Outcomes of distal ulna locking plate in management of unstable distal ulna fractures: a prospective case series.

INTRODUCTION: Given the absence of a satisfying plate system to deal with multifragmentary or subcapital distal ulnar fractures, the Distal Ulna Locking Plate (DUL, I.T.S. GmbH, Graz, Austria) could become a useful treatment option. This study aimed to evaluate the results of this anatomically pre-contoured plate regarding patients with unstable or displaced distal ulnar fractures. METHODS: In a prospective clinical trial, 20 patients (18 female, two male; mean age 70 years (24-91 years)) with unstable or displaced distal ulna fractures between December 2010 and August 2015 were analyzed. All patients were treated with open reduction and internal fixation using the DUL. They were evaluated at three follow-up appointments at 3, 6 and 12 months postoperatively regarding their bone healing, ulnar variance (UV), range of motion (ROM) and grip strength. Patient related outcomes were measured using the Disability of the Arm, Shoulder and Hand (DASH), the Patient Rated Wrist Evaluation (PRWE) questionnaires, and the Visual Analogue Scale (VAS). The results after one year were compared to the outcome of the healthy contralateral side. RESULTS: All fractures treated with open reduction and internal fixation using the Distal Ulna Locking Plate healed within 6 months and showed stable ulnar variances after surgery. ROM (rotational plane 81.1 ± 9.0°, sagittal plane 55.1 ± 14.6°, frontal plane 33.0 ± 9.4°) and grip strength (18.7 ± 7.1 N) at the follow-up after 12 month had similar values compared with the uninjured side. The mean DASH score (36.4 ± 29.0), the PRWE-score (14.5 ± 27.0), and the VAS (at rest 0.5 ± 1.1, during activity 1.2 ± 2.4) after one year had no significant difference to the uninjured side. The surgeon's overall satisfaction rate regarding plate handling reached 81.8%. CONCLUSION: Stabilization of unstable distal ulna fractures using the DUL restores nearly normal anatomy and function. Its pre-countered design, volar placement, and enhanced stability present a satisfying plate system. TRIAL REGISTRATION:  The trial was retrospectively Registered at www. CLINICALTRIALS: gov on 16 December 2021 (Trial Registration Number: NCT05329012).

Mid-term follow-up of surgically treated and healed scaphoid fractures.

The aim of this study was to evaluate the mid-term results of surgically treated scaphoid fractures since we were concerned that good results might deteriorate over time due to osteoarthritis or functional impairment. Thirty-three out of 121 surgically treated patients (isolated scaphoid fractures n = 23; scaphoid fractures with concomitant injuries n = 10) were evaluated retrospectively (47-138 months). Five patients (4%) had a non-union after internal fixation and were excluded because of additional treatment. The remaining 83 patients were not available for a follow-up examination. Patients with an isolated scaphoid fracture had a mean extension-flexion of 68°-0°-64°, a radial-ulnar deviation of 27°-0°-41° and a grip strength of 39 kg (corresponding to 87-98% of the uninjured contralateral wrist), while patients with concomitant injuries had a mean extension-flexion of 60°-0°-44°, radial-ulnar deviation of 22°-0°-38° and a grip strength of 42 kg (corresponding to 73-98% of the uninjured contralateral wrist). The Michigan Hand Questionnaire score was 85 and 75 and the Patient-Rated Wrist Evaluation score was 8 and 21, respectively. Fifteen patients had radiological signs of radiocarpal osteoarthritis with a significantly higher occurrence in those who had concomitant injuries compared to those with isolated scaphoid fractures (p < 0.01). There was no significant group difference in scaphotrapeziotrapezoid (STT) osteoarthritis (p = 0.968). One STT osteoarthritis case occurred after plate fixation, one after antegrade screw fixation and 10 after retrograde screw fixation. Surgical treatment of an acute isolated scaphoid fracture has excellent clinical, functional, and radiologic mid-term results, while scaphoid fractures with concomitant wrist injuries have slightly inferior results.

