Does access through the pronator quadratus influence pronation strength in palmar plate fixation of distal radius fractures in elderly patients?

INTRODUCTION: Palmar plate fixation of the distal radius fracture involves dissecting the pronator quadratus (PQ). This is regardless of whether the approach is radial or ulnar to the flexor carpi radialis (FCR) tendon. It is not yet clear whether and to what extent this dissection leads to a functional loss of pronation or pronation strength. The aim of this study was to investigate the functional recovery of pronation and pronation strength after dissection of the PQ without suturing. MATERIALS AND METHODS: From October 2010 to November 2011, patients aged over 65 with fracture were prospectively enrolled in this study. Fracture stabilisation was performed via the FCR approach without suturing the PQ. Follow-up examinations took place 8 weeks and 12 months postoperatively, and pronation and supination strength were analysed by means of an especially developed measuring device. RESULTS: 212 patients were initially screened and 107 were enrolled. The range of motion compared to the healthy opposite side was Ext/Flex 75/66% 8 weeks postoperatively. Pronation was 97% with a pronation strength of 59%. After 1 year, the scores improved to Ext/Flex 83/80%. Pronation recovered to 99% and pronation strength to 78%. CONCLUSION: The present study can show a recovery of pronation as well as pronation strength in a large patient population. At the same time, the pronation strength is still significantly lower 1 year after the operation than on the opposing healthy side. As the pronation strength recovers as the grip strength and is at all times on a par with the supination strength, we believe that we can continue to refrain from re-fixating the pronator quadratus.

Intrabody application of eptotermin alpha enhances bone formation in osteoporotic fractures of the lumbar spine; however, fails to increase biomechanical stability - results of an experimental sheep model.

This study analyses the effect of eptotermin α application into fractured vertebrae. It is hypothesized that eptotermin α is capable to enhance bony healing of the osteoporotic spine. In 10 Merino sheep osteoporosis induction was performed by ovariectomy, corticosteroid therapy and calcium/phosphorus/vitamin D-deficient diet; followed by standardized creation of lumbar vertebral compression fractures (VCFs) type A3.1 and consecutive fracture reduction/fixation using expandable mesh cages. Randomly, intravertebral eptotermin α (G1) or no augmentation was added (G2). Macroscopic, micro-CT, and biomechanical evaluation assessed bony consolidation two months postoperatively: Micro-CT data revealed bony consolidation for all cases with significant increased callus development for G2 (60%) and BV/TV (bone volume/total volume 73.45%, osteoporotic vertebrae 35.76%). Neither group showed improved biomechanical stability. Eptotermin α enhanced mineralisation in VCFs in an experimental setup with use of cementless augmentation via an expandable cage. However, higher bone mineral density did not lead to superior biomechanical properties.

Prediction of complications in a high-risk cohort of patients undergoing corrective arthrodesis of late stage Charcot deformity based on the PEDIS score.

BACKGROUND: All diabetic neuroosteoarthropathy (Charcot arthropathy) treatment concepts are focused on a long-term infection-free, ulcer-free, and plantigrade sufficiently stable foot in order to avoid amputation. Reconstructive arthrodesis techniques for severe deformities are associated with high postoperative complication rates. This study reports a detailed complication analysis and provides a strategy that may help detect patients at risk for a complicated postoperative course. METHODS: The study comprised 43 feet in 37 patients with severe non-plantigrade or unstable Charcot deformity, Eichenholtz stages II/III (Sanders and Frykberg types II-V), who underwent reconstructive arthrodesis of the mid- and/or hindfoot. Patients were retrospectively enrolled 4.5 years postoperatively (range 1.8-11.2 years). All patients showed at least two out of five positive Pinzur high-risk criteria (immuno-compromising illnesses, large bone deformity, longstanding ulcer overlying infected bone, regional osteopenia, obesity). Follow-up included a detailed clinical analysis and radiologic assessment with emphasis on complication analysis and evaluation in accordance to the PEDIS classification system. RESULTS: Significantly lower overall complication rates, as well as re-operation, reulceration and amputation counts were found for patients with a cumulative PEDIS count below 7. For PEDIS single criteria, significantly lower overall complication rates were found for patients without signs of occlusive peripheral artery disease, an ulcer extent <0.9 cm(2), ulcer depth including erosion and inflammation of the skin and subcutaneous tissues only. Soft-tissue complications affected 49 % of patients, hardware breakage 33 %, hardware loosening 19 %, non-union 18 % and amputation 21 %. Radiographs revealed a correct reconstruction and restoration of all foot axes postoperatively with partial recollapse at the lateral foot column; however, fixation strength for the medial column was maintained. CONCLUSIONS: Internal corrective arthrodesis for patients within the deformed stages of Charcot deformity can provide adequate reconstruction, as assessed by intraoperative radiographic measures, that exhibit superior long-term stability for the medial column. Despite a high risk patient population, a favourable outcome in terms of overall complication, re-ulceration, and amputation rates for patients/feet with a cumulative PEDIS count below 7 was found. The cut-off value of 7 may aid clinical decision-making during preoperative planning for Charcot deformity.

