[Comparison of open versus percutaneous treatment for humeral head fracture]. / Vergleich der offenen vs. perkutanen Versorgung der Oberarmkopffraktur.

BACKGROUND: The hypothesis of this study was that percutaneous techniques lower the risk of post-traumatic avascular necrosis. MATERIALS AND METHODS: In this retrospective study 83 patients were followed up clinically and radiologically for signs of avascular necrosis and nonunion after open or percutaneous treatment of proximal humerus fractures. Mean age was 50 years. Fractures were classified in 22 patients (26.5%) as two part, in 21 patients (25.3%) as three part, in 39 patients (47%) as four part, and in 1 patient (1.2%) as fracture dislocation (Neer classification). Fractures were treated in 12 patients (14.5%) by ORIF (open reduction and internal fixation) and in 71 patients (85.5%) by CRPF (closed reduction and percutaneous fixation). Both groups were statistically equally distributed according to fracture type (Mann-Whitney U, p=0.267) and age (One-way-Annova, p=0.740). The postoperative regime did not differ between the two groups. RESULTS: Patients suffered significantly more avascular necrosis after open treatment [five patients (50%) versus eight patients (12.7%) in the percutaneous group, Mann-Whitney, p=0.004]. The risk for avascular necrosis and nonunion increased with age. Mean age of patients with avascular necrosis was 57 years, and the age of patients with nonunion was 67 years. CONCLUSION: Percutaneous treatment of humeral head fractures seems to be a reliable method for lowering the risk of avascular necrosis in young patients.

[Tibial growth after isolated femoral shaft fracture in the growth stage]. / Das Tibiawachstum nach isolierter Femurschaftfraktur im Wachstumsalter.

The aim of the present study is to investigate the growth of the tibia after femoral shaft fractures in children. We were able to follow up 44 patients (32 male and 12 female) after a mean of 8 years (range, 5 to 15 years). The age in the time of injury was 3 till 13 years (mean 7 years). The length of the femur, tibia and leg was measured on X-rays of the entire leg, and the measurements were compared with the contralateral side. A statistically significant number of tibial elongations were observed in fractures that had healed in considerable malalignment (at least 1 cm shortening, dislocation of at least a half of the breadth of the femoral shaft, angular deformity of more than 10 degrees) (p = 0.003) and in fractures that were subjected to manipulation (secondary reduction, change of treatment or traction weight) during the healing process (p = 0.007). Furthermore, all 7 patients who had infection requiring treatment at the tibial plateau extension had more pronounced tibial growth. No significant difference was found between tibial growth and the age of the child at the time of injury, the type of fracture, the location of fracture and the mode of treatment. The following factors were evaluated as being clinically relevant: primary, largely anatomic reduction, avoidance of secondary manipulation and prevention of infection at the tibial plateau extension.

[Arthroscopic extra-articular Bankart procedure]. / Die arthroskopische extraartikuläre Bankart-Operation.

The arthroscopic extraarticular Bankart procedure tries to imitate the open Bankart procedure. An anterior-inferior transmuscular approach through the subscapular muscle permits to implant self-locking tacks into the anterior inferior third of the glenoid rim. The extraarticular location of the implants makes a superomedial capsular shift possible, if required. A total of 257 arthroscopic repairs following traumatic recurrent anterior shoulder dislocation have been carried out between 1992 and 1996. 177 patients were treated only with bioabsorbable Suretac device. Clinical and radiological follow up was possible in 165 patients. According to the Rowe score 69.7% were classified as excellent, 10.9% as good, 9.7% fair and 9.7% poor. Postoperative complications: the recurrence rate was 9.7%, allergic reactions representing a foreign body reaction to the synthetic material were seen in 5 cases (3%) and a frozen shoulder in 6 cases 3.6%). 61% of the patients involved in overhead or contact sports returned to their preoperative sport activities.

[Post-traumatic ischemia of the talus. Is talus necrosis unavoidable?]. / Die posttraumatische Durchblutungsstörung des Talus. Ist die Talusnekrose obligat?

