Evaluation of the efficiency of an ultrasound-supported infiltration technique in patients with tennis elbow applying the ITEC medical device: a multicenter study.

Background: The treatment of lateral epicondylitis remains unsatisfactory in certain cases. The aim of this study is to investigate the efficiency of an ultrasound-guided infiltration combined with fenestration of the extensor tendon postulating a 50% reduction in pain on exertion within 6 months. Methods: In a prospective, nonrandomized, multicenter study design, 68 patients with chronic lateral epicondylitis and symptoms lasted for at least 6 weeks were included. Each hospital has been assigned for Traumeel (A), autologous whole blood (B), or dextrose (C) in advance. Preinterventional, 6 weeks, 12 weeks, 6 and 12 months after infiltration, patient-related outcome parameter, and dorsal wrist extension strength were documented. Preinterventional (obligate) and after 6 months (optional) radiological evaluation (magnetic resonance imaging) was performed. Results: The Visual Analog Scale showed a significant reduction after 6 months in all groups (A. 4.8-2.5, B. 6.2-2.3, C. 5.8-2.4). Similar results could be observed with Subjective elbow value, Disabilities of Arm, Shoulder, and Hand Score, Mayo Elbow Performance Score, and Patient Rated Tennis Elbow Evaluation. The loss of strength could be completely compensated after about 6 months. Magnetic resonance imaging did not fully reflect clinical convalescence. Re-infiltrations were sometimes necessary for final reduction of symptoms (A = 11, B = 8, C = 4). Switching to surgical intervention was most frequently observed in group C (A = 2, B = 1, C = 5). In 14.5% of the cases, no improvement of the symptoms could be achieved with this method. Conclusion: The primary hypothesis of a significant long-term pain reduction of at least 50% could be achieved regardless of the medication chosen.

Does a prehospital applied pelvic binder improve patient survival?

INTRODUCTION: Pelvic fractures are serious and oftentimes require immediate medical attention. Pelvic binders have become a critical tool in the management of pelvic injuries, especially in the prehospital setting. Proper application of the pelvic binder is essential to achieve the desired result. This study evaluates the effectiveness of prehospitally applied pelvic binders in improving outcomes for patients with pelvic fractures. METHODS: This retrospective cohort study analyzed 66 patients with unstable pelvic ring fracture classified as AO61B or 61C, who were treated at a Level I hospital in the emergency room between January 2014 and December 2018. The ideal position for a pelvic binder was determined, and patients were divided into three sub-groups based on whether they received a pelvic binder in the ideal position, outside the optimal range, or not at all. The primary outcome measure was the survival rate of the patients. RESULTS: 66 trauma patients with unstable pelvic fractures were enrolled, with a mean age of 53.8 years, who presented to our ER between 2014 and 2018. The mean ISS score was 21.9, with 60.3 % of patients having a moderate to severe injury (ISS > 16 points). Pelvic binder usage did not differ significantly between patients with an ISS < or ≥ 16 points. A total of 9 patients (13.6 %) died during hospitalization, with a mean survival time of 8.1 days. The survival rate did not differ significantly between patients with or without a pelvic binder, or between those with an ideally placed pelvic binder versus those with a binder outside the ideal range. The ISS score, heart rate, blood pressure at admission, and hemoglobin level were significantly different between the group of patients who died and those who survived, indicating their importance in predicting outcomes. CONCLUSION: Our study found that prehospital pelvic binders did not significantly impact patient outcomes for unstable pelvic fractures, with injury severity score (ISS) being the strongest predictor of survival. Assessing injury severity and managing blood loss remain crucial for these patients. While pelvic binders may not impact survival significantly, they still play a role in stabilizing pelvic fractures and managing blood loss.

[Infectious, pathologic humeral fracture in a patient with sickle cell disease-A rare case?] / Infizierte, pathologische Humerusfraktur bei Sichelzellanämie ­ noch ein Einzelfall?