Clinical and radiological midterm outcome after treatment of pilonoidal fracture dislocations of the proximal interphalangeal joint with a parabolic dynamic external fixator.

INTRODUCTION: Several methods treating proximal interphalangeal joint (PIP) fracture dislocations have been established providing early joint mobilization. The aim of this study was to evaluate the clinical and radiological outcome of unstable fracture dislocations of the PIP treated with a parabolic dynamic external fixator consisting of two Kirschner (K)-wires. MATERIALS AND METHODS: Twenty-one patients who sustained a pilonoidal fracture of the PIP joint and were treated with a dynamic external fixator were evaluated retrospectively. The active range of motion, pain level, DASH score, Buck Gramcko Score, and the patient's satisfaction and acceptance were assessed. X-ray images were evaluated for bone healing, joint alignment, and signs of osteoarthritis. RESULTS: Mean PIP joint range of motion was 76°. Patients showed very mild discomfort (mean 0.7), high patient satisfaction (mean 1.9), and a moderate acceptance (mean 2.7). The mean DASH score was 11.6 and the Buck Gramcko score 13. All patients showed bone healing. One patient suffered from a recurrent dislocation, and another a subluxation of the PIP joint while wearing the fixator. Both joints could be corrected by modifying the fixator under image intensifier. Twenty patients (95%) showed a concentric and stable aligned joint. Three patients showed an osteoarthritis stage 0, five stage 1, nine stage 2, three stage 3, and one stage 4 according to the Kellgran-Lawrence Score. CONCLUSION: The use of a parabolic dynamic external fixator constructed from two K-wires restores joint alignment and stability in unstable pilonoidal PIP joint disclocation fractures. It allows immediate PIP joint mobilization to avoid adhesions. Modifications of the radius of the parabolic construct within cases of postoperative malalignment, without anesthesia, can restore joint axis and malalignment. This fixator is a cost-effective alternative, showing a good clinical outcome.

[Wide awake hand surgery based on application examples]. / Wide-awake-Technik in der Handchirurgie anhand von Anwendungsbeispielen.

OBJECTIVE: Anesthesiologic method with low bleeding level, risk level, and complication rate for surgical procedures on the hand without a tourniquet on an unsedated patient with the possibility for functional testing during surgery. INDICATIONS: Surgical procedures of the hand can be carried out using the wide awake technique depending on the patient's suitability and preference considering individual risk factors. CONTRAINDICATIONS: Absolute contraindications are allergies to the local anesthetic or its components. Relative contraindications are severe hepatic or renal insufficiency, infections in the injection area, acute circulatory disorders, or higher cardiac function impairment. INJECTION TECHNIQUE: Infiltration of a lidocaine/epinephrine mixture with 8.4% sodium bicarbonate in a ratio of 10:1.5 at least 30 min prior to surgery. Perpendicular puncture of the skin and slow injection. Continue injection until reaching a pale skin area of at least 1 cm around the entire operating area. If the needle tip always remains in a cushion of local anesthetic, a "hole-in-one" anesthesia can be achieved (only the first needle puncture is felt). POSTOPERATIVE MANAGEMENT: Elevated care and awareness for numb body parts by the patient because of impaired sensation. Follow-up treatment according to the surgeon's specifications. Postoperative use of painkillers. RESULTS: Of 38 patients, 32 felt that the procedure was not stressful, 6 rated it as a bit stressful. Pain perception on a visual analog scale (0 = no pain, 10 = severe pain) scored an average of 1.6 during infiltration, 0.5 during the operation, 3.5 during the reduction of the anesthesia, and 2.9 on the following day. All patients would undergo surgery again using the wide awake technique.

Carpal tunnel syndrome assessment with diffusion tensor imaging: Value of fractional anisotropy and apparent diffusion coefficient.

