Does implant removal of superior clavicle plate osteosynthesis affect the functional outcome: a prospective trial.

BACKGROUND: Elective implant removal (IR) accounts for up to 30% of all orthopaedic surgeries. While there is general acceptance about the need of implant removal for obvious reasons, such as infections or implant failure, little is known about the beneficial aspects in cases of minor reasons such as patients' wish for IR. Therefore, we initiated this study to define patients' benefit of elective implant removal following plate osteosynthesis of displaced clavicle fractures. PATIENTS AND METHODS: Prospective evaluation of patients was conducted before implant removal and 6 weeks postoperative. Subjective and objective criteria included pain rating on a visual analogue scale (VAS) and active range of motion (ROM) pre- and 6 weeks postoperative. Functional scoring included Constant-Murley Score, DASH (Disabilities of Arm, Shoulder and Hand Score), MSQ (Munich Shoulder Questionnaire) and SPADI (Shoulder Pain and Disability Index). RESULTS: 37 patients were prospectively enrolled in this study and implant removal was performed after 16 ± 6.1 months. No re-fractures nor other complications were detected during routine follow up. Functional outcome increased through all scores (Constant score 73.3 ± 14.6 preoperative to 87.4 ± 12.0 postoperative (p = 0.000), MSQ 85.0 ± 7.3 preoperative to 91.8 ± 9.0 postoperative (p = 0.005), DASH Score 7.4 ± 8.2 preoperative to 5.7 ± 9.5 postoperative (p = 0.414), SPADI 93.4 ± 6.6 preoperative to 94.0 ± 10.1 postoperative (p = 0.734). CONCLUSIONS: Discomfort during daily activities or performing sports as well as limited range of motion were the main reasons for patients' wish for implant removal. We found increased functional outcome parameters and decreased irritation after implant removal. Therefore we suggest implant removal in case of patients' wish and completed fracture consolidation. TRIAL REGISTRATION: Trial registration no: NCT04343118, Retrospective registered: www.clinicaltrials.gov .

[Functional outcome of 111 metatarsal fractures following conservative in comparison to operative treatment]. / Funktionelles Outcome nach konservativer im Vergleich zu operativer Therapie von 111 Mittelfußfrakturen.

BACKGROUND: Fractures of the metatarsal bones are common injuries of the foot and particularly occur in patients aged 40-50 years. Especially multiple metatarsal fractures can lead to permanent limitations. Therefore, the aim of this study was to investigate the functional outcome of metatarsal fractures after conservative and surgical treatment using a validated self-reported patient-based outcome questionnaire. MATERIAL AND METHODS: All patients suffering from metatarsal fractures between 2003 and 2015 were enrolled in this retrospective analysis. The following data were collected: demographic data, AO classification, treatment, reoperation rate and the foot and ankle outcome score (FAOS). For outcome analysis, the nonparametric Mann-Whitney U­test and Fisher's exact test were performed. RESULTS: In total the functional outcome of 111 patients with metatarsal fractures were analyzed, 81 patients suffered of an isolated metatarsal fracture and 30 of multiple fractures. The mean age of the patients was 45 ± 15.2 years with a total of 48 men (43%) and 63 women (57%). Patients with an isolated metatarsal fracture had an FAOS of 88 ± 17.1, while patients with multiple metatarsal fractures achieved an FAOS of 78 ± 17.7 (p = 0.046). In the group of isolated metatarsal fractures 43 patients (53%) were surgically treated and of these 36 patients showed a type C fracture (84%). In the group of multiple metatarsal fractures 16 patients (53%) underwent operative treatment. CONCLUSION: Overall, the functional outcome of isolated metatarsal fractures following operative as well as conservative treatment is good to very good. Simple fractures can be successfully treated conservatively and complex multifragment fractures can be safely managed surgically. If more than one metatarsal bone is fractured, the functional outcome is significantly worse with patients reporting lasting limitations involving the range of motion and stiffness.

Patient reported outcome of 33 operatively treated talar fractures.

