Joint-preserving treatment for type 3 sequelae following fracture of the proximal humerus with small head fragments.

BACKGROUND: Although nonunions of the proximal humerus are rare, they cause significant disability to patients. Surgical reconstruction is challenging, especially with small and excavated head fragments. A promising surgical option is open reduction and stabilization using the Humerusblock device along with tension wires. The aim of this retrospective investigation was to evaluate the clinical and radiological results of this procedure. MATERIALS AND METHODS: Fifteen patients with symptomatic surgical neck nonunions were treated with open reduction and internal fixation using the Humerusblock device without bone grafting. All patients showed a loss of bone stock, leading to excavated head fragments. The mean interval from injury to the described treatment was 6.2 months (range, 3.4-10.7). At a mean follow-up of 40.5 months, the Constant-Murley score was documented, pain and patient satisfaction were evaluated using a visual analogue scale, and x-rays were taken in two planes. RESULTS: The patients' mean age was 69.7 years (range, 52-83). The mean Constant-Murley score improved from 24 points before surgery to 62 points at follow-up, which was an average of 80.8% of the score obtained for the contralateral arm. Radiological examination confirmed bony healing in 14 patients. All but one patient felt satisfied with the results. Three patients required revision surgery because of a hematoma, and early metal removal was performed in one patient because of infection. CONCLUSION: Nonunions of humeral surgical neck fractures can be successfully treated by fixation using the Humerusblock device along with tension wires without the need for additional bone grafting. Especially in patients with flat, concave head fragments, this procedure remains a promising reconstructive option to arthroplasty. LEVEL OF EVIDENCE: Level IV; Therapeutic retrospective case series.

The "triple dislocation fracture": anterior shoulder dislocation with concomitant fracture of the glenoid rim, greater tuberosity and coracoid process-a series of six cases.

BACKGROUND: A combined fracture of the glenoid rim, greater tuberosity, and coracoid process after anterior shoulder dislocation is a rare event. Only 1 patient has been reported in the literature. METHODS: All patients with a first-time traumatic anterior shoulder dislocation in a level A trauma center were retrospectively reviewed. Among the 2068 patients treated between 1998 and 2013, we identified 6 patients (0.3%; 1 female, 5 male) with "triple dislocation fracture" (anterior shoulder dislocation with concomitant fracture of the glenoid rim, greater tuberosity, and coracoid process). All patients underwent surgery and had computed tomography scans before surgery and the first postoperative day. Mean follow-up time was 59 months. Clinical and radiographic evaluation, Constant-Murley Score, Simple Shoulder Test, and Subjective Shoulder Value were performed at the final follow-up. RESULTS: Surgery was determined individually according to the radiologic findings, patient's age, and personal demands. Glenoid reconstruction was performed in all 6 patients, greater tuberosity refixation in 4 patients, and coracoid process refixation in 3. Two patients needed revision surgery due to loss of reduction. At the final follow-up, mean abduction was 133°, mean anterior flexion was 138°; the mean Constant-Murley Score was 72 points; the mean Simple Shoulder Test was 9 points; and the mean Subjective Shoulder Value was 72%. No recurrent instability occurred. CONCLUSIONS: A "triple dislocation fracture," especially coracoid process fractures, can easily be overlooked in radiographs. Computed tomography scans are strongly recommended in patients with a first-time traumatic shoulder dislocation. Because recurrent joint instability and secondary arthropathy are serious complications after anterior shoulder dislocation, surgery should be considered and provides satisfying to excellent results.

Rupture of the spleen following thoracoscopic spine surgery in a patient with chronic pancreatitis.

PURPOSE: To highlight the perioperative risk of intracapsular haematoma of the spleen or splenic ruptures during thoracoscopic spine surgery in patients with chronic pancreatitis. METHODS: A 38-year-old patient with an L1 burst fracture (AO A3.3) underwent a standard thoracoscopic corpectomy and replacement of the vertebral body with an extendable vertebral body replacement 10 days after posterior instrumentation of T12-L2. In patients history chronic abusive alcoholism with related diseases such as pancreatitis, followed by hemipancreatectomy was found. Six hours after the surgery, the patient became hemodynamically unstable. An emergency CT scan revealed a splenic rupture. Emergent splenectomy was performed. RESULTS: After surgical treatment of the L1 burst fracture, a rupture of the spleen was detected. An immediate splenectomy was performed. At the 18-month follow-up, an unchanged stable position of the cage was observed on CT. CONCLUSIONS: Due to its proximity to the thoracolumbar junction, the spleen is vulnerable to injury during spine surgery. If the patient has undergone previous intra-abdominal operations or chronic inflammation of the pancreas is found, special care of the spleen during the operation is necessary.