The vaso-occlusive crises of sickle cell disease are accompanied by bone necrosis, which favors endogenous bacterial colonization and thus osteomyelitis. This poses a major challenge for eradication and fracture management.A 22-year-old patient with sickle cell disease sustained a multifragmentary, humeral shaft fracture. During surgical management, pus drained from the fracture site and further diagnostic work-up revealed osteomyelitis with evidence of Klebsiella aerogenes. Septicemia due to Klebsiella aerogenes had been treated 5 months prior to the accident, which occured because of a vaso-occlusive crisis. This is associated with clustered bone necrosis and endogenous germ colonization. Eradication of the germs and fracture care become a challenge. Repeated surgical procedures with segmental transfer can be a successful treatment option.

Introduction to the Masterclass Series.

How to cite this article: Harwood P, Mader K, Nayagam S. Introduction to the Masterclass Series. Strategies Trauma Limb Reconstr 2023;18(1):1.

[Infiltration therapies for lateral epicondylopathy]. / Infiltrationstherapien am Ellenbogengelenk bei Epicondylopathia humeri radialis.

The therapy of the lateral epicondylopathy (tennis elbow) includes drug injection into the extensor tendon insertion in chronic cases. The choice of medication and the type of injection is decisive for the success of therapy. Furthermore, accurate application is indispensable for therapy success (e.g. peppering injection technique, ultrasound-supported injection technique). Corticosteroid injection is often associated with short-term success, so that other options have found their way into everyday practice. Objectification of treatment success is usually defined by Patient-Reported Outcome Measurements (PROM). With the introduction of Minimal Clinically Important Differences (MCID), statistically significant results are put into perspective in terms of clinical significance. Therapy for lateral epicondylopathy was considered effective if the mean difference in score results between baseline and follow-up exceeded 1.5 points for the Visual Analogue Scale (VAS), 16 points for Disabilities of Arm, Shoulder and Hand Score (DASH), 11 points for Patient-Rated Tennis Elbow Evaluation (PRTEE), and 15 points for Mayo Elbow Performance Score (MEPS). However, the effectiveness must still be critically questioned according to meta-analytical evaluations, in which healing within 12 months was found in 90% of the cases of untreated chronic tennis elbow in the placebo groups. The use of substances, such as Traumeel (Biologische Heilmittel Heel GmbH, Baden-Baden, Germany), hyaluronic acid, botulinum toxin, platelet rich plasma (PRP), autologous blood or polidocanol, are based on various mechanisms. In particular, the use of PRP or autologous blood for the treatment of musculotendinous and degenerative articular pathologies has become popular, although the studies regarding effectiveness are inconsistent. PRP can be divided into leukocyte-rich (LR-PRP) and leukocyte-poor plasma (LP-PRP) according to its preparation. In contrast to LP-PRP, LR-PRP incorporates the middle and intermediate layers, but there is no standardized preparation described in the literature. Conclusive data regarding effective efficacy are still pending.

Morphology of the acromioclavicular-joint score (MAC).

INTRODUCTION: To date there is no generally accepted specific definition or classification of acromioclavicular (AC) joint osteoarthritis. The aim of this study is to analyze morphological parameters using magnetic resonance imaging (MRI) and to develop a scoring system as a basis for decision making to perform an AC-joint resection. MATERIALS AND METHODS: In a retrospective-monocentric matched pair study, healthy and affected subjects were investigated using T2 MRI scans in the transverse plane. There were two groups, group 1 (n = 151) included healthy asymptomatic adults with no history of trauma. In group 2, we included n = 99 patients with symptomatic AC joints, who underwent arthroscopic AC-joint resection. The central and posterior joint space width and the AC angle were measured. Morphological changes such as cartilage degeneration, cysts and bone edema were noted. Malalignment of the joint was defined as: posterior joint space width < 2 mm in conjunction with an AC angle > 12°. A scoring system consisting of the measured morphologic factors was developed. RESULTS: Symptomatic and asymptomatic patients showed significant differences in all measured items. We observed a significant difference in the MAC score for symptomatic and asymptomatic patients (mean 10.4 vs. 20.6, p = 0.0001). The ROC (receiver operator characteristic) analysis showed an excellent AUC of 0.899 (p = 0.001). The sensitivity of the MAC score was 0.81 and the specificity 0.86. The MAC score shows a significant moderate correlation with age (r = 0.358; p = 0.001). The correlation of age and the development of symptoms was only weak (r = 0.22, p = 0.001). Symptomatic patients showed significantly more frequent malalignment compared to asymptomatic patients (p = 0.001), but the positive predictive value that a patient with malalignment is also symptomatic is only 55%. CONCLUSION: Patients with symptomatic AC joints showed a typical pattern of morphological changes on axial MRI scans with early posterior contact of the joint surfaces, reduction of joint space and malalignment as the basis for the development of a scoring system. The MAC score shows excellent test characteristics, and therefore, proved to be both an appropriate guidance for clinical practice as well as an excellent tool for comparative studies and is superior to the assessment of malalignment alone. LEVEL OF EVIDENCE: Level IV, retrospective diagnostic study.

