Medical Library

[Comparison of the treatment of slipped capital femoral epiphysis with k-wires and cannulated titanium screws.]

AIM: The treatment of slipped capital femoral epiphysis (SCFE) is usually treated operatively, but there is still no consensus about the method to be used. Up to a 30 degrees degree of slipping, the epiphysis is normally fixed in situ. The aim of our study was to compare the intermediate results after fixation in situ by K-wires versus cannulated titanium screws (Königsee-Implantate, Königsee-Aschau, Germany). METHODS: In this study 46 patients with SCFE grade I and II and mostly chronic slipping of the epiphysis were included. After fixation in situ and, if necessary, careful, closed reposition, the patients were clinically and radiologically followed-up for one year. The clinical results were documented by the score adapted from Heyman and Herndon. Furthermore, MRI scans were done to evaluate the vitality of the epiphysis pre- and postoperatively, when titanium screws were used. RESULTS: Clinical follow-up showed comparable results in the clinical scores after fixation by K-wires or cannulated titanium screws (3.13 +/- 1.02 vs. 3.10 +/- 1.01). After the treatment with titanium screws we saw a higher rate of abnormal gait (33.3 % vs. 19 %), a decreased rate of the positive Drehmann sign (10 % vs. 38 %) and a lower rate of revisions (16 % vs. 50 %) in comparison to K-wire fixation. After displacement of the K-wires we saw chondrolysis and prearthrosis in one case. Removal of the K-wires was done without any complications, while the removal of the cannulated titanium screws failed in 4 of 10 cases. CONCLUSION: The treatment of SCFE with K-wires and cannulated titanium screws showed comparable results in the clinical follow-up. The treatment with cannulated titanium screws reduces the number of necessary revisions, but the removal of the material is hindered. Because of the lower rate of complications we prefer in the meantime the use of cannulated steel screws.

Maus U, Ihme N, Niedhart C, Abeler E, Kochs A, Gravius S, Ohnsorge JA, Andereya S.

Orthopädische Klinik, Universitätsklinikum der RWTH Aachen.

[Reliability of digital measurement of acetabular index in hip dysplasia to the time children start walking.]

AIM: An assessment of the reproducibility of the acetabular index on the basis of anteroposterior radiographs of the pelvis was performed in order to rule out residual dysplasia of the hip in the second year of life. METHOD: 51 consecutive patients (41 girls, 10 boys) with congenital dysplasia of the hip (35 bilateral, 16 unilateral) were included. Approximately at the time children started walking (mean age: 13.9 months; range: 10 - 22 months), digitised anteroposterior radiographs of the pelvis were recorded. Acetabular indices were measured bilaterally and blinded by two observers (O1 and O2), then classified according to the normal values of the hip joint described by Tönnis et al. (normal = lower single standard deviation [s], light dysplasia = above single standard deviation [s - 2 s] and severe dysplasie = above double standard deviation [2 s]). O2 repeated a second set of observations 6 weaks after the first. 306 values of the acetabular index (O1: 102 values; O2: 204 values) were statistically evaluated. Reliability was expressed by Pearson\’s correlation coefficient (PCC) and 95 % confidence interval. The rater agreement of the classification into normal values of the hip joint was calculated with the kappa coefficient. RESULTS: The PCC for intraobserver/interobserver reliability was 0.928/0.875. The 95 % confidence interval for intraobserver reliability was +/- 3.1 degrees and for interobserver reliability - 3.1 degrees /+ 5.9 degrees . A comparison of the first series of measurements by O1 with the series of measurements by O2 presented congruence in 66 of 102 hip joints classified according to the normal values of the hip joint as described by Tönnis. In 36 hip joints the classification was deviant, in 15 the classification differed between normal and s, in 21 between s and 2 s. The kappa coefficient of 0.51 showed moderate interobserver agreement. CONCLUSION: The reproducibility of radiological surveillance in congenital hip dysplasia, approximately to the time children start walking, can be considered as adequate. Correct positioning of the patient and exact definition of radiological landmarks are essential. In spite of good statistical values for reliability, decreasing accuracy in classifying into Tönnis\’ normal values of the hip joint is seen with increasing degree of dysplasia. In marginal cases, before coming to the decision for operative treatment, a second reading, ideally by the same observer and with a chronological shift, is advisable.

