Acute and chronic menisco-capsular separation in the young athlete: diagnosis, treatment and results in thirty seven consecutive patients.

PURPOSE: Menisco-capsular separation (MCS) is an avulsion type of injury of the medial and/or lateral meniscus and is defined as detachment of the meniscus from its capsular attachment. The aims of this study were to show the results of arthroscopic all-inside menisco-capsular repair in a large number of consecutive patients with acute or chronic MCS, emphasise the advantages of this safe treatment option and stress the superiority of the treatment on the basis of thorough physical examination of the knee joint over magnetic resonance imaging (MRI) diagnosis in MCS. METHODS: We evaluated data of patients treated between October 2011 and July 2012. Inclusion and exclusion criteria were defined and demographic variables evaluated. All patients were examined physically and with MRI. Knee arthroscopy was performed and the MCS repaired through all-inside menisco-capsular repair. Postoperative treatment was standardised. Patients were followed up for at least 24 weeks. RESULTS: Thirty-seven athletes (12 women, 25 men) were evaluated. Only in six patients was MCS detected on MRI. In all patients, MCS was diagnosed via physical examination. Arthroscopic treatment led to significant (p < 0.01) improvement. There were no complications reported postoperatively. CONCLUSION: Isolated MCS is not as rare a meniscus pathology after trauma in young athletes as could be expected after reviewing current literature. It is occult on MRI scans in most of the cases and should therefor be taken into consideration in patients with acute or chronic tenderness at the level of the joint line and negative MRI scans. Thorough physical examination has higher diagnostic value than MRI alone, as shown in this study. Treatment of MCS using all-inside nonabsorbable sutures, as described in this study using Ultra FasT Fix®, is effective if performed by an experienced surgeon.

Cutaneous innervation of the ankle: an anatomical study showing danger zones for ankle surgery.

Three nerves innervate the skin in the foot and ankle region: the saphenous, sural, and superficial peroneal nerves. Because they are close to the medial and lateral malleoli, these nerves are at significant risk during orthopedic interventions. The aims of this study were to investigate the distal courses of the three cutaneous nerves of the ankle and to determine their exact relationships with easily identifiable bony landmarks. Ten freshly frozen and 40 embalmed lower extremities of adults were dissected. The positions of the superficial peroneal, sural, and saphenous nerves were determined using reference lines based on easily palpable osseous landmarks. The frequencies and distributions of all three nerves and their branches were converted into absolute numbers. A danger zone for each nerve was established on the basis of the distribution of crossings between the nerves and the different reference lines. Determination of the exact orientation of the nerves around the ankle should help minimize the nerve injury rate during surgical approaches in this area. Using this easily translatable new grid system, the course and danger zones of each cutaneous nerve around the ankle can be estimated clinically.

Calcium phosphate cement augmentation after volar locking plating of distal radius fracture significantly increases stability.

PURPOSE: Distal radius fractures represent the most common fractures in adults. Volar locking plating to correct unstable fractures has become increasingly popular. Although reasonable primary reduction is possible in most cases, maintenance of reduction until the fracture is healed is often problematic in osteoporotic bone. To our knowledge, no biomechanical studies have compared the effect of enhancement with biomaterial on two different volar fixed-angle plates. METHODS: Human fresh-frozen cadaver pairs of radii were used to simulate an AO/OTA 23-A3 fracture. In a total of four groups (n = 7 for each group), two volar fixed-angle plates (Aptus 2.5 mm locking fracture plate, Medartis, Switzerland and VA-LCP two-column distal radius plate 2.4, volar, Synthes, Switzerland) with or without an additional injection of a biomaterial (Hydroset Injectable HA Bone Substitute, Stryker, Switzerland) into the dorsal comminution zone were used to fix the distal metaphyseal fragment. Each specimen was tested load-controlled under cyclic loading with a servo-hydraulic material testing machine. Displacement, stiffness, dissipated work and failure mode were recorded. RESULTS: Improved mechanical properties (decreased displacement, increased stiffness, decreased dissipated work) were found in both plates if the biomaterial was additionally injected. Improvement of mechanical parameters after biomaterial injection was more evident in the Synthes plate compared to the Aptus plate. Pushing out of the screws was noticed as a failure mode only in samples lacking supplementary biomaterial. CONCLUSIONS: Injection of a biomaterial into the dorsal comminution zone increases stability after volar locking plating of distal radius fractures in vitro.

Anterior Cruciate Ligament Reconstruction Using a Fascia Lata Graft With FiberTape Augmentation.