50 patients following talar fractures type Marti 2, 3 and 4 during the years 1972-1993, could be analysed retrospectively. Evaluated factors effecting posttraumatic avascular necrosis of the body of the talus are: type of fracture, age of the patient, additional fracture of the medial malleolus and time of non weight bearing. The Hawkins sign is reliable to show vitality in the body of the talus. We could see vascular impairment in 51% of all Marti 3 fractures and in 100% of all Marti 4 fractures. Patients with a concomitant fracture of the inner malleolus showed positive influence on the blood supply of the talus. In this case the ligamentum deltoideum and the ramus deltoideus of the arteria tibialis posterior remained intact. In addition to this the prognosis was better in young patients. A long period of non weight bearing could not preserve vitality of the talus. Necrosis of the talus did only appear in 34% of the Marti 3 and in 51% of the Marti 4 fractures. This means that early anatomic reconstruction of the talus is necessary. Primary arthrodesis of the ankle joint and talectomie are not up to date.

The arthroscopic extraarticular Bankart repair.

The arthroscopic extraarticular Bankart procedure tries to imitate the open Bankart procedure. An anterior-inferior transmuscular approach through the subscapular muscle permits to implant self-locking tacks into the anterior inferior third of the glenoid rim. The extraarticular location of the implants makes a superomedial capsular shift possible, if required. A total of 257 arthroscopic repairs following traumatic recurrent anterior shoulder dislocation have been carried out between 1992 and 1996. 177 patients were treated only with bioabsorbable Suretac device. Clinical and radiological follow up was possible in 165 patients. According to the Rowe score 69,7 % were classified as excellent, 10,9 % as good, 9,7 % fair and 9,7 % poor. Postoperative complications: the recurrence rate was 9,7 %, allergic reactions representing a foreign body reaction to the synthetic material were seen in 5 cases (3 %) and a frozen shoulder in 6 cases 3,6 %). 61 % of the patients involved in overhead or contact sports returned to their preoperative sport activities.

Arthroscopic extra-articular Bankart repair for the treatment of recurrent anterior shoulder dislocation.

This study describes a new arthroscopic procedure for the stabilization of recurrent anterior shoulder dislocations. The technique involves two important features. The first is the anterior inferior transmuscular approach through the subscapularis muscle, which permits self-locking implants to be inserted into the anterior inferior third of the glenoid rim so that they oppose the direction of pull of the capsule. This approach was studied on 79 cadaveric shoulders before clinical application. The second feature is the extracapsular (extra-articular) location of the self-locking implants, which permits a superomedial capsular shift as required. The technique offers a high degree of capsular stability. Of a total of 318 patients undergoing this procedure, the first 100 shoulders (98 patients) were evaluated postoperatively at an average of 35 months (range, 18 to 62 months). The diagnosis in all cases was traumatic recurrent anterior shoulder dislocation. Repair of the capsule was performed initially with screws and later with absorbable tacks. The overall recurrence rate was 9% (9 shoulders). Excluding the first 30 shoulders to take account of the learning curve, the recurrence rate for the subsequent 70 shoulders was only 5.7%. Limitation of external rotation at 0 degrees abduction averaged 6.7 degrees and 6.1 degrees at 90 degrees abduction for all shoulders; 61% of participants in overhead sports and 70% of participants in contact sports resumed their preinjury activities. The recurrence rate for patients involved in overhead sports was 10% and for collision sports it was 14%. There were no recurrences in the case of patients whose sports involve minimum risk to the shoulder (cycling, jogging). Most recurrences were observed in patients with lax shoulders and small Bankart lesions.

[Ultrasound diagnosis of the shoulder]. / Sonographie der Schulter.

Sonography of the shoulder joint is a well-established technique in the hands of the experienced examiner, when using a standardized protocol. It has proved invaluable in assessing pathological soft tissue changes, especially after trauma. The static evaluation of anatomy and dynamic assessment of function are especially helpful in both preoperative staging and postoperative follow-up. The normal anatomy, examination techniques, including our own variations, and pathological conditions are discussed. The findings and various classifications of impingement syndrome, rotator cuff injuries, biceps tendon lesions and inflammatory changes are examined. Review of the major articles in the literature shows excellent correlation with our results, the overall sensitivity in the case of rotator cuff lesions being over 90%. A well-performed ultrasound examination in most cases obviates the need for the more invasive arthroscopy and the more cumbersome and expensive MRI examinations.

