Minimal invasive plating of distal radius fractures. A safe procedure?

BACKGROUND: Minimal invasive plate osteosynthesis (MIPO) with preservation of the pronator quadratus (PQ) muscle represents a new technique for stabilization of distal radius fractures. However, the complex anatomy of the distal radius metaphysis requires implants with features that address all morphologic specifics of this area to avoid complications, which are still reported with this technique. It was the aim of our anatomic investigation to evaluate the feasibility of plate insertion via a minimal transverse approach as well as the risk of soft- tissues compromise with the use of an implant, which is only partially adapted to the characteristics of distal radius metaphysis. METHODS: Twenty forearm specimens, conservated with Thiels method, have been used for this study. The majority (n = 19/20) of implants (2.4 mm small fragment juxta-articular locking compression/ LCP T-plate -5-hole; Depuy - Synthes®, Solothurn, Switzerland) could be inserted easily and all were seated proximal to the so called "watershed line" (n = 20/20). RESULTS: In a total of 8/20 specimens close contacts or potential compromise to neighboring soft- tissues was seen: perforation of the PQ muscle by the plate occurred in 2/20 specimens and was related to an extreme muscle morphology. In 7/20 specimens close contacts between the T-plate and other soft tissues were observed, which were exclusively located at the radial edge of the distal transverse bar. They affected the brachio-radialis tendon (elevation: 2/20, side-to-side contact: 3/20, overriding: 1/20) and the radial artery (elevation: 4/20, side-to-side contact: 2/20, overriding: 1/20). No significant differences of morphologic types of PQ muscle and the difficulty of plate insertion, adjustment on the bone, PQ muscle damage and contact to neighboring soft-tissues could be evaluated. CONCLUSIONS: Insertion of volar radius plates through a MIPO approach can be easily accomplished without detachment and damage to the PQ muscle even with grossly adapted implants. However, perfectly pre-shaped plates which are adapted to all anatomic aspects of the distal radius metaphysis are required to achieve optimal contact with the metaphyseal bone and to avoid potential complications.

Diagnostic parameters in periprosthetic infections: the current state of the literature.

Despite progress in recent years, a definitive diagnosis of PPI is not yet possible. Due to new diagnostic possibilities and the further development of already existing diagnostic tools, a more accurate diagnostic clarification of uncertain cases should be possible. The following article includes an overview of common existing diagnostic tools and instruments, which will likely gain importance in the future.

Reverse shoulder arthroplasty combined with latissimus dorsi transfer: A systemic review.

Reverse shoulder arthroplasty (RSA) combined with latissimus dorsi transfer (LDT) is described for patients with cuff arthropathy and a combined loss of abduction and external rotation. The purpose of this systemic review was to present clinical and radiological outcomes following RSA combined with LDT. A comprehensive literature review was performed to identify studies reporting clinical and radiological results of RSA combined with LDT. Seven articles that describe the treatment of 116 patients were selected. Functional scores, range of motion, radiological outcome, complications, rehabilitation regime, surgical technique, patient demographics and indication were analyzed and discussed. All studies reported significant improvement in functional scores and abduction and external rotation. Complications occurred in 26% of patients. Although high-level studies are lacking, this systemic review shows that RSA combined with LDT is a reliable surgical method with which to treat patients with loss of active abduction and loss of external rotation. The available data are insufficient to draw conclusions regarding the long-term outcomes of this procedure. LEVEL OF EVIDENCE: IV.

Impact of Sagittal Balance on Clinical Outcomes in Surgically Treated T12 and L1 Burst Fractures: Analysis of Long-Term Outcomes after Posterior-Only and Combined Posteroanterior Treatment.

Objective. Long-term radiological and clinical outcome retrospective study of surgical treatment for T12 and L1 burst fractures in perspective of sagittal balance measures. Methods. Patients with age of 16-60 years, complete radiographs, early surgical treatment surgery, and follow-up (F/U) > 18 months were included and strict exclusion criteria applied. Regional and thoracolumbar kyphosis angles (RKA and TLA) were measured preoperatively and at final F/U, as were parameters of the spinopelvic sagittal alignment. Clinical outcomes were assessed using validated measures. Results. 36 patients with age mean age of 39 years and F/U of 69 months were included. 61% of patients were treated with bisegmental posterior instrumentation (POST-I) and 39% with combined posteroanterior instrumented fusion (PA-F). At F/U, several indicators for clinical outcomes showed a significant correlation with radiographic measures in the overall cohort with inferior clinical outcomes corresponding with increasing residual deformity and sagittal malalignment. Statistical analysis failed to reach level of significance for the differences between POST-I and PA-F group at final F/U. Only a strong trend towards better restoration of the thoracolumbar alignment was observed for the PA-F group in terms of the RKA and TLA. Conclusions. Results in a surgically treated cohort of T12 and L1 burst fracture patients indicate that superior clinical outcomes depend on restoration of sagittal alignment.

Long-term outcome following upper extremity replantation after major traumatic amputation.

