Monteggia fractures: analysis of patient-reported outcome measurements in correlation with ulnar fracture localization.

BACKGROUND: Monteggia fractures and Monteggia-like lesions result after severe trauma and have high complication rates. Preliminary biomechanical studies suggested a correlation between ulnar fracture localization and clinical result. OBJECTIVES: Key objective was to evaluate whether the site of the ulnar fracture can be correlated to clinical outcome after open reduction and internal stabilization. METHODS: In a retrospective, monocentric study 35 patients who underwent surgical treatment after suffering a Monteggia injury or Monteggia-like lesion were included. Fractures were classified according to Bado and Jupiter, the site of the fracture location at the proximal ulna and regarding the potential accompanying ligamentary injury. In a follow-up examination validated patient-reported outcome measures and functional parameters were evaluated. Furthermore, treatment strategy and complications were analysed. RESULTS: Mean patient age was 51.9 years (± 18.0). 69% were females (n = 24). Follow-up took place after 50.5 months (± 22.1). Fractures were classified according to Bado (I:2, II:27, III:4, IV:2). Bado II-fractures were further classified according to Jupiter (A:7, B:16, C:3, D:1). Cases were divided into subgroups depending upon the distance of the ulnar fracture site in respect to its distal endpoint (A: < 7 cm and B: > 7 cm). Average overall MEPS was 84.1 (± 19.0). Oxford elbow score and DASH were 37.2 (± 10.5) and 20.4 (± 20.5). Average extension capability reached - 7° (± 7.5). Mean flexion was 134.8° (± 19.7). Average pain according to visual analogue scale was 1.6 (± 1.9). We found no differences between the subgroups regarding the PROMs. Subgroup A displayed a worse extension capability (p = 0.027) and patients were significantly older (p < 0.01). Comparing patients with and without fracture of the radial head, we observed no differences. Patients with an accompanying injury of the coronoid process displayed higher pain levels (p = 0.011), a worse functionality (p = 0.027) and overall lower scoring in PROM. CONCLUSION: The presented results suggest that in Monteggia fractures and Monteggia-like lesions, the localization of the ulna fracture can give a hint for its postoperative outcome. However, we could not confirm the hypothesis of an increasing instability in ulnar fractures located further distally (high severity of the potential ligamentous injury). Intraarticular fractures or injuries with a close relation to the joint have a worse prognosis, especially if the coronoid process is injured. Trial registration Registration was done with ClinicalTrials.gov under NCT05325268.

Prospective randomized controlled trial in the treatment of lateral epicondylitis with a new dynamic wrist orthosis.

BACKGROUND: In the treatment of lateral epicondylitis (LE), the role of a new dynamic wrist orthosis is unclear. PATIENTS AND METHODS: Patients suffering from a LE longer than 3 months were multicentrically and prospectively randomized into a physiotherapeutic group (PT group) and in a physiotherapy group plus wrist orthosis (PT + O group). Physiotherapy consisted of daily eccentric strengthening exercises under initial professional supervision. Inclusion criteria were a Placzek score greater than 4. Exclusion criteria were previous surgery, rheumatic arthritis, elbow instability, radicular symptoms, higher-grade extensor tendon rupture, or cervical osteoarthritis. The clinical evaluation was performed after 12 weeks and 12 months. The Patient-Rated Tennis Elbow Evaluation (PRTEE) scale, Placzek Score, the pain rating (VAS), range of motion and the Subjective Elbow Score were evaluated. RESULTS: Of the initially 61 patients, 31 were followed up after 12 weeks and 22 after 12 months. Twenty-nine patients (43%) were male, the mean age was 46, and 44 patients (66%) had the right elbow involved. At 12 weeks, there was a pain reduction on the VAS in both groups (PT + O: 6.5-3.7 [p = .001]; PT: 4.7-4.1 [p = .468]), albeit it was only significant for the PT + O group. At 12 months, reduction was significant in both groups (PT + O: 1.1 [p = .000]; PT: 1.3 [p = .000]). The painless maximum hand strength in kg improved in both groups significant after 3 and 12 months. The Placzek score was reduced from 8.25 to 3.5 [p = .001] after 12 weeks for the PT + O group and from 8.1 to 3.8 [p = .000] in the PT group, as well as after 12 months in the PT + O group to 0 [p = .000] and in the PT group to 2.0 [p = .000]. The PRTEE improved in both groups after 12 weeks (PT + O: 52.8--31.3 [p = .002]; PT: 48.6-37.6 [p = .185]) and 12 months (PT + O: 16.15 [p = .000]; PT: 16.6 [p = .000]), although the reduction at 12 weeks was not significant for the PT group. CONCLUSION: The elbow orthosis appears to accelerate the healing process with respect to the PRTEE and pain on the VAS (12 weeks follow-up), although there is an adjustment after 12 months in both groups and a significant improvement of symptoms is achieved in all endpoints.