[Arthroscopic replacement of the anterior cruciate ligament with a double semitendinosus tendon]. / Der arthroskopische vordere Kreuzbandersatz mit der gedoppelten Semitendinosussehne.

At the university hospital of emergency surgery in Innsburck and at the emergency services department of the hospital in Schwaz, anterior cruciate ligament reconstruction was performed in 467 patients between January 1992 and September 1993. In 117 cases, a double semitendinous tendon was used as an autograft. A total of 60 of these patients were followed up at an average of 20 months (13-33) after reconstruction. The results were rated according to the OAK and the Tegner scores. Objective measurements of instability were carried out by a KT 1000 arthrometer. In addition, 21 patients underwent computer-interfaced dynamometer testing using a Cybex 6000. Standardized loading of the thigh muscles was performed at angular velocities of 60 degrees/s (3 repetitions) and 240 degrees/s (30 repetitions): peak torques and total work were analyzed. The mean age was 23.5 years (17-55): 48 were male, 21 female. The main reasons for the ACL ruptures were sports injuries (51 cases). The patients were classified into three groups according to the data of the repair (group 1 reconstruction up to 1 week after trauma-28 patients: group 2: reconstruction between the 2nd and 6th week after trauma-15 patients: group 3: reconstruction 6 and more weeks after trauma-26 patients). In group 1. additional ruptures of the menisci. lesions of the MCL. and chondromalacia were seen in 71.4%. in group 2 in 73.3% and in group 3 in 80.8%. The average rating in the OAK score was 90.16 points: 38 patients (55.70%) had excellent results. 18(26.09%) were good. 9(13.04%) were fair and 4(5.80%) were poor. The Tegner activity score showed a reduction of 0.36 points on average. The largest amount of anterior translation was performed with the KT 1000 manual drawer test (2.29 mm on average compared with the contralateral side). Dynamometer testing showed a statistically significant difference in flexor and extensor mechanism (compared with the non-involved side) in both peak torques and total work. A repeat arthroscopy became necessary in five cases: arthrofibrosis in three and incipient joint infection in two cases.

[Prognosis of epidural hematoma: is emergency burr hole trepanation in craniocerebral trauma still justified today?]. / Prognose nach epiduralem Hämatom: ist die notfallmässige Bohrlochtrepanation beim Schädel-Hirn-Trauma heute noch zeitgemäss?

We made a retrospective study of the records of 80 patients with epidural haematoma, to investigate whether delay between injury and surgery and neurological status upon admission affect outcome after 3-6 months. Outcome was classified on a four-grade scale, grade 1 meaning full recovery and grade 4, death. Overall mortality was 13%. Patients operated on within 7 h after injury made a full recovery in 52%, and mortality in this group was 6%. Patients operated on between 7 h and 14 h after injury made a full recovery in 20%; mortality was 16%. Among the patients who were not comatose on admission a good outcome was achieved in 55% and mortality was 3%. The outcome in patients who were comatose on admission was rated grade 1 in 15% and grade 4 in 25%. The proportion of comatose patients and the mortality were higher in patients transferred from general hospitals. Textbook signs of epidural haematoma are not reliable aids to diagnosis and localization; for example a lucid interval occurred in only 58% of our patients. It is concluded that emergency burr hole trepanation might improve the outcome in patients showing signs of brain stem dysfunction after head injury, but prior computed tomography is necessary to guide such an intervention at the district hospital level.

[The value of sonography in ruptures of the rotator cuff]. / Die Wertigkeit der Sonographie bei Rupturen der Rotatorenmanschette.

In 375 patients ultrasonography of the rotator cuff was carried out before operation. All the patients underwent acromioplasty, either alone or with additional repair of a full-thickness tear. The ultrasound findings were then compared with the intraoperative findings. Two hundred and seventy-two tears of the rotator cuff were seen on ultrasonography, and in 262 cases this was confirmed at operation. In 103 patients no rupture was diagnosed by ultrasound, but in 26 of these cases a full-thickness tear was detected on operation. These figures yield sensitivity of 91%, specificity of 89% and accuracy of 90%; the positive predictive value was 96%, the negative predictive value 75%. In most cases of incorrect evaluation the size of the tears was underestimated by ultrasonography.