Influence of Fracture Reduction on the Functional Outcome after Intramedullary Nail Osteosynthesis in Proximal Humerus Fractures.

Background: Optimal treatment of proximal humeral fractures (PHF) is still controversial. Therefore, we aim to investigate the influence of fracture reduction after intramedullary nailing of a PHF on the clinical outcome. Methods: Patients treated with intramedullary nail for PHF from 2013−2018, (minimum follow-up 12 months) were retrospectively included. Constant Score (CS), DASH and Simple Shoulder Test (SST) were collected. Postoperative radiographs were used to determine head-shaft-alignment (HSA), head-shaft-displacement (HSD), integrity of the medial hinge and the cranialization of the greater tuberosity (CGT). The results of fracture reduction were categorized as either "anatomical", "acceptable" or as "malreduction". Malreduction exists when at least one of the following parameters are present: HSA > 150/< 110°, HSD >5 mm, CTM > 5 mm or lack of integrity of the medial hinge. Results: 42 patients (mean age 65.5 ± 14.1 years, 15 male, 27 female) with a mean follow-up time of 43 months were included. The average CS was 60 ± 30, DASH 49.8 ± 24.3 and SST 62.9 ± 26.9. There was an "anatomic" reduction in 9 (21.4%), "acceptable" in 7 (16.6%) and a "malreduction" in 26 (62%) patients. Comparing the combined "anatomical" and "acceptable" reduction group with the "malreduction" group, worse scores were observed in the "malreduction" group (CS 67.2 vs. 55.2, DASH 45.2 vs. 51.9, SST: 69.3 vs. 58.6) without statistical significance (CS: p = 0.095, DASH: p = 0.307, SST: p = 0.400). By means of multiple logistic regression analyses no statistically significant risk factors were identified for lower DASH, CS and SST scores. Conclusions: Anatomical fracture reduction using intramedullary nails has a positive effect on postoperative outcome for the 3 scores recorded, without reaching statistical significance.

Treatment of Unstable Elbow Injuries with a Hinged Elbow Fixator: Subjective and Objective Results.

Introduction: Injuries around the elbow pose a challenging problem for orthopaedic surgeons. The complex bony architecture of the joint should be restored and the thin soft tissue envelope needs to be handled with meticulous care. Elbow instability is a complication seen after dislocations and fractures of the elbow and remains a treatment challenge. The purpose of this study was to provide subjective and objective results following the surgical treatment of unstable elbow dislocations with an external hinged fixation technique. Methods: Forty-six consecutive patients with complex trauma of the elbow with instability after ligament reconstruction were enrolled between January 2017 and December 2019. The parameters used to quantify the subjective and objective functional results were the Mayo Elbow Score (MES, objective) and Oxford Elbow Score (OES, subjective), and clinical stability of the elbow joint. We also performed a radiological follow-up of the fractures. Results: The mean MES and OES scores were good at the 12-month follow-up. We had 38 patients with stable joints and 8 patients with minor instability. Using the stress test, we saw a significant difference in the affected joint under varus stress (6.7 ± 1.8 mm) compared to the healthy joint (5.8 ± 1.2 mm) laterally. Furthermore, medially the gap was significantly larger (5.8 ± 0.8 mm, treated elbow) than the contralateral gap under valgus stress (4.3 ± 0.8 mm) (p <0.001). Twenty-one complications occurred in 46 patients (46%): Seven patients had a clinical change of elbow axis: Three valgus (6%), four varus (9%); Superficial wound infection occurred in one case (2%) and ulnar nerve dysfunction in two (4%). The most common medium-term complication was post-traumatic osteoarthritis in eight cases (17%). Heterotopic ossification occurred in five patients (11%) and elbow stiffness in five cases (11%). Conclusion: The use of the hinged elbow external fixator in the treatment of complex elbow trauma is a valid therapeutic adjunct to ligamentous reconstruction showing encouraging results with acceptable complications. How to cite this article: Meccariello L, Caiaffa V, Mader K, et al. Treatment of Unstable Elbow Injuries with a Hinged Elbow Fixator: Subjective and Objective Results. Strategies Trauma Limb Reconstr 2022;17(2):68-73.

