Exoskelettales Rehabilitationstraining bei Querschnittgelähmten

Background

Treatment of midshaft clavicle fractures underwent a fundamental change from nonoperative towards surgical therapy. The process of fracture consolidation is protracted and therapy is susceptible to complications.

Risk factors for complications

Recent studies provided evidence of poor results after nonoperative treatment of displaced fractures and identified risk factors for complications. The main complications leading to revision surgery are malunion with clavicle shortening and nonunion. Patients often complain about discomfort from implanted hardware and hypaesthesia due to the surgical approach.

Aim of this article

This article describes diagnostic steps and the classification of midshaft clavicle fractures as well as the planning of the therapeutic concept.

Treatment

Nonoperative treatment nowadays is considered the therapeutic standard for undisplaced fractures only. Displaced and multifragmentary fractures are treated by open reduction and internal plate fixation; simple fracture patterns can be fixed internally by elastic nails. Revision surgery of midshaft clavicle nonunion involves autologous spongiosa graft. Complex and chronic cases of osteitis with large bone defects may require specialized procedures such as free vascularized fibula grafts or corticoperiosteal bone graft.     

Acute midshaft clavicular fracture

Clavicular fractures represent 2.6% to 5% of all fractures, and middle third fractures account for 69% to 82% of fractures of the clavicle. The junction of the outer and middle third is the thinnest part of the bone and is the only area not protected by or reinforced with muscle and ligamentous attachments. These anatomic features make it prone to fracture, particularly with a fall on the point of the shoulder, which results in an axial load to the clavicle. Optimal treatment of nondisplaced or minimally displaced midshaft fracture is with a sling or figure-of-8 dressing; the nonunion rate is very low. However, when midshaft clavicular fractures are completely displaced or comminuted, and when they occur in elderly patients or females, the risk of nonunion, cosmetic deformity, and poor outcome may be markedly higher. Thus, some surgeons propose surgical stabilization of a complex midshaft clavicular fracture with either plate-and-screw fixation or intramedullary devices. Further randomized, prospective trials are needed to provide better data on which to base treatment decisions.     

Displaced mid-shaft clavicular fractures: surgical treatment with intramedullary screw fixation

Introduction

Clavicle fractures account for around 4 % of all fractures and up to 44 % of fractures of the shoulder girdle. Fractures of the middle third account for approximately 80 % of all clavicle fractures. Management of mid-shaft clavicular fractures is often challenging and the outcome can be unsatisfactory.

Materials and methods

We prospectively evaluated 20 patients (16 males and 4 females) with an average age of 31 years (range 18–50 years) presented with fresh mid-shaft clavicular fractures who underwent open intramedullary fixation using a 6.5 partially threaded cancellous screw. The screw was inserted from the lateral fragment after retrograde drilling of that fragment. Average follow-up period was 16 months (range 10–24).

Results

All cases united within 7–9 weeks (mean 8.2). Superficial infection was observed in one patient, three experienced decreased sensation over the site of incision, and four had symptoms of frozen shoulder.

Discussion and conclusion

The technique is safe, simple, reliable method for fixation of displaced mid-shaft clavicle fractures with minimal complications and excellent functional outcomes. No complaints or indications for hardware removal after fractures healing.     

Konservative und operative Therapie der Klavikulaschaftfrakturen

Nonoperative treatment, e.g. with a sling or a figure-of-eight bandage, has so far been considered to be the gold standard for midshaft clavicle fractures even when substantial displacement has been present. However, more recent studies have shown poorer results following nonoperative treatment of dislocated clavicle fractures compared with operative treatment. The main reasons are a higher nonunion and shortening rate of displaced midshaft fractures, which often result in poor functional outcome and low patient satisfaction. Operative methods, e.g. locking plates or intramedullary fixation technique have proven to have much better outcome in the treatment of midshaft clavicle fractures with displacement and comminution than conservative methods. Adults with a displaced midshaft fracture have for example a nonunion rate of up to 15% after conservative therapy whereas it is 2–3% after operative treatment. The traditional view that clavicular midshaft fractures no matter what grade of dislocation and what type of fracture should be treated conservatively is no longer valid today. Instead possible complications and risks of the conservative and operative treatment always have to be taken into account and weighed individually for therapy decision-making in the clinical routine. The analysis of current studies shows that patients with dislocated comminuted fractures benefit from surgery.     