Reconstruction of the anterior cruciate ligament (ACL) is one of the most popular orthopedic surgical procedures. To date, numerous studies are available focusing on different reconstruction techniques using established autografts, such as hamstrings, bone patellar-tendon bone (BPTB), quadriceps tendon, or allograft tendons. In the present article, we describe a minimally invasive ACL reconstruction technique using a fascia lata autograft in combination with FiberTape (Arthrex, Naples, FL) augmentation using the TightRope II (Arthrex). The minimally invasive harvesting procedure is performed by using the new QuadPro Tendon Harvester (Arthrex). This technique is recommended for acute and chronic complete ACL ruptures or bundle ruptures in athletes or patients with high physical activity. The technique might allow early full weight bearing due to less donor site morbidity, early free range of motion, and early active rehabilitation due to the use of FiberTape as a augmentation device to reinforce the autograft. Clinical studies are necessary to prove the principle.

Arthroscopy with Lipoaspirate and Plasma Infiltration Using Adipose-Derived Stem Cells Plus Platelet-Rich Plasma: Harvesting and Injection for Arthroscopic Treatment of Cartilage Defects of the Knee.

Osteoarthritis, predominantly of the knee, is a highly prevalent disease leading to pain, reduced quality of life, and significantly reduced ability to work. With autologous orthobiologic options, new regenerative treatment methods have emerged, offering an alternative to early surgical intervention. Supercharged Liparthroplasty combines arthroscopy with lipoaspirate and plasma infiltration of the joint. Lipoaspirate contains high levels of adipose-derived stem cells, which show chondroprotective and anti-inflammatory qualities. Intra-articular injection, combined with platelet-rich plasma administration for accelerated cartilage metabolism, thus provides an optional approach in osteoarthritis treatment. This article aims to provide in detail our regimen for Supercharged Liparthroplasty, including tissue harvesting and preparation of the injectables, therefore enabling physicians to adopt this point-of-care technique.

Extracorporeal Shockwave Therapy Improves Outcome after Primary Anterior Cruciate Ligament Reconstruction with Hamstring Tendons.

PURPOSE: The decision regarding the timepoint of a return to sports after anterior cruciate ligament (ACL) reconstruction is complex and depends on many factors, including objectively tested physical and psychological readiness as well as biological healing. The aim of this study was to investigate the influence of repetitive extracorporeal shockwave therapy (ESWT) on return-to-sports duration, clinical results and MRI results after ACL reconstruction with hamstring tendons (HT). MATERIAL AND METHODS: In this prospective controlled study, all patients with acute ACL ruptures were treated by ACL reconstruction with HT. Patients were randomized into two groups (Group A: ESWT group; Group B: control group). Patients in the ESWT group received focused shockwave therapy 4, 5 and 6 weeks after ACL surgery. Follow-up investigations including IKDC score, Lysholm score, VAS and evaluation regarding return-to-sports timepoints that were conducted 3-, 6-, 9- and 12-months post-operation. An MRI investigation was performed 12-months post-operation and graft maturation (signal intensity ratio (SIR)) as well as femoral and tibial tunnel characteristics (bone marrow oedema, tunnel fluid effusion) were assessed. RESULTS: In total, 65 patients (27.65 ± 7.07 years; 35 male/30 female) were included in this study. The mean timepoint for "return-to-pivoting-sports" was 27.92 weeks (±2.99) in the ESWT group as well as 42.64 weeks (±5.18) in the control group (p < 0.001). In the ESWT group 31 patients (vs. CONTROL GROUP: n = 6) attained the "pre-injury activity level", whereas 6 patients (vs. CONTROL GROUP: n = 22) did not reach this level within 12 months post-operation. The IKDC score, Lysholm score, and VAS showed significant improvement in the ESWT group compared with the control group for all time-points (p < 0.001). The mean SIR in the ESWT group revealed 1.81 (±0.88), whereas the control group showed a mean SIR of 2.68 (±1.04) (p < 0.01). DISCUSSION: In conclusion, this is the first study investigating the effect of repetitive ESWT on ACL reconstruction with clinical outcome measurements, including the duration of return-to-sports activity and an MRI follow-up examination. Return-to-sports parameters, clinical scores and graft maturation were significantly improved in the ESWT group. This study may support an earlier return-to-sports timepoint by ESWT and is of high clinical relevance as ESWT is a cost-effective treatment option with no relevant side effects.

Assessment of a novel biomechanical fracture model for distal radius fractures.

