RESUMEN
The relevance of geriatric ankle fractures is continuously increasing. Treatment of these patients remains challenging and requires adapted diagnostic and therapeutic strategies, as compliance to partial weight bearing is difficult to maintain compared to younger patients. In addition, in the elderly even low impact injuries may lead to severe soft tissue trauma, influencing timing and operative strategies. Recently, the direct posterolateral approach and plate fixation techniques, angular stable implants as well as intramedullary nailing of the distal fibula have been found to improve stategical concepts. This article aims to provide a comprehensive overview of the diagnostic and recent aspects with respect to how this difficult entity of injuries should be approached.
RESUMEN
INTRODUCTION: This study investigated the effects of a small posterior malleolar fragment (PMF), containing less than 25% articular surface area, on ankle joint stability via computed tomography (CT) scanning under full weight bearing in a human cadaveric ankle fracture model. MATERIALS AND METHODS: A trimalleolar fracture with a PMF of less than 25% articular surface area was created in 6 pairs of fresh-frozen human cadaveric lower legs. The specimens were randomized into 2 groups stabilized by internal fixation including a positioning screw for syndesmotic reconstruction. In Group I the PMF was addressed by direct screw osteosynthesis, whereas in Group II the fragment was not fixed. Six predefined distances within the ankle were measured under axial loading. CT scans of each specimen were performed in intact and fixated states in neutral position, dorsiflexion and plantar-flexion of the ankle. RESULTS: In plantar-flexion, significant differences were detected between the groups with regard to rotational instability. Group II demonstrated a significantly increased inward rotation of the fibula compared with Group I. No significant differences were detected between the groups for each one of the measured distances in any of the three foot positions. CONCLUSIONS: Additional reduction and fixation of a small PMF seems to neutralize rotational forces in the ankle more effectively than a sole syndesmotic screw. Clinically, this becomes relevant in certain phases of the gait cycle. Direct screw osteosynthesis of a small PMF stabilizes the ankle more effectively than a positioning screw.
Asunto(s)
Fracturas de Tobillo , Fracturas de Tobillo/diagnóstico por imagen , Fracturas de Tobillo/cirugía , Articulación del Tobillo/cirugía , Tornillos Óseos , Cadáver , Fijación Interna de Fracturas/métodos , Humanos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
INTRODUCTION: Valid epidemiological data about distal fibular fractures and their treatment strategies are missing. Innovative osteosynthesis techniques were introduced and improved during the past 15 years. The aim of this study was to investigate the epidemiologic development and the implementation of new treatment strategies in a nationwide register in Germany over a period of 15 years. MATERIALS AND METHODS: Data of the German Federal Statistical Office from 2005 until 2019 were screened. Adults with a fracture of the distal fibula were included. Data were separated for gender, age and treatment strategy. RESULTS: During the past 15 years, there was a steady annual incidence of distal fibula fractures of 74 ± 32 per 100,000 people without any significant changes (p = 0.436). 60.1% ± 0.6% of all fractures occurred in females. The annual incidence for male was nearly constant over the different age groups, whereas for female, there was a clear increase in incidence above the age of 40. Whereas 66% of fractures in between 20 and 30 years of age occurred in male, approximately 70% of fractures above the age of 60 occurred in females. The relative quantity of locking plates increased from 2% in 2005 to 34% in 2019. In 2019, only 1.02% of the patients were operated with an intramedullary nail. CONCLUSIONS: Operatively treated distal fibular fractures revealed an age dependent increase in incidence in postmenopausal women compared to younger females. Regarding the treatment strategy, there was an increase in application of locking plates. The data implicate a typical fragility fracture related age and gender distribution for distal fibula fractures.