Acromioclavicular joint dislocations: radiological correlation between Rockwood classification system and injury patterns in human cadaver species.

INTRODUCTION: The classification system of Rockwood and Young is a commonly used classification for acromioclavicular joint separations subdividing types I-VI. This classification hypothesizes specific lesions to anatomical structures (acromioclavicular and coracoclavicular ligaments, capsule, attached muscles) leading to the injury. In recent literature, our understanding for anatomical correlates leading to the radiological-based Rockwood classification is questioned. The goal of this experimental-based investigation was to approve the correlation between the anatomical injury pattern and the Rockwood classification. MATERIALS AND METHODS: In four human cadavers (seven shoulders), the acromioclavicular and coracoclavicular ligaments were transected stepwise. Radiological correlates were recorded (Zanca view) with 15-kg longitudinal tension applied at the wrist. The resulting acromio- and coracoclavicular distances were measured. RESULTS: Radiographs after acromioclavicular ligament transection showed joint space enlargement (8.6 ± 0.3 vs. 3.1 ± 0.5 mm, p < 0.05) and no significant change in coracoclavicular distance (10.4 ± 0.9 vs. 10.0 ± 0.8 mm). According to the Rockwood classification only type I and II lesions occurred. After additional coracoclavicular ligament cut, the acromioclavicular joint space width increased to 16.7 ± 2.7 vs. 8.6 ± 0.3 mm, p < 0.05. The mean coracoclavicular distance increased to 20.6 ± 2.1 mm resulting in type III-V lesions concerning the Rockwood classification. CONCLUSIONS: Trauma with intact coracoclavicular ligaments did not result in acromioclavicular joint lesions higher than Rockwood type I and II. The clinical consequence for reconstruction of low-grade injuries might be a solely surgical approach for the acromioclavicular ligaments or conservative treatment. High-grade injuries were always based on additional structural damage to the coracoclavicular ligaments. Rockwood type V lesions occurred while muscle attachments were intact.

Antithrombin reduces inflammation and microcirculatory perfusion failure in closed soft-tissue injury and endotoxemia.

BACKGROUND: Closed soft-tissue trauma leads to activation of the coagulation cascade and is often complicated by systemic inflammation and infection. Previous investigations have shown potent anti-inflammatory properties of antithrombin. We herein report on the action of antithrombin on skeletal muscle injury in experimental endotoxemia. MATERIALS AND METHODS: By using a pneumatically driven computer-controlled impact device, closed soft-tissue trauma was applied on the left hind limb of pentobarbital-anesthetized rats. Six hours later, endotoxemia was induced by intraperitoneal injection of Escherichia coli lipopolysaccharide. An equivalent volume of physiological saline was given in controls. At the same time point, treatment of animals was started by intravenous injection of antithrombin (250 IU/kg body weight) or vehicle solution. Twenty-four hours after trauma, the extensor digitorum longus muscle was microsurgically exposed and analyzed by means of high-resolution multifluorescence microscopy. RESULTS: Traumatic soft-tissue injury with additional endotoxemia was characterized by nutritive perfusion failure (functional capillary density: 379±20cm/cm;), tissue hypoxia (nicotinamide adenine dinucleotide autofluorescence: 77±4 aU), and enhanced leukocyte-endothelial cell interaction (773±35 cells/mm;). Therapeutic intervention with antithrombin 6 hrs after trauma restored nutritive perfusion and tissue oxygenation (functional capillary density: 469±22cm/cm; nicotinamide adenine dinucleotide autofluorescence: 61±5 aU [p < 0.05]) and reduced inflammatory leukocyte adherence (237±20 cells/mm; [p < 0.05]) toward values found in nontraumatized controls (functional capillary density: 573±13cm/cm; nicotinamide adenine dinucleotide autofluorescence: 56±2 aU; leukocyte adherence: 204±20 cells/mm;). CONCLUSION: Antithrombin ameliorates microcirculatory dysfunction and tissue injury in traumatized animals during endotoxemia. Furthermore, a reduced inflammatory cell response helps to prevent leukocyte-dependent secondary tissue injury.