BACKGROUND: Distal radius fractures (DRF) are one of the most common fractures and often need surgical treatment, which has been validated through biomechanical tests. Currently a number of different fracture models are used, none of which resemble the in vivo fracture location. The aim of the study was to develop a new standardized fracture model for DRF (AO-23.A3) and compare its biomechanical behavior to the current gold standard. METHODS: Variable angle locking volar plates (ADAPTIVE, Medartis) were mounted on 10 pairs of fresh-frozen radii. The osteotomy location was alternated within each pair (New: 10 mm wedge 8 mm / 12 mm proximal to the dorsal / volar apex of the articular surface; Gold standard: 10 mm wedge 20 mm proximal to the articular surface). Each specimen was tested in cyclic axial compression (increasing load by 100 N per cycle) until failure or -3 mm displacement. Parameters assessed were stiffness, displacement and dissipated work calculated for each cycle and ultimate load. Significance was tested using a linear mixed model and Wald test as well as t-tests. RESULTS: 7 female and 3 male pairs of radii aged 74 ± 9 years were tested. In most cases (7/10), the two groups showed similar mechanical behavior at low loads with increasing differences at increasing loads. Overall the novel fracture model showed a significant different biomechanical behavior than the gold standard model (p < 0,001). The average final loads resisted were significantly lower in the novel model (860 N ± 232 N vs. 1250 N ± 341 N; p = 0.001). CONCLUSION: The novel biomechanical fracture model for DRF more closely mimics the in vivo fracture site and shows a significantly different biomechanical behavior with increasing loads when compared to the current gold standard.

Results of dynamic treatment of fractures of the proximal phalanx of the hand.

BACKGROUND: The treatment of fractures of the proximal phalanx in three-phalanx fingers has for a long time been the domain of conservative static treatment in a plaster cast. After removal of the plaster, there was usually limitation of mobility of the interphalangeal joints. Fractures of the proximal phalanx are managed with conservative functional treatment in our clinic. The aim of this method is to achieve bony healing and free mobility at the same time and not in succession. We evaluated our treatment outcomes in a follow-up study. METHODS: The dressing consists of a dorsopalmar plaster splint and a so-called finger splint. The wrist and metacarpophalangeal joints are immobilized with the plaster cast. The wrist is dorsiflexed 30 degrees, and the metacarpophalangeal joints are flexed 70 degrees to 90 degrees. In this intrinsic plus position, the extensor aponeurosis is taut and covers two-thirds of the proximal phalanx, thus leading to firm splinting of the fracture. RESULTS: Sixty-five patients (46 men and 19 women) with 78 proximal phalanx fractures were followed up after an average of 23 months (12-69 months). The average age of the patients was 41 years (18-93 years). Among our patients, the ring finger was affected most often, with transverse fractures predominating. As regards the location, fractures in the proximal third were most frequent (51%). All fractures consolidated. Delayed fracture healing or pseudarthrosis was not observed. Sixty-seven fingers (86%) showed full range of motion at follow-up. In 11 cases (14%), there was limitation of finger joint movements, with inhibition of extension of the proximal interphalangeal joint in nine patients up to a maximum of 20 degrees. Two patients had limitation of flexion with a fingertip-palm distance of 1.1 cm. CONCLUSION: The aim of functional treatment of proximal phalanx fractures is to achieve bony healing and free mobility at the same time and not in succession. Active exercises in the proximal and distal interphalangeal joints prevent limitations of mobility and the subsequent occurrence of rotational and axial deformities.

First experiences with a new adjustable plate for osteosynthesis of scaphoid nonunions.

BACKGROUND: Plate osteosynthesis of the scaphoid, as reported earlier by Ender, has lost its importance in the past few years, after Herbert's introduction of the simple and successful technique of screw osteosynthesis. Only in rare cases does one encounter failed healing or instability of the fragments. Even with a vascularized bone chip, it is not always possible to achieve consolidation. Particularly in these situations, poor interfragmentary stability seems to be the reason for failed healing. METHODS: Between January 2007 and August 2009, we treated 7 men and 4 women of mean age 37 years (22-53 years) by scaphoid plate osteosynthesis. All the patients had fractures of the waist of the scaphoid with established nonunion persisting for at least 6 months after the causative injury, with wrist pain, weakness, or both. All 11 patients had clinical and radiologic follow-up for at least 6 months. RESULTS: All the fractures united at a median time from operation of ∼4 months. All patients reported an improvement in their symptoms and function. The mean DASH score was 28 points. CONCLUSIONS: Scaphoid plate osteosynthesis should be regarded as a salvage procedure, and the indication for the procedure should be established accordingly. It is a simple procedure in terms of technique. The plate can be adjusted very well to the anatomic shape of the scaphoid, and one can achieve a high degree of stability, particularly rotational stability.