A cost-effectiveness analysis of reverse total shoulder arthroplasty compared with locking plates in the management of displaced proximal humerus fractures in the elderly: the DelPhi trial.

AIM: To evaluate the cost-effectiveness of surgical treatment with reverse total shoulder arthroplasty (RTSA) compared with open reduction and internal fixation (ORIF) with a locking plate for patients 65-85 years old with a displaced proximal humerus fracture. METHODS: A cost-utility analysis was conducted alongside a multicenter randomized controlled trial, taking a health care perspective. A total of 124 patients with displaced proximal humerus fractures were randomized to treatment with RTSA (n = 64) or ORIF (n = 60) during a 2-year period. The outcome measure was quality-adjusted life years derived from the generic questionnaire 15D in an intention to treat population. The results were expressed as incremental cost-effectiveness ratios, and a probabilistic sensitivity analysis was performed to account for uncertainty in the analysis. RESULTS: At 2 years, 104 patients were eligible for analyses. The mean quality-adjusted life year was 1.24 (95% confidence interval: 1.21-1.28) in the RTSA group and 1.26 (95% confidence interval: 1.22-1.30) in the ORIF group. The mean cost in the RTSA group (€36.755 [€17,654-€55,855]) was higher than that in the ORIF group (€31.953 [€16,226-€47,279]). Using incremental cost-effectiveness ratio, ORIF was the dominant treatment. When using a probabilistic sensitivity analysis with 1000 replications, the plots were centered around origo. This indicates that there is no significant difference in cost or effect. CONCLUSION: In the cost-utility analysis of treatment of displaced proximal humeral fractures, there were no differences between RTSA and ORIF.

Complications and range of motion of patients with an elbow dislocation treated with a hinged external fixator: a retrospective cohort study.

PURPOSE: Elbow dislocations are at risk for persistent instability and stiffness of the joint. Treatment with a hinged external fixation provides elbow joint stability, and allows early mobilization to prevent stiffness. Mounting a hinged elbow fixator correctly, however, is technically challenging. The low incidence rate of elbow dislocations with persistent instability suggests that centralization would result in higher surgeon exposure and consequently in less complications. This study aimed to investigate the results of treatment of elbow dislocations with a hinged elbow fixator on the rate of complications, range of motion, level of pain and restrictions in activities of daily living. METHODS: A retrospective observational cohort study in a level I trauma center, in which the majority of patients was treated by a dedicated elbow surgeon, was performed. All patients of 16 years or older treated with a hinged external elbow fixator between January 1, 2006 and December 31, 2017 were included. The fixator could be used (1) for the treatment of persistent instability in acute/residual simple and complex dislocations or (2) as revision surgery to treat joint incongruency or a stiff elbow. Patient and injury characteristics, details on treatment, complications, secondary interventions, and range of motion were extracted from the patients' medical files. RESULTS: The results of treatment of 34 patients were analyzed with a median follow-up of 13 months. The fixator was removed after a median period of 48 days. Fixator-related complications encountered were six pintract infections, one redisclocation, one joint incongruency, one muscle hernia, and one hardware failure. The median range of motion at the end of follow-up was 140° flexion, 15° constraint in extension, 90° pronation, and 80° supination. CONCLUSION: A hinged elbow fixator applied by a dedicated elbow surgeon in cases of elbow instability after elbow dislocations can result in excellent joint function. Fixator-related complications are mostly mild and only temporary.