Dornacher D, Cakir B, Reichel H, Nelitz M.

Orthopädie, Orthopädische Universitätsklinik Ulm am RKU.

[The small-fragment double plate osteosynthesis in c1 to c3 fractures of the tibial pilon.]

Intra-articular fractures of the tibial pilon always have been a challenge for the surgeon and his operative technique. With conservative or operative management, we have to take care of destroyed articular surfaces and traumatised soft tissues. Therefore, tibial pilon fractures are known in the literature as complicated lesions with a high rate of complications. Between 1993 and 2001 twenty-one patients who were between 18 and 65 years old and suffered a monotrauma of the tibial pilon of the type C1 to C3 of the AO classification, were treated with a staged reconstruction. Stabilisation was done by small-fragment double plate osteosynthesis. In this retrospective study, we could review 17 patients clinically and radiologically and assess their outcome with the ankle hindfoot and the Bargon scores. In accordance with the ankle hindfoot score, there were 11 excellent and good results, 5 moderate and one poor. In accordance with the Bargon score, 41 % of the patients had a severe arthrosis, 24 % a moderate and 35 % a light to no arthrosis. Our results show that the small-fragment double plate osteosynthesis offers a high stability, allows careful soft tissue handling and can be done with a low ratio of complications. Long-term results are gratifying, although the radiological examinations often show a certain degree of arthrosis of the ankle joint.

Dietz SO, Müller-Bongartz F, Rommens PM.

Klinik und Poliklinik für Unfallchirurgie, Klinikum der Johannes-Gutenberg-Universität Mainz.

[2D-Fluoroscopic Navigated Screw Osteosynthesis of Acetabular Fractures: A Preliminary Report.]

INTRODUCTION: The current gold standard for operatively treated acetabular fractures is open reduction and internal fixation. In this study we report the early results of percutaneous screw osteosynthesis of acetabular fractures in 14 cases, using a computer navigation system to reduce screw misplacement, approach associated risks and radiation exposure. RESULTS: All 36 acetabular screws were placed correctly without any perioperative complication. The mean operation time per screw was 54 min, the mean fluoroscopic time per screw was 87 s. In the follow-up examinations (current rate: 71 %, mean follow-up: 13.1 +/- 1.8 months) no fixation failure or development of post-traumatic osteoarthritis was seen. One wound infection occured. CONCLUSION: Our first experience with this novel approach is promising and serious advances of fluoroscopic navigated percutaneous screw osteosynthesis of well selected acetabular fractures can be expected.

Gras F, Marintschev I, Mendler F, Wilharm A, Mückley T, Hofmann GO.

Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Klinikum der Friedrich-Schiller-Universität Jena.

[Parkinson\’s disease influences the perioperative risk profile in trauma patients.]

AIM: Parkinson\’s disease (PD) is one of the most common degenerative diseases of the central nervous system affecting elderly patients with increasing demographic prevalence. The aim of this study was to define the perioperative risk profile in trauma patients suffering from Parkinson\’s disease in order to improve treatment options in these patients. METHOD: Over a period of 13 years, 16 patients suffering from Parkinson\’s disease treated in the department of trauma surgery were retrospectively compared using matched-pair analysis with 16 controls not affected by PD. Both groups of patients were assessed regarding morbidity, length of treatment and rehabilitation. RESULTS: Trauma patients suffering from Parkinson\’s disease showed an increase in morbidity risk. Postoperative falls occurred significantly, infections of the urinary tract and pneumonia tendentiously more often in PD patients. Postoperative stay and length of treatment were significantly longer in patients with PD. These patients also tended to stay longer preoperatively and remained longer in intensive care. PD patients required on-ward rehabilitation significantly more often. CONCLUSION: Concomitant Parkinson\’s disease is a significant factor of perioperative morbidity in trauma patients. Perioperative morbidity in PD patients may be influenced by early diagnostic and therapeutic measures.

