[Is the static external fixator a suitable method in the treatment of multi-fragmented fractures of the distal radius?]. / Ist der statische Fixateur externe eine geeignete Methode zur Behandlung von Mehrfragmentfrakturen des distalen Speichenendes?

We present a retrospective study of 21 patients treated with an external fixator for comminuted fractures of the distal radius from May 1993 until May 1994. Mean follow-up was 14.5 months after operation. The 21 patients were on average 59 years old. The distal radius fractures were classified according to the AO: Type A2 (four times), Type A3 (two times), Type C1 (one time), C2 (nine times), C3 (five times). We mounted the external fixator generally in a static way. After two weeks it was dynamized. The fixator was removed after four to at least six weeks. An additional osteosynthesis with Kirschner wires was performed in twenty cases. Three times we added a primary cancellous bone graft, in one case an implantation of Endobone was used.

The tendon defect after anterior cruciate ligament reconstruction using the midthird patellar tendon--a problem for the patellofemoral joint?

Retrospective clinical and radiographic evaluation was performed on 41 patients seen at the Salzburg General Hospital Department of Traumatology on average 2 years following ACL reconstruction. In 26 patients (61%) clinical examination revealed pain trigger points over the donor site of the midthird patellar tendon and in the patellofemoral joint. Functional pain during kneeling activities was observed in 19 patients (46%). Objective measurement of the length of the patellar tendon in bilateral radiographs demonstrated exactly equal patellar tendon length in both knees in 11 patients (27%). The radiographs showed tendon shortening following harvesting of the midthird patellar tendon by 1-3 mm in 7 patients (17%), by 4-6 mm in 16 (39%), and by 6-9 mm in 7 (17%). Average length change in the patellar tendon on the donor side was -3 mm, representing a patellar tendon shortening of 9.8%. On the basis of the OAK score, however, good and very good results were recorded in 33 patients (80%). On the whole, these good overall results were compromised only be patellar tendon defect morbidity. In addition to the local scarring problems at the donor site, shortening of the patellar tendon was observed with changes to patella position and interference with the mechanics of the patellofemoral joint. Tendon shortening can be explained on the basis of cicatricial contraction in the process of autorepair to the tendon defect. The problems affecting the patellofemoral joint are inherent in the therapy and must be treated as a negative factor. In the case of patients whose work requires mainly a kneeling position and those who make significant functional demands of the extension system of the knee, a critical assessment is required of the use of the midthird patellar tendon for anterior cruciate ligament reconstruction.

[Spontaneous tendon ruptures. Etiology, pathogenesis and therapy]. / Spontane Sehnenrupturen. Atiologie, Pathogenese und Therapie.

Spontaneous tendon ruptures are ascribed to recurrent microtrauma resulting from continuous mechanical loading in a critical zone, to muscular imbalance combined with poor coordination as a result of inappropriate training, and also to deteriorating circulation with increasing age. Ruptures of the rotator cuff occur more frequently with increasing age, and the size of the rupture also correlates with age. The frequency of the complaint in men, the predominant involvement of the dominant shoulder, and also the above-average occurrence in occupations involving strenuous physical work indicate that degenerative change plays a role. In about 50% of patients presenting with a ruptured rotator cuff, the genesis is clearly traumatic. A trauma will almost always be the cause of an isolated rupture of the subscapularis tendon. The choice of reconstruction technique for a ruptured rotator cuff depends on the patient's age and level of activity in daily life. In the case of young patients, further surgical measures to repair the defect are indicated following failure of primary suture of the tendon, but in older patients subacromial debridement alone is considered the appropriate procedure. Rupture of the long head of the biceps tendon is usually a sequela of a rotator cuff rupture and the resulting loss of protective cover. Isolated ruptures of the long head of the biceps tendon are much rarer. They tend to occur in middle-aged patients and are usually the result of a relatively minor trauma. Ruptures of the distal biceps tendon are also relatively rare (3%) and are always of traumatic origin. There is no absolute indication for surgical intervention for a ruptured long head of the biceps tendon. Surgical repair is essential in the case of rupture of the distal biceps tendon. Transosseous reinsertion at the tuberosity of the radius is the recommended method of repair. Today's frequent cases of rupture of the Achilles tendon in the framework of sports activities are ascribed to inappropriate training procedures in combination with poor muscular coordination. An exogenous cause is the administration of local injections for pain relief in the form of a so-called tendon anesthetic. Today an increasingly important role is assigned to functional therapy with ultrasound support, although suturing the tendon is still the intervention of choice to meet the high functional demands imposed in the framework of top-level sports.(ABSTRACT TRUNCATED AT 400 WORDS)

[Primary humerus head replacement in dislocated proximal humeral fracture. Indications, technique, results]. / Primärer Kopfersatz der dislozierten Oberarmkopffraktur. Indikation, Technik, Ergebnisse.