[Corrective osteotomies for posttraumatic elbow deformities]. / Korrekturosteotomien bei posttraumatischen Fehlstellungen des Ellenbogengelenks.

OBJECTIVES: Correcion of elbow joint deformities that usually develop secondary to direct or indirect trauma of the arm or elbow with subsequent inadequate healing and consecutive axial/rotational malalignment and may be associated with cosmetic or functional deficits of the arm. INDICATIONS: Relevant malalignment of the arm axis with corresponding cosmetic or functional deficits for the patient. CONTRAINDICATIONS: Pre-existing degenerative and chronic inflammatory changes. SURGICAL TECHNIQUE: Generally, two-dimensional supracondylar open or closed wedge osteotomies are used. In the presence of a three-dimensional deformity (with rotational component), an additional derotational correction is necessary. Extra-articular deformities following extension fractures should be treated preferably with an open wedge osteotomy, extra-articular deformities of flexion fractures with a closed wedge osteotomy. Valgus/varus deformities may also require a closed/open wedge osteotomy primarily through a dorsal or alternatively radial approach. POSTOPERATIVE MANAGEMENT: The arm should be immobilized with a brachial cast splint for 2-3 weeks, with passive exercises of the elbow starting on postoperative day 7. RESULTS: In general, the results for a three-dimensional osteotomy of the distal humerus are expected to be good to very good. Only in rare cases (2.5%) is a mostly transient irritation of the ulnar nerve observed.

[Control of diffuse bleeding in unstable pelvic fractures with compression plate packing: presentation of the surgical technique]. / Kontrolle diffuser Blutungen bei instabiler Beckenfraktur mittels Kompressionsplattentamponade: Vorstellung der chirurgischen Technik.

Current recommendations on surgical management of unstable pelvic fracture with hemorrhagic shock include reduction and fixation, i.e., with a C-clamp and external fixator, angiographic embolization of injured pelvic arteries, and preferably extraperitoneal packing to control diffuse bleeding from the venous plexus and fracture site. However, the recently reported lethality at 40-60% remains seriously high. One possible reason could be the unsatisfactory efficiency of extraperitoneal packing in the case of a traumatically or surgically opened retroperitoneal compartment. In this paper, a new approach, so-called compression plate packing, is proposed to control diffuse bleeding. In this technique, the essential pressure of the packing on the bleeding site is set up with small fragment plates with screw fixation to the pelvic ring. In two first clinical cases of severe pelvic trauma the hemorrhage could be controlled reliably.

Ovine bone marrow mesenchymal stem cells: isolation and characterization of the cells and their osteogenic differentiation potential on embroidered and surface-modified polycaprolactone-co-lactide scaffolds.