Factors associated with avascular necrosis of the femoral head and nonunion in patients younger than 65 years with displaced femoral neck fractures treated with reduction and internal fixation

Introduction

Few studies have evaluated treatment of displaced femoral neck fractures in patients younger than 65 years, and risk factors for AVN or nonunion have not been clearly delineated within this age range.

Method

To determine factors associated with avascular necrosis of the femoral head (AVN) and nonunion in patients younger than 65 years with displaced femoral neck fractures treated with reduction and internal fixation, we conducted a retrospective study of 29 displaced femoral neck fractures in 29 consecutive patients treated at a single institution. The influence of age, trauma energy, open reduction, and time from fracture to treatment on development of AVN and nonunion was evaluated.

Results

Patients who developed AVN were significantly older and suffered lower energy trauma than cases without AVN. No recorded variables were associated with nonunion. Logistic regression determined that only age was independently associated with AVN. Age was a good predictor for developing AVN, with a C statistics of 0.861, and a best cutoff determined at 53.5 years.

Conclusion

Patients between 53.5 and 65 years presented a higher risk of AVN. A primary arthroplasty should be considered in this subgroup.     

Schultergelenknahe knöcherne Verletzungen beim Snowboarden

Background

The fracture of the clavicle is the second most common fracture in snowboarding after the distal radius fracture. Nonsurgical treatment is frequently the treatment of first choice. For displaced fractures, surgical treatment is recommended.

Methods

In general, internal fixation can be performed with a plate osteosynthesis or an intramedullary nail. Clinical studies were able to show similar and even slightly better functional results of the intramedullary nail in comparison to plate osteosynthesis. Because of less surgical trauma and better cosmetic results, intramedullary systems are increasingly preferred.

Results

Lateral clavicular fractures are more complex regarding surgical treatment due to their potential for concomitant ligamentous injuries. The hooked plate shows good clinical results with the advantage of addressing the fracture as well as the ligament injury in one step. The limitation of mobility during the first few postoperative weeks is the technique’s main disadvantage.

Conclusions

Ligament reconstruction with suture pulley systems as a stand-alone treatment or in combination with a locking plate osteosythesis are increasingly used due to their excellent clinical results with early postoperative mobilization.     

Single-bone intramedullary fixation of unstable both-bone diaphyseal forearm fractures in children leads to increased re-displacement: a multicentre randomised controlled trial

Introduction

Both-bone diaphyseal forearm fractures in children can be stabilised without cast by a flexible intramedullary nail in both the radius and the ulna. Adequate results with single-bone fixation combined with a complementary cast are also reported. However, because those results are based on a selection of children, this trial investigates whether single-bone intramedullary fixation, compared with both-bone intramedullary fixation, results in similar pronation and supination in children with an unstable diaphyseal both-bone forearm fracture.

Materials and methods

In four Dutch hospitals, 24 consecutive children aged <16 years with a displaced unstable both-bone diaphyseal forearm fracture were randomly allocated to single-bone or both-bone intramedullary fixation. Primary outcome was limitation of pronation and supination 9 months after initial trauma. Secondary outcomes were limitation of flexion/extension of wrist/elbow, complication rate, operation time, cosmetics of the fractured arm, complaints in daily life, and assessment of radiographs.

Results

Between January 2006 and August 2010, 11 children were randomised to single-bone fixation and 13 to both-bone fixation. In the both-bone fixation group, two fractures were stabilized by only one nail. In both groups, median limitation of pronation/supination at 9-month follow-up was 5°–10°. In both groups operation time was similar but in the single-bone fixation group cast immobilisation was longer (median of 37 vs. 28 days). In four children, re-displacement of the fracture occurred in those fractures without an intramedullary nail.

Conclusions

These results caution against the use of single-bone fixation in all both-bone forearm fractures. This method may lead to increased re-displacement and reduced clinical results.     

Operative versus nonoperative treatment for displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials

Introduction

There is insufficient evidence to indicate whether operative or nonoperative treatment is better for treating displaced midshaft clavicular fractures. We undertook a systematic review and meta-analysis of randomized controlled trials (RCTs) to compare the effects of the two treatments.