Müller MC, Jüptner U, Wüllner U, Wirz S, Türler A, Wirtz DC, Hirner A, Standop J.

Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn.

[Clinical Results after Replacement of Comminuted Radial Head Fractures (Mason III and IV) by the Bipolar Radial Head Prosthesis of Judet.]

AIM: Long-term results after resection of comminuted fractures of the radial head (Mason III and IV) may lead to valgus elbow instability, radius proximalisation and rotatory instability. Radial head replacement has been used to prevent and treat these complications. The aim of this study was to define the value of the bipolar radial head prosthesis of Judet for treating comminuted fractures of the radial head. METHOD: Over a 5-year period, 14 radial head prosthesis were implanted in 12 patients. Retrospectively, we studied the clinical and radiological results. RESULTS: Eleven patients with thirteen implants were analysed at a mean follow-up of 33.4 +/- 20.4 months. In all patients, the elbow was stable. Subjectively, we found good and excellent results with one exception. Compared to the pre-trauma status, the subjective rate was 78 +/- 12 %. According to the score of Radin and Riseborough, five of the results were found to be good and eight to be fair. According to the Broberg and Morrey score, one result was found to be very good, seven to be good and five to be fair. The mean DASH score was 10.2 +/- 10.1 points. Two temporary nerve lesions were observed. CONCLUSION: In comminuted fractures of the radial head (Mason III and IV), bipolar radial head replacement with the Judet prosthesis leads subjectively to very good and good and functionally to good and fair results on the medium-term view. Joint stability is achieved and secondary complications like valgus elbow deformity and proximal radial migration are prevented. Patients must be informed about the possibility of temporary nerve lesions, heterotopic ossification causing limitation of motion and the lack of long-term results.

Müller MC, Burger C, Striepens N, Wirtz CD, Weber O.

Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn.

[Reconstruction of the rotational centre of the humeral head depending on the prosthetic design.]

AIM: The displacement of the rotation centre of the humeral head in relation to the axis of the shaft varies strongly between individuals. The Affinis shoulder endoprosthesis has a double excentric adjustment possibility that permits us to adapt the head to the medial and dorsal offset. So far, such examinations have taken place exclusively on anatomic preparations. This raises the question of whether the need for such a prosthetic system can be derived from the anatomic variation of the pivot points. METHOD: In 49 patients with an implanted Affinis shoulder prostheses, we calculated the individual rotation centres of the head from the position of the relocatable prosthetic cone and the excentric position of the head. In addition, we used the Constant score to record the clinical function. RESULTS: In the examined case material, we needed the entire setting range of 12 mm mediolateral and 6 mm dorsoventral of the prosthesis, as it presented a great variation of the rotational centres of the head. The majority of the head centres were displaced in a posterior-lateral direction. The examination showed that none of the found anatomic head centres could have been reconstructed exactly with a conventional prosthesis. Prostheses with a single excentricity would allow correct adjustment in only 9 cases, as the adjustable rotational centres of the head are situated in an orbit, which limits the setting possibilities. In 20 of the 49 patients humeral head prosthesis were implanted in cases of primary osteoarthritis. The Constant score of this group improved from 18 points preoperatively to 76 points after 24.1 months in the mean. CONCLUSION: The high variation of the head centres indicates the necessity of a freely adjustable system, such as in a double excentric bearing. This is a way that permits an optimal reconstruction of the anatomic conditions. Therefore all technical chances for bony balancing should be used to adapt the prosthesis to the bone and not the bone to the prosthesis.

Irlenbusch U, Rott O, Gebhardt K, Werner A.

Orthopädische Klinik, Marienstift Arnstadt.

[Shoulder resurfacing in patients with rotator cuff arthropathy and remaining subscapularis function.]