The current study was undertaken with the goal being isolation, cultivation, and characterization of ovine mesenchymal stem cells (oMSC). Furthermore, the objective was to determine whether biological active polycaprolactone-co-lactide (trade name PCL) scaffolds support the growth and differentiation of oMSC in vitro. The oMSC were isolated from the iliac crest of six merino sheep. Three factors were used to demonstrate the MSC properties of the isolated cells in detail. (1) Their ability to proliferate in culture with a spindle-shaped morphology, (2) presence of specific surface marker proteins, and (3) their capacity to differentiate into the three classical mesenchymal pathways, osteoblastic, adipogenic, and chondrogenic lineages. Furthermore, embroidered PCL scaffolds were coated with collagen I (coll I) and chondroitin sulfate (CS). The porous structure of the scaffolds and the coating with coll I/CS allowed the oMSC to adhere, proliferate, and to migrate into the scaffolds. The coll I/CS coating on the PCL scaffolds induced osteogenic differentiation of hMSC, without differentiation supplements, indicating that the scaffold also has an osteoinductive character. In conclusion, the isolated cells from the ovine bone marrow have similar morphologic, immunophenotypic, and functional characteristics as their human counterparts. These cells were also found to differentiate into multiple mesenchymal cell types. This study demonstrates that embroidered PCL scaffolds can act as a temporary matrix for cell migration, proliferation, and differentiation of oMSC. The data presented will provide a reliable model system to assess the translation of MSC-based therapy into a variety of valuable ovine experimental models under autologous settings.

[Perspectives of clinical stem cell therapy in the treatment of musculoskeletal diseases in Germany]. / Perspektiven klinischer mesenchymaler Stammzelltherapie bei muskuloskeletalen Erkrankungen in Deutschland.

AIM: The treatment of large bone defects remains a challenge for the orthopaedic surgeon. Regenerative therapies with the use of mesenchymal stem cells (MSC) may provide an alternative to autogenous bone transplantation, callus distraction or the use of allografts. MATERIAL AND METHODS: On the occasion of an expert workshop of the German Society for Orthopaedic and Trauma Surgery, a literature search regarding studies with the use of MSC was performed to evaluate its potential for future clinical studies. Furthermore, the legislative requirements were examined. RESULTS: Various in vitro and animal studies showed the benefit of MSC in bone regeneration. However, there are sparse data from clinical studies. Due to recent legislative changes there are several regulatory demands to meet if clinical studies are performed with MSC. CONCLUSIONS: For further evaluation of the role of MSC in the treatment of bone defects there is a need for clinical trials. The current paper provides some assistance for the successful application for clinical trials with MSC. Planning and performance of these studies may require early consultation with the regulatory authorities and cooperation of research centres in order to obtain authorisation for the evaluation of MSC. Preclinical data have to be obtained according to good laboratory practice with equivalent protocols that will be used in the clinical trials. In the latter the implementation of the guidelines for good clinical practice are mandatory.

[Internal fixation of meta- and diaphyseal intercalary bone defects after tumour resection with intramedullary nailing and porous polymethylmetacrylate (PMMA) spacer]. / Stabilisierung von meta- und diaphysären Segmentdefekten nach Tumorresektion durch Marknagelung und Polymethylmetacrylat- (PMMA-)Formkörper.