BACKGROUND: Management of talar fractures remains to be one of the most challenging aspects in trauma surgery. Unfortunately, the evidence regarding the correct treatment of these fractures is mainly based on retrospective case series, while studies assessing the patient-reported outcome are rare. Therefore, the aim of this trial was to analyze the patient reported outcome in context of trauma mechanism and concomitant injuries following operative treatment of talar fractures. METHODS: A retrospective outcome study of patients with operatively treated talar fractures between 2003 and 2015 was conducted. The fractures were classified according to AO-/Hawkins classification system and to the Marti-Weber classification. Data was collected via patient registry, radiographs and a validated patient-reported outcome measure (PROM) for foot and ankle pathologies (Foot and Ankle Outcome Score = FOAS). An analysis regarding the functional outcome, concomitant injury and timing of surgery using the nonparametric Mann-Whitney U test and Spearman`s rank correlation was performed. RESULTS: In total the functional outcome of 32 patients suffering from fractures to the talus were analyzed. The median age of the study cohort was 35±12.2 years, including 9 female (28 %) and 23 male (72 %) patients. The median FAOS score was 72±22.7 (range 13-94). Patients with an isolated talar fracture had an FAOS of 87±20 and with concomitant injury a score of 60±23.4 (p = 0.016). Patients with a closed talar fracture without emergency operation due to dislocation or polytrauma, showed no correlation between timing of surgery and FAOS (r= -0.17, p = 0.43). 10 % of the patients developed an avascular necrosis and 25 % showed signs of a posttraumatic arthritis. The follow-up time was 41 months (range: 16-145). CONCLUSIONS: Talar fractures were typically caused by high-energy trauma often associated with additional injuries of the lower extremity. The majority of the patients showed a fair to poor functional long-term outcome. Concomitant injuries of the lower extremity led to a lower FAOS. In closed talar fractures without the necessity of an emergency surgical intervention, time to surgery did not influence the patient reported outcome. Relating to the presented data, delayed surgery after soft tissue consolidation was not associated with a higher risk of developing an avascular necrosis.

Is early full weight bearing safe following locking plate ORIF of distal fibula fractures?

BACKGROUND: In the modern western world appraisal of economical points such as treatment and disability after trauma present a financial burden. In this context open reduction internal fixation techniques allowing for early full weight bearing might not only improve the clinical outcome but also shorten the period of disability in working life. The aim of the study was to analyze whether ORIF of ankle fractures using either a standard semitubular plate or a new polyaxial locking plate system result in a better clinical outcome. METHODS: In this prospective study, all patients with distal fibula fractures (AO 44 B1.1, B1.2, B1.3), with indication for surgery were included. Patients were randomized to either the DePuy Synthes® one-third semitubular plate (Group I) or NEWCLIP TECHNICS, Active Ankle® polyaxial locking plate (Group II). Primary outcome parameter was function of the ankle joint, assessed by the Olerud and Molander ankle score, Foot and Ankle outcome score and Karlsson and Peterson Scoring System for Ankle function. Secondary outcome parameter were postoperative complications. Superficial wound infection, delayed wound healing, mechanically prominent implant, skin irritations were considered as minor and deep wound infection, material loosening, loss of reduction were regarded as major complications requiring revision surgery. Clinical and radiological follow-up were performed 6 and 12 weeks, 6 months and 1 year postoperatively. RESULTS: Fifty-two patients (31 W/21 M) with a mean age of 43 yrs. (range 22-64 yrs.) were enrolled. Seven patients (13.5%) were excluded, so that 45 patients were available for follow up. Twenty-five patients were treated with DePuy Synthes® one-third semitubular plate (55.6%; group I) while 20 patients received an anatomically preformed polyaxial locking plate (44.4%, group II). Four minor complications occurred in Group I (16%) compared to two minor complications in group II (10%). Significant better clinical results regarding OMAS (p < 0.02, < 0.04), KPSS (p < 0.04) and FAOS (p < 0.02, < 0.03) were observed 6 and 12 weeks after surgery in group II. CONCLUSIONS: The results of the presented study demonstrate a significant better clinical functional outcome in the early postoperative follow-up in patients treated with a polyaxial locking plate. Furthermore, our data show that ORIF using polyaxial locking plates in combination with an early postoperative weight bearing presents a safe, stable treatment option for ankle fractures so that patients benefit especially in the early stages of recovery. TRIAL REGISTRATION: Registered 20 April 2020, retrospectively on ClinicalTrails.gov ( NCT04370561 ).

Validation of a new classification for periprosthetic shoulder fractures.