Reverse Shoulder Arthroplasty Is Superior to Plate Fixation at 2 Years for Displaced Proximal Humeral Fractures in the Elderly: A Multicenter Randomized Controlled Trial.

BACKGROUND: Almost one-third of patients with proximal humeral fractures are treated surgically, and the number is increasing. When surgical treatment is chosen, there is sparse evidence on the optimum method. The DelPhi (Delta prosthesis-PHILOS plate) trial is a clinical trial comparing 2 surgical treatments. Our hypothesis was that reverse total shoulder arthroplasty (TSA) yields better clinical results compared with open reduction and internal fixation (ORIF) using an angular stable plate. METHODS: The DelPhi trial is a randomized controlled trial comparing reverse TSA with ORIF for displaced proximal humeral fractures (OTA/AO types 11-B2 and 11-C2) in elderly patients (65 to 85 years of age). The primary outcome measure was the Constant score at a 2-year follow-up. The secondary outcome measures included the Oxford Shoulder Score and radiographic evaluation. Results were reported as the mean difference with 95% confidence interval (CI). The intention-to-treat principle was applied for crossover patients. RESULTS: There were 124 patients included in the study. At 2 years, the mean Constant score was 68.0 points (95% CI, 63.7 to 72.4 points) for the reverse TSA group compared with 54.6 points (95% CI, 48.5 to 60.7 points) for the ORIF group, resulting in a significant mean difference of 13.4 points (95% CI, 6.2 to 20.6 points; p < 0.001) in favor of reverse TSA. When stratified for fracture classification, the mean score was 69.3 points (95% CI, 63.9 to 74.7 points) for the reverse TSA group and 50.6 points (95% CI, 41.9 to 59.2 points) for the ORIF group for type-C2 fractures, which yielded a significant mean difference of 18.7 points (95% CI, 9.3 to 28.2 points; p < 0.001). In the type-B2 fracture group, the mean score was 66.2 points (95% CI, 58.6 to 73.8 points) for the reverse TSA group and 58.5 points (95% CI, 49.6 to 67.4 points) for the ORIF group, resulting in a nonsignificant mean difference of 7.6 points (95% CI, -3.8 to 19.1 points; p = 0.19). CONCLUSIONS: At a 2-year follow-up, the data suggested an advantage of reverse TSA over ORIF in the treatment of displaced OTA/AO type-B2 and C2 proximal humeral fractures in elderly patients. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Current and Future Concepts for the Treatment of Impaired Fracture Healing.

Bone regeneration represents a complex process, of which basic biologic principles have been evolutionarily conserved over a broad range of different species. Bone represents one of few tissues that can heal without forming a fibrous scar and, as such, resembles a unique form of tissue regeneration. Despite a tremendous improvement in surgical techniques in the past decades, impaired bone regeneration including non-unions still affect a significant number of patients with fractures. As impaired bone regeneration is associated with high socio-economic implications, it is an essential clinical need to gain a full understanding of the pathophysiology and identify novel treatment approaches. This review focuses on the clinical implications of impaired bone regeneration, including currently available treatment options. Moreover, recent advances in the understanding of fracture healing are discussed, which have resulted in the identification and development of novel therapeutic approaches for affected patients.

Radial head resection and hemi-interposition arthroplasty in patients with multiple hereditary exostoses: description of a new surgical technique.

Multiple hereditary exostoses (MHE) are a rare disorder characterized by the growth of bony protrusions. Elbow involvement is found in a considerable number of patients and varies from the presence of a simple osteochondroma to severe forearm deformities and radial head dislocation. Patients encounter a variety of symptoms, for example, pain, functional impairment, and cosmetic concerns. Several types of surgical procedures, therefore, can be offered, ranging from excision of symptomatic osteochondromas to challenging reconstructions. In this paper, we will discuss the essential basics of visualizing, planning, and treatment options of forearm deformities in MHE. In more detail, we will describe our current surgical technique as a salvage procedure for Masada type II forearm deformities in patients with MHE.

Multiple osteochondromas (MO) in the forearm: a 12-year single-centre experience.