Influence of medial parapatellar nail insertion on alignment in proximal tibia fractures--special consideration of the fracture level.

INTRODUCTION: Although a lateral starting point for tibial nailing is recommended to avoid valgus misalignment, higher rates of intra-articular damage were described compared with a medial parapatellar approach. The aim of this anatomic study was to evaluate the fracture level allowing for a safe medial nail entry point without misalignment or dislocation of fragments. MATERIALS AND METHODS: Thirty-two fresh-frozen cadaver lower extremities were used to create 1-cm osteotomies at four different levels (n = 8) from 2 cm to 8 cm below the tibial tuberosity. Nine-millimeter unreamed solid titanium tibial nails (Connex, I.T.S. Spectromed, Lassnitzhohe, Austria) were inserted from a medial parapatellar incision. Misalignment (degree) and dislocation of the distal fragment were measured in the frontal and sagittal plane. RESULTS: A medial parapatellar approach for tibial nail insertion mainly caused valgus and anterior bow misalignment and ventral and medial fragment displacement. Mean misalignment and fragment displacement did not exceed 0.5 degree if the osteotomy was performed 8 cm to 9 cm below the tibial tuberosity. DISCUSSION: According to the results of this study, a medial parapatellar approach can be performed without misalignment and fragment dislocation in proximal tibia fractures extending 8 cm or more below the tibial tuberosity.

Unstable distal radius fractures in the elderly patient--volar fixed-angle plate osteosynthesis prevents secondary loss of reduction.

BACKGROUND: Because of demographic changes in industrialized countries, signifying a growing population of the aged and a markedly increased life expectancy, the incidence of the distal radius fracture is expected to increase by a further 50% until the year 2030. Osteoporosis characterizes the radius fracture in elderly patients. Primarily weakening metaphyseal bone, osteoporosis renders simple fractures unstable and makes distal bone fixation a challenge. The introduction of fixed-angle plate systems for extension fractures of the radius was evaluated in a prospective study performed at our hospital after selection and acquisition of a new plating system. The focus of our interest was whether a secondary loss of reduction can be prevented by this plating system in the elderly patient. METHODS: We reviewed 58 patients aged 75 years or older treated for unstable distal radius fractures using a volar fixed-angle plate. Postoperative management included immediate finger motion, early functional use of the hand, wrist splint used for 4 weeks, and physiotherapy. At the time of follow-up, after a mean period of 13 months (range, 12-15 months), standard radiographic and clinical fracture parameters were measured and final functional results were assessed. RESULTS: Bone healing had occurred in all patients at the time of follow-up. On X-rays taken at the time of follow-up, 53 patients (91%) had no radial shortening, 5 patients (9%) had a mean radial shortening occurred during follow-up of only 1.3 mm (range, 1-2 mm) compared with the contralateral side. Comparing the first postoperative X-rays with those taken at final evaluation showed no measurable loss of reduction in the volar tilt or radial inclination. Castaing's score yielded a perfect outcome in 25 cases, a good outcome in 30 cases, and an adequate outcome in 3 cases. On an average, the range of motion was reduced by 19% during extension/flexion, by 13% during radial/ulnar deviation, and by 9% in pronation/supination compared with the contralateral side. Grip strength was 55% higher than that of the contralateral side. Eleven patients (19%) reported pain at rest with a mean Visual Analog Pain Scale score of 3.1 (range, 1-6), whereas 30 patients (52%) had pain on load-bearing with a mean Visual Analog Pain Scale score of 3.4 (range, 1-8). The mean disabilities of the arm, shoulder, and hand (DASH) score (Jester A, Harth A, Germann G. J Hand Surg Am. 2005;30:1074.e1-1074.e10) was 28 points. A carpal tunnel syndrome with abnormal nerve conduction velocity was diagnosed in three patients, a rupture of the flexor pollicis longus tendon was seen in one patient. CONCLUSION: Fixed-angle plate osteosynthesis at the distal radius in the elderly patient signifies a significant improvement in the treatment of distal radial fractures in terms of restoration of the shape and function of the wrist associated with a low complication rate. This technique with its simple palmar access, allows exact anatomic reduction of the fracture, allows early return to function, and minimizes morbidity in the elderly patient. Secondary correction loss can be prevented by this procedure.