Comparison between minimally invasive, percutaneous osteosynthesis and locking plate osteosynthesis in 3-and 4-part proximal humerus fractures.

BACKGROUND: The ideal method for the surgical treatment of proximal humeral fractures has not yet been found. We therefore conducted a retrospective matched-pair analysis and compared osteosynthesis with open reduction and internal fixation and that with an angular stable plate with minimally invasive, closed reduction, percutaneous fixation with the Humerusblock. METHODS: During a study period of 3 years, we matched 30 patients treated with angular stable plates (group 1) for age, gender, fracture type and handedness (dominant or nondominant) to 30 patients treated using the Humerusblock (group 2). At a minimal follow-up of 24 months, clinical evaluation included the Constant-Murley score, the UCLA score and the Simple Shoulder Test. Subjective pain was evaluated using the VAS pain scale. Patients were asked to rate their subjective satisfaction of final outcome as excellent, good, satisfied or dissatisfied. RESULTS: The mean CMS, UCLA score and SST differed significantly between groups 1 and 2 (60.9 vs 71.9, p < 0.01), (25.1 vs 29.5, p < 0.01) and (8.1 vs 9.4, p < 0.05), respectively. The VAS pain score was significantly lower in group 2 than in group 1 (1.2 vs 2.4; p < 0.01). The mean abduction (109.7° vs 133.7°; p < 0.01) and anterior flexion (128.3° vs 145.7°; p < 0.01) were significantly worse in group 1. The mean operation time was significantly shorter in group 2 (117.3 vs 72.1, p < 0.01). Complications occurred in 30 % (group 1) and 23 % (group 2) of patients. CONCLUSIONS: In this study, the functional outcome is superior in the Humerusblock group. However, the general outcome after surgical treatment of 3-and 4-part fractures is moderate, and the complication rate has to be considered, even though it can be lowered with the use of minimally invasive implants.

Comparison of revision strategies for failed C2-posterior cervical pedicle screws: a biomechanical study.

STUDY PURPOSE: With increasing usage within challenging biomechanical constructs, failures of C2 posterior cervical pedicle screws (C2-pCPSs) will occur. The purpose of the study was therefore to investigate the biomechanical characteristics of two revision techniques after the failure of C2-pCPSs. MATERIALS AND METHODS: Twelve human C2 vertebrae were tested in vitro in a biomechanical study to compare two strategies for revision screws after failure of C2-pCPSs. C2 pedicles were instrumented using unicortical 3.5-mm CPS bilaterally (Synapse/Synthes, Switzerland). Insertion accuracy was verified by fluoroscopy. C2 vertebrae were potted and fixed in an electromechanical testing machine with the screw axis coaxial to the pullout direction. Pullout testing was conducted with load and displacement data taken continuously. The peak load to failure was measured in newtons (N) and is reported as the pullout resistance (POR). After pullout, two revision strategies were tested in each vertebra. In Group-1, revision was performed with 4.0-mm C2-pCPSs. In Group-2, revision was performed with C2-pedicle bone-plastic combined with the use of a 4-mm C2-pCPSs. For the statistical analysis, the POR between screws was compared using absolute values (N) and the POR of the revision techniques normalized to that of the primary procedures (%). RESULTS: The POR of primary 3.5-mm CPSs was 1,140.5 ± 539.6 N for Group-1 and 1,007.7 ± 362.5 N for Group-2; the difference was not significant. In the revision setting, the POR in Group-1 was 705.8 ± 449.1 N, representing a reduction of 38.1 ± 32.9 % compared with that of primary screw fixation. For Group-2, the POR was 875.3 ± 367.9 N, representing a reduction of 13.1 ± 23.4 %. A statistical analysis showed a significantly higher POR for Group-2 compared with Group-1 (p = 0.02). Although the statistics showed a significantly reduced POR for both revision strategies compared with primary fixation (p < 0.001/p = 0.001), the loss of POR (in %) in Group-1 was significantly higher compared with the loss in Group-2 (p = 0.04). CONCLUSIONS: Using a larger-diameter screw combined with the application of a pedicle bone-plastic, the POR can be significantly increased compared with the use of only an increased screw diameter.