A pan-caspase inhibitor reduces myocyte apoptosis and neuropathic pain in rats with chronic constriction injury of the sciatic nerve.

BACKGROUND: Chronic constriction injury is a widely used model for neuropathic pain in rats. It presents with symptoms resembling human neuropathic pain, such as spontaneous pain, hyperalgesia, and allodynia. Recently, myocyte apoptosis was found in neuropathic rats as a possible promoter of pain and motor dysfunction. Our aim in this study was to demonstrate whether muscle cell apoptosis contributes to neuropathic pain in this animal model. METHODS: To clarify this issue, we examined pain, nutritive perfusion, and inflammation in muscle tissue as well as myocyte apoptosis in rats with neuropathic pain established by chronic constriction injury of the sciatic nerve. Animals received either the pan-caspase inhibitor zVAD (OMe)-fmk (n = 5) or equivalent volumes of vehicle (n = 6). Sham-operated rats served as controls (n = 6). RESULTS: At day 4 after nerve ligation, there were no signs of perfusion failure or muscle tissue inflammation in all experimental groups. However, animals treated with the vehicle had marked myocyte apoptosis, which was found almost completely blocked in zVA-Dtreated animals. The zVA-Dtreated animals presented with a significant reduction of pain upon heat, cold, and mechanical stimulation comparable with values found in sham controls. CONCLUSIONS: Myocyte apoptosis possibly contributes to thermal and mechanical allodynia in this experimental model for neuropathic pain. The development of neuropathic pain symptoms did not depend on disturbances in microcirculation or muscle tissue inflammation.

Non-bridging external fixation employing multiplanar K-wires versus volar locked plating for dorsally displaced fractures of the distal radius.

BACKGROUND: The aim of this study was to compare non-bridging external fixation to palmar angular stable plating with respect to radiological outcome, wrist function, and quality of life. METHODS: One hundred and two consecutive patients (mean age: 63 years) were enrolled in the study. Fifty-two patients were randomized for plate osteosynthesis (2.4 mm, Synthes), 50 patients received non-bridging external fixation (AO small fixator). Objective (range of motion, grip strength), patient rated outcomes (quality of life, pain), and radiological outcome were assessed 8 weeks, 6 months, and 1 year after surgery. RESULTS: Loss of radial length of more than 3 mm was not detected in any group. Volar tilt was better restored by external fixation (7.2°) than by volar plating (0.1°). Wrist function was good in both groups. The external fixator was tolerated very well, and the quality of life assessment revealed comparable results in both groups. Osteoporosis was found in 54 % of patients and had no influence on radiological and functional outcome. CONCLUSION: Non-bridging external fixation employing multiplanar K-wires is a suitable treatment option in intra- and extra-articular fractures of the distal radius even in osteoporotic bone.

Residual dorsal displacement following surgery in distal radial fractures: A cause for trouble?

PURPOSE: Distal radius fractures have great impact on activities of daily living of affected patients. Repeatedly, a non-anatomic restoration of the volar tilt can be observed in a minimum of 20% in postoperative X-ray control examinations. Hence, the question arises whether the achieved reduction is functionally acceptable, or whether a further attempt should be made to improve the surgical outcome. METHODS: The data presented here originate from a prospective analysis including three therapy studies on surgical treatment options for fractures of the distal radius between 2004 and 2011. For this study, the participants were divided into two groups: The first group represents the cases with non-anatomical restoration of the volar tilt with - 5° to 5°. The second group contains patients with an anatomical volar tilt between 6° and 15°. RESULTS: A total of 624 patients were screened according to the inclusion criteria. Radiological evaluation showed consolidation of all fractures. The mean volar tilt as measured in standard x-rays of the wrist was 0° and 8°, respectively. The range of wrist motion in relation of the healthy opposite side was comparable in all directions (for example comparison group 1: Ext/Flex 94/94%; group 2: Ext/Flex 93/93%). Functional assessment of postoperative midterm results employing the Castaing and Gartland & Werley scores 2.3 years after surgery did not reveal significant differences between both groups. CONCLUSION: According to the available data, a volar tilt in the range of - 5° to 5° can be tolerated intraoperatively without any risk of loss of function regarding the patient's manual abilities.