Arthroscopic repair of superior glenoid labral detachment (the SLAP lesion).

Complete detachment of the glenoid labrum from the superior pole of the glenoid, which is associated with a destabilization of the origin of the long biceps tendon, leads to altered function in the shoulder joint. This is especially noticeable when the shoulder is used in overhead activities. Two operative techniques are described for reattachment of the glenoid labrum to the glenoid. In the first six patients the glenoid labrum was reattached with small cannulated titanium screws. In five patients these screws were inserted under arthroscopic control from a cranial direction. The labrum was always reattached just behind the origin of the long biceps tendon. The most favorable portal was identified by percutaneous probing with a Kirschner wire. If the superior glenoid pole could not be reached via a portal placed anterior or medial to the acromion, a hole was drilled through the acromion, and a transacromial approach was used. The screws were removed by arthroscopy after 3 to 5 months. In the last eight patients, absorbable tacks were used instead of screws. Of 18 patients who showed a complete detachment of the glenoid labrum from the superior pole of the glenoid with destabilization of the attachment of the biceps tendon, 14 underwent reattachment as described previously. The minimum follow-up time was greater than 6 months (mean follow-up time 18 months, maximum follow-up time 30 months). At follow-up, eight patients felt completely rehabilitated and had resumed their previous overhead activities (overhead sports). Four patients believed their conditions were improved. Two patients had not experienced any improvement. Of the patients who had not undergone reattachment and who had undergone shaving of the free margin of the glenoid labrum, only one had experienced improvement, while the other three patients did not report any improvement.

[Arthroscopic and percutaneous bone screw techniques with a new screw system]. / Arthroskopische und perkutane Verschraubungstechniken mit einem neuen Verschraubungssystem.

A new screwdriver is presented with which small titanium screws can be introduced into a joint under arthroscopic guidance. The screws are centrally cannulated, 2.7 mm thick (thread diameter), and available with and without a washer (5 mm in diameter, serrated and convex, flexible but not removable). The screwdriver has a special screw-holding device which allows the screw to be grasped and released making it possible to remove a screw already implanted in the joint at an earlier time. This arthroscopic screwing system has been used in 81 cases to date. In 59 patients with shoulder instability, arthroscopic refixation of the detached labrum-capsule complex was performed. In the first 32 of these cases an intra-articular screwing technique was used and in the following 27 cases an extra-articular screwing technique was applied. In addition, in 9 patients a fractured and displaced greater tuberosity was reduced and fixated percutaneously under the guidance of an image intensifier by means of this screwdriver. Other fields of application were the knee joint (type III fracture of the intercondylar eminence in 5 patients) and the ankle (displaced fracture of the talus in 2 patients and osteochondritis dissecans in 1). Complications were seen only in the patients with shoulder instability who were treated by the intra-articular screwing technique (screw loosening in 4 patients). This was the reason why the intra-articular technique was replaced by the extra-articular method. Since that time no further complications caused by the screws have been seen. Redislocation of the shoulder joint occurred in 1 case 7 months after operation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Early and intermediate results of conservatively and surgically treated lateral clavicular fractures]. / Früh- und mittelfristige Ergebnisse konservativ und operativ behandelter lateraler Klavikulafrakturen.

Between 1986 and 1988 67 patients with distal clavicular fracture were treated at the trauma hospital in Innsbruck. Depending on type of fracture conservative treatment (using a spica or other bandages) was performed in those cases without dislocation. Operation was necessary if coracoclavicular ligament was ruptured and dislocation of the distal clavicular end was found in X-rays. The most common practice was the use of K-wires and wire-loops. Plate fixation was necessary in one case of delayed fracture healing. No pseudarthrosis was seen in X-rays, mobility of the shoulder girdle was good and symptoms of pain were rare.

[Growth in length after femoral shaft fracture in childhood]. / Das Längenwachstumsverhalten nach Oberschenkelschaftfraktur im Kindesalter.