Reliability of a new standardized measurement technique for reverse Hill-Sachs lesions in posterior shoulder dislocations.

PURPOSE: The purpose of this study was to determine whether standardized measurements are more reliable than mere estimation in determining the extent of the defect in reverse Hill-Sachs lesions. METHODS: Twelve patients with 13 reverse Hill-Sachs lesions and available computed tomographic scans were included in this study. Based on the computed tomographic scans, estimation and measurement of the defect size in reverse Hill-Sachs lesions using a novel standardized method were carried out twice by 6 observers (3 experts and 3 residents), with an interval of 3 months between observations. To assess and compare the reliability of the estimation of the defect size and the measurement of the defect size, intraclass correlation coefficients were computed. RESULTS: Estimation of the defect size showed a low interobserver reliability of 0.61 (95% confidence interval [CI], 0.38 to 0.83) and 0.47 (95% CI, 0.24 to 0.74) and a moderate intraobserver reliability of 0.71 (95% CI, 0.51 to 0.89). The estimations of the different observers showed statistically significant differences (P < .001). The standardized measurements reached high interobserver reliability (at least ≥0.81) and excellent intraobserver reliability (at least ≥0.88). Residents provided less reliable estimations compared with experts; however, they obtained similarly high reliability when applying the standardized measurements. CONCLUSIONS: The mere estimation of the size of reverse Hill-Sachs lesions showed poor reliability, raising the concern for potential overestimation or underestimation in clinical practice. Standardized measurements, which showed good reliability, should be used whenever analyzing the size of a reverse Hill-Sachs defect. LEVEL OF EVIDENCE: Level IV, diagnostic case series.

The interobserver reliability in diagnosing osseous lesions after first-time anterior shoulder dislocation comparing plain radiographs with computed tomography scans.

BACKGROUND: Recurrence after first-time traumatic anterior shoulder dislocation is frequent. The prevalence of glenoid bone loss ranges from 41% after a first-time dislocation to 86% with recurrent dislocation. Postoperative recurrence can occur in up to 10% of cases. Thus, misdiagnosis of bony glenoid rim lesions has been assumed a major cause for failure. We evaluated the interobserver reliability of radiologic diagnoses after first-time traumatic shoulder dislocation based on radiographs and computed tomography (CT) images. METHODS: Digital radiographs before and after reduction and CT images after reduction of 20 patients with a first-time shoulder dislocation were assessed by 6 observers. It was recorded whether they diagnosed a lesion at the greater tuberosity, a lesion at the glenoid rim, a Hill-Sachs lesion, or any other skeletal pathology. The average agreement among the investigators was evaluated, and radiographic diagnoses were compared with those based on CT images. RESULTS: Of the 10 cases that presented with a glenoid rim fracture, each investigator had overlooked at least 1 fracture (range, 1-4) on the radiographs. No investigator had diagnosed all 8 Hill-Sachs lesions on the presented images. The average overall agreement among the investigators and corresponding sensitivity and specificity were calculated. Agreement of diagnoses based on radiographs with those based on CT images was lowest for glenoid rim fractures and Hill-Sachs lesions. CONCLUSION: Radiographs seem inferior to CT scans for assessing osseous lesions especially at the glenoid rim. We suggest performing a CT scan of the shoulder after primary dislocation to apply the correct treatment early and potentially avoid further dislocations.

Does the choice of approach for hip hemiarthroplasty in geriatric patients significantly influence early postoperative outcomes? A randomized-controlled trial comparing the modified Smith-Petersen and Hardinge approaches.