Displaced three- and four-part fractures of the humeral head detached from their blood supply are at high risk for a poor functional outcome after internal fixation. Primary prosthetic replacement can restore the pretraumatic anatomy, and early function is possible. Head replacement within 2 weeks after trauma, reapproximation of the tuberosities, and reconstruction of the rotator cuff tear establishes early stability and good functional results in up to 80%.

[Dorsal fixation of the thoracic and lumbar spine with grooved plates in combination with the Universal Spine Instrumentation System. A short stretch, angle-stable alternative]. / Dorsale Instrumentierung der Brust- und Lendenwirbelsäule durch Kerbenplatten in Kombination mit USIS. Eine kurzstreckige, winkelstabile Alternative.

In the Department of Surgery in the University Hospital "Bergmannsheil" in Bochum, 67 patients with unstable injuries of the thoracic and lumbar spine were analyzed in a retrospective study. The sagittal correction loss was greatest about 6 months after dorsal stabilization--6 degrees on the average--after stabilization with a plate alone. The correction loss after stabilization with plates combined with the Universal Spine Instrumentation System (USIS), which was developed for ventral derotational spondylodesis or after implantation of an internal fixation device, however, amounted to 3 degrees on the average. The clinical results show that by combining the plate and USIS the injuries can be stabilized for short stretches and without correction loss. The main advantage of this combination over internal fixation is the smaller amount of metal used, which means the soft tissue in loss compromised and there is a possibility of fitting the implant more directly. In 10 patients (15%) the implants broke at the place of maximum shear stress between 4 and 8 months postoperatively after consolidation of the fracture and without spoiling the result. This occurred equally often with all types of implants. Efficient use of the three systems is discussed with regard to the different pathomechanical modes of injury. A causative scheme of treatment is presented.

[Axis-related spontaneous correction after tibial fractures in childhood]. / Achsenbezogenes Spontankorrekturverhalten nach Unterschenkelbrüchen im Kindesalter.

In the Department of Surgery at the Bergmannsheil University Hospital, a total of 50 children with measurable post-traumatic deformity of the axis after fracture of the lower limb were examined. Clinical and radiological monitoring was carried out 6 years after their accidents, which they had sustained at the age of 3-15 years. The real degree of axis deformity remaining was determined mathematically, and the correction tendency was analysed in three dimensions and projected graphically using sum vectors. This showed better results in the correction of axis deformations of the lower limb visualized on a-p X-ray photographs as varus or valgus than of deformations seen as ante- and recurvation of lateral X-ray photographs. The excentric arrangement of muscles in the dorsal part of the lower limb could be one reason for this. All 50 patients experienced a reliable spontaneous correction of the axis deformity with no complications of stimulatory growth disturbance with showing good functional results. Shaft fractures of the lower limb in children are generally treated conservatively, operative treatment being indicated only in the case of severe lesions of the soft tissue and in adolescent patients.

[Increasing compartment pressure in tibial intramedullary nailing. A phenomenon inherent in the therapy?]. / Die Logendruckerhöhung bei Unterschenkelmarknagelung. Ein therapieimmanentes Phänomen?

At the Department of Surgery of the Bergmannsheil Hospital, a total of 58 patients treated with intramedullary nailing were reviewed with reference to the condition of the soft tissue. During intra- and postoperative treatment a bilateral fasciotomy was required in 8 patients. The subfascial pressure in the deep flexor compartment measured in 11 patients during secondary closed placement of intramedullary nails showed a slight increase of pressure in the deep flexor compartment from 8 mmHg to 40 mmHg after extension of the leg positioned on the operating table. After reduction the pressure increased significantly, from 50 mmHg to 80 mmHg. The postoperative pressure measured after 20 min was less than 50 mmHg in 9 patients. In 2 patients with manifest compartment syndrome (compartment pressure greater than 50 mmHg) immediate fasciotomy was required. Besides commonly known traumatic effects, parameters inherent in the therapy caused an increase in compartment pressure were critically reviewed with reference to their clinical relevance. The reasons for an increase in compartment pressure during closed placement of intramedullary nails in the lower leg are high position of the leg (hydrostatic effect), stretching of the soft tissue by reduction (decrease of volume), and possibly hematoma with outflow into the deep flexor compartment (increase of content).