INTRODUCTION: Successful treatment of periprosthetic shoulder fractures depends on the right strategy, starting with a well-structured classification of the fracture. Unfortunately, clinically relevant factors for treatment planning are missing in the pre-existing classifications. Therefore, the aim of the present study was to describe a new specific classification system for periprosthetic shoulder fractures including a structured treatment algorithm for this important fragility fracture issue. METHODS: The classification was established, focussing on five relevant items, naming the prosthesis type, the fracture localisation, the rotator cuff status, the anatomical fracture region and the stability of the implant. After considering each single item, the individual treatment concept can be assessed in one last step. To evaluate the introduced classification, a retrospective analysis of pre- and post-operative data of patients, treated with periprosthetic shoulder fractures, was conducted by two board certified trauma surgery consultants. RESULTS: The data of 19 patients (8 male, 11 female) with a mean age of 74 ± five years have been analysed in our study. The suggested treatment algorithm was proven to be reliable, detected by good clinical outcome in 15 of 16 (94%) cases, where the suggested treatment was maintained. Only one case resulted in poor outcome due to post-operative wound infection and had to be revised. CONCLUSIONS: The newly developed six-step classification is easy to utilise and extends the pre-existing classification systems in terms of clinically-relevant information. This classification should serve as a simple tool for the surgeon to consider the optimal treatment for his patients.

Return to sports after plate fixation of humeral head fractures 65 cases with minimum 24-month follow-up.

BACKGROUND: Humeral head fractures requiring surgical intervention are severe injuries, which might affect the return to sports and daily activities. We hypothesize that athletic patients will be constrained regarding their sporting activities after surgically treated humeral head fractures. Despite a long rehabilitation program physical activities will change and an avoidance of overhead activities will be noticed. METHODS: Case series with 65 Patients, with a minimum follow-up of 24 months participated in this study. All patients were treated using a locking plate fixation. Their sporting activity was investigated at the time of the injury and re-investigated after an average of 3.83 years. The questionnaire setup included the evaluation of shoulder function, sporting activities, intensity, sport level and frequency evaluation. Level of evidence IV. RESULTS: At the time of injury 61 Patients (94%) were engaged in recreational sporting activities. The number of sporting activities declined from 26 to 23 at the follow-up examination. There was also a decline in sports frequency and duration of sports activities. CONCLUSION: The majority of patients remains active in their recreational sporting activity at a comparable duration and frequency both pre- and postoperatively. Nevertheless, shoulder centered sport activities including golf, water skiing and martial arts declined or were given up.

Mid-term outcome following revision surgery of clavicular non- and malunion using anatomic locking compression plate and iliac crest bone graft.

BACKGROUND: Treatment of clavicular non- and malunion is still challenging. Current surgical procedures often result in frustrating functional outcome along with high-grade subjective impairment and increased rates of revision surgery. However, the combination of biological augmentation with vital bone graft and a biomechanically sufficient fixation system seems to be a promising concept of treatment. METHODS: In this retrospective study, 14 patients with a mean age of 44 years (26-67 years) suffering from non-union (n = 11) and/or malunion (n = 3) of the clavicle were enrolled. All patients were surgically treated using an anatomical precontoured locking compression plate (LCP) and autologous iliac crest bone graft. Functional outcome was assessed using the age- and sex-specific relative Constant Score. RESULTS: Mean follow-up was 27 months (range 12-44 months). The relative Constant Score significantly improved from preoperative 61 ± 8 (43-72) to 82 ± 10 (65-100) points at the final follow-up examination (p < 0.05). All patients showed bony union radiographically. One patient presented with a re-fracture of the clavicle nearly 3 years after revision surgery and 5 weeks after implant removal. Secondary fractures at the donor site of the anterior superior iliac spine were recorded in two patients. CONCLUSIONS: Iliac crest bone graft and anatomic locking plate fixation allow for a safe and adequate stabilization and radiographical bony union in non- and malunions of the clavicle with a high degree of patient satisfaction. However, secondary fractures of the anterior superior iliac spine constitute relevant complications and the time of hardware removal should be considered carefully.

Polyaxial locking plates in treating distal humeral fractures: a comparative randomized trial for clinical outcome.