[Successful in-hospital clamshell thoracotomy in a young male patient with polytrauma (ISS 57) : A case report]. / Erfolgreiche innerklinische Clamshell-Thorakotomie bei einem jungen polytraumatisierten (ISS 57) Patienten : Ein Fallbericht.

Life-threatened injured patients who suffer a cardiovascular arrest after a trauma are still enormously challenging for both the paramedics and the trauma team in the clinic. This case illustrates the treatment of a 16-year-old boy who suffered a blunt abdominal trauma with a traumatic cardiac arrest followed by an open resuscitation after clamshell thoracotomy. Subsequently, the treatment after damage control is discussed regarding the current literature and recommendations for treatment.

Hook plate fixation for acromioclavicular joint separations restores coracoclavicular distance more accurately than PDS augmentation, however presents with a high rate of acromial osteolysis.

INTRODUCTION: Hook plate fixation of acromioclavicular (AC) joint separations carries the disadvantage of compulsory implant removal, occasional implant fatigue and secondary loss of reduction. This study compares the clinical and radiological outcome of a new polyaxial angular stable hook plate (HP) with absorbable polydioxansulfate (PDS) sling. MATERIALS AND METHODS: Between 2002 and 2009, out of a consecutive series of 81 patients with symptomatic Rockwood type V lesions 52 patients received clinical and radiographic follow-up (HP: n = 27; PDS: n = 25). HP patients were prospectively analyzed and retrospectively compared with the PDS group. Radiological follow-up included comparative coraco- and acromioclavicular distance (CCD/ACD) measurements as percentage of the uninjured shoulder. For clinical follow-up a standardized functional shoulder assessment with Constant Score, DASH Score, Taft Score and a self-report questionnaire including the visual analog scale (VAS) was carried out. RESULTS: Direct postoperative radiographs showed an overcorrection of CCD in the HP group (-4.4% of the uninjured side) and failure of anatomic correction in the PDS group (+11.0%). After implant removal, CCD increased in the HP group extensively to 16.7% (overall loss of reduction: 21.1%) and 23.9% in the PDS group. Redisplacement (100% increase of CCD) occurred in five cases (HP: 2, PDS: 3) and partial loss of reduction in four cases of each group. Comparing functional results no differences could be seen between both the groups (Constant-Score HP: 91.2 points, PDS: 94.6 points; Taft-Score HP: 9.4 points, PDS: 10.0 points). The DASH-Score revealed better results for PDS group (3.4 points, HP: 8.0 points). Signs of acromial osteolysis appeared in five cases (18.5%) in HP group. There was no case of implant failure. The X-rays of six patients (HP: 4, PDS: 2) showed AC-joint-osteoarthritis. CONCLUSION: Hook plate fixation employing a polyaxial angular stable plate finally restores the coracoclavicular distance more accurately than augmentation with a PDS sling. Although in HP group no implant failure occurred, major disadvantages are initial overcorrection and acromial osteolysis. Both have no influence on final functional results.

Reliability and consequences of intraoperative 3D imaging to control positions of thoracic pedicle screws.

INTRODUCTION: The insertion of thoracic pedicle screws (T1-T10) is subject to a relevant rate of malplacement. The optimum implantation procedure is still a topic of controversial debate. Currently, a postoperative computed tomography is required to evaluate the screw positions. The present study was undertaken to clarify whether intraoperative 3D imaging is a reliable method of determining the position of thoracic pedicle screws. METHODS: This prospective study involved 40 consecutive patients with thoracic spinal injuries, with intraoperative 3D scans being performed to determine the positions of 240 pedicle screws in T1-T10. The results of the 3D scans were compared with the findings of postoperative CT scans, using a clinical classification system. RESULTS: The positions of 204 pedicle screws could be viewed by means of both 3D and CT scans and the results compared. The 3D scans achieved a sensitivity of 90.9 % and a specificity of 98.8 %. The rate of misclassification by the 3D scans was 2.5 %. Nine pedicle screws were classified as misplaced and their position corrected intraoperatively (3.8 %). No screws required postoperative revision. CONCLUSIONS: Performing an intraoperative 3D scan enables the position of thoracic pedicle screws to be determined with sufficient accuracy. The rate of revision surgery was reduced to 0 %.