BACKGROUND: Minimally invasive surgical approaches for total hip replacement, such as the modified Smith-Petersen approach, have been reported to be advantageous over alternative techniques because of reduced soft tissue damage and improved immediate postoperative rehabilitation. This study compares the advantages of the Smith-Petersen approach against the lateral Hardinge approach for femoral neck fractures in geriatric patients. METHODS: In a randomized-controlled trial, 48 patients were treated by a hemiarthroplasty of the hip using either a modified Smith-Petersen or a Hardinge approach. Age, American Society of Anesthesiologists score, body mass index, blood loss, pain, and postoperative mobilization were compared between groups to detect statistically significant differences. The same outcome measures were analyzed for significant differences between patients with or without complications in each group. RESULTS: The Smith-Petersen approach yielded a statistically significant increase in postoperative pain within the first 4 days and an increase in operation time. Complications were also associated with a significantly higher intraoperative time in the same group. However, 6 months postoperatively, there were no significant differences in the Harris Hip score between groups. CONCLUSIONS: Despite early postoperative differences, postoperative mobility does not seem to be greatly influenced by the choice of either an anterior modified Smith-Petersen or a lateral Hardinge approach for hip hemiarthroplasty. Operative time was significantly linked to postoperative complications. In this respect, it can be concluded that it is not be the approach itself that determines the early postoperative result, but the routine the individual surgeon has with it.

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.

Magnetic resonance imaging-controlled results of the pectoralis major tendon transfer for irreparable anterosuperior rotator cuff tears performed with standard and modified fixation techniques.

HYPOTHESIS: Irreparable ruptures of the subscapularis tendon lead to impaired function of the shoulder joint. In such cases, transfer of the pectoralis major tendon has led to encouraging results. The procedure fails periodically, typically associated with insufficient in-growth of the transferred tissue. We hypothesized that tendon harvest with chips of cancellous bone would improve the tendon-bone interface. MATERIALS AND METHODS: Of 62 consecutive pectoralis tendon transfers, 54 shoulders were followed-up at an average of 35 months. In all shoulders, the transferred tendon was rerouted behind the conjoint tendon and fixed by transosseous sutures. In 29 shoulders, the tendon was harvested with a cuff of cancellous bone. In 25 shoulders, the conventional technique with sharp detachment of the tendon was used. Apart from detailed clinical examination of all shoulders, a magnetic resonance image (MRI) was available in 52 shoulders. RESULTS: The overall Constant score had improved from an average of 38.8 points preoperatively to 63.4 points at follow-up. Shoulders treated with the new fixation technique scored 64.4 compared with 62.2 for the conventional fixations. The MRI showed intact tendons and muscles in 80.8% of shoulders. In 7 shoulders (13.5%), the transferred tendon was ruptured. Two of these were treated with the new fixation technique. Mean patient satisfaction score was 8.2 points. DISCUSSION: A secure method of fixation that avoids secondary ruptures despite insufficiency of the transferred tendon is of great importance. Also the rerouting of the transferred tendon under the conjoined tendon is essential to imitate the natural force vector and the function of an intact subscapularis tendon. Patients in this investigation were also monitored by MRI to verify the integrity of the transferred tendon. CONCLUSION: As a salvage procedure, the pectoralis major tendon transfer provides good results in most cases. Sufficient in-growth of the transferred tissue is essential for the success of the procedure. This seems to be facilitated by both methods.

How severe are initially undetected injuries to the knee accompanying a femoral shaft fracture?

BACKGROUND: Fractures of the femur are severe injuries that quickly attract the physician's attention. Previous reports have shown that injuries to the ipsilateral knee can occur. In most cases, such injuries were diagnosed on delay. Excluding cases in which a knee injury was apparent already at admission, we sought to investigate the number and severity of initially undetected lesions to the knee concomitant with a femoral shaft fracture and give an overview of the literature referring to these combined injuries. METHODS: Charts and X-rays of patients treated for a femoral shaft fracture from January 2000 until December 2007 were reviewed. Patients, in whom any other injury of the affected limb apart from a midshaft femoral fracture was initially diagnosed, were excluded. Also patients, in whom an injury to the knee had been diagnosed at admission, were excluded. RESULTS: Fifty-three patients with 55 midshaft femoral fractures were available for analysis. An injury to the knee was diagnosed in three cases (5%). There was one partial tear of the posterior cruciate ligament and two grade two lesions of the medial meniscus. All lesions were conservatively treated without any after-effects. CONCLUSION: Physical examinations under anesthesia, arthroscopy and magnetic resonance imaging have shown lesser correlation among each other than one would expect. More severe injuries to the knee with femoral shaft fractures are more likely to be detected early, than minor ones. Pain about the knee communicated by the awake patient should be the indication for further apparative examination by magnetic resonance imaging or arthroscopy.