OBJECTIVES: To quantitatively assess carpal tunnel syndrome (CTS) with DTI by evaluating two approaches to determine cut-off values. METHODS: In forty patients with CTS diagnosis confirmed by nerve conduction studies (NCs) and 14 healthy subjects (mean age 58.54 and 57.8 years), cross-sectional area (CSA), apparent diffusion coefficient (ADC) and fractional anisotropy (FA) at single and multiple levels with intraobserver agreement were evaluated. RESULTS: Maximum and mean CSA and FA showed significant differences between healthy subjects and patients (12.85 mm2 vs. 28.18 mm2, p < 0.001, and 0.613 vs. 0.524, p=0.007, respectively) (10.12 mm2 vs. 19.9 mm2, p<0.001 and 0.617 vs. 0.54, p=0.003, respectively), but not maximum and mean ADC (p > 0.05). For cut-off values, mean and maximum CSA showed the same sensitivity and specificity (93.3 %). However, mean FA showed better sensitivity than maximum FA (82.6 % vs. 73.9 %), but lower specificity (66.7 % vs. 80 %), and significant correlation for maximum CSA, 97 % (p < 0.01), with good correlation for maximum ADC and FA, 84.5 % (p < 0.01) and 62 % (p=0.056), respectively. CONCLUSIONS: CSA and FA showed significant differences between healthy subjects and patients. Single measurement at maximum CSA is suitable for FA determination. Key Points • DTI showed that FA is stronger than ADC for CTS diagnosis. • Single- and multiple-level approaches were compared to determine FA and ADC. • Single-level evaluation at the thickest MN cross-sectional area is sufficient.

Total wrist arthrodesis for septic wrist arthritis and loss of the bony carpus following percutaneous pinning of the fifth carpometacarpal joint: a case report.

We report on a patient who developed septic wrist arthritis with destruction of the entire carpus due to osteomyelitis following percutaneous pinning of a fifth metacarpal base fracture. Arthrodesis was performed using a 6 cm vascularized iliac bone graft. This case report may sharpen the surgeon's awareness of risks in orthopedic surgeries, even though the procedure seems to be rather simple and the patient is young and seems to be healthy.

[Biomechanics of distal radius fractures : Basics principles and GPS treatment strategy for locking plate osteosynthesis]. / Biomechanik distaler Radiusfrakturen : Grundlagenverständnis und GPS-Behandlungsstrategie bei winkelstabiler Plattenosteosynthese.

Fractures of the distal radius are most commonly caused by hyperextension injuries of the wrist. Tensile forces and force vectors, strength of impact, bone strength and soft tissue tension create individually different fracture patterns. Metaphyseal comminution, loss of cortical support, ligament avulsion and shear fragments are defining parameters for fracture instability. The dislocation of the articular fragment follows the force vectors of the extrinsic forearm muscles bridging the joint. The goal-plan-standardized (GPS) treatment strategy has proven to be helpful in choosing the ideal individual treatment. It is based on individual patient demands on wrist function and an analysis of fracture instability in computed tomography (CT) scans. The "goal" is a realistic expectation assessed by patient and surgeon. The "plan" includes a benefit-risk analysis and selection of an appropriate treatment modality. The "standardized treatment" of surgical and follow-up treatment is based on biomechanical knowledge. Locking plate osteosynthesis aims to neutralize dislocating force vectors and to allow early active mobility. Unidirectional instability can be indirectly neutralized by palmar locking plate systems. A multidirectional instability can be addressed by multiple plating following the column theory. Distal shear and avulsion fractures may require a fragment-specific osteosynthesis approach.

[Treatment concept for a traumatic lesion of the prepatellar bursa]. / Behandlung der traumatisch eröffneten Bursa praepatellaris.