Ebselen reduces inflammation and microvascular perfusion failure after blunt skeletal muscle injury of the rat.

BACKGROUND: Soft tissue trauma induces an local inflammatory response and yields a microvascular perfusion failure due to trauma-induced oxidative stress. Using high-resolution multifluorescence microscopy, we herein report on the efficiency of treatment with the oxygen radical scavenger ebselen to improve compromised perfusion of traumatized muscle tissue and to minimize secondary tissue damage. METHODS: By using a pneumatically driven computer-controlled impact device, closed soft tissue trauma of the left hind limb was induced in pentobarbital-anesthetized rats that received either ebselen (30 mg/kg body weight, intraperitoneally) or equal volumes of the vehicle dimethyl sulfoxide (DMSO). In an additional series of animals, ebselen or DMSO were applied without soft tissue trauma. RESULTS: Ebselen restored microcirculatory impairment within the injured muscle, as given by values of nutritive perfusion (763 +/- 44 cm/cm2), nicotinamide adenine dinucleotide levels (56 +/- 3 aU) and inflammatory cell interaction (leukocytes: 226 +/- 31 mm(-2)) at 24 hours after trauma, being not different to those found in noninjured muscle tissue of controls. In contrast, skeletal muscle in DMSO-treated animals revealed persistent perfusion failure (564 +/- 32 cm/cm2) with tissue hypoxia (nicotinamide adenine dinucleotide 75 +/- 11 aU) and enhanced endothelial interaction of leukocytes (383 +/- 18 mm(-2)) at 24 hours after trauma. CONCLUSIONS: Treatment of skeletal muscle soft tissue trauma with the glutathione peroxidase mimic ebselen is highly effective in restoration of disturbed microcirculation. Moreover, reduced inflammatory cell response helps to prevent leukocyte-dependent secondary tissue injury.

Intraoperative position determination of bone cement trocars by 3-dimensional imaging in patients with osteoporotic vertebral fractures.

STUDY DESIGN: A prospective diagnostic study to evaluate the use of intraoperative 3-dimensional (3D) imaging. OBJECTIVE: To evaluate the accuracy of an intraoperative 3D imaging predicting trocar positions in osteoporotic fractured vertebral bodies before cement injection. SUMMARY OF BACKGROUND DATA: Malpositioned needles in vertebroplasty and kyphoplasty increase the risk of extravertebral cement leakage and the associated complications. This study was intended to clarify whether the position of trocars can adequately be determined before the cement application by an intraoperative 3D imaging. METHODS: Between August 2006 and July 2008 the positions of 84 trocars in 42 fractured vertebrae between T11 and L5 were measured by intraoperative 3D imaging before injection of the cement. The external diameter of the needles was 9 to 10 G. The positions of the trocars were classified in the axial plane by a new classification system. RESULTS: Forty 3D scans covered 84 injection cannulae in 42 fractured vertebral bodies. The average duration of the entire scanning procedure was 7.1 minutes. All 3D scans could be evaluated with adequate degree of certainty. Intraoperative evaluation of the 3D scans showed 78 correct needle positions. Two trocars were in an acceptable lateral malposition. There were 4 medial malpositions that required revision. In total, 4.8% of the trocars were positioned not acceptably. Postoperative computed tomography was performed in 17 patients. The positions of 34 needles determined by computed tomography conformed 100% to the results of the 3D scans. CONCLUSIONS: It is possible to reliably determine the position of trocars in vertebral bodies with the aid of an intraoperative 3D scan. This can lead to a reduction in the morbidity rates associated with puncture errors in kyphoplasty and vertebroplasty. The amount of time required is small. The increased radiation exposure is acceptable.

Microcirculatory sequelae of the rotator cuff after antegrade nailing in proximal humerus fracture.