At the Innsbruck Trauma Department a total of 75 children with closed femoral shaft fractures were reviewed with reference to length discrepancy. The femurs were measured radiologically two times within four years to find out, if overriding of the fragments is useful to prevent overgrowth of the broken limb. In 60 patients conservative treatment and in 15 cases operative treatment was performed. The cases may be divided in two age groups: one ten years of age or younger, the other eleven years to 15 years. Shortening of the fragments shows no evident advantage preventing overgrowth of the broken limb, but in elder children it may provoke a persisting shortening of the limb. As a matter of fact anatomical reduction in conservative treatment of femoral shaft fractures, especially in elder children, should be performed. After operative treatment the children ten years of age to 15 years showed not even more lengthening of the femur than the patients with conservative treatment.

[Clinical management of lesions of the rotator cuff]. / Klinisches Management bei Läsionen der Rotatorenmanschette.

Lesions of the rotator cuff are caused in most cases by degenerative changes in the critical area around the tuberosities of the humerus. Clinical examination reveals atrophy of the supra- and infraspinatus muscles, a painful arc of movement and, especially, pain at night. There are many clinical tests that can be helpful in the diagnosis. Both ultrasonography and arthrography have proved to be very sensitive methods for the detection of rotator cuff tears. Ultrasonography allows determination of the size and location in addition. Conservative treatment includes rest, physical therapy and anti-inflammatory medication. In many cases the symptoms are improved by many weeks of conservative treatment alone. Operative treatment becomes necessary when no pain relief and no satisfactory movement can be achieved. Complete correction of the tendon defect is important for postoperative care. Passive exercise must allow the tendon repair to remain intact without subjecting it to undue stress.

[The pattern of injuries of the ankle joint in ski boots--a retrospective analysis]. / Das Verletzungsmuster des Sprunggelenkes im Skischuh--eine retrospektive Analyse.

This study is dealing with the analysis of isolated ankle fractures in ski boots which are nowadays very seldom. Modern equipment and excellent prepared skiing facilities reduced this kind of trauma. In the early sixties about 60% of lower extremity injuries were caused by ankle fractures. Now, 25 years later, only 10% of injuries concerning to lower extremity are injuries of medial and lateral ankle or of the talofibular ligaments. At the department of trauma surgery of the university hospital of Innsbruck we use a questionnaire for winter sports injuries. We made a retrospective follow up study of the last three years, in which we found 100 patients with ankle injuries. Pilon tibial- and tibia shaft fractures are not included. The classification was made by the Lauge-Hansen system. Supination-inversion and supination-eversion fractures were found more often than others. Fractures of both medial and lateral ankles were only seen in three cases. One reason for this result could be a lack of movement of the ankle in the ski-boot. Modern plastic boots seem to protect ankle and distal tibia and fibula. Another remarkable result was the fact that we could not find any difference in the types of fractures comparing patients with released and not released bindings.

[Shoulder dislocation and -subluxation]. / Schulterluxation und -subluxation.

The diagnosis and treatment of shoulder instability require basic differentiation between unidirectional, multidirectional, and voluntary dislocation. Within unidirectional instability primary dislocation, recurrent dislocation, and recurrent subluxation need to be considered separately.--Primary dislocation: In 160 patients with primary dislocation a follow-up was done by questionnaire. In the case of atraumatic primary dislocation the redislocation rate was 100%. Predisposing factors inherent in the bony, cartilaginous, and capsular components of the joint favoured the tendency of primary dislocation. In the case of traumatic primary dislocation the redislocation rate was lower after immobilisation of the joint than without when it had not been immobilised.--Recurrent subluxation: In 52 patients with a clinical diagnosis of recurrent subluxation a tear of the glenoid labrum was found by arthroscopy. In 21 cases the detached labrum was refixed arthroscopically and in 18 cases the repair was done by an open Bankart procedure. Seventy-two percent of the patients who underwent arthroscopic repair showed good to excellent results. In all cases but one in which the Bankart procedure was applied the results were excellent.--Recurrent dislocation: Since 1984 a total of 183 patients were operated on for recurrent shoulder dislocation. All these patients were examined preoperatively by CT scan. The CT findings were used in selection of the appropriate procedure. In 114 patients the Bankart procedure was applied and in 39 cases, a bone-block method. The remaining patients were subjected to various other procedures. Not one of the patients showed postoperative redislocation. (ABSTRACT TRUNCATED AT 250 WORDS)