Methods

We searched the PubMed, EMBASE and Cochrane Library databases, and identified RCTs to compare the Constant score, DASH score, nonunion, malunion, and adverse events between operative and nonoperative groups of patients with displaced midshaft clavicular fractures.

Results

A total of 507 patients from 6 RCTs were subjected to meta-analysis. Operative treatment has an effect on improving function, which is demonstrated by significantly higher Constant scores (P = 0.0003) and lower DASH scores (P = 0.03). The rate of nonunion and the rate of malunion were significantly lower in operative group compared with that in nonoperative group (both P < 0.0001). However, the rate of adverse events was significantly higher in operative group compared with that in nonoperative group (P = 0.003).

Conclusions

Operative treatment provided a significantly better functional outcome, a lower rate of nonunion and malunion, but was accompanied with a higher rate of adverse events. However, the results should be interpreted with caution and further large-scale, well-designed RCTs on this topic are still needed.     

Pertrochanteric fractures: tips and tricks in nail osteosynthesis

Introduction

Intramedullary fixation of intertrochanteric fractures has become the standard method of fixation especially in unstable fracture types. Even though there have been developments on implant design and technology, the surgical technique of reduction and implant positioning remains the mandatory factor in treating these fractures successfully. The advantages of nailing in the mainly elderly patients sustaining intertrochanteric femur fractures are a short lever arm and a lateral support in the trochanter supplied by the nail. The disadvantages are that it is often harder to achieve a closed reduction of a displaced fracture and to maintain the reduction with the intramedullary implant.

Tips and tricks

To obtain and maintain anatomic reduction and a secure fracture fixation, the surgical approach and fixation technique is of great importance. It starts with correct patient positioning, fracture reduction (accounting for varus dislocation and dislocation of flexed fragments), choosing the correct nail entry point and perfect lag screw positioning within the head-neck fragment and distal locking. To maintain the reduction achieved intraoperatively, the decision has to be made to use a cerclage wiring or to tolerate fracture gaps in the metaphyseal area. Intraoperative controlled compression of the neck or the subtrochanteric area is of great importance to reduce delayed unions or nonunions.

Summary

Intramedullary fixation of unstable per-, inter- or subtrochanteric fractures shows biomechanical advantages compared to extramedullry fixation techniques. Even though there have been several amendments and developments of implants, a better implant does not compensate for an inadequate surgical approach or deficient surgical techniques which are paramount for successful treatment. When fixing fractures with intramedullary nailing systems, the surgeon should always try to achieve anatomic reduction and a perfect implant positioning to allow immediate full weight bearing without an increased risk of cut-out, non-union and implant failure.     

Targon® Femoral Neck for femoral-neck fracture fixation: lessons learnt from a series of one hundred and thirty five consecutive cases

Purpose

Internal fixation versus joint replacement for treating intracapsular hip fractures is still a major debate. The Targon® FN fixation concept is innovative; two small case series are promising. We present the first larger series.

Methods

We conducted prospective documentation of all Targon® FN cases since 2006. The implant was used for all undisplaced fractures, and for displaced fractures in patients of a biological age ≤60 years. Besides demographic data and fracture classification, we analysed infection, haematoma, implant perforation, nonunion and operative revision procedures.

Results

In 135 cases (mean age 71 years; average operation time 60 minutes; average hospital stay ten days), we found a surgical complication rate of 16.4 %. Conversion to joint replacement was necessary in 9.6 %. Complication rate was significantly higher in displaced fractures.

Conclusions

Our study confirms low general complication rates. However, implant perforation seems to be underestimated. Optimised reduction technique may help to reduce this complication.     

Surgical fixation of displaced midshaft clavicle fractures: elastic intramedullary nailing versus precontoured plating

Background

This prospective comparative study was done to evaluate the effectiveness of implants of different design (titanium elastic intramedullary nail versus anatomical precontoured dynamic compression plate) in treatment of displaced midshaft clavicular fractures.

Materials and methods

Sixty-six patients between 18 and 65 years of age were included in this study. They were randomized in two groups to be treated with either elastic intramedullary nail (EIN) or plate. Clinical and radiological assessments were performed at regular intervals. Outcomes and complications of both groups over 2 years of follow-up time were compared.