OBJECTIVE: Rapid recovery of the skin and soft tissue of the affected knee joint with surgical debridement of the wound and gentle, as well as risk-balanced partial resection of the traumatic lacerated prepatellar bursa. Functional aftercare with directed administration of antibiotics only. INDICATIONS: Acute, traumatic laceration of the prepatellar bursa. CONTRAINDICATIONS: Heavy contamination of the wound. Large, not closable skin defect or deep abrasion. Preexisting local infection. Additional fracture of the patella. Limited patient's cooperation, e. g., alcohol addiction or dementia. SURGICAL TECHNIQUE: Subdermal application of local anesthesia through the exposed wound margins. Exploration of the wound and excision of the wound margins. Dissection of the boundary layer between the bursa and the subcutaneous fat. Debridement of the wound and excision of the bruised and contaminated bursa tissue. Repetitive rinsing. Insertion of loop drainage. Single-layer wound closure. Crepe bandage. POSTOPERATIVE MANAGEMENT: Crepe bandage until the first wound inspection. Wound inspection on postoperative day 2 with removal of the loop. Pain-adapted functional treatment. Antithrombotic therapy until full weight-bearing. Removal of the stitches on postoperative day 14. Antibiotic prophylaxis (1st generation cephalosporin) for immunocompromised or polymorbid patients or heavily contaminated wounds. RESULTS: In 2013, we treated 50 traumatic lacerations of the prepatellar bursa. Four had to undergo further surgical treatment after primary care. In two other patients, one infected and one non-infected wound healing complication developed, which could be treated conservatively.

Ulnar shortening with the ulna osteotomy locking plate.

OBJECTIVE: Ulnar shortening for ulnocarpal unloading using a new device enabling parallel osteotomy, rotation-secured compressive shortening, lag screw placement and hybrid stabilization combined in a solely locking plate construct. INDICATIONS: Idiopathic ulnar impaction syndrome. Posttraumatic radial shortening without major tilting of the radius in the sagittal or frontal plane, rotation deformity and/or translation of the distal fragment. CONTRAINDICATIONS: Advanced arthritis of the distal radioulnar joint (DRUJ), DRUJ type III according to Tolat, malunion of the distal radius with major tilting of the radius in the sagittal or frontal plane, rotation deformity and/or translation of the distal fragment. SURGICAL TECHNIQUE: Mounting of the UOL plate system on the palmar surface of the ulna using standard ulnopalmar exposure. Two parallel 45° osteotomies are performed using an osteotomy guide followed by rotation secured shortening and compression. Stabilization is gained by inserting an interfragmentary lag screw perpendicular to the osteotomy site and applying locking and compression screws. POSTOPERATIVE MANAGEMENT: Lower arm cast for 4 weeks until radiological signs of bone healing become apparent. To limit negative influence of rotational forces during bone healing, patients were instructed to limit forearm rotation up to 30° in pro-/supination. RESULTS: Sixteen ulnar shortening osteotomies were performed in 15 patients (6 men, 9 women, average age 49 years) and evaluated retrospectively. In 10 cases a trauma-related pathology was the indication for the procedure. The average follow-up time was 53 weeks (range 12-93 weeks). Bone union was observed at a median of 10 weeks (range 6-33 weeks). Overall good clinical results could be achieved with an average shortening of 3.7 mm (range 2.1-16 mm). In this series, there was one nonunion.

Clinical pharmacology of the hypocholesterolemic agent K 12.148 (lifibrol) in healthy volunteers.

K 12.148 (INN:lifibrol), a new cholesterol synthesis inhibitor, was studied in healthy volunteers to evaluate tolerance/safety, the effects on lipids, and pharmacokinetics. In a sequential block design the doses of 150, 300, 600, or 900 mg, given once daily in the morning for 14 consecutive days, were examined in 40 healthy young males (8 active drug and 2 placebo per group, randomized) under well-controlled conditions. Total and LDL cholesterol serum levels decreased significantly in the 300, 600, and 900 mg groups (-13.4%, -23.8%, -25.6%, and -14.7%, -33.3%, -34.8%, respectively). whereas no significant change was seen with placebo and 150 mg. The antiatherogenic index Apo A-I/B increased in a dose-dependent manner between 300 and 900 mg. Changes in HDL cholesterol and triglycerides were not statistically significant. The study compound was tolerated well, and safety laboratory parameters did not show any relevant alterations, K 12.148 might be a very effective drug for the treatment of hypercholesterolemia.