[Arthrolysis of post-traumatic stiff elbow. Which factors influence the end result]. / Die Arthrolyse posttraumatischer Ellenbogensteifen. Welche Faktoren beeinflussen das Endergebnis?

In a retrospective study of 59 patients the results obtained with elbow arthrolysis performed for the treatment of posttraumatic stiffness were analyzed. The intraoperative functional result was classified as excellent in all cases, while an average of 27 months after the operation the range of movement was decreased again to varying extents. This deficit correlated with the type of injury, timing of arthrolysis, duration of metal implants and timing and type of postoperative rehabilitation program. The relative increase in function was better after simple fractures, with 47%, than after fracture dislocations, with 35%. After arthrolysis within 3 months of onset of posttraumatic stiffness the range of improvement was 55%, compared with an increase of only 30% after 10 months' stiffness. When arthrolysis was combined with metal removal and the implants had been in place for longer than 9 months the increase achieved was only 15%. Patients mobilized on the 1st day postoperatively lost only 15% of their intraoperative function. If mobilization was delayed to between the 2nd and 5th days, 30% was lost. Changing splints for maximal joint flexion and extension at 4-h intervals resulted in a 35% loss of range of movement postoperatively. In contrast there was a loss of only 17% in the group with combined additional physiotherapy and continuous passive motion. The results show that the prognosis of elbow arthrolysis is determined by optimal operative planning and a meticulous rehabilitation program. The time to arthrolysis should be as short as possible, as should the time to removal of metal implants. The aim of the rehabilitation program is immediate postoperative mobilization.(ABSTRACT TRUNCATED AT 250 WORDS)

[Fixation or screws in arthrodeses of the upper ankle joint. A retrospective comparison of 76 patients]. / Fixateur oder Schraube bei Arthrodesen am oberen Sprunggelenk. Ein retrospektiver Vergleich bei 76 Patienten.

In a retrospective study, the results of 76 patients treated by different methods for arthrodesis of the ankle joint were compared. With external-compression clamps, solid fusion was achieved in 48 patients after an average of 4.5 months, with lag-screw fixation in 25 patients after 3 months. The nonunion rate was only 4% in the group with external clamps, the followup time was 2 years (maximum 6 years, minimum 6 months). Eighty percent of the patients reported pain relief, 58% in the lag-screw reported being free of symptoms, 23% as did of the external-clamps group. Most of the complications after external fixation were related to pin-site infections (48%). Infection, instability and inability to undergo physiotherapy were the main problems after clamps. Arthrodesis with lag screws provides optimal biomechanical fixation, with early functional treatment and a fusion within 3 months. Compared to external clamps arthrodesis, the lag-screw group had fewer problems with skin and bone healing and could be discharged earlier.

[Calculation of the true angle in malposition of the skeletal system using electronic data processing. Retrospective study of 53 axis deviations in healed femoral fractures]. / Die Berechnung des wahren Winkels bei Fehlstellungen des Skelettsystems mit elektronischer Datenverarbeitung. Retrospektive Studie von 53 mit Achsenfehlstellung geheilten kindlichen Oberschenkelschaftbrüchen.

Under standard conditions deformations in the skeletal system are diagnosed by two X-ray photographs whose planes of projection form a right angle. The degree of deviation from the axis is measured directly on the X-ray photograph with a protractor. The analysis of the position of the axis of a tabular bone is carried out by determining the varus/valgus or ante/recurvation deformities resp. in the a.-p. and lateral rays. The degree of deformation is expressed through the supplementary angle. We asked ourselves whether a diagnostic procedure using X-rays taken in two planes is suitable for substantiating the evidence of a deformation of the axis. Example: If a fracture of the lower leg shows a varus deformity of 20 degrees in the a.-p. and a normal position of the axis in the lateral photograph, the actual angle is 20 degrees. This situation is an expection in that most cases the defect of the axis is a so-called combined defect (dislocation from the axis in both planes). In this case it can maintained that the measurable angle of deviation in the a. -p. and lateral X-ray photographs is smaller than the angle that is actually included by both fragments. We call this angle true angle. If you think of a fractured tubular bone as a cylinder it can be shown in a diagram that its deformation can only occur in one plane (Figure 1). Only from the perspective of a ray falling vertically on the curve k we would be able to determine the true angle directly from the photograph with a protractor.(ABSTRACT TRUNCATED AT 250 WORDS)