BACKGROUND: Radical resection of bone tumours localized in the meta- or diaphysis of long bones frequently results in segmental defects. Several stabilization techniques with preservation of the adjacent joint have been published, but the failure rate appears to be considerable. The objective of this study is the experimental and clinical testing of a new technique which combines unreamed nailing with support of the defect by a porous polymethylmetacrylate (PMMA) spacer. METHODS: For spacer preparation, PMMA spheres were adhered to a cylindrical spacer (Ø 32 mm) with interconnective porosity. Axial strength was determined, as was the stiffness/strengths of the combination osteosynthesis in human cadaver tibias (defect lengths 6 cm; empty defect served as a control). An experiment was also conducted with sheep. A 3 cm diaphyseal tibia defect was prepared and stabilized by nailing. For the control there was an empty defect. Group A had support of the defect with a PMMA spacer and group B a PMMA spacer coated with osteoconductive RGD-peptide. Evaluation after was made after 6 months including histology and a determination of relative torsional strength. In addition, a clinical study has been under way since October 1998, with 13 patients (defect lengths between 3-15 cm) being operated. RESULTS: Axial stability was 12,750+/-300 N (17.56+/-0.59 MPa). There was an enhancement of 4-point bending stiffness by 35% (P=0.028), of axial stiffness by 36% (ns) and of axial strength by 553% (P=0.028). Histology showed the formation of a new bone at the spacer/muscle interface. For the sheep, relative torsional strength was enhanced by 95% (P=0.08) in group A and by 91% (P=0.047) in group B. For the patients studied, the mean follow-up period was 16.1 months, max. 48 months. One mechanical failure occurred after 24 months, which was solved by callus distraction. CONCLUSIONS: Combination osteosynthesis is suitable for stabilizing segmental bone defects. The risk of mechanical failure appears to be low. Nevertheless, this technique should only be applied as a definitive solution if callus distraction is unfavourable due to advanced age or a poor lifetime prognosis. The method can also be used for temporary internal stabilization during prolonged postoperative chemotherapy.

[Percutaneous dorsal versus open instrumentation for fractures of the thoracolumbar border. A comparative, prospective study]. / Perkutane dorsale versus offene Instrumentation bei Frakturen des thorakolumbalen Ubergangs. Eine vergleichende prospektive Untersuchung.

STUDY DESIGN: A prospective clinical study. OBJECTIVE: To evaluate whether a percutaneous dorsal instrumentation of thoracolumbar fractures prevents irreversible damage to the spinal muscles. METHODS: A total of 57 patients with thoracolumbar fractures (Th12-L4) were divided into two groups, comparable in terms of gender, fracture level, classification and surgical concept. In the first, 24/57 patients were treated using an open procedure (OP-G); in the second, 33/57 were treated via percutaneous dorsal instrumentation (PER-G). Fracture localisation and classification, accuracy of pedicle screw placement, perioperative blood loss, OR- and image converter time as well as muscle damage (needle-EMG) were evaluated. RESULTS: OR- and image converter time as well as the accuracy of pedicle screw placement were not statistically different between groups. The difference in perioperative blood loss [43 (10-90) ml (PER-G) vs [870 (570-1,200 ml (OP-G)] was statistically significant (P <0.005). Needle EMG revealed no muscle damage, and the physiological activity and muscle potentials were normal (PER-G). In the OP-G, polyphasic EMG signals were most common (80%), a sign of the drop-out of numerous motor units. CONCLUSIONS: The open procedure caused permanent and significant damage to the strongest extensors of the autochthonus back musculature, the m. multifidus, which results from multisegment combined damage to the r. posterior nervi spinalis and muscle fibres. In contrast, percutaneous placement of an internal fixative reduces perioperative access morbidity causing little iatrogenic damage to back muscles and only a minor perioperative blood loss.

[Foot injuries in the polytraumatized patient]. / Verletzungen des Fusses beim polytraumatisierten Patienten.

Foot injuries in polytraumatized patients are not critical for survival but for the later quality of life. Closed fractures or dislocations of the foot are frequently overlooked or misinterpreted in association with polytrauma, which leads to severe functional impairment in those patients who survive. Repeated clinical examinations and early radiographic examinations are essential in the unconscious patient after resuscitation. Emergent indications for surgery even in the presence of multiple injuries are open injuries, incarcerated soft tissues, manifest compartment syndrome of the foot, and neurovascular injury. The decision on limb salvage or amputation has to be individualized with respect to the patient's overall condition and the severity of local trauma to the foot. The "life before limb" principle has to be respected. Emergent reduction of fracture dislocations of the talus, calcaneus, Chopart's and Lisfranc's joints via direct approaches and temporary transfixation with K-wires should be attempted in a first step whenever possible. Additional external fixation facilitates wound care and prevents soft tissue contractions until definite internal fixation becomes feasible. Early soft tissue coverage is always sought in order to avoid infection.