Asunto(s)
Fracturas de Tobillo , Fijación Intramedular de Fracturas , Fracturas de la Tibia , Adulto , Femenino , Humanos , Masculino , Peroné/cirugía , Placas Óseas , Fracturas de la Tibia/cirugía , Incidencia , Fijación Interna de Fracturas/métodos , Fracturas de Tobillo/cirugía , Resultado del TratamientoRESUMEN
OBJECTIVE: Anatomical restoration of the function and anatomy of the talocrural joint, anatomical reduction of fractures of the lateral and medial malleoli and to address ligamentous instability when achieving exercise stability. INDICATIONS: Dislocated and intra-articular fractures of the lateral and medial malleoli. CONTRAINDICATIONS: Infections, peripheral arterial occlusive disease, critical soft tissue conditions. SURGICAL TECHNIQUE: Placement in a supine position, lateral and medial access, reduction of the fractures by manipulation of the fragments with Kirschner wires or use of reduction clamps, control of the joint reduction, definitive fixation with traction screws and plate osteosynthesis of the distal fibula, screw, tension-band or plate osteosynthesis of the medial malleolus, in cases of syndesmosis instability exact restoration of the talocrural joint by implantation of adjusting screws, alternatively dynamic fixation with a suture-button system. POSTOPERATIVE MANAGEMENT: Movement exercises of the talocrural joint after postoperative day 1, mobilization with partial weight-bearing of the affected leg with 20kg postoperatively for 6-8 weeks, with implantation of adjusting screws removal after 8 weeks and staged increase of weight-bearing, if necessary postoperative insertion of an orthesis. RESULTS: The anatomical reconstruction is decisive. Surgically treated bimalleolar fractures show good to excellent long-term results, the increasing number of affected malleoli correlates with a poorer outcome.
Asunto(s)
Fracturas de Tobillo , Fracturas de Tobillo/diagnóstico por imagen , Fracturas de Tobillo/cirugía , Placas Óseas , Hilos Ortopédicos , Fijación Interna de Fracturas , Humanos , Resultado del TratamientoRESUMEN
As a result of the demographic developments ankle fractures in older patients are part of routine trauma surgery. Due to comorbidities, such as diabetes mellitus, reduced bone quality and limited compliance in follow-up treatment, these fractures are prone to complications. The primary goal in the treatment of older patients with ankle fractures is to maintain mobility. In contrast to young patients most fractures are unstable pronation-abduction injuries. In the diagnostics the recognition and optimization of factors influencing the outcome, such as the blood perfusion and the generous use of computed tomography (CT) are recommended. As in the case of younger patients, conservative treatment is reserved for stable fracture forms and, if there are contraindications, should also be initiated in the case of unstable injuries. The choice of approaches is different for surgical treatment, which is adapted to the soft tissues, if necessary minimally invasive and increasingly carried out by a posterolateral approach. The initial transfixation can reduce soft tissue problems. Special surgical techniques and implants that provide a high level of stability, such as dorsal plate positioning, hook plates, angular stable plate systems and intramedullary systems as well as additional options, such as tibia pro fibula constructs are used. Primary retrograde nail arthrodesis is reserved as a salvage procedure only for exceptional cases. As part of the follow-up treatment, an interdisciplinary approach with respect for and optimization of concomitant diseases seems to make sense.
Asunto(s)
Fracturas de Tobillo , Fijación Intramedular de Fracturas , Fracturas de la Tibia , Anciano , Fracturas de Tobillo/diagnóstico por imagen , Fracturas de Tobillo/cirugía , Articulación del Tobillo , Placas Óseas , Fijación Interna de Fracturas , Humanos , Radiografía , Fracturas de la Tibia/diagnóstico por imagen , Resultado del TratamientoRESUMEN
BACKGROUND: The purpose of this human specimen experimental study was to compare the fixation stability of clinically used bilayer collagen membrane with fibrin glue with trilayer collagen prototype without fibrin glue in chondral defects at the medial or lateral talar shoulder (both matrices from Geistlich Pharma AG, Wollhusen, Switzerland). METHODS: Eleven human specimens were used. The membranes were implanted in standardized chondral defects at the medial and lateral talar shoulder randomized. All tests were performed in load-control 15 kg. Range of motion ROM of each ankle was examined individually before testing. The average ROM was 10° dorsiflexion range 0°-20° and 30° plantarflexion range 20°-45°. 1,000 testing cycles with the defined ROM were performed. Two independent investigators, blinded to membrane and fixation type, visually assessed the membrane fixation integrity for peripheral detachment, area of defect uncovered, membrane constitution and delamination. RESULTS: The clinically used bilayer collagen membrane plus fibrin glue showed higher fixation stability than the trilayer prototype (all p < 0.05). No significant differences occurred between medial and lateral talar shoulder location (all p > 0.05). CONCLUSIONS: The fixation stability of the trilayer collagen prototype without fibrin glue is lower than of the clinically used bilayer membrane with fibrin glue in chondral defects at the medial and lateral talar shoulder in an experimental human specimen test. Clinical use of trilayer collagen prototype without fibrin glue has to be validated by clinical testing to evaluate if the lower stability of fixation is still sufficient.