Results

Length of incision, operation time, blood loss and duration of hospital stay were significantly less for the EIN group. American Shoulder and Elbow Surgeons (ASES) and Constant Shoulder scores were significantly higher (p < 0.05) in the plating group than the EIN group for the first 2 months but there was no significant difference found between the two groups regarding functional and radiological outcome at the 2-year follow-up. Significantly higher rates of refracture after implant removal (p = 0.045) in the plating group was observed. Infection and revision surgery rates were also higher in the plate group, but this difference was insignificant (p > 0.05).

Conclusions

EIN is a safe, minimally invasive surgical technique with a lower complication rate, faster return to daily activities, excellent cosmetic and comparable functional results, and can be used as an equally effective alternative to plate fixation in displaced midshaft clavicle fractures.

Level of evidence

Level 2.     

Plate versus titanium elastic nail in treatment of displaced midshaft clavicle fractures: A comparative study

Background:

With changing trends in treatment of displaced midshaft clavicle fractures (DMCF), plating remains the standard procedure for fixation. An attracting alternative method of fixation is the titanium elastic nailing (TEN). However, prospective randomized studies comparing the two methods of fixation are lacking. We assessed the effectiveness of minimally invasive antegrade TEN and plating technique for the treatment of DMCF.

Materials and Methods:

80 unilateral displaced midclavicular fractures operated between October 2010 and May 2013 were included in study. This prospective comparative study was approved by the local ethical committee. Followups were at 2^nd and 6^th weeks and subsequently at 3, 6, 12, 18 and 24 months postoperatively. Primary outcome was measured by the Constant score, union rate and difference in clavicular length after fracture union. Secondary outcome was measured by operative time, intraoperative blood loss, wound size, cosmetic results and complications.

Results:

During analysis, we had 37 patients in the plate group and 34 patients in the TEN group. There was no significant difference in Constant scores between the two groups. However, faster fracture union, lesser operative time, lesser blood loss, easier implant removal and fewer complications were noted in the TEN group.

Conclusion:

The use of minimally invasive antegrade TEN for fixation of displaced midshaft clavicle fractures is recommended in view of faster fracture union, lesser morbidity, better cosmetic results, easier implant removal and fewer complications; although for comminuted fractures plating remains the procedure of choice.     

Klavikulaschaftfrakturen

Background

The objective of this systematic review was to summarize the current evidence on efficacy and safety of the various treatment options for midshaft clavicle fractures, taking into account fracture type and other variables.

Material and methods

A search for systematic reviews and controlled studies published between 1998 and 2009 was carried out.

Results

There is moderate evidence that operative treatment for midshaft clavicle fractures results in a lower rate of fracture non-union and improved patient-oriented outcome compared to non-operative treatment. However, because union rates are generally high and there are complications which are unique to surgical intervention, risks have to be considered and weighed before a decision on treatment is made. The most important risk factors for non-union are major displacement and fracture comminution. Of all surgical procedures the best evidence of efficacy is presently available for plate fixation and elastic stable intramedullary nailing.

Conclusion

This paper presents an algorithm derived from the current evidence which may be useful for therapy decision-making in the clinical routine.     

Predictors associated with nonunion and symptomatic malunion following non-operative treatment of displaced midshaft clavicle fractures—a systematic review of the literature

Purpose

The aim of this study was to survey existing literature in order to identify all reported predictors associated with nonunion or symptomatic malunion in adult patients with displaced midshaft clavicle fractures treated non-operatively.

Method

A systematic literature search in Medline was carried out in order to identify publications in English, reporting on predictors for nonunion and malunion in adults with displaced midshaft clavicle fractures. After applying inclusion and exclusion criteria, eight publications were included in this systematic review.

Results

A total of 2,117 midshaft clavicle fractures were included in the eight publications. All publications reported on predictors for nonunion but none were found to report on predictors for malunion. The studies were characterized by different definitions for nonunion and symptomatic malunion if at all present. A total of 13 potential factors associated with nonunion were identified, six of these (displacement, comminution, shortening, age, gender and smoking) were reported as predictors for nonunion. Outcome definitions varied among the studies.