Volar fixed-angle plating of extra-articular distal radius fractures--a biomechanical analysis comparing threaded screws and smooth pegs.

BACKGROUND: Distal radius fractures represent the most common fractures in adult individuals. Volar fixed-angle plating has become a popular modality for treating unstable distal radius fractures. Most of the plates allow insertion of either threaded locking screws or smooth locking pegs. To date, no biomechanical studies compare locking screws and pegs under axial and torsional loading. METHODS: Ten Sawbones radii were used to simulate an AO/OTA A3 fracture. Volar fixed-angle plates (Aptus Radius 2.5, Medartis, Switzerland) with threaded locking screws (n = 5) or smooth locking pegs (n = 5) were used to fix the distal metaphyseal fragment. Each specimen was tested under axial compression and under torsional load with a servohydraulic testing machine. Qualitative parameters were recorded as well as axial and torsional stiffness, torsion strength, energy absorbed during monotonic loading and energy absorbed in one cycle. RESULTS: Axial stiffness was comparable between both groups (p = 0.818). If smooth pegs were used, a 17% reduction of torsional stiffness (p = 0.017) and a 12% reduction of minimum torque (p = 0.012) were recorded. A 12% reduction of energy absorbed (p = 0.013) during monotonic loading and unloading was recorded if smooth pegs were used. A 34% reduction of energy absorbed in one cycle (p < 0.007) was recorded if threaded screws were used. Sliding of the pegs out of the distal radius metaphyses of the synthetic bones was recorded at a mean torque of 3.80 Nm ± 0.19 Nm. No sliding was recorded if threaded screws were used. CONCLUSIONS: According to the results of this study using Sawbones, volar fixed-angle plates with threaded locking screws alone are mechanically superior to volar fixed-angle plates with smooth locking pegs alone under torsional loading.

Urine toxicology screening in Austrian trauma patients: a prospective study.

INTRODUCTION: The question as to whether the patient consumed drugs prior to the trauma and which drugs were consumed, is of prime importance for the anesthesia required during surgery. However, many patients are unwilling or unable (including those with multiple trauma or impaired consciousness, or unconscious patients) to answer this question. The purpose of our prospective multicenter study was to collect data about drug consumption in Austria to determine whether drugs are identifiable in the urine of recently injured individuals and to establish the types of drugs consumed. MATERIALS AND METHODS: This prospective study included severely and moderately injured patients admitted to the Lorenz Boehler Trauma Hospital (Vienna, Austria), the Trauma Hospital Linz (Linz, Austria) and the Department of Trauma Surgery of the General Hospital Horn (Horn, Austria) during an 18-month period (October 2003-March 2005). All patients were suffering from injuries urgently requiring surgery. Urine samples were gained from all patients immediately after admission. Urinary samples were tested by Immuno-Assay (Triage 8 Immuno-Assay, Biosite, San Diego, USA). Urine samples were screened simultaneously for opiates, methadone, cocaine, barbiturates, amphetamines, cannabinoids, benzodiazepines and tricyclic antidepressants. RESULTS: Our prospective study included a total of 664 patients (320 from Vienna, 193 from the city of Linz, and 151 from Horn). Six hundred and forty-two patients were moderately injured (ISS < 16), suffering mostly from injuries to the extremities (504 patients) and 22 patients were severely injured (ISS > 16). Of the 664 patients, 178 (26.8%) tested positive for one or more drugs. The drugs most commonly detected were benzodiazepines (111 patients, 16.7%), cannabinoides (39 patients, 6%), tricyclic antidepressants (28, 4.2%) and opiates (26, 3.9%). CONCLUSION: Drug use is widespread in patients presenting to urban trauma centers in Austria. Physicians should maintain a high index of suspicion that their patients may be intoxicated and should perform drug testing routinely.

Anatomical assessment of the Hoffa fat pad during insertion of a tibial intramedullary nail--comparison of three surgical approaches.