INTRODUCTION: Antegrade nailing allows a stable fixation and, thus, an early functional after treatment in proximal humerus fractures. Since the surgical procedure in antegrade humeral nailing requires a split of the supraspinatus tendon, the question arises whether the surgical approach causes microcirculatory dysfunction of the tendon. MATERIALS AND METHODS: A total of 15 consecutive patients suffering from proximal humerus fractures were enrolled. During the implantation of an antegrade humerus nail, microvascular perfusion of the supraspinatus tendon was directly visualized after the exposition and stabilization of the fracture using the OPS-imaging technique. RESULTS: Immediately after exposure, the nutritive perfusion showed physiological values of tendon microcirculation. After implanting antegrade humeral nails, the perfusion of the supraspinatus tendon reduced markedly. Capillary width was unaffected by the surgical procedure. CONCLUSION: The trauma leading to proximal humerus fracture causes no fundamental impairment of nutritive perfusion of the rotator cuff. Whereas the implantation of an antegrade humerus nail, which necessarily includes a splitting of the rotator cuff, nearly halves the functional capillary density of the supraspinatus tendon. Even though this effect seems to be reversible, the surgical dissection of the supraspinatus tendon should be performed in a soft tissue sparing way.

Benefit and accuracy of intraoperative 3D-imaging after pedicle screw placement: a prospective study in stabilizing thoracolumbar fractures.

Internal fixation is the established dorsal standard procedure for the treatment of thoracolumbar fractures. The main problem of the procedure is the false positioning of the pedicle screws. The exact determination of pedicle screws has up to now only been possible through postoperative computed tomography. This study was intended to clarify the diagnostic value of intraoperative 3D scans after pedicle screw implantation in thoracolumbar spine surgery. The direct intraoperative consequences of the 3D scans are reported and the results of the 3D scans are compared with the postoperative computed tomography images. Intraoperative 3D scans were prospectively carried out from June 2006 to October 2008 on 95 patients with fractures of the thoracolumbar spine that have been treated with internal fixation. Screws positions were categorised intraoperatively, screws in relevant malposition were repositioned immediately. A computed tomography of the involved spinal section was carried out postoperatively for all patients. The positions of the pedicle screws were determined and compared in the axial reconstructions of both procedures. Four hundred and fourteen pedicles with enclosed screws were evaluated by the 3D scans. The time needed for carrying out the 3D scan amounts to an average of 8.2 min. Eleven screws (2.7%) in ten patients were primarily intraoperatively repositioned on the basis of the 3D scan evaluation. Two of 95 patients had to have false positions of the screws revised secondarily following evaluation of the computed tomographies. The secondary postoperative revision rate of the patients amounts to 2.1%. In relation to the number of screws, this is a revision rate of 0.5%. The postoperative computed tomographies showed 323 pedicles without cortical penetration by the screws (78.0%). Ninety-one screws penetrated the pedicle wall (22%). It was possible to postoperatively compare the position classifications of 406 pedicle screws. The CT showed 378 correct screw positions, while 28 screws were positioned falsely. On the basis of the 3D scans, 376 of 378 correct positions were correctly assessed. Twenty-one of 28 false positions could be correctly classified. The sensitivity of all 3D scans reached 91.3% and the specificity 98.2%. The position of 97.8% of the pedicle screws was correctly recognised by the intraoperative 3D scan. Nine screws were classified falsely (2.2%). The comparison of the classification results showed significantly higher error findings by the 3D scan in the spinal section T1-10 (P = 0.014). The image quality of the 3D scan correlates significantly with the width of the scanned pedicle, with the body mass index, the scanned spinal section and the extent of the fixation assembly. 3D scans showed a high accuracy in predicting pedicle screw position. Primary false placement of screws and primary neurovascular damage cannot be avoided. But intraoperative evaluation of the 3D scans resulted in a primary revision rate of 2.7% of the pedicle screws and we could lower the secondary revision rate to 0.5%.

Calcaneal fracture fixation using a new interlocking nail reduces complications compared to standard locking plates - Preliminary results after 1.6 years.