Asunto(s)
Articulación del Tobillo/cirugía , Enfermedades de los Cartílagos/cirugía , Colágeno/farmacología , Adhesivo de Tejido de Fibrina/farmacología , Prótesis e Implantes , Articulación del Tobillo/diagnóstico por imagen , Articulación del Tobillo/fisiopatología , Cadáver , Enfermedades de los Cartílagos/fisiopatología , Femenino , Humanos , Masculino , Rango del Movimiento Articular , Astrágalo/diagnóstico por imagen , Astrágalo/cirugíaRESUMEN
BACKGROUND: The goal of this study was to analyze trends in Foot and Ankle surgery in Germany during the past ten years. METHODS: Data of the German Federal Statistical Office from 2008 until 2018 were screened. We focused on the analysis of fusions and total joint replacements. RESULTS: The total amount of the surgeries increased (+39.5%). Especially fusions like arthrodesis of the ankle (+31%) and of the MTP-1 joint (+77%) were on the rise. In 2017 60% of ankle arthrodesis were conducted in men, while 69% of MTP-1 arthrodesis were performed in women. The amount of joint replacements showed a decline during the last decade, in TAR (-39%) and in the MTP-1 (-48%). Regarding the patients age while undergoing a TAR, we observed a shift of the peak age group from 65 to 70 years in 2008 towards 55-60 years in 2017. CONCLUSION: Our study represents actual health care reality in Germany and shows a constant increase of ankle arthritis surgeries in the last decade, while there was a massive shift regarding the ratio of TAR in favour of fusion procedures.
Asunto(s)
Articulación del Tobillo/cirugía , Artritis/epidemiología , Artritis/cirugía , Artrodesis/tendencias , Artroplastia de Reemplazo de Tobillo/tendencias , Adulto , Anciano , Anciano de 80 o más Años , Tobillo/cirugía , Artrodesis/métodos , Artroplastia de Reemplazo de Tobillo/métodos , Femenino , Alemania/epidemiología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
Arthrodesis of the upper ankle and subtalar joint are still frequently used and at the moment the gold standard in the therapy of severe arthritis and deformity of the ankle joint and hindfoot. The spectrum of indications is wide, beginning from posttraumatic or degenerative changes to postinfectious, rheumatoid and diabetic causes of arthritis and as a salvage procedure after failed ankle arthroplasty. The types of arthrodesis have to be differentiated from each other: tibiotalar, subtalar and tibiotalcalcaneal fusion. Soft tissue conditions have to be taken into account; these and individual factors like comorbidities and osseous conditions require an individual planning of the approaches and types of fixation.
