at 3 months plus 1 week (3M+). The reproducibility, internal consistency, floor and ceiling effects, construct validity, and responsiveness of the German LEM were assessed. RESULTS: A total of 106 patients completed the LEM and SF-36 (mean age 75.5; 67% women) at baseline (mean of 4.9 days after operation), and 88 completed both questionnaires at both the 3M and 3M+ assessments. At each assessment time point, between 6% and 23% of the patients answered 7 questions as "not applicable." Reproducibility and internal consistency were high (intraclass correlation coefficient = 0.93; Cronbach's α = .96). No floor effect (0%) and a minor ceiling effect (7.87%) were found for the total LEM score. The strongest correlation was found between the LEM and the SF-36 subscale pf (Spearman ρ = .93). Responsiveness was similar for the SF-36 pf subscale and the LEM when using effect size (SF-36 pf 0.71 vs LEM 0.72) and better for the LEM when using standardized response mean (SF-36 pf 0.65 vs LEM 0.76). DISCUSSION: The German LEM is a reliable, valid, and responsive measure for the self-assessment of patients after hip fracture surgery. As a number of questions are not applicable to elderly patients, the added value of this lengthy questionnaire in these often frail, sometimes cognitively impaired patients is still open for debate.

The Influence of Local Bone Density on the Outcome of One Hundred and Fifty Proximal Humeral Fractures Treated with a Locking Plate.

BACKGROUND: There is biomechanical evidence that bone density predicts the mechanical failure of implants. The aim of this prospective study was to evaluate the influence of local bone mineral density on the rate of mechanical failure after locking plate fixation of proximal humeral fractures. METHODS: We enrolled 150 patients who were from fifty to ninety years old with a closed, displaced proximal humeral fracture fixed with use of a locking plate from July 2007 to April 2010. There were 118 women and thirty-two men who had a mean age of sixty-nine years. Preoperative computed tomography (CT) scans were done to assess bone mineral density of the contralateral humerus, and dual x-ray absorptiometry of the distal end of the radius of the unaffected arm was conducted within the first six weeks postoperatively. At follow-up evaluations at six weeks, three months, and one year postoperatively, pain, shoulder mobility, strength, and multiple functional and quality-of-life outcome measures (Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire; Shoulder Pain and Disability Index [SPADI]; Constant score; and EuroQuol-5D [EQ-5D]) were done and standard radiographs were made. We defined mechanical failure as all complications related to bone quality experienced within one year. RESULTS: After locking plate fixation, fifty-three (35%) of 150 patients had mechanical failure; loss of reduction and secondary screw loosening with perforation were common. CT assessments of local bone mineral density showed no difference between patients with and without mechanical failure (89.82 versus 91.51 mg/cm3, respectively; p = 0.670). One-year DASH, SPADI, and Constant scores were significantly better for patients without mechanical failure (p ≤ 0.05). CONCLUSIONS: We did not find evidence of an association between bone mineral density and the rate of mechanical failures, which may suggest that patients with normal bone mineral density are less prone to sustain a proximal humeral fracture. Future studies should target other discriminating factors between patients with and without mechanical failure. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Central head perforation, or "cut through," caused by the helical blade of the proximal femoral nail antirotation.

OBJECTIVE: This study was designed to investigate the specific type and incidence of implant failure in patients with a proximal femur fracture treated with a proximal femoral nail antirotation. This device has a helical-shaped blade as a neck-head holding device, instead of the lag screw used in other intramedullary nails. The advantage of the blade is believed to originate from bone impaction and a larger bone-implant interface in comparison with the lag screw design, with consequential greater mechanical resistance to torsion in the cancellous bone. PATIENTS AND METHODS: This is a retrospective cohort study conducted at the state hospital of Winterthur, Switzerland. From December 2006 until November 2008, 210 consecutive patients were treated with a pertrochanteric femur fracture (OTA type 31-A1, 31-A2, and 31-A3) using a proximal femoral nail antirotation. One hundred and twelve patients were followed up clinically for a minimum of 12 months after discharge. Clinical and radiologic assessment of fracture healing and/or implant failure was investigated. RESULTS: We report 7 cases of implant failure with a "Cut Through," defined as a postoperative central perforation of the spiral blade into the hip joint, without any displacement of the neck-head fragment. CONCLUSIONS: Cut through needs to be distinguished from the well-known anterocranial perforation combined with a varus displacement of the neck-head fragment, known as "Cut Out," seen with intramedullary nails utilizing lag screws. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Anatomic reconstruction of unstable lateral clavicular fractures.

BACKGROUND: Fractures of the lateral clavicle result in a high rate of nonunion compared with midshaft fractures. Many operative treatment methods of unstable lateral clavicle fractures have been described, but no single method has become generally accepted. This study reports our experience treating unstable lateral clavicle fractures with coracoclavicular ligament rupture. METHODS: Within 7 years, 19 patients with acute unstable lateral clavicle fractures were treated using a 2.4-mm T-plate and a coracoclavicular polydioxanone cord. The follow-up averaged 5.3 years (range, 2.0-8.8). Shoulder function was assessed using the Constant score and Disabilities of the Arm, Shoulder and Hand score. General health of the patients was evaluated according to the Short Form 36 questionnaire. RESULTS: Eighteen of the 19 patients treated with our method achieved union at 8.8 weeks (range, 6-14), a Constant Murley score of 91.5 (range, 72-100) on the injured side versus 93.5 (range, 80-100) on the contralateral side, a Disabilities of the Arm, Shoulder and Hand score of 1.4 (range, 0-9.2), and a Short Form 36 Health Score of 85 (range, 89-100). One patient showed breakage of the plate and a delayed union at the radiologic follow-up 4 months after surgery. CONCLUSION: This study shows that treatment of unstable lateral clavicular fractures with an angular stable locking plate together with a polydioxanone cord ligament augmentation leads to excellent results with a 95% union rate. Additional coracoclavicular augmentation next to plate fixation of the clavicle may partially solve the problem of uncertain plate fixation if the lateral fragment is small and multifragmented, as often observed.

Osteosynthesis of traumatic manubriosternal dislocations and sternal fractures with a 3.5/4.0 mm fixed-angle plate (LCP).

INTRODUCTION: We present a case series of three patients with manubriosternal dislocation and/or sternal fractures. METHOD: We describe our experiences of invasive surgical treatment with 3.5/4.0 mm fixed-angle plate (Locking compression plate, LCP) in this group of patients. Recommended nonoperative treatment options, e.g. correction tape or plaster bandage, symptomatic pain treatment, application of ice, and several weeks without sports are associated with a not inconsiderable rate of subluxations or reluxations with an increased risk of pseudarthrosis and chronic pain syndrome. RESULTS: Due to a small number of cases and the lack of controlled studies, a standardized operative procedure could, therefore, so far not been established. CONCLUSION: Our positive experiences with the operative treatment using 3.5/4.0 mm fixed-angle plate (LCP) may help to establish the operative procedure of first choice in this group of patients.

First report of an accessory popliteal muscle: detection with MRI.

During an MRI examination of the knee in a 48-year-old patient suffering from degenerative changes of a partly resected medial meniscus and concomitant osteoarthritis of the knee joint, an unusual variant of an accessory muscle in the popliteal fossa was found. To our best knowledge this muscle has never been described before. Because of the close relationship to the popliteal muscle with regard to course and localisation in the deep popliteal fossa ventral to the popliteal artery, the term "accessory popliteal muscle" is proposed.