Multiple osteochondromas (MO) are a rare autosomal dominant disorder characterized by the presence of osteochondromas located on the long bones and axial skeleton. Patients present with growth disturbances and angular deformities of the long bones as well as limited motion of affected joints. Forearm involvement is found in a considerable number of patients and may vary from the presence of a simple osteochondroma to severe forearm deformities and radial head dislocation. Patients encounter a variety of problems and symptoms e.g., pain, functional impairment, loss of strength and cosmetic concerns. Several surgical procedures are offered from excision of symptomatic osteochondromas to challenging reconstructions of forearm deformities. We describe visualizing, planning and treating these forearm deformities in MO and, in particular, a detailed account of the surgical correction of Masada type I and Masada type II MO forearm deformities.

Complex forearm deformities: operative strategy in posttraumatic pathology.

Complex posttraumatic forearm deformities have a significant impact on the integrity of the upper extremity leading to pain, instability in both the proximal and/or distal radioulnar articulation, and reduced range of forearm motion. Corrective osteotomy or more advanced procedures for malunited fractures or other posttraumatic deformities of the upper extremity, especially in the forearm are challenging procedures. In this review we will discuss the essential aspects of anatomy and pathomechanics, clinical and radiological assessment and the pathway from preoperative planning to the actual deformity correction surgery, either with one-stage correction or using gradual lengthening with external fixation ("callotasis techniques") and finally the functional outcome we can expect for our patients. In addition we will analyze the modern computer-assisted techniques available to date.

Treatment of displaced proximal fifth metatarsal fractures using a new one-step fixation technique.

BACKGROUND: Fractures of the tuberosity of the fifth metatarsal are common after foot twisting injuries, and operative treatment is recommended in cases of displacement. The purpose of this study was to report the radiologic outcome and clinical results of displaced fractures of the tuberosity of the fifth metatarsal treated using fine-threaded K-wires (FFS). METHODS: In 3 years' time, in a total of 35 cases, patients had an initial fracture displacement of more than 2 mm for isolated extraarticular fractures and an involvement of the cuboidal joint surface of more than 30%. After 15 months to 60 months (mean, 30.6), 32 of these patients participated in a clinical follow-up examination and questionnaire according to a clinical rating system for midfoot fractures. Radiologic outcome measurements were the remaining postoperative intraarticular step off and the healing time. RESULTS: The mean midfoot scale score was 96.5 points. All the patients returned to prior activities after operative treatment. Seven patients reported minor pain during longer periods of walking. One patient with secondary wound healing experienced frequent pain. Radiologically, in 32 of 35 patients, there was a remaining step off of less than 1 mm and in three patients less than 3 mm. All fractures except one healed within the first 3 months to 6 months. CONCLUSION: Operative treatment of displaced proximal fifth metatarsal fractures using the FFS system leads to a good clinical and radiologic outcome. The FFS system provides a new treatment option for this fracture type.

Treatment of chronically unreduced complex dislocations of the elbow.

Chronic dislocation of the elbow is an exceedingly disabling condition associated with severe instability, limitation of elbow function and significant pain. Due to the potentially conflicting goals of restoring elbow stability and regaining a satisfactory arc of motion, successful treatment is a challenge for the experienced trauma surgeon. We report our treatment strategy in three patients suffering from chronically unreduced fracture-dislocations of the elbow. The treatment protocol consists of in situ neurolysis of the ulnar nerve, distraction and reduction of the joint using unilateral hinged external fixation and repair of the osseous stabilizers. A stable elbow was achieved in all patients, without the need of reconstruction of the collateral ligaments. At final follow-up, the average extension/flexion arc of motion was 107 degrees (range, from 100 degrees to 110 degrees ). The average MEPI score at follow-up was 93, and the average DASH score was 19. This is a promising treatment protocol for the treatment of chronically unreduced complex elbow dislocations to restore elbow stability and regain an excellent functional outcome.

Olecranon fracture fixation with a new implant: biomechanical and clinical considerations.