Asunto(s)
Artritis , Articulación Talocalcánea , Tobillo , Articulación del Tobillo/diagnóstico por imagen , Articulación del Tobillo/cirugía , Artrodesis , Humanos , Articulación Talocalcánea/diagnóstico por imagen , Articulación Talocalcánea/cirugíaRESUMEN
INTRODUCTION: Non-union is a regular complication of arthrodeses. Standard treatment includes revision surgery with frequent need for re-revision due to persistent non-union. Particularly patients with concomitant diseases are at risk of secondary complications. There is a need for evaluation of alternative treatment options. The aim of this study is to provide first evidence on union-rate and pain course after focussed extracorporeal shock-wave therapy of arthrodesis non-unions. PATIENTS AND METHODS: In a retrospective single-centre study, 25 patients with non-union following arthrodesis received one session of focussed extracorporeal shock-wave therapy (energy flux density 0.36 mJ/mm2, 3000 impulses, 23 kV, 4 Hz). Radiographic and clinical results were recorded 6, 12 and 24 weeks after treatment. RESULTS: 24 patients were followed-up. After 24 weeks arthrodeses of the hand healed in 80%, of the upper ankle in 50%, of subtalar joint in 27.2% and of the midfoot in 0% of the cases. Pain decreased from 4.8 (± 2.8) points on the visual analogue scale to 3.4 (± 2.3), 2.9 (± 2.5) and 2.4 (± 2.8) points after 6, 12 and 24 weeks, respectively (p < 0.0001). CONCLUSION: Our data indicate that the effect of focussed, high-energy shock wave therapy depends on body region and is effective for the treatment of non-unions of the hand as well as for pain relief. LEVEL OF EVIDENCE: Level IV.
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Artrodesis/efectos adversos , Tratamiento con Ondas de Choque Extracorpóreas , Complicaciones Posoperatorias/terapia , Articulaciones del Pie/fisiopatología , Articulaciones del Pie/cirugía , Articulaciones de la Mano/fisiopatología , Articulaciones de la Mano/cirugía , Humanos , Complicaciones Posoperatorias/fisiopatología , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Ankle fractures are the second most common fractures of the lower extremities. Nonetheless, no standardized treatment protocol for unstable ankle fractures of the elderly exists today. Choices to treat ankle fractures are debated controversially, including (1) conservative treatment, (2) open reduction and internal fixation (ORIF), and (3) primary hind-foot arthrodesis. This retrospective study aimed to examine the healing result in patients treated by ORIF after unstable ankle fractures. METHODS: The study was designed as a retrospective comparative series. The American Orthopaedic Foot and Ankle Society (AOFAS) score was followed to assess the postsurgical outcome. Data was obtained from 66 patients younger than 65 (median age, 42 years; range, 18-63) and 28 patients aged 65 or older (median age, 71 years; range, 65-81). The mean follow-up period for the younger-than-65 group was 48 months; for patients older than 65, it was 49 months. RESULTS: An AOFAS score of 86.4 in the older and 92.4 in the younger group was determined, p-value<0.05. Elderly patients suffered from significantly more open-ankle fractures and comorbidities than the younger group did, p-value<0.05 each. The duration of hospital stay and the time needed to reach sufficient self-mobilization were both significantly different between the two groups, p-value<0.05. CONCLUSION: ORIF treatment of ankle fractures resulted in good functional assessment after a mean follow-up of 49 months in the elderly. Pre-fracture health condition positively affected the healing results in younger patients. This study confirms the basic AO Foundation principles for good postsurgical results. LEVEL OF EVIDENCE: Level III, retrospective comparative series.
Asunto(s)
Fracturas de Tobillo/cirugía , Artrodesis , Fijación de Fractura , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Curación de Fractura , Humanos , Persona de Mediana Edad , Recuperación de la Función , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
INTRODUCTION: 3T MRI has become increasingly available for better imaging of interosseous ligaments, TFCC, and avascular necrosis compared with 1.5T MRI. This study assesses the sensitivity and specificity of 3T MRI compared with arthroscopy as the gold standard. PATIENTS AND METHODS: Eighteen patients were examined with 3T MRI using coronal T1-TSE; PD-FS; and coronal, sagittal, and axial contrast-enhanced T1-FFE-FS sequences. Two musculoskeletal radiologists evaluated the images independently. Patients underwent diagnostic arthroscopy. RESULTS: The classifications of the cartilage lesions showed good correlations with the arthroscopy findings (κ = 0.8-0.9). In contrast to the arthroscopy, cartilage of the distal carpal row was very good and could be evaluated in all patients on MRI. The sensitivity for the TFCC lesion was 83%, and the specificity was 42% (radiologist 1) and 63% (radiologist 2). For the ligament lesions, the sensitivity and specificity were 75 and 100%, respectively, with a high interobserver agreement (κ = 0.8-0.9). DISCUSSION: 3T MRI proved to be of good value in diagnosing cartilage lesions, especially in the distal carpal row, whereas wrist arthroscopy provided therapeutic options. When evaluating the surgical therapeutical options, 3T MRI is a good diagnostic tool for pre-operatively evaluating the cartilage of the distal carpal row.