INTRODUCTION: Surgical treatment of displaced intra-articular calcaneal fractures using a standard extended lateral approach for plate fixation is frequently associated with substantial wound healing complications and infections. This matched pairs analysis compares the new minimally-invasive calcaneal interlocking nailing technique to standard locking plate fixation in terms of reduction capacity, complication rates, and functional outcomes. METHODS: Forty feet in 38 patients (mean patient age 52.5 years, range 27-78) were treated with calcaneal locking nail (LN)(n=20) or locking plate (LP)(n=20) and followed clinically and radiologically for 20 months. Follow-up included radiological assessments and functional evaluations including the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and the Foot Function Index (R-FFI). RESULTS: Times for surgery were similar for both techniques (LN 93min, range 34 to 175 vs. LP 101min, range 53 to 305). Length of hospital stay was significantly lower in the LN group (7.6 days, range 3 to 14 vs. LP 11 days, range 6 to 37). Time away from work was shorter by 3.5 days in LN group. LP group had superior range of motion in plantarflexion, eversion, and inversion at follow-up, while LP patients were superior in demonstrating a secure heelstrike (79% vs. LN 58%) and fewer needed permanent walking aids. AOFAS and FFI scores revealed no differences for both groups. Radiographs indicated an adequate reconstruction in both groups, followed by a slight loss of reduction at follow-up (LP 4.7° postoperative vs. follow-up; LN 5.1°). The overall complication rate between groups was significant with 5% complications in the LN group vs. 50% in the LP group (5% deep infection, 35% impaired wound healing, 5% hardware breakage, 5% superficial wound infection; LN: 5% superficial wound infection). CONCLUSIONS: The new calcaneal interlocking nail shows promising results in terms of reduction capacity and safety. Use of the minimally invasive locking nail technique minimized the risk of postoperative wound complications and achieved superior functional outcomes compared with standard locking plate fixation via the extended lateral approach.

Imaging in early posttraumatic complex regional pain syndrome: a comparison of diagnostic methods.

OBJECTIVES: The complex regional pain syndrome type I (CRPS I) still is difficult to diagnose in posttraumatic patients. As CRPS I is a clinical diagnosis the characteristic symptoms have to be differentiated from normal posttraumatic states. Several diagnostic procedures are applied to facilitate an early diagnosis, although their value for diagnosing posttraumatic CRPS I is unclear. METHODS: One hundred fifty-eight consecutive patients with distal radial fracture were followed up for 16 weeks after trauma. To assess the diagnostic value of the commonly applied methods a detailed clinical examination was carried out 2, 8, and 16 weeks after trauma in conjunction with bilateral thermography, plain radiographs of the hand skeleton, three phase bone scans (TPBSs), and contrast-enhanced magnetic resonance imaging (MRI). All imaging procedures were assessed blinded. RESULTS: At the end of the observation period 18 patients (11%) were clinically identified as having CRPS I and 13 patients (8%) revealed an incomplete clinical picture which were defined as CRPS borderline cases. The sensitivity of all diagnostic procedures used was poor and decreased between the first and the last examinations (thermography: 45% to 29%; TPBS: 19% to 14%; MRI: 43% to 13%; bilateral radiographs: 36%). In contrast a high specificity was observed in the TPBS and MRI at the eighth and sixteenth-week examinations (TPBS: 96%, 100%; MRI: 78%, 98%) and for bilateral radiographs 8 weeks after trauma (94%). The thermography presented a fair specificity that improved from the second to the sixteenth week (50% to 89%). DISCUSSION: The poor sensitivity of all tested procedures combined with a reasonable specificity produced a low positive predictive value (17% to 60%) and a moderate negative predictive value (79% to 86%). These results suggest, that those procedures cannot be used as screening tests. Imaging methods are not able to reliably differentiate between normal posttraumatic changes and changes due to CRPS I. Clinical findings remain the gold standard for the diagnosis of CRPS I and the procedures described above may serve as additional tools to establish the diagnosis in doubtful cases.

Ischemic preconditioning prevents skeletal muscle tissue injury, but not nerve lesion upon tourniquet-induced ischemia.