BACKGROUND: Management of distal humeral fractures remains to be one of the most challenging aspects in trauma surgery. Low profile plating systems with variable angle screw fixation represent a crucial advancement to the established angular stable locking plates with considerable attention in current research. The aim of the prospective randomized trial was to review the preliminary results and patients' outcome following treatment with these newly developed implants and to rule out potential differences in fracture treatment of two different plating systems. METHODS: Twenty patients with distal humeral fractures (AO 13-A1 - AO 13-C3) were included in the current study since 2014. After completing the randomization plan, patients were distributed into two groups for different variable angle locking plates (DePuy Synthes® VA-LCP vs. Medartis® Aptus Elbow). Functional elbow scoring (ROM, MEPS, QuickDASH) served as primary outcome parameter, while radiological fracture consolidation served as secondary outcome parameter. Follow-ups were conducted 6 weeks, 12 weeks, 6 months and 12 months after the operation. RESULTS: Seventeen of 20 patients (85%) concluded all follow-up examinations. Postoperative elbow extension deficiencies showed significant differences between the two groups in all follow-up examinations with a mean of Ø 18 +/- 7.4 degrees in the DePuy Synthes® VA-LCP group compared to a mean of Ø 6.5 +/- 7.5 degrees in the Medartis® Aptus Elbow group (p = 0.002) 12 months postoperatively. Functional scoring showed a disparate pattern. The Medartis® Aptus Elbow group achieved significantly better MEP scores during follow-up. However, the analysis of the QuickDash revealed better results of the DePuy Synthes® VA-LCP group in the first half and better results of the Medartis® Aptus Elbow group in the second half of the follow-up examination instead. CONCLUSIONS: Considering the complexity of distal humeral fractures, the usage of anatomically preshaped low profile variable angle locking plates for operative treatment leads to good clinical results. Even though there might be some advances of the Medartis® Aptus Elbow plating system concerning postoperative ROM and elbow function, a consistent difference in the overall clinical outcome between the two plating systems could not be detected. TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT03272490 Retrospectively Registered 1. September 2017.

The Elbow Self-Assessment Score (ESAS): development and validation of a new patient-reported outcome measurement tool for elbow disorders.

PURPOSE: To develop and validate an elbow self-assessment score considering subjective as well as objective parameters. METHODS: Each scale of the American Shoulder and Elbow Surgeons-Elbow Score, the Broberg and Morrey rating system (BMS), the Patient-Rated Elbow Evaluation (PREE) Questionnaire, the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score (OES) and the Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) was analysed, and after matching of the general topics, the dedicated items underwent a fusion to the final ESAS's item and a score containing 22 items was created. In a prospective clinical study, validity, reliability and responsiveness in physically active patients with traumatic as well as degenerative elbow disorders were evaluated. RESULTS: Validation study included 103 patients (48 women, 55 men; mean age 43 years). A high test-retest reliability was found with intraclass correlation coefficients of at least 0.71. Construct validity and responsiveness were confirmed by correlation coefficients of -0.80 to -0.84 and 0.72-0.84 (p <0.05). Correlation coefficients of the ESAS and well-established elbow rating systems BMS, PREE, MEPS, OES and Quick-DASH were between 0.70 and 0.90 (p < 0.05). CONCLUSIONS: With this novel Elbow Self-Assessment Score (ESAS), a valid and reliable instrument for a qualitative self-assessment of subjective and objective parameters (e.g. range of motion) of the elbow joint is demonstrated. Quantitative measurement of elbow function may not longer be limited to specific elbow disorders or patient groups. The ESAS seems to allow for a broad application in clinical research studying elbow patients and may facilitate the comparison of treatment results in elbow disorders. The treatment efficacy can be easily evaluated, and treatment concepts could be reviewed and revised. LEVEL OF EVIDENCE: Diagnostic study, Level III.

Concomitant intra-articular glenohumeral injuries in displaced fractures of the lateral clavicle.

PURPOSE: To detect concomitant intra-articular glenohumeral injuries, in acute displaced fractures of the lateral clavicle, initially missed due to unfeasible clinical evaluation of the acutely injured shoulder. METHODS: All patients suffering from an acute displaced lateral clavicle fracture with indication to surgical treatment underwent diagnostic shoulder arthroscopy prior to open reduction and internal fixation. In case of therapy-relevant intra-articular glenohumeral injuries, subsequent surgical treatment was performed. RESULTS: Intra-articular injuries were found in 13 of 28 patients (46.4 %) with initially suspected isolated lateral clavicle fracture. Additional surgical treatment was performed in 8 of 28 cases (28.6 %). Superior labral anterior-posterior (SLAP) lesions were observed in 4 of 28 patients (14.3 %; SLAP II a: 1; II b: 1; III: 1; and IV: 1). Lesions of the pulley system were found in 3 of 28 patients (10.7 %; Habermeyer III°). One partial articular supraspinatus tendon avulsion lesion (3.6 %) and one lesion of the subscapularis tendon (3.6 %; Fox and Romeo II°) were observed. CONCLUSIONS: Traumatic concomitant glenohumeral injuries in lateral clavicle fractures seem to be more frequent than expected in general. Subsequent surgical treatment of these formerly missed but therapy-relevant injuries may increase functional outcome and reduce complication rate. LEVEL OF EVIDENCE: IV.