BACKGROUND: Interlocking nailing is a standard procedure in the surgical treatment of tibial fractures. Despite it has been described to be a safe technique with excellent functional results compared with conservative treatment, a common problem is the development of anterior knee pain. The anatomic relation of Hoffa's fat pad with its nociceptors to the nail entry point has not been investigated, yet. METHODS: Eighteen formalin-fixed lower cadaver extremities of 11 cadavers (five females, six males) were matched into three groups: three approaches (medial paratendinous, transligamentous, and lateral paratendinous) were performed and the anterosuperior tibial cortex was opened with a cheese cutter. To investigate the relationship of the nail entry point and Hoffa's fat pad, the joint capsule was incised, and Hoffa's fat pad was exposed and then dissected carefully. Damage to the fat pad was recorded as well as meniscal lesions, cartilage lesions, and ligamentous lesions. After full extension and flexion of the knee joint, the motion of Hoffa's fat pad (millimeter) was recorded with a measuring gauge. The zone for safe nail insertion (millimeter square) without any lesion to intra-articular structures was recorded. RESULTS: Violation of Hoffa's fat pad was recorded if the lateral and transligamentous approach were used. With the medial approach, no damage of the fat pad was recorded. Total mean lateralization of the fat pad from extension to flexion over 90 degrees was 18.5 mm compared with its location in the fully extended knee. The safe zone for nail insertion without violation of menisci, cartilage, or ligaments was a triangle in the posteromedial aspect of the Hoffa with a mean dimension of 19.4 mm2. CONCLUSION: On the basis of our results, we can recommend the nail insertion via a medial paratendinous surgical approach to avoid injuries to the Hoffa fat pad and to menisci, cartilage, and ligaments.

Micromotion at the fracture site after tibial nailing with four unreamed small-diameter nails--a biomechanical study using a distal tibia fracture model.

BACKGROUND: Intramedullary nailing is the treatment of choice in tibia fractures allowing for closed fracture reduction and internal fixation. Small-diameter nails that preserve the endosteal blood supply act as load-sharing devices after proximal and distal locking. Despite fracture healing is influenced by movements at the fracture gap, no data are available reporting on the micromovements at the fracture site if small-diameter nails were used. METHODS: Using a Sawbone distal tibia fracture model, we assessed offset, elastic, plastic, permanent, and overall deformation at the fracture site for four small-diameter tibia nails (Expert, Synthes, Saluburg, Austria; Connex, ITS Spectromed, Lassnitzhöhe, Austria; Versanail, DePuy, Vienna, Austria; T2, Stryker, Vienna, Austria) after mechanical testing with a servohydraulic material testing machine. Cyclic loading was performed with a sinusoidal load of 700 N (+/-600) for 40,000 cycles representing 6 weeks of full weight bearing. RESULTS: Offset deformation was significantly higher for the Connex nail when compared with other nails (p < 0.001). Regarding elastic deformation, no significant difference was recorded between the implants. Plastic deformation was significantly lower if the Connex nail was used (0.134 [+/-0.053] mm; p < 0.001). Elastic deformation did not exceed 0.7 mm and plastic deformation did not exceed 0.4 mm. Regarding permanent and overall deformation, no significant difference between the implants was recorded. CONCLUSIONS: Considerable deformation at the fracture gap can be assumed even after partial weight bearing with 100 N. Despite comparable material properties, differences in axial micromotion were recorded among the nail types used in this series. The number of distal locking screws (three or four) did not substantially influence the axial movements at the fracture gap.

Influence of an additional locking screw on fracture reduction after volar fixed-angle plating-introduction of the "protection screw" in an extra-articular distal radius fracture model.

BACKGROUND: Though, volar fixed-angle plating has become increasingly popular to treat distal radius fractures no studies are available comparing the mechanical properties of different screw configurations to fix the plate to the shaft. The aim of the present study was to evaluate the effect of an additional locking screw directly proximal to the fracture site and to assess if such a screw might be protective against secondary loss of reduction after volar fixed-angle plating. METHODS: Ten Sawbones radii were used to simulate an extra-articular distal radius fracture model (AO/OTA 23-A3). In the first group (n = 5), volar fixed-angle plates (Aptus Radius 2.5, Medartis, Switzerland) were fixed to the radius shaft with a single nonlocking cortex screw in the oval hole and with two locking screws in the holes proximal to the long hole (LLNx); in the second group, the plates were fixed identically as in the first group, but an additional locking screw was inserted into the plate-hole distal to the oval hole, proximal to the fracture site (LLNL). After embedding, specimens were tested with a servohydaulic material testing machine under cyclic axial loading with 800 N for 2,000 cycles. Axial stiffness, elastic axial deformation (elastic dorsal tilt angle), and plastic deformation (plastic dorsal tilt angle) were recorded. RESULTS: After 2,000 cycles, stiffness was 761.6 (+/-59.5) N/mm in group LLNx and 628.9 (+/-37.6) N/mm in group LLNL without significant difference. Elastic deformation and elastic tilt angle were 1.05 (+/-0.08) mm and 3.9 (+/-0.3) degree in group LLNx. In group LLNL, elastic deformation and elastic tilt angle were 1.27 (+/-0.08) mm and 4.7 (+/-0.3) degree, respectively. Plastic deformation and plastic tilt angle were significantly higher in group LLNx (p < 0.001). After 2,000 cycles, dorsal tilt angle was 1.9 (+/-0.3) degree in group LLNx and 0.7 (+/-1.0) in group LLNL. CONCLUSION: This study showed the mechanical superiority of volar fixed-angle plates with a "protection screw" in an extra-articular fracture model. Further clinical investigation is needed to verify the results.