UNLABELLED: This study aims to describe the first clinical results in the treatment of dislocated olecranon fractures with 2.2-mm, fine-threaded wires with a washer. Furthermore, in the second part of the article, the stability of these new implants has been compared to standard tension band wiring in a sawbone model. PATIENTS: The radiological and clinical outcomes in 24 patients (mean age: 53.6 years) with 24 isolated Mayo type I and II fractures of the olecranon were evaluated in a prospective study after open reduction and internal fixation (ORIF) with a new fixation device (FFS; Orthofix). The quality of reduction with the implementation of 24 FFS constructions was compared with 24 tension band-wiring procedures performed by six different surgeons in a standard sawbone Mayo type IIa fracture model. Stability was tested in all constructs using a single cycle load to failure protocol (group I), cyclic loading for 300 cycles between 10 and 500 N (group II) and incremental sinusoidal loading from 10 to 200 N with an incremental increase of 10 N per cycle (group III) in a laboratory study. RESULTS: The Morrey elbow score was excellent in 23 patients and good in one patient, with mean DASH score of 1.6. No implant migration, secondary dislocation or nonunion was observed. In the sawbone model, the quality of reduction was the same with the FFS implants compared to the tension band wiring in the sawbone model. Here, bending moments in all three groups showed no significant difference, whereas displacement at failure was significantly greater in the tension band-wiring group at a single cycle load (p=0.017). CONCLUSION: Clinical results were comparable to tension band wiring and stability of the implants in the sawbone model was the same; thus, we conclude that the FFS technique can serve as an alternative treatment option for isolated olecranon fractures.

[Distraction arthrodiatasis in elbow stiffness]. / Die Distraktionsarthrolyse bei Arthrofibrose des Ellenbogengelenks.

OBJECTIVE: Loss of motion of the elbow is not uncommon after trauma, burns, or coma and severely impairs upper limb function. Loss of motion may be difficult to avoid and is challenging to treat. Detailed analysis of the etiology and diagnostic evaluation are of utmost importance for planning any surgical intervention for elbow stiffness. Most activities of daily living are possible, if the elbow has a range of motion of 100 degrees (30-130 degrees of flexion, Morrey's arc of motion). INDICATIONS: Stiff elbow, usually defined as less than 30 degrees extension or less than 130 degrees flexion. CONTRAINDICATIONS: Poor compliance, poorly controlled diabetes mellitus, active hepatitis B and C infection, HIV infection, acute articular infection. SURGICAL TECHNIQUE: Current operative techniques, such as closed distraction with external fixation (arthrodiatasis), are presented and evaluated. Elbow arthrolysis is a technically demanding procedure. POSTOPERATIVE MANAGEMENT: If indication and techniques are used correctly and surgeon, physiotherapist, and patient are familiar with the procedure, good long-term results may be achieved. RESULTS: In 14 children and adolescents the results after 5 years showed an increase of preoperative range of motion from 37 degrees to 108 degrees (flexion/extension; 75-130 degrees ) postoperatively.

Femoral bone tunnel placement using the transtibial tunnel or the anteromedial portal in ACL reconstruction: a radiographic evaluation.

Correct placement of the tibial and femoral bone tunnel is prerequisite to a successful anterior cruciate ligament (ACL) reconstruction. This study compares the resulting radiographic femoral bone tunnel position of two commonly used techniques for arthroscopically assisted drilling of the femoral bone tunnel: the transtibial approach or drilling through the anteromedial arthroscopy portal. The resulting bone tunnel position was assessed in postoperative knee radiographs of 70 patients after ACL reconstruction. Three independent observers identified the femoral bone tunnel and determined its position in the lateral and A-P view. Differences in femoral tunnel position between transtibial and anteromedial drilling were evaluated. In the sagittal plane, significantly more femoral bone tunnels were positioned close to the reference value using an anteromedial drilling technique (86%) when compared to transtibial drilling (57%). Drilling through the transtibial tunnel resulted in a significantly more anterior position of the femoral tunnel. In the frontal plane, femoral bone tunnels which were placed through the anteromedial arthroscopy portal displayed a significantly greater angulation towards the lateral condylar cortex (50.92 degrees ) when compared to transtibial drilling (58.82 degrees ). In conclusion, drilling the femoral tunnel through the anteromedial arthroscopy portal results in a radiographic femoral bone tunnel position which is suggested to allow stabilization of both anterior tibial translation and rotational instability when using a single bundle reconstruction technique. Further studies may evaluate if there are any clinical advantages using the anteromedial portal technique.