Using an anatomically preshaped low-profile locking plate system leads to reliable results in comminuted radial head fractures.

INTRODUCTION: For comminuted and displaced fractures of the radial head open reduction and internal fixation (ORIF) is recommended nowadays as the treatment of choice. Due to the development of locking plates the possibilities of ORIF in complex fracture types were extended. The purpose of this retrospective survey therefore was to review the preliminary subjective and objective results in patients treated by anatomically preshaped locked plating. A reliable fracture healing for these recently introduced plating devices was hypothesized. MATERIALS AND METHODS: Subjective and objective criteria included patient's satisfaction, pain rating on a visual analogue scale (VAS) and active range of motion (ROM) compared to the contralateral armside. Functional scoring included the Morrey elbow performance score (MEPS), the QuickDASH and the elbow self-assessment score (ESAS). Furthermore, follow-up radiographs were reviewed. RESULTS: Between 2011 and 2014 a total of 24 patients were managed with ORIF using anatomically preshaped low-profile locking plates. All patients had suffered from comminuted radial head fractures (type III-IV according to Mason classification). Twenty of 24 patients returned for follow-up examination after a mean of 30 months (range 18-53 months). Patients' satisfaction was rated as highly satisfied in 17 cases and satisfied in 3 cases. An unrestricted ROM for extension-flexion arc and pronation-supination arc was rated in 10 cases. Minor ROM deficiencies with a 5° limited extension compared to the contralateral side was evaluated in 6 cases. Only four patients were rated with and extension and supination deficiency of 10°, one of whom with an additional pronation deficiency of 10°. The calculated MEPS was Ø 98 ± 4 (range 85-100), and the QuickDASH was Ø 3 ± 6 (range 0-21). The ESAS was completed by 18 patients with a mean of Ø 96.54 ± 2.95 (range 94-100) indicating a non-restricted elbow function. CONCLUSIONS: The treatment of comminuted radial head fractures using anatomically preshaped locking radial head plates represents a reliable and safe surgical approach, leading to good to excellent functional results. Being aware of the importance of the radial head for elbow stability, open reduction and internal fixation should be preferred prior to radial head resection or replacement in complex radial head fractures. Further trials with a higher number of patients are needed to confirm the advantages of preshaped radial head plates.

The Munich Wrist Questionnaire (MWQ) - development and validation of a new patient-reported outcome measurement tool for wrist disorders.

BACKGROUND: Although self-assessment questionnaires for the wrist joint are numerous, most validation studies focus on a specific pathology and patient collectives. In addition the available questionnaires focus on subjective parameters such as pain, usual and specific activities but the range of motion (ROM) as an essential objective parameter in wrist disorders is rarely considered. Therefore the purpose of the presented study was to develop and validate a new universally applicable self-assessment score, the Munich Wrist Questionnaire (MWQ), which allows for the assessment of subjective as well as objective parameters of the wrist joint. METHODS: The MWQ consists of 16 items addressing three domains: pain, work and activities of daily living and wrist function including range of motion and grip strength. In a prospective clinical study validity, reliability and responsiveness of the MWQ of physical active patients were evaluated. RESULTS: Validation study included 100 patients (mean age 41 years, SD 16.3 years; range, 18-77 years). Test-retest reliability was substantial, with intraclass correlation coefficients ranging from 0.75 to 0.83 for the three domains. Construct validity and responsiveness were confirmed by correlation coefficients of at least 0.86 for construct validity and for responsiveness ranging from 0.61 to 0.65. CONCLUSIONS: The MWQ presents a valid and reliable instrument for a qualitative self-assessment of subjective and objective parameters (e.g. range of motion) of the wrist joint. Quantitative measurement of wrist function may not longer be limited to specific wrist disorders or patient groups. The MWQ seems to allow for a broad application in clinical research and may facilitate the comparison of treatment results in wrist disorders.

Short- to long-term follow-up of total femoral replacement in non-oncologic patients.