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Artralgia , Artroscopía , Imagen por Resonancia Magnética , Traumatismos de la Muñeca , Muñeca , Artralgia/diagnóstico por imagen , Artralgia/cirugía , Humanos , Sensibilidad y Especificidad , Muñeca/diagnóstico por imagen , Muñeca/cirugía , Traumatismos de la Muñeca/diagnóstico por imagen , Traumatismos de la Muñeca/cirugíaRESUMEN
BACKGROUND: Although retrograde intramedullary nails for tibiotalocalcaneal arthrodesis (TTCA) are an established fixation method, few studies have evaluated the stability of the available nail systems. The purpose of this study was to compare biomechanically the primary stability of 2 nail-systems, A3 (Small Bone Innovations) and HAN (Synthes), in human cadavers and analyze the exact point of instability in TTCA by means of optical measurement. METHODS: In 6 pairs of lower legs (n = 12) of fresh-frozen human cadavers with osteoporotic bone structure, bone mineral density (BMD) was determined. Pairwise randomized implantation of either an HAN or A3 nail was executed. Performance and stability were measured by quasi-static tests using 3D motion tracking (NDI Optotrak-Certus) followed by cyclic loading tests during dorsi- and plantarflexion. RESULTS: 3D optical analysis in quasi-static tests showed a significantly lower degree of movement for the HAN nail in rotational and dorsi-/plantarflexion, especially in the subtalar joint. Cyclic loading tests were consistent with quasi-static tests. CONCLUSION: The A3 nail offered lower stability during axial torsion in the ankle and subtalar joints and during plantar- and dorsiflexion in the subtalar joint in osteoporotic bones. This study was the first to examine the primary stability of different arthrodesis nails in TTCA and their bony parts with a 3D motion analysis. CLINICAL RELEVANCE: The better stability of the locking-only HAN nail in this osteoporotic test setup could lead to more favorable results in comparison to the A3 nail in clinical use.
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Artrodesis/métodos , Densidad Ósea/fisiología , Calcáneo/cirugía , Fijación Intramedular de Fracturas/métodos , Articulación Talocalcánea/cirugía , Astrágalo/cirugía , Tibia/cirugía , Fenómenos Biomecánicos , Clavos Ortopédicos , Cadáver , Calcáneo/fisiología , Humanos , Astrágalo/fisiología , Tibia/fisiologíaRESUMEN
A fracture of the os peroneum is a rare cause of ankle and foot pain and is often overlooked and not assumed. Only a few case reports have discussed the different etiologies, options for diagnosis, and therapeutic interventions for acute cases. We present a case of delayed diagnosis of an os peroneum fracture due to a distortion of the ankle that occurred during air sports. Initial diagnostic testing with magnetic resonance imaging demonstrated a rupture of the peroneus longus tendon with no pathologic abnormalities at the peroneus brevis tendon. During surgery, a combination of an os peroneum fracture and a peroneus brevis tendon split was found and was successfully treated with bone and tendon repair using a lasso stich technique.