Conservative management of thoracolumbar and lumbar spine compression and burst fractures: functional and radiographic outcomes in 136 cases treated by closed reduction and casting.

INTRODUCTION: Both fractures of the lumbar spine and at the thoracolumbar junction are quite common. The treatment of these fracture types is discussed controversially. Some authors advocate surgical treatment even in fractures without neurologic compromise while other series report good results after non-operative treatment. MATERIALS AND METHODS: Between January 1997 and April 2004, 324 patients with spinal fractures were admitted to our institution. Hundred and thirty-six patients with compression and burst type fractures treated by closed reduction and casting were available for follow-up. Their medical records, radiographs and computer tomography scans were reviewed and their functional status was assessed. RESULTS: 94 male (69.1%) and 42 female (30.9%) patients with a mean age of 48.6 years (range 17-81) at time of injury were included. The thoracolumbar junction (T11-L1) was affected in 104 patients (76.5%). 23.5% had lumbar fractures. All of the burst type fractures with involvement of the posterior column affection were type A3.3. fractures according to the Magerl classification. Significant correction of radiographic parameters was achieved in the early postreduction period (P < 0.0001). Reduction could not be maintained at the final follow-up but still showed slight improvement compared to the initial presentation. Reduction could be maintained better in the thoracolumbar region than in the lumbar spine. Neurologic function was restored in all patients with unilateral radicular pain but only one patient recovered fully after cauda equina-syndrome. Patients after lumbar spine indicated a higher level of pain when compared to patients with fractures at the thoracolumbar junction. DISCUSSION: Closed reduction and casting is a safe and effective method for treatment of compression and burst type fractures at the thoracolumbar junction and can restore neurologic function in patients with unilateral radicular pain. It is of limited value in lumbar fractures and in burst type fractures with posterior column involvement.

Volar fixed-angle plate osteosynthesis of unstable distal radius fractures: 12 months results.

BACKGROUND: With an incidence of about 2-4 per 1,000 residents per year, the distal radial fracture is the most common fracture in the human skeleton. The introduction of fixed-angle plate systems for extension fractures at the radius was evaluated in a prospective study performed at our hospital after selection and acquisition of a new system. The focus of our interest was whether a secondary loss of reduction can be avoided by this plating system. METHODS: We reviewed 80 patients treated for unstable distal radius fractures using a volar fixed-angle plate. Postoperative management included immediate finger motion, early functional use of the hand, a wrist splint used for 4 weeks and physiotherapy. Standard radiographic and clinical fracture parameters after 12 months (range 12-14 months) were measured and final functional results where assessed. RESULTS: Bone healing had occurred in all patients at the time of follow-up after 1 year. On X-rays taken at the time of follow-up 60 patients (75%) had no radial shortening, 20 patients (25%) had a mean radial shortening of only 1.8 mm (range 1-3 mm) compared to the contralateral side. The radial tilt was on average 22 degrees (range 14 degrees-36 degrees); the volar tilt was on average 6 degrees (range 0 degrees-18 degrees). Comparing the first postoperative X-rays with those taken at final evaluation showed no measureable loss of reduction in the volar or radial tilt. Castaing's score, which includes the radiographic results, yielded a perfect outcome in 30 cases, a good outcome in 49 cases and an adequate outcome in one case. The range of motion was on average reduced by 21% during extension/flexion, by 11% during radial/ulnar deviation and by 7% in pronation and supination compared to the contralateral side. Grip strength was 65% that of the contralateral side. The mean DASH score was 25 points. CONCLUSION: Fixed-angle plate osteosynthesis at the distal radius signifies a significant improvement in the treatment of distal radial fractures in terms of restoration of the shape and function of the wrist. The technically simple palmar access, with a low rate of complications, allows exact anatomical reduction of the fracture. The multidirectional fixed-angle system we used provides solid support for the joint surface even in osteoporotic bone and allows simple subchondral placement of screws with sustained retention of the outcome of reduction. Secondary correction loss can be avoided by this procedure. Early mobilisation can be achieved and is recommended.