Foot function after subtalar distraction bone-block arthrodesis. A prospective study.

Subtalar distraction bone-block arthrodesis for malunited calcaneal fractures was performed in 31 patients (26 men, five women), with a mean age of 38.5 years. The mean time from injury to arthrodesis was 36 months. There were no cases of nonunion. One patient had an early dislocation of the bone block requiring a repeat arthrodesis, and one had a soft-tissue infection. The mean AOFAS hindfoot score improved significantly from 23.5 before operation to 73.2 at a mean follow-up of 33 months (p > 0.001). Compared with the unaffected side, the talocalcaneal height was corrected by 61.8%, the talus-first metatarsal axis by 46.5%, the talar declination angle by 38.5% and the talocalcaneal angle by 35.4%. Dynamic pedobarography revealed a return to normal of the pressure distribution during roll-over and a more energetic gait. The distribution of local transfer of load correlated well with the AOFAS score. The amount of correction of the heel height correlated with a normal pattern of pressure transfer on the heel (p < 0.05).

[Advantages of minimally-invasive reposition, retention, and Ilizarov-(hybrid)fixation for pilon-tibial-fractures fractures with particular emphasis on C2/C3 fractures]. / Vorteile der minimal-invasiven Reposition, Retention und Ilizarov-(Hybrid)Fixation bei Pilon-tibiale-Frakturen unter besonderer Berücksichtigung von C2-/C3-Frakturen.

Between October 1993 and September 1999 a total of 62 tibial pilon fractures in 59 patients were treated at the Clinic for Trauma and Reconstructive Surgery, University Hospital Carl-Gustav-Carus, Technical University Dresden. In a retrospective study 49 patients with 50 tibial pilon fractures (81%) could be examined an average of 28 months after injury. The purpose of this study was to compare clinically and radiographically the healing results obtained after using the Ilizarov technique in combination with minimally invasive internal fixation (group I) with those after a conventional surgical procedure (internal fixation with a plate, external fixation with or without minimally invasive internal fixation, and screw fixation exclusively, group II) and to evaluate the efficacy of the Ilizarov technique. Data analysis showed a significantly higher incidence of 43 C2/C3 fractures in Ilizarov group I (73%) than in group II (33.3%). Severe soft tissue injuries and particularly open injuries had a significantly higher incidence in Ilizarov group I (100%) than in group II (38%). Despite the high incidence of C2/C3 fractures and severe soft tissue injuries in group I, there was no incidence of pseudarthrosis or osteitis in the further course and there was no need for arthrodesis during the long-term course. After therapy with a conventional surgical technique, the incidence of osteitis was 5% and of delayed union of a fracture 2.5% and arthrodesis was necessary in 8%. A disadvantage of the Ilizarov system was the relatively frequent incidence of pin infection (45%) necessitating surgical debridement in 18%. The efficacy of the treatment of 43 C2/C3 fractures with the Ilizarov technique was obvious by a statistically significantly better Maryland Foot Score in comparison with group II. More than 87% of the patients treated with the Ilizarov technique and only 38% of the patients treated with a conventional surgical procedure obtained a very good or good score. According to these findings, the Ilizarov technique in combination with minimally invasive internal fixation is an effective method to treat complicated tibial pilon fractures with severe soft tissue trauma.

[Calcaneus fractures. Open reduction and internal fixation]. / Calkaneusfrakturen--offene Reposition und interne Stabilisierung.