BACKGROUND: Compromised bone stock and heavily impaired structural integrity after multiple endoprosthetic revision surgeries can lead to a comparable condition as encountered in musculoskeletal tumor surgery. Total femoral replacement (TFR) can restore femoral integrity and allow patients to resume ambulation. Even though several authors reported their results of TFR, so far many questions are still on debate: Which patients are at risk to experience low functional outcome? Do complications and clinical outcome after TFR depend on the indication for the surgery (e.g. periprosthetic fractures or aseptic loosening) or the age of the patients? The purpose of the present study was to compare complication rates after TFR performed with modular total femur prosthesis MML (Fa. ESKA/Orthodynamics) in patients without malignant disease. METHODS: We conducted a retrospective chart review and functional investigation of patients treated with a TFR for non-oncologic conditions from 1995 to 2015 and a minimum follow-up of 2 years. Complications were recorded according to the Henderson-Classification; outcome was evaluated with established clinical scores. The indication for TFR was periprosthetic fracture (Group A, n = 11) or aseptic loosening (Group B, n = 7) with massive bone defect of the femur deemed unsuitable for conventional arthroplastic or biologic reconstruction. RESULTS: Eighteen patients matched the inclusion criteria and could be investigated clinically after a mean follow-up of 80 months (range: 28-132). Before TFA, all patients had previously undergone multiple operations (range: 1-8). The overall failure rate for any reason was 72% (n = 13/18), leading to a total of 37 surgical revisions with total exchange of TFR in 22% (n = 4/18). Most common failure mechanism was Type I (soft tissue), followed by Type IV (infection) and Type III (mechanical failure). According to Enneking's functional evaluation method (MSTS-Score), the function ranged from 1 to 15 with a mean of 10 ± 4 out of 30. CONCLUSION: TFR is a salvage procedure to restore mechanical integrity and regain functional ability after extensive femoral bone loss. Outcome of the patients in the present study did mainly depend on the age at reconstruction and not on the indication for TFR.

Evaluation of a new imaging tool for use with major trauma cases in the emergency department.

BACKGROUND: The aim of this study was to evaluate potential benefits of a new diagnostic software prototype (Trauma Viewer, TV) automatically reformatting computed tomography (CT) data on diagnostic speed and quality, compared to CT-image data evaluation using a conventional CT console. METHODS: Multiple trauma CT data sets were analysed by one expert radiology and one expert traumatology fellow independently twice, once using the TV and once using the secondary conventional CT console placed in the CT control room. Actual analysis time and precision of diagnoses assessment were evaluated. The TV and CT-console results were compared respectively, but also a comparison to the initial multiple trauma CT reports assessed by emergency radiology fellows considered as the gold standard was performed. Finally, design and function of the Trauma Viewer were evaluated in a descriptive manner. RESULTS: CT data sets of 30 multiple trauma patients were enrolled. Mean time needed for analysis of one CT dataset was 2.43 min using the CT console and 3.58 min using the TV respectively. Thus, secondary conventional CT console analysis was on average 1.15 min shorter compared to the TV analysis. Both readers missed a total of 11 diagnoses using the secondary conventional CT console compared to 12 missed diagnoses using the TV. However, none of these overlooked diagnoses resulted in an Abbreviated Injury Scale (AIS) > 2 corresponding to life threatening injuries. CONCLUSIONS: Even though it took the two expert fellows a little longer to analyse the CT scans on the prototype TV compared to the CT console, which can be explained by the new user interface of the TV, our preliminary results demonstrate that, after further development, the TV might serve as a new diagnostic feature in the trauma room management. Its high potential to improve time and quality of CT-based diagnoses might help in fast decision making regarding treatment of severely injured patients.

Does a minimal invasive approach reduce anterior chest wall numbness and postoperative pain in plate fixation of clavicle fractures?