Conclusion

The included publications varied greatly in design, sample size, and quality. Based on the present literature most of the predictors were found to be of limited evidence, however displacement seems to be the most likely factor that can be used to predict for nonunion. Treating all clavicle fractures with displacement surgically would inevitably lead to overtreatment, which is why future studies need to focus on predictive factors in order to differentiate between patients that would benefit from surgery and those who would not.     

A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN)

Introduction

The aim of this study was to present clinical experience and outcomes of intramedullary nailing of proximal, midshaft and distal tibia fractures with the Expert Tibia Nail (ETN; Synthes GmbH, Switzerland), an implant offering a wide range of proximal and distal locking options in multiple planes to increase stability of the implant and bone construct.

Patients and methods

180 patients with 185 tibia fractures were enclosed between July 2004 and May 2005 from ten trauma units (Levels I, II and III) and treated with intramedullary reamed and unreamed nailing with the ETN. Patients attended examinations at 12?weeks and 1?year. The occurrence of postoperative complications was documented as well as the outcomes of fracture healing, primary and secondary malalignment, implant failure, rate of infection and the need for reoperation.

Results

The 1-year follow-up rate was 81?%. At 1?year, the prevalence of delayed union was 12.2?% and higher for open fractures (18.2?%) compared to closed fractures (9.7?%). According to the fracture location, the percentage of delayed union was 5.9, 16.7 and 10.5?% in proximal third, midshaft and distal third cases, respectively. Patients with a plated fibula fracture had an eightfold higher risk of delayed union. The rate of malalignment >5° in any plane 1?year after surgery was 5.5?%. Proximal third fractures were at a higher risk of postoperative malalignment (17.6?%). The rate of secondary malalignment was 1.4?%. The risk of unplanned reoperation was 9.2?%.

Conclusion

Intramedullary ETN fixation of tibia fractures results in low rates of delayed union, primary and secondary malalignment, implant-related complications, and secondary surgery. Fibula plating had a negative effect on the healing of the tibia.     

Clinical outcomes and prognostic factors of ipsilateral hip and femoral shaft fractures

Introduction

The aim of this study was to analyze prognostic factors by investigation of the diagnostic process and clinical outcomes in patients with surgical management of ipsilateral hip and femoral shaft fractures.

Methods

Between August 1995 and January 2012, 26 cases who underwent fixation of ipsilateral fractures of hip and femoral shaft were reviewed. We evaluated patients' age, sex, location and type of the fracture, timing of diagnosis and surgery, method of fixation, combined injuries, time of bone union, and complications. Postoperative functions were assessed by Friedman and Wyman's criteria.

Results

Femoral shaft fractures healed in 23 cases of 26 cases and in 3 cases of nonunion. Hip fractures healed in 25 cases of 26 cases, and in 1 case, there was nonunion. According to the outcome score followed by Friedman and Wyman's criteria, 13 cases had good results, 9 cases had fair results, and 4 cases had poor results. Timing of bone union and union rate were significantly different according to the degree of femoral shaft fracture comminution. Postoperative function was significantly different according to the degree of femoral shaft fracture comminution and the presence of ipsilateral fractures around the knee.

Conclusions

In cases of ipsilateral hip and femoral shaft fractures, more comminuted fractures of the femoral shaft and ipsilateral fractures around the knee, which resulted in delayed rehabilitation, caused poor postoperative functional outcomes. Because avascular necrosis and the presence of nonunion of femoral head are important in prognosis, delicate physical examination and radiologic evaluation of hip fractures are needed primarily before emphasizing anatomical reduction of hip fractures followed by rigid internal fixation.     

Simple and comminuted displaced olecranon fractures: a clinical comparison between tension band wiring and plate fixation techniques

Introduction

The purpose of this retrospective study is to compare the clinical, functional outcome and complications occurrence between tension band wiring (TBW) and plate fixation both for simple and comminuted displaced olecranon factures.

Materials and methods

Between January 2005 and June 2012 (minimum 1-year follow-up), 78 consecutive patients with Mayo type IIA and IIB fractures were treated with the following methods: tension band wire or plate and screws fixation. The primary outcome of this study was the functional outcome, assessed by the following self-administered evaluation scales: the disabilities of the arm, shoulder and hand, and the Mayo Elbow Performance Score. Secondary outcome measures included the assessment of pain level, analysis of passive range of motion, and the occurrence of any early or late complications.