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Articulación del Tobillo/fisiopatología , Imagen por Resonancia Magnética/métodos , Procedimientos de Cirugía Plástica/métodos , Huesos Tarsianos/lesiones , Traumatismos de los Tendones/diagnóstico por imagen , Adulto , Dolor Crónico/diagnóstico , Dolor Crónico/etiología , Diagnóstico Tardío , Estudios de Seguimiento , Traumatismos de los Pies/diagnóstico por imagen , Traumatismos de los Pies/patología , Traumatismos de los Pies/cirugía , Fracturas Óseas/diagnóstico por imagen , Fracturas Óseas/cirugía , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Dimensión del Dolor , Rango del Movimiento Articular/fisiología , Recuperación de la Función , Medición de Riesgo , Rotura/diagnóstico por imagen , Rotura/cirugía , Traumatismos de los Tendones/complicaciones , Resultado del TratamientoRESUMEN
BACKGROUND: Tibiotalocalcaneal arthrodesis (TTCA) using intramedullary nails is a salvage procedure for many diseases in the ankle and subtalar joint. Despite "newly described intramedullary nails" with specific anatomical shapes there still remain major complications regarding this procedure. The following study presents a modified biomechanical test setup for investigations of the hindfoot. METHODS: Nine fresh-frozen specimens from below the human knee were anaysed using the Hindfoot Arthrodesis Nail (Synthes) instrument. Quasi-static biomechanical testing was performed for internal/external rotation, varus/valgus and dorsal/plantar flexion using a modified established setup (physiological load entrance point, sledge at lever arm to apply pure moments). Additionally, a 3D optical measurement system was added to allow determination of interbony movements. RESULTS: The mean torsional range of motion (ROM) calculated from the actuator data of a material testing machine was 10.12° (SD 0.6) compared to 10° (SD 2.83) as measured with the Optotrak® system (between tibia and calcaneus). The Optotrak showed 40 % more rotation in the talocrural joint. Mean varus/valgus ROM from the material testing flexion machine was seen to be 5.65° (SD 1.84) in comparison to 2.82° (SD 0.46) measured with the Optotrak. The subtalar joint showed a 70 % higher movement when compared to the talocrural joint. Mean ROM in the flexion test was 5.3° (SD 1.45) for the material testing machine and 2.1° (SD 0.39) for the Optotrak. The movement in the talocrural joint was 3 times higher compared to the subtalar joint. CONCLUSION: The modified test setup presented here for the hindfoot allows a physiological biomechanical loading. Moreover, a detailed characterisation of the bone-implant constructs is possible.
Asunto(s)
Articulación del Tobillo/fisiopatología , Artrodesis/instrumentación , Clavos Ortopédicos , Ensayo de Materiales/métodos , Rango del Movimiento Articular , Articulación Talocalcánea/fisiopatología , Anciano , Anciano de 80 o más Años , Articulación del Tobillo/cirugía , Artrodesis/efectos adversos , Artrodesis/métodos , Fenómenos Biomecánicos , Calcáneo/cirugía , Femenino , Pie/cirugía , Humanos , Imagenología Tridimensional , Masculino , Ensayo de Materiales/instrumentación , Rotación , Articulación Talocalcánea/cirugía , Astrágalo/cirugía , Tibia/cirugíaRESUMEN
INTRODUCTION: Ankle fractures are increasing in incidence. The more complicated the lesion is, the higher the risk of developing posttraumatic arthrosis. Severe posttraumatic arthrosis results in a reduced quality of life. Therefore, the treatment of a trimalleolar fractures is crucial. However, the treatment guidelines for posterior malleolar fractures (PMF) are still based on recommendations from 1940. Only a few retrospective studies have been conducted, which analysed patient outcomes based on lateral X-rays of the ankle. The purpose of this retrospective analysis was to survey patient outcomes in relation to the size of the PMF on the basis of CT-scans. METHODS: We retrospectively examined 42 patients with trimalleolar fractures with an average follow-up of 2.5 years. Twenty-four patients (57%) received a CT scan of the ankle joint. The radiologic images were analysed for the size of the PMF and the involvement of the joint surface using lateral X-rays and available CT images. We examined all 42 patients clinically and radiologically, and estimated the grade of arthrosis of the ankle in accordance with the Bargon Score and assigned AOFAS Scores for each patient. We divided our patients into different groups according to the size of their PMF and evaluated patient outcomes in accordance with the compiled data first on the basis of X-ray data and then on the basis of CT data. RESULTS: Comparing the measurement results by two different radiologic methods revealed that CT results in a more precise determination of PMF size in contrast to lateral X-rays, by which measurements were generally overrated. The statistical evaluation of our data demonstrated that patients with an osteosynthesis of the PMF and a PMF size of >25% showed signs of posttraumatic arthrosis but had better outcomes in accordance to the AOFAS score. All results were not significant. CONCLUSION: An exact evaluation of CT images of posterior malleolar fractures in patients with trimalleolar ankle fractures is crucial for the decision to perform an osteosynthesis of the PMF and, therefore, an analysis of patient outcomes. The results of previous studies should be evaluated cautiously due to missing CT data. To date, this is the largest retrospective patient series of patient outcomes based on CT data.