AIM OF THIS STUDY: Critical analysis of the medium-term results of open reduction and internal fixation (ORIF) of displaced intra-articular calcaneus fractures with a standardized protocol in a greater patient cohort. METHODS: From October 1993 to December 1999 314 patients (mean age 42.3 years) with 348 calcaneus fractures were seen at the Dresden University Hospital. 41 fractures were open, 4 with 1st degree, 28 with 2nd and 9 with 3rd degree soft tissue damage. 275 displaced intra-articular fractures were treated with ORIF, 262 (95.3 %) with plate osteosynthesis via an extended lateral approach. 169 patients could be evaluated at a mean of 18 months (range 10-47 months) postoperatively with an extended protocol of questionnaire, physical and radiographic examination. RESULTS: The Maryland Foot Score after 18 months follow-up averaged 80.8/100, the mean Zwipp score averaged 146.4/200. The functional result with the Merle d'Aubigné score was judged good to excellent in 86% of cases. Rates of deep infection and superficial wound edge necrosis increased significantly with open fractures and delay in surgery of more than 2 weeks after injury in closed fractures. Clinical results were adversely affected by even minor residual steps in the posterior facet (1-2 mm) as judged by CT or Brodén views (p < 0.001). Böhler's tuberosity-joint-angle had an impact on the final result when falling short compared to the unaffected contralateral side by more than 30% (p < 0.001). CONCLUSIONS: Management of intra-articular calcaneus fractures with a standardized protocol of ORIF and early mobilization leads to reproducible good or excellent clinical results in a majority of patients. New approaches like an interlocking calcaneus plate, the use of subtalar arthroscopy, early soft tissue coverage for complex open injuries and percutaneous screw fixation for selected fractures should further improve prognosis.

[Clinical evaluation of the distal femoral nail]. / Klinische Erprobung des distalen Femurnagels.

METHOD: The clinical results after DFN-osteosynthesis of n=56 AO-classification 33A-fractures (32%), 33C-fractures (43%), 32X-fractures (21%) and pseudarthrosis treatment (4%) are presented. RESULTS: Follow up was available for 54 fractures (96%) after a mean of 1.2 years (range 0.2-2.8 years). 95% of patients showed full-weight-bearing with a knee flexion of 120 (60-140) degrees. Extension-deficit >10 degrees was observed in 5.4%. All fractures were consolidated. One soft-tissue infection, one partial loss of reduction and one implant failure were observed. A significant axial malalignment was found radiologically in 17%, a loosened spiralblade or locking screw in 7.4%. In 91% of cases the result was judged as good to excellent by patients and surgeons. CONCLUSION: The mechanical stability of the implant allows a save osteosynthesis of unstable supracondylar and complete articular femoral fractures without additional bone grafting. Mechanical stability and minimal invasive operative technique permit a safe bone healing without major complications.

[Intramedullary nail placement with percutaneous Kirschner wires. Illustration of method and clinical examples]. / Intramedulläre Nagelplatzierung mit perkutanen Kirschner-Drähten. Darstellung der Methode und klinische Beispiele.

Unreamed nailing is an established method for internal fixation of femoral und tibial shaft fractures. The interlocking technique allows the stabilization of metaphyseal fractures, too, but the risk of malalignment increases. The "palisade method" presented here allows the precise positioning of the nail in the marrow cavity and works as a tool for successful minimally invasive nailing in the meta/epiphyseal region. The method is easy to use and suited particularly in combination with the UFN and UTN, but is in principal applicable to other nails, too. In contrast to the "Poller Screw" method developed by Krettek et al., no biomechanical augmentation of the osteosynthesis remains.

External skin excision in the sebaceous nose and supratip deformity.

Some sebaceous noses cannot be properly reduced in size because of redundant skin. After standard rhinoplasty some noses develop a supratip deformity that recurs even after subcutaneous removal of the scar tissue. These noses can be corrected only by wedge-shaped skin excision. Most patients much prefer a pleasantly shaped nose, even at the cost of a midline scar on the nose. Most surgeons are hesitant to add scars to the face. However, the vast experience with wounds following accidents, tumor excisions, or corrections of malformations has shown that generally scar formation on the nose is inconspicuous. Nineteen patients were treated successfully by skin excision at the time of primary rhinoplasty or by a second operation.