Primary Radial Nerve Lesions in Humerus Shaft Fractures-Revision or Wait and See.

Background: This study investigates the surgical state-of-the-art procedure for humeral shaft fractures with primary radial nerve palsy based on its own case series in relation to the current and established literature. Methods: Retrospective review of treated cases between January 2018 and December 2022 describing radial nerve palsy after humerus shaft fractures, radiological fracture classification, intraoperative findings, surgical procedure, patient follow-up and functional outcome. Results: A total of 804 patients (463 women and 341 men) with humerus shaft fractures were identified. A total of 33 patients showed symptomatic lesions of the radial nerve (4.1%). The primary lesion was identified in 17 patients (2.1%). A broad and inhomogeneous distribution of fractures according to the AO classification was found. According to the operative reports, the distraction of the radial nerve was found eleven times, bony interposed three times and soft tissue constricted/compressed three times. In every case the radial nerve was surgically explored, there was no case of complete traumatic nerve transection. Four intramedullary nails and thirteen locking plates were used for osteosynthesis. Complete recovery of nerve function was seen in 12 cases within 1 to 36 months. Three patients still showed mild hypesthesia in the thumb area after 18 months. Two patients were lost during follow-up. Conclusions: With this study, we support the strategy of early nerve exploration and plate osteosynthesis in humeral fractures with primary radial nerve palsy when there is a clear indication for surgical fracture stabilisation. In addition, early exploration appears sensible in the case of palsies in open fractures and secondary palsy following surgery without nerve exposure as well as in the case of diagnostically recognisable nerve damage. Late nerve exploration is recommended if there are no definite signs of recovery after 6 months. An initial wait-and-see strategy with clinical observation seems reasonable for primary radial nerve palsies without indication for surgical fracture stabilisation.

3D C-arm navigated acromioclavicular joint stabilization.

INTRODUCTION: Surgical treatment options for acromioclavicular joint separations are varied. Frequently, suspension devices (SD) are inserted for stabilization under arthroscopic view. This study investigates the feasibility and accuracy of three-dimensional (3D) digital-volume-tomography (DVT) C-arm navigated implantation with regard to the general trend toward increasingly minimally invasive procedures. MATERIALS AND METHODS: The implantation of a TightRope® suture button system (SD) via a navigated vertical drill channel through the clavicle and coracoid was investigated in 10 synthetic shoulder models with a mobile isocentric C-arm image intensifier setup in the usual parasagittal position. Thereby, in addition the placement of an additive horizontal suture cerclage via a navigated drill channel through the acromion was assessed. RESULTS: All vertical drill channels in the Coracoclavicular (CC) direction could be placed in a line centrally through the clavicle and the coracoid base. The horizontal drill channels in the Acromioclavicular (AC) direction ran strictly in the acromion, without affecting the AC joint or lateral clavicle. All SD could be well inserted and anchored. After tensioning and knotting of the system, the application of the horizontal AC cerclage was easily possible. The image quality was good and all relevant structures could be assessed well. CONCLUSION: Intraoperative 3D DVT imaging of the shoulder joint using a mobile isocentric C-arm in the usual parasagittal position to the patient is possible. Likewise, DVT navigated SD implantation at the AC joint in CC and AC direction on a synthetic shoulder model. By combining both methods, the application in vivo could be possible. Further clinical studies on feasibility and comparison with established methods should be performed.

First experiences with a surgery supporting computer system in regard to education, efficiency and complications.

Purpose: Since October 2019 a computer software named SPM (surgical process manager) is used in a Level I Trauma center. Workflows were developed for distinct surgical procedures (distal radius fractures, proximal femur fractures, ankle fractures, proximal humerus fractures and vertebral fractures). In addition, these workflows were separated in a shortened "Expert"-versions for consultants and a more detailed "Learner"- versions for residents.This investigation was intended to show, if and what kind of benefits in regard to efficiency (incision to suture and suture to incision time), education and complications a surgery supporting software can bring. Methods: SPM was used in 90 cases during October 2019 to June 2022. A control trial with 108 patients was developed, including patients of the same age, having same kind of injuries, receiving the same surgery technique without using the SPM.The software was installed on the computer in the operation room, projected on head monitors and operated by a foot pedal. Complications could also be documented using the pedal.Groups were divided in surgical procedures and fracture type, qualification of the surgeon, complications and surgery time. Surgery times were taken from the hospital computer system (SAP IS-H). A statistical analysis was performed by using the chi square and Fischer exact test with significance set at a P value <0.05. Results: In 51 cases the software was used for the distal radius (control group 54 patients), in 20 cases for Weber fractures (control group 21 patients), in 9 cases for the proximal femur (control group 19 patients), in 5 cases for vertebral fractures (control group 7 patients) and in 5 cases for the proximal humerus (control group 6 patients).Time from incision to closure was significant higher in the intervention group (49 vs 42 min, p- value 0,018) and wasn't significant lower in the "expert" group, fixing radius and ancle fractures (39 to 46 min, p value 0,186).Comparing the SPM and control group concerning closing to incision time, no difference could be observed (56 to 58,5 min, p value 0,828).The greatest time deviation between "Learners"und "Experts"was observed in reduction and fixation (p value 0,006) in ankle fractures. The "Expert"group also needed less time for the approach (p value 0,008) in case of distal radius fractures.Unexpected events were more often observed in the intervention group (5,5 vs 3,7 %). Conclusions: A surgery supporting computer system might be a good tool for detecting and optimizing workflows in the operation room and for improving and analyzing the training of residents and surgical assistants.In addition, it offers the opportunity to document intraoperative complications. However, a saving of time wasn't observed in this study. Further investigations with bigger number of cases and a longer follow-up are necessary to proof these findings statistically.