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Fracturas de Tobillo/patología , Fracturas de Tobillo/cirugía , Fijación Interna de Fracturas , Fracturas Intraarticulares/patología , Fracturas Intraarticulares/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Fracturas de Tobillo/diagnóstico por imagen , Fracturas de Tobillo/epidemiología , Femenino , Fijación Interna de Fracturas/métodos , Alemania/epidemiología , Humanos , Fracturas Intraarticulares/diagnóstico por imagen , Fracturas Intraarticulares/epidemiología , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
PURPOSE: To analyse the biomechanical characteristics of locking plates under cyclic loading compared to a nonlocking plate in a diaphyseal metacarpal fracture. METHODS: Oblique diaphyseal shaft fractures in porcine metacarpal bones were created in a biomechanical fracture model. An anatomical reduction and stabilization with a nonlocking and a comparable locking plate in mono- or bicortical screw fixation followed. Under cyclic loading, the displacement, and in subsequent load-to-failure tests, the maximum load and stiffness were measured. RESULTS: For the monocortical screw fixation of the locking plate, a similar displacement, maximum load, and stiffness could be demonstrated compared to the bicortical screw fixation of the nonlocking plate. CONCLUSIONS: Locking plates in monocortical configuration may function as a useful alternative to the currently common treatment with bicortical fixations. Thereby, irritation of the flexor tendons would be avoided without compromising the stability, thus enabling the necessary early functional rehabilitation.
Asunto(s)
Placas Óseas , Fracturas Óseas/fisiopatología , Fracturas Óseas/cirugía , Fenómenos Biomecánicos , Humanos , Estrés MecánicoRESUMEN
BACKGROUND: The aim of the study was to compare the initial construct stability of two retrograde intramedullary nail systems for tibiotalocalcaneal arthrodesis (TTCF) (A3, Small Bone Innovations; HAN, Synthes) in a biomechanical cadaver study. METHODS: Nine pairs of human cadaver bones were instrumented with two different retrograde nail systems. One tibia from each pair was randomized to either rod. The bone mineral density was determined via tomography to ensure the characteristics in each pair of tibiae were similar. All tests were performed in load-control. Displacements and forces were acquired by the sensors of the machine at a rate of 64Hz. Specimens were tested in a stepwise progression starting with six times ±125N with a frequency of 1Hz for 250cycles each step was performed (1500cycles). The maximum load was then increased to ±250N for another 14 steps or until specimen failure occurred (up to 3500cycles). RESULTS: Average bone mineral density was 67.4mgHA/ccm and did not differ significantly between groups (t-test, p=.28). Under cyclic loading, the range of motion (dorsiflexion/plantarflexion) at 250N was significantly lower for the HAN-group with 7.2±2.3mm compared to the A3-group with 11.8±2.9mm (t-test, p<0.01). Failure was registered for the HAN after 4571±1134cycles and after 2344±1195cycles for the A3 (t-test, p=.031). Bone mineral density significantly correlated with the number of cycles to failure in both groups (Spearman-Rho, r>.69, p<0.01). CONCLUSIONS: The high specimen age and low bone density simulates an osteoporotic bone situation. The HAN with only lateral distal bend but two calcaneal locking screws showed higher stability (higher number of cycles to failure and lower motion such as dorsiflexion/plantarflexion during cyclic loading) than the A3 with additional distal dorsal bend but only one calcaneal locking screw. Both constructs showed sufficient stability compared with earlier data from a similar test model. CLINICAL RELEVANCE: The data suggest that both implants allow for sufficient primary stability for TTCF in osteoporotic and consequently also in non-osteoporotic bone. LEVEL OF EVIDENCE: Not applicable, experimental basic science study.