BACKGROUND: Fractures of the clavicle present very common injuries with a peak of incidence in young active patients. Recently published randomized clinical trials demonstrated an improved functional outcome and a lower rate of nonunions in comparison to non-operative treatment. Anterior chest wall numbness due to injury of the supraclavicular nerve and postoperative pain constitute common surgery related complications in plate fixation of displaced clavicle fractures. We recently developed a technique for mini open plating (MOP) of the clavicle to reduce postoperative numbness and pain. The purpose of this study was to analyze the size of anterior chest wall numbness and the intensity of postoperative pain in MOP in comparison to conventional open plating (COP) of clavicle fractures. METHODS: 24 patients (mean age 38.2 ± 14.2 yrs.) with a displaced fracture of the clavicle (Orthopaedic Trauma Association B1.2-C1.2) surgically treated using a locking compression plate (LCP) were enrolled. 12 patients underwent MOP and another 12 patients COP. Anterior chest wall numbness was measured with a transparency grid on the second postoperative day and at the six months follow-up. Postoperative pain was evaluated using the Visual Analog Scale (VAS). RESULTS: Mean ratio of skin incision length to plate length was 0.61 ± 0.04 in the MOP group and 0.85 ± 0.06 in the COP group (p < 0.05). Mean ratio of the area of anterior chest wall numbness to plate length was postoperative 7.6 ± 5.9 (six months follow-up 4.7 ± 3.9) in the MOP group and 22.1 ± 19.1 (16.9 ± 14.1) in the COP group (p < 0.05). Mean VAS was 2.6 ± 1.4 points in the MOP group and 3.4 ± 1.6 points in the COP group (p = 0.20). CONCLUSIONS: In our study, MOP significantly reduced anterior chest wall numbness in comparison to a conventional open approach postoperative as well as at the six months follow-up. Postoperative pain tended to be lower in the MOP group, however this difference was not statistically significant. TRIAL REGISTRATION: ClinicalTrials.gov NCT02247778 . Registered 21 September 2014.

Clinical and radiological outcome following treatment of displaced lateral clavicle fractures using a locking compression plate with lateral extension: a prospective study.

BACKGROUND: Treatment of lateral fractures of the clavicle is challenging and has been controversially discussed for a long time due to high non-union rates in non-operative treatment and high complication rates in surgical treatment. Acromioclavicular joint instability due to the injury of the closely neighbored coraco-clavicular ligaments can result in a cranialization of the medial clavicle shaft. A recently developed implant showed a promising functional outcome in a small collective of patients. METHODS: In this prospective study, 20 patients with a mean age of 40.7 ± 11.3 years with a dislocated fracture of the lateral clavicle (Jäger&Breitner I-III, Neer I-III) were enrolled. All patients were surgically treated using the locking compression plate (LCP) for the superior anterior clavicle (Synthes®). Functional outcome was recorded using the Munich Shoulder Questionnaire (MSQ) allowing for qualitative self-assessment of the Shoulder Pain and Disability Index (SPADI), of the Disability of the Arm, Shoulder and Hand (DASH) score and of the Constant Score. Acromioclavicular joint stability was evaluated using the Taft-Score. RESULTS: The mean follow-up was 14.2 ± 4.0 months. The mean MSQ was 87.0 ± 7.4 points, the mean SPADI 91.1 ± 11.3 points, the mean DASH score 7.6 ± 7.3 points and the mean normative age- and sex-specific Constant Score 85.6 ± 8.0 points. The mean Taft Score resulted in 10.7 ± 1.0 points. The mean Taft Score in lateral clavicular fractures with fracture gap between the coracoclavicular ligaments in combination with a rupture of the conoid ligament (J&B II a, Neer II B; n =11) was with 10.3 ± 0.9 points significantly lower than the mean Taft Score of all other types of lateral clavicle fractures (J&B I, II b, III; n =9) which resulted in 11.3 ± 0.9 points (p<0.05). CONCLUSIONS: The Synthes® LCP superior anterior clavicle plate allows for a safe stabilization and good functional outcome with high patient satisfaction in fractures of the lateral clavicle. However, in fractures type Jäger&Breitner II a, Neer II B a significant acromioclavicular joint instability was observed and additional reconstruction of the coracoclavicular ligaments should be performed. TRIAL REGISTRATION: ClinicalTrials.gov NCT02256059. Registered 02 October 2014.

[Surgical treatment of intra-articular calcaneus fractures with plate osteosynthesis via the sinus tarsi approach]. / Operative Versorgung intraartikulärer Kalkaneusfrakturen mittels Plattenosteosynthese über den Sinus-tarsi-Zugang.