Results

Comparing the clinical results between the two groups, at mean 33 months follow-up, no significant differences in the functional and clinical outcome were observed. Complications were reported in 48 and 17 % of cases, following TBW and plate fixation in patients treated for type IIA fractures, and similarly in 40 and 23 % of cases in type IIB fractures, respectively. Hardware removal was more frequently performed in TBW group: 38 versus 17 % for type IIA fractures and 20 versus 6 % for type IIB fractures.

Conclusions

The findings of this study indicate that both with the use of TBW and plate fixation excellent/good clinical outcomes with minimal loss of physical capacity, little pain and disability can be obtained in the majority of patients with simple and comminuted displaced olecranon fractures. Hardware removal was most frequently observed after TBW.

Level of evidence

Therapeutic IV.     

The effect of renal function on surgical outcomes of intracapsular hip fractures with osteosynthesis

Background

Chronic kidney disease (CKD) affects many physiologic systems, including bone quality, nutrition, and cardiovascular condition. Femoral neck fractures in patients on dialysis are associated with frequent complications and a high risk of mortality. However, the effect of CKD on clinical outcomes of patients with hip fractures treated with osteosynthesis remains unclear.

Methods

One hundred and thirty patients with 130 femoral neck fractures treated with internal fixation were divided into two groups and the data were then analyzed. Group 1 consisted of 98 patients (98 hip fractures) with normal renal function (estimated glomerular filtration rate, or eGFR, ≥60 ml/min/1.73 m²). Group 2 was composed of 32 patients (32 hip fractures) with CKD (eGFR <60 ml/min/1.73 m²) without dialysis. Clinical outcomes as well as early and late complications were recorded for each group. Survivorship analysis was performed, and the mortality and complication rates for the groups were then compared.

Results

In Group 1, 32 complications (32.6 %) occurred in 98 hips, including 5 cases of nonunion and 16 cases of osteonecrosis. In Group 2, 24 complications (75 %) developed in 32 hips; these included 8 cases of nonunion and 3 cases of osteonecrosis. The mean duration of follow-up was 32 months. The overall mortality rate was 11.5 %. No difference was noted in early, late, or overall mortality rate between two groups. Patient with CKD had a higher nonunion rate (OR = 5.9, P = 0.023). Meanwhile, CKD and displaced fracture pattern were independent predictors for revision surgery (OR = 3.0, P = 0.032; OR = 6.9, P = 0.001, respectively).

Conclusions

Osteosynthesis is a safe and effective treatment for femoral neck fractures; however, patients with femoral neck fracture and CKD have a higher risk of nonunion and subsequent surgical revision.

Level of relevance

Prognostic studies, Level III.     

Management of acute displaced midshaft clavicular fractures using Herbert cannulated screw: Technique and results in 114 patients

Purpose:

A new and simple operative technique has been developed to provide internal fixation for midshaft clavicle fractures. This involves the use of a large fragment Herbert Screw that is entirely embedded within the bone. Screw fixation is combined with bone grafting from intramedullary reamings of the fracture fragments. The purpose of this report is to assess the outcomes following treatment of midshaft clavicular fracture using this method.

Materials and Methods:

One hundred and fourteen patients with acute displaced midshaft fracture were identified between 2002 and 2007. All patients were followed until fracture union. Patients’ medical records were reviewed. Disability of the Arm, Shoulder, and Hand questionnaire (DASH), and American Shoulder and Elbow Surgeons Elbow form (ASES) were posted to all patients. Outcome measures included union rate, time to union, implant removal rate, DASH, and ASES scores.

Results:

Patients’ median age was 29.5 years (interquartile range, 19-44 years). The most common injury mechanism was sports injury (28%). The median time from injury to surgery was 5 days (interquartile range, 2-9 days). Union occurred in an average of 8.8 weeks. Non-union occurred in three cases (2.6%). The re-operation rate for symptomatic hardware prominence screw was 1.7%. The median DASH score was 0.83 and the median ASES was 100 (n = 35).

Conclusions:

Intramedullary fixation using cannulated Herbert screw can be used as an effective approach for operative management of midshaft clavicular fractures. Using this method, an appropriate outcome could be achieved and a second intervention for implant removal could be avoided in great majority of cases.

Level of Evidence:

Level III