Asunto(s)
Artrodesis/instrumentación , Inestabilidad de la Articulación/cirugía , Anciano , Anciano de 80 o más Años , Articulación del Tobillo/fisiopatología , Articulación del Tobillo/cirugía , Fenómenos Biomecánicos , Clavos Ortopédicos , Cadáver , Calcáneo/cirugía , Femenino , Humanos , Inestabilidad de la Articulación/fisiopatología , Masculino , Astrágalo/cirugía , Tibia/cirugíaRESUMEN
BACKGROUND: The acute ankle sprain is one of the most common injuries seen in trauma departments. Ankle sprains have an incidence of about one injury per 10 000 people a day. In contrast tarsal coalition is a rare condition occurring in not more than one percent of the population. CASE PRESENTATION: We present the case of a 23 year old male patient with pain and local swelling after an acute ankle sprain. Initial clinical and radiological examination showed no pathologies. Due to prolonged pain, swelling and the inability of the patient to weight bear one week after trauma further diagnostics was performed. Imaging studies (MRI and CT) revealed a fracture of a talocalcaneal coalition. To the knowledge of the authors no fracture of a coalition was reported so far. CONCLUSION: This report highlights the presentation of symptomatic coalitions following trauma and furthermore, it points out the difficulties in the diagnosis and treatment of a rare entity after a common injury. A diagnostic algorithm has been developed to ensure not to miss a severe injury.
Asunto(s)
Traumatismos del Tobillo/diagnóstico , Dolor/diagnóstico , Esguinces y Distensiones/diagnóstico , Articulación Talocalcánea/lesiones , Traumatismos del Tobillo/complicaciones , Diagnóstico Diferencial , Humanos , Masculino , Dolor/etiología , Esguinces y Distensiones/complicaciones , Articulación Talocalcánea/patología , Adulto JovenRESUMEN
BACKGROUND: Complicated tibial fractures with severe soft tissue trauma are challenging to treat. Frequently associated acute compartment syndrome can result in scarring of muscles with impaired function. Several studies have shown a relationship between angiogenesis and more effective muscle regeneration. Vascular endothelial growth factor (VEGF) is associated with angiogenesis but it is not clear whether it would restore muscle force, reduce scarring, and aid in muscle regeneration after acute musculoskeletal trauma. QUESTIONS/PURPOSES: Therefore, we asked whether local application of VEGF (1) restores muscle force, (2) reduces scar tissue formation, and (3) regenerates muscle tissue. METHODS: We generated acute soft tissue trauma with increased compartment pressure in 22 rabbits and shortened the limbs to simulate fracture débridement. In the test group (n = 11), a VEGF-coated collagen matrix was applied locally around the osteotomy site. After 10 days of limb shortening, gradual distraction of 0.5 mm per 12 hours was performed to restore the original length. Muscle force was measured before trauma and on every fifth day after trauma. Forty days after shortening we euthanized the animals and histologically determined the percentage of connective and muscle tissue. RESULTS: Recovery of preinjury muscle strength was greater in the VEGF group (2.4 N; 73%) when compared with the control (1.8 N; 53%) with less connective and more muscle tissue in the VEGF group. The recovery of force was related to the percentage of connective tissue versus muscle fibers. CONCLUSIONS: Local application of VEGF may improve restoration of muscle force by reducing connective tissue and increasing the relative amount of muscle fibers. CLINICAL RELEVANCE: VEGF may be useful to improve skeletal muscle repair by modulating muscle tissue regeneration and fibrosis reduction after acute trauma.