Intraoperative 3D imaging in plate osteosynthesis of proximal humerus fractures.

INTRODUCTION: Proximal humerus fractures are common and often associated with osteoporosis in the elderly. Unfortunately, the complication and revision rate for joint-preserving surgical treatment using locking plate osteosynthesis is still high. Problems include insufficient fracture reduction and implant misplacement. Using conventional intraoperative two dimensional (2D) X-ray imaging control in only two planes, a completely error-free assessment is not possible. MATERIALS AND METHODS: The feasibility of intraoperative three-dimensional (3D) imaging control for locking plate osteosynthesis with screw tip cement augmentation of proximal humerus fractures was retrospectively studied in 14 cases with an isocentric mobile C-arm image intensifier set up parasagittal to the patients. RESULTS: The intraoperative digital volume tomography (DVT) scans were feasible in all cases and showed excellent image quality. One patient showed inadequate fracture reduction in the imaging control, which then could be corrected. In another patient, a protruding head screw was detected, which could be replaced before augmentation. Cement distribution in the humeral head was consistent around the screw tips with no leakage into the joint. CONCLUSION: This study shows that insufficient fracture reduction and implant misplacement can be easily and reliably detected by intraoperative DVT scan with an isocentric mobile C-arm set up in the usual parasagittal position to the patient.

Blade Augmentation in Nailing Proximal Femur Fractures-An Advantage despite Higher Costs?

BACKGROUND: Proximal femoral fractures occur with increasing incidence, especially in the elderly. Commonly used implants for surgical treatment are cephalomedullary nails. To increase stability, a perforated femoral neck blade can be augmented with cement. The study investigated whether this results in a relevant clinical advantage and justifies the higher cost. MATERIALS AND METHODS: This is a single-center retrospective study of 620 patients with proximal femur fractures treated with cephalomedullary nailing. Between January 2016 and December 2020, 207 male and 413 female patients were surgically treated with a proximal femur nail (DePuy Synthes) using a perforated blade and cement augmentation in cases with severe osteoporosis. Primary outcome measures were the rate of cut-out, tip apex distance and the positioning of the blade in the femoral head. Secondary outcome measures were the implant costs and operating times. RESULTS: Of the 620 femoral neck blades, 299 were augmented with cement. A total of six cut-outs were seen in the first 3 months after the operation. There were three in the cement-augmented group (CAB = cement-augmented blade) and three in the conventional group (NCAB = non-cement-augmented blade). There was a significant positive correlation between age and augmentation, with a mean difference of 11 years between the two groups (CAB 85.7 ± 7.9 vs. NCAB 75.3 ± 15.1; p < 0.05). There was no difference in the tip-apex distance (CAB 15.97 vs. 15.69; p = 0.64) or rate of optimal blade positions between the groups (CAB 81.6% vs. NCAB 83.2%; p = 0.341). Operation times were significantly longer in the cemented group (CAB 62.6 21.2 min vs. NCAB 54.1 7.7 min; p < 0.05), and the implant cost nearly doubled due to augmentation. CONCLUSION: When the principles of anatomic fracture reduction, optimal tip-apex distance and optimal blade position are combined with cement augmentation in cases of severe osteoporosis, a cut-out rate of less than 1% can be achieved. Nevertheless, it should be noted that augmentation remains expensive and prolongs surgery time without definite proof of mechanical superiority.

Osteochondritis dissecans of both knees, both elbows, and the first metatarsophalangeal joint in a female soccer player.

A 19-year-old female soccer player presented for evaluation of pain at the base of the right hallux after a recent sports injury. She had a history of 4 operations, 1 each at both knees and both elbows, for the treatment of osteochondritis dissecans (OCD). Examination showed tenderness to palpation and limited range of motion of the first metatarsophalangeal (MP) joint, and radiographs showed stage 4 OCD of the first metatarsal head with a detached osseous fragment. Diagnostic arthroscopy confirmed the presence of OCD, and treatment included arthrotomy, excision of the loose body, and microfracture of the defect. Evaluation at 3 months after surgery showed that the first MP joint pain and limited motion had completely resolved, and the patient returned to soccer practice. Although OCD at 1 location is diagnosed frequently in athletes, involvement of 5 different joints in the same patient is uncommon.