BACKGROUND: Prolonged ischemia followed by reperfusion (I/R) of skeletal muscle results in significant tissue injury. Ischemic preconditioning (IPC), achieved by brief periods of ischemia before sustained ischemia, has been shown to ameliorate I/R injury in a variety of tissues. We demonstrate that tourniquet hind limb ischemia-induced injury of the muscle benefits from IPC, whereas the peripheral nerve suffers from prolonged ischemia time and mechanical deterioration on IPC. METHODS: In anesthetized rats, hind limb ischemia was induced by tourniquet for 3 hours followed by 24 hours of reperfusion. In an additional series of experiments, IPC (three cycles of 10 minutes I/10 minutes R) preceded hind limb ischemia. Sham-operated animals without ischemia served as controls. Skeletal muscle tissue injury was assessed with respect to microcirculation, inflammatory cell response, and cell integrity using intravital fluorescence microscopy, Western blot protein analysis, and tissue histochemistry. Analysis of tactile and thermal allodynia served as indicators for postischemic pain. In addition, motor nerve conduction velocity and transmission electron microscopy allowed assessing postischemic nerve lesion. RESULTS: Tourniquet of the hind limb caused marked perfusion failure, enhanced leukocyte-endothelial cell interaction, and apoptotic cell death. IPC was able to improve microvascular perfusion and to reduce inflammatory cell response. Of interest, apoptotic cell death, assessed by cell nuclear morphology in vivo as well as Western blot and immunohistochemical analysis of caspase-3 cleavage, can be substantially reduced by IPC in tourniquet ischemia of the hind limb. Application of the tourniquet abolished nerve conduction in all animals. Non-IPC-treated animals still showed tactile allodynia, whereas IPC further caused loss of pain sensation and motor function of the postischemic hind limb. CONCLUSIONS: High susceptibility of the peripheral nerve to compression-induced ischemic injury disproves IPC in its clinical application for surgical procedures requiring prolonged tourniquet ischemia.

Early diagnosis in post-traumatic complex regional pain syndrome.

Since prospective studies confirmed an incidence of >10% of complex regional pain syndrome complication in patients after distal radial fracture, early diagnosis is important. Therapy should be commenced immediately with a systematic approach to avoid chronicity of the disease. Despite this, epidemiological studies revealed an extreme delay in effective treatment among complex regional pain syndrome patients, who were repeatedly referred to different physicians and often treated inadequately before being referred to specialized pain clinics. In post-traumatic patients, the clinical examination still is preferred to establish the diagnosis of complex regional pain syndrome. First, possible differential diagnoses must be excluded. Next the clinical criteria of the consensus definition should be checked and documented, if possible with the help of verifying procedures. Imaging methods could be applied; however, they are not useful for early diagnosis since sensitivity is low and the consequences of trauma may interfere with potential complex regional pain syndrome findings. In questionable cases repeated examinations after short periods detect the presence of complex regional pain syndrome in orthopedic patients, particularly if symptoms are progressive or an expected improvement does not occur.

Exaggeration of tissue trauma induces signs and symptoms of acute CRPS I, however displays distinct differences to experimental CRPS II.

As CRPS I frequently develops after tissue trauma, we proposed that an exaggerated inflammatory response to tissue trauma may underlie CRPS I. Therefore, we studied the vascular inflammatory, nociceptive and apoptotic sequelae of (i) soft tissue trauma and (ii) exaggerated soft tissue trauma in comparison to those of (iii) sciatic nerve chronic constriction injury, modeling CRPS II. Standardized soft tissue trauma (TR) was induced by means of a controlled impact injury technique in the hind limb of pentobarbital-anesthetized rats. Additional animals received soft tissue trauma and femoral arterial infusion of mediator-enriched supernatant achieved by homogenization and centrifugation of traumatized muscle tissue in order to provoke an exaggerated trauma response (ETR). Infusion of supernatant of non-traumatized muscle served as control intervention (STR, sham trauma response). Neuropathy was induced by chronic constriction injury of the sciatic nerve (CCI). Untreated animals served as controls (CO). Detailed nociceptive testing showed temporarily decreased mechanical pain thresholds in ETR animals that resolved within 14 days, while TR and STR animals, i.e. those with singular limb trauma, and controls remained free of pain. Neither cold- nor heat-evoked allodynia developed in post-traumatic animals, whereas CCI animals presented the well-known pattern of ongoing neuropathic pain. Using high-resolution in vivo multifluorescence microscopy, muscle tissue of traumatized animals revealed an enhanced inflammatory response that was found most pronounced in ETR animals. CCI of the sciatic nerve was not accompanied by tissue inflammation; however, induced myocyte apoptosis. Collectively, these data indicate that exaggeration of trauma response induces signs and symptoms of acute CRPS I. Pain perception displays differences to that in CRPS II. Apoptosis turns out to be a distinctive marker for CRPS, warranting further evaluation in clinical studies.