Long-term investigation of nonsurgical treatment for thoracolumbar and lumbar burst fractures: an outcome analysis in sight of spinopelvic balance.

The nonsurgical treatment of thoracolumbar (TLB) and lumbar burst (LB) fractures remains to be of interest, though it is not costly and avoids surgical risks. However, a subset of distinct burst fracture patterns tend to go with a suboptimal radiographic and clinical long-term outcome. Detailed fracture pattern and treatment-related results in terms of validated outcome measures are still lacking. In addition, there are controversial data on the impact of local posttraumatic kyphosis that is associated, in particular, with nonsurgical treatment. The assessment of global spinal balance following burst fractures has not been assesed, yet. Therefore, the current study intended to investigate the radiographical and clinical long-term outcome in neurologically intact patients with special focus on the impact of regional posttraumatic kyphosis, adjacent-level compensatoric mechanisms, and global spine balance on the clinical outcome. For the purpose of a homogenous sample, strong in- and exclusion criteria were applied that resulted in a final study sample of 21 patients with a mean follow-up of 9.5 years. Overall, clinical outcome evaluated by validated measures was diminished, with 62% showing a good or excellent outcome and 38% a moderate or poor outcome in terms of the Greenough Low Back Outcome Scale. Notably, vertebral comminution in terms of the load-sharing classification, posttraumatic kyphosis, and an overall decreased lumbopelvic lordosis showed a significant effect on clinical outcome. A global and segmental curve analysis of the spine T9 to S1 revealed significant alterations as compared to normals. But, the interdependence of spinopelvic parameters was not disrupted. The patients' spinal adaptability to compensate for the posttraumatic kyphotic deformity varied in the ranges dictated by pelvic geometry, in particular the pelvic incidence. The study substantiates the concept that surgical reconstruction and maintenance of a physiologically shaped spinal curve might be the appropriate treatment in the more severely crushed TLB and LB fractures.

Minimally Invasive Treatment of Displaced Proximal Humeral Fractures in Patients Older Than 70 Years Using the Humerusblock.

Background. Surgical treatment of proximal humeral fractures (PHF) in osteoporotic bone of elderly patients is challenging. The aim of this retrospective study was to evaluate the clinical and radiological outcome after percutaneous reduction and internal fixation of osteoporotic PHF in geriatric patients using the semirigid Humerusblock device. Methods. In the study period from 2005 to 2010, 129 patients older than 70 years were enrolled in the study. After a mean follow-up of 23 months, a physical examination, using the Constant-Murley score and the VAS pain scale, was performed. Furthermore radiographs were taken to detect signs of malunion, nonunion, and avascular necrosis. Results. The recorded Constant-Murley score was 67.7 points (87.7% of the noninjured arm) for two-part fractures, 67.9 points (90.8%) for three-part fractures, and 43.0 points (56.7%) for four-part fractures. In ten shoulders (7.8%) loss of reduction and in four shoulders (3.1%) nonunion were the reason for revision surgery. Avascular humeral head necrosis developed in eight patients (6.2%). Conclusions. In two- and three-part fractures postoperative results are promising. Sufficient ability for the activities of daily living was achieved. In four-part fractures the functional results were less satisfying regarding function and pain with a high postoperative complication rate. In those patients other treatment strategies should be considered. Study design. Therapeutic retrospective case series (evidence-based medicine (EBM) level IV).

Extensor pollicis longus rupture after distal radius fracture: results of reconstruction by transposition of the extensor indicis tendon and postoperative dynamic splinting.

Injury of the extensor pollicis longus tendon is one of the commonest extensor tendon injuries after distal radius fracture. In 2003-2005 we performed extensor indicis transfer in 31 patients with loss of function of the EPL tendon and postoperative dynamic splinting. In 25 patients, a distal radius fracture managed surgically led to the EPL rupture (wire internal fixation in 23 patients, plate internal fixation in 2 patients). In 6 patients, the cause was a distal radius fracture treated conservatively. Out of our 25 followed-up patients, 9 (36%) had a very good and 15 (60%) a good result in the Geldmacher score. We did not identify any re-rupture. In injuries of the extensor pollicis tendon, transposition of the extensor indicis tendon is a simple and uncomplicated procedure. Considerable improvement of thumb extension can be achieved through this substitution repair.