Functional recovery at a minimum of 2 years after multiple injury-development of an outcome score.

BACKGROUND: Early mortality of patients with multiple injuries has been reduced within the past three decades, and now restoration of functional outcome afterward has become the primary goal. The following study was conducted to examine the long-term outcome of a population of patients with multiple injuries, and to develop a score that allows quantification of the outcome. METHODS: Three hundred eighty-six patients with multiple injuries were collected in a prospectively gathered database at our institution, a Level I trauma center. Demographic data as well as injury severity, injury patterns, and mortality rates were analyzed in 192 patients who were reexamined between February and July 2003. In those patients, outcome after trauma was described using self-reports and physician examinations. One hundred ninety-two patients who were reexamined and 107 patients who died during hospital stay were used to correlate outcome data with injury severity. Furthermore, based on the outcome data, an injury outcome score was developed. Interobserver agreement was assessed using the kappa-statistic (2 level kappa). RESULTS: The mean age was 30.3 (+/-29.8) years, and the mean Injury Severity Score (ISS) was 30.6 (+/-21.5). Most patients suffered injuries from motor vehicle crashes (n = 62.5%), followed by falls from heights (25.0%), and other reasons (12.5%). In the collective undergoing reexamination protocol (n = 192), 172 (89.6%) patients still had complaints about at least 1 body region. Fifty (26.0%) patients still needed medical treatment or were integrated in a rehabilitation process. The mean Injury Outcome Score (IOS) was 30.5 (+/-33.9) with a range from 0 to 75. A significant positive correlation (r = 0.598; p < 000.1) between ISS and IOS was demonstrated. Interobserver agreement was excellent with kappa = 0.92. The subscores for "head" (r = 0.725; p < 0.001; 95% CI: 0.52-0.80), "spine" (r = 0.686; p < 0.001; 95% CI: 0.32-0.82), and "extremity" (r = 0.546; p < 0.001; 95% CI: 0.24-0.68) have significant influence on the total IOS. In the subgroup of patients suffering lower extremity fractures, IOS (mean IOS, 16.3 [range, 4-24]) was significantly higher (p < 0.001) when compared with patients without lower extremity fractures (mean IOS, 10.1 [0-13]). CONCLUSION: Our results suggest that the ISS not only be used for mortality prediction but also can be related to the long-term outcome after 2 years. In summary, the IOS seems to provide useful information for assessment of the outcome after severe blunt trauma. Especially after head, spinal, and extremity injuries, significant influence on the overall long-term outcome can be assumed.

Factors influencing the injury pattern and injury severity after high speed motor vehicle accident--a retrospective study.

INTRODUCTION: Motor vehicular accidents (MVA) are the leading cause of death among people under 40 years of age. Despite improvement in car safety and driver awareness of the use of safety devices, fatalities and severe injuries continue to occur. MATERIAL AND METHODS: From 1997 to 2004, 13,678 patients after MVA were admitted to our institution. Out of this cohort, 584 (4.3%) patients suffered blunt major trauma defined as Injury Severity Score (ISS) >or=16 and at least one life-threatening injury in one body region. Preclinical data were recorded in 458 patients matching the inclusion criteria. The circumstances of the trauma scene such as weather conditions were analysed as well as technical crash data such as direction of impact, security devices used and type and severity of automobile damage. In a retrospective trial, the influence of preclinical variables on the injury pattern and on injury severity was investigated. RESULTS: 314 (68.6%) patients were male and 144 (31.4%) female. Injury severity (p=0.015) and rate of multiple injuries (p=0.012) were higher in patients after side-impact crashes. If automobiles with SIPS were used, injury severity was significantly reduced in case of side-impact crashes (p=0.003). Patients after frontal impact crashes had a higher rate of severe traumatic brain injury (TBI) compared to the overall cohort (p=0.014). Patients suffering blunt aortic (n=29) dissection were involved in frontal crashes with seat belt use (p<0.001). If patients were entrapped, injury severity (p=0.021) and rate of multiple injuries (p=0.018) were significantly higher. Rear-end collisions with trucks without rear protection led to higher mortality rates (p=0.011). CONCLUSION: According to our data significant association between technical crash data and injury pattern and injury severity can be assumed. In case of high speed MVA in rural areas the trauma mechanism and the circumstances (i.e., impact direction, automobile deformation) should be considered to identify patients at high risk of severe blunt trauma and multiple injuries.