INTRODUCTION: Glenohumeral arthritis with a massive rotator cuff tear is a devastating condition that seriously compromises the comfort and function of the shoulder. Cuff tear arthropathy presents a unique surgical challenge and many arthroplasty options were used for its treatment. The purpose of this study was to evaluate the clinical and radiological results of Copeland cementless surface replacement arthroplasty (CSRA) applied in patients with cuff tear arthropathy and intact subscapularis function. PATIENTS AND METHODS: The study was conducted on twenty-five shoulders in twenty-five patients with cuff tear arthropathy with the subscapularis tendon still intact. The patients were prospectively followed-up clinically and radiologically for a mean of 26 months (range: 15 - 38 months). There were 16 female and 9 male patients. The mean age was 69.04 years (range: 53 - 83 years). The mean operative time was 38 minutes (range: 28 - 56 minutes). The clinical assessment was performed with the Constant score. RESULTS: The Constant score significantly improved from a mean of 14.04 points preoperatively to 53.17 points postoperatively. Of the patients, 88 % considered the shoulder to be much better or better as a result of the operation. Radiologically, the humeral offset, the lateral glenohumeral offset (coracoid base to the greater tuberosity), height of centre of instant rotation and the acromiohumeral distance were significantly increased. No intra- or postoperative complications were encountered. CONCLUSION: Our early results with the use of Copeland surface replacement in selected cases with cuff tear arthropathy are encouraging. The patients showed significant clinical (pain and range of motion) and radiological improvements. Moreover, if the surface replacement were to fail for any reason, it can be revised to a reverse prosthesis type as there is no lack of bone stock.

Jerosch J, Schunck J, Morsy MG.

Klinik für Orthopädie und Unfallchirurgie, Johanna-Etienne-Krankenhaus, Neuss.

[Influence of the Surgical Approach on Postoperative Rehabilitation after TKA.]

BACKGROUND: Minimising the soft tissue trauma and early rehabilitation are among the major aims using the MIS technique in joint replacement. AIM: The aim of this prospective randomised study is to compare the results after TKA using an MIS approach versus a standard approach. METHOD: We compared 30 TKA using a mini-midvastus approach (MIS group) with 30 conventionelly performed TKA using a midvastus approach (control group). In all cases the same implants (NexGen LPS) were used. The Knee Society score (KSS), an activity score, the visual analogue scale, myoglobin and creatinine kinase as well as the blood loss were measured up to 12 weeks postoperatively. Implant positioning was evaluated using the Knee Society Roentgenographic evaluation and scoring system. RESULTS: Advantages of the MIS group were measured in KSS and activity score up to 12 weeks postoperatively. The increase of myoglobin and creatinine kinase was lower in the MIS group up to 24 hours or 72 hours, respectively. No differences were found comparing the implant positioning and blood loss. CONCLUSION: The MIS technique in TKA with minimisation of the soft tissue trauma leads to better clinical and functional results in the early postoperative time and does not modify the implant positioning.

Wohlrab D, Gutteck N, Hildebrand M, Zeh A, Hein W.

Zentrum für Erkrankungen der Haltungs- und Bewegungsorgane, Klinik und Poliklinik für Orthopädie , und Physikalische Medizin, Martin-Luther-Universität Halle-Wittenberg, Halle.

[Radiological Mid-term Results of Total Knee Arthroplasty with Femoral Components of Different Materials.]

AIM: The present work aimed at evaluating the radiological mid-term results of femoral components of different materials in an identically designed total knee system. METHOD: 31 knees with zirconium femoral components and 32 standard femoral components were evaluated about 4 years following surgery using the Roentgenographic Evaluation and Scoring System of the Knee Society. RESULTS: In both groups, the implant position was correct. There was a statistically significant higher rate of radiolucent lines in zones 1 and 4 at the tibia site in the zirconium group. CONCLUSION: Our clinical results disagree with the results of biomechanical studies of the same type of prosthesis. However, there are some findings from animal studies showing that zirconium ions may inhibit the mineralisation of osteoid, which could be an explanation for the higher rate of radiolucent lines seen in the present study.

Göbel F, Ulbricht S, Hein W, Bernstein A.

Zentrum für Erkrankungen und Verletzungen der Haltungs- und Bewegungsorgane (ZHBO), Martin-Luther-Universität Halle-Wittenberg, Halle.