OBJECTIVE: Surgical treatment of intra-articular calcaneus fractures via a minimally invasive approach. INDICATIONS: Intra-articular dislocated calcaneus fractures. CONTRAINDICATIONS: Fracture older than 14 days; poor soft tissue quality in the surgical area. SURGICAL TECHNIQUE: Patient in lateral position. Identifying the anatomic landmarks. Incision (3-5 cm) from the tip of the fibula to metatarsal IV. Preparation through the subcutis. Retraction of the peroneal tendons. Preparation of the lateral calcaneal wall and later plate position via raspatory. Placement of a Schanz screw in the calcaneal tuberosity from lateral or posterior as a reduction aid for restoring of the calcaneal length and reduction of the hindfoot varus. Reduction of the sustentaculum fragment with the help of fluoroscopy from lateral. Elevation of the subtalar articular surface. Positioning of the calcaneal plate and fixation of the sustentaculum fragment by placing a cannulated screw through the long hole. Afterwards, definite internal fixation of the reduction with locking screws. Completion of the operation with final X­rays and, if available, an intraoperative computed tomography. Wound closure with closing of the peroneal sheath. POSTOPERATIVE MANAGEMENT: Lower leg-foot orthoses. Mobilization with partial weight-bearing of the injured foot with 15 kg for 6-8 weeks; subsequently increased load bearing. RESULTS: Due to the smaller incision and the associated lower soft tissue trauma, the risk of wound healing complications can be reduced. Radiographic and functional outcomes are comparable to the outcomes of calcaneal fractures treated via the extended lateral approach.

Treatment strategies for complex ankle fractures-current developments summarized in a narrative review.

Background and Objective: Ankle fractures occur frequently in patients throughout all ages. Due to the many pitfalls associated with their treatment, complex ankle and especially tibial pilon fractures remain a challenge for surgeons. As there is still need for improvement in treating complex ankle fractures and treatment options are steadily increasing this review aims to summarize current practice and aims to highlight current developments by reviewing the literature. Methods: We conducted a thorough search of PubMed database in December 2022 to identify relevant articles on complex ankle and tibial pilon fractures. Articles in English and German were included in this study. Key Contents and Findings: Complication rates, especially wound infection are still high, emphasizing the need for careful preoperative planning. Soft tissue management is crucial to reduce complication rates and will often dictate the treatment plan utilized. Open reduction and internal fixation (ORIF) remains the treatment of choice. Nevertheless, in select cases alternative methods such as external fixation, tibiotalocalcaneal nailing or conservative treatment need to be considered as well. Furthermore, additional treatment options such as arthroscopically assisted surgery might help to improve functional outcome after complex ankle fractures. The incidence of complex ankle fractures in geriatric patients keeps rising with our aging population. This group of patients demands particular care and further high-quality studies are needed to warrant best results. Conclusions: However, more randomized controlled trials are need in order to enhance evidence of newly developed treatment options.

[Analysis of rising treatment cost of elevated BMI in patients with proximal femoral fracture]. / Analyse steigender Behandlungskosten bei erhöhtem BMI von Patienten mit proximaler Femurfraktur.

Driven by the aging population, the proximal femoral fracture is a rising fracture entity, challenging trauma surgeons as well as the German healthcare system as a whole. The rising average age of the population is accompanied by a rising BMI in the German population, resulting in longer operation times, longer average length of stay (ALOS) as well as more postoperative complications.The aim of this study was to demonstrate the economic correlation between body mass index and hospital costs. The retrospective analysis of 950 patient cases suffering from a proximal femoral fracture resulted in the finding of rising treatment costs being positively associated with rising BMI due to longer operation times and longer length of hospitalization (10,452 €, 11,505 €, 12,085 € and 13,681 € for patients with BMI < 18.5 kg/m2, BMI = 18.5-24.9 kg/m2, BMI = 25.0-29.9 kg/m2 and BMI ≥ 30.0 kg/m2, respectively).

High return to sports rates after operative treatment of patella fractures.

BACKGROUND: Patella fractures are relatively rare fractures and only little is known about the postoperative return to sports after patella fractures. METHODS: This retrospective study presents information on functional outcome after operative treatment of patella fractures as well as time until return to sports and patients' complaints after open-reduction internal-fixation (ORIF) of patella fractures. RESULTS: Overall, 39 patients after ORIF of patella fractures were evaluated at our Level-I trauma center with a mean follow-up of 42 months. The mean time until return to sports was 7 ± 3.9 months. No significant difference was found for functional outcome with respect to body mass index (BMI) or age. Fracture consolidation was accomplished after a mean of 6.9 ± 2.9 months besides a relatively low complication rate of 5.1% (n = 2). CONCLUSION: The results demonstrate a high return to sports rate of 90.3%. However, only 51.6% were able to perform sports on their pre-injury level or above. Trial Registration The study was retrospectively registered at DRKS (No: DRKS00031146).