BACKGROUND: Amputations in general and amputations of upper extremities, in particular, have a major impact on patients' lives. There are only a few long-term follow-up reports of patients after macro-replantation. We present our findings in contrast with the existing literature. METHODS: Sixteen patients with traumatic macro-amputation of an upper extremity were eligible for inclusion in this study. Altogether, the patients underwent replantation in 3 institutions between 1983 and 2011. RESULTS: Twelve male and four female patients with an average age at injury of 40.6 years (range, 14-61 years) were included in this study. The mean follow-up period was 13.5 years (range, 4.4-32.6 years; SD, 5.7 years). The mean disabilities of the arm, shoulder and hand (DASH) outcome measure was 41 (range, 5.2-94.8; SD, 18.2), functional independence measurement (FIM) was 125 (range, 120-126; SD, 1.8). Chen I representing very good function was accounted in six, Chen II representing good function in eight, Chen III (fair) in one and Chen IV (bad function) in one patient. CONCLUSIONS: We found that while the majority of the included patients exhibited good or very good function of the extremity, none of the replanted appendages regained normal levels of functionality. In addition, all participants were very satisfied with their outcomes. Positive long-term results with high rates of subjective satisfaction are possible after replantation of upper extremities.

[Minimally invasive treatment of intra-articular calcaneal fractures with the 2­point distractor]. / Minimal-invasive Versorgung intraartikulärer Fersenbeinfrakturen mit dem 2­Punkt-Distraktor.

OBJECTIVE: Open treatment of calcaneus fractures often has an increased risk of wound healing. Minimally invasive treatment with small incisions reduces complications. INDICATIONS: Calcaneal fractures with malalignment/comminution >1-2 mm; broadening, varus alignment of the calcaneal length axis or shortening; emergency surgery for open fractures or compartment syndrome. CONTRAINDICATIONS: Local or general contraindications. SURGICAL TECHNIQUE: Standardised positioning; restoration of length/axis with 2­point distractor under fluoroscopic control. Fragment reduction via small incisions. Fixation with 7.3 mm cannulated screws and 4.0 mm sustentaculum screws. POSTOPERATIVE MANAGEMENT: Cast-free and no weight bearing for 6 weeks; then weight bearing in a heel off-loading shoe for another 6 weeks with physiotherapy; if needed postoperative cast until soft tissue consolidation. RESULTS: Of 212 calcaneal fractures, 182 were treated with this technique. Wound healing complication rate was 2.7%; 4.7% of patients required secondary arthrodesis of the subtalar joint.

[Pre-requisites, observations and benefits of the DGU trauma registry in Austria]. / Voraussetzungen, Erfahrungen und Nutzen des Traumaregisters der DGU in Österreich.

The trauma registry of the DGU was founded in 1992 with the objective of collecting data on severely injured patients. The purpose of this registry, in which Austrian trauma units have taken part since 1998, is to answer questions related to the field of trauma management. Using the example of the Linz Trauma Center (UKH Linz), which has actively participated since 2012, the authors would like to share their experiences of collecting data in order to motivate other departments to participate in the trauma registry. We would like to make suggestions regarding implementation methods for high-quality data acquisition.However, the availability of essential human resources must be guaranteed, since the recording of data from severely injured patients sometimes takes 60-90 min. Additionally, an automatic data acquisition method is currently unavailable for technical reasons.

[Posttraumatic arthrosis of the glenohumeral joint. From partial resurfacing to reverse shoulder arthroplasty]. / Posttraumatische Arthrose des Glenohumeralgelenks. Von der Teil- bis zur inversen Prothese.

BACKGROUND: Arthroplasty of symptomatic sequelae after fractures of the proximal humerus is a demanding procedure for surgeons. Exact preoperative planning is crucial in order to achieve acceptable functional results. OBJECTIVE: Discussion of preoperative considerations in planning the procedure and choosing the appropriate implant taking the osseous anatomy and surrounding soft tissue situation into consideration. METHODS: Selective literature review and description of personal experience. RESULTS: The geometry and consolidation status of bone fragments as well as the conditions of the surrounding soft tissue have to be taken into account and influence the choice of implant used. Insufficient planning will not only cause intraoperative technical problems but can also greatly influence the subjective patient assessment of the postoperative outcome. Unequal strain distribution can cause early loosening of components resulting in malfunctioning of the implant. In this respect, knowledge of the position and consolidation status of fractured tuberosities with respect to the humeral shaft is essential and allows an approximate estimation of the achievable outcome. This is taken into account by the classification of Boileau which can also help to decide on which type of implant to use. Because such cases are scarce, reported results in the literature are heterogeneous, which is discussed in this article. CONCLUSION: Each case needs a thorough and individualized preoperative assessment along with exact planning and should therefore be reserved for experienced shoulder surgeons only.

[Complications in reverse shoulder arthroplasty - causes, prevention and treatment options]. / Komplikationen nach inversen Schulterprothesen - Ursache, Prävention und Behandlungsstrategien.

After introduction of the reverse shoulder prosthesis in the 1970 s, clinical outcome was poor. This was mostly caused by the constraint design and the lateralised centre of rotation, which caused shear forces and glenoid failure. In the 1980 s the centre of rotation was medialised and caudalised, a larger glenosphere and a neck/shaft angle of 155° were used. The clinical outcome data became better and the reverse shoulder prosthesis established as a treatment option. Initially used for symptomatic glenohumeral arthritis in combination with severe rotator cuff pathologies, the indications have been expanded. In spite of its great popularity, the reverse shoulder prosthesis is associated with higher complication rates than anatomic shoulder arthroplasties. Typical complications include scapular notching, baseplate failure, periprosthetic fractures, scapular fractures, infections, haematoma, instability and nerve leasions. Only few publications